High-dose chemotherapy followed by autologous hematopoietic rescue for Hodgkin's disease patients following first relapse after chemotherapy

Cost-effectiveness of brentuximab vedotin compared with conventional chemotherapy for relapsed or refractory classic Hodgkin lymphoma in China

BACKGROUND

Relapsed or refractory classic Hodgkin lymphoma (RRcHL) associates with poor prognosis and heavy disease burden to patients. This study evaluated the cost-effectiveness of brentuximab vedotin (BV) in comparison to conventional chemotherapy in patients with RRcHL, from a Chinese healthcare perspective.

METHODS

The lifetime cost and quality adjusted life years (QALYs) were estimated through a partitioned survival model with three health states (progression free, post progression, and death). Two cohorts for each BV arm and chemotherapy arm were built, representing patients with and without transplant after BV or chemotherapy, respectively. Clinical parameters were retrieved from BV trials and the literature. Resource utilization data were mainly collected from local expert surveys and cost parameters were reflecting local unit prices. Utility values were sourced from the literature. A discount rate of 5% was employed according to the Chinese guideline. A series of deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness and uncertainty associated with the model.

RESULTS

Results of the base case analysis showed that the incremental cost-effectiveness ratio (ICER) for BV versus chemotherapy was $2,867 (¥19,774). The main model driver was the superior progression-free and overall survival benefits of BV. The ICERs were relatively robust in a series of sensitivity analyses, all under a conventional decision threshold (1 time of Chinese per capita GDP). With this conventional threshold, the probability of BV being cost-effective was 100%.

CONCLUSIONS

Brentuximab vedotin can be considered a cost-effective treatment versus conventional chemotherapy in treating relapsed or refractory classic Hodgkin lymphoma in China.

Antibody based therapies in Hodgkin lymphoma

Multimodality treatment approaches, with systemic therapies at their core, have made Hodgkin Lymphoma a highly curable cancer. Unmet needs remain. Resistance to therapy manifested by refractory and relapsed disease, and treatment related short- and long-term morbidity are the key challenges. Patient outcomes have improved in the recent past with the advent of novel therapies and are borne out of a better understanding of the disease biology and translational medicine. Antibody based therapies, more broadly immunotherapies, are leading the change in the way we treat this disease. This review looks at the tumor antigen-directed immunotherapies, and immune checkpoint inhibitors that are attempting to overcome the unmet challenges.

Brentuximab vedotin and its use in the treatment of advanced Hodgkin's lymphoma

Brentuximab vedotin (BV), a CD30-directed antibody-drug conjugate, is US FDA approved for treatment of classic Hodgkin lymphoma (cHL) after progression or relapse of at least two prior lines of chemotherapy or autologous stem cell transplantation, as consolidation therapy after autologous stem cell transplantation for high-risk patients and as a front-line therapy for previously untreated, advanced-stage cHL in combination with chemotherapy. BV is a well-tolerated treatment in previously heavily pretreated relapsed/refractory cHL and in treatment-naive patients. BV use, in combination with other antineoplastic agents for cHL, is under investigation in multiple prospective clinical trials.

Pharmacotherapeutic Management of Pediatric Lymphoma

Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) comprise approximately 15% of all childhood malignancies. Cure rates for both lymphoma entities have evolved tremendously during the last couple of decades, raising the 5-year survival rates to almost 100% for HL and to 85% for NHL. The mainstay therapy for both malignancies is still chemotherapy-with different regimens recommended for different types of disease. In HL, combined modality treatment, i.e., chemotherapy followed by radiotherapy, has long been the standard regimen. In order to reduce long-term side effects, such as second malignancies, most major pediatric HL consortia have studied response-based radiotherapy reduction strategies over the last 3 decades. For recurrent disease, high-dose chemotherapy followed by an autologous or an allogeneic hematopoietic stem-cell transplant is an option. No targeted agents have yet gained regulatory approval for use in pediatric patients with lymphoma. For adult lymphoma patients, the CD20 antibody rituximab and the CD30 antibody-drug conjugate brentuximab vedotin are targeted agents used regularly in first- and second-line treatment regimens. More recently, immune checkpoint inhibitors, phosphatidyl-inositol-3-kinase inhibitors, and Bruton's tyrosine kinase inhibitors appear to be very promising new treatment options in adult lymphoma. Here, we discuss the current experience with these types of agents in pediatric lymphoma patients.

Advances in the pathophysiology and treatment of relapsed/refractory Hodgkin's lymphoma with an emphasis on targeted therapies and transplantation strategies

Hodgkin’s lymphoma (HL) is highly curable with first-line therapy. However, a minority of patients present with refractory disease or experience relapse after completion of frontline treatment. These patients are treated with salvage chemotherapy followed by autologous stem cell transplantation (ASCT), which remains the standard of care with curative potential for refractory or relapsed HL. Nevertheless, a significant percentage of such patients will progress after ASCT, and allogeneic hematopoietic stem cell transplantation remains the only curative approach in that setting. Recent advances in the pathophysiology of refractory or relapsed HL have provided the rationale for the development of novel targeted therapies with potent anti-HL activity and favorable toxicity profile, in contrast to cytotoxic chemotherapy. Brentuximab vedotin and programmed cell death-1-based immunotherapy have proven efficacy in the management of refractory or relapsed HL, whereas several other agents have shown promise in early clinical trials. Several of these agents are being incorporated with transplantation strategies in order to improve the outcomes of refractory or relapsed HL. In this review we summarize the current knowledge regarding the mechanisms responsible for the development of refractory/relapsed HL and the outcomes with current treatment strategies, with an emphasis on targeted therapies and hematopoietic stem cell transplantation.

Autologous Hematopoietic Stem Cell Transplantation-10 Years of Data From a Developing Country

Intensive chemotherapy followed by autologous stem cell transplantation is the treatment of choice for patients with hematological malignancies. The objective of the present study was to evaluate the outcomes of patients with mainly lymphoma and multiple myeloma after autologous stem cell transplant. The pretransplant workup consisted of the complete blood count, an evaluation of the liver, kidney, lung, and infectious profile, chest radiographs, and a dental review. For lymphoma, all patients who achieved at least a 25% reduction in the disease after salvage therapy were included in the study. Mobilization was done with cyclophosphamide, followed by granulocyte colony-stimulating factor, 300 µg twice daily. The conditioning regimens included BEAM (carmustine, etoposide, cytarabine, melphalan) and high-dose melphalan. A total of 206 transplants were performed from April 2004 to December 2014. Of these, 137 were allogeneic transplants and 69 were autologous. Of the patients receiving an autologous transplant, 49 were male and 20 were female. Of the 69 patients, 26 underwent transplantation for Hodgkin's lymphoma, 23 for non-Hodgkin's lymphoma, and 15 for multiple myeloma and 4 and 1 for Ewing's sarcoma and neuroblastoma, respectively. The median age ± SD was 34 ± 13.1 years (range, 4-64). A mean of 4.7 × 10⁸ ± 1.7 mononuclear cells per kilogram were infused. The median time to white blood cell recovery was 18.2 ± 5.34 days. Transplant-related mortality occurred in 10 patients. After a median follow-up period of 104 months, the overall survival rate was 86%. High-dose chemotherapy, followed by autologous stem cell transplant, is an effective treatment option for patients with hematological malignancies, allowing further consolidation of response.

Stratification of treatment intensity in relapsed pediatric Hodgkin lymphoma

Risk-adapted, response-based therapies for pediatric Hodgkin lymphoma have resulted in 5-year survival exceeding 90%. Although high-dose chemotherapy and autologous hematopoietic stem cell transplantation (AHSCT) are considered standard for most patients with relapsed or refractory Hodgkin lymphoma, a subset of children with low risk relapse do not require AHSCT for cure. Currently there are no widely accepted criteria defining who should receive standard dose chemotherapy and/or radiotherapy, nor is there a standardized treatment regimen. We propose a risk-stratified, response-based algorithm for children with relapsed or refractory Hodgkin lymphoma that is based on a critical appraisal of published outcomes and prognostic factors.

Impact of conditioning regimen on outcome of 2-year disease-free survivors of autologous stem cell transplantation for Hodgkin lymphoma

BACKGROUND

Autologous stem cell transplantation is the standard of care for patients with relapsed HL and the long-term outcomes for survivors 2 years after ASCT have not been well described. No prospective trials have compared the effect of different conditioning regimens on outcomes.

