Sequential BV-AVD Therapy in Richter Transformation: Insights Into the Management of Elderly Patients

Hodgkin-variant Richter's transformation (HvRT) is a rare evolution of chronic lymphocytic leukemia (CLL) into a lymphoma with histological characteristics akin to those of classical Hodgkin lymphoma (cHL), overall occurring in < 1% of CLL cases. Due to its rarity, treatment is not standardized and is commonly adapted from cHL regimens, although toxicity limits their use in older or heavily pretreated patients. We describe two cases of HvRT treated with a modified sequential brentuximab vedotin-AVD-brentuximab vedotin (BV-AVD-BV) regimen, previously explored in elderly patients with cHL. Sequential BV-AVD-BV was feasible and manageable in both cases, with acceptable hematologic toxicity. One patient achieved a durable complete metabolic remission, while the other required immune checkpoint inhibitor-based salvage therapy followed by autologous stem cell transplantation, resulting in complete metabolic response. These cases suggest that sequential BV-AVD-BV may represent a tolerable and effective therapeutic option for selected patients with HvRT. Incorporation of modern Hodgkin-directed strategies, including sequential regimens and immune checkpoint inhibitors, warrants further evaluation in this rare clinical setting.