Anti-infective vaccination strategies in patients with hematologic malignancies or solid tumors-Guideline of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO)

Infectious complications are a significant cause of morbidity and mortality in patients with malignancies specifically when receiving anticancer treatments. Prevention of infection through vaccines is an important aspect of clinical care of cancer patients. Immunocompromising effects of the underlying disease as well as of antineoplastic therapies need to be considered when devising vaccination strategies. This guideline provides clinical recommendations on vaccine use in cancer patients including autologous stem cell transplant recipients, while allogeneic stem cell transplantation is subject of a separate guideline. The document was prepared by the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) by reviewing currently available data and applying evidence-based medicine criteria.

A New Approach to Phenotyping Disseminated Tumor Cells: Methodological advances and Clinical Implications

At the time of primary therapy (surgery, systemic chemotherapy and/or radiation), disseminated tumor cells in the bone marrow can be found in almost one-third of patients with cancer of the breast, ovary, esophagus, stomach, colon, and other solid tumors. Whereas the prognostic impact of the mere presence of these cells is still a matter of debate, it has been shown that expression of tumor-associated antigens in disseminated tumor cells is linked to more aggressive disease. Therefore, further characterization of disseminated tumor cells at the protein and gene level has become increasingly important. To date, the most common detection method for disseminated tumor cells in the bone marrow is an immunocytochemical approach using cytokeratin-directed antibodies for detection of epithelial cells and the APAAP system for their visualization. We have established a new double immunofluorescence technique enabling simultaneous detection, phenotyping, and antigen quantification of disseminated tumor cells. Mononuclear cells from bone marrow are enriched by Ficoll gradient centrifugation and cytospins are prepared. Double immunofluorescence is performed using antibodies against cytokeratins 8/18/19 (mAb A45B/B3) and the uPA receptor CD87 (pAb HU277). CD87 expression is recorded by confocal laser scanning microscopy (CLSM) using fluorescence labeled latex beads as the reference; staining intensities of all the scans are then summed and quantified (extended focus). This protocol, originally designed for disseminated tumor cells in bone marrow, can also be applied to disseminated tumor cells in blood, to leukapheresis cells or to cells present in malignant ascites or other malignant effusions. The tumor cells detected may be used for gene and mRNA analyses. Furthermore, disseminated tumor cells also represent interesting targets for clinical studies on patient prognosis or prediction of therapy response as well as for specific tumor-biological therapies.

Diagnosis and empirical treatment of fever of unknown origin (FUO) in adult neutropenic patients: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Fever may be the only clinical symptom at the onset of infection in neutropenic cancer patients undergoing myelosuppressive chemotherapy. A prompt and evidence-based diagnostic and therapeutic approach is mandatory. A systematic search of current literature was conducted, including only full papers and excluding allogeneic hematopoietic stem cell transplant recipients. Recommendations for diagnosis and therapy were developed by an expert panel and approved after plenary discussion by the AGIHO. Randomized clinical trials were mainly available for therapeutic decisions, and new diagnostic procedures have been introduced into clinical practice in the past decade. Stratification into a high-risk versus low-risk patient population is recommended. In high-risk patients, initial empirical antimicrobial therapy should be active against pathogens most commonly involved in microbiologically documented and most threatening infections, including Pseudomonas aeruginosa, but excluding coagulase-negative staphylococci. In patients whose expected duration of neutropenia is more than 7 days and who do not respond to first-line antibacterial treatment, specifically in the absence of mold-active antifungal prophylaxis, further therapy should be directed also against fungi, in particular Aspergillus species. With regard to antimicrobial stewardship, treatment duration after defervescence in persistently neutropenic patients must be critically reconsidered and the choice of anti-infective agents adjusted to local epidemiology. This guideline updates recommendations for diagnosis and empirical therapy of fever of unknown origin in adult neutropenic cancer patients in light of the challenges of antimicrobial stewardship.

