Canterbury DHB

Lymphoma

Diffuse Large B cell Lymphoma and transformed low-grade lymphoma

Autologous SCT as part of 1st line therapy is not currently recommended for any IPI group outside of a clinical trial.

Autologous SCT is recommended as salvage therapy for chemo-sensitive relapsed/refractory DLBCL. No upper age limit has been defined if a patient is otherwise fit. No evidence exists on the optimal number of pre-transplant chemotherapy cycles but at least a PR (>50% reduction in the sum of the product of involved nodes) is necessary. In the pivotal PARMA study of relapsed patients a 5-year EFS and 0S of 46% and 53% were seen. There is less data on primary refractory patients although single-centre studies support this approach. In the rituximab era the CORAL study 50% were alive after 3 years although only about 50% of patients received the intended transplant.

Autologous SCT is recommended as salvage therapy in transformed FL based on expert opinion and accepted clinical practice.

Allogeneic SCT is a clinical option for transplant-eligible (fit with an available donor) patients relapsing after autologous SCT or selected high risk relapsed patients in CR2. A patient who has relapsed within 12 months after rituximab-containing 1st line therapy and has a 2nd-line age-adjusted IPI of ≥2 has less than 25% chance of long-term survival after autologous SCT.

Recommended reading:

• Klyuchnikov, E., et al. (2014). "Allogeneic hematopoietic cell transplantation for diffuse large B cell lymphoma: who, when and how?" Bone Marrow Transplant 49(1): 1-7.
• Mounier, N., et al. (2012). "High-Dose Therapy and Autologous Stem Cell Transplantation in First Relapse for Diffuse Large B Cell Lymphoma in the Rituximab Era: An Analysis Based on Data from the European Blood and Marrow Transplantation Registry." Biol Blood Marrow Transplant 18(5): 788-793.
• ASBMT (2011). "The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of diffuse large B cell lymphoma: update of the 2001 evidence-based review." Biol Blood Marrow Transplant 17(1): 18-19.

Indolent NHL

The ASBMT and ESMO do not recommend autologous SCT in first remission for any sub-group of patients.

A review of all published studies relating to stem cell transplantation and evidence-based guidelines has recently been published by the American Society for Blood and Marrow Transplantation (Oliansky, Gordon et al. 2010) and updated guidelines have been released by ESMO (Dreyling, Ghielmini et al. 2011).

Based on the CUP and GELA trials, which were in the pre-rituximab era, there is a prolonged progression-free and overall survival in chemo-sensitive relapsed/refractory indolent lymphoma. Recently, the FL2000 study and EBMT retrospective data have been published showing an OS benefit for ASCT irrespective of prior rituximab. The 3-year OS for all patients after ASCT and chemotherapy was 72% and 52% in R-naïve and R-treated patients respectively.

The role of allografting remains uncertain, but RIC may have a role in this situation. For further information, see Winter et al, ASH EPB, 2004.

Recommended reading:

• ASBMT (2011). "The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of follicular lymphoma." Biol Blood Marrow Transplant 17(2): 190-1.
• Ban-Hoefen, M., J. L. Kelly, et al. (2012). "High-dose therapy and autologous stem cell transplant for transformed non-Hodgkin lymphoma in the rituximab era." Leuk Lymphoma 53(5): 830-5.
• Dreyling, M., M. Ghielmini, et al. (2011). "Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up." Ann Oncol 22 Suppl 6: vi59-63.
• Oliansky, D. M., L. I. Gordon, et al. (2010). "The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of follicular lymphoma: an evidence-based review." Biol Blood Marrow Transplant 16(4): 443-68.
• Le Gouill, S., S. De Guibert, et al. (2011). "Impact of the use of autologous stem cell transplantation at first relapse both in naive and previously rituximab exposed follicular lymphoma patients treated in the GELA/GOELAMS FL2000 study." Haematologica 96(8): 1128-1135.

Topic Code: 8158