Intensive therapy for non-Hodgkin lymphoma: indications and modalities

Widening indications: Intensive therapy is being used more and mere often for non-Hodgkin lymphoma (NHL) since the publication of 2 prospective randomized studies. This therapeutic approach is indicated in case of recurrence in chemosensitive cases and in << high-risk >> NHL. Other indications are under study for partial responders and non-responders to first line treatment, follicular and mantle lymphomas, and high-grade lymphomas such as Burkitt's lymphoma and anaplastic lymphoma. No randomized study of these lymphoid diseases is available and most reports concern case studies examining treatment feasibility or comparisons with historical series. No definitive conclusion can be drawn as to the therapeutic impact of intensifying treatment protocols. Multiple protocols: Hematopoietic stem cells can be obtained from peripheral blood or bone marrow. The number of peripheral stem cells required caries from 15-20 x 10(4) CFU-GM/kg and 1-3 x 10(6) CD34+/kg. Several protocols are used to mobilize peripheral stem cells: chemotherapy alone, chemotherapy with hematopoietic growth factors or hematopoietic growth factors alone. Peripheral stem cells are being used more widely in intensification protocols. Compared with bone marrow stem cells, use of peripheral stem cells can shorten hospital stay and the period of neutropenia and reduce the number of transfusions needed. Preparation: Several techniques are used. Alternatives include total body irradiation, and use of etoposide, thiotepa or mitoxantrone. In vitro treatment of the graft (ex vivo chemotherapy, anti-CD34+ monoclonal antibodies) should allow a reduction in tumoral contamination with peripheral stem cells but could also affect the reconstitution of hematopoietic capacity. Perspectives: Two therapeutic trials have demonstrated the usefulness of intensive therapy in NHL. Other studies are needed to possibly extend indications for autografts and evaluate different treatment modalities. (C) 1998, Masson, Paris.