[Specific infections in organ transplantation]

This article is concerned with the important topic of infections associated with organ transplantation and includes a discussion on four subtopics. The first section describes the current options in the prevention and therapy of viral hepatitis in association with liver transplantation. Infections with hepatitis B, C, D (delta) and E are discussed with special emphasis on the interferon-free treatment of hepatitis C with the new antiviral drugs.The second section deals with Pseudomonas aeruginosa (PA) infections following lung transplantation (LuTx), which is one of the most frequently detected pathogens in the airway after LuTx. Patients with cystic fibrosis are particularly affected. This is important because studies have shown a clear correlation between chronic PA infections after LuTx and development of chronic transplant failure. Even if the data are still sparse, recommendations on prevention and therapeutic strategies are given. The theme of the third section is the high importance of viral infections after kidney transplantation. In addition to acquired infections, the transplanted organ as well as the recipient can be the source of the infection. The better the transplanted organ is tolerated under moderate immunosuppression, the less common and severe virus infections are. The focus of this section is on three common pathogens: cytomegalovirus, polyomavirus BK and hepatitis viruses.The final section deals with Aspergillus infections following transplantation of various organs. In this context Aspergillus spp. are one of the most commonly occurring fungal diseases. The epidemiology, risk factors, diagnostics, prophylaxis and therapy of invasive aspergillosis are presented.

Pharmacology and metabolism of voriconazole and Posaconazole in the treatment of invasive aspergillosis: review of the literature

Invasive fungal infections, predominantly aspergillosis and candidiasis, are among the most important causes of morbidity and mortality in immunocompromised patients. Primarily, patients with acute leukemia undergoing myelosuppressive chemotherapy and allogeneic stem cell transplant recipients are affected. Up to 60% of patients with invasive aspergillosis, the most common invasive mycosis among patients with hematologic malignancies, may still die of their infection, once it has become clinically overt. The spectrum of antifungal agents for clinical use now has expanded over the past ten years and includes the novel class of the echinocandins and two newer generation triazoles with an extended spectrum of activity against a wide range of fungal pathogens. This review will address pharmacological characteristics of the two broad-spectrum antifungal azoles, voriconazole and Posaconazole, which are important for their proper use in clinical practice.

[A 65-year-old female patient with breast cancer accompanied by thrombocytopenia and hyperfibrinolysis]

Tumor diseases can be accompanied by paraneoplastic syndromes. Low platelet counts and hyperfibrinolysis led to the diagnosis of recurrent breast cancer in this case. A tumour disease with disturbed hemostasis caused by both plasmatic coagulation and thrombocytopenia has not yet been reported.

Phase I/II trial of multicycle high-dose chemotherapy with peripheral blood stem cell support for treatment of advanced ovarian cancer

Ovarian cancer is chemosensitive, but most patients with advanced disease die from tumor progression. As 25% of the patients can be cured by chemotherapy, it is reasonable to evaluate high-dose chemotherapy (HDCT). Forty-eight patients with untreated ovarian cancer were entered in a multicenter phase I/II trial of multicycle HDCT. Median age was 46 (19-59 years); International Federation of Gynecology and Obstetrics-stage was III in 79% and IV in 21%; 31% had residual disease >1 cm after surgery. Two courses of induction/mobilization therapy with cyclophosphamide (250 mg/m2) and paclitaxel (250 mg/m2) were used to collect peripheral blood stem cells. HDCT consisted of two courses of carboplatin (area under curve (AUC) 18-22) and paclitaxel followed by one course of carboplatin and melphalan (140 mg/m2) with or without etoposide (1600 mg/m2). Main toxicity was gastrointestinal. Limiting carboplatin to AUC 20 and eliminating etoposide resulted in manageable toxicity (69% without grade 3/4 toxicity). One patient died from treatment-related pneumonitis. At 8 years median follow-up, median progression-free-survival (PFS) and overall survival (OS) is 13.3 and 37.0 months. Five-years PFS and OS is 18 and 33%. Multicycle HDCT is feasible in a multicenter setting. A European phase III trial based on this regimen is evaluating the efficacy of HDCT.

