Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Follicular non-Hodgkin lymphoma: long-term results of stem-cell transplantation Paul M. Barr and Hillard M. Lazarus Introduction Follicular lymphoma is the most common indolent non- Hodgkin lymphoma (NHL) and demonstrates a pattern of multiple relapses in nearly all patients. Recent advances in immunotherapy, however, may be changing the anticipated patient outcome for this disease and may improve the overall survival (OS) for this population [1,2]. In recent years, hematopoietic stem-cell transplantation (SCT) has become a safer and more efficacious therapy. Survival advantages have been demonstrated in some patients who received high-dose chemotherapy with autologous stem-cell transplantation (autoSCT). In addition, allogeneic stem-cell transplantation (alloSCT) offers the possibility of cure and reduced-intensity con- ditioning (RIC) makes this procedure more applicable to the older population afflicted with follicular lymphoma. We review the recent advances in autoSCT and alloSCT and discuss long-term results. Autologous stem-cell transplantation AutoSCT is the treatment of choice in patients with relapsed, aggressive NHL, but the role of this modality in follicular lymphoma is less clear. In theory, application of this therapy early in the disease course would seem to predict for greater efficacy. When compared with historic controls, encouraging phase II results support this [3–7]. Subsequent randomized phase III trials, however, have produced mixed results and are depicted (Table 1) and discussed below. Two groups reported a low treatment-related mortality (TRM) and a marked improvement in progression-free survival (PFS) for autoSCT as compared with maintenance interferon-a and standard therapy, respectively [8,9]. No OS advantage was noted, however, primarily due to an increase in secondary malignancies in the autoSCT arm, most commonly myelodysplastic syndrome (MDS) and acute myelogenous leukemia (AML). In the largest of the three prospective randomized trials, the Groupe d’Etude des Lymphomes de l’Adulte demonstrated no difference in event-free survival or OS between patients transplanted in first remission versus those treated with maintenance interferon-a [10]. The European Group for Blood and Marrow Transplan- tation (EBMT) Lymphoma Working Party completed Department of Medicine, Case Comprehensive Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio, USA Correspondence to Hillard M. Lazarus, MD, FACP, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA Tel: +1 216 844 3629; fax: +1 216 844 5979; e-mail: hillard.lazarus@case.edu Current Opinion in Oncology 2008, 20:502–508 Purpose of review Hematopoietic stem-cell transplantation is an effective treatment option for follicular lymphoma. This review summarizes recent updates of the literature focusing on the available long-term follow-up of high-dose therapeutic approaches. Recent findings Autologous transplantation can prolong overall survival in relapsed disease and can extend progression-free survival in first remission. With more than 10 years of follow-up, the survival curves demonstrate a plateau indicating a potential cure in certain patients. Use of allogeneic transplantation may result in cure as well, but has been plagued by high treatment-related mortality rates when myeloablative conditioning is used. The decreased toxicity of reduced-intensity conditioning is more applicable to the older follicular lymphoma population, but long-term follow-up data are lacking. Summary For selected patients, both autologous and allogeneic transplantation offer the possibility of prolonged survival and can result in a cure in up to 25 – 45% of cases. It is unclear whether to incorporate monoclonal antibody or radioimmunoconjugate therapy. Stem-cell transplantation should at least be considered in patients younger than 60 years, possibly early in the disease course. Late consequences such as an increased risk of second malignancy may compromise this approach and close patient follow-up is essential. Keywords allogeneic transplantation, autologous transplantation, follicular lymphoma Curr Opin Oncol 20:502–508 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-8746 1040-8746 ß 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins