Invasive aspergillosis as an opportunistic infection in nonallografted patients with multiple myeloma: a European Organization for Research and Treatment of Cancer/ Invasive Fungal Infections Cooperative Group and the Intergroupe Français du Myélome

Invasive Fungal Diseases in Patients With Multiple Myeloma: Experience at a Large, Urban Referral Center

BACKGROUND

Although infections are a leading cause of morbidity and mortality among patients with multiple myeloma (MM), the epidemiology of invasive fungal disease (IFD) is less well characterized in this population than in other hematologic malignancies.

METHODS

We conducted a nested 3:1 case-control study of IFD at a large MM referral center to identify risk factors for IFD in this population.

RESULTS

In a cohort of 2960 patients, we identified 32 episodes of IFD among 31 patients between 01/2011 and 06/2019. There was a median of 3.6 years from MM diagnosis to IFD, and patients had a median of four lines of chemotherapy (range 1-12) before IFD. Seventeen (53%) had previous autologous hematopoietic cell transplants. At the time of IFD, 23 (72%) had progressive disease status. Fifteen (47%) and 13 (41%) had severe neutropenia and lymphopenia, respectively, and 18 (56%) had hypogammaglobulinemia. Microbiologic etiologies included Aspergillus (n = 18), Candida (n = 6), Cryptococcus (n = 3), Mucorales (n = 3), Histoplasma (n = 1), and undetermined organism (n = 1). In the case-control analysis, progressive disease status (OR 1.35, p = 0.02) and neutropenia (OR 17.5, p = 0.02) were significant risk factors for IFD. In addition, ≥3 prior lines of chemotherapy trended toward statistical significance (OR 5.6, p = 0.07).

CONCLUSION

This is the largest detailed description of IFD epidemiology in MM patients and the largest controlled analysis of risk factors in this population. Overall, the risk of IFD was low.

Recommendations on prevention of infections during chimeric antigen receptor T-cell and bispecific antibody therapy in multiple myeloma

Chimeric antigen receptor T (CAR T) cell and bispecific antibody therapies have shown unprecedented efficacy in heavily pretreated patients with multiple myeloma (MM). However, their use is associated with a significant risk of severe infections, which can be attributed to various factors such as hypogammaglobulinemia, neutropenia, lymphopenia, T-cell exhaustion, cytokine-release syndrome and immune-effector cell-associated neurotoxicity syndrome. As these therapies have been recently approved by regulatory agencies, it is crucial to establish practical guidelines for infection monitoring and prevention until robust data from prospective clinical trials become available. To address this issue, a panel of experienced investigators from the Academic Consortium to Overcome Multiple Myeloma through Innovative Trials (COMMIT) developed consensus recommendations for mitigating infections associated with CAR T-cell and bispecific antibody therapies in MM patients.

Adverse Hematological and Non-Hematological Events in Patients With Relapsed/Refractory Multiple Myeloma That Are Responsive to Daratumumab, Pomalidomide and Dexamethasone

Background

Daratumumab, pomalidomide, and dexamethasone (DPd) is an effective option for treatment of patients with relapsed/refractory multiple myeloma (RRMM). In this study, we sought to analyze the risk of hematological and non-hematological toxicities in patients who responded to DPd treatment.

Methods

We analyzed 97 patients with RRMM who were treated with DPd between January 2015 and June 2022. The patients and disease characteristics, as well as safety and efficacy outcomes were summarized as descriptive analysis.

Results

The overall response rate for the entire group was 74% (n = 72). The most common grade III/IV hematological toxicities in those who responded to treatment were neutropenia (79%), leukopenia (65%), lymphopenia (56%), anemia (18%), and thrombocytopenia (8%). The most common grade III/IV non-hematological toxicities were pneumonia (17%) and peripheral neuropathy (8%). The incidence of dose reduction/interruption was 76% (55/72), which was due to hematological toxicity in 73% of the cases. The most common reason for discontinuing treatment was disease progression in 61% (44 out of 72 patients).

Conclusions

Our study revealed that patients who respond to DPd are at high risk of dose reduction or treatment interruption because of hematological toxicity, typically due to neutropenia and leukopenia leading to increased risk of hospitalization and pneumonia.

