Allogeneic bone marrow transplantation for lymphoma

Newest Approaches in Immunotherapy for Non-Hodgkin’s Lymphoma

Immunotherapy has revolutionised the treatment of haematologic malignancies. Patients with relapsed/refractory non-Hodgkin’s lymphoma have poor response rates and short survival times when conventional cytotoxic chemotherapies are used. Immunotherapy offers a novel way to harness the host immune system to target malignant cells in patients whose disease may no longer respond to cytotoxic therapy. The increased and refined use of immunotherapy in this patient population has recently shown promise in a group with previously poor outcomes. In this paper, the authors describe the available data for immunotherapy use in non-Hodgkin’s lymphoma, including checkpoint inhibition, T cell engager antibodies, and adoptive immunotherapy with chimeric antigen receptor T cell therapy.

Allogeneic hematopoietic stem cell transplantation in patients with diffuse large B cell lymphoma relapsed after autologous stem cell transplantation: a GITMO study

Patients who relapse after an autologous hematopoietic stem cell transplantation (SCT) have a very poor prognosis. We have retrospectively analyzed diffuse large B cell lymphoma patients who underwent an allo-SCT after an auto-SCT relapse reported in the Gruppo Italiano Trapianto di Midollo Osseo (GITMO) database. From 1995 to 2008, 3449 autologous transplants were reported in the GITMO database. Eight hundred eighty-four patients relapsed or progressed after transplant; 165 patients, 19% of the relapsed patients, were treated with allo-transplant. The stem cell donor was related to the patient in 108 cases. A reduced intensity conditioning regimen was used in 116. After allo-SCT, 72 patients (43%) obtained a complete response and 9 obtained a partial response with an overall response rate of 49%; 84 patients (51%) experienced rapid progression of disease. Ninety-one patients died, 45 due to disease and 46 due to treatment-related mortality. Acute graft-versus-host disease was recorded in 57 patients and a chronic GvHD in 38 patients. With a median follow-up of 24 months (2-144) after allo, overall survival (OS) was 39%, and after a median of 21 months (2-138) after allo, progression-free survival (PFS) was 32%. Multivariate analysis indicated that the only factors affecting OS were status at allo-SCT, and those affecting PFS were status at allo-SCT and stem cell donor. This retrospective analysis shows that about one-fifth of patients with diffuse large B cell lymphoma who experience relapse after autologous transplantation may be treated with allogeneic transplantation. Moreover, the only parameter affecting either OS or PFS was the response status at the time of allo-SCT.

Cure of a patient with profoundly chemotherapy-refractory primary mediastinal large B-cell lymphoma: Role of rituximab, high-dose therapy, and allogeneic stem cell transplantation

Patients with primary large B-cell lymphomas of the mediastinum (PMBL) who suffer early relapse have a low likelihood of achieving a prolonged second remission with conventional salvage therapy. Here we describe the case of a 33-year-old woman with PMBL refractory to 6 lines of therapy before undergoing salvage therapy with rituximab, ifosfamide and etoposide followed by high-dose therapy, autologous transplantation, and sequential non-myeloablative allogeneic transplantation, who remains in ongoing complete remission for more than 39 months and is apparently cured. The specific roles of the components of the successful salvage therapy are discussed.

Favorable Long-Term Survival After Reduced-Intensity Allogeneic Transplantation for Multiple-Relapse Aggressive Non-Hodgkin's Lymphoma

Purpose

The role of allogeneic transplantation with reduced-intensity conditioning in diffuse large B-cell lymphoma (DLBCL) is currently unclear, with relatively little published data. We report the outcome of reduced-intensity transplantation (RIT) in a cohort of 48 consecutive patients with relapsed/refractory DLBCL (30 patients with de novo disease and 18 patients with transformed follicular lymphoma) who underwent transplantation with an alemtuzumab-containing regimen, with a median follow-up of 52 months.

Patients and Methods

Patients had experienced treatment failure with a median of five lines of prior therapy, including autologous transplantation in 69%, and 17% of patients were chemotherapy refractory at transplantation. Median age was 46 years, and 38% of patients had matched/mismatched unrelated donors. Conditioning was with alemtuzumab, fludarabine, and melphalan, and additional graft-versus-host disease (GVHD) prophylaxis was with cyclosporine.

Results

All patients were successfully engrafted. Only 17% of patients developed grade 2 to 4 acute GVHD, with 13% experiencing extensive chronic GVHD. Four-year estimated nonrelapse mortality was 32%, and relapse risk was 33%. Twelve patients received donor lymphocyte infusions ± chemoimmunotherapy for relapse, and five patients obtained durable remissions, giving current progression-free survival (PFS) and overall survival (OS) rates at 4 years of 48% and 47%, respectively. Patients who had chemotherapy-sensitive disease before RIT had current PFS and OS rates at 4 years of 55% and 54%, respectively. Chemotherapy-refractory patients had a poor outcome.

