Acute Lymphoblastic Leukaemia

Four recent prospective studies (Ribera, Oriol et al. 2005, Goldstone, Richards et al. 2008, Cornelissen, van der Holt et al. 2009, Kako, Morita et al. 2011) and three meta-analyses (Yanada, Matsuo et al. 2006, Ram, Gafter-Gvili et al. 2010, Gupta, Richards et al. 2013) have been published which overall show a survival advantage for allogeneic SCT performed in CR1 in young standard-risk Ph-negative patients although the studies gave conflicting results on the benefit in high risk disease and older patients.

The BSBMT guidelines published in 2010 (BSBMT 2010) recommend allogeneic SCT for standard and poor risk patients in CR1 from a MSD but not MUD. MSD or MUD is recommended for all patients with Ph+ ALL and patients in CR2. MUD is a clinical option for high risk patients in CR1. Allo SCT is generally not recommended (GNR) for patients unless in CR. Autografting is GNR for any patient group. [Note: These guidelines are poorly referenced and mainly reflect conclusions from the UKALL12 study.]

The ASBMT 2006 evidence-based review was updated in 2011 (Oliansky, Larson et al. 2011). New recommendations were (1) myelo-ablative allogeneic transplant is appropriate for all adults (<35 yrs) in CR1; (2) RIC may produce similar outcomes to MAC; (3) autologous transplant may be suitable for patients without an allogeneic donor but has a higher relapse rate; (4) it is appropriate to consider CBT for patients without an HLA-matched donor; (5) imatinib before and/or after allogeneic transplant improves outcomes in Ph+ ALL. Recommendations which were strengthened or remain unchanged were (1) allogeneic SCT remains superior to chemotherapy beyond CR1; (2) allogeneic SCT is superior to autologous; (3) there are similar survival outcomes after MRD and MUD allogeneic SCT.

Philadelphia-positive ALL

The ALLG ALL5 trial showed that some adults with Ph-positive ALL remain in long-term molecular remission following intensive chemotherapy followed by maintenance therapy with a tyrosine kinase inhibitor. This remains an experimental approach and relapses continue to occur. Post-transplant therapy with TKI is also under investigation and should be prescribed on an individual basis.

SCT in Relapsed Patients

The median survival after relapse in patients treated with chemotherapy alone in the UKALL 12 trial was 23 weeks. For patients treated with chemotherapy who relapsed within 2 years the OS at 1 year was only 5%. Patients aged less than 50 years who achieve CR2 could be considered for a standard myeloablative allograft but only a small proportion of patients will actually receive a transplant due to relapse, donor availability and fitness.

References


About this Canterbury DHB document (8148):
Document Owner:	Andrew Butler (see Who's Who)
Last Reviewed:	December 2016
Next Review:	December 2018
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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