Revolution of Therapy in Acute Lymphoblastic Leukemia - Episode 21

Allogeneic Transplant at First Remission of ALL


Max S. Topp, MD: Regarding the role of allogeneic transplantation in first-remission patients, you have to decipher right from the beginning if a patient is standard risk or high risk based on the initial work-up you did. So in the standard-risk patients, if they remain MRD [minimal residual disease] negative, in my mind there’s no role of allotransplantation. Only those patients who have an unfavorable response and become MRD positive…are candidates for transplantation. For the high-risk patient group, they are per se always candidates for transplantation.

And experimentally, we are looking at the question: Can we downscale those patients who become MRD negative? Can we then drop transplantation? There are data from the Spanish study group that showed it’s potentially possible. We’re looking at this question in our study group prospectively. And this scenario is, I think, very clear for the patient group up to about age 55. I think despite the higher mortality rate in patients older than 40, it’s still clear that we have to act like that. Obviously, if a patient is 55 to 75 years old, the risk stratification is not quite as clean as for the younger patients. I think the majority of us, if we have a 4;11 translocation in that age group, would be in favor for transplantation. And obviously in patients who have a good performance status and are MRD positive after frontline therapy.

But then it becomes, with the new data of blinatumomab, more and more complicated. Do I take a patient who’s 55 to transplant, or would I actually now give them blinatumomab in that context? And if they respond, great. Watch them, wait with them, and do the MRD testing. And if they relapse, give them inotuzumab ozogamicin and then take them to transplant, because we have 2 modalities now that have been quite successful in that context. But overall, the goal will be to reduce the rate of transplantation in patients, generally speaking. I think that’s what is happening when we’re in the field in our country.

Transcript Edited for Clarity