A Single Institution Long-Term Experience Using Autologous Stem Cell Transplantation for the Management of Hodgkin’s Lymphoma.

Patients with stage III – IV Hodgkin’s lymphoma (HL), and those with bulky stage I/II disease have a disease relapse rate of 30–40% after primary treatment. High dose chemotherapy with stem cell transplantation is a treatment option after relapse or in those with primary induction failure. In the present study, we retrospectively examined long term outcomes in 45 relapsed/primary induction failure HL patients undergoing autologous peripheral stem cell (25 patients), bone marrow (17 patients) or combination (3 patients) transplantation between 1985 and December 2003. The median age was 32 yrs(16–64), 38 had Nodular Sclerosing HL, 17 patients had stage I/II, 13 stage III and 15 stage IV disease, and 33 had B symptoms at diagnosis. Twenty patients were previously treated with 1–2 prior regimens, while 25 had ≥3 treatment regimens. Sixteen patients had sensitive disease to salvage therapy given prior to transplantation, 27 had resistance to salvage therapy while 2 did not undergo salvage therapy prior to transplantation. Five patients had primary resistant disease, 33 had evidence of relapsed disease and 7 patients were in CR at the time of transplantation. CBV was used in 30 patients, BEAM in 9 patients and 5 patients received CY/TBI based regimens. Six patients (13%) had early mortality (< 100 days) directly attributable to the procedure. Four of these deaths were cardiac related and two were due to infection. The overall response was 93% with CR achieved in 28 (62%) and incomplete response in 14 (31%). The median overall survival (OS) was 5.5 yrs, the median disease free survival (DFS) was 1 yr with DFS at 5 yrs of 26%. For patients achieving a CR after transplantation, 67% remain alive at a median of 7 yrs from transplant, however, the median progression free survival in these patients was 3.7yrs. For 15 patients not achieving CR after transplantation, 3(20%) have survived, the median time to death in this group was 20 months. Seventeen patients are alive, 2 are lost to follow-up and 21 patients have died. Fourteen patients died from disease progression (31%), 2 (4%) died from MDS/AML occurring after 32 and 66 mnths, 2 died of late occurring infections, 2 related to respiratory failure and a further patient from late cardiac failure. OS and DFS did not differ between peripheral stem cell vs bone marrow transplantation, those with B symptoms at diagnosis, sex differences, age <20yrs vs >20yrs, high dose therapy regimens but a difference in OS (p=0.04) and DFS (p=0.03) was seen in patients transplanted in CR vs active disease at transplantation. Patients whose disease displayed sensitivity to salvage therapy immediately prior to transplant did show a trend towards improved OS and DFS, but this was not statistrically significant. High dose chemotherapy and autologous stem cell transplantation can be expected to lead to long term DFS in approximately 25–35% of patients. Cardiac mortality (11%) appears to be a higher than expected complication in this patient group.