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
- 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:
- ECOG 0-1
- Adequate pre-transplant investigations including cardiac and pulmonary function tests.
- Stable disease and no sign of disease progression since the last chemotherapy treatment
- 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)
- 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:
- ECOG 0-1
- Adequate pre-transplant investigations including cardiac and pulmonary function tests.
- Stable disease and no sign of disease progression since the last chemotherapy treatment
- 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)
- 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)
- 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
- 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.
- > 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.
- 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