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Capelli D, Saraceni F, Fiorentini A, Chiarucci M, Menotti D, Poloni A, Discepoli G, Leoni P, Olivieri A. Feasibility and Outcome of a Phase II Study of Intensive Induction Chemotherapy in 91 Elderly Patients with AML Evaluated Using a Simplified Multidimensional Geriatric Assessment. Adv Ther 2020; 37:2288-2302. [PMID: 32297279 PMCID: PMC7467471 DOI: 10.1007/s12325-020-01310-4] [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: 02/03/2020] [Indexed: 12/04/2022]
Abstract
Introduction We prospectively tested in a phase II study high-dose aracytin and idarubicin plus amifostine as induction regimen in 149 patients with acute myeloid leukaemia (AML) aged ≥ 60 years, evaluated by a simplified multidimensional geriatric assessment (MGA). Methods Ninety-one fully or partially fit patients (61%) were allocated to intensive chemotherapy and 58 (39%) frail patients to best supportive care (BSC). Intensively treated patients, showing early death and complete response (CR) rate respectively of 5.5% and 73.6%, received 61 consolidations, followed by autologous transplant (ASCT), stem cell transplantation (SCT) or gemtuzumab ozogamicin, depending on mobilization outcome and donor availability. Results The 8-year overall survival (OS) of these patients was 20.4%, with median duration of 11.4 months significantly superior to the 1.5 months of BSC arm (p < 0.001). Hyperleukocytosis and cytogenetics were predictors of survival with a relative risk of 1.8 in patients with poor karyotype without hyperleukocytosis (p = 0.02) and 3 in those with hyperleukocytosis (≥ 50,000/μl) (p = 0.002). Conclusion MGA allowed tailored post-consolidation in 53.8% of patients after high-dose aracytin induction, with long-term survival doubling that reported in the literature after standard-dose cytarabine regimens. Trial Registration The study was registered with the Umin Clinical Trial Registry (www.umin.ac.jp/ctr), number R000014052. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01310-4) contains supplementary material, which is available to authorized users.
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Vinorelbine-Cyclophosphamide compared to cyclophosphamide in peripheral blood stem cell mobilization for multiple myeloma. Hematol Oncol Stem Cell Ther 2018; 11:225-232. [PMID: 29705566 DOI: 10.1016/j.hemonc.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/19/2018] [Accepted: 04/09/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND High dose Cyclophosphamide (Cy) and Vinorelbine Cyclophosphamide (Vino-Cy) are stem cell (SC) mobilisation options for patients with multiple myeloma (MM). We present a comparison of mobilisation outcomes using these regimens. PATIENTS AND METHODS Vino-Cy patients received Vinorelbine 25 mg/m2 on day 1, cyclophosphamide 1500 mg/m2 on day 2, and pegylated GCSF on day 4 or GCSF 10 mcg/kg/day from day 4 onwards. Cy patients were given cyclophosphamide 4000 mg/m2 on day 1 and GCSF10 mcg/kg/day from day 5 onwards. The target CD34 + SC collection was 5 × 106 per kg/BW. RESULTS 149 patients were included. SC collection was lower in the Vino-Cy group (8.20 × 106/Kg BW) compared to the Cy group (11.43 × 106/Kg BW), with adjusted geometric mean ratio of 0.59 (95% CI 0.41 to 0.86, p = 0.006). Time taken to achieve an adequate PB SC count was shorter for Vino-Cy (9 ± 1 day compared to 12 ± 2 days for Cy, adjusted absolute mean difference -3.95, 95% CI -4.85 to -3.06, P < .001). Mobilisation related toxicities (in particular, neutropaenic fever) were greater for Cy. CONCLUSION Vino-Cy is a potential alternative to Cy given the need for effective mobilisation protocols with acceptable toxicity.
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Catamero D, Noonan K, Richards T, Faiman B, Manchulenko C, Devine H, Bertolotti P, Gleason C, Board A. Distress, Fatigue, and Sexuality: Understanding and Treating Concerns and Symptoms in Patients With Multiple Myeloma. Clin J Oncol Nurs 2017; 21:7-18. [DOI: 10.1188/17.cjon.s5.7-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lahoud OB, Sauter CS, Hamlin PA, Dahi PB. High-Dose Chemotherapy and Autologous Stem Cell Transplant in Older Patients with Lymphoma. Curr Oncol Rep 2015. [PMID: 26201264 DOI: 10.1007/s11912-015-0465-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
High-dose chemotherapy followed by autologous hematopoietic stem cell transplant (HDT/ASCT) can improve survival in patients with lymphoma. Limited experience is available on the safety and efficacy of HDT/ASCT in elderly patients. In this article, we review the published data on the role of HDT/ASCT in management of lymphoma in older patients. Based on available data, evaluation of comorbidities, functional status, and comprehensive geriatric assessment (CGA) will help identify those who can benefit most from this intervention. Prospective clinical trials focusing on HDT/ASCT in older patients with lymphoma are needed to establish optimal management protocols in this select population.
