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Bionghi N, Daftary A, Maharaj B, Msibi Z, Amico KR, Friedland G, Orrell C, Padayatchi N, O'Donnell MR. Pilot evaluation of a second-generation electronic pill box for adherence to Bedaquiline and antiretroviral therapy in drug-resistant TB/HIV co-infected patients in KwaZulu-Natal, South Africa. BMC Infect Dis 2018; 18:171. [PMID: 29642874 PMCID: PMC5896111 DOI: 10.1186/s12879-018-3080-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The introduction of Bedaquiline, the first new antimycobacterial drug in over 40 years, has highlighted the critical importance of medication adherence in drug-resistant tuberculosis (DR-TB) treatment to prevent amplified drug-resistance and derive sustained benefit. Real-time electronic dose monitoring (EDM) accurately measures adherence and allows for titration of adherence support for anti-retroviral therapy (ART). The goal of this study was to evaluate the accuracy and acceptability of a next-generation electronic pillbox (Wisepill RT2000) for Bedaquiline-containing TB regimens. METHODS Eligible patients were DR-TB/HIV co-infected adults hospitalized for the initiation of Bedaquiline-containing treatment regimens in KwaZulu-Natal, South Africa. A one-way crossover design was used to evaluate levels of adherence and patient acceptance of EDM. Each patient was given a Wisepill device which was filled with ART, Levofloxacin or Bedaquiline over three consecutive weeks. Medication adherence was measured using Wisepill counts, patient-reported seven-day recall, and weekly pill count. An open-ended qualitative questionnaire at the end of the study evaluated participant acceptability of the Wisepill device. RESULTS We enrolled 21 DR-TB/HIV co-infected inpatients admitted for the initiation of Bedaquiline from August through September 2016. In aggregate patients were similarly adherent to Bedaquiline (100%) compared to Levofloxacin (100%) and ART (98.9%) by pill count. Wisepill was more sensitive (100%) compared to seven-day recall (0%) in detecting non-adherence events (p = 0.02). Patients reported positive experiences with Wisepill and expressed willingness to use the device during a full course of DR-TB treatment. There were no concerns about stigma, confidentiality, or remote monitoring. CONCLUSION In this pilot study patients were highly adherent to Bedaquiline by all adherence measures. However, there was lower adherence to ART by pill count and Wisepill suggesting a possible challenge for adherence with ART. The use of EDM identified significantly more missed doses than seven-day recall. Wisepill was highly acceptable to DR-TB/HIV patients in South Africa, and is a promising modality to support and monitor medication adherence in complex treatment regimens.
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Affiliation(s)
- N Bionghi
- Columbia University College of Physicians and Surgeons, NY, NY, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - A Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,McGill International TB Centre, McGill University, Montreal, Canada
| | - B Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Z Msibi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K R Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - C Orrell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - N Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - M R O'Donnell
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa. .,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA.
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Zelnick JR, Seepamore B, Daftary A, Amico KR, Bhengu X, Friedland G, Padayatchi N, Naidoo K, O'Donnell MR. Training social workers to enhance patient-centered care for drug-resistant TB-HIV in South Africa. Public Health Action 2018; 8:25-27. [PMID: 29581940 DOI: 10.5588/pha.17.0114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 01/22/2018] [Indexed: 11/10/2022] Open
Abstract
KwaZulu-Natal, South Africa, is the epicenter of an epidemic of drug-resistant tuberculosis (DR-TB) and human immunodeficiency virus (HIV) co-infection, characterized by low rates of medication adherence and retention in care. Social workers may have a unique role to play in improving DR-TB-HIV outcomes. We designed, implemented and evaluated a model-based pilot training course on patient-centered care, treatment literacy in DR-TB and HIV coinfection, patient support group facilitation, and self-care. Ten social workers participated in a 1-day training course. Post-training questionnaire scores showed significant overall gains (P = 0.003). A brief training intervention may be a useful and feasible way to engage social workers in patient-centered care for DR-TB and HIV coinfection.
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Affiliation(s)
- J R Zelnick
- Touro College Graduate School of Social Work, New York, New York, USA.,Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - B Seepamore
- Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,School of Applied Human Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - A Daftary
- Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,McGill International TB Centre, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - K R Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - X Bhengu
- King DinuZulu Hospital Complex, Sydenham, South Africa
| | - G Friedland
- Yale School of Medicine, New Haven, Connecticut, USA
| | - N Padayatchi
- Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K Naidoo
- Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - M R O'Donnell
- Centre for AIDS Programme of Research in South Africa, South African Medical Research Council HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Zelnick JR, O'Donnell MR, Ahuja SD, Chua A, Sullivan Meissner J. Health care provider perspectives on tuberculosis care for foreign-born populations in New York City. Int J Tuberc Lung Dis 2018; 20:1625-1632. [PMID: 27931338 DOI: 10.5588/ijtld.16.0299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) in foreign-born patients is a key determinant of TB epidemiology in low-burden settings. In New York City (NYC), foreign-born TB populations are heterogeneous and face diverse challenges in accessing care. OBJECTIVE To characterize barriers and facilitators to health care services and identify potential mechanisms to improve TB care for foreign-born patients in NYC. DESIGN Semi-structured interviews with health care providers identified through the NYC TB registry and snowball sampling. Transcripts were analyzed using a modified grounded theory approach. RESULTS Fourteen providers from private practice (21%), community clinic (36%), and hospitals (43%) were interviewed. Barriers clustered into thematic areas: interrelated social and economic issues that impact TB care and treatment (documentation status, poverty, mental/behavioral health issues), challenges of fragmented health system (care continuity, costs), latent tuberculous infection, and relative lack of resources and significant barriers for clinic and private practice providers. Health care providers' deep commitment to foreign-born TB patients was evidenced by their attitudes and actions. CONCLUSION Improving access to TB care for foreign-born patients in NYC requires strategies that address specific social, economic and structural barriers. Improving linkages between private providers and public health initiatives is a key challenge. Health care providers' commitment to foreign-born communities is a significant resource.
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Affiliation(s)
- J R Zelnick
- Touro College Graduate School of Social Work, New York
| | - M R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York
| | - S D Ahuja
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, New York
| | - A Chua
- Division of Pulmonary Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, New York, New York, USA
| | - J Sullivan Meissner
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, New York
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Abstract
Clofazimine (CFZ), a riminophenazine and a key component of the treatment regimen for lepromatous leprosy, has been rehabilitated clinically for the treatment of multidrug-resistant tuberculosis (MDR-TB). Observational studies and a randomized control trial suggest efficacy in the treatment of MDR-TB and the potential for treatment shortening. Animal and translational research have shown mixed results. In this article, we review key clinical, animal, and translational data to better understand the potential role of CFZ in the treatment of MDR-TB and in shortening anti-tuberculosis treatment.
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Affiliation(s)
- M R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York City, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York City, New York, USA; CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - N Padayatchi
- CAPRISA MRC-HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
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O'Donnell MR, Daftary A, Frick M, Hirsch-Moverman Y, Amico KR, Senthilingam M, Wolf A, Metcalfe JZ, Isaakidis P, Davis JL, Zelnick JR, Brust JCM, Naidu N, Garretson M, Bangsberg DR, Padayatchi N, Friedland G. Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV. Int J Tuberc Lung Dis 2017; 20:430-4. [PMID: 26970149 DOI: 10.5588/ijtld.15.0360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.
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Affiliation(s)
- M R O'Donnell
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - A Daftary
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M Frick
- Treatment Action Group, New York, USA
| | - Y Hirsch-Moverman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - K R Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | | | - A Wolf
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | | | - J L Davis
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J R Zelnick
- Touro College Graduate School of Social Work, New York, New York, USA
| | - J C M Brust
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA
| | - N Naidu
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - M Garretson
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | | | - N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - G Friedland
- Yale University School of Public Health, New Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Disseminated Mycobacterium tuberculosis is a leading cause of bloodstream infection and severe sepsis in sub-Saharan African settings with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. Despite the high prevalence of M. tuberculosis bacteremia in these settings it is under-recognized. This is in part because timely diagnosis of M. tuberculosis bacteremia is difficult using traditional TB diagnostics. Novel triage algorithms and rapid diagnostic tests are needed to expedite the identification and treatment of patients with severe sepsis due to M. tuberculosis bacteremia. In this article, we emphasize the importance of M. tuberculosis bacteremia as an under-recognized etiology of severe sepsis, and discuss the potential role of two emerging rapid diagnostic tests in the triage and prognostication of critically ill patients with advanced HIV infection and suspected disseminated M. tuberculosis. We conclude with the recommendation that clinicians in high TB-HIV burden settings strongly consider empiric anti-tuberculosis treatment in patients with advanced HIV infection and severe sepsis in the appropriate clinical context. Future studies are needed to assess diagnostic and prognostic algorithms for severe sepsis caused by disseminated M. tuberculosis in these settings, and the safety, efficacy, and duration of empiric anti-tuberculosis treatment.
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Affiliation(s)
- M J Cummings
- Department of Medicine, Columbia University Medical Center, New York, USA
| | - M R O'Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
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Hicks RM, Padayatchi N, Shah NS, Wolf A, Werner L, Sunkari VB, O'Donnell MR. Malnutrition associated with unfavorable outcome and death among South African MDR-TB and HIV co-infected children. Int J Tuberc Lung Dis 2016; 18:1074-83. [PMID: 25189555 DOI: 10.5588/ijtld.14.0231] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Pediatric multidrug-resistant tuberculosis (MDR-TB) is complicated by difficult diagnosis, complex treatment, and high mortality. In South Africa, these challenges are amplified by human immunodeficiency virus (HIV) co-infection; however, evidence on treatment outcomes among co-infected children is limited. OBJECTIVE Using conventional and new pediatric definitions, to describe treatment outcomes and identify risk factors for unfavorable outcome and mortality in children aged <15 years with MDR-TB or extensively drug-resistant TB (XDR-TB) in KwaZulu-Natal, South Africa. DESIGN Retrospective cohort study in a regional TB referral hospital. RESULTS From January 2009 to June 2010, 84 children (median age 8 years, IQR 4-12) with MDR-TB (n = 78) or XDR-TB (n = 6) initiated treatment. Sixty-four (77%) were HIV-positive and 62 (97%) received antiretroviral therapy. Sixty-six (79%) achieved favorable treatment outcomes. Overall mortality was 11% (n = 9) at 18 months after initiation of treatment. Malnutrition (aOR 27.4, 95%CI 2.7-278.7) and severe radiographic findings (aOR 4.68, 95%CI 1.01-21.9) were associated with unfavorable outcome. New pediatric outcome definitions increased the proportion classified as cured. CONCLUSION It is possible to successfully treat pediatric MDR-TB-HIV even in resource-poor settings. Malnutrition is a marker for severe TB-HIV disease, and is a potential target for future interventions in these patients.
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Affiliation(s)
- R M Hicks
- Albert Einstein College of Medicine, New York, New York, USA
| | - N Padayatchi
- Centre for AIDS Programme of Research in South Africa, Durban, South Africa
| | - N S Shah
- Albert Einstein College of Medicine, New York, New York, USA
| | - A Wolf
- Albert Einstein College of Medicine, New York, New York, USA
| | - L Werner
- Centre for AIDS Programme of Research in South Africa, Durban, South Africa
| | - V B Sunkari
- King DinuZulu Hospital, Sydenham, South Africa
| | - M R O'Donnell
- Albert Einstein College of Medicine, New York, New York, USA
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O'Donnell MR, Chamblee S, von Reyn CF, Marsh BJ, Moreland JD, Narita M, Johnson LS, Horsburgh CR. Sustained reduction in tuberculosis incidence following a community-based participatory intervention. Public Health Action 2015; 2:23-6. [PMID: 26392941 DOI: 10.5588/pha.11.0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 02/12/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rates of latent tuberculosis infection (LTBI) and tuberculosis (TB) disease are elevated in the rural southeastern United States and among US- and foreign-born Black residents. To prevent TB and reduce TB transmission, community-based strategies are essential. OBJECTIVE To describe a community-based participatory intervention for improving the detection and treatment of LTBI and TB and reducing TB incidence. DESIGN In rural Florida, we carried out a community educational TB campaign from 1997 to 2000, including presentations at community events, a media campaign and working with local community groups to develop culturally appropriate prevention messages. The campaign was implemented concurrently with a population-based LTBI survey. RESULTS The annual TB incidence rate in the intervention area decreased from 81 per 100 000 in 1994-1997, to 42/ 100 000 in 1998-2001, and to 25/100 000 in 2002-2005 (P = 0.001). This decrease was not observed in communities where the intervention was not implemented. There was no decrease in the TB incidence rate ratio between Blacks and non-Blacks in either region during the study period. CONCLUSIONS We conclude that community participation in LTBI screening and TB education was associated with a substantial reduction in TB rates. Although the TB incidence rate ratio did not decrease between Blacks and non-Blacks, TB incidence fell in all racial groups.
