André Tichelli

Malignant Tumors Occurring after Treatment of Aplastic Anemia

BACKGROUND AND METHODS Recent studies have shown that long-term survivors of acquired aplastic anemia may be at high risk for malignant diseases. We assessed the risk of cancer after aplastic anemia was treated with immunosuppression or bone marrow transplantation and sought to identify risk factors according to treatment. The study population consisted of 860 patients treated by immunosuppression and 748 patients who had received bone marrow transplants for the treatment of severe aplastic anemia. The risk of cancer was analyzed overall and according to treatment relative to the risk in the general population. In calculating relative risk, we excluded patients with myelodysplastic syndromes or acute leukemias arising less than 6 months after treatment, and solid cancers arising less than 12 months after treatment, because of a possible association with aplastic anemia itself rather than with the treatment received. RESULTS Forty-two malignant conditions were reported in the 860 patients who received immunosuppressive therapy: 19 cases of myelodysplastic syndrome, 15 cases of acute leukemia, 1 case of non-Hodgkins lymphoma, and 7 solid tumors. Nine were reported in the 748 patients who received bone marrow transplants: two cases of acute leukemia and seven solid tumors. After the exclusions listed above, the overall relative risk of cancer was 5.50 (P < 0.001) as compared with that in the general European population; the risk was 5.15 (P < 0.001) after immunosuppressive therapy and 6.67 (P < 0.001) after transplantation. The 10-year cumulative incidence rate of cancer was 18.8 percent after immunosuppressive therapy and 3.1 percent after transplantation. The risk factors for myelodysplastic syndrome or acute leukemia after immunosuppressive therapy included the addition of androgens to the immunosuppressive treatment (relative risk = 0.28), older age (relative risk = 1.03), treatment in 1982 or later, as compared with 1981 or earlier (relative risk = 3.01), splenectomy (relative risk = 3.65), and treatment with multiple courses of immunosuppression (relative risk = 2.26). Risk factors for solid tumors after bone marrow transplantation were age (relative risk = 1.11 per year) and the use of radiation as a conditioning regimen before transplantation (relative risk = 9.56); such tumors occurred only in male patients. CONCLUSIONS Survivors of aplastic anemia are at high risk for subsequent malignant conditions. Myelodysplastic syndrome and acute leukemia tend to follow immunosuppressive therapy, whereas the incidence of solid tumors is similar after immunosuppression and after bone marrow transplantation.

Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe 2009

The European Group for Blood and Marrow Transplantation regularly publishes special reports on the current practice of haematopoietic SCT for haematological diseases, solid tumours and immune disorders in Europe. Major changes have occurred since the first report was published. HSCT today includes grafting with allogeneic and autologous stem cells derived from BM, peripheral blood and cord blood. With reduced-intensity conditioning regimens in allogeneic transplantation, the age limit has increased, permitting the inclusion of older patients. New indications have emerged, such as autoimmune disorders and AL amyloidosis for autologous HSCT and solid tumours, myeloproliferative syndromes and specific subgroups of lymphomas for allogeneic transplants. The introduction of alternative therapies, such as imatinib for CML, has challenged well-established indications. An updated report with revised tables and operating definitions is presented.

Risk Score for Outcome After Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective Analysis

It was investigated whether the European Group for Blood and Marrow Transplantation risk score, previously established for chronic myeloid leukemia, could be used to predict outcome after allogeneic hematopoietic stem cell transplantation (HSCT) for hematological disease in general.

Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation

Advances in hematopoietic cell transplantation (HCT) technology and supportive care techniques have led to improvements in long-term survival after HCT. Emerging indications for transplantation, introduction of newer graft sources (e.g. umbilical cord blood) and transplantation of older patients using less intense conditioning regimens have also contributed to an increase in the number of HCT survivors. These survivors are at risk for developing late complications secondary to pre-, periand post-transplant exposures and risk-factors. Guidelines for screening and preventive practices for HCT survivors were published in 2006. An international group of transplant experts was convened in 2011 to review contemporary literature and update the recommendations while considering the changing practice of transplantation and international applicability of these guidelines. This review provides the updated recommendations for screening and preventive practices for pediatric and adult survivors of autologous and allogeneic HCT.

Late haematological complications in severe aplastic anaemia

137 patients with severe aplastic anaemia (SAA) were treated in Basel from 1976 to 1986. 34 underwent bone marrow transplantation (BMT) and 103 received antilymphocyte globulin (ALG) therapy. We have analysed the incidence of late haematological complications in both groups of patients.