PATIENTS AND METHODS

We searched the Nebraska Lymphoma Study Group database to identify patients with HL who received ASCT from 1984 to 2007. Patients were conditioned with either CBV (cyclophosphamide, carmustine, and etoposide) or BEAM (carmustine, etoposide, cytarabine, and melphalan).

RESULTS

At a median follow-up of 8 (range, 2-26) years, 225 patients were alive and disease-free 2 years after ASCT. Analysis was limited to these patients. At 5 years, the progression-free survival (PFS) was 92% for BEAM and 73% for CBV (P = .002) and the overall survival (OS) was 95% for BEAM and 87% for CBV (P = .07). At 10 years, the PFS was 79% for BEAM and 59% for CBV (P = .01) and the OS was 84% for BEAM and 66% for CBV (P = .02).

CONCLUSION

Patients with HL who are disease-free and alive 2 years after ASCT have favorable outcomes. We observed lower risk of progression and longer survival associated with use of BEAM vs. CBV. Patients in the BEAM group received a transplant in more recent years so we cannot exclude the possibility that the superior outcomes seen in the BEAM group are because of better supportive care, use of peripheral blood stem cell grafts, or improvements in salvage therapies before transplantation.

Advances in the treatment of relapsed or refractory Hodgkin's lymphoma

Hodgkin's lymphoma (HL) is diagnosed in 20,000 men and women annually in North America and Europe. Despite treatment advancements for HL resulting in an overall survival rate of 80%, patients with advanced stage disease continue to have suboptimal outcomes, with relapse rates of 30%-40%. An additional 10%-15% of patients present with primary refractory disease. For patients who relapse after initial treatment, salvage chemotherapy followed by autologous stem cell transplant in those with chemotherapy-sensitive disease is the standard of care. Patients who relapse after second-line therapy have a median survival time in the range of 6-36 months, and the optimal management of these patients remains unclear. Unfortunately, there have been no new agents approved for relapsed HL treatment since the 1970s. Consequently, clinical decision making in this population is difficult. Recently however, several agents have emerged that have shown clinical promise in this poor-risk population. This review discusses the management of these patients and also discusses several newer agents showing clinical promise in the treatment of HL.

Current status of autologous stem cell transplantation in relapsed and refractory Hodgkin's lymphoma

Despite the relatively high long-term disease-free survival (DFS) rate for patients with Hodgkin lymphoma (HL) with modern combination chemotherapy or combined modality regimens, ∼20% of patients die from progressive or relapsed disease. The standard treatment for relapsed and primary refractory HL is salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation (ASCT), which has shown a 5-year progression-free survival rate of ∼50%-60%. Recent developments in a number of diagnostic and therapeutic modalities have begun to improve these results. Functional imaging, refinement of clinical prognostic factors, and development of novel biomarkers have improved the predictive algorithms, allowing better patient selection and timing for ASCT. In addition, these algorithms have begun to identify a group of patients who are candidates for more aggressive treatment beyond standard ASCT. Novel salvage regimens may potentially improve the rate of complete remission prior to ASCT, and the use of maintenance therapy after ASCT has become a subject of current investigation. We present a summary of developments in each of these areas.

Second-line salvage chemotherapy for transplant-eligible patients with Hodgkin's lymphoma resistant to platinum-containing first-line salvage chemotherapy

BACKGROUND

The management of patients with relapsed or refractory Hodgkin's lymphoma who achieve less than a partial response to first-line salvage chemotherapy is unclear. The objective of this study was to evaluate response and outcomes to second-line salvage and autologous stem cell transplantation in patients not achieving a complete or partial response to platinum-containing first-line salvage chemotherapy.

DESIGN AND METHODS

Consecutively referred transplant-eligible patients with relapsed/refractory Hodgkin's lymphoma after primary chemotherapy received gemcitabine, dexamethasone, and cisplatin as first salvage chemotherapy. Those achieving a complete or partial response, and those with a negative gallium scan and stable disease with bulk <5 cm proceeded to high-dose chemotherapy and autologous stem cell transplantation. Patients with progressive disease or stable disease with a positive gallium scan or bulk ≥ 5 cm were given second salvage chemotherapy with mini-BEAM (carmustine, etoposide, cytarabine, melphalan). Patients who responded (according to the same definition) proceeded to autologous stem cell transplantation.

RESULTS

One hundred and thirty-one patients with relapsed/refractory Hodgkin's lymphoma received first-line salvage gemcitabine, dexamethasone, and cisplatin; of these patients 99 had at least a partial response (overall response rate 76%). One hundred and twelve (85.5%) patients proceeded to autologous stem cell transplantation, while the remaining 19 (14.5%) patients received mini-BEAM. Among these 19 patients, six had at least a partial response (overall response rate 32%), and nine proceeded to autologous stem cell transplantation. The remaining ten patients received palliative care. Seven of the nine patients transplanted after mini-BEAM had a subsequent relapse. Patients receiving second salvage mini-BEAM had poor outcomes, with a 5-year progression-free survival rate of 11% and a 5-year overall survival rate of 20%.

CONCLUSIONS

Patients who require a second salvage regimen to achieve disease control prior to autologous stem cell transplantation have a relatively poor outcome and should be considered for alternative treatment strategies.

Hematopoietic Cell Transplantation for Lymphomas

Background

The heterogeneity of lymphomas results in numerous treatment options, including both autologous and allogeneic hematopoietic cell transplantation. However, the type of transplantation, the timing the procedure, and the selection of suitable patients for transplant continue to evolve.

Methods

We reviewed the current medical literature to provide a succinct synthesis for the most common types of lymphoma and the indications for transplantation.

Results

This review discusses the outcomes of autologous and allogeneic transplantation for patients with diffuse large B-cell lymphoma, follicular lymphoma, HIV-associated lymphomas, mantle cell lymphoma, T-cell lymphoma, and Hodgkin lymphoma.

Conclusions

Each of these histologies differs in the indications and timing for transplantation. However, ongoing clinical trials support the continuing role of both autologous and allogeneic transplantation for lymphoma management.

Autologous stem-cell transplantation in Hodgkin's lymphoma: analysis of a therapeutic option

OBJECTIVE

To report the clinical progress of patients with Hodgkin's lymphoma treated with autologous transplantation after failure or relapse of first-line treatment with chemotherapy and/or radiation therapy.

METHODS

The results of a retrospective analysis of 31 patients submitted to autologous transplantation as second-line treatment, between April 2000 and December 2008, were analyzed. Fourteen men and seventeen women, with a median age of 27 years, were submitted to autologous transplantation for relapsed (n = 21) or refractory (n = 10) Hodgkin's lymphoma.

RESULTS

Mortality related to treatment in the first 100 days after transplant was 3.2%. With a mean follow-up period of 18 months (range: 1 to 88 months), the probability of global survival and progression-free survival in 18 months was 84 and 80%, respectively. The probability of global survival and progression-free survival at 18 months for patients with chemosensitive relapses (n = 21) was 95 and 90%, respectively, versus 60 and 45% for patients with relapses resistant to chemotherapy (n = 10) (p = 0.001 for global survival; p = 0.003 for progression-free survival). In the multivariate analysis, absence of disease or pretransplant disease < 5 cm were favorable factors for global survival (p= 0.02; RR: 0.072; 95%CI: 0.01-0.85) and progression-free survival (p= 0.01; RR: 0.040; 95%CI: 0.007-0.78).

CONCLUSION

Autologous transplantation of stem-cells is a therapeutic option for Hodgkin's lymphoma patients after the first relapse. Promising results were observed in patients with a low tumor burden at transplant.

Prognostic significance of FDG-PET in relapsed or refractory classical Hodgkin lymphoma treated with standard salvage chemotherapy and autologous stem cell transplantation

Positron emission tomography using [(18)F]fluorodeoxyglucose (FDG-PET) has emerged as the standard response assessment tool in frontline therapy for classical Hodgkin lymphoma (cHL). The ability of FDG-PET to predict outcomes in patients with relapsed cHL treated with modern standard salvage chemotherapy and autologous stem cell transplantation (ASCT) remains uncertain. Forty-six patients with relapsed/refractory cHL treated from 2001 to 2007 with standard salvage/ASCT therapy had FDG-PET available for blinded review. The results of pre-ASCT FDG-PET interpreted by the international harmonization project (IHP) criteria were compared with published prognostic models for prediction of event-free survival (EFS) and overall survival (OS). Overall, 3-year EFS was 62% and OS was 78%, with a median follow-up of 38 months. Pre-ASCT FDG-PET response significantly predicted 3-year EFS in FDG-PET-negative (82%) versus FDG-PET-positive (41%) patients (P = .02). A trend was observed for 3-year OS comparing FDG-PET-negative (91%) versus -positive (64%) patients (P = .08). Multivariate analysis demonstrated the independent prognostic significance of pre-ASCT FDG-PET for EFS with a hazard ratio (HR) of 3.2 (confidence interval [CI] 1.1-9.0, P = .03). Pre-ASCT FDG-PET scans predict EFS in patients with relapsed cHL patients treated with modern salvage/ASCT therapy and warrant prospective evaluation.

