Sequential vs myeloablative vs reduced intensity conditioning for patients with myelodysplastic syndromes with an excess of blasts at time of allogeneic haematopoietic cell transplantation: a retrospective study by the chronic malignancies working party of the EBMT

The optimal conditioning for patients with higher risk MDS receiving potentially curative allogeneic haematopoietic stem cell transplant(allo-HCT) remains to be defined. This is particularly the case for patients with excess of blasts at time of allo-HCT. Sequential (Seq) conditioning, whereby chemotherapy is followed rapidly by transplant conditioning, offers an opportunity to decrease disease burden, potentially improving outcomes allo-HCT outcomes. Herein we present the only analysis comparing Seq to myeloablative (MAC) and reduced intensity conditioning (RIC) specifically focussed on MDS patients with excess of blasts at allo-HCT. 303 patients were identified in the EBMT registry, receiving RIC (n = 158), Seq (n = 105), and MAC (n = 40). Median follow-up was 67.2 months and median age at allo-HCT was 59.5 years (IQR 53.5-65.6). For the entire cohort, 3 y overall survival (OS) was 50% (95% CI 45-56%) and relapse free survival (RFS) 45% (95% CI 40-51%). No significant differences in OS (log-rank p = 0.13) and RFS (log-rank p = 0.18) were observed between conditioning protocols. On multivariable analysis, lower performance status, worse IPSS-R cytogenetics, sibling donor (compared to 8/8 MUD) and ≥20% blasts at allo-HCT were associated with worse outcomes. In conclusion, the Seq protocol did little to influence the outcome in this high-risk group of patients, with outcomes mostly determined by baseline disease risk and patient characteristics such as performance status.

Clinical validation of SARC-F by proxy as a practical tool to evaluate sarcopenia in dependent older adults

INTRODUCTION

Sarcopenia is a prevalent disorder in older adults with significant adverse outcomes and regular screening is recommended for those at risk. The SARC-F questionnaire is the most commonly recommended screening tool for sarcopenia. However, as a self-reported tool, it cannot be applied to dependent individuals with communication problems. We hypothesized that implementation of the proxy-reported SARC-F (SARC-F by proxy) would be non-inferior in screening sarcopenia when compared with the standard SARC-F. Thus, we aimed to investigate the clinical validity of the SARC-F by proxy in identifying sarcopenia in older adults and to compare its performance with the standard SARC-F. Additionally, we aimed to determine the ideal cut-off of SARC-F by proxy in screening sarcopenia.

MATERIALS AND METHODS

This is a validation study including older adults aged ≥60 years without communication problems and their close proxies. The participants were recruited from a geriatric outpatient clinic of a tertiary health center and a nursing home. Standard SARC-F was transformed to SARC-F by proxy and administered to the proxies of older adults, and standard SARC-F was administered to the patients simultaneously in different rooms. We defined sarcopenia as probable and confirmed by the EWGSOP2 consensus report. We performed receiver operating characteristics (ROC) and sensitivity/specificity analyses of SARC-F by proxy for diagnosing sarcopenia and compared its performance with standard SARC-F by the DeLong test.

RESULTS

We included 172 older adults (median age: 72; 44.8% female) and 107 proxies in close contact (median age: 55, 63.2% female). The prevalence of probable and confirmed sarcopenia was 18.9% and 12.9%, respectively. For both definitions, area under the curve (AUC) values of SARC-F by proxy and standard SARC-F were moderate and similar [probable sarcopenia: 0.619 and 0.624 (p = 0.9); confirmed sarcopenia 0.613 and 0.645 (p = 0.7), respectively]. The best balance between sensitivity and specificity was achieved with a SARC-F by proxy score of ≥2 for both sarcopenia definitions (sensitivity levels were 74.7% and 77.8%, and specificity levels were 50.0% and 49.6%, for probable and confirmed sarcopenia, respectively).

DISCUSSION

SARC-F by proxy showed a similar, non-inferior performance compared to the standard SARC-F in the evaluation of sarcopenia. Our results suggest that it can be used instead of standard SARC-F to screen sarcopenia in older patients with communication problems. Further validation studies in different populations are warranted to support our findings.