Case Report: Invasive Fungal Infection and Daratumumab: A Case Series and Review of Literature

Life expectancy of multiple myeloma (MM) patients has improved in last years due to the advent of anti-CD38 monoclonal antibodies in combination with immunomodulators and proteasome inhibitors. However, morbidity and mortality related to infections remain high and represent a major concern. This paper describes the “real life” risk of invasive fungal infections (IFI) in patients treated with daratumumab-based therapy and reviews the relevant literature. In a series of 75 patients we only observed three cases of fungal pneumonia. Unfortunately, the early signs and symptoms were not specific for fungal infection. Diagnostic imaging, microbiology and patient history, especially previous therapies, are critical in the decision to start antifungal treatment. Recognising the subgroup of MM patients with high risk of IFI can increase the rate of diagnosis, adequate treatment and MM-treatment recovery.

Inflammation and infection in plasma cell disorders: how pathogens shape the fate of patients

The role of infection and chronic inflammation in plasma cell disorders (PCD) has been well-described. Despite not being a diagnostic criterion, infection is a common complication of most PCD and represents a significant cause of morbidity and mortality in this population. As immune-based therapeutic agents are being increasingly used in multiple myeloma, it is important to recognize their impact on the epidemiology of infections and to identify preventive measures to improve outcomes. This review outlines the multiple factors attributed to the high infectious risk in PCD (e.g. the underlying disease status, patient age and comorbidities, and myeloma-directed treatment), with the aim of highlighting future prophylactic and preventive strategies that could be implemented in the clinic. Beyond this, infection and pathogens as an entity are believed to also influence disease biology from initiation to response to treatment and progression through a complex interplay involving pathogen exposure, chronic inflammation, and immune response. This review will outline both the direct and indirect role played by oncogenic pathogens in PCD, highlight the requirement for large-scale studies to decipher the precise implication of the microbiome and direct pathogens in the natural history of myeloma and its precursor disease states, and understand how, in turn, pathogens shape plasma cell biology.

Cryptococcosis in a patient with multiple myeloma receiving pomalidomide: a case report and literature review

While overall survival with multiple myeloma (MM) has improved, patients suffer from overwhelming tumor burden, MM-associated comorbidities, and frequent relapses requiring administration of salvage therapies. As a result, this vicious cycle is often characterized by cumulative immunodeficiency stemming from a combination of disease- and treatment-related factors leading to neutropenia, T-cell deficiency, and hypogammaglobulinemia. Infectious etiologies differ based on the duration of MM and treatment-related factors, such as number of previous treatments and cumulative dose of corticosteroids. Herein, we present the case of a patient who was receiving pomalidomide without concomitant corticosteroids for MM and was later found to have cryptococcosis, as well as findings from a literature review. Most cases of cryptococcosis are reported in patients with late-stage MM, as well as those receiving novel anti-myeloma agents, such as pomalidomide, in combination with corticosteroids or following transplantation. However, it is likely cryptococcosis may be underdiagnosed in this population. Due to the cumulative immunodeficiency present in patients with MM, clinicians must be suspicious of cryptococcosis at any stage of MM.

Risk factors and prophylaxis against invasive fungal disease for haematology and stem cell transplant recipients: an evolving field

INTRODUCTION

Due to increasing intensity and complexity of therapies and longer survivorship, many patients with haematologic malignancy (HM) are at risk of invasive fungal disease (IFD). Mortality from IFD is high and treatment of an episode of IFD results in an excess length of hospital stay and costs and delays delivery of curative therapy of the underlying haematologic condition. Therefore, prevention and early recognition and treatment of IFD are crucial. Areas covered: Risk factors particular to certain HMs and haematopoietic stem cell transplantation, as well as those risk factors universal to all HM groups are examined. Expert commentary: Risk stratification identifies those patients who would benefit most from mould active versus yeast active prophylaxis and those who can be safely managed with monitoring and clinically driven interventions for IFD. This approach aids in antifungal stewardship.

Could Histoplasma capsulatum Be Related to Healthcare-Associated Infections?

Healthcare-associated infections (HAI) are described in diverse settings. The main etiologic agents of HAI are bacteria (85%) and fungi (13%). Some factors increase the risk for HAI, particularly the use of medical devices; patients with severe cuts, wounds, and burns; stays in the intensive care unit, surgery, and hospital reconstruction works. Several fungal HAI are caused by Candida spp., usually from an endogenous source; however, cross-transmission via the hands of healthcare workers or contaminated devices can occur. Although other medically important fungi, such as Blastomyces dermatitidis, Paracoccidioides brasiliensis, and Histoplasma capsulatum, have never been considered nosocomial pathogens, there are some factors that point out the pros and cons for this possibility. Among these fungi, H. capsulatum infection has been linked to different medical devices and surgery implants. The filamentous form of H. capsulatum may be present in hospital settings, as this fungus adapts to different types of climates and has great dispersion ability. Although conventional pathogen identification techniques have never identified H. capsulatum in the hospital environment, molecular biology procedures could be useful in this setting. More research on H. capsulatum as a HAI etiologic agent is needed, since it causes a severe and often fatal disease in immunocompromised patients.

