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Lymphoma Editorial Autologous Transplantation in Relapsed or Refractory Hodgkin’s Lymphoma – The Challenges Christian Gisselbrecht Professor of Haematology, Hôpital Saint Louis, Paris Abstract Failure to initiate treatment remains a challenge in Hodgkin’s lymphoma (HL). For years, chemotherapy and stem cell transplantation salvaged less than half of relapses. Nowadays, positron emission tomography can predict the outcome under treatment. Two targeted agents are dramatically improving therapy, alone or in association with chemotherapy or stem cell transplantation. Brentuximab vedotin is an immunoconjugate anti-CD30 and anti-programmed death 1 nivolumab induces blockade of immune checkpoint. How to use them are discussed in the context of relapses/refractory HL. Keywords Hodgkin’s lymphoma, brentuximab, nivolumab, PET scan Disclosure: Christian Gisselbrecht has no disclosures in relation to this article. No funding was received for the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 24 August 2015 Published Online: 16 November 2015 Citation: European Oncology & Haematology, 2015;11(2):121–2 Correspondence: Christian Gisselbrecht, Professor of Haematology, Hôpital Saint Louis, Paris 75010, France. E: christian.gisselbrecht@gmail.com Approximately 10 % of patients with localised Hodgkin’s lymphoma (HL) and 20  % with disseminated HL fail to respond to or relapse after a first-line treatment. The standard of care indicated by a randomised study 1 is salvage chemotherapy followed by consolidation with autologous stem cell transplant (ASCT). Salvage chemotherapy followed by ASCT induces long-term remission in ~50 % of patients. 2 However, there is a limited impact on survival. 1,3 The increase in the cumulative incidence of second malignancies in the transplanted patients compared with conventionally treated HL patients is still a major issue. 4 The main point is to achieve a major response with complete remission (CR) prior to transplantation, because a suboptimal response to pretransplant salvage chemotherapy is the major determinant of ASCT failure. 5 The introduction of the pretransplantation positron emission tomography (PET) scan has changed the paradigm of treatment. Standardisation of criteria of responses with PET scan was based on the Deauville criteria or the Five-Point Scale 6. In a series of 111 consecutive patients, a 5-year progression-free survival (PFS) of 23  % and 79  % (p<0.001) and a 5-year overall survival (OS) of 55  % and 90  % (p=0.001) were documented in patients with or without 18-Fluoro-deoxyglucose (FDG)- avid lymphoma lesions at ASCT, respectively. 7 Patients with a positive PET after a second-line salvage therapy have a worse event-free survival (EFS) and require new approaches. The European intergroup study Hodgkin disease relapse 2 (HDR2) showed that adding sequential high-dose chemotherapy after salvage chemotherapy and before ASCT does not improve a prognosis and is associated with additional adverse effects. 8 Tou ch MEd ica l MEdia Transplantation Strategy – Auto or Allo or Tandem? A single ASCT is appropriate for intermediate-risk patients. Various conditioning regimens have been used as chemotherapy prior to ASCT. However, there have been no prospective comparison trials. BEAM (carmustine, etoposide, cytarabine and melphalan) has been one of the most popular regimens since its introduction in the 1980s. More data regarding newer regimens, including active agents such as bendamustine, busulfan and fotemustine, are required. To improve the outcomes of patients with high-risk disease, tandem transplantation could be proposed provided they display chemosensitivity and that there is no progression between the two transplants. The LYmphoma Study Association (LYSA) reported a prospective multicentre trial that evaluated a risk-adapted salvage treatment without a PET scan with a single or tandem ASCT for 245 relapse or refractory patients. 9 Of the poor-risk patients, 105 (70 %) received a tandem ASCT, whereas 92 intermediate-risk patients (97  %) received a single ASCT. The 5-year PFS and OS estimates were 73  % and 85  %, respectively, for the intermediate-risk group and 46  % and 57  %, respectively, for the poor-risk group. The outcomes for the primary refractory and poor-risk/ relapsed HL groups were similar. As improvements in OS after an allogeneic haematopoietic cell transplantation (allo-SCT) has been reported (following the introduction of reduced intensity conditioning [RIC] regimens, improvements in human leukocyte antigen [HLA] typing, and more careful patient selection), this strategy was also tested in HL. A large, prospective 121