I have a patient with relapsed t-ALL after allogeneic hematopietic stem cell transplantation (AHSCT). She had received hyper-CVAD, Nelarabine, ICE and PEG-Asparaginase before we performed AHSCT for her. She presented with axillary and inguinal lymphadenopathy about day +45 after AHSCT, and lymph node core biopsy showed t-ALL. I have started an accelerated tapering of her Prograf, and I would like to administer chemotherapy before giving donor lymphocyte infusion (DLI) to her.
The response rate of ALL to DLI are higher in the setting of molecular or cytogenetic relapse . Second allogenic HSCT should involved. careful consideration of appropriate donor.
Br J Haematol. 2011 Aug;154(4):482-5. doi: 10.1111/j.1365-2141.2011.08752.x. Epub 2011 Jun 21. Early UK experience in the use of clofarabine in the treatment of relapsed and refractory paediatric acute lymphoblastic leukaemia. O'Connor D1, Sibson K, Caswell M, Connor P, Cummins M, Mitchell C, Motwani J, Taj M, Vora A, Wynn R, Kearns PR.
Abstract
Clofarabine is a second-generation purine nucleoside analogue, which has shown promising activity in relapsed and refractory paediatric acutelymphoblastic leukaemia (ALL). This report summarizes the early United Kingdom experience of clofarabine for the treatment of paediatric ALL in 23 patients, outside of the context of a clinical trial. Our results demonstrated that clofarabine-based chemotherapy regimes were effective and well-tolerated in this heavily pre-treated group, with an overall response rate of 67% when used in combination regimes. Responses were seen in both B and T cell disease and in patients with adverse cytogenetics.
Was the transplant performed in CR? If not, I'm afraid your (her) case is quite bad. Even if you performed the transplant in CR, the prognosis is terrible.
The experience of a second allo after early relapse is usually bad, unless your patient is very young and very fit and you perforded a RIC transplant. You can add toxicity witout actually doing anything of consequence.
I tink you have done the best you can. As the comment above points out, the best would be to try new drugs that aren't too agressive. Clofarabine or even gemcitabine i associtation with other drugs could be of help. If you achieve some kind of remission, then you can plan other things.
Besides, I'd inform the patient of her ominous situation.
She was not in CR when we transplanted her. I am planning to start her on Clofarabine. Then, I would give her DLI. I have already discussed the guarded prognosis with her.
I would agree with Guiseppe... There is data about using Nelarabine post allo, we have experience with several patients (unpublisshed) for the use of nelarabine and pegaspar. The first patient we treated went into a CR and was able to get a second haplo. Hope this helps.
The patient received Nelarabine in 2013 and after 1 cycle she progressed. My plan is to give her Clofarabine, and DLI afterwards. However, haplo looks reasonable, too. I wonder if you recommend myeloablative or reduced intensity haplo.
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