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Myeloablative intravenous busulfan-containing regimens for allo-HSCT in AML or MDS patients over 54 years old: combined results of three phase II studies. Int J Hematol 2020; 112:510-523. [DOI: 10.1007/s12185-020-02941-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 01/05/2023]
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Leon-Rodriguez E, Rivera-Franco MM, Lastra-German IK. Predominant low Hematopoietic Cell Transplantation Specific Comorbidity Index (HCT-CI) score in a Mexican referral center: a selection bias caused by limited-resources? Hematol Transfus Cell Ther 2020; 43:249-255. [PMID: 32540216 PMCID: PMC8446236 DOI: 10.1016/j.htct.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/12/2019] [Accepted: 03/23/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION To date, many studies have validated the Hematopoietic Cell Transplantation Specific Comorbidity Index (HCT-CI) scoring system in allogeneic hematopoietic stem cell transplantation (allo-HSCT), but studies from developing countries remain scarce. OBJECTIVE The aim of this study was to evaluate and categorize Mexican patients using the HCT-CI at a referral center. METHODS One hundred and nineteen consecutive patients undergoing allo-HSCT at the National Institute of Medical Sciences and Nutrition in Mexico City were included. Patients were classified according to the HCT-CI scores. RESULTS The median age was 31 years and most were males (56%). Most patients had hematological malignancies (73%) and a low HCT-CI score (72%). The non-relapse mortality and survival were predicted according to the score. CONCLUSIONS This is one of the few studies to evaluate the HCT-CI in adults with HLA-matched donors in a developing country and our findings suggest that the high percentage of patients with a low HCT-CI scores, contrary to international reports, could be explained by different comorbidities and demographics, but mainly due to stricter filters applied to HSCT candidates and consequently, a potential selection bias caused by limited resources.
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Affiliation(s)
- Eucario Leon-Rodriguez
- Stem Cell Transplantation Program, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico.
| | - Monica Magdalena Rivera-Franco
- Stem Cell Transplantation Program, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Isabel Katherine Lastra-German
- Stem Cell Transplantation Program, Department of Hematology and Oncology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
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Adachi Y, Ukai S, Sagou K, Fukushima N, Ozeki K, Kohno A. Promising Outcome of Umbilical Cord Blood Transplantation in Patients with Multiple Comorbidities. Biol Blood Marrow Transplant 2018; 24:1455-1462. [DOI: 10.1016/j.bbmt.2018.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/10/2018] [Indexed: 01/08/2023]
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Impact of Pretransplantation Indices in Hematopoietic Stem Cell Transplantation: Knowledge of Center-Specific Outcome Data Is Pivotal before Making Index-Based Decisions. Biol Blood Marrow Transplant 2017; 23:677-683. [PMID: 28063962 DOI: 10.1016/j.bbmt.2017.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/02/2017] [Indexed: 02/07/2023]
Abstract
Outcome after allogeneic hematopoietic stem cell transplantation is influenced by patient comorbidity, disease type, and status before treatment. We performed a retrospective study involving 521 consecutive adult hematopoietic stem cell transplantation patients who underwent transplantation for hematological malignancy at our center from 2000 to 2012 to compare the predictive value of the hematopoietic cell transplantation-specific comorbidity index (HCT-CI) and the disease risk index (DRI) for overall survival and transplantation-related mortality. Patients in the highest HCT-CI risk group (HCT-CI score ≥3) had a lower 5-year overall survival rate (50%) than the low-risk group (63%; P < .01). Subset analysis of donor origin showed greater 5-year overall survival in siblings than in matched unrelated donors, regardless of HCT-CI score (eg, 67% 5-year overall survival in siblings despite an HCT-CI score of >6 [n = 9]). Five-year overall survival in the highest DRI risk group was significantly poorer (44%) than in the low-risk group (63%; P < .01). Both indices failed to predict differences in transplantation-related mortality (HCT-CI, P = .54; DRI, P = .17). We conclude that HCT-CI and DRI were predictive of overall survival in our patient population. Even so, our data show that different patient groups may have different outcomes despite sharing the same index risk group and that indices should, therefore, be evaluated according to local data before clinical implementation at the single-center level.