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Affiliation(s)
- Oscar B Lahoud
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Capelli D, Chiarucci M, Poloni A, Saraceni F, Mancini G, Trappolini S, Troiani E, Montanari M, Scortechini I, Offidani M, Rupoli S, Scortechini AR, Gini G, Discepoli G, Leoni P, Olivieri A. Mobilization-Driven Postconsolidation Therapy in Elderly Patients with Acute Myeloid Leukemia: Feasibility and Efficacy of Autologous Stem Cell Transplantation versus Low-Dose Gemtuzumab Ozogamicin. Biol Blood Marrow Transplant 2014; 20:1399-406. [DOI: 10.1016/j.bbmt.2014.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 05/21/2014] [Indexed: 10/25/2022]
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Long-term results of a prospective randomized trial evaluating G-CSF priming in intensive induction chemotherapy followed by autologous stem cell transplantation in elderly patients with acute myeloid leukemia. Ann Hematol 2013; 93:193-202. [PMID: 23978944 DOI: 10.1007/s00277-013-1873-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
Few studies have evaluated granulocyte colony-stimulating factor (G-CSF) priming in elderly patients with intensively treated acute myeloid leukemia (AML), and no data are available for genetically defined AML subgroups. We provide long-term results (median follow-up 7.6 years) of a randomized trial in which 183 patients (median age 67 years) received G-CSF prior to (G-CSF priming) or after two cycles of induction chemotherapy. CR rates with G-CSF priming and G-CSF post-chemotherapy were comparable (57 vs. 67 %, p = 0.153), with overall survival (OS) probabilities of 14 vs. 17 % at 10 years. Induction mortality was significantly higher with G-CSF priming (23 vs. 10 %, p = 0.015), primarily in normal karyotype (NK) AML. In this subgroup, a trend for better relapse-free survival (RFS) was observed with G-CSF priming (44 vs. 22 % at 10 years, p = 0.074) but did not translate into an OS benefit. G-CSF priming had no impact on AML with FLT3-ITD and NPM mutations and did not improve outcome in patients with adverse cytogenetics. In a landmark analysis, late consolidation with autologous stem cell transplantation or a second consolidation cycle significantly improved RFS compared with one consolidation cycle (21.0 vs. 12.8 months, p = 0.046). Future studies on G-CSF priming should be restricted to NK AML and used only in post-remission therapy.
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Hung YC, Bauer J, Horsley P, Waterhouse M, Bashford J, Isenring E. Changes in nutritional status, body composition, quality of life, and physical activity levels of cancer patients undergoing autologous peripheral blood stem cell transplantation. Support Care Cancer 2013; 21:1579-86. [DOI: 10.1007/s00520-012-1698-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/20/2012] [Indexed: 12/22/2022]
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Olivieri A, Gini G, Bocci C, Montanari M, Trappolini S, Olivieri J, Brunori M, Catarini M, Guiducci B, Isidori A, Alesiani F, Giuliodori L, Marcellini M, Visani G, Poloni A, Leoni P. Tailored therapy in an unselected population of 91 elderly patients with DLBCL prospectively evaluated using a simplified CGA. Oncologist 2012; 17:663-72. [PMID: 22531362 DOI: 10.1634/theoncologist.2011-0355] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Elderly patients with diffuse large B-cell lymphoma (DLBCL) are a heterogeneous population; clinical trials have evaluated a minority of these patients. PATIENTS AND METHODS Ninety-one elderly patients with DLBCL received tailored treatment based on a comprehensive geriatric assessment (CGA). Three groups were identified: I, fit patients; II, patients with comorbidities; III, frail patients. Group I received 21-day cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP-21), group II received R-CHOP-21 with liposomal doxorubicin, and group III received 21-day cycles of reduced-dose CHOP. Fifty-four patients (59%) were allocated to group I, 22 (25%) were allocated to group II, and 15 (16%) were allocated to group III. RESULTS The complete response (CR) rates were 81.5% in group I, 64% in group II, and 60% in group III. With a median follow-up of 57 months, 42 patients are alive, with 41 in continuous CR: 31 patients (57%) in group I, seven patients (32%) in group II, and four patients (20%) in group III. The 5-year overall survival, event-free survival, and disease-free survival rates in all patients were 46%, 31%, and 41%, respectively. Multivariate analysis selected group I assignment as the main significant prognostic factor for outcome. CONCLUSIONS This approach in an unselected population of elderly DLBCL patients shows that treatment tailored according to a CGA allows the evaluation of elderly patients who are currently excluded from clinical trials.
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Affiliation(s)
- Attilio Olivieri
- Clinica di Ematologia e Clinica Medica, Università Politecnica delle Marche, Ancona, Italy.
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Grulke N, Albani C, Bailer H. Quality of life in patients before and after haematopoietic stem cell transplantation measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire QLQ-C30. Bone Marrow Transplant 2011; 47:473-82. [PMID: 21602898 DOI: 10.1038/bmt.2011.107] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The EORTC Quality of Life Core Questionnaire QLQ-C30 is widely used, but no reference values are available for patients receiving HSCT. We retrieved data for 38 samples from 33 papers in English and German that provided evaluable information on QLQ-C30 scores (mean, s.d.) covering about 2800 patients. Results are presented as a table that provides reference data that allow QLQ-C30 scores at different points during the disease trajectory to be put in context. With respect to their central tendency and their variance, scores vary over time. Quality of life is lowest during inpatient time. About 1 year after HSCT, the pre-transplant level is reached. Physical functioning is the scale reaching the highest level of all scales. Fatigue, dyspnoea and insomnia are symptoms that remain at an elevated level and should thus be considered as persisting problems after HSCT. For the interpretation of differences between scores, a very conservative recommendation would be to set the s.d. at 30 points. Doing so, one could be quite sure of having found a clinically significant change if the difference of two scores exceeds 15 points. Differences below 5 points should be interpreted with caution.
