Second malignancy following high-dose therapy and autologous stem cell transplantation: incidence and risk factor analysis

To establish incidence and risk factors for development of second malignant neoplasms after high-dose chemo/radiotherapy (HDT) and autologous hematopoietic stem cell transplantation (AHSCT), the case files of 800 consecutive patients who underwent AHSCT at our institution between June 1982 and December 2000 were reviewed. In all, 26 patients developed 29 second malignancies (nine myelodysplastic syndrome (MDS)/acute myelogenous leukemia (AML), 16 solid tumors and four lymphoproliferative disorders (LPDs)) for a 15-year cumulative incidence of 11% (95% confidence interval (CI), 5-18%). These second tumors occurred at a median of 68 (range 1.5-177) months following AHSCT. The relative risk (RR) compared to the general population of developing a second malignancy following AHSCT was 3.3 (CI 2.2-4.7) P<0.001. The RR of developing MDS/AML, LPD and a solid tumor was 47.2 (CI 21.5-89.5) P<0.001, 8.1 (2.2-20.7) P=0.002 and 1.98 (1.1-3.2) P=0.009, respectively. In multivariate analysis, age >or=35 years at the time of AHSCT (P=0.001) and an interval from diagnosis to AHSCT >or=36 months (P=0.03) were associated with a greater risk of developing a second malignancy. Patients who have undergone HDT and AHSCT are at significant risk for developing a second malignancy and should receive indefinite follow-up.

Cytogenetic abnormalities in primary myelodysplastic syndrome are highly predictive of outcome after allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) is the only curative therapy available for patients with myelodysplastic syndrome (MDS). In an attempt to identify prognostic factors influencing outcome, we collected data retrospectively on 60 consecutive adult patients who had undergone BMT at our center for primary MDS or acute myelogenous leukemia evolving from preexisting primary MDS (sAML). Patients were divided into subgroups according to cytogenetic abnormalities based on a recently described International MDS Workshop categorization system. The 7-year actuarial event-free survival (EFS), relapse rate, and nonrelapse mortality (NRM) for all patients were 29% (95% confidence interval [CI], 16% to 43%), 42% (CI, 24% to 67%), and 50% (CI, 37% to 64%), respectively. The EFS for the good-, intermediate-, and poor-risk cytogenetic subgroups were 51% (CI, 30% to 69%), 40% (CI, 16% to 63%), and 6% (CI, 0% to 24%), respectively (P = .003). The corresponding actuarial relapse rates were 19% (CI, 6% to 49%), 12% (CI, 2% to 61%), and 82% (CI, 48% to 99%), respectively (P = . 002) with no difference in NRM between the subgroups. Univariate analysis showed cytogenetic category, French-American-British (FAB) subtype, and graft-versus-host disease (GVHD) prophylaxis used to be predictive of relapse and EFS. In multivariate analysis, only the cytogenetic category was predictive of EFS, with the relative risk of treatment failure for the good-, intermediate-, and poor-risk cytogenetic subgroups being 1.0, 1.5, and 3.5, respectively (P = . 004). For adults with primary MDS and sAML, even after BMT, poor-risk cytogenetics are predictive of an unfavorable outcome; novel treatment strategies will be required to improve results with allogeneic BMT in this patient population.

High incidence of extramedullary relapse of AML after busulfan/cyclophosphamide conditioning and allogeneic stem cell transplantation

While allogeneic stem cell transplantation (SCT) is curative for a significant number of patients with AML, relapse of disease within the bone marrow and/or extramedullary (EM) sites following high-dose therapy continues to limit the success of this treatment. Between October 1985 and December 1996, 81 adults underwent allogeneic SCT for de novo AML at our centre. Forty-two patients remain alive and free of leukaemia with a median follow-up of 50 months. The 5-year actuarial event-free survivals (EFS) for all patients and for those undergoing SCT in CR1 or with advanced disease were 46% (95% confidence interval (CI) 34-58%), 63% (CI 46-76%), and 19% (CI 7-36%), respectively. Twenty-two patients relapsed at a median of 8 (range 1.6-54.5) months with the actuarial risk of relapse for all, CR1 and advanced disease patients being 38%, (CI 27-52%), 23% (CI 13-40%) and 68% (CI 46-88%), respectively. Ten patients relapsed at EM sites; six of these (27% of relapses) had an isolated EM relapse at a median of 31 (range 8.5-54) months. Three of the patients with isolated EM relapse survived > or =24 months following relapse and two patients remain disease-free at 29+ and 33+ months. BuCy conditioning followed by allogeneic SCT in AML results in satisfactory EFS although there is a significant risk of late isolated EM relapse.

