THE ROLE OF INTENSIVE THERAPY AND AUTOLOGOUS BLOOD AND MARROW TRANSPLANTATION FOR CHEMOTHERAPY-SENSITIVE RELAPSED AND PRIMARY REFRACTORY NON-HODGKINS-LYMPHOMA - IDENTIFICATION OF MAJOR PROGNOSTIC GROUPS

Patients with intermediate grade non-Hodgkin's lymphoma (NHL) who rela pse or fail to achieve a complete remission after anthracycline-contai ning induction regimens have a poor outcome with conventional-dose sal vage treatment. This outcome may be improved with intensive therapy an d autologous transplantation (ABMT) but even in patients with proven c hemotherapy-sensitive disease, relapse rates of up to 60% are observed . Reliable and powerful prognostic indicators are needed to identify a ppropriate patients for this expensive procedure and those subjects to whom alternative or additional treatment should be offered. We were i nterested in testing the hypothesis that tumour burden, and hence remi ssion status immediately prior to transplant, is an important prognost ic indicator of survival. We aggressively treated patients with conven tional-dose salvage chemotherapy to maximum tumour response, and teste d, by multivariate regression analysis, predictors of outcome post-tra nsplant. We studied 81 consecutive patients with intermediate grade an d immunoblastic NHL who achieved either a partial (PR) or complete rem ission (CR) following repetitive cycles of conventional-dose salvage t herapy. Intensive therapy consisted of etoposide (60 mg/kg) and intrav enous melphalan (160-180 mg/m(2)) with or without total body irradiati on (TBI) followed by infusion of autologous unpurged bone marrow and/o r blood cells. The predicted 4-year survival and progression-free surv ival (PFS) with a median follow-up of 37 months was 58% and 48% (95% c onfidence interval (CI) 37-55%), respectively. The only factor predict ive of outcome was remission status at transplant (P = 0.0001). The PF S at 4 years for the CR group was 61% (95% CI 53-75%). In contrast, on ly 25% (95% CI 11-40%) of patients undergoing autotransplant in PR wer e progression free at 4 years. We conclude that remission status at tr ansplant after maximum tumour reduction is a powerful prognostic indic ator.