Conclusion

The encouraging survival rates with extended follow-up suggest a role for RIT in chemotherapy-sensitive relapsed DLBCL, even in patients who have previously experienced treatment failure with autologous transplantation. Future studies will be required to determine whether any subset of patients with relapsed DLBCL should be considered for RIT versus autologous transplantation.

Nine-year survival of lymphoblastic lymphoma patients

This study aimed to analyze the overall survival period of adult lymphoblastic lymphoma patients treated with various therapeutic regimens, and to assess the determinants affecting survival outcome. Twenty-five adult patients with lymphoblastic lymphoma who had been treated at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea from June 1996 to June 2005 were analyzed retrospectively. As an initial remission induction chemotherapy, the hyper-CVAD regimen was performed in eight patients, the Stanford/Northern California Oncology Group (NCOG) regimen in five, the CAVOP regimen in four, the m-BACOP regimen in three, and the CHOP regimen in one patient. Patients were divided into two groups according to their therapeutic modalities. Twenty patients received conventional chemotherapy alone and five received subsequent PBSCT after conventional chemotherapy. Four patients of the PBSCT group underwent autologous PBSCT and one underwent allogeneic PBSCT. The overall response rate was 80% (60% showing a complete response, 20% showing a partial response) and the relapse rate was 73.3%. The overall survival (OS) rate was 55.1% at 1 year, 31.5% at 5 years, and 23.6% at 9 years. The disease-free survival (DFS) rate was 46.7% at 1 year and 30.0% at 7 years. The 5-year OS rate in relation to the regimens was 60% with the Stanford/NCOG regimen, 50% with the CAVOP regimen, and 33.3% with the m-BACOP regimen. The patients treated with the hyper-CVAD regimen had an 18.2% 2-year OS rate, and other patients with CHOP or COPBLAM-V expired early in their course. The OS rate in patients treated with conventional chemotherapy alone was 19.8%, whereas patients treated with subsequent PBSCT after chemotherapy showed 50% overall survival (p=0.25). The age at presentation influenced the outcome of the patients (p=0.01). The Stanford/NCOG regimen is an effective initial choice of therapy for lymphoblastic lymphoma patients, and is superior to the hyper-CVAD regimen in complete response rate and overall survival rate (p =0.36). Addition of PBSCT after chemotherapy may be needed for achieving optimal outcomes.

Granulocyte Colony-Stimulating Factor Mobilizes More Dendritic Cell Subsets Than Granulocyte-Macrophage Colony-Stimulating Factor with No Polarization of Dendritic Cell Subsets in Normal Donors

Dendritic cells (DCs) are effective antigen-presenting cells. We hypothesized that increasing the DC populations in donor lymphocyte infusions (DLIs) may augment the graft versus malignancy effect, particularly if granulocyte-macrophage colony-stimulating factor (GM-CSF) mobilization resulted in increased precursor dendritic cell (pDC) 1 cells. Mature DCs, pDC1 cells, pDC2 cells, and CD34(+) cells from the same donor were compared after granulocyte colony-stimulating factor (G-CSF) mobilized peripheral blood stem cell collections and GM-CSF mobilized DLI collections. Mobilization with G-CSF resulted in up to a 10-fold larger number of CD34(+) cells per kg and a 3-5-fold larger number of mature DCs, pDC1 cells, and pDC2 cells within the same donor compared with GM-CSF. The ratio of pDC1 to pDC2 in each donor remained constant with either cytokine. In this small sample of normal donors, it appears that G-CSF mobilizes more CD34(+) cells, mature DCs, pDC1 cells, and pDC2 cells within the same donor than does GM-CSF, with no significant polarization by G-CSF or GM-CSF for either pDC1 or pDC2 cells.

Rituximab combined with CHOP for successful treatment of aggressive recurrent, pediatric B-cell large cell non-Hodgkin's lymphoma

This report is the first to describe the successful treatment of a 14-year-old boy with aggressive recurrent, CD20-positive, B-cell large cell non-Hodgkin's lymphoma. The patient responded to three 4-week courses of rituximab (MabThera) given every 6 months and six cycles of CHOP given every 3 weeks in addition to a modified BFM 86 protocol. Transient neutropenia and lymphopenia occurred but with no clinical significance. The boy has been disease-free for the last 48 months (after 64 months of follow-up); his organ functions are normal. Rituximab and CHOP in addition to chemotherapy may be an alternative treatment for aggressive recurrent, pediatric CD20-positive B-cell large cell non-Hodgkin's lymphoma if highly intensive chemotherapy and stem cell transplantation are not available.

