Active acute leukaemia: should transplant be offered to all patients?

[HLA-10/10 matched unrelated donor versus sibling donor hematopoietic stem cell transplantation for adult acute myeloid leukemia]

目的

观察人类白细胞抗原（HLA）匹配的无关供者造血干细胞移植（MUD-HSCT）治疗成人急性髓系白血病（AML）的疗效。

方法

回顾性分析2008年1月至2017年4月接受MUD-HSCT的成人AML病例资料，并以同期同胞全相合供者移植（MSD-HSCT）病例为对照，分析两组患者总生存（OS）率、无病生存（DFS）率、复发率、非复发死亡率（NRM）、植活率及急慢性移植物抗宿主病（aGVHD、cGVHD）发生率的差异。

结果

共247例连续性病例入组，MUD组46例，MSD组201例。除1例MSD组患者早期死亡外，两组患者均获粒细胞植活，但MUD组中位植活时间长于MSD组（15 d对14 d，P=0.017），血小板累积植活率差异无统计学意义（93.5%对98.0%，P=0.128）。两组患者aGVHD、cGVHD累积发生率差异无统计学意义（50.0%对46.3%，P=0.421；37.8%对43.0%，P=0.581）。与MSD组相比，MUD组患者3年累积NRM显著升高（22.0%对10.4%，P=0.049），但累积复发率差异无统计学意义（20.5%对28.3%，P=0.189）。两组患者3年OS率和DFS率差异均无统计学意义（61.6%对63.3%，P=0.867；57.5%对61.6%，P=0.760）。经多因素分析发现，患者年龄≥45岁、移植前第2次完全缓解（CR₂）及以上或未缓解状态、有髓外浸润病史及Ⅲ~Ⅳ度aGVHD是影响生存的独立危险因素。

结论

与MSD-HSCT相比，MUD-HSCT治疗成人AML的NRM较高，粒细胞植活中位时间较长，但GVHD发生率、复发率、OS率及DFS率并无显著差异，是缺乏MSD的成人AML患者的理想替代移植方案。

Second allogeneic hematopoietic cell transplantation enables long-term disease-free survival in relapsed acute leukemia

Allogeneic hematopoietic cell transplantation (HCT) is the treatment of choice for high-risk myeloid and lymphoid leukemias. Relapse after allogeneic HCT is associated with a dismal prognosis and further therapeutic options are limited. One potential curative approach is a second allogeneic HCT. However, there is no consensus about optimal transplant modalities, suitable patients, and entities. We performed a retrospective analysis of our institutional database to evaluate risk factors that influence survival after a second allogeneic HCT for the treatment of relapsed acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). We identified 40 patients (AML, n = 29; ALL, n = 11) that received a second allogeneic HCT at our institution. At time of second HCT, 48% of patients were in complete remission (CR). Current overall survival (OS) was 14/40 patients with a median follow-up of 64 months (range 4-140) of patients alive resulting in a Kaplan-Meier estimated 2-year event-free survival (EFS) and OS of 32%, respectively. Cumulative incidence of non-relapse mortality (NRM) and relapse at 2 years was 31 and 37%, respectively. We identified several independent risk factors influencing OS: > 6 months from first to second transplant (p = 0.02), complete remission prior to transplant (p = 0.003), and the subsequent occurrence of chronic graft-versus-host disease (p = 0.003) were associated with a significantly improved OS. In conclusion, our data suggest that a second allogeneic HCT is a curative treatment option for relapsed acute leukemias in selected patients.

Outcome following second allogeneic hematopoietic cell transplantation: A single-center experience

OBJECTIVE

Second allogeneic hematopoietic cell transplantation (HCT) may be indicated following relapse or graft failure following first HCT. Our retrospective single-center study sought to investigate parameters that influence post-second allogeneic HCT survival.

METHOD

We investigated 92 patients who underwent second allogeneic HCT between 1980 and 2016 for relapse or graft failure following first HCT. Median age at second HCT was 41 years (range 16-68), performed for relapse in 59 patients (64%) and for graft failure in 33 patients (36%).

RESULTS

On univariate analysis, 3-year OS of the entire cohort was 35% (95% CI=25-45). Eastern Cooperative Oncology Group (ECOG) score (3-year OS 48% for ECOG 0-1, 18% for ECOG 2-3, P=.0006), second HCT indication (3-year OS 43% for relapse, 20% for graft failure, P=.02), time from first HCT to relapse/graft failure (3-year OS for <12months 21%, for ≥12months 46%, P=.009), and conditioning intensity (3-year OS for MA 42% vs other regimens 23%, P=.08) significantly influenced OS. Multivariable analysis confirmed ECOG score (HR=2.15 for ECOG 2-3, 95% CI=1.32-3.51, P=.002) and second HCT indication (HR=1.67 for graft failure, 95% CI=1.02-2.75, P=.04) to independently influence survival.

CONCLUSION

Second HCT may offer long-term survival particularly to patients with good performance status who relapse post-first HCT.