Endonasal endoscopic approach for sellar metastatic pathologies: a national observation

PURPOSE

Sellar metastases are rare lesions. Recent improvements in diagnosis and treatment strategies have prolonged survival but increased the probability of metastatic tumors. Evaluation with clinical symptomatology and meticulous laboratory examination is crucial. We present our multicenter national study on sellar metastases to evaluate and underline the main clinical, endocrine, and radiological considerations regarding the diagnosis and endonasal endoscopic management of such rare lesions.

METHODS

A medical literature-based retrospective study was planned across 13 neurosurgical centers in Turkey, where a data survey was conducted to collect information regarding sellar metastases surgically treated using the endoscopic endonasal approach, including clinical presentation, radiographic features, primary tumor origin, histopathological confirmation, time to metastasis, treatment, and patient outcomes.

RESULTS

Between 2010 and 2020, 54 patients (22 women [40.7%] and 32 men [59.3%]) who underwent surgery with the endonasal endoscopic approach and had pathologically proven sellar metastases (overall incidence, 0.54%) were included. Of the patients, 59.3% had no known malignancy and presented with new-onset symptoms, 79.6% reported headache, 51.9% complained of some degree of visual deficits, and 50% had cranial nerve symptoms. Tissue biopsy was performed in 7.4% of the patients, whereas gross or subtotal resection was achieved in the remaining patients.

CONCLUSION

To our knowledge, this is the largest series of patients surgically treated with the endonasal endoscopic approach for sellar metastases. For these patients, the treatment focus should be on management modalities for increasing quality of life instead radical treatment options with survival benefit.

Allogeneic Hematopoietic Stem Cell Transplantation for Primary Myelofibrosis: A 20-year Experience in a Single Center

Background

Allogeneic hematopoietic stem cell transplantation is a well-established approach for patients diagnosed with primary myelofibrosis and remains the only potentially curative treatment.

Aims

To present the overall outcome of patients with myelofibrosis treated with allogeneic hematopoietic stem cell transplantation.

Study Design

A retrospective cross-sectional study.

Methods

This study is a retrospective analysis of 26 consecutive patients with primary myelofibrosis who underwent transplantation at our center between January 2002 and January 2022. Disease and transplant variables contributing to outcomes were analyzed.

Results

The median age at the time of transplantation was 52.5 (range, 32-63) years and the median time from diagnosis to allogeneic hematopoietic stem cell transplantation was 25 (range, 3.1-156.8) months. Myeloablative conditioning and reduced-intensity conditioning regimens were used in 8 (30.8%) and 18 (69.2%) transplantations, respectively. Neutrophil and platelet engraftment was achieved in 23 patients at a median follow-up of 21.2 months (range, 12 days to 234.8 months). Primary graft failure occurred in 1 of 23 patients (4.3%). Neutrophil and platelet engraftment occurred at a median of 16 (range, 12-39) days and 20 (range, 11-78) days, respectively. Acute graft-versus-host disease was seen in 11 of 22 patients engrafted allografts, of which 7 (31.8%) were grade 3-4 acute graft-versus-host disease. Eight patients (36.4%) developed chronic graft-versus-host disease, and three cases were extensive. Four patients (19%) relapsed after a median of 5.5 months, and three patients received donor lymphocyte infusion. The 3-year overall survival rate of the entire study population was 46.2%. The median overall survival was not reached in the myeloablative conditioning group; however, it was 11.9 months in the reduced-intensity conditioning group (p =0.3). According to the donor graft source, the median overall survival was 0.73 months in mismatched unrelated graft recipients, 12 months in matched sibling donors, and not reached in matched unrelated graft recipients (p = 0.03). The 3-year progression-free survival rate of patients who survived > 100 days was 74.7%. The effect of JAK-2 status, graft source, conditioning regimen or dynamic international prognostic scoring system on progression-free survival was not statistically significant.

Conclusion

Given the poor prognosis of non-transplant recipients and the lack of non-transplant curative approaches, our results support the consideration of allogeneic hematopoietic stem cell transplantation for eligible patients with primary myelofibrosis.

The efficacy and safety of second allogeneic hematopoietic stem cell transplantation

