The bulk of available evidence has made a persuasive case for
early bone marrow transplantation as the treatment of choice for
patients with relapsed Hodgkin's disease, Philip J. Bierman, MD,
said at a lymphoma conference sponsored by the University of Texas
M.D. Anderson Cancer Center.
However, Dr. Bierman's confidence in autologous bone marrow transplantation
(ABMT) hinges on an important caveat: The procedure has not been
shown to improve overall survival.
"In most clinical situations, the failure-free survival following
high-dose therapy with ABMT for Hodgkin's disease is superior
to conventional dose salvage chemotherapy," he said, "but
transplantation's ability to improve overall survival has not
been demonstrated. However, at our institution, we recommend transplantation
for any patient who has relapsed after chemotherapy."
To date, only a single randomized trial has compared ABMT with
conventional salvage therapy for relapsed Hodg-kin's disease.
This trial was conducted by the British National Lymphoma Investigation
and was stopped early after accrual of only 40 patients due to
improved outcome in the patients receiving high-dose therapy,
said Dr. Bierman, associate professor of medicine, University
Conventional Salvage Chemo
Conventional salvage chemotherapy has produced unspectacular results
in a number of studies, Dr. Bierman said. National Cancer Institute
investigators have reported 24% long-term survival among patients
who had initial remissions of 12 months or more after MOPP therapy
and were treated with MOPP-based therapy in relapse. Among patients
with shorter remissions, only about 10% survived long term, Dr.
The best reported results have come from an Italian study showing
a 46% long-term failure-free survival in patients who had long
initial remissions and then were treated at relapse with MOPP,
ABVD, or a combination of the two. However, Dr. Bierman noted
that the study excluded patients who developed secondary leukemias
or who had cardiac or pulmonary deaths.
In general, other studies of conventional salvage chemotherapy
have found long-term failure-free survival in no more than 25%
to 30% of patients, with much worse results in patients with short
initial remissions or induction failure.
Good results have been achieved with radiation therapy, but in
relatively small numbers of patients, some of whom also received
chemotherapy. In five published studies with about 100 patients
total, complete responses rates have ranged as high as 92%. Disease-free
survival at 5 years has ranged between 24% and 50%.
The best results have occurred in patients with initial remissions
exceeding a year and in those without extranodal disease. "If
you wanted to argue, you could say that the disease-free survival
results with radiation therapy have been as good as any salvage
therapy or, in fact, as good as bone marrow transplantation,"
Dr. Bierman said.
Survival With ABMT
Studies of high-dose salvage therapy with ABMT or peripheral blood
stem cell support have shown encouraging results, he said. At
the University of Nebraska, 5-year failure-free survival is 40%
among 85 patients. British investigators have reported a 47% long-term
failure-free survival, including 57% in patients with long initial
remissions and 41% in patients with short initial remissions.
Stanford researchers have reported a 60% progression-free survival
in patients treated with ABMT after relapse or failure to achieve
remission, compared with 30% for another group treated with conventional
chemotherapy. Overall survival favored the transplant group (55%
vs 46%) but did not reach statistical significance, Dr. Bierman
The best results have come from a Vancouver study that showed
an 80% to 85% failure-free survival in patients with long initial
remissions. Overall, two thirds of the 57 patients remained failure
free at 7 years. "These results are clearly better than anything
that has ever been reported in the literature," Dr. Bierman