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5
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I.v. BU/fludarabine plus melphalan or TBI in unrelated cord blood transplantation for high-risk hematological diseases. Bone Marrow Transplant 2015; 50:607-9. [DOI: 10.1038/bmt.2014.316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nakaya A, Mori T, Tanaka M, Tomita N, Nakaseko C, Yano S, Fujisawa S, Sakamaki H, Aotsuka N, Yokota A, Kanda Y, Sakura T, Nanya Y, Saitoh T, Kanamori H, Takahashi S, Okamoto S. Does the Hematopoietic Cell Transplantation Specific Comorbidity Index (HCT-CI) Predict Transplantation Outcomes? A Prospective Multicenter Validation Study of the Kanto Study Group for Cell Therapy. Biol Blood Marrow Transplant 2014; 20:1553-9. [DOI: 10.1016/j.bbmt.2014.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 06/02/2014] [Indexed: 12/21/2022]
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Keller JW, Andreadis C, Damon LE, Kaplan LD, Martin TG, Wolf JL, Ai WZ, Venstrom JM, Smith CC, Gaensler KML, Hwang J, Olin RL. Hematopoietic cell transplantation comorbidity index (HCT-CI) is predictive of adverse events and overall survival in older allogeneic transplant recipients. J Geriatr Oncol 2014; 5:238-44. [PMID: 24894413 DOI: 10.1016/j.jgo.2014.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 02/03/2014] [Accepted: 04/24/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Our goal was to evaluate the ability of the hematopoietic cell transplantation comorbidity index (HCT-CI) to predict outcomes after allogeneic stem cell transplant (SCT) within the context of an older patient population, where multiple comorbidities are common. MATERIALS AND METHODS We performed a retrospective cohort study of SCT patients ≥50years of age at our institution, identifying 59 patients with complete HCT-CI data collected prospectively. RESULTS HCT-CI category distribution in our sample was disproportionate, with almost half of patients having scores ≥3. High HCT-CI score (≥3 vs <3) was associated with significantly inferior OS (median OS not reached for HCT-CI <3 vs 14months for HCT-CI ≥3; hazard ratio (HR) 2.2, p=0.02). HCT-CI score was a better predictor of OS than age, performance status or conditioning intensity. When adjusted for disease relapse risk, HCT-CI score conferred a worse prognosis in the low risk group (HR 1.43, p=0.03) but not in the intermediate/high risk group (HR 1.08, p=0.65). NRM was low in the total sample (6% at one year) and was not associated with HCT-CI score. Grade 3-4 non-hematologic adverse events within the first 100days after SCT were significantly more common in the higher HCT-CI groups (p=0.02). CONCLUSIONS In our older patient cohort with a high incidence of multiple comorbidities, HCT-CI score ≥3 was significantly associated with OS, particularly in the subset of patients with a low disease relapse risk.
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Affiliation(s)
- Jesse W Keller
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Charalambos Andreadis
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Lloyd E Damon
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Lawrence D Kaplan
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Thomas G Martin
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Jeffrey L Wolf
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Weiyun Z Ai
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Jeffrey M Venstrom
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Catherine C Smith
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Karin M L Gaensler
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Jimmy Hwang
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Rebecca L Olin
- Adult Blood and Marrow Transplant Program, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94143, USA.
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Devillier R, Fürst S, El-Cheikh J, Castagna L, Harbi S, Granata A, Crocchiolo R, Oudin C, Mohty B, Bouabdallah R, Chabannon C, Stoppa AM, Charbonnier A, Broussais-Guillaumot F, Calmels B, Lemarie C, Rey J, Vey N, Blaise D. Antithymocyte globulin in reduced-intensity conditioning regimen allows a high disease-free survival exempt of long-term chronic graft-versus-host disease. Biol Blood Marrow Transplant 2013; 20:370-4. [PMID: 24315846 DOI: 10.1016/j.bbmt.2013.11.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
Nonmyeloablative (NMA) regimens allow the use of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients considered unfit for standard myeloablative conditioning (MAC) regimens using high-dose alkylating agents with or without total body irradiation (TBI). Reduced-intensity conditioning (RIC) regimens, based on fludarabine (Flu), busulfan (Bu), and rabbit antithymocyte globulin (r-ATG), represent an intermediate alternative between NMA and MAC regimens. This platform was subsequently optimized by the introduction of i.v. Bu and the use of 5 mg/kg r-ATG, based on the hypothesis that these modifications would improve the safety of RIC allo-HSCT. Here we report a study conducted at our institution on 206 patients, median age 59 years, who underwent allo-HSCT after conditioning with Flu, 2 days of i.v. Bu, and 5 mg/kg r-ATG (FBx-ATG) between 2005 and 2012. The prevalence of grade III-IV acute graft-versus-host disease (GVHD) was 9%, and that of extensive chronic GVHD was 22%. Four-year nonrelapse mortality (NRM), relapse, and overall survival (OS) rates were 22%, 36%, and 54%, respectively. NRM tended to be influenced by comorbidities (hematopoietic cell transplantation-specific comorbidity index [HCT-CI] <3 versus HCT-CI ≥3: 18% versus 27%; P = .075), but not by age (<60 years, 20% versus ≥60 years, 25%; P = .142). Disease risk significantly influenced relapse (2 years: low, 8%, intermediate, 28%, high, 34%; very high, 63%; P = .017). Both disease risk (hazard ratio [95% confidence interval]: intermediate, 2.1 [0.8 to 5.2], P = .127; high, 3.4 [1.3 to 9.1], P = .013; very high, 4.0 [1.1 to 14], P = .029) and HCT-CI (hazard ratio [95% confidence interval]: HCT-CI ≥3, 1.7 (1.1 to 2.8), P = .018) influenced OS, but age and donor type did not. The FBx-ATG RIC regimen reported here is associated with low mortality and high long-term disease-free survival without persistent GVHD in both young and old patients. It represents a valuable platform for developing further post-transplantation strategies aimed at reducing the incidence of relapse, particularly in the setting of high-risk disease.
