Cytotoxic Therapy with Hematopoietic Cell Transplantation in the Treatment of Hodgkin Lymphoma

Publication Date: March 14, 2015
Last Updated: March 14, 2022

Recommendations for ASCT for HL

ASCT should not be offered as first-line therapy for advanced disease. (1+, A)
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ASCT should be offered as first-line therapy for patients who fail to achieve CR. (2++, B)
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ASCT should be offered as salvage therapy over nontransplantation (except localized disease, where IFRT may be considered, or patients with low-stage disease and late relapse, where chemotherapy may be considered). (1+, A)
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ASCT should be offered to pediatric patients with primary refractory disease or high-risk relapse who respond to salvage therapy. (2++, B)
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Several salvage chemotherapy regimens may be considered before ASCT in adult patients. (2++, B)
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Several salvage chemotherapy regimens may be considered before ASCT in pediatric patients. (2++, B)
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BEAM or CBV are the most common conditioning regimens for ASCT in standard-risk patients. (2++, B)
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IFRT should be considered in patients with bulky disease not previously irradiated. (2+, C)
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Tandem ASCT is not routinely recommended in standard-risk patients. (2+, C)
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Maintenance therapy with brentuximab vedotin post-ASCT is recommended inhigh-risk patients. (1+, A)

High-risk patients were defined in the AETHERA trial as having 1 of the following: refractory to frontline therapy, relapse <12 months after frontline therapy, or relapse 12 months after frontline therapy with extranodal disease.

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Chemosensitive disease and negative functional imaging are associated with improved outcome.

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Recommendations for Allo-HCT for HL

Allo-HCT should be used instead of conventional therapy for relapse after ASCT. (2++, B)
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RIC is the recommended regimen intensity. (2++, B)
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All donor sources can be considered. (1+, A)
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DLI can be given for relapse or progressive disease (limited data for mixed donor chimerism). (2++, B)
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There are limited data for tandem ASCT/Allo-HCT. (4, D)
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Allo-HCT is preferred over ASCT as second HCT (except in late relapse). (2+, C)
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ASCT versus Nontransplantation Therapy

Should ASCT be offered as first-line therapy for advanced disease?

No (1+, A)
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Should ASCT be offered as first-line therapy for patients who fail to achieve a CR?

Yes (2++, B)
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Should ASCT or nontransplantation be offered as salvage therapy?

ASCT (1+, A)
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Additional Considerations for ASCT

What are common regimens of salvage therapy before ASCT in adult patients?

ICE, ESHAP, or GDP (2++, B)

More recent studies have incorporated brentuximab vedotin in the salvage setting (see text for details).

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What are common regimens of salvage therapy before ASCT in pediatric patients?

GV, IV (2++, B)
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What is the recommended conditioning regimen for ASCT?

BEAM, CBV, Bu/Cy (Et), Bu/Mel, or TLI/chemotherapy (2++, B)
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Is there a role for tandem ASCT?

Not in standard-risk patients (2+, C)
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What is the role of IFRT and when should it be performed?

Recommended in bulky disease previously not irradiated, post-ASCT in most centers (2+, C)
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Should maintenance therapy be given after ASCT?

Yes (1+, A)

Maintenance with brentuximab vedotin is recommended in high-risk patients, defined in the AETHERA trial as having 1 of the following: refractory to frontline therapy, relapse < 12 months after frontline therapy, or relapse 12 months after frontline therapy with extranodal disease.

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What is the role of comorbidities in outcomes?

Paucity of data (, )
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Should ASCT be offered to pediatric patients?

Yes

(2++, B)
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Prognostic Factors for ASCT

Which factors at relapse predict poor outcomes?

  • Anemia (hemoglobin < 10 g/dL)
  • Stage (III/IV)
  • Early relapse (<12 mo)
  • Systemic symptoms (B Sx)
  • Extranodal sites
  • Bulky disease at diagnosis
(2++, B)
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Which pre-ASCT factors predict better outcomes?

  • Chemosensitivity
  • CR or PR before transplant
  • Number of salvage regimens ≤2
(2+, C)
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What is the role of FDG-PET imaging?

Negative PET before transplant is associated with improved outcome. (2++, B)
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Allo-HCT in Patients with HL

Should allo-HCT be used instead of conventional therapy for patients who relapse after ASCT?

Yes (2++, B)
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What is the recommended regimen intensity?

RIC (2++, B)
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Is there a preferred donor source?

No (1+, A)
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When should DLI be given?

  • Progressive disease/ relapsed
(2++, B)
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  • Incomplete donor chimerism
(3, D)
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What is the role of comorbidities in outcomes?

Paucity of data (, )
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Autologous versus Allogeneic SCT

Should allo-HCT be performed instead of ASCT as first SCT?

No (2+, C)
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Should allo-HCT be performed instead of ASCT as second SCT in most patients?

Yes (2+, C)
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Should second ASCT be considered for patients who relapse after ASCT?

Not within 1 year (2+, C)
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Is there a role for tandem autologous-allogeneic HCT?

No (4, D)
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Prognostic Factors for Allo-SCT

Are there useful prognostic factors before allo-HCT?

Yes (2++, B)
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Is there a role for PET imaging?

To be determined (2+, C)
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Survivorship after Autologous or Allogeneic HCT

What is the long-term toxicity of ASCT?

  • Second malignancy
  • Organ impairment
  • Reduced quality of life
(2++, B)
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What is the long-term toxicity of allo-HCT?

Chronic graft-versus-host disease, organ impairment, reduced quality of life (2++, B)
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Are there guidelines for follow-up?

Yes
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Recommendation Grading

Disclaimer

Overview

Title

Role of Cytotoxic Therapy with Hematopoietic Cell Transplantation in the Treatment of Hodgkin Lymphoma

Authoring Organization

Publication Month/Year

March 14, 2015

Last Updated Month/Year

June 27, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D007938 - Leukemia, D006689 - Hodgkin Disease

Keywords

Hodgkin lymphoma, Allogeneic transplant, Hematopoietic cell transplantation, Autologous transplant

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
176
Literature Search Start Date
July 1, 2012
Literature Search End Date
April 1, 2013