High-dose chemotherapy and autologous stem cell transplantation of patients with multiple myeloma in an outpatient setting

Oral minocycline as systemic therapy for uncomplicated venous access device-related bloodstream infection with coagulase-negative staphylococci after allogeneic hematopoietic cell transplantation

BACKGROUND

Venous access device-related bloodstream infection (VAD-BSI) with coagulase-negative staphylococci (CoNS) is a common complication after allogeneic hematopoietic cell transplantation (alloHCT). Standard systemic antimicrobial therapy for uncomplicated VAD-BSI with methicillin-resistant CoNS consists of intravenous (IV) vancomycin (vanco). This requires hospitalization, needs new competent venous access, exposes patients to potential toxicity (mainly renal) and increases the risk of commensal flora dysbiosis with selection of vanco-resistant enterococci. Combined with VAD management (removal or antibiotic locks), oral minocycline (mino) has been evaluated as an alternative systemic therapy for the treatment of uncomplicated VAD-BSIs with CoNS at our center, primarily when the reference treatment with IV vanco was not possible (renal failure or allergy) or when hospitalization was refused by patients. Here, we retrospectively report our single center experience with this mino-based approach.

PATIENTS AND METHODS

From January 2012 to December 2020, 24 uncomplicated VAD-BSIs with CoNS in 23 alloHCT patients were treated with oral mino as systemic antibiotic therapy in combination with VAD management. VAD were implantable ports (n = 17), tunneled catheter (n = 1) or PIC-lines (n = 6). Staphylococci were S. epidermidis (n = 21) or S. haemolyticus (n = 3). Mino was administered with a loading dose of 200 mg followed by 100 mg BID for 7-14 days. For 8 VAD-BSIs, patients were initially treated with IV vanco for the first 1-3 days followed by oral mino, while 16 VAD-BSIs were treated with oral mino as the sole antimicrobial agent for systemic therapy. VAD management consisted of catheter removal (for tunneled catheters and PIC-lines, n = 7) or antibiotic locks with vanco (n = 15) or gentamicin (n = 2) administered at least 3 times a week for 14 days (for ports).

RESULTS

Overall, clearance of bacteremia (as assessed by negativity for the same CoNS of surveillance peripheral blood cultures drawn between day+ 3 and +30 after initiation of systemic therapy) was achieved in all but 1 patient (with port) who had persistent bacteremia at day +9. No complication such as suppurative thrombophlebitis, endocarditis, distant foci of infection or BSI-related death was observed in any patient during the 3-month period after initiation of treatment. Regarding the 17 port-BSI cases for which VAD conservative strategy was attempted, failure of 3-month VAD preservation was documented in 7/17 cases and 3-month recurrence of VAD-BSI was observed in 3/17 cases (with 1 patient with cellulitis). Treatment with mino was well tolerated except for a mild skin rash in one patient.

CONCLUSION

Further prospective studies are needed to evaluate efficacy and safety of this approach.

Efficacy and Safety of High-Dose Chemotherapy with Treosulfan and Melphalan in Multiple Myeloma

(1) Background: Upfront treatment consolidation with high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) has relevantly contributed to achieving durable remissions following induction treatment in multiple myeloma (MM) patients. The optimization of HDCT regimens can, therefore, essentially contribute to improving the depth and duration of tumor remissions. To date, melphalan at 200 mg/m² is the standard HDCT regimen for fit MM patients. In our previous work, we showed promising efficacy and safety results for treosulfan (14 g/m²) and melphalan (200 mg/m²) (TreoMel) in acute myeloid leukemia (AML) patients receiving ASCT. Based on these data, TreoMel became the standard of care for fit MM patients at our institution. (2) Methods: We identified 115 consecutive MM patients who underwent consolidation with TreoMel between 01/2020 and 08/2022 at the University Hospital of Bern. We analyzed the safety and efficacy data, as well as the treosulfan pharmacokinetics, correlating them with tumor responses. (3) Results: A complete response (CR) rate of 84% was achieved, which is comparable to the CR rate reported for the quadruplet combination. The median PFS was 30 months (95% CI: 20.4-not reached), and the 31-month OS rate was 83%. The median area under the curve (AUC) for treosulfan was 952.5 mg*h/L (range: 527.4-1781.4), and the median peak level was 332.3 mg/L (range: 168-554). The treosulfan pharmacokinetics showed no significant correlation with MM responses after HDCT and ASCT. However, female patients had a significantly higher AUC (p = 0.007) and peak value (p = 0.001), and the higher values were associated with longer hospitalizations. (4) Conclusions: Treatment consolidation with TreoMel HDCT demonstrated a promising efficacy and safety profile in our cohort of MM patients and deserves further investigation in prospective studies.

