The role of high-dose therapy and autologous bone marrow reinfusion in the treatment of Hodgkin's disease

In a significant fraction of patients with Hodgkin's disease, a condition develops that is resistant to conventional chemotherapy. Experience using high-dose chemotherapy, with or without TBI, and ABMR is expanding. In Hodgkin's disease, remissions can be achieved in approximately half of the patients with relapsed advanced disease. High-dose chemoradiotherapy regimens are toxic and require extensive supportive care. Relapse frequently occurs in areas of previous disease, which suggests failure of the conditioning regimen rather than infusion of occult tumor cells in the autologous bone marrow. Thus, the role of marrow purging in this therapy needs to be evaluated further. It is also important to evaluate the effects of more vigorous attempts at cytoreduction of bulky disease prior to high-dose therapy and ABMR. We recommend that high-dose therapy and ABMR in an investigational setting be used in patients with Hodgkin's disease who experience relapse after MOPP and ABVD or equivalent regimens. Toxicity can be decreased and efficacy increased only if therapy is administered to patients who have not been heavily pretreated and who have lower tumor burden and a good performance status. Finally, high-dose therapy with ABMR has a definite role in salvaging patients with refractory Hodgkin's disease. Many issues need to be resolved, including the optimal timing of this approach and the optimal conditioning regimen. In the years to come these questions may be answered by the many studies now under way.