The role of allogeneic transplantation in non-Hodgkin's lymphoma

The evolution of combination chemotherapy regimens, combined with improvements in supportive care, has incrementally improved survival outcomes for patients with non-Hodgkin's lymphomas (NHL). Although 40-60% of younger patients with diffuse large cell lymphoma can now expect to be cured, significant numbers will either fail to achieve a remission or relapse after attaining a remission. In addition, certain histological subtypes are associated with particularly poor prognoses with combination chemotherapy alone (e.g. mantle cell lymphoma, B-cell prolymphocytic leukaemia). Relatively few of these patients can achieve long-term responses. Other NHL subtypes, whilst associated with more favourable prognoses in terms of overall survival, are rarely, if ever, cured (e.g. most low grade NHL including follicular lymphoma, chronic lymphocytic leukaemia and small lymphocytic lymphoma). For these reasons dose escalation and allogeneic transplantation have been investigated as potential ways of improving outcome, although this has mainly been in the setting of advanced disease. Any possible benefits have frequently been out-weighed by procedural morbidity and mortality. The parallel development of transplantation approaches that limit procedural toxicity along with advances in supportive care require that the role of allogeneic haematopoietic stem cell transplantation in the management of lymphoma be re-evaluated.

Graft-versus-lymphoma effects: clinical review, policy proposals, and immunobiology

The indubitable existence of a graft-versus-lymphoma (GVL) effect is difficult to prove directly. This article reviews the difficulties in interpreting the current literature in this field and, with a number of caveats, argues for the existence of a clinically meaningful GVL effect in follicular, mantle cell, small lymphocytic, and Hodgkin lymphomas. The evidence, however, for a potent GVL effect in diffuse large-cell lymphoma and Burkitt lymphoma is not convincing. Policies for allografting in lymphoma are proposed on the basis of this evidence. The immunobiology of GVL effects is discussed--in particular, the expression of HLA class I and II and co-stimulatory molecules on lymphomas that influence the generation of alloreactive T cells--together with future directions in immunotherapy that may help to eradicate chemoresistant disease.

Treatment of indolent non-Hodgkin's lymphoma with cladribine as single-agent therapy and in combination with mitoxantrone

The term indolent in describing a non-Hodgkin's lymphoma (NHL) generally refers to a group of B-cell NHLs composed of predominantly small cells that make up several categories, including follicular lymphoma, small lymphocytic lymphoma, and lymphoma of mucosa-associated lymphoid tissue. Most patients with follicular lymphoma respond to therapy, and the average survival time in large series is approximately 10 years. Patients who achieve a complete remission with initial treatment have an approximately 25% chance of remaining free of disease for 10 years. However, this means that more than 80% of patients will require salvage therapy. Cladribine is a newer purine analogue and is of particular interest because it is resistant to deamination by adenosine deaminase. It is cytotoxic to both proliferating and resting lymphocytes, making it an attractive agent for the treatment of indolent NHL. In this review article, we summarize the current treatment approaches for indolent NHL and the results of cladribine monotherapy studies in Japan and cladribine studies in Germany that have focused on a combination therapy with mitoxantrone. Cladribine is a potent inhibitor of DNA repair. The combination of a DNA-damaging agent with an inhibitor of DNA repair constitutes the rationale for combining cladribine with mitoxantrone. A German study has demonstrated that the combination of reduced-dose cladribine and mitoxantrone is a highly active regimen with favorable toxicity profiles. Cladribine is highly effective as a single agent and in combination with mitoxantrone in the treatment of indolent NHL, and its availability broadens the range of therapeutic options for indolent NHL.

Allogeneic Hematopoietic Stem Cell Transplantation for Lymphoma

For patients with relapsed or refractory Hodgkin's or non-Hodgkin's lymphomas, allogeneic hematopoietic stem cell transplantation (HSCT) is a treatment option when autologous HSCT fails to achieve durable remission or is deemed inappropriate. Allogeneic HSCT can result in long-term survival even in patients with refractory lymphomas. The efficacy of allogeneic HSCT is attributed, at least in part, to an immune-mediated graft-versus-lymphoma (GVL) effect that can also be associated with significant toxicity resulting from graft-versus-host disease. However, clinical evidence of a potent GVL effect is inconsistent. Reduced-intensity conditioning before allogeneic HSCT can facilitate the use of this treatment in older patients and those at high risk. The decrease in toxicity with reduced-intensity regimens may be associated with a loss of antitumor effects. Patients with lymphoma should be selected for allogeneic HSCT on the basis of characteristics that strongly influence transplant outcomes, including histology, chemosensitivity, and donor source.