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Affiliation(s)
- M R O'Donnell
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - S Chamblee
- Glades Health Initiative Inc, Belle Glade, Florida, USA
| | - C F von Reyn
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - B J Marsh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - J D Moreland
- C L Brumback Health Center, Belle Glade, Florida, USA
| | - M Narita
- Tuberculosis Control Program, Public Health, Seattle and King County, Seattle, Washington, USA ; University of Washington School of Medicine, Seattle, Washington, USA
| | | | - C R Horsburgh
- Boston University School of Public Health, Boston, Massachusetts, USA
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Padayatchi N, Gopal M, Naidoo R, Werner L, Naidoo K, Master I, O'Donnell MR. Clofazimine in the treatment of extensively drug-resistant tuberculosis with HIV coinfection in South Africa: a retrospective cohort study. J Antimicrob Chemother 2014; 69:3103-7. [PMID: 24986495 DOI: 10.1093/jac/dku235] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Extensively drug-resistant (XDR) tuberculosis (TB) and HIV coinfection is associated with low cure rates and high mortality. Clofazimine has shown activity in vitro against Mycobacterium tuberculosis, but clinical experience with clofazimine in XDR-TB and HIV coinfection is limited. METHODS This was a retrospective cohort study of adult XDR-TB patients in KwaZulu-Natal, South Africa, treated with either a clofazimine- or non-clofazimine-containing XDR-TB treatment regimen. The primary outcome measure was TB culture conversion at 6 months. Survival analysis and multivariate logistic regression compared time to event in different strata and identified risk factors for TB culture conversion. RESULTS Between August 2009 and July 2011, eligible XDR-TB patients (n = 85) were initiated on treatment for XDR-TB. Most patients (86%) were HIV-infected and receiving antiretroviral therapy (90%). Patients receiving a clofazimine-containing regimen (n = 50) had a higher percentage of culture conversion (40%) compared with patients (n = 35) receiving a non-clofazimine regimen (28.6%). On multivariate analysis, there was a 2-fold increase in TB culture conversion at 6 months (hazard rate ratio 2.54, 95% CI 0.99-6.52, P = 0.05) in the group receiving a clofazimine-containing regimen. Adverse effects due to clofazimine were minor and rarely life-threatening. CONCLUSIONS Clofazimine was associated with improved culture conversion in the treatment of XDR-TB/HIV. Adverse effects were minor and non-life-threatening. Based on these preliminary data, further study of clofazimine in XDR-TB/HIV treatment is warranted. Given the present low rates of culture conversion in XDR-TB treatment, we recommend empirical inclusion of clofazimine in treatment regimens for XDR-TB.
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Affiliation(s)
- N Padayatchi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - M Gopal
- Gulf Coast Pulmonary Medicine, Port Charlotte, FL 33952, USA
| | - R Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - L Werner
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - K Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa
| | - I Master
- King Dinuzulu Hospital, PO Box Dormerton 4015, South Africa
| | - M R O'Donnell
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Private Bag X7, Congella, 4013, South Africa Division of Pulmonary Medicine, Department of Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
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10
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Abstract
The increased incidence of drug-resistant tuberculosis has created an urgent necessity for the development of new and effective anti-tuberculosis drugs and for alternative therapeutic regimens. Clofazimine (CFZ) is a fat-soluble riminophenazine dye used in the treatment of leprosy worldwide. CFZ has also been used as a Group 5 drug in the treatment of tuberculosis (TB). A large cohort study from Bangladesh published in 2010 described a treatment regimen for multidrug-resistant tuberculosis (MDR-TB) including CFZ as being highly effective against MDR-TB. We searched multiple databases for studies published through February 2012 that reported use of CFZ in MDR- and extensively drug-resistant TB (XDR-TB) treatment regimens. We identified nine observational studies (6 MDR-TB and 3 XDR-TB) including patients with drug-resistant TB treated with CFZ. Overall, 65% (95% confidence interval [95%CI] 54-76) of the patients experienced favorable outcomes, defined as either cure or treatment completion. Using random effects meta-analysis, 65% (95%CI 52-79) of those with MDR-TB and 66% (95%CI 42-89) of those with XDR-TB experienced favorable treatment outcomes. High-quality prospective cohort studies and clinical trials examining the effect of CFZ as part of drug-resistant TB treatment regimens are needed.
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Affiliation(s)
- M Gopal
- Division of Pulmonary Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
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Kirschbaum MH, Synold T, Stein AS, Tuscano J, Zain JM, Popplewell L, Karanes C, O'Donnell MR, Pulone B, Rincon A, Wright J, Frankel P, Forman SJ, Newman EM. A phase 1 trial dose-escalation study of tipifarnib on a week-on, week-off schedule in relapsed, refractory or high-risk myeloid leukemia. Leukemia 2011; 25:1543-7. [PMID: 21625235 PMCID: PMC3165084 DOI: 10.1038/leu.2011.124] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Inhibition of farnesyltransferase (FT) activity has been associated with in vitro and in vivo anti-leukemia activity. We report the results of a phase 1 dose escalation study of tipifarnib, an oral FT inhibitor, in patients with relapsed, refractory, or newly diagnosed (if over age 70) acute myelogenous leukemia (AML), on a week-on, week-off schedule. Forty-four patients were enrolled, 2 patients were newly diagnosed, the rest were relapsed or refractory to previous treatment, with a median age of 61 (range 33–79). The maximum tolerated dose was determined to be 1200 mg given orally twice-daily (bid) on this schedule. Cycle one dose-limiting toxicities were hepatic and renal. There were 3 complete remissions seen, 2 at the 1200 mg bid dose and one at the 1000 mg bid dose, with minor responses seen at the 1400 mg bid dose level. Pharmacokinetic studies performed at doses of 1400 mg bid showed linear behavior with minimal accumulation between days 1–5. Tipifarnib administered on a week-on week-off schedule shows activity at higher doses, and represents an option for future clinical trials in AML.
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Affiliation(s)
- M H Kirschbaum
- Department of Hematology/HCT, City of Hope, Duarte, CA, USA.
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O'Donnell MR, Chamblee S, von Reyn CF, Ellerbrock TV, Johnson J, Marsh BJ, Moreland JD, Narita M, Pedrosa M, Johnson LS, Horsburgh CR. Racial disparities in primary and reactivation tuberculosis in a rural community in the southeastern United States. Int J Tuberc Lung Dis 2010; 14:733-740. [PMID: 20487612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
SETTING A rural section of a county in central Florida. BACKGROUND Racial disparities in tuberculosis disease (TB) are substantial in the United States. OBJECTIVE To determine if TB was attributable to primary infection, reactivation or both. DESIGN A population-based survey of latent tuberculosis infection (LTBI), a case-control analysis of TB, and a cluster analysis of TB isolates were performed between 1997 and 2001. RESULTS Of 447 survey participants, 135 (30%) had LTBI. Black race was strongly associated with LTBI among US-born (OR 2.6, 95%CI 1.3-5.5) and foreign-born subjects (OR 4.3, 95%CI 2.2-8.4). Risk factors for TB included human immunodeficiency virus (HIV; OR 27.4, 95%CI 10.1-74.1), drug use (OR 4.6, 95%CI 1.7-12.4) and Black race (OR 3.4, 95%CI 1.2-9.6). The population risk of TB attributable to Black race was 64%, while that attributable to HIV was 46%. Cluster analysis showed 67% of TB cases were clustered, but Blacks were not at a significantly increased risk of having a clustered isolate (OR 2.1, 95%CI 0.12-36.0). CONCLUSION Both reactivation TB and recent TB transmission were increased among Blacks in this community. Therefore, LTBI screening and intensive contact tracing, both followed by LTBI treatment, will be needed to reduce TB in Blacks.
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Affiliation(s)
- M R O'Donnell
- Section of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts 02118, USA.
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13
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Nakamura R, Rodriguez R, Palmer J, Stein A, Naing A, Tsai N, Chang K, Slovak ML, Bhatia R, Spielberger R, Kogut N, Pullarkat V, Kirschbaum M, Forman SJ, O'Donnell MR. Reduced-intensity conditioning for allogeneic hematopoietic stem cell transplantation with fludarabine and melphalan is associated with durable disease control in myelodysplastic syndrome. Bone Marrow Transplant 2007; 40:843-50. [PMID: 17724447 DOI: 10.1038/sj.bmt.1705801] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We retrospectively evaluated the outcome of reduced-intensity conditioning (RIC) followed by allogeneic hematopoietic stem cell transplantation (HCT) in 43 patients with myelodysplastic syndrome (MDS) or AML arising from MDS. All patients received fludarabine plus melphalan followed by an allogeneic HCT from an HLA-identical sibling (SIB: n=19) or unrelated donor (MUD: n=24). Median age was 58 years (range: 30-71). Diagnoses at transplantation were RA (n=8), RARS (n=1), RAEB (n=13), RAEB-T (n=6), or AML arising from MDS (n=15). Of 28 patients with MDS, two patients had low, 10 had intermediate-1, nine had intermediate-2 and seven had high-risk MDS by IPSS criteria. All patients initially engrafted with the median neutrophil recovery of 15 days (range: 9-27). The 2-year overall survival, disease-free survival, relapse and transplant-related mortality were 53.5% (CI 45.2-61.1), 51.2% (CI 43.3-58.5), 16.3% (CI 7.9-30.7) and 35.2% (26.4-45.7), respectively. Grade II-IV acute graft-versus-host disease occurred in 27 (63%) patients. There was no significant survival difference between SIB and MUD-HCT, but the relapse rate was higher among SIB donor recipients when compared to MUD (38.5 versus 7%, P=0.02). RIC with fludarabine plus melphalan was associated with durable disease control and acceptable toxicity in this high-risk cohort.
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Affiliation(s)
- R Nakamura
- Division of Hematology/Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA.
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14
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Erba HP, Rizzieri DA, O'Donnell MR, Lundberg AS, Ajami AM, Rampersad AD, Capizzi RL. Amonafide and ara-C treatment for secondary acute myeloid leukemia (sAML). J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.7065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7065 Background: sAML portends a poor prognosis due to disease (unfavorable cytogenetics and multidrug resistance (MDR) phenotype) and patient (pt) characteristics (elderly w/comorbid illnesses). Amonafide, a topoisomerase II inhibitor, is not a substrate for the MDR efflux pump, P-glycoprotein (see Chau et al, ASCO 2007). Phase 1 trials of amonafide alone or together with ara-C reported a 50% CR rate (10/20) in pts with sAML (Allen et al, ASCO 2006). The dose-limiting toxicities of amonafide were manageable. Methods: In a Phase II trial pts with sAML (prior MDS or leukemogenic therapy, i.e., tAML) received amonafide 600 mg/m2/day on days 1–5 and CIV ara- C 200 mg/m2/day on days 1–7. A 2nd course could be given if day 14 marrow showed persistent leukemia. CR pts received either stem cell transplant or intermediate/high dose ara-C depending on age. An independent Data Safety Monitoring Board and central morphology review participated in the study. Primary endpoint was CR rate. Results: Enrollment has been completed. 44 % of 80 pts achieved CR. Details are available for the 1st 40 pts: median age 63 yrs (range 26 –87); prior MDS, 57%; tAML, 43%; unfavorable cytogenetics, 40%. 16/40 (40%) achieved CR (15 CR+1CRp). Subgroup CR analysis: MDS→AML without and with prior therapy for MDS (mostly azacytidine), 64% & 33%; tAML, 29%; intermediate and unfavorable cytogenetics, 58% and 18%; <60yrs, 42%; ≥60yrs, 39%. With a median follow up of 39 weeks, the median duration of CR is 28 weeks (range 20+ to 40+ weeks), with 8 of 16 patients in continuous CR. Median overall survival for CR patients has not been reached (range 1–47+ weeks). Death in first 28 days from consequences of hypoplasia was 17.5%. Grade 3, 4 non-heme adverse events occurring in > 10% pts were hypotension 23%, pneumonia 18%, dyspnea 13%, and diarrhea 13%. Data on all patients will be updated. Conclusions: Amonafide and ara-C is well tolerated in patients with poor prognosis sAML. A 64% CR was achieved in pts with untreated MDS→AML. Lower CR occurred with prior therapy for MDS, tAML and unfavorable cytogenetics. Age ≥60 yrs did not affect CR. Amonafide and ara-C may be a promising alternative for patients with sAML, especially those with over-expression of P-glycoprotein. No significant financial relationships to disclose.
