Long-term follow-up of allogeneic bone marrow transplantation in patients with poor prognosis non-Hodgkin's lymphoma

Risk-adapted, treosulfan-based therapy with auto- and allo-SCT for relapsed/refractory aggressive NHL: a prospective phase-II trial

Since the outcome of relapsed/refractory aggressive non-Hodgkin's lymphoma (NHL) is highly variable, a risk-adapted treatment approach was evaluated. After two cycles of DHAP, patients received high-dose treosulfan/etoposide/carboplatinum (TEC) and autologous stem cell rescue. After TEC, low-risk patients with late relapse (>1 year after first CR who achieved CR after DHAP received no further treatment. Patients with late relapse who achieved CR or PR only after TEC underwent a second cycle of TEC. High-risk patients with early relapse/refractory disease received treosulfan/fludarabine followed by allogeneic transplantation. Rituximab was added in patients with B-cell lymphoma (86%). At entry, 36% of all 57 patients had refractory disease, 32% early and 32% late relapse. During DHAP treatment, progression occurred in 32% of patients. Of 33 patients who received TEC, 5 received second TEC and 15 allogeneic transplantation. Main toxicity after TEC was oral mucositis (CTC grades 3 and 4 in 50% and 13%, respectively). In total, 42% patients achieved CR. Median OS was 21.4 months for all patients and 32.6 for those who underwent allogeneic transplantation. International prognostic index (IPI) at study entry was highly discriminative at predicting OS (P<0.0001). Risk-adapted, treosulfan-based therapy with auto- and allo-SCT is feasible. Long-term survival is possible with allogeneic transplantation.

Alternate donor hematopoietic cell transplantation (HCT) in non-Hodgkin lymphoma using lower intensity conditioning: a report from the CIBMTR

We analyzed the outcomes of 248 (61% male) adult recipients of HLA-matched unrelated and HLA-mismatched related donor hematopoietic cell transplantation (HCT) for non-Hodgkin lymphoma (NHL) after reduced or lower intensity conditioning (RIC), reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) from 1997 to 2004. Median age was 52 (range: 18-72 years); 31% had a Karnofsky performance score <90. Follicular NHL (43%) was the major histology. Incidence of grades II-IV acute graft-versus-host disease (aGVHD) was 43% at 100 days; and chronic GVHD (cGVHD) was 44% at 3 years. Treatment-related mortality (TRM) at 100 days was 24%. Three-year overall survival (OS) and progression-free survival (PFS) were 41% and 32%, respectively. In multivariate analysis, use of antithymocyte globulin (ATG) and HLA mismatch were associated with increased TRM. High-grade histology, ATG use, and chemotherapy resistance were associated with lower PFS. Older age, shorter interval from diagnosis to HCT, non-total body irridiation (TBI) conditioning regimens, ex vivo T cell depletion, and HLA-mismatched unrelated donors were associated with mortality. GVHD did not influence relapse or PFS. Older age, aggressive histology, and chemotherapy resistance correlated with poorer survival. For selected patients with NHL, lack of an available sibling donor should not be a barrier to allogeneic HCT.

Allogeneic haematopoietic cell transplantation after nonmyeloablative conditioning in patients with T-cell and natural killer-cell lymphomas

Patients with T-cell and natural killer-cell lymphomas have poor outcomes. This study examined the role of allogeneic haematopoietic cell transplantation (allo-HCT) after nonmyeloablative conditioning in this setting. Seventeen patients with T-cell lymphoma or NK-cell lymphoma, including three patients in first complete remission, received allo-HCT after 2 Gy total-body irradiation and fludarabine. The median age was 57 (range, 18-73) years. The median number of prior therapies was 3 (range, 1-7), six patients (35%) had failed prior autologous HCT, and five patients (29%) had refractory disease at the time of allograft. Postgrafting immunosuppression was provided with mycophenolate mofetil with ciclosporin or tacrolimus. After a median follow-up of 3.3 (range, 0.3-8.0) years among surviving patients, the estimated probabilities of 3-year overall and progression-free survival were 59% and 53%, respectively, while the estimated probabilities of non-relapse mortality and relapse at 3 years were 19% and 26%, respectively. Sixty-five percent of patients developed grades 2-4 acute graft-versus-host disease and 53% of patients developed chronic graft-versus-host disease. Allo-HCT after nonmyeloablative conditioning is a promising salvage option for selected patients with T-cell and NK-cell lymphomas. These results suggest that graft-versus-T-cell lymphoma activity is responsible for long-term disease control.

