Individualized PEAM Conditioning for Autologous Stem Cell Transplantation in Relapsed Classical Hodgkin Lymphoma With Severe Drug-Induced Liver Injury

High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT) is a standard consolidation strategy for patients with relapsed classical Hodgkin lymphoma with chemosensitive disease. However, conventional BEAM conditioning may be challenging in patients with significant preexisting hepatic injury because of the potential for worsening hepatotoxicity and sinusoidal obstruction syndrome. We report the use of PEAM conditioning instead of BEAM in a patient with relapsed Hodgkin lymphoma, hepatic involvement at relapse, and subsequent severe cholestatic drug-induced liver injury.

A 42-year-old man was diagnosed with classical Hodgkin lymphoma in March 2021 and received six cycles of ABVD, achieving complete remission. In October 2025, he developed stage IV relapse with biopsy-proven hepatic infiltration, presenting with jaundice and dark urine. Salvage therapy with brentuximab vedotin plus nivolumab was administered, with the last dose given on January 10, 2026. Treatment was complicated by resolved oropharyngeal candidiasis and urinary tract infection, immune-related cutaneous lesions without evidence of malignancy, and marked cholestatic drug-induced liver injury. The objective was to describe the multidisciplinary assessment and individualized conditioning strategy used to permit ASCT while reducing anticipated hepatic toxicity.

Restaging PET/CT demonstrated a second complete metabolic remission, with resolution of previously identified nodal and extranodal lesions. At pretransplant evaluation, the patient was asymptomatic, had an ECOG performance status of 0, was hemodynamically stable, and had recovered his baseline functional status. Laboratory assessment showed mild anemia and leukopenia, with preserved neutrophil and platelet counts. Liver biopsy demonstrated mixed hepatitis with a cholestatic pattern, focal bile duct injury, and F2 fibrosis, consistent with drug-induced liver injury. There was no active malignant hepatic infiltration or cirrhosis, and hepatic synthetic function remained preserved. Cardiac and pulmonary assessments showed no contraindication to transplantation. Infectious evaluation revealed no active infection, and prophylaxis was planned for latent tuberculosis and opportunistic infections.

Because of the previous severe hepatic injury, underlying fibrosis, and increased risk of conditioning-related hepatotoxicity and sinusoidal obstruction syndrome, conventional BEAM was avoided. The patient proceeded to ASCT using the institutional PEAM conditioning regimen (Using cisplatin instead of carmustine), selected as an individualized alternative intended to limit additional hepatic injury. Close monitoring of bilirubin, transaminases, weight, fluid balance, and clinical signs of sinusoidal obstruction syndrome was incorporated into the peri-transplant management plan. ASCT occurred with no hepatic complication achieving hematologic recovery on day +10.

This case illustrates that prior severe cholestatic liver injury and moderate hepatic fibrosis do not necessarily preclude ASCT in a fit patient with relapsed classical Hodgkin lymphoma in second complete remission. Multidisciplinary evaluation, exclusion of active hepatic lymphoma and cirrhosis, confirmation of preserved hepatic synthetic function, and individualized conditioning selection were essential. PEAM enabled transplantation to proceed when conventional BEAM was considered to pose an unacceptable hepatic risk. This experience supports personalized conditioning strategies for carefully selected transplant candidates with substantial preexisting hepatic injury.