Some 20-30 % of patients with Hodgkin’s lymphoma achieve a remission and then relapse and some do not respond to standard therapy, such as ABVD and are called refractory. In general, the longer the initial complete remission, the better the outlook with any form of salvage therapy.
A variety of treatment regimens have been used for patients in these groups of Hodgkin’s disease. In addition to MOPP or ABVD in patients who received the opposite regimen initially, a number of other treatments have been used, including ICE chemotherapy. Unfortunately, the number of patients achieving extended survival free of Hodgkin’s disease is quite poor, although patients with no adverse risk characteristics (see above) have been reported to have 5-year failure-free survivals as high as 50%. For this reason a variety of high dose approaches have been studies. Autologous bone marrow transplantation can cure patients with multiply relapsed Hodgkin’s disease. Because of the superior results in patients treated early in the course of the disease, most advocates of bone marrow transplantation would prefer to use it as part of the treatment of the initial relapse following any effective initial chemotherapy regimen. In this setting, patients who receive an alternate standard chemotherapy regimen and achieve at least a partial remission then undergo autologous transplantation. Rerfractory patients also benefit from ASCT. The results in this setting have yielded durable remissions in 47% to 85% of patients. In a randomized trial conducted in Europe, patients with relapsed, chemosensitive Hodgkin’s disease had a significantly better failure-free survival with transplantation rather than continuing standard dose chemotherapy. This patient fits into this group.
In some patients in whom HDC fails, allogeneic HSC transplantation may be a viable option. In this method, myeloablative therapy (chemotherapy and sometimes RT) is followed by the infusion of HSCs from a genetically matched donor. This offers the potential for an immunological antitumor effect from T-cells provided by the HSC donor, which may improve the chances for cure of the disease. Historically, allogeneic transplantation for Hodgkin disease has been considered too high risk for most patients due a high transplant-related mortality. However, evolution of transplant protocols to include less toxic conditioning regimens, such as min-ablative approaches, will likely expand the utility of this option for patients with refractory Hodgkin disease. Allogeneic transplantation for Hodgkin is considered standard of care already at this time. For example, NCCN (HODG-12) lists it as a category 3 recommendation.
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