Outcomes of auto-SCT for lymphoma in subjects aged 70 years and over

The safety and efficacy of auto-SCT for lymphoma in older patients is not well established, particularly in those ≥70 years old. We performed a retrospective analysis comparing 17 auto-SCT recipients ≥70 years old with 39 recipients aged 65-69 years. Hematopoietic cell transplantation comorbidity index (HCT-CI) scores were similar in both groups. Nonrelapse mortality (NRM) was increased in patients aged 70 years and older (hazard ratio (HR) 6.04, P=0.0029), and OS was decreased (HR 1.98, P=0.082). 1-year NRM was 35% in patients aged ≥70 years vs 8% in those aged 65-69 years (P=0.017). The incidence of in-hospital falls was higher in those aged ≥70 years (29 vs 8%, P=0.047). In a secondary exploratory analysis, we found that the occurrence of in-hospital falls was strongly associated with inferior OS (HR 3.36, P=0.0023) and NRM (HR 4.60, P=0.009) among all patients of aged 65 years and older. We conclude that auto-SCT is feasible in older patients but that mortality rates appear increased in those over age of 70 years. In-hospital falls were correlated with higher mortality, and prevention of falls may improve outcomes. Susceptibility to falls may indicate underlying frailty and should be explored prospectively as a means of selecting older patients for auto-SCT.

Autologous peripheral blood stem cell transplantation in children with refractory or relapsed lymphoma: results of Children's Oncology Group study A5962

This prospective study was designed to determine the safety and efficacy of cyclophosphamide, BCNU, and etoposide (CBV) conditioning and autologous peripheral blood stem cell transplant (PBSCT) in children with relapsed or refractory Hodgkin and non-Hodgkin lymphoma (HL and NHL). Patients achieving complete remission (CR) or partial remission (PR) after 2 to 4 courses of reinduction underwent a granulocyte-colony stimulating factor (G-CSF) mobilized PBSC apheresis with a target collection dose of 5 × 10⁶ CD34(+)/kg. Those eligible to proceed received autologous PBSCT after CBV (7200 mg/m², 450-300 mg/m², 2400 mg/m²). Forty-three of 69 patients (30/39 HL, 13/30 NHL) achieved a CR/PR after reinduction. Thirty-eight patients (28 HL, 10 NHL) underwent PBSCT. All initial 6 patients who received BCNU at 450 mg/m² experienced grade III or IV pulmonary toxicity compared to none of the subsequent 32 receiving 300 mg/m² (P < .0001). The probability of overall survival (OS) at 3 years for all patients is 51% and for transplanted patients is 64%. The 3-year event-free survival (EFS) is 38% (45% for HL; 30% NHL). The 3-year EFS in transplanted patients is 66% (65% HL; 70% NHL). Initial duration of remission of ≥12 versus <12 months was associated with a significant increase in OS (3 years OS 70% versus 34%) (P = .003). BCNU at 300 mg/m(2) in a CBV regimen prior to PBSCT is well tolerated in relapsed or refractory pediatric lymphoma patients. A short duration (<12 months) of initial remission is associated with a poorer prognosis. Last, a high percentage of patients achieving a CR/PR after reinduction therapy can be salvaged with CBV and autologlous PBSCT.

High-dose chemo-radiotherapy for relapsed or refractory Hodgkin lymphoma and the significance of pre-transplant functional imaging

We previously reported that three risk factors (RF): initial remission duration <1 year, active B symptoms, and extranodal disease predict outcome in relapsed or refractory Hodgkin lymphoma (HL). Our goal was to improve event-free survival (EFS) for patients with multiple RF and to determine if response to salvage therapy impacted outcome. We conducted a phase II intent-to-treat study of tailored salvage treatment: patients with zero or one RF received standard-dose ifosfamide, carboplatin, and etoposide (ICE); patients with two RF received augmented ICE; patients with three RF received high-dose ICE with stem cell support. This was followed by evaluation with both computed tomography and functional imaging (FI); those with chemosensitive disease underwent high-dose chemoradiotherapy and autologous stem cell transplantation (ASCT). There was no treatment-related mortality. Compared to historical controls this therapy eliminated the difference in EFS between the three prognostic groups. Pre-ASCT FI predicted outcome; 4-year EFS rates was 33% vs. 77% for patients transplanted with positive versus negative FI respectively, P = 0.00004, hazard ratio 4.61. Risk-adapted augmentation of salvage treatment in patients with HL is feasible and improves EFS in poorer-risk patients. Our data suggest that normalisation of FI pre-ASCT predicts outcome, and should be the goal of salvage treatment.

Mitoxantrone, vinblastine and CCNU: long-term follow-up of patients treated for advanced and poor-prognosis Hodgkin's disease

Advanced-stage or relapsed/refractory Hodgkin's disease (HD) has a poor prognosis despite aggressive chemotherapy regimens and the use of high-dose therapy with autologous stem cell support. Mitoxantrone, vinblastine and CCNU (lomustine) (MVC) combines the most effective chemotherapeutic agents of previous regimens for poor prognosis HD, and eliminates marginally active agents with unnecessary toxicities, such as bleomycin and dacarbazine. Sixty-eight patients with HD (23 newly diagnosed and 45 with relapsed/refractory disease, one patient treated both de novo and years later in relapse) were treated with the MVC regimen (mitoxantrone 8 mg/m(2)/day i.v. days 1 - 3; vinblastine 8 m/m(2)/day days 1 and 22; and CCNU (lomustine) 100 mg/m(2) on day 1, repeated at 6 - 8 weeks) in a single-arm Phase II study. All patients responded to treatment in the newly diagnosed group (overall response = 100%). The median response duration was not reached, but was in the range 7.6 - 180 + months, and median survival was 94 months. Eleven complete responses are ongoing at 39 - 180 + months. In the previously-treated patients, 41 responded to MVC (OR = 91%). The median response duration for this group was 11 months, and the median survival was 34 months after initiating MVC. Four secondary myeloid leukemias occurred, three in de novo, and one in the relapsed/refractory group, at a median follow-up of 14 years. MVC regimen for HD is highly active, for both de novo and relapsed/refractory disease, with high response rates and survival that compare favourably with the results obtained by high-dose therapy with stem-cell transplantation. Although significant, the toxicities associated with this regimen were manageable.

Autologous and allogeneic stem cell transplantation in Hodgkin's lymphoma

Newly diagnosed patients who have advanced-stage Hodgkin's lymphoma have an excellent prognosis because most of them can be cured with initial treatment. In contrast, the prognosis for patients relapsing after first-line therapy with either combination chemotherapy or chemotherapy followed by radiotherapy remains poor in many cases. In most of these cases, high-dose chemotherapy and autologous stem cell transplantation (ASCT) is currently considered to be the treatment of choice. However, results of ASCT in primary refractory patients are poor and new therapeutic alternatives should be sought for these patients. Allogeneic stem cell transplantation has been used increasingly in relapsed or refractory Hodgkin's lymphoma patients, with the introduction of reduced-intensity conditioning protocols.

