Impact of age on outcome of patients with cancer undergoing autologous bone marrow transplant

Human induced neural stem cells support functional recovery in spinal cord injury models

Spinal cord injury (SCI) is a clinical condition that leads to permanent and/or progressive disabilities of sensory, motor, and autonomic functions. Unfortunately, no medical standard of care for SCI exists to reverse the damage. Here, we assessed the effects of induced neural stem cells (iNSCs) directly converted from human urine cells (UCs) in SCI rat models. We successfully generated iNSCs from human UCs, commercial fibroblasts, and patient-derived fibroblasts. These iNSCs expressed various neural stem cell markers and differentiated into diverse neuronal and glial cell types. When transplanted into injured spinal cords, UC-derived iNSCs survived, engrafted, and expressed neuronal and glial markers. Large numbers of axons extended from grafts over long distances, leading to connections between host and graft neurons at 8 weeks post-transplantation with significant improvement of locomotor function. This study suggests that iNSCs have biomedical applications for disease modeling and constitute an alternative transplantation strategy as a personalized cell source for neural regeneration in several spinal cord diseases.

Delivery of affordable and scalable encapsulated allogenic/autologous mesenchymal stem cells in coagulated platelet poor plasma for dental pulp regeneration

The main goal of regenerative endodontics procedures (REPs) is to revitalize teeth by the regeneration of healthy dental pulp. In this study, we evaluated the potential of combining a natural and accessible biomaterial based on Platelet Poor Plasma (PPP) as a support for dental pulp stem cells (DPSC) and umbilical cord mesenchymal stem cells (UC-MSC). A comparison study between the two cell sources revealed compatibility with the PPP based scaffold with differences noted in the proliferation and angiogenic properties in vitro. Additionally, the release of growth factors including VEGF, HGF and DMP-1, was detected in the media of cultured PPP and was enhanced by the presence of the encapsulated MSCs. Dentin-Discs from human molars were filled with PPP alone or with MSCs and implanted subcutaneously for 4 weeks in mice. Histological analysis of the MSC-PPP implants revealed a newly formed dentin-like structure evidenced by the expression of Dentin sialophosphoprotein (DSPP). Finally, DPSC induced more vessel formation around the dental discs. This study provides evidence of a cost-effective, xenofree scaffold that is compatible with either autologous or allogenic strategy for dental pulp regeneration. This attempt if successfully implemented, could make REPs treatment widely accessible, contributing in improving global health conditions.

Survival Rate and Prognostic Factors Among Patients Undergoing Hematopoietic Stem Cell Transplantation: Using the Joint Model

Background: Hematopoietic stem cell transplantation (HSCT) is the most effective of all hematologic malignancies treatments, resulting in a significant improvement in survival rate. Objectives: This study aimed at determining the survival rate and factors affecting the survival in patients undergoing hematopoietic stem cell transplantation, using the joint model. Methods: This study was a retrospective cohort study, used for collecting data from patients with hematopoietic malignancies who underwent hematopoietic stem cell transplantation in Taleghani Hospital (Shahid Beheshti University of Medical Sciences), Tehran, Iran during the years 2007 and 2015 and were followed up till 2017. A Bayesian joint model of longitudinal and survival was chosen, using Win Bugs software. Results: A total of 395 patients were enrolled. The median overall survival was 6.3 years (95% CI (5.86, 6.76)). Eighty-one patients had died. The obtained results from this study manifested that age (HR: 1.02, 95% CI: (1.002, 1.04)) and pre-transplantation relapse (HR = 1.64, 95% CI: (1.09, 2.4)) have incremental impact on death after transplantation, while malignancy type (NHL (HR: 0.33, 95%CI: (0.152, 0.73)) and AML (HR: 0.62, 95% CI: (0.29, 0.7)) are also effective in reducing death after transplantation. Similarly, the correlation index between longitudinal and survival models proved to be significant (HR: 0.6, 95% CI: (0.0802, 0.37)). Conclusions: This study showed that age, per-transplantation relapse, and malignancy type are the effective factors in the survival rate. Moreover, the link parameter between longitudinal response (WBC) and the survival indicated that an increase in WBC count leads to a decrease in the death risk.

Providing both autologous and allogeneic hematopoietic stem cell transplants (HSCT) may have a stronger impact on the outcome of autologous HSCT in adult patients than activity levels or implementation of JACIE at Belgian transplant centres

While performance since the introduction of the JACIE quality management system has been shown to be improved for allogeneic hematopoietic stem cell transplants (HSCT), impact on autologous-HSCT remains unclear in Europe. Our study on 2697 autologous-HSCT performed in adults in 17 Belgian centres (2007-2013) aims at comparing the adjusted 1 and 3-yr survival between the different centres & investigating the impact of 3 centre-related factors on performance (time between JACIE accreditation achievement by the centre and the considered transplant, centre activity volume and type of HSCT performed by centres: exclusively autologous vs both autologous & allogeneic). We showed a relatively homogeneous performance between Belgian centres before national completeness of JACIE implementation. The 3 centre-related factors had a significant impact on the 1-yr survival, while activity volume and type of HSCT impacted the 3-yr survival of autologous-HSCT patients in univariable analyses. Only activity volume (impact on 1-yr survival only) and type of HSCT (impact on 1 and 3-yr survivals) remained significant in multivariable analysis. This is explained by the strong relationship between these 3 variables. An extended transplantation experience, i.e., performing both auto & allo-HSCT, appears to be a newly informative quality indicator potentially conveying a multitude of underlying complex factors.

Hematopoietic Cell Transplant (HCT) in the Elderly: Myths, Controversies and Unknowns

The incidence of most hematological malignancies increases with age. Despite the higher incidence of hematological malignancies in the elderly, the geriatric population is poorly represented in the early oncology clinical trials that established the current standards of care. Hematopoietic cell transplant (HCT), either upfront or at relapse, provides a potentially life-prolonging, often curative option for many patients with hematological malignancies and is considered the standard of care, at least for younger patients. Historically, the concern that older adults undergoing HCT may experience higher morbidity and transplant-related complications has limited the use of this potentially curative option to younger adults, particularly in allogeneic (allo-) HCT. There is growing evidence to support the feasibility, tolerability, and relatively similar effectiveness of both autologous and allo-HCT in the geriatric population. In the allo-HCT setting, nonmyeloablative/reduced-intensity conditioning (NMA/RIC) has expanded the spectrum of patients that can be considered for this approach. Overall survival is largely affected by disease stage, performance status, and comorbidities rather than by chronological age per se. Comprehensive geriatric assessment (CGA) is a promising tool that can uncover frequently undocumented vulnerabilities in an elderly transplant-eligible patient. Serial study of CGA throughout the peri-HCT period may help predict the short- and long-term impact of HCT on an older adult's functional status and quality of life. Further research is needed to evaluate whether early intervention to improve such vulnerabilities can improve survival and quality of life of these older patients.

