Autologous hematopoietic cell transplantation in follicular lymphoma
- Arnold S Freedman, MD
Arnold S Freedman, MD
- Section Editor — Lymphoproliferative Disorders
- Professor of Medicine
- Harvard Medical School
- Jonathan W Friedberg, MD
Jonathan W Friedberg, MD
- Professor of Medicine
- James P Wilmot Cancer Center, University of Rochester
Follicular lymphoma (FL) is the second most common type of non-Hodgkin lymphoma (NHL). It is the most common of the clinically indolent NHLs defined as those lymphomas in which survival of the untreated patient is measured in years. (See "Classification of the hematopoietic neoplasms".)
The initial treatment of FL depends upon the stage of disease at presentation. Patients with early stage disease may be cured with radiation therapy, while patients with advanced stage disease are initially managed with an immunotherapy-based regimen (eg, rituximab plus chemotherapy). The use of either autologous or allogeneic hematopoietic cell transplantation (HCT) in FL is controversial and the subject of ongoing clinical trials. Autologous HCT may result in prolonged remissions and has a low treatment-related mortality rate. In comparison, allogeneic HCT may cure a higher percentage of patients with advanced stage FL, but is associated with substantial treatment-related mortality.
The use of autologous HCT in FL is reviewed below. The use of allogeneic HCT in FL and comparison with other treatment options are presented separately. (See "Initial treatment of limited stage (I/II) follicular lymphoma" and "Treatment of relapsed or refractory follicular lymphoma" and "Primary cutaneous follicle center lymphoma" and "Allogeneic hematopoietic cell transplantation in follicular lymphoma".)
TIMING OF TRANSPLANT
The ideal timing of hematopoietic cell transplantation (HCT) in follicular lymphoma (FL) is unknown. Outside of a clinical trial, HCT is reserved for patients with relapsed or refractory FL or for those with histologic transformation to a more aggressive histology. Among patients with relapsed FL, a choice between HCT and chemotherapy without HCT is made on an individual basis. HCT is generally preferred for patients with clinically aggressive disease as demonstrated by a short remission duration. This is primarily based upon prospective randomized trials that have demonstrated a survival benefit from HCT in patients with relapsed FL, but failed to demonstrate a survival benefit in patients with previously untreated disease. HCT is also a reasonable treatment option for select patients with FL that has transformed to a more aggressive non-Hodgkin lymphoma subtype.
Interpretation of the trials that have investigated the relative value of HCT versus combination chemotherapy alone for patients with FL is complicated by subsequent changes in the standard care of FL. Importantly, the routine incorporation of rituximab or its radioimmunoconjugates into the standard treatment of FL has improved survival rates among patients who do not undergo HCT. Survival advantages seen in some early trials of HCT may not have been evident had the combination chemotherapy treatment arms involved the addition of these agents. Conversely, a lack of survival advantage seen in other early trials may have been because the patients did not receive sufficient chemotherapy immediately before transplantation, leading to incomplete disease control and/or infusion of occult lymphoma cells contaminating the stem cell infusate.
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- TIMING OF TRANSPLANT
- Relapsed disease
- - Efficacy
- - Long-term efficacy
- Following histologic transformation
- Previously untreated disease
- DETERMINING TRANSPLANT ELIGIBILITY
- COLLECTION AND STORAGE OF STEM CELLS
- PREPARATIVE REGIMEN
- CARE DURING THE TRANSPLANTATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS