Autologous stem cell transplant for follicular lymphoma – pro

Follicular lymphoma is a low-grade lymphoma. This means that it is not generally curable with chemotherapy; at the same time, it grows slowly and tends to have a response and recurrence pattern. It cannot be cured by conventional chemotherapy but is sometimes cured with high dose chemo and transplantation. There are now 3 conflicitng studies of autologous transplant for follicular lymphoma but guidelines now recommend it. However, they recommend it in second line and here it is being done in first line.

Despite nearly identical eligibility criteria and the use of an anthracycline-based induction treatment in all studies, the results are quite different. The previous studies found a significant advantage to autologous stem cell transplantation (ASCT). The German Lymphoma Study Group (GLSG) reported that patients randomized to transplantation had a 64.7% progression-free survival (PFS) rate at 5 years versus 33% with conventional chemotherapy. The Groupe Ouest-Est d’Etude des Leucémies aigues et autres Maladies du Sang (GOELAMS) group reported 60% PFS for those randomized to autologous transplantation versus 48% with conventional chemotherapy. By contrast, the Groupe d’Etude des Lymphomes de l’Adulte ( GELA) study does not show a significant PFS advantage for autologous transplantation.

The overall role of ASCT in follicular lymphoma continues to be debated. It is an excellent treatment option for the management of younger patients with recurrent disease. In advanced newly diagnosed lymphoma, a survival advantage has yet to be shown; with more prolonged follow-up it may still emerge in the GLSG study. An increased risk for therapy-related acute myeloid leukemia (t-AML) was observed in the GLSG and GOELAMS studies, but this risk may be minimized by modulation of induction and mobilization therapy preceding transplantation. Despite spectacular advances since the introduction of rituximab, many patients with advanced disease and a high Follicular Lymphoma International Prognostic Index (FLIPI) score have disease recurrences. For such patients, the continued study of autologous transplantation, possibly in combination with rituximab for in vivo purging, remains an important area of investigation.

The 2016 NCCN )FOLL-6) recommends autologous transplantation in “second-line” and says that allogeneic transplantation is appropriate in selected cases. ESMO, representing an European approach says: “•Myeloablative consolidation followed by autologous stem cell transplantation prolongs PFS and overall survival but its role has to be redefined in the rituximab era [I, B]. A potentially curative allogeneic stem cell transplantation (optionally with dose-reduced conditioning) may be discussed in relapsed disease.” In 2013, NCCN says(FOLL-B, 1) that for second line consolidation autologous stem cell transplantation can be done, or allogeneic for “highly selected patients”.

Koen van Besien Autologous transplantation for follicular lymphoma? Not too soon! Blood, 15 October 2006, Vol. 108, No. 8, pp. 2496-2497. M. Dreyling on behalf of the ESMO Guidelines Working Group Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for treatment and follow-upAnn Oncol (2010) 21 (suppl 5): v181-v183.

Issa F. Khouri Eight-year experience with allogeneic stem cell transplantation for relapsed follicular lymphoma after nonmyeloablative conditioning with fludarabine, cyclophosphamide, and rituximab Blood June 15, 2008 vol. 111 no. 12 5530-5536

Ronjon Chakraverty et al, Allogeneic Transplantation for Lymphoma JCO 2011 29:1855-1863

NCCN, Follicular FOLL-6, 2016

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