JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Risk Analysis for Overal Survival
Survival at 5 Years
Risk factor Histologic diagnosis HL vs NHL Age at transplant < 50 years ≥ 50 years
p-value
0.24
33.9 % 51.6%
p <0.10
0.45
44.9% 43.4%
Gender Male
0.88
56.4% 38.1%
Female
Ethnicity
0.76
Figure 2: Overall survival comparing time of transplant 1998-2009 with 2010-2015
African American Caucasian
47.3% 32.1%
Table 2: Risk analysis for overall survival
Four patients with relapse after autoSCT (3 HL, 1 NHL) went on to receive an allogeneic transplant. The engraftment of myeloid cells (ANC > 500/ µl) occurred on average 10.0 ± 2.7 days after transplant (median 10 days), and the engraftment of platelets (count > 20 000/ µl without transfusion) on average 18.7 ± 14.6 days after transplantation (median 16 days). Patients who were determined to be in complete remission post-transplant had a much longer survival than patients with active disease (see Fig.3). Patients who had a shorter interval from diagnosis to transplant had a non-significant trend for longer OS compared to patients transplanted after a longer interval (data not shown).
p <0.001
DISCUSSION
The role and outcomes of autoSCT for relapsed and refractory lymphomas have been debated because patients with more aggressive disease come to transplant and more salvage treatments are available. A survey of the EBMT Lymphoma Working Party showed overall improved survival in diffuse large B-cell lymphoma over the last 20 years. 4 In relapsed or refractory HL, immunochemotherapy with brentuximab plays a significant role, but a panel of experts still recommends autoSCT as the standard approach. 5 In younger patients, an alternative to autoSCT is allogeneic transplant, which provides stem cells not exposed to previous chemotherapy but has the risk of graft- versus-host disease. The ideal conditioning regimen for autoSCT for lymphomas is not well defined. In a survey of the CIBMTR spanning 1995-2008, the most commonly used regimens were BEAM (BCNU, etoposide, cytarabine and melphalan) and CBV (Cyclophosphamide, BCNU, and etoposide). 6 At our center, the combinationof busulfan, cyclophosphamideandetoposide (BCE protocol) was used and can result, as shown here, in long-term survival. The toxicity might have been less if targeted busulfan was used. No differences in survival were found according
Figure 3: Overall survival according to disease status after transplant (complete remission versus not in complete remission)
to age, gender or ethnicity. Outcomes tended to improve for patients treated in recent years, which may be related to earlier referral and better supportive measures. Patients who reached complete remission after transplant had the best outcomes. In the literature, seven studies from other centers used the same conditioning regimen (seeTable 3). The questionwhat is the best conditioning regimen for aggressive lymphomas was already debated 10 years ago. 7 The OS and DFS rates varied widely. Very few studies gave a direct comparison between the different conditioning regimens. The transplant-related mortality has decreased from less than 10% to less than 3% despite older patients and patients with more aggressive disease being transplanted. For example, oral busulfan in the older studies resulted in more mucositis. In the present time, intravenous busulfan and fine-tuning with busulfan levels lessened this problem. More recently Damaj et reviewed the choices for
J La State Med Soc VOL 170 MARCH/APRIL 2018 37
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