Comments on: Mini-Allo Transplant Statistics

By: chaya

chaya — Fri, 18 Apr 2008 01:05:05 +0000

Eric:

Actually, the success stats for adult matched unrelated donors (MUD) are better than those for related (sibling) donors – as reported in a seminal paper from the Hutch that we reviewed in our article “The only real cure” on http://www.clltopics.org .

Therefore I was pleasantly surprised that even in this series of almost all related donors at MDA the results were so encouraging. It is also important to take into account that many of these transplants were done in the early 2000’s. Eight years is a lot of time in a fast expanding field, lots of improvements have been made between then and now.

Stem cells obtained directly from the bone marrow are becoming a rarity. Most of the stem cells from adult donors (whether related or unrelated) are now obtained from peripheral blood. This is a trend that is likely to continue. There are some papers suggesting that GVHD is more of an issue with stem cells obtained from peripheral blood, compared to stem cells obtained from bone marrow. But the lowest risk of GVHD is seen with cord blood stem cells.

You are right, not every one has the luxury of a sibling or matched unrelated adult donor, especially if the patient is from ethnic minorities. But getting good cord blood matches is becoming progressively easier as the size of public cord blood banks increase.

Harvey is a case in point. No sibling match, no MUD (adult) match. But two good sized cord blood units matched and we look forward to a successful mini-allo transplant.

By: Eric

Eric — Thu, 17 Apr 2008 21:38:16 +0000

Thank you (once again) for making us aware of this very relevant and timely article!

Another key consideration here is the number of related donors (45) vs. MUD’s (2). I’ve seen another article by Caballero et al. (CCR 2005) with similarly rosy statistics for mini-allo SCT’s for poor-prognostic B-CLL, but featuring all related donors. Alas, a related donor is something the majority of patients do not have… but for those that do, they’re definitely sitting in the cat-bird seat!

On the other hand, it’s interesting to note the source of stem cells: 45 from PB, only 2 from marrow. It’s my understanding that the incidence of GVHD is greater when using PBSC vs. marrow, but this may only apply to MUD’s?

By: Burke

Burke — Thu, 17 Apr 2008 17:01:26 +0000

I had a transplant specialist tell me yesterday that he thinks CLL can be cured with a transplant.

By: Randall Shannon

Randall Shannon — Wed, 16 Apr 2008 15:54:31 +0000

Chaya,

Thanks!

As a CLL’er circling the MINI BMT option- came up to the plate but had to take care of a kidney challenge first- I appreciate your clear candor on this issue…

God Bless,

Randy Shannon

By: Paul

Paul — Wed, 16 Apr 2008 14:44:14 +0000

Chaya, thanks for pointing these articles out! Although I thought I already had a good idea about the lay of the land of continued treatment vs. transplant, it’s really great to see good data to re-inforce our sketchy information. Hopefully, this will help all of make the right decisions and at the right time for treatment vs. transpant. I’ve been following Harvey’s journey and am very pleased at the outcome so far. Our prayers and thoughts are with you and Harvey!

By: David & Marilyn

David & Marilyn — Wed, 16 Apr 2008 05:37:27 +0000

It’s important to see the forest for the trees. Bad GVHD is a risk of transplant, as is death. Fortunately, otherwise healthy people who enter transplant as an elective matter seem to do rather well, though there are of course no guarantees.

Treating and retreating Bucket C CLL with chemo may not have the short-term intense discomfort and window of immune vulnerability associated with transplant (though even that might be debatable), but the outcome is always inevitably the same when the drugs stop working and the disease becomes resistant: death.

So, on the one hand we have certain death, and on the other hand we have a very good shot — as high as 80% perhaps — of a cure.

Remove your fears from the equation, think logically, and this is a no-brainer.

By: chaya

chaya — Wed, 16 Apr 2008 01:41:05 +0000

The statistics quoted in the MDA article do not support deathly fear of graft-versus-host disease:

“The incidence of grade II-IV acute GVHD was 11%. Only five patients were still undergoing immunosuppressive therapy at the time of last follow-up”.

Going through the full length article I noted that 7 patients died in this protocol, all of them due to infections and none due to GVHD. While there is no question that even the mini-allo approach contributes to a window of vulnerability when the immune system is not quite up to the job of protecting patients – and therefore contributes to the death-due-to-infections risk, it seems to me that the mere fact of having Fl and any therapy one goes through to control it is very likely going to leave patients immune compromised. What would be the risk of death due to infections if the patients had not been transplanted but instead went through conventional W&W followed by chemotherapy to control their FL?

Stem cell transplant technology and treatment options for GVHD are improving rapidly. I would advice patients to look for the latest statistics on this subject since we are making major improvements on both fronts.

By: Burke

Burke — Wed, 16 Apr 2008 00:58:45 +0000

And, of course, there is always the problem of chronic graft-to-host disease long after the transplant is complete. Dr. Hamblin wrote that he thought anyone considering an allograft should talk to someone with chronic graft-to-host disease first.