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Background: Second allogeneic hematopoietic cell transplant (sAHCT) might be indicated following a graft failure or disease relapse after the first one; although it might emerge with high rates of morbidities and mortality. Currently, there is a limited number of publications on this matter in the literature, here we aimed to share our sAHCT experience from a single center. Methods: Data from 51 patients who were eligible for sAHCT between 2001 and 2021 was evaluated retrospectively. All data was obtained from the Ankara University Faculty of Medicine, Department of Hematology and Bone Marrow Transplant Unit. Results: 51 patients were included in the present study. Median age at sAHCT was 34 (18- 65) and female/ male ratio 19/ 32 (37.3% / 62.7%). The same donor from the first transplant was eligible for sAHCT for most patients (n= 46, 90.2 %). sAHCT indication was graft failure for 11 patients (21.6 %) whereas 40 (78.4 %) patient went on sAHCT for disease relapse. Patients’ diagnoses were as follows: acute myeloid leukemia (n= 26, 50.9 %), acute lymphoblastic leukemia (n=9, 17.6 %), myelodysplastic syndrome (n= 6, 11.8 %), aplastic anemia (n= 6, 11.8 %) and others (CMML, CML, biphenotypic leukemia). Median number of transplanted CD34+ hematopoietic cells was 5.77 x x106/ kg (1.11- 8.29). Stem cell source was either bone marrow (n= 5, 9.8%) or peripheral blood (n= 46, 90.2 %). Myeloablative conditioning regimens were used for most sAHCTs (n= 30, 58.8%). Median overall survival (OS) rates for graft failure and disease relapse groups were 12.8 and 18.7 months, respectively (p= 0.63). During early transplant phase, 20 patients (39.2 %) died due to bone marrow aplasia, transplant failure or other complications. 1 year OS of the entire cohort was 33.3 % whereas 2-y- OS was 21.6% (95% CI= 25-45). 2 patients (3.9 %) died due to COVID19 during transplant process. On univariate analysis, sex, time from the first transplant (<12 months/ ≥12 months), conditioning intensity, sAHCT indication did not statistically significantly influence OS. Multivariate analysis confirmed a lower ECOG score (<2) at sAHCT significantly increased OS (p= 0.001). Conclusions: Based on this single center study, sAHCT is an efficacious treatment modality especially for patients with lower ECOG scores. sAHCT may offer long term survival for both graft failure and disease relapse states.

Allogeneic Hematopoietic Stem Cell Transplantation For Heavily Pretreated Patients With Mycosis Fungoides and Sezary Syndrome

Allogeneic hematopoietic stem cell transplantation (AHSCT) is a promising strategy for treatment of heavily pretreated mycosis fungoides/Sezary syndrome (MF/SS). Herein, we aimed to evaluate the outcomes of AHSCT for heavily pretreated patients with MF/SS retrospectively. This analysis included consecutive 19 patients with MF/SS who received 20 AHSCT between 2012-2021 in our transplant center. Eight patients have been previously reported. Fifteen patients had diagnosis of MF and referred to SS in five patients. In our cohort, all cases had advanced disease (stages IIB: n = 1, IIIA: n = 7; IIIB: n = 4, IVA: n = 4, IVB: n = 3). Nine patients (47.4%) had developed large cell transformation. Only two patients received AHSCT in complete response (CR), one very good partial response (VGPR) and two partial response (PR) while the others had progressive disease (PD) (n = 15) before transplant. Seven (35%) patients were alive at the time of analysis, with a median follow up of 10.5 months (range, 0.3-113 months) after AHSCT. Nine patients (47.4%) died without disease relapse or progression. NRM was 35.9% at 1 year and 26.9% at 3 years and therafter. For all patients the probability of OS was 48.5% and 32.3% at 1- and 5- year post-transplant, respectively. AHSCT for MF/SS resulted in an estimated PFS of 45.4% at 1 year. Given the poor prognosis of patients not receiving transplants and in the absence of curative non-transplantation therapies, our results support that AHSCT is able to effectively rescue 32.3% of the population of transplant eligible, heavily pretreated patients in 5 years. This article is protected by copyright. All rights reserved.

Brentuximab vedotin consolidation therapy after autologous stem-cell transplantation in patients with high-risk Hodgkin lymphoma: Multicenter retrospective study

The AETHERA trial reported an increased progression-free survival (PFS) when brentuximab vedotin (BV) was used as maintenance therapy in high-risk Hodgkin lymphoma (HL) after autologous stem cell transplantation (ASCT). Thus, we aimed to determine the impact and safety of BV as maintenance after ASCT in real-world patients. Seventy-five patients with relapsed/refractory HL started on BV consolidation therapy after ASCT due to high risk of relapse, between January 2016 and July 2019, from 25 institutions, were included in the study. The median follow-up time was 26 months. The most common high-risk features were primary refractory or relapsed disease <12 months (n = 61), lack of complete response (CR) to the last salvage regimen (n = 51), and having had at least two salvage regimens (n = 29). At the time of analysis, 42 patients completed consolidation courses, and BV was discontinued in 33 patients. Fifty patients had an ongoing response (CR in 41, PR in 6, and SD in 3 patients), 25 had progressed. Ten died in the follow-up, eight with progressive disease and two due to infection while in CR. The 2-year PFS and OS rates were 67.75% (95% confidence interval [CI]: 0.55-0.77) and 87.61% (95% CI: 0.76-0.94), respectively. Seventeen patients (23%) received BV in the pre-ASCT treatment lines, and there was no survival difference between the BV-naïve and BV-exposed groups. The most common adverse events were neutropenia (27%) and peripheral neuropathy (21%). Sixteen patients (21.3%) experienced grade 3 or 4 toxicity. BV was discontinued due to adverse event in 12 patients. Consolidation with BV after ASCT can achieve a 2-year PFS of 67.75% (95% CI: 0.55-0.75) with an acceptable toxicity profile.

