AML second relapse

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Hi all hopefully somebody here can give me a little advice please

One of my patients is a young girl of 15 years old, she was diagnosed with AML standard risk in 2007. She was treat with standard induction and consolidation chemo and attained CR1. Four month later she relapse with cutis ( a lump in her skin) she was again brought into remission and went on to SCT with a 10/10 matched sibling donor. After a 13 month second remission she was rushed to ER with pneumonia, while in ER AML was found in her lungs after further checks she was found to have 85% blasts in her BM. She was also found to be 100% patient cells, previously this had been 100% donor..

She has again be brought into remission CR3 with flag ide and high dose ARA-C, the oncologist has used DLI (donor lymphocte infusion) as consolidation treatment.. They have told my patients parent " this is not a cure " I'm unsure of how to approach this, has anyone any experience of this situation.. I have never had a patient in CR3 so this is unknown to me

Could this actually work? or is it just to extend life, if so how long a remission can she hope for?

Thank you in advance

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Specializes in Medical and general practice now LTC.

Moved to the oncology forum

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Specializes in Oncology/Haemetology/HIV.

First, I am used to adult pts. Please name the drugs used for "flag IDE". I am presuming that IDE is idarubicin - is flag flavoperidol with gm-csf ?

Second, as harsh as it sounds, the MD has given you your answer. This is not a cure and will not get rid of the disease. This, as with such treatments, it is either to extend life or maintain comfort. Given the side effects of DLI, it certainly is not for comfort. Thus it is to give the pt more time, life.

Given the limited use of DLI(it hasn't been in use for that long),'there are no ideas as to how long CR will be with the pt. Also given pts hx and not knowing the subtype of AML or the genetics, chromosomal abnormalities, it would be impossible to surmise. I am presuming that this pt was treated at a teaching facility or cancer center, thus the Attending MD would be the best source of data as they would be party to this data. The ones that I work with love to teach. If yours are more indifferent, often the Fellow in charge of the case, might give you some estimates.

Given that the pt converted from 100percent donor to 100'percent pt, prognosis generally would not be good with any tx. Some adults have gotten lower match rate allo transplants to get higher amounts of GVHD but that is adults and has really bad side effects, as well as a mortality rate from just the transplant. And much depends on the chromosomal makeup.

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Firstly thank-you for your reply, I will try respond as best as I can..

This is the protocol my patient was given and it's timings, she had two waves to treat her second relapse followed by 1 round of high dose ARA-C.... These got her into CR3

G-CSF (growth factor) given by injection under the skin in the tummy or leg for 7 days (days 1-7)

Fludarabine given via an infusion (drip) over 30 minutes, once a day for 5 days (day 2-6)

Ara-C (Cytarabine) given via an infusion (drip) over 4 hours, once a day (4 hours after the Fludarabine) for 5 days (day 2-6)

Her AML subtype it between M4 and M5

Her latest BMB shows she has returned to 100% donor, and is in remission. She had her DLI in October.

She also has acute GVHD in her skin, gut and liver, she did not have any GVHD after her original SCT.... Parent thinks this is a good thing

We are in the UK and our oncologists really don't tell us a lot...

Thank you

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Specializes in Medical and general practice now LTC.

Is there a oncology nurse specialist? If so maybe have a chat with them. I used to find some consultants would talk to us when we had questions and some wouldn't but you usually could find someone to chat to about it. Also if you have a register try them

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Specializes in Oncology/Haemetology/HIV.

Again the MD has given you an answer - this is not a cure.

Having said that, this is something to prolong life.

First, there is not enough longterm data on DLI to give results on. Which is probably why the MD said very little - there may be little that can be definitively said.

I work with a number of research protocols, many in their initial trials in adults. One thing, they and their family members will literallly beg for data, remission rates, survival rates, when they will come out neutropenia/pancytopenia, comparison with other individuals of same age group. They often are angry when we cannot give them that - we cannot give them what we just do not have because it is just not available. When we are working in new and rare things, there is no reliable longterm data - and even minor variations in the pts health can make the difference.

I will say, in my experience and knowledge base, that if there is some GVHD now, that was not with the original allo BMT, that would in my mind indicate that the graft (DLI) is attempting to fight the residual host marrow/diseased marrow, whereas in the intial transplant, there was no GVHD and the thus original host/diseased bone marrow was not suppressed by the transplant.

This is why in some specific adults, they occasionally try lower matches - the mismatching causing more GVHD and thus fighting the host leukemia. But as you may have noted, the side effects are uglier and it has a more significant mortality/morbidity. It is also sometimes hard to get a good balance - allowing enough GVHD to keep the cancer suppressed, while suppressing enough to keep the pt comfortable and healthy.

Sorry, I cannot give more definitive data - the team in charge of the transplant would be your best source.

It can be hard to accept these issues, especially when the pt is so young. I often have very young adults (20s) come in and go through repeated therapies and yet no go into remission. It can be heartbreaking and you really want answers but no definite ones are forthcoming.

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Hi, and thanks again for the replies...

I'm just her district carer, and hence don't really meet with her consultants etc. This is the difficulty.

She asks me questions which I just can't answer, and she thinks i'm not being 100% honest with her..... I just don't know the answers :(

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Specializes in Oncology.

We often use DLI's to get a handle on the leukemia before sending the patient for a 2nd SCT. Obviously this girl's prognosis is very poor at this point, though.

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Hi she has not in fact had DLI,the procedure was a reduced intensity transplant, this confuses me even more as they have used the original sibling donor again.. I thought it was DLI as she was out of hospital so quickly

How can this be beneficial ? She was 100% donor before the transplant, and in remission ( CR3 ) I can not understand the reason for transplant, hasn't the original donor failed ?

She now has GVHD, and is on a number of steroids to control it.. The medicine is making her poorly, and weak..

I really don't get it...

Thanks for your help guys XX

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