Low rate of infectious enterocolitis in allogeneic stem cell transplant recipients with acute diarrhea: A prospective study by the GETH-TC

Acute diarrhea is a common and debilitating complication in recipients of an allogeneic hematopoietic stem cell transplantation (HCT). In this prospective, observational, and multi-center study we examined all episodes occurring in the first 6 months of 142 consecutive adult patients who underwent a reduced-intensity conditioning (RIC) HCT in 10 Spanish tertiary University Hospitals. Fifty-four patients (38%) developed a total of 75 acute diarrhea episodes. The median time from HCT to the first episode was 38 days (4-157). The main cause of enterocolitis was lower GI-aGVHD (38%), followed by infections (21%) and drug-related toxicity (8%). Causative infectious causes were identified in only 16/75 episodes (21%). C. difficile-related infection (CDI) was the most common infectious agent with an incidence and recurrence of 13% and 2%, respectively. With a median follow-up for survivors of 32 months, the NRM and the overall survival (OS) at 1 year, were 20% (95% C.I.: 14-28%) and 69% (95% C.I.: 61-77%), respectively. Development of enterocolitis was not associated with higher NRM (p = 0.37) or worse OS (p = 0.9). This real-life study confirms that the diagnosis and management of acute diarrhea in the early stages after HCT is challenging. Nosocomial infections, seem to be relatively uncommon, probably due to more rational use of antibiotics.

[Second allogeneic progenitor cell transplantation for leukemia relapse: results in 10 patients]

BACKGROUND

Leukemia relapse is an important cause of treatment failure after allogeneic progenitor cells transplantation. A minority of patients achieve a long-term disease free survival with a second transplant, but the majority die of toxicity or relapse. We report our experience with second allogeneic transplant for leukemia relapse.

PATIENTS AND METHODS

Ten patients were treated with a second transplant. Their diagnosis were chronic myelogenous leukemia (n = 5) and acute leukemia (n = 5). The interval between transplants ranged from 4 to 59 months (median 26 months). Conditioning regimens were busulfan alone (n = 1), associated to cyclophosphamide (n = 6) or to cyclophosphamide plus etoposide (n = 3). Acute graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin (CSA) (n = 4), CSA plus methotrexate (n = 4), CSA plus prednisolone (n = 1), or CSA, methotrexate plus partial T cell depletion (n = 1).

RESULTS

All patients engrafted after second transplant. Seven developed acute GVHD. Four out of the nine patients at risk (44%) developed chronic GVHD. Three had clinical criteria of hepatic veno-occlusive disease. Three patients died in complete remission due to treatment-related toxicity: pulmonary invasive aspergillosis during an acute GVHD, interstitial pneumonitis plus chronic GVHD, and, hepatic veno-occlusive disease, respectively. Two patients relapsed 4 and 5 months after second transplant. Five remained alive in complete remission after a median follow-up of 27 months. In all of them acute or chronic GVHD incidence and severity after second transplant was higher than after the first transplant. All surviving patients were transplanted more than 12 months after the first transplant.

CONCLUSIONS

A proportion of patients that relapse after an allogeneic progenitor cells transplant may benefit from second transplant; especially, young patients having a good performance status, and with a long interval between transplants.

Rapid engraftment without significant graft-versus-host disease after allogeneic transplantation of CD34+ selected cells from peripheral blood

We have prospectively evaluated the feasibility and results of the biotin-avidin immunoadsorption method (Ceprate SC system) for a phase I/II study of T-cell depletion of granulocyte colony-stimulating factor (G-CSF) mobilized peripheral blood progenitor cells (PBPC) for allogeneic transplantation. Twenty consecutive patients, median age, 40 years (21 to 54) and diagnoses of chronic myeloid leukemia in chronic phase (n = 5), acute myeloblastic leukemia (n = 7), acute lymphoblastic leukemia (n = 2), chronic myelomonocytic leukemia (n = 1), refractory anemia with excess of blasts in transformation (n = 3), histiocytosis X (n = 1), and chronic lymphocytic leukemia (n = 1), were conditioned with cyclophosphamide (120 mg/kg) and total body irradiation (13 Gy; 4 fractions). HLA identical sibling donors received G-CSF at 10 microg/kg/d subcutaneously (SC); on days 5 and 6 (19 cases) and days 5 to 8 (1 case) donors underwent 10 L leukapheresis. PBPC were purified by positive selection of CD34+ cells using immunoadsorption biotin-avidin method (Ceprate SC) and were infused in the patients as the sole source of progenitor cells. No growth factors were administered posttransplant. The median recovery of CD34+ cells after the procedure was of 65%. The median number of CD34+ cells infused in the patients was 2.9 (range, 1.5 to 8.6) x 10(6)/kg. The median number of CD3+ cells administered was 0.42 x 10(6)/kg (range, 0.1 to 2). All patients engrafted. Neutrophil counts >500 and >1,000/microL were achieved at a median of 14 days (range, 10 to 18) and 15 days (range, 11 to 27), respectively. Likewise, platelet counts >20,000 and >50,000/microL were observed at a median of 10 days (range, 6 to 23) and 17 days (range, 12 to 130), respectively. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine plus methylprednisolone. No patient developed either grade II to IV acute or extensive chronic GVHD. After a median follow-up of 7.5 months (range, 2 to 22) three patients have relapsed, and one of them is again in hematologic and cytogenetic remission after infusion of the donor lymphocytes. Two patients died in remission: one on day +109 of pulmonary aspergillosis and the other on day +251 of metastasic relapse of a previous breast cancer. Sixteen of the 20 patients are alive in remission after a median follow-up of 7.5 months (range, 2 to 22). In conclusion, despite the small number of patients and limited follow-up, it appears that this method allows a high CD34+ cell recovery from G-CSF mobilized PBPC and is associated with rapid engraftment without significant GVHD, and with low transplant related mortality.