Factors affecting long-term outcome after allogeneic haematopoietic stem cell transplantation for acute myelogenous leukaemia: a retrospective study of 172 adult patients reported to the Austrian Stem Cell Transplantation Registry

Immunological profile of periapical endodontic infection in patients undergoing haematopoietic transplantation

OBJECTIVES

To evaluate the mRNA expression levels of cytokines interferon-γ, tumour necrosis factor-α, interleukin IL-1β, IL-10, and the chemokine CCL2/MCP-1, CCL4, and CXCR4 in the periapical interstitial fluid from root canal infections before and after bacterial load reduction in patients undergoing haematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

The case group was composed of 10 patients undergoing HSCT, and our control group included 10 healthy patients. Clinical samples were taken from teeth with pulp necrosis. Three paper points were placed in the RCS and maintained for 2 min for microbial evaluation before cleaning and shaping procedures. After cleaning and drying the canal, three paper points were introduced into the root canal, passing passively through the root apex (2 mm) into the periapical tissues for 1 min. Samples were collected immediately after root canal cleaning and 7 days later (restrained root canal bacterial load) to characterize gene expression using real-time PCR.

RESULTS

The results showed significantly reduction in the microbial load on day 7. An increased expression level of TNF-α and IFN-γ on day 7 in control and case groups was observed (p < 0.05). The mRNA levels of IL-1β and IL-10 in the pre-HSCT group increased in the samples from day 7 (p < 0.05). The chemokine CCL-2/MCP-1 was not detected in pre-HSCT group. Chemokine receptor CXCR4 levels increased in samples obtained from the day 7 in the control group (p < 0.05).

CONCLUSIONS

Individuals undergoing HSTC presented similar cytokine and chemokine mRNA expression compared with healthy individuals. However, it was observed the total absence of mRNA MCP-1/CCL2 expression in those individuals undergoing HSCT.

CLINICAL RELEVANCE

Patients undergoing HSCT are at higher risk of infection. No study has analysed the periapical immune responses to root canal infections in HSCT individuals.

Allogeneic hematopoietic cell transplantation for patients with a history of multiple relapses of acute myeloid leukemia

The prognosis of patients with acute myeloid leukemia (AML) is dismal after experiencing multiple relapses. This study retrospectively analyzed outcomes of allogeneic hematopoietic cell transplantation (HCT) for 192 adults with AML in third or subsequent complete remission (CR3+), 300 in second relapse (REL2), and 50 in third or subsequent relapse (REL3+) who were enrolled in a Japanese nationwide transplantation registry. The study population included patients undergoing umbilical cord blood transplantation, but not those undergoing haploidentical HCT. Patients transplanted in CR3+ had better survival than those transplanted in REL2 and REL3+ (48%, 21%, and 12% at 4 years; P < 0.001), and this was due to a reduction in post-transplant relapse (23%, 57%, and 52%; P < 0.001). The corresponding cumulative incidence of non-relapse mortality was 33%, 26%, and 36% (P = 0.022). Multivariate analysis revealed significantly lower relapse and overall mortality for those in CR3+ and significantly lower non-relapse mortality for those in REL2. Hazard ratios (95% confidence intervals) for overall mortality were 2.02 (1.56-2.64) for REL2+ versus CR3+ (P < 0.001) and 2.12 (1.40-3.19) for REL3+ versus CR3+ (P < 0.001). Our analysis demonstrates the curative potential of allogeneic HCT for patients with a history of multiple AML relapses and suggests the potential benefits and risks of reinduction attempt before transplantation, highlighting the need for an individualized approach in determining whether to give reinduction therapy in this setting.

Intensive consolidation with G-CSF support: Tolerability, safety, reduced hospitalization, and efficacy in acute myeloid leukemia patients ≥60 years

The aim of this study was to evaluate the efficacy and feasibility of intensified consolidation therapy employing fludarabine and ARA-C in cycle 1 and intermediate-dose ARA-C (IDAC) in cycles 2 through 4, in elderly acute myeloid leukemia (AML) patients and to analyze the effects of pegfilgrastim on the duration of neutropenia, overall toxicity, and hospitalization-time during consolidation in these patients. Thirty nine elderly patients with de novo AML (median age 69.9 years) who achieved complete remission (CR) after induction-chemotherapy were analyzed. To examine the effect of pegfilgrastim on neutropenia and hospitalization, we compared cycles 2 and 4 where pegfilgrastim was given routinely from day 6 (IDAC-P) with cycle 3 where pegfilgrastim was only administered in case of severe infections and/or prolonged neutropenia. All four planned cycles were administered in 23/39 patients (59.0%); 5/39 patients (12.8%) received 3 cycles, 3/39 (7.7%) 2 cycles, and 8/39 (20.5%) one consolidation-cycle. The median duration of severe neutropenia was 7 days in cycle 2 (IDAC-P), 11.5 days in cycle 3 (IDAC), and 7.5 days in cycle 4 (IDAC-P) (P < .05). Median overall survival was 1.1 years and differed significantly between patients aged <75 and ≥75 years (P < .05). The probability to be alive after 5 years was 32%. Together, intensified consolidation can be administered in AML patients ≥60, and those who are <75 may benefit from this therapy. Routine administration of pegfilgrastim during consolidation shortens the time of neutropenia and hospitalization in these patients.

