Health Professionals  /  Non-Hodgkin’s lymphoma

Non-Hodgkin’s lymphoma

Diffuse large B cell lymphoma

Age-adjusted international prognostic index

Risk Category	Number of Risk factor	% CR	5 years RFS	5 years OS
Low	0	92	86	83
Low - Intermediate	1	78	66	69
Intermediate – High	2	57	53	46
High	3	46	58	32

Autologous SCT

Recurrent disease ≤ 65 years

All patients with recurrent DLBCL will be candidate for dose intensification and autologous SCT if their disease is chemosensitive to second line salvage chemotherapy ( ≥ obtention partial remission). Patient should received 2-4 cycles of salvage chemotherapy (ex: R-ESHAP-ICE-DHAP) prior proceeding to stem cell transplant.

Recurrent disease 66-69 years

• High dose chemotherapy and autologous Stem Cell transplant could be considered in older patient in a good performence status, with no significant co-morbidity and chemosensitive disease.
• Patient should obtain at least a partial remission with second line chemotherapy.

Non myeloablative allogeneic stem cell transplant

Eligibility criteria

• Failure to collect an autologous graft in patient between 55-65 years old with a related donor.
• Recurrent disease post autologous SCT with a chemosensitive disease (a maintained PR for at least 4 weeks) and minimal state disease (lymph node < 2 cm).

Myeloablative allogeneic SCT

Eligibility criteria

• Failure to collect Stem Cell in patient < 55 years.
• Related are unrelated donor identified.

Follicular lymphoma

FLIPI prognostic index

Parameters

• Age ≥ 60 years
• Number of lymph node site involved > 4
• Stage III-IV
• Hemoglobin < 120 g/L
• LDH > normal

Risk Category	Number of parameters	5 years survival	10 years survival
Low	0-1	90.6	70.7
Intermediate	2	77.6	50.9
High	≥3	52.5	35.5

Stem cell transplant indications

1. 1st relapse within 24 months of a chemo-immunotherapy combination treatment: an autologous SCT is recommended
   • Recommendation based on CUP trial (JCO 2003, Nov 1, p. 3918) demonstrating an overall survival benefit in patients in 2nd PR/CR receiving an autologous SCT compare second line to chemotherapy alone.
   • Patient should received a second line salvage chemotherapy, ex.: R-ESHAP, R-DHAP, R-ICE x 2 cycles
   • Patient achieving a PR will be eligible for an autologous SCT
   • Patient not achieving a PR is eligible to a third line chemotherapy; responsive patient achieving a PR after a third line chemotherapy can proceed to autologous SCT.
   • Non myeloablative allogeneic SCT could be proposed at time of relapse to patient achieving only a 2nd PR prior autologous SCT.
   Autologous SCT followed by non-myeloablative allogeneic SCT
   The patient not achieving a PR despite 2 lines of salvage chemotherapy could proceed to an autologous transplant followed by a non-myeloablative allogeneic SCT (tandem approach) if all the following criterias are present:
   1. ECOG 0-1
   2. Adequate pre-transplant investigations including cardiac and pulmonary function tests.
   3. Stable disease and no sign of disease progression since the last chemotherapy treatment
   4. Available donor to proceed to NMA allogeneic transplant within 90-120 days post auto-SCT (up to 65 years for related transplant and up to 55 years for unrelated transplant)
2. 2nd relapse, patient previously treated Rituximab containing regimen who never received a transplant: autologous followed by a NMA allogeneic SCT.
   • Patient will first undergo salvage chemotherapy, like R-ESHAP, R-DHAP or R-ICE x 2-4 cycles
   • Patient achieving a PR can proceed to autologous SCT
   • Patient not achieving a PR is eligible to a third line chemotherapy; responsive patient achieving a PR after a third line chemotherapy can proceed to autologous SCT
   • If an HLA identical sibling donor is available (up to the age of 65 years), the patient could be proposed a tandem approach . This treatment remains experimental with a significant morbidity and mortality; several studies reported an overall survival of 70% at 3 years post mini-allo.
   • The allo-SCT will take place within 90-120 days post autologous transplant in the abscence of disease progression between the two transplants
   • If there is no sibling donor, unrelated allogeneic non myeloablative transplant could be proposed as a consolidation treatment post autologous SCT in patient < 50 year with a 9/10 molecular donor (1 DQB1 mismatch acceptable)
   • The patient not achieving a PR despite 2 lines of salvage chemotherapy could proceed to an autologous transplant followed by a non-myeloablative allogeneic SCT (tandem approach) if all the following criterias are present:
     1. ECOG 0-1
     2. Adequate pre-transplant investigations including cardiac and pulmonary function tests.
     3. Stable disease and no sign of disease progression since the last chemotherapy treatment
     4. Available donor to proceed to NMA allogeneic transplant within 90-120 days post auto-SCT (up to 65 years for related transplant and up to 55 years for unrelated transplant)
3. relapse post autolous SCT: NMA allogeneic SCT
   • If related donor and < 66 year
   • If unrelated donor and < 56 year
   • Chemosensitive disease (at least in PR prior transplant)
4. transformed follicular lymphoma
   • The patient is eligible to first line autologous SCT after receiving 6-8 cycles of R-CHOP like chemotherapy and achieving a CR if not previously treated.
   • The patient beyond 1st remission is eligible to autologous SCT if chemosensitive disease.
   • The patient will become a candidate to the tandem approach (autologous SCT followed by NMA allogeneic SCT) according to the same criteria of the non transformed FCL.

Mantle cell lymphoma

1. 1st partial/complete remission
   • Patient < 66 year will be proposed an autologous SCT to improve is DFS.
   • Patient between the age of 66 and 69, could be proposed an autologous SCT if in a good PS and without significant co-morbidities.
   • Patient < 66 year with an HLA identical sibling donor is eligible to a consolidation NMA allogeneic SCT post autologous tranaplant (tandem approach). This is an experimental approach associated to a significant morbidity and mortality.
2. > 1st remission
   • Patient presenting with a chemosensitive disease and achieving at least a PR is eligible to the tandem approach if:
   • ≤ 65 year with an HLA identical sibling
   • ≤ 55 year with ≥ 9/10 molecular unrelated donor
   • Patient without an allogeneic compatible donor will not be eligible to the autologous transplant in regards to the poor outcome of this population despite the auto SCT.
3. Recurrent disease post autologous SCT
   • Patient with a chemosensitive disease achieving at least a PR with salvage treatment will be eligible to a NMA allo-SCT if
   • ≤ 65 year with a match sibling donor
   • ≤ 55 year with ≥ 9/10 unrelated donor