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Affiliation(s)
- H. P. Erba
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - D. A. Rizzieri
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - M. R. O'Donnell
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - A. S. Lundberg
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - A. M. Ajami
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - A. D. Rampersad
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
| | - R. L. Capizzi
- Univ of Michigan Health Syst, Ann Arbor, MI; Duke University Medical Center, Durham, NC; City of Hope National Medical Center, Duarte, CA; Xanthus Pharmaceuticals, Inc., Cambridge, MA
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15
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Rodriguez R, Parker P, Nademanee A, Smith D, O'Donnell MR, Stein A, Snyder DS, Fung HC, Krishnan AY, Popplewell L, Cohen S, Somlo G, Angelopoulou M, Al-Kadhimi Z, Falk PM, Spielberger R, Kogut N, Sahebi F, Senitzer D, Slovak M, Schriber J, Forman SJ. Cyclosporine and mycophenolate mofetil prophylaxis with fludarabine and melphalan conditioning for unrelated donor transplantation: a prospective study of 22 patients with hematologic malignancies. Bone Marrow Transplant 2005; 33:1123-9. [PMID: 15064696 DOI: 10.1038/sj.bmt.1704493] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In an attempt to decrease toxicity in high-risk patients undergoing unrelated donor hematopoietic stem cell transplantation (URD HSCT), we tested a combination of cyclosporine (CSP) and mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis with the reduced-intensity conditioning regimen fludarabine/melphalan (Flu/Mel). A total of 22 adult patients with advanced myeloid (n=15) and lymphoid (n=7) malignancies were treated. All patients received Flu 25 mg/m2 for 5 days and Mel 140 mg/m2, with CSP 3 mg/kg daily and MMF 15 mg/kg three times a day. The median age was 49 years (range 18-66). Durable engraftment was seen in all but one patient with myelofibrosis. The 1-year nonrelapse mortality was 32%, 27% from GVHD. The cumulative incidence of acute GVHD grade 2-4 and 3-4 was 63 and 41%, respectively. With a median follow-up of 18 months, the disease-free survival (DFS) and overall survival (OS) are 55 and 59%, respectively. For patients with AML and MDS (n=14), the DFS and OS is 71%. For patients undergoing a second transplant (n=14), the DFS and OS is 57%. In conclusion, this regimen is associated with acceptable toxicity but high rates of GVHD in high-risk patients undergoing URD HSCT. Encouraging disease control for patients with advanced myeloid malignancies was observed.
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Affiliation(s)
- R Rodriguez
- City of Hope National Medical Center, Duarte, CA 91010, USA.
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16
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Fung HC, Cohen S, Rodriguez R, Smith D, Krishnan A, Somlo G, Sahebi F, Senitzer D, O'Donnell MR, Stein A, Snyder DS, Spielberger R, Bhatia R, Falk P, Molina A, Nademanee A, Parker P, Kogut N, Popplewell L, Vora N, Margolin K, Forman SJ. Reduced-intensity allogeneic stem cell transplantation for patients whose prior autologous stem cell transplantation for hematologic malignancy failed. Biol Blood Marrow Transplant 2003; 9:649-56. [PMID: 14569561 DOI: 10.1016/s1083-8791(03)00241-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Autologous hematopoietic stem cell transplantation (autoSCT) is an effective treatment for patients with various hematologic malignancies. Despite the significant improvement in the overall outcome, disease progression after transplantation remains the major cause of treatment failure. With longer follow-up, therapy-related myelodysplasia/acute myelogenous leukemia is becoming an important cause of treatment failure. The prognosis for these 2 groups of patients is very poor. Allogeneic hematopoietic stem cell transplantation (alloSCT) is a potential curative treatment for these patients. However, the outcome with conventional myeloablative alloSCT after failed autoSCT is typically poor because of high transplant-related mortality. In an attempt to reduce the treatment-related toxicity, we studied a reduced-intensity conditioning regimen followed by alloSCT for patients with progressive disease or therapy-related myelodysplasia/acute myelogenous leukemia after autoSCT. This report describes the outcomes of 28 patients with hematologic malignancies who received a reduced-intensity alloSCT after having treatment failure with a conventional autoSCT. Fourteen patients received a hematopoietic stem cell transplant from a related donor and 14 from an unrelated donor. The conditioning regimen consisted of low-dose (2 Gy) total body irradiation with or without fludarabine in 4 patients and the combination of melphalan (140 mg/m(2)) and fludarabine in 24. Cyclosporine and mycophenolate mofetil were used for posttransplantation immunosuppressive therapy, as well as graft-versus-host disease (GVHD) prophylaxis, in all patients. All patients engrafted and had >90% donor chimerism on day 100 after SCT. Currently, 13 patients (46%) are alive and disease free, 7 patients (25%) developed disease progression after alloSCT, and 8 (32%) died of nonrelapse causes. Day 100 mortality and nonrelapse mortality were 25% and 21%, respectively. With a median follow-up of 24 months for surviving patients, the 2-year probabilities of overall survival, event-free survival, and relapse rates were 56.5%, 41%, and 41.9%, respectively. Six patients (21%) developed grade III to IV acute GVHD. Among 21 evaluable patients, 15 (67%) developed chronic GVHD. We conclude that (1) reduced-intensity alloSCT is feasible and has an acceptable toxicity profile in patients who have previously received autoSCT and that (2) although follow-up was short, a durable remission may be achieved in some patients who would otherwise be expected to have a poor outcome.
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Affiliation(s)
- H C Fung
- Division of Hematology and Bone Marrow Transplantation, Kaiser Permanente-City of Hope BMT Program, City of Hope Cancer Center, 1500 E. Duarte Road, Duarte, CA 91010, USA.
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17
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Chang KL, O'Donnell MR, Slovak ML, Dagis AC, Arber DA, Niland JC, Forman SJ. Primary myelodysplasia occurring in adults under 50 years old: a clinicopathologic study of 52 patients. Leukemia 2002; 16:623-31. [PMID: 11960342 DOI: 10.1038/sj.leu.2402391] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2001] [Accepted: 07/13/2001] [Indexed: 11/08/2022]
Abstract
Although myelodysplastic syndromes (MDSs) are generally thought to be diseases of elderly patients, younger patients also have rarely been diagnosed with MDS. This is a report of the clinical, morphologic and cytogenetic features of 52 cases of primary MDS occurring in adults under the age of 50 years. Cases secondary to chemotherapy or radiotherapy were excluded. There were 31 males and 21 females. The median age at presentation was 39 years (range, 18 to 49 years). The interval between onset of symptoms and diagnosis was brief (median, 4 weeks; range, 1-32 weeks). Of the 49 patients for whom information about duration of symptoms was available, 13 (27%) were asymptomatic. Forty-two (81%) of the patients were classified using FAB criteria for blood and bone marrow morphology: refractory anemia (RA), 11; refractory anemia with ringed sideroblasts (RARS), four; refractory anemia with excess blasts (RAEB), 12; chronic myelomonocytic leukemia (CMML), three; refractory anemia with excess blasts in transformation (RAEB-T), 12 patients. Ten patients could not be categorized. Abnormalities involving chromosome 7 was the most frequent cytogenetic abnormality (31%). Partial chromosomal deletion and chromosome gain were also common abnormalities (22% and 9%, respectively). Translocations accounted for only 9% of the main cytogenetic abnormalities encountered in this patient population. For the 49 patients for whom information regarding AML transformation was available, 23 (47%) progressed to acute myeloid leukemia, with an overall median time to progression of 2 months (range 3 weeks to 3 years). In each category except for RARS, approximately half of the patients progressed, with a slightly less median time to progression in RAEB-T than for the other subtypes of MDS. Thirteen patients underwent bone marrow transplantation at the time of presentation of their disease.
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Affiliation(s)
- K L Chang
- Division of Pathology, City of Hope National Medical Center, Duarte, CA 91010, USA
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18
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Zhou W, Vasquez JC, O'Donnell MR, Paz BI. Clinical manifestations of gastrointestinal granulocytic sarcoma requiring surgical treatment. Am Surg 2001; 67:764-6. [PMID: 11510579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Granulocytic sarcoma is a rare extramedullary soft-tissue tumor of granulocytic lineage with an incidence of 3 to 5 per cent in patients with acute myelogenous leukemia. The most common sites of involvement are bone, soft tissue, lymph nodes, and skin. Here we report three unusual cases of granulocytic sarcoma involving the gastrointestinal tract that required surgical intervention.
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Affiliation(s)
- W Zhou
- Department of Surgery, University of California-San Diego Medical Center, 92103-8402, USA
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19
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Storb R, Blume KG, O'Donnell MR, Chauncey T, Forman SJ, Deeg HJ, Hu WW, Appelbaum FR, Doney K, Flowers ME, Sanders J, Leisenring W. Cyclophosphamide and antithymocyte globulin to condition patients with aplastic anemia for allogeneic marrow transplantations: the experience in four centers. Biol Blood Marrow Transplant 2001; 7:39-44. [PMID: 11215697 DOI: 10.1053/bbmt.2001.v7.pm11215697] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This report summarizes the experience with a conditioning regimen of cyclophosphamide and antithymocyte globulin in patients with severe aplastic anemia given HLA-matched related marrow grafts at 4 transplantation centers. Enrolled were 94 consecutive patients, of whom 87 had received multiple transfusions and 38 had failed immunosuppressive therapy. Their ages ranged from 2 to 59 years. After transplantation, 89 patients received a methotrexate/cyclosporine regimen for graft-versus-host disease (GVHD) prevention. Cyclosporine with or without prednisone was given in 4 patients, and no immunosuppression was given in 1 patient. Ninety-six percent of patients had sustained grafts, whereas 4% rejected grafts between 2 and 7 months after transplantation. Of the 4 rejecting patients, 3 are alive with successful second engraftments. Acute grade II GVHD was seen in 21% of patients, grade III in 7%, and grade IV in 1% of patients. Chronic GVHD was seen in 32% of patients, most of whom responded completely to immunosuppressive therapy. With a median follow-up of 6.0 years (range, 0.5-11.6 years), the survival rate was 88%. No unusual long-term side effects have been seen with the regimen. We conclude that the cyclophosphamide/antithymocyte globulin regimen combined with methotrexate/cyclosporine after transplantation is well tolerated and effective in heavily pretreated patients with aplastic anemia.
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Affiliation(s)
- R Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle 98109, USA.
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20
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Kashyap A, Kandeel F, Yamauchi D, Palmer JM, Niland JC, Molina A, Fung H, Bhatia R, Krishnan A, Nademanee A, O'Donnell MR, Parker P, Rodriguez R, Snyder D, Spielberger R, Stein A, Nadler J, Forman SJ. Effects of allogeneic bone marrow transplantation on recipient bone mineral density: A prospective study. Biol Blood Marrow Transplant 2001; 6:344-51. [PMID: 10905772 DOI: 10.1016/s1083-8791(00)70061-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Allogeneic bone marrow transplant (BMT) recipients have many known risk factors for developing decreased bone mineral density (BMD) after transplantation. We performed a prospective sequential evaluation of BMD in the lumbar spine and nondominant hip using dual-energy x-ray absorptiometry (DEXA) in a cohort of 47 adult patients (median age, 43 years) who were undergoing radiation-based BMT for hematologic malignancies. Baseline DEXA studies were performed before BMT and repeated at 3 to 4 months, 6 to 8 months, and 12 to 14 months after BMT. The majority of patients (60%) had been minimally treated with combination cytotoxic chemotherapy, having received no more than 1 treatment regimen before BMT. Graft-versus-host disease prophylaxis consisted of cyclosporine in combination with either methotrexate or prednisone, or both. Mean lumbar spine and hip BMD were normal before BMT (spine: 1.01 g/cm2, z score = 96%; hip: 0.86 g/cm2, z score = 100%) and gradually decreased (spine: 0.98 g/cm2, z score = 94%; hip: 0.76 g/cm2, z score = 91%) at 12 to 14 months. These declines were statistically significant (P < .006 and < .002 for lumbar spine; P < .001 and < .001 for hip). In addition, the sharpest decline occurred during the first 6 months after BMT and was more marked in the hip than the lumbar spine. These data suggest that BMT adversely affects BMD in this patient population.
