Summary Of Treatment Options For Relapsed And Refractory

Enrolment of patients onto well-designed clinical trials should always be at or near the top of therapeutic options. However, if an appropriate clinical trial is not available or if patients decline participation, the following represents a brief summary of therapeutic options for patients with primary induction failure or recurrent AML.

The only curative approach for patients with AML who fail primary induction is allogeneic HCT, so every effort should be made to identify a donor and proceed to transplant if the patient is a suitable candidate. If no donor is available, investigational or palliative therapy should be considered.

In considering therapeutic approaches for patients with AML who achieve a CR and then relapse, the first question to address is whether the individual patient is a possible candidate for an ablative transplant approach. If so, and if the patient is in early relapse and is known to have a matched sibling, proceeding directly to an allogeneic transplant is recommended. An autologous transplant in untreated first relapse can also be considered if stem cells were stored in first remission and the first remission was of reasonable length. If the patient is a candidate for an ablative transplant but a donor has not been identified, no stem cells were stored, or there are substantial numbers of circulating blasts at the time relapse, then reinduction therapy is needed. Although the published literature does not permit the identification of a single regimen as the best, based on randomized trials regimens combining high-dose cytarabine with a second agent seem justified, and in at least one randomized trial the use of a multidrug-resistance inhibitor seemed to further improve outcome.33

If patients are not transplantation candidates because of age or comorbidities, the wisdom of using aggressive chemotherapy with their accompanying toxicities should be questioned, and consideration for the use of less aggressive therapy, such as single-agent gemtuzumab ozogamicin, might be considered.

0 0

Post a comment