Why aren't we performing more allografts for aggressive non-Hodgkin's lymphoma?

Allogeneic stem cell transplantation has an under-appreciated role in the management of intermediate-grade non-Hodgkin's lymphoma. It provides several advantages over autologous stem cell transplantation including provision of a lymphoma-free graft, reduced rates of secondary myelodysplastic syndrome and leukemia, and a potentially curative graft-versus-lymphoma effect. When applied to chemosensitive patients, the lower relapse rates and reasonable long-term outcomes make allogeneic transplantation a promising therapy to pursue. Patient populations, such as those with bone marrow involvement or very high-risk disease, can be identified as having suboptimal outcomes after autotransplantation and may benefit from such an approach. While the exact role of allogeneic stem cell transplantation remains to be determined, broad recommendations can be suggested for the management of patients with intermediate-grade lymphoma. New approaches to allogeneic transplantation, including the use of matched-unrelated donors and reduced-intensity conditioning regimens, may expand the applicability of this potentially curative modality.

Role of nonmyeloablative allogeneic stem-cell transplantation after failure of autologous transplantation in patients with lymphoproliferative malignancies

PURPOSE

Conventional allogeneic stem-cell transplantation (SCT) after a prior failed autograft is associated with a transplant-related mortality rate of 50% to 80%. The aim of the current study was to evaluate the safety and efficacy of sibling, HLA-matched, nonmyeloablative allogeneic SCT with donor lymphocyte infusion (DLI) in patients with lymphoid malignancy after failure of autologous SCT.

PATIENTS AND METHODS

A total of 38 patients with refractory, progressive, or relapsed disease after autologous SCT were entered onto this study. The conditioning regimen consisted of the humanized monoclonal antibody CAMPATH-1H, fludarabine, and melphalan. Fifteen of 35 assessable patients received DLI after SCT.

RESULTS

Sustained neutrophil engraftment was achieved in 37 recipients, and platelet engraftment was achieved in 35 patients. The estimated transplant-related mortality was 7.9% at day 100 and 20% at 14 months, the median duration of follow-up. Eight patients experienced grade I/II acute graft-versus-host disease (GVHD) after transplantation, but no grade III/IV GVHD was observed in this setting. However, grade III/IV GVHD occurred in seven patients who received DLI. The actuarial overall survival at 14 months was 53%, with a progression-free survival of 50%. DLI produced a further response in three of 15 recipients.

CONCLUSION

Nonmyeloablative allogeneic SCT after CAMPATH-1H-containing conditioning is a relatively safe option compared with conventional allogeneic transplantation for patients who have failed previous autologous SCT. The low incidence of early GVHD enabled the subsequent administration of DLI to improve further clinical responses in this poor-risk group of lymphoma and myeloma patients.

Nonmyeloablative stem cell transplantation for solid tumors: expanding the application of allogeneic immunotherapy

In the arena of tumor immunology, there is a growing perception that the graft-versus-leukemia (GVL) reaction that follows allogeneic stem cell transplantation represents the most potent form of cancer immunotherapy currently in clinical use. While allogeneic stem cell transplantation has become an accepted form of "immunotherapy" for the treatment of hematological malignancies, its efficacy in inducing antitumor effects against nonhematological cancers has, until recently, been largely unexplored. The investigational application of nonmyeloablative allogeneic stem cell transplantation (NST) in solid tumors represents the logical consequence of almost 50 years of experimental and clinical research into the immunological basis for the cure of hematological malignancies following allogeneic bone marrow transplant (BMT). Here we review the historical background, development, and preliminary clinical results of allogeneic stem cell transplantation as immunotherapy for solid tumors.

Diffuse large cell lymphoma

A review of new or emerging ideas concerning diffuse large B-cell lymphomas is presented, with particular emphasis on histologic classification, genetic prognostic factors, first-line and salvage treatments, and specific locations such as neurologic, cutaneous, or gastrointestinal sites. This lymphoma remains the most heterogeneous of all lymphomas for its clinical characteristics and outcome. This heterogeneity is probably secondary to the fact that a large proportion of lymphomas seems to occur from a transformation of an unknown indolent lymphoma.

Advances in the management of patients with non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma is the fifth most common cause of death due to cancer and has been rising at a rate of 4% per year for the last four decades. Although 'traditional' chemotherapy and radiotherapy have had important contributions to improving outcomes, new tools in the treatment of non-Hodgkin's lymphoma are needed. This review describes therapeutic modalities that are currently being used or are in the process of being developed and which are based on concepts divergent from 'traditional' approaches to managing non-Hodgkin's lymphoma.