A Chemotherapy-Only Regimen of Busulfan, Melphalan, and Fludarabine, and Rabbit Antithymocyte Globulin Followed by Allogeneic T-Cell Depleted Hematopoietic Stem Cell Transplantations for the Treatment of Myeloid Malignancies

We sought to develop a myeloablative chemotherapeutic regimen to secure consistent engraftment of T-cell depleted (TCD) hematopoietic stem cell transplantations (HSCT) without the need for total body irradiation, thereby reducing toxicity while maintaining low rates of graft-versus-host disease (GVHD) and without increasing relapse. We investigated the myeloablative combination of busulfan (Bu) and melphalan (Mel), with the immunosuppressive agents fludarabine (Flu) and rabbit antithymocyte globulin (r-ATG) as cytoreduction before a TCD HSCT. No post-transplantation immunosuppression was administered. Between April 2001 and May 2008, 102 patients (median age, 55 years) with a diagnosis of primary or secondary myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) underwent cytoreduction with Bu/Mel/Flu, followed by TCD grafts. TCD was accomplished by CD34⁺-selection followed by E-rosette depletion for peripheral blood stem cell grafts and, for bone marrow grafts, by soybean agglutination followed by E-rosette depletion. Donors included matched and mismatched, related and unrelated donors. Risk stratification was by American Society for Blood and Marrow Transplantation risk categorization for patients with primary disease. For patients with secondary/treatment-related MDS/AML, those in complete remission (CR) 1 or with refractory anemia were classified as intermediate risk, and all other patients were considered high risk. Neutrophil engraftment occurred at a median of 11 days in 100 of 101 evaluable patients. The cumulative incidences of grades II to IV acute and chronic GVHD at 1 year were 8.8% and 5.9%, respectively. Overall- and disease-free survival (DFS) rates at 5 years were 50.0% and 46.1%, respectively, and the cumulative incidences of relapse and treatment-related mortality were 23.5% and 28.4%, respectively. Stratification by risk group demonstrated superior DFS for low-risk patients (61.5% at 5 years) compared with intermediate- or high-risk (34.2% and 40.0%, respectively, P = .021). For patients with AML, those in CR1 had superior 5-year DFS compared with those in ≥CR2 (60% and 30.6%, respectively, P = .01), without a significant difference in incidence of relapse (17.1% and 30.6%, respectively, P = .209). There were no differences in DFS for other patient, donor, or disease characteristics. In summary, cytoreduction with Bu/Mel/Flu and r-ATG secured consistent engraftment of TCD transplantations. The incidences of acute/chronic GVHD and disease relapse were low, with favorable outcomes in this patient population with high-risk myeloid malignancies.

The need for endodontic treatment and systemic characteristics of hematopoietic stem cell transplantation patients

The aim of this study is to investigate the relationship between the epidemiological and clinical profiles of patients before and after hematopoietic stem cell transplantation (HSCT) and the need for endodontic treatment. The subjects included 188 individuals enrolled in the dental care program for transplanted patients of the School of Dentistry, Federal University of Minas Gerais (Faculdade de Odontologia da Universidade Federal de Minas Gerais, FO-UFMG) from March 2011 through March 2016. The patients were subjected to an HSCT conditioning dental regimen based on a thorough clinical and radiographic evaluation. Intraoral periapical and bite-wing X-rays were obtained, and after evaluation, specific dental treatment was planned and performed. The following demographic and clinical data were collected from the patients' medical records: age, gender, transplantation stage, primary disease, transplant type, medication used, complete blood count at the time of visit, and need for endodontic treatment. The Kolmogorov-Smirnov and the chi-square tests were used. Leukemia (31.3%) and multiple myeloma (17.9%) were the most prevalent primary diseases. Most patients were subjected to allogeneic-related transplantation (83.6%). Most patients exhibited platelet counts and hemoglobin concentrations below the reference values in the pre-transplantation stage, while the neutrophil and platelet counts and the hemoglobin levels were within the reference ranges in the post-transplantation stage. The proportions of individuals requiring endodontic treatment were similar between the pre- and post-transplantation groups: 24.3% and 24.7%, respectively. The systemic conditions of the patients referred for dental treatment were compromised.

