Abstract
AbstractThe relative efficacy of autologous hematopoietic cell transplant (auto-HCT) vs chimeric antigen receptor T-cell (CAR-T) therapy in patients with diffuse large B-cell lymphoma (DLBCL) who achieve a partial remission (PR) after salvage chemotherapy is not known. Using the Center for International Blood & Marrow Transplant Research registry database, we identified adult patients with DLBCL who received either an auto-HCT (2013-2019) or CAR-T treatment with axicabtagene ciloleucel (2018-2019) while in a PR by computed tomography or positron emission tomography scan. We compared the clinical outcomes between the 2 cohorts using univariable and multivariable regression models after adjustment for relevant baseline and clinical factors. In the univariable analysis, the 2-year progression-free survival (52% vs 42%; P = .1) and the rate of 100-day nonrelapse mortality (4% vs 2%; P = .3) were not different between the 2 cohorts, but consolidation with auto-HCT was associated with a lower rate of relapse/progression (40% vs 53%; P = .05) and a superior overall survival (OS) (69% vs 47%; P = .004) at 2 years. In the multivariable regression analysis, treatment with auto-HCT was associated with a significantly lower risk of relapse/progression rate (hazard ratio = 1.49; P = .01) and a superior OS (hazard ratio = 1.63; P = .008). In patients with DLBCL in a PR after salvage therapy, treatment with auto-HCT was associated with a lower incidence of relapse and a superior OS compared with CAR-T. These data support the role of auto-HCT as the standard of care in transplant-eligible patients with relapsed DLBCL in PR after salvage therapy.
Highlights
Diffuse large B-cell lymphoma (DLBCL) is a curable disease, and ~60% of patients do not require further treatment after an initial anthracycline-based and rituximab-containing regimen
(1) The current standardof-care for fit patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL), including for patients with early therapy failure, comprises treatment with an alternative salvage regimen(s) followed by high-dose chemotherapy and autologous hematopoietic cell transplant consolidation in those who achieve either complete remission (CR) or partial remission (PR).(2-4) While there seems to be a universal agreement in this approach for patients who achieve a CR, the practice is less uniform in the case of PR patients since they are potential candidates for chimeric antigen receptor T-cell (CAR-T) therapy.[5,6,7]
Other common causes were infections (6%) and organ failure (4%) in the auto-HCT group and infections (4%), cytokine release syndrome (4%), organ failure (4%), and malignancies (4%) in the chimeric antigen receptor T-cells (CAR-T) group. In this retrospective analysis using the CIBMTR registry, we compared the outcomes of patients with DLBCL treated with auto-HCT or CAR-T therapy while in a PR after the last therapy line
Summary
Diffuse large B-cell lymphoma (DLBCL) is a curable disease, and ~60% of patients do not require further treatment after an initial anthracycline-based and rituximab-containing regimen. Ongoing randomized trials in the subset of DLBCL patients with early treatment failure are comparing salvage therapy followed by auto-HCT consolidation in responding patients versus (vs.) proceeding directly with CAR-T treatment without attempting salvage therapy (NCT03570892, NCT03575351, and NCT03391466) These trials are not designed to address the management of DLBCL patients already achieving a PR in response to salvage therapies. Conclusions: In patients with DLBCL in a PR after salvage therapy, treatment with auto-HCT was associated with a lower incidence of relapse and a superior OS compared with CAR-T These data support the role of auto-HCT as the standard-of-care in transplant-eligible patients with relapsed DLBCL in PR after salvage therapy.
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