Optimizing Management of the Central Nervous System in Patients with Acute Lymphoblastic Leukemia Undergoing Allogeneic Stem Cell Transplantation

Downloadable Content

g445cd60p?file=thumbnail
Read in Browser Download

Item Description

Description
  • Optimizing Management of the Central Nervous System in Patients with Acute Lymphoblastic Leukemia Undergoing Allogeneic Stem Cell Transplantation Background: High-risk acute lymphoblastic leukemia (ALL) patients often undergo allogeneic hematopoietic stem cell transplantation (HSCT) utilizing total body irradiation (TBI)-based conditioning regimens to achieve durable remission and cure. As ALL has a predilection for central nervous system (CNS) involvement, a radiation therapy boost is often given to the CNS in the form of cranial or craniospinal irradiation along with HSCT. The purpose of this work was to evaluate clinical outcomes and patterns of failure, specifically in regards to the central nervous system (CNS), in adult ALL patients undergoing HSCT utilizing TBI-based conditioning regimens with and without CNS boost. Methods: All adult (≥ 18 y/o) patients with ALL undergoing allogeneic HSCT utilizing TBI-based conditioning regimens treated from 1995-2020 at Duke University Medical Center were evaluated. Various patient, disease, and treatment-related factors were collected, including CNS prophylaxis and treatment interventions. Clinical outcomes, including freedom from CNS relapse, were calculated using the Kaplan-Meier method for patients with and without CNS disease at presentation. Results: 115 ALL patients were included the analysis (myeloablative-110; non-myeloablative-5). Of the 110 patients undergoing a myeloablative regimen, most (n=100) did not have CNS disease prior to transplant. For this subgroup, peri-transplant intrathecal (IT) chemotherapy was administered in 76% (median of 4 cycles) and 10 received a radiation boost to the CNS (cranial irradiation-5; craniospinal-5). Only 4 failed in the CNS after transplant with freedom from CNS relapse at 5 years of 95% (95% CI, 84-98%). Freedom from CNS relapse was not improved with an RT boost to the CNS (100% vs. 94%, p=0.59). Overall survival, leukemia-free survival, and non-relapse mortality at 5 years were 50%, 42%, and 36%, respectively. Among the 10 patients with CNS disease prior to transplant, 10/10 received IT chemotherapy and 7 received a radiation boost to the CNS (cranial irradiation-1; craniospinal-6) and none subsequently failed in the CNS. A non-myeloablative HSCT was pursued for 5 secondary to advanced age or comorbidities. None of these patients had prior CNS disease or received a CNS or testicular boost, and none failed in the CNS after transplant. Conclusions: A CNS boost may not be necessary in patients with high-risk ALL without CNS disease undergoing a myeloablative HSCT utilizing a TBI-based regimen. Favorable outcomes were observed with a low-dose craniospinal boost in patients with CNS disease.
Date created
Creator
Orcid
  • 0000-0002-4477-6906
Subject
Mentor
Research type
Study program
Research Location
In Collection:

QR Code

Items