ICML 2025 | The evolving role of autoSCT for B-cell lymphoma in the era of CAR-T & selecting patients for SCT

So historically we have been utilizing autologous stem cell transplant for patients with aggressive B-cell lymphoma who were chemo-sensitive, so patients who tended to relapse longer than one year from frontline treatment and overall transplant eligible, so young and fit enough to be able to receive autologous stem cell transplant. But recently we had two approvals in the second line setting which is the setting where we tended to use the most autologous stem cell transplant for CAR-T. Yescarta is currently approved by the FDA for primary chemo refractory, aggressive B-cell lymphoma, and second line. Breyanzi both for primary chemo refractory but also for chemo-sensitive as long as they’re deemed to be transplant ineligible. Now you may argue that transplant eligibility tends to be in the eye of the beholder and quite subjective, but I would like to emphasize that there’s still a fraction of patients, young patients, fit patients who have late relapses after frontline anthracycline-based chemo, they may have nice responses to platinum-based salvage chemo and may be cured with autologous stem cell transplant. So definitely that’s the first scenario where transplant should be considered. We’re now starting to develop experience as we are moving CAR-T to the second line with the utilization of platinum-based chemo followed by high-dose chemo and autologous stem cell transplant for patients who relapse after CAR-T is still a very limited experience and we need to put together our efforts and hopefully generate multi-centered real-world experience. Finally, definitely allogeneic stem cell transplant has fallen out of favor with the introduction of CAR-T, but we still have some very sad cases of patients who relapse after CAR-T and potentially autologous stem cell transplant, where in case of achievement of CR with any biological therapy before allogeneic stem cell transplant, allo itself may provide a cure to a small fraction of patients. We have to be very mindful that these patients may be at very high risk for GvHD within a short time frame for CAR-T cell infusion due to alteration of their immune microenvironment, so there definitely needs to be a multidisciplinary discussion before sending any patient to allogeneic stem cell transplant after CAR-T. But overall, the CIBMTR and real-world experience seems to still be in favor of this as an option.

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