EHA 2026 | Is autologous transplant still needed in relapsed Hodgkin lymphoma?

Transplantation, as you say, has been the standard second-line therapy for relapsed Hodgkin’s lymphoma, but I think it is changing. We know that there is obviously acute toxicity with transplantation, but also longer-term toxicity in terms of late infections, cardiovascular risk. So I think we are trying to identify patients where maybe a transplant isn’t necessary. There’s interesting data about using pembrolizumab maintenance as opposed to a stem cell transplant, a paper by Alison Moskowitz that looked at using pembrolizumab maintenance after up to four cycles of pembrolizumab and GVD. And interestingly, it did show a good two-year PFS benefit of 60%. So there were patients that did relapse both on treatment and soon after stopping pembrolizumab maintenance. But I think there are patients that potentially could avoid autograft with this mechanism. I think there’s other data also using brentuximab, for example, in combination with escalated chemotherapy, looking for better complete metabolic response rates. And then again, using brentuximab vedotin opposed to an autograft. And the data from there is quite intriguing that maybe that is an option for some patients. There’s also other options looking at brentuximab vedotin, very good PFS rates, using that combination for those patients who have an autograft. But additionally, adding in nivolumab to brentuximab vedotin does seem to result in some very good PFS rates for certain patients avoiding autografts. So again, I think that’s really encouraging data. I think it’s been very much established in the pediatric setting rather than the adult setting. The GHSG group have looked at this and defining low-risk patients. So those being patients that have had prolonged time to relapse or have had a very good response to the first line of relapse treatment with at least 50% reduction in tumor volume and defining them as low risk. And then the high-risk patients being those with progressive disease or that have had an inadequate response to relapse treatment. And if you look at comparing those groups, given either for the low-risk group, just chemotherapy and radiotherapy or a BEAM autograft, actually the outcomes look very similar, really suggesting that you could restrict autograft to those patients with primary progressive disease or inadequate response to relapse treatment. And similarly, there’s the Checkmate 744 trial, which looked at using brentuximab vedotin for low-risk patients. Patients who had complete metabolic response continue with brentuximab vedotin. Patients who had less than a complete response then had brentuximab vedotin and bendamustine. And again, avoiding transplant in these patients with very good PFS and overall survival rates. So I think there are patients that we can avoid transplantation. This has been sort of extrapolated into the adult setting, a paper by Paul Brockelmann, who looked at exactly this, looking at early stage Hodgkin’s consolidation then either with chemotherapy or a transplant and actually showed equivalent overall survival and PFS rates. So I think this is a direction to travel that we’d like to go in. I think we probably need clinical trials to actually establish which patients. I think we do need to be better at risk stratifying patients. So I’ve very much talked about dividing patients into low and high risk based on their response, but I think we do have better mechanisms of doing that. We have PET imaging but probably circulating tumor DNA we could use to identify low-risk patients, patients that have responded very well to treatment and where a maintenance type approach may be better rather than autografted.

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