Bone Marrow Transplantation (2006) 37, 455–461
& 2006 Nature Publishing Group All rights reserved 0268-3369/06 $30.00
www.nature.com/bmt
ORIGINAL ARTICLE
Fludarabine phosphate and melphalan: a reduced intensity conditioning
regimen suitable for allogeneic transplantation that maintains the graft
versus malignancy effect
RK Dasgupta1, S Rule2, P Johnson3, J Davies3, A Burnett4, C Poynton4, K Wilson4, GM Smith5,
G Jackson6, C Richardson6, E Wareham7, AC Stars7, SM Tollerfield7 and GJ Morgan8
1
Department of Haematology, University Hospital Aintree, Liverpool, UK; 2Derriford Hospital, Plymouth, UK; 3Western General
Hospital, Edinburgh, UK; 4University Hospital of Wales, Cardiff, UK; 5The General Infirmary, Leeds, UK; 6Royal Victoria
Infirmary, Newcastle, UK; 7Schering Health Care Limited, Burgess Hill, UK and 8The Royal Marsden Hospital, Sutton, UK
Reduced intensity conditioning (RIC) for allogeneic stem
cell transplantation allows stable donor cell engraftment
with the maintenance of a graft versus malignancy effect.
Many different regimens exist employing various combinations of chemotherapy, radiotherapy and T-cell depletion. We examined the role of non-T-cell depleted RIC
regimens in 56 patients with haematological malignancies.
Patients received fludarabine phosphate for 5 days
(30 mg/m2 in 35 patients, 25 mg/m2 in 21 patients) and
melphalan for 1 day (140 mg/m2 in 36 patients, 100 mg/m2
in 20 patients). Immunosuppression was with CyA alone in
33 patients and CyA/MTX in 23 patients. Twenty-four of
the 26 patients with chimerism data showed 495% donor
chimerism at 3 months post transplant. aGVHD occurred
in 18% of patients receiving CyA/MTX compared to
53% of patients receiving CyA. The 100-day mortality
rate was 0.16 (95%CI 0.08–0.28) and 1-year nonrelapse
mortality was 0.24 (95%CI 0.13–0.38). Thirty-three
patients remained alive and in CR at a median of 19
months post transplant (range 3–38 months). We have
shown that patients transplanted with fludarabine phosphate, melphalan 100 mg/m2 and with CyA/MTX as post
transplant immunosuppression can achieve good disease
control with an acceptable level of toxicity. Further
studies are required to confirm these findings.
Bone Marrow Transplantation (2006) 37, 455–461.
doi:10.1038/sj.bmt.1705271; published online 23 January
2006
Keywords: allogeneic transplantation; reduced intensity
conditioning; fludarabine phosphate; melphalan; haematological malignancy
Correspondence: Dr RK Dasgupta, Department of Haematology,
University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL UK.
E-mail: [email protected]
Received 7 April 2005; revised 1 December 2005; accepted 2 December
2005; published online 23 January 2006
Introduction
Reduced intensity conditioning (RIC) regimens have
allowed the potential benefits of a graft versus malignancy
effect to be offered to an older and less fit population than
standard dose conditioning regimens would allow.1,2
However, despite the reduced intensity of the conditioning,
rates of graft-versus-host disease (GvHD) and transplantrelated mortality can be comparable to those seen following
fully myeloablative transplants.3,4 Over 30 different RIC
regimens have been reported in the literature using a variety
of chemotherapy, radiotherapy and GvHD prophylaxis
regimens.5 The majority of current regimens use fludarabine phosphate in combination with another myelosuppressive chemotherapeutic agent or low dose total
body irradiation. Regimens have been classified according
to the degree of myelosuppression and immunosuppression
that they induce.6 These differences have been shown to
influence the kinetics of engraftment and response.7–11
The combination of fludarabine phosphate with melphalan (Flu/Mel) in RIC regimens is a moderately intensive
regimen.1,2,6 When compared to less myelosuppressive RIC
regimens this combination has been associated with a faster
time to full donor chimerism, less graft rejection, lower
relapse rates and, in some studies, improved overall
survival.7,12 This, however, has been at the expense of
increased rates of GvHD and increased transplant-related
mortality (TRM) and morbidity. Early studies with the
Flu/Mel combination employed melphalan doses of
140 mg/m2 (MEL140) to 180 mg/m2 (MEL180).1,13–15 The
rates of GvHD in these studies were comparable to those
seen following myeloablative conditioning regimens. A
particular problem was high rates of mucositis especially
when melphalan was combined with MTX as GvHD
prophylaxis.16,17 Rates of GvHD following RIC regimens
are influenced by the post transplant immunosuppression
used. The combination of Flu/Mel140 with Cyclosporin
alone as post transplant immunosuppression has been
shown in one small study to result in acute GvHD
(aGvHD) in 40% of patients with this rising to 70% post
prophylactic DLI.18 The addition of methotrexate or
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
456
tacrolimus to CyA in post transplant immunosuppression
has been associated with a lower but still significant rate
of aGvHD of 0–43%.14,15,19–22 Furthermore the use of antithymocyte globulin (ATG) or alemtuzumab (Campath),
has been associated with less aGvHD23,24 but with an
increased risk of delayed donor chimerism, increased use
of donor leukocyte infusions, increased risk of relapse
and increased infectious complications when compared to
non-T-cell depleted regimens.25,26 A comparative casecontrolled nonrandomised study comparing a Flu/Mel
regimen employing CyA/MTX or alemtuzumab immunosuppression showed reduced aGvHD in the alemtuzumab
group, but an increased relapse rate and no significant
difference in overall survival between the two populations.26 Thus a reduction in aGvHD can be achieved but at
the potential expense of disease control. This has been
particularly shown in patients with acute leukaemia or
relapsed/refractory disease at the time of transplantation.