Comparison of outcomes after unrelated cord blood and unmanipulated haploidentical stem cell transplantation in adults with acute leukemia

Outcomes after unmanipulated haploidentical stem cell transplantation (Haplo) and after unrelated cord blood transplantation (UCBT) are encouraging and have become alternative options to treat patients with high-risk acute leukemia without human leukocyte antigen (HLA) matched donor. We compared outcomes after UCBT and Haplo in adults with de novo acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Median follow-up was 24 months. Analysis was performed separately for patients with AML, n=918 (Haplo=360, UCBT=558) and ALL, n=528 (Haplo=158 and UCBT=370). UCBT was associated with delayed engraftment and higher graft failure in both AML and ALL recipients. In multivariate analysis, UCBT was associated with lower incidence of chronic graft-vs-host disease both in the AML group (hazard ratio (HR)=0.63, P=0.008) and in the ALL group (HR=0.58, P=0.01). Not statistically significant differences were observed between Haplo and UCBT for relapse incidence (HR=0.95, P=0.76 for AML and HR=0.82, P=0.31 for ALL), non-relapse mortality (HR=1.16, P=0.47 for AML and HR=1.23, P=0.23 for ALL) and leukemia-free survival (HR 0.78, P=0.78 for AML and HR=1.00, P=0.84 for ALL). There were no statistically differences on main outcomes after unmanipulated Haplo and UCBT, and both approaches are valid for acute leukemia patients lacking a HLA matched donor. Both strategies expand the donor pool for patients in need.

A survey on unmanipulated haploidentical hematopoietic stem cell transplantation in adults with acute leukemia

The use of unmanipulated graft is increasingly adopted in the setting of allogeneic hematopoietic stem cell transplantation from haploidentical family donors (haplo-SCT) in acute leukemia (AL). We analyzed the outcome of 229 adult patients with de novo AL, who received an unmanipulated haploidentical transplant as their first allo-SCT between 2007 and 2011. Median follow-up was 30 months. Disease status at transplant was: first complete remission (CR1) for 77, second CR (CR2) for 56, and advanced for 96 patients. One hundred and seventy-one patients received in vivo T-cell depletion by monoclonal antibodies (75%). The 60-day cumulative incidence (CI) of engraftment was 93±2%. The 100-day CI of acute graft-versus-host disease (GvHD) was 32±3% for grade II-IV, 12±3% for grade III-IV. The 3-year CI of chronic GvHD was 34±3%. The 3-year CI of non-relapse mortality was 31±4% with in vivo T-cell depletion and 17±5% without. At 3 years, for patients transplanted in CR1, CR2 or advanced disease leukemia-free survival was 44±6, 42±7 and 12±3%, overall survival was 55±6, 51±7 and 14±4% and CI of relapse was 32±6, 24±6 and 61±5%, respectively. These data suggest that unmanipulated haplo-SCT is a valid treatment option for adult AL patients in complete remission lacking a matched donor.

Effects of infectious complications on patients' survival in peritoneal dialysis

AIM

To investigate the impacts of infectious complications on mortality and morbidity; and to identify the other potential factors effective in mortality in peritoneal dialysis (PD) patients.

PATIENTS AND METHODS

We included patients who initiated therapy between 2001-2011. Patients were divided into two groups regarding to presence or absence of infectious complications. Socio-demographic data and clinical courses were compared and the reasons for PD withdrawal were obtained. Survival analysis of all patients was performed and the effects of infectious complications on mortality were investigated.

RESULTS

301 patients were included in this retrospective study. 214 patients (mean follow-up time 28.7±16.5 months) had infection history, 87 patients (mean follow-up time 48.9±29.6 months) had no infection history. There were no statistically significant difference in comparison of the groups in terms age, gender, education levels, hemodialysis history. In patients with infection history, 465 peritonitis and 213 catheter exit site infection attacks were diagnosed. The most frequently agent was methicillin-sensitive Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus in both conditions, while 25% of catheter exit site infection and 25% of peritonitis attacks were culture negative. During follow-up period, 60 patients transferred to hemodialysis, 58 patients died, 18 patients had renal transplantation in patients with infection history. In other group, 27 patients died, 23 patients had renal transplantation and 11 patients transferred to hemodialysis. Mean survival times were 56.3±2.8 months in patients with infection history and 86.8±6.1 months in other group. Mortality rate was found higher in patients with infection history (long-rank: 0.030). PD preference (OR: 5.213, p < 0.001), pretreatment low serum albumin (OR: 0.378, p = 0.001), low hemoglobin levels (OR: 0.810, p = 0.029) were found as predictors of survival in patients with infection history.

