Bone marrow transplant for pediatric lymphoma gives children with relapsed or refractory Hodgkin, anaplastic large cell, Burkitt, large B-cell or lymphoblastic lymphoma a second chance at cure. High-dose chemotherapy is followed by the child's own stem cells or cells from a sibling, unrelated or parent donor. Our pediatric transplant team plans salvage treatment, cell collection, conditioning and long-term follow-up, with a coordinator for families from abroad.
About This Department
Pediatric Hematology
Most children with lymphoma are cured with chemotherapy alone. When the lymphoma resists treatment or comes back, a stem cell transplant gives a second chance at cure.
Bone marrow transplant for pediatric lymphoma, also called stem cell transplantation for childhood lymphoma, follows high-dose chemotherapy with an infusion of blood-forming stem cells, either the child's own cells collected earlier or cells from a donor. Children's oncologists use it for Hodgkin lymphoma and non-Hodgkin lymphomas, such as anaplastic large cell, Burkitt, diffuse large B-cell and lymphoblastic lymphoma, after relapse or when first treatment fails. The type of lymphoma decides the type of transplant. In a German and Austrian study of 74 children with relapsed anaplastic large cell lymphoma, 77 percent of those who received the recommended autologous transplant were alive five years later (Woessmann and colleagues, J Clin Oncol, 2011). This page explains which children need a transplant, autologous and allogeneic options for each lymphoma type, getting into remission first, conditioning, the hospital stay, risks, newer treatments, life after transplant, and how families from abroad arrange a bone marrow transplant for pediatric lymphoma at Biruni Hospital in Istanbul.
77%
Five-year survival after autologous transplant for relapsed anaplastic large cell lymphoma in children
52%
Five-year progression-free survival in 606 young patients after autologous transplant for Hodgkin lymphoma
67%
Survival in relapsed Burkitt lymphoma after rituximab-based reinduction and a donor transplant
Free
Review of your child's scans and pathology by our pediatric transplant team
Lymphoma is a cancer of the lymphocytes, white blood cells that live in the lymph nodes, spleen, chest and bone marrow. It ranks third among childhood cancers, after leukemia and brain tumors, and modern chemotherapy cures the large majority of children.
When a transplant enters the plan
A transplant comes into the picture in a small group of children. These are children whose lymphoma comes back after treatment, called relapse, and those whose lymphoma does not respond to the first treatment, called refractory disease. A transplant is almost never part of first treatment for childhood lymphoma.
The goal of the transplant is cure. High-dose treatment kills lymphoma cells that survived standard doses, and the new stem cells rebuild the bone marrow afterward.
Autologous or allogeneic
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Autologous transplant
The child's own stem cells are collected from the blood when the lymphoma is in remission and frozen. After high-dose chemotherapy, the cells are thawed and returned.
A donor gives the stem cells. The donor's immune system then recognizes and attacks remaining lymphoma cells, an effect called graft versus lymphoma.
A brother or sister with the same tissue type is the first-choice donor, and each full sibling has a one in four chance of matching.
An unrelated registry donor or a half-matched parent can donate when no sibling matches.
Our pediatric bone marrow transplant page covers donors in detail.
Choosing the type
Situation
Usual choice
Reason
First relapse of Hodgkin lymphoma, responding to chemotherapy
Autologous
Good results, lower risk
Lymphoblastic lymphoma relapse
Allogeneic
Autologous results are poor
Relapse after an autologous transplant
Allogeneic
Donor immune effect needed
Hodgkin lymphoma
Hodgkin lymphoma that comes back
Between one in ten and one in seven children and teenagers with Hodgkin lymphoma relapse or do not respond fully to first treatment. Salvage chemotherapy, now combined with brentuximab vedotin or immunotherapy, followed by an autologous transplant is the standard route to cure.
Autologous transplant for Hodgkin lymphoma in 606 children, adolescents and young adults
Measure
Result
Note
Progression-free at 1 year
66 percent
All patients
Progression-free at 5 years
52 percent
All patients
Progression-free at 10 years
47 percent
Durable cure in many
Low-risk group at 5 years
72 percent
Good condition, chemosensitive, no extranodal disease
Children in good general condition, with lymphoma that shrinks on salvage chemotherapy and no disease outside the lymph nodes, do best after transplant (Satwani and colleagues, 2015).
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Relapse within a year
Relapse less than a year after diagnosis predicted lower progression-free survival in the same study, and our team plans extra treatment after the transplant for these children.
Radiotherapy to sites of relapse is added for some teenagers, planned on our Elekta Versa HD linear accelerator with the lowest dose to the heart, lungs and breasts.
Anaplastic large cell lymphoma
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Autologous for most first relapses
In the German and Austrian study of 74 children with relapsed anaplastic large cell lymphoma, five-year survival after first relapse was 57 percent, and 77 percent among the 39 children who received the recommended reinduction chemotherapy and autologous transplant.
Ten children with a relapse that carried a marker called CD3 received an allogeneic transplant, and none of them relapsed again (Woessmann and colleagues, 2011).
