Impact of Risk Factors on Long-Term Survival and Post-Transplant Failure Management in 200 Aggressive Non-Hodgkin Lymphoma Patients Who Underwent High-Dose Chemotherapy and Autologous Stem Cell Transplantation.
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Patients with diffuse large B-cell lymphoma (DLBCL) or aggressive non-Hodgkin lymphoma (NHL) who are refractory or relapse after anthracycline-based chemotherapy may still benefit from high-dose chemotherapy (HDC) and autologous stem cell transplantation (auto-SCT). Patients failing HDC auto-SCT have dismal outcomes. We report the outcomes of HDC auto-SCT, post-transplant treatment failure, and the impact of diverse prognostic factors in patients with DLBCL and aggressive NHL treated at our institution. This retrospective, single-institution cohort study, approved by the Institutional Research/Ethics Committee. Fifteen factors were subjected to univariate analysis, followed by multivariate analysis. Outcomes were analyzed using the Fine and Gray competing risk model, a regression model, and the Kaplan-Meier method (KM) for survival analysis. The research included 200 consecutive NHL patients, of whom 169 (84.5%) had DLBCL. The cohort comprised 127 (63.5%) males, with 87 (43.5%) classified as refractory and 37 (18.5%) experiencing relapse within 12 mo. All patients underwent HDC auto-SCT between 1996 and 2019. The median age at transplantation was 41.8 yr, with a median follow-up of 103 mo. Disease status after salvage chemotherapy and before HDC auto-SCT was as follows: complete remission (CR) in 103 (51.5%) patients, partial remission (PR) in 93 (46.5%), and no response/stable disease in 5 (2.5%) patients. Post-transplant, disease status was continuous CR in 97 (48.5%) patients, CR/CR-unconfirmed in 56 (28%) patients, PR in 9 (4.5%), progressive disease (PD) in 35 (37.5%) patients, and other statuses in 3 patients. KM-estimated overall survival (OS) at 12, 24, 36, 60, and 120 mo was 75%, 63.8%, 59.7%, 55.2%, and 53.9%, respectively. At the last follow-up, 107 (53.5%) patients were alive. Multivariate analysis identified three significant adverse risk factors for disease-related death: disease status before HDC-no CR (HR = 2.2, CI = 1.1 to 3.7, P = .002), spleen involvement (HR = 1.8, CI = 1.1 to 2.9, P = .01), and extranodal involvement (HR = 1.68, CI = 1 to 2.8, P = .05). Five-year OS for patients with 0 to 1 (63.5%), 2 (51.3%), and 3 (14.8%) risk factors was highly significant (P < .0008). The cumulative incidence of death for patients with 0 to 1, 2, and 3 risk factors was 22.3%, 36.2%, and 85.25%, respectively (P < .001). The median OS for 82 patients who failed SCT was 5.4 mo: 67%:48%:31%:22%:15%:15% at 3:6:12:18:24:60 mo, respectively. For these 82, treatment failures were: 7 (8.5%) persistent/residual disease, 34 (41.5%) PD, and 41 (50%) relapsed disease. Only 17 (20.7%) achieved CR after post-HDC treatment interventions. A total of 32 of 34 patients with PD, 3 of 7 with persistent disease, and 34 of 41 with relapsed disease have died. Only 13 of 82 (15.9%) patients remain alive. A total of 13 patients underwent a second SCT. OS for relapsed disease (9 mo) versus PD disease (3.2 mo) was significant (P = .030). Three t-MDS and 5 other malignancies were observed. Despite their high-risk status, these patients demonstrated encouraging survival following HDC auto-SCT. Prognostic factors can help predict survival, and high-risk patients may benefit from emerging treatment strategies and clinical trials.