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Background: Patients with advanced AML ie those not in first (CR1) or second complete remission (CR2) have poor outcome and are considered poor transplant candidates. The purpose of this study was to identify a subgroup of patients with active disease at the time of transplant that benefits from allogenic transplantation.
Patients and Methods: Between 2005 and 2013, 782 patients underwent allogeneic transplant from a fully matched (10/10) related or unrelated donor at our center. Of these 361 patients with advanced disease, defined as patient not in CR1 or CR2, were included in this analysis. Cox proportional hazards regression analysis was used for univariate and multivariate analysis to predict overall survival. Variables considered in the analysis were age, sex, SWOG cytogenetics risk group, BM and PB blast%, regimen intensity (myeloablative v/s reduced intensity) and type of AML (de novo, secondary to MDS or MPD or therapy related AML).
Results: At a median follow up of 26 months in the surviving patients, OS, PFS, NRM and relapse rate were 26%, 24%, 23% and 48%,respectively. In a univariate analysis poor risk cytogenetics (P<0.001) and bone marrow blasts >4% (P 0.006) or any blasts in peripheral blood (P<.001) indicated adverse outcome for OS. When poor risk cytogenetics and peripheral and/or bone marrow blasts were considered simultaneously (Table 1, fig 1), significantly superior survival was observed in patients with less than 5% BM blasts without any circulating blast and good or intermediate risk cytogenetics. This impact was also seen for PFS and disease progression. At 3 years PFS and OS were 44% and 46% in this subgroup.
|
| Outcomes at 3 years
|
|
|
|
| |
N
| Progression
| P
| PFS
| P
| OS
| P
| |
Bad Risk Cytogenetics/ Blasts BM >4% or PB blast>0%
|
|
| |||||
No / No
| 77
| 35%
| Ref.
| 44%
| Ref.
| 46%
| Ref
|
Yes / No
| 31
| 39%
| 0.1
| 28%
| 0.02
| 30%
| 0.01
|
No / Yes
| 117
| 50%
| 0.002
| 21%
| <0.001
| 23%
| <0.001
|
Yes / Yes
| 110
| 57%
| <0.001
| 14%
| <0.001
| 16%
| <0.001
|
Conclusion: Patients with low blast counts in the absence of poor-risk cytogenetics should be considered for transplant, even if they are not in remission.