Factors that guide the choice in anaplastic large cell lymphoma
Factor
Better result with
Transplant
Time of relapse
Relapse after first treatment ended
Autologous
Progression during first treatment
Donor immune effect
Allogeneic
CD3 on lymphoma cells
Donor immune effect
Allogeneic
Bone marrow or brain involvement
Intensive approach
Allogeneic
Burkitt and large B-cell lymphoma
Mature B-cell lymphomas
Burkitt lymphoma and diffuse large B-cell lymphoma grow fast and respond fast. Relapse in these children is rare, and it carries a serious outlook, so speed matters at every step.
A study of 157 children and teenagers with relapsed Burkitt lymphoma or leukemia found a survival of 67 percent with rituximab combined with continuous-infusion chemotherapy followed by an allogeneic transplant, against 18 percent with all other approaches (Woessmann and colleagues, 2020). Children who did not reach complete remission before transplant rarely survived.
Results by lymphoma type
Five-year event-free survival after transplant in 182 children with recurrent or refractory non-Hodgkin lymphoma
Lymphoma
Allogeneic
Autologous
Diffuse large B-cell
50 percent
52 percent
Burkitt
31 percent
27 percent
Anaplastic large cell
46 percent
35 percent
Lymphoblastic
40 percent
4 percent
Lymphoblastic lymphoma
Lymphoblastic lymphoma behaves like acute lymphoblastic leukemia and starts in the chest or lymph nodes.
First treatment follows leukemia protocols over two years.
After relapse, an allogeneic transplant from a donor offers the best chance.
In the international registry study of children with recurrent or refractory non-Hodgkin lymphoma, five-year event-free survival in lymphoblastic lymphoma was 40 percent after allogeneic transplant against 4 percent after autologous transplant (Gross and colleagues, 2010). The donor immune effect makes the difference.
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Donor search early
For a child with lymphoblastic lymphoma relapse, we start tissue typing of siblings and a registry search in the first week of salvage chemotherapy.
Total body irradiation is part of the conditioning for many children with lymphoblastic lymphoma over four years of age, as in leukemia.
Donor options for allogeneic transplant
Donor
Availability
Note
Matched sibling
One in four siblings
First choice
Matched unrelated
One to three months
Registry search
Haploidentical parent
Days
Almost every child has one
What the studies show
Remission decides almost everything.
In a registry study of 182 children aged 18 years or younger with recurrent or refractory Burkitt, lymphoblastic, diffuse large B-cell and anaplastic large cell lymphoma, transplanted at centers reporting to the Center for International Blood and Marrow Transplant Research between 1990 and 2005, event-free survival was lower in every lymphoma type when the child was not in complete remission at transplant, whatever the donor, and outside lymphoblastic lymphoma the results of autologous and allogeneic transplant were similar (Gross and colleagues, 2010). The same pattern runs through the Hodgkin and anaplastic large cell lymphoma studies, where children with lymphoma that responded well to salvage chemotherapy had the best results. For families, the practical message is simple and it shapes our plan, because the weeks of salvage treatment before the transplant matter as much as the transplant itself, and every scan during that time guides the next step.
Results keep improving. Newer drugs help.
Getting into remission first
Salvage chemotherapy brings the lymphoma back into remission before the transplant. Two to four cycles are given, depending on the lymphoma type and response.
Salvage treatment by lymphoma type
Lymphoma
Salvage treatment
Goal before transplant
Hodgkin
Brentuximab vedotin with chemotherapy, or immunotherapy
Complete metabolic response on PET-CT
Anaplastic large cell
Reinduction chemotherapy, ALK inhibitors in some
Complete remission
Burkitt and large B-cell
Rituximab with intensive chemotherapy
Complete remission
Lymphoblastic
Leukemia-type reinduction
Complete remission
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PET-CT after salvage
A PET-CT scan after salvage treatment shows whether any active lymphoma remains, and it guides the timing and type of transplant.
For an autologous transplant, stem cells are collected once the lymphoma responds, before the bone marrow is damaged by further treatment.
A new biopsy at relapse
Tests at relapse
Test
Purpose
Timing
Biopsy
Confirms relapse and lymphoma type
Before salvage treatment
PET-CT
Maps active disease
Before and after salvage
Bone marrow and spinal fluid
Checks spread
Before salvage
Cell collection and conditioning
Collecting the child's own cells
Growth factor injections for four to five days move stem cells from the bone marrow into the blood. A machine then collects them through a central line over one or two sessions of four to five hours, and the cells are frozen until the transplant.
Smaller children need a special collection line and careful fluid balance, and our pediatric intensive care team supports collections in the youngest patients.
Conditioning regimens
Regimen
Used in
Note
BEAM, four chemotherapy drugs
Autologous transplant for Hodgkin and non-Hodgkin lymphoma
Six days
Total body irradiation with chemotherapy
Allogeneic transplant for lymphoblastic lymphoma
Over four years of age
Reduced-intensity regimens
Allogeneic transplant after earlier autologous transplant
Lower toxicity
The conditioning regimen is chosen by our transplant board for each child, based on the lymphoma, earlier treatment and organ function.