Intensive care outcomes in adult hematopoietic stem cell transplantation patients

Although outcomes of intensive care for patients undergoing hematopoietic stem cell transplantation (HSCT) have improved in the last two decades, the short-term mortality still remains above 50% among allogeneic HSCT patients. Better selection of HSCT patients for intensive care, and consequently reduction of non-beneficial care, may reduce financial costs and alleviate patient suffering. We reviewed the studies on intensive care outcomes of patients undergoing HSCT published since 2000. The risk factors for intensive care unit (ICU) admission identified in this report were primarily patient and transplant related: HSCT type (autologous vs allogeneic), conditioning intensity, HLA mismatch, and graft-versus-host disease (GVHD). At the same time, most of the factors associated with ICU outcomes reported were related to the patients’ functional status upon development of critical illness and interventions in ICU. Among the many possible interventions, the initiation of mechanical ventilation was the most consistently reported factor affecting ICU survival. As a consequence, our current ability to assess the benefit or futility of intensive care is limited. Until better ICU or hospital mortality prediction models are available, based on the available evidence, we recommend practitioners to base their ICU admission decisions on: Patient pre-transplant comorbidities, underlying disease status, GVHD diagnosis/grade, and patients’ functional status at the time of critical illness.

Allogeneic Hematopoietic Stem Cell Transplantation in FLT3-ITD-Positive Acute Myelogenous Leukemia: The Role for FLT3 Tyrosine Kinase Inhibitors Post-Transplantation

In recent years, allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become increasingly common in patients with acute myelogenous leukemia (AML) due to improved donor availability and the use of nonmyeloablative regimens. However, despite the potential clinical gains with allo-HSCT, the post-transplantation outcomes for many patients, especially those with high-risk disease, remain dismal. Patients with AML who have internal tandem duplication mutations in the tyrosine kinase receptor FLT3 (FLT3-ITD) face particularly poor outcomes, even after allo-HSCT, which appears to only partially mitigate the poor prognosis associated with this mutation. Experimental treatments to reduce the likelihood of relapse and improve survival following allo-HSCT include maintenance with FLT3-specific tyrosine kinase inhibitors (TKIs), several of which are currently being evaluated in clinical studies. Preliminary data and case reports suggest that FLT3 TKIs can be effective in the post-transplantation setting, particularly for patients with FLT3-ITD mutations. Improvements in donor matching, transplantation procedures, and supportive care have allowed a greater number of patients to undergo allo-HSCT than ever before. For these patients, it is essential to identify effective post-transplantation therapies to reduce the risk of relapse and improve disease-free survival.

Extramedullary relapse of acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation: incidence, risk factors and outcomes

Extramedullary relapse after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia is a contributor to post-transplant mortality but risk factors for, and outcomes of, this condition are not well characterized. We analyzed 257 consecutive patients undergoing allogeneic stem cell transplantation for acute myeloid leukemia at our institution to characterize extramedullary relapse, identify predictive variables and assess outcomes. The 5-year cumulative incidence of isolated extramedullary or bone marrow relapse was 9% and 29%, respectively. Extramedullary relapse occurred later than marrow relapse and most frequently involved skin and soft tissue. Factors predictive of extramedullary relapse after transplantation included previous extramedullary disease, French-American-British classification M4/M5 leukemia, high risk cytogenetics, and advanced disease status at the time of transplantation. Children were more likely than adults to develop extramedullary relapse, a finding probably explained by an overrepresentation of extramedullary disease prior to transplantation and M4/M5 leukemia in children. Acute graft-versus-host disease was not protective against relapse. Unlike medullary relapse, chronic graft-versus-host disease was not protective against extramedullary relapse. The survival rate after extramedullary relapse was 30% at 1 year and 12% at 2 years. Extramedullary relapse is a significant contributor to mortality after allogeneic transplantation for acute myeloid leukemia and appears to be resistant to the immunotherapeutic effect of allogeneic grafting. Effective strategies for patients with extramedullary relapse are needed to improve outcomes after transplantation.

Extramedullary relapse of acute myeloid leukemia following allogeneic hematopoietic stem cell transplantation: incidence, risk factors and outcomes

