Implications and Management of Central Nervous System Involvement before Allogeneic Hematopoietic Cell Transplantation in Acute Lymphoblastic Leukemia.
Acute lymphoblastic leukemia (ALL) with a history of central nervous system (CNS) involvement, either at diagnosis or relapse, poses challenges when the decision is made to proceed with allogeneic hematopoietic cell transplantation (alloHCT), as there is no evidence-based consensus on the best peri-transplantation approach to reduce subsequent CNS relapse risk. Here, we retrospectively analyzed outcomes of 87 patients with ALL and a history of CNS involvement who later underwent alloHCT. Patients with pretransplantation CNS involvement had higher risk of CNS relapse after transplantation (2-year CNS relapse: 9.6% versus 1.4%, P < .0001), inferior event-free survival (EFS) (hazard ratio [HR], 1.52; P = .003), and worse overall survival (OS) (HR, 1.55; P = .003) compared with patients without pretransplantation CNS involvement (n = 543). There was no difference in post-transplantation CNS relapse, EFS, or OS among patients presenting with CNS involvement at diagnosis, those with isolated CNS relapse, and those with combined bone marrow and CNS relapse before HCT. Interestingly, neither pretransplantation cranial irradiation, use of total body irradiation-based conditioning, nor post-transplantation prophylactic intrathecal chemotherapy were associated with a reduction of CNS relapse risk after transplantation. Thus, among the patients in the cohort studied, there was no clear benefit of CNS-directed therapy in the peri-transplantation period among patients who had prior CNS involvement and underwent subsequent alloHCT.
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California. Electronic address: ialdoss@coh.org.
Ibrahim
I
Aldoss
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
Monzr M
MM
Al Malki
Department of Information Science, City of Hope, Duarte, California.
Tracey
T
Stiller
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
Thai
T
Cao
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
James F
JF
Sanchez
Department of Information Science, City of Hope, Duarte, California.
Joycelynne
J
Palmer
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
Stephen J
SJ
Forman
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California.
Vinod
V
Pullarkat
D000293:Adolescent; D000328:Adult; D064591:Allografts; D016543:Central Nervous System Neoplasms / Q000401:mortality / Q000628:therapy; D002648:Child; D002675:Child, Preschool; D018572:Disease-Free Survival; D005260:Female; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000401:mortality / Q000628:therapy; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate
Acute lymphoblastic leukemia; Allogeneic; Central nervous system; Intrathecal chemotherapy; Stem cell transplantation; Total body radiation