Sunday, January 13, 2008

Transplants in CLL

I thought you might be interested in this provisional guideline for when to do a transplant in CLL.

1. Very high risk CLL defined as CLL with >20% cells showing del 17p or purine analogue refractory. These patients should be treated with p53 independent therapy such as high dose methyl prednisolone and/or alemtuzumab to maximum response and then allografted if possible in first complete remission.

2. High risk CLL defined according to EBMT criteria:{Dreger, 2007}
(i) Relapse within 6 months of Purine Analog therapy
(ii) Relapse within 2 years of intensive therapy including Purine Analog/alkylator combinations, chemo-immunotherapy or autologous transplantation, in second complete remission.

3. Richter's transformation in first complete remission.

It would be standard therapy to treat all of these categories of patients with either a sibling or volunteer matched transplant with reduced intensity conditioning.

4. Other indications. Includes patients not fulfilling criteria 1 or 2 who are in second or subsequent relapse with at least one of the other commonly recognised adverse features listed below:
(i) Bone marrow failure according to Binet criteria
(ii) Unmutated VH genes (<98% germline or V3.21)
(iii) ZAP 70+ (>20%)
(iv) CD38+ (>7%)
(v) Del 11q

For this category a reduced intensity conditioning sibling or volunteer donor transplant is not standard, but might be ordered by a CLL expert.

Umbilical cord blood transplants are experimental and should only be performed in the context of a clinical trial in patients for whom no adult donor is available.

Autografts are generally not recommended.


Anonymous said...

Do you know the relative risk of a matched, unrelated SCT versus an umbilical cord transplant?

Terry Hamblin said...

Umbilical cord transplants are a form of matched unrelated SCT, but because teh cord cells are less immunoreactive you can normally get away with only partial matching - they are therefore much more available. The main disadvantage seems to be the high incidence of EBV related lymphoma - as high as 20%.