Testicular relapse of acute promyelocytic leukemia after allogeneic BMT

After treatment of acute leukemia (typically ALL and the monocytic variants of AML), relapse may occur at sites other than the marrow. Isolated extramedullary relapse of acute promyelocytic leukemia (APL) however, is rare. We describe such an event in a man who underwent allogeneic BMT for APL in second relapse and 4 years later presented with testicular relapse. The marrow was morphologically and cytogenetically normal, but RT-PCR analysis revealed the specific PML/RAR chimeric RNA transcript.

Trisomy 14 is a non-random karyotypic abnormality associated with myeloid malignancies

Isolated gain of chromosome 14 (trisomy 14 or +14) has been reported in myeloid malignancy. Seven cases were identified by review of all diagnostic bone marrow specimens with cytogenetics performed at our institution from 1983 to 1995. Median age was older (72 years) and diagnosis was myelodysplasia in the majority of cases. Although trilineage dysplasia occurred, platelet counts were relatively well preserved (median 131 x 10(9)/l). Mosaic karyotype (normal plus abnormal metaphases) was seen in the majority of cases, and survival from diagnosis was short (<2 years). These features are consistent with data from 30 previously published cases, and support the hypothesis that trisomy 14 occurs as a non-random cytogenetic abnormality in association with myeloid malignancy.

Induction failure in de novo acute myelogenous leukemia is associated with expression of high levels of CD34 antigen by the leukemic blasts

The prognostic significance of CD34 antigen expression in acute myelogenous leukemia (AML) is controversial. Most studies to date have reported on CD34 positivity and not the level of antigen present. In this study of 62 patients with de novo AML, 48 (77%) patients were CD34+ in varying levels (0-85 mean channels of fluorescence (MCF)). Forty seven of 62 were treated with combination chemotherapy and 39 (83%) of them achieved complete remission (CR). Patients with CD34- blasts were more likely to achieve CR; however, this trend was not statistically significant (p = .11). On the other hand, patients with higher levels of CD34 antigen on the blasts were less likely to attain CR (p < 0.001, multivariate analysis). The patients who achieved CR expressed lower levels of CD34 (0-57; median 9 MCF) as compared to those who did not achieve CR (15-85; median 30 MCF). Of the other antigens tested, partial or complete absence of CD33 (CD33 absent in > or =25% blasts) correlated with failure to achieve CR (p = 0.0029). These results are in keeping with the hypothesis that more primitive AML blasts with high levels of CD34 are chemoresistant.

Criteria for marrow engraftment: comparison of reticulocyte maturity index with conventional parameters

Reticulocyte maturity index (RMI) has recently been proposed as an early indicator of marrow engraftment. We compared the RMI with conventional bone marrow engraftment criteria including total leukocyte count (WBC), absolute neutrophil count (ANC), reticulocyte count (RC) and the day of last platelet transfusion required to maintain the platelet count (PC) > or = 20 x 10(9)/l in 37 patients undergoing allo- or autologous BMT. There was no discrepancy in predicting engraftment between RMI, ANC, WBC and RC. RMI indicated engraftment earlier (median day 17, range 10-63 days) than the ANC (median day 19, range 8-63 days), WBC (median day 19, 9-71), RC (median day 19, 11-125) or PC (median day 29, 11-237). RMI heralded engraftment preceded ANC, WBC, RC or PC in 22, 21, 34 and 32 patients, respectively. RMI signal occurred 6 days prior to the rise in ANC in patients who engrafted later than 25 days (n = 7). Trend analysis showed that ANC fluctuated more frequently (6/37 patients) than RMI (1/37). Combined use of ANC and RMI (whichever increased first) predicted engraftment earlier (median 15 days) and more confidently (no false starts) than either used alone.