Changing treatment paradigms for patients with plasma cell myeloma: impact upon immune determinants of infection

Plasma cell myeloma (PCM) is increasing in prevalence in older age groups and infective complications are a leading cause of mortality. Patients with PCM are at increased risk of severe infections, having deficits in many arms of the immune system due to disease and treatment-related factors. Treatment of PCM has evolved over time with significant impacts on immune function resulting in changing rates and pattern of infection. Recently, there has been a paradigm shift in the treatment of PCM with the use of immunomodulatory drugs and proteasome inhibitors becoming the standard of care. These drugs have wide-ranging effects on the immune system but their impact on infection risk and aetiology remain unclear. The aims of this review are to discuss the impact of patient, disease and treatment factors on immune function over time for patients with PCM and to correlate immune deficits with the incidence and aetiology of infections seen clinically in these patients. Preventative measures and the need for clinically relevant tools to enable infective profiling of patients with PCM are discussed.

Infections in patients with leukemia and lymphoma

Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.

Clinical and economic burden of invasive fungal diseases in Europe: focus on pre-emptive and empirical treatment of Aspergillus and Candida species

Invasive fungal diseases (IFDs) have been widely studied in recent years, largely because of the increasing population at risk. Aspergillus and Candida species remain the most common causes of IFDs, but other fungi are emerging. The early and accurate diagnosis of IFD is critical to outcome and the optimisation of treatment. Rapid diagnostic methods and new antifungal therapies have advanced disease management in recent years. Strategies for the prevention and treatment of IFDs include prophylaxis, and empirical and pre-emptive therapy. Here, we review the available primary literature on the clinical and economic burden of IFDs in Europe from 2000 to early 2011, with a focus on the value and outcomes of different approaches.

Invasive pulmonary aspergillosis due to Emericella nidulans var. echinulata, successfully cured by voriconazole and micafungin

A 78-year-old male who was undergoing prolonged glucocorticoid treatment experienced cough and expectoration for 2 weeks. Galactomannan antigen analysis and a chest computed tomography (CT) scan suggested a diagnosis of invasive pulmonary aspergillosis. DNA sequencing indicated that Emericella nidulans var. echinulata was the causative agent. A combination of voriconazole and micafungin successfully treated the illness.

Nosocomial fungal infections: epidemiology, infection control, and prevention

Fungal infections are an increasing cause of morbidity and mortality in hospitalized patients. This article reviews the current epidemiology of nosocomial fungal infections in adult patients, with an emphasis on invasive candidiasis and aspergillosis. Recently published recommendations and guidelines for the control and prevention of these nosocomial fungal infections are summarized.

Primary invasive aspergillosis of the digestive tract: report of two cases and review of the literature

Background:

Disseminated aspergillosis is thought to occur as a result of vascular invasion from the lungs with subsequent bloodstream dissemination, and portals of entry other than sinuses and/or the respiratory tract remain speculative.

Methods:

We report two cases of primary aspergillosis in the digestive tract and present a detailed review of eight of the 23 previously-published cases for which detailed data are available.

Results and Conclusion:

These ten cases presented with symptoms suggestive of typhlitis, with further peritonitis requiring laparotomy and small bowel segmental resection. All cases were characterized by the absence of pulmonary disease at the time of histologically-confirmed gastrointestinal involvement with vascular invasion by branched Aspergillus hyphae. These cases suggest that the digestive tract may represent a portal of entry for Aspergillus species in immunocompromised patients.

