SPECIAL REPORT
Allogeneic and autologous transplantation for haematological diseases,
solid tumours and immune disorders: current practice in Europe 2009
P Ljungman
1
, M Bregni
2
, M Brune
3
, J Cornelissen
4
, T de Witte
5
, G Dini
6
, H Einsele
7
, HB Gaspar
8
,
A Gratwohl
9
, J Passweg
10
, C Peters
11
, V Rocha
12
, R Saccardi
13
, H Schouten
14
, A Sureda
15
, A Tichelli
9
,
A Velardi
16
and D Niederwieser
17
, for the European Group for Blood and Marrow Transplantation
1
Department of Haematology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden;
2
Unit of Medical
Oncology, San Giuseppe Hospital, Milan, Italy;
3
Section of Haematology, Department of Medicine, Sahlgren’s University Hospital,
Go¨teborg, Sweden;
4
Department of Hematology, Erasmus MC-Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands;
5
Department of Hematology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands;
6
Department of Paediatric
Haematology and Oncology, IRCCS ‘G.Gaslini’, Genoa, Italy;
7
Department of Haematology and Oncology, University of Wu¨rzburg,
Wu¨rzburg, Germany;
8
Molecular Immunology Unit, UCL Institute of Child Health, London, UK;
9
Haematology Division, University
Hospital, Basel, Switzerland;
10
Haematology Division, Geneva University Hospital, Geneva, Switzerland;
11
BMT Unit, St Anna
Kinderspital, Vienna, Austria;
12
BMT Unit, Department of Haematology and Eurocord office, Hoˆpital St Louis, Paris, France;
13
Department of Haematology, Careggi Hospital & University of Florence, Florence, Italy;
14
Section of Haematology, Department of
Internal Medicine, University Hospital, Maastricht, The Netherlands;
15
Clinical Haematology Division, Hospital de la Santa Creu i
Sant Pau, Barcelona, Spain;
16
Department of Haematology, University of Perugia, Perugia, Italy and
17
Department of Haematology
and Oncology, University of Leipzig, Leipzig, Germany
The European Group for Blood and Marrow Transplan-
tation regularly publishes special reports on the current
practice of haematopoietic SCT for haematological
diseases, solid tumours and immune disorders in Europe.
Major changes have occurred since the first report was
published. HSCT today includes grafting with allogeneic
and autologous stem cells derived from BM, peripheral
blood and cord blood. With reduced-intensity conditioning
regimens in allogeneic transplantation, the age limit has
increased, permitting the inclusion of older patients. New
indications have emerged, such as autoimmune disorders
and AL amyloidosis for autologous HSCT and solid
tumours, myeloproliferative syndromes and specific sub-
groups of lymphomas for allogeneic transplants. The
introduction of alternative therapies, such as imatinib for
CML, has challenged well-established indications. An
updated report with revised tables and operating defini-
tions is presented.
Bone Marrow Transplantation (2010) 45, 219–234;
doi:10.1038/bmt.2009.141; published online 6 July 2009
Keywords: haematopoietic SCT; indications; recommen-
dations; Europe
Introduction
This report is the fifth report from the European Group for
Blood and Marrow Transplantation (EBMT) classifying
allogeneic and autologous haematopoietic SCT procedures
according to prevailing clinical practice in Europe.
1–4
Since
the first report, major changes have occurred in clinical
practice based on new scientific and technical developments
of new indications but also changed indications for HSCT
based on important developments in non-transplant
management of haematological malignancies. Limitations
for the transplant procedures such as age and comorbidities
have been modified because of the introduction of reduced-
intensity conditioning regimens. The updated classifications
are presented below (Tables 1 and 2). As in the previous
reports, we have attempted to summarize the opinions and
practices of clinicians working in transplant centres in
Europe in 2008. The EBMT recommendations are based on
existing prospective clinical trials, registry data and expert
opinion, but not on a formal extensive review of the
literature. Therefore, some recommendations have been
made on the basis of analogy, inference and expertise. Each
section of the recommendations has been discussed within
the appropriate working party of the EBMT. The EBMT
recommendations are not meant to decide for an individual
patient whether a transplant is the correct choice of
procedure. It is also outside the scope of this report to
classify indications on the basis of the use of a particular
conditioning regimen or of a particular stem cell source.