Allogeneic hematopoietic cell transplantation in patients with myelofibrosis: A single center experience

Myelofibrosis (MF) is a rare disease responsible for an increasing ineffective hematopoesis by a progressive fibrosing process in the bone marrow. The only curative treatment option is allogeneic hematopoietic cell transplantation (HCT). In this single-center analysis, we evaluated retrospectively 54 consecutive patients suffering from primary or secondary MF which underwent HCT from 1997 to 2014 after either myeloablative (MAC, n = 19) or reduced-intensity conditioning (RIC, n = 35). Overall survival (OS) and disease-free survival (DFS) after 3 years was 54/53 % for RIC versus 63/58 % for MAC (p = 0.8/0.97). Cumulative incidence of relapse was 34 % after RIC and 8 % after MAC (p = 0.16). Three-year non-relapse mortality (NRM) was 15 % after RIC and 34 % after MAC (p = 0.29). We found that RIC was associated with a lower incidence of acute graft versus host disease (GvHD; II-IV 26 vs. 0 %, p = 0.004). Evaluation of prognostic relevance of the Dynamic International Prognostic Scoring System (DIPSS) score showed a significant better OS in patient with risk score ≤3 versus >3 (after 3 years, 71 vs. 39 %, p = 0.008). While similar OS and DFS were observed with MAC or RIC, the use of RIC resulted in lower incidence of acute GvHD. RIC regimens may be therefore the preferred conditioning approach for allogeneic HCT in patients with MF.

Monoclonal Gammopathy of Undetermined Significance and Multiple Myeloma in Older Adults

Multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS) are plasma cell disorders of aging. The landscape of the diagnosis and management of MM and MGUS are rapidly changing. This article provides an updated understanding of the clinical presentation, evaluation, diagnosis, and management of older adults with MM and MGUS. Because most oncology providers are not formally trained in geriatric medicine, geriatricians play a key role in providing oncologists with a broader understanding of patient health status in the hope of improving outcomes for older adults with MM.

High-Dose Chemotherapy and Autologous Stem Cell Transplant in Older Patients with Lymphoma

High-dose chemotherapy followed by autologous hematopoietic stem cell transplant (HDT/ASCT) can improve survival in patients with lymphoma. Limited experience is available on the safety and efficacy of HDT/ASCT in elderly patients. In this article, we review the published data on the role of HDT/ASCT in management of lymphoma in older patients. Based on available data, evaluation of comorbidities, functional status, and comprehensive geriatric assessment (CGA) will help identify those who can benefit most from this intervention. Prospective clinical trials focusing on HDT/ASCT in older patients with lymphoma are needed to establish optimal management protocols in this select population.

Multiple myeloma in the older adult: better prospects, more challenges

PURPOSE

Multiple myeloma (MM) is disproportionately diagnosed in older adults; with the aging of the population, the number of older adults diagnosed with MM will increase by nearly 80% in the next two decades. Duration of survival has improved dramatically over the last 20 years, but the improvements in older adults have not been as great as those in younger adults with MM.

METHODS

In this article, we address treatment approaches in older adults who are eligible for and those ineligible for high-dose therapy with autologous stem-cell transplantation as well as supportive care considerations and the potential role for geriatric assessment in facilitating decision making for older adults with MM.

RESULTS

The evidence from recent studies demonstrates that combinations of novel and conventional antimyeloma agents result in improved response rates and, in some cases, improved progression-free and overall survival. However, some older adults are particularly vulnerable to toxicities of therapy and discontinuation of therapy and, consequently, they have poorer survival. In addition, older adults may prioritize other outcomes of therapy, such as quality of life, over more conventional end points such as disease response and duration of survival. Geriatric assessment can facilitate risk-stratification of older adults at greater risk for adverse events from therapy and aid in personalizing therapy for vulnerable or frail older adults.

CONCLUSION

Survival in older adults with MM is improving with novel therapeutics, but efficacy must be balanced with risk of toxicity of therapy and maintenance of quality of life. Novel instruments such as geriatric assessment tools may facilitate these aims.

Hematopoietic stem cell transplantation for hematologic malignancies in older adults: geriatric principles in the transplant clinic

Hematopoietic cell transplantation (HCT) provides a life-prolonging or potentially curative treatment option for patients with hematologic malignancies. Given the high transplant-related morbidity, these treatment strategies were initially restricted to younger patients, but are increasingly being used in older adults. The incidence of most hematologic malignancies increases with age; with the aging of the population, the number of potential older candidates for HCT increases. Autologous HCT (auto-HCT) in older patients may confer a slightly increased risk of specific toxicities (such as cardiac toxicities and mucositis) and have modestly lower effectiveness (in the case of lymphoma). However, auto-HCT remains a feasible, safe, and effective therapy for selected older adults with multiple myeloma and lymphoma. Similarly, allogeneic transplant (allo-HCT) is a potential therapeutic option for selected older adults, although fewer data exist on allo-HCT in older patients. Based on currently available data, age alone is not the best predictor of toxicity and outcomes; rather, the comorbidities and functional status of the older patient are likely better predictors of toxicity than chronologic age in both the autologous and allogeneic setting. A comprehensive geriatric assessment (CGA) in older adults being considered for either an auto-HCT or allo-HCT may identify additional problems or geriatric syndromes, which may not be detected during the standard pretransplant evaluation. Further research is needed to establish the utility of CGA in predicting toxicity and to evaluate the quality of survival in older adults undergoing HCT.

Influence of age and histology on outcome in adult non-Hodgkin lymphoma patients undergoing autologous hematopoietic cell transplantation (HCT): a report from the Center For International Blood & Marrow Transplant Research (CIBMTR)

To compare the clinical outcomes of older (age > or =55 years) non-Hodgkin lymphoma (NHL) patients with younger NHL patients (<55 years) receiving autologous hematopoietic cell transplantation (HCT) while adjusting for patient-, disease-, and treatment-related variables, we compared autologous HCT outcomes in 805 NHL patients aged > or =55 years to 1949 NHL patients <55 years during the years 1990-2000 using data reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). In multivariate analysis, older patients with aggressive histologies were 1.86 times (95% confidence interval [CI] 1.43-2.43, P < .001) more likely than younger patients to experience treatment-related mortality (TRM). Relative death risks were 1.33 times (CI 1.04-1.71, P = .024) and 1.50 times (CI 1.33-16.9, P < .001) higher in older compared to younger patients with follicular grade I/II and aggressive histologies, respectively. Autologous HCT in older NHL patients is feasible, but most disease-related outcomes are statistically inferior to younger patients. Studies addressing supportive care particular to older patients, who are most likely to benefit from this approach, are recommended.

