From Uncertainty to Clarity: How a Hodgkin Lymphoma Patient in Israel Found a Path Forward with a US Second Opinion
- Medebound HEALTH
- 2 days ago
- 13 min read
Introduction
She had lived with uncertainty for over a decade. In 2013, at the age of 57, a patient we will call Miriam (alias, now 70 years old) was told she had a blood cancer called chronic lymphocytic leukemia—in plain terms, a slow-growing cancer of the white blood cells. The news was difficult, but manageable. Chemotherapy controlled it. For nearly ten years, she carried on.
Then, in 2024, everything changed. A new and far more aggressive cancer was now growing inside her—a Hodgkin lymphoma that had transformed from the original leukaemia, an event her doctors called a Richter transformation. She was 70 years old, had already endured multiple treatment lines, a stem cell transplant, and a cascade of infections. The cancer had come back, spread to her bones, and the current plan—two years of immunotherapy infusions every three weeks—felt to her family like a long road with an unclear destination.
She had questions. Important ones. And she wanted someone with deep expertise in exactly this kind of rare, complicated case to answer them. What followed was a medical second opinion from Dr. Aubrey (alias), a haematological oncologist affiliated with Dana-Farber Cancer Institute at Harvard Medical School—and the clinical insights she received would reshape her understanding of her options entirely.
The Diagnosis and the Treatment She Was Facing
Miriam’s medical history is complex, but its shape is important to understand. She was first diagnosed with CLL/SLL—chronic lymphocytic leukemia / small lymphocytic lymphoma, two closely related blood cancers—in May 2013. Her initial treatment consisted of six rounds of a chemotherapy regimen called RCVP combined with rituximab (a targeted antibody therapy), which kept her disease stable for nearly a decade.
In May 2022, her doctors noticed enlarged lymph nodes in her left armpit. A biopsy revealed that the leukaemia cells were still present but also showed scattered abnormal cells called Reed-Sternberg cells—in plain terms, the cells that define Hodgkin lymphoma. This was the beginning of a process that was formally confirmed in April 2024 as a Richter transformation: her leukemia had transformed into classic Hodgkin lymphoma, a much more aggressive and difficult-to-treat disease.
Over the following two years, Miriam underwent an intensive sequence of treatments. Five cycles of a combined immunotherapy-chemotherapy regimen called Nivolumab-AVD were started, but had to be stopped because she developed a serious muscle complication called immune-mediated myopathy—a known risk of the immunotherapy drug nivolumab. A second regimen, brentuximab vedotin combined with bendamustine, followed, with enough success to allow her to proceed to an autologous stem cell transplant in March 2025. The transplant worked: by May 2025, scans showed a complete metabolic remission—no detectable cancer activity.
The relief was short-lived. By September 2025, scans identified new activity in her abdominal lymph nodes. A third attempt with brentuximab vedotin produced only a partial response and had to be stopped after three cycles due to severe adverse reactions. By January 2026, a PET-CT scan—a whole-body imaging technique that maps cancer activity—confirmed the disease had progressed further, now involving bone tissue, including the right hip bone and the spine. Blood tests in February showed pancytopenia—in plain terms, critically low counts of red blood cells, white blood cells, and platelets, meaning her body’s blood-producing system was under serious stress.
At the time of the second opinion in March 2026, Miriam was two cycles into a new immunotherapy drug called pembrolizumab (brand name Keytruda), with a plan to continue treatment every three weeks for two years. Her weight had dropped by 15 kilograms. She was sleeping poorly. Her medical team was also administering prednisone (a steroid) prophylactically to protect her from the muscle complication she had suffered before.
Her family had a pressing concern: was this plan the best available? Was there something being missed? Were there additional options that had not yet been considered?
Why the Family Decided to Seek a Hodgkin Lymphoma Second Opinion
The decision was not made lightly. Miriam’s local medical team had worked with her for years and earned her trust. But the complexity of her situation—a rare transformation of one cancer into another, a stem cell transplant, now a third relapse with bone involvement, and a treatment plan that felt open-ended—left her family with questions that felt too important to leave unanswered.
Several specific concerns drove the decision:
The current immunotherapy plan involved two years of treatment, but the family was uncertain whether monotherapy—a single drug given alone—was truly sufficient given how aggressively the disease had behaved.
Prednisone was being given alongside immunotherapy, and the family had read that steroids can sometimes interfere with how immunotherapy drugs work. They wanted expert clarity on this.
Miriam’s new abdominal lymph node involvement was a site that had not been biopsied. Her family wanted to understand whether a tissue sample from the new site was needed to confirm exactly what the disease was doing—because, as they had learned, Miriam also still had the underlying leukemia, which could be behaving independently.
A donor stem cell transplant had been mentioned as a possibility, but the family was unsure whether Miriam’s age made this realistic.
