Successful Treatment of Childhood Hodgkin’s Lymphoma and Secondary Myelofibrosis Resistant to Intensive Therapy, Including Allogeneic Transplantation

Myelofibrosis is a rare complication in children with Hodgkin's lymphoma and presents significant treatment challenges due to the disease's low tolerance to chemotherapy.This condition often necessitates dose reductions, which can negatively impact patient outcomes and prognosis [1,2].An 8-year-old male was admitted to the Pediatric Hematology and Oncology Outpatient Clinic at Erciyes University with a 6-month history of malaise, anorexia, weight loss, and nocturnal leg pain.Physical examination revealed dyspnea, tachycardia, a 3-cm supraclavicular lymphadenopathy, and hepatosplenomegaly.Laboratory tests showed leukopenia (white blood cell: 1,940/mm 3 ), neutropenia (absolute neutrophil count: 950/mm 3 ), lymphopenia (absolute lymphocyte count: 740/mm 3 ), thrombocytopenia (platelet: 85,000/mm 3 ), and severe anemia (hemoglobin: 4.9 g/dL).His erythrocyte sedimentation rate was elevated at 83 mm/h.Thoracic computed tomography revealed multiple mediastinal lymph nodes.Axillary lymph node excision and bone marrow biopsy were performed based on clinical findings.Histopathological examination of the excised axillary lymph node and bone marrow biopsy specimen confirmed a diagnosis of the mixed-cell type of classical Hodgkin lymphoma.Additionally, the bone marrow biopsy revealed the presence of myelofibrosis (Figure 1).A positron emission tomography-computed tomography (PET-CT) scan showed diffuse conglomerate lesions with hypermetabolic activity in the mediastinal lymph nodes as well as osteosclerotic lesions in cortical bones.Screening results indicated diffuse nodal and extranodal involvement of the primary disease (lymphoma), affecting the liver, spleen, bones, and bone marrow (Figure 2).Whole-exome analysis performed on a peripheral blood sample, along with the JAK2, CALR, and MPL pathological variant studies on a bone marrow aspiration sample, yielded normal results.The patient was diagnosed with stage IVB Hodgkin lymphoma and secondary myelofibrosis.Treatment included eight cycles of chemotherapy: four cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine, followed by four cycles of cyclophosphamide, vincristine, procarbazine, and prednisone.Post-treatment bone marrow analysis was normal.Four months after completing chemotherapy, the patient presented with persistent fever and lymph node swelling.A biopsy of a suspected cervical lymph node confirmed Hodgkin's lymphoma recurrence.The patient received two cycles of a combination regimen comprising brentuximab and etoposide, carboplatin, and ifosfamide.However, PET-CT imaging showed no response to treatment.Consequently, an alternative two-cycle regimen containing brentuximab, prednisolone, ifosfamide, vinorelbine, and gemcitabine was initiated.Given the diagnosis of relapsed/refractory Hodgkin's lymphoma and the inability to collect autologous stem cells or the patient underwent haploidentical transplantation.