Comorbidities, not age, impact outcomes in autologous stem cell transplant for relapsed non-Hodgkin lymphoma

High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation is a widely applied treatment for advanced non-Hodgkin lymphoma (NHL), but few studies have analyzed the tolerability and outcomes in older patients compared with younger patients treated in a homogeneous manner. We retrospectively reviewed 152 consecutive patients who underwent autologous stem cell transplantation (ASCT) following BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan) for NHL from January 2000 through August 2004 at our institution. We compared 59 patients age > or =60 years and 93 patients age <60 years. Supportive care was identical for all patients. The frequency of comorbidities was similar between both groups. CD34+ cell doses, days to neutrophil recovery, and days to platelet count >20,000/mm3 were similar in younger and older patients, although days to platelet count >50,000/mm3 were longer in the older patients (median 30.0 days versus 22.5 days, P = .01). Patients over the age of 60 were more likely to develop grade III/IV mucositis than their younger counterparts (37.7% versus17.4%, P = .0063). Otherwise, the frequency of other grade III/IV toxicities were similar between younger and older patients. Treatment-related mortality (TRM) was similar between older and younger patients (8.5% versus 5.4%, P = .45). Although age was not associated with TRM, the Charlson Comorbidity Index Score was significantly correlated with TRM (P = .03). Median disease-free survival was similar between older and younger patients (21.8 months versus 29.9 months, P = .93), as was overall survival (OS) (47.7 months versus 62.5 months, P = .20). After controlling for age, the Charlson Comorbidity Index Score influenced OS [P = .013]. Overall, our cohort of patients with NHL over the age of 60 who underwent ASCT following BEAM conditioning experienced toxicities and survival similar to their younger counterparts. Comorbidities significantly influenced TRM and OS in this retrospective cohort. Future study should focus on improving tolerability of conditioning and careful prospective evaluation of comorbidities and their association with outcomes.

Autologous stem cell transplantation in patients of 70 years and older with multiple myeloma: Results from a matched pair analysis

High-dose therapy and autologous stem cell transplant (HDT) have been shown to prolong survival in multiple myeloma (MM) in randomized trials, but only included patients of 65 years or younger. Given the median age at diagnosis of 66 years, it is important to have a better understanding of the outcome of transplantation in the older patients. We identified 33 patients with MM, who were > or =70 years at the time of their HDT. We matched them to a group of 60 patients, 65 years or younger, (two controls for each patient), based on time to transplant, disease status at transplant, Durie-Salmon stage, labeling index, presence of cytogenetic abnormalities, and presence of circulating plasma cells. The median age of the two groups were 55.6 (range, 37.3-64.9) and 71.7 (range 70-75.8) years at transplant. Although more of the older patients received dose reduced melphalan, the overall response rate was similar (97% vs. 98%) as was the median time to progression (28.5 months vs. 17.8 months, P = 0.7) for the elderly group compared to the younger patients. The median overall survival from transplant was not reached for the elderly patient group compared to 53.2 months for the younger patients, P = 0.7. HDT is feasible in selected patients with multiple myeloma over 70 years. The toxicity of transplant as well as the outcome appears comparable to younger patients. Patients with MM should not be excluded from HDT solely on the basis of their chronological age.

Profound thrombocytopenia and survival of hematopoietic stem cell transplant patients without clinically significant bleeding, using prophylactic platelet transfusion triggers of 10 x 10(9) or 20 x 10(9) per L

BACKGROUND

A trigger of 10 x 10(9) per L for prophylactic platelet (PLT) transfusions is generally recommended for stable thrombocytopenic patients who receive chemotherapy, based on studies showing similar incidence, severity, and fatality of bleeding compared with the 20 x 10(9) per L trigger. The outcome of thrombocytopenic nonbleeding patients has not been well described. This retrospective analysis evaluates thrombocytopenia and survival of 381 hematopoietic stem cell transplant (HSCT) patients without clinically significant bleeding, with 10 x 10(9) and 20 x 10(9) per L prophylactic triggers.

STUDY DESIGN AND METHODS

A total of 170 patients who received prophylactic PLT transfusions at 20 x 10(9) per L (1997-1998, SP1) and 211 patients who had prophylaxis at 10 x 10(9) per L (1999-2001, SP2) were identified as nonbleeding patients. PLT counts and clinical complications were assessed within 100 days from HSCT.

RESULTS

PLT counts less than or equal to 10 x 10(9) per L were found in 69.2 percent of patients in SP2 and 38.3 percent in SP1 (p < 0.001). Profound thrombocytopenia (4+ PLT counts <or=10 x 10(9)/L) was found in 19.0 percent of patients in SP2 and 7.0 percent in SP1 (p = 0.001). Patients with profound thrombocytopenia had significantly increased early mortality (odds ratio [OR], 3.18; 95% confidence interval [CI], 1.25-8.07) and significantly reduced overall survival (hazard ratio [HR], 1.95; 95% CI, 1.28-2.97) compared to patients with 0 to 3 PLT counts less than or equal to 10 x 10(9) per L. The association of profound thrombocytopenia with early mortality was more notable in SP2.

CONCLUSION

The 10 x 10(9) per L transfusion trigger is associated with significantly greater exposure to low PLT counts. Nonbleeding patients with profound thrombocytopenia were at significantly greater risk of dying compared with nonthrombocytopenic patients. These results suggest that safety of the 10 x 10(9) per L trigger should be more thoroughly evaluated.

Autologous stem cell transplantation in the elderly including pre- and post-treatment options

Multiple myeloma (MM) is a disease of the elderly with a median age at diagnosis of 67 years in a referral population. High-dose chemotherapy (HDT) and autologous stem cell transplantation has been shown to improve survival in patients with MM in randomized trials and remains the preferred option for eligible patients. However, the randomized clinical trials demonstrating an advantage for HDT included only patients younger than 65 years and evidence supporting its role for the elderly patients has been based on retrospective reviews. The introduction of thalidomide, lenalidomide and bortezomib has changed the paradigm for treatment of myeloma and improved the outcome for these patients. Several ongoing clinical trials are evaluating the role of these novel agents in this population, specifically comparing these to HDT-based approaches. Other trials are examining the role of maintenance therapy post-HDT with these novel drugs with or without steroids. The role of HDT will be further redefined in the coming years with improvements in other therapies.