Long-term results of autologous stem cell transplantation for primary refractory or relapsed Hodgkin's lymphoma

Autologous hematopoietic stem cell transplantation (ASCT) has become standard therapy for primary refractory (PR REF) or relapsed (REL) Hodgkin's lymphoma (HL); however, more than half of these patients eventually relapse and die of their disease. We studied long-term outcomes and evaluated factors influencing progression-free survival (PFS) in 141 patients with PR REF or REL HL who underwent ASCT between 1985 and 2003. Median age at ASCT was 30 years (range, 7-60 years); 21 patients had PR REF, and 120 had REL HL. With a median follow-up of 6.3 years (range, 1-20 years), the probability of PFS at 5 and 10 years was 48% (95% confidence interval [CI], 39%-57%) and 45% (95% CI, 36%-54%) and that of overall survival (OS) was 53% (95% CI, 44%-62%) and 47% (95% CI, 37%-57%), respectively. Transplant-related mortality at 100 days was 1.4%. Among 45 5- to 20-year survivors, no late relapses of HL were observed. In multivariate analysis, 3 factors were independently predictive of poor PFS: chemoresistant disease (relative risk [RR], 2.9; 95% CI, 1.7-5.0), B-symptoms at pretransplantation relapse (RR, 2.1; 95% CI, 1.3-3.4), and presence of residual disease at the time of transplantation (RR, 2.3; 95% CI, 1.1-4.8). Patients with 0 or 1 of these 3 adverse factors (low-risk disease) had a 5-year PFS of 67% (95% CI, 55%-79%) compared with 37% (95% CI, 22%-52%) in those with 2 factors (intermediate-risk group) and 9% (95% CI, 0-20%) in those with all 3 factors (high-risk group) (P < .001). The rates of OS at 5 years were 71% (95% CI, 60%-82%), 49% (95% CI, 33%-65%) and 13% (95% CI, 0-27%) in the 3 groups, respectively (P < .001). ASCT is associated with durable PFS in appropriately selected patients with PR REF or REL HL. Using a simple prognostic model, we can identify patients with high-risk disease who have predictably unfavorable outcome after ASCT and require novel therapeutic approaches. A risk-adapted approach should be followed in determining treatment options for patients with PR REF and REL HL.

Prognostic impact of pretransplantation computed tomography and gallium scans in patients with Hodgkin lymphoma with poor prognosis undergoing hematopoietic stem cell transplantation

BACKGROUND

The present study evaluated computed tomography (CT) and Gallium-67 scanning (67Ga) before transplantation as prognostic factors for overall survival (OS) and event-free survival (EFS) in patients with relapsed or primary refractory Hodgkin lymphoma undergoing high-dose chemotherapy and stem cell transplantation.

PATIENTS AND METHODS

Forty-five patients were included. Of these, 10 (22%) had positive CT and 67Ga scan results, 21 (47%) had negative results of both techniques, 12 (27%) had positive CT/negative 67Ga scan results, and 2 (5%) had negative CT/positive 67Ga scan results.

RESULTS

Patients with positive CT/67Ga scan results had a significantly worse EFS and OS at 5 years than those with negative 67Ga scan results, whether it was associated with positive or negative CT scan results (0 and 25% vs. 83% and 90% vs. 74% and 83%, respectively; P < 0.001). With a median follow-up of 59 months (range, 6-150 months), no differences were observed between patients with negative CT/67Ga scan results and those with positive CT/negative 67Ga scan results, with an EFS and OS at 5 years of 74% vs. 83% and 83% vs. 90%, respectively. In multivariate analysis, the presence of pretransplantation positive CT/67Ga scan results adversely influenced EFS and OS (hazard ratio, 39; 95% confidence interval, 8-202 [P < 0.001] and hazard ratio, 24; 95% confidence interval, 4-135 [P < 0.001], respectively).

CONCLUSION

Gallium-67 scans help to identify pretransplantation CT-positive patients with a different outcome. A group of patients with positive CT/negative 67Ga scan results before transplantation who showed a favorable outcome with a low rate of relapse and another group of patients with positive CT/67Ga scan results before transplantation who showed poor prognosis did not benefit from autologous stem cell transplantation. They should be offered other therapeutic strategies.

Tandem high-dose chemotherapy and autologous stem cell transplantation in refractory/relapsed Hodgkin's lymphoma: a monocenter prospective study

We designed a prospective study to evaluate the feasibility and efficacy of tandem high-dose chemotherapy (HDCT) in the treatment of refractory or relapsed Hodgkin's lymphoma (HL). Thirty-two patients were treated with salvage chemotherapy (IGEV, ifosfamide, gemcitabine, and vinorelbine) and chemo-sensitive patients received a first HDCT course with melphalan 200 mg/m(2) (MEL200) and a second BEAM course. The median time interval between the two HDCT courses was 66 days. The median number of reinfused CD34(+) cells was 4.7 x 10(6)/kg after MEL200 and 5.8 x 10(6)/kg after BEAM. The hematological reconstitution after both HDCT courses did not differ. No grade III or IV renal, hepatic, lung, cardiac, and neurological toxicity was observed. Severe (grade III and IV) oral mucositis was the most prominent complication affecting 60 and 50% of patients after MEL200 and BEAM, respectively. Fever of unknown origin occurred in 65 and 70% of patients after MEL200 and BEAM, respectively. One patient died from septic shock during the aplasia period following BEAM. In an intention-to-treat analysis, the overall response rate increased after each stage of protocol, ranging from 47% to 65% and 75% after IGEV, MEL200, and BEAM, respectively. Tandem HDCT is feasible and effective in patients with relapsed or refractory HL.

Prognostic factors affecting long-term outcome after stem cell transplantation in Hodgkin's lymphoma autografted after a first relapse

PURPOSE

To analyse outcome and prognostic factors for overall survival (OS) and time to treatment failure (TTF) in 357 patients with Hodgkin's lymphoma (HL) undergoing an autologous stem cell transplantation (ASCT) after a first relapse and reported to the The Grupo Espanol de Linfomas/Trasplante Autologo de Medula Osea (GEL/TAMO) Cooperative Group.

METHODS

Two hundred and twenty males and 137 females with a median age of 29 years were autografted in second remission (n=181), first sensitive relapse (n=148) and first resistant relapse (n=28).

RESULTS

Five-year actuarial TTF and OS were of 49% +/- 3% and 57% +/- 3%. Advanced stage at diagnosis, complementary radiotherapy before ASCT, a short first complete response (CR) and detectable disease at ASCT adversely influenced TTF. Year of transplant < or =1995, bulky disease at diagnosis, a short first CR, detectable disease at ASCT and > or =1 extranodal areas involved at ASCT were adverse factors for OS.

CONCLUSIONS

ASCT constitutes a therapeutic option for HL patients after a first relapse. Promising results are observed in patients with low tumour burden at diagnosis, autografted after a long CR and without detectable disease at ASCT. Innovative approaches should be pursued for patients with risk factors at relapse.

High-dose therapy and autologous hematopoietic stem-cell transplantation for recurrent or refractory pediatric Hodgkin's disease: results and prognostic indices

PURPOSE

To evaluate the outcome of pediatric patients with refractory or relapsed Hodgkin's disease (HD) who undergo high-dose therapy and autologous hematopoietic stem-cell transplantation (AHSCT).

PATIENTS AND METHODS

From 1989 to 2001, 41 pediatric patients with relapsed or primary refractory HD underwent high-dose therapy followed by AHSCT according to one of four autologous transplantation protocols at Stanford University Medical Center (Stanford, CA). Pretreatment factors were analyzed by univariate and multivariate analysis for prognostic significance for 5-year overall survival (OS), event-free survival (EFS), and progression-free survival (PFS).

RESULTS

At a median follow-up of 4.2 years (range, 0.7 to 11.9 years), the 5-year OS, EFS, and PFS rates were 68%, 53%, and 63%, respectively. Multivariate analysis determined the following three factors to be significant predictors of poor OS and EFS: extranodal disease at first relapse, presence of mediastinal mass at time of AHSCT, and primary induction failure. Two of these factors also predicted for poor PFS (extranodal disease at time of first relapse and presence of mediastinal mass at time of transplantation).

CONCLUSION

More than half of children with relapsed or refractory HD can be successfully treated with the combination of high-dose therapy and AHSCT, confirming the efficacy of this approach. Further investigation is now required to determine the optimal timing of AHSCT, as well as to develop alternative regimens for those patients with factors prognostic for poor outcome after AHSCT.

Outcome and prognostic factors in advanced Hodgkin's disease treated with high-dose chemotherapy and autologous stem cell transplantation: a study of 341 patients

BACKGROUND

The reported probability of survival of patients with Hodgkin's disease (HD) following high-dose chemotherapy with autologous stem cell transplantation (HDC/ASCT) is 35-65% at 5 years. The Polish Lymphoma Research Group investigated retrospectively prognostic factors for overall survival (OS) and event-free survival (EFS), and the risk of secondary malignancies in a large series of patients who underwent HDC/ASCT.

PATIENTS AND METHODS

The data of 341 consecutive patients treated in 10 centers from 1990 to 2002 were collected and analyzed.

