A multi‐institutional analysis of peritransplantation radiotherapy in patients with relapsed/refractory Hodgkin lymphoma undergoing autologous stem cell transplantation

Abstract

BACKGROUND No consensus exists regarding the use of radiotherapy (RT) in conjunction with high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT) for patients with relapsed/refractory classical Hodgkin lymphoma (HL). The objectives of the current study were to characterize practice patterns and assess the efficacy and toxicity of RT at 2 major transplantation centers. METHODS Eligible patients underwent HDC/ASCT from 2006 through 2015 using the combination of either carmustine (BCNU), etoposide, cytarabine, and melphalan (BEAM) or cyclophosphamide, BCNU, and etoposide (CBV). RESULTS For the cohort of 189 patients, the 4-year overall survival rate was 80%, the progression-free survival rate was 67%, and the local control (LC) rate was 68%. RT was used within 4 months of ASCT for 22 patients (12%) and was given more often for disease that was early stage, primary refractory, or [18F]fluorodeoxyglucose (FDG)-avid at the time of HDC/ASCT. Disease recurrence occurring after HDC/ASCT was associated with primary refractory disease and FDG-avidity at the time of HDC/ASCT. RT was not found to be associated with LC, progression-free survival, or overall survival on univariate analysis. In a model incorporating primary refractory HL and FDG-avid disease at the time of HDC/ASCT, RT was found to be associated with a decreased risk of local disease recurrence (hazard ratio, 0.3; P=.02). In patients with primary refractory HL and/or FDG-avid disease at the time of HDC/ASCT, the 4-year LC rate was 81% with RT versus 49% without RT (P=.03). There was one case of Common Terminology Criteria for Adverse Events grade ≥ 3 RT-related toxicity (acute grade 3 pancytopenia). CONCLUSIONS In patients undergoing ASCT for relapsed/refractory HL, peritransplantation RT was used more often for disease that was early stage, primary refractory, or FDG-avid after salvage conventional-dose chemotherapy. RT was associated with improved LC of high-risk localized disease and was well tolerated with modern techniques.

Outcomes of patients with relapsed/refractory Hodgkin lymphoma progressing after autologous stem cell transplant in the current era of novel therapeutics: A retrospective analysis

“…These data suggest that the survival benefit observed with post‐ASCT radiotherapy in our population is unrelated to prior radiation therapy or disease burden at initial diagnosis. Milgrom and colleagues recently described practice patterns pertaining to radiation therapy in those undergoing ASCT for RR‐HL and found that patients treated with radiation therapy in the peritransplant setting were more likely to have early stage disease both at initial diagnosis and upon relapse, although radiation therapy was not associated with improved PFS or OS in that study . One explanation for improved survival in patients treated with post‐ASCT radiotherapy in the current study is the presence of more localized disease upon relapse, though this association was not explored specifically in the present study.…”

Patterns of Relapse After Salvage Autologous Stem Cell Transplant for Hodgkin's Lymphoma: Should Sites of Relapse Relative to Initially Involved Sites Be Used to Guide Indications for Peri-Transplant Radiation Therapy

“…With no prospective studies to date to guide the application of peri-transplant RT and mixed results in retrospective studies, the role of peri-transplant RT has remained controversial. [10][11][12] An older study from the mid-1990s, when RT was part of the standard upfront therapy (55% of included patients received upfront RT as part of combined modality therapy), highlighted the increased risk of relapse in sites of previous involvement, which was abrogated by the addition of peri-transplant RT. 13 In addition, more recent multi-institutional data have shown that the omission of RT as part of upfront therapy was associated with decreased salvage rates with ASCT.…”

Így kezeljük az autológ őssejt-transzplantáció után kiújult Hodgkin-lymphomát

“…Ezekben a csoportokban a négyéves lokális kontroll 81% volt az RT-ben részesülő betegekben, szemben azokkal, akik nem kaptak RT-t (49%, p = 0,03). Ez alapján a relapsus szempontjából nagy rizikójú betegeknél alkalmazása előnyösnek tűnik [23].…”

“…Az RT dózisát vizsgálva felmerült, hogy a kemorefrakter betegeknek ≥35 Gy RT alkalmazása szükséges lehet [23,24]. Az RT alkalmazása döntően az AHSCT után javasolt, hiszen előtte alkalmazva a betegség a nem besugarazott területeken progrediálhat, illetve a csontvelő károsításával az aplasia idejét nyújthatja [23].…”