Extramedullary relapse after allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia is a contributor to post-transplant mortality but risk factors for, and outcomes of, this condition are not well characterized. We analyzed 257 consecutive patients undergoing allogeneic stem cell transplantation for acute myeloid leukemia at our institution to characterize extramedullary relapse, identify predictive variables and assess outcomes. The 5-year cumulative incidence of isolated extramedullary or bone marrow relapse was 9% and 29%, respectively. Extramedullary relapse occurred later than marrow relapse and most frequently involved skin and soft tissue. Factors predictive of extramedullary relapse after transplantation included previous extramedullary disease, French-American-British classification M4/M5 leukemia, high risk cytogenetics, and advanced disease status at the time of transplantation. Children were more likely than adults to develop extramedullary relapse, a finding probably explained by an overrepresentation of extramedullary disease prior to transplantation and M4/M5 leukemia in children. Acute graft-versus-host disease was not protective against relapse. Unlike medullary relapse, chronic graft-versus-host disease was not protective against extramedullary relapse. The survival rate after extramedullary relapse was 30% at 1 year and 12% at 2 years. Extramedullary relapse is a significant contributor to mortality after allogeneic transplantation for acute myeloid leukemia and appears to be resistant to the immunotherapeutic effect of allogeneic grafting. Effective strategies for patients with extramedullary relapse are needed to improve outcomes after transplantation.

Outcomes from unrelated donor hematopoietic stem cell transplantation

BACKGROUND

Allogeneic hematopoietic cell transplantation (HCT) offers a curative treatment option for management of a variety of hematologic malignancies. While sibling donors have been the gold standard for adult patients in need of an HCT, not all patients have a suitable family donor. The availability of unrelated volunteer donor registries and alternative stem cell sources has expanded the wide application of this procedure.

METHODS

PubMed and MEDLINE were searched for human trials and the English language from 2001 to 2011. Factors influencing transplantation outcomes involving unrelated donors over the last decade are discussed, and feasible alternative stem cell sources when a matched unrelated donor is not available are reviewed.

RESULTS

HCT using a matched unrelated donor offers outcomes comparable to sibling HCT due to current molecular-based HLA typing and improvements in conditioning regimens and/or supportive care. The primary factor that contributes to improved outcome is the degree of donor-to-recipient HLA matching. The selection of younger unrelated donors has also been associated with improved outcomes in HCT. Evidence supports the universal application of matched unrelated donors even in high-risk leukemia and/or older patients. In adult patients without a matched related donor, other promising options as stem cell source includes mismatched unrelated donors, umbilical cord blood units, and haploidentical donors.

CONCLUSIONS

With current methodologies for molecular HLA typing and supportive care tools, outcomes of transplants with matched unrelated donors are comparable to those achieved with sibling donors. Alternative stem cell donors when a matched unrelated donor is not available are feasible expanding the stem cell donor pool.

Relative survival of long-term hematopoietic cell transplant recipients approaches general population rates

Whether the annual mortality rates of long-term hematopoietic cell transplant (HCT) survivors ever return to that of the general population is unclear. This study sought to determine the annual long-term mortality rates of allogeneic and autologous HCT recipients who had survived 5 years or more disease-free posttransplant and calculate their relative survival rates. Patients were included if they had a first allogeneic or syngeneic HCT for acute leukemia, chronic myelogenous leukemia (CML) or myelodysplastic syndromes (MDS), or autologous HCT for acute myelogenous leukemia (AML) or lymphoma in Australia or New Zealand between 1992 and 2001, recorded on the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR) database, and were known to have survived, disease free, 5 years or more posttransplant. The annual mortality rates of 5-year transplant survivors were compared to standard Australian and New Zealand populations using relative survival. A total of 1461 HCT survivors (688 postallograft, 773 postautograft) were included in this study. The 10-year survival probability for 5-year allograft survivors was slightly higher than that of 5-year autologous survivors (93.4% versus 89.6%, P=.06). The relative survival of both allogeneic and autologous 5-year survivors was never <97% of that of the general population. However, it was statistically significantly lower than expected in the sixth to ninth years posttransplant, with no obvious pattern of either improvement or deterioration from 6 to 10 years posttransplant. This study indicates that annual relative survival rates of long-term survivors of allogeneic HCT performed in Australia and New Zealand for acute lymophoblastic leukemkia (ALL), AML, CML, and MDS are slightly, but significantly lower than population rates in the 6th to 10th years posttransplant. Annual relative survival rates of long-term survivors of autologous HCT performed in Australia and New Zealand for AML and lymphomas are also slightly lower than population rates up to the 10th year posttransplant. Late deaths from transplant and disease-related causes are unusual, but continue to occur for many years post-HCT.

