DR SEHN: This was a 72-year-old woman who presented really with months of growing lymphadenopathy that was a little hard to diagnose initially. She had a few fine-needle aspirate biopsies, then core biopsies that were inconclusive and ultimately went on to a cervical lymph node biopsy that proved to be a peripheral T-cell lymphoma not otherwise specified. On staging, she had Stage IV disease with widespread lymphadenopathy.

And the one peculiar thing that’s most noteworthy with her is, she actually had infiltration of her hard pallet. And so one of her clinical symptoms was that she actually had difficulty speaking and swallowing because of this infiltration of her pallet, so a little bit of an unusual site of involvement.

At 72 years old, she was not the best candidate for multiagent chemotherapy or any intensive approaches, but we did treat her with what is commonly used as a standard front-line treatment strategy for peripheral T-cell lymphoma, and that’s CHOP chemotherapy. Unfortunately, she received actually 3 cycles of that and really had no benefit whatsoever. So we then switched her to an alternate salvage chemotherapy. We actually switched her to GDP, which is a gemcitabine- and cisplatin-based regimen.

Gemcitabine actually is quite an effective agent in some patients with T-cell lymphoma. So it is our preferred salvage regimen for patients who’ve failed front-line therapy. She had a little bit better response to that, so some regression in her adenopathy and improvement in this infiltration in her pallet. So her symptoms improved, but she didn’t really achieve what I would call a full partial remission by restaging.

But nonetheless, after 2 successive lines of chemotherapy, we stopped at that point and observed her. But it wasn’t long before her symptoms started to recur again, so about a year after stopping the GDP, she started to have the same symptoms, regrowth of this disease in her pallet, regrowth of the adenopathy.

And the frustrating thing is that although we’re seeing a variety of targeted agents come on board for the management of B-cell lymphomas, there’s really a paucity of targeted agents and treatments available for T-cell lymphoma. So at this point, we actually elected to treat her with romidepsin, which is a drug that’s been specifically approved for the management of T-cell lymphomas.

DR LOVE: So did she have CD30 testing?

DR SEHN: That’s a good question, actually. She was CD30-negative.

DR LOVE: So I’m assuming or guessing that you typically would test most patients with any type of T-cell lymphoma for CD30?

DR SEHN: Yes. So the reason to test patients for CD30 is because there is some data that brentuximab, which targets CD30, might be helpful for these patients. So we are actually now routinely testing patients with T-cell lymphoma for CD30. It’s often part of the usual tests that pathology will do up front, because some of the designations of T-cell lymphoma, like anaplastic large cell lymphoma, rely on CD30 presentation.

And it often is a panel of the immunohistochemistry that’s done by pathologists to subtype T-cell lymphoma. So most of the time we’ll actually have that information in the initial report. If not, we usually do ask the pathologists to get that data for us, to see whether or not brentuximab might be a treatment option for these patients.

DR LOVE: So when patients are CD30-negative, you hear people talking about romidepsin, pralatrexate and belinostat. What caused you to choose romidepsin, and what happened?

DR SEHN: Yes. So all of those drugs are potentially treatment options for patients with T-cell lymphoma. I have to say, in my own clinic we’re a little bit challenged. We don’t have pralatrexate or belinostat available or funded. So romidepsin was the drug that we have available, but it is a drug that, as I said, has been specifically approved for T-cell lymphoma, because in the pivotal trial it actually demonstrated that there is a subset of patients, about 25% of patients, that actually have remarkable benefit from that drug and can have quite durable responses.

So we treated this patient with romidepsin. At 72, after several lines of chemotherapy, it’s not the easiest drug to give. So she did experience significant cytopenias. We had to actually have quite a few dose interruptions and delays, but we actually ultimately managed to get her through 6 cycles of therapy. And she actually had a remarkable response.

So I’d say that she had the best response that she’d had to any drug so far. She didn’t quite achieve a complete response, but she had a very good partial response and right now is currently on observation without need for further therapy.

DR LOVE: So wow! That’s certainly something I haven’t heard too much about. But I have heard — it’s good that you have that one available of the three, because that’s kind of the one I’ve heard about people turning to. What I hear is better tolerated than, particularly, pralatrexate, although I guess there are problems that occur. Did this patient have any quality-of-life issues? Any nausea, fatigue?

DR SEHN: Yes. So romidepsin can be very beneficial for some patients. As I said, unfortunately these patients with T-cell lymphoma are very challenging to treat. And we haven’t hit, in my mind, the big home run drug with very high response rates across the board in T-cell lymphoma. But romidepsin, for many patients, there’s that subset of patients that they can get a very durable and good benefit. But it’s not without toxicity. And it’s also a drug that’s quite effortful to give.

So it’s given on a day 1, 8 and 15 schedule. It’s a rather prolonged infusion, so it requires patients coming into the clinic on a weekly basis and receiving an infusion that goes on for over 4 hours. Patients can experience nausea and vomiting, but we treat all of our patients with antiemetics. Fatigue, I’d say — this patient had fatigue from her lymphoma, but it definitely got worse while she was on romidepsin, until we got her off the drug. So there are definitely symptoms associated with receiving the drug as well as, as I said, the risks of cytopenias and infection that come with it as well.

Non-Hodgkin lymphoma (NHL), Hodgkin lymphoma and chronic lymphocytic leukemia (CLL)

Acute and chronic leukemias and myeloproliferative neoplasms

Multiple myeloma (MM)