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Affiliation(s)
- N Grulke
- Luisenklinik-Zentrum für Verhaltensmedizin, Bad Dürrheim, Germany
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Potrata B, Cavet J, Blair S, Howe T, Molassiotis A. Understanding distress and distressing experiences in patients living with multiple myeloma: an exploratory study. Psychooncology 2011; 20:127-34. [PMID: 20336642 DOI: 10.1002/pon.1715] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE The aim of this study was to gain greater insight into the symptoms and distressing experiences of patients living with myeloma. METHODS A qualitative interview evaluation of distressing experiences in patients with myeloma, following a grounded theory approach, was used. Sampling was purposive, with particular attention to diversity in age and ethnic minority patients. RESULTS Fifteen patients were interviewed. Key findings suggest that (a) many individual symptoms were not considered as particularly distressing beyond the acute phase of the disease and its treatment, except when they occurred in a context that was threatening to the patients; (b) visible symptoms that showed to other people one's disease condition may be particularly distressing, and (c) the conditioning phase of the transplant was particularly stressful and a violation to one's body, described by some patients as 'being somehow dead'. CONCLUSION The personal meaning ascribed to symptoms and treatments as well as the context in which they occur are important determinants of distress. Such patient meanings and contexts should be explored by health professionals in-depth, in order to prepare patients for the experience and support them more fully.
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ANDERSSON I, AHLBERG K, STOCKELBERG D, PERSSON LO. Patients' perception of health-related quality of life during the first year after autologous and allogeneic stem cell transplantation. Eur J Cancer Care (Engl) 2011; 20:368-79. [DOI: 10.1111/j.1365-2354.2009.01174.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Puig N, Pintilie M, Seshadri T, al-Farsi K, Franke N, Keating A, Kuruvilla J, Crump M. High-dose chemotherapy and auto-SCT in elderly patients with Hodgkin's lymphoma. Bone Marrow Transplant 2011; 46:1339-44. [PMID: 21243027 DOI: 10.1038/bmt.2010.294] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our purpose was to assess efficacy and toxicity of high-dose chemotherapy (HDCT) and ASCT in patients with relapsed and refractory Hodgkin's lymphoma (HL) aged 60 years and older and compare the results with a group of younger HL patients treated in a similar manner. We identified 15 consecutive patients, with HL aged 60 years and older who underwent HDCT (etoposide 60 mg/kg+ melphalan 160 mg/m(2)) and ASCT at our institution from May 2001 to March 2008. The results were compared with a cohort of 157 younger HL patients treated in a similar manner from January 1999 to December 2006. After a median follow-up of 2.5 years, PFS at 3 years after ASCT was 73% (95% confidence interval (CI) 37-90) for the older group and 56% (95% CI 46-64) for the younger group (P=0.45); OS after ASCT was 88% (95% CI 39-98) for the older group and 84% (95% CI 75-90) for the younger group (P=0.80). No transplant-related deaths were seen. Our study suggests that ASCT is feasible for selected elderly patients with HL, giving similar results to younger patients in terms of survival and toxicity.
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Affiliation(s)
- N Puig
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Ontario, Canada
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Tempescul A, Ianotto JC, Hardy E, Quivoron F, Petrov L, Berthou C. Peripheral blood stem cell collection in elderly patients. Ann Hematol 2009; 89:317-21. [PMID: 19693499 DOI: 10.1007/s00277-009-0812-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 08/05/2009] [Indexed: 10/20/2022]
Abstract
Intensive treatments like autologous blood stem cell transplantations are standard consolidation treatments for lymphoma and myeloma in young people. The upper age limit for these procedures is constantly increasing. Instead of studying the impact of aging on harvesting peripheral blood stem cells (PBSC), we performed a retrospective study to explore the feasibility of collecting stem cells from patients older than 65 years and compared the efficacy to harvest in younger patients. During a period of 7 years, we identified 108 patients with myeloma or lymphoma who were older than 65 years who underwent PBSC collection. Only eight patients failed to produce a successful harvest. The majority of patients only needed one apheresis (71%). There was a median number of 5.3 x 10(6) CD34+ cells/kg. Our study demonstrated that older patients can also undergo PBSC harvests similar to younger patients.
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Affiliation(s)
- Adrian Tempescul
- Department of Clinical Haematology, Institute of Cancerology and Hematology, CHU Morvan, 29609 Brest, France.