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Affiliation(s)
- A Kashyap
- Division of Hematology/Bone Marrow Transplantation City of Hope National Medical Center, Duarte, California 91010, USA
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21
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Bhatia S, Louie AD, Bhatia R, O'Donnell MR, Fung H, Kashyap A, Krishnan A, Molina A, Nademanee A, Niland JC, Parker PA, Snyder DS, Spielberger R, Stein A, Forman SJ. Solid cancers after bone marrow transplantation. J Clin Oncol 2001; 19:464-71. [PMID: 11208840 DOI: 10.1200/jco.2001.19.2.464] [Citation(s) in RCA: 255] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the incidence and associated risk factors of solid cancers after bone marrow transplantation (BMT). PATIENTS AND METHODS We analyzed 2,129 patients who had undergone BMT for hematologic malignancies at the City of Hope National Medical Center between 1976 and 1998. A retrospective cohort and nested case-control study design were used to evaluate the role of pretransplantation therapeutic exposures and transplant conditioning regimens. RESULTS Twenty-nine patients developed solid cancers after BMT, which represents a two-fold increase in risk compared with a comparable normal population. The estimated cumulative probability (+/- SE) for development of a solid cancer was 6.1% +/- 1.6% at 10 years. The risk was significantly elevated for liver cancer (standardized incidence ratio [SIR], 27.7; 95% confidence interval [CI], 1.9 to 57.3), cancer of the oral cavity (SIR, 17.4; 95% CI, 6.3 to 34.1), and cervical cancer (SIR, 13.3; 95% CI, 3.5 to 29.6). Each of the two patients with liver cancer had a history of chronic hepatitis C infection. All six patients with squamous cell carcinoma of the skin had chronic graft-versus-host disease. The risk was significantly higher for survivors who were younger than 34 years of age at time of BMT (SIR, 5.3; 95% CI, 2.7 to 8.6). Cancers of the thyroid gland, liver, and oral cavity occurred primarily among patients who received total-body irradiation. CONCLUSION The risk of radiation-associated solid tumor development after BMT is likely to increase with longer follow-up. This underscores the importance of close monitoring of patients who undergo BMT.
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Affiliation(s)
- S Bhatia
- Division of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010-3000, USA.
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22
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Chao NJ, Snyder DS, Jain M, Wong RM, Niland JC, Negrin RS, Long GD, Hu WW, Stockerl-Goldstein KE, Johnston LJ, Amylon MD, Tierney DK, O'Donnell MR, Nademanee AP, Parker P, Stein A, Molina A, Fung H, Kashyap A, Kohler S, Spielberger R, Krishnan A, Rodriguez R, Forman SJ, Bluzme KG. Equivalence of 2 effective graft-versus-host disease prophylaxis regimens: results of a prospective double-blind randomized trial. Biol Blood Marrow Transplant 2000; 6:254-61. [PMID: 10871150 DOI: 10.1016/s1083-8791(00)70007-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We have previously demonstrated a decrease in the incidence of acute graft-versus-host disease (GVHD) with the addition of methotrexate (MTX) to cyclosporine (CSP) and prednisone (PSE) chemotherapy in patients with leukemia. We have now completed a prospective randomized trial comparing the 3-drug regimen (CSP/MTX/PSE, including 3 doses of MTX) to the standard 2-drug regimen (CSP/MTX, including 4 doses of MTX) to investigate the benefit of PSE used up front for the prevention of acute and chronic GVHD. In the trial, 193 patients were randomized and 186 were included in the final analysis. All patients received a bone marrow graft from a fully histocompatible sibling donor. The preparatory regimen consisted of fractionated total-body irradiation (fTBI) and etoposide in all but 13 patients, who received fTBI and cyclophosphamide. The patients were randomized to receive either CSP/MTX/PSE or CSP/MTX. The 2 groups were well balanced with respect to diagnosis, disease stage, age, donor-recipient sex, and parity. In an intent-to-treat analysis, the incidence of acute GVHD was 18% (95% confidence interval [CI] 12-28) for the CSP/MTX/PSE group compared with 20% (CI 10-26) for the CSP/,MTX group (P = .60), with a median follow up of 2.2 years. Overall survival was 65% for those receiving CSP/MTX/PSE and 72% for those receiving CSP/MTX (P = .10); the relapse rate was 15% for the CSP/MTX/PSE group and 12% for the CSP/MTX group (P = .83). The incidence of chronic GVHD was similar (46% versus 52%; P = .38), with a follow-up of 0.7 to 6.0 years. Of interest, 21 patients went off study due to GVHD (5 in the CSP/MTX/PSE group and 16 in the CSP/MITX group [P = .02]), and 11 patients went off study because of alveolar hemorrhage (3 in the CSP/MTX/PSE group and 8 in the CSP/MTX group [P = .22]). The addition of PSE did not result in a higher incidence of infectious complications, bacterial (66% versus 58%), viral (77% versus 66%), or fungal (20% versus 20%), in those receiving CSP/MTX/PSE versus CSP/MTX, respectively. These data suggest that the addition of PSE was associated with a somewhat lower incidence of early posttransplantation complications but did not have a positive impact on the incidence of acute or chronic GVHD or event-free or overall survival.
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Affiliation(s)
- N J Chao
- Duke University, Durham, North Carolina, USA.
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23
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Stein AS, O'Donnell MR, Slovak ML, Nademanee A, Dagis A, Schmidt GM, Parker PM, Snyder DS, Smith EP, Somlo G, Margolin KA, Arber D, Niland J, Forman SJ. High-dose cytosine arabinoside and daunorubicin induction therapy for adult patients with de novo non M3 acute myelogenous leukemia: impact of cytogenetics on achieving a complete remission. Leukemia 2000; 14:1191-6. [PMID: 10914541 DOI: 10.1038/sj.leu.2401839] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cytogenetic abnormalities are used to define prognostic subgroups of acute myelogenous leukemia (AML) with respect to achieving complete remission (CR) and remaining disease free. These prognostic groups for obtaining CR were based on an induction regimen mainly using standard dose cytosine arabinoside (Ara-C) + daunorubicin (DNR). We have reviewed our experience with 122 adult patients with de novo non-M3 AML who were treated with high-dose (HD) Ara-C 3 g/m2 given over 3 h every 12 h for a total of eight doses followed by DNR 60 mg/m2 daily for 2 days. CR was obtained in 80% while 16% had refractory disease and 4% died of sepsis during hypoplasia. CR rate for favorable, intermediate and unfavorable cytogenetic groups were 87%, 79% and 62%, respectively (P = 0.32). High white blood cell count, age, FAB subtype and LDH levels did not adversely affect CR rate. Eighty-five percent of patients achieved CR with one course of treatment and 87% of complete responders were able to receive post remission therapy. High-dose Ara-C/DNR appears to offer an excellent chance of achieving remission for patients with AML including those with poor risk cytogenetics, without an increase in early toxic deaths.
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Affiliation(s)
- A S Stein
- Division of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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Nademanee A, Molina A, Dagis A, Snyder DS, O'Donnell MR, Parker P, Stein A, Smith E, Planas I, Kashyap A, Spielberger R, Fung H, Krishnan A, Bhatia R, Wong KK, Somlo G, Margolin K, Chow W, Sniecinski I, Vora N, Slovak M, Niland JC, Forman SJ. Autologous stem-cell transplantation for poor-risk and relapsed intermediate- and high-grade non-Hodgkin's lymphoma. Clin Lymphoma 2000; 1:46-54. [PMID: 11707813 DOI: 10.3816/clm.2000.n.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The primary objective of this study was to evaluate the outcome of patients treated with high-dose chemo-/radiotherapy or high-dose chemotherapy and autologous stem-cell transplant (ASCT) for relapsed, refractory, or poor-risk intermediate-grade (IG) and high-grade (HG) non-Hodgkin's lymphoma (NHL). The secondary objectives were to determine prognostic factors for relapse and survival. Between February 1987 and August 1998, 264 patients, 169 (64%) IG and 95 (36%) HG, underwent high-dose therapy and ASCT at City of Hope National Medical Center (COHNMC). There were 157 (59%) males and 107 (41%) females with a median age of 44 years (range, 5-69 years). The median number of prior chemotherapy regimens was 2 (range, 1-4), and 71 (27%) had received prior radiation as part of induction or as salvage therapy. The median time from diagnosis to ASCT was 10.8 months (range, 3-158 months). Ninety-four patients (36%) underwent transplantation in first complete/partial remission (CR/PR), 40 (15%) in induction failure, and 130 (49%) in relapse or subsequent remission. Two preparative regimens were used: total body irradiation/high-dose etoposide/cyclophosphamide (TBI/VP/CY) in 208 patients (79%) and carmustine/etoposide/cyclophosphamide (BCNU/VP/CY) in 56 patients (21%). One hundred sixty-three patients (62%) received peripheral blood stem cells (PBSC) and 101 (38%) received bone marrow (BM) alone or BM plus PBSC. At a median follow-up of 4.43 years for surviving patients (range, 1-12.8 years), the 5-year Kaplan-Meier estimates of probability of overall survival (OS), progression-free survival (PFS), and relapse for all patients are 55% (95% confidence interval [CI]: 49%-61%), 47% (95% CI: 40%-53%), and 47% (95% CI: 40%-54%), respectively. There were 27 deaths (10%) from nonrelapse mortality, including seven (3%) patients who developed second malignancies (five with myelodysplasia/acute myelogenous leukemia and two with solid tumors). By stepwise Cox regression analysis, disease status at ASCT was the only prognostic factor that predicted for both relapse and survival. The 5-year probability of PFS for patients transplanted in first CR/PR was 73% (95% CI: 62%-81%) as compared to 30% (95% CI: 16%-45%) for induction failure and 34% (95% CI: 26%-42%) for relapsed patients. Our results further support the role of high-dose therapy and ASCT during first CR/PR for patients with poor-risk intermediate- and high-grade NHL. Early transplant is recommended for patients failing initial induction therapy or relapsing after chemotherapy-induced remission. Relapse continues to be the most common cause of treatment failure. An alternative approach to prevent relapse, the incorporation of radioimmunotherapy into the high-dose regimen, is being investigated. The development of a second malignancy is a serious complication of high-dose therapy, which requires close surveillance.
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Affiliation(s)
- A Nademanee
- Division of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA.