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Affiliation(s)
- Raynier Devillier
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Aix-Marseille Université, Marseille, France; Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France
| | - Sabine Fürst
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Jean El-Cheikh
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Luca Castagna
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Hematology Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Milano, Italy
| | - Samia Harbi
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Aix-Marseille Université, Marseille, France
| | - Angela Granata
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Roberto Crocchiolo
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Hematology Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Milano, Italy
| | - Claire Oudin
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Aix-Marseille Université, Marseille, France
| | - Bilal Mohty
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Reda Bouabdallah
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Christian Chabannon
- Aix-Marseille Université, Marseille, France; Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France; Cell Therapy Facility, Institut Paoli Calmettes, Marseille, France; Inserm CBT-510, Centre d'Investigations Cliniques en Biothérapie, Institut Paoli Calmettes, Marseille, France
| | - Anne-Marie Stoppa
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Aude Charbonnier
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | | | - Boris Calmels
- Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France; Cell Therapy Facility, Institut Paoli Calmettes, Marseille, France; Inserm CBT-510, Centre d'Investigations Cliniques en Biothérapie, Institut Paoli Calmettes, Marseille, France
| | - Claude Lemarie
- Cell Therapy Facility, Institut Paoli Calmettes, Marseille, France; Inserm CBT-510, Centre d'Investigations Cliniques en Biothérapie, Institut Paoli Calmettes, Marseille, France
| | - Jèrôme Rey
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France
| | - Norbert Vey
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Aix-Marseille Université, Marseille, France; Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France
| | - Didier Blaise
- Hematology Department, Transplantation Program, Institut Paoli Calmettes, Marseille, France; Aix-Marseille Université, Marseille, France; Centre de Recherche en Cancérologie de Marseille (CRCM), Marseille, France.
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Hashmi S, Oliva JL, Liesveld JL, Phillips GL, Milner L, Becker MW. The hematopoietic cell transplantation specific comorbidity index and survival after extracorporeal photopheresis, pentostatin, and reduced dose total body irradiation conditioning prior to allogeneic stem cell transplantation. Leuk Res 2013; 37:1052-6. [DOI: 10.1016/j.leukres.2013.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 03/05/2013] [Accepted: 06/08/2013] [Indexed: 12/01/2022]
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Crocchiolo R, Esterni B, Castagna L, Fürst S, El-Cheikh J, Devillier R, Granata A, Oudin C, Calmels B, Chabannon C, Bouabdallah R, Vey N, Blaise D. Two days of antithymocyte globulin are associated with a reduced incidence of acute and chronic graft-versus-host disease in reduced-intensity conditioning transplantation for hematologic diseases. Cancer 2012; 119:986-92. [PMID: 23096591 DOI: 10.1002/cncr.27858] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/15/2012] [Accepted: 09/12/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal combination of fludarabine, busulfan, and antithymocyte globulin (ATG) for reduced-intensity conditioning (RIC) transplantation has not been established. ATG plays a pivotal role in the prevention of graft-versus-host disease (GvHD), but it is associated with a higher relapse rate and an elevated incidence of infections when high doses are used. METHODS The authors retrospectively compared 2 different doses of ATG combined with fludarabine and busulfan in 229 adult patients who underwent transplantation at their institution. ATG was administered over 1 day (FBA1) or over 2 days (FBA2) at a daily dose of 2.5 mg/kg. RESULTS There were 124 patients in the FBA2 cohort and 105 patients in the FBA2 cohorts. Patients in the FBA2 cohort were older and more frequently underwent transplantation from an unrelated donor; 93% of patients in the FBA2 cohort received intravenous busulfan versus only 5% in the FBA1 cohort. The incidence of grade 2 through 4 acute GvHD was 23% in the FBA2 cohort versus 42% in the FBA1 cohort (P = .002); the incidence of grade 3 through 4 acute GvHD was 10% versus 23%, respectively (P = .006); and the incidence of chronic GvHD was 35% versus 69%, respectively (P < .0001). The 2-year rates of overall survival, nonrelapse mortality, and relapse/progression for the FBA1 and FBA2 cohorts were 65% versus 67%, respectively (P = .99), 20% versus 19%, respectively (P = .61), and 30% versus 19%, respectively (P = .09). The results were confirmed in multivariate analysis. CONCLUSIONS The use of ATG at a dose of 5 mg/kg was correlated significantly with reduced incidence and severity of GvHD without impairing disease control. Taken together, the current results suggest that this conditioning represents a step forward in the optimization of RIC.
