Relapse After SCT - Advice Needed
 

I have a question for the group. After receiving Vidaza for Myeodysplasia, my father relapsed to AML. Then, his first induction chemotherapy failed. Though his doctor described it as a "hail mary,", the salvage regimen of FLAG was brought his blasts down enough to have a stem cell transplant.

Now, 8 months post transplant, he has relapsed again (AML), and it's progressing rapidly (80% blasts)

As I understand it, we have a two options (assuming we are shooting for another transplant).

1. Try the MEC regimen -- It's the natural next salvage course. I know, however, that this is likely to really kick his butt, as he's already quite weak. I'm worried he won't survive it.

2. Repeat the FLAG regimen which got him into a sustainable enough remission for the SCT. His doctor is open to this idea.

Here's my question, and it's related to the role of the donor stem cells, engraftment, and the power of a new immune system against leukemic cells.

If FLAG (or MEC) works enough -- and that's a big if -- there will likely still be some leukemic cells remaining. I believe he relapsed from his recent transplant due to a lack of immune response. He experienced very little GVHD, so the mutant drug tolerant cells were able to proliferate (unrelated 9/10 donor, by the way).

What IS the power of GVHD in killing/thwarting the remaining disease. Can it (the donors immune system, essentially) do what the chemo couldn't. Can it finish the job against these final stubborn cells?

I have what I like to call pigeon knowledge of all this, so I hope my question makes sense. Please let me know if I can clarify anything. And, of course, thank you in advance for your thoughts.

Jason,

first off, i am very sorry that your father is having to go through all of this. it can be a very difficult ride.

a lot of doctors like to see some gvhd as it frequently demonstrates some graft versus leukemia effect and in some cases helps clean up what was missed during the transplant conditioning process. unfortunately, it's not a catch all and the New immune system doesn't always finish the job. i am currently taking vidaza post transplant to try and support my donor cells and increase this graft versus leukemia, or in my case mds effect. one other approach that is added is a donor lymphocyte infusion to add more donor cells after additional conditioning sometimes instead of a full blown transplant, but there are many factors that go into the next treatment option that is best.

My husband relapsed after his SCT also at 8 months. He is currently going through induction chemo again with the hope of DLI. There was really no other option. He has an amazing attitude and a fighting spirit which is so important. For him, Vidaza did not work. It is so hard to make these difficult decisions and I am sorry that you have to go through this. I wish you and your father the best.

As far as your question regarding GVHD, my husband experienced a little of it both of the skin and the gut. The doctors seemed pleased at the time. However, he still relapsed. They are counting on the GVL effect this time if he does get the DLI. It is all one big science experiment really.