Recommended Timing for Transplant Consultation

These guidelines for transplant consultation have been developed jointly by the National Marrow Donor Program (NMDP) and the American Society for Blood and Marrow Transplantation (ASBMT) and are based upon current clinical practice and the medical literature, including comprehensive evidence-based reviews. [1]

One critical factor in the outcome of hematopoietic cell transplantation is the appropriate planning and timing of the transplant. The intent of these guidelines is to identify patients at risk of disease progression and, therefore, which patients should be evaluated for transplantation.

While transplant may be immediately indicated for some patients with these factors, it may not be for all patients. The consultation helps ensure there are plans in place for the patient to move quickly to transplant, if needed, before disease progresses or complications develop. If allogeneic transplant is a possibility, it helps provide adequate time for an unrelated donor or cord blood search.

Adult leukemias and myelodysplasia

Acute myelogenous leukemia (AML)

• High-risk AML including:
  • Antecedent hematological disease [e.g., myelodysplasia (MDS)]
  • Treatment-related leukemia
  • Induction failure
• CR1 with poor-risk cytogenetics or molecular markers 
• CR2 and beyond

Acute lymphoblastic leukemia (ALL)

• CR1 up to age 35

• High-risk over age 35 including:
  • Poor-risk cytogenetics (e.g., Philadelphia chromosome [t(9;22)] or 11q23 rearrangements)
  • High WBC (>30,000 - 50,000) at diagnosis
  • CNS or testicular leukemia
  • No CR within 4 weeks of initial treatment
  • Induction failure
• CR2 and beyond

Myelodysplastic syndromes (MDS)

• Intermediate-1 (INT-1), intermediate-2 (INT-2) or high IPSS score which includes either:
  • >5% marrow blasts
  • Other than good risk cytogenetics [not 5q- or normal]
  • >1 lineage cytopenia

Chronic myelogenous leukemia (CML)

• No hematologic or minor cytogenetic response 3 months post-imatinib initiation
• No complete cytogenetic response 6 to 12 months post-imatinib initiation
• Disease progression
• Accelerated phase
• Blast crisis [myeloid or lymphoid]

Pediatric acute leukemias

Acute myelogenous leukemia (AML)

• Monosomy 5 or 7
• Age <2 years at diagnosis
• Induction failure
• CR1 with HLA matched sibling donor
• CR2 and beyond

High-risk acute lymphoblastic leukemia (ALL)

• Induction failure
• Philadelphia chromosome positive
• WBC > 100,000 at diagnosis
• 11q23 rearrangement
• Mature B cell phenotype (Burkitt's lymphoma)
• Infant at diagnosis
• CR1 duration <18 months
• CR3 and beyond

Lymphomas

Non-Hodgkin's lymphoma

• Follicular
  • Poor response to initial treatment
  • Initial remission duration <12 months
  • Second relapse
  • Transformation to diffuse large B-cell lymphoma
• Diffuse Large B-Cell
  • At first or subsequent relapse
  • CR1 for patients with high or high-intermediate IPI risk
  • No CR with initial treatment
• Mantle Cell
  • Following initial therapy

Hodgkin's lymphoma

• No initial CR
• First or subsequent relapse

Multiple myeloma

Multiple myeloma

• After initiation of therapy
• At first progression

References

1. Evidence-based Reviews, American Society for Blood and Marrow Transplantation. 2008. Published in Biology of Blood and Marrow Transplantation and available online at: http://www.asbmt.org/policystat/policy.html

These guidelines are also available in a printable version (PDF). You can order free printed copies of the guidelines online or by calling the NMDP at (800) 526-7809 ext. 8519.