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Should high risk NHL get
upfront autologous SCT??
Didier Blaise, MD
AUBHO 2015,Bangkok
August, 28th, 2015
20-year long question
• 1995: Auto BMT vs Salvage Chemotherapy in
relapsed chemo-sensible NHL; NEJM, T Philip et al
• 2000: LNH 87.2 Protocol: JCO, V Haioun et al
• 2000-2012: Phases 2 and Meta-analyses
• 2013: auto transplantation as consolidation for
agressive NHL; NEJM, P Stiff et al
LNH 87.2
3C Haioun et al, JCO, 2000
HD chemo with auto-SCT in 1rst-line treatment of aggressive
NHL– Results of a comprehensive meta-analysis
4
Event Free Survival Overall Survival
A Greb et al, Cancer Treat Rev, 2007
CONCLUSIONS
• No evidence that HDCT improved OS and EFS in
good risk NHL patients.
• The evidence for poor risk patients is inconclusive.
• HDCT
– should not be further investigated in good risk patients
with aggressive NHL
– but high quality studies in poor risk patients are
warranted.
5
A Greb et al, Cancer Treat Rev, 2007
Auto HSCT as Consolidation
for Aggressive NHL
6
P Stiff et al, NEJM, 2013
Auto Transplantation as Consolidation for
Aggressive NHL
7
P Stiff et al, NEJM, 2013
Auto Transplantation as Consolidation for
Aggressive NHL
8
P Stiff et al, NEJM, 2013
Auto Transplantation as Consolidation for
Aggressive NHL
9
P Stiff et al, NEJM, 2013
Auto Transplantation as Consolidation for
Aggressive NHL
10
P Stiff et al, NEJM, 2013
32%
Auto Transplantation as Consolidation for
Aggressive NHL
• Early auto-SCT among high-intermediate or High
Risk NHL
– Higher EFS
– Not different OS
• Impact of salvage therapy
• Early auto-SCT for High Risk NHL
– Higher EFS
– Higher OS
– But low number of patients
11
P Stiff et al, NEJM, 2013
Long-term follow-up of Auto SCT
12
BT Hill et al, BJH, 2011
Long-term follow-up of Auto SCT
13
BT Hill et al, BJH, 2011
CONCLUSION
• International Prognostic index: useful
– Good Risk: no indication of early auto-SCT
– Intermediate risk: no indication of early auto-SCT
– High risk: to be further investigated
• Clinical trials
• Other prognostic factors?
14
Prognostic impact of pre-transplant computed
tomography and 67gallium scanning in chemosensitive
DLBC NHL in pts undergoing HSCT
15
I Escobar et al, Ann Nucl med, 2008
Prognostic significance of interim 18F-FDG
PET/CT after 3 or 4 cycles of R-CHOP
chemotherapy in the trt of DLBC NHL
16
DH Yang et al, EUR J Cancer, 2011
Concurrent Expression of MYC and BCL2 in
DLBC NHL Treated With RCHOP
17
N Johnson et al, JCO, 2012
CONCLUSION
• International Prognostic index: useful
– Good Risk: no indication of early auto-SCT
– Intermediate risk: no indication of early auto-SCT
– High risk: to be further investigated
• Clinical trials
• Other prognostic factors
– Pet-scan
– MYC/BCL2 expression
• Auto SCT is not sufficient when no chemo-
sensibility
18
Tandem Transplantations in Lymphoma
Best of Both Worlds
19
N Gosh, BBMT, 2015
YB Chen, BBMT, 2015
Tandem Transplantations in Lymphoma
Best of Both Worlds
20
N Gosh, BBMT, 2015
YB Chen, BBMT, 2015
Post-Transplant Immunommodulation
21
Current Recommandations
22
23
A Sureda et al, BMT, 2015
24
N Majhail et al, BBMT, 2015
CONCLUSION
• International Prognostic index: useful
– Good Risk: no indication of early auto-SCT
– Intermediate risk: no indication of early auto-SCT
– High risk: to be further investigated
• Clinical trials
• Other prognostic factors
– Pet-scan
– MYC/BCL2 expression
• Auto SCT is not sufficient when no chemo-sensibility
– Tandem auto-allo
– Post-Transplant immunomodulation
25
26

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Upfront AutoSCT in High Risk NHL