To further investigate the role of non-T cell depleted
Flu/Mel based conditioning regimens, we have studied
a series of 56 patients who have been treated with this
regimen, employing two different doses of melphalan and
different post transplant immunosuppression regimens.
Patients and methods
Patient population and demographics
Data were collected on 56 patients transplanted from
January 1999 to November 2002. All patients had haematological malignancies known to be susceptible to a graftversus-disease effect and were considered unsuitable for
a standard conditioned stem cell transplant (23 on the basis
of age alone, six due to age and comorbid conditions, one
due to age and previous treatment, nine due to comorbid
conditions alone, six due to previous treatment, 10 due to
disease subtype where a conventional allograft was not
deemed appropriate, and one due to patient choice).
Thirteen patients were enrolled prospectively in a phase II
clinical trial assessing the safety and efficacy of a non-T-cell
depleted nonmyeloablative stem cell transplant conditioning regimen (patient numbers 44–56, see Tables 1 and 2).
Data were also retrospectively collected on a further 43
patients concurrently treated at the research sites with a
similar conditioning regimen but not registered on the trial
protocol. Most nontrial patients had haematological
malignancies that would have excluded them from entry
into the clinical study.
Conditioning and GvHD prophylaxis
The 13 trial patients were treated with fludarabine phosphate
30 mg/m2 intravenous infusion for 5 days followed by
intravenous melphalan 140 mg/m2 on 1 day. Post transplant immunosuppression was intended to be CyA alone,
although two of the trial patients were prescribed MTX in
addition. A further 22 patients, not included in the study,
were treated with an identical conditioning regimen plus
CyA alone, and one other patient received fludarabine
phosphate 25 mg/m2 for 5 days and melphalan 140 mg/m2
with CyA/MTX immunosuppression.
Bone Marrow Transplantation
Data were collected on a further 20 patients treated
at the same transplant centers using a lower dose of
melphalan (and a lower dose of fludarabine phosphate).
This regimen consisted of fludarabine phosphate 25 mg/m2
for 5 days and melphalan 100 mg/m2 for one day with
CyA/MTX (FLU/MEL100/CyA/MTX) as post transplant
immunosuppression.
Study patients were to have received filgrastim (5 mcg/
kg/day) from day þ 1 until neutrophil recovery, for a
maximum of 28 days. The use of GCSF in off-study
patients was according to local practice. Patients receiving
FLU/MEL100/CyA/MTX did not receive growth factor
support following conditioning.
Data collection and statistical analysis
Post transplant data were collected including time to
neutrophil and platelet recovery, defined as neutrophils
40.5 109/l and platelets 420 109/l, respectively, length
of stay in hospital, incidence and grade of aGvHD and
cGvHD, incidence of cytomegalovirus (CMV) reactivation,
time to donor engraftment, use of donor leukocyte
infusions (DLI), day 100 mortality and disease response.
Chimerism analysis was performed according to local
protocols. Available data on the local assessment of disease
response/status at 3 months post transplant were collected
and summarized.
Variables were summarized using standard summary
statistics applicable to the nature of the data, quantitative
or qualitative. All available data were used when summarizing the variables of interest without applying any
imputation techniques for missing data. The overall
survival (OS) and progression free survival (PFS) were
summarized using Kaplan–Meier survival methods. Survival time was defined as the time from the date of patient
registration to the date of death with surviving patients
being censored on the date on which they were last known
to be alive. PFS was defined as the time from the date
of patient registration to the date of death or progression of
disease with a patient being censored on the date on which
they were last known to be alive and progression free.