CONCLUSIONS

Infectious complications have negative effects on patient survival. Nature of PD preference, initial hypoalbuminemia and anemia were found to increase the mortality rate. The major causes of deaths were peritonitis and/or sepsis in patients with infectious complications, while the major cause of death was cardiac reasons in patients without infectious complications.

Fungal peritonitis in peritoneal dialysis: a 10 year retrospective analysis in a single center

INTRODUCTION

Fungal peritonitis (FP) is a rare but serious complication in patients undergoing peritoneal dialysis (PD), and is associated with higher morbidity, mortality. We aimed to analyze the predisposing factors, etiological agents, outcome and treatment of FP in patients with PD.

METHODOLOGY

We evaluated retrospectively all PD patients PD center between 2001 and 2011. Sixteen patients with FP were included into the study.

RESULTS

The clinical records of 16 patients with FP among 355 patients were reviewed for the clinical and laboratory data. Among 506 episodes of PD-related peritonitis in 10 years, we identified 16 episodes of FP. Median PD duration was 36.7±22.2 months. In 87.5% of patients had one or more previous episode of bacterial peritonitis that were treated with multiple broad-spectrum antibiotics. FP was primary infection in five patients, whereas eleven patients experienced FP during the course of treatment of bacterial peritonitis. Six patients died due to the fungal infection whereas others were transferred to haemodialysis.

CONCLUSIONS

Treatment of bacterial peritonitis with broad spectrum antibiotics was an important risk factor predisposing to the development of FP. The catheter removal and initiation of antifungal therapy as soon as possible are obligatory in episode of FP because it is responsible from high mortality rate.

Effects of rosiglitazone treatment on insulin resistance and TNF-alpha levels in patients with chronic kidney disease: a prospective study

AIM

The aim of the study was to investigate the effects of rosiglitazone treatment on insulin resistance (IR) and tumor necrosis factor-alpha (TNF-alpha) levels in non-diabetic chronic kidney disease (CKD) patients with IR.

PATIENTS AND METHODS

Thirty non-diabetic CKD patients with IR were enrolled in the study. Patients were grouped into two: group 1 (n = 15) received rosiglitazone 4 mg tablet for 3 months and patients who did not receive rosiglitazone treatment constituted the group 2 (n = 15). Baseline and after rosiglitazone treatment, homeostatis model assessment-insulin resistance (HOMA-IR) and TNF-alpha levels were measured.

RESULTS

There were no statistical differences in gender, age, HOMA-IR and TNF-alpha levels among group 1 and group 2 (p > 0.05 for all). Compared to baseline in group 1, significant differences were found in HOMA-IR and TNF-alpha levels after 3 months (p = 0.023; p = 0.001, respectively).

CONCLUSIONS

Our study indicates that, rosiglitazone treatment improves the IR and decreases TNF-alpha levels in non-diabetic patients CKD with IR.

Risk factors for progression of renal disease in patient with diabetic nephropathy

AIM

The aim of this study was to investigate the annual rate of glomerular filtration rate (GFR) decline and associated risk factors with this decline in diabetic nephropathy patients.

PATIENTS AND METHODS

A total of 122 type 2 diabetes mellitus (DM) patients (66F, mean follow up time 39 +/- 19 months, mean age 56 +/- 10 years, mean duration of diabetes diagnosis 12.1 +/- 9.5 years) between 2003 and 2010 were evaluated retrospectively. Socio-demographic characteristics and blood pressure data, laboratory parameters, HbAlc, daily urine protein excretion both of the first and last visits of all patients were recorded. Patients were separated into three groups according to rate of GFR decline. Group 1 (n:35), group 2 (n:42) and group 3 (n:45) consisted of patients < 1 ml/dk/1.73 m2, 1-5 ml/dk/1.73 m2 and > 5 ml/dk/1.73 m2 annual rate of GFR decline respectively. Demographics, laboratory data and their treatments were compared in all three groups and were investigated factors that may influence the rate of GFR decline.