Acute monocytic leukemia: a single institution experience

Using strict FAB criteria, 39 cases of monocytic leukemia were identified in 463 consecutive cases of AML. Patients had a median age of 49 with no sex predominance. Extramedullary disease and hyperleukocytosis were common (54% and 36% of patients respectively). Cytogenetic analysis was successful in 38 of 39 patients; 71% had a cytogenetic abnormality and 42% of these involved chromosome 11; 14 of 16 chromosome 11 abnormalities involved the region of 11q23. Non-chromosome 11 abnormalities tended to occur in older patients and to be associated with a lower platelet count; patients with the translocation 9;11 tended to have a lower white count and a higher incidence of therapy-related leukemia. 35 patients were treated with induction therapy including intensive chemotherapy (n = 33) and allogeneic BMT at presentation (n = 2). Patients who entered remission underwent consolidation chemotherapy, autologous BMT, or allogeneic BMT depending on policies at the time of diagnosis. Of 6 patients who underwent further intensive chemotherapy there is 1 long-term disease-free survivor. 3 of 8 patients undergoing autologous BMT and 2 of 3 patients undergoing allogeneic BMT are long-term disease-free survivors. We conclude that this specific subtype of AML, relatively rare when strict criteria are applied, is associated with unique biologic and clinical features and that the high relapse rate associated with conventional therapy makes new treatment approaches involving stem cell transplantation or immunomodulation necessary.

Blood transfusion as a cause of leucocytosis in critically ill patients

The diagnosis of infection in the intensive care unit is confounded by the presence of non-infectious causes of leucocytosis. Unless such causes are recognised, time and effort will be spent on unnecessary investigations and treatments. In a prospective study we have shown that the transfusion of blood frequently (45/50 patients) causes an acute leucocytosis in such patients. This effect was not seen in 8 patients who received plasma. Blood transfusion should be added to the list of non-infectious causes of leucocytosis in the critically ill.

Con: desmopressin is not of value in the treatment of post-cardiopulmonary bypass bleeding

Following two early promising reports that treatment with intravenous DDAVP was helpful in reducing postoperative hemorrhage and the amount of transfusion with homologous blood products in patients who had undergone cardiac surgery with CPB, these results were not repeated in any of the follow-up studies. At the present time, the routine prophylactic use of DDAVP in cardiac surgery cannot be recommended for patients undergoing closure of atrial septal defect, valve repair or replacement, primary CABG, or in children requiring cardiac surgery. The use of DDAVP in complicated procedures or for control of severe postoperative bleeding remains controversial. In the authors' opinion, DDAVP should not be used in cardiac surgery except in patients with a presurgical DDAVP-responsive coagulopathy.

Hemoglobin CHarlem (Georgetown) trait in British Columbia

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A trial of desmopressin (1-desamino-8-D-arginine vasopressin) to reduce blood loss in uncomplicated cardiac surgery

Previous studies have suggested that desmopressin may reduce the bleeding diathesis that often complicates open-heart surgery. To pursue this question further, we performed a double-blind, randomized, placebo-controlled trial to determine whether the previously reported beneficial effect of desmopressin on hemostasis during complex cardiac surgery was applicable to all elective cardiac surgical procedures involving cardiopulmonary bypass. In 150 consecutive patients, most of whom underwent primary coronary-artery bypass grafting, we compared the effects of intravenous desmopressin (0.3 microgram per kilogram of body weight) with those of saline placebo on postoperative blood loss and the need to replace blood products. The median amount of blood lost within the first 24 hours after operation was similar in the desmopressin and placebo groups (865 vs. 738 ml; P = 0.26). The postoperative use of blood replacement products did not differ significantly between the groups (1025 ml [95 percent confidence interval, 300 to 4140 ml] in the desmopressin group and 860 ml [247 to 5346 ml] in the placebo group). Desmopressin is believed to exert its hemostatic effect by releasing von Willebrand factor. The level of ristocetin cofactor, a functional index of the level of von Willebrand factor, was increased approximately twofold from base line in both treatment groups 90 minutes and 24 hours after the administration of medication. Similarly, the levels of von Willebrand factor multimers increased uniformly in both groups. These findings may be consistent with a normal stress response of von Willebrand factor to major surgery and could explain our failure to detect a therapeutic effect of desmopressin. We conclude that the majority of patients who undergo elective cardiac surgery receive no hemostatic benefit from the use of desmopressin.

