A supersaturated calcium phosphate solution seems to effectively prevent and treat oral mucositis in haematopoietic stem cell transplanted cancer patients - single centre experience

PURPOSE

Oral mucositis (OM) is one of the most frequent and bothersome complications of high-dose chemotherapy with subsequent auto- and allogeneic haematopoietic stem cell transplantation (HSCT). We have assessed the effectiveness of supersaturated calcium phosphate rinse (Caphosol ®) and palifermin (Kepivance®) in the prophylaxis of OM caused by HSCT.

METHODS

Caphosol® and Kepivance® were prospectively evaluated in OM prophylaxis in 64 patients after HSCT and compared against themselves and an historical control group.

RESULTS

Grade 3 and 4 OM was not observed in patients treated with Caphosol® and palifermin. None of those patients needed total parenteral nutrition (TPN), too. In the Caphosol® group 40.9% of the patients did not develop OM, and 70% of patients treated with palifermin were free of any kind of OM symptoms. In the control group OM was observed in all cases.

CONCLUSION

Caphosol® seems to decrease the incidence, severity and duration of OM, the demand for opioids and for TPN. It needs to be tested in randomized trials, because its easy administration and cost-effectiveness may render it a valuable addition to the standard care in the treatment of OM.

Palonosetron in prevention of nausea and vomiting after highly emetogenic chemotherapy before haematopoietic stem cell transplantation-single center experience

OBJECTIVE

A clinical study of palonosetron was performed to evaluate its efficacy in preventing both acute and delayed emesis after high-dose chemotherapy (HDC) before hematopoietic stem cell transplantation (HSCT) using a historical control group of patients treated with ondansetron as the comparative drug.

METHODS

Among the 46 evaluated patients 20 with lymphoma received BEAM as the conditioning regimen; 16 has relapsed germ cell tumors treated with CARBOPEC; and 10 with acute myeloid leukemia received BuCY. Increasing severity of nausea was evaluated according to the following 4-grade scale: none (no nausea); mild (slight nausea but no disruption to daily activities); moderate (nausea and some disruption to daily activities); and severe (extreme nausea and severe disruption to daily activities). The emetic response rate was evaluated using the criteria: complete (no emetic episode); major (1-2 episodes); minor (3-5 episodes); and failure (>5 episodes). The response rate of the study drugs was evaluated by the following 4-grade scale based on the condition of nausea and vomiting: highly effective, moderately effective, slightly effective, and not effective.

RESULTS

Patients treated with palonosetron showed significantly greater response rates than those receiving ondansetron during the both the acute and the delayed phases: highly and moderately effective: acute phase 15% versus 5% CARBOPEC; 70% versus 35% BEAM and 32% versus 20% BuCY; delayed phase: 60% versus 30% BuCY; 100% versus 50% BEAM and 25% versus 10% CARBOPEC.

CONCLUSIONS

Single-dose palonosetron was more effective than ondansetron treatment to prevent acute and delayed nausea and vomiting following HDC before HSCT.

Palifermin for prevention of oral mucositis after haematopoietic stem cell transplantation- single centre experience

PURPOSE

Oral mucositis (OM) is one of the most debilitating and common side effects in patients treated with high-dose chemotherapy supported by haematopoietic stem cell transplantation (HSCT). We tested the effectiveness of palifermin to avoid oral mucosal injury induced by the conditioning regimen.

PATIENTS AND METHODS

Twenty patients with haematological malignancies were treated with palifermin for prevention of OM during HSCT procedures. Nine patients received allogeneic haematopoietic stem cells, and in 11 autologous HSCT was performed. The control group was composed of patients who had been treated with HSCT previously, before the palifermin era. The source of graft was peripheral blood.

RESULTS

Among patients treated with palifermin no grade 2-4 OM was observed. No patient had to receive opioid analgesics or total parenteral nutrition. 30% of the patients developed grade 1 OM of 4-5 days' duration. In the control group OM was observed in all cases, with 50% of the patients developing grade 3-4 OM. Median duration of OM was 10 and 12 days for auto- and allogeneic patients, respectively. In comparison with the control group, treatment with palifermin was associated with significant reduction of grade 2-4 OM, shorter duration of OM, less analgesics intake, and reduced number of days with antibiotic treatment. Additionally, allogeneic patients treated with palifermin had shorter time to platelet engraftment.

CONCLUSION

Palifermin reduces incidence, severity and duration of OM, and decreases the number of days with analgesics and antibiotics. For allogeneic patients it can shorten the time to platelet engraftment, but this observation needs further studies.

