Changing Paragidms In The Prognostic Assessment Of Hodgkin Lymphoma

Overview

Classical Hodgkin's Lymphoma (cHL) is a rare but highly treatable malignancy of the immune system, primarily affecting young adults. Despite significant therapeutic advancements, frontline treatment failure occurs in up to 30% of cases, with relapse or refractory disease affecting over 50% of these patients. The main therapeutic challenge in cHL remains achieving an optimal balance between disease control and reducing long-term adverse effects. Current prognostic tools only partially capture patient heterogeneity, and cHL continues to evolve spatially and temporally throughout the course of the disease. Personalized treatment strategies require novel integrated tools that better monitor tumor complexity and anticipate disease progression. Fluorodeoxyglucose positron emission tomography (FDG-PET) has improved risk stratification in cHL, as metabolic response during or after chemotherapy strongly correlates with disease progression and survival. However, FDG-PET has limitations, including the absence of standardized criteria and the necessity to initiate treatment before response assessment. To overcome these limitations, molecular profiling and radiomic analysis of baseline FDG-PET data may provide deeper insights into tumor biology, improving prognostic accuracy. This observational study aims to dissect the genetic and phenotypic heterogeneity of cHL at diagnosis and during disease evolution, with the goal of identifying novel prognostic biomarkers. These findings could lead to better treatment personalization, increasing cure rates while minimizing treatment-related toxicity. The study is based on the hypothesis that correlating DNA profiling at diagnosis, gene expression, and radiomic features may enable the identification of high-risk signatures, refining prognostic models in cHL. Additionally, liquid biopsy represents a non-invasive method for assessing tumor mutational complexity. The analysis of circulating DNA (cDNA) throughout disease progression could provide insights into genetic evolution and help predict overt progression before clinical manifestations occur. The primary objective is to define the genetic mutational profile of cHL at disease progression. As secondary objectives, it will evaluate whether liquid biopsy can accurately recapitulate the genetic heterogeneity observed in tumor tissue, determine the predictive accuracy of liquid biopsy in anticipating disease progression, and correlate genomic and radiomic features with patient outcomes to refine risk stratification and therapeutic decision-making. By integrating molecular and imaging-based biomarkers, this study aims to enhance personalized treatment strategies, improve risk-adapted therapeutic approaches, and ultimately optimize curability and quality of life for patients with cHL.

Detailed description

This study has both retrospective and prospective components. The prospective part includes patients with Classical Hodgkin's Lymphoma (cHL) who have completed active treatment and entered follow-up (Cohort A), as well as patients with a histological confirmation of relapse or progression (Cohort B). The retrospective cohort (Cohort C) consists of 235 consecutive cHL patients collected from the archives of the Hematology Unit of AUSL-IRCCS between 2004 and 2019, along with up to 250 cHL patients diagnosed between 2016 and 2021 from other Italian hematology centers.

Primary outcome measures

• Genetic Mutational Profiling of cHL at Progression [Time frame: At enrollement]

Secondary outcome measures (4)

• Liquid Biopsy Ability to Recapitulate Tissue Genetic Heterogeneity [Time frame: Up to 4 years]
• Accuracy of Liquid Biopsy in Anticipating Disease Progression [Time frame: From 2 up to 4 years]
• Correlation between Gene Expression Profiling and Progression-free survival (PFS) [Time frame: Up to 4 years]
• Correlation between Gene Expression Profiling and cnical events like relapse and refractoriness [Time frame: Up to 4 years]

Eligibility criteria

Inclusion criteria

• Age >18 anni
• Written informed consent signed

Cohort A

• Age >18 years
• Histologically confirmed diagnosis of relapsed/refractory classical Hodgkin lymphoma identified during induction or follow-up
• Available formalin-fixed, paraffin-embedded (FFPE) biopsy at diagnosis and at the time of progression/relapse
• Available plasma sample at progression (before the beginning of salvage therapy)
• Available FDG-PET evaluation at study enrollment
• Available clinical, laboratory, and radiologic data at diagnosis and relapse

Cohort B

• Diagnosis of classical Hodgkin lymphoma
• Completion of first-line standard systemic treatment (chemotherapy-based or chemoradiotherapy combined modality)
• Available plasma sample at the end of treatment (at least 30 days from the last chemotherapy)
• Available FFPE biopsy at diagnosis
• No further treatment planned
• Available clinical, laboratory, and radiologic data at diagnosis and response evaluation
• Patient's willingness to undergo 6 months follow-up plasma sample collection and to attend regular follow-up