The classifications are aimed to give guidance and have to
be considered together with the risk of the disease, the risk
of the transplant procedure and the results of non-
transplant strategies. When the recommendations are
interpreted, it is important, besides a possible survival
Received 19 January 2009; revised 26 March 2009; accepted 24 April
2009; published online 6 July 2009
Correspondence: Dr P Ljungman, Department of Haematology,
Karolinska Institutet, Karolinska University Hospital/Huddinge, M54,
Stockholm S-14186, Sweden.
E-mail: Per.Ljungman@ki.se
Bone Marrow Transplantation (2010) 45, 219–234
& 2010 Macmillan Publishers Limited All rights reserved 0268-3369/10 $32.00
www.nature.com/bmt

Table 1 Proposed classification of transplant procedures for adults—2009
Disease Disease status Sibling donor Allogeneic Autologous
Well-matched
unrelated
mm unrelated
41Agmm
related
Leukaemia
AML CR1 (low risk
a
) CO/II D/II GNR/II CO/I
CR1 (intermediate
a
) S/II CO/II D/II S/I
CR1 (high risk
a
) S/II S/II CO/II CO/I
CR2 S/II S/II CO/II CO/II
CR3, incipient relapse S/III CO/III D/III GNR/III
M3 molecular persistence S/II CO/II GNR/III GNR/III
M3 molecular CR2 S/II CO/II GNR/III S/II
Relapse or refractory CO/II D/II D/II GNR
ALL CR1 (standard/intermediate
a
) D/II GNR/II GNR/III D/III
CR1 (high risk
a
) S/II S/II CO/II D/II
CR2, incipient relapse S/II S/II CO/II GNR/II
Relapse or refractory CO/II D/II D/II GNR/III
CML First chronic phase (CP), failing imatinib S/II S/II CO/III D/II
Accelerated phase or 4first CP S/II S/II CO/II D/III
Blast crisis CO/II CO/II CO/II GNR/III
Myelofibrosis Primary or secondary with an S/II S/II D/III GNR/III
intermediate or high Lille score
Myelodysplastic syndrome RA, RAEB S/II S/II CO/II GNR/III
RAEBt, sAML in CR1 or CR2 S/II S/II CO/II CO/II
More advanced stages S/II CO/II D/III GNR/III
CLL Poor-risk disease S/II S/II D/III CO/II
Lymphomas
Diffuse large B-cell lymphoma CR1 (intermediate/high IPI at dx) GNR/III GNR/III GNR/III CO/I
Chemosensitive relapse; XCR2 CO/II CO/II GNR/III S/I
Refractory D/II D/II GNR/III GNR/II
Mantle cell lymphoma CR1 CO/II D/III GNR/III S/II
Chemosensitive relapse; XCR2 CO/II D/II GNR/III S/II
Refractory D/II D/II GNR/III GNR/II
Lymphoblastic lymphoma and
Burkitt’s lymphoma
CR1 CO/II CO/II GNR/III CO/II
Chemosensitive relapse; XCR2 CO/II CO/II GNR/III CO/II
Refractory D/III D/III GNR/III GNR/II
Follicular B-cell NHL CR1 (intermediate/high IPI at dx) GNR/III GNR/III GNR/III CO/I
Chemosensitive relapse; XCR2 CO/II CO/II D/III S/I
Refractory CO/II CO/II D/II GNR/II
T-cell NHL CR1 CO/II D/II GNR/III CO/II
Chemosensitive relapse; XCR2 CO/II CO/II GNR/III D/II
Refractory D/II D/II GNR/III GNR/II
Hodgkin’s lymphoma CR1 GNR/III GNR/III GNR/III GNR/I
Chemosensitive relapse; XCR2 CO/II CO/II CO/II S/I
Refractory D/II D/II GNR/II CO/II
Lymphocyte predominant
nodular HL
CR1
Chemosensitive relapse; XCR2
GNR/III
GNR/III
GNR/III
GNR/III
GNR/III
GNR/III
GNR/III
CO/III
Refractory GNR/III GNR/III GNR/III CO/III
Other diseases
Myeloma CO/I CO /II GNR/III S /I
Amyloidosis CO/II CO/II GNR/III CO/II
Severe aplastic anaemia Newly diagnosed S/II CO/II GNR/III GNR/III
Relapsed/refractory S/II S/II CO/II GNR/III
PNH S/II CO/II CO/II GNR/III
Breast cancer Adjuvant high risk GNR/III GNR/III GNR/III CO/I
Breast cancer Metastatic responding D/II D/II GNR/III D/CO/II
Germ cell tumours Sensitive relapses GNR/III GNR/III GNR/III CO/II
Indications for SCT in Europe
P Ljungman et al
220
Bone Marrow Transplantation