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Which Non-Hodgkin's Lymphoma Patients Benefit From ABMT?

Which Non-Hodgkin's Lymphoma Patients Benefit From ABMT?

I would like to take issue with Dr. Bruce Cheson's response to a reader's question on the role of high-dose chemotherapy/autologous bone marrow transplantation (ABMT) in patients with non-Hodgkin's lymphoma (Oncology News International, December, 1995, page 25).

Granted that this is an extremely broad topic to cover in a limited space, I nonetheless found Dr. Cheson's response misleading with regard to two important subgroups of patients: those who fail to achieve a complete remission with initial chemotherapy and those who are in first remission but are at very high risk for relapse and are thus considered for high-dose therapy as "consolidation."

In the first case, Dr. Cheson writes that those patients not responding to initial treatment (induction failures) achieve a durable remission with high-dose therapy in less than 10% of cases. This statement is true for those who are absolutely refractory to initial chemotherapy, but is not true for those who obtain a partial remission with induction therapy.

In this setting, the majority of patients can be converted to a complete remission with high-dose chemotherapy and ABMT, and at least half of them will have durable remissions [1-4].

Regarding patients in first remission, Dr. Cheson cites the study by Haioun et al (J Clin Oncol 12:2543-2551, 1994), which showed no advantage for the patients randomized to transplant. However, he fails to note that the study was flawed from its outset by the intense consolidation given in the "standard" treatment arm, the less than maximal doses used in the transplant arm, and the inclusion of very few "high risk" patients.

Indeed, at the American Society of Hematology (ASH) December, 1995, meeting, the French group presented its updated data with an expanded number of high-risk patients treated in this study [5]. These updated data do indeed now indicate an advantage for disease-free survival (57% vs 36%, P = .01) as well as overall survival (65% vs 52%, P = .06) in favor of the transplant arm.

Based on these data and other data cited in the references below, I believe that strong consideration should be given to high-dose chemotherapy in these two clinical situations.

References

1. Verdonck LF, Dekker AW, de Gast GC, et al: Salvage therapy with ProMACE-MOPP followed by intensive chemoradiotherapy and ABMT for patients with non-Hodgkin's lymphoma who failed to respond to first-line CHOP. J Clin Oncol 10:1949-1954, 1992.

2. Haioun C, Lepage E, Gisselbrecht C, et al: Autologous transplantation versus conventional salvage therapy in aggressive non-Hodgkin's lymphoma (NHL) partially responding to first line chemotherapy: A study of 96 patients enrolled in the LNH87-2 protocol. Blood 86(suppl 1):211a, 1995 (abstract 833).

3. Prince HM, Crump M, Imrie K, et al: Long-term event-free survival (EFS) after intensive therapy with etoposide, melphalan, and autotransplant in patients failing front-line therapy for Hodgkin's disease and non-Hodgkin's lymphoma. Blood 86(suppl 1):209a, 1995 (abstract 825).

4. Gherlinzoni F, Martelli M, Mazza P, et al: ABMT vs DHAP in aggressive non-Hodgkin's lymphomas (NHL) partially responding to first-line chemotherapy. Blood 84(suppl 1):234a, 1994 (abstract 922).

5. Haioun C, Lepage E, Gisselbrecht C, et al: ABMT versus sequential chemotherapy for aggressive non-Hodgkin's lymphoma (NHL) in first complete remission (CR): A study of 542 patients (LNH87-2 protocol). Blood 86(suppl 1):457a, 1995 (abstract 1816).

 
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