RESULTS

The actuarial 5-year OS and EFS were 64% [95% confidence interval (CI) 57% to 71%] and 45% (95% CI 39% to 51%), respectively. In the multivariate model, unfavorable prognostic factors for EFS were less than partial response at the time of ASCT [relative risk (RR), 2.92 (95% CI 1.68-5.08); P<0.001] and three or more previous chemotherapy lines (RR, 2.16; 95% CI 1.42-3.30; P<0.001). These two factors were also associated with unfavorable OS (RR, 3.32; 95% CI 1.90-5.79; P<0.001 and RR, 2.34, 95% CI 1.51-3.64; P<0.001). Five-year cumulative risk of secondary malignancy was 8.4% (95% CI 2% to 13%) and the only identified risk factor was splenectomy (P=0.02).

CONCLUSIONS

HDC/ASCT should be considered early in the course of disease for patients with a response after standard therapy.

Outcome after autologous hemopoietic stem cell transplantation in relapsed or refractory childhood Hodgkin disease

OBJECTIVES

To determine the clinical outcome and prognostic factors for overall survival in children with recurrent and/or primary refractory Hodgkin disease (HD) after high-dose therapy and autologous hemopoietic stem cell transplantation (AHSCT). The survival outcome of this treatment was compared with conventional salvage therapy without stem cell transplantation.

METHODS

Clinical records of 51 patients with relapsed or refractory HD who underwent AHSCT were reviewed. The source of the stem cells was bone marrow (n = 22) or peripheral blood (n = 29). At the time of high-dose therapy, 39 patients were in complete remission and 1 was in partial remission, while the remaining 11 had refractory disease. The records of 78 patients from the HD 1 trial who underwent conventional salvage treatment but without AHSCT for relapsed or refractory HD were also reviewed. All patients received HDT without radiation for conditioning.

RESULTS

Overall survival from diagnosis of patients treated with AHSCT did not differ significantly from that of those treated with conventional salvage therapy (hazard ratio = 1.5; 95% confidence interval = 0.9-8.2; P = 0.4). There were also no statistically significant differences in survival data between the two approaches for patients whose duration of first remission was less than or greater than 1 year (P = 0.5; stratified log-rank). Of the 11 patients who received AHSCT for refractory disease, 9 remain alive and well with followups ranging from 2 to 18 years. No deaths due to treatment-related complications were seen in the AHSCT group.

CONCLUSIONS

Stem cell transplantation does not offer any significant survival advantage over conventional salvage therapy in children with relapsed HD, although it may be of benefit for patients with primary refractory disease.

High-dose CEB vs BEAM with autologous stem cell transplant in lymphoma

Between January 1996 and July 2002, 72 patients with non-Hodgkin's lymphoma or Hodgkin's disease underwent high-dose chemotherapy with autologous stem cell transplant conditioned with either cyclophosphamide, etoposide, carmustine (CEB) or carmustine, etoposide, cytarabine, melphalan (BEAM) at a single institution. In all, 52 patients received CEB and 20 patients received the BEAM regimen. Patient characteristics that were significantly different between the two groups are tumor grade and extranodal involvement (P = 0.0196, 0.0341, respectively). Regimen-related toxicities examined yielded only diarrhea occurring at a higher rate in the BEAM group (81 vs 51%, P = 0.0026), although cases were milder (92 vs 57%). Patients treated with CEB developed mucositis at a slightly higher rate (79%) than patients treated with BEAM (75%), but this difference did not reach statistical significance. However, the mucositis that occurred within the BEAM group was predominately mild (67%) in contrast to the predominance of moderate to severe cases in the CEB group (74%). In addition, patients treated with CEB required growth factor support for a longer time than patients treated with BEAM (P = 0.0399). Response rates were high in both groups, with trends favoring the BEAM group. Overall survival was higher after treatment with BEAM than with CEB (84 vs 60%).

An update on the management of relapsed and primary refractory Hodgkin’s disease

With the use of combined modality therapy for early stage disease and a risk-adapted approach for advanced stage disease, nearly 90% of patients with Hodgkin's lymphoma are cured with initial therapy. However, in patients who have primary refractory or relapsed disease, high-dose therapy and autologous stem cell transplantation is the best curative option. The use of peripheral blood progenitor cells has decreased transplant related mortality to less than 3%; but long-term progression-free survival as increased minimally. Although prognostic factors have been used to tailor therapy in de novo Hodgkin's lymphoma their utility in the relapsed-refractory setting has not been exploited. This update will discuss these important prognostic factors and try to guide oncologists in treatment decisions in this setting.

Value of F-18 fluorodeoxyglucose positron emission tomography for predicting the clinical outcome of patients with aggressive lymphoma prior to and after autologous stem-cell transplantation

STUDY OBJECTIVES

To determine and compare the values of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG) and CT for predicting clinical outcome of patients with aggressive lymphoma undergoing salvage cytoreductive chemotherapy followed by high-dose chemotherapy and autologous stem-cell transplantation (ASCT).

PATIENTS AND METHODS

Forty-three patients with lymphoma who underwent ASCT with FDG-PET evaluation were studied. Group 1 (n = 20) patients (6 patients with Hodgkin disease [HD], and 14 patients with non-Hodgkin lymphoma [NHL]) underwent PET 2 to 5 weeks after initiation of salvage chemotherapy, prior to ASCT. Group 2 (n = 23) patients (6 patients with HD, and 17 patients with NHL) underwent PET within a median interval of 2.4 months (range, 2 to 6 months) after ASCT.

MEASUREMENTS AND RESULTS

Study end points were complete remission, relapse, or death. In group 1, 8 of 20 patients (40%) were disease free after a median follow-up of 13.3 months; 12 patients relapsed or died. PET findings were true-negative in 7 of 8 patients and true-positive in 11 of 12 patients who relapsed after ASCT. In group 2, 9 of 23 patients (39%) were disease free after a median follow-up of 16.5-months; 14 patients relapsed. PET findings were true-negative in 8 of 9 patients and true-positive in 13 of 14 patients who relapsed. Positive and negative predictive values of PET were 92% and 88% (group 1) and 93% and 89% (group 2), respectively. Predictive accuracy values of PET were 90% and 91% for group 1 and group 2, respectively, vs 58% and 67% for CT (p < 0.05).

CONCLUSIONS

PET findings but not CT results were strongly correlated with disease-free survival (p < 0.01). Our results show that FDG-PET can be used to predict the post-ASCT outcome of lymphoma patients with high accuracy.

High-dose sequential chemotherapy and peripheral blood progenitor cell autografting in patients with refractory and/or recurrent Hodgkin lymphoma: a multicenter study of the intergruppo Italiano Linfomi showing prolonged disease free survival in patients treated at first recurrence

BACKGROUND

The objective of the current study was to evaluate in a multicenter setting the feasibility and efficacy of a high-dose sequential (HDS) chemotherapy regimen that combined intensive debulking and high-dose therapy (HDT) with peripheral blood progenitor cell (PBPC) autografting in patients with refractory or recurrent Hodgkin lymphoma (HL).

METHODS

Data were collected from 102 patients with HL who were treated with the HDS regimen at 14 centers associated with the Intergruppo Italiano Linfomi. Twenty-four patients had primary refractory HL, 59 patients had their first recurrence of HL (within 1 year in 32 patients and > 1 year in 27 patients), and 19 patients had multiple disease recurrences. The HDS regimen included the sequential delivery of high-dose (hd) cyclophosphamide with PBPC harvesting, methotrexate, etoposide, then HDT (usually hd mitoxantrone plus L-phenylalanine mustard) with PBPC autografting. In addition, radiotherapy was delivered to 36 patients at sites of bulky or persistent disease.

RESULTS

Ninety-two patients (90%) completed the HDS program. There were five toxic deaths (treatment-related mortality rate, 4.9%) and six secondary malignan cies (five patients developed myelodysplastic syndrome/acute myelogenous leukemia, and one patient developed colorectal carcinoma). At a median follow-up of 5 years, the 5-year overall survival (OS) and event-free survival (EFS) projections were 64% (95% confidence interval [95% CI], 54-74%) and 53% (95% CI, 43-63%), respectively. Patients with their first recurrence had the most favorable outcome, with 5-year OS and EFS projections of 77% (95% CI, 66-88%) and 63% (95% CI, 50-76%), respectively. There were no significant differences between patients with early first recurrence and late first recurrence. The poorest outcome was observed in patients with refractory HL, with 5-year OS and EFS projections of 36% (95% CI, 16-55%) and 33% (95% CI, 14-52%), respectively. Patients who received HDS chemotherapy after multiple recurrences had an intermediate outcome. Multivariate analysis showed that refractory disease and systemic symptoms at the time of initial presentation were associated significantly associated with poor OS and EFS.

CONCLUSIONS

The use of HDS chemotherapy for patients with refractory and/or recurrent HL is feasible at the multicenter level. The combination of intensive debulking and HDT with PBPC autografting offers a good chance of prolonged disease free survival for patients with their first recurrence of HL.