Hematopoietic cell transplantation as curative therapy for idiopathic myelofibrosis, advanced polycythemia vera, and essential thrombocythemia

A total of 104 patients, aged 18 to 70 years, with a diagnosis of chronic idiopathic myelofibrosis (CIMF), polycythemia vera (PV), or essential thrombocythemia (ET) with marrow fibrosis were transplanted from allogeneic (56 related and 45 unrelated) or syngeneic (n = 3) donors. Busulfan (BU) or total body irradiation (TBI)-based myeloablative conditioning regimens were used in 95 patients, and a nonmyeloablative regimen of fludarabine plus TBI was used in 9 patients. The source of stem cells was bone marrow in 43 patients and peripheral blood in 61 patients. A total of 63 patients were alive at a follow-up of 1.3-15.2 years (median, 5.3 years), for an estimated 7-year actuarial survival rate of 61%. Eleven patients had recurrent/persistent disease, of whom 8 died. Nonrelapse mortality was 34% at 5 years. Patients conditioned with targeted BU (plasma levels 800-900 ng/mL) plus cyclophosphamide (tBUCY) had a higher probability of survival (68%) than other patients. Dupriez score, platelet count, patient age, and comorbidity score were statistically significantly associated with mortality in univariate models. In a multivariable regression model, use of tBUCY (P = .03), high platelet count at transplantation (P = .01 for PV/ET; P = .39 for other diagnoses), younger patient age (P = .04), and decreased comorbidity score (P = .03) remained statistically significant for improved survival. Our findings show that hematopoietic cell transplantation offers potentially curative treatment for patients with ICMF, PV, or ET.

Acute bleeding complications in patients after hematopoietic stem cell transplantation with prophylactic platelet transfusion triggers of 10�נ109and 20�נ109per L

BACKGROUND

Prophylactic platelet (PLT) transfusions are given as a standard care in patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT). This retrospective analysis evaluates utilization of blood transfusions, risk of bleeding, and survival in 480 HSCT patients at 10 x 10(9) and 20 x 10(9) per L prophylactic trigger levels.

STUDY DESIGN AND METHODS

A total of 224 patients received prophylactic PLT transfusions at 20 x 10(9) per L threshold (1997-1998, SP1); 256 patients had prophylaxis at 10 x 10(9) per L (1999-2001, SP2). Bleeding scores were assigned daily.

RESULTS

A slight reduction in PLT transfusions per patient in SP2 compared with SP1 was not statistically significant (odds ratio, 0.82; 95% confidence interval, 0.51-1.33; p = 0.416), yet a significantly higher proportion of patients in SP2 had PLT counts less than or equal to 10 x 10(9) per L compared to SP1 (p < 0.001). In patients who bled, however, there was no excess exposure to low PLT counts before bleeding started. A substantial number of patients who bled received PLT transfusions above the goal before bleeding started (82.9% in SP2, 41.5% in SP1) because of medical complications that associated with increased risk of bleeding. Bleeding incidence was similar in both study periods (21.9% in SP1, 16.4% in SP2; p = 0.526). Bleeding was significantly associated with reduced survival in both study periods.

CONCLUSIONS

Patients who bled were usually placed on a higher threshold before the onset of their major bleeding event and were not exposed to additional risk of bleeding from thrombocytopenia. Similarity in bleeding incidence between study periods appears to associate with adjustments to high-risk conditions and may not reflect consequences of the lower transfusion threshold.

High-dose [131I]tositumomab (anti-CD20) radioimmunotherapy and autologous hematopoietic stem-cell transplantation for adults > or = 60 years old with relapsed or refractory B-cell lymphoma

PURPOSE

The majority of patients with relapsed or refractory B-cell non-Hodgkin's lymphoma (NHL) are older than 60 years, yet they are often denied potentially curative high-dose therapy and autologous stem-cell transplantations (ASCT) because of the risk of excessive treatment-related morbidity and mortality. Myeloablative anti-CD20 radioimmunotherapy (RIT) can deliver curative radiation doses to tumor sites while limiting exposure to normal organs and may be particularly suited for older adults requiring high-dose therapy.

PATIENTS AND METHODS

Patients older than 60 years with relapsed B-cell NHL (B-NHL) received infusions of tositumomab anti-CD20 antibody labeled with 185 to 370 Mbq (5 to 10 mCi) [131I]-tracer for dosimetry purposes followed 10 days later by individualized therapeutic infusions of [131I]tositumomab (median, 19.4 Gbq [525 mCi]; range, 12.1 to 42.7 Gbq [328 to 1,154 mCi]) to deliver 25 to 27 Gy to the critical normal organ receiving the highest radiation dose. ASCT was performed approximately 2 weeks after therapy.

RESULTS

Twenty-four patients with a median age of 64 years (range, 60 to 76 years), who had received a median of four prior regimens (range, two to 14 regimens), were treated. Thirteen patients (54%) had chemotherapy-resistant disease. The estimated 3-year overall and progression-free survival rates were 59% and 51%, respectively, with a median follow-up of 2.9 years (range, 1 to 6 years). All patients experienced expected myeloablation with engraftment of platelets (> or = 20 K/microL) and neutrophils ( 500/microL), occurring at a median of 9 and 15 days after ASCT, respectively. There were no treatment-related deaths, and only two patients experienced grade 4 nonhematologic toxicity.

CONCLUSION

Myeloablative RIT and ASCT is a safe and effective therapeutic option for older adults with relapsed B-NHL.

Severe mucositis is associated with reduced survival after autologous stem cell transplantation for lymphoid malignancies

Mucositis is a known complication of autologous stem cell transplantation (ASCT). This study retrospectively reviewed 191 patients with lymphoid malignancies undergoing ASCT following a uniform mobilising regimen of etoposide (VP-16)/granulocyte colony-stimulating factor and a uniform high-dose preparative regimen of busulfan/cyclophosphamide/VP-16. Eighty-seven patients experienced severe mucositis (modified Oral Mucositis Assessment Scale > or =1). Patient characteristics compared between mucositis groups were balanced according to disease status, prior exposure to radiation therapy, time from radiation therapy and actual body weight. Log-rank analysis revealed that severe mucositis was associated with inferior overall survival (P = 0.002). A 12-month landmark analysis showed this difference in survival occurred within 1 year post-transplant. Multivariate analysis of all-cause mortality showed lower pretransplant albumin and severe mucositis to be significant risk factors. Multivariate analysis for relapse mortality revealed severe mucositis to be a risk factor (P = 0.047), while lower pretransplant albumin was significant for non-relapse mortality (NRM; P = 0.009). Kaplan-Meier estimates of survival based on relapse and NRM were significantly worse for patients with severe mucositis. Reduced pretransplant forced expiratory volume in 1 s (FEV(1)) and carbon monoxide (CO) diffusing capacity (DLCO) were also associated with severe mucositis. Our data suggest that studies of new treatment strategies for mucositis should include relapse and survival endpoints and that pretransplant factors, such as FEV(1) and DLCO may be useful to risk-stratify patients entered onto such trials.

Factors predicting success or failure associated with common types of transplants

The ability to predict clinical outcomes is essential to accurate medical decision analysis. Many accepted bone marrow transplant related prognostic variables are derived from data that is over 20-years old and may or may not be applicable to current medical practice. This report reviews both older data concerning bone marrow transplantation prognostic factors as well as more current reports. In addition to pretransplant variables, this review examines easily measured post-transplant variables that may affect prognosis, as well as data concerning the cellular component of the infused graft in both allogeneic and autologous transplantation.

