JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Bu-Cy-Etoposide Conditioning for LymphomasUndergoingAutologous Stem Cell Transplantation: Long TermOutcomes
Thomas Atkinson, MD, Zaid Al-Qurayshi, MD, Yordanka Koleva, MPH, Reinhold Munker, MD, Nakhle Saba, MD, Alan Miller, MD, PhD, Roy Weiner, MD, Hana Safah, MD
Autologous hematopoietic stem cell transplantation is widely used for relapsed Hodgkin and non-Hodgkin lymphomas and can result in long-term remissions or even cures. The optimal conditioning regimen for autologous transplantation remains to be determined. The objective of this study is to describe long-term outcomes of the B-C-E (busulfan- cyclophosphamide and etoposide) protocol at our center. A retrospective analysis of all patients undergoing autologous transplant using the BCE regimen was performed. A total of 51 patients (24 Hodgkin and 27 non-Hodgkin lymphomas) were treated between 1998 and 2015. At five years, the overall survival was 44.2% and the freedom from progression 21.2%. No statistical differences in outcomes were found between disease types or according to age at transplant, gender or ethnicity. The long-term outcome was best for patients who reached complete remission after transplant. In conclusion, BCE has manageable toxicity, compares well with other preparative regimens and can result in long-term survival. Remission after autologous transplantation is a platform for innovative approaches to increase cure rates.
INTRODUCTION
protocols98-1and99-2 (modification for autologous transplants) protocol 99-2 with the BCE protocol. The median follow-up was 23.7 months (range 0.13-165.) Patient details are shown in Table 1. All protocols were approved by the Institutional Review Board. The salvage chemotherapy before stem cell collection was documented in 43 patients (14 received DHAP, 20 ESHAP, 7 ICE, and one each received HyperCVAD and MINE chemotherapy). After 2003, patients with CD20 positive lymphomas (total of 19) received rituxan as part of salvage chemotherapy. During the conditioning, one patient with HL and two patients with NHL received rituxan. In order to proceed to stem cell collection and transplant, the patients had to meet the standard eligibility criteria with regards to cardiac, pulmonary, kidney and liver function. Briefly, Busulfan was given intravenously at a dose of 0.8 mg/kg every 6 hours on days -8, -7, -6 and -5 for a total of 16 doses. Etoposide was given on day -4 intravenously at a dose of 40 mg/kg over one hour. Cyclophosphamide was given intravenously at a dose of 60 mg/kg over one hour on days -3 and -2. Peripherally harvested stem cells were infused on day 0. Standard procedures (including hydration and phenytoin) were followed. Stem cells were collected following stimulation by 10 µg/ kg filgrastim for four days. In case of insufficient collection, a bone marrow harvest was performed. During the neutropenic period following the stem cell transplant, prophylactic oral anti-infective agents were given (ciprofloxacin, fluconazole and acyclovir). The patients were regularly followed after discharge and assessed for response at three months post transplant (usually by complete physical examination and imaging with CT or PET-
Autologous stem cell transplantation (autoSCT) is a standard treatment for relapsed and refractory Hodgkin (HL) and non- Hodgkin lymphomas. The rationale for high-dose chemotherapy with stem cell rescue is that patients with relapsed disease who generally have aggressive disease can be brought into a state of minimal disease. The doses used in these protocols are three or five timeshigher than instandardprotocols. Especially inyounger patients who undergo transplant early in the course of their disease, autoSCT can result in cure or long-term remission. 1,2 In T cell non-Hodgkin lymphoma (NHL), autologous transplant may also be considered as a treatment (consolidation) for patients in their first complete remission (CR). A variety of protocols for myeloablative conditioning are available, however, the optimal conditioning regimen for autologous transplant is not clearly defined. The French Society of Bone Marrow Transplantation and Cellular Therapy recently reviewed all protocols in use for autoSCT. 3 The busulfan-cyclophosphamide-etoposide (BCE) protocol (with busulfan given intravenously) was described as providing superior survival in patientswith refractory or relapsed NHL. 4 Recently, with the advent of immunochemotherapy, the value of autoSCT has been called into question. The outcomes may be actually worse because patients relapse with more aggressive disease. 5 In this manuscript we present the long term outcomes of 51 patients with lymphomas (22 HL and 29 NHL) who underwent autoSCT at our center using BCE conditioning.
MATERIALS AND METHODS
Patients
Between 1998 and 2015, a total of 51 patients were treated at Tulane University Medical Center on two different phase 2
J La State Med Soc VOL 170 MARCH/APRIL 2018 35
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