Clinical evidence of a graft-versus-lymphoma effect against relapsed diffuse large B-cell lymphoma after allogeneic hematopoietic stem-cell transplantation

BACKGROUND

A graft-versus-lymphoma effect against diffuse large B-cell lymphoma (DLBCL) is inferred by sustained relapse-free survival after allogeneic stem-cell transplantation; however, there are limited data on a direct graft-versus-lymphoma effect against DLBCL following immunotherapeutic intervention by either withdrawal of immunosuppression or donor lymphocyte infusion (DLI).

MATERIALS AND METHODS

An analysis was carried out to determine whether a direct graft-versus-lymphoma effect exists against DLBCL. The analysis was restricted to patients with DLBCL, who were either not in complete remission at day +100 after allogeneic stem-cell transplantation or subsequently relapsed beyond this time point.

RESULTS

Fifteen patients were identified as either not in complete remission (n = 13) at their day +100 evaluation or subsequently relapsed (n = 2) and were assessed for subsequent responses after withdrawal of immunosuppression or DLI. Eleven patients were treated with either withdrawal of immunosuppression (n = 10) or a DLI (n = 1) alone; four patients received chemotherapy with DLI to reduce tumor bulk. Nine (60%) patients subsequently responded (complete = 8, partial = 1). Six responses occurred after withdrawal of immunosuppression alone. Six patients are alive (range 42-83+ months) in complete remission without further treatment.

CONCLUSION

The demonstration of sustained complete remission following immunotherapeutic intervention provides direct evidence of a graft-versus-lymphoma effect against DLBCL.

Graft-versus-host disease and graft-versus-leukemia after donor leukocyte infusion

Although dramatically effective for relapsed chronic myelogenous leukemia (CML), successful donor leukocyte infusion (DLI) remains limited primarily by inadequate responses for patients with diseases other than CML and by toxicity related to graft-versus-host disease (GVHD). Acute GVHD grades 2 to 4 follows 34% to 47% of infusions and chronic GVHD occurs in 33% to 61% of cases. Strategies to reduce the incidence and severity of GVHD while preserving the graft-versus-leukemia (GVL) effect, such as low-dose DLI, depletion of GVHD effector cells, and tumor-specific DLI, are reviewed.

The role of allogeneic transplantation in non-Hodgkin's lymphoma

The evolution of combination chemotherapy regimens, combined with improvements in supportive care, has incrementally improved survival outcomes for patients with non-Hodgkin's lymphomas (NHL). Although 40-60% of younger patients with diffuse large cell lymphoma can now expect to be cured, significant numbers will either fail to achieve a remission or relapse after attaining a remission. In addition, certain histological subtypes are associated with particularly poor prognoses with combination chemotherapy alone (e.g. mantle cell lymphoma, B-cell prolymphocytic leukaemia). Relatively few of these patients can achieve long-term responses. Other NHL subtypes, whilst associated with more favourable prognoses in terms of overall survival, are rarely, if ever, cured (e.g. most low grade NHL including follicular lymphoma, chronic lymphocytic leukaemia and small lymphocytic lymphoma). For these reasons dose escalation and allogeneic transplantation have been investigated as potential ways of improving outcome, although this has mainly been in the setting of advanced disease. Any possible benefits have frequently been out-weighed by procedural morbidity and mortality. The parallel development of transplantation approaches that limit procedural toxicity along with advances in supportive care require that the role of allogeneic haematopoietic stem cell transplantation in the management of lymphoma be re-evaluated.

