Low-grade lymphoma: The optimal timing

Abstract 

The median survival of patients with follicular lymphoma (FL), the most frequent low-grade non-Hodgkin's lymphoma, is 7 to 10 years with most patients exhibiting a pattern of relapsing disease and increasing drug resistance. The subset with poorest prognostic features, however, has a median survival of less than 2 years. The failure of conventional chemotherapy to cure such patients has led to the evaluation of high-dose therapy (HDT) and hemopoietic stem cell transplantation. Although no large randomized trials have been performed, historical comparisons within individual centers as well as registry analysis appear to support HDT with autologous stem cell support in patients with relapsed and refractory FL. Appropriate patient selection on the basis of prognostic markers as well as transplantation earlier in the course of the disease have been identified as key issues that predict the success of transplantation in these patients. HDT with autologous support as part of planned initial therapy or in first remission has also been the subject of a number of studies including at least two large randomized trials. Although preliminary analyses suggest an advantage in the HDT approach, longer follow-up will be required before definitive conclusions can be drawn. A variety of purging strategies have been evaluated for autologous transplants but results are still inconclusive. Allogeneic transplantation is an option for selected patients, although its wider application is restricted by transplant-related complications. Experience with nonmyeloablative conditioning strategies is limited, and as yet the expectation of a reduction of transplant-related morbidity and mortality remains to be demonstrated.