Background: The co-occurrence of classic Hodgkin lymphoma (cHL) with gynecologic neoplasms is a rare event that can pose challenges for diagnosis, management, and treatment monitoring. We present a case of a woman who was simultaneously diagnosed with relapsed cHL and ovarian carcinoma, proving the usefulness of the long-term ctDNA monitoring of both malignancies in routine practice.
Case Summary: A 42-year-old woman in remission from intermediate-stage nodular-sclerosis cHL for 7 years was referred in August 2019 with enlarged axillary lymph nodes (LNs). PET/CT surprisingly detected an asymptomatic pelvic tumor mass. Extensive surgical tumor resection revealed an advanced serous OC (FIGO IIIA, pT3aN0M0R0). Concurrently, axillary LNs biopsy confirmed cHL relapse. NGS panel identified MRD markers from the paraffin-embedded tissues from the OC (BRAF V600E mutation) and the cHL (STAT6 gene, N417Y/N421S). Those targets were followed using ctDNA throughout the disease course (Fig 1). The diagnosis of OC has been prioritized, and the patient received adjuvant chemotherapy with 4 cycles of paclitaxel with carboplatine out of planned 6 (terminated early in January 2020 for intolerance). The patient achieved CR of OC with persistent supradiaphragmatic lymph node enlargement and skeletal involvement (July 2020, cHL CS IVEA). The patient was given 2 cycles of miniBEAM and subsequent autologous stem cell rescue, with very good PR (December 2020), followed by the maintenance therapy of brentuximab-vedotin. After 8 cycles of BV (July 2021), pt progressed and started nivolumab (flat dose of 240 mg) a month later. PET/CT scan after 12 doses of nivolumab proved PR; next PET/CT scan performed after one year of nivolumab showed residual inguinal and axillar LNs - involved-site RT (30 Gy) of the inguinal LNs was indicated for possible abscopal effect in October 2022. Following PET/CT scan in March 2023, regression in all localities except the axillary nodes was found. Nivolumab (36th dose) was terminated on August 2023, and the patient was indicated to be PET-guided IF RT (36 Gy) of the small axillary LNs. She remained in the CR of OC.
Conclusion: In our case, we discussed the co-occurrence of two clonally unrelated malignancies in a single patient being eventually treated with the same drug (nivolumab) and followed using cell-free DNA.
Acknowledgement: Supported by MZ ČR – RVO (FNOl, 00098892), AZV NU22-03-0018.
Veronika Hanáčková, Jan Grohmann, Patrik Flodr, Tomáš Papajík, Jana Navrátilová, Vít Procházka