Patient characteristics
Patient characteristics are detailed in Table 1. In summary,
the median age of the patients at time of transplant was 51
years (range 19–68); 32 patients (57%) were male and 24
patients (43%) were female. A range of haematological
malignancies were treated: 20 patients had non-Hodgkin’s
lymphoma (NHL) (five diffuse large B-cell lymphoma
(DLBCL), five follicular lymphoma, two transformed
follicular lymphoma, one indolent lymphoma undefined,
three mantle cell lymphoma, two small lymphocytic
lymphoma, one marginal zone lymphoma, one peripheral
T-cell lymphoma), 16 patients had acute myeloid leukaemia
(AML), seven patients had multiple myeloma (MM), four
patients had Hodgkin’s disease (HD), three patients had
acute lymphocytic leukaemia (ALL), three patients had
myelodysplasia, one patient had chronic lymphocytic
leukaemia (CLL), and two patients had myeloproliferative
disease (one chronic myeloid leukaemia (CML), one
essential thrombocythaemia (ET)). Forty-two of the 56
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
457
Table 1
Patient characteristics
Patient ID
Age/Sex
Diagnosis
19
23
28
34
10
17
35
7
8
38
39
41
42
45
46
56
54
43
27
29
37
26
1
11
9
5
47
51
52
53
55
2
4
3
6
33
40
14
48
22
44
12
49
50
13
16
15
24
20
30
31
25
36
32
18
21
39/male
44/female
56/female
58/female
60/female
54/female
47/male
57/male
46/female
51/male
50/male
19/male
61/female
62/female
50/female
51/female
52/female
44/male
55/male
62/male
41/male
56/female
32/male
37/male
65/female
44/female
56/male
48/female
55/male
41/female
46/male
31/female
49/female
37/male
34/male
55/male
52/male
41/male
54/male
57/female
55/male
62/female
26/female
51/female
46/male
58/female
68/male
35/male
47/male
25/male
53/female
19/male
20/male
57/male
60/male
54/male
AML
AML
AML
AML
AML
AML
AML
AML+CLL
tAML
AML
AML
AML
AML
AML
AML
AML
MDS
MDS
MDS
CML
MPD
ALL
ALL
ALL
MM
MM
MM
MM
MM
MM
MM
HD
HD
HD
HD
CLL
LG NHL
LG NHL
LGNHL
FL
FL
FL
FL
FL
tFL
tFL
MCL
MCL
MCL
DLBCL
DLBCL
DLBCL
DLBCL
DLBCL
MZL
PTCL
No. previous treatments
3
1
1
1
1
2
2
1
4
1
2
1
2
6
1
4
1
2
2
2
2
2
2
6
3
3
4
4
5
3
4
5
4
11
4
3
5
3
3
1
7
4
2
10
6
4
2
1
3
3
6
2
4
4
3
1
Prior transplant
CMV status patient/donor
Conditioning regimen used
No
No
No
No
No
No
No
No
Autograft
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Allograft
Autograft
No
Autograft
Autograft
Autograft
No
Autograft
Autograft
Autograft
Autograft
Autograft
No
No
No
No
No
No
Autograft
No
No
Autograft
No
No
No
No
Autograft
No
No
Autograft
Autograft
No
No
ve/ve
+ve/+ve
ve/ve
ve/+ve
+ve/+ve
+ve/ve
ve/ve
+ve/ve
+ve/+ve
+ve/ve
ve/+ve
ve/ve
+ve/+ve
+ve/+ve
+ve/ve
+ve/+ve
+ve/+ve
ve/ve
+ve/+ve
+ve/ve
ve/ve
+ve/+ve
ve/ve
+ve/+ve
+ve/ve
+ve/+ve
+ve/ve
ve/+ve
ve/+ve
ve/ve
ve/ve
+ve/ve
+ve/+ve
ve/ve
ve/ve
+ve/+ve
+ve/ve
+ve/+ve
ve/+ve
ve/ve
ve/+ve
ve/ve
ve/ve
ve/+ve
+ve/ve
ve/ve
+ve/+ve
+ve/+ve
ve/ve
ve/+ve
ve/+ve
ve/ve
ve/ve
+ve/+ve
ve/ve
+ve/+ve
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
Flu
30/Mel
25/Mel
25/Mel
25/Mel
30/Mel
30/Mel
25/Mel
30/Mel
30/Mel
25/Mel
25/Mel
25/Mel
25/Mel
30/Mel
30/Mel
30/Mel
30/Mel
25/Mel
25/Mel
25/Mel
25/Mel
25/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
25/Mel
25/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
30/Mel
25/Mel
30/Mel
25/Mel
25/Mel
25/Mel
25/Mel
25/Mel
30/Mel
30/Mel
140
140
100
100
140
140
100
140
140
100
100
100
100
140
140
140
140
100
100
100
100
100
140
140
140
140
140
140
140
140
140
140
140
140
140
100
100
140
140
140
140
140
140
140
140
140
140
100
140
100
100
100
100
100
140
140
CyA
CyA/MTX
CyA/MTX
CyA/MTX
CyA
CyA
CyA/MTX
CyA
CyA
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA
CyA
CyA
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA/MTX
CyA
CyA
CyA
CyA
CyA/MTX
CyA/MTX
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA
CyA/MTX
CyA
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA/MTX
CyA
CyA
ALL ¼ acute lymphoblastic leukaemia; HD ¼ Hodgkin’s disease; MM ¼ multiple myeloma; AML ¼ acute myeloid leukaemia; tAML ¼ treatment related
AML; CLL ¼ chronic lymphocytic leukaemia; MCL ¼ mantle cell lymphoma; MZL ¼ marginal zone lymphoma; MDS ¼ myelodysplastic syndrome;
CML ¼ chronic myeloid leukaemia; DLBCL ¼ diffuse large B-cell lymphoma; MPD ¼ myeloproliferative disease; MM ¼ multiple myeloma; FL ¼ follicular
lymphoma; tFL ¼ transformed follicular lymphoma; PTCL ¼ peripheral T cell lymphoma, LGNHL ¼ low grade non Hodgkin’s lymphoma unspecified.