RESULTS

The annual rate of GFR decline was 1.4 +/- 2.3 ml/sec, -2.9 +/- 1.0 ml/sec and -11.9 +/- 9.1 ml/sec in group 1, 2 and 3 respectively. Daily urine protein excretion was 0.9 +/- 1.3, 1.2 +/- 1.5 and 5.2 +/- 5.5 g in groups respectively, was found significantly higher in group 3 (p < 0.001). Serum albumin level was significantly lower in group 3 (p < 0.001). We found positive correlation between annual rate of GFR decline and last visit systolic blood pressure (SBP), daily proteinuria and parathormone levels (r: 0.339, 0.447 and 0.289 p < 0.001, < 0.001 and 0.02 respectively) and negative correlation between GFR decline and deltaSBP (delta systolic blood pressure), pretreatment albumin, calcium and hemoglobin levels (r: -0.409, -0.526, -0.233 and -0.467, p < 0.001, < 0.001, < 0.001 and 0.016 respectively).

CONCLUSIONS

Proteinuria, hypoalbuminemia, anemia, and a change in SBP were found most effective in annual rate of GFR decline in patients with diabetic nephropathy. The early detection of these factors may slow the progression of nephropathy.

Correlation between the resistive index values of renal and orbital arteries

BACKGROUND

Resistive index (RI) is an indirect measurement of blood flow resistance that can be used to evaluate vascular damage.

AIMS

The purpose of this study is to evaluate the association between RI values of orbital and intrarenal arteries by means of Doppler ultrasonography (US).

METHODS

We evaluated 103 diabetic patients. As a control group, 30 subjects were examined. The patients were divided into two groups. Group 1 consisted of patients with urinary albumin excretion (UAE) <300 mg/day and estimated glomerular filtration rate (eGFR) levels >90 ml/min (n = 50); Group 2 had a UAE >300 mg/day and/or eGFR levels between 89 and 60 ml/min (n = 53). The association between RI values obtained with Doppler US of the ophthalmic artery, central retinal artery, posterior ciliary artery and intrarenal arteries were calculated.

RESULTS

Both orbital and intrarenal arterial RI values in Group 1 and Group 2 were higher than the control group (p = 0.001); furthermore, values were higher in Group 2 than in Group 1 (p = 0.0004/0.029/0.036, p = 0.016, respectively). A positive correlation was found between orbital and intrarenal arterial RI values in Group 2 (r = 0.475, 0.285, 0.363, p < 0.01, respectively).

CONCLUSION

Both orbital and renal arterial RI values were shown to be higher than the control group. Further, a trend towards higher RI values was observed with renal disease. RI may be useful as one of the markers for early diagnosis and follow-up of diabetic nephropathy and retinopathy.

Effect of Olmesartan on serum cystatin C levels in the patients with essential hypertension

AIM

We aimed to investigate whether Olmesartan had an effect on cystatin C levels in hypertensive patients, and evaluate its correlation with blood pressure (BP).

MATERIALS AND METHODS

Seventy-two patients essential hypertension patients with a known for, at most, the last 3 years were enrolled to the study. Patients were divided in three groups (group 1; receives 20 mg/day olmesartan; group 2, receives 40 mg/day olmesartan; group 3, receives Olmesartan plus hydrochlorothiazide), according to their BP measurements. Blood samples (serum urea, creatinine, sodium, potassium and cystatin C) were collected initially and at the end of the study from all patients and the correlation of these parameters with BP and drug use was investigated.

RESULTS

There were no significantly difference between the groups in terms of age, gender, serum urea, creatinine, cystatin C and diastolic BP levels (p > 0.05); while, systolic BP was significantly higher in group 3 at baseline (p = 0.001). After 3 months of olmesartan treatment, the mean serum cystatin C (p: 0.001, 0.023 and 0.018 respectively), systolic (p: 0.001, 0.001 and 0.001 respectively) and diastolic BP levels (p: 0.001, 0.001 and 0.001 respectively) decreased in all groups. However, there was no significant difference in serum creatinine levels (p > 0.05). There were not found correlation between the changes of systolic and diastolic BP and cystatin C levels.

CONCLUSIONS

Cystatin C is a more sensitive marker to detect of early kidney dysfunction compared to serum creatinine level. Olmesartan treatment led to a decrease of cystatin C level. Therefore, olmesartan can be used to prevent the renal damage in patients with hypertensive and it is independent of drop in blood pressure.

