EBMT updates Hodgkin lymphoma HCT guidelines, integrating brentuximab vedotin and checkpoint inhibitors

Hodgkin lymphoma (HL), once often fatal, now has improved outcomes with combined modality therapy. However, a significant challenge remains in managing relapsed or refractory disease, where standard-of-care treatments often fall short, necessitating more aggressive strategies like haematopoietic cell transplantation (HCT). Despite HCT's role, optimal integration of newer agents like brentuximab vedotin and checkpoint inhibitors into transplantation protocols for adult patients with relapsed/refractory HL has lacked clear, unified guidance, leading to practice variability and suboptimal outcomes. This consensus addresses that gap.

The European Group for Blood and Bone Marrow Transplantation (EBMT) Practice Harmonisation and Guidelines Committee, alongside the Lymphoma Working Party, convened 23 experts in Hodgkin lymphoma, transplantation, and radiation oncology. They conducted a structured literature review and a 2-day workshop to develop consensus recommendations for autologous and allogeneic HCT in adult patients with relapsed or refractory Hodgkin lymphoma. The panel established guidance across major clinical decision points, synthesizing existing evidence and expert opinion into a unified set of protocols.

The expert panel issued several key recommendations for managing relapsed/refractory Hodgkin lymphoma. Salvage therapy should incorporate brentuximab vedotin or checkpoint inhibitors, or both, with a metabolic complete response (CR) being preferred before proceeding to autologous HCT. The BEAM conditioning regimen (carmustine, etoposide, cytarabine, melphalan) remains the most commonly used, and autologous HCT is confirmed as the standard for chemosensitive relapse.

For high-risk patients, brentuximab vedotin consolidation is specifically recommended. Allogeneic HCT is advised for eligible patients experiencing relapse after autologous HCT, ideally utilizing reduced intensity conditioning (RIC) and post-transplantation cyclophosphamide (PTCy) for graft-versus-host disease prophylaxis. Routine maintenance after allogeneic HCT is not recommended; instead, relapse management should be individualized, potentially involving donor lymphocyte infusion (DLI), brentuximab vedotin, checkpoint inhibitors, chemotherapy, radiotherapy, or clinical trial enrollment. Peri-transplantation radiotherapy may be considered for PET-positive or residual disease.