patients (75%) were in remission or had responsive disease
at the time of transplant, 14 patients (25%) were in relapse/
progression, or their disease was refractory or active/
persistent, at the time of transplant (Table 2). The patient
population had received a median of three lines of therapy
(range 1–11) prior to transplant. Fifteen of the 56 patients
(27%) had received a prior autograft and one patient a
previous allograft.
The median age of the 55 stem cell donors with these data
available was 48 years (range 20–75 years). Donor–recipient
sex pairing was female to male in nine patients and female to
female in eight patients (the remaining 39 donor–recipient pairs
Bone Marrow Transplantation
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
458
Table 2
Patient response and outcome data
Patient ID Age/Sex Diagnosis
Disease status at
transplant
Response at 3 months
post transplant
19
23
28
34
10
17
35
7
8
38
39
41
42
45
46
56
54
43
27
29
37
26
1
11
9
5
47
51
52
53
55
2
4
3
6
33
40
14
48
22
44
12
49
50
13
16
15
24
20
30
31
25
36
32
18
21
CR3
CR
CR
PR
CR/hypoplasia
CR2
CR
CR
CR
Persistent disease
Persistent disease
Persistent disease
CR
CR
CR
Relapse in skin
CR
CR
CR
CR
active disease
CR
PR
Refractory relapse
2nd plateau
PR
2nd plateau
1st plateau
2nd plateau
2nd plateau
2nd plateau
Progression
Progression
Resistant
PR
Stable disease
PR
PR
PR
Progression
CR
Untreated relapse
PR
PR
CR
Refractory relapse
PR
CR
PR
Active disease
CR
PR
Persistent disease
PR
PR
PR1
CR
CR
CR
Relapse
Not known
CR
CR
Relapse
N/A (died)
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
Relapse
PR
N/A (died)
CR
N/A (died)
N/A (died)
Not known
Progression
CR
N/A (pt died)
CR
CR
PR
PR
CRU
CR
CR
CRU
CR
CR
Good PR
CR
CRU
CR
N/A (pt died)
CRU
N/A (pt died)
Not known
CR
N/A (died)
CR
CR
Relapse
PR
CR
CR
N/A (died)
39/M
44/F
56/F
58/F
60/F
54/F
47/M
57/M
46/F
51/M
50/M
19/M
61/F
62/F
50/F
51/F
52/F
44/M
55/M
62/M
41/M
56/F
32/M
37/M
65/F
44/F
56/M
48/F
55/M
41/F
46/M
31/F
49/F
37/M
34/M
55/M
52/M
41/M
54/M
57/F
55/M
62/F
26/F
51/F
46/M
58/F
68/M
35/M
47/M
25/M
53/F
19/M
20/M
57/M
60/M
54/M
AML
AML
AML
AML
AML
AML
AML
AML+CLL
TAML
AML
AML
AML
AML
AML
AML
AML
MDS
MDS
MDS
CML
MPD
ALL
ALL
ALL
MM
MM
MM
MM
MM
MM
MM
HD
HD
HD
HD
CLL
LGNHL
LGNHL
LGNHL
FL
FL
FL
FL
FL
tFL
tFL
MCL
MCL
MCL
DLBCL
DLBCL
DLBCL
DLBCL
DLBCL
MZL
PTCL
Progression post Status when last seen
transplant
(months post transplant)
Yes
Yes
Yes
Yes
Yes
yes
Yes
Yes
Yes
Died (8)
CR (26)
CR (25)
Died (7)
Died (6)
CR (12)
CR (4)
Progression (3)
Died (1)
CR (25)
CR (33)
CR (3)
CR (25)
Died (16)
CR (18)
CR (23)
CR (26)
CR (4)
CR (4)
CR (20)
Persisting disease (19)
Died (o1)
CR (15)
Died (2)
Died (o1)
PR (2)
Died (8)
CR (19)
Died (1)
CR (36)
CR (27)
Progression (9)
PR (1)
CRU (16)
CR (6)
CR (4)
CRU (9)
Died (26)
CR (38)
CR (14)
CR (21)
CR (15)
CR (30)
Died (o1)
CR (12)
Died (o1)
Died (12)
CR (13)
Died (2)
CR (20)
CR (14)
Died (10)
PR (3)
CR (10)
CR (37)
Died (1)
Cause of death
Sepsis
Disease
GvHD
TTP
Chest infection
sepsis
Pneum./GvHD
Renal failure
Septicaemia
Acute GvHD
Sepsis/GvHD
Acute GvHD
Septic shock
Diss Varicella
Sepsis
Lymphoma
GvHD
TTP ¼ Thrombotic thrombocytopenic purpura.