Nano-scale superhydrophobicity: suppression of protein adsorption and promotion of flow-induced detachment

Wall adsorption is a common problem in microfluidic devices, particularly when proteins are used. Here we show how superhydrophobic surfaces can be used to reduce protein adsorption and to promote desorption. Hydrophobic surfaces, both smooth and having high surface roughness of varying length scales (to generate superhydrophobicity), were incubated in protein solution. The samples were then exposed to flow shear in a device designed to simulate a microfluidic environment. Results show that a similar amount of protein adsorbed onto smooth and nanometer-scale rough surfaces, although a greater amount was found to adsorb onto superhydrophobic surfaces with micrometer scale roughness. Exposure to flow shear removed a considerably larger proportion of adsorbed protein from the superhydrophobic surfaces than from the smooth ones, with almost all of the protein being removed from some nanoscale surfaces. This type of surface may therefore be useful in environments, such as microfluidics, where protein sticking is a problem and fluid flow is present. Possible mechanisms that explain the behaviour are discussed, including decreased contact between protein and surface and greater shear stress due to interfacial slip between the superhydrophobic surface and the liquid.

Bacillus circulans paracardiac infection in non-hodgkin lymphoma--a case report

A case report is presented concerning Bacillus circulans paracardiac infection in a 27 year old woman with non-hodgkin lymphoma.

Miniaturised nucleic acid analysis

The application of micro total analysis systems has grown exponentially over the past few years, particularly diversifying in disciplines related to bioassays. The primary focus of this review is to detail recent new approaches to sample preparation, nucleic acid amplification and detection within microfluidic devices or at the microscale level. We also introduce some applications that have as yet to be explored in a miniaturised environment, but should benefit from improvements in analytical efficiency and functionality when transferred to planar-chip formats. The studies described in this review were published in commonly available journals as well as in the proceedings of three major conferences relevant to microfluidics (Micro Total Analysis Systems, Transducers and The Nanotechnology Conference and Trade Show). Although an emphasis has been placed on papers published since 2002, pertinent articles preceding this publication year have also been included.

Treatment of primary resistant or relapsed multiple myeloma with high-dose chemoradiotherapy, hematopoietic stem cell rescue, and granulocyte-macrophage colony-stimulating factor

In this prospective, multicenter, phase 2 study, multiple myeloma (MM) patients with primary resistant disease or recurrent chemosensitive disease, in chemoresistant relapse, or in second or subsequent remission were treated with high-dose chemoradiotherapy followed by autologous peripheral blood stem cell (PBSC) rescue. PBSCs were collected using granulocyte-macrophage colony-stimulating factor (GM-CSF) 5 microg/kg per day subcutaneously for 3 days. Patients underwent high-dose chemoradiotherapy consisting of melphalan (140 mg/m2 x 1 day), cyclophosphamide (60 mg/kg per day x 2 days), methylprednisolone (2 g/d x 7 days), and total body radiation (150 cGy bid x 3 days) followed by peripheral blood stem cell reinfusion (> or = 1.2 x 10(9) mononucleated cells per kg) and GM-CSF support (5 microg/kg per day) and were evaluated for response, survival, and toxicity. Thirty-six patients, median age 53.4 years, completed the study. The mean pretransplantation cumulative melphalan dose was 464 +/- 72 mg. Excluding the 3 patients (8.3%) who failed to engraft, the median times to engraftment and platelet recovery were 10 days (range, 8-39 days) and 17 days (range, 7-67 days), respectively. Four patients (11.1%) died of complications related to the regimen (main causes of death, sepsis and acute respiratory distress syndrome) within the first 100 days. Twenty-two patients (61.1%) achieved complete response (CR), 8 (22.2%) partial response, and 2 (5.5%) no response. Two patients developed myelodysplastic syndrome after achieving CR. For all 36 patients, the probability of overall survival at 5 years was 27.3%. Median survival was 31 months (range, 0.3-81 months) in all patients and 42 months (range, 3.4-81 months) in those with CR. The probabilities of overall and disease-free survival at 5 years for the 22 patients who achieved CR were 43.6% and 15.7%, respectively. This high-dose chemotherapy regimen coupled with PBSC rescue is associated with a high CR rate and is capable of inducing long-term survival in a subset of heavily pretreated patients with primary resistant or recurrent MM.

