You Make the Call: Readers’ Response
We asked, and you an-
swered! Here are a few
responses from this
month’s “You Make the
Call.”
For the full description
of the clinical dilemma,
and to see how the
expert responded, turn
to page 41.
If the patient is a fit 66-year-old woman with no
major, or at least controlled, comorbidities (low
HCT-comorbidity index), my recommendation is to
move forward with alloHCT. A matched related donor
(MRD) would be optimal, although matched unrelated
donors (MUD) or other donors (haploidentical) can be
suitable. Last, the use of post-remission alloHCT is
controversial, and I would not consider using it if the
patient continues to be MRD-negative after alloHCT.
Optimization of post-remission alloHCT with tyrosine
kinase inhibitors (TKI) in this population is challenging
(Carpenter PA, Johnston L, Fernandez HF, et al. Blood.
2017:130:1170-2).
Clinical Dilemma:
I have a 66-year-old female patient recently diagnosed
with Philadelphia chromosome (Ph)–positive B-cell
acute lymphocytic leukemia (ALL). After four cycles of
hyper-CVAD (cyclophosphamide, vincristine, doxorubi-
cin, dexamethasone) plus dasatinib, PCR is negative.
Bone marrow aspirate is also negative for ALL. Should
she be considered for allogeneic hematopoietic cell
transplantation (alloHCT)?
Jose D. Sandoval-Sus, MD
Moffitt Cancer Center
Pembroke Pines, FL
Based on the data from the ECOG/MRC trial, five-year
overall survival for Ph-positive B-cell ALL undergoing
treatment after first complete remission (CR1) with
MRD alloHCT versus MUD alloHCT versus chemotherapy
alone is 44 percent versus 35 percent versus 19 percent,
respectively. If the patient has a MUD or MRD available,
reduced-intensity conditioning followed by alloHCT
would be the ideal approach for long-term survival. She
will need careful evaluation of her performance status,
comorbidities, and social support.
Hamza Hashmi, MD
James Graham Brown Cancer Center
University of Louisville School of Medicine
Louisville, KY
Yes. I would consider for alloHCT.
Anastasios Raptis, MD
Lemieux Center for Blood Cancers
Pittsburgh, PA
Change to ponatinib to prevent the evolution of T315I
mutants. After dasatinib, you can find this mutation in
more than 50 percent of patients. AlloHCT is associated
with >20 percent acute mortality.
Erwin Wolber, MSc, PhD
Lübeck, Germany
See more reader responses at ashclinicalnews.org/category/training-
education/you-make-the-call.
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