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Ferrara F, Palmieri S, Celentano M, De Simone M, Pollio F, D'Amico MR, Copia C, Mele G. Feasibility of autologous peripheral blood stem cell transplantation in elderly patients with acute myeloid leukemia. Leuk Lymphoma 2009; 47:1593-8. [PMID: 16966271 DOI: 10.1080/10428190600624730] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Most studies showing that autologous stem cell transplantation (ASCT) is feasible in older patients with acute myeloid leukemia (AML) referred to highly selected patients considered as eligible after complete remission (CR) achievement and bone marrow or peripheral blood stem cell (PBSC) collection. This study evaluated the feasibility of ASCT from 155 consecutive AML patients aged over 60 years (median age 72 years, range 61 - 94) programmed to receive ASCT by using PBSCs after CR achievement. Overall, 90 out of 155 patients (58%) were judged as eligible for aggressive chemotherapy and 45 (50%) achieved CR. Among these, 36 (80%) received consolidation and 32 (89% of consolidated) were monitored for PBSC mobilization. A successful collection was registered in 25/32 patients (78% of monitored). Finally, 20 patients received ASCT. Reasons for not autografting five mobilizing patients included relapse pre-ASCT, toxicity, and refusal. Median survival was 4 months for the whole patient population and 19 months for patients actually autografted. Overall, 20 out of 90 patients accrued into intensive chemotherapy (22%) and 20 out of the entire patient population (13%) underwent ASCT. It is concluded that APBSCT can result in an improvement of therapeutic results in AML of the elderly, but it is feasible in a minority of selected patients.
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Affiliation(s)
- Felicetto Ferrara
- Division of Haematology and Stem cell Transplantation Unit, Cardarelli Hospital, Naples, Italy.
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Robertson MJ, Abonour R, Hromas R, Nelson RP, Fineberg NS, Cornetta K. Augmented high-dose regimen of cyclophosphamide, carmustine, and etoposide with autologous hematopoietic stem cell transplantation for relapsed and refractory aggressive non-Hodgkin's lymphoma. Leuk Lymphoma 2009; 46:1477-87. [PMID: 16194894 DOI: 10.1080/10428190500158466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Progressive disease is the major cause of treatment failure after autologous hematopoietic stem cell transplantation for relapsed or refractory non-Hodgkin's lymphoma. An augmented high-dose regimen of cyclophosphamide 7,200 mg/m2, carmustine 300 - 400 mg/m2, and etoposide 2,400 mg/m2 (CBV) was developed in an attempt to improve disease control post-transplant. Sixty-seven adult patients received augmented CBV followed by infusion of unpurged autologous peripheral blood stem cells. Thirty seven patients had relapsed after standard chemotherapy, 28 patients had primary refractory disease, and 2 patients had transformed lymphoma in first partial response. Treatment-related mortality was 4%. Actuarial four year overall survival and progression-free survival were 46+/-8% and 36+/-6%, respectively. Risk factors for disease progression were histologic involvement of marrow by lymphoma and infusion of increased numbers of CD34 + cells per kg in the stem cell autograft. The outcome for patients with relatively chemorefractory disease (defined as 25 - 49% reduction in tumor volume after salvage chemotherapy) was no different than that for patients with chemosensitive disease. Compared to standard high-dose CBV regimens, augmented CBV does not appear to have substantially improved disease control. Prospective study of the association between inferior progression-free survival and infusion of higher CD34 + cell doses in stem cell autografts is warranted.
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Affiliation(s)
- Michael J Robertson
- Bone Marrow and Stem Cell Transplantation Program, Indiana University Medical Center, 1044 West Walnut Street, Indianapolis, IN 46202, USA.
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Rodriguez V, Anderson PM, Litzow MR, Erlandson L, Trotz BA, Arndt CAS, Khan SP, Wiseman GA. Marrow irradiation with high-dose 153Samarium-EDTMP followed by chemotherapy and hematopoietic stem cell infusion for acute myelogenous leukemia. Leuk Lymphoma 2009; 47:1583-92. [PMID: 16966270 DOI: 10.1080/10428190600580817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In four patients, aged 15 - 20 years, with high-risk acute myeloid leukemia (AML), high-dose samarium 153-labelled ethylenediaminetetramethylenephosphonate (153Sm-EDTMP) was used for targeted marrow irradiation before preparative chemotherapy conditioning regimens and allogeneic (three patients) or autologous (one patient) hematopoietic stem cell transplantation. The dose of 153Sm-EDTMP was 703 MBq/kg (n = 1) or 1110 MBq/kg (n = 3). No side-effects occurred during the 30-min infusion of 153Sm-EDTMP. Samarium - melphalan regimens were given to three patients; one had 153Sm-EDTMP - busulfan + cyclophosphamide. Total body radioactivity was below the 133 MBq safe limit before infusion of stem cells (day 14 after 153Sm-EDTMP). No hemorrhagic cystitis, nephrotoxicity or serious infections occurred. Leukocyte engraftment (white blood cell count >0.5 x 10(9)/l) occurred between 12 and 23 days after stem cell infusion (mean of 17 days). Complete cytogenetic and morphologic remission of AML was evident on follow-up marrow aspirate and biopsy specimens from all patients. In two of the four study patients, the disease remains in complete remission and the patients have an excellent quality of life (Eastern Cooperative Oncology Group performance status 0; no medications) and no organ toxicity more than 2 years and more than 4 years, respectively, after their blood and bone marrow transplantations. Thus, in adolescents and adults, 153Sm-EDTMP may provide a relatively simple and effective means for using irradiation to eliminate AML within the marrow.