were either male to male, or male to female). All donors were
serologically fully matched siblings of the patients. Peripheral
blood stem cells alone were donated by 52 (93%) donors. Bone
marrow alone was harvested from a further three donors and
the remaining donor provided both bone marrow and
peripheral blood stem cells. In the 42 patients with data
available, a median of 3.85 106 CD34 þ cells per kg of the
recipient’s body weight were infused (range 1.43–13.50).
Bone Marrow Transplantation
Results
Engraftment and haematological recovery
Engraftment occurred in 52 of the 56 patients (93%).
Engraftment could not be fully confirmed in four cases: two
patients died of septic shock on day þ 6 and day þ 22; and
two patients died of grade IV aGvHD on day þ 21 and day
þ 54 respectively. For the 52 patients with data available,
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
459
the median time to an absolute neutrophil count of
0.5 109/l was 11 days (range 8–42); filgrastim was used
to support neutrophil recovery in 23 (46%) of these
patients. Assessable patients receiving FLU/MEL140/CyA
had a shorter median time to neutrophil recovery compared
to the assessable patients receiving FLU/MEL100/CyA/
MTX (9 days (range 9–14) versus 20.5 days (range 16–42)
respectively). However, patients receiving the latter regimen
did not receive G-CSF post transplantation. For the 49
patients with platelet recovery data available the median
time to a platelet count of 20 109/l was 14 days (range 7–
92 days). Patients spent a median of 29 days (range 15–78
days) in hospital. Patients remained on CyA for a median
of 5 months (range o1–27 months). The use of MTX was
not associated with a significant difference in the length of
time on immunosuppression compared to the use of CyA
alone (data not shown).
Chimerism
Twenty-four of 26 patients (92%) with data available at 3
months post transplant had 495% donor chimerism. Of
the two other patients, one had 100% donor chimerism at 6
months and one at 11 months post transplant without the
use of DLIs. Two patients received DLI post transplant
for relapsed disease (one HD and one AML/CLL). Both
responded to DLI but relapsed at a later date.
Graft-versus-host disease
Two patients died prior to engraftment and were not
assessable for aGvHD. For patients receiving FLU/
MEL140/CyA, 17 of 33 (52%) suffered aGvHD (two grade
I, six grade II, five grade III, three grade IV and one of
unknown grade) compared to four of the 20 patients (20%)
receiving FLU/MEL100/CyA/MTX (3 grade I, and one
grade II). The three patients with grade IV GvHD, and one
of the patients with grade III GvHD, died as a consequence
of this.
Of the 47 patients surviving for at least 90 days, 23 (49%)
developed cGvHD. Of these, 10 had extensive cGvHD, 10
had limited cGvHD and three had cGvHD of unknown
extent. For patients receiving FLU/MEL140/CyA, 16 of
the 25 (64%) patients developed cGvHD (five limited, eight
extensive, three of unknown extent) compared to five of 19
(26%) patients receiving FLU/MEL100/CyA/MTX (three
limited, two extensive).
Toxicities
Fourteen patients (25%) experienced CMV reactivation
post transplant and four of these went on to develop CMV
disease. CMV reactivation was generally treated with
ganciclovir. Other reported toxicities included bacterial
sepsis (six patients), fungal infection (four patients),
cardiac complications (two patients), renal failure (two
patients, requiring dialysis in one patient), seizures (three
patients), fatal thrombotic thrombocytopenic purpura
(one patient), and fatal disseminated varicella infection
(one patient). There was no notable difference in the
incidence of toxicities based on melphalan dose or
immunosuppression used.