Prospective Follow-up of Panel Reactive Antibodies From Diagnosis Until Completion of Therapy Including Allogeneic Stem Cell Transplantation Among Patients With Acute Leukemia

OBJECTIVES

Existence of panel reactive antibodies is the limiting step in both solid-organ and hematopoietic stem cell transplantation. There are hypotheses related to panel reactive antibody formation, but there is no knowledge about its formation in acute leukemia at diagnosis and during the chemotherapy period, in which there is a strong myelosuppression and immunosuppression. We aimed to determine the panel reactive antibodies positivity in acute leukemia patients at diagnosis and during the entire therapy period, including stem cell transplantation.

MATERIALS AND METHODS

In this single-center prospective study, we enrolled 35 patients with acute leukemia (8 with acute lymphoblastic leukemia, 27 with acute myeloid leukemia). Serum samples were obtained before induction therapy and every 3 months thereafter until the last follow-up or death, for a median of 369 days (minimum-maximum, 9-725 days). Panel reactive antibodies were defined with single-antigen bead assays on a Luminex platform.

RESULTS

A total of 10 patients (29%) were found to have panel reactive antibodies at any time point. At diagnosis, 5 patients (14.3%) had antibodies of either class I (n = 2) or II (n = 1) or both (n = 2), and in 4 patients these persisted during median follow-up of 168 days (minimum-maximum, 9-322 days). Among the remaining 30 patients, an additional 5 (17%) developed de novo antibodies. Incidence rate of development of de novo antibodies was 5.5 per 10 000 person-days. There was no effect of transfusion load on the development of panel reactive antibodies. Differences in percentages in males versus females, blood type mismatch, and graftversus-host disease were higher in patients who had de novo antibodies after transplantation. Positivity at any time had no statistically significant effect on overall survival (P = .71).

CONCLUSIONS

Panel reactive antibodies do not occur frequently in the acute leukemia setting despite intensive transfusions.

Thyroid dysfunctions in adult patients after allogeneic hematopoietic stem cell transplantation

INTRODUCTION

Thyroid dysfunction (TD) is one of the major endocrinopathies shown after allogeneic hematopoietic stem cell transplantation over the long term. The incidence and the risk factors for TD have varied widely.

PATIENTS AND METHODS

Two hundred and fifty-nine patients with pre-transplant normal thyroid function tests who survived at least 1 year after allo-HSCT between 2006-2016 were included in the study.

RESULTS

Sixty-four patients (25%) developed TD at median of 34 months (range, 1-112 months). Hypothyroidism was detected in 32 patients (12%): 5 patients had primary hypothyroidism, and subclinical hypothyroidism occurred in 27 patients. 18 patients (7%) were diagnosed with hyperthyroidism: 2 patients (0.07%) were treated for primary hyperthyroidism, and 16 patients (6%) were followed for subclinical hyperthyroidism. Euthyroid sick syndrome occurred in 14 cases. None of the patients with thyroid dysfunction developed secondary thyroid malignancy. Receiving high-dose TBI (P = .001) was found to be significant risk for hypothyroidism; older age than median (P = .01) and pre-transplant active disease (P < .0001) were related to hyperthyroidism.

CONCLUSIONS

Thyroid dysfunction, mostly hypothyroidism, is a long-term complication after allo-HSCT in 25% of patients. Older age, pre-transplant active disease, and receiving TBI are among the risk factors. Sustained long-term monitoring of thyroid function test should be considered post allo-HSCT.

Blastic Plasmacytoid Dendritic Cell Neoplasm: Single Center Experience on a Rare Hematological Malignancy

Purpose

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and poor prognostic hematological malignancy. There is still no standard treatment established for BPDCN patients. We aim to summarize the main clinical, biological features and treatment of 9 BPDCN patients.

Methods

Nine patients with BPDCN who had been diagnosed between July 2008 and December 2018 in Ankara University School of Medicine, were retrospectively evaluated.

