BSBMT Indications for BMT

A committee wrote the 2008 indications table:
David Marks (chair), Jenny Byrne, Charlie Craddock, Steve Devereux, Judith Marsh, Ghulam Mufti, Tony Pagliuca, Steve Robinson, and Nigel Russell

The aim was to provide an up to date indications table for transplanters, referring haematologists and purchasers recognising that the EBMT table is out of date and may not apply to UK practice. Several rarer diseases are not covered but will be added subsequently.

Members of the committee worked in their specific areas of expertise but all members had an opportunity to review and comment on the final table. This table will require updating regularly. Comments are welcomed

Table last updated 30th May 2008

Click here to download this table.

BSBMT Indications for BMT

Section 1

CML




	Sibling transplant	MUD transplant	Reduced Intensity Allo/MUD	Autograft
Chronic phase -TKI refractory or resistant¹	S¹	S¹	CO²	GNR³
Accelerated Phase - After initial therapy with Imatinib or other TKI	S⁴	S⁴	D⁶	GNR
Blast crisis	GNR	GNR	GNR	GNR
2^nd Chronic Phase	S⁵	S⁵	D⁶	D⁷ (if Ph –ve cells have been stored)

For definitions see Baccarani¹

Myeloma
	Sibling transplant - myeloablative if aged < 40 yrs - RIC if aged > 40 yrs	MUD transplant	First autograft	Second autograft
At first response	CO⁸ - Selected young patients <55 years or as part of clinical trial	GNR (unless in the context of a clinical trial)	S⁹ - for patients suitable for intensive treatment	CO^10,11 (Tandem autograft may be considered if no CR after 1^st autograft)
Relapse	D¹² -Selected young patients <55 years or as part of clinical trial	D	CO (If not done in first response but patient is considered fit)	CO¹³ -If time to re treatment after 1^st autograft >18m or as part of NCRN Myeloma 10 trial
Plasma cell leukaemia	CO¹⁵ - If chemo responsive disease	D¹⁵ - If chemo responsive disease	S¹⁵ - If no suitable donor or unfit for allograft	GNR
Other Plasma Cell Dyscrasias
AL amyloid	GNR	GNR	CO¹⁴ - As directed by National Amyloid Centre in selected cases (UKATT trial)	GNR
POEMS	GNR	GNR	D¹⁶ - Cases discussed with Neurologists	GNR

General Comments

1. Generally RIC transplants are performed for patients >45-50 years of age or for patients with significant co morbidities using the HSCT co morbidity index or for patients with lymphoma. In the context of certain clinical trials the age for choosing a RIC transplant may be lower. Patients with a score >3 are generally not suitable for any HSCT

2. For unrelated donor transplants usually either a full 10/10 match at HLA A, B, C and DR is required or a single mismatch

3. Cord Blood transplants are an alternative for patients lacking a sibling or unrelated donor (as defined above). Usually these patients are from ethnic minority.

