Hodgkin's disease and transplantation: a room with a (nontransplanter's) view.

Hodgkin's disease is a malignancy curable by combination chemotherapy in newly diagnosed patients. Management of refractory disease or relapse has been unsatisfactory with salvage chemotherapy alone, although some patients with long initial remission can be cured with this approach. Because correlations between dose intensity and response to treatment in animal models and in clinical studies have been positive, high-dose chemotherapy (HDT) with bone marrow (BM) or peripheral blood stem-cell (PBSC) transplantation support has been used in an attempt to improve disease-free and overall survival in patients with refractory disease or relapse. Controversy exists over who and when to transplant. Results are difficult to interpret because of the heterogeneous nature of the patients under study and short follow-up times. In general, patient disease-free and overall survival appear to be improved with HDT and PBSC support when compared with historical controls. Allografting has also been tried in Hodgkin's disease as well, but is not recommended due to high associated mortality. Improvements in supportive care for transplantation in general, and antiviral and graft-versus-host disease prophylaxis in particular, have decreased early mortality associated with allografting in other malignancies, but not yet in Hodgkin's disease. The fact that allografted patients who survive the initial transplant procedure have an impressively lower relapse rate makes Hodgkin's disease patients potential candidates for future studies of allografting under more modern circumstances. Some suggestions are made about the introduction of new approaches to treatment.