Results

All patients (n = 9) were male, median age was 64 (21-80). Five patients (55.6%) had bone marrow infiltration, 5 patients (55.6%) cutaneous lesions, 6 patients (66.7%) lymph node involvement, 2 patients (22.2%) central nervous system involvement and 2 patients (22.2%) spleen involvement at time of diagnosis. Complex karyotype was observed in 2 patients. CHOP was given to 5 patients (55.6%), hyper-CVAD to 2 patients (22.2%), fludarabine, cyclophosphamide and mitoxantrone to 1 patient (11.1%) and cyclophosphamide, etoposide, methylprednisolone to 1 patient (11.1%) as first line chemotherapy. Four patients (44.4%) underwent allogeneic hematopoietic stem cell transplantation (AHSCT) in complete remission (CR) 1. Venetoclax was given to a transplant ineligible patient who had skin and lymph node involvement, with the off-label use. The median follow-up time was 15.9 months (3-48.6 months). Estimated median overall survival was 15.9 + 1.6 (95% CI 12.7-19.1) months.

Conclusion

Intensive induction therapies followed by AHSCT in CR seems to be best approaches for patients with BPDCN. Thus, more effective treatment strategies particularly targeted therapies should be warranted to improve the survival of patients with this rare disease.

Allogeneic hematopoietic stem cell transplantation for primary myelofibrosis: A single-center experience

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Background: Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is a well-established treatment modality for patients with Myelofibrosis (MF) and still remains the only potentially curative therapy. The aim of this study was to determine overall outcomes of myelofibrosis patients treated with allo-HSCT in our center. Methods: This is a retrospective single-center analysis of 26 patients (female/male: 8/18) suffering from MF who underwent allogeneic HSCT at our center between 2002-2019. Forty-two percentages of the patients were at least MF intermediate-2 status based on DIPSS score (calculated at the time of transplantation). Results: All patients were in chronic phase of PMF at the time of the transplant. The median age at diagnosis was 48.2 years (range, 32-63 years). Median follow up of the patients were 15 months (range, 3-213 mo) and median time from diagnosis to HSCT was 25 months. Three of the patients had splenectomy before allo-HSCT. Splenomegaly was found in 20 patients and resolved completely in 6 patients. Myeloablative and RIC regimens were used for 8 (36.4%) and 18 (69.2%) of the 26 transplant procedures. All patients experienced engraftments of neutrophil and platelet except the five who died in aplasia period. Neutrophil and platelet engraftments occurred at median of 16 days (12-39 d) and 20 days (range, 11-78 d). There were no statistically significant differences in engraftment time between the types of conditioning regimens. Acute GVHD occurred with 11 of 26 transplanted allografts, with 6 of these being grade 3-4 acute GVHD. Chronic GVHD was seen 7 (26.9%) of the patients and 3 of these being extensive. A total of 26 out of the 11 patients died and 9 of the these 15 patients were alive and GVHD free at the end of our study. Relapse occurred in 3 patients after a median of 12 months and was treated with DLI in one case. The probability of 3-year progression free survival (PFS) and overall survival (OS) in all patients were 86.2%±9.1% and 58.7±11.4%, respectively. No statistical significance was observed for mean estimated 3-year OS in terms of the conditioning regimens. Conclusions: Despite the small number of patients, our results suggest that allo-HSCT may provide a curative treatment for patients with PMF.

A real-world single-center retrospective study on efficacy and safety of pegylated interferon alpha-2a in patients with myeloproliferative neoplasm

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Background: Pegylated forms of interferon (PEG-IFN) have a better pharmacologic profile than short-acting interferons, resulting in a more convenient less-frequent schedule of injections, less immunogenicity and possibly less toxicity. Several clinical studies of PEG-IFN-α-2a have reported promising results in patients with essential thrombocythemia (ET) and polycythemia vera (PV). Herein, we present the outcomes of MPN patients treated with PEG-IFN-α-2a seen outside of a clinical trial setting at a single center. Methods: Thirty-five MPN Patients treated with PEG-IFN-α-2a between January 2014 and October 2019 were included this retrospective analyses. Therapeutic responses for ET and PV were calculated by the revised ELN/IWG-MRT criteria. Responses in myelofibrosis (MF) were calculated by both EUMNET and ELN/IWG-MRT criteria. Best responses over all cycles of treatment were assessed. Molecular data was limited to JAK V617F. Results: Twenty patients with ET, 13 with PV and two with MF were enrolled in this study. The median age at diagnosis was 47 years (range; 21-83 years). JAK2 V617F mutation was detected in 16 patients (45.7%). Overall, the majority of patients (62.9%) had received at least one prior cytoreductive therapy for underlying disease. Median starting dose of PEG-IFN-α-2a was 90 mcg/week via self injection (range: 45-135 mcg/w). Treatment duration was pursued for a median duration of 21.4 months (range: 1.2-109.8). In the PV/ET group 33 patients were evaluated and overall best response rate was 87.8% (CR in 15 pts and PR in 14 pts). In the MF group (n = 2); a PR was seen in one patient and CR in one patient. No vascular events occurred within the cohort while on therapy. Of the eight patients receiving at least phelebotomy per month, all patients became phelobotomy independent with therapy. Of the 20 ET patients, 12 patients (60%) had platelet normalization (< 450 x 109/L). Among all patients, fatigue (31.4%), muscle pain (20%) and depression (8.6%) were the most common adverse events (AEs). Any grade of hematological AEs was not seen with PEG-IFN-α-2a. Eleven patients discontinued therapy secondary to: treatment associated severe AEs in 8 patients, lack of response in two patients and pregnancy in one patient. No death was reported during the analyses period. Conclusions: Our results suggest that PEG-IFN-α-2a remains a viable treatment option especially for younger patients who want to avoid prolonged cytotoxic therapy.