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Affiliation(s)
- Vilmarie Rodriguez
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Gertz MA, Ansell SM, Dingli D, Dispenzieri A, Buadi FK, Elliott MA, Gastineau DA, Hayman SR, Hogan WJ, Inwards DJ, Johnston PB, Kumar S, Lacy MQ, Leung N, Micallef INM, Porrata LF, Schafer BA, Wolf RC, Litzow MR. Autologous stem cell transplant in 716 patients with multiple myeloma: low treatment-related mortality, feasibility of outpatient transplant, and effect of a multidisciplinary quality initiative. Mayo Clin Proc 2008; 83:1131-8. [PMID: 18828972 DOI: 10.4065/83.10.1131] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We report on the feasibility of outpatient transplant in 716 patients undergoing autologous stem cell transplant for multiple myeloma at Mayo Clinic's site in Rochester, MN, from January 1, 2000, through October 31, 2007. We also report on the development and effect of a multidisciplinary quality initiative implemented by the Mayo Clinic Blood and Marrow Transplant Program involving physicians, nurses, pharmacists, dietitians, and financial specialists for outpatient management of patients undergoing stem cell transplant. This approach uses an electronic ordering system for diagnostic tests and chemotherapy to minimize medical errors. Analysis of hospitalization trends since inception of the program showed that 278 (39%) of the 716 patients treated completed the transplant procedure as outpatients. The median duration of hospitalization for all patients was 4 days; age and serum creatinine levels were predictive of the need for and duration of hospitalization. We also assessed recent treatment-related mortality rates during a 33-month period after implementation of the program (between January 1, 2005, and October 1, 2007). The 100-day survival rate was 99.5% for patients with low-risk myeloma (transplant during first plateau; n=201) and 97.2% for patients with high-risk myeloma (refractory, relapsing or second or greater plateau; n=71). The overall 100-day survival rate was 98.9%. Our experience shows that outpatient transplant is feasible for all patients with multiple myeloma and results in shorter hospital stays and low treatment-related mortality rates.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Wildes TM, Augustin KM, Sempek D, Zhang QJ, Vij R, Dipersio JF, Devine SM. Comorbidities, not age, impact outcomes in autologous stem cell transplant for relapsed non-Hodgkin lymphoma. Biol Blood Marrow Transplant 2008; 14:840-6. [PMID: 18541205 DOI: 10.1016/j.bbmt.2008.05.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 05/05/2008] [Indexed: 11/18/2022]
Abstract
High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation is a widely applied treatment for advanced non-Hodgkin lymphoma (NHL), but few studies have analyzed the tolerability and outcomes in older patients compared with younger patients treated in a homogeneous manner. We retrospectively reviewed 152 consecutive patients who underwent autologous stem cell transplantation (ASCT) following BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan) for NHL from January 2000 through August 2004 at our institution. We compared 59 patients age > or =60 years and 93 patients age <60 years. Supportive care was identical for all patients. The frequency of comorbidities was similar between both groups. CD34+ cell doses, days to neutrophil recovery, and days to platelet count >20,000/mm3 were similar in younger and older patients, although days to platelet count >50,000/mm3 were longer in the older patients (median 30.0 days versus 22.5 days, P = .01). Patients over the age of 60 were more likely to develop grade III/IV mucositis than their younger counterparts (37.7% versus17.4%, P = .0063). Otherwise, the frequency of other grade III/IV toxicities were similar between younger and older patients. Treatment-related mortality (TRM) was similar between older and younger patients (8.5% versus 5.4%, P = .45). Although age was not associated with TRM, the Charlson Comorbidity Index Score was significantly correlated with TRM (P = .03). Median disease-free survival was similar between older and younger patients (21.8 months versus 29.9 months, P = .93), as was overall survival (OS) (47.7 months versus 62.5 months, P = .20). After controlling for age, the Charlson Comorbidity Index Score influenced OS [P = .013]. Overall, our cohort of patients with NHL over the age of 60 who underwent ASCT following BEAM conditioning experienced toxicities and survival similar to their younger counterparts. Comorbidities significantly influenced TRM and OS in this retrospective cohort. Future study should focus on improving tolerability of conditioning and careful prospective evaluation of comorbidities and their association with outcomes.
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Affiliation(s)
- Tanya M Wildes
- Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Hosing C, Saliba RM, Okoroji GJ, Popat U, Couriel D, Ali T, De Padua Silva L, Kebriaei P, Alousi A, De Lima M, Qazilbash M, Anderlini P, Giralt S, Champlin RE, Khouri I. High-dose chemotherapy and autologous hematopoietic progenitor cell transplantation for non-Hodgkin's lymphoma in patients >65 years of age. Ann Oncol 2008; 19:1166-71. [PMID: 18272911 DOI: 10.1093/annonc/mdm608] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PATIENTS AND METHODS We present a retrospective analysis of 99 consecutive patients with relapsed non-Hodgkin's lymphomas who were older than 65 years at the time of high-dose chemotherapy and autologous progenitor cell transplantation. RESULTS Median age at transplant was 68 years (range 65-82). Thirty-six percent of patients had a hematopoietic cell transplantation comorbidity index of >2 at the time of transplantation. The cumulative nonrelapse mortality was 8% [95% confidence interval (CI) 4-17] at 26 months and the 3-year overall survival (OS) was 61% (95% CI 49-71). On multivariate analysis, disease status at transplant and lactate dehydrogenase (LDH) > normal were significant predictors for OS (P = 0.002). Comorbidity index of >2 did not impact OS but did predict for higher risk of developing grade 3-5 toxicity (P = 0.006). Eight patients developed secondary myelodysplastic syndrome/acute myelogenous leukemia after transplantation (cumulative incidence 16%). CONCLUSIONS Patients with relapsed lymphomas who are >65 years of age should be considered transplant candidates, particularly if they have chemosensitive disease and normal LDH levels at the time of transplantation. Patients with comorbidity index of >2 can also undergo transplantation with acceptable outcomes but may be at higher risk for developing toxicity.
