For patients with ALL who relapse following allo-SCT, only a second SCT provides a realistic chance for long-term disease remission. We retrospectively analyzed the outcomes of 31 patients with relapsed ALL after a prior allo-SCT, who received a second SCT (SCT2) at our center. With a median follow-up of 3 years, 1-and 3-year PFS was 23 and 11% and 1-and 3 year OS rates were 23 and 11%. Twelve patients (39%) were transplanted with active disease, of whom 75% attained a CR. We found a significant relationship between the time to treatment failure following first allograft (SCT1) and PFS following SCT2 (P ¼ 0.02, hazard ratio ¼ 0.93/month). In summary, a second transplant remains a potential treatment option for achieving response in a highly refractory patient population. While long-term survival is limited, a significant proportion of patients remains disease-free for up to 1 year following SCT2, providing a window of time to administer preventive interventions. Notably, our four long-term survivors received novel therapies with their second transplant underscoring the need for a fundamental change in the methods for SCT2 to improve outcome.

Dose intensity is important for disease control in patients undergoing allogeneic stem cell transplantation. We conducted a phase I/II controlled adoptive randomized study to determine the optimal dosing schedule of i.v. busulfan. Patients with advanced hematologic malignancies, ≤ 75 years with HLA-compatible donor were eligible. All patients received fludarabine at 30mg/m2/d for 4 days and busulfan was administered in different doses in oral or i.v. formulations. As determined by the phase I trial, i.v. busulfan at a dose of 11.2 mg/kg/d was utilized for the phase II expansion cohort. Altogether, 80 patients with a median age of 56 years were enrolled. Forty percent had active disease at the time of transplant. Engraftment occurred in 91% and a complete response was achieved in 79% of patients post-transplant. At a median follow up of 91 months in the surviving patients, the outcomes for i.v. busulfan dose of 11.2 mg/kg/d vs. other doses were: non-relapse mortality: 34% vs. 23% (p=0.4); cumulative incidence of relapse: 43% vs. 68% (p=0.02); relapse-free-survival (RFS): 25% vs. 9% (p=0.017); overall-survival (OS): 27% vs. 9% (p=0.02). We conclude that optimizing intravenous busulfan dose intensity in the preparative regimen may overcome disease associated poor prognostic factors.

NCT00936936.

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