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Introduction Patients with Hodgkin (HL) or Non-Hodgkin Lymphoma (NHL) who have either bulky masses at relapse or residual disease post salvage therapy, have poor outcome even after autologous stem cell transplantation (ASCT). Involved field radiotherapy (IFRT) to the bulky/residual disease sites is widely used to minimize the risk of relapse post ASCT. However, the proper time for IFRT remains controversial. IFRT delivery before ASCT could cause toxicity which might delays the ASCT increasing the risk of disease progression. Moreover, the pre-ASCT IFRT may also damages the marrow niche impairing thus the engraftment. On the contrary, the IFRT early after ASCT as adjuvant therapy (adj-IFRT) offers the advantage of irradiation delivery after sufficient disease response, without affecting the engraftment, maximizing potentially a favorable outcome, with lower irradiation in restricted areas. Aim In this study we sought to investigate the safety and the efficacy of the adj-IFRT in autografted patients for relapsed/refractory HL or NHL. Methods We evaluated retrospectively 23 patients (HL=12, NHL=11), aged of 34(16-76) years, who underwent ASCT, for primary refractory (n=15) or relapsed (n=8) disease, and received adj-IFRT post ASCT. They had previously salvaged with a median of 2 lines of therapy. Patients with bulky mass at relapse or localized residual disease post salvage treatment, were candidates for adj-IFRT. Results All patients had chemosensitive disease before ASCT. However, 15(80%) had residual disease while 4(20%) were in complete remission. The preparative regimens were: single agent Melphalan (n=9), Busulfan-Etoposide-Melphalan (n=7), BEAM (n=4) and Bendamustin-Etoposide-Cytarabine-Melphalan (n=3). Filgrastim was given at 5mcg/kg after the 5th day of graft infusion till neutrophills recovery, while anti–bacterial, -fungal, -viral and –PCP prophylaxis were administered from the conditioning regimen initiation till the completion of adj-IFRT. The engraftment was successful. No patient had any toxicity or active infection before adj-IFTR. Though we planned to give adj-IFRT within 3 months post ASCT, finally it was delivered after a median of 4,5 (2-7) months; the median irradiation dose was 30 (24-36) Gy The adj-IFRT was well tolerated. No patient experienced toxicity grade>3 and none required hospitalization. Currently, 19/23 patients are alive and well; the 5-ys overall and progression free survival rates are 70% and 64% respectively. Four patients died; 2 due to relapsed disease and 2 heavily pretreated patients due to secondary myelodyspalstic syndrome. Conclusion In this study, the use of adj-IFRT post ASCT was well tolerated and safe. The promising survival rates in these poor risk patients suggest that the adj-IFRT is also an effective approach. Well designed clinical trials are needed to clarify the role of adj-IFRT in the ASCT setting. |
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