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We conducted a national survey of 62 pediatric bone marrow transplant practitioners regarding their use of routine BM/CSF analysis post-AlloHCT. For acute lymphoblastic leukemia (ALL) patients, 41 physicians (66%) reported performing routine BM analysis in all such patients; 15 (24%) in some patients; and 6 (10%) in no patients. For acute myeloid leukemia (AML), 39 (63%) reported doing so in all patients; 9 (14%) in some patients; and 14 (23%) in no patients.
No standard exists dictating the proper timing or frequency of screening. For ALL, 11 physicians (24%) reported performing one BM biopsy in the first year, 11 (24%) perform two, 6 (13%) perform three, 12 (27%) perform four, and 5 (12%) perform 5-10. The most common time points to perform such screening were day 90-100 and day 365. Data were similar for AML.
The practice of performing routine CSF analysis is even more varied. Eleven physicians (18%) reported doing so in all post-AlloHCT ALL patients; 28 (45%) in no such patients; and 23 (37%) only in previously CNS-positive patients. In AML patients, most practitioners do not perform routine CSF analysis. Routine usage of intra-thecal chemotherapy is variable as well.
We also performed a retrospective chart review of 108 patients who underwent BM/CSF analysis at routine intervals following AlloHCT at our center. There were 41 relapses with a median time to relapse of 171 days. Five of these relapses occurred after day 365. Of the 41 relapses, 11 (27%) were identified by routine screening procedures (10 by BM, 1 by CSF). All relapses identified by routine surveillance were detected before day 365.
Thirty-eight patients had routine day 365 BM analyses; zero of 38 had evidence of relapse. Of these, 13 had ALL and 25 had AML (median age 11 years); median WBC count was 5.8 x 109/L (range 1.8 to 15.6); median platelet count was 173 x 109/L (range 36 to 424); mean peripheral blood chimerism was 96.9% donor.
With the ultimate goal of reducing HCU, we analyzed procedure charges and time data. Median charges associated with routine BM/CSF analysis amounted to $6,613. Median time spent by families and physicians in the procedure suite was 3 hours and 34 minutes, respectively.
This data confirms a lack of consensus regarding routine BM/CSF relapse surveillance following AlloHCT in children with leukemia. We documented a questionable yield from this surveillance with an associated high health care utilization. Therefore, the utility of these routine procedures at day 365 may not be sufficiently high to justify their continued routine use. Prospective collaboration among pediatric AlloHCT centers may help to provide conclusive evidence.