Who is fit for allogeneic transplantation?

Abstract

The use of allogeneic hematopoietic cell transplantation (HCT) has expanded progressively, facilitated by the increasing availability of unrelated donors and cord blood, and the inclusion of older patients as transplantation candidates. Indications remain diagnosis-dependent. As novel nontransplantation modalities have been developed concurrently, many patients come to HCT only when no longer responding to such therapy. However, patients with refractory or advanced disease frequently relapse after HCT, even with high-dose conditioning, and more so with reduced-intensity regimens as used for patients of older age or with comorbid conditions. Thus, patients with high-risk malignancies who have substantial comorbidities or are of advanced age are at high risk of both relapse and nonrelapse mortality and should probably not be transplanted. Being in remission or at least having shown responsiveness to pre-HCT therapy is generally associated with increased transplantation success. In addition, to handle the stress associated with HCT, patients need a good social support system and a secure financial net. They must be well informed, not only about the transplantation process, but also about expected or potential post-HCT events, including graft-versus-host disease and delayed effects that may become manifest only years after HCT.

Figure 1

Selected conditioning regimens of different dose intensities. BU indicates busulfan; CY, cyclophosphamide; TBI, total body irradiation; Flu, fludarabine (various dosing schedules); AraC, cytosine arabinoside; ATG, antithymocyte globulin (or thymoglobulin); and ¹³¹I, anti-CD45 antibody conjugated to ¹³¹I. *“High-dose” TBI (800-1320 cGy). †“Low-dose” TBI (200-400 cGy).