No abstract

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is frequently applied as part of treatment in acute myeloid leukemia (AML) in first or subsequent remission. It reduces relapse, but non-relapse mortality (NRM) and morbidity may counterbalance that beneficial effect. Here we review recent studies reporting new disease specific prognostic markers as well as alloHSCT related risk factors to be identified at specific time points during treatment. We propose risk assessment as a dynamic process during treatment, incorporating both disease and transplant related factors for the decision to proceed either to alloHSCT or with a non transplant strategy, whereby alloHSCT may be favored if projected disease free survival can be expected to be improved by at least 10%, based on individual risk assessment. Pivotal for such an approach are initial disease risk assessment, search for a sibling or unrelated donor early after diagnosis, and the incorporation of time dependent risk factors, all within the context of an integrated therapeutic management approach.4

working group of the European Group for Blood and Marrow Transplantation (EBMT) and the European LeukemiaNet (ELN) GVHD remains the major impediment to broader application of allogeneic haematopoietic SCT. It can be prevented completely, but at the expense of other complications, rejection, relapse or delayed immune reconstitution. No optimal prevention or treatment method has been defined. This is reflected by enormous heterogeneity in approaches in Europe. Retrospective comparisons between different policies, although warranted, do not give definite answers. In order to improve the present situation, an European Group for Blood and Marrow Transplantation and the European LeukemiaNet working group has developed in a Delphilike approach recommendations for prophylaxis and treatment of GVHD in the most common allogeneic transplant setting, transplantation from an HLA-identical sibling or unrelated donor for standard risk malignant disease. The working group proposes these guidelines to be adopted as routine standard in transplantation centres and to be used as comparator in systematic studies evaluating the advantages and disadvantages of practices differing from these recommendations.

In this multicenter retrospective study, the outcomes of 836 patients with myelodysplastic syndrome (MDS) who underwent transplantation with a human leukocyte antigen (HLA)-identical sibling donor were analyzed according to 2 types of conditioning: reduced-intensity conditioning (RIC) in 215 patients, and standard myeloablative (or high-dose) conditioning (SMC) in 621 patients. In multivariate analysis, the 3-year relapse rate was significantly increased after RIC (hazard ratio [HR], 1.64; 95% confidence interval [95% CI], 1.2-2.2; P ‫؍‬ .001), but the 3-year nonrelapse mortality (NRM) rate was decreased in the RIC group (HR, 0.61; 95% CI, 0.41-0.91; P ‫؍‬ .015). The 3-year probabilities of progression-free and overall survivals were similar in both groups (39% after SMC vs 33% in RIC; multivariate P ‫؍‬ .9; and 45% vs 41%, respectively; P ‫؍‬ .8). In conclusion, the lower 3-year NRM after RIC is encouraging, since these patients were older (age > 50 years in 73% RIC vs 28% in SMC, P < .001) and had more adverse pretransplantation variables. However, based on the higher risk of relapse, patients with no contraindications for SMC should not receive RIC outside of prospective randomized trials, which are needed to establish the position of RIC-based transplantation in the treatment of patients with MDS. (Blood. 2006;108:836-846)