Classical Hodgkin's lymphoma: the Lymphoma Study Association guidelines for relapsed and refractory adult patients eligible for transplant

Abstract

The Hodgkin's Lymphoma Committee of the Lymphoma Study Association (LYSA) gathered in 2012 to prepare guidelines on the management of transplant-eligible patients with relapsing or refractory Hodgkin's lymphoma. The working group is made up of a multidisciplinary panel of experts with a significant background in Hodgkin's lymphoma. Each member of the panel of experts provided an interpretation of the evidence and a systematic approach to obtain consensus was used. Grades of recommendation were not required since levels of evidence are mainly based on phase II trials or standard practice. Data arising from randomized trials are emphasized. The final version was endorsed by the scientific council of the LYSA. The expert panel recommends a risk-adapted strategy (conventional treatment, or single/double transplantation and/or radiotherapy) based on three risk factors at progression (primary refractory disease, remission duration < 1 year, stage III/IV), and an early evaluation of salvage chemosensitivity, including (18)fluorodeoxy glucose-positron emission tomography interpreted according to the Deauville scoring system. Most relapsed or refractory Hodgkin's lymphoma patients chemosensitive to salvage should receive high-dose therapy and autologous stem-cell transplantation as standard. Efforts should be made to increase the proportion of chemosensitive patients by alternating non-cross-resistant chemotherapy lines or exploring the role of novel drugs.

Figure 1.

Definition of response to salvage chemotherapy: recommendations by the LySA HL committee.

Figure 2.

The suggested strategy for patients belonging to this group is tandem transplantation if chemosensitive to salvage therapy. Consolidation RT could be considered after transplantation in selected indications. ASCT is standardly recommended as second transplant. In selected patients, RIC-allo could be considered as second transplant procedure. Decision between tandem ASCT or a single ASCT followed by RIC-allo should be made individually taking into account risk factors, the benefit to risk ratio and donor availability (see text for more informations). HTD: high-dose therapy; ASCT: autologous stem cell transplantation; RIC-alloSCT: reduced intensity conditioning allogeneic transplantation; RT: radiotherapy.

Figure 3.

The suggested strategy for patients belonging to this group is single ASCT in patients chemosensitive to salvage therapy. For patients who achieve chemosensitivity only after ≥ third-line salvage chemotherapy, tandem ASCT could be considered. Consolidation RT could be considered after transplantation in selected indications. HTD: high-dose therapy; ASCT: autologous stem cell transplantation; RT: radiotherapy.

Figure 4.

The suggested strategy for patients belonging to this group is single ASCT in patients chemosensitive to salvage therapy. For selected chemosensitive patients with no additional RF such as relapse in a previously irradiated site, B symptoms or bulky relapse, a non-ASCT strategy could be considered with only RT in consolidation after salvage chemotherapy. For patients who have undergone ASCT, consolidation RT could be considered in selected indications. RF: risk factors; HTD: high-dose therapy; ASCT: autologous stem cell transplantation; RT: radiotherapy.