Alberta Bone Marrow and Blood Cell Transplant Program ...

Guideline Resource Unit

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Alberta Bone Marrow and Blood

Cell Transplant Program:

Standard Practice Manual

BMT Standard Practice Manual

Cancer Care Alberta

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Table of Contents

Indications

Acute Myeloid Leukemia (AML)

Acute Lymphoblastic Leukemia (ALL)

Myelodysplastic Syndromes (MDS)

Chronic Myelogenous (CML)

Bcr-Abl-Negative Myeloproliferative Neoplasms (MPN)

Chronic Lymphocytic Leukemia (CLL)

Lymphoma

Myeloma, Amyloidosis

Severe Aplastic Anemia (SAA)

Hemoglobinopathies

Multiple Sclerosis (MS)

Scleroderma/ Systemic Sclerosis (SSc)

Germ Cell Tumours (GCT)

Complications

Graft-vs-Host Disease (GVHD)

CMV, VZV, HSV, HHV6

EBV/Posttransplant Lymphoproliferative Disorder (PTLD)

Pneumocystis and Bacterial Prophylaxis

Fungal Prophylaxis

Graft Failure and Poor Graft Function

Donor Lymphocyte Infusion (DLI), 2nd HCT for Relapse

Neutropenic Fever

Central Venous Catheter (CVC) Complications

Hepatic Complications and Viral Hepatitis

Cytokine Release Syndrome (CRS) and Neurotoxicity (ICANS)

Cytopenia, Transfusions

Other Topics

Conditioning for HCT

Patient Eligibility

Donor Selection

Stem Cell Mobilization

Chimerism

Vaccination

Cord Blood Transplantation (CBT)

ABO-Incompatible Graft

Long-Term Follow-Up

Nutritional Support

Microbially-Contaminated or Non-Conforming Cellular Therapy Products

BMT Standard Practice Manual

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Appendices

Follow-up Test Guidelines

Post Autologous Transplant

Post Allogeneic Transplant

Post CAR T-cell Transplant

Additional Information

Copyright

Conflict of Interest

Glossary of Abbreviations

Revision History

BMT Standard Practice Manual

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Indications

BMT Standard Practice Manual

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Acute Myeloid Leukemia (AML)

Summary

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Presented by: Lynn Savoie

Disease risk stratification will be based on the cytogenetic and molecular features of the tumour

cells, response to first induction, presence of secondary or therapy related disease, white blood cell

(WBC) at diagnosis and measurable residual disease.

Patients with favourable cytogenetics and no unfavourable molecular changes show good response

to chemo-immunotherapy and in the majority of cases will enter a second remission if relapse

occurs. Patients with t(8;21) or inv(16)/t(16;16) without evidence of MRD should undergo allogeneic

stem cell transplant in CR2.

Patients with a normal karyotype who are FLT3 ITD negative and either NPM1 mutation positive or

CEBP¦Á biallelic mutation positive are expected to have a favourable outcome to chemoimmunotherapy and should be offered an allogeneic stem cell transplant in CR2.

Patients in the intermediate cytogenetic risk group may be offered a transplant from a matched

sibling or a matched unrelated donor in CR1. This includes patients with a normal karyotype as well

as non-informative cytogenetic changes. Patients with t(8;21) or inv(16)/t(16;16) and a KIT mutation

appear to fall into this risk group. Patients with FLT3 ITD at low allelic ratio and with FLT3 TKD

mutation also appear to fall into this risk group.

Patients with high-risk features will likely not be salvageable at relapse and should be offered

transplant in first complete remission. This includes high-risk cytogenetics, those with a normal

karyotype who are FLT3 ITD positive, various molecular findings on NGS, those requiring more

than one chemotherapy cycle to achieve a complete remission, as well as those with secondary or

therapy related disease or measurable residual disease after two cycles of chemotherapy.

Patients who relapse after conventional chemotherapy should undergo stem cell transplantation in

CR2.

It is preferable for patients to be in complete remission (defined as fewer than 5% blasts and no

active extra-medullary disease) at the time of transplantation. Patients with untreated or refractory

CNS disease or with circulating blasts are not eligible for transplantation.

Patients should receive at least one cycle of post-remission therapy prior to transplantation if

transplantation cannot occur within 4 weeks of the complete remission being achieved.

Background

Risk stratification in AML has traditionally relied on patient and disease characteristics at diagnosis

(chiefly: age, cytogenetics, white blood cell count at diagnosis and the presence of an antecedent

hematological disorder or therapy related disease) and on the response to induction chemotherapy.

While patients in favourable risk categories may enjoy long-term disease-free survival, AML may be

virtually incurable with conventional treatment in patients with high-risk features and those with poor

response to chemotherapy. Recently, the interaction of molecular abnormalities with cytogenetic risk

BMT Standard Practice Manual

Last Reviewed: Feb 13, 2024

Effective Date: Feb 13, 2024

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