Graft-versus-lymphoma effects: clinical review, policy proposals, and immunobiology

The indubitable existence of a graft-versus-lymphoma (GVL) effect is difficult to prove directly. This article reviews the difficulties in interpreting the current literature in this field and, with a number of caveats, argues for the existence of a clinically meaningful GVL effect in follicular, mantle cell, small lymphocytic, and Hodgkin lymphomas. The evidence, however, for a potent GVL effect in diffuse large-cell lymphoma and Burkitt lymphoma is not convincing. Policies for allografting in lymphoma are proposed on the basis of this evidence. The immunobiology of GVL effects is discussed--in particular, the expression of HLA class I and II and co-stimulatory molecules on lymphomas that influence the generation of alloreactive T cells--together with future directions in immunotherapy that may help to eradicate chemoresistant disease.

Cellular immunotherapy after allogeneic stem cell transplantation in hematologic malignancies

PURPOSE OF REVIEW

The chimeric state after allogeneic stem cell transplantation provides an ideal platform for adoptive immunotherapy of hematologic malignancies using donor-derived cells. The present review aims to summarize recent results of the transfusion of donor-derived cells with regard to the diseases treated, the cells used for treatment, and the origin of these cells.

RECENT FINDINGS

The transfusion of donor lymphocytes has been studied widely, not only in patients with recurrent disease, persistent disease, and mixed chimerism but also in a variety of hematologic malignancies. Donors of lymphocytes and hematopoietic stem cells have been HLA-identical siblings, HLA-matched unrelated donors, and HLA-different haploidentical family members. A variety of cells have been used for adoptive immunotherapy, including plain lymphocytes, selected T cells, T cell lines, and T cell clones. The possible therapies have been expanded by natural killer cells and natural killer T cells as well as antibodies directing the effector cells toward the malignancy.

SUMMARY

Adoptive immunotherapy in chimeras has become not only a routine form of treatment of recurrent hematologic malignancy but also a prophylactic measure in high-risk leukemia and lymphoma.

Syngeneic hematopoietic stem-cell transplantation for non-Hodgkin's lymphoma: a comparison with allogeneic and autologous transplantation--The Lymphoma Working Committee of the International Bone Marrow Transplant Registry and the European Group for Blood and Marrow Transplantation

PURPOSE

To compare results of syngeneic, allogeneic, and autologous hematopoietic stem-cell transplantation for non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

The databases of the International Bone Marrow Transplant Registry (IBMTR) and the European Group for Blood and Marrow Transplantation were used to identify 89 NHL patients who received syngeneic transplants. These patients were compared with NHL patients identified from the IBMTR and the Autologous Blood and Marrow Transplant Registry who received allogeneic (T-cell depleted and T-cell replete) and autologous (purged and unpurged) transplants.

RESULTS

No significant differences in relapse rates were observed when results of allogeneic transplantation were compared with syngeneic transplantation for any histology. T-cell depletion of allografts was not associated with a higher relapse risk, but was associated with improved overall survival for patients with low-grade and intermediate-grade histology. Patients who received unpurged autografts for low-grade NHL had a five-fold (P =.008) greater risk of relapse than recipients of syngeneic transplants, and recipients of unpurged autografts had a two-fold (P =.0009) greater relapse risk than patients who received purged autografts. Among low-grade NHL patients, the use of purging was associated with significantly better disease-free survival (P =.003) and overall survival (P =.04) when compared with patients who received unpurged autografts.

CONCLUSION

These analyses failed to find evidence of a graft-versus-lymphoma effect, but do provide indirect evidence to support the hypothesis that tumor contamination may contribute to lymphoma relapse, and that purging may be beneficial for patients undergoing autologous hematopoietic stem-cell transplantation for low-grade NHL.

