Stem cell transplantation for chronic lymphocytic leukemia: should not more patients get a transplant?

Novel therapeutic approaches with conventional chemotherapy and monoclonal antibody combinations have improved the complete remission rates in chronic lymphocytic leukemia. However, cure remains elusive, particularly in fludarabine-refractory patients, whose prognosis remains poor. Autologous stem cell transplantation (SCT) has been explored for such patients, lengthening the time to treatment failure in selected patients, but there is little hope that it will improve the cure rate. The strategy is particularly ineffective in patients with poor biological prognostic factors, such as abnormal cytogenetics and unmutated immunoglobulin heavy-chain variable region. Allogeneic SCT remains the only curative approach, producing an extended disease-free survival in 25-60%, mainly via the graft-versus-leukemia effect. The treatment-related mortality with such an approach has been significant, however, with a 30-40% risk of death within 100 days of the transplant. Nonmyeloablative (NMA) conditioning regimens may produce high response rates and lower morbidity, especially for patients with chemosensitive disease. Randomized trials designed according to the new biologic prognostic parameters described in chronic lymphocytic leukemia are required to better define the role of NMA SCT in the near future.