Hematopoietic stem-cell transplantation for Hodgkin's disease (HD): current status

Not all patients with Hodgkin's disease (HD) respond to standard chemotherapy and/or radiation, and hematopoietic stem-cell transplantation has been gaining increasing acceptance in the management of HD. Phase II and, to a lesser extent, phase III studies of high-dose chemotherapy and autologous stem cell transplantation carried out at multiple institutions worldwide have proven the feasibility of the procedure and provided extended progression-free survival (and possibly cure) in a sizable number of patients with relapsed or refractory HD. Prognostic factors have been identified by multiple investigators (with response to chemotherapy being the most impressive one) and may ultimately allow a risk-adapted strategy. While early and late treatment-related morbidity and mortality remains an issue, with current supportive care modalities most patients tolerate this procedure with only minor or manageable complications. Disease recurrence remains a problem in many patients, and this can unfortunately occur as late as six or seven years after a seemingly successful transplant. New chemotherapeutic agents and strategies (such as post-transplant maintenance and possibly immunomodulation) will be required to successfully tackle this issue. Allogeneic stem-cell transplantation from HLA-compatible donors has yielded largely unsatisfactory results in the published studies in the literature, despite favorable results in a small minority of patients. Recently, however, newer approaches and strategies (such as the introduction of reduced-intensity, purine analog-based conditioning regimens and possibly cellular immunotherapy in the form of donor lymphocyte infusions) have provided very encouraging early results and seem to brighten the outlook for this procedure.

Hodgkin's lymphoma: biology and treatment strategies for primary, refractory, and relapsed disease

Hodgkin's lymphomas belong to the most curable tumor diseases in adults. About 80% of patients in all anatomical stages and of all histological subtypes can be cured with modern treatment strategies. In spite of the great clinical progress, the pathogenesis of this peculiar lymphoproliferative entity has not been elucidated completely up until now. In Section I Drs. Stein, Hummel, and Zollinger describe the different pro-proliferative and antiapoptotic pathways and molecules involved in the transformation of the germinal center B-lymphocyte to the malignant Hodgkin-Reed-Sternberg cell. They use a comprehensive gene expression profiling (Affymetrix gene chip U133A) on B- and T-Hodgkin cell lines and state that the cell of origin is not the dominant determinant of the Hodgkin cell phenotype, but the transforming event. H-RS cells lack specific functional markers (B-T-cell receptors) and physiologically should undergo apoptosis. Why they do not is unclear and a matter of intensive ongoing research. In Section II Dr. Diehl summarizes the commonly used primary treatment strategies adapted to prognostic strata in early, intermediate and advanced anatomical stages using increasing intensities of chemotherapy (two, four, eight courses of chemotherapy such as ABVD) and additive radiation with decreased doses and field size. ABVD is without doubt the gold standard for early and intermediate stages, but its role as the standard regimen for advanced stages is challenged by recent data with time- and dose-intensified regimens such as the escalated BEACOPP, demonstrating superiority over COPP/ABVD (equivalent to ABVD) for FFTF and OS in all risk strata according to the International Prognostic Score. In Section III, Dr. Connors states that fortunately there is a considerably decreased need for salvage strategies in Hodgkin's lymphomas since primary treatment results in a more than 80% tumor control. Nevertheless, a significant number of patients experience either a tumor refractory to therapy or an early or late relapse. Therefore, one of the continuing challenges in the care for Hodgkin's lymphomas today is to find effective modes for a second tumor control. High-dose chemotherapy followed by autologous stem cell support has proved to be the treatment of choice when disseminated tumors recur after primary chemo- and or radiotherapy. Nodal relapses respond well to local radiation when they recur outfield of primary radiation without B-symptoms and in stages I-II at relapse. Allogeneic stem cell support needs further intensive evaluation in controlled studies to become an established alternative.

CD34(+) cell enrichment depletes atypical CD30(+) cells from PBPC grafts in patients with HD

BACKGROUND

European Group for Blood and Marrow Transplantation (EBMT) registry data indicate that patients with relapsed HD given high-dose therapy (HDT), supported with PBPC might have a poorer outcome compared with those given BM. Since this can be due to the infusion of contaminating tumor cells in the PBPC products, we studied the presence of minimal residual disease and tested whether CD34(+) cell enrichment was able to remove atypical CD30(+) cells from PBPC grafts.

METHODS

Eighteen HD patients eligible for HDT were included in the study. By the use of immunocytochemistry (ICC), mononuclear cells from BM and peripheral blood (PB) before mobilization, PBPC products and selected CD34(+) fractions were stained using anti-CD30 MAb (Ber-H2) and the APAAP (alkaline phosphatase-anti-alkaline phosphatase) method. Cells scored as atypical CD30(+) cells were large- to medium-sized, with membranous, cytoplasmatic and/or Golgi positivity for CD30.

RESULTS

Nine out of 11 BM tested were positive, while 14 of 14 PB and 18 of 18 PBPC contained atypical CD30(+) cells. The total number of atypical CD30(+) cells was significantly higher in PBPC than in the corresponding BM. CD34(+) cell enrichment employing ISOLEX 300I gave a purity and yield of 99.2% (range 97.8-99.7) and 49.6% (range 30.0-78.4), respectively. After HDT a median of 5.8 x 10(6) (range 2.7-20) CD34(+) cells/kg was infused. Neutrophil counts of > 0.5 x 10(9)/L and platelet counts of > 20 x 10(9)/L were achieved at Day 12 (range 10-17) and at Day 10 (range 7-15), respectively. Sixteen of 18 CD34(+) selected products had no detectable atypical CD30(+) cells, while two had a low number. After HDT, the overall survival was 80% and the event-free survival was 69%, with a median follow-up of 24 months (range 1-36).

DISCUSSION

We show that contaminating atypical CD30(+) cells in PBPC can efficiently be removed by CD34(+) cell enrichment, and the use of such grafts following HDT gives fast and sustained engraftment.

The International Prognostic Factors Project score for advanced Hodgkin's disease is useful for predicting outcome of autologous hematopoietic stem cell transplantation

BACKGROUND

The International Prognostic Factors Project on Advanced Hodgkin's Disease developed a seven-factor prognostic score consisting of serum albumin, hemoglobin, gender, stage, age, leukocytosis and lymphocytopenia for newly diagnosed Hodgkin's disease patients who receive chemotherapy. The purpose of this study was to determine whether this prognostic score would also be useful for Hodgkin's disease patients undergoing autologous hematopoietic stem cell transplantation.

PATIENTS AND METHODS

We performed a retrospective review of 379 patients who had autologous transplants for Hodgkin's disease, at the University of Nebraska Medical Center between October 1984 and December 1999. Multivariate analysis was performed to determine whether the prognostic factors identified by the International Prognostic Factors Project adversely influenced event-free survival (EFS) or overall survival (OS).

RESULTS

Low serum albumin, anemia, age and lymphocytopenia were associated with poorer EFS and OS. Gender, stage and leukocytosis were not associated with significantly poorer outcomes. Estimated 10-year EFS was 38%, 23% and 7% for patients with 0-1, 2-3 or > or =4 of the adverse prognostic characteristics identified by the International Prognostic Factors Project, respectively.

CONCLUSIONS

The prognostic score for advanced disease is also useful for relapsed and refractory Hodgkin's disease patients undergoing high-dose therapy followed by autologous hematopoietic stem cell transplantation.

Front-line high-dose therapy with autologous stem cell transplantation for high risk Hodgkin's disease: comparison with combined-modality therapy

This retrospective study compares high-dose therapy (HDT) with autologous stem cell transplantation and combined-modality treatment (CT) as a first-line therapy for Hodgkin's disease (HD) for patients with both a clinical stage (CS) IV and/or a mediastinal mass > or =0.45 of the thoracic diameter (MM > or =0.45) at diagnosis, and an incomplete response after the first-line chemotherapy. Data on 42 grafted patients (GP) in Nantes Hospital, France and on 108 combined-modality treated patients (CTP) from two protocols of the GOELAMS group, France (POF 81 and H90) was analyzed. Both groups were comparable except for pulmonary disease in excess in the grafted group (P = 0.01). Among GP, 95% were in complete response at the end of first-line treatment and 77% among CTP. Median follow-up was 53 months (range, 7 to 128 months) for GP and 88 months (range, 25 to 181 months) for CTP. The 5-year freedom from progression (FFP) and event-free survival (EFS) rates were better for GP (87% vs 55% for FFP: P = 0.0004 and 81% vs 51% for EFS: P = 0.0004) whereas the overall survival (OS) rates did not differ significantly (85% for GP vs 71% for CTP: P = 0.06). Similar results were obtained for the groups with a response > or =50% after initial chemotherapy: 91% vs 65% for FFP, P = 0.01; 87% vs 61% for EFS, P = 0.02; and 92% vs 77% for OS, P = 0.2; and for the groups with a response <50%: 80% vs 22% for FFP, P = 0.0003; 72% vs 13% for EFS, P = 0.0001; and 76% vs 46% for OS, P = 0.04. This study shows a better control of the disease with HDT.