Pharmacology of anticancer drugs in the elderly population

Modifications to bodily functions and physiology are known to occur with age. These changes can have a considerable impact on the pharmacokinetic processes of absorption, distribution, metabolism and excretion and the pharmacodynamic properties of administered drugs. For many drugs with a high therapeutic index, this will be clinically unimportant, but for anticancer drugs, which usually have a low therapeutic index, these pharmacological changes can lead to dramatic consequences, such as excessive drug concentrations and unacceptable toxicity, or subtherapeutic drug concentrations and ineffective treatment. Despite the increased susceptibility of the elderly to these changes, doses are rarely adapted on the basis of pharmacokinetics and pharmacodynamics, with the exception of changes secondary to altered renal function. Until recently, only a few large prospective randomised trials have provided evidence-based data for dose adaptations in elderly patients. However, with increasing knowledge of the pharmacokinetics of anticancer drugs, advances in the knowledge of pharmacokinetic behaviour with aging, and documented efficacy and toxicity data in the elderly population, it is possible to highlight aspects of prescribing anticancer drugs in the elderly. In general, and for most drugs, age itself is not a contraindication to full-dose chemotherapy. The main limiting factors are comorbidity and poor functional status, which may be present in a significant number of the elderly population. Elderly patients with cancer are part of the daily practice of oncologists, but currently clinicians can often only estimate whether dose modification is advantageous for the elderly. This review attempts to elucidate the factors that can influence the pharmacokinetics of anticancer drugs frequently used in the elderly, and the clinical or biochemical parameters that form the basis for dose adjustments with age.

Prognostic importance of the platelet count 100 days post allogeneic bone marrow transplant

We assessed the prognostic importance of the platelet count 100 days post transplant of 107 consecutive patients receiving ablative allogeneic bone marrow transplant (BMT) between 7/96 and 12/00 who survived at least 100 days. Diagnoses included AML (n=36), chronic myelogenous leukemia (n=27), NHL (n=14), ALL (n=16), MDS (n=9), aplastic anemia (n=3), and one Hodgkin's disease and myelofibrosis each. In total, 64% were in remission or in chronic phase or had aplastic anemia (good risk), and 36% had active disease at the time of transplant (bad risk). In all, 70% were matched sibling transplants and 30% were matched unrelated donor transplants. The mean follow-up for the patients remaining alive is 48 months. Survival was powerfully influenced by the 100-day platelet count: 4-year survival was 19% for patients with a platelet count <30 x 10(9)/l; 41% for patients with a platelet count of 30-50; and 72% for those with a platelet count >50 (P<0.001; log-rank test). In a multivariable analysis, the most powerful risk factors for mortality after allogeneic BMT were low 100-day platelet count (P<0.001) and bad risk disease (P=0.009). We conclude that the platelet count 100 days post transplant is a powerful predictor of overall survival.

Are predictive factors clinically useful in bone marrow transplantation?

Variables that accurately predict the clinical outcome of any procedure, including bone marrow transplantation (BMT), are of paramount importance when assessing the risks and benefits of the procedure. This review of the world's literature of variables affecting overall outcome after myeloablative BMT critically appraises the value of many bone marrow transplant dogmas. There is a relative paucity of data supporting many commonly used transplant practices, including having an upper age limit for eligibility criteria, and absolute requirements for cardiac and pulmonary function pre transplant. In contrast, recently published literature suggests that several parameters occurring soon after a BMT has been performed may accurately predict transplant outcome. Ultimately, given the rapidly evolving nature of BMT, renewed clinical research of variables predictive of transplant outcome is needed.

Feasibility and toxicity of high-dose therapy (HDT) supported by peripheral blood stem cells in elderly patients with multiple myeloma and non-Hodgkin's lymphoma: survey from a single institution

The aim of this retrospective study was to investigate the feasibility of high-dose therapy (HDT) followed by peripheral blood stem cell transplantation (PBSCT) in elderly patients with hematological malignancies. From April 1998 to November 2001, 40 elderly patients (defined as > or =60 years) with non-Hodgkin's lymphoma (12 patients) and multiple myeloma (28 patients) were evaluated. Seven lymphoma and one myeloma patients were in complete remission (CR), 27 in partial remission (PR), two had stable disease (SD), and three progressive disease (PD). The median age was 65 years (range 60-71). Thirty-nine patients were mobilized with chemotherapy plus granulocyte-colony stimulating factor (G-CSF) and one with G-CSF alone. Patients received HDT including melphalan alone in 32 cases or combined with other drugs in six and BEAM in two. The median number of collected CD34(+) cells was 12.4 x 10(6)/kg (range 2.0-68.9). The median number of re-infused CD34(+) cells was 9.9 x 10(6)/kg (range 2.0-68.9). All patients engrafted after PBSC and the median time to neutrophil recovery (N > 500/micro l) and platelet recovery (PLT > 20,000/micro l) was 8 days (range 5-18) and 6 days (range 5-18), respectively. Nonhematological toxicity was mild and no patient died from transplant-related toxicity (TRM). Median duration of hospitalization was 18 days (range 12-24). To date, 32 patients are alive and eight died from disease progression at a median follow-up interval of 24 months. HDT supported by PBSC is a feasible procedure in selected elderly patients, and an age of more than 60 years should not be considered a contraindication for HDT.

Why aren't we performing more allografts for aggressive non-Hodgkin's lymphoma?

Allogeneic stem cell transplantation has an under-appreciated role in the management of intermediate-grade non-Hodgkin's lymphoma. It provides several advantages over autologous stem cell transplantation including provision of a lymphoma-free graft, reduced rates of secondary myelodysplastic syndrome and leukemia, and a potentially curative graft-versus-lymphoma effect. When applied to chemosensitive patients, the lower relapse rates and reasonable long-term outcomes make allogeneic transplantation a promising therapy to pursue. Patient populations, such as those with bone marrow involvement or very high-risk disease, can be identified as having suboptimal outcomes after autotransplantation and may benefit from such an approach. While the exact role of allogeneic stem cell transplantation remains to be determined, broad recommendations can be suggested for the management of patients with intermediate-grade lymphoma. New approaches to allogeneic transplantation, including the use of matched-unrelated donors and reduced-intensity conditioning regimens, may expand the applicability of this potentially curative modality.

Obesity and autologous stem cell transplantation in acute myeloid leukemia

In the bone marrow transplant setting, several authors hypothesized that severely overweight patients are at increased risk of transplant-related toxicity, but different definitions of obesity, different body weight groupings and heterogeneous samples of patients were analyzed. To overcome these limitations, we retrospectively considered a homogeneous group of 54 patients (median age 36.5 years), with a diagnosis of de novo acute myeloid leukemia (AML), autografted in first complete remission (CR) with the Bu-Cy2 conditioning regimen, dosed on actual body weight. Patients were classified into three groups (obese, non-obese, underweight) using body mass index (BMI = kg/m(2)); for each group we analyzed transplant-related toxicity and mortality, overall survival and disease-free survival (OS/DFS). In spite of the relatively small number of patients, in our results high BMI appears a predictive factor for an increase of treatment-related toxicity and mortality. Moreover, 30 (55%) patients are currently alive in continuous CR, and after a median follow-up of 76.5 months (range 14-137) statistically significant differences in OS and DFS were detected between obese and non-obese groups (P = 0.012 and 0.021, respectively). Our study suggests that obesity may represent an independent risk factor for autograft in AML and further investigations are warranted.