They found Medebound HEALTH through an online search and submitted her records for a specialist review. The process, they were told, would involve her imaging, blood work, pathology reports, and treatment history being reviewed by a senior hematological oncologist with specific expertise in lymphoma.
The Hodgkin Lymphoma Second Opinion Process: What Happened
Through Medebound HEALTH, the family submitted a comprehensive package of medical records, including PET-CT scan reports dating back to 2013, detailed pathology biopsy results from May 2024, complete blood count and biochemistry results from February and March 2026, a full record of every treatment line administered, and a summary of Miriam’s current complaints and concerns.
These materials were reviewed by Dr. Aubrey (alias), a board-certified medical oncologist—currently appointed at Dana-Farber Cancer Institute—one of the most respected haematological oncology programmes in the world. Dr. Aubrey holds the position of Director of the Fellowship in Haematology/Oncology and is an Associate Professor of Medicine at Harvard Medical School, with deep clinical expertise specifically in lymphoma, chronic lymphocytic leukaemia, and stem cell transplantation.
The review involved both a written clinical assessment and a video discussion in which the family could ask questions directly. The full written opinion was rendered on March 23, 2026.
If you’ve received a complex diagnosis and would like a Top US specialist to review your records, our team can explain the process at no cost.
What Dr. Aubrey Found: Key Clinical Insights
Dr. Aubrey’s review confirmed the complexity of Miriam’s situation and offered several substantive clinical insights that added meaningfully to the picture her local team had drawn.
1. Pembrolizumab Monotherapy Is Unlikely to Achieve Long-Term Control
Dr. Aubrey noted that while pembrolizumab—an immune checkpoint inhibitor that helps the immune system recognise and attack cancer cells—was a reasonable current choice, the evidence for it achieving durable, long-term disease control in Miriam’s specific situation was limited. In plain terms: a single immunotherapy drug on its own is unlikely to keep this particular cancer in check permanently, especially because Miriam had already failed nivolumab, a drug from the same family, when used in combination with chemotherapy.
Dr. Aubrey therefore recommended that if follow-up imaging after three to four cycles showed insufficient response, the treating team should move promptly to add additional treatments rather than continuing monotherapy. Specific options discussed included:
A reduced-dose chemotherapy regimen combining gemcitabine, vinorelbine, and pegylated liposomal doxorubicin (brand name Doxil) alongside the pembrolizumab
Hypomethylating agents—drugs such as decitabine or azacitidine that work by resetting abnormal gene regulation in cancer cells—as an alternative combination partner
If bone marrow biopsy confirmed active CLL/SLL, adding a BTK inhibitor such as zanubrutinib, which targets a specific protein (Bruton’s tyrosine kinase) that helps leukaemia cells survive
The key recommendation was to perform a repeat PET-CT scan after three to four doses of pembrolizumab to evaluate whether it was working, and to be prepared to escalate treatment without delay if the disease was not responding.
2. Steroid Use Is Interfering with Immunotherapy
One of the most clinically significant observations in Dr. Aubrey’s report concerned the prednisone. Steroids like prednisone suppress the immune system—and pembrolizumab works precisely by activating the immune system. In plain terms: the two drugs are working against each other.
Dr. Aubrey acknowledged that Miriam’s local doctors had a legitimate reason for prescribing the steroid, given her history of immune-related muscle inflammation. However, the recommendation was to reduce and taper prednisone as much as physically tolerable, rather than maintaining it at its current dose alongside active immunotherapy. Dr. Aubrey noted that after an autologous stem cell transplant, a patient’s immune system changes, and the risk of the original myopathy recurring at the same intensity was lower than before.
3. The Abdominal Lymph Nodes Must Be Biopsied
Dr. Aubrey placed considerable emphasis on the need for tissue samples from Miriam’s new abdominal disease sites. This recommendation addressed a critical diagnostic uncertainty: the disease had spread from its original location in the left armpit to entirely new locations in the abdomen. Without a biopsy, the team could not be certain whether this represented Hodgkin lymphoma spreading, active CLL/SLL behaving independently, or a combination of both.
The recommended approach was a CT-guided core needle biopsy—a minimally invasive procedure where a thin needle, guided by imaging, removes a small tissue sample from a lymph node without surgery. A bone marrow biopsy was also strongly recommended. The purposes of the bone marrow biopsy were threefold: to assess whether Hodgkin lymphoma had invaded the bone marrow, to determine whether residual CLL/SLL activity in the marrow was driving the low blood counts, and to evaluate the bone marrow’s capacity to tolerate further treatment.
Dr. Aubrey’s reasoning was precise: the choice of which additional drugs to add to pembrolizumab should not be made without this pathological evidence. Different findings would lead to meaningfully different treatment choices.