Biochemical indices for the assessment of nutritional status during hematopoietic stem cell transplantation: are they worth using? A single center experience

Hematopoietic stem cell transplantation (HSCT) is being used increasingly in an attempt to cure many hematological disorders, solid tumors and autoimmune diseases. One of the major challenges in the post-transplant period is nutrition. The purpose of this investigation was to assess changes in the biochemical indices of nutritional status during HSCT and compare them with acute-phase protein levels to find the best parameters for nutritional support qualification. Nutritional status was assessed in 54 patients during autologous (30 cases) and allogeneic (24 cases) transplantation. Fifteen patients had to be treated with total parenteral nutrition (TPN), eight of them needing prolonged hospitalization. All nutritional indices and acute-phase protein levels were evaluated during the day before the beginning of conditioning regimen, after chemotherapy completion and every 7 days until engraftment, at least three times after stem cells infusion. Wilcoxon test and canonical analysis were used for statistical analyses. The measurement of retinol-binding protein and transferrin can be useful for nutritional assessment during autologous and allogeneic HSCT, respectively. Prealbumin level, measured 8 days after the end of conditioning regimen, is helpful in making a decision about starting TPN.

Multimodality treatment of germ cell cancer patients who had progression or relapse after high dose chemotherapy and autologous bone marrow transplantation

PURPOSE

When a patient with germ cell tumor (GCT) fails to be cured with high dose chemotherapy (HDC) and autologous haematopoietic stem cell transplantation (auto- BMT) the overall prognosis is very poor and any further treatment has only palliative character. A question requiring answer is how intense should this kind of treatment be, and what can be expected from it.

PATIENTS AND METHODS

Of 44 patients with GCT who were transplanted after HDC in our centre between 1999- 2005, 17 experienced treatment failure. Amongst them 14 had marker-positive relapse or confirmed germ cell histology. Another 3 had second primary neoplasms. Of the 17 patients 14 received further treatment that consisted of surgery alone in 2, chemotherapy in 2, radiotherapy in 1, combined surgery + chemotherapy in 5, chemotherapy +surgery + radiotherapy in 3 and chemotherapy + radiotherapy in 1 patient.

RESULTS

The median survival from the time of relapse was 3 months in all patients, and 6 months in the 14 patients who received further treatment. In 6 patients with relapse confined to a single site the median survival was 11 months. Three patients in this group are alive with overall survival (OS) of 37.4+, 24.3+ and 6.2+ months (all had multimodal treatment: chemotherapy + surgery or radiotherapy, and all achieved durable complete response/CR).

CONCLUSION

Our results suggest that GCT patients who have relapsed/ progressed after HDC may benefit from further treatment. Best chances for long term survival have those who experience relapse confined to one metastatic site and receive combined treatment (surgery or radiotherapy plus systemic therapy).

Nutritional assessment during allogeneic hematopoietic stem cell transplantation: single centre experience

PURPOSE

The aim of this study was to analyse the changes in several parameters of nutritional status, acute phase proteins' levels and evaluation of the usefulness of the investigated parameters for qualification for total parenteral nutrition (TPN) during allogeneic hematopoietic stem cell transplantations (HSCT).

PATIENTS AND METHODS

The nutritional status was assessed in 24 patients. Biochemical and anthropometric indices of nutritional status as well as body fat and resting energy expenditure were assessed. The levels of acute phase proteins were estimated at the same time. All parameters were evaluated during the day before starting a conditioning regimen, after chemotherapy completion and every 7 days until engraftment, at least 3 times after stem cells infusion. Wilcoxon test and canonical analysis were used for statistical analyses.

RESULTS

The measurement of body weight and estimation of transferrin levels can be useful for the nutritional assessment during allogeneic HSCT from sibling donors. Prealbumin level, measured 8 days after the conditioning regimen, can be helpful to make a decision for TPN. Statistically significant differences were found in the levels of biochemical indices of nutritional status and in resting energy expenditure (REE) between patients who received stem cells from the bone marrow and from peripheral blood. Values were lower and decreased earlier after transplantation when bone marrow was the source of HSCT.

CONCLUSION

These findings may indicate that the influence of transplantation procedures over patients' nutritional status is bigger when bone marrow is used as a source of hematopoietic stem cells.

How can we help patients with refractory chronic graft versus host disease- single centre experience

Chronic graft-versus-host disease (cGVHD) is a major cause of morbidity and mortality in long-term survivors of allogeneic haematopoietic stem cell transplantation (alloHSCT). Ocular involvement as well as dermal sclerosis, joint contractures and pathological changes in oral cavity are often refractory to treatment. This kind of patients require complex aggressive immunosuppressive therapy. We are still waiting for drugs against cGVHD, characterized by decreased infectious complications, encouraging efficacy and rare and reversible side effects. We describe eight patients who developed extensive chronic graft versus host disease with eye involvement after alloHSCT. All had ocular manifestations, which were refractory to the first and second line of systemic immunosuppressive therapy. All patients responded to the topical cyclosporine therapy, but clinical improvement was seen only since the fifth month of starting treatment. Topical cyclosporine was well tolerated. Other four patients with sclerodermoid type of skin changes, refractory to second line systemic immunosuppressive therapy, were treated with clofazimine. Clofazimine is a drug used to treat leprosy. Because of its anti-inflammatory effects, clofazimine is used also as a second or third line therapy for various skin disorders including: pyoderma gangrenosum, lupus erythematosus, palmoplantar pustulosis and chronic graft versus host disease. All patients,who received clofazimine due to dermal sclerosis, joint contractures and oral manifestations, achieved partial or complete responses and were able to reduce other immunosuppressive drugs. Clofazimine was generally well tolerated.