Association of bone marrow natural killer cell dose with neutrophil recovery and chronic graft-versus-host disease after HLA identical sibling bone marrow transplants

Allogeneic bone marrow (BM) transplant (BMT) outcomes have been correlated with the infused nucleated, CD34(+), and T- cell dose. The potential impact of natural killer (NK) BM infused cell dose has however not been established. We analysed the outcomes of 78 patients receiving an HLA identical BMT. A higher NK cell dose was associated with the speed of neutrophil (P = 0.05) and platelet recovery (P = 0.04). Higher nucleated cells, CD34(+), CD3(+), CD3(+)/4(+), CD3(+)/8(+) and NK cell dose were associated with a lower incidence of chronic GvHD (cGvHD) in univariate analysis. In multivariate analysis, the risk of cGvHD was increased by a lower NK cell dose [hazard ratio (HR) = 2.3 (1.2-4.4) for cell dose <0.9 x 10(6)/kg; P = 0.01] and an older age [HR = 1.4 /10 years (1.1-1.8); P = 0.002]. In addition, a higher CD3(+)/4(+) and NK cell dose were associated with a decreased incidence of viral infections (P = 0.03 and P = 0.06 respectively). No specific cell subpopulation infused dose was associated with survival. In conclusion, a higher BM NK cell dose is associated with an increased speed of neutrophil recovery and a decreased incidence of cGvHD.

Aspergilloses au cours de maladies systémiques traitées par corticoïdes et/ou immunosuppresseurs : analyse de neuf cas et revue de la littérature

This is a multicentric retrospective study of aspergillosis in patients treated by corticosteroids and/or immunosuppressive drugs for systemic diseases and a review of the literature. Nine patients, 5 men and 4 women, mean age of 62.8 years old were included among which Horton's diseases (3 cases), systemic lupus erythematosus (2), polymyositis (1), microscopic polyangiitis (1), idiopathic thrombocytopenic purpura (1), rheumatoid polyarthritis (1). Aspergillosis occurred in average 28.4 month after the diagnosis of systemic disease, and 28 months after the beginning of its treatment: corticosteroids in all cases, at a dose of 50.8 mg/day (equivalent prednisone) in average, cyclophosphamide (2 cases), methotrexate (1), intravenous immunoglobulins (1), leflunomide (1). All cases were invasive or chronic pulmonary aspergillosis located in the lungs (6 cases), or in the brain (3). Revealing symptoms were mild and non specific. Lymphopenia was severe in most cases, in average 472 lymphocytes/mm3 and 283 CD4+/mm3. The diagnosis was confirmed 20.75 days after the first symptoms in invasive aspergillosis, and 18.5 months in the chronic pulmonary cases, by cultures in 7 cases (broncho-alveolar lavage: 4; cerebral biopsy: 3), and direct microscopy examination of broncho-alveolar lavage in 2 cases. Specific serology was positive in 4 cases. Patients were treated by voriconazole (4 cases), itraconazole (2), amphotericin B (1), association of caspofungin and voriconazole (1), successive voriconazole and itraconazole (1). Six patients recovered from aspergillosis with 10.8 months of following time, 3 patients died a few days after confirmation of the diagnosis. Fifty-four cases of the literature are analysed.

Emerging Fungal Diseases

The epidemiology of invasive fungal infection is evolving. Yeasts other than Candida albicans and molds other than Aspergillus fumigatus have emerged as significant causes of invasive mycoses in severely immunocompromised patients. Although, in some instances, these changes may be related to medical interventions, such as the use of antifungal agents in prophylaxis, in the majority of cases, they seem to be a consequence of changes in the host, such as more-severe immunosuppression or different types of immunosuppression impacting both risk periods and the infections that occur. These factors have altered the epidemiology of infection in organ transplant recipients, premature newborns, and critically ill patients. This review discusses the epidemiology of some fungal infections that have emerged in the past few years, with an emphasis on the potential factors associated with their emergence and on practical implications of these epidemiological changes.

Prise en charge diagnostique et thérapeutique des infections à Aspergillus sp. chez le patient immunodéprimé. Recommandations du CHRU de Lille — version 4 — novembre 2004

Invasive aspergillosis is a severe complication in immunocompromised patients. The arrival of new antifungal agents motivated the redaction of guidelines, regularly updated, by a Lille University hospital multidisciplinary task force. These guidelines assess diagnostic and therapeutic issues. The main recommended diagnosis tool is the chest CT scan, ordered at the smallest suspicion and, also, measure of the blood and broncho alveolar lavage fluid galactomannan. Treatment guidelines assess prophylaxis, empirical and documented therapy. Primary prophylaxis is warranted in only two cases, pulmonary graft or stem cell transplant in patients with chronic GVH and receiving corticosteroids. Empirical therapy should use one of the available amphotericin B formulations, chosen according to the patient history. Caspofungin is another choice. Documented therapy, depending on presentation, can be a single drug or a combination. First line therapy for single drug is i.v. voriconazole. Lipid formulations of amphotericin B are another choice. A combination therapy can be used as a first line treatment, for multiple lesions, or as salvage therapy. It must include caspofungin, associated with liposomal amphotericin B or voriconazole. A tight cooperation with thoracic surgeons is recommended.

