Autologous hematopoietic stem cell transplantation (HSCT) is the most appropriate treatment option for patients with recurrent Hodgkin lymphoma, particularly those who achieve a complete response to salvage chemotherapy. Prospective trials have consistently demonstrated a survival advantage when patients with chemotherapy-sensitive disease are treated with autologous HSCT compared with patients treated with continued salvage chemotherapy. Because this patient has achieved a complete remission following two cycles of dexamethasone, ifosfamide, cisplatin, and etoposide (DICE) chemotherapy, the next step is to administer hematopoietic growth factors, with or without chemotherapy, to mobilize, collect, and store hematopoietic progenitor cells. Once a sufficient quantity of hematopoietic progenitor cells are collected (>3 million CD34+ cells/kg patient body weight), high-dose multiagent chemotherapy followed by reinfusion of the stored progenitor cells can be completed.
Allogeneic HSCT is not indicated for patients with chemotherapy-sensitive recurrent Hodgkin lymphoma because of the significant risk of morbidity and mortality associated with allogeneic transplantation. The risk for fungal and viral infections occurring 3 months or more after transplantation is significantly greater after allogeneic than autologous transplantation. Lymphocytes derived from the donor can mount an immune response to the recipient's organs, leading to graft-versus-host disease, which may affect the skin, gastrointestinal tract, liver, ocular adnexa, lungs, bone marrow, and soft tissues. However, in patients with chemotherapy-resistant recurrent Hodgkin lymphoma, including patients who develop a relapse after autologous HSCT, allogeneic HSCT may result in prolonged disease-free survival.
Continuation of DICE chemotherapy is not optimal treatment for this patient because, as noted, patients with chemotherapy-sensitive Hodgkin lymphoma who are treated with autologous HSCT have a survival advantage compared with patients treated with continued salvage chemotherapy.
Radiation therapy in the salvage setting can be effective for patients with limited disease and may be associated with long-term disease-free survival. However, radiation therapy is much less likely to result in long-term disease-free survival in patients with advanced recurrent disease. In addition, radiation therapy would adversely affect the hematopoietic stem cells in patients being considered for autologous HSCT.