FEATURE
Drawing First Blood
We invite two experts to debate controversial
topics in hematology and health care
To Transplant or Not To Transplant in
First Remission?
Navneet Majhail, MD
Alan K. Burnett, MD
Most patients with newly
diagnosed acute myeloid leukemia (AML) will achieve a first
complete remission with standard induction chemotherapy.
Durable remission or cure can
only be attained, though, with
further treatment – either
post-remission consolidation
chemotherapy or hematopoietic
cell transplant. Questions about
the optimal timing of transplant, as well as which patients
will benefit from the procedure,
remain an area of debate. In this
edition of “Drawing First Blood,”
ASH Clinical News has invited
Navneet Majhail, MD, MS, and
Alan K. Burnett, MD, to debate
the question: Should intermediate-risk AML be transplanted
in first complete remission?
Dr. Majhail will argue for transplant and Dr. Burnett will argue
against.
Alan K. Burnett, MD: This is certainly
an evolving field, and actually defining
“intermediate risk” is complex. There are
few data showing that patients’ survival is
made worse by transplant, so I think the
debate, really, is about the optimal use of
the procedure – selecting the appropriate
candidates who will benefit from transplant and whether it should be used in
CR1 or later if needed.
the high-risk patients defined by this score
had an FLT3-ITD mutation.
To decide whether the remaining 25
percent of FLT3-mutated patients are
candidates for transplant in CR1, we use
the interplay between FLT3 and NPM1. If
a patient has an FLT3 mutation without
associated mutant NPM1, he or she is at
higher risk of relapse and benefits from
a myeloablative transplant. For patients
with FLT3 and associated NPM1 mutations, however, we do not have definitive
evidence that they benefit from – or, for
that matter, are harmed by – transplant.
Additionally, mutations in the CCAAT/
enhancer binding protein-alpha (CEBPA)
gene are associated with a relatively favorable prognosis especially if the mutation
is bi-alleilic, so, for the approximately five
to 10 percent of patients who have CEBPA
mutations, transplant can be avoided.
Dr. Majhail: I think there have been great
Dr. Majhail: I agree, there are definite cases
Navneet Majhail, MD: In the debate about
whether or not to transplant in first complete remission (CR1) in intermediate-risk
AML patients, we have to acknowledge
that the definition of “intermediate ɥͯ