Safety and outcome of allogeneic stem cell transplantation in mycosis fungoides and Sezary syndrome: A seven-year tertiary center analysis

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Background: Allogeneic hematopoietic stem cell transplantation (AHSCT) is a promising strategy for treatment of advanced-stage mycosis fungoides/Sezary syndrome (MF/SS). In this study, we retrospectively analyzed the outcomes of AHSCT for MF/SS and found that MF/SS appears to be susceptible to graft versus leukemia (GVL) effects. Methods: We studied outcomes in a consecutive series of 14 patients with MM/SS who underwent AHSCT between January 2012-November 2019 at our center. Treatment response was evaluated according to the Consensus WHO criteria for MF/SS. Results: The median age of patients 51.5 years (range: 28-68 years). Eight patients had MF and six patients had SS. Nine of those 14 patients had large cell transformation. All patients had advanced disease (stages IIB: n = 1, IIIA: n = 2, IIIB: n = 6, IVA1: n = 2 and IVB = 3). The median interval from disease onset to AHSCT was 3.7 years (range: 10.5 mos-11.3 years). All of the patients received at least three lines of treatments prior to AHSCT. Four patients achieved CR (3 are alive and still in CR) and all the other patients had progressive disease (PD) at the time of AHSCT. Graft source was peripheral blood stem cell in all patients. Six patients underwent transplantation from 9/10 HLA-matched unrelated donors and eight patients from HLA-identical sibling donors. Most of the patients (12/14) received RIC regimen (Flu-Cy-TBI) and ATG-Fresenius also added the protocol in AHSCT from unrelated donors. Five patients had stage 2-4 cutaneous acute GVHD and chronic GVHD developed in four patients (mild: n = 1, moderate: n = 2, severe: n = 1). Six patients who underwent transplantation at PD attained CR after AHSCT however relapse occurred in four patients at a median of four months (range: 3-10 months) after HSCT. At the time of data collection, nine patients have deceased; three were due to early TRM, three were underlying disease, two had aspergillus infection and one had nocardia infection. Two patients were alive with disease being treated by the Brentixumab vedotin, gemcitabine and DLI. With a median follow up period of 8.7 months after AHSCT, the estimated 1-year OS and PFS was 40.4%±5% and 35.4%±3.9%, respectively. Conclusions: AHSCT is an effective treatment option for advanced-stage MF/SS. Further studies are warranted to improve the outcome after AHSCT.

Upper respiratory viral infections in patients with haematological malignancies after allogeneic haematopoietic stem cell transplantation: a retrospective study

BACKGROUND

Community respiratory viruses (CRVs) are associated with upper respiratory viral infections (URI), pneumonia or life-threatening respiratory disease in patients with allogeneic haematopoietic stem cell transplantation (allo-HSCT). Our aim is to demonstrate our URI experience related to CRVs after allo-HSCT.

METHODS

From January 2013 to November 2015, 39 post allo-HSCT patients with acute URI symptoms were included in the study. We evaluated CRVs by multiplex PCR from nasopharyngeal wash and throat swabs.

RESULTS

The median age of the patients was 39 (range 20-67 years). A total of 25 patients (64%) had viral panel positivity at a median 140 days post-transplant (range 3-617 days). The most common agents detected were respiratory syncytial virus (32%) and parainfluenza (32%). The patients with viral panel positivity had significantly lower lymphocyte count (1.05×10⁹/l versus 3.09×10⁹/l; P=0.013). During follow-up, 20 patients (80%) were diagnosed with pneumonia. Patients with concurrent bacterial or fungal infections were more likely to have pneumonia (100% versus 68%; P=0.023). 10 patients (40%) died due to pneumonia and related complications. Lower lymphocyte counts and higher C-reactive protein levels at the time of viral panel positivity were risk factors for mortality (1.5×10⁹/l versus 0.39×10⁹/l, P=0.007; 74.2 versus 199.7, P=0.006).

CONCLUSIONS

The viral panel was positive in 64% of patients with acute URI symptoms. Lower lymphocyte count was detected in CRV-positive patients. The onset of concomitant bacterial or fungal infections increased the risk of lower respiratory infection disease. Indeed, prospective studies should be designed for risks and outcomes of CRVs in allo-HSCT recipients.

