VI Autologous Bone Marrow Transplantation.pdf - Blog Science ...

"unstimulated" 11
peripheral blood cells. No post-transplant therapy was given
until definite progression occurred. Eighteen patients received planned qrowth
factor support post-AuBMT.12
RESULTS
All but 2 patients had recovery of the absolute neutrophil count (ANC) > 0.5
x 10VL on a median of day +16 (range +9 to +33) post-AuBMT. Fifty-three patients
became independent from platelet transfusions on a median of day +19
(range +6 to +103). (As expected, patients receiving hematopoietic growth factors
generally had the more rapid ANC recoveries. 12)
At present, 42 of these 58 patients are alive and disease-free, almost all with
Karnofsky scores of 100%. Conversely, 13 patients relapsed and 3 suffered nonrelapse
mortality. Actuarial progression-free survival is 64% at 6 years (95% CI
47% to 80%) (Figure 3). Of analyzed factors, the presence of "B" symptoms at the
time of AuBMT (p < 0.001) and an initial progression-free interval of < 12
months following primary chemotherapy (p = 0.025) were significant adverse
prognostic factors in multivariate testing. (As noted above, this result was similar
- althouqh not identical - to one obtained after analyzing all 53 B.C. patients
in first untested relapse, regardless of treatment, between 1970 and 1988. 13
) The
results in patients classified by a lymphoma-free interval of > versus < 12
months is of interest, as such is often used to determine whether or not patients
should proceed to AuBMT; the former had -30% and the latter -85% subsequent
progression-free survival post-AuBMT.
CONCLUSIONS
The most definitive way to evaluate whether first untested relapse (as compared
to any tested relapse) is indeed the proper timing for HD is to perform an
appropriate randomized clinical trial. However, for a number of reasons, such a
trial is unlikely to be performed - at least in the near future. Our results encourage
us to consider first untested relapse as the current optimal timing for
AuBMT in most patients. Of course, many patients transplanted in first untested
relapse are not cured, especially those with the adverse prognostic factors noted
above, and it is important to consider new ways of treating such "high-risk" patients
which will reduce relapses post-AuBMT without producing an excessive
number of deaths due to toxicity. Various methods to upgrade conditioning
regimens are being evaluated;14 an alternative approach would be the development
and verification of post-AuBMT immunomodulation. 15
Although perhaps more controversial, the reliable identification of patients
at extremely high risk of relapse during their initial remission would permit the
use of the AuBMT procedure as "consolidation" after primary therapy. Such an
approach has been pursued by Carella, et all 6
and has produced favorable preliminary
results, but these require confirmation. Each approach has certain advantages
and disadvantages and should be tested further.
REFERENCES
1. Armitage JO. Bone marrow transplantation in the treatment of patients with
lymphoma. Blood 1989;73:1749-58.
2. Canellos GP. The second chance for advanced Hodgkin's disease. J Clin Oncol
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SIXTH INTERNATIONAL SYMPOSIUM ON AUTOLOGOUS BONE MARROW TRANSPLANTATION