NCCN CLINICAL PRACTICE GUIDELINES IN ONCOLOGY Hematopoietic Cell Transplantation, Version 2.2020 Ayman Saad, MD1,*; Marcos de Lima, MD2,*; Sarah Anand, MD3; Vijaya Raj Bhatt, MBBS4,*; Ryan Bookout, PharmD5; George Chen, MD6,*; Daniel Couriel, MD, MS7; Antonio Di Stasi, MD8; Areej El-Jawahri, MD9; Sergio Giralt, MD10; Jonathan Gutman, MD11; Vincent Ho, MD12; Mitchell Horwitz, MD13; Joe Hsu, MD14; Mark Juckett, MD15; Mohamed Kharfan Dabaja, MD16,*; Alison W. Loren, MD, MSCE17; Javier Meade, MD18; Marco Mielcarek, MD, PhD19,*; Jonathan Moreira, MD20; Ryotaro Nakamura, MD21; Yago Nieto, MD, PhD22; Julianna Roddy, PharmD, BCOP1,*; Gowri Satyanarayana, MD23; Mark Schroeder, MD24,*; Carlyn Rose Tan, MD25; Dimitrios Tzachanis, MD, PhD26; Jennifer L. Burns27; and Lenora A. Pluchino, PhD27 ABSTRACT NCCN CATEGORIES OF EVIDENCE AND CONSENSUS Category 1: Based upon high-level evidence, there is uniform Hematopoietic cell transplantation (HCT) involves the infusion of hema- NCCN consensus that the intervention is appropriate. topoietic progenitor cells into patients with hematologic disorders with Category 2A: Based upon lower-level evidence, there is uniform the goal of re-establishing normal hematopoietic and immune function. NCCN consensus that the intervention is appropriate. HCT is classified as autologous or allogeneic based on the origin of he- ’ Category 2B: Based upon lower-level evidence, there is NCCN matopoietic cells. Autologous HCT uses the patient sowncellswhile consensus that the intervention is appropriate. allogeneic HCT uses hematopoietic cells from a human leukocyte antigen-compatible donor. Allogeneic HCT is a potentially curative Category 3: Based upon any level of evidence, there is major treatment option for patients with certain types of hematologic malig- NCCN disagreement that the intervention is appropriate. nancies, and autologous HCT is primarily used to support patients under- All recommendations are category 2A unless otherwise going high-dose chemotherapy. Advances in HCT methods and supportive noted. care in recent decades have led to improved survival after HCT; however, disease relapse and posttransplant complications still commonly occur Clinical trials: NCCN believes that the best management of in both autologous and allogeneic HCT recipients. Allogeneic HCT re- any patient with cancer is in a clinical trial. Participation in cipients may also develop acute and/or chronic graft-versus-host clinical trials is especially encouraged. disease (GVHD), which results in immune-mediated cellular injury of sev- PLEASE NOTE eral organs. The NCCN Guidelines for Hematopoietic Cell Transplantation focus on recommendations for pretransplant recipient evaluation and the The NCCN Clinical Practice Guidelines in Oncology (NCCN ® management of GVHD in adult patients with malignant disease. Guidelines ) are a statement of evidence and consensus of the authors regarding their views of currently accepted appro- J Natl Compr Canc Netw 2020;18(5):599–634 aches to treatment. Any clinician seeking to apply or consult doi: 10.6004/jnccn.2020.0021 the NCCN Guidelines is expected to use independent medi- cal judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National ® ® 1The Ohio State University Comprehensive Cancer Center - James Cancer Comprehensive Cancer Network (NCCN ) makes no repre- Hospital and Solove Research Institute; 2Case Comprehensive Cancer Center/ sentations or warranties of any kind regarding their content, University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig use, or application and disclaims any responsibility for their Cancer Institute; 3University of Michigan Rogel Cancer Center; 4Fred & Pamela application or use in any way. Buffett Cancer Center; 5Moffitt Cancer Center; 6Roswell Park Comprehensive © National Comprehensive Cancer Network, Inc. 2020. All Cancer Center; 7Huntsman Cancer Institute at the University of Utah; 8O’Neal rights reserved. The NCCN Guidelines and the illustrations Comprehensive Cancer Center at UAB; 9Massachusetts General Hospital herein may not be reproduced in any form without the express 10 11 Cancer Center; Memorial Sloan Kettering Cancer Center; University of written permission of NCCN. Colorado Cancer Center; 12Dana-Farber/Brigham and Women’s Cancer Center; 13Duke Cancer Institute; 14Stanford Cancer Institute; 15University of Wisconsin Disclosures for the NCCN Hematopoietic Cell Carbone Cancer Center; 16Mayo Clinic Cancer Center; 17Abramson Cancer Transplantation Panel 18 Center at the University of Pennsylvania; The Sidney Kimmel Comprehensive At the beginning of each NCCN Guidelines Panel meeting, Cancer Center at Johns Hopkins; 19Fred Hutchinson Cancer Research Center/ fl 20 panel members review