Antiviral prophylaxis in patients with haematological malignancies and solid tumours: Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Oncology (DGHO)

Morbidity and mortality in patients with malignancies are increased by viral infections. These mostly are reactivations of asymptomatic latent infections. They primarily concern clinical entities associated with the reactivation of herpes viruses, such as varicella zoster virus (VZV) and cytomegalovirus (CMV). Respiratory tract infections caused by influenza, parainfluenza or respiratory syncytial virus (RSV) are less common. Since reactivation of latent infections has major clinical impact, antiviral prophylaxis is an attractive approach for patients expecting immunosuppression. The main risk factor for clinically relevant reactivation is profound disruption of cellular immune response. Duration and severity of chemotherapy induced neutropenia are of lesser importance. The risk of viral complications rises significantly in the presence of sustained suppression of T-cell function, e.g. in recipients of allogeneic stem cell transplants or of alemtuzumab (Campath-1H) antibody therapy. The objective of this guideline is to review the basis of prophylactic strategies and to provide recommendations for clinicians treating patients with haematological malignancies and solid tumors.

Pitfalls in imaging Hodgkin's disease with computed tomography and positron emission tomography using fluorine-18-fluorodeoxyglucose

We report on a patient with Hodgkin's disease who presented with hypodense splenic lesions and corresponding increased glucose metabolism in FDG-PET imaging, four months after completion of initial treatment, suggestive of early relapse. Serological testing for toxoplasma gondii, however, showed evidence of a recently reactivated or newly acquired infection. Three weeks after immediate antibiotic treatment with Daraprime and Sulfadiazin, the splenic lesions had completely resolved. Additionally, serological titers for toxoplasma gondii were normalized and whole body FDG-PET imaging showed no metabolic activity. Although the positive predictive value of PET imaging to indicate lymphoma is reported to be higher than CT, hypermetabolic lesions are not specific for malignant tissue. Whereas benign tumors typically show low glucose metabolism, activated granulocytes and macrophages may display significantly increased glucose consumption. In conclusion, our case report shows that although therapeutic decisions are often based on the results of imaging modalities, the taking of a detailed history and the acquisition of histological confirmation of the suspected lymphoma relapse are also advisable where possible. Cellular immunodeficiency can result in severe infections even in patients with intermediate stage Hodgkin's lymphoma in remission after combined modality treatment. Therefore, despite the high sensitivity of FDG-PET imaging for the detection of recurrent lymphoma, the differential diagnosis of infectious lesions should be kept in mind, in particular in immunocompromised patients.

Epstein-Barr virus-negative Hodgkin's lymphoma after mycosis fungoides: molecular evidence for distinct clonal origin

The association of mycosis fungoides (MF) and Hodgkin's lymphoma is a relatively frequent occurrence, but the potential clonal relationship of the two neoplasms is still controversial. We report a case of a patient with a history of MF in Clinical Stage 1A who developed retroperitoneal lymphadenopathy 9 years after the initial diagnosis of MF. A bone marrow biopsy obtained at this time showed nodular involvement by a mixed cellular infiltrate with large, atypical cells consistent with Hodgkin and Reed-Sternberg (RS) cells. These atypical cells were positive for CD30 and CD15 and did not express B- or T-cell markers. In addition, they lacked evidence of infection by Epstein-Barr virus, both by immunohistochemical staining for latent membrane protein 1 and by in situ hybridization for EBER1/2. The background population consisted mainly of small T cells without morphological or phenotypical signs of malignancy. Review of the skin biopsy obtained 9 years before showed the typical features of MF. Polymerase chain reaction analysis of the T-cell receptor T-gene confirmed the presence of a clonal T-cell rearrangement in the skin specimen. The bone marrow biopsy, however, showed a polyclonal pattern both for the T-cell receptor gamma-gene, as well as for immunoglobulin heavy chain genes. Isolation of RS cells stained for CD30 was performed by laser capture microdissection. Polymerase chain reaction analysis of several groups of RS cells showed a reproducible biallelic rearrangement of IgH genes, which was confirmed by cloning and sequencing of polymerase chain reaction products. To our knowledge, this is the first case in which a distinct clonal origin of MF and Hodgkin's lymphoma arising in the same patient is clearly demonstrated, based on molecular analysis of microdissected RS cells.

