Second Allogeneic Transplant in ALL – pro
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.
Relapsed patients can re-transplanted, receive DLI or go into clinical trials. O’Brien looked at 288 patients who received second salvage therapy for ALL and found that they have poor prognosis. It is tempting to retransplant patients who relapse despite an allogeneic transplant. A second BMT results in long-term event-free survival in only 10–20% of patients with relapsed ALL. Only 7–20% of patients has 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 unless something different is done.
Fagioli, F, Zecca, M, Rognoni, C, et al. Allogeneic Hematopoietic Stem Cell Transplantation for Philadelphia-Positive Acute Lymphoblastic Leukemia in Children and Adolescents: A Retrospective Multicenter Study of the Italian Association of Pediatric Hematology and Oncology (AIEOP). Biol Blood Marrow Transplant. 2011 Oct 20.
Gonzalez-Vicent, M, Molina, B, Andion, M, et al. Allogeneic hematopoietic transplantation using haploidentical donor vs. unrelated cord blood donor in pediatric patients: a single-center retrospective study. Eur J Haematol. 2011 Jul;87(1):46-53.
Nemecek, ER, Ellis, K, He, W, et al. Outcome of myeloablative conditioning and unrelated donor hematopoietic cell transplantation for childhood acute lymphoblastic leukemia in third remission. Biol Blood Marrow Transplant. 2011 Dec;17(12):1833-40. PM
Pui, CH, Pei, D, Campana, D, et al. Improved prognosis for older adolescents with acute lymphoblastic leukemia. J Clin Oncol. 2011 Feb 1;29(4):386-91.
Arellano ML, Langston A, Winton E, Flowers CR, Waller EK. Treatment of relapsed acute leukemia after allogeneic transplantation: a single center experience.Biol Blood Marrow Transplant. 2007 Jan;13(1):116-23.
Terwey TH, Massenkeil G, Tamm I, Hemmati PG, Neuburger S, Martus P, Dörken B, Hoelzer D, Arnold RSO Allogeneic SCT in refractory or relapsed adult ALL is effective without prior reinduction chemotherapy.Bone Marrow Transplant. 2008;42(12):791.
B O’Brien S, Thomas D, Ravandi F, Faderl S, Cortes J,orthakur G, Pierce S, Garcia-Manero G, Kantarjian HMSOCancer. Outcome of adults with acute lymphocytic leukemia after second salvage therapy. Cancer 2008;113(11):3186.
NCCN, ALL, ALL-7 2012