The use of venetoclax-based salvage therapy for post-hematopoietic cell transplantation relapse of acute myeloid leukemia.

For patients with high risk myeloid disease, allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy. Unfortunately, many of these patients relapse after HCT and have a limited survival. The recent approval of venetoclax, an orally bioavailable BCL-2 inhibitor, resulted in significant responses in treatment naïve acute myeloid leukemia (AML), and off-label use in the relapsed/refractory setting is increasing. We report the outcomes of 21 patients who underwent allogeneic HCT for myeloid disease, relapsed with AML, and were treated with venetoclax. Several patients had poor risk features including antecedent hematologic malignancy (6/21), complex karyotype (6/21), and TP53 mutations (5/21). The median age was 64.5 years and time from HCT to relapse was 5.7 months (range: 0.9 to 44.9 months). Of the 19 patients who were assessed for response, there were meaningful treatment responses seen in eight patients: five CR, three CRi, zero PR, for an ORR of 42.1%. Treatment effect was seen in six additional patients, including four in the morphologic leukemia-free state. Nine patients maintained their response for ≥3 months and eight were receiving therapy at data cut. Post-HCT AML relapse has an exceedingly poor outcome, and venetoclax-based therapy is a potent therapy option that should be studied prospectively in this setting.

Indications for Allogeneic Hematopoietic Cell Transplantation in Myelodysplastic Syndrome.

PURPOSE OF REVIEW: Myelodysplastic syndromes (MDS) are heterogeneous diseases that principally affect older adults. Allogeneic hematopoietic cell transplantation (HCT) is the only potentially curative therapy; however, non-relapse mortality (NRM) accounts for as many as 40% of deaths after HCT and underscores the need for careful patient selection. We review the common indications and causes of failure after HCT in MDS. RECENT FINDINGS: Appropriate patient selection is necessary to optimize HCT outcomes and maximize the life-expectancies of MDS patients. The international prognostic scoring systems (IPSS) and revised IPSS (IPSS-R) are used to identify high-risk patients and guide decision making. Neither scoring system incorporates molecular mutations, which are now recognized as important predictors of disease biology and clinical outcomes. Patient and disease characteristics including age, comorbid conditions, iron overload, blast percentage, and other features may impact post-HCT outcomes. An accurate assessment of the disease risk and patient qualities that affect NRM is necessary to optimize post-HCT outcomes. In this review, we summarize the risk factors for, and common causes of NRM, as well as markers of poor-risk disease that should lead providers to consider allogeneic HCT in MDS patients.

Making inroads to the cure: Barriers to clinical trial enrollment in hematopoietic cell transplantation.

A significant barrier to advancing the standard of care for patients with hematologic malignancies undergoing stem cell transplantation is access and willingness to participate in clinical trials. The importance of clinical trial enrollment is magnified in an era of targeted therapies, accelerated drug discovery, and investment by the pharmaceutical industry. As disease targets are identified, novel therapies are being evaluated in efforts to reduce treatment-related toxicity and improve progression-free and overall survival. The enrollment of hematopoietic cell transplantation (HCT) patients on clinical studies is essential to promote the development of such therapies. Increasing clinical trial participation requires understanding of potential barriers to enrollment, including patient concerns, institutional and provider hurdles, and disease-specific characteristics.