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Autologous Stem Cell Transplantation for High-Risk Hodgkin's Disease

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Autologous Stem Cell Transplantation for High-Risk Hodgkin's Disease Haematologica 2000; 85:167-172 Transplantation & Cell Therapy original paper Autologous stem cell transplantation for high-risk Hodgkin’s disease: improvement over time and impact of conditioning regimen MARICEL SUBIRÀ, ANNA SUREDA, RODRIGO MARTINO, JOAN GARCÍA,* ALBERT ALTÉS, CARME CANALS, ANDREU DOMINGO-ALBÓS,† SALUT BRUNET, JORGE SIERRA Clinical Hematology Division, Hospital de la Santa Creu i Sant Pau, *Cryobiology and Cellular Therapy Department, Can- cer Research Institute, Barcelona, Spain †Deceased ABSTRACT Background and Objectives. High-dose chemo/radio- p to 80% of patients with advanced Hodgkin’s therapy with autologous stem cell support is increas- disease (HD) can be cured by combination 1 ingly being used in Hodgkin’s disease (HD) patients Uchemotherapy (CT). Despite these encour- who do not respond to or who relapse after conventional aging overall results, patients refractory to the initial chemotherapy. In this work we analyze the results of 56 treatment and those relapsing after an initial consecutive high-risk HD patients autografted in our response frequently cannot be cured by convention- institution and the role of possible prognostic factors. al therapy with only 20% becoming long-term dis- ease-free survivors.2,3 These poor results led us toin- Design and Methods. There were 34 males and 22 vestigate the efficacy of high-dose therapy followed females with a median age of 31 years. At transplan- by autologous stem cell transplantation (ASCT) in tation, 24 patients (43%) were in complete remission this population. ASCT in poor prognosis HD and 32 (57%) were autografted while with active dis- patients has been reported by several authors to give ease. Twenty-nine patients were autografted before complete response (CR) rates ranging between 50- January 1993. Bone marrow was used as the source 80% and disease-free survival (DFS) rates between of stem cells in 40 patients (71%) and peripheral blood 20% and 60%.4-8 Nevertheless, in this setting there is (PB) in 16 (29%). Forty-five patients received chemo- only one randomized study, carried out by the British therapy-based conditioning regimens (40 CBV and 5 National Lymphoma Investigation Group, which has BEAM) while the remaining 11 received cyclophos- demonstrated a clear advantage in terms of event- phamide (Cy) and total body irradiation (TBI). free survival (EFS) in favor of high-dose therapy com- Results. Two bone marrow transplantation (BMT) pared to conventional-dose treatment.9 recipients did not engraft. Hematologic recovery was Several prognostic factors have been reported to be significantly faster in patients transplanted with PB predictors of a poor outcome following ASCT: pres- progenitor cells. Early transplant-related mortality (ear- ence of B symptoms, extranodal disease at relapse, ly TRM) (before day 100 after transplantation) was extensive therapy before transplant, brief first CR 9%; it was higher in patients transplanted before Jan- duration, bulky tumor at transplant, poor perfor- uary 1993 than in patients transplanted afterwards mance status at ASCT, resistance to conventional sal- (14% vs 4%) and in patients receiving TBI (18% vs vage CT and disease status at transplantation.4,5,8,10–13 7%), although these differences did not reach statis- In addition, some studies suggest that the use of TBI tical significance. Overall TRM (before and after day worsens the final outcome of these patients.14-16 100) was 14%. TBI-containing regimens significantly The significance of each of the prognostic factors increased overall TRM (36% and 9%, p = 0.03). Actu- listed has not been uniformly confirmed in the liter- arial 3.5-year overall survival (OS), event-free survival ature, and for this reason we investigated the vari- (EFS) and progression-free survival (PFS) were 57%, ables influencing the results of ASCT in patients with 58% and 65%, respectively. On multivariable analysis, poor prognosis HD treated at our institution over TBI containing regimens and transplantation before the last 10 years. 