Disease response post transplant
Of the 44 patients with 3-month response data available, 34
(77%) were in complete remission (CR) or unconfirmed
CRU, five (11%) were in partial remission (PR) or good PR
and five (11%) had relapsed or progressed. Of the
remaining 12 patients, nine had died by month 3, and
three patients did not have a response assessment available
at month 3. Twenty-three out of the 44 patients (52%)
appeared to show an improvement at month 3 from their
disease status at the time of transplant (Table 2). Thirty-six
patients were not in CR at the time of transplant. Of these,
19 patients (53%) were in complete remission at 3 months,
five patients (14%) showed an improvement in remission
status but were not in CR, three patients (8%) had
progressed/relapsed, and the 3-month-response assessment
was not available or not applicable (i.e. patient died before
month 3) for nine patients (25%). There was no obvious
difference in disease response between patients treated
with FLU/MEL140/CyA or FLU/MEL100/CyA/MTX
(see Table 2).
Progression and overall survival
With a median follow-up of 363.5 days (range 7–1158) at
the time of data collection, nine patients (16%) had
relapsed or progressed (three patients with AML, one with
CML, one with MPD, two with MM, one with HD and one
with DLBCL) at a median of 3 months (range o1–8
months) post transplant. The overall 100-day mortality rate
was 0.16 (95% CI 0.08–0.28) with a 1-year nonrelapse
mortality rate of 0.24 (95%CI 0.13–0.38). Seventeen
patients (30%) had died at a median of 2 months post
transplant (range o1–26 months). Cause of death in each
case is listed in Table 2. Fourteen patients receiving CyA
alone as GvHD prophylaxis died during follow-up. Eight
of these died within 3 months of transplant before disease
response could be assessed, and a further six patients died
beyond 3 months. Three patients receiving CyA/MTX as
post transplant immunosuppression had died: two had died
of disease (at 7 months (AML) and 10 months (DLBCL))
and one patient died prior to disease assessment at 1 month
post transplant. For the whole group the 1 year PFS for
all patients was 63% (95% CI 50–77%) (Figure 1). The
median PFS has not yet been reached. The 1 year OS
is 70% (95% CI 57–83%). The median OS has not yet
been reached (Figure 1). Thirty-nine patients remain alive
of whom 33 are in CR at a median of 19 months post
transplant (range 3–38 months).
Discussion
We have collected data on two different RIC regimens,
one employing FLU/MEL140/CyA and the other FLU/
MEL100/CyA/MTX.
Although a comparison of the two regimens is complicated by differences in patient demographics, disease status,
and the retrospective nature of the nonstudy data collection, it is clear that patients treated with the more
aggressive FLU/MEL140/CyA had a higher rate of acute
and chronic GvHD, early transplant related death, and
Bone Marrow Transplantation
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
460
1.0
0.9
0.8
Probability
0.7
OS
0.6
0.5
PFS
0.4
0.3
0.2
0.1
= censored event
0.0
0
200
400
600
800
1000
Time from transplant (days)
1200
Figure 1
OS and PFS for 56 patients following fludarabine phosphate
and melphalan RIC stem cell allografts.
progression-free death. However, full donor chimerism was
achieved early in the post-transplant period without the
need for DLI. Of eight patients with active or resistant
disease treated with this regimen, 6 patients showed disease
response, with three achieving a CR, suggesting that despite
the high-toxicity disease control is good. This is in keeping
with other studies employing CyA alone as post transplant
immunosuppression.18 Thus although rapid disease control
may be achieved by this regimen, we feel the toxicities
would preclude it from routine use except perhaps in those
patients with the poorest risk disease.
Disease response appears also to be maintained in
patients treated with FLU/MEL100/CyA/MTX, but with
the additional benefit of a low incidence of acute and
chronic GvHD. Of nine FLU/MEL100/CyA/MTX patients
in CR at transplantation seven remained in CR at month 3
and were progression-free at the last follow-up (median of
14 months; range 4–25 months). Although chimerism was
not routinely monitored in the patients receiving this
regimen due to differences in local practices, rapid donor
engraftment is suggested by the responses seen in those
patients not in remission at transplantation. Of 11 patients
not in remission at transplantation seven had achieved and
maintained a CR (including three patients with persistent
AML, one with CLL, one LGNHL and two with DLBCL)
at a median follow-up of 10 months post transplant (range
3–33 months). Four patients progressed despite transplantation (one with AML, one with MPD, one with CML, and
one with DLBCL). No patient had relapsed from a CR
achieved post transplantation, suggesting ongoing disease
control. These figures are in keeping with other studies
employing similar post transplant immunosuppression but
with higher doses of melphalan which have been associated
with high-transplant toxicity rates especially related to
mucositis.15,17,22 Transplant-related mortality was also low
in our patients receiving FLU/MEL100/CyA/MTX with
only one transplant related death prior to 100 days post
transplant. Two further patients died of disease progression
at 7 and 10 months (one AML, one DLBCL); neither was
in CR at transplant.