Allogeneic Hematopoietic Stem Cell Transplantation with Non-Myeloablative Conditioning in Patients with Acute Myelogenous Leukemia Eligible for Conventional Allografting: A Prospective Study

Using a non-myeloablative stem cell trasplantation (NST) program, 25 allografts were prospectively given to 24 patients with acute myelogenous leukemia (AML) eligible for conventional allografting; 2 individuals had secondary forms of AML. The median age of the patients was 35 years, with a range of 12 to 56. All patients engrafted; median time to achieve an absolute neutrophil count > 0.5 x 10(9)/1 was 12 days (range 0-26), whereas the median time to a platelet count > 20 x 10(9)/1 was 13 days (range 0-26). Patients developed mixed chimerism 15 to 100 (median 30) days after the allograft. The follow-up periods range between 33 and 2670 days (median 450). The median post-transplant overall survival of the patients has not been reached and is above 89 months, whereas the 683 days both overall and progression-free survival is 66%. In 14 grafts (56%) acute GVHD ensued; in 12 cases grades I-II and in 2 cases grade IV which was fatal in both. In 9/19 patients (47%) limited chronic GVHD developed. In 22 cases (88%), the procedure could be completed fully on an outpatient basis. The 100-day and the transplant-related mortality were both 8%. NST appears to be an effective additional therapeutic option for patients with AML in remission and a matched donor available.

The role of cytotoxic therapy with hematopoietic stem cell transplantation in the therapy of acute myelogenous leukemia in adults: an evidence-based review

Clinical research examining the role of hematopoietic stem cell transplantation (HSCT) in the therapy of acute myelogenous leukemia (AML) in adults is presented and critically evaluated in this systematic evidence-based review. Specific criteria were used for searching the published literature and for grading the quality and strength of the evidence and the strength of the treatment recommendations. Treatment recommendations based on the evidence are presented in Table 3, entitled Summary of Treatment Recommendations Made by the Expert Panel for Adult Acute Myelogenous Leukemia, and were reached unanimously by a panel of AML experts. The identified priority areas of needed future research in adult AML include: (1) What is the role of HSCT in treating patients with specific molecular markers (eg, FLT3, NPM1, CEBPA, BAALC, MLL, NRAS, etc.) especially in patients with normal cytogenetics? (2) What is the benefit of using HSCT to treat different cytogenetic subgroups? (3) What is the impact on survival outcomes of reduced intensity or nonmyeloablative versus conventional conditioning in older (>60 years) and intermediate (40-60 years) aged adults? (4) What is the impact on survival outcomes of unrelated donor HSCT vesus chemotherapy in younger (<40 years) adults with high risk disease?

Long-term outcome of unrelated donor transplantation for AML using myeloablative conditioning incorporating pretransplant Alemtuzumab

The outcome of 55 patients who underwent matched unrelated donor (MUD) transplantation for acute myelogenous leukemia (AML) following a conditioning regimen of cyclophosphamide and total-body irradiation (TBI) with the addition of Alemtuzumab 10 mg/kg/day on days -5 to -1 is described. All patients received graft-versus-host disease (GVHD) prophylaxis with cyclosporine as well as 3 doses of posttransplant methotrexate. Forty-one patients were transplanted in complete remission (CR) (20 in CR1, 20 in CR2, and 1 in CR3), and 14 were not in remission at the time of transplantation as they were refractory to chemotherapy either at induction or at relapse. The group consisted of adult patients with a median age of 37 years. Thirty-five patients were fully matched at HLA-A, -B, -C, and -DRB1. All patients engrafted and there were no cases of graft rejection. Grade II-IV acute GVHD occurred in only 2 patients. Chronic GVHD developed in 30% of patients but was extensive in only 3 cases. The predicted TRM was 11% at day 100 and 26% at 1 year. In multivariate analysis the receipt of an HLA mismatched transplant was associated with a higher transplant-related mortality (TRM) (55% versus 15%). Twelve of the 14 transplant-related deaths were due to infection. The 5-year cumulative incidence of relapse was 36% for the whole group and 28% for patients in CR at transplantation. The 5-year cumulative survival for the whole group was 38% and was 49% for those in remission at transplantation. Seven of the 12 patients transplanted in CR1 with adverse risk cytogenetics remain alive and in remission, and the predicted 5-year overall survival (OS) for this group is 50%. These results support the use of Alemtuzumab for unrelated donor hematopoietic stem cell transplant (HSCT) for poor risk AML in CR1 and for relapsed AML in CR2. The addition of Alemtuzumab is highly effective in preventing both rejection and severe acute and extensive chronic GVHD without an increased relapse risk.

The cost-effectiveness of stem cell transplantations from unrelated donors in adult patients with acute leukemia

OBJECTIVE

Hematopoietic stem cell transplantation is an accepted treatment of hematological malignancies, but the cost-effectiveness of this technology has not been fully explored. This study aims to assess the cost-effectiveness of stem cell transplantation from either cord blood or bone marrow/peripheral blood compared with no transplantation in adult patients with acute leukemias not expected to be cured with chemotherapy.

METHODS

A systematic review was performed to estimate the efficacy of unrelated cord blood and bone marrow/peripheral blood stem cells (BM/PBSC) transplantations in adults with acute leukemia. A Markov decision analysis model using Monte Carlo simulations was used to calculate the incremental cost-effectiveness ratio (ICER) and 95% confidence intervals (CIs).

