autologous blood and marrow transplantation - Blog Science ...

68 Chapter 2: ALL
in parallel, and to make a choice depending on the results and the time delay of
donor search. PBSCT could be considered in patients for whom a matched
unrelated donor is not found within 3 months from diagnosis.
For favorable subgroups, such as mature B-ALL as well as T-ALL and B
precursor ALL without risk factors, the results of chemotherapy are at present
superior to overall results of auto- or MUD BMT and most probably also to
alloBMT, although BMT results for ALL subgroups have so far not been reported.
BMT should, therefore be employed in first relapse or second or subsequent CR
(Table 4).
The indications for BMT in CR1 in adult ALL need to be continuously
redefined depending on BMT results, chemotherapy results, and new prognostic
factors.
FUTURE INDIVIDUALIZED BMT INDICATIONS
BASED ON MINIMAL RESIDUAL DISEASE
In the future, additional BMT indications will most probably arise from
prospective evaluation of minimal residual disease (MRD). 23
Still, 40-50% of the
patients with standard-risk ALL eventually relapse. These patients at present
cannot be identified with known prognostic factors. The evaluation of MRD may
provide new, individual prognostic parameters. The majority of reports
demonstrate a strong correlation between relapse risk and MRD status in ALL.
Thus, patients with a high MRD level (>10 3
) after induction therapy,
independent of other risk factors, have a significantly higher relapse risk compared
with patients with lower or negative MRD status. 2425
According to cumulative data
from six trials after induction treatment, 10% of MRD-negative, 18% of "low
MRD," and 79% of "high MRD" patients eventually relapse. If these results are
confirmed in prospective trials in adult ALL, early BMT might be a reasonable
Table 4. Risk-adapted BMT indications in ALL
CR1
BMT
High risk B-lineage ALL (WBC >30,000/iiL, CR >4 weeks, proB, Ph +
)
High risk T-lineage ALL (WBC >100,000/uL, CR >4 weeks, proT)
No BMT
Standard risk B- or T-lineage ALL (LFS 40-50%)
Mature B-ALL (LFS >50%)
CR2 \
Relapsed ) BMT for all patients
Refractory /