Bone Marrow Transplantation
The aGvHD incidence and non-relapse mortality are in
line with other non-T-cell depleted RIC regimens.5,15,17
Although some of these studies included patients receiving
stem cells from unrelated donors comparison has been
made with patients receiving matched related transplants
where such data are given. In this study, the rate of aGvHD
in patients given the FLU/MEL100/CyA/MTX regimen
was lower than reported in patients receiving RIC regimens
with higher doses of melphalan.13,15,17,26 These differences
may simply be due to chance, although the effect of
lowering the melphalan dose and including the additional
immunosuppression of MTX cannot be excluded. The use
of T-cell depletion has been shown to reduce the risk of
GvHD with low transplant related mortality, however,
there is possibly a detrimental effect on disease control,
especially in patients at high risk of relapse/progression.7,25–27
We have shown that patients transplanted with FLU/
MEL100/CyA/MTX can achieve good disease control with
an acceptable level of toxicity. Further studies are required
to confirm these findings.
Acknowledgements
The authors would like to acknowledge the contribution of
Ralph Bloomfield, Senior Statistician at Schering Health Care
Limited. This work was supported by Schering Germany.
Professor GJ Morgan is supported by the Leukaemia Research
Fund. Three of the authors were employed by a company
(Schering Health Care Limited) whose product was studied in
the present work, and these authors were involved in the
management of the company-sponsored clinical trial.
References
1 Giralt S, Estey E, Albitar M, van Besien K, Rondón G,
Anderlini P et al. Engraftment of allogeneic hematopoietic
progenitor cells with purine analog-containing chemotherapy:
harnessing graft-versus-leukemia without myeloablative
therapy. Blood 1997; 89: 4531–4536.
2 Slavin S, Nagler A, Naparstek E, Kapelushnik Y, Aker M,
Cividalli G et al. Nonmyeloablative stem cell transplantation
and cell therapy as an alternative to conventional bone marrow
transplantation with lethal cytoreduction for the treatment of
malignant and nonmalignant hematologic diseases. Blood
1998; 91: 756–763.
3 McSweeney PA, Niederwieser D, Shizuru JA, Sandmaier BM,
Molina AJ, Maloney DG et al. Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor
effects. Blood 2001; 97: 3390–3400.
4 Massenkeil G, Nagy M, Neuburger S, Tamm I, Lutz C, le
Coutre P et al. Survival after reduced-intensity conditioning is
not inferior to standard high-dose conditioning before
allogeneic haematopoietic cell transplantation in acute leukaemias. Bone Marrow Transplant 2005; 36: 683–689.
5 Robinson SP, Goldstone AH, Mackinnon S, Carella A,
Russell N, de Elvira CR et al. Chemoresistant or aggressive
lymphoma predicts for a poor outcome following reducedintensity allogeneic progenitor cell transplantation: an analysis
from the Lymphoma Working Party of the European Group
for Blood and Bone Marrow Transplantation. Blood 2002;
100: 4310–4316.
Fludarabine/melphalan RIC allografts
RK Dasgupta et al
461
6 Kassim AA, Chinratanalab W, Ferrara JLM, Mineishi S.
Reduced-intensity allogeneic hematopoietic stem cell transplantation for acute leukemias: ‘what is the best recipe?’. Bone
Marrow Transplant 2005; 36: 565–574.
7 Anderlini P, Saliba R, Acholonu S, Okoroji G-J, Donato M,
Giralt S et al. Reduced-intensity allogeneic stem cell transplantation in relapsed and refractory Hodgkin’s disease:
low transplant-related mortality and impact of intensity
of conditioning regimen. Bone Marrow Transplant 2005; 35:
943–951.
8 Valcárcel D, Martino R, Caballero D, Mateos MV, PérezSimón JA, Canals C et al. Chimerism analysis following
allogeneic peripheral blood stem cell transplantation with
reduced-intensity conditioning. Bone Marrow Transplant 2003;
31: 387–392.
9 Mohr B, Koch R, Thiede C, Kroschinsky F, Ehninger G,
Bornhäuser M. CD34+ cell dose, conditioning regimen and
prior chemotherapy: factors with significant impact on the early
kinetics of donor chimerism after allogeneic hematopoietic cell
transplantation. Bone Marrow Transplant 2004; 34: 949–954.
10 Pérez-Simón JA, Caballero D, Diez-Campelo M, Lopez-Pérez
R, Mateos G, Cañizo C et al. Chimerism and minimal residual
disease monitoring after reduced intensity conditioning (RIC)
allogeneic transplantation. Leukemia 2002; 16: 1423–1431.
11 Baron F, Baker JE, Storb R, Gooley TA, Sandmaier BM,
Maris MB et al. Kinetics of engraftment in patients with
hematologic malignancies given allogeneic hematopoietic cell
transplantation after nonmyeloablative conditioning. Blood
2004; 104: 2254–2262.
12 de Lima M, Anagnostopoulos A, Munsell M, Shahjahan M,
Ueno N, Ippoliti C et al. Nonablative versus reduced-intensity
conditioning regimens in the treatment of acute myeloid
leukemia and high-risk myelodysplastic syndrome: dose is
relevant for long-term disease control after allogeneic hematopoietic stem cell transplantation. Blood 2004; 104: 865–872.
