Questions & Answers

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Question from Perttu Koskenvesa, Helsinki

What is your view on TKI maintenance after allogenic transplant?

1) patient gaining CPII and evident molecular response with TKI for AP/BC transformation.

2) patient going into allo after failing prior TKI therapy

Answer of Dr Dragana Milojkovic, London:

“My view on TKI maintenance after allogenic transplant:

Recommended in order to defer giving DLI until 1 year post stem cell transplantation (SCT) if the patient has molecular persistence/relapse post withdrawal of immune suppression.

Ad patient 1)
The usual practice is to resume TKI (or start the TKI if the patient has not failed pre SCT) post count recovery, often at day +30. It is important to manage any haematological toxicity carefully post SCT to preserve engraftment. For advanced phase disease the TKI has been continued long-term post SCT, to maintain CMR.

Ad patient 2)
After SCT, monitor the PCR during withdrawal of cyclosporin (or institutional immune suppression).  As with other diseases where chimerism is used instead of the PCR for BCR-ABL, the rapidity of cyclosporin withdrawal is adjusted.  For molecular relapse/persistence (in our institution >0.02%) then a TKI would be started until one year post SCT. After 1 year post SCT if possible, a DLI programme would be commenced, and the TKI withdrawn according to the molecular response/chimerism.”

Ref:
Response to donor lymphocyte infusions for chronic myeloid leukemia is dose-dependent: the importance of escalating the cell dose to maximize therapeutic efficacy.
Simula MP, Marktel S, Fozza C, Kaeda J, Szydlo RM, Nadal E, Bua M, Rahemtulla A, Kanfer E, Marin D, Olavarria E, Goldman JM, Apperley JF, Dazzi F.
Leukemia. 2007 May;21(5):943-8