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Affiliation(s)
- Roberto Crocchiolo
- Department of Hematology and Medical Oncology, Paoli-Calmettes Institute, Marseille, France.
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Validation of the Hematopoietic Cell Transplantation-Specific Comorbidity Index: a prospective, multicenter GITMO study. Blood 2012; 120:1327-33. [PMID: 22740454 DOI: 10.1182/blood-2012-03-414573] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The development of tools for the prediction of nonrelapse mortality (NRM) after allogeneic hematopoietic stem cell transplantation (HSCT) would offer a major guidance in the therapeutic decision. Recently, the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) has been associated with increased NRM risk in several retrospective studies, but its clinical utility has never been demonstrated prospectively in an adequately sized cohort. To this aim, we prospectively evaluated a consecutive cohort of 1937 patients receiving HSCT in Italy over 2 years. HCT-CI was strongly correlated with both 2-year NRM (14.7%, 21.3%, and 27.3% in patients having an HCT-CI score of 0, 1-2, and ≥ 3, respectively) and overall survival (56.4%, 54.5%, and 41.3%, respectively). There was an excellent calibration between the predicted and observed 2-year NRM in patients having an HCT-CI score of 0 and 1-2, whereas in the ≥ 3 group the predicted NRM overestimated the observed NRM (41% vs 27.3%). HCT-CI alone was the strongest predictor of NRM in patients with lymphoma, myelodysplastic syndrome, and acute myeloid leukemia in first remission (c-statistics 0.66, 064, and 0.59, respectively). We confirm the clinical utility of the HCT-CI score that could also identify patients at low NRM risk possibly benefiting from an HSCT-based treatment strategy.
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Zinke-Cerwenka W, Valentin A, Posch U, Beham-Schmid C, Groselj-Strele A, Linkesch W, Wölfler A, Sill H. Reduced-intensity allografting in patients with therapy-related myeloid neoplasms and active primary malignancies. Bone Marrow Transplant 2011; 46:1540-4. [PMID: 21860429 DOI: 10.1038/bmt.2011.165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Therapy-related myeloid neoplasms (t-MNs) are severe long-term consequences of cytotoxic treatments for a primary, often, malignant disorder. So far, the majority of patients eligible for transplantation have undergone myeloablative allo haematopoietic SCT (HSCT) as a potentially curative treatment, but it has been associated with high transplantation-related mortality (TRM) rates. In this retrospective study, we analysed the outcome of patients with t-MNs undergoing HSCT with reduced-intensity conditioning (RIC). Of 55 patients, seen at a single centre over a 10-year period, 17 underwent RIC HSCT with related or unrelated donors. The estimated overall survival was 53% at 1 year and 47% at 3 years, and disease-free survival was 47% at 1 year. At 1 year, the cumulative incidence of relapse and TRM were 24% and 30%, respectively. Of five patients with active primary neoplasms who underwent transplantation, two are alive beyond 1 year and show CR of both t-MNs and the primary malignancy. These data indicate that RIC HSCT is an encouraging approach for patients with t-MNs. The issue of primary malignancies not being in remission at the time of transplantation should be explored in further studies.
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Affiliation(s)
- W Zinke-Cerwenka
- Division of Haematology, Medical University of Graz, Graz, Austria
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