To Transplant or Not
A 64-year-old man presented with acute myelogenous leukemia. His white blood count at presentation was 34 109/L with 90% blasts. His cytogenetics studies showed t(8;21). His molecular studies were negative. He achieved complete remission following standard therapy with “7&3”. He also received a cycle of consolidation with high dose ARA-C. He has no other medical conditions except for a well-controlled arterial hypertension.
The patient is Caucasian. He has 2 siblings, male and female, ages 60 and 54 years. He has 2 sons, ages 34 and 36 years and a daughter, age 39 years.
Is allogeneic hematopoietic transplant indicated?
2 Comments
Dr. A. Samer Al-Homsi · April 10, 2023 at 12:56 pm
There is no substitution to the art of counseling
The traditional teaching is in “favorable” acute myelogenous leukemia, allogeneic hematopoietic stem cell transplantation (HSCT) is not indicated.
Allogeneic transplantation is recommended when its benefit outweighs its detriment. Allogeneic transplantation has been consistently shown to represent the best anti-leukemic therapy. This benefit is often offset by treatment-related mortality (TRM). To quantify these two competing factors, I often refer to a paper by Ossenkoppele et al. According to table 3 in the paper, the risk of relapse of this patient following anti-tumor chemotherapy is 50%-55% (taking into account his WBC at presentation). The risk of relapse after allogeneic transplant is 20%-25%. The risk of TRM with an HCT-CI of 0, is less than 10%. Taking together, this patient’s long-term survival following transplant is about 20% higher in comparison to anti-tumor chemotherapy.
Many might argue that in patients who achieve MRD negativity following induction, have lower risk of relapse. However, the same is true when these patients undergo transplantation.
Another factor that must be taken into account is center-specific outcomes. Centers must take into account their own data in term of TRM and survival.
This patient will likely have a well-matched donor (siblings or unrelated). At our center, based on our center-specific data, we favor haploidentical donor over unrelated.
In sum, I would recommend allogeneic transplant in this case. But like I always tell patients at the conclusion of my counseling, my job in the process of deciding whether to proceed with allogeneic transplant is done when patients are well-informed of the potential benefits and risk. The final say belongs to the patient.
Ref: Ossenkoppele GJ et al. Haematologica, 2016, 101:20-25
Dr. Ayman Saad · April 13, 2023 at 2:41 pm
Great discussion! Given the age >60 years old (with likely inherent bad biology), I would agree. However, for younger folks, I would stay away from HCT if MRD negative after first induction.