Very low toxicity and good quality of life in 48 elderly patients autotransplanted for hematological malignancies: a single center experience

Between May 1994 and May 2000, we autotransplanted 48 consecutive patients, 21 females and 27 males aged over 60 years (range: 60-78, median: 63). Sixteen patients had multiple myeloma (MM), 14 high-grade non-Hodgkin's lymphoma (HGNHL), six low-grade non-Hodgkin's lymphoma (LGNHL), nine acute myeloid leukemia (AML), one chronic lymphocytic leukemia (CLL), one Hodgkin's disease (HD) and one breast cancer; the performance status (WHO) was 0-1. Seventeen patients were in 1st CR (35.4%) and one in 2nd CR (2.1%), 25 in PR (52.1%), while five patients had been transplanted with progressive disease (10.4%); seven patients with MM received a double transplant. Patients received high-dose therapy including melphalan alone (13) or associated with other drugs (26), busulfan-cyclophosphamide (three), BEAM (11) and TBI (two). All patients took a median of 11 (range: 8-25) days to reach neutrophils >500/microl, 13 (range: 9-83) days to reach platelets > 20,000/microl and 17 (range: 11-83) days to reach platelets > 50,000/microl. Hematological toxicity, hospital stay and supportive care did not differ from those of a cohort of younger patients. At present, 31 patients are alive (14 in CR, five in PR, five in PD and seven in relapse) and 16 died from PD at a median follow-up of 37 months (1-67). Only one patient died from transplant-related toxicity. Quality of life, evaluated using a QLQ-C30 questionnaire in 25 patients at day +90, was good. In our experience PBPC mobilization and transplantation is feasible in patients aged > or = 60 years and the toxicity of this procedure is acceptable, with an early transplant-related mortality of 1.8%; therefore patients with hematological malignancies potentially curable with high-dose therapy (HDT) should also be candidates for HDT.

Efficacy of high-dose therapy and autologous hematopoietic stem cell transplantation for non-Hodgkin's lymphoma in adults 60 years of age and older

High-dose therapy (HDT) with autologous stem cell transplantation (ASCT) is the optimal treatment for patients with relapsed aggressive non-Hodgkin's lymphoma (NHL). HDT, however, is often reserved for relatively younger patients due to limited data in older adults. We treated 53 patients aged 60 years and older (median age 62 years, range 60.3-67.7 years) with HDT and ASCT for NHL at our centers. Forty-four patients (83%) had aggressive histology, 75% had chemosensitive disease and all had failed anthracycline therapy. Conditioning regimens included busulfan, melphalan, and thiotepa (45%); cyclophosphamide (CY), etoposide (VP-16), and total body irradiation (TBI) (30%); CY and TBI (15%); and other regimens (10%). Estimated 4-year overall survival (OS), progression-free survival, and treatment-related mortality (TRM) were 33%, 24% and 22%, respectively. A multivariable analysis demonstrated that patients with chemosensitive disease (P = 0.03) and < or =3 prior regimens (P = 0.03) had superior survival. Four-year OS in patients with chemosensitive disease was 39% vs 15% in patients with chemoresistant disease. Reduced TRM was associated with the CY, VP-16 and TBI regimen (P = 0.02). HDT therapy with ASCT may result in prolonged survival and potential cure for about a quarter of elderly patients, and for almost 40% with chemosensitive disease. Optimal conditioning regimen selection may further improve outcome by reducing TRM. Age alone should not be used to exclude patients from receiving myeloablative therapy with ASCT.

Transplant-related mortality in patients older than 60 years undergoing autologous hematopoietic stem cell transplantation

Although high-dose therapy with autologous hematopoietic stem cell transplantation (ASCT) is a widely used method of dose intensification in patients with hematological malignancies, patients aged over 60 are generally excluded. We evaluated high-dose therapy and ASCT in 29 cases involving 27 such patients (median age 63 years; range 61-68) with different malignancies. Patients were eligible if they had a good performance status, normal cardiac, respiratory, and hepatic function and a serum creatinine concentration of less than 2 mg/dl (<5 mg/dl in myeloma patients). Engraftment was assessable in 27 procedures. The median time to attain 0.5 and 1 x 10(9) PMN/l was 13 days (range 9-30) and 14 days (range 10-66), respectively. The median time taken to reach a platelet count greater than 50 x 10(9)/l was 14 days (range 8-223). Five patients (17%) died in the first 100 days after transplant, in two cases due to disease progression. The remaining three patients died as a consequence of transplant-related complications, with an overall transplant-related mortality of 10%. Five patients relapsed and died between 5 and 36 months after transplant. The remaining 17 patients are still alive without disease progression, with an actuarial overall survival of 47% at 42 months (95% CI 33-61). We consider that high-dose therapy with ASCT should be considered in those elderly patients with good performance status and without general organ impairment.

Feasibility and toxicity of high-dose chemotherapy supported by peripheral blood stem cell transplantation in elderly patients (>/=60 years) with non-Hodgkin's lymphoma: comparison with patients <60 years treated within the same protocol

Limited data are available concerning feasibility and toxicity of progenitor cell mobilization and high-dose therapy (HDT) supported by peripheral blood stem cell transplantation (PBSCT) in elderly patients (>/=60 years) with non-Hodgkin's lymphoma (NHL). From 1995 to 1999, 17 elderly NHL patients (median age 63 years, range 60-70) entered our HDT program and were mobilized with CY (4 g/m2) followed by G-CSF. Mobilization was successful in 13 patients, who then received BEAM or BEAC followed by PBSCT. The feasibility and toxicity of progenitor cell mobilization and HDT in the elderly patients were compared with experiences in 62 NHL patients <60 years (median 46 years, range 16-59), who received the same mobilization protocol and of whom 48 patients received HDT supported by PBSCT. No significant differences were observed between these groups in the success rate of progenitor cell mobilization, in the number of CD34-positive cells collected or in the number of aphereses needed. HDT appeared to be somewhat more toxic in the elderly patients: a higher peak CRP value (P = 0.08) and longer in-hospital stay (P = 0. 05) were observed. No differences were found in transplant-related mortality or severe organ toxicity between these age groups except for oral mucositis grade >2, which tended to be more common in the elderly patients (P = 0.07). We conclude that progenitor cell mobilization and HDT supported by PBSCT is also feasible in selected elderly patients with NHL. Bone Marrow Transplantation (2000) 26, 737-741.