Allogeneic bone marrow transplantation for Philadelphia-chromosome positive acute lymphoblastic leukemia

Allogeneic bone marrow transplantation (BMT) produced remission in three patients with Philadelphia-chromosome (Ph1)-positive acute lymphoblastic leukemia (ALL) in relapse. Two patients had remissions which lasted longer than two years. Since the prognosis of Ph1-positive ALL treated with conventional therapy is poor, BMT is indicated in first remission in this disease.

The response of an acquired Factor V inhibitor to activated Factor IX concentrate

A 91-year-old man developed a severe bleeding diathesis postoperatively. Laboratory studies showed an inhibitor to factor V which was identified as IgG. The patient failed to respond to fresh-frozen plasma and platelet transfusions, but demonstrated both clinical and laboratory improvement after transfusion with an activated prothrombin complex concentrate (Autoplex). Patients with refractory inhibitors to factors VIII or IX have been managed successfully with this concentrate; however, this case demonstrates that is also may be of value in managing patients with refractory inhibitors to factor V.

Acquired hemolytic anemia due to "auto"-anti-A or "auto"-anti-B induced by group O homograft in renal transplant recipients

Three patients developed severe but self-limited hemolytic anemia within 2 weeks of renal transplantation. All three had received kidneys from cadaver donors who were blood group O. Two of the recipients were blood group B while the third was blood group A. There was no pretransplant preparation of the donors or the recipients. Preoperative crossmatch and antibody screen were negative; however, subsequent to the hemolytic episodes, group-specific blood was incompatible and the patients were transfused with group O crossmatch-compatible blood. Blood bank serological tests showed a positive direct antiglobulin test (DAT), and anti-A and anti-B were eluted from group A and B patients, respectively. There was no evidence of hemolysis despite the positive DAT at 37 days following transplantation in two of the three patients who were maintained on cyclosporine immunosuppression. Retrospective analysis of renal transplant records showed that these "autoantibodies" appeared in three of the four renal transplant recipients who were on an immunosuppressive regimen of cyclosporine , with or without prednisone, but not in the 21 recipients who received radiotherapy to the donor kidney in addition to cyclosporine or azathioprine (p = less than 0.001). The possible pathogenetic mechanism for "autoantibody" formation by donor kidney and the role of immunosuppressive agents are discussed.

Prospective randomized trial of piperacillin monotherapy versus carboxypenicillin-aminoglycoside combination regimens in the empirical treatment of serious bacterial infections

Piperacillin as a single agent was compared in a prospective randomized trial with carboxypenicillin-aminoglycoside combinations in empirical therapy of serious bacterial infections. The difference in the clinical response rates with piperacillin (77% of 26 infection episodes) and combination therapy (75% of 24 infection episodes) were not statistically significant. Fewer adverse effects occurred in the piperacillin-treated group (42%) than in the combination-treated group (71%) (P = 0.0399 by Fisher's exact test), although neither nephrotoxicity nor hypokalemia alone was significantly less frequent in patients receiving piperacillin. However, the emergence of resistant organisms during therapy was more frequent among patients receiving piperacillin alone (42% of patients) than among patients receiving combination therapy (17% of patients) (P = 0.465 by Fisher's exact test). Moreover, emergence of resistance accounted for 5 of 9 patients with treatment failure, superinfection, or both when piperacillin was used as a single agent, compared with 2 of 10 similar patients in the combination group (P = 0.1299 by Fisher's exact test). The use of piperacillin as a single agent in the treatment of serious bacterial infections is not advocated, and the addition of an aminoglycoside to prevent emergence of resistance during empirical therapy of such infections is strongly recommended.

Ultrasonography and computed tomography of hepatic candidiasis in immunosuppressed patients

The ultrasonic appearance of Candida infection in the livers of immunosuppressed patients is quite characteristic. Cystic, target-like lesions were found in three patients receiving chemotherapy for myeloproliferative diseases. The computed tomographic appearance is less characteristic. A possible explanation for the appearance of these lesions is presented.

Intramural hematoma of the gastric cardia

A case of intramural hematoma of the gastric cardia occurring in a young woman with S.L.E. and on warfarin is presented and discussed. This unusual case illustrates the importance of careful evaluation of radiological mass lesions of the cardia.