  • 1. Should high risk NHL get upfront autologous SCT?? Didier Blaise, MD AUBHO 2015,Bangkok August, 28th, 2015
  • 2. 20-year long question • 1995: Auto BMT vs Salvage Chemotherapy in relapsed chemo-sensible NHL; NEJM, T Philip et al • 2000: LNH 87.2 Protocol: JCO, V Haioun et al • 2000-2012: Phases 2 and Meta-analyses • 2013: auto transplantation as consolidation for agressive NHL; NEJM, P Stiff et al
  • 3. LNH 87.2 3C Haioun et al, JCO, 2000
  • 4. HD chemo with auto-SCT in 1rst-line treatment of aggressive NHL– Results of a comprehensive meta-analysis 4 Event Free Survival Overall Survival A Greb et al, Cancer Treat Rev, 2007
  • 5. CONCLUSIONS • No evidence that HDCT improved OS and EFS in good risk NHL patients. • The evidence for poor risk patients is inconclusive. • HDCT – should not be further investigated in good risk patients with aggressive NHL – but high quality studies in poor risk patients are warranted. 5 A Greb et al, Cancer Treat Rev, 2007
  • 6. Auto HSCT as Consolidation for Aggressive NHL 6 P Stiff et al, NEJM, 2013
  • 7. Auto Transplantation as Consolidation for Aggressive NHL 7 P Stiff et al, NEJM, 2013
  • 8. Auto Transplantation as Consolidation for Aggressive NHL 8 P Stiff et al, NEJM, 2013
  • 9. Auto Transplantation as Consolidation for Aggressive NHL 9 P Stiff et al, NEJM, 2013
  • 10. Auto Transplantation as Consolidation for Aggressive NHL 10 P Stiff et al, NEJM, 2013 32%
  • 11. Auto Transplantation as Consolidation for Aggressive NHL • Early auto-SCT among high-intermediate or High Risk NHL – Higher EFS – Not different OS • Impact of salvage therapy • Early auto-SCT for High Risk NHL – Higher EFS – Higher OS – But low number of patients 11 P Stiff et al, NEJM, 2013
  • 12. Long-term follow-up of Auto SCT 12 BT Hill et al, BJH, 2011
  • 13. Long-term follow-up of Auto SCT 13 BT Hill et al, BJH, 2011
  • 14. CONCLUSION • International Prognostic index: useful – Good Risk: no indication of early auto-SCT – Intermediate risk: no indication of early auto-SCT – High risk: to be further investigated • Clinical trials • Other prognostic factors? 14
  • 15. Prognostic impact of pre-transplant computed tomography and 67gallium scanning in chemosensitive DLBC NHL in pts undergoing HSCT 15 I Escobar et al, Ann Nucl med, 2008
  • 16. Prognostic significance of interim 18F-FDG PET/CT after 3 or 4 cycles of R-CHOP chemotherapy in the trt of DLBC NHL 16 DH Yang et al, EUR J Cancer, 2011
  • 17. Concurrent Expression of MYC and BCL2 in DLBC NHL Treated With RCHOP 17 N Johnson et al, JCO, 2012
  • 18. CONCLUSION • International Prognostic index: useful – Good Risk: no indication of early auto-SCT – Intermediate risk: no indication of early auto-SCT – High risk: to be further investigated • Clinical trials • Other prognostic factors – Pet-scan – MYC/BCL2 expression • Auto SCT is not sufficient when no chemo- sensibility 18
  • 19. Tandem Transplantations in Lymphoma Best of Both Worlds 19 N Gosh, BBMT, 2015 YB Chen, BBMT, 2015
  • 20. Tandem Transplantations in Lymphoma Best of Both Worlds 20 N Gosh, BBMT, 2015 YB Chen, BBMT, 2015
  • 23. 23 A Sureda et al, BMT, 2015
  • 24. 24 N Majhail et al, BBMT, 2015
  • 25. CONCLUSION • International Prognostic index: useful – Good Risk: no indication of early auto-SCT – Intermediate risk: no indication of early auto-SCT – High risk: to be further investigated • Clinical trials • Other prognostic factors – Pet-scan – MYC/BCL2 expression • Auto SCT is not sufficient when no chemo-sensibility – Tandem auto-allo – Post-Transplant immunomodulation 25
  • 26. 26