Thrombotic thrombocytopenic purpura in metastatic carcinoma of the breast

We present a case of a 52-year-old woman with thrombotic thrombocytopenic purpura associated with progressive metastatic adenocarcinoma of the breast. The patient received plasma exchange therapy. Thrombocytopenic purpura resolved 2 months after discontinuation of plasma exchange while the patient received chemotherapy. After 3 more months, a fulminant relapse of the thrombocytopenic purpura developed, and there were signs of tumor progression. She died despite adequate treatment. We conclude that effective treatment of the underlying tumor can be crucial to control cancer-associated thrombocytopenic purpura.

Molecular evidence of bone marrow involvement in advanced case ot Tgammadelta lymphoma with secondary myelofibrosis

We describe the case of a middle-aged man with long indolent course of generalized Tgammadelta lymphoma. The onset of secondary myelofibrosis made cytological monitoring of the bone marrow infiltrates impossible. As during progression of the disease splenectomy revealed typical histological features of a high-grade hepatosplenic Tgammadelta lymphoma, the low-grade bone infiltrate was considered a secondary lymphoma. The use of the polymerase chain reaction helped to detect a constant and identical monoclonal rearrangement pattern of the T-cell receptor gamma-chain gene in both bone marrow and splenic T-cell infiltrates. The notion of a secondary spread of malignant T-cells to the bone marrow was thereby confirmed despite striking cytological differences between bone marrow and splenic infiltrates. This is the first report of a diagnostic DNA-based molecular approach using fixed decalcified bone marrow. This method may provide a major tool when dealing with myelofibrosis, which normally hampers sampling of cytological specimens.

Rearranged Ig heavy chain DNA is detectable in cell-free blood samples of patients with B-cell neoplasia

Tumor-derived DNA has been shown in various cell-free body fluids. In this study, soluble tumor-derived DNA was analyzed in serum and plasma samples of patients with B-cell malignancies. DNA was extracted from tumor cell specimens as well as serum and plasma samples collected from 110 patients with non-Hodgkin's lymphoma and acute B-precursor lymphoblastic leukemia and was subjected to polymerase chain reaction (PCR) analysis for rearranged immunoglobulin heavy chain DNA. In 54% of serum or plasma samples analyzed at different times before and during treatment, clonal DNA from a rearranged immunoglobulin heavy chain locus was detectable. When examined at diagnosis and before any treatment, clonotypic DNA was found in serum or plasma of 86% of the patients. Serum or plasma from patients with systemic or bulky disease was uniformly PCR positive, whereas clonotypic DNA was also recovered from the serum or plasma from the majority of patients with limited disease stages. Degradation of clonal DNA by nucleases in vitro was shown to be one cause of false-negative PCR results. This technical drawback can be relieved by adding a nuclease inhibitor like EDTA, ie, by using plasma instead of serum for PCR analysis. Treatment of patients with cytotoxic drugs was followed by rapid clearance of DNA from the peripheral blood, suggesting that soluble tumor-derived DNA might be associated with viable and proliferating tumor cells. Follow-up studies showed a close correlation of persisting soluble tumor-derived DNA with resistant disease or early relapse. In summary, these data suggest that tumor-derived DNA can be detected in serum or plasma of the majority of patients with B-cell malignancies and that testing of serum or plasma for tumor-associated DNA may be a novel parameter for monitoring response to treatment.

Haematopoietic reconstitution after autologous transplantation of CD34(+)-selected versus non-selected peripheral blood progenitor cells

Selection of CD34+ cells for autologous transplantation is increasingly being used to reduce potential tumor cell contamination of the autograft. Haematopoietic reconstitution in 40 patients after transplantation of CD34(+)-selected versus non-selected G-CSF-mobilized PBPC was compared and was almost identical in the two groups of patients. Delayed platelet engraftment was only observed in patients transplanted with a CD34+ cell dose of < 2.5 x 10(6)/kg body weight. It has to be shown whether the positive selection of CD34+ cells will improve the disease free survival after autologous PBPC transplantation.