4. Donor Stem Cell Transplantation: Age Is Not a Barrier
Perhaps the most reassuring element of Dr. Aubrey’s assessment addressed the family’s question about transplant eligibility. Dr. Aubrey was explicit: Miriam’s age of 70 is not, in itself, a reason to rule out an allogeneic stem cell transplant—a procedure using stem cells donated by a matched donor, which replaces the patient’s damaged immune system with a new, healthy one. Clinical evidence includes successful transplants in patients of 70 and above.
Dr. Aubrey described allogeneic transplantation as the only potentially curative option for Miriam’s situation, and recommended a staged approach: first, achieve disease remission through the combination treatment described above; second, allow Miriam to regain weight and physical strength; third, evaluate transplantation when her clinical condition was stable enough to tolerate it.
Dr. Aubrey also noted that patients who have previously received pembrolizumab and other checkpoint inhibitors generally have a better outcome after allogeneic transplant—meaning that Miriam’s current treatment, if effective, could improve her transplant candidacy rather than preclude it.
5. Mirtazapine as a Steroid Alternative for Quality of Life
On the question of Miriam’s appetite loss, sleep disturbance, and reduced mobility, Dr. Aubrey recommended considering low-dose mirtazapine as a supportive medication. Mirtazapine is an antidepressant that, at low doses, has well-documented effects on appetite stimulation, sleep quality, and mood stabilisation simultaneously. In plain terms: a single low-dose tablet at night could address three of Miriam’s most pressing daily quality-of-life issues without suppressing her immune system, as prednisone does.
Original Treatment Plan vs. Second-Opinion Insights
Aspect | Local Treatment Plan | Second-Opinion Insights |
Current therapy | Pembrolizumab (Keytruda) monotherapy every 3 weeks for 2 years | Monotherapy unlikely to achieve long-term control given prior immunotherapy failure; combination strategy recommended |
Steroid use | Prednisone given prophylactically to prevent myopathy recurrence | Prednisone interferes with pembrolizumab efficacy; gradual taper advised; mirtazapine suggested as alternative |
Diagnostic gaps | New abdominal lymph node involvement noted; cause unconfirmed | CT-guided core needle biopsy of abdominal nodes + bone marrow biopsy recommended to clarify Hodgkin vs. CLL activity |
Long-term plan | Pembrolizumab continuation; transplant acknowledged but not prioritised | Allogeneic stem cell transplantation is the only potentially curative option; age 70 is not a contraindication |
Supportive care | Prednisone for appetite and mobility | Low-dose mirtazapine to improve appetite, sleep, and mood simultaneously |
Individual results will vary. The outcome described reflects this patient’s specific clinical circumstances. Speak with your own physician to understand what results may be realistic for your situation.
Miriam’s Response to the Second Opinion
For Miriam’s family, Dr. Aubrey’s report did not so much contradict her local care as it added structure, specificity, and a longer-range plan to it. The second opinion did not tell them that her doctors had been wrong—it gave them a clearer framework for understanding what questions to bring back to her treating team.
The family found particular clarity in three areas. First, understanding that the prednisone might actually be undermining the immunotherapy gave them a concrete, evidence-based point to raise with her oncologist—not as a criticism, but as a clinical question worth discussing. Second, the emphasis on biopsy gave Miriam’s family confidence that pushing for this procedure was medically justified and important, not simply anxious over-investigation. Third, the clear statement that a donor transplant was not ruled out by age was, in the family’s own words, genuinely encouraging.
“We didn’t know what questions to ask, or whether we were even asking the right ones. The report gave us a framework. We went back to her doctor with real questions, not fears.”
The family shared Dr. Aubrey’s hodgkin lymphoma second opinion (written) with Miriam’s treating team in Israel. Dr. Aubrey’s recommendations regarding biopsy timing, steroid tapering, and the consideration of combination treatment if pembrolizumab monotherapy proved insufficient were entered into the active clinical discussion. Miriam was also in the process of transferring her care to a haematology team in Tel Aviv, a move Dr. Aubrey explicitly endorsed as clinically sound.
Like Miriam’s family, if you are navigating a complex hematological diagnosis and want expert input from a specialist in lymphoma or blood cancers
Where Things Stand: Current Status
At the time of publication, Miriam is two cycles into pembrolizumab treatment. Her weight, which had fallen by 15 kilograms over the course of her treatment history, was beginning to stabilise and showing early signs of improvement. Her stamina remained reduced but was not deteriorating further. Prednisone was being tapered.
