Autologous stem cell transplantation for follicular lymphoma: no benefit for early transplant?

Autologous stem cell transplantation (SCT) is widely used as salvage treatm ent for patients with relapsed follicular lymphoma (FL). Although SCT can i nduce prolonged remissions, it does not appear to be curative in the vast m ajority of patients. The purpose of this study was to investigate if incorp oration of SCT into first-line therapy can improve its efficacy. Fifty-five patients underwent sequential high-dose therapy as up-front (n=33) or salv age treatment (n=22) for advanced stage FL at our institution. Treatment co nsisted of intensive chemotherapy with dexamethasone, carmustine (BCNU), et oposide, cytarabine, and melphalan (Dexa-BEAM) for mobilization of peripher al stem cells and reduction of tumor load, followed by one of three differe nt myeloablative regimens and SCT. With a median followup of 4 years, proje cted event-free survival (EFS) and overall survival (OS) at 4 years post tr ansplant was 59% and 84%, respectively, with no evidence of plateau in the survival curves. By univariate and multivariate analysis weighing age, sex, stage, BM and extranodal involvement, timing of transplant, ex vivo purgin g, and conditioning regimen [total body irradiation (TBI) vs non-TBI], the only significant factor predicting for superior Zn EFS and OS was up-front vs salvage transplant (4-year EFS 76% vs 38%, p=0.02; 4-year OS 92% vs 73%, P=0.033). However, when calculated from diagnosis, EFS and OS of the up-fr ont and salvage groups were virtually identical, implying that the longer s urvival post SCT in the up-front group was completely compensated by the lo nger interval between diagnosis and transplant in the salvage group. Median OS from diagnosis was 13.5 years. Except for one case of anaplastic large cell lymphoma, secondary neoplasms have not occurred to date. In conclusion , our data indicate that SCT might improve the prognosis of patients with d isseminated FL, although it is probably not curative even if applied early during the course of the disease. The optimum timing of SCT remains to be d etermined by the ongoing randomized multicenter trial of the German Low-gra de Lymphoma Study Group. The impact of radiotherapy on the success of SCT d oes not seem to be as essential as originally believed.