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Diffuse large B-cell lymphoma: the challenge of relapse after an autologous stem cell transplant

Bone Marrow Transplantation volume 52, pages 199–200 (2017)Cite this article

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Patients with diffuse large B-cell lymphoma (DLBCL) relapsing after, or refractory to contemporary first-line immunochemotherapy have a poor prognosis.1 For transplant-eligible patients the standard of care has been to induce a response to non-cross-resistant salvage therapy, harvest autologous stem cells, and proceed to high-dose therapy (HDT) and an autologous stem cell transplant (autoSCT).2 The results achieved with this paradigm are, however, disappointing. Failure to respond to salvage induction results in only half of the patients proceeding to HDT, and then a half of the transplanted patients will relapse within 2 years of the procedure.3, 4, 5 Management of patients failing at each of these hurdles remains challenging.

In this issue of Bone Marrow Transplantation, Van Den Neste et al.6 describe the outcome of the 75 patients who relapsed after HDT and an autologous stem cell transplant performed as part of the CORAL trial. Not surprisingly, the prognosis was poor, with a median overall survival (OS) from relapse of 10 months. An early relapse, a high IPI at relapse and failure to achieve at least a partial response to subsequent salvage therapy were all predictors of a worse OS. While this study is subject to the limitations of a retrospective subgroup analysis, it does provide important descriptive data outlining the outcome of patients who have received the current standard of care for relapsed DLBCL. Management of these patients represents an important unmet medical need and there is currently no uniform therapy employed. Options for these patients include palliation, conventional salvage induction, recruitment into clinical trials of novel agents and consolidation with a reduced intensity allogeneic SCT (alloSCT) in selected cases. It is encouraging that 33 (44%) patients in this report responded to a third-line salvage regimen that had been selected on an individual patient basis. It is not clear, however, which third-line regimen is optimal, but these results should be built upon by developing salvage strategies that incorporate conventional and novel targeted agents and immunotherapeutics. A wide array of B-cell receptor inhibitors, monoclonal antibodies, immune checkpoint inhibitors and chimeric antigen receptor-modified T cells are undergoing evaluation in B-cell malignancies. Many of these agents offer novel mechanisms of action and are associated with minimal myelotoxicity, making them ideal agents to use in the relapse post-autoSCT setting. However, identifying the optimal salvage regimen can only be achieved through clinical studies and recruitment to trials is recommended.

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  1. Department of Haematology, Bone Marrow Transplant Unit, University Hospital Bristol NHS Foundation Trust, Bristol, UK

    S P Robinson

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Correspondence to S P Robinson.

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Robinson, S. Diffuse large B-cell lymphoma: the challenge of relapse after an autologous stem cell transplant. Bone Marrow Transplant 52, 199–200 (2017). https://doi.org/10.1038/bmt.2016.292

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