Varicella zoster virus infections following allogeneic bone marrow transplantation: frequency, risk factors, and clinical outcome

Reactivation of varicella zoster virus (VZV) is a common event in patients undergoing allogeneic bone marrow transplantation (BMT) and may lead to life-threatening complications. We retrospectively analyzed the incidence, clinical outcome, and risk factors for VZV infections occurring within the first 5 years of transplantation in 100 consecutive adults undergoing allogeneic BMT between 1992 and 1997. Forty-one patients (41%) developed VZV reactivation a median of 227 days (range 45-346 days) post-transplantation. Twelve percent of VZV reactivation occurred in the first 100 days and 88% within the first 24 months. Among those who survived for 2 or more years after transplantation (n = 47), 59% developed VZV infection. Forty percent of patients with VZV reactivation required admission with a mean hospital stay of 7.2 days. Two patients developed encephalitis, and 1 died despite antiviral therapy. The most frequent complications were post-herpetic neuralgia and peripheral neuropathy (68%). Thoracic dermatomal zoster represented 41% of the infections; disseminated cutaneous involvement was observed in 17% of patients. No clinical or epidemiologic risk factors were associated with recurrence. Administration of ganciclovir for prevention of cytomegalovirus infection delayed the onset of VZV infection beyond 4 months (P = .06). In a further subset analysis, patients with a limited chronic graft-versus-host disease (GVHD) had a lower estimated incidence of VZV reactivation compared with those with extensive chronic GVHD (P = .11). We conclude that complications from reactivation of VZV infection are common and associated with considerable morbidity and mortality in patients undergoing allogeneic BMT.

Role of splenic irradiation in patients with chronic myeloid leukemia undergoing allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) has become the treatment of choice for patients of appropriate age with chronic myeloid leukemia (CML). In an attempt to enhance tumor cytoreduction, splenic radiation therapy (RT) has been done before the allogeneic transplant, but the role of splenic RT in this setting remains controversial. The purpose of this study is to evaluate the role of splenic RT before allogeneic BMT in patients with CML. Thirty-seven patients with chronic (n=33) or accelerated (n=4) phase CML underwent BMT from April 1990 to January 1998. All patients received splenic RT consisting of 500 cGy in five daily fractions (n=36) or 250 cGy in five daily fractions (n=1) completed within 10 days before BMT. The conditioning regimen included total-body irradiation and cyclophosphamide; etoposide was added to the regimen of patients in the accelerated phase. Continuous-infusion cyclosporine and pulse methotrexate were administered to all patients for prophylaxis of graft-vs.-host disease (GVHD). All patients achieved hematologic and cytogenetic remission. At a median follow-up of 37 months, the freedom from progression (FFP) and overall survival (OS) were 90 and 82%, respectively. None of the patients in accelerated phase have relapsed. Five patients have died of late transplant-related complications while in complete remission. Acute GVHD of grade > or = II was observed in 20% (14% grade II, 6% grade III). Fifty-one percent of patients developed limited chronic GVHD. The median posttransplant creatinine level was 1.2 mg/dL (range 0.6-4.2). Renal dysfunction, manifested as a persistent elevation in serum creatinine level (> 1.2 mg/dL), was observed in 40% of the patients. Only 8.5% had a creatinine level > 2.0 mg/dL, and no patient required dialysis as a result of renal dysfunction. Seven patients (18.9%) developed pulmonary complications, which included idiopathic interstitial pneumonitis (two), biopsy-proven interstitial fibrosis (four), and alveolar hemorrhage (one). The low relapse rate observed in this study may reflect the use of splenic RT as a part of the cytoreductive regimen before BMT. The fractionation schedule of 500 cGy in five daily fractions was well tolerated and did not appear to increase the toxicity of the preparative regimen. These favorable results indicate that splenic RT deserves further investigation and may be of benefit as a part of the conditioning regimen for patients receiving allogeneic BMT for CML.