Allogeneic haemopoietic stem cell transplantation for non-Hodgkin's lymphoma

This chapter outlines the rationale for allogeneic haemopoietic stem cell transplantation in non-Hodgkin's lymphoma and pertinent results from published studies. Trials comparing allogeneic with autologous transplantation are discussed, as are disease-specific results for low-grade (including transformed), mantle cell and high-grade (Burkitt's and lymphoblastic) subtypes of the disease. Allogeneic transplantation for non-Hodgkin's lymphoma in the paediatric population, the use of unrelated donors, allografting after failed autologous or allogeneic transplantation, the graft-versus-lymphoma effect, the use of donor leukocyte infusions and non-myeloablative allografts are considered.

Allogeneic bone marrow transplantation in patients with follicular lymphoma: a single center study

The role of allogeneic BMT for follicular lymphoma remains to be established. From 1995 to 2000, 16 patients with follicular lymphoma underwent allogeneic BMT at our center. At the time of transplantation, two patients were in complete remission, 11 in partial remission and three had refractory disease. Fourteen patients were transplanted using a standard myeloablative conditioning regimen and two a nonmyeloablative conditioning regimen. With a median follow-up of 1184 days (range 403-1999 days) after BMT, 11 patients were alive, whereas five died of transplant-related mortality. Eight patients remained in CR 284+ to 1022+ days (median 560+ days) after BMT. Two patients relapsed 63 and 1073 days after BMT. They achieved a further complete remission after salvage treatment and remained alive 403 and 1224 days after BMT, respectively. One patient with autologous reconstitution had never been in CR after BMT. He was retreated with salvage chemotherapy but only achieved CR with subsequent rituximab treatment and was still alive, 1999 days after transplantation. The estimated 2-year overall survival and event-free survival rates were 68% and 55%, respectively. Age greater than 37 years at diagnosis, positive recipient CMV serology and ECOG performance status > or =1 at diagnosis were associated with shorter overall survival (P = 0.05, P = 0.009 and P = 0.03, respectively). Ann Arbor III-IV stage at diagnosis was associated with shorter event-free survival (P < 0.04). Allogeneic BMT seems to be effective for patients with follicular lymphoma. However, the relatively high rate of early transplant-related mortality emphasizes the need to define indications and use prospective protocols involving a less toxic transplant procedure.

Nonmyeloablative allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is the most effective treatment for selected hematological malignancies. Its curative potential is largely mediated by an immune-mediated destruction of malignant cells by donor lymphocytes termed graft-versus-leukemia (GVL) effect. However, because of its toxicity, conventional allogeneic HSCT is restricted to younger and fitter patients. These observations led several groups to set up new (less toxic) transplant protocols (nonmyeloablative stem cell transplantation or NMSCT) based on a two-step approach: first, the use of immunosuppressive (but nonmyeloablative) preparative regimens providing sufficient immunosuppression to achieve engraftment of allogeneic hematopoietic stem cells and, in a second step, destruction of malignant cells by the GVL effect. Preliminary results showed that NMSCT were feasible with a relatively low transplant-related mortality (TRM), even in patients older than 65 years. In addition, strong antitumor responses were observed in several hematological malignancies as well as in some patients with renal cell carcinoma. After discussing the mechanisms and efficacy of the GVL effect as well as the rationale for NMSCT strategies, this article reviews the first results of ongoing clinical trials. Innovative modalities that may permit amplification of the GVL effect while minimizing the risk of GVHD are discussed. Because the benefits of NMSCT over alternative forms of treatment remain to be demonstrated, this strategy should be restricted to patients included in clinical trials.

Advances in the management of patients with non-Hodgkin's lymphoma

Non-Hodgkin's lymphoma is the fifth most common cause of death due to cancer and has been rising at a rate of 4% per year for the last four decades. Although 'traditional' chemotherapy and radiotherapy have had important contributions to improving outcomes, new tools in the treatment of non-Hodgkin's lymphoma are needed. This review describes therapeutic modalities that are currently being used or are in the process of being developed and which are based on concepts divergent from 'traditional' approaches to managing non-Hodgkin's lymphoma.