Overview of autologous stem cell transplantation

There has been a dramatic increase in the number of autologous peripheral blood stem cell transplants over the last decade. Faster recovery of cell counts, lesser transplant morbidity, shorter hospital stay and reduced cost compared with marrow autografts have been the main advantages of autologous peripheral blood cell over marrow transplants. In this paper we attempt to review the advances in the biology and mobilization of stem cells, and focus on clinical results of autologous peripheral stem cell and marrow transplants for disease specific sites such as breast cancer, myeloma, autoimmune diseases, germ cell tumors, the acute and chronic leukemias, the non-Hodgkin's lymphomas and Hodgkin's disease. We also discuss transplant related complications, gene therapy and the different methods of purging. This review was intended for autologous peripheral stem cell transplants, however, unavoidably, it also discusses autologous marrow transplantation and aspects common to both procedures.

Allogeneic hematopoietic transplantation for chronic lymphocytic leukemia and lymphoma: potential for nonablative preparative regimens

There is increasing interest in the use of allogeneic blood and marrow transplants for chronic lymphocytic leukemia (CLL) and lymphomas. Numerous studies indicate efficacy in patients with advanced disease and demonstrate existence of a potent graft-versus-malignancy effect against these disorders. Allogeneic transplantation is most effective in CLL and low-grade lymphomas, but precise indications and timing of allogeneic transplants in these indolent disorders are not well defined. Allotransplantation is an effective, potentially curative approach, albeit with substantial risks; it is indicated in selected categories of patients. Allogeneic transplants are also promising for mantle cell lymphoma. In large-cell lymphoma, relapses are reduced in allogeneic compared with autologous transplants, but the benefit of allotransplantation has been offset by increased risk of treatment-related complications, and its indications are controversial. A promising new strategy is the use of less toxic, nonmyeloablative preparative regimens to achieve engraftment and allow development of graft-versus-malignancy effects that can produce durable remission in selected categories of lymphoid malignancies.

Allogeneic and syngeneic marrow transplantation for myelodysplastic syndrome in patients 55 to 66 years of age

We carried out bone marrow transplantation (BMT) in 50 patients with myelodysplastic syndrome (MDS) who were 55.3 to 66.2 years of age (median, 58.8 years). According to the criteria of the French-American-British (FAB) classification, 13 patients had refractory anemia (RA), 19 had RA with excess blasts (RAEB), 16 had RAEB in transformation or acute myelogenous leukemia (RAEB-T/AML), and 2 had chronic myelomonocytic leukemia (CMML). According to the recently established International Prognostic Scoring System (IPSS), available for 45 patients, 2 patients were considered low risk; 14, intermediate 1 risk; 19, intermediate 2 risk; and 10, high risk. Conditioning regimens were cyclophosphamide (CY) (120 mg/kg of body weight) plus 12-Gy fractionated total-body irradiation (FTBI) (n = 15), CY plus FTBI with lung and liver shielding (n = 4), busulfan (7 mg/kg) plus FTBI (n = 4), or busulfan (16 mg/kg) plus CY (n = 27). The busulfan-plus-CY group included 16 patients in whom busulfan was targeted to plasma levels of 600 to 900 ng/mL. In these 16 patients, steady-state levels of busulfan actually achieved were 714 to 961 ng/mL (mean ± SD, 845 ± 64 ng/mL; median, 838 ng/mL). The donors were HLA-identical siblings for 34 patients, HLA-nonidentical family members for 4, identical twins for 4, and unrelated volunteers for 6. All 46 patients surviving &gt; 21 days had engraftment, and 22 patients (44%) are surviving 9 to 80 months after BMT. Specifically, among 13 patients with RA, 1 had relapse (cumulative incidence [CI] at 3 years, 8%) and 8 are surviving, for a Kaplan-Meier (KM) estimate of survival at 3 years of 59% (disease-free survival [DSF], 53%). Among 19 patients with RAEB, 3 had relapse (CI at 3 years, 16%), and 8 are surviving disease free (KM estimate at 3 years, 46%). Among 18 patients with RAEB-T/AML or CMML, 6 had relapse (CI at 3 years, 28%), and the KM estimate of DSF at 3 years is 33%. Relapse-free survival had an inverse correlation with cytogenetic risk classification and with the risk score according to the IPSS. Survival in all FAB categories was highest among patients enrolled in a protocol in which busulfan plasma levels were targeted to 600 to 900 ng/mL. These data indicate that BMT can be carried out successfully in patients with MDS who are older than 55 years of age.

Aggressive lymphoma in the elderly

Persons 65 years of age and older are the fastest growing segment of the United States population. Over the next 30 years they will comprise approximately 20% of the population. There will be a parallel rise in the number of patients with non-Hodgkin's lymphoma. Age has long been known to be an adverse prognostic factor. Clinical trials of older patients are complicated by the effect of comorbid illness, particularly its effect on overall survival. CHOP (cyclophosphamide, Adriamycin, vincristine, prednisone) remains the standard therapy for all patients with aggressive non-Hodgkin's lymphoma. There are a number of regimens which may be beneficial for older patients with significant comorbidity and poor performance status. The randomized trials in the elderly has reaffirmed CHOP and emphasize the need for adequate dosing, maintaining schedule and anthracyclines. Relapsed patients have a poor prognosis but selected fit older patients may benefit from aggressive reinduction regimens and possibly bone marrow transplantation. Future research should include defining the role of comorbidity, measurement of organ dysfunction and assessment of performance status with geriatric functional scales. New drug treatments should also be explored.

Acute bleeding after allogeneic bone marrow transplantation: association with graft versus host disease and effect on survival

BACKGROUND

Hemorrhagic complications are frequently implicated clinically for the high morbidity and mortality of acute graft versus host disease (GVHD), however, only few reports characterize the incidence and timing of bleeding in relation to GVHD, and essentially no study has quantified the effect of bleeding on survival of allogeneic patients with GVHD. This study examines the association of bleeding with acute GVHD and the effect of both complications on survival.

METHODS

A total of 463 allogeneic patients transplanted at the Johns Hopkins Hospital, were included in the study. Bleeding evaluation was based on daily scores of intensity and blood transfusions. All bleeding sites were recorded. GVHD staging was defined by the extent of rash, serum bilirubin, diarrhea, and confirmatory histology.

RESULTS

The incidence of GVHD was 27.4%, bleeding occurred in 40.2%. The incidence of bleeding was higher in patients with GVHD as compared with non-GVHD, and correlated with GVHD severity. The higher bleeding incidence in GVHD was due to gastrointestinal hemorrhage, hemorrhagic cystitis, and pulmonary hemorrhage. While the majority of bleeding (51/75) in non-GVHD patients initiated within 30 days after bone marrow transplantation (BMT), only 32.3% (21/65) of the bleeding in the GVHD group initiated within 30 days, and the risk for bleeding continued until day 100. Bleeding was a late event compared to GVHD, however, most bleeding episodes were associated with active GVHD. Both GVHD and bleeding were individually associated with reduced survival, with profound additive adverse effect: median survival in 221 nonbleeding non-GVHD was >83.2 months, GVHD nonbleeding (39 patients) had median of 10.6 months, bleeding non-GVHD (99 patients) had median of 4.3 months, and median survival of the GVHD bleeding group (85 patients) was 3.2 months.