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25
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Krishnan A, Bhatia S, Slovak ML, Arber DA, Niland JC, Nademanee A, Fung H, Bhatia R, Kashyap A, Molina A, O'Donnell MR, Parker PA, Sniecinski I, Snyder DS, Spielberger R, Stein A, Forman SJ. Predictors of therapy-related leukemia and myelodysplasia following autologous transplantation for lymphoma: an assessment of risk factors. Blood 2000; 95:1588-93. [PMID: 10688812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
We analyzed data on 612 patients who had undergone high-dose chemoradiotherapy (HDT) with autologous stem cell rescue for Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) at the City of Hope National Medical Center, to evaluate the incidence of therapy-related myelodysplasia (t-MDS) or therapy-related acute myeloid leukemia (t-AML) and associated risk factors. A retrospective cohort and a nested case-control study design were used to evaluate the role of pretransplant therapeutic exposures and transplant conditioning regimens. Twenty-two patients developed morphologic evidence of t-MDS/t-AML. The estimated cumulative probability of developing morphologic t-MDS/t-AML was 8.6% +/- 2.1% at 6 years. Multivariate analysis of the entire cohort revealed stem cell priming with VP-16 (RR = 7.7, P = 0.002) to be independently associated with an increased risk of t-MDS/t-AML. The influence of pretransplant therapy on subsequent t-MDS/t-AML risk was determined by a case-control study. Multivariate analysis revealed an association between pretransplant radiation and the risk of t-MDS/t-AML, but failed to reveal any association with pretransplant chemotherapy or conditioning regimens. However, patients who had been primed with VP-16 for stem cell mobilization were at a 12. 3-fold increased risk of developing t-AML with 11q23/21q22 abnormalities (P = 0.006). Patients undergoing HDT with stem cell rescue are at an increased risk of t-MDS/t-AML, especially those receiving priming with VP-16 for peripheral stem cell collection. (Blood. 2000;95:1588-1593)
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Affiliation(s)
- A Krishnan
- Divisions of Hematology and Bone Marrow Transplantation, Pediatric Oncology, Biostatistics and Pathology, City of Hope National Medical Center, Duarte, CA 91010-3000, USA
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26
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Snyder DS, Nademanee AP, O'Donnell MR, Parker PM, Stein AS, Margolin K, Somlo G, Molina A, Spielberger R, Kashyap A, Fung H, Slovak ML, Dagis A, Negrin RS, Amylon MD, Blume KG, Forman SJ. Long-term follow-up of 23 patients with Philadelphia chromosome-positive acute lymphoblastic leukemia treated with allogeneic bone marrow transplant in first complete remission. Leukemia 1999; 13:2053-8. [PMID: 10602428 DOI: 10.1038/sj.leu.2401589] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Between 1984 and 1997, 23 consecutive patients with Philadelphia chromosome-positive acute lymphoblastic leukemia in first complete remission were treated with allogeneic bone marrow transplants from HLA-matched siblings. All patients but one were conditioned with fractionated total body irradiation (1320 cGy) and high-dose etoposide (60 mg/kg). One patient received high-dose cyclophosphamide instead of etoposide, and another patient received both drugs. Nine patients died following BMT, two from relapsed leukemia, and seven from transplant-related causes. The 3-year probabilities of disease-free survival and relapse are 65% and 12%, respectively. For patients transplanted after 1992, these probabilities are 81% (48-95%, 95% confidence interval) and 11% (2-50%), respectively. The relatively low relapse rate in this group of patients compared to published reports may reflect the enhanced anti-leukemic activity of etoposide in combination with FTBI compared to other conditioning regimens. The enhancement in overall survival for patients transplanted after 1992 may reflect improvements in supportive care, in particular, the prophylaxis of serious fungal and viral infections.
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Affiliation(s)
- D S Snyder
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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27
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Ross M, Schmidt GM, Niland JC, Amylon MD, Dagis AC, Long GD, Nademanee AP, Negrin RS, O'Donnell MR, Parker PM, Smith EP, Snyder DS, Stein AS, Wong RM, Forman SJ, Blume KG, Chao NJ. Cyclosporine, methotrexate, and prednisone compared with cyclosporine and prednisone for prevention of acute graft-vs.-host disease: effect on chronic graft-vs.-host disease and long-term survival. Biol Blood Marrow Transplant 1999; 5:285-91. [PMID: 10534058 DOI: 10.1016/s1083-8791(99)70003-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Graft-vs.-host disease (GVHD) is a major predictor of outcome following allogeneic bone marrow transplantation (BMT). For patients alive at day 100 after BMT, the presence or absence of chronic GVHD is one of the most important determinants of survival and quality of life. We wished to determine the effects on chronic GVHD of two regimens used for the prophylaxis of acute GVHD: cyclosporine, methotrexate, and prednisone (CSA/MTX/PSE) and cyclosporine and prednisone (CSA/PSE). One hundred forty-nine evaluable patients were entered into the acute GVHD study. As of 31 March 1997, 63 months after the last patient underwent BMT, the median survival time was 4.5 years (range 0.09-9.9). The incidence of chronic GVHD was independent of the prophylactic regimen (55 vs. 54%), and extensive chronic GVHD occurred in 25 and 24% of patients receiving CSA/MTX/PSE and CSA/PSE, respectively. Of note, the median Karnofsky performance status of both groups was 100% (range 70-100%), reflecting the low incidence of extensive chronic GVHD. Survival rates free of chronic GVHD were 52 vs. 42% (p = 0.29) for patients receiving CSA/MTX/PSE vs. CSA/PSE. The incidence of relapse was also similar in both groups of patients. These data suggest that the combinations of CSA/MTX/PSE and CSA/PSE result in comparable chronic GVHD-free survival without an increase in leukemic relapse.
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Affiliation(s)
- M Ross
- Stanford University Medical Center Stanford, California, USA
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28
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Nademanee A, Molina A, Fung H, Stein A, Parker P, Planas I, O'Donnell MR, Snyder DS, Kashyap A, Spielberger R, Bhatia R, Krishnan A, Sniecinski I, Vora N, Slovak M, Dagis A, Niland JC, Forman SJ. High-dose chemo/radiotherapy and autologous bone marrow or stem cell transplantation for poor-risk advanced-stage Hodgkin's disease during first partial or complete remission. Biol Blood Marrow Transplant 1999; 5:292-8. [PMID: 10534059 DOI: 10.1016/s1083-8791(99)70004-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Complete remission rates of 70-90% can be achieved following combination chemotherapy for patients with advanced-stage Hodgkin's disease (HD). Patients who present with unfavorable poor prognostic factors, however, have a 5-year disease-free survival of only 40-50%. In an attempt to improve the prognosis of 20 patients with poor-risk advanced-stage HD, we evaluated the role of early high-dose therapy (HDT) and autologous bone marrow/stem cell transplantation (ASCT) during the first complete or partial remission (CR/PR). Patients were eligible for ASCT if they either achieved a PR (defined as > 50% regression) (six patients), or achieved a CR (14 patients) but had presented with three or more of the following unfavorable features: stage IV disease with bone marrow involvement or > or = 2 extranodal sites of involvement; bulky mass > 10 cm or bulky mediastinal mass > 1/3 of mediastina/thoracic ratio; B symptoms; and elevated serum lactate dehydrogenase (LDH) level. The study included 11 men (55%) and 9 women (45%). The median age was 37 years (range 20-57). Seventeen patients (85%) had stage IV disease; 14 (70%) had B symptoms; 13 (65%) had bulky mass > 10 cm; 14 (70%) had > or = 2 extra nodal sites involvement; and eight patients (40%) had elevated LDH levels. All patients were treated with standard four or 7-8 drug combination chemotherapy regimens until they achieved maximal response prior to ASCT with a median of six cycles (range 4-11). Six patients also received involved field radiotherapy to residual bulky mass > 5 cm or bony lesions before ASCT. The median time from diagnosis to ASCT was 8.6 months (range 5.5-18.9). Preparative regimens consisted of fractionated total body irradiation (FTBI) 1200 cGy in combination with etoposide 60 mg/kg and cyclophosphamide 100 mg/kg in all patients except one who had borderline pulmonary function and received lomustine 15 mg/kg instead of FTBI. All patients engrafted and there was no transplant-related mortality. One patient developed congestive cardiomyopathy at 4 years post-ASCT. All patients remain alive and in remission at a median follow-up of 42.8 months (range, 13.2-149.2). These preliminary results suggest that HDT and ASCT can be performed safely during first CR/PR in selected patients with advanced-stage HD who have an unfavorable prognosis. Further randomized studies comparing HDT and ASCT during first CR with conventional chemotherapy and ASCT at relapse in poor-risk advanced-stage HD should be conducted. The prognostic factors and risk groups described recently by an international prognostic study can be used to identify high-risk patients who may be candidates for more intensive therapy.
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Affiliation(s)
- A Nademanee
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, California 91010, USA
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29
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Margolin KA, Van Besien K, Wright C, Niland J, Champlin R, Fung HC, Kashyap A, Molina A, Nademanee AP, O'Donnell MR, Parker P, Smith E, Spielberger R, Somlo G, Snyder D, Stein A, Woo D, Thomas M, Sniecinski I, Forman SJ. Interleukin-2-activated autologous bone marrow and peripheral blood stem cells in the treatment of acute leukemia and lymphoma. Biol Blood Marrow Transplant 1999; 5:36-45. [PMID: 10232739 DOI: 10.1053/bbmt.1999.v5.pm10232739] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this pilot trial of interleukin (IL)-2-treated autologous bone marrow (BM) and peripheral stem cell (PSC)-supported high-dose chemoradiotherapy, we report 36 patients with poor-prognosis leukemia and lymphoma who received BM and/or granulocyte colony-stimulating factor (G-CSF)-mobilized autologous PSCs that had been exposed to IL-2 for 24 hours ex vivo. Patients then received IL-2 by low-dose continuous intravenous (i.v.) infusion until hematologic reconstitution and then by intermediate-dose continuous i.v. infusion for six 2-week maintenance cycles given at 1-month intervals. The median Day to neutrophils over 500/microL was 22 with BM and 10 with PSCs (p = 0.01). The median Day to platelets >20,000/microL was 50 for BM and 25 for PSCs, and to platelets >50,000/microL was 138 for BM and 34 for PSCs (p not significant). After the first three patients received IL-2 at 2 mIU x m(-2) x day(-1) and had slow reconstitution, four patients were treated without IL-2 until the maintenance phase following reconstitution. The remaining 29 patients received the initial "post-infusion" IL-2 at 1 mIU x m(-2) x day(-1). Toxicities associated with the infusion of IL-2-activated cells consisted of chills and fever in about one-half of the patients and transient hypotension in 12%. Low-dose IL-2 by continuous i.v. infusion in the early posttransplant period was associated with exacerbation of fever, diarrhea, and altered mental status in a minority of patients. The major dose-limiting toxicities of maintenance IL-2 were fever, fatigue, gastrointestinal symptoms, skin rash, and dyspnea. Among 24 lymphoma patients, nine are in continuous complete remission (CCR) from 18-48 months, and 15 have died (12 due to relapse and three of therapy-related toxicities). Of 12 acute leukemia patients, two with acute lymphoblastic leukemia (ALL) are in CCR at 38 and 43 months, and one patient who was in cytogenetic but not molecular remission of Philadelphia chromosome-positive ALL died of progressive leukemia at Day 108. Three of nine with myeloid leukemia are in CCR at 21, 46, and 53 months; one is in hematologic and cytogenetic remission of acute promyelocytic leukemia at 55 months with multiple new cytogenetic abnormalities; one is alive at 54 months with pancytopenia after incomplete hematologic recovery followed by multiple new cytogenetic abnormalities (myelodysplasia); and one had an unrelated donor transplant after relapsing 4 months following protocol therapy. One myeloid leukemia patient remains without evidence of relapse, but is transfusion-dependent at 15 months following transplant.
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Affiliation(s)
- K A Margolin
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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30
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Guardiola P, Anderson JE, Bandini G, Cervantes F, Runde V, Arcese W, Bacigalupo A, Przepiorka D, O'Donnell MR, Polchi P, Buzyn A, Sutton L, Cazals-Hatem D, Sale G, de Witte T, Deeg HJ, Gluckman E. Allogeneic stem cell transplantation for agnogenic myeloid metaplasia: a European Group for Blood and Marrow Transplantation, Société Française de Greffe de Moelle, Gruppo Italiano per il Trapianto del Midollo Osseo, and Fred Hutchinson Cancer Research Center Collaborative Study. Blood 1999; 93:2831-8. [PMID: 10216077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Agnogenic myeloid metaplasia (AMM) is a chronic myeloproliferative disorder in which patients with poor prognostic features, receiving conventional treatments, have a median survival of less than 3 years. In this retrospective multicenter study, we analyze the results and try to define the indications for allogeneic stem cell transplantation in AMM. From January 1979 to November 1997, 55 patients with a median age of 42 years were transplanted from HLA-matched related (n = 49) or alternative (n = 6) donors for AMM. A multivariate analysis was conducted to identify factors associated with posttransplant outcome. The median posttransplant follow-up was 36 months (range, 6 to 223). The 5-year probability of survival was 47% +/- 8% for the overall group, and 54% +/- 8% for patients receiving an unmanipulated HLA-matched related transplant. The 1-year probability of transplant-related mortality was 27% +/- 6%. Hemoglobin level </=100 g/L and osteomyelosclerosis before transplant adversely affected the outcome. The probability of developing grade III-IV acute graft-versus-host disease (GVHD) was 33% +/- 8%. Sixteen of 45 patients developed extensive chronic GVHD. At last follow-up, 22 patients were in complete histohematologic remission. Treatment failure was observed in 13 cases. Age at transplant and karyotype were predictors of treatment failure. Allogeneic stem cell transplantation is an effective treatment leading to cure in a substantial number of patients with AMM. A better characterization of the variables affecting the posttransplant outcome should lead to a decreased transplant-related mortality and an improvement in these results.
