Treatment of Acute Myeloid Leukemia With Hematopoietic Stem Cell Transplantation

Cortney V. Jones; Edward A. Copelan

Disclosures

Future Oncol. 2009;5(4):559-568. 

In This Article

Allogeneic Transplantation Using Unrelated Adult or Cord Blood Donors

Results of transplantation using unrelated adult or cord blood donors were substantially inferior to those obtained using HLA-identical sibling donors until the last several years. Whereas serologic matching was utilized in the 1990s to select unrelated donors, the present use of DNA-based typing methods is more precise and has improved matching, reduced the risk of GVHD[52] and improved survival. For patients with eight out of eight allelic matches at HLA-A, -B, -C and DRB1, results of allotransplantation using adult unrelated donors are similar to those achieved with HLA-identical sibling donors.[53,54] Rates of sustained survival are substantially reduced for donors who are HLA mismatched with the recipient at one site. Additional mismatches further compromise results.[52]

Similarly, results using cord blood in adult recipients were initially inferior due to inclusion of extensively HLA-mismatched cord units and low cell doses. Results have improved markedly within the last several years, based on selection of donors with closer HLA matching and higher cell doses.[55] Less stringent HLA matching is required for cord bloods with less GVHD for the extent of mismatch, but better matches improve results. Cord blood is limited in volume, but rich in hematopoietic stem cells. Higher cell doses can be achieved in some cases by using two matched cords, leading to higher engraftment rates and better results.[56] Paradoxically, sustained engraftment is achieved by only one of the cord units.

In patients at high risk of relapse with post-remission chemotherapy, and the ability to tolerate transplantation based on comorbidity indices, it is reasonable to perform allogeneic transplantation in first remission using a well-matched unrelated donor or cord blood in the absence of an HLA-identical sibling donor. Both retrospective and prospective studies support this approach in selected patients.[35,57]

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