Repeat Allogeneic Stem Cell Transplantation for ALL

ALL is the most common cancer diagnosed in children and young adults, represents almost 25% of cancers in children younger than 15 years. Complete remission of disease is now typically achieved with pediatric chemotherapy regimens in approximately 95% of children with ALL, with up to 85% long-term survival rates. Young adults are treated as children, but the relapse rate is higher.  Allogeneic stem cell transplantation is an important salvage option for those who don’t respond. But what happens when ALL comes back after a transplant?

Relapsed patients can re-transplanted, receive Donor Lymphocyte Infusions or go into clinical trials. How good of a choice is re-transplanting?

O’Brien looked at 288 patients who received second salvage therapy for ALL and found that they have a poor prognosis. It is tempting to re-transplant patients who relapse despite having had an allogeneic transplant But results are not impressive. A second BMT results in long-term event-free survival in only 10–20% of patients with relapsed ALL. It is true that most patients who relapsed after a transplant are not great candidates for a repeat transplant. Only 7–20% of patients have been reported to reach the stage of a second BMT after relapse according to the performance and remission status after salvage chemotherapy. Moreover, second BMT is associated with extremely high treatment-related mortality, ranging from 40% to 50%.

Thus, the outlook for patients with post-transplant relapse of acute leukemia is extremely poor; currently, no single therapy consistently results in durable remissions. There are no guidelines recommending a second allogeneic transplant and it is hard to see why a stem cell transplant would work better a second time around unless something different is done.

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