Autologous hematopoietic stem cell transplantation in intermediate and high grade non-Hodgkin's lymphoma: A review

Abstract

High dose therapy with or without hematopoietic stem cell rescue has been widely used in the past decade for treating aggressive Non-Hodgkin's lymphoma. Recent data in high and intermediate grade lymphoma were reviewed. Evidence that dose intensity is a critical factor for remission in poor prognosis lymphoma has been accumulated, although the impact on survival has not been clearly established through randomized studies. Intensive treatment with autologous bone marrow transplantation (ABMT) have been reported in more than 1,000 relapsing patients in non randomized trials. For those who are still sensitive to salvage chemotherapy, at 5 years a 40% probability of disease free survival has been uniformly noted. ABMT is accepted by most centers as the treatment of choice for relapsing lymphoma. Consequently, very few randomized studies testing ABMT vs. conventional chemotherapy such as the PARMA protocol are in progress. In patients achieving complete remission, ABMT has been proposed for consolidation in a group of lymphoma sharing adverse prognostic factors with a high risk of relapse. Results from pilot studies were encouraging. However, interim analysis of the large randomized trial LNH87, did not show at the present time an advantage for ABMT performed after CR when compared to conventional chemotherapy. Such a strategy should be only proposed in prospective studies. For patients who did not achieve CR after conventional treatment, but who are still sensitive to chemotherapy, ABMT may improve the results. Pilot studies as well as recent randomized study are in support of this approach. For lymphoblastic lymphoma and Burkitt's lymphoma the place of ABMT in first CR is not well defined, although results from pilot studies are supporting the use of ABMT in lymphoblastic lymphoma with adverse prognostic factors. In conclusion, data supporting the use of ABMT in lymphoma in different setting come from numerous non randomized trials. However, randomized studies at the present time are either absent or unable to clearly demonstrate a benefit for ABMT in most clinical situations. Novel strategies with peripheral hematopoietic stem cell in well defined subgroup of patients may provide new alternative in poor prognosis aggressive lymphoma.