References

1. Baccarani et al, Blood 2006, 108: 1809-20

2. Crawley et al, Blood 2005, 106: 2969-76

3. Cancer Treatment Rev, 2007, 33: 39-47

4. Weisser et al, leuk Lymphoma 2007, 48: 295-201

5. Current Treat Options Oncol 2000, 1 : 51-62

6. Kebriaei et al, Blood 2007, 110 : 3456-62

7. Bhatia et al, Haem/Onc Clin North Am 2004, 18 : 715-732

8. Gahrton et al, Haematologica 2007, 92: 1513-8

9. Child et al, New Engl J Med 2003, 348: 1875-8

10. Abdellcefi et al, Blood 2007, e-pun Nov 8

11. Cavo et al, J Clin Onc 2007, 25: 2434-41

12. Elice et al, Am J Haematol 2006, 81: 426-31

13. Alvares et al, Haematologica 2006, 91: 141-2

14. Perfetti et al, Haematologica 2006, 91: 1635-43

15. Saccaro et al, Am J Haematol, 2005, 78: 288-94

16. Jaccard et al, Blood 2002, 99: 3055-9

Section 2

AML

Sibling transplant

MUD transplant

Autograft

Comments

APL CR1

APL CR2

PCR+

APL CR2

PCR-

GNR

BCSH

guidelines

AML - good risk CR1

CR2

GNR

BCSH guidelines AML15/16 trial protocols

AML - standard risk CR1

CR2

GNR

AML 15/16 protocols

AML - poor risk* CR1

CR2

GNR

AML 15/16 protocols

AML not in remission

GNR

Fung et al ¹, Cook et al ²

* poor risk defined as either 1. cytogenetics (MRC criteria), 2. secondary or therapy – related AML, 3. failure to achieve CR with standard AML induction therapy

References

1. Fung HC, Stein A, Slovak M, et al. A long-term follow-up report on allogeneic stem cell transplantation for patients with primary refractory acute myelogenous leukemia: impact of cytogenetic characteristics on transplantation outcome. Biol Blood Marrow Transplant. 2003;9:766-771.

2. Cook G, Clark RE, Crawley C, et al. The outcome of sibling and unrelated donor allogeneic stem cell transplantation in adult patients with acute myeloid leukemia in first remission who were initially refractory to first induction chemotherapy. Biol Blood Marrow Transplant. 2006;12:293-300.

Section 3

ALL
	Sibling transplant	MUD transplant	Autograft
CR1 - standard risk - poor risk	S¹ S¹	GNR CO²	GNR GNR
CR2	S	S	GNR³
Not in remission	GNR	GNR	GNR
Philadelphia positive ALL	S	S	GNR

References

1. Rowe et al. Blood 2006 (ASH plenary session)108:127, abstract no 2

2. Rowe and Goldstone Blood 110:2268-2275, 2007. Poor risk is defined as adverse cytogenetics, T-ALL with WCC>100, B-ALL with WCC>30, MRD positive after phase 2. Ideally this should be discussed with a member of the NCRI ALL group

3. Autografts, although inferior to chemotherapy in CR1 patients and inferior to allografts in CR2 patients may be justified when all other therapeutic options have been explored or the optimal therapy (eg chemotherapy) cannot be delivered

Abbreviations

S = standard of care

CO = clinical option, can be considered after assessment of risks and benefits

D = developmental, further trials are needed

GNR = generally not recommended

Section 4 BSBMT Indications For Haematopoietic Stem Cell Transplantation In Lymphoma

General Comments

An allogeneic stem cell transplant may be considered in any disease category where autologous stem cell harvesting has failed.
A MUD should be a 10/10, 8/8 or 9/10 allelic level match.

Hodgkin’s Disease
	Autograft	Sibling transplant	MUD transplant
CR1	GNR	GNR	GNR
CR>1	S¹	CO²	CO²
Relapse/ Primary Refractory -Chemosensitive -Chemorefractory	S¹ CO	CO² CO²	CO² CO²
Relapse post autograft	GNR	CO³	CO³

References

Linch et al Lancet 1993; 341: 1050-1054, Schmitz et al Lancet 2002; 359: 2065-2071
Patients considered at high risk of failing an auto in CR1 eg CR1<1 year, PET⁺ post salvage, less than PR post salvage, chemorefractory
Peggs Lancet 2005; 365: 1906-1908., Sureda JCO 2008; 26: 455-462

Mantle Cell Lymphoma
	Autograft	Sibling transplant	MUD transplant
CR1/PR1	S¹	CO²	CO²
CR/PR>1	S¹	CO²	CO²
Chemorefractory	GNR	D	D
Relapse post autograft	GNR	CO³	CO³

References

Dreyling Blood 2005; 105:2677–2684
Khouri JCO 2003, Maris Blood 2004; 104: 3535, proposed NCRN trial (Rule et al)
Robinson Blood 2004; 104: 2322, Faulkner Blood 2004; 103: 428 - 434.

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CML

Myeloma

At first response

Relapse

AML

ALL

Section 4

BSBMT Indications For Haematopoietic Stem Cell Transplantation In Lymphoma

Hodgkin’s Disease

Mantle Cell Lymphoma

Follicular Lymphoma