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

INDICATIONS FOR AUTOLOGOUS BONE MARROW
TRANSPLANTATION IN HODGKIN'S DISEASE
A. M. Carella.
ABMT Unit, Ospedale San Martino, 16132 Genoa (ITALY)
During the Sixth International Symposium on ABMT, some of the most pertinent
questions on the place of high-dose therapy in patients with Hodgkin's
disease have been discussed. To this round-table participated: G.L. Phillips
(Vancouver), T. Ahmed (New York), A. Vriesendorp (Houston), A.M. Carella
(Genoa). The crucial point was to define which patient population was most
likely to benefit from HDT/ABMT procedure. All the authors agreed to systematically
subdivide poor prognostic patients into those who never enter CR, those
who have a CR of less than 12 months and those who have a first CR longer than
12 months but who ultimately relapse. The characteristics of these primary refractory
patients seem related to the amount of tumor burden. For the vast majority
of these truly resistant lymphomas, conventional salvage yields poor results,
and better results might now be achieved only with dose escalation and
marrow or peripheral stem cell rescue. In those patients who do get an initial
but short CR, salvage therapy at relapse with conventional dose chemotherapy
yields a poor outcome. In this particular situation, high dose chemotherapy
with ABMT can offer superior results. If, however, patients have initially been
treated with a four drug regimen only, e.g. MOPP or ABVD, the outcome may
be different. Following CR with MOPP alone at relapse, salvage with ABVD
gives 65% of CR of which 35% remain alive and well at five years.
The above represents the patients entering a first CR which lasts less than a
year but a further category of poor prognosis patients is characterized by patients
whose disease relapse occurs after an initial CR longer than one year. In
this subgroup, treatment with the same chemotherapy protocol as employed in
induction can induce a second CR in about 60-70% of cases with a 5 year freedom
from second relapse of 50%.
A number of characteristics have been associated with unfavorable remission
rates, duration, and overall survival in patients with advanced-stage disease.
They include B symptoms, older age than 40 years, mediastinal bulk, multiple
extranodal sites of involvement, low hematocrit, high serum lactate dehydrogenase
(LDH) and high erythrocyte sedimentation rate (ESR).
Patients presenting with advanced disease and other unfavorable prognostic
factors, achieve complete remission at a relatively lower rate, relapse more
frequently, respond poorly to salvage therapies and, as a whole, have a rather
lower chance of cure. Using the prognostic model of Gobbi et al (22), patients
with unfavorable HD (age >40 years, mediastinal bulky disease, B symptoms,
more than one extranodal site of disease, MC or LD histology, high ESR, low
albumin levels) have a 10-year survival rate of about 20%.
As recently reported in 185 newly diagnosed adults with advanced HD
254 SIXTH INTERNATIONAL SYMPOSIUM ON AUTOLOGOUS BONE MARROW TRANSPLANTATION