Can autologous stem cell transplantation abrogate the poor prognosis associated with high LDH in myeloma patients?

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Background: Multiple myeloma (MM) is a plasma cell neoplasia characterized by a diffuse clonal plasma cell infiltration of the bone marrow. Serum lactate dehydrogenase (LDH) is a relevant biomarker in MM and in the era of novel agents, LDH confirmed its negative impact on survival in newly diagnosed setting (Bal et al., presented at ASH2018). Methods: This single center retrospective study included 208 patients with a diagnosis of MM who underwent ASCT at our center between January 2008 - Mart 2018 were prospectively analyzed. We identified patients with baseline serum LDH values (ULN = 247 U/L). We compare baseline characteristics and outcomes of ASCT according to LDH values. Results: All clinical data were available in 208 cases (High LDH: 92 (44.2%), Normal LDH: 116 (55.8%)) There were 87 (41.8 %) female and 87 (41.8 %) male patients. The median age at diagnosis of MM was 63 years (range, 37-77 years). The median time of follow-up was 48 months (range, 2.8-197.5 months). Of the 92 patients with high LDH who underwent ASCT, median age was 65 years and ECOG performance status was 1 and 58.6 % were male. There was no statistically differences in performance status, induction treatment regimens and the number of treatment line prior to ASCT. Induction therapy consisted of 3 drugs in 91.3% and 2 drugs in 8.7 % in high LDH group (p = NS). Forty-eight (53.3%) patients with high LDH received a bortezomib-based induction and 35 patients (40.2 %) achieved ³ very good partial remission (VGPR) after the induction therapy. During follow up, 45 relapses were occurred and all relapsed patients died. According to the long-rank test, estimated 5-year OS was not significantly different between normal and high LDH categories (63.3 %±0.6 % vs. 64.6 %±0.5 %; p = 0.99). Median PFS was 101.4 months (95% CI: 73.7-129) in high LDH group and 92.1 months (95% CI: 71.1-113.1) in normal LDH group (p = 0.99). Conclusions: Elevated LDH was confirmed as a poor prognostic factor in previous reports. In our transplanted patients with high LDH cohort, clinical outcomes are favorable and similar those have normal LDH. Therefore, further studies of larger randomized cohorts are required to clarify the impact of pre-transplant LDH levels on ASCT outcomes.

Pretransplant hemoglobin and serum creatinine levels correlate with progression free survival in myeloma patients undergoing autologous stem cell transplantation

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Background: High dose melphalan and autologous stem cell transplantation (ASCT) significantly prolong survival for patients with multiple myeloma (MM). The purpose of this study is to assess the effects of hemoglobin (Hgb) and serum creatinine (Crea) values at the time of transplantation on the overall outcome of patients with multiple myeloma treated at our transplant center. Material & Methods: This analysis included 247 consecutive patients who underwent ASCT for MM between 2010-2016. Hemoglobin was grouped as low or high relative to their sample median. Patients were also stratified according to serum Crea value at the time of transplantation ( < 2 or ³2 mg/dl). Results: The median age was 57 (29-75) years and most patients were male (n = 151, 61.1%), IgG subtype (n = 124, 50.2%), and ISS stage 3 (n = 122, 49.4%). The interval from the time of diagnosis to ASCT was median 7 months and median follow-up from ASCT was 49 months (range, 3-198 months). The most commonly induction regimens included VAD (vincristine, doxorubicin and dexamethasone) and VCD (bortezomib, cyclophosphamide, dexamethasone), respectively. Since maintenance was not an approved treatment in myeloma most patients did not receive any. For the entire cohort, the median Hgb and Crea were 11.5 g/dL and 0.9 mg/dL respectively. No difference in progression free survival (PFS) was observed between a lower and higher Hgb (82 vs. 81 months, p = 0.96). However, the median PFS was significantly longer in patients with a lower Crea compared to those with a higher Crea (83 vs. 48 months, p = 0.01). Patients with both a lower hemoglobin and higher Crea experienced shorter PFS compared to those with a higher hemoglobin and lower Crea (45 vs. 82 months, p < 0.001). We failed to demonstrate the impact of creatinin levels on time to neutrophil and platelet engraftment. There were no differences in OS according to lower vs. higher Hgb (58 vs. 52 months; p = 0.29, respectively) but in higher crea cohort worse OS was observed (41 months vs. 57 months; p = 0.02, respectively). Conclusions: We demonstrate that hemoglobin and creatinine represent important determinants of clinical outcomes after ASCT. A lower hemoglobin and higher creatinine, individually and when combined, were associated with shorter PFS. Therefore, further studies of larger randomized cohorts are required to clarify the impact of pre-transplant Hgb and Crea levels on ASCT outcomes.