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Affiliation(s)
- P Guardiola
- Department of Hematology, Bone Marrow Transplant, Hôpital Saint-Louis, Paris, France.
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31
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Khalidi HS, O'Donnell MR, Slovak ML, Arber DA. Adult precursor-B acute lymphoblastic leukemia with translocations involving chromosome band 19p13 is associated with poor prognosis. Cancer Genet Cytogenet 1999; 109:58-65. [PMID: 9973961 DOI: 10.1016/s0165-4608(98)00153-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cytogenetic translocations involving chromosome band 19p13, the site of the E2A gene, have previously been reported in pediatric acute lymphoblastic leukemias (ALL) in association with a precursor-B cell immunophenotype and poor prognosis. We studied the frequency, pathologic findings, and clinical course of adults with leukemia with 19p13 translocations. Six patients with t(1;19) (q23;p13) and one patient with t(17;19)(q21;p13), all with ALL, were identified over an 8-year period from among 183 adult ALL patients (2.7%); t(1;19) was observed in 2.2% and t(17;19) in 0.5% of these patients. The seven patients (four females and three males) ranged from 18 to 59 years of age (median 33). All cases had a precursor-B cell immunophenotype, and a distinctive expression of surface markers (CD10, CD19, TdT, and HLA-Dr positive, usually negative for CD20, CD34, and negative for myeloid-associated antigens CD13, CD14, and CD33). The blast cells in one case expressed CD15. All patients were treated with combination chemotherapy and three patients received allogeneic bone marrow transplantation. All patients had early (range 6-20 months) relapses, and died due to progressive disease 7-29 months after diagnosis. Similar to pediatric patients, adults with 19p13 leukemias usually do not respond to intensive therapy and have short survival. The poor prognosis of this group of adult ALL patients highlights the importance of detecting 19p13 translocations by cytogenetic analysis or molecular studies.
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Affiliation(s)
- H S Khalidi
- Division of Pathology, City of Hope National Medical Center, Duarte, CA 91010, USA
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32
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Smith EP, Sniecinski I, Dagis AC, Parker PM, Snyder DS, Stein AS, Nademanee A, O'Donnell MR, Molina A, Schmidt GM, Stepan DE, Kapoor N, Niland JC, Forman SJ. Extracorporeal photochemotherapy for treatment of drug-resistant graft-vs.-host disease. Biol Blood Marrow Transplant 1998; 4:27-37. [PMID: 9701389 DOI: 10.1016/s1083-8791(98)90007-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Extracorporeal photochemotherapy (EP) is a therapeutic approach to the treatment of drug-resistant graft-vs.-host disease (GVHD) that uses the known immunosuppressive and immunomodulatory effects of ultraviolet light. In 1990, we initiated a pilot study to evaluate the efficacy and safety of EP in patients with refractory GVHD. Between 1991 and 1996, six patients with acute grade IV liver GVHD, 12 patients with chronic following acute GVHD, and six patients with de novo chronic GVHD were treated with EP. All patients had failed to respond to conventional GVHD immunosuppressive drug therapy of cyclosporine and prednisone. The six patients with acute liver GVHD had also received antithymocyte globulin (ATG); therapy for chronic GVHD included thalidomide in eight patients, psoralen plus ultraviolet A in five patients, and ATG in two patients. All patients with acute liver GVHD had progressive liver failure with short survival despite frequent EP. The response rate with EP treatment was 3 of 6 for patients with de novo chronic GVHD and 3 of 12 for patients with chronic following acute GVHD. Three patients with bronchiolitis obliterans had either no response or no documented disease progression while undergoing EP. Side effects of EP were minor and included gastrointestinal upset frequently, catheter-related sepsis in four patients, increased red blood cell and platelet transfusion requirements in one patient, and leukopenia in two patients. EP was discontinued in three patients because of side effects, including GI upset in one patient and bone marrow suppression in two patients. Side effects were reversible with the discontinuation of EP. We were unable to correlate response to EP with the level of methoxypsoralen, number of lymphocytes treated, or pattern of pre- and posttreatment CD4/CD8 ratio. We concluded that EP has some efficacy in the treatment of drug-resistant chronic GVHD, with minor overall toxicity.
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Affiliation(s)
- E P Smith
- University of Wisconsin Medical School, Madison 53792, USA
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David DS, Tegtmeier BR, O'Donnell MR, Paz IB, McCarty TM. Visceral varicella-zoster after bone marrow transplantation: report of a case series and review of the literature. Am J Gastroenterol 1998; 93:810-3. [PMID: 9625133 DOI: 10.1111/j.1572-0241.1998.230_a.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Infection with varicella-zoster virus after bone marrow transplantation (BMT) is a common cause of morbidity and mortality. Visceral involvement with varicella-zoster may be incorrectly ascribed to graft-versus-host disease, resulting in delayed diagnosis and misguided therapy. METHODS A 4-yr retrospective chart review was performed to determine the presenting symptoms and clinical outcome of visceral varicella-zoster virus infection in BMT recipients. RESULTS Ten BMT recipients who subsequently developed visceral varicella-zoster virus infection were identified. The mean age at diagnosis was 40 yr (range 27-56 yr). Primary hematological malignancies were leukemia (N = 7), myelodysplasia (N = 2), and myelofibrosis (N = 1). Bone marrow transplants in affected patients were autologous (N = 2), related allogeneic (N = 5), or matched unrelated allogeneic (N = 3). The mean time interval from BMT to symptomatic visceral varicella-zoster virus infection was 153 days (range 60-280 days). Presenting symptoms included abdominal pain in all patients, nausea (60%), fever > 38 degrees C (60%), vomiting (50%), pneumonitis (50%), skin rash (40%), and diarrhea (30%). All patients had moderately or profoundly elevated aminotransferases and most had elevated pancreatic enzymes (80%). The mean time interval from the development of abdominal pain to the characteristic skin rash and then diagnosis was 6 and 7 days, respectively (range 4-10 and 4-14 days). Active graft-versus-host disease had previously been documented in five of the eight allogeneic BMT recipients. Immunosuppressive medications were increased at the onset of the abdominal pain in seven of these eight patients for suspected exacerbation of graft-versus-host disease. After recognition of varicella infection, antiviral therapy was promptly initiated; despite this, mortality was still 50%. CONCLUSIONS Visceral involvement with varicella-zoster virus infection can occur as a late complication after both allogeneic and autologous BMT. In these cases, symptoms of severe abdominal pain with associated nausea, vomiting, and diarrhea and elevated liver and pancreatic enzymes preceded the vesicular skin eruption and were confused with graft-versus-host disease. With the increasing application of high-dose chemotherapy followed by stem cell rescue for both hematological and solid tumors, clinicians should be aware of this potentially treatable and often lethal complication.
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Affiliation(s)
- D S David
- Department of Gastroenterology, City of Hope National Medical Center, Duarte, California 91010, USA
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34
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Nademanee A, Molina A, O'Donnell MR, Dagis A, Snyder DS, Parker P, Stein A, Smith E, Planás I, Kashyap A, Spielberger R, Fung H, Wong KK, Somlo G, Margolin K, Chow W, Sniecinski I, Vora N, Blume KG, Niland J, Forman SJ. Results of high-dose therapy and autologous bone marrow/stem cell transplantation during remission in poor-risk intermediate- and high-grade lymphoma: international index high and high-intermediate risk group. Blood 1997; 90:3844-52. [PMID: 9354650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We have conducted a pilot study to investigate the role of high-dose therapy and autologous bone marrow/stem cell transplantation (ASCT) during first complete or partial remission in 52 patients with poor-risk aggressive lymphoma. There were 42 patients with intermediate-grade or immunoblastic lymphoma who were considered to be high (60%) and high-intermediate risk (40%) groups at diagnosis based on the age-adjusted International Prognostic Index (IPI) and 10 patients with high-grade, SNCCL (small non-cleaved cell, Burkitt's, and non-Burkitt's), who at presentation had poor-risk features defined as elevated serum lactate dehydrogenase level, stage IV, and bulky mass >/=10 cm. The median age was 34 years (range, 16 to 56 years). Thirty-nine were transplanted in first complete remission and 13 in first partial remission after conventional therapy. Conditioning regimens consisted of total body irradiation (TBI) administered as a single fraction 750 cGy in 3 patients and in fractionated doses for a total of 1,200 cGy in 44 patients, in combination with 60 mg/kg etoposide and 100 mg/kg cyclophosphamide. Five patients with prior radiotherapy received 450 mg/m2 carmustine instead of TBI. Stem cell sources were either bone marrow and/or peripheral blood. No in vitro purging was used. All patients engrafted. Two SNCCL patients died of venoocclusive disease at 25 days and acute leukemia at 27 months posttransplantation. There were six relapses at 1.5 to 12.8 months posttransplantation. At a median follow-up of 44 months (range, 1 to 113 months), the estimated 3-year overall survival (OS) and disease-free survival (DFS) for all patients was 84% (95% confidence interval [CI], 70% to 92%) and 82% (95% CI, 68% to 91%), respectively. In the subset of patients with intermediate-grade and immunoblastic lymphoma, the 3-year DFS was 89% (95% CI, 74% to 96%) for all patients, 87% (95% CI, 67% to 96%) for high-risk patients, and 92% (95 CI, 61% to 99%) for high-intermediate risk patients. The 3-year OS and DFS for SNCCL patients were identical at 60% (95% CI, 30% to 84%). These results suggest that high-dose therapy and ASCT during first remission may improve the survival and prognosis of patients with poor-risk intermediate- and high-grade lymphoma. A prospective randomized study comparing high-dose therapy and ASCT with conventional chemotherapy in IPI high-risk patients with aggressive non-Hodgkin's lymphoma should be undertaken.
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Affiliation(s)
- A Nademanee
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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O'Donnell MR, Appelbaum F, Bishop M, Estey EH, Grever M, Maslak P. NCCN Acute Leukemia Practice Guidelines. The National Comprehensive Cancer Network. Oncology (Williston Park) 1996; 10:205-21. [PMID: 8953604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M R O'Donnell
- City of Hope Medical Center, Duarte, California, USA
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Parker P, Chao NJ, Ben-Ezra J, Slatkin N, Openshaw H, Niland JC, Linker CA, Greffe BS, Kashyap A, Molina A, Nademanee A, O'Donnell MR, Planas I, Sheibani K, Smith EP, Snyder DS, Spielberger R, Stein AS, Stepan DE, Blume KG, Forman SJ. Polymyositis as a manifestation of chronic graft-versus-host disease. Medicine (Baltimore) 1996; 75:279-85. [PMID: 8862349 DOI: 10.1097/00005792-199609000-00004] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A syndrome indistinguishable from idiopathic polymyositis occurred in 11 patients as a manifestation of chronic GVHD. All patients had elevation of creatine phosphokinase (CPK). Immunohistology demonstrated the effector cells in the muscle infiltrates as cytotoxic T cells, a finding similar to idiopathic polymyositis. Polymyositis is a rarely reported complication of chronic graft-versus-host disease (GVHD) with only 8 cases described in the literature. We encountered this syndrome in a small but significant percentage of our patients with chronic GVHD. Polymyositis associated with chronic GVHD does not affect the overall prognosis for the patient. Moreover, polymyositis can be the only manifestation of chronic GVHD. Awareness of this complication is important because it can be confused with other causes of muscle weakness after bone marrow transplantation. Finally, prompt initiation of corticosteroid therapy results in a rapid improvement of the associated symptoms.
