Evaluation Of The Pre-Transplantation Workup Before Allogeneic Transplantation and Reasons For Delaying Or Cancelling Transplant

Before allogeneic transplantation, an extensive workup is generally performed to evaluate disease status, prior organ damage and ability to tolerate intensive treatment. Due to lack of specific guidelines, the extent of the workup varies substantially among centers. In an attempt to understand the significance of the different components of pretransplant workup, we evaluated 150 consecutive transplants at our center. Furthermore, we analyzed reasons for delaying or cancelling transplants after admission for workup.

Between May 2010 and October 2012, 157 allogeneic transplants were planned in 99 men and 58 women with a median age of 51 y (19-70). Diagnoses were acute leukemia (n=80), myelodysplastic syndrome (n=23), multiple myeloma (n=15), lymphoma (n=25), myeloproliferative disease (n=10) or aplastic anemia (n=4). 26 transplants were not performed as initially scheduled but were delayed for a median of 21 days (4-146). Seven transplants were cancelled due to progressive disease (n=6) or lack of indication upon reevaluation (n=1) and were excluded from further analysis.

At the time of analysis, the pretransplant workup consisted of an MRI of the head, a CT-scan of the chest and upper abdomen, gynecology, ophthalmology, ears nose and throat (ENT), and dental evaluation, pulmonary function testing (PFT) and an echocardiography, as well as microbiological tests not included in this analysis. All patients received a history and thorough physical examination, as well as disease staging. Some examinations were cancelled due to scheduling issues.

We assessed the results of the various examinations, categorizing these into “normal or minor finding”, “major finding”, meaning the result had significant consequences such as further testing or therapy, or “delay”, meaning scheduled transplant was postponed due to a major finding. In case of a major finding or delay, we also considered whether this was incidental, or whether the patient had clinical symptoms or a previous history indicating the patient was at risk for the given finding.

The number of major findings and delayed transplants are shown in Table 1 for the respective examinations, along with the number of findings that were incidental. The majority of findings in CT were pulmonary infiltrates, and 4 cases of new liver lesions. Major ENT findings consisted of sinusitis or rhinitis in most cases; the majority of dental findings were severe caries or periodontitis. Of note is the fact that sanitation of dental or ENT foci before transplant was recommended in 4 cases, but not performed due to time constraints. Disease staging revealed unexpected progression in 7 patients, so that transplant was delayed for reinduction therapy. Clinical evaluation showed signs of infection leading to postponement of transplant in 8 patients, while in 2 patients planned conditioning intensity was reduced due to poor general health. Finally in 4 patients, transplant was delayed for reasons unrelated to the pretransplant workup, including donor issues (n=3) and unexpected toxicity of the conditioning regimen (n=1).

In summary, while extensive testing seems justified before allogeneic transplant, only a minority of exams performed in our center led to a significant number of major findings that necessitated further testing or therapy, or to postponement of the transplant. Furthermore, many of the major findings were not incidental but were either symptomatic or previously known. CT-scan of the chest and upper abdomen and dental evaluation had the highest yield of incidental major findings (in 9% of screened patients, each), and led to delay of several transplants. Furthermore, the significant number of transplants delayed at short notice suggest that the pretransplant workup should possibly be performed at an earlier timepoint, allowing time for necessary interventions. In a next step, we will perform a cost efficiency analysis of the pretransplant workup, based on the results presented here.

No relevant conflicts of interest to declare.