CONCLUSIONS

Our results support an association of bleeding with acute GVHD, suggesting that GVHD is a risk factor for bleeding after BMT. The occurrence of bleeding clearly identified poor outcome subgroup within GVHD, suggesting further evaluation for clinical application of bleeding in the assessment of GVHD severity.

Cancer chemotherapy in the elderly

As the geriatric population is growing, it is increasingly important to be familiar with chemotherapy for the elderly. Age-related changes in pharmacokinetics are documented for doxorubicin, etoposide, ifosfamide, daunorubicin, mitomycin, cisplatin and methotrexate. The hematological toxicity of most standard-dose chemotherapy is not affected by age in patients with normal organic functions and good performance status, although increased toxicity with aging is suggested in the use of actinomycin-D, etoposide, vinblastin, methotrexate, methyl-CCNU, doxorubicin and mitomycin, and in dose-intensive chemotherapy. Among non-hematological toxicities, only doxorubicin-induced cardiomyopathy and bleomycin-induced pulmonary toxicity are demonstrated to be accelerated in the elderly. There is no evidence that advanced age decreases the efficacy of chemotherapy for tumors, except for Hodgkin's disease and acute leukemia. These results suggest that advanced chronological age alone is not always associated with severe toxicity and poor prognosis, and that many elderly patients with cancer will benefit from chemotherapy. To answer questions regarding the optimal chemotherapy regimen, dose and intensity in this population, the influence of age should be analyzed in a multivariate approach in future studies.

Conditioning regimens before transplantation in patients with aggressive non-Hodgkin's lymphoma

Substantial progress has been made in understanding the role of autotransplantation in aggressive non-Hodgkin's lymphoma. At present, the clinical indications for high-dose therapy include patients with relapsed or poor prognosis disease. Hematopoietic reconstitution with peripheral stem cells has rendered transplantation less toxic but the optimal preparative regimen remains to be found. It should combine a high antitumor activity with acceptable toxicity to normal tissues. The literature, on combinations of drugs with or without total body irradiation, was reviewed with regard to this objective. BEAM, CBV and ICE, the most common chemotherapy regimens can be considered safe as they cause low transplant-related morbidity. The combination of fractionated TBI and etoposide or cyclophosphamide was not found to be superior. However, it must be kept in mind that comparisons were made on registry data or retrospectively. In every case, relapse of the residual primary disease argue for the need for more effective strategies such as tandem transplantation or sequential high-dose chemotherapy with stem-cell support. To obtain an objective evaluation, these new preparative regimens need to be tested in controlled trials with treatment groups stratified for known prognostic factors.

Acute Bleeding After Bone Marrow Transplantation (BMT)— Incidence and Effect on Survival. A Quantitative Analysis in 1,402 Patients

Acute bleeding after bone marrow transplantation (BMT) was investigated in 1,402 patients receiving transplants at Johns Hopkins Hospital between January 1, 1986 and June 30, 1995. Bleeding categorization was based on daily scores of intensity used by the blood transfusion service. Moderate and severe episodes were analyzed for bleeding sites. Analysis of the cause of death and the interval of the bleeding episode to outcome endpoints was recorded. Survival estimates were computed for 1,353 BMT patients. The overall incidence was 34%. Minor bleeding was seen in 10.6%, moderate bleeding was seen in 11.3%, and severe bleeding was seen in 12% of all patients. Fourteen percent of patients had moderate or severe gastrointestinal hemorrhage, 6.4% had moderate or severe hemorrhagic cystitis, 2.8% had pulmonary hemorrhage, and 2% had intracranial hemorrhage. Sixty-one percent had 1 bleeding site and 34.4% had more than 1 site. Moderate and severe bleeding was more prevalent in allogeneic (31%) and unrelated patients (62.5%) compared with autologous patients (18.5%). Significant distribution of incidence was found among the different diagnoses, but not by disease status in acute myeloid leukemia, acute lymphoblastic leukemia, chronic myelogenous leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma. Bleeding was associated with significantly reduced survival in allogeneic, autologous, and unrelated BMT and in each disease category except multiple myeloma. Survival was correlated with the bleeding intensity, bleeding site, and the number of sites. Although close temporal association was evident to mortality, bleeding was recorded as the cause of death in only the minority of cases compared with other toxicities after BMT (graft-versus-host disease, infections, and preparative regimen toxicity). Acute bleeding is a common complication after BMT that is profoundly associated with morbidity and mortality. Although bleeding was not a direct cause of death in the majority of cases, it has a potential prognostic implication as a predictor of poor outcome in clinical assessment of patients after BMT.

Idiopathic pneumonia syndrome after high-dose chemotherapy for relapsed Hodgkin's disease

The risk of idiopathic pneumonia syndrome (IPS) in patients with Hodgkin's disease (HD) undergoing high-dose chemotherapy (HDC) is significant, and once developed IPS is potentially fatal. The aim of this study was to quantify this risk accurately and determine prognostic factors for its development and course. Using a computerized database, all patients with HD treated with BCNU (carmustine) containing HDC and haematopoietic support at The Royal Marsden between November 1985 and March 1994 were identified. Patient characteristics, previous treatments, disease status at HDC, dose of BCNU, incidence and severity of IPS and survival were all determined and analysed. During the study period, 94 patients received HDC, of whom 26 (28%) had a first episode of IPS within a year of HDC and 23 within 6 months. The median time to presentation after HDC was 93 days (range 12-336 days). The only factors that significantly increased the risk of developing IPS on multivariate analysis were dose of BCNU (P for trend = 0.03) and female sex (P = 0.04). Of these 26 patients, 14 had complete resolution of all symptoms, three had persisting pulmonary symptoms at 6 months and the remaining nine died of IPS at a median of 74 days (19-418 days). All the patients who died from IPS had the first symptoms within 6 months of HDC and all received doses of BCNU > 475 mg m(-2) (P for trend = 0.001). For women receiving > 475 mg m(-2) the risk of death was significantly higher than for men (P = 0.035) but not for those receiving < 475 mg m(-2). Previous lung disease, persisting residual disease before HDC, previous bleomycin or previous mantle radiotherapy did not increase either the incidence of IPS or risk of a fatal outcome. We conclude that the main avoidable risk factor for fatal IPS after HDC is dose of BCNU, and this is especially true for women. If < 475 mg m(-2) is given, even patients with previous mantle radiotherapy and/or previous bleomycin have a very low risk of developing fatal lung toxicity if lung function tests are normal.