To transplant or not: Clinical decisions in elderly patients with AML
Although intensive induction chemotherapy can lead to complete remission rates of 40-60% in elderly patients with acute myeloid leukemia (AML), median survival is typically less than 12 months, according to the authors of this review article. The authors’ review challenges a common perception that older patients cannot tolerate intensive therapies. Evaluation of recent research demonstrates that older age per se is not a contraindication for allogeneic hematopoietic cell transplantation (HCT), and that high comorbidity index score and poor performance status are more predictive of poor outcomes. They conclude that HCT is feasible and can provide approximately 40% survival at two years in select older patients and note that “the short duration of CR demands that leukemia and transplant physicians collaborate immediately after diagnosis to move quickly toward HCT.”
In this review, the authors examine the role of allogeneic and autologous HCT in the treatment of adults with Burkitt lymphoma (BL). They note that although intensive chemotherapy can often result in long-term disease-free survival, a significant proportion of patients with high-risk BL will have refractory disease or will relapse. Topics discussed include identifying high-risk patients, offering upfront autologous HCT vs. HCT for relapsed or refractory disease, standard and reduced-intensity allogeneic HCT, and HCT in HIV-positive BL patients and those with B-cell lymphoma unclassified. The authors identify future research directions that may improve outcomes in BL, such as molecular diagnostics, FDG-PET scanning, and minimal residual disease monitoring.
Comparable outcomes in AML/MDS using related, unrelated donors
Matched unrelated or matched sibling donors can lead to comparable transplant survival, according to a single-center research study of 108 patients with AML (n=63) and MDS (n=45). In this study of reduced-intensity HCT, median age at transplant was 57 years (range, 20-68), and donors and patients were matched at high resolution at 10/10 HLA loci. Unrelated donor recipients were more likely to receive anti-thymoglobulin (ATG) than sibling donor recipients: 68% vs. 44%, respectively (p=0.026). Donor age was significantly lower for recipients receiving cells from unrelated donors than those with sibling donors: 30 vs. 52 years, respectively (p<0.0001). After adjustment for age, cytogenetic risk, ATG, and number of CD34+ cells infused, donor type still did not influence three-year overall survival: Sibling donor 45%; unrelated donor 49%; (p=0.98).
Two reviews: Minimal residual disease in acute leukemia
In these two review articles on minimal residual disease (MRD) in patients with acute leukemia, the authors discuss the recent research showing that the likelihood of relapse after transplant is directly associated with levels of MRD before transplant. They propose that MRD be considered along with cytogenetics and molecular markers to identify patients unlikely to be cured by standard chemotherapy and who should therefore be referred for possible HCT. In addition, they note that MRD analysis can be used to determine the optimal timing of HCT, guide the selection of conditioning regimens, and select post-transplant strategies that maximize the graft-versus-leukemia effect.
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