Early infection in bone marrow transplantation: quantitative study of clinical factors that affect risk

Infections remain common life-threatening complications of bone marrow transplantation. To examine clinical factors that affect infection risk, we retrospectively studied patients who received bone marrow transplants (53 autologous and 51 allogeneic). Over a median of 27 hospital days, 44 patients developed documented infections. Both autologous transplantation and hematopoietic growth factor use were associated with less prolonged neutropenia and decreased occurrence of infection (P < or = .05). In a survival regression model, variables independently associated with infection risk were the log10 of the neutrophil count (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.32-0.75), ciprofloxacin prophylaxis (HR, 0.42; 95% CI, 0.19-0.95), empirical intravenous antibiotic use (HR, 0.09; 95% CI, 0.03-0.32), and an interaction between neutrophil count and intravenous antibiotic use (HR, 1.86; 95% CI, 1.06-3.29). In this model, infection risk increases steeply at low neutrophil counts for patients receiving no antibiotic therapy. Ciprofloxacin prophylaxis and particularly intravenous antibiotic therapy provide substantial protection at low neutrophil counts. These results can be used to model management strategies for transplant recipients.

Extramedullary tumors of myeloid blasts in adults as a pattern of relapse following allogeneic bone marrow transplantation

BACKGROUND

Extramedullary tumors of lymphoid and myeloid blasts outside the well-defined sanctuaries following allogeneic bone marrow transplantation (allo-BMT) are rare. Little is known about the biology, treatment, and outcome of these tumors in this setting.

METHODS

In this retrospective analysis, 134 consecutive patients with acute myeloid leukemia (AML) or chronic myeloid leukemia (CML) who underwent allo-BMT at a single institution between 1990 and 1998 were reviewed. Five cases of isolated extramedullary myeloid sarcoma that occurred as patterns of recurrence following allo-BMT between 1990 and 1998 are reported. These patients were treated with radiotherapy, systemic chemotherapy, or a second allo-BMT. Clinical outcome is compared with posttransplantation bone marrow relapses observed during the same period at the same institution. The literature on the clinical characteristics, currently available treatment, and outcome of posttransplantation myeloid sarcoma patients was reviewed.

RESULTS

Excluding isolated skin and central nervous system recurrences, the frequency of extramedullary myeloid sarcoma encountered as a relapse pattern following allo-BMT was determined to be 3.7% among patients with acute or chronic leukemia of myeloid origin. The survival of patients who were managed with radiotherapy and systemic chemotherapy was less than 4 months. A patient who underwent a second allo-BMT following local radiotherapy is alive and in complete remission more than 33 months after the diagnosis of myeloid sarcoma. The median survival of 17 patients with posttransplantation bone marrow relapse following allo-BMT was 2.2 months. When posttransplantation medullary recurrences are analyzed, patients with CML had a median survival of 12 months, with a significantly better 5-year survival rate than patients with AML (0 vs. 60%, P = 0.015; median survival, 12 months).

CONCLUSIONS

The clinical outcomes of patients with recurrent isolated extramedullary myeloid sarcoma following allo-BMT are poor, as in any leukemic relapse, with the exception of patients with CML in this setting.

Bolus and continuous infusion mitoxantrone in newly diagnosed adult acute lymphoblastic leukemia: results of two consecutive phase II clinical studies

Two consecutive phase II clinical studies were designed to evaluate the efficacy and safety of bolus and continuous infusion (CI) mitoxantrone (MTZ) in 39 patients with newly diagnosed acute lymphocytic leukemia (ALL). MTZ was used as part of the classical ALL induction regimen. Twenty patients were treated with bolus MTZ (10 mg/m2 for 3 days) combined with vincristine and prednisone. The same regimen was given to a second set of 19 patients, except that MTZ was administered as a 24-hr CI. Both groups received bimonthly intensifications with vincristine and prednisone for 3 years, along with oral maintenance therapy. Patients in the CI-MTZ study arm received additional MTZ on the first day of intensification cycles. Seventeen patients (85%) in the bolus arm and 15 patients (79%) in the CI arm achieved complete remission (CR). Median disease-free survivals (DFS) in the bolus and CI groups were 11 and 15 months after median follow-ups of 16 (3.5-96) and 13 (2.3-32) months, respectively. At 2.5 years, DFS rates were 29.4% and 34.4% in the bolus and CI groups (p > 0.05). There were no significant differences between two groups in rates of early death, degree of organ toxicity, or duration of neutropenia and thrombocytopenia. Significant cardiac toxicity was not observed in either group. Bolus or CI administration of MTZ was equally effective and was well tolerated. Neither the mode of administration nor increasing the dose intensity of MTZ by incorporating intensification cycles reduced relapse rates. Development of new antileukemia agents and novel treatment approaches are still needed to improve the high relapse rates in adult ALL once a complete response is achieved.

