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World Lymphoma Awareness Day 2017
15/09/2017
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Small Things Making A Difference In Transplantation

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The majority of patients with malignant lymphoma may be treated successfully with chemotherapy combined with immunological agents such as antibodies. However, it is recognised that for some patients undergoing intensive chemotherapy and a bone marrow transplant may represent their best treatment option. Emerging data over the last year has described how relatively minor changes to transplant protocols may have profound effects on the success of this therapy.

For example, for many years it has been recognised that high dose therapy followed by an autologous stem cell transplant for patients with relapsed follicular lymphoma may lead to prolonged remissions of the disease and potentially cure. However, between 50 and 80% of patients will relapse and require further therapy. By administering just 4 infusions of Rituximab antibody therapy in the months following the transplant researchers have shown that the chance of relapse may be significantly reduced. At the last ICML meeting in Lugano researchers described how at 12 years following the transplant 58% of patients remained alive and in remission with this approach. It is anticipated that with even longer follow up very few of these patients will relapse and thus prove to be cured. For patients that did not receive the Rituximab only 30% remained in remission at this time. The extra 4 infusions of Rituximab were also very well tolerated with minimal side effects making this a very attractive treatment option. 

Another challenging area in transplantation has been the identification of suitable donors when an allogeneic transplant (transplantation of bone marrow from a donor) is required. The best donor is a matched brother or sister but only 20-30% of patients (depending on the number of brothers and sisters) find themselves in this fortunate situation. When a matched family donor is not available the international bone marrow donor registries are searched for a matched unrelated donor. However, despite there being in excess of 16 million registered bone marrow donors around the world the chance of finding a suitably matched and healthy unrelated donor varies between 25 and 70% depending on the ethnic origin of the patient. In an attempt to broaden the availability of donors researchers have for many years studied using half matched family members, so called haploidentical donors. This form of transplantation has however been hazardous due to the greater degree of mismatch between donor and recipient leading to a greater risk of rejection, graft versus host disease and infection. However, a recent improvement to the transplant protocol whereby the patients receive just one or two days of extra chemotherapy following the transplant (so called “post transplant cyclophosphamide”) has resulted in a significant reduction in the toxicity of haploidentical transplants. A number of different research groups have recently published data suggesting that the outcome of haploidentical transplants when this technique is used may result in outcomes as good as those seen when a matched family donor is used. Given that almost every single patient will have available at least one half matched family donor (which may be a parent, a brother or sister or a child), this form of transplantation makes allogeneic transplantation available for almost all patients irrespective of their ethnicity. So this one small change in a transplant protocol may enable the universal provision of allogeneic donors.

These improvements in transplant practice for lymphoma patients have come about through careful research and it is vitally important we continue to support such endeavours for the benefit of future patients.


Silvia Montoto and Stephen Robinson
EBMT Lymphoma Working Party

 

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