Hospital and outpatient models for Hematopoietic Stem Cell Transplantation: A systematic review of comparative studies for health outcomes, experience of care and costs

The number of Hematopoietic Stem Cell Transplantations has risen in the past 20 years. The practice of outpatient Hematopoietic Stem Cell Transplantation programs is increasing in an attempt to improve the quality of patient care and reduce the demand for hospital admission. A systematic review of 29 comparative studies between in-hospital and outpatient treatment of Hematopoietic Stem Cell Transplantation, with no restriction by outpatient regime was conducted. This study aims to analyse the current evidence on the effects of the outpatient model on patient-centred outcomes, comparing both in-hospital and outpatient models for autologous and allogeneic HSCT using the Triple Aim framework: health outcomes, costs and experience of care. We found evidence on improved health outcomes and quality of life, on enhanced safety and effectiveness and on reduced overall costs and hospital stays, with similar results on overall survival rates comparing both models for autologous and allogeneic patients. We also found that the outpatient Hematopoietic Stem Cell Transplantation is a safe practice as well as less costly, it requires fewer days of hospital stay both for autologous and allogeneic transplantations. Under a situation of an increasing number of transplants, rising healthcare costs and shortages of hospital capacity, incorporating outpatient models could improve the quality of care for people requiring Hematopoietic Stem Cell Transplantation programs.

Creating and Validating a Predictive Model for Suitability of Hospital at Home for Patients With Solid-Tumor Malignancies

PURPOSE

Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH.

METHODS

In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model.

RESULTS

Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts.

CONCLUSION

Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.

The Burden in Caregivers of Multiple Myeloma Patients Undergoing Outpatient Autologous Stem-Cell Transplantation Compared to Inpatient Transplantation

BACKGROUND

The application of different models of autologous stem-cell transplantation (ASCT) in multiple myeloma has demonstrated the feasibility and safety of outpatient-based programs of care. Although several systematic reviews have evaluated the burden of caregivers, only a few studies have included outpatient ASCT.

PATIENTS AND METHODS

The feelings of lack of family support, daily activities, and general health were compared between caregivers of 2 groups of patients with multiple myeloma who underwent inpatient (n = 71) or outpatient (n = 25) ASCT.

RESULTS

The 3 features did not significantly differ between the 2 study groups at baseline, before, and 3 months after ASCT. Multivariate modeling showed that the baseline values were significantly related to the changes in study outcomes independent of patient and caregiver characteristics. Other correlates were caregivers' work and patient age for impact on daily activities and disease burden across time for impact on general health (all P < .05).

CONCLUSION

The outpatient model neither improves nor impairs global caregivers' burden compared to standard ASCT care. Further research is needed to confirm this observation and to better assess the burden and quality of life of caregivers and their influence on patient outcomes and quality of life.

The avoidance of G-CSF and the addition of prophylactic corticosteroids after autologous stem cell transplantation for multiple myeloma patients appeal for the at-home setting to reduce readmission for neutropenic fever

BACKGROUND

Autologous stem cell transplantation (ASCT) remains the standard of care for young multiple myeloma (MM) patients; indeed, at-home ASCT has been positioned as an appropriate therapeutic strategy. However, despite the use of prophylactic antibiotics, neutropenic fever (NF) and hospital readmissions continue to pose as the most important limitations in the outpatient setting. It is possible that the febrile episodes may have a non-infectious etiology, and engraftment syndrome could play a more significant role. The aim of this study was to analyze the impact of both G-CSF withdrawal and the addition of primary prophylaxis with corticosteroids after ASCT.

METHODS

Between January 2002 and August 2018, 111 MM patients conditioned with melphalan were managed at-home beginning +1 day after ASCT. Three groups were established: Group A (n = 33) received standard G-CSF post-ASCT; group B (n = 32) avoided G-CSF post-ASCT; group C (n = 46) avoided G-CSF yet added corticosteroid prophylaxis post-ASCT.

RESULTS

The incidence of NF among the groups was reduced (64%, 44%, and 24%; P<0.001), with a non-significant decrease in hospital readmissions as well (12%, 6%, and 2%; P = 0.07). The most important variables identified for NF were: HCT-CI >2 (OR 6.1; P = 0.002) and G-CSF avoidance plus corticosteroids (OR 0.1; P<0.001); and for hospital readmission: age ≥60 years (OR 14.6; P = 0.04) and G-CSF avoidance plus corticosteroids (OR 0.07; P = 0.05).

CONCLUSIONS

G-CSF avoidance and corticosteroid prophylaxis post ASCT minimize the incidence of NF in MM patients undergoing at-home ASCT. This approach should be explored in a prospective randomized clinical trial.

