Ongoing Role of Transplant in Chronic Lymphocytic Leukemia

The role of hematopoietic stem cell transplantation in the management of chronic lymphocytic leukemia (CLL) has changed in the last couple of years, comments Jennifer Brown, MD, PhD. The procedure was previously indicated for patients with short response duration to prior chemoimmunotherapy or 17p deletions in both the frontline and relapse settings. However, the introduction of the novel B-cell receptor (BCR) pathway inhibitors, such as ibrutinib and idelalisib, has altered this treatment paradigm.

The BCR agents have positive activity in patients with 17p deletion and are associated with significantly improved survival, states William Wierda, MD, PhD. Following the introduction of these effective small molecule inhibitors, patients are not being routinely sent to transplant during their first remissions. This is important, since stem cell transplant is a long-term commitment that is associated with morbidity and mortality, adds Wierda.

Eligible patients for small molecule inhibitors are those with a complex karyotype on standard metaphase karyotyping, explains Wierda. However, results have shown that individuals with complex karyotype have a shorter progression-free survival after ibrutinib, potentially indicating more aggressive disease that may not be adequately controlled with small molecule inhibitors alone. For these patients, stem cell transplantation may still be an option following first remission, suggests Javier Pinilla-Ibarz, MD, PhD.