RESULTS

The estimated cumulative survival at 1 and 10 years were 27.9% and 14%, respectively, for cord blood recipients and 47% and 17.7%, respectively, for BM/PBSC recipients. Using conservative assumptions, the cost per life-year gained compared with no transplantation was US 16,346 dollars (95% CI 8695 dollars, 38,006 dollars) for BM/PBSC transplantation and US 34,360 dollars (95% CI 23,101 dollars, 89,417 dollars) for cord blood transplantation.

CONCLUSIONS

Although both types of stem cell transplantations are associated with a high short-term mortality and high cost, the cumulative gains in life-years of survivors can be substantial, resulting in ICERs compared with no transplantation that are usually considered acceptable. However there is less certainty about this conclusion with cord blood transplantation.

Equivalent survival for sibling and unrelated donor allogeneic stem cell transplantation for acute myelogenous leukemia

Recent studies have shown comparable survival outcomes for unrelated donor (URD) stem cell transplantation in chronic myelogenous leukemia compared to sibling donors. We compared outcomes for 105 patients aged 16 to 59 years undergoing URD transplants for acute myelogenous leukemia (AML) who were reported to the Australasian Bone Marrow Transplant Recipient Registry between 1992 and 2002, and a strictly selected matching set of 105 HLA-matched sibling donor (MSD) transplants. There was no significant difference between URD and MSD controls in the distributions of time from diagnosis to transplant, donor-recipient sex match, prior therapies, donor age, or performance status. The median follow-up of live URD patients was 4.4 years and for live MSD controls was 6.3 years. There were 18 good risk (complete remission [CR]1) and 87 poor risk (>CR1) recipients in both URD and sibling groups. Five-year disease-free survival (DFS) was not significantly different for good-risk URD and sibling donor recipients (62% versus 40%, P = .2), or poor-risk URD and sibling recipients (21% versus 25%, P = .2). In a stratified multivariate Cox regression model, the independent adverse risk factors for DFS were recipient cytomegalovirus positivity (P = .01) and the interaction of URD and earlier year of transplant (P = .006). Both neutrophil and platelet engraftment were significantly more rapid in the sibling group, but transplant-related mortality at 100 days was not significantly different. There was no difference in the cumulative incidence of acute graft-versus-host disease grade II or above at 100 days. Relapse occurred in 28% of good risk URD subjects and 16% of siblings (P = .3), and in poor risk subjects 39% and 29%, respectively (P = .2). Based on this data, URD allografts should be considered in AML patients without a matched sibling donor. This study provides a rationale for a larger prospective study of risk factors in allogeneic transplantation for AML and a guide on the subset of patients who may most benefit from an unrelated donor allograft in AML.

Severe mucositis is associated with reduced survival after autologous stem cell transplantation for lymphoid malignancies

Mucositis is a known complication of autologous stem cell transplantation (ASCT). This study retrospectively reviewed 191 patients with lymphoid malignancies undergoing ASCT following a uniform mobilising regimen of etoposide (VP-16)/granulocyte colony-stimulating factor and a uniform high-dose preparative regimen of busulfan/cyclophosphamide/VP-16. Eighty-seven patients experienced severe mucositis (modified Oral Mucositis Assessment Scale > or =1). Patient characteristics compared between mucositis groups were balanced according to disease status, prior exposure to radiation therapy, time from radiation therapy and actual body weight. Log-rank analysis revealed that severe mucositis was associated with inferior overall survival (P = 0.002). A 12-month landmark analysis showed this difference in survival occurred within 1 year post-transplant. Multivariate analysis of all-cause mortality showed lower pretransplant albumin and severe mucositis to be significant risk factors. Multivariate analysis for relapse mortality revealed severe mucositis to be a risk factor (P = 0.047), while lower pretransplant albumin was significant for non-relapse mortality (NRM; P = 0.009). Kaplan-Meier estimates of survival based on relapse and NRM were significantly worse for patients with severe mucositis. Reduced pretransplant forced expiratory volume in 1 s (FEV(1)) and carbon monoxide (CO) diffusing capacity (DLCO) were also associated with severe mucositis. Our data suggest that studies of new treatment strategies for mucositis should include relapse and survival endpoints and that pretransplant factors, such as FEV(1) and DLCO may be useful to risk-stratify patients entered onto such trials.

Factors predicting success or failure associated with common types of transplants

The ability to predict clinical outcomes is essential to accurate medical decision analysis. Many accepted bone marrow transplant related prognostic variables are derived from data that is over 20-years old and may or may not be applicable to current medical practice. This report reviews both older data concerning bone marrow transplantation prognostic factors as well as more current reports. In addition to pretransplant variables, this review examines easily measured post-transplant variables that may affect prognosis, as well as data concerning the cellular component of the infused graft in both allogeneic and autologous transplantation.