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Affiliation(s)
- C Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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20
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Bishton M, Gilyead M, Das Gupta E, Williams C, Russell NH, Byrne JL. High dose melphalan or intermediate dose melphalan can be well tolerated and result in good response rates in selected elderly patients with myeloma. Leuk Res 2007; 31:1063-8. [PMID: 17324463 DOI: 10.1016/j.leukres.2006.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Revised: 10/31/2006] [Accepted: 12/21/2006] [Indexed: 11/24/2022]
Abstract
We have used two strategies for treating myeloma patients aged 65-75 years. Those fit enough underwent Cyclophosphamide mobilisation and PBSCT using melphalan 200mg/m(2) (HDM) (n=15, median 67 years). Those less fit were mobilised with G-CSF and received melphalan 70mg/m(2) (IDM) (n=15, median 69 years). Where possible sufficient PBSC were collected so that patients not in CR after their first IDM, underwent a second IDM procedure (n=6). The treatment was well tolerated with zero day+100 TRM. Median cell dose was 4.85x10(6)CD34+cells/kg and 2.7x10(6) in the HDM and IDM groups, respectively. Neutrophil engraftment was faster in the HDM group but despite this there was a trend to earlier discharge in the IDM group (13 days versus 15 days) and lower antibiotic and anti-fungal usage, suggesting better tolerability. Response rates were similar with CRs achieved in 7/15 patients receiving HDM and 9/15 receiving IDM (6 after the first and 3 after the second procedure). Three patients did not undergo a second IDM due to insufficient cells. In the IDM group 11/15 remain alive at a median follow up of 14 months with 5 in CR, whilst in the HDM group 12/15 are alive with 5 in CR at a median follow up of 15.5m. We conclude both approaches have comparable efficacy but that IDM may be better tolerated in an older age group.
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Affiliation(s)
- M Bishton
- Department of Haematology, Nottingham City Hospital, Nottingham, UK
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21
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Ferrara F, Viola A, Copia C, Falco C, D'Elia R, Tambaro FP, Correale P, D'Amico MR, Vicari L, Palmieri S. Age has no influence on mobilization of peripheral blood stem cells in acute myeloid leukemia. Hematol Oncol 2007; 25:84-9. [PMID: 17361983 DOI: 10.1002/hon.810] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The upper age limit for autologous stem cell transplantation (ASCT) in acute myeloid leukemia (AML) is increasing and peripheral blood (PB) represents the standard source of stem cell (SC). However, no data are available on the impact of age on SC mobilization in AML. We analyzed a cohort of 150 consecutive AML patients in first complete remission in order to make a comparison between patients up to 60 years and above 60 years, by evaluating CD34+ cells mobilization into PB and the number of leukapheresis needed to collect at least one single SC graft. The successful mobilization rate (>2 x 10(6) CD34+ cells/kg) was comparable between the two groups (87% vs. 80%, p = 0.29). In addition, no statistically significant difference was found in terms of either median number of CD34+ cells collected (p = 0.54) or CD34+ cells peak in PB (p = 0.70). Both groups of patients needed a median of two apheresis and no difference was found in the median number of CD34+ cells collected per single apheresis (p = 0.67). Finally, no correlation was found between age and total number of CD34+ cells collected (r = 0.003, p = 0.58). We conclude that age has no impact on mobilization of PBSCs in AML.
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Affiliation(s)
- Felicetto Ferrara
- Division of Hematology and Stem cell Transplantation Unit, Cardarelli Hospital, Naples, Italy.
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22
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Abstract
Along with improved supportive care and thus reduced treatment-related mortality, an increasing number of elderly patients (> 60 years) with haematological malignancies are now considered for high-dose therapy (HDT) supported by autologous stem cell transplantation (ASCT). ASCT is feasible in selected elderly patients with multiple myeloma and those with non-Hodgkin's lymphoma. As elderly patients have generally been excluded from randomized studies evaluating efficacy of ASCT in comparison with non-transplant approaches, limited data are available on the efficacy of ASCT in this patient population. Recent developments in supportive care including amifostine and palifermin may increase feasibility of ASCT in elderly patients. Prospective studies are needed to evaluate feasibility and efficacy of ASCT in patients over 60 years of age. Also, further studies are needed in order to decrease toxicity of high-dose regimens in this patient group where co-morbid conditions may modify the toxicity of HDT in a clinically significant manner.
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Affiliation(s)
- E Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.
