Which Non-Hodgkin's Lymphoma Patients Benefit From ABMT?

I would like to take issue with Dr. Bruce Cheson's response toa reader's question on the role of high-dose chemotherapy/autologousbone marrow transplantation (ABMT) in patients with non-Hodgkin'slymphoma (Oncology News International, December, 1995, page 25).

Granted that this is an extremely broad topic to cover in a limitedspace, I nonetheless found Dr. Cheson's response misleading withregard to two important subgroups of patients: those who failto achieve a complete remission with initial chemotherapy andthose who are in first remission but are at very high risk forrelapse and are thus considered for high-dose therapy as "consolidation."

In the first case, Dr. Cheson writes that those patients not respondingto initial treatment (induction failures) achieve a durable remissionwith high-dose therapy in less than 10% of cases. This statementis true for those who are absolutely refractory to initial chemotherapy,but is not true for those who obtain a partial remission withinduction therapy.

In this setting, the majority of patients can be converted toa complete remission with high-dose chemotherapy and ABMT, andat least half of them will have durable remissions [1-4].

Regarding patients in first remission, Dr. Cheson cites the studyby Haioun et al (J Clin Oncol 12:2543-2551, 1994), which showedno advantage for the patients randomized to transplant. However,he fails to note that the study was flawed from its outset bythe intense consolidation given in the "standard" treatmentarm, the less than maximal doses used in the transplant arm, andthe inclusion of very few "high risk" patients.

Indeed, at the American Society of Hematology (ASH) December,1995, meeting, the French group presented its updated data withan expanded number of high-risk patients treated in this study[5]. These updated data do indeed now indicate an advantage fordisease-free survival (57% vs 36%, P = .01) as well as overallsurvival (65% vs 52%, P = .06) in favor of the transplant arm.

Based on these data and other data cited in the references below,I believe that strong consideration should be given to high-dosechemotherapy in these two clinical situations.

References:

1. Verdonck LF, Dekker AW, de Gast GC, et al: Salvage therapywith ProMACE-MOPP followed by intensive chemoradiotherapy andABMT for patients with non-Hodgkin's lymphoma who failed to respondto first-line CHOP. J Clin Oncol 10:1949-1954, 1992.

2. Haioun C, Lepage E, Gisselbrecht C, et al: Autologous transplantationversus conventional salvage therapy in aggressive non-Hodgkin'slymphoma (NHL) partially responding to first line chemotherapy:A study of 96 patients enrolled in the LNH87-2 protocol. Blood86(suppl 1):211a, 1995 (abstract 833).

3. Prince HM, Crump M, Imrie K, et al: Long-term event-free survival(EFS) after intensive therapy with etoposide, melphalan, and autotransplantin patients failing front-line therapy for Hodgkin's disease andnon-Hodgkin's lymphoma. Blood 86(suppl 1):209a, 1995 (abstract825).

4. Gherlinzoni F, Martelli M, Mazza P, et al: ABMT vs DHAP inaggressive non-Hodgkin's lymphomas (NHL) partially respondingto first-line chemotherapy. Blood 84(suppl 1):234a, 1994 (abstract922).

5. Haioun C, Lepage E, Gisselbrecht C, et al: ABMT versus sequentialchemotherapy for aggressive non-Hodgkin's lymphoma (NHL) in firstcomplete remission (CR): A study of 542 patients (LNH87-2 protocol).Blood 86(suppl 1):457a, 1995 (abstract 1816).