Low-dose peripheral blood stem cell graft after high-dose chemotherapy - an evaluation of hematopoietic reconstitution

Background

High-dose (HD) chemotherapy followed by autologous blood stem-cell transplantation (ASCT) is the standard treatment for multiple myeloma (MM) patients. However, the collection of sufficient peripheral blood stem cell (PBSC) grafts can be challenging, and the question arises whether reinfusion of low-dose grafts will lead to a hematopoietic recovery.

Methods

The hematopoietic recovery of 148 MM patients who underwent HD melphalan chemotherapy and received PBSC transplants with varying CD34+ cells doses (3–4 × 10⁶ [n = 86], 2–2.5 × 10⁶ [n = 53], < 2 × 10⁶ [n = 9] per kg body weight [bw]) was analyzed in this retrospective single-center study.

Results

All patients reached hematopoietic reconstitution, even those who received < 2 × 10⁶ CD34+ cells/kg bw. 62 (42%) patients received granulocyte-colony-stimulating factor (G-CSF). The median duration to leukocyte recovery ≥1.0 × 10⁹/L was 12 days in every group. The median duration to platelet recovery ≥20 × 10⁹/L was 11, 13 and 13 days, respectively. In the multivariate analysis, a low number of reinfused CD34+ cells was associated with prolonged time until leukocyte reconstitution (p = 0.010, HR 0.607) and platelet recovery (p < 0.001, HR 0.438). G-CSF support significantly accelerated leukocyte (p < 0.001, HR 16.742) but not platelet reconstitution.

Conclusion

In conclusion, reinfusion of low- and even very-low-dose PBSC grafts leads to sufficient hematopoietic reconstitution. No severe adverse events were observed during or after HD chemotherapy and ASCT in the analyzed cohort. While the impact of CD34+ cell dose is marginal, G-CSF significantly accelerates the leukocyte recovery.

Impact of intensifying primary antibiotic prophylaxis in at-home autologous stem cell transplantation program for lymphoma patients

Despite the use of fluoroquinolone (FQ) prophylaxis, neutropenic fever (NF) is the most frequent cause of hospital readmission in ambulatory care programs for patients treated with autologous stem cell transplantation (ASCT). We analyzed the impact of intensifying primary prophylaxis with the addition of piperacillin/tazobactam (PT) to FQ. Between January 2002 and August 2018, 154 lymphoma patients conditioned with BEAM were included (40% received ceftriaxone (Ct) plus FQ and 60% PT plus FQ). NF and hospital readmission were required in 84 vs. 41% (p < .0001) and 12 vs. 1% (p = .007) of patients within the Ct and PT groups, respectively. The multivariate analysis showed that PT plus FQ retained its independent protective factor for NF (odds ratio (OR): 0.13; p < .001) and for hospital readmission (OR: 0.07; p = .01). The use of PT and FQ prophylaxis may effectively prevent episodes of NF and hospitalizations in lymphoma patients managed in our at-home ASCT care model.

Risk of febrile neutropenia among patients with multiple myeloma or lymphoma who undergo inpatient versus outpatient autologous stem cell transplantation: a systematic review and meta-analysis

Background

Outpatient autologous stem cell transplantations (ASCTs) in multiple myeloma and lymphoma patients have been shown to reduce the overall costs and improve the quality of life relative to inpatient ASCTs. This systematic review and meta-analysis was performed with the aim of comprehensively comparing the risk of febrile neutropenia developing in ASCT outpatients and inpatients who have multiple myeloma or lymphoma.

Methods

To be eligible for the meta-analysis, studies needed to be either randomized, controlled studies or cohort studies. They also need to have two groups of patients with multiple myeloma or lymphoma who underwent ASCT, with the treatment being provided to one group in an outpatient setting and to the other on an inpatient basis. The studies had to report our primary outcome of interest, the rate of febrile neutropenia after stem cell infusion, for both groups. The Mantel–Haenszel method was used to pool the effect estimates and 95% confidence intervals of each study.

Results

From 9 eligible studies, a total of 1940 patients were included in the meta-analysis. Contrary to conventional concerns, the patients who underwent the outpatient ASCT had a significantly lower risk of developing febrile neutropenia than those admitted for ASCT, with a pooled odds ratio (OR) of 0.44 (95% confidence interval [CI]: 0.29–0.65; p < 0.0001; I² = 52%). The risk of septicemia was also significantly lower for the outpatients than the inpatients, with a pooled OR of 0.40 (95% CI: 0.16–0.97; p = 0.04; I² = 23%). Additional analyses found that the odds of having grade 2–3 mucositis and transplant-related mortality were numerically lower for the outpatient group, although the pooled result was not statistically significant. The odds of surviving at 2–3 years was also numerically higher for the ASCT outpatients, but the difference did not reach statistical significance.