The heart, lungs, kidneys and liver are tested before conditioning, because many children have already received heart-straining and lung-straining drugs during earlier treatment.
The hospital stay
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Day zero
The stem cells are infused through the central line like a blood transfusion, in the child's room, over thirty minutes to a few hours.
A typical course for autologous transplant
Phase
Timing
Focus
Conditioning
Days -6 to -1
Chemotherapy, fluids, anti-nausea medicines
Low counts
Days 0 to 12
Infection prevention, transfusions
Engraftment
Days 10 to 14
White cells return
Discharge
Weeks three to four
Eating, drinking, normal temperature
Children stay in single rooms with filtered air in our pediatric transplant unit, with one parent in the room day and night. Allogeneic transplants need a longer stay, four to six weeks, and closer follow-up for graft versus host disease.
Treatment-related deaths after autologous transplant in children are uncommon. The risk is higher with allogeneic transplant and with poor general condition at transplant.
Risks specific to allogeneic transplant
Risk
Signs
Treatment
Acute graft versus host disease
Rash, diarrhea, jaundice
Steroids, ruxolitinib
Chronic graft versus host disease
Dry eyes and mouth, skin and lung changes
Long-term immune treatment
Virus reactivation
Found on weekly blood tests
Early antiviral medicines
We explain each risk in writing before consent, together with the steps our team takes to reduce it.
Growth and puberty are checked yearly.
Heart and lung tests follow earlier anthracycline, bleomycin and chest radiotherapy.
Second cancers are rare and screened for in long-term follow-up.
Late effects depend more on the total treatment a child has received over the years than on the transplant alone.
Newer treatments
Targeted drugs and immunotherapy
Brentuximab vedotin targets CD30 on Hodgkin and anaplastic large cell lymphoma cells. Checkpoint inhibitors such as nivolumab and pembrolizumab work well in relapsed Hodgkin lymphoma, and ALK inhibitors help children with ALK-positive anaplastic large cell lymphoma.
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Before or after the transplant
These drugs help bring the lymphoma into remission before the transplant, and some are given after an autologous transplant to lower the risk of relapse.
CAR-T cell therapy is an option for some teenagers with relapsed large B-cell lymphoma, and our page on CAR-T cell therapy covers it in detail.
Life after transplant
Childhood comes back.
Most children return to school three to six months after an autologous transplant, and six to twelve months after an allogeneic transplant, once the immune system has recovered and revaccination has started. Sperm freezing for teenage boys and ovarian or testicular tissue freezing for younger children are discussed before conditioning, and a long-term follow-up clinic checks growth, hormones, heart, lungs and learning every year into adulthood.
For families from abroad
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter for the child, parents and any donor, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Length of stay in Istanbul
Transplant
Total stay
Includes
Autologous
Six to eight weeks
Collection, conditioning, transplant, early follow-up
Allogeneic
Three to four months
Donor workup, transplant, follow-up to around day 100
What to send for review
Pathology reports and slides or blocks, PET-CT and CT reports with images, treatment summaries with drug doses, and the latest blood tests. Our pediatric hematology team replies with an opinion and a plan.
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Fitness to fly and after you return home
Fitness to fly is confirmed when counts are stable and infections are controlled. Your local oncologist receives a full report, and we continue follow-up by video and blood tests at home.
Cost
What the quote covers
The written quote covers salvage treatment if given here, cell collection, conditioning, the transplant admission, medicines at discharge and early follow-up.
Autologous transplant costs less than allogeneic transplant, and a donor search, total body irradiation, newer drugs such as brentuximab vedotin and complications change the final cost. We send the quote after reviewing your child's reports, before you travel.
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Comparing quotes
Compare the same transplant type, the same conditioning and the same length of stay.
Registry fees
An unrelated donor search and cell shipment add registry fees, listed separately in the quote.
References
Gross TG, Hale GA, He W, et al. Hematopoietic stem cell transplantation for refractory or recurrent non-Hodgkin lymphoma in children and adolescents. Biol Blood Marrow Transplant. 2010;16(2):223-230.
Satwani P, Ahn KW, Carreras J, et al. A prognostic model predicting autologous transplantation outcomes in children, adolescents and young adults with Hodgkin lymphoma. Bone Marrow Transplant. 2015;50(11):1416-1423.
Woessmann W, Zimmermann M, Lenhard M, et al. Relapsed or refractory anaplastic large-cell lymphoma in children and adolescents after Berlin-Frankfurt-Muenster (BFM)-type first-line therapy, a BFM-group study. J Clin Oncol. 2011;29(22):3065-3071.
Woessmann W, Zimmermann M, Meinhardt A, et al. Progressive or relapsed Burkitt lymphoma or leukemia in children and adolescents after BFM-type first-line therapy. Blood. 2020;135(14):1124-1132.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assoc. Dr. Hasret AYYILDIZ CİVAN, Pediatric Gastroenterology.
