Hematopoietic stem cell transplantation in Europe 1998

Pharmacotherapy in Pediatric Hematopoietic Cell Transplantation

Hematopoietic cell transplantation (HCT) is a curative treatment option for both malignant and nonmalignant diseases. Success of the procedure mainly depends on disease control and treatment-related complications. Pharmacotherapy plays a major role in HCT and significantly impacts the outcomes. Main drug use within HCT includes conditioning, GvHD prophylaxis, and prevention/treatment of infections.Increasing evidence suggests individualized dosing in (pediatric) HCT may improve outcome. Dose individualization may result in a better predictable drug treatment in terms of safety and efficacy, including timely immune reconstitution after HCT and optimal tumor or disease control, which may result in improved survival chances.

The EBMT risk score

The European Group for Blood and Marrow Transplantation (EBMT) risk score provides a simple tool to assess instantly chances and risks of hematopoietic SCT(HSCT) for an individual patient pre-transplant. Five factors, age of the patient, stage of the disease, time from diagnosis, donor type and donor recipient gender combination augment risk for an individual patient with increasing score from 0 as best to 7 as worst in an additive way. The score holds for all acquired hematological disorders, for allogeneic and autologous HSCT (score 0-5), is independent of the HSCT technology and is valid for standard or reduced intensity conditioning. Survival is uniformly worse for older patients, transplanted in advanced disease stage after a long-time interval and with a mismatched donor than for younger patients, transplanted soon in early stage with a well matched donor. Additional risk factors such as performance score, CMV serostatus or cytokine polymorphisms improve prediction but to different extents for low or high-risk patients. Comparative assessment of disease risk and global pre-transplant risk should guide decisions for each patient with his/her specific disease between HSCT and a non-transplant approach and replace the traditional 'donor vs no donor' with such a risk-adapted individualized strategy.

Acute myelogenous leukemia in a donor after granulocyte colony-stimulating factor-primed peripheral blood stem cell harvest

This article describes the first case of acute myeloid leukemia (AML) in a healthy donor at 14 months after granulocyte colony-stimulating factor (G-CSF)-primed peripheral blood stem cell (PBSC) harvest. In September 2001, a healthy 61-year-old female was given G-CSF prior to PBSC harvest for her brother with multiple myeloma. In spite of successful engraftment, the recipient died from a disease relapse. In November 2002, the donor, admitted with high fever and leukocytosis with 98.5% blastoid cells, was diagnosed as having AML (M1). Her leukemia cells were positive for CD13, CD33, and G-CSF receptor without chromosomal abnormality and responded to G-CSF in vitro. During chemotherapy, she died of progressive pneumonia. If our case is truly the first, the incidence of leukemia in donors may not be higher than that of naturally occurring leukemia. However, efforts towards an international long-term study, or at least to report every case similar to ours, would be required to be conclusive.

Haemopoietic stem cell transplants: the impact of haemorrhagic complications

Acute graft-versus-host disease (GVHD) is the most important complication of allogeneic haemopoietic stem cell transplantation (HSCT), increasing susceptibility to haemorrhage and risk of early mortality. We evaluated 807 allogeneic HSCT patients to assess both the association between bleeding and GVHD, and the influence of haemorrhagic complications on clinical outcome. Up to 55% of patients with grade III-IV GVHD experienced bleeding, compared with 23% of patients with grades 0-l. Furthermore, 45% of patients receiving non-HLA-identical transplants suffered haemorrhage, whereas only 23% of patients receiving transplants from HLA-identical donors experienced bleeding. This can be explained by the higher incidence of severe GVHD among recipients of non-HLA-identical transplants. Our findings also demonstrated that haemorrhagic complications--particularly bleeding from the GI tract--markedly increase patient mortality. An ongoing, multi-centre, randomised, double-blind trial is currently investigating the efficacy and safety of recombinant factor VIIa (rFVIIa; NovoSeven) in the treatment of HSCT-associated bleeding. The trial will examine the ability of three dose levels of rFVIIa to reduce--or even eliminate entirely--the incidence and severity of haemorrhage following such procedures. A total enrollment of 100 patients is anticipated, and preliminary data are expected at the end of 2003.

Hematopoietic stem cell transplantation activity in Europe 1999

This survey on transplantation of hematopoietic stem cells from blood or bone marrow in Europe, the 10th in a series, reports the numbers of transplants performed in 1999 and concentrates on changes in indications and donor types. Members of the European Group for Blood and Marrow Transplantation and associated teams are invited every year to report their transplant numbers by indication, donor type and stem cell source. In 1999, a total 21 430 transplants were performed by 580 teams in 35 European countries. Of these transplants 18 720 were first transplants, 5879 (31%) allogeneic, 12 841 (69%) autologous; an additional 562 allogeneic and 2148 autologous transplants were re- or multiple transplants. Ninety-five percent of the autologous transplants and 45% of the allogeneic transplants were peripheral blood stem cell transplants. A total of 103, respectively 1.8% of the allogeneic transplants, were cord blood cell transplants. Main indications in 1999 were leukemias with 6289 transplants (34%), 70% thereof allogeneic transplants; lymphomas with 8219 transplants (44%), 92% thereof autologous transplants; solid tumors with 3302 transplants (18%), 99% thereof autologous transplants; nonmalignant disorders with 715 transplants (4%), 85% thereof allogeneic transplants. Absolute numbers of allogeneic transplants continued to increase as in previous years by 10%, in contrast, there was for the first time in 10 years a decrease in autologous transplants, mainly for solid tumors. Reasons therefore are discussed. These data reflect the most recent changes in utilisation and document current status of blood and marrow transplantation in Europe.