# Transplant or CAR-T at second line in diffuse large B-cell lymphoma

Source: https://onco.cc/terms/lymphoma-decision-transplant-or-car-t/  
OnCo record `lymphoma-decision-transplant-or-car-t` (Term). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

If a large B-cell lymphoma comes back within a year of first treatment, two trials found that engineered T cells worked better than salvage chemotherapy followed by a transplant of the person's own stem cells, and a third trial of a different T-cell product found no difference. If it comes back later, the transplant route is still standard.

## Summary

**What the choice is.** After first-line chemoimmunotherapy fails, the older path is two or three cycles of salvage chemotherapy, then, for whoever responds, high-dose chemotherapy with a transplant of the person's own stem cells. The newer path is a single infusion of the person's own T cells, re-engineered to recognise a protein on the lymphoma, with a wait of several weeks while the cells are made. The two are not interchangeable: the timing of the relapse is what decides which is on the table.

**What the trials found.** ZUMA-7 randomised 359 people whose large B-cell lymphoma was refractory to first-line treatment or had relapsed within 12 months of it, to axicabtagene ciloleucel or to standard care. At a median of 24.9 months, median event-free survival was 8.3 months with the cell therapy and 2.0 months with standard care, and 24-month event-free survival was 41 per cent against 16 per cent. The prespecified survival analysis at five years, with a median follow-up of 47.2 months, found median overall survival not reached in the cell-therapy group and 31.1 months in the standard-care group, with estimated four-year survival of 54.6 per cent against 46.0 per cent. These are trial-population figures: 74 per cent of those enrolled had primary refractory disease or other high-risk features.

**What the trial that failed found.** BELINDA randomised 322 people with the same kind of early relapse to tisagenlecleucel or to salvage chemotherapy and transplant, and found median event-free survival of 3.0 months in both groups. Two things in that trial are worth knowing when the conversation turns to the wait: the median time from cell collection to infusion was 52 days, and 25.9 per cent of the cell-therapy group had lymphoma progression by week 6, against 13.8 per cent of the standard-care group. The result is usually read as a statement about the product, the bridging treatment and the waiting time together, not about the idea.

**What this means for the person in front of the decision.** If the relapse was early, the question is usually which cell therapy and how quickly it can be arranged, and the honest difficulty is the wait. If the relapse was late, salvage chemotherapy and an autologous transplant remain the standard route, and the cell therapy is held for afterwards. Only about a third of the standard-care group in BELINDA actually reached a transplant, which is the other half of the comparison: the transplant route only helps the people whose lymphoma responds to the salvage chemotherapy first.

**What each costs you.** Lymphoma Action describes the transplant route as high-dose chemotherapy with several weeks in hospital, and the cell-therapy route as apheresis, a wait of several weeks while the cells are made, lymphodepleting chemotherapy, at least ten days in hospital, four weeks living within about an hour of the centre with someone else present at all times, and a one-in-five chance of needing intensive care. Both routes leave the immune system low for a long time afterwards.

## Fields

- Kind: Term
- Last checked: 2026-10-01
- Also known as: Second-line DLBCL decision; Autologous transplant or CAR-T; ZUMA-7 decision; Early relapse large B-cell lymphoma

## Sources

- Locke et al., axicabtagene ciloleucel as second-line therapy for large B-cell lymphoma (ZUMA-7), New England Journal of Medicine 2022: https://doi.org/10.1056/NEJMoa2116133
- Westin et al., survival with axicabtagene ciloleucel in large B-cell lymphoma (ZUMA-7 five-year analysis), New England Journal of Medicine 2023: https://doi.org/10.1056/NEJMoa2301665
- Bishop et al., second-line tisagenlecleucel or standard care in aggressive B-cell lymphoma (BELINDA), New England Journal of Medicine 2022: https://doi.org/10.1056/NEJMoa2116596
- Lymphoma Action: CAR-T cell therapy: https://lymphoma-action.org.uk/information-and-support/lymphoma-treatment/car-t-cell-therapy
- Lymphoma Action: autologous (your own) stem cell transplant: https://lymphoma-action.org.uk/information-and-support/lymphoma-treatment/stem-cell-transplants/self-autologous-stem-cell
- Lymphoma Action: diffuse large B-cell lymphoma: https://lymphoma-action.org.uk/information-and-support/types-lymphoma/non-hodgkin-lymphoma/diffuse-large-b-cell-lymphoma
- Lymphoma Action: when lymphoma comes back, or does not respond: https://lymphoma-action.org.uk/information-and-support/living-and-beyond-lymphoma/lymphoma-comes-back-relapses-or-doesnt-respond

## Connected records

- cancers: [Diffuse large B-cell lymphoma](https://onco.cc/cancers/dlbcl/), [Non-Hodgkin lymphoma (all types)](https://onco.cc/cancers/non-hodgkin-lymphoma/), [Primary mediastinal (thymic) large B-cell lymphoma](https://onco.cc/cancers/primary-mediastinal-b-cell-lymphoma/)
- technologies: [Autologous stem cell transplant (high-dose therapy)](https://onco.cc/technologies/autologous-stem-cell-transplant/), [CAR-T cell therapy](https://onco.cc/technologies/car-t/)
- terms: [Autologous stem cell transplant (ASCT)](https://onco.cc/terms/autologous-transplant/), [Cytokine release syndrome (CRS)](https://onco.cc/terms/crs/), [ICANS (neurotoxicity)](https://onco.cc/terms/icans/), [Low antibodies and infection risk for years after anti-CD20 and bispecific antibodies](https://onco.cc/terms/lymphoma-living-infection-years-after/), [Stem cell transplant in lymphoma: what it is still for](https://onco.cc/terms/lymphoma-tx-transplant-role/), [The CAR-T pathway in lymphoma: referral, apheresis, bridging and the waiting](https://onco.cc/terms/lymphoma-tx-car-t-pathway/), [Treatment at the local hospital or at a cell-therapy centre far from home](https://onco.cc/terms/lymphoma-decision-local-or-car-t-centre/)
- trials: [BELINDA](https://onco.cc/trials/belinda/), [TRANSFORM](https://onco.cc/trials/transform/), [ZUMA-7](https://onco.cc/trials/zuma-7/)

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