Navigating Autologous vs Allogeneic Transplant Selection in T-Cell Lymphoma

T-cell lymphomas represent a heterogeneous and often aggressive group of hematologic malignancies for which the optimal consolidation strategy, autologous or allogeneic hematopoietic stem cell transplantation (HSCT), remains an area of active investigation shaped by disease subtype, depth of response, and an evolving landscape of novel agents.

CancerNetwork® spoke with Mary Jo Lechowicz, MD, about navigating transplant decision-making in T-cell lymphoma based on her session at the 2026 Society of Hematologic Oncology (SOHO) Annual Meeting in Houston, Texas.¹

Lechowicz began by identifying the specific T-cell lymphoma subtypes, including adult T-cell leukemia/lymphoma (ATLL) and hepatosplenic T-cell lymphoma (HSTCL), in which allogeneic transplant is preferred upfront. She then addressed how a partial response (PR) to induction should influence transplant strategy, noting that responsiveness to chemotherapy is fundamental to autologous outcomes and that allogeneic eligibility should be evaluated early in patients with high-risk disease.

Lechowicz further discussed how reduced-intensity conditioning (RIC) and post-transplant cyclophosphamide (PT-Cy)–based graft-versus-host disease (GvHD) prophylaxis have expanded the eligible population for allogeneic HSCT and described the significant graft-versus-tumor activity observed in both peripheral T-cell lymphoma (PTCL) and cutaneous T-cell lymphoma (CTCL). She outlined how novel agents such as brentuximab vedotin (Adcetris) are being studied to define their impact on the role of autologous transplant in CD30-positive disease.

Moreover, Lechowicz described her institution’s approach to bridging patients after autologous transplant failure to allogeneic transplant, including early donor typing at diagnosis. She closed by encouraging registration in bone marrow donor registries.

Lechowicz is an associate professor of hematology and medical oncology at Winship Cancer Institute of Emory University.

CancerNetwork: Given the biological heterogeneity of PTCLs, what specific clinical, histopathologic, or molecular biomarkers should multidisciplinary teams use to identify patients who should proceed directly to allogeneic HSCT in first complete remission vs those adequately served by autologous consolidation?

Lechowicz: In the current day and age of T-cell lymphoma, we have a number of newer molecular markers, though some of them are not yet translating into clinical therapy. From the standpoint of subtypes where autologous transplantation does not work particularly well, we heard from a colleague today about ATLL, which is driven by a virus. Because of that viral etiology, you want an allogeneic transplant instead if one is able to access that option. Unfortunately, only about 30% to 40% of patients are able to reach an allogeneic transplant, largely because of how the virus is transmitted.

The other subtype I discussed is a rare entity known as HSTCL, which is [predominantly] seen in 30-year-old [patients] and in men, and historically carried a very poor prognosis. If at all feasible, that is another subtype where we go automatically to a first consolidative allogeneic transplant.

In light of data suggesting that pre-transplant depth of response strongly correlates with post-transplant relapse-free survival, how should multidisciplinary care teams approach patients who achieve only a PR following induction? Is there a clear threshold at which transition from an autologous to an allogeneic HSCT strategy is mandatory?

It is always going to be patient specific in terms of what is mandatory and who is able to have an allogeneic transplant. While retrospective data show that patients with a PR can derive some benefit from autologous transplant, we know that autologous transplantation is based on responsiveness [to chemotherapy]. For both autologous and allogeneic transplant, depth of remission portends toward longer-term progression-free survival.

The other critical consideration is toxicity. Some patients may not be eligible for an allogeneic transplant, and in those situations, we consider proceeding to autologous consolidation. However, if a patient achieves only a PR, there is real concern about primary refractory disease or early relapse; those are the patients we would type and evaluate for an allogeneic transplant option.

Allogeneic transplant offers the potential for a curative graft-versus-lymphoma effect, yet high non-relapse mortality remains a significant challenge. How do newer RIC protocols and PT-Cy–based GvHD prophylaxis alter the risk-benefit equation when weighing allogeneic against autologous approaches in older or comorbid populations?

There are a couple of important dimensions here. In terms of allogeneic transplantation, we continue to move toward decreasing toxicity…By moving away from historically myeloablative conditioning regimens, these reduced-intensity approaches have made [allogeneic transplant] an option for patients who previously would not have been candidates.

For T-cell lymphomas specifically, one of the themes we addressed today was the historical concern about whether there would be any graft-versus-tumor effect at all in this disease. In contrast to those earlier concerns, we see quite significant graft-versus-tumor activity in both PTCL and CTCL. As a result, even if patients relapse after an allogeneic transplant, donor lymphocyte infusions can be incredibly helpful.

How does the recent integration of novel upfront and relapse agents, including brentuximab vedotin in CD30-positive disease, reshape the historic role of autologous transplant?

This is a timely question because it is exactly what our randomized phase 3 trial is trying to address, not only from a disease subtype perspective, but also in the context of incorporating brentuximab vedotin into upfront regimens for CD30-positive disease. With brentuximab vedotin, we have quite [some] data, and there is ongoing discussion about whether it can meaningfully reduce the need for transplant consolidation in some patients. With some of the newer agents, however, we do not yet have sufficient long-term follow-up to draw firm conclusions. Many of my colleagues were asked today whether we believe there is a cure that allows autologous transplant to be avoided entirely, and that is what we are all hoping for.

For patients whose disease progresses following autologous transplant, what is the optimal multidisciplinary workflow for bridging to a donor search and subsequent allogeneic transplant, particularly regarding the timing and selection of salvage therapies to avoid excessive organ toxicity prior to allogeneic conditioning?

The workflow is going to be institution dependent. What I can share is our institutional approach; because a significant proportion of patients still present with primary refractory disease—disease that progresses within 6 cycles of induction therapy or within 6 months of completing treatment—we initiate donor typing early, ideally at the time of initial diagnosis. The idea is if a patient is a transplant candidate, they are likely to receive either an autologous or allogeneic transplant at some point, and having that information in hand early avoids delays when disease progresses. There is no single universally established approach to optimal timing; but the clock effectively starts at the point of primary refractory or progressive disease, which is why we build in that preparation from the beginning.

Is there anything else that you would like to highlight?

The one message I would share—and this is something of a public service announcement—is about bone marrow donor registration. Similar to donating blood, registering as a potential marrow donor is something that as many people as possible should consider. What was once a blood test is now a swab in their mouth. [Like] giving blood, these donations can be curative and lifesaving. I ask everyone to think about that.

Reference

Lechowicz MJ. Auto versus allo transplant for T-cell lymphomas. Presented at: 2026 Society of Hematologic Oncology (SOHO) Annual Meeting; September 9-12, 2026; Houston, TX.