CASE REPORTS
Autologous hematopoetic stem cell transplantation for HIV-related Non-Hodgkin's Lymphomas (NHL)
Henrique Bittencourt
Autologous hematopoetic stem cell transplantation (AHSCT) consist of a myeloablative chemotherapy followed by a rescue with autologous peripheral stem cell transplantation collected and cryopreserved before. The principle is to deliver a maximum tolerated dose of chemotherapy and rescue the bone marrow function with the infusion of hematopoetic stem cells. Data from the CIBMTR show that multiple myeloma, non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) are the most frequent indications of AHSCT in North America. Specifically for NHL, AHSCT is indicated for patients in second remission or in chemosensitive relapse. A randomized trial published in 1995 showed that AHSCT provided superior overall and disease-free survival when compared to salvage chemotherapy alone. (Philip T, N Engl J Med 1995)
NHL is the second most frequent cancer in HIV patients. It is usually very aggressive, with a worst prognostic compared to non-HIV-related NHL. Difuse large-cell lymphoma and small non-cleaved cell lymphoma comprised more that 95% of the NHL in HIV-patients. Initial approach to treat HIV-related NHL using the same regimens employed in non-HIV patients. Toxicity was for more superior and results inferior. Next step was to decrease intensity of chemotherapy in order to reduce toxicity, maintaining the initial response rate. More recently, aggressive regimens (EPOCH, CDE) associated with HAART, improved response rate and survival, with acceptable toxicity. Nevertheless, more than half of patients eventually relapse. For this patients, salvage chemotherapy only, as in non-HIV patients, is only palliative and associated with high toxicity. Initial attempts using AHSCT for relapsed HIV-related NHL patients failed due to a high frequency of opportunistic infections and AIDS evolution. Furthermore, collection of peripheral blood stem cell (PBSC) was very difficult, due to the use of AZT. More recently, with the availability of HAART, new approaches to relapsed HIV-related NHL were tried. A prospective trial was published in 2003 on JCO. Sixteen patients with HIV-related NHL or HD were treated sequentially by salvage chemotherapy, followed by mobilization of PBSC with cyclophosphamide and conditioning with BEAM (BCNU, etoposide, Ara-C and melphalan). Tem patients received the AHSCT, with 7 complete and 2 partial remissions. Six patients maintained remission after 8 months of follow-up. (Re A, et al. J Clin Oncol 2003) A retrospective study in France in relapsed HIV-related NHL showed that, after AHSCT, 10 out of 14 patients achieved complete remission. After a median follow-up of 25months, 5/15 patients were alive. (Gabarre J, et al. Haematologica 2004) Recently, the group from City of Hope published a trial where 20 patients with high-risk features, in relapse or refractory, with AHSCT. With a median follow-up of more than 2.5 years, 17 out of 20 were alive in remission and toxicity was low.(Krishnan A, et al. Blood 2005)
Recently trial listed above pointed to AHSCT as a valuable alternative to treat high-risk or relapsed HIV-related NHL. Its results are far superior compared to salvage chemotherapy only. Nevertheless, this results must be taken with caution. This series are relatively small and non-controlled trials. A randomized and larger clinical trial is needed.
Publication Dates
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Publication in this collection
06 Jan 2006 -
Date of issue
Oct 2005
