Disease
Autologous
Allogeneic
AML
X
X
ALL
–
X
MDS
–
X
CML
–
X
Lymphoma
X
X
Myeloma
X
X
Germ cell
X
–
Bone marrow failure
–
X
Congenital disorders
–
X
Table 4.2
Risk stratification for AML
Risk group | Cytogenetics | Molecular markers |
|---|---|---|
Favorable | Inv(16) or t(16;16) t(8;21) t(15;17) | Isolated NPM1 mutation (normal karyotype) Isolated CEBPA mutation (normal karyotype) |
Intermediate | Normal + 8 only t(9;11) Other abnormalities not defined | c-KIT mutation with core binding factor leukemia |
Poor | Complex (≥ 3 abnormalities) − 5, del 5q − 7, del 7q 3q21q26 t(6;9) t(9;22) 11q23 abnormalities except t(9;11) 17p abnormalities | FLT3 ITD (normal karyotype) |
a.
Complete remission 1 (CR1)—all AML except for good risk
b.
Antecedent hematologic disease
c.
Therapy-related AML
d.
Primary induction failure or relapse
e.
Presence of minimal residual disease after therapy
2.
Pediatric AML:
a.
CR1—all except good risk
b.
Induction failure or relapse
c.
Monosomy 5 or 7
d.
Age < 2 years at diagnosis
e.
Treatment-related AML
f.
Presence of minimal residual disease after therapy
3.
Adult acute lymphoblastic leukemia (ALL):
a.
CR1—all except for young adults treated on pediatric protocols (recent data suggest that adults have improved outcomes when treated on highly aggressive pediatric regimens as compared to standard adult treatment regimens)
b.
High risk
i.
Ph + t(9;22)
ii.
MLL (11q23) rearrangements
iii.
High white blood cell (WBC) at diagnosis (> 30 K for B cell, > 100 K for T cell)
c.
Induction failure or relapse
d.
Presence of minimal residual disease after therapy
4.
Pediatric ALL:
a.
High-risk CR1:
i.
Ph + t(9;22)
ii.
MLL (11q23) rearrangement
iii.
Infant
iv.
WBC at diagnosis > 100 K
b.
Induction failure or relapse
c.
Presence of minimal residual disease after therapy
5.
Myelodysplastic syndrome (MDS):
a.
Intermediate or high-risk revised international prognostic staging score (IPSS-R)—see Table 4.3:
Table 4.3
International prognostic staging system for myelodysplasia
Prognostic variable | 0 | 0.5 | 1 | 1.5 | 2 | 3 | 4 |
|---|---|---|---|---|---|---|---|
Cytogenetics | Very good | – | Good | – | Intermediate | Poor | Very poor |
Marrow blast % | ≤ 2 % | > 2– < 5 % | – | – | 5–10 % | > 10 % | – |
Hemoglobin | ≥ 10 | – | 8– < 10 | < 8 | – | – | – |
Platelets | ≥ 100 | 50– < 100 | < 50 | – | – | – | – |
ANC | ≥ 0.8 | < 0.8 | – | – | – | – | – |
Risk category | Risk score |
|---|---|
Very low | ≤ 1.5 |
Low | > 1.5–3 |
Intermediate | > 3–4.5 |
High | > 4.5–6 |
Very high | > 6 |
1.
Cytogenetics:
Very good: del(11q), -Y
Good: normal, del(20q), del(5q) alone and double
Intermediate: + 8, 7q-, i(17q), + 19, + 21, any other single or double, independent clones
Poor: der(3)q21/q26, -7, double including 7q-, complex (three abnormalities)
Very poor: complex (> 3 abnormalities)
b.
Treatment-related MDS
c.
Transfusion dependence or refractory cytopenias
6.
Chronic myelogenous leukemia (CML):
a.
Chronic phase:
1.
Failure to achieve a hematologic or cytogenetic response to either nilotinib (Tasigna®) or dasatinib (Sprycel®)
2.
Intolerance to/failure of two tyrosine kinase inhibitors (TKIs)
3.
Any T3151 mutation
b.
Accelerated phase:
1.
Newly diagnosed patients who do not achieve an optimal response to TKIs
2.
TKI-treated patients who progress from chronic phase
c.
Blast crisis (myeloid or lymphoid)
7.
Myeloproliferative disorders (BCR-ABL negative):
a.
High-risk cytogenetics
b.
Poor initial response or at progression
8.
Follicular and low-grade non-Hodgkin’s lymphoma (NHL):
a.
Less than partial response to initial treatment
b.
Initial remission duration < 12 months
c.
Second or subsequent relapse
d.
Transformation to diffuse large B cell lymphoma (DLBCL)
9.
DLBCL and aggressive NHL:
a.
First or subsequent relapse
b.
No CR with initial treatment
c.
CR1 with high-intermediate or high-risk international prognostic index (IPI; see Table 4.4)
Table 4.4
International prognostic index (IPI) for large-cell lymphoma
Risk factors |
|---|
Age > 60 |
Performance status > 1 |
Elevated LDH |
Extranodal sites > 1 |
Stage III–IV |
Risk group | Number factors |
|---|---|
Low | 0–1 |
Low intermediate | 2 |
High intermediate | 3 |
High | 4–5 |
d.
Double- or triple-hit lymphoma
e.
Peripheral T cell lymphoma
10.
Mantle cell NHL:
a.
Following initial therapy
11.
Hodgkin lymphoma:
a.
Primary induction failure
b.
First or subsequent relapse
12.
Multiple myeloma:
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