Improved survival after bone marrow transplantation for early leukemia using busulfan-cyclophosphamide and individualized prophylaxis against graft-versus-host disease: a long-term follow-up
J. Aschan et al., Improved survival after bone marrow transplantation for early leukemia using busulfan-cyclophosphamide and individualized prophylaxis against graft-versus-host disease: a long-term follow-up, CLIN TRANSP, 13(6), 1999, pp. 512-519
To minimize immunosuppression, allow a graft-versus-leukemia (GVL) effect,
and reduce relapse incidence, 73 leukemic recipients of human leukocyte ant
igens-identical sibling marrow were given graft-versus-host disease (GVHD)
prophylaxis based on the estimated risk of GVHD development. Methotrexate (
MTX) monotherapy was given to patients with an estimated low risk of develo
ping GVHD, whereas MTX + cyclosporine (CsA) was given to 'high-risk' patien
ts. After engraftment, CsA was discontinued, and weekly MTX was reinstitute
d and given until 3 months post-bone marrow transplant. Conditioning consis
ted of busulfan (BU) + cyclophosphamide (CY) (n = 35) or CY + total body ir
radiation (TBI) (n = 38). Retrospective controls were given CY + TBI and MT
X + CsA (n = 39). The median observation time was 5 yr 11 months. Chronic G
VHD increased to 53% in the individual BU + CY group and 46% in the individ
ual CY + TBI group, compared to 25% in the control group (p = 0.05). This i
ncrease was restricted to the limited form. The actuarial relapse incidence
decreased to 20% in the individual BU + CY group, compared to 52% in the c
ontrol group, p = 0.03. In the individual CY + TBI group, the relapse incid
ence was 44% (n.s. versus controls, p = 0.04 versus individual BU + CY). Th
e 5-yr relapse-free survival (RFS) in the individual BU + CY group was 66%,
in the control group, 41% (p = 0.07), and in the individual CY + TBI group
, 45% (p = 0.1 versus individual BU + CY). Patients with early leukemia in
the individual BU + CY group had a RFS of 83%, compared to 44% in the contr
ol group (p = 0.02) and 42% in the individual CY + TBI group (p = 0.01). In
the multivariate analysis, advanced leukemia beyond first complete remissi
on and first chronic phase and conditioning with CY + TBI were correlated t
o poor RFS. In summary, the individualized prophylaxis itself did not reduc
e the relapse incidence. However, in patients with early leukemia condition
ing with BU + CY, our method of individualizing the GVHD prophylaxis might
be of value, since this group had the best RFS in this study.