Allogeneic transplantation from an HLA-matched sibling is standard therapy for advanced acute leukemia (AAL; CR1). For those lacking a matched sib, an autograft (ABMT) or allograft from a partially mismatched related (PMRDT) or an unrelated donor are options. We compared the outcome of ABMT (n=131; 2-73 y, median 18; RMH) and PMRDT (n=181 ; 1-54 y, median 22; 92% mismatched on 2 antigens; SCCC) in AAL. 53 (29%) PMRDT patients were in CR compared -with 111 (85%) ABMT patients (P<0.0001). The ABMT patients in CR had cells collected in the current (the majority) or a prior (a minority) CR, whereas the 15% with active disease had cells stored in a prior CR. Of the 128 PMRDT patients with active disease, 71 (55%) were refractory to salvage chemotherapy. Thus, the ABMT group was biologically selected because patients failing to attain CR who had no cells stored could not undergo ABMT at all. The majority of ABMT patients received unpurged marrow and melphalan-based conditioning. PMRDT patients received TBI. cyclophosphamide, ARA-C, VP16, ATG, and methylprednisolone, with partial T-cell depletion (OKT3/T10B9), steroids, ATG, and cyclosporine as GVHD prophylaxis. 95 PMRDT patients experienced non-relapse mortality (NRM) (3-y prob 65%) compared with 21 ABMT patients (3-y prob 20%; P<0.0001). 54 PMRDT patients relapsed (3-y prob 52%)(51 died) compared with 69 ABMT patients (3-y prob 59%; P=0.2)(64 died). When adjusted for disease status at transplant (CR vs active), PMRDT resulted in lower relapse (P=0.004). 35 PMRDT patients were alive and well at the last follow-up (3-y prob 18%) compared with 46 ABMT patients (3-y prob 37%; P<0.0001). Adjustment for disease status diminished the significance of the survival difference (P=0.01). Cox analysis showed that PMRDT (P<0.0001) and age 20 (P=0.01) were associated with higher NRM, active disease at transplant (P=0.0003) and ABMT (P=0.003) with higher relapse, and age 20 (P=0.007), PMRDT (P=0.01), and active disease at transplant (P=0.05) with lower survival. We conclude that ABMT results in lower NRM than PMRDT in AAL. Relapse rates are lower with PMRDT; presumably due to graft-vs-leukemia. ABMT may be preferable to PMRDT in patients with available autologous cells (CR or previously stored cells). However, in the substantial number of patients who have no stored cells or have refractory disease, PMRDT is a reasonable option because better supportive care can improve the outcome by decreasing NRM.
|Original language||English (US)|
|Issue number||11 PART I|
|State||Published - Dec 1 2000|
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