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Affiliation(s)
- P Parker
- Bone Marrow Transplantation Programs, City of Hope National Medical Center, Duarte, CA 91010, USA
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Abstract
PURPOSE Bone marrow transplantation (BMT) is often associated with profound neutropenia. Allogeneic transplant recipients also have defects in both humoral and cellular immunity and thus are subject to increased risk of serious, often life-threatening, infection even beyond the period of granulocyte recovery. The current study was undertaken to evaluate patients who required operative intervention for perianal sepsis following BMT. METHODS The bone marrow transplant database at a single institution was used to identify all patients diagnosed with perianal infections after autologous or allogeneic BMT. Charts were reviewed in a retrospective manner. RESULTS Over a ten-year period ending in November 1993, 963 BMT were performed at the City of Hope National Medical Center. Twenty-four patients were diagnosed with perianal infections following their transplants. Fifteen patients did not have purulent collections requiring drainage and were treated with antibiotics and supportive measures alone. Nine patients (37.5 percent) required surgical intervention between 10 and 380 days following transplantation. At the time of surgical intervention, seven patients had purulent collections and two patients had acute and chronic inflammation, tissue necrosis, and fibrosis. Of the two patients with an absolute neutrophil count less than 1,000, a purulent collection was found in one of the patients. Cultures taken from perianal abscesses were almost all polymicrobial, and the most common organisms were Escherichia coli, Bacteroides, Enterococcus, and Klebsiella. For those patients undergoing surgical intervention, mean time to complete wound closure by secondary intention was 37.6 days; five patients healed in less than 15 days, two patients healed at 93 and 114 days, and two patients had persistent, open wounds at time of death, which was unrelated to their perianal disease. Five patients were receiving systemic steroids at time of surgical intervention; this did not appear to affect time to wound healing. CONCLUSIONS Perianal infections are a rare complication of BMT. Majority of these infections are polymicrobial, and organisms isolated are similar to those seen in the perianal infections of nonimmunosuppressed patients. Despite steroid use, granulocytopenia does not exclude the possible presence of purulent collections, and clinical examination should guide the decision for surgical drainage. In general, perianal wound healing is not prolonged in BMT patients.
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Affiliation(s)
- J S Cohen
- Department of General Oncologic Surgery, City of Hope National Medical Center, Duarte, California 91010, USA
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Stein AS, O'Donnell MR, Chai A, Schmidt GM, Nademanee A, Parker PM, Smith EP, Snyder DS, Molina A, Stepan DE, Spielberger R, Somlo G, Margolin KA, Vora N, Lipsett J, Lee J, Niland J, Forman SJ. In vivo purging with high-dose cytarabine followed by high-dose chemoradiotherapy and reinfusion of unpurged bone marrow for adult acute myelogenous leukemia in first complete remission. J Clin Oncol 1996; 14:2206-16. [PMID: 8708709 DOI: 10.1200/jco.1996.14.8.2206] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To evaluate in a prospective study the efficacy of autologous bone marrow transplantation (BMT) in adult patients with acute myelogenous leukemia (AML) in first remission, using a single course of high-dose Cytarabine (HD Ara-C) consolidation therapy as in vivo purging. PATIENTS AND METHODS Sixty consecutive adult patients with AML in first complete remission (CR) were treated with HD Ara-C consolidation therapy as a method of in vivo purging before marrow collection. High-dose therapy consisted of fractionated total-body irradiation (FTBI) 12 Gy, intravenous etoposide 60 mg/kg, and cyclophosphamide 75 mg/kg, followed by reinfusion of cryopreserved marrow. RESULTS Sixty patients underwent consolidation treatment with HD Ara-C with the intent to treat with autologous BMT. Sixteen patients were unable to proceed to autologous BMT (10 patients relapsed, one died of sepsis, one developed cerebellar toxicity, two had inadequate blood counts, and two refused). Forty-four patients underwent autologous BMT and have a median follow-up time of 37 months (range, 14.7 to 68.7) for patients who are alive with no relapse. The cumulative probability of disease-free survival (DFS) at 24 months in the intent-to-treat group is 49% (95% confidence interval [CI], 37% to 62%) and in those who actually underwent autologous BMT is 61% (95% CI, 46% to 74%). The probability of relapse was 44% (95% CI, 31% to 58%) and 33% (95% CI, 20% to 49%) for the intent-to-treat and autologous BMT patients, respectively. CONCLUSION This approach offers a relatively high DFS rate to adult patients with AML in first CR. The results of this study are similar to those achieved with allogeneic BMT.
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Affiliation(s)
- A S Stein
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA.
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O'Donnell MR, Long GD, Parker PM, Niland J, Nademanee A, Amylon M, Chao N, Negrin RS, Schmidt GM, Slovak ML. Busulfan/cyclophosphamide as conditioning regimen for allogeneic bone marrow transplantation for myelodysplasia. J Clin Oncol 1995; 13:2973-9. [PMID: 8523063 DOI: 10.1200/jco.1995.13.12.2973] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE A non-radiation-containing regimen of busulfan and cyclophosphamide (BU/CY) was evaluated for toxicity, relapse, and long-term survival in patients who received allogeneic bone marrow transplantation (BMT) for myelodysplasia (MDS). PATIENTS AND METHODS Thirty-eight patients with MDS, including eight with therapy-related MDS, were prepared for BMT using BU/CY. RESULTS Fourteen patients remain in first remission 18 to 60 months posttransplant. Five patients relapsed after BMT, and four of these patients died. Eight additional patients died of acute or chronic graft-versus-host disease (GVHD), and 11 died of regimen-related toxicity, primarily systemic mycoses. Overall survival rate at 2 years was 45% (95% confidence interval [CI], 0.30 to 0.61), with a 24% probability of relapse (95% CI, 0.10 to 0.49). Regimen-related toxicity was manifested primarily as hepatic dysfunction in 72% of patients, with 16% developing overt venoocclusive disease (VOD). CONCLUSION Non-radiation-containing preparative regimens offer long-term survival in allogeneic BMT for MDS that is comparable to that of radiation-containing regimens, and are useful in patients with therapy-related MDS. Monitoring BU levels may reduce regimen-related mortality and improve survival.
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Affiliation(s)
- M R O'Donnell
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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Parker PM, Chao N, Nademanee A, O'Donnell MR, Schmidt GM, Snyder DS, Stein AS, Smith EP, Molina A, Stepan DE, Kashyap A, Planas I, Spielberger R, Somlo G, Margolin K, Zwingenberger K, Wilsman K, Negrin RS, Long GD, Niland JC, Blume KG, Forman SJ. Thalidomide as salvage therapy for chronic graft-versus-host disease. Blood 1995; 86:3604-9. [PMID: 7579470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Thalidomide has been reported to be an effective agent for treatment of chronic graft-versus-host disease (CGVHD). To determine the efficacy of this agent in patients with refractory CGVHD a total of 80 patients who failed to respond to prednisone (PSE) or PSE and cyclosporine (CSA) were treated with thalidomide. Sixteen patients (20%) had a sustained response, 9 with a complete remission and 7 with a partial response. Twenty-nine patients (36%) had thalidomide discontinued because of side effects, which included sedation, constipation, neuritis, skin rash, and neutropenia. Side effects were reversible with drug discontinuation except for mild residual neuritis in one case. Rashes and neutropenia have not previously been reported as thalidomide side effects when used for CGVHD treatment. We conclude thalidomide is immunosuppressive and active in the treatment of CGVHD. A high incidence of reversible side effects limited dose intensity and reduced the number of patients who could benefit from treatment.
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Affiliation(s)
- P M Parker
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA
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Spielberger RT, Tegtmeier BR, O'Donnell MR, Ito JI. Fatal Scedosporium prolificans (S. inflatum) fungemia following allogeneic bone marrow transplantation: report of a case in the United States. Clin Infect Dis 1995; 21:1067. [PMID: 8645825 DOI: 10.1093/clinids/21.4.1067] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Nademanee A, O'Donnell MR, Snyder DS, Schmidt GM, Parker PM, Stein AS, Smith EP, Molina A, Stepan DE, Somlo G. High-dose chemotherapy with or without total body irradiation followed by autologous bone marrow and/or peripheral blood stem cell transplantation for patients with relapsed and refractory Hodgkin's disease: results in 85 patients with analysis of prognostic factors. Blood 1995; 85:1381-90. [PMID: 7858268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Eight-five consecutive patients with relapsed or refractory Hodgkin's disease (HD) underwent high-dose chemotherapy or chemo/radiotherapy followed by autologous bone marrow (ABMT) and/or peripheral blood stem cell (PBSC) transplantation. Two preparative regimens were used. Twenty-two patients (26%) without prior radiation received fractionated total body irradiation (FTBI) 1,200 Gy in combination with high-dose etoposide (VP-16) 60 mg/kg and cyclophosphamide (CTX) 100 mg/kg. Sixty-three patients (74%) with prior radiotherapy received carmustine (BCNU) 450 mg/m2 instead of FTBI. The median age was 32 years (range, 16 to 56). The median number of prior chemotherapy regimens was three (range, 1 to 7). Forty-three patients (51%) received transplants in first relapse or second complete remission (CR), whereas 33 (39%) received transplants after second or subsequent relapse. All relapsed patients, except one, received conventional salvage chemotherapy and/or radiotherapy in an attempt to reduce tumor bulk before transplant. At the time of analysis in April 1994, fifty-seven patients (67%) are alive, including 44 (52%) in continuous CR, with a median follow-up for the surviving patients of 28 months (range, 7 to 66). Thirty patients (35%) relapsed at a median of 9 months (range, 1 to 43). Eleven patients (13%) died of transplant-related complications including veno-occlusive disease of the liver (VOD) in five, acute and late interstitial pneumonitis in three, graft failure in one, cerebral hemorrhage in one, and therapy-induced myelodysplasia (MDS)/acute leukemia in one patient. At a median follow-up of 25 months (range, 0.6 to 66), the cumulative probability of 2-year overall and disease-free survival (DFS) of all 85 patients is 75% (95% confidence interval [CI] 64% to 84%) and 58% (95% CI 47% to 69%), respectively. Three independent prognostic variables were identified by univariate analysis: number of prior chemotherapy regimens, prior radiotherapy, and extranodal disease at ABMT. Multivariate stepwise Cox regression identified the number of prior chemotherapy regimens as the only significant prognostic factor predicting for both relapse and DFS. There were no significant differences in the outcome of the treatment between the two preparative regimens. Our results confirm that high-dose therapy and ABMT is an effective therapy for patients with relapsed or refractory HD. Earlier transplantation is recommended before the development of drug resistance and end organ damage that results from repeated attempts of salvage therapy.
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Affiliation(s)
- A Nademanee
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010
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Nademanee A, Sniecinski I, Schmidt GM, Dagis AC, O'Donnell MR, Snyder DS, Parker PM, Stein AS, Smith EP, Molina A. High-dose therapy followed by autologous peripheral-blood stem-cell transplantation for patients with Hodgkin's disease and non-Hodgkin's lymphoma using unprimed and granulocyte colony-stimulating factor-mobilized peripheral-blood stem cells. J Clin Oncol 1994; 12:2176-86. [PMID: 7523609 DOI: 10.1200/jco.1994.12.10.2176] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate (1) the effect of granulocyte colony-stimulating factor (G-CSF) on peripheral-blood stem-cell (PBSC) mobilization; (2) the rate of hematopoietic recovery after G-CSF-mobilized PBSC transplantation; and (3) the outcome of high-dose myeloablative therapy and PBSC transplantation in patients with relapsed or refractory lymphoma. PATIENTS AND METHODS Ninety-five patients with lymphoma underwent high-dose therapy followed by PBSC transplant in three sequentially treated cohorts of patients in a nonrandomized study. The first 30 patients received nonmobilized PBSCs (unprimed) without G-CSF after transplant, the next 26 patients received PBSC that were mobilized with G-CSF 5 micrograms/kg/d (primed-5) plus G-CSF after transplant, and the last 39 patients received PBSC mobilized by G-CSF 10 micrograms/kg/d (primed-10) plus G-CSF after transplant. The conditioning regimen consisted of fractionated total-body irradiation (FTBI) 12 Gy in combination with etoposide 60 mg/kg and cyclophosphamide 100 mg/kg. Patients with prior radiotherapy received carmustine (BCNU) 450 mg/m2 instead of FTBI. RESULTS The use of G-CSF-mobilized PBSCs in combination with G-CSF posttransplant resulted in a significantly accelerated time to recovery of both granulocyte and platelet when compared with the unprimed group. The median number of days to an absolute granulocyte count (ANC) of greater than 0.5 x 10(9)/L was 10 days for G-CSF primed versus 20 days for the unprimed (P = .0001). The median days to platelet transfusion independence was 16 and 31 days (P = .0001) for the G-CSF primed and unprimed, respectively. There were also significant reductions in the number of platelet (P = .02) and RBC transfusions (P = .006) for the G-CSF primed. Multivariate analysis of prognostic factors identified CD34+ cell dose as the only additional factor predicting engraftment. Sixty-nine patients are alive at a median follow-up of 15.9 months (range, 7.4 to 63.7). The cumulative probability of 2-year disease-free survival is 59% (95% confidence interval [CI], 36% to 79%) and 39% (95% CI 25% to 55%) for patients with Hodgkin's disease and non-Hodgkin's lymphoma, respectively. CONCLUSION The use of G-CSF-mobilized PBSC after high-dose myeloablative therapy resulted in a rapid, complete, and sustained hematopoietic recovery. Disease-free survival over 2 years can be achieved in some patients with relapsed lymphoma after high-dose therapy and PBSC transplantation. However, longer follow-up is required to confirm the curability of this approach.
