Introduction When a child with leukaemia relapses after an allogeneic stem cell transplant, the benefits of further chemotherapy and immunotherapy are uncertain in both controlling symptoms and prolonging life. A very limited number of patients may go on to receive a second transplant with some evidence that a younger age and relapse >1 year is associated with positive outcomes.
Aim To review the trend in further intervention and its impact in children with relapse after allogeneic transplant.
Method We identified 23 patients between 1 April 2001 and 31 July 2010 who relapsed after an allogeneic stem cell transplant in our Paediatric Oncology centre.
Results Of the 23 patients: 12 ALL, 9 AML, 2 transformed JMML and 1 patient moved out of area. Median time from transplant to relapse was 148 days (range 64–1380 days). Second transplant procedures had been performed in 4/22.Two have sustained durable remissions 2 years and 17 months respectively. A further two patients currently survive: one patient having recently relapsed and another 470 days post relapse managed with immunotherapy. The remaining 18 patients died with a median time from relapse post transplant to death of 94 days (range 6–214 days). Nine patients underwent further cytotoxic or immunomodulatory treatments. All with CNS involvement received intrathecal chemotherapy.
From 2001–2005, 83% of children received palliative care only (including steroids and transfusion support) but from 2006 to 2010 this fell to 24%.
Conclusions Our 10 year review showed that despite the trend over time to increased intervention, survival improvement in the very short term (at 3 months) were not sustained at 6 months (table 1). With occasional children having sustained or prolonged remission and a few surviving a second transplant, it makes navigating clinical decision-making around interventions at relapse challenging. Increasingly families may seek further medical intervention and/or the Haematologist may be more willing to provide them. Questions around best interest of the individual child reflecting the balanced of frequent hospital visits and intensity of further treatment against symptom care within the community should be brought to the discussion.
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