Bone marrow transplantation in the treatment of acute lymphoblastic leukaemia

Whilst the treatment of acute lymphoblastic leukaemia (ALL) with conventional chemotherapy in childhood is undeniably improving, there remain a small number of children who might benefit from bone marrow transplantation. These would certainly include children who have relapsed either on or off chemotherapy and have re-entered remission. In addition we feel that those with the B-cell phenotype or others with a very high tumour burden at presentation (WBC > 100 x 10⁹/l) should be considered. Acute lymphoblastic leukaemia associated with certain cytogenetic phenotypes also merits consideration. We would include those who are Philadelphia t(22q̄:9(+)(q))(+ve) and perhaps those with a hypodiploid karyotype. For reasons that are still largely unexplained, adults fare less well with conventional chemotherapy than children. We currently recommend bone marrow transplantation (BMT) for adults with any ALL phenotype who present with a white blood count (WBC) in excess of 20 x 10⁹/l. In addition, B-cell phenotype and the cytogenetically abnormal groups quoted above would be included irrespective of their presenting WBC. On the basis of current experience the choice of BMT technique is first HLA matched sibling allograft, second syngeneic and third autologous BMT. HLA mismatched or phenotypically matched unrelated BMTs remain experimental and are presently only used by our group in circumstances where no alternative is available and the underlying condition would be lethal beyond doubt. The upper age limit for allogeneic BMT is 45 years and autologous probably 60 years of age.