High-dose thiotepa, etoposide and carboplatin as conditioning regimen for autologous stem cell transplantation in patients with high-risk Hodgkin's lymphoma

Replacing carmustine by thiotepa and cyclophosphamide for autologous stem cell transplantation in Hodgkin's and non-Hodgkin's B-cell lymphoma

This study aimed to compare the real-life results of TECAM, a thiotepa-based conditioning regimen consisting of thiotepa (40 mg/m² days -5 to -2), etoposide (200 mg/m² days -6 to -3), cytarabine (200 mg/m² days -4 to -1), cyclophosphamide (60 mg/kg day -3), and melphalan (60 mg/m² days -2 to -1) with that of the conventional carmustine-based regimen BEAM. We reviewed 125 consecutive patients who underwent a first autologous transplantation (ASCT) for B-cell lymphomas at a large tertiary transplantation center between 1999 and 2014. TECAM (n=65) and BEAM (n=60) had comparable results (3yPFS 49 vs 62%, P=0.16; 3yOS 64 vs 71%, P=0.44; TRM 1.6 vs 5%, P=0.35) without a difference in toxicity or time to engraftment. Notably, comparable outcomes were observed even though patients treated with TECAM were older (55 vs 44) and had a trend towards more prior lines of therapy (>2 prior lines: 43 vs 27%, P=0.08). In this regard, 23% of TECAM patients were over the age of 65 yet could withstand therapy with similar results to younger patients. We conclude that, replacing carmustine by thiotepa and cyclophosphamide for ASCT conditioning, has comparable efficacy and safety profiles with a possible advantage in older patients.

Thiotepa-based high-dose therapy for autologous stem cell transplantation in lymphoma: a retrospective study from the EBMT

Clinical information about thiotepa-based autologous stem cell transplantation (auto-SCT) outside the primary central nervous system lymphoma (PCNSL) field is sparse. In this registry-based retrospective study, we evaluated potential risks and benefits of thiotepa-based preparative regimens compared with BEAM (carmustine, etoposide, cytarabine, melphalan) in auto-SCT for diffuse large B-cell lymphoma (DLBCL, excluding PCNSL), follicular lymphoma (FL) or Hodgkin lymphoma (HL). A total of 14 544 patients (589 thiotepa and 13 955 BEAM) met the eligibility criteria, and 535 thiotepa- and 1031 BEAM-treated patients were matched in a 1:2 ratio for final comparison. No significant differences between thiotepa and BEAM groups for any survival end point were identified in the whole sample or disease entity subsets. For a more detailed analysis, 47 TEAM (thiotepa, etoposide, cytarabine, melphalan)-treated patients were compared with 75 matched BEAM patients with additional collection of toxicity data. Again, there were no significant differences between the two groups for any survival end point. In addition, the frequency of common infectious and non-infectious complications including secondary malignancies was comparable between TEAM and BEAM. These results indicate that thiotepa-based high-dose therapy might be a valuable alternative to BEAM in DLBCL, HL and FL. Further evaluation by prospective clinical trials is warranted.

Advancement in high dose therapy and autologous stem cell rescue in lymphoma

Although advanced stage aggressive non-Hodgkin’s lymphomas and Hodgkin’s disease are thought to be chemotherapy-responsive cancers, a considerable number of patients either relapse or never attain a remission. High-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) is often the only possibility of cure for most of these patients. However, many controversial issues still remain with respect to HDT/ASCT for lymphomas, including its role for, the optimal timing of transplantation, the best conditioning regimen and the potential use of localized radiotherapy or immunologic methods to decrease post-transplant recurrence. Recently, mainly due to the unavailability of carmustine, several novel conditioning protocols have been clinically developed, with the aim of improving the overall outcome by enhancing the anti-lymphoma effect and, at the same time, by reducing short and long-term toxicity. Furthermore, the better safety profiles of novel approaches would definitively allow patients aged more than 65-70 years to benefit from this therapeutic option. In this review, we will briefly discuss the most relevant and recent data available regarding HDT/ASCT in lymphomas.

Role of cytotoxic therapy with hematopoietic cell transplantation in the treatment of Hodgkin lymphoma: guidelines from the American Society for Blood and Marrow Transplantation

The role of hematopoietic cell transplantation (HCT) in the therapy of Hodgkin lymphoma (HL) in pediatric and adult patients is reviewed and critically evaluated in this systematic evidence-based review. Specific criteria were used for searching the published literature and for grading the quality and strength of the evidence and the strength of the treatment recommendations. Treatment recommendations based on the evidence are included and were reached unanimously by a panel of HL experts. Both autologous and allogeneic HCT offer a survival benefit in selected patients with advanced or relapsed HL and are currently part of standard clinical care. Relapse remains a significant cause of failure after both transplant approaches, and strategies to decrease the risk of relapse remain an important area of investigation.

Novel conditioning regimens for Hodgkin’s and non-Hodgkin’s lymphoma

SUMMARY Autologous stem cell transplantation (ASCT), in chemosensitive relapsed patients with Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL), is associated with superior event-free survival (EFS) compared with salvage chemotherapy alone. BEAM is one of the most commonly used regimens in both HL and NHL because of its acceptable toxicity and high effectiveness. The nonrelapsed mortality (NRM) ranges from 7 to 10% in historical studies. More recent investigations have demonstrated a lower NRM, probably due to various factors such as the use of peripheral blood precursor cells and better support therapy. Recently, in order to reduce the toxicity of carmustine and increase antilymphoma activity, several groups have introduced conditioning regimens similar to BEAM. The incorporation of newer drugs (anti-CD20 monoclonal antibodies ± radiolabeled) to ‘classic’ BEAM, or the substitution of carmustine with other drugs (thiotepa, bendamustine and fotemustine) may be a valuable strategy in this patient setting. In this review, we will discuss the data available on HDC followed by ASCT in lymphoma using new conditioning regimens, namely second-generation BEAM.