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Multicenter Study
. 2009 Oct;15(10):1314-22.
doi: 10.1016/j.bbmt.2009.06.011. Epub 2009 Aug 3.

Salvage allogeneic hematopoietic cell transplantation with fludarabine and low-dose total body irradiation after rejection of first allografts

Boglarka Gyurkocza  1 , Thai M Cao, Rainer F Storb, Thoralf Lange, Wendy Leisenring, Georg N Franke, Mohamed Sorror, Richard Hoppe, David G Maloney, Robert S Negrin, Judith A Shizuru, Brenda M Sandmaier
Affiliations
Multicenter Study

Salvage allogeneic hematopoietic cell transplantation with fludarabine and low-dose total body irradiation after rejection of first allografts

Boglarka Gyurkocza et al. Biol Blood Marrow Transplant. 2009 Oct.

Abstract

We summarized results in 38 consecutive patients (median age=56 years) with hematologic malignancies (n=35), aplastic anemia (n=2), or renal cell carcinoma (n=1), who underwent salvage hematopoietic cell transplantation (HCT) for allograft rejection. In 14 patients, the original donors were used for salvage HCT, and, in 24 cases, different donors were used. Conditioning for salvage HCT consisted of fludarabine (Flu) and either 3 or 4 Gy total body irradiation (TBI). Sustained engraftment was achieved in 33 patients (87%). Grafts were rejected in 5 patients (13%), 4 of whom had myelofibrosis. With a median follow-up of 2 years (range: 0.3 to 7.8 years), the 2- and 4-year estimated survivals were 49% and 42%, respectively. The 2-year relapse rate and nonrelapse mortality (NRM) were 36% and 24%, respectively. The 2-year cumulative incidences of grades II-IV acute and moderate-severe chronic graft-versus-host disease (aGVHD, cGVHD) were 42% and 41%, respectively. In this cohort, TBI dose, grafts from original versus different donors, related versus unrelated donors, and HCT comorbidity scores did not have an impact on outcomes. We concluded that graft rejection after allogeneic HCT could be overcome by salvage transplantation using conditioning with Flu and low-dose TBI.

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Figures

Figure 1
Figure 1. Outcomes of Salvage HCT
Neutrophil engraftment (A). Thirty-three of 38 patients had sustained engraftment (probability of engraftment: 0.87; 95 % CI: 0.74, 0.95). The median time to neutrophil engraftment was 15 (range 9 – 42) days. Survival (B) The 2 and 4-year estimated probabilities of survival were 0.49 (95% CI: 0.31, 0.66) and 0.42 (95% CI: 0.23, 0.61), respectively. Non-relapse mortality (C) The 2 year estimated probability of non-relapse mortality was 0.24 (95% CI: 0.11, 0.41). Relapse/Progression (D) The estimated probability of relapse/progression at 2 years was 0.36 ( 95% CI: 0.20, 0.52). The dashed lines represent 95% CI.
Figure 2
Figure 2. GVHD
Grades 2–4 acute GVHD (A) The cumulative incidence of grades 2–4 acute GVHD at day 100 was 0.42 (95% CI: 0.26, 0.57). The cumulative incidences of grade 3 and grade 4 acute GVHD were 0.05, each (95% CI: 0.009, 016). Moderate-severe chronic GVHD (B) The cumulative incidence of moderate-severe chronic GVHD at 2 years was 0.41 (95% CI: 0.25, 0.57). The dashed lines represent 95% CI.
Figure 3
Figure 3
Impact of donor type (A), using same vs. different donor (B), TBI dose (C) and HCT comorbidity index score (D) on overall survival.
See this image and copyright information in PMC

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