Therapy Of Relapse After Transplantation

Relapse after allogeneic transplantation for AML is not uncommon and represents a difficult challenge to the clinician. Rates of response to donor lymphocyte infusions (DLI) are roughly the same for AML as for ALL and occur in roughly 15-40% of cases.52,92,93 Most of these responses are short-lived and are often associated with either acute or chronic GVHD. To be effective most DLI must be performed in remission.

For patients who do not respond to DLI, the option of a second allogeneic transplant exists. Using a second, matched related donor, 3 year leukemia-free survival among 125 patients with relapsed AML after a first matched, related transplant was 27%.59 The majority of these patients received allografts from the same donor, and the majority had myeloablative conditioning regimens. Factors that predicted survival included the length of remission from initial transplant, remission status at the time of second transplant, and the age of the recipient.59 Similar findings were reported from three European studies94-96, although the transplant-related mortality in the French study was 68%.96 In this study, chronic GVHD was associated with a more favorable outcome (hazard rate 3.2 for overall survival, p = 0.0005), suggesting that GVL is required for favorable long-term outcome.96 These outcomes are only observed if the transplant takes place more than a year after the first transplant. Attempts at transplantation within 1 year are associated with increased transplant-related mortality. The use of unrelated donors to harness more potent GVL effects97 and the use of nonmyeloablative conditioning to reduce transplant-related mortality have been attempted as well.98

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