Hematopoietic Stem-Cell Transplantation for Acute Leukemia in Relapse or Primary Induction Failure

Abstract

A B S T R A C T PurposePatients with acute leukemia refractory to induction or reinduction chemotherapy have poor prognoses if they do not undergo hematopoietic stem-cell transplantation (HSCT). However, HSCT when a patient is not in complete remission (CR) is of uncertain benefit. We hypothesized that pretransplantation variables may define subgroups that have a better prognosis. Patients and MethodsOverall, 2,255 patients who underwent transplantation for acute leukemia in relapse or with primary induction failure after myeloablative conditioning regimen between 1995 and 2004 were reported to the Center for International Blood and Marrow Transplant Research. The median follow-up of survivors was 61 months. We performed multivariate analysis of pretransplantation variables and developed a predictive scoring system for survival. ResultsThe 3-year overall survival (OS) rates were 19% for acute myeloid leukemia (AML) and 16% for acute lymphoblastic leukemia (ALL). For AML, five adverse pretransplantation variables significantly influenced survival: first CR duration less than 6 months, circulating blasts, donor other than HLA-identical sibling, Karnofsky or Lansky score less than 90, and poor-risk cytogenetics. For ALL, survival was worse with the following: first refractory or second or greater relapse, Ն 25% marrow blasts, cytomegalovirus-seropositive donor, and age of 10 years or older. Patients with AML who had a predictive score of 0 had 42% OS at 3 years, whereas OS was 6% for a score Ն 3. Patients with ALL who had a score of 0 or 1 had 46% 3-year OS but only 10% OS rate for a score Ն 3. ConclusionPretransplantation variables delineate subgroups with different outcomes. HSCT during relapse can achieve long-term survival in selected patients with acute leukemia.

Achieving stringent CR is essential before reduced-intensity conditioning allogeneic hematopoietic cell transplantation in AML

“…14,15,42 This is particularly applicable for RIC allo-HCT. 11,21,[43][44][45] We observed a reduced risk of relapse in CMV seropositive recipients. Although we did not evaluate CMV reactivation after allo-HCT, CMV reactivation after allo-HCT has been associated with a decreased risk of relapse, 46 possibly due to promotion and persistence of educated natural killer cells.…”

“…9 It is clear that patients with active leukemia had more relapse and worse OS after allo-HCT regardless of donor type or patient age. [10][11][12][13][14][15] Following allo-HCT, 40-60% of AML patients in CR1 enjoy long-term OS, whereas o20% of refractory or relapsed AML patients survive. 1,11 Yet even for allo-HCT during CR, relapse remains the most frequent complication of allo-HCT.…”

“…[10][11][12][13][14][15] Following allo-HCT, 40-60% of AML patients in CR1 enjoy long-term OS, whereas o20% of refractory or relapsed AML patients survive. 1,11 Yet even for allo-HCT during CR, relapse remains the most frequent complication of allo-HCT. 16 As relapse has been reported more frequently after RIC allo-HCT compared with myeloablative conditioning (MAC) allo-HCT in patients with AML, this suggests heterogeneity in the interpretation of a CR, which may be more important after RIC allo-HCT.…”

Concise Review: The Role of Hematopoietic Stem Cell Transplantation in the Treatment of Acute Myeloid Leukemia

“…Survival at 3 years was 19% for 1,673 patients with AML not in remission at the time of HSCT [37]. CR1 duration <6 months, presence of circulating blasts, having a donor other than a matched sibling, performance status <90%, and adverse cytogenetics were associated with poor outcome.…”

Recent decrease in non-relapse mortality due to GVHD and infection after allogeneic hematopoietic cell transplantation in non-remission acute leukemia

“…The impact on transplant outcome of detailed disease status in non-remission patients 41 was not assessed because of the lack of information. In addition, detailed data regarding the incidences of infection or other complications were not available.…”