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Blood, 1 May 2002, Vol. 99, No. 9, pp. 3151-3157
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
Unrelated marrow transplantation for children with acute
lymphoblastic leukemia in second remission
Nancy Bunin,
Michael Carston,
Donna Wall,
Roberta Adams,
James Casper,
Naynesh Kamani,
Roberta King, and
the National
Marrow Donor Program Working Group
From the National Marrow Donor Program, Minneapolis,
MN; Children's Hospital of Philadelphia, Philadelphia, PA; Texas
Transplant Institute, San Antonio, TX; University of Utah, Salt Lake
City, UT; Children's National Medical Center, Washington, DC; and
Children's Hospital of Wisconsin, Milwaukee, WI. Members of the ALL
Working Group who also contributed to this work are listed in an
appendix at the end of this article.
Allogeneic bone marrow transplantation (BMT) may be curative for
more patients than chemotherapy for the child with relapsed acute
lymphoblastic leukemia. This study reviewed the outcomes of 363 children with acute lymphoblastic leukemia in second remission who
received unrelated donor BMT from 1988 to 2000 in order to define
prognostic factors that affect leukemia-free survival (LFS). Median
patient age was 9 years (range, 0-19 years), and median follow-up 29 was months (range, 0-125 months). The median duration of first
remission was 24 months (range, 0-109 months). Prognostic factors,
including age, duration of first remission, HLA matching, and
graft-versus-host (GVH) disease, were analyzed using both univariate
and multivariate analyses. Overall survival was 38%, and LFS was 36%
at 5 years. LFS was significantly worse for patients 15 years or older
(log-rank, P = .009). HLA matching was associated with
improved LFS. Acute GVH disease developed in 71%, with 29% having
grades III-IV. The incidence of chronic GVH disease was 39% for
patients who survived more than 80 days and was significantly higher
for female patients receiving marrow from female donors (P = .0009). Transplantation-related mortality was 42%
and was associated with HLA mismatches, age 15 years and older, and
first remission less than 12 months. The 5-year estimate for relapse was 22%, with first remission at least 6 months associated with a
lower risk. Results of unrelated donor BMT appear similar to multi-institutional studies of matched related donor BMT, and this
approach appears to be curative for many patients. However, innovative
approaches are needed for patients with initial remissions of less than
6 months and for older teenagers.
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