Risk factors for invasive aspergillosis in neutropenic patients with hematologic malignancies

Risk factors for invasive aspergillosis (IA) are incompletely identified and may undergo changes due to differences in medical practice. A cohort of 189 consecutive, adult patients with neutropenia hospitalized in the hemato-oncology ward of the University hospital Berne between 1995 and 1999 were included in a retrospective study to assess risk factors for IA. In total, 45 IA cases (nine proven, three probable, 33 possible), 11 patients with refractory fever and 133 controls were analyzed. IA cases had more often acute leukemia or myelodysplastic syndrome (MDS) (88 vs 38%, P < 0.001) and a longer duration of neutropenia (mean 20.6 vs 9.9 days, P < 0.001). They also had fewer neutropenic episodes during the preceding 6 months (mean 0.42 vs 1.03, P < 0.001), that is, confirmed (82%) and probable (73%) IA occurred most often during the induction cycle. A short time interval ( < or = 14 days) between neutropenic episodes increased the risk of IA four-fold (P = 0.06). Bacteremia, however, was not related to the number of preceding neutropenic episodes. Therefore, neutropenic patients with leukemia or MDS have the highest risk of IA. The risk is highest during the first induction cycle of treatment and increases with short-time intervals between treatment cycles.

Invasive aspergillosis in the hematologic and immunologic patient: new findings and key questions in leukemia

Patients suffering from acute leukemia are at high risk for invasive aspergillosis and a large review and a recent clinical trial have shown that they represent the largest group of patients developing the disease. New host groups such as patients with multiple myeloma or low-grade lymphoproliferative disorders have contributed to an increase in the incidence of invasive aspergillosis over recent years. There are substantial differences in the diagnostic strategy and therapeutic outcome of disease between patients with a hematological malignancy and other host groups such as allogeneic hematopoietic stem cell transplant patients. Galactomannan detection ELISA test is more specific in adult patients with hematological malignancies than in hematopoietic stem cell transplantation recipients. As a result of possible improvement of the underlying immune deficiency upon recovery from neutropenia, survival is higher in leukemic patients with invasive aspergillosis than in other host groups. However, there is currently no evidence of an effective antifungal prophylaxis strategy against aspergillosis in leukemic patients. As these patients account for a majority of the aspergillosis cases, clinical trials on prophylaxis should not only be focused on allogeneic stem transplant recipients but also be designed for the patient with leukemia.

Development and validation of a quantitative real-time PCR assay using fluorescence resonance energy transfer technology for detection of Aspergillus fumigatus in experimental invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) is a frequently fatal infection in immunocompromised patients that is difficult to diagnose. Present methods for detection of Aspergillus spp. in bronchoalveolar lavage (BAL) fluid and in tissue vary in sensitivity and specificity. We therefore developed an A. fumigatus-specific quantitative real-time PCR-based assay utilizing fluorescent resonance energy transfer (FRET) technology. We compared the assay to quantitative culture of BAL fluid and lung tissue in a rabbit model of experimental IPA. Using an enzymatic and high-speed mechanical cell wall disruption protocol, DNA was extracted from samples of BAL fluid and lung tissues from noninfected and A. fumigatus-infected rabbits. A unique primer set amplified internal transcribed spacer regions (ITS) 1 and 2 of the rRNA operon. Amplicon was detected using FRET probes targeting a unique region of ITS1. Quantitation of A. fumigatus DNA was achieved by use of external standards. The presence of PCR inhibitors was determined by use of a unique control plasmid. The analytical sensitivity of the assay was </=10 copies of target DNA. No cross-reactivity occurred with other medically important filamentous fungi. The assay results correlated with pulmonary fungal burden as determined by quantitative culture (r = 0.72, Spearman rank correlation; P </= 0.0001). The mean number of genome equivalents detected in untreated animals was 3.86 log(10) (range, 0.86 to 6.39 log(10)) in tissue. There was a 3.53-log(10) mean reduction of A. fumigatus genome equivalents in animals treated with amphotericin B (AMB) (95% confidence interval, 3.38 to 3.69 log(10); P </= 0.0001), which correlated with the reduction of residual fungal burden in lung tissue measured in terms of log(10) CFU/gram. The enhanced quantitative sensitivity of the real-time PCR assay was evidenced by detection of A. fumigatus genome in infarcted culture-negative lobes, by a greater number of mean genome equivalents compared to the number of CFU per gram in tissue and BAL fluid, and by superior detection of therapeutic response to AMB in BAL fluid compared to culture. This real-time PCR assay using FRET technology is highly sensitive and specific in detecting A. fumigatus DNA from BAL fluid and lung tissue in experimental IPA.

