Elsevier

Seminars in Hematology

Volume 47, Issue 1, January 2010, Pages 51-58
Seminars in Hematology

Transplant Outcomes in Acute Leukemia (II)

https://doi.org/10.1053/j.seminhematol.2009.10.005Get rights and content

Currently, it is possible to find a hematopoietic stem cell (HSC) donor for virtually all patients with acute leukemia who have an indication to receive an allogeneic hematopoietic stem cell transplant (HSCT) and lack a human leukocyte antigen (HLA)-identical sibling or a well-matched HLA unrelated donor (URD). According to the ethnicity of the patients and the donor registry, approximately 25% to 60% of patients will not find an 8/8 HLA-matched unrelated donor. Other alternative donors, such as HLA-mismatched related donor or unrelated donor umbilical cord blood (UCB), have emerged to solve the lack of a sibling or well-matched URD. In the haploidentical HSCT setting, new techniques of T-cell depletion, new approaches using combinations of immunosuppressive drugs or different conditioning regimens, and developments on immunotherapy have focused attention on this option. Therefore, any physician has to carefully evaluate, for each patient in need of an allograft, all of the possible alternatives in order to choose the best HSC donor, taking into account type of disease to be transplanted, urgency of transplantation, donor characteristics, and center experience. This review evaluates the current status of haploidentical HSCT in acute leukemia, its advantages and remaining limitations compared to other stem cell sources, and how these data may be used in the development of donor selection algorithms.

Section snippets

HFD HSCT for Acute Leukemia

Early experiences attempting HFD HSCT were frustrated by poor engraftment and a prohibitive incidence of graft-versus-host disease (GVHD),4, 5, 6 consequent on the difficulties of crossing major histocompatibility barriers. However, considerable progress has been made over the last two decades; vigorous T-cell depletion, using automated technology, has reduced the incidence of GVHD to a level comparable with URD HSCT7, 8, 9, 10 and high primary engraftment rates can now be achieved by the

Comparison of HFD HSCT With Other Stem Cell Sources

Table 2 summarizes studies that have compared the outcomes of HFD HSCT with other stem cell sources for acute leukemia.

The Eurocord group, in collaboration with the Acute Leukemia Working Party and the Pediatric Diseases Working Party of the EBMT, have retrospectively compared the outcome of both children and adults given either a single-unit UCB transplant (UCBT) or HFD HSCT35, 36 (Table 2). Children (16 years or younger) had received either HFD HSCT (n = 118) or UCBT (n = 341) in

Donor Selection Hierarchy for Patients With Acute Leukemia

This review and the preceding article have summarized the current status of URD and alternative donor transplantation for children and adults with acute leukemia and have demonstrated that, in the absence of an HLA-matched sibling donor, unrelated donor BMT (UBMT), UCBT, and HFD HSCT offer acceptable alternative stem cell sources for allogeneic transplantation (Table 3).

In children, matched (antigen level at HLA-A and -B, allelic level at HLA-DRB1) UCBT is at least equivalent and possibly

Conclusion

Allogeneic HSCT is the only curative therapy currently available for patients with selected high-risk acute leukemia. It is now possible to find a suitable donor for almost all patients. We have outlined donor selection algorithms based on current best evidence. Such strategies will undoubtedly evolve over time as further technological advances are made in the specific approaches described.

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    R.H. is a trustee of the UK Cord Blood Charity.

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