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Tumor Discovery BrECADD-induced ileus and GI hemorrhage

BV treatment group. In addition, a review of the Food efficacy while reducing toxicity. The phase 3 HD21 trial,
11
and Drug Administration adverse event reporting system a multicenter, open-label, randomized study, compared
indicated that antibody-drug conjugates, including BV, may BrECADD with the escalated bleomycin, etoposide,
elevate the risk of a broad spectrum of GI adverse events. 12 doxorubicin, cyclophosphamide, vincristine, procarbazine,
In our patient, neutropenic enteritis likely led to mucosal and prednisone (BEACOPP) regimen in patients aged
1
compromise, stenosis, and eventual bleeding. The absence 18 – 60 years with newly diagnosed AS-cHL. The trial
of prior surgeries and lymphoma involvement suggests a demonstrated that BrECADD was superior to BEACOPP
direct link to chemotherapy toxicity. Our patient was initially in terms of progression-free survival (PFS) and had a more
managed conservatively with nasogastric decompression, favorable safety profile. At a median follow-up of 48 months,
prokinetic agents, intravenous fluids, parenteral nutrition, the 4-year PFS was 94.3% for BrECADD compared to 90.9%
and antibiotics. Despite initial resolution, the patient for BEACOPP (hazard ratio: 0.66; p=0.035). Furthermore,
experienced severe GI bleeding, necessitating surgical treatment-related morbidity was significantly lower in
intervention and intensive care support. the BrECADD group (42%) compared to the BEACOPP
group (59%; p<0.0001). Notably, the BrECADD regimen
3.2. Chemotherapy-associated GI hemorrhage was associated with a lower incidence of severe sensory
polyneuropathy and improved recovery rates of gonadal
GI bleeding is a well-recognized complication in cancer function compared to BEACOPP. The reported rate of
patients undergoing chemotherapy. However, massive GI severe GI adverse events was 8% for the BrECADD cohort,
hemorrhage resulting in hemodynamic compromise is a apparently without any cases of bowel obstruction.
rare and serious event. The management of GI bleeding
in this population involves a multidisciplinary approach A single-arm cohort within the phase II HD21 trial,
that combines supportive care with targeted interventional examining the BrECADD protocol in adults up to 75 years
procedures. 13 of age, concluded that the regimen is feasible and safe in
older patients, although it requires more frequent dose
Initial treatment typically includes transfusion of blood 16
products such as red blood cells, platelets, fresh frozen adjustments.
plasma, and coagulation factors to stabilize the patient Historically, patients older than 60 years received ABVD
and correct any underlying coagulopathies. Endoscopic (doxorubicin, bleomycin, vinblastine, and dacarbazine)
2
techniques play a central role in controlling bleeding and therapy. This treatment standard has since evolved – first
may include argon plasma coagulation, hemoclipping, to BV, doxorubicin, vinblastine, and dacarbazine (BV-AVD)
or epinephrine injection, depending on the source and and more recently to nivolumab, doxorubicin, vinblastine,
severity of the hemorrhage. 13 and dacarbazine (Nivo-AVD). 17,18 The phase III S1826
study demonstrated significantly improved outcomes and a
In cases where endoscopic therapy is either unsuccessful
or not feasible, trans-arterial embolization has emerged as more favorable safety profile with six cycles of Nivo-AVD
compared to BV-AVD. The complete remission rate at
18
an effective alternative. Surgical intervention remains a the end of treatment with Nivo-AVD was 83.1%, which is
14
last resort, reserved for refractory cases, but it is associated similar to the 82% reported with BrECADD. After a median
with a significantly higher risk – particularly in patients follow-up of 2.1 years, the 2-year PFS for the overall cohort,
with advanced malignancies or poor performance status. as well as for the subgroup of patients aged 18 – 60 years,
A retrospective analysis of 156 patients with was 92%. Although numerically slightly lower than the PFS
pancreatic cancer undergoing chemoradiation found reported for BrECADD, direct comparison of these results is
that approximately 25% experienced GI bleeding, most not appropriate due to significant differences in trial design
commonly from the upper GI tract. Among these, there and populations. For instance, the S1826 trial included
were eight fatal cases. Management strategies in that patients younger than 18 years and those aged 60 and above,
cohort included transfusion support, pharmacologic and enrolled a racially and ethnically diverse population.
measures, and endoscopic therapy, which demonstrated a Nevertheless, the safety profile of Nivo-AVD is clearly more
high success rate in most patients. 15 favorable, with fewer severe adverse events and treatment
discontinuations due to toxicity compared to BrECADD. 1,18
3.3. Contemporary treatment strategies for advanced-
stage HL: Spotlight on BrECADD and Nivo-AVD 3.4. Clinical considerations of chemotherapy
The BrECADD regimen – comprising BV, etoposide, selection in our patient
cyclophosphamide, doxorubicin, dacarbazine, and In our patient, we opted to administer BrECADD due
dexamethasone – was developed to improve the treatment to the highly aggressive and symptomatic nature of the
of advanced-stage classical HL (AS-cHL) by enhancing disease. Before diagnosis, the patient was in excellent

Volume 4 Issue 3 (2025) 107 doi: 10.36922/TD025180033