Glucocorticoids and invasive fungal infections

Since the 1990s, opportunistic fungal infections have emerged as a substantial cause of morbidity and mortality in profoundly immunocompromised patients. Hypercortisolaemic patients, both those with endogenous Cushing's syndrome and, much more frequently, those receiving exogenous glucocorticoid therapy, are especially at risk of such infections. This vulnerability is attributed to the complex dysregulation of immunity caused by glucocorticoids. We critically review the spectrum and presentation of invasive fungal infections that arise in the setting of hypercortisolism, and the ways in which glucocorticoids contribute to their pathogenesis. A better knowledge of the interplay between glucocorticoid-induced immunosuppression and invasive fungal infections should assist in earlier recognition and treatment of such infections. Efforts to decrease the intensity of glucocorticoid therapy should help to improve outcomes of opportunistic fungal infections.

Intravenous itraconazole followed by oral itraconazole for the treatment of amphotericin-B-refractory invasive pulmonary aspergillosis

The efficacy and safety of 2 weeks of intravenous itraconazole (200 mg twice daily for 2 days, then 200 mg once daily for 12 days) followed by 12 weeks of oral itraconazole capsules 200 mg twice daily were evaluated in a multicentre, open trial in 31 immunocompromised patients with invasive pulmonary aspergillosis (IPA). We report on a subset of 21 patients who had amphotericin-B-refractory IPA. All patients had haematological malignancies, 10 patients had failed prophylaxis, 12 patients had failed empirical therapy and 2 patients had failed treatment of confirmed infection with amphotericin B. By the second day of treatment, all patients assessed (n = 12) had trough plasma concentrations of itraconazole greater than 250 ng/ml. Mean trough plasma concentrations increased throughout the intravenous and oral treatment periods. Of the 10 patients who completed the 14 weeks of therapy, 9 (90%) had a complete or partial response and the remaining patient had stable disease. Overall, 11 of the 21 patients (52%) had a complete or partial response at their last assessment and three additional patients had stable disease. During intravenous treatment, 18 patients (86%) experienced adverse events; during oral treatment, 11 patients (52%) experienced adverse events. Most adverse events were not related to itraconazole treatment and all were expected in this patient population. In conclusion, intravenous itraconazole followed by oral itraconazole is an effective and well-tolerated treatment for amphotericin-B-refractory IPA.

Myeloma: update on supportive care strategies

Despite substantial innovations in the treatment of multiple myeloma (MM), it remains an incurable disease. In addition, it is debatable whether the progress in survival is attributable simply to the therapy used to destroy the tumor clone or if it is also because of therapy designed to ameliorate disease complications. Supportive therapy has evolved greatly alongside general supportive measures used in hematologic malignancies (such as new antibiotics, antifungal agents, and growth factors) in addition to better indications in complementary treatments such as radiotherapy, dialysis, and surgery. However, in MM, several specific adjuvant therapies have also been introduced (eg, bisphosphonates and erythroid-stimulating factors), which have conferred a key role to supportive therapy in the general treatment of patients with MM.

Long-term results (12 years) of high-dose therapy in 127 patients with de novo multiple myeloma

This report describes the long-term outcome of a cohort of 127 de novo multiple myeloma patients treated with at least one course of high-dose therapy (HDT) in a single institution between June 1985 and December 1995, for whom the minimum follow-up duration for survivors is 6 years. The 12-year overall survival (OS) and event-free survival (EFS) rates are 24.9% and 3.1%, respectively, and the median survival and EFS are 49 and 17 months, respectively. Only four patients are alive and disease-free 79, 90, 132 and 153 after the first HDT, respectively. Three of them received a subsequent allogeneic bone marrow transplantation. Three factors significantly influence OS in this series: B2M at diagnosis, age, and the completion of a second HDT. The 10-year survival is 18.9% for the group of patients with B2M level >3 mg/l at diagnosis as compared with 41% for patients with B2M < or =3, with a median survival of 31 months vs 73 (P = 0.01). The 10-year survival is 23.4% for the group of patients aged >55 years as compared with 36.5% for patients aged <55 years, with a median survival of 34.5 months vs 70.5 (P = 0.04). The 10-year survival is 20.4% for the group of patients who did not receive a second HDT as compared with 35.2% for patients who completed a second HDT, with a median survival of 29 months vs 70 (P = 0.02). In this study we show that some patients treated with HDT experience durable remission and prolonged survival. This survival is significantly influenced by age (< or =55 years), B2M at diagnosis (< or =3 mg/l) and by the completion of two cycles of HDT.

