Canterbury DHB

Context

Acute Myeloid Leukaemia

For a general view of this topic, see Cornlissen and Lowenberg, ASH EPB, 2005.

Further reading:

Allogeneic SCT in First Remission

Which young adults should receive allogeneic HCT in CR1?

For patients enrolled in a clinical trial, e.g. AML19 , it is recommended that patients follow the protocol and if a deviation is planned this is discussed with the trial organizers.

In patients with high risk AML survival after conventional chemotherapy is <20%. After allogeneic transplantation OS is 34-42% with comparable outcomes after MUD and MSD (Gupta, Tallman et al. 2010). In addition patients with normal cytogenetics in the intermediate risk group have 50% relapse risk with only a small chance of obtaining CR2 and also benefit from transplantation. Meta-analysis confirmed allogeneic SCT has significant RFS and overall survival benefit for intermediate- and poor-risk AML but not for good-risk AML in first complete remission (Koreth, Schlenk et al. 2009).

The NCCN and ASBMT both recommend [myeloablative] allogeneic SCT for patients with poor risk AML in CR1 up to the age of 55 yrs (Oliansky, Appelbaum et al. 2008). They recommend chemotherapy only for patients with good risk AML in CR1 and find insufficient evidence to recommend alloSCT in intermediate risk patients although it is described as “a reasonable approach”. There is insufficient evidence to recommend RIC over chemo in >55 year old outside of a clinical trial.

Allogeneic SCT is not recommended for good risk patients:

Allogeneic SCT may be recommended for fit patients with:

Allogeneic SCT is performed within a clinical trial for

Note: Autologous SCT for AML is no longer being performed in Christchurch outside of clinical trials.

Which older adults should receive allogeneic HCT in CR1?

Biological age is more important than chronological age in patients aged >60 years. All patients should be considered based on individual circumstances, however certain rules of thumb can be applied.

Older patients aged 60 to 75 years who should NOT receive HSCT:

SCT in Second or Subsequent Remissions

Several international transplant groups have published guidelines that were recently analysed by Hubel at al (Hubel, Weingart et al. 2011). The EBMT, ASBMTR, BCSH and ESMO groups (Milligan, Grimwade et al. 2006; Oliansky, Appelbaum et al. 2008; Fey and Dreyling 2009; Ljungman, Bregni et al. 2010) recommend allogeneic SCT for all patients in CR2 with an available donor.

Key points to consider are:

Recommended reading:

Prognostic scores in relapsed AML

GOELAMS score

Points

CR1 duration

 

  • ≥12 months

0

  • <12 months

1

FLT3-ITD status

 

  • Negative

0

  • Positive

 

Cytogenetics

 

  • Not high risk

0

  • High risk

1

Two year outcome: 0 points (good): OS 58%, EFS 45%; 1 point (intermediate): OS 37%, EFS 31%; 2 or 3 points (poor): OS 12%, EFS 12%.

EPI score

Points

CR1 duration

 

  • ≥18 months

0

  • 7-18

3

  • ≤6 months

5

Cytogenetics at diagnosis

 

  • t(16;16) or inv(16)

0

  • t(8;21)

3

  • Other

5

SCT before 1st relapse

 

  • No

0

  • Yes

2

Age at relapse

 

  • ≥35 years

0

  • 36-45 years

1

  • >45 years

2

One-year/5-year outcome: 0-6 points (good) OS 70%/46%; 7-9 points (intermediate) OS 49%/18%; 10-14 points (poor) OS 16%/4%.

About this Canterbury DHB document (8145):

Document Owner:

Andrew Butler (see Who's Who)

Issue Date:

December 2016

Next Review:

December 2018

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 8145