Idarubicin and high-dose cytarabine in the treatment of refractory and relapsed acute lymphoblastic leukemia

We present 60 patients with refractory (n ¼ 8) or relapsed (n ¼ 52) adult ALL who received allogeneic hematopoietic SCT (HSCT) with (n ¼ 41) or without (n ¼ 19) prior reinduction chemotherapy. In our center, omission of reinduction is recommended if a suitable donor is promptly available, tumor burden is moderate and disease features suggest a highly aggressive course. Overall survival (OS) of the whole cohort at 1, 2 and 5 years was 42, 33 and 28%, respectively. Leukemia-free survival at 1, 2 and 5 years was 37, 33 and 24%. Deaths were due to relapse (n ¼ 25), acute or chronic GVHD (n ¼ 7), infections (n ¼ 8) or toxicity (n ¼ 4). Interestingly, patients who did not receive reinduction before HSCT had better outcomes than patients who received reinduction with OS at 1, 2 and 5 years being 58 vs 34%, 47 vs 25% and 47 vs 18%, respectively (P ¼ 0.039). Importantly, even achievement of a second CR after reinduction was not associated with improved survival compared to patients directly proceeding to HSCT. We conclude that patients who undergo HSCT for refractory or relapsed ALL can achieve longterm survival. In selected patients, reinduction chemotherapy can be omitted if immediate HSCT is feasible.

Section: Discussionmentioning

confidence: 99%

Allogeneic SCT in refractory or relapsed adult ALL is effective without prior reinduction chemotherapy

Terwey

Massenkeil

Tamm

et al. 2008

“…She was diagnosed as ALL-L3 and started a leukemia relapse protocol (AIEOP REC 98). 8 In June 1999, she attained second complete morphological and molecular BM remission and as early as September 1999 the MRI showed a marked improvement in the bone lesions. At that time she was planned to receive an 'allogeneic' BMT from her brother.…”

Section: The Sistermentioning

confidence: 97%

Reciprocal bone marrow transplantation between brother and sister

Rana

Caniglia

et al. 2002

Summary:A child with AML underwent allogeneic BMT from an HLA-identical sister donor. Prompt and stable trilineage engraftment occurred and after few months he returned to a normal life. Eight years later a primary NHL of bone developed in his sister. A partial remission was obtained by means of standard NHL treatment, but 3 months later rapid disease progression occurred with complete bone marrow invasion (ALL-L3). She was treated with a leukemia relapse protocol, obtaining a second partial remission. Unpurged bone marrow harvested from the brother, transplanted for AML 8 years earlier, was infused after conditioning with TBI and thiothepa. No GVHD prophylaxis was given. Neutrophil engraftment occurred by 14 days and platelet engraftment by 20 days after BMT. No acute GVHD was observed, but unexpectedly she developed skin and liver GVHD-like symptoms 80 days after BMT. Since the liver biopsy was suggestive of liver GVHD and in the absence of any other evidence as a possible cause of the hepatic damage, the patient started mycophenolate. Two months later serum hepatitis B markers were detectable.

“…Relapsed ALL in an adult is not curable, but remissions are sometimes achieved with re-induction with either a standard vincristine, prednisone and anthracycline or with a cytarabine-based regimen, particularly high-dose Ara-C combined with an anthracycline or clofarabine. [31][32][33] Available data from the IBMTR show that patients transplanted from an HLA-identical sibling for ALL in second CR (CR2) have approximately a 35-40% chance of long-term DFS, while those transplanted with disease not in remission have a DFS of only 10-20%. 34 Figure 4 shows the overall DFS for patients with ALL, depending on their remission status, who underwent allogeneic transplantation.…”

Section: Introductionmentioning

confidence: 99%

Allogeneic transplantation for ALL in adults

Stein

Forman

2008

Allogeneic transplantation is an effective treatment for adult patients with high-risk ALL, including patients in first or second remission. Although only a few studies have evaluated the optimal transplant regimens, the data would suggest that a TBI-based regimen results in better disease control. Although not as potent as it is in other hematologic malignancies, the GVL effect is an important component of achieving cure of ALL. Because of the toxicity of the fully ablative regimen, reduced-intensity transplants are being explored in older patients with ALL when the prognosis is especially poor with standard chemotherapy.