Association of CD34 cell dose with hematopoietic recovery, infections, and other outcomes after HLA-identical sibling bone marrow transplantation

Although CD34 cell dose is known to influence outcome of peripheral stem cell- and/or T-cell-depleted transplantation, such data on unmanipulated marrow transplantation are scarce. To study the influence of CD34(+) cell dose on hematopoietic reconstitution and incidence of infections after bone marrow transplantation, we retrospectively analyzed 212 patients from January 1994 to August 1999 who received a transplant of an unmanipulated graft from an HLA-identical sibling donor. Median age was 31 years; 176 patients had hematologic malignancies. Acute graft-versus-host disease prophylaxis consisted mainly in cyclosporin associated with methotrexate (n = 174). Median number of bone marrow nucleated cells and CD34(+) cells infused were 2.4 x 10(8)/kg and 3.7 x 10(6)/kg, respectively. A CD34(+) cell dose of 3 x 10(6)/kg or more significantly influenced neutrophil (hazard ratio [HR] = 1.37, P =.04), monocyte (HR = 1.47, P =.02), lymphocyte (HR = 1.70, P =.003), erythrocyte (HR = 1.77, P =.0002), and platelet (HR = 1.98, P =.00008) recoveries. CD34(+) cell dose also influenced the incidence of secondary neutropenia (HR = 0.60, P =.05). Bacterial and viral infections were not influenced by CD34 cell dose, whereas it influenced the incidence of fungal infections (HR = 0.41, P =.008). Estimated 180-day transplantation-related mortality (TRM) and 5-year survival were 25% and 56%, respectively, and both were highly affected by CD34(+) cell dose (HR = 0.55, P =.006 and HR = 0.54, P =.03, respectively). Five-year survival and 180-day TRM were, respectively, 64% and 19% for patients receiving a CD34(+) cell dose of 3 x 10(6)/kg or more and 40% and 37% for the remainders. In conclusion a CD34(+) cell dose of 3 x 10(6)/kg or more improved all hematopoietic recoveries, decreased the incidence of fungal infections and TRM, and improved overall survival.

Achievements and goals of the EORTC Invasive Fungal Infections Group. European Organisation for Research and Treatment of Cancer

Invasive fungal infections are an increasing complication for patients with cancer. These infections still are difficult to diagnose and to treat and thus still have a high fatality rate. New strategies should include evaluation of new diagnosis tools and large-scale assessment of these new methods will need multidisciplinary collaboration. High-quality clinical trials dedicated to establish 'state-of-the-art' prevention and treatment are also directly needed. Created in 1991, the EORTC Invasive Fungal Infection Group has faced several of these challenges and significantly improved the knowledge and management of these infections in Europe.

Role of early diagnosis and aggressive surgery in the management of invasive pulmonary aspergillosis in neutropenic patients

Invasive pulmonary aspergillosis (IPA) occurs mostly in immunocompromised hosts and especially in neutropenic patients. Improved prognosis for IPA requires early diagnosis. We report our experience in the management of IPA in patients with hematological malignancies. In prolonged neutropenia (> 10 days), thoracic CT scanning seems to be the best choice for the diagnosis of IPA (with CT halo or air-crescent signs). Its systematic use allows a dramatic reduction in the time to achieve the diagnosis, if there is evidence of a halo sign. The systematic screening for the detection of Aspergillus antigenemia with an ELISA test is helpful for early diagnosis. The detection of Aspergillus antigen (with the less sensitive latex agglutination test) on bronchoalveolar lavage (BAL) fluid may also be as useful. The treatment of IPA relies on amphotericin B (or its lipid formulations) or on azole antifungal agents. Pulmonary surgical resection should be considered either as an emergency procedure (despite persistent neutropenia) to avoid massive hemoptysis, or as an elective or diagnostic procedure. This global strategy for the management of IPA is associated with a 75-80% success rate in hematological patients. Nevertheless, the control of underlying malignancy remains a major prognostic factor.