all potential con icts of interest. NCCN, Seattle Cancer Care Alliance; Robert H. Lurie Comprehensive Cancer Center in keeping with its commitment to public transparency, of Northwestern University; 21City of Hope National Medical Center; 22The 23 publishes these disclosures for panel members, staff, and University of Texas MD Anderson Cancer Center; Vanderbilt-Ingram Cancer NCCN itself. Center; 24Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; 25Fox Chase Cancer Center; 26UC San Diego Individual disclosures for the NCCN Hematopoietic Cell Moores Cancer Center; and 27National Comprehensive Cancer Network Transplantation Panel members can be found on page 634. (The most recent version of these guidelines and accompanying *Discussion Writing Committee Member. disclosures are available at NCCN.org.) The complete and most recent version of these guidelines is See page 645 for related commentary. available free of charge at NCCN.org. JNCCN.org | Volume 18 Issue 5 | May 2020 599 NCCN GUIDELINES® Hematopoietic Cell Transplantation, Version 2.2020 Overview Marrow Transplant Research (CIBMTR) estimated that Hematopoietic cell transplantation (HCT) involves the 9,028 allogeneic transplants and 14,709 autologous trans- infusion of hematopoietic progenitor cells into patients plants were performed in the United States in 2018.4 Acute with malignant or nonmalignant hematologic disorders myeloid leukemia (AML), acute lymphocytic leukemia with the goal of re-establishing normal hematopoietic (ALL), and myelodysplastic syndromes (MDS) were and immune function.1,2 HCT is a potentially curative the most common malignancies treated with alloge- treatment option for patients with certain types of neic HCT, while autologous HCT was used most fre- hematologic malignancies and is also used to support quently in multiple myeloma, non-Hodgkin lymphoma, patients undergoing high-dose chemotherapy for the and Hodgkin lymphoma.4 treatment of certain solid tumors. HCT is classified as Outcomes of HCT vary according to the type and autologous or allogeneic based on the origin of he- stage of the disease being treated, the overall health of matopoietic cells. An autologous HCT uses the patient’s the patient, the degree of HLA-mismatch between donor own cells while an allogeneic HCT uses hematopoietic and recipient (for allogeneic HCT), and the source of cells from a human leukocyte antigen (HLA)-compatible the hematopoietic cells.2 Hematopoietic cells can be donor. Prior to HCT, most patients receive chemother- obtained from peripheral blood, BM, or umbilical cord apy, serotherapy, and/or radiation for pretransplant blood (UCB). Several clinical factors should be consid- conditioning (preparative regimen). In allogeneic HCT, ered when determining the optimal graft source for an in- preparative regimens are administered to eradicate dividual patient, including disease type, disease stage, patient malignant cells in the bone marrow (BM; if using comorbidities, and the urgency for transplantation.5 Mo- myeloablative regimen) and induce immunosuppres- bilization of peripheral blood progenitor cells (PBPCs) by sion so that engraftment of healthy donor cells occurs.1 granulocyte-colony stimulating factor has largely replaced In autologous HCT, high-dose myeloablative regimens use of BM grafts (in particular for autologous HCT) due to are used to treat the malignancy. This is followed by theeaseofcollection,avoidance of general anesthesia, rescue infusion of the patient’s own cells, which are more rapid engraftment rates, reduced risk of graft failure, harvested before high-dose therapy, to restore hema- and lower transplant-related mortality.6–8 However, allo- topoiesis and reconstitute the immune system. geneic PBPC transplants are associated with an increased The number of HCTs has increased in the United States risk of graft-versus-host disease (GVHD) compared with in recent years.3 The Center for International Blood and BM transplants.8,9 Allogeneic BM transplant continues to 600 © JNCCN—Journal of the National Comprehensive Cancer Network | Volume 18 Issue 5 | May 2020 Hematopoietic Cell Transplantation, Version 2.2020 NCCN GUIDELINES® be indicated in certain conditions such as severe aplastic Advances in HCT methods and supportive care have led anemia and other nonmalignant disorders, owing to a to improved survival after HCT.11 However, disease relapse lower risk of GVHD. Furthermore, several investigators and long-term complications continue to pose a major have advocated for the use of BM grafts for haploidentical threat to HCT survivors. Disease relapse is higher with ad- HCT10 and unrelated donor HCT.9 Advantages of using vanced disease and with the use of nonmyeloablative UCB grafts