Autologous marrow transplantation for Hodgkin's disease current techniques and prospects

Hodgkin's disease is a chemotherapeutically curable malignancy, but cure is rare if a complete remission is not achieved with initial therapy. Drugs that have myelosuppression as a major dose-limiting toxic effect, can be given at high doses and may be combined together at close to the maximum tolerated dose with marrow rescue. Multiple chemotherapy drugs given at high doses with marrow rescue are best utilized if they possess dissimilar extramedullary toxicity. The use of growth factors and improved storage methods may also help reduce hematopoietic toxicity. There is currently no consensus on the ideal treatment regimen, although combinations of etoposide, carmustine, and cyclophosphamide are frequently used and are associated with decent disease-free survival. The frequency of pulmonary complications is higher with regimens containing higher doses of carmustine. There are no prospective comparative randomized trials between standard chemotherapy and high dose chemotherapy with marrow support. Patients transplanted earlier in the course of their disease appear to do best, as do patients with good performance status and low tumor burden who have had less than two prior regimens. In such patients the long-term disease-free survival after autologous bone marrow transplantation may be in excess of 80%. Patients with Hodgkin's disease refractory to front line chemotherapy do poorly with high dose chemotherapy with autologous marrow rescue and often do not achieve remission. Newer regimens need to be explored and developed for patients at high risk of relapse.