Blood, Vol. 91 No. 12 (June 15), 1998:
pp. 4810-4811
CORRESPONDENCE
Autologous or Allogeneic Stem Cell Transplantation in
Advanced Low-Grade Lymphomas?
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LETTER |
To the Editor:
In the November 15, 1997 issue of Blood, Verdonck et
al1 reported their results with autologous and allogeneic
bone marrow transplantation (BMT) in patients with refractory or
recurrent low-grade non-Hodgkin's lymphoma. Their experience deserves
several comments, because, in our opinion, the investigators describe an unrealistically good outcome after allotransplantation and nonrepresentative poor results in autologous recipients.
Ten patients received an allogeneic BMT in their series. Despite the
fact that 7 of them had chemotherapy-resistant disease, all allografted
patients achieved a complete remission after the procedure. In
addition, there were no relapses at a median follow-up of 41 months.
Transplant-related mortality occurred in 3 patients, which is a
relatively low rate for a series with a median age of 43 years. To our
knowledge, only one other series has reproduced such
impressive results after allogeneic transplantation for follicular lymphoma.2 In that study, the MD Anderson team
reported 8 survivors in a series of 10 patients with advanced
chemoresistant disease.2 In contrast, most BMT groups have
less encouraging experience in this setting. A recent report from the
IBMTR3 has summarized the results obtained in 81 patients
who received an allograft for poor-risk low-grade lymphoma. It is
noteworthy that the 3-year relapse rate was 24% and the
transplant-related mortality was 44%. These findings translated into a
43% disease-free survival and a 46% overall survival. These data
probably appear more realistic to many physicians involved in this
field, ie, advanced low-grade lymphomas do relapse after allogeneic
transplant and treatment-related mortality is considerable, at least as
high as seen in other situations in groups of patients of comparable
age. However, the report of Verdonck et al1 provides
further support for the continuing clinical research in the
application of allogeneic stem cell transplantation for the management
of low-grade lymphoproliferative disorders.
On the other hand, the results of the study of Verdonck et
al1 with autologous BMT are unreasonably poor. In their
group of 18 patients, all with advanced but chemosensitive disease, the
2-year progression-free survival was only 22% and the probability of
relapse was as high as 83%. Fifteen of the 18 patients relapsed, despite the fact that, in all instances, the procedure was performed as
treatment for chemosensitive disease. More specifically, 11 of 12 patients autografted in partial remission relapsed, in addition to 4 of
6 patients in complete remission before transplantation. This relapse
rate is much higher than that reported by other
studies1,4-8 and compares unfavorably with our own
results.5 At our institution, we have autografted 27 patients (median age, 46 years) suffering from relapsed or primary
refractory low-grade lymphoma. After a median follow-up of 16 months, 6 patients have progressed between 6 and 19 months posttransplantation.
The estimated 2-year progression-free survival is 67%.5
Our results are similar to those of previous reports showing
disease-free survival rates of 53% to 76% at 2 years and 43% to 59%
at 4 years.4-8 Treatment-related mortality after
autotransplantation is usually low, usually less than 10% (4% in our
series). To justify the discrepancies observed, a shorter follow-up of
our patients compared with those of the series of Verdonck et
al1 could be argued. However, in their report, 14 of the 15 relapses were observed in the first 16 months after autograft, the
median follow-up time of our series.
We recognize that autologous transplantation is associated with a
continuous rate of relapse and with the development of
secondary myelodysplasia.4 However, we feel that
this procedure offers a better perspective than that
reflected in the report by Verdonck et al.1
Allogeneic transplantation merits further research. The
short-term risks of this procedure have to be seriously taken into account, and despite a likely graft-versus-lymphoma
effect, disease recurrence remains a problem in a significant
proportion of patients.
Rosario López
Rodrigo Martino
Salut Brunet
Jorge Sierra
Clinical Hematology
Division
Hospital de la Santa Creu i Sant Pau
Barcelona,
Spain
| |
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