Promising utilization areas of therapeutic plasmapheresis in cardiovascular surgery practice

OBJECTIVE

Apheresis is performed for treatment of numerous diseases by removing auto-antibodies, antigen-antibody complexes, allo-antibodies, paraproteins, non-Ig proteins, toxins, exogenous poisons. In current study, we present our experience of using therapeutic plasma exchange (TPE) in patients with different types of clinical scenarios.

METHODS

Between January 2013 and May 2016, we retrospectively presented the results of 64 patients in whom postoperative TPE was performed in ICU setting after cardiac surgery. Patients were grouped into four as; 1-sepsis (n = 26), 2-hepatorenal syndrome(n = 24), 3-antibody mediated rejection(AMR) following heart transplantation(n = 4) and 4-right heart failure(RHF) after left ventricular asist device(LVAD)(n = 10). Hemodynamic parameters were monitored constantly, pre- and post-procedure peripheral blood tests including renal and liver functions and daily complete blood count (CBC), sedimentation, C-reactive protein and procalcitonin (ng/ml) levels were studied.

RESULTS

The mean age was 61 ± 17.67 years old and 56.25% (n = 36) were male. Mean Pre TPE left ventricular ejection fraction (LVEF) (%), central venous pressure (CVP)(mmHg) pulmonary capillary wedge pressure (PCWP)(mmHg) and pulmonary arterial pressure (PAP)(mmHg) were measured as 41.8 ± 8.1, 15.5 ± 4.4, 17.3 ± 3.24 and 39.9 ± 5.4, respectively. Procalcitonin (ng/ml) level of patients undergoing TPE due to sepsis was significantly reduced from 873 ± 401 ng/ml to 248 ± 132 ng/ml. Seventeen (26.5%) patients died in hospital during treatment, mean length of intensive care unit (ICU) stay(days) was 13.2 ± 5.1.

CONCLUSION

This study shows that TEP is a safe and feasible treatment modality in patients with different types of complications after cardiac surgery and hopefully this study will lead to new utilization areas.

Comparison of myeloablative vs reduced intensity conditioning regimens in stem cell transplantations for acute myeloid leukemia

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Background: The development of reduced intensity conditioning (RIC) regimens enabled allogeneic hematopoietic stem cell transplantations (allo-HSCT) also for patients who had contraindications and comorbidities for myeloablative conditioning (MAC) regimens. The aim of this study is to evaluate the effects of conditioning regimens on outcomes of alllo-HSCT for patients with acute myeloid leukemia. Methods: We retrospectively analysed 362 acute myeloid leukemia patients who underwent allo-HSCT between November 1989 to November 2016. We compared the outcomes of MAC vs RIC by Fisher’s test and chi-square test. Results: Engraftment was achieved in 87% of RIC and 95% of MAC recipients (p = 0.03).Incidences of acute and chronic graft vs host disease were not statistically different in groups (41% vs 47%, p = 0.7; 32% vs 43%, p = 0.2).Relapse rate was higher in RIC group (45% vs 25%, p = 0.02).Both 1-year overall survival (OS) and 1-year relapse free survival (RFS) rate were lower in the patients treated with RIC (71% vs 35%; 55% vs 16%).The higher OS was related with patients who were transplanted in remission, received grafts from related donors as well as having acute and chronic graft vs host disease. Conclusions: In the treatment of young patients who do not have comorbidities for intense conditioning regimens, show good performance status and are high risk; the initial use of standard myeloablative conditioning regimens is feasible. However, the lower number of RIC transplants and the variations between groups in terms of patient and donor characteristics might effect the results of this study. [Table: see text]

A single center experience with two decades of follow-up on patients with hairy cell leukemia

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Background: HCL is a rare chronic lymphoid malignancy and frequency is 2% in all leukemia and diagnosed mostly in middle ages. Patients generally respond to purine analogues treatment. In this study our aim is to present our HCL patients with demographic features, treatment modalities and responses. Methods: 39 HCL patients who were diagnosed and treated at Ankara University Department of Hematology between 1984 and 2016 were retrospectively evaluated. Ki-square test and student t test were used in comparison. P < 0.05 was considered statistically significant. Results: Median age of patients were 51 (range, 31-79). 30 of patients (77%) were male. The average leucocyte, hemoglobin, platelet, lactate dehydrogenase (LDH) levels and the spleen size at diagnosis were as follows: 5,1 x 10^9/L (range, 1,5-20), 12,5 g/dl (range, 9-17,5), 116x10^9/L (range,15-300), 178 IU (range,107-394), 155 mm (range,110-290). BRAF mutation could be evaluated in two patients and revealed as positive. 9 patients (23%) underwent splenectomy prior to chemotherapy. All patients received cladribine (0.1mg/kg, 7 days) as a first line treatment; 8 patients (21%) had two courses for remission. 11 patients (30%) had treatment related febrile neutropenia, 2 patients (0.05%) had transient skin rash after infusion. 8 patients (21%) had a relapse and 1 patients received pentostatin (4mg/m2, 1 dose every 2 weeks, 6 months), 7 patients were retreated with the first line treatment and achieved complete response. The overall survival was 67 months, respectively. Leucocyte, hemoglobin, platelet levels were lower, LDH levels were higher and spleen size was increased in patients with relapse however no statistical difference were detected. The patients with splenectomy had improved survival compared to patients without splenectomy (144 vs 329 months, P = 0.024). Conclusions: We detected 18% relapse rate in our series and all patients were followed in remisson after second line purine analogue treatment. Splenectomy has improved overall survival and possibly still has a role to play in HCL therapy. Generally, HCL is a chronic disease with a favorable prognosis.