Long-term clinical and molecular remission after allogeneic stem cell transplantation (SCT) in patients with poor prognosis non-Hodgkin's lymphoma

From 1987 to 1999 35 patients with poor prognosis non-Hodgkin's lymphoma (NHL) underwent allogeneic stem cell transplantation (SCT) at the University Hospitals of Vienna and Graz. Initial biopsy specimens were reclassified according to the Revised European-American Classification of Lymphoid Neoplasms (REAL). All patients surviving 28 days engrafted. Twenty-eight of them (93%) attained clinical remission. At the last follow-up 14 patients were alive and disease-free at a median of 5.0 (range, 2.3-12.9) years after allogeneic SCT. The actuarial overall survival is 35%. Five patients relapsed 1.8 to 27.6 months after transplant, the probability of relapse is 23%. Of the 21 deaths following SCT, seven were due to relapse/refractory disease and 14 due to transplant-related causes. The probability of treatment-related mortality is 48%. After SCT, minimal residual disease (MRD) was monitored by polymerase chain reaction (PCR) in seven patients with a BCL-2/IgH translocation and in 13 with a clonal immunoglobulin heavy chain (IgH) rearrangement. All 20 patients attained clinical remission rapidly and converted to PCR negativity. In the follow-up nine of these patients are in long-term clinical and molecular remission, six PCR-negative patients died of transplant-related causes and five patients relapsed. In summary, allogeneic stem cell transplantation has a curative potential for patients with refractory and recurrent non-Hodgkin's lymphoma. In our series long-term disease-free survival was associated with molecular disease eradication after SCT. Treatment-related mortality rate was high, thus earlier referral of selected patients to allogeneic SCT should be considered.

Allogeneic or autologous stem cell transplantation (SCT) for relapsed and refractory Hodgkin's disease and non-Hodgkin's lymphoma: a single-centre experience

PURPOSE OF THE STUDY

The aim of the study was to evaluate which patient might benefit most from allogeneic stem cell transplantation (SCT) in the treatment of relapsed and/or refractory lymphoma.

PATIENTS AND METHODS

Thirty-eight consecutive lymphoma patients receiving either autologous (n = 24) or allogeneic (n = 14) stem cell grafts at our institution from 1986 to 1998 were retrospectively analysed regarding overall survival (OS), disease-free survival (DFS), transplant-related mortality (TRM), and relapse incidence (RI). Uni- and multivariate analyses were performed to identify patient characteristics predictive for outcome after SCT.

RESULTS

The probabilities of OS, DFS, TRM, and relapse were 57%, 51%, 29%, and 30% following autologous and 43%, 43%, 29%, and 38% following allogeneic SCT. Disease status (sensitive versus refractory) and the time interval between diagnosis and SCT were the most powerful predictive parameters for OS and TRM, whereas elevated serum LDH levels were signifcant in determining relapse.

CONCLUSIONS

In patients with elevated serum LDH levels and bone marrow involvement at the time of transplantation allogeneic was superior to autologous SCT and resulted in better outcome due to a lower relapse incidence strongly suggesting the existence of a graft-versus-lymphoma effect.

Adoptive allogeneic immunotherapy--history and future perspectives

For more than 30 yrs allogeneic hematopoietic stem cell transplantations have been successfully performed in patients with hematologic malignancies and bone marrow aplasia. Over the years the field of transplantation has changed dramatically. More and more unrelated donors became available, regimens for haploidentical transplantations were introduced and G-CSF mobilized peripheral blood stem cells and fetal cells from umbilical cord became available as alternate sources of hematopoietic stem cells. However, especially the introduction of donor lymphocyte infusions (DLI) for the successful treatment of leukemic relapses after allogeneic stem cell transplantations improved our understanding of transplantation immunology and opened amazing perspectives in allogeneic transplantation. It was long believed, that myeloablative therapy with high-dose chemotherapy and total body irradiation (TBI) are the sole antileukemic principles in allogeneic transplantations. But by now it became clear, that donor lymphocytes exert a very potent antileukemic effect, now referred as the graft-versus-leukemia (GVL) or graft-versus-malignancy (GVM) reaction. The efficacy of DLI in controlling leukemic relapses suggests that myeloablative therapy is not essential for long-term disease control. By exploiting the GVL or GVM reaction more intensively the role of chemotherapy and TBI is changing to immunosuppression. Sufficient immunosuppression to allow grafting, however, can be achieved with much lower doses as those which have been used in conventional transplants. Therefore allogeneic transplants have become also available for the elderly or for patients with concurrent medical conditions, which would have excluded them from conventional transplants. Moreover, this allogeneic transplantation strategy with reduced intensity conditioning is now also under investigation in patients with susceptible solid tumors and autoimmune diseases. However, one major obstacle in allogeneic transplantations, namely the graft-versus-host disease (GVHD), remains to be solved.