The clinical pathway ahead, as shaped by the second opinion, involves three sequential objectives:
Complete a repeat PET-CT scan after three to four pembrolizumab cycles to evaluate treatment response
Proceed with CT-guided abdominal lymph node biopsy and bone marrow biopsy, the results of which will determine whether to add chemotherapy, hypomethylating agents, or a BTK inhibitor to her regimen
If remission is achieved and physical condition improves, enter a formal evaluation for allogeneic stem cell transplantation
Miriam’s treating team was aware of Dr. Aubrey’s recommendations. The second opinion had added both clinical options and a structured decision framework to a situation that had previously felt like a waiting game.
Dr. Aubrey’s report also addressed quality of life explicitly—noting that Hodgkin lymphoma, even in its more advanced and complex forms, tends to progress more slowly than many solid tumours, and that Miriam and her family had time to make considered decisions rather than feeling forced into urgency. This framing, the family said, was itself a form of clinical value: it replaced panic with a plan.
Clinical Timeline: Diagnosis to Second Opinion
Date / Period | Event |
May 2013 | Diagnosed with CLL/SLL; treated with RCVP chemotherapy (6 cycles, June–Dec 2013) |
May 2022 | Suspicious left axillary lymph node (3.7 cm); biopsy suggests CLL infiltration with scattered HRS cells |
April 2024 | Confirmed diagnosis: classic Hodgkin lymphoma via Richter transformation from CLL |
June–July 2024 | Nivolumab + AVD (5 cycles); discontinued due to immune-mediated myopathy |
Nov–Dec 2024 | Brentuximab vedotin + bendamustine; PET-CT shows significant improvement (DS3) |
Feb 2025 | Left axillary radiotherapy administered |
March 2025 | Autologous stem cell transplantation performed |
May 2025 | PET-CT: Complete Metabolic Remission confirmed |
Sept 2025 | Suspected recurrence; new abdominal lymph node uptake detected |
Oct–Nov 2025 | Brentuximab vedotin re-treatment; partial response only; discontinued after 3 cycles due to adverse reactions |
Jan 2026 | PET-CT: Disease progression confirmed with bone involvement (right iliac bone, vertebra D12); abdominal cluster 4.2 × 2.6 cm |
Feb–March 2026 | Blood tests: pancytopenia, elevated TSH, elevated ferritin; pembrolizumab treatment commenced (2 cycles) |
March 23, 2026 | Medical second opinion rendered by specialist at Dana-Farber Cancer Institute, Harvard Medical School |
What Miriam’s Story Teaches Us About Second Opinions
Miriam’s case is unusual in its clinical complexity, but the lessons it illustrates apply to a much wider group of patients facing difficult diagnoses.
A hodgkin lymphoma second opinion is not a vote of no-confidence in your doctor. It is additional expert information. Miriam’s family found that Dr. Aubrey’s report gave them better questions, not different doctors.
Rare or evolving diagnoses benefit most. When a disease transforms, spreads to new sites, or fails multiple treatment lines, the complexity can exceed what any single clinical team can optimally manage alone. Expert second opinions are specifically valuable here.
Clinical detail matters. Dr. Aubrey’s recommendation to biopsy the new abdominal sites before deciding on combination therapy was not a general suggestion—it was a precise, individualised clinical call. That level of specificity is what distinguishes a genuine specialist review from generic advice.
Age is rarely an absolute barrier. Dr. Aubrey’s confirmation that 70 years old is not a contraindication for allogeneic stem cell transplantation is a finding backed by clinical evidence. Assumptions about age and treatment eligibility are worth challenging.
Quality of life is part of clinical planning. The recommendation of mirtazapine over steroids was not a minor footnote—it addressed appetite, sleep, and mood in a single, immune-system-friendly intervention. Supportive care questions belong in the second-opinion conversation.
Research published by the Mayo Clinic and others consistently shows that second opinions lead to meaningful changes in diagnosis or treatment in approximately 20–88% of complex cancer cases, depending on the study population and the nature of the second review. For patients with rare transformations, relapsed disease, or multiple prior treatment lines, the proportion is generally higher.
“I would tell anyone in a situation like ours: ask the second question. You don’t need to have all the answers. You just need to know what questions to ask.”
How Medebound HEALTH Connects International Patients to Top U.S. Cancer Experts
Medebound HEALTH is a U.S.-based medical coordination service that facilitates second opinions from independent U.S.-licensed physicians affiliated with leading cancer centers such as MD Anderson, Mayo Clinic, Memorial Sloan Kettering and Johns Hopkins. Since 2016, the service has supported 3000+ international patients, primarily from Asia, seeking expert input before major oncology decisions.
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Disclaimer
We strive to maintain the accuracy and provide regular updates for the treatment information described in this article. However, treatment outcomes may vary between individuals. The information provided here is not intended as a diagnostic or treatment recommendation and should not replace the careful evaluation and advice of your attending physician. The service is independently operated by Medebound HEALTH and is not provided, partnered, or affiliated with any hospital center as an institution.
