Autologous stem cell transplantation in treatment of aggressive non-Hodgkin's lymphoma

There is no doubt that autologous stem cell transplantation is useful for patients with relapsed aggressive non-Hodgkin's lymphoma if they are responsive to the chemotherapy given before the transplantation. A small subset of patients with primary refractory disease still profits from this high dose chemotherapy regimen, but only if chemosensitive and if presenting with favorable risk factors at the moment of transplant eligibility. Autologous stem cell transplantation as upfront first line therapy for patients with aggressive non-Hodgkin's lymphoma does not contribute to a better outcome, most certainly not if it concerns patients with a favorable risk profile. There is still some doubt whether there is any place for autologous stem cell transplantation as first line therapy for patients with all unfavorable risk profile. Most randomized studies do not show an advantage, but more data are needed to definitely assess the place for this therapy option

Therapy for stage I aggressive non-Hodgkin's lymphoma

Although radiotherapy was considered sufficient for stage I and limited stage II aggressive non-Hodgkin's lymphoma in the past, new data from randomized studies have shown that intensified chemotherapy or combined modality therapy (multiagent chemotherapy followed by involved field radiotherapy) can result in complete remission in 75-90% of the cases, with 5-year overall survival ranging between 82% and 89%. However, not all patients benefit from this management. Patients above 60 years of age, with high lactate dehydrogenase concentration, poor performance, or extranodal disease localized in the testis or central nervous system have a much worse outcome. Therefore, typical extranodal character of this disease (40-57% of the patients show a primary extranodal localization) needs to be recognized and therapy adapted to these subcategories

Treatment of initial parenchymal central nervous system involvement in systemic aggressive B-cell lymphoma

Central nervous system (CNS) involvement in systemic B-cell non-Hodgkin lymphoma (B-NHL) at diagnosis (sysCNS) is rare. We investigated the outcome of 21 patients with sysCNS, most commonly diffuse large B-cell lymphoma, treated with high dose methotrexate (HD-MTX) and R-CHOP. The median number of cycles of HD-MTX and R-CHOP was 4 (range 1–8) and 6 (range 0–8), respectively. Consolidative whole brain radiotherapy (WBRT) was given to 33% (7/21) patients. With a median follow-up of 44 months the 3-year progression free survival (PFS) and overall survival (OS) were 45% (95%CI 34–56%) and 49% (95%CI 38–60%), respectively. Over 90% of patients had an unfavorable international prognostic index score, reflected by treatment-related mortality of 19% (4/21) and relapse-related mortality of 28% (6/21). The outcome of these patients was, however, unexpectedly good when compared to secondary CNS relapses. Prospective studies are needed to define the optimal treatment for patients with sysCNS, but its rarity might be challenging