Cohort C

• Histologically confirmed diagnosis of classical Hodgkin lymphoma
• Standard treatment as per available guidelines (e.g., ESMO guidelines)
• Available treatment data, response, and follow-up data
• Available FFPE biopsy at diagnosis
• Available FDG-PET evaluation at study enrollment

Exclusion criteria

• Patients with nodular lymphocyte predominant Hodgkin lymphoma are not eligible; all other subtypes including nodular sclerosis, lymphocyte-depleted, lymphocyte-rich, and mixed cellularity Hodgkin lymphoma may be enrolled.
• Active HIV, HBV, HCV viral infection
• Concomitant neoplasm not treated with a curative aim

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Observational model

Cohort

Study locations

Italy · 12 centers

• ASST Grande Ospedale Metropolitano Niguarda — Milan
• Azienda USL IRCCS di Reggio Emilia — Reggio Emilia
• A.O.S.G. Moscati — Avellino
• Spedali Civili Brescia — Brescia
• Istituto Oncologico Veneto — Padova
• Azienda Ospedaliera "Ospedali Riuniti Villa Sofia-Cervello" — Palermo
• Azienda Ospedaliera di Perugia — Perugia
• Ospedale S. Maria della Misericordia, Azienda Ospedaliera di Perugia — Perugia
• … and 4 more centers

Publications

• Merli F, Luminari S, Gobbi PG, Cascavilla N, Mammi C, Ilariucci F, Stelitano C, Musso M, Baldini L, Galimberti S, Angrilli F, Polimeno G, Scalzulli PR, Ferrari A, Marcheselli L, Federico M. Long-Term Results of the HD2000 Trial Comparing ABVD Versus BEACOPP Versus COPP-EBV-CAD in Untreated Patients With Advanced Hodgkin Lymphoma: A Study by Fondazione Italiana Linfomi. J Clin Oncol. 2016 Apr 10;34 PMID 26712220
• Andre MPE, Girinsky T, Federico M, Reman O, Fortpied C, Gotti M, Casasnovas O, Brice P, van der Maazen R, Re A, Edeline V, Ferme C, van Imhoff G, Merli F, Bouabdallah R, Sebban C, Specht L, Stamatoullas A, Delarue R, Fiaccadori V, Bellei M, Raveloarivahy T, Versari A, Hutchings M, Meignan M, Raemaekers J. Early Positron Emission Tomography Response-Adapted Treatment in Stage I and II Hodgkin Lymph PMID 28291393
• Eichenauer DA, Aleman BMP, Andre M, Federico M, Hutchings M, Illidge T, Engert A, Ladetto M; ESMO Guidelines Committee. Hodgkin lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1;29(Suppl 4):iv19-iv29. doi: 10.1093/annonc/mdy080. No abstract available. PMID 29796651
• Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Armand P, Bello CM, Benitez CM, Bierman PJ, Chen R, Dabaja B, Dean R, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Maddocks K, Maloney DG, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Rabinovitch R, Seropian S, Tao R, Winter JN, Yahalom J, Burns JL, Ogba N. NCCN Guidel PMID 29523663
• Luminari S, Donati B, Casali M, Valli R, Santi R, Puccini B, Kovalchuk S, Ruffini A, Fama A, Berti V, Fragliasso V, Zanelli M, Vergoni F, Versari A, Rigacci L, Merli F, Ciarrocchi A. A Gene Expression-based Model to Predict Metabolic Response After Two Courses of ABVD in Hodgkin Lymphoma Patients. Clin Cancer Res. 2020 Jan 15;26(2):373-383. doi: 10.1158/1078-0432.CCR-19-2356. Epub 2019 Oct 23. PMID 31645353
• Rossi D, Spina V, Bruscaggin A, Gaidano G. Liquid biopsy in lymphoma. Haematologica. 2019 Apr;104(4):648-652. doi: 10.3324/haematol.2018.206177. Epub 2019 Mar 7. No abstract available. PMID 30846503
• Spina V, Bruscaggin A, Cuccaro A, Martini M, Di Trani M, Forestieri G, Manzoni M, Condoluci A, Arribas A, Terzi-Di-Bergamo L, Locatelli SL, Cupelli E, Ceriani L, Moccia AA, Stathis A, Nassi L, Deambrogi C, Diop F, Guidetti F, Cocomazzi A, Annunziata S, Rufini V, Giordano A, Neri A, Boldorini R, Gerber B, Bertoni F, Ghielmini M, Stussi G, Santoro A, Cavalli F, Zucca E, Larocca LM, Gaidano G, Hohaus PMID 29449275

Identifiers

NCT: NCT06822855 · 696/2021/TESS/IRCCSRE

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