Autologous Stem Cell Transplantation Is Feasible and of Potential Benefit In Very Elderly Patients with Lymphoma and Limited Comorbidities

In patients with Hodgkin lymphoma (HL) and non-Hodgkin's lymphoma (NHL) for whom initial therapy is not curative, high dose chemotherapy followed by autologous stem cell transplantation (AutoSCT) may offer a second chance for cure or long term remission. Because of the potential toxicities of this therapy, elderly patients are usually not considered candidates for this approach. Although recent publications have suggested that AutoSCT may benefit some patients over 65 years of age, data regarding feasibility in older patients (69 or greater) are lacking.

The stem cell transplant database at Weill Cornell Medical College was reviewed to identify patients with a diagnosis of lymphoma (HL or NHL) age 69 or greater who had undergone AutoSCT. Patients were included if age, date of transplant, response and survival data were available. Baseline Charlson comorbidity risk index (CCI) was calculated and correlated with outcome.

Twenty-one patients aged 69 or greater (range 69–86, median 71) with adequate records were identified who underwent autologous stem cell transplantation for treatment of lymphoma. Thirteen patients had diffuse large B cell lymphoma, 3 had transformed indolent lymphoma, 2 had Burkitt lymphoma, one had peripheral T cell lymphoma, one had follicular lymphoma, and one had HL. Sixteen patients underwent AutoSCT in first relapse with chemotherapy sensitive disease, 2 patients had primary refractory lymphoma, 2 were in 2^nd or greater relapse, and one patient was in first complete remission (CR). Two patients underwent total body irradiation (TBI) as part of conditioning, while the other 19 patients underwent conditioning with chemotherapy alone. Sixteen patients (76%) achieved CR following autoSCT, while 3 patients did not achieve CR; 2 patients died before response assessment could be undertaken. With median follow up of 20 months, the median progression-free survival following autoSCT was 10 months and median overall survival was 18 months. Age was associated with PFS (HR 1.18, p=0.05, 95% C.I. 1.05–1.33) but not OS (HR 1.11, p=0.09, 95% C.I. 0.98–1.25). Eight of 18 patients with adequate follow up (44%) remained in remission for at least 18 months post-transplant. CCI data were available for 19 patients. Four patients (19%) died within or shortly after 100 days, all of transplant-related toxicity. Two of these 4 patients were high risk by CCI, one was medium risk, and CCI data were not available for the fourth patient. Three other patients were of medium risk; 2 are alive in CR and one died of progressive lymphoma 19 months after transplantation. Thirteen patients were of low risk by CCI. Of these patients, 9 (69%) are either alive at time of follow up or survived for greater than one year after transplant, while 4 (31%) died within one year of progressive lymphoma.

Autologous stem cell transplantation is feasible and of potential benefit in selected elderly patients with lymphoma. Age alone need not exclude patients with good functional status and limited comorbidity from this therapeutic approach. Consideration of comorbidities may allow selection of patients most likely to tolerate and benefit from AutoSCT.

Furman:GlaxoSmithKline: Clinical research funding, Consultancy, Research Funding, Speakers Bureau; Genentech: Clinical Research Funding, Consultancy, Research Funding, Speakers Bureau; Cephalon: Speakers Bureau, Speakers bureau; Calistoga: Consultancy, Honoraria; Celgene: Clinical Research, Consultancy, Research Funding. Leonard:Hospira: Consultancy, Honoraria; Cell Therapeutics: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; GlaxoSmithKline: Consultancy, Honoraria; Biogen IDEC: Consultancy, Honoraria; Calistoga: Consultancy, Honoraria; Johnson and Johnson: Consultancy, Honoraria; EMD Serono: Consultancy, Honoraria; Sanofi Aventis: Consultancy, Honoraria; Millenium: Consultancy, Honoraria; Biotest: Consultancy, Honoraria; Cephalon: Consultancy, Honoraria; Pharmion: Consultancy, Honoraria; Eisai: Consultancy, Honoraria; Cougar Biotechnology: Consultancy, Honoraria; Immunomedics: Honoraria; Genentech: Consultancy, Honoraria; Novartis: Consultancy, Honoraria.