A rare complication after allogeneic stem cell transplantation: post-transplant erythrocytosis

Post-transplant erythrocytosis is an infrequent complication and has been reported after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in aplastic anemia, acute myeloid leukemia, and chronic myeloid leukemia. The pre-disposing factors and treatment are not clearly defined. We present 11 post-transplant erythrocytosis cases. More studies should be conducted to distinguish the pathogenesis and follow-up for this rare complication.

The current status in hematopoietic stem cell mobilization

Hemotopoietic stem cell mobilization with cytokines alone, has still been widely accepted as the initial attempt for stem cell mobilization. Chemotherapy based mobilization can be preferred as first choice in high risk patients or for remobilization. But mobilization failure still remains to be a problem in one third of patients. Salvage mobilization strategies have been composed to give one more chance to 'poor mobilizers'. Synergistic effect of a reversible inhibitor of CXCR4, plerixafor, with G-CSF has opened a new era for these patients. Preemptive approach in predicted poor mobilizers, immediate salvage approach for patients with suboptimal mobilization or remobilization approach of plerixafor in failed mobilizers have all been demonstrated convincing results in various studies. Alternative CXCR4 inhibitors, VLA4 inhibitors, bortezomib, parathormone have also been emerged as novel agents for mobilization failure.

Dengue virus transmission by blood stem cell donor after travel to Sri Lanka; Germany, 2013

Three days after donation of peripheral blood stem cells to a recipient with acute myeloblastic leukemia, dengue virus was detected in the donor, who had recently traveled to Sri Lanka. Transmission to the recipient, who died 9 days after transplant, was confirmed.

Diagnosis of large granular lymphocytic leukemia in a patient previously treated for acute myeloblastic leukemia

Large granular lymphocytic (LGL) leukemia is a lymphoproliferative disease characterized by the clonal expansion of cytotoxic T or natural killer cells. We report on a patient diagnosed with T-cell LGL leukemia two years after the achievement of hematologic remission for acute myeloblastic leukemia.

Philadelphia-positive acute lymphoblastic leukemia in daily practice: A multicenter experience

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Background: The prognosis of Philadelphia-positive acute lymphoblastic leukemia (Ph+ALL) is generally poor. Currently, allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only accepted therapy with curative potential. Herein, we report our experience with Ph+ALL patients treated off-study. Methods: Data were collected from medical records of Ph+ALL patients diagnosed between 2005 and 2012. Survival rates were calculated using the Kaplan-Meier method and the log-rank test was used for comparison between groups. Results: This retrospective study included 41 patients (21 females and 20 males) from 7 centers in Turkey. The median age of the patients was 42 years (range, 19-70 years). Thirty (73%) patients received TKI and concurrent chemotherapy, 10 (24%) patients received chemotherapy alone and 1 (3%) patient received TKI alone. Of the patients receiving TKI, 24 (77%) received imatinib and 7 (23%) received dasatinib as induction therapy. Following induction therapy, 77% and 10% of the patients achieved complete hematologic remission and complete response with incomplete hematologic recovery, respectively. Eight (20%) patients had relapsed/resistant disease and received rescue therapy. The most common complication during therapy was febrile neutropenia (n=7, 17%). The induction mortality rate was 5% (n=2). Allo-HSCT was performed in 16 (39%) patients, 12 (75%) of whom underwent HSCT in first complete remission. Donor sources were matched siblings in 14 (88%) and unrelated donors in 2 (12%) patients. Fifteen (37%) patients died during follow-up. The Kaplan-Meier analysis revealed a median overall survival (OS) period of 12 months (range, 1-86 months) for all patients. The median OS period was 17 months (range, 5-86 months) and 2 months (range, 1-24 months) for patients who did or did not undergo HSCT, respectively (p=0.014). The Kaplan-Meier estimate of OS was 69.3% at 12 months and 49.1% at 24 months, for all patients. Conclusions: Allo-HSCT is the most important denominator of survival and the only curative therapy for Ph+ALL patients. For patients without a suitable donor or who are unable to undergo HSCT, TKI with concurrent chemotherapy is a reasonable alternative.