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Alert Number 116

What to Avoid in Stem Cell Transplants

Date: August 6, 2005

Several recent reviews on our website have described the increasingly encouraging statistics of stem cell transplants. A lot has changed in the past few years, and the picture is becoming clear. We summarized some simple transplant doís and doníts for you, and the very high pedigree abstract below is pretty clear in its advice as well.

Autologous stem cell transplants (where they use your own stem cells) are not expected to cure patients. Everyone relapses, sooner or later, barring the odd statistical exception. Mind you, it is possible to get long and trouble-free remissions from auto transplants, if you happen to be one of the lucky ones.

Risk Adapted Strategies

Matched donor transplants (allogeneic stem cell transplants) are looking pretty good, provided you can find a perfect 10-point match. As the abstract below points out, it is really not a good idea to rush into a transplant with less than perfectly matched donor. "Treatment related mortality" (TRM, or what I call death-by-therapy) is much higher if the match is not good.

Matching Made Simple

Over the last 5 years, "mini" transplants have come into their own. This procedure uses much lower intensity conditioning before the transplant ("non-myeloablative") and depends on the graft-versus-leukemia effect to root out the remaining traces of CLL. The survival statistics for this approach are getting better and better, especially in patients with few other medical complications. There is hope that this approach represents the possibility of a full CURE for a large percent of patients. The recently reviewed data from the Hutch suggests MUD (matched unrelated donor) transplants are better than sibling donor transplants.

Only Real Cure Out There

Since the old fashioned full myeloablative stem cell transplants have a much higher risk of death-by-therapy, I suggest you stay away from that approach!

For a change, the picture is clear and the advice from the experts is unambiguous: if a stem cell transplant is the way to go, 10-point matched Mini-MUD transplants for patients with no additional health complications are looking pretty good!

Be well,

Chaya
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Abstract

J Clin Oncol. 2005 Jul 25.

Unrelated Donor Marrow Transplantation for B-Cell Chronic Lymphocytic Leukemia After Using Myeloablative Conditioning: Results From the Center for International Blood and Marrow Transplant Research.

Pavletic SZ, Khouri IF, Haagenson M, King RJ, Bierman PJ, Bishop MR, Carston M, Giralt S, Molina A, Copelan EA, Ringden O, Roy V, Ballen K, Adkins DR, McCarthy P, Weisdorf D, Montserrat E, Anasetti C.

National Cancer Institute, Bethesda, MD; M.D. Anderson Cancer Center, Houston, TX; Center for International Blood and Marrow Transplant Research; National Marrow Donor Program; University of Minnesota, Minneapolis, MN; University of Nebraska Medical Center, Omaha, NE; City of Hope National Cancer Center, Duarte, CA; Ohio State University, Columbus, OH; Karolinska University Hospital, Huddinge, Sweden; Mayo Clinic, Jacksonville; Massachusetts General Hospital, Boston, MA; Washington University School of Medicine, St Louis, MO; Roswell Park Cancer Institute, Buffalo, NY; and Hospital Clinic, IDIBAPS, University of Barcelona, Spain; H. Lee Moffitt Cancer Center, Tampa, FL.

PURPOSE: To determine the role of myeloablative conditioning and unrelated donor (URD) bone marrow transplantation in the treatment of patients with advanced B-cell chronic lymphocytic leukemia (CLL).
PATIENTS AND METHODS: A total of 38 CLL patients received a matched URD transplant using bone marrow procured by the National Marrow Donor Program. The median age was 45 years (range, 26 to 57 years), the median time from diagnosis was 51 months, and the median number of prior chemotherapy regimens was three. Fifty-five percent of patients were chemotherapy refractory and 89% had received fludarabine. Conditioning included total-body irradiation in 92% of patients. Graft-versus-host disease (GVHD) prophylaxis consisted of methotrexate with cyclosporine or tacrolimus for 82% of patients.
RESULTS: Twenty-one patients (58%) achieved complete response and six (17%) achieved partial response. Incidences of grades 2 to 4 acute GVHD were 45% at 100 days and incidences of chronic GVHD were 85% at 5 years. Eleven patients are alive and disease free at a median of 6 years (range, 3.0 to 9.0 years). Five-year overall survival, failure-free survival, disease progression rates, and treatment-related mortality (TRM) were 33%, 30%, 32%, and 38% respectively.
CONCLUSION: These data demonstrate that lasting remissions can be achieved after URD transplantation in patients with advanced CLL. High TRM suggest that myeloablative conditioning and HLA-mismatched donors should be avoided in future protocols, and it is mandatory to investigate transplant strategies with a lower morbidity and mortality, including the use of nonmyeloablative regimens.

PMID: 16043827
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