Myeloablative conditioning is well tolerated by older patients receiving T-cell-depleted grafts

Older age has been linked to increased transplant-related mortality from graft-versus-host disease (GvHD). Depletion of T cells from stem cell grafts seems to protect from complications of GvHD particularly in older patients. After myeloablative conditioning, patients with haematological malignancies received allogeneic grafts from HLA identical siblings. For GvHD prophylaxis, PBPC grafts were treated ex vivo with anti-CD52, and therapeutic doses of cyclosporin until day +90. Survival of patients younger or older than the population age median was analysed. In all, 62 consecutive patients with a median age of 42.5 years were studied. Death was procedure related in 17% and from relapse of malignancy in five. At a median, follow-up is 662 (7-2316) days, 74% survive disease free. The rate of haematopoietic recovery and treatment-related mortality was similar in both groups. A total of 73% of 30 individuals in the younger group and 75% (P=0.8) in the older cohort survive at a median follow-up of 444 and 806 days (P=0.4). GvHD occurred in 13% and was the only adverse factor for survival (P<0.04). Myeloablative conditioning is well tolerated up to the age of 59 in patients receiving T-cell-depleted grafts. This information is useful to more precisely select patients who would benefit most from reduced intensity conditioning schedules.

Survival after reduced-intensity conditioning is not inferior to standard high-dose conditioning before allogeneic haematopoietic cell transplantation in acute leukaemias

To assess the role of allogeneic stem cell transplantation (SCT) after reduced-intensity conditioning (RIC) in acute leukaemias, we retrospectively compared 25 patients with acute lymphoblastic leukaemia or acute myelogenous leukaemia after RIC to a historical group of 50 matched controls after high-dose conditioning. Engraftment, acute GvHD and severe infections were comparable in both groups. During the observation period, 1/25 patients (4%) after RIC and 14/50 (28%) after standard SCT died due to transplant-related causes; cumulative nonrelapse mortality (NRM) was 4% after RIC and 24% after standard SCT (P=0.029). In total, 15/25 patients (60%) relapsed after RIC and 20/50 (40%) after standard SCT; probability of disease-free survival (DFS) at 3 years was 43% after RIC and 49% after standard SCT (NS). Overall survival (OS) was 40% after RIC and 37% after standard SCT (NS). Stage of disease, cytogenetic risk profile, acute and chronic GvHD, chimerism status at day 90 and severe infections after transplantation were risk factors with significant impact on DFS and/or OS. In retrospective analysis, patients with acute leukaemias who receive RIC because of contraindications against standard SCT have a comparable outcome to standard SCT, but the higher relapse rate warrants further studies.

Impact of disease burden at time of allogeneic stem cell transplantation in adults with acute myeloid leukemia and myelodysplastic syndromes

The impact of disease burden on the outcome of patients with acute myeloid leukemia (AML) undergoing allogeneic stem cell transplantation (SCT) has not been well defined. Data from several retrospective series suggest that overt leukemia at the time of transplant increases the risk of relapse. We reviewed the outcomes of 68 consecutive adults with AML (n=60) or myelodysplastic syndromes (MDS) (n=8) who received an allogeneic SCT at the University of Chicago between May 1986 and October 2002 to confirm the importance of currently recognized risk factors for overall survival (OS) and progression-free survival (PFS). In addition, we wanted to determine whether quantification of residual disease by blast percentage or cytogenetic abnormalities at the time of SCT was correlated with outcome. AML subtypes based on the FAB classification were as follows: M0=9, M1=9, M2=16, M3=2, M4=16, M5=3, M6=5. Cytogenetic analysis was available from 52 patients. Using standard morphologic criteria, 34 patients were in complete remission (CR) and 34 had visible leukemia present. The majority of donors were HLA-identical siblings (n=55). In all, 56 patients received myeloablative conditioning regimens and 12 received a reduced-intensity, fludarabine-based conditioning regimen. OS and PFS times were 7.1 months (95% CI, 4.8-10.4) and 5.1 months (95% CI, 3.2-7.8), respectively. Median follow-up from SCT was 4.6 years (range, 0.6-17.0) for survivors. In multivariate analysis, the following factors were found to be associated with worse survival: (1) increased percentage of blasts in the bone marrow at the time of SCT, (2) presence of acute graft-versus-host disease, (3) mismatched donor, (4) Zubrod performance score of >/=2, and (5) age >/=45 years. We also found a trend towards improved outcome among patients in cytogenetic remission as compared to those who had residual cytogenetic abnormalities and those in overt relapse. These data support an association between pre-transplant disease burden and poor outcome after SCT.