The spectrum of pulmonary infections in cancer patients

The lung is a common site of infection in patients with cancer. The spectrum of pulmonary infection depends on the underlying immunologic deficit or deficits. In neutropenic patients, gram-negative bacterial infections predominate early, whereas fungal infections (Aspergillus, Zygomycetes, Fusarium species) are common if neutropenia persists. In patients with impaired cellular immunity, viral infections (cytomegalovirus, other herpes viruses) predominate and may coexist with bacterial (Legionella, Nocardia), mycobacterial, and fungal (Aspergillus, Histoplasma, etc.) infections. Pneumocystis carinii pneumonia is also common in this setting. Infections caused by Streptococcus pneumoniae and Haemophilus influenzae are the primary bacterial infections encountered in patients with impaired humoral immunity. In patients with primary or metastatic pulmonary neoplasms, postobstructive pneumonitis, lung abscess, and occasionally empyema of mixed bacterial etiology (Staphylococcus species, gram-negative bacilli, anaerobes) are frequent. Patients with brain tumors and head and neck cancer develop aspiration pneumonitis, which is usually caused by organisms living in the oropharynx and upper airways. Several immunologic deficits might be present in the same patient, making such a patient susceptible to a wide variety of opportunistic pathogens.

Infections in multiple myeloma

Multiple myeloma is a relatively rare but severe hematologic malignancy. Marked depression in production of normal immunoglobulins, mild neutropenia, and alkylant/steroid therapy or BMT/SCT all produce major suppression of the immune system in the totality of patients. Recurrent bacterial, fungal, and viral infections are an important cause of morbidity and the most common cause of death in these subjects. Prompt diagnosis and appropriate anti-infective chemotherapy are essential in order to reduce the risk of mortality.

An overview of fungal infections

The incidence of fungal infections is increasing at an alarming rate, presenting an enormous challenge to healthcare professionals. This increase is directly related to the growing population of immunocompromised individuals, resulting from changes in medical practice such as the use of intensive chemotherapy and immunosuppressive drugs. HIV and other diseases which cause immunosuppression have also contributed to this problem. Superficial and subcutaneous fungal infections affect the skin, keratinous tissues and mucous membranes. Included in this class are some of the most frequently occurring skin diseases, affecting millions of people worldwide. Although rarely life threatening, they can have debilitating effects on a person's quality of life and may in some circumstances spread to other individuals or become invasive. Most superficial and subcutaneous fungal infections are easily diagnosed and readily amenable to treatment. Systemic fungal infections may be caused by either an opportunistic organism that infects an at-risk host, or may be associated with a more invasive organism that is endemic to a specific geographical area. Systemic infections can be life threatening and are associated with high morbidity and mortality. Because diagnosis is difficult and the causative agent is often confirmed only at autopsy, the exact incidence of systemic infections is difficult to determine. The most frequently encountered pathogens are Candida albicans and Aspergillus spp. but other fungi such as non-albicans Candida spp. are increasingly important.

Fungal infections in patients with neutropenia: challenges in prophylaxis and treatment

Fungal infections are a leading cause of mortality in patients with neutropenia. Candidiasis and aspergillosis account for most invasive fungal infections. General prophylactic measures include strict hygiene and environmental measures. Haemopoietic growth factors shorten the duration of neutropenia and thus may reduce the incidence of fungal infections. Fluconazole is appropriate for antifungal prophylaxis and should be offered to patients with prolonged neutropenia, such as high-risk patients with leukaemia undergoing remission induction or consolidation therapy and high-risk stem cell transplant recipients. Empirical antifungal therapy is mandatory in patients with persistent febrile neutropenia who fail to respond to broad-spectrum antibacterials. Intravenous amphotericin B at a daily dose of 0.6 to 1 mg/kg is preferred whenever aspergillosis cannot be ruled out. Lipid formulations of amphotericin B have demonstrated similar efficacy and are much better tolerated. Fluconazole is the best choice for acute candidiasis in stable patients; amphotericin B should be used in patients with unstable disease. Use of fluconazole is restricted by the existence of resistant strains (Candida krusei and, to a lesser extent, C. glabrata). Amphotericin B still remains the gold standard for invasive aspergillosis. Lipid formulations of amphotericin B are effective in aspergillosis and because they are less nephrotoxic are indicated in patients with poor renal function. Itraconazole is an alternative in patients who have good intestinal function and are able to eat. Mucormycosis, trichosporonosis, fusariosis and cryptococcosis are less common but require specific management. New antifungal agents, especially new azoles, are under development. Their broad in vitro spectrum and preliminary clinical results are promising.