Stem cell transplantation for Hodgkin's disease: a review of the literature

High-dose chemotherapy followed by autologous peripheral-blood stem cell transplantation has resulted in long-term disease-free survival of 30%-60% in selected patients with refractory and relapsed Hodgkin's disease. In addition, a significant reduction in early transplant-related mortality in more recent studies has led to the widespread acceptance of autografting. Comparatively few studies of allografting for Hodgkin's disease have been performed. Although no prospective randomized trials have been performed, historical results show a significantly lower relapse rate when allografting results are compared to autografting results. These results suggest that a graft-versus-Hodgkin's disease effect may exist. Unfortunately, the lower relapse rate following allografting is offset by higher transplant-related mortality. The use of low-intensity nonmyeloablative regimens for allografting may harness a graft-versus-Hodgkin's disease effect with less morbidity and mortality than that observed following conventional allografting.

Approach to Hodgkin's lymphoma in the new millennium

Approximately 75% of patients with Hodgkin's lymphoma can be cured with modern chemotherapy and radiation. Most patients are treated according to clinical stage and the associated prognostic factors. For patients with limited stage Hodgkin's lymphoma, combined modality treatment has replaced subtotal nodal irradiation as the preferred treatment option. This approach eliminates laparotomy and potentially decreases the long-term toxicity secondary to extended field irradiation and splenectomy. Furthermore, recent studies suggest that it may improve disease control and possibly survival. Multiple novel regimens have been tested in the past 20 years in patients with advanced Hodgkin's lymphoma including dose-intense regimens, but current evidence suggests that ABVD remains the treatment of choice outside clinical trials. Over the past decade, the treatment-related morbidity and mortality associated with autologous stem cell transplantation have reduced significantly and stem cell transplant is becoming the treatment of choice for most patients with primary refractory or recurrent Hodgkin's lymphoma. With longer follow-up, long-term complications, in particular secondary malignancy have become the leading cause of late treatment failure for patients with Hodgkin's lymphoma. To improve the overall outcome of patients with Hodgkin's lymphoma, future studies need to focus on reducing the therapy-related toxicity for patients with good risk disease as well as improving disease control for patients with poor risk disease through a risk-adapted approach.

Gemcitabine in hematologic malignancies

Gemcitabine is a pyrimidine analogue that showed significant activity in solid malignancies. Gemcitabine acts by inhibiting DNA synthesis through chain termination and ribonucleotide reductase inhibition. During initial phase I and II studies, gemcitabine had a low toxicity profile and was well tolerated as a single agent and in combination therapy. Recently, there has been more interest in studying the activity of gemcitabine in hematologic malignancies. Gemcitabine demonstrated good activity in refractory Hodgkin disease patients, non-Hodgkin lymphoma, cutaneous T-cell lymphoma, and acute leukemias. There is a preponderance of evidence on the activity of gemcitabine in vitro in myeloma and leukemic cell lines. The activity of gemcitabine in these disorders will pave the way for incorporating this agent into the early phases of therapy.

High-dose therapy in lymphomas: a review of the current status of allogeneic and autologous stem cell transplantation in Hodgkin's disease and non-Hodgkin's lymphoma

Autologous stem cell transplantation has proven to be beneficial in selected patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). In patients with HD, transplantation appears to increase event-free survival in patients who fail to enter complete remission with initial therapy. When a patient relapses after a complete remission, transplantation is probably the best option and particularly so if the remission lasted less than 1 year. Transplantation as part of primary therapy for very high-risk patients may be beneficial, but is not standard therapy at this time. For patients with diffuse large-cell NHL, transplantation can be considered standard therapy for relapsed patients if they have chemotherapy-sensitive disease. The use of transplantation for high-risk patients in complete remission is promising, but definite recommendations cannot be made at this time. For follicular lymphomas, selected patients seem to benefit and studies are ongoing. Finally, the use of allogeneic stem cell transplantation can be useful in a select group of younger patients.

Autologous stem-cell transplantation for Hodgkin's disease: results and prognostic factors in 494 patients from the Grupo Español de Linfomas/Transplante Autólogo de Médula Osea Spanish Cooperative Group

PURPOSE

To analyze clinical outcome and significant prognostic factors for overall (OS) and time to treatment failure (TTF) in a group of 494 patients with Hodgkin's disease (HD) undergoing autologous stem-cell transplantation (ASCT).

PATIENTS AND METHODS

Detailed records from the Grupo Español de Linfomas/Transplante Autólogo de Médula Osea Spanish Cooperative Group Database on 494 HD patients who received an ASCT between January 1984 and May 1998 were reviewed. Two hundred ninety-eight males and 196 females with a median age of 27 years (range, 1 to 63 years) received autografts while in complete remission (n = 203) or when they had sensitive disease (n = 206) or resistant disease (n = 75) at a median time of 26 months (range, 4 to 259 months) after diagnosis. Most patients received high-dose chemotherapy without radiation for conditioning (n = 443). The graft consisted of bone marrow (n = 244) or peripheral blood (n = 250).

RESULTS

The 100-day mortality rate was 9%. The 5-year actuarial TTF and OS rates were 45.0% (95% confidence interval [CI], 39.5% to 50.5%) and 54.5% (95% CI, 48.4% to 60.6%), respectively. In multivariate analysis, the presence of active disease at transplantation, transplantation before 1992, and two or more lines of therapy before transplantation were adverse prognostic factors for outcome. Sixteen patients developed a secondary malignancy (5-year cumulative incidence of 4.3%) after transplantation. Adjuvant radiotherapy before transplantation, the use of total-body irradiation (TBI) in the conditioning regimen, and age > or = 40 years were found to be predictive factors for the development of second cancers after ASCT.

CONCLUSION

ASCT achieves long-term disease-free survival in HD patients. Disease status before ASCT is the most important prognostic factor for final outcome; thus, transplantation should be considered in early stages of the disease. TBI must be avoided in the conditioning regimen because of a significantly higher rate of late complications, including secondary malignancies.

Autotransplants for Hodgkin's disease in first relapse or second remission: a report from the autologous blood and marrow transplant registry (ABMTR)

Although patients with relapsed Hodgkin's disease have a poor prognosis with conventional therapies, high-dose chemotherapy and autologous hematopoietic stem cell transplantation (autotransplantation) may provide long-term progression-free survival. We reviewed data from the Autologous Blood and Marrow Transplant Registry (ABMTR) to determine relapse, disease-free survival, overall survival, and prognostic factors in this group of patients. Detailed records from the ABMTR on 414 patients with Hodgkin's disease in first relapse (n = 295) or second complete remission (CR) (n = 119) receiving an autotransplant from 1989 to 1995 were reviewed. Median age was 29 (range, 7-64) years. Median time from diagnosis to relapse was 18 (range, 6-219) months; median time from relapse to transplant was 5 (range, <1-215) months. Most patients received high-dose chemotherapy without total body irradiation for conditioning (n = 370). The most frequently used high-dose regimen was cyclophosphamide, BCNU, VP-16 (CBV) (n = 240). The graft consisted of bone marrow (n = 246), blood stem cells (n = 112), or both (n = 56). Median follow-up was 46 (range, 5-96) months. One hundred-day mortality (95% confidence interval) was 7 (5-9)%. One hundred and sixty-five of 295 patients (56%) transplanted in relapse achieved CR after autotransplantation. Of these, 61 (37%) recurred. Twenty-four of 119 patients (20%) transplanted in CR recurred. The probability of disease-free survival at 3 years was 46 (40-52)% for transplants in first relapse and 64 (53-72)% for those in second remission (P < 0.001). Overall survival at 3 years was 58 (52-64)% after transplantation in first relapse and 75 (66-83)% after transplantation in second CR (P < 0.001). In multivariate analysis, Karnofsky performance score <90% at transplant, abnormal serum LDH at transplant, and chemotherapy resistance were adverse prognostic factors for outcome. Progression of Hodgkin's disease accounted for 69% of all deaths. Autotransplantation should be considered for patients with Hodgkin's disease in first relapse or second remission. Future investigations should focus on strategies designed to decrease relapse after autotransplantation, particularly in patients at high risk for relapse.