13 Devine SM, Sanborn R, Jessop E, Stock W, Huml M, Peace D
et al. Fludarabine and melphalan-based conditioning for
patients with advanced hematological malignancies relapsing
after a previous hematopoietic stem cell transplant. Bone
Marrow Transplant 2001; 28: 557–562.
14 Giralt S, Thall PF, Khouri I, Wang X, Braunschweig I,
Ippolitti C et al. Melphalan and purine analog-containing
preparative regimens: reduced-intensity conditioning for patients with hematologic malignancies undergoing allogeneic
progenitor cell transplantation. Blood 2001; 97: 631–637.
15 Giralt S, Aleman A, Anagnostopoulos A, Weber D, Khouri I,
Anderlini P et al. Fludarabine/melphalan conditioning for
allogeneic transplantation in patients with multiple myeloma.
Bone Marrow Transplant 2002; 30: 367–373.
16 Wong R, Giralt SA, Martin T, Couriel DR, Anagnostopoulos
A, Hosing C et al. Reduced-intensity conditioning for
unrelated donor hematopoietic stem cell transplantation as
treatment for myeloid malignancies in patients older than 55
years. Blood 2003; 102: 3052–3059.
17 van Besien K, Devine S, Wickrema A, Jessop E, Amin K,
Yassine M et al. Regimen-related toxicity after fludarabine-
18
19
20
21
22
23
24
25
26
27
melphalan conditioning: a prospective study of 31 patients
with hematologic malignancies. Bone Marrow Transplant 2003;
32: 471–476.
de Lima M, Bonamino M, Vasconcelos Z, Colares M,
Diamond H, Zalcberg I et al. Prophylactic donor lymphocyte
infusions after moderately ablative chemotherapy and stem
cell transplantation for hematological malignancies: high
remission rate among poor prognosis patients at the expense
of graft-versus-host disease. Bone Marrow Transplant 2001;
27: 73–78.
Gómez-Núñez M, Martino R, Caballero MD, Pérez-Simón
JA, Canals C, Mateos MV et al. Elderly age and prior
autologous transplantation have a deleterious effect on
survival following allogeneic peripheral blood stem cell
transplantation with reduced-intensity conditioning: results
from the Spanish multicenter prospective trial. Bone Marrow
Transplant 2004; 33: 477–482.
Ueno NT, Cheng YC, Rondón G, Tannir NM, Gajewski JL,
Couriel DR et al. Rapid induction of complete donor
chimerism by the use of a reduced-intensity conditioning
regimen composed of fludarabine and melphalan in allogeneic
stem cell transplantation for metastatic solid tumors. Blood
2003; 102: 3829–3836.
Ritchie DS, Morton J, Szer J, Roberts AW, Durrant S,
Shuttleworth P et al. Graft-versus-host disease, donor chimerism, and organ toxicity in stem cell transplantation after
conditioning with fludarabine and melphalan. Biol Blood
Marrow Transplant 2003; 9: 435–442.
Khouri IF, Lee MS, Saliba RM, Jun G, Fayad L, Younes A
et al. Nonablative stem-cell transplantation for advanced/
recurrent mantle-cell lymphoma. J Clin Oncol 2003; 21:
4407–4412.
Kottaridis PD, Milligan DW, Chopra R, Chakraverty RK,
Chakrabarti S, Robinson S et al. In vivo CAMPATH-1H
prevents graft-versus-host disease following nonmyeloablative
stem cell transplantation. Blood 2000; 96: 2419–2425.
Bacigalupo A. Third EBMT/AMGEN Workshop on reducedintensity conditioning allogeneic haemopoietic stem cell
transplants (RIC-HSCT), and panel consensus. Bone Marrow
Transplant 2004; 33: 691–696.
Hartwig UF, Winkelmann N, Wehler T, Kreiter S, Schneider
PM, Meyer RG et al. Reduced-intensity conditioning followed
by allografting of CD34-selected stem cells and o106/kg
T cells may have an adverse effect on transplant-related
mortality. Ann Hematol 2005; 84: 331–338.
Perez-Simon JA, Kottaridis PD, Martino R, Craddock C,
Caballero D, Chopra R et al. Nonmyeloablative transplantation with or without alemtuzumab: comparison between 2
prospective studies in patients with lymphoproliferative
disorders. Blood 2002; 100: 3121–3127.
Glass B, Nickelsen M, Dreger P, Claviez A, Hasenkamp J,
Wulf G et al. Reduced-intensity conditioning prior to
allogeneic transplantation of hematopoietic stem cells: the
need for T cells early after transplantation to induce a graftversus-lymphoma effect. Bone Marrow Transplant 2004; 34:
391–397.
Bone Marrow Transplantation