The Utility of Stem Cell Transplant in T-Cell Lymphoma

John Lister, MD

Both chemotherapy and stem cell transplant (SCT) are staples in the treatment of T-cell lymphoma, according to John Lister, MD. However, there have been therapeutic advances that have changed the setting in which SCT is given. Further, there is ongoing research that may impact the landscape in the future.

“Stem cell transplant, whether autologous or allogeneic, is a well-defined therapeutic technique. What we can say is that it in the upfront setting, in first remission, it can be applied to patients who have high risk for relapsed disease. In the relapse setting, there is also the consideration of allogeneic transplant if the patient is fit, relatively young, and has an appropriate donor, said Lister, chief of the Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, in an interview with Targeted Oncology.

In the interview, Lister discussed the utility of SCT in T-cell lymphoma, including ongoing clinical trials and future needs.

Image Credit: Artur - www.stock.adobe.com

TARGETED ONCOLOGY: What role does SCT currently play in the treatment of T-cell lymphoma?

Lister: There are mechanisms that allow us to risk stratify patients with T-cell lymphoma, and all but the very lowest risk patients would get chemotherapy. If they achieve a remission, they will then undergo autologous peripheral blood stem cell transplantation in first remission. The exceptions, as I said, would be those patients with low-risk T-cell lymphoma.

Can you discuss the latest advances in SCT for T-cell lymphoma?

Not a lot has occurred in T-cell, particularly T-cell lymphoma. The landscape has changed with the advent of certain drugs that appear to be more active in this cohort of diseases, one of which is brentuximab vedotin [Adcetris]. Still, even in the relapsed setting, patients that are still responsive to chemotherapy, if they have not undergone an autologous transplant, would go to a first autologous transplant in the situation, whereby they had relapsed after initial therapy and then still respond to conventional therapy.

Do you see the role of transplant changing with the development of CAR T-cell therapy?

There are a limited number of clinical trials that address novel ways of trying to make CAR T cells to target T cells without the CAR T cells killing themselves. Those are still in clinical trials. There are no approved CAR T-cell therapies for T-cell lymphoma at this point. We would hope that in the future, we will have some of these promising clinical trials that are being conducted with various forms of altered CAR T cells to eliminate fratricide, that being the CAR T cells kill themselves. That will be useful in the future in treating these patients, particularly in the relapsed setting.

Which SCT clinical trials are you interested in right now?

I am interested in the application of allogenic transplant that being when the patient's donor is not themselves, but when somebody else introduces the possibility that the graft will react against the malignancy. We call that a graft-vs-lymphoma, or graft-vs-tumor, or graft-vs-leukemia effect. We would hope that this is more readily delineated in the future so that we know which patients we can apply this therapy to with some chance of having a reasonable proportion of them achieve long-term survival without the presence of their disease.

What do you think are the key needs in this space?

I think that there's a great need to find new forms of therapy for treating T-cell lymphoma. Some of the clinical trials that are addressing this are repurposing older agents for a new purpose. We're participating in a clinical trial that combines the variable regimen, incorporating pembrolizumab [Keytruda] with decitabine, which is a hypomethylating agent, and pralatrexate, a standard form of treatment for T-cell lymphoma. We're hopeful that these combinations of agents will introduce newer possibilities, higher response rates, and open up the application of stem cell transplantation to more patients in first remission.

What is your key advice to oncologists/hematologists regarding SCT for T-cell lymphoma?

Stem cell transplant, whether autologous or allogeneic, is a well-defined therapeutic technique. What we can say is that it in the upfront setting, in first remission, it can be applied to patients who have high risk for relapsed disease. In the relapse setting, there is also the consideration of allogeneic transplant if the patient is fit, relatively young, and has an appropriate donor.