Role of splenic irradiation in patients with chronic myeloid leukemia undergoing allogeneic bone marrow transplantation.

Allogeneic bone marrow transplantation (BMT) has become the treatment of choice for patients of appropriate age with chronic myeloid leukemia (CML). In an attempt to enhance tumor cytoreduction, splenic radiation therapy (RT) has been done before the allogeneic transplant, but the role of splenic RT in this setting remains controversial. The purpose of this study is to evaluate the role of splenic RT before allogeneic BMT in patients with CML. Thirty-seven patients with chronic (n=33) or accelerated (n=4) phase CML underwent BMT from April 1990 to January 1998. All patients received splenic RT consisting of 500 cGy in five daily fractions (n=36) or 250 cGy in five daily fractions (n=1) completed within 10 days before BMT. The conditioning regimen included total-body irradiation and cyclophosphamide; etoposide was added to the regimen of patients in the accelerated phase. Continuous-infusion cyclosporine and pulse methotrexate were administered to all patients for prophylaxis of graft-vs.-host disease (GVHD). All patients achieved hematologic and cytogenetic remission. At a median follow-up of 37 months, the freedom from progression (FFP) and overall survival (OS) were 90 and 82%, respectively. None of the patients in accelerated phase have relapsed. Five patients have died of late transplant-related complications while in complete remission. Acute GVHD of grade > or = II was observed in 20% (14% grade II, 6% grade III). Fifty-one percent of patients developed limited chronic GVHD. The median posttransplant creatinine level was 1.2 mg/dL (range 0.6-4.2). Renal dysfunction, manifested as a persistent elevation in serum creatinine level (> 1.2 mg/dL), was observed in 40% of the patients. Only 8.5% had a creatinine level > 2.0 mg/dL, and no patient required dialysis as a result of renal dysfunction. Seven patients (18.9%) developed pulmonary complications, which included idiopathic interstitial pneumonitis (two), biopsy-proven interstitial fibrosis (four), and alveolar hemorrhage (one). The low relapse rate observed in this study may reflect the use of splenic RT as a part of the cytoreductive regimen before BMT. The fractionation schedule of 500 cGy in five daily fractions was well tolerated and did not appear to increase the toxicity of the preparative regimen. These favorable results indicate that splenic RT deserves further investigation and may be of benefit as a part of the conditioning regimen for patients receiving allogeneic BMT for CML.