Histologic transformation of follicular lymphoma after allogeneic bone marrow transplantation

A 38-year-old man with refractory follicular lymphoma underwent allogeneic BMT from an HLA-identical sibling donor. He had generalized lymphadenopathy, hepatosplenomegaly and lymphoma infiltration of the marrow, all of which disappeared within 3 months following transplantation. Six months post-transplant, progressive hepatomegaly developed in the absence of splenomegaly and lymphadenopathy, and he died from hepatic failure. Autopsy disclosed diffuse large B cell lymphoma of the liver, into which the follicular lymphoma had transformed. Future issues to be investigated should include the optimal timing of allogeneic BMT for low-grade lymphomas.

Treatment of non-Hodgkin lymphoma

Preliminary results of new therapies in the areas of cytotoxic agents and immunotherapy for advanced indolent lymphomas have been encouraging. Long-term follow-up on high-dose therapy suggests a potential role for this modality in this group of lymphomas. In aggressive lymphomas, CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) continues to hold ground as first-line therapy when compared against other regimens. Several studies reinforce past findings that patients with chemosensitive relapse are better candidates for high-dose therapy. In relapsed or refractory disease, selected compounds appear to have activity as single agents and others have shown activity in combination therapy. Despite high treatment-related mortality rates, allogeneic transplantation in relapsed aggressive lymphoma warrants further investigation. Last, as patients are surviving longer, complications of therapy are having to be addressed.

Allogeneic bone marrow transplantation for lymphoma

Registry data show that use of allogeneic transplantation for non-Hodgkin's lymphoma, and to a lesser extent, Hodgkin's disease is increasing. Although no prospective randomized trials have been performed, most comparisons show a significantly lower relapse rate when allogeneic transplant results are compared to results of autologous hematopoietic stem cell transplantation. The lower relapse rate following allogeneic transplantation, as well as several other lines of evidence, support the existence of a graft-versus-lymphoma effect. Nevertheless, in most comparisons, the lower relapse rate following allogeneic transplantation is offset by higher transplant-related mortality. These results make it difficult to find situations where definite overall survival advantages associated with the use of allogeneic transplantation can be demonstrated. The use of low-intensity non-myeloablative regimens for allogeneic transplantation is attracting attention. It is hoped that this approach may harness a graft-versus-lymphoma effect with less morbidity and mortality than conventional allogeneic transplantation, but more data are required to assess the value of this treatment.

Stem cell transplantation for indolent lymphoma

Stem cell transplantation (SCT) has become the treatment of choice for patients with relapsed aggressive non-Hodgkin's lymphoma (NHL). The role of SCT in the management of patients with low-grade NHL remains more controversial, although increasing numbers of patients with advanced-stage follicular lymphoma, mantle cell lymphoma, and chronic lymphocytic leukemia are now undergoing SCT. To date, most patients with NHL have been treated with autologous SCT, currently using peripheral blood stem cells (PBSC) mobilized by chemotherapy and recombinant growth factors. There is increasing concern regarding toxicity of autologous SCT, especially the higher than expected long-term risk of development of myelodysplastic syndrome. This, among other factors, has led to renewed interest in the role of allogeneic SCT for patients with NHL. A major advantage of allogeneic SCT is the potential to exploit a graft-versus-lymphoma effect, and many studies are underway exploring the possibility of manipulating donor cells to maximize T cell responsiveness against lymphoma.