Vancomycin-resistant enterococcal infections in bone marrow transplant recipients

Vancomycin-resistant enterococci (VRE) infections have been increasingly reported in immunosuppressed individuals over the past decade. Emergence of this pathogen in the bone marrow transplantation (BMT) setting, in the form of bacteremia or positive stool cultures, is of concern because of lack of effective antimicrobial therapy. We report episodes of vancomycin-resistant E. faecium bacteremia in two patients undergoing BMT including the first case of VRE meningitis observed in this setting. Since the outcome in these patients undergoing matched unrelated donor BMT was fatal, we believe that routine screening for VRE in high risk patients should be considered. Management of VRE carrier state in BMT candidates is unclear at present.

Arginine butyrate downregulates p210 bcr-abl expression and induces apoptosis in chronic myelogenous leukemia cells

Downregulation of bcr-abl expression in the chronic myelogenous leukemia cell line K562 using antisense oligonucleotides has been shown to enhance the sensitivity of the cells to apoptotic stimuli, suggesting that p210 bcr-abl, like bcl-2 functions as an anti-apoptosis factor (McGahon A et al, Blood 1994, 83: 1179). In these experiments, the inhibition of p210 bcr-abl expression alone was not sufficient to induce apoptosis. We demonstrated that exposure to low doses (0.5 mM) of a butyric acid analog, arginine butyrate, was capable of inducing apoptosis in selected leukemia cell lines, including K562 cells, and in fresh leukemia cells from patients with chronic myelogenous leukemia. To further explore the mechanisms of this effect, we examined expression of p210 bcr-abl after butyrate exposure and found a dose-related inhibition of p210 bcr-abl protein without concordant change in other phosphoproteins, including the JAK-1 kinase. Further analysis revealed that the inhibition of bcr-abl expression occurs due to transcriptional regulation of the bcr-abl gene by arginine butyrate. These results suggest that arginine butyrate and other butyrate analogs alone or in combination may be useful in the therapy of patients with chronic myelogenous leukemia or bcr-abl expressing acute leukemias.

Costimulation of cutaneous T-cell lymphoma cells by interleukin-7 and interleukin-2: potential autocrine or paracrine effectors in the Sézary syndrome

PURPOSE

To examine interleukin-7 (IL7)- and interleukin-2 (IL2)-induced proliferation of Sézary lymphoma cells and to consider if an autocrine or paracrine growth-stimulatory circuit involving IL7 exists in the Sézary syndrome (SS).

MATERIALS AND METHODS

Fresh Sézary lymphoma cells were maintained in short-term culture in the presence of cytokines, and growth was measured by incorporation of (3H)-thymidine (TdR). Expression of IL7 and IL7 and IL2 receptors (IL7-R and IL2-R, respectively) was assessed by polymerase chain amplification of first-strand complementary DNA (RT-PCR), by affinity cross-linking of radioactive iodine-125-IL7, and by dual-color fluorescence-activated cell analysis. IL-7 production was measured by immunoassay.

RESULTS

Sézary lymphoma cells from seven patients showed synergistic (five of seven) or additive (two of seven) proliferation when cultured in the presence of IL2 and IL7, as compared with culture with either cytokine alone. Two patients with evidence of synergistic stimulation of [3H]-TdR incorporation showed IL7-R gene expression by RT-PCR and IL7 affinity cross-linking. Incubation of all seven patients' cells with IL7 induced coexpression to varying degrees of IL7-R and IL2-R. Sézary lymphoma cells from at least three of five patients studied expressed IL7 mRNA, and skin from three of five patients studied, as well as normal skin, expressed IL7 mRNA by RT-PCR.

CONCLUSION

Sézary lymphoma cells respond by proliferation to IL7 plus IL2, and in some instances produce IL7. Therapeutic maneuvers should be pursued to take advantage of this potential autocrine or paracrine growth-stimulatory mechanism.