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Affiliation(s)
- A Nademanee
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010
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44
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Snyder DS, Negrin RS, O'Donnell MR, Chao NJ, Amylon MD, Long GD, Nademanee AP, Stein AS, Parker PM, Smith EP. Fractionated total-body irradiation and high-dose etoposide as a preparatory regimen for bone marrow transplantation for 94 patients with chronic myelogenous leukemia in chronic phase. Blood 1994; 84:1672-9. [PMID: 8068956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Ninety-four consecutive patients with chronic myelogenous leukemia in first clinical chronic phase, median age of 34.0 years (range, 6.8 to 52.4 years), with a histocompatible sibling donor, were treated with fractionated total body irradiation (1,320 cGy) and high-dose etoposide (60 mg/kg) followed by allogeneic bone marrow transplantation (BMT). The median time from diagnosis to BMT was 7.0 months (range, 2.3 to 72.0 months). Sixty patients were treated before BMT with hydroxyurea alone, four patients with busulfan alone, one patient with interferon alone, and the other 29 patients were treated with various combinations of these drugs. Cumulative probabilities of overall survival, event-free survival, and relapse at 5 years were 73%, 64%, and 14%, respectively. The median follow-up time for surviving patients was 38 months, ranging from 12 to 88 months. By stepwise Cox regression analysis, significant prognostic variables were age at transplant, acute graft-versus-host disease > or = grade II, cytomegalovirus-associated interstitial pneumonitis, and years from diagnosis to BMT.
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MESH Headings
- Adolescent
- Adult
- Bone Marrow Transplantation/immunology
- Bone Marrow Transplantation/mortality
- Cause of Death
- Child
- Chromosome Aberrations
- Chromosome Disorders
- Cyclosporine/therapeutic use
- Cytogenetics
- Drug Therapy, Combination
- Etoposide/therapeutic use
- Female
- Graft vs Host Disease/prevention & control
- Humans
- Immunosuppression Therapy/methods
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Male
- Methotrexate/therapeutic use
- Methylprednisolone/therapeutic use
- Middle Aged
- Recurrence
- Survival Rate
- Whole-Body Irradiation
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Affiliation(s)
- D S Snyder
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010
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45
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O'Donnell MR, Schmidt GM, Tegtmeier BR, Faucett C, Fahey JL, Ito J, Nademanee A, Niland J, Parker P, Smith EP. Prediction of systemic fungal infection in allogeneic marrow recipients: impact of amphotericin prophylaxis in high-risk patients. J Clin Oncol 1994; 12:827-34. [PMID: 8151325 DOI: 10.1200/jco.1994.12.4.827] [Citation(s) in RCA: 109] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To identify risk factors that might predict for systemic fungal infections in marrow transplant recipients within the first 100 days and to assess the efficacy of low-dose amphotericin B used as prophylaxis for candidemia and infection with invasive Aspergillus species in patients at risk. PATIENTS AND METHODS A retrospective analysis of transplant outcomes for 331 allogeneic marrow recipients transplanted between 1983 and 1989 was performed to identify patients who might be at increased risk of fungal infection. Factors analyzed included disease, remission status, transplant regimen, graft-versus-host disease (GVHD) prophylaxis, duration of neutropenia, and development of GVHD. A trial of low-dose amphotericin (5 to 10 mg/d) begun on day +1 and continuing for 2 to 3 months posttransplant was begun in 1987 to evaluate its utility in reducing systemic mycoses. RESULTS There were 18 episodes of candidemia and 18 systemic mycoses documented by blood or tissue culture or by biopsy. The initiation of high-dose (0.5 to 1 mg/kg/d) corticosteroids early as a component of GVHD prophylaxis in 1986 was identified as the most important risk factor for fungal infections, with a sixfold increase in infections as compared with the previous GVHD regimen (P < .0001); this was despite a significant decrease in the incidence of grade II to IV GVHD (7% v 43%; P = .0001). Low-dose amphotericin B initiated before the start of high-dose corticosteroid GVHD prophylaxis reduced the incidence of fungal infections from 30% to 9% (P = .01) without renal toxicity. Cyclosporine levels were lower in the patients who received amphotericin, leading to an increase in the rate of GVHD to 19% (P = .02). Controlling for GVHD prophylaxis, prolonged neutropenia (P = .00), and grade II to IV GVHD (P = .01) were also identified as risk factors for fungal infection. CONCLUSION Amphotericin B can be used in low doses as prophylaxis for fungal infections early in the posttransplant course. However, cyclosporine doses need to be monitored to maintain target levels.
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Affiliation(s)
- M R O'Donnell
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010
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46
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Riley DK, Galgiani JN, O'Donnell MR, Ito JI, Beatty PG, Evans TG. Coccidioidomycosis in bone marrow transplant recipients. Transplantation 1993; 56:1531-3. [PMID: 8279031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D K Riley
- Division of Infectious Diseases, University of Utah
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47
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Snyder DS, Chao NJ, Amylon MD, Taguchi J, Long GD, Negrin RS, Nademanee AP, O'Donnell MR, Schmidt GM, Stein AS. Fractionated total body irradiation and high-dose etoposide as a preparatory regimen for bone marrow transplantation for 99 patients with acute leukemia in first complete remission. Blood 1993; 82:2920-8. [PMID: 8219241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Ninety-nine consecutive patients with acute leukemia in first complete remission under age 50 (median age 27 years; age range 1 to 47 years) with a histocompatible sibling donor were treated with fractionated total body irradiation (1,320 cGy) and high-dose etoposide (60 mg/kg) followed by allogeneic bone marrow transplantation. Sixty-one patients were diagnosed with acute myelogenous leukemia (AML), 34 patients with acute lymphoblastic leukemia (ALL), 3 patients with biphenotypic acute leukemia, and 1 patient with acute undifferentiated leukemia. Thirty of the 34 patients with ALL had at least one of the following high-risk factors: age greater than 30, white blood cell count at presentation > 25,000/microL, extramedullary disease, certain chromosomal translocations, or the need for greater than 4 weeks of induction chemotherapy to achieve first complete remission. Cumulative probabilities of disease-free survival and relapse at 3 years were 61% and 12%, respectively, for the 61 patients with AML and 64% and 12%, respectively, for the 34 patients with ALL. By stepwise Cox regression analysis, significant prognostic variables for patients with acute myelogenous leukemia were the presence of acute graft-versus-host disease and increasing age, whereas for patients with acute lymphoblastic leukemia, significant variables were age and the development of cytomegalovirus-associated interstitial pneumonia. Complications related to graft-versus-host disease and relapse of leukemia were the major causes of death.
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Affiliation(s)
- D S Snyder
- Department of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010
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Chao NJ, Schmidt GM, Niland JC, Amylon MD, Dagis AC, Long GD, Nademanee AP, Negrin RS, O'Donnell MR, Parker PM. Cyclosporine, methotrexate, and prednisone compared with cyclosporine and prednisone for prophylaxis of acute graft-versus-host disease. N Engl J Med 1993; 329:1225-30. [PMID: 8413388 DOI: 10.1056/nejm199310213291703] [Citation(s) in RCA: 194] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Acute graft-versus-host disease (GVHD) following allogeneic bone marrow transplantation remains a serious problem. In a clinical trial, we tested the combination of cyclosporine and prednisone with and without methotrexate for the prevention of GVHD. METHODS One hundred fifty patients with either acute leukemia in first complete remission, chronic myelogenous leukemia in first chronic phase, or lymphoblastic lymphoma in first complete remission were enrolled in the study. All the patients were given fractionated total-body irradiation (1320 cGy) and etoposide (60 mg per kilogram of body weight) in preparation for transplantation, and received bone marrow from genotypically histocompatible donors. To prevent GVHD, they were randomly assigned to prophylactic treatment with either cyclosporine, methotrexate, and prednisone or cyclosporine and prednisone without methotrexate. All the patients received standardized supportive care after transplantation, including intravenous gamma globulin. RESULTS Patients receiving cyclosporine, methotrexate, and prednisone had a significantly lower incidence of acute GVHD of grades II to IV (9 percent) than those receiving cyclosporine and prednisone (23 percent, P = 0.02). Multivariate regression analysis demonstrated that an increased risk of acute GVHD was associated with an elevated serum creatinine concentration (P = 0.006) and treatment with cyclosporine and prednisone alone (P = 0.02). The lower incidence of acute GVHD was not associated with a higher rate of relapse of leukemia or lymphoma. There was no significant difference in disease-free survival at three years between the two treatment groups (64 percent with the three-drug regimen vs. 59 percent with the two-drug regimen, P = 0.57). CONCLUSIONS The combination of cyclosporine, methotrexate, and prednisone was more effective in preventing acute GVHD of grades II to IV than was the combination of cyclosporine and prednisone without methotrexate.
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Affiliation(s)
- N J Chao
- Bone Marrow Transplantation Program, Stanford University, Calif
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Abstract
BACKGROUND Acalculous cholecystitis (ACC) is an uncommon disorder of the biliary tract, accounting for approximately 6% of acute cholecystitis cases. In this study, cholecystitis was seen in 8 of 770 bone marrow transplant recipients, with ACC occurring in five (63%). METHODS Records of 592 allogenic and 150 autologous BMT patients were reviewed for risk factors associated with ACC. RESULTS Only the number of blood transfusions administered and the use of total parenteral nutrition were associated with ACC development. ACC occurred in 4 of 42 (9%) allogeneic recipients who required exchange transfusion for ABO incompatibility. ACC developed in one autogolous recipient alongside venoocclusive disease of the liver. There was no association between ACC development and preparative regimen, cyclosporine usage, graft versus host disease, or cytomegalovirus infection. CONCLUSIONS ACC occurs more frequently in patients after ABO incompatible BMT requiring exchange transfusion than in other transplant recipients.
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Affiliation(s)
- L A Jardines
- City of Hope National Medical Center, Duarte, California
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50
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Nademanee A, Schmidt GM, O'Donnell MR, Snyder DS, Parker PA, Stein A, Smith E, Lipsett JA, Sniecinski I, Margolin K. High-dose chemoradiotherapy followed by autologous bone marrow transplantation as consolidation therapy during first complete remission in adult patients with poor-risk aggressive lymphoma: a pilot study. Blood 1992; 80:1130-4. [PMID: 1515634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Twenty consecutive patients with poor-risk aggressive lymphoma who at presentation either had elevated serum lactic dehydrogenase level (LDH) and any one of the other poor-prognostic features: bulky mass greater than or equal to 10 cm, advanced stage III or IV, and greater than or equal to 2 extranodal sites, or normal LDH level and all other three features, underwent high-dose chemo/radiotherapy followed by unmanipulated autologous bone marrow transplantation (BMT) during their first complete remission. Eighteen had B-cell lymphoma and 2 had T-cell lymphoma. Eleven patients had high-grade (7 immunoblastic, 3 small noncleaved, non-Burkitt's, and 1 Burkitt's) and 9 had diffuse large cell lymphoma. All patients had achieved a complete remission following conventional chemotherapy. Four patients had also received involved field radiotherapy to areas of bulky disease. The preparative regimen consisted of high-dose etoposide 60 mg/kg and cyclophosphamide 100 mg/kg in combination with fractionated total body irradiation (FTBI) 1,200 cGy (15 patients), or single-dose TBI 750 cGy (2 patients), or carmustine 450 mg/m2 (3 patients). All patients tolerated the treatment well and achieved complete hematologic recovery. Three patients have relapsed at days 79, 196, and 401 after transplantation. Seventeen patients (84%) are alive and relapse-free with a median follow-up of 34 months (range 2 to 54). We conclude that high-dose chemo/radiotherapy followed by autologous BMT can be given as consolidation therapy during first remission in these patients with minimal transplant-related toxicity.
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Affiliation(s)
- A Nademanee
- Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte 91010
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