Conclusions

This study found a significantly lower odds of developing febrile neutropenia and septicemia among patients with multiple myeloma and lymphoma who received an outpatient ASCT than among those who had an inpatient ASCT.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5054-6) contains supplementary material, which is available to authorized users.

Advances in delivery of ambulatory autologous stem cell transplantation for multiple myeloma

PURPOSE OF REVIEW

Autologous stem cell transplantation (ASCT) is generally performed in the inpatient setting in its entirety. Several centers have demonstrated the feasibility of performing ASCT for myeloma in the ambulatory setting. We review the safety, cost-effectiveness, complications and outcomes of outpatient ASCT for myeloma.

RECENT FINDINGS

Published studies are heterogeneous but suggest that outpatient ASCT for myeloma is cost-effective and associated with a shorter or no initial hospitalization, albeit there is a high rate of readmission for complications. The transplant-related mortality rate is less than 1%. Stringent patient selection criteria that include emphasis on functional status, caregiving support and psychosocial aspects for each patient are critical for identifying patients most appropriate for ASCT in the ambulatory setting. There exists considerable variability in outpatient transplant models and supportive care guidelines and data do not support preference for one delivery model over another. Survival and other transplant-related outcomes have not been reported widely and whether patients fare better with outpatient transplantation remains to be explored.

SUMMARY

Outpatient ASCT for multiple myeloma is feasible and well tolerated in selected patients. Several care models for outpatient ASCT exist and can be implemented based on transplant resources and preference.

Outcome after high-dose chemotherapy and autologous stem cell transplantation in patients with aggressive B-cell non-Hodgkin's lymphoma

OBJECTIVE

For more than two decades, high-dose chemotherapy (HDT) and autologous blood stem cell transplantation (ABSCT) were treatment options for patients with aggressive B-cell non-Hodgkin's lymphoma (B-NHL). However, the ideal timing and the collective patient benefits are still being debated.

METHOD

We retrospectively analyzed the data of 163 patients with B-NHL who received an HDT protocol followed by ABSCT between 2001 and 2007. Patients were analyzed according to the time point of HDT/ABSCT to compare upfront (directly after induction, n = 72, 44%) versus secondary transplantation (at first relapse, n = 91, 56%).

RESULTS

The overall response rate was 100% and 94% after upfront and secondary HDT/ABSCT, respectively. No significant differences were found for hematopoietic recovery and toxicity profile. The progression-free survival (PFS) and overall survival (OS) probability were found to be significantly higher in the upfront HDT/ABSCT treatment group (P = .018 and P = .004). In multivariate analysis, upfront HDT/ABSCT and low IPI risk score had a significant beneficial effect on OS (P = .031 and P = .019).

CONCLUSION

HDT and ABSCT directly after induction chemotherapy were confirmed to be feasible with high PFS and OS rates. In addition, for patients with relapse after first-line therapy and consecutively poor prognosis, HDT/ABSCT also offers an effective treatment strategy.

Inpatient vs outpatient autologous hematopoietic stem cell transplantation for multiple myeloma

BACKGROUND

High-dose chemotherapy and autologous hematopoietic stem cell transplantation (auto-HCT) are commonly performed for multiple myeloma (MM) patients and may be as safe in the outpatient setting as in the inpatient setting.

METHODS

We performed a single-center retrospective analysis of all MM patients undergoing auto-HCT between January 2008 and December 2012. We categorized patients as outpatient vs inpatient auto-HCT and compared clinical characteristics and outcomes between the groups.

RESULTS

One thousand and forty-six patients were included (669 inpatients, 377 outpatients). Patients transplanted as outpatients were significantly younger (58 [34-78] vs 62 [31-82], P < .001) and more likely to have an hematopoietic stem cell comorbidity index (HCT-CI) score <2 (P = .003) and creatinine <2 (P < .001). There were no differences in treatment-related mortality (TRM) but the inpatient group experienced significantly more grade 2-5 (P = .003) and grade 3-5 (P = .003) adverse events (AEs). 2 year progression-free survival (PFS) was significantly longer in the outpatient group (60% vs 50%, HR =HR 0.7, 95% CI 0.6-0.9, P = .005). 2 year OS was also longer in the outpatient group (83% vs 77%, HR 0.6, 95% CI 04-0.9, P = .01).

CONCLUSION

Outpatient auto-HCT can be safely performed for selected patients with MM. Differences in outcomes are likely related to baseline clinical characteristics rather than choice of treatment setting.