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23
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Jantunen E, Itälä M, Juvonen E, Leppä S, Keskinen L, Vasala K, Remes K, Wiklund T, Elonen E, Nousiainen T. Autologous stem cell transplantation in elderly (>60 years) patients with non-Hodgkin's lymphoma: a nation-wide analysis. Bone Marrow Transplant 2006; 37:367-72. [PMID: 16415893 DOI: 10.1038/sj.bmt.1705266] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Limited experience is available on the feasibility and efficacy of autologous stem cell transplantation (ASCT) in elderly patients with non-Hodgkin's lymphoma (NHL). In 1994-2004 altogether 88 NHL patients > 60 years old received ASCT in six Finnish transplant centres. There were 57 male and 31 female patients with a median age of 63 years (range 60-70 years); 17 patients were>65 years. The histology included diffuse large B cell (n = 29), mantle cell (n = 27), follicular (n = 15), peripheral T cell (n = 12) and other (n = 5). Disease status at ASCT was I complete remission/partial remission (CR/PR) in 53 patients, II CR/PR in 30 patients and other in five patients. The conditioning regimens included BEAC (n = 49), BEAM (n = 34), TBI-CY (n = 4) and other (n = 1). Eighty-four patients received PB grafts. The medians to reach neutrophils > 0.5 and platelets > 20 were 10 and 14 days, respectively. The early treatment-related mortality (TRM) (<100 days) was 11%. With a median follow-up of 21 months for all patients, 45 patients (51%) are alive. A relapse or progression after ASCT has been observed in 32 patients (36%). ASCT is feasible in selected elderly patients with NHL, but the early TRM seems to be higher than in younger patients.
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Affiliation(s)
- E Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.
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24
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Annunziata M, Celentano M, Pocali B, D'Amico MR, Palmieri S, Viola A, Copia C, Falco C, Del Vecchio L, Ferrara F. Vinorelbine plus intermediate dose cyclophosphamide is an effective and safe regimen for the mobilization of peripheral blood stem cells in patients with multiple myeloma. Ann Hematol 2006; 85:394-9. [PMID: 16538502 DOI: 10.1007/s00277-005-0058-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 09/08/2005] [Indexed: 10/24/2022]
Abstract
High dose cyclophosphamide (HD-Cy) is commonly used to mobilize stem cells in multiple myeloma (MM). However, timing of collection is variable and incidence of side effects is substantial. We evaluated a combination of vinorelbine (VNB) (25 mg/m(2) day 1) plus Cy (1.5 g/m(2) day 2) and G-CSF as mobilizing regimen in 37 patients with MM. Results were compared to those achieved in 41 previously diagnosed patients mobilized with Cy at 4 g/m(2). Overall, 36/37 patients receiving VNB-Cy (97%) mobilized, as opposed to 40/41 (97%) in the controls (p:0.51). Median CD34+ cells peak was 94/mul for VNB-Cy patients and 96 for controls, p=0.36; median number of CD34+ cells collected was 9.2x10(6)/kg and 8.7x10(6)/kg, respectively (p=0.85). Median number of days to the highest CD34 count was shorter for VNB-Cy patients (nine vs 11, p=0.001). No VNB-Cy patient experienced grade 3-4 neutropenia and thrombocytopenia, as opposed to 63 and 19% in the controls (p=0.001 and 0.01, respectively). Hospitalization from toxicity was never required in VNB-Cy patients as compared to 19% in control group (p=0.01). We conclude that an outpatient combination of VNB plus intermediate dose Cy plus G-CSF is a safe, predictable, and highly effective mobilization regimen for patients with newly-diagnosed MM.
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Affiliation(s)
- Mario Annunziata
- Division of Hematology and Stem Cell Transplantation Unit, Cardarelli Hospital, Naples, Italy
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25
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Mileshkin LR, Seymour JF, Wolf MM, Gates P, Januszewicz EH, Joyce P, Prince HM. Cardiovascular toxicity is increased, but manageable, during high-dose chemotherapy and autologous peripheral blood stem cell transplantation for patients aged 60 years and older. Leuk Lymphoma 2006; 46:1575-9. [PMID: 16236612 DOI: 10.1080/10428190500235884] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
High-dose therapy (HDT) for non-Hodgkins lymphoma (NHL) and multiple myeloma (MM) is considered a feasible option for patients aged 60 years. This study compared the outcomes for all patients aged 60 years treated with HDT at the center to a matched cohort group aged <60 years. Results for patients who were 60 years at HDT between 1997--2002 were retrospectively analysed to assess efficacy and safety. Event-free (EFS) and overall survival (OS) rates were compared with a cohort group, matched by disease type, chemotherapy sensitivity, year of treatment and conditioning regimen. Patients with NHL were also matched by International Prognostic Index score. Forty patients aged 60 years were identified. Median age was 65 (range 60--76) with 22 MM and 18 NHL; 50% had 1 or more co-morbidity; 35% had cardiovascular co-morbidity vs. 18% of controls (p=0.075). Response rates (RR) following HDT for MM were: 4 (18%) complete responses (CR) and 18 (82%) partial responses (PR), giving an overall response rate (ORR) of 100%, vs. 77% for controls (p=0.02). For NHL patients there were: 8 CR (44%) and 4 PR (22%), giving an ORR of 67%, vs. 83% for controls (p=0.3). Transplant-related mortality was 8% compared to 5% in controls (p=0.6). Toxicities were similar with the exception of cardiac toxicity, which was significantly higher in patients aged 60 years vs. controls (50% grade 3 vs. 10%: p<0.0001). Atrial fibrillation was the most frequent cardiovascular toxicity (9 patients). At a median follow-up of 33 months, there is no significant difference between older vs. younger patients in median EFS (24 vs. 38 months: p=0.78) or OS (40 months vs. not reached: p=0.23). HDT is feasible and effective in selected patients 60 years with MM and NHL. Patients 60 years are more susceptible to cardiovascular toxicities, particularly atrial fibrillation, but have similar or better response rates following HDT and similar long-term outcomes to younger patients.