Aggressive radiotherapy adjuvant to peripheral blood stem cell transplant for relapsed Hodgkin's disease

The role of radiotherapy in conjunction with high-dose chemotherapy and autologous bone marrow transplant for relapsed Hodgkin's disease remains to be clearly defined. Although there is substantial evidence that radiotherapy enhances local tumor control, prospective trials in the transplant setting have not been reported, and the potential toxicity of radiotherapy need to be considered. However, certain patients are at high risk of posttransplant tumor recurrence, most notably those with tumors unresponsive to pretransplant chemotherapy. We report the use of aggressive radiotherapy in three high-risk patients, including the first reported case of whole lung irradiation after a high-dose carmustine-based chemotherapy regimen. Two of these patients received repeat partial lung irradiation, including one patient with carmustine-related pulmonary toxicity. Radiotherapy (30-34.5 Gy; 1.5 Gy/fraction) was tolerated well without significant acute or late toxicity, and all patients remain disease free 40 to 62 months after irradiation without severe sequelae. We conclude that radiotherapy may be of benefit for patients at high risk of local tumor relapse, and should be considered in such cases despite potential toxicity.

Double high-dose therapy for Hodgkin's disease with dose-intensive cyclophosphamide, etoposide, and cisplatin (DICEP) prior to high-dose melphalan and autologous stem cell transplantation

We previously reported a 50% (95% CI = 33-76%) 5 year event-free survival (EFS) rate for 23 patients with Hodgkin's disease (HD) who received salvage therapy with single agent high-dose melphalan (HDM) and autologous stem cell transplantation (ASCT). Predictors of poor outcome included bulky disease and initial remission <1 year. Since 1995, similar poor prognosis patients have been treated with double high-dose therapy consisting of dose-intensive cyclophosphamide 5.25 g/m2, etoposide 1.05 g/m2, cisplatin 105 mg/m2 (DICEP) for tumor cytoreduction and stem cell mobilization followed by HDM/ASCT. The purpose of the present study is to determine if the use of DICEP is associated with improved event-free (EFS) and overall survival (OAS) for patients treated with HDM/ASCT. From February 1981 to June 1999, 46 consecutive patients received HDM/ASCT for relapsed (n = 35) or refractory (n = 11) HD. DICEP re-induction and blood stem cell mobilization was used for 21 patients. Factors considered for univariate and multivariate analyses included age at transplant, number of failed chemotherapy regimens, prior radiotherapy, length of initial remission, relapsed or refractory disease status, extranodal relapse, B symptoms at relapse, bulk, post-ASCT radiotherapy, and DICEP re-induction therapy. Cox proportional hazards models were constructed for both event and death. DICEP and HDM were well tolerated with no early treatment-related mortality or toxicity requiring life-sustaining measures. For all 46 patients, the projected 5 year EFS was 52% (95% CI = 38-72%) and OAS was 57% (95% CI = 40-82). Factors independently associated with relapse in multivariate analysis included bulk >5 cm (RR = 6.38, P = 0.002), prior radiotherapy (RR = 3.59, P = 0.027), and not using DICEP (RR = 5.29, P = 0.005). Factors independently associated with death included bulk >5 cm (RR = 5.13, P = 0.009), > or =3 prior chemotherapy regimens (RR = 4.72, P = 0.019), and not using DICEP (RR = 7.49, P = 0.015). This study demonstrates that DICEP re-induction prior to HDM/ASCT is feasible. The preliminary data are sufficiently encouraging to warrant a multicenter phase II or a phase III trial evaluating DICEP followed by HDM/ASCT as salvage therapy for HD.

Current treatment of Hodgkin's disease

In spite of the fact that Hodgkin's disease (HD) remains still an enigma its management and treatment yield a cure rate of about 80% of all patients. However, this management has two limits: on one side favourable cases which should not be overtreated because of unacceptable side-effects, and on the other side very unfavourable cases which should be treated differently because of a very high rate of failure and/or relapse. Then it becomes necessary to precise as thoroughly as possible these two limits in order to choose the adequate treatment for the patient. Prognostic factors based on patient and disease characteristics allow a relatively exact classification of favourable and unfavourable cases. This distinction in two prognostic groups has therapeutic implications in terms of chemotherapy (regimen, duration) and radiotherapy (extension, doses). Other specific situations have to be considered, e.g. pediatric cases, pregnancy, old age and HIV-infected patients who need an adapted management according to very different situations.

Gemcitabine in the treatment of refractory Hodgkin's disease: results of a multicenter phase II study

PURPOSE

To explore the use of gemcitabine for the treatment of patients with relapsing or refractory Hodgkin's disease.

PATIENTS AND METHODS

Eligible patients had measurable disease and more than one previous chemotherapy regimen. Patients previously treated with high-dose chemotherapy with autologous bone marrow or peripheral stem-cell support were not included. Gemcitabine, 1,250 mg/m(2), was administered as a 30-minute intravenous infusion on days 1, 8, and 15 of each 28-day cycle of therapy. The dosing schedule remained fixed, and any dose of gemcitabine that could not be given on time was omitted. Patients who had not experienced any hematologic or nonhematologic toxicity after one complete cycle of therapy were permitted to have subsequent doses increased by 20%: that is, from 1, 250 mg/m(2) to 1,500 mg/m(2).

RESULTS

Of the 23 enrolled patients, 22 were assessable for response; all 23 patients were included in the efficacy analysis. Disease status for two patients (9%) reached a state of complete remission, and seven patients (30%) achieved a partial response, for an overall response rate of 39% (95% confidence interval, 19.7% to 61.5%). The likelihood of achieving a response was not influenced by a patients' main pretreatment characteristics or by their response to their last prior chemotherapy. The median duration of response was 6.7 months (range, 2 to 33+ months), and the median overall survival time was 10.7 months (range, 4 to 34.7+ months). In general, toxicities were mild; no treatment-related deaths occurred, and only one life-threatening adverse event was reported for this study.

CONCLUSION

Gemcitabine was shown to be active in heavily pretreated patients with Hodgkin's disease, producing a response rate of 39%. Additionally, drug-related toxicities were mild, which thus suggests the possible inclusion of gemcitabine in an earlier phase of treatment.

High-dose BEAM chemotherapy with autologous peripheral blood progenitor-cell transplantation for unselected patients with primary refractory or relapsed Hodgkin's disease

BACKGROUND

The use of autologous peripheral blood progenitor cells (PBPC) expedites hematologic recovery and reduces the costs of transplantation in comparison with autologous bone marrow; however, its efficacy in patients with Hodgkin's disease has been questioned. We evaluated the results of autologous PBPC transplantation in a population of unselected and uniformly treated patients with primary refractory or relapsed Hodgkin's disease.

PATIENTS AND METHODS

Forty consecutive adult patients with primary refractory (n = 7) or relapsed (n = 33) Hodgkin's disease received high-dose BEAM (BCNU, etoposide, ara-C, and melphalan) followed by autologous PBPC infusion. Twenty-four patients (60%) received high-dose BEAM as outpatients. Consolidative radiation therapy was administered to 14 patients (35%).

RESULTS

Thirty-seven patients (92%) achieved a post transplant complete response. The 3-year progression-free survival (PFS) was 69%, and the 3-year overall survival (OS) was 77%, with a median follow-up of surviving patients of 28 months. Severe non-hematologic toxicities included gastrointestinal side effects (diarrhea 17%, mucositis 25%), and interstitial pneumonitis (15%). One patient died of acute transplant-related complications (mortality rate 2.5%). Strong predictors of poor PFS were chemoresistant versus chemosensitive/untested disease (actuarial PFS 89% versus 22%, P = 0.0000) and stage IIB-IV versus I-IIA at relapse/progression (86%, versus 46%, P = 0.005). All five patients with elevated lactate dehydrogenase at the time of transplantation died of their disease. There was a trend toward worse PFS for patients receiving a higher number of CD34+ cells (> or = 11 x 10(6) per kg).

CONCLUSIONS

High-dose BEAM chemotherapy with autologous PBPC transplantation is associated with low mortality and results in satisfactory PFS for patients with primary refractory or relapsed Hodgkin's disease. The subset of patients with progressive disease at the time of transplantation performs poorly and may benefit from alternative strategies.