High dose intermittent ARA-C (HiDAC) for consolidation of patients with de novo AML: a single center experience

High dose intermittent ARA-C (2x3 g/m(2) i.v., days 1, 3, 5)=HiDAC was introduced as consolidation in AML by the CALGB-group in 1994. We treated 44 de novo AML patients in CR with up to four cycles of HiDAC (four cycles: 56.8%; three cycles: 22.7%; two cycles: 6.8%; one cycle: 13.7%). Median duration of aplasia (ANC<0.5x10(9)/l) was 12 days. Neutropenic fever occurred in 38.6% of the patients during the first, 52.6% during the second, 45.7% during the third, and in 40% during the fourth cycle. Non-hematologic toxicity was tolerable. The median overall- and disease-free survival were 19.3 and 11.3 months, respectively. The best outcome was seen in patients aged <40 years. These results confirm that HiDAC is a safe and effective consolidation in AML.

Significance of one human leukocyte antigen mismatch on outcome of nonmyeloablative allogeneic stem cell transplantation from related donors using the Mexican schedule

Using the Mexican approach to conduct nonablative stem cell transplantation (NST), we have prospectively performed 58 allografts in individuals with various malignant and nonmalignant hematological diseases using sibling donors, either HLA identical (6/6) or compatible, with one mismatch (5/6). When comparing allografts obtained from HLA identical (n=40) or compatible (n=18) siblings, respectively, the overall median survival was found to be 33 vs 8 months (P<0.01), the 52-month survival was 47 vs 38% (P>0.2), the prevalence of acute graft-versus-host disease (GVHD) 57 vs 38%, that of chronic GVHD 25 vs 11% and the relapse rate 45 vs 55%. The two patients who failed to engraft were both 5/6 matches. Probably stemming from the low number of patients, and despite a trend toward worse results in patients allografted from HLA compatible (5/6) siblings, most differences in outcome were not significant. It seems that NST can be offered to individuals with either an HLA identical or a compatible sibling donor.

Bone marrow microvessel density and its prognostic significance in AML

Microvessel density reportedly is increased in various hematologic disorders including acute lymphatic and myeloid leukemias. In these patients the bone marrow microvessel density (BM-MVD) appears to be associated with an unfavorable prognosis. In the present study, we have retrospectively analyzed the BM-MVD (at diagnosis) in 31 patients with acute myeloid leukemia (AML) (median age: 38 years; range: 21-53 years; f:m-ratio: 1:1,4) who underwent conventional chemotherapy and consecutive allogeneic bone marrow transplantation (BMT). The median BM-MVD at diagnosis was 30/mm2 (range: 17-48/mm2) and thus was significantly higher compared to controls (n = 9; BM-MVD: median 7/mm2, range 2-11/mm2; P < 0.05). In patients who failed to achieve a complete remission (CR) in response to induction chemotherapy, the BM-MVD was significantly higher (median: 41.5/mm2) at diagnosis than in patients who entered CR (median: 28.5/mm2, P < 0.05). In addition, patients with high BM-MVD ( > 30 mm2) had a significantly shorter overall survival compared to patients with a lower BM-MVD ( < 30 mm2, P < 0.05). Moreover, patients with a high BM-MVD ( > 30 mm2) were found to have a significantly higher risk of relapse (P < 0.05). In 4 patients in whom a continuous complete remission was documented after BMT, the BM-MVD levels were analyzed at diagnosis as well as between day + 80 and day + 100 after BMT. In all 4 patients, the BM-MVD was found to decrease in response to BMT until day 100 (P < 0.05). Together, our data suggest that the BM-MVD could be a prognostic parameter concerning survival in patients with AML undergoing allogeneic BMT.

Risk factors in pediatric stem cell transplantation for leukemia

To investigate which factors impact on survival, relapse, relapse free survival, transplant-related mortality (TRM) and graft-versus-host disease (GVHD) in children who undergo allogeneic stem cell transplantation, we included all 181 children transplanted due to leukemia at our unit. At the end of follow up 54% of the patients were alive, 27% had died due to relapse while 19% had died of other causes. Survival was similar in recipients of related (55%) and unrelated grafts (48%). Risk factors identified in univariate analysis were brought into a multivariable analysis. However, an unrelated donor was not identified as a risk factor for any of the five end-points analysed. A donor positive for three to four herpes viruses increased the risk of acute GVHD, TRM and death. A female to male transplant increased the risk of TRM, particularly if combined with a mismatch. Early stage of disease as well as human leukocyte antigen (HLA)-matching independently predicted survival. The risk of relapse increased after 1992. Chronic GVHD independently decreased the risk of relapse (relative risk RR, 0.39) and death (RR 0.42). We conclude that in children with leukemia other specific donor characteristics such as HLA-matching, gender, parity, and exposure to herpes viruses were more important for outcome than relationship.