1993 significantly reduced OS and EFS. Design and Methods Interpretation and Conclusions. Our results confirm that high-dose therapy followed by autologous stem Inclusion criteria cell transplantation is associated with sustained PFS Between March 1987 and December 1997, 56 in a remarkable proportion of patients with HD unlike- consecutive patients with HD received an ASCT in ly to be cured with standard chemotherapy. Results our institution. Pathologic diagnosis was reviewed improved over time and TBI containing regimens had in all referred patients. Patients were accepted for a negative effect on post-transplant outcome. ASCT on the basis of the presence of poor prognos- ©2000, Ferrata Storti Foundation tic features with conventional therapy: 1) need for 2 st Key words: Hodgkin’s disease, autologous stem cell trans- or more CT lines to obtain a 1 CR, 2) achievement plantation, conditioning regimens of a partial remission (PR) or disease progression after 1st line therapy, 3) 1st CR of short duration (<12 nd Correspondence: Anna Sureda, M.D., Clinical Hematology Division, months) and 4) 2 or subsequent relapses. Four Hospital de la Santa Creu i Sant Pau, Antoni Maria i Claret 167, 08025 patients with 2 or more adverse prognostic factors Barcelona, Spain. Phone: international +34-93-2919396 – Fax: inter- according to the Strauss classification17 were auto- national +34-93-2919466 – E-mail: [email protected] Haematologica vol. 85(2):February 2000 168 M. Subirà et al. grafted in 1st CR achieved after first line convention- Table 1. Patients’ characteristics at diagnosis and ASCT. al CT. Patients’ characteristics at diagnosis and ASCT are shown in Table 1. No. (%) Conditioning regimen for transplantation Sex Forty-five patients were conditioned with chemo- Males/females 34 (61)/22 (39) therapy; 40 received the CBV protocol (Cy 1.5-1.8 Age [median (range)] 31 (15–65) years g/m2 iv ϫ 4 days, etoposide 150–400 mg/m2 twice Histology daily iv 3 days and BCNU 300–600 mg/m2 iv x 1 Nodular sclerosis 35 (63) day) and the other 5 the BEAM regimen (BCNU 300 Mixed cellularity 17 (30) mg/m2 iv ϫ 1 day, etoposide 200 mg/m2 iv ϫ 4 days, Lymphocyte predominance 4 (7) 2 ϫ Ann Arbor stage at diagnosis cytarabine 200 mg/m twice daily iv 4 days and I–II/III–IV 19 (34)/37 (66) 2 ϫ melphalan 140 mg/m iv 1 day). Eleven patients B symptoms 36 (64) received Cy (60 mg/kg iv ϫ 2 days) plus TBI (12 Gy Bulky disease (> 10 cm) 15 (27) in 4 fractions over 4 days). No. extranodal sites 0–1/≥ 2 15 (27)/2 (4) Source of stem cells BM involvement 6 (11) Stem cells were obtained from BM for 40 patients First line therapy (71%). A median (range) number of 1.11 ϫ 108/kg Chemotherapy 50 (89) (0.36 to 4) MNC and 3.83ϫ104/kg (0.4 to 66.7) CFU- MOPP-like regimens 21 (37) GM were infused. Mobilized peripheral blood (PB) ABVD 8 (14) was used for the remaining 16 (29%) patients; 8 MOPP/ABVD 14 (25) patients received low-dose Cy (1.5 g/m2 iv) + G-CSF Hybrid protocol 5 (9) 18 Others 2 (4) at 5 µg/kg/day sc as mobilization protocol and the Radiotherapy 6 (11) remaining 8 the IAPVP-16 salvage chemotherapy (ifos- Extended field radiotherapy 23 (41) famide 5 g/m2 iv ϫ 1 day, VP-16 100 mg/m2 iv ϫ 3 Duration of first CR (n = 45) days, Ara-C 1.2 g/m2 twice daily ϫ 2 days and methyl- ≤ 12 months 19 (39) prednisolone 80 mg/m2 iv ϫ 5 days) plus G-CSF.19 A > 12 months 18 (37) median of 2 (1 to 6) aphereses were performed to col- Unknown 13 (29) lect a target number of 2.5ϫ106 CD34+ cells/kg. A ϫ 8 No. lines of previous therapy median (range) number of 4.89 10 /kg MNC (2.73 ≥ ϫ 4 1 – 2/ 3 38 (67)/18 (32) to 12.9), 8.40 10 /kg CFU-GM (2.22 to 59.6) and Disease status at ASCT ϫ 6 + 4.14 10 /kg CD34 cells (2.43 to 17.25) were Complete remission 24 (43) infused. Sixteen patients (15 recipients of BMT and 1 1st complete remission 7 (12) recipient of PBSCT), were given G-CSF 5 µg/kg/day sc 2nd complete remission 11 (20) from day +1 to hematologic recovery (neutrophil 3rd complete remission 6 (11) count > 1.5ϫ109/L for 3 consecutive days). Active disease 32 (57) Primary refractory disease 5 (9) Additional treatment and follow-up after Untreated relapse 4 (7) transplantation Sensitive relapse 17 (30) Six patients received involved-field RT after ASCT; 3 Resistant relapse 6 (11) because of residual disease and 3 because of prior Ann Arbor stage at ASCT (n = 32) I–II/III–IV 13 (41)/19 (59) bulky disease. To assess response to ASCT, patients’ B symptoms (n = 32) 5 (16) clinical examination and CT scan were performed 3 Bulky disease (n = 32) 5 (16) months after transplantation. Subsequent controls Extranodal involvement (n = 32) 7 (22) were every six months for the first 2 years, and yearly Date of ASCT afterwards. Patients showing no evidence of disease Before January 1993/After January 1993 29 (52)/27 (48) on CT scans were considered to be in CR, those achieving a greater than 50% reduction in tumor mass were defined as being in PR and those with a less than 50% reduction in tumor mass as non-responders. ANC >0.5ϫ109/L, days to platelet count >25ϫ109/L, Statistics Ann Arbor stage, B symptoms, extranodal involve- Clinical characteristics at diagnosis and at ASCT ment, BM involvement and bulky disease. The last 5 were summarized using descriptive statistics.
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