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Affiliation(s)
- L R Mileshkin
- Haematology Service, Peter MacCallum Cancer Centre and University of Melbourne, Australia.
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26
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Magagnoli M, Castagna L, Balzarotti M, Sarina B, Timofeeva I, Bertuzzi A, Compasso S, Nozza A, Siracusano L, Santoro A. Feasibility and toxicity of high-dose therapy (HDT) supported by peripheral blood stem cells in elderly patients with multiple myeloma and non-Hodgkin's lymphoma: survey from a single institution. Am J Hematol 2003; 73:267-72. [PMID: 12879431 DOI: 10.1002/ajh.10384] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of this retrospective study was to investigate the feasibility of high-dose therapy (HDT) followed by peripheral blood stem cell transplantation (PBSCT) in elderly patients with hematological malignancies. From April 1998 to November 2001, 40 elderly patients (defined as > or =60 years) with non-Hodgkin's lymphoma (12 patients) and multiple myeloma (28 patients) were evaluated. Seven lymphoma and one myeloma patients were in complete remission (CR), 27 in partial remission (PR), two had stable disease (SD), and three progressive disease (PD). The median age was 65 years (range 60-71). Thirty-nine patients were mobilized with chemotherapy plus granulocyte-colony stimulating factor (G-CSF) and one with G-CSF alone. Patients received HDT including melphalan alone in 32 cases or combined with other drugs in six and BEAM in two. The median number of collected CD34(+) cells was 12.4 x 10(6)/kg (range 2.0-68.9). The median number of re-infused CD34(+) cells was 9.9 x 10(6)/kg (range 2.0-68.9). All patients engrafted after PBSC and the median time to neutrophil recovery (N > 500/micro l) and platelet recovery (PLT > 20,000/micro l) was 8 days (range 5-18) and 6 days (range 5-18), respectively. Nonhematological toxicity was mild and no patient died from transplant-related toxicity (TRM). Median duration of hospitalization was 18 days (range 12-24). To date, 32 patients are alive and eight died from disease progression at a median follow-up interval of 24 months. HDT supported by PBSC is a feasible procedure in selected elderly patients, and an age of more than 60 years should not be considered a contraindication for HDT.
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Affiliation(s)
- Massimo Magagnoli
- Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Rozzano-Milan, Italy.
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27
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Bitran JD, Klein L, Link D, Kosirog-Glowacki J, Stewart C, Raack D, Sheahan P, Lisowski J, Rowen J. High-dose myeloablative therapy and autologous peripheral blood progenitor cell transplantation for elderly patients (greater than 65 years of age) with relapsed large cell lymphoma. Biol Blood Marrow Transplant 2003; 9:383-8. [PMID: 12813446 DOI: 10.1016/s1083-8791(03)00099-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Eleven elderly patients (older than 65 years) with relapsed large cell lymphoma were treated with high-dose myeloablative therapy and autologous peripheral blood progenitor cell support (ABMT). All 11 patients were in sensitive relapse at the time of ABMT. Treatment-related mortality was 9%. Median CD34 cell collection was 4.8 x 10(6) cells/kg. Median time to hematologic recovery was 11 days for granulocytes (range, 9 to 16 days) and 18 days for platelets (range, 14 to 42 days). Nine of 11 patients (81%) achieved a complete response following ABMT. Median time to treatment failure was 17 months. The 4-year disease-free and overall survival is projected to be 44%. When compared with a cohort of patients under age 65 years with sensitive relapsed large cell lymphoma treated with ABMT during the same time interval, disease-free and overall survival are comparable. ABMT is feasible, tolerable, and effective in elderly patients with relapsed large cell lymphoma with disease-free survival rates comparable to younger patients.
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Affiliation(s)
- Jacob D Bitran
- Department of Medicine, Division of Hematology/Oncology, Lutheran General Hospital Cancer Care Center, 1700 Luther Lane, Park Ridge, IL 60068, USA.
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28
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Recent publications in hematological oncology. Hematol Oncol 2002. [PMID: 11921016 DOI: 10.1002/hon.690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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29
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Salvagno L, Errante D, Bianco A, Palmisano V, Ballerini F, Boccalon M, Aversa S, Monfardini S. Treatment of Non-Hodgkin's Lymphoma in the Elderly. The Italian Studies. TUMORI JOURNAL 2002; 88:S20-5. [PMID: 11989915 DOI: 10.1177/030089160208800107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Luigi Salvagno
- Unit of Medical Oncology, General Hospital of Vittorio Veneto
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