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Very late relapse of AML after allogeneic hematopoietic cell transplantation is often extramedullary

Bone Marrow Transplantation volume 51, pages 1013–1015 (2016)Cite this article

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Although AML is usually fatal, ~40% of younger patients can be cured.1, 2 Each successive year of first CR (CR1) correlates with prolonged survival and cure.3 To this end, we recently analyzed Eastern Cooperative Oncology Group (ECOG) data and observed that there were very few relapses in patients who maintained CR1 for at least 3 years (14/1229, 1.1%).4 Relapses occurring after 3 years from CR1 were considered late (LR), and usually occurred between 3 and 5 years after CR1 (12/14, 86%); two very LRs occurred after 5 years. Interestingly, the majority of LRs (82%) occurred in patients with normal cytogenetics, and no patients had an unfavorable karyotype. Of the 183 patients that underwent allogeneic hematopoietic cell transplantation (allo-HCT) on protocol (in CR1), there was only one LR (0.6%). Here, we describe three additional very LRs after allo-HCT (where post-transplant CR lasted >5 years) that occurred subsequent to our initial report. All four cases (Table 1) featured extramedullary relapses, suggesting a common post-transplant mechanism.

Table 1 Characteristics of four AML patients with late or very LR after allogeneic HCT
Full size table

In our first case, a 37-year-old white female presented with AML without cellular maturation. Her karyotype was normal. She achieved CR1 with standard therapy followed by four cycles of consolidation. She relapsed ~16 months after CR1 with dysplastic changes and 6% blasts. She proceeded directly to allo-HCT using PBSC from her HLA-matched brother. Conditioning consisted of cyclophosphamide and TBI. Cyclosporine and methotrexate were used as GvHD prophylaxis. She remained disease-free post transplant for 11 years, until she noted a small red nodule on her right lower leg. Lesional biopsy revealed AML with monocytic features (involving recipient cells as indicated by karyotyping). Blood counts were normal and a marrow biopsy revealed no evidence of AML (cytogenetics: 46, XY comprising donor cells). Positron emission tomography (PET) and CSF studies confirmed an isolated relapse. The patient was treated with involved field radiation therapy (IFRT) followed by high-dose cytarabine (HiDAC) and was in continuous remission for 2 years. She then had another cutaneous relapse on the right leg, again treated with IFRT, this time followed by maintenance lenalidomide and she has remained in third remission post transplant for 1 year to date.

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Acknowledgements

This study was supported by the Eastern Cooperative Oncology Group (ECOG-ACRIN).

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Authors and Affiliations

  1. Miller School of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA

    J M Watts & R T Swords

  2. Dana-Farber Cancer Institute, Boston, MA, USA

    X V Wang

  3. Harvard School of Public Health, Boston, MA, USA

    X V Wang

  4. Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    E Paietta

  5. Leukemia Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA

    D Douer & M S Tallman

  6. University of Pennsylvania, Philadelphia, PA, USA

    S M Lugar

  7. H Lee Moffitt Cancer Center and Research Institute,, Tampa, FL, USA

    H F Fernandez

  8. Shaare Zedek Medical Center, Jerusalem, Israel

    J M Rowe

  9. Case Western Reserve University, Cleveland, OH, USA

    H M Lazarus

  10. Mayo Clinic, Rochester, MN, USA

    M R Litzow

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  1. J M Watts
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Correspondence to J M Watts.

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Watts, J., Wang, X., Swords, R. et al. Very late relapse of AML after allogeneic hematopoietic cell transplantation is often extramedullary. Bone Marrow Transplant 51, 1013–1015 (2016). https://doi.org/10.1038/bmt.2016.44

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