Paraneoplastic pruritus presenting with Hodgkin’s lymphoma: a case report

Abstract

IntroductionParaneoplastic pruritus is defined as pruritus that occurs before or during the natural evolution of a hematologic disease. The reported prevalence is 30% in patients with Hodgkin’s lymphoma. The severity of this pruritus has a very negative impact on patients’ quality of life. Very few studies have been made to examine the efficacy of pharmacological treatments for this type of pruritus. One drug that appears to be effective in this respect is off-label aprepitant, a neurokinin 1 receptor antagonist.Case presentationA 20-year-old Caucasian woman presented with lateral neck nodes, sweating, and pruritus and was diagnosed with stage IIB nodular sclerosis Hodgkin’s lymphoma. Throughout this period during the disease the pruritus was ever-present. Improvement was achieved with some of the chemotherapy treatments, but the symptom returned when the various treatments were withdrawn due to disease progression or poor tolerance. In the middle of the seventh year, she was admitted to our hospital with uncontrolled pruritus that resulted in severe lesions due to scratching. In response, aprepitant (off-label) 80mg/day was added to the chemotherapic treatment of the pruritus, after studying the various treatment options. She reported a score of 9 on a visual analogue scale for the pruritus, and a score of 3 on the Eastern Cooperative Oncology Group performance status scale of performance status. After two weeks of treatment with aprepitant, she reported a score of 5 on the visual analogue scale for the pruritus, and this improved to a score of 4 in a month, which allowed her to lead a better quality of life, with an Eastern Cooperative Oncology Group performance status score between 1 and 2.ConclusionsSeveral cases and case series have been reported on the use of aprepitant for paraneoplastic pruritus, but none have referred to its use for Hodgkin’s lymphoma. A prospective study was carried out to evaluate the efficacy of this drug in refractory pruritus secondary to Sezary syndrome, and other authors have studied the effectiveness of aprepitant against pruritus, secondary to biological therapy with erlotinib. In our case report, treatment was started with daily doses of aprepitant 80mg. Pruritus improvement appeared to be attributable exclusively to the administration of aprepitant.

Need for Flexible Adjustment of the Treatment Schedule for Aprepitant Administration against Erlotinib-Induced Refractory Pruritus and Skin Rush

“…Recently, there have been the various successful scientific reports of aprepitant administration for the treatment of refractory pruritus. In these reports, the treatment schedules are not unified, showing 125 mg on day 1, 80 mg on days 3 and 5 [ 6 ]; 125 mg on day 1, 80 mg on days 2–3 [ 4 , 7 ]; 125 mg on day 1, 80 mg on days 2–3, followed by alternating days of 125mg and 80mg thereafter [ 8 ]; 125 mg on day 1, 80 mg on days 2–3, every 2 weeks [ 9 , 10 ]; 80 mg/day [ 5 , 11 , 12 , 13 , 14 , 15 ]; and 80 mg, every 3 days [ 16 ]. Notably, Santini et al have conducted a prospective pilot study for evaluating the efficacy of aprepitant administration in 45 patients, with metastatic solid tumors, treated with EGFR-targeted biological drugs, and with first onset of severe pruritus during the treatment [ 6 ].…”

“…Therefore, erlotinib was again discontinued, and she was started on aprepitant at 125 mg on day 1 after discontinuation, 80 mg on day 3, and 80 mg on day 5 with the aim of treating the pruritus and skin rush. This treatment schedule for aprepitant administration was decided after studying the various treatment schedules on the basis of the scientific reports of aprepitant administration [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Then, the prompt improvement was observed within 5 days after starting the first dose of aprepitant, leading to a score of 2 for the pruritus on the VAS (Fig.…”

Resolution of refractory pruritus with aprepitant in a patient with microcystic adnexal carcinoma

“…5 Aprepitant treatment has been used with success for pruritus associated with both malignant and nonmalignant conditions in at least 74 patients, 6 among whom the malignant conditions included cutaneous T-cell lymphoma, Hodgkin lymphoma, and metastatic solid tumors. [5][6][7] Aprepitant has also been used for erlotinib-and nivolumab-induced pruritus in non-small cell lung cancer, which suggests a possible future role for aprepitant in the treatment of pruritus secondary to novel cancer therapies, perhaps including immune checkpoint inhibitors. [8][9][10] However, despite those reports, and likely owing to the multifactorial nature of pruritus, aprepitant is not unviversally effective.…”

Emerging Treatments and Novel Pathways in Pruritus

“…To date, around 80 cases have been published in the literature. [46][47][48][49][50][51][52][53][54][55][56][57][58][59] Its indications serve to treat severe itch in cutaneous lymphomas or pruritus in association with biological oncologic treatments, namely epidermal growth factor receptor tyrosine kinase inhibitor. [47][48][49][50][51][52][53][54][55] Indeed, a pilot study testing aprepitant for 1 week demonstrated an impressive reduction of 8/10 to 0-1 on the VAS in patients with biological cancer treatment-related pruritus.…”