Abstract
To identify potential barriers to reduced-intensity conditioning (RIC) allogeneic stem cell transplantation (ASCT) in patients with chronic lymphocytic leukemia (CLL) we performed a retrospective review of patients referred for transplant consultation at our center. Of the 209 patients evaluated, a substantial proportion of patients who were appropriate candidates for RIC-ASCT were unable to attain disease control to proceed (18.3%) with this therapy. Fludarabine resistance at the time of consultation (p=0.026) and the presence of complex karyotype on metaphase cytogenetics (p=0.048) were observed more frequently among patients unable to receive a transplant, suggesting that the timing of transplant evaluation earlier in the course of treatment for high risk genomic patients is critical for being able to incorporate this treatment modality.
Highlights
Chronic lymphocytic leukemia (CLL) is the most common hematologic malignancy in the Western world, representing 30% of leukemias [1]
Reduced-intensity conditioning (RIC)-allogeneic stem cell transplant (ASCT) was introduced as a way to minimize the toxicity of transplant but preserve the graft-versus-leukemia effect
The majority of patients who did not undergo transplantation did not have an indication for transplant at the time of evaluation, which, in many cases, reflected previous standards of care prior to the understanding of the poor prognosis of patients with highrisk karyotypes and fludarabine-refractory CLL
Summary
Chronic lymphocytic leukemia (CLL) is the most common hematologic malignancy in the Western world, representing 30% of leukemias [1]. Utilization of new combinations of chemotherapeutic agents, as well as the introduction of biologic agents, and the identification of prognostic markers that have led to better risk stratification and more tailored treatments have led to longer remissions, but CLL is still considered incurable outside the transplant setting [2]. Treatment for young and otherwise healthy patients has traditionally involved fludarabine, typically in combination with other agents [3]. Reduced-intensity conditioning (RIC) allogeneic stem cell transplant (ASCT) is one such option. In spite of RIC ASCT being the only potentially curative option available for CLL, relatively few patients who are referred for transplant evaluation eventually go on to receive one. The purpose of this study was to quantify how many patients are evaluated versus how many eventually receive a transplant, to evaluate differences between patients who received a transplant and those who did not, and to attempt to elucidate why this therapeutic option is not pursued more frequently
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