Malignant Neoplasms in Long-Term Survivors of Bone Marrow Transplantation

Bone marrow transplantation offers a chance for cure to patients with leukemia, lymphoma, and severe aplastic anemia (1-3). However, long-term survival may be impaired by the development of secondary neoplasms (4). Secondary malignant diseases are known complications of the radiation and chemotherapy used to treat primary cancers (5-7). An increased risk for malignant neoplasms has also been reported in patients who receive organ transplants (8, 9) and those treated with immunosuppression for aplastic anemia (10). Patients who receive marrow transplants are at increased risk for malignant neoplasms because of several risk factors: ionizing radiation and chemotherapy used for pretransplantation conditioning and treatment of the primary malignant disease, immune deficiency due to delayed and incomplete recovery of the immune system, immune stimulation and immunosuppression by the graft-versus-host reaction, and immunosuppressive therapy for graft-versus-host disease. Most reports on malignant neoplasm after marrow transplantation have included patients early after transplantation and have had short follow-up (1, 4, 11-15). A recent multicenter study of more than 19 000 patients (16) included patients early after transplantation and evaluated solid cancers only. The aim of this study was to assess the risk for malignant neoplasm in long-term survivors of marrow transplantation and to identify risk factors for new malignant disease. Methods Marrow transplantation programs were started in Europe in the early 1970s in several university hospitals. The indication for marrow transplantation changed with time: Before 1976, the main indication was severe aplastic anemia, whereas after 1980, the main indication was leukemia. The European Cooperative Group for Blood and Marrow Transplantation (EBMT) was founded in 1977. A central registry of all cooperating centers was instituted at the University of Leiden; this registry includes basic information on disease-related and transplant-related variables, including the form of radiation, radiation dose, dose rate, fractionation, and treatment times. Patients We studied 1036 patients who underwent transplantation in 45 European centers cooperating in the EBMT. We limited our study to patients surviving more than 5 years for two reasons. First, mortality due to transplant-related complications other than malignant neoplasm and recurrence of the original disease are high in the first years after transplantation. These causes of death may interfere in a nonrandom manner with the development of malignant neoplasms. In addition, most major complications other than malignant neoplasm occur within that time, and their influence on the development of new malignant disease can be studied independently. Data Collection The EBMT registry provided basic data on patients who underwent transplantation before 1986 and on the transplantation centers, including age and sex of the patient and his or her donor; diagnosis and status of the disease at the time of transplantation; histocompatibility with the donor in the transplantation categories of monozygotic twin, HLA-identical family member, HLA-mismatched family member, and autologous; conditioning treatment, including radiation, radiation source, radiation field, radiation dose, dose rate, fractionation schedule, number of days with radiation, and the form of chemotherapy; methods of prevention of graft-versus-host disease; and the occurrence of acute graft-versus-host disease, graded on a 0 to 4 scale, and chronic graft-versus-host disease, graded on a 0 to 2 scale. Additional information on occurrence of a secondary neoplasm, date of tumor detection, International Classification of Diseases code, histology report on the tumor, recurrence and treatment of the original disease, agents used for the treatment of graft-versus-host disease, the date of last follow-up, clinical performance status at the time of last follow-up, and cause of morbidity or death was requested. The transplantation centers were asked to check the registry data and to provide the additional information. Furthermore, they were asked to report all consecutive patients undergoing transplantation who survived more than 5 years. Copies of the original histology reports were provided for 62% of all tumors. Radiation as preparative treatment was classified as single-dose or fractionated total-body radiation and partial-body radiation, including total lymphoid and thoracoabdominal radiation. The radiation source, dose, acute dose rate, number of fractions, number of days with radiation, and dose to the lungs were scored as radiation variables. Statistical Analysis Kaplan-Meier survival analysis was performed to estimate the risk for malignant neoplasm with time after transplantation (8, 17). The date of onset of a pathologically confirmed malignant neoplasm was the date on which the clinical diagnosis was first suspected. The risk for neoplasms in the observation group was compared with that in the general population; patients were matched for age and sex. Data were provided by the Danish Cancer Registry and the Cancer Registry of the Saarland/Germany (18) on the annual incidence of malignant cancer at all body sites, including the skin. These registries are representative of the European population. The expected number of cases (E) in the cohort was calculated by using age, sex, and length of follow-up, and the incidence rates were compared with the incidence in the transplant cohort (O). Significance was assessed under the null hypothesis that O is equal to E in a Poisson distribution. A standardized ratio (O/E) was also calculated. Analysis of potential risk factors was performed with the time to diagnosis of malignant neoplasm in a log-rank test for univariate analysis. Multivariate regression analysis was performed with the Cox model for proportional hazards. Analyses were performed by using the NCSS statistical package (Dr. J.L. Hintze, Kaysville, Utah). Results Survival The median duration of observation was 128 months; the longest observation was 265 months (Figure 1). 90 patients died more than 5 years after transplantation. Causes of death were recurrence of the original disease in 44 patients, chronic graft-versus-host disease with or without pulmonary complications in 22 patients, secondary malignant neoplasm in 10 patients, AIDS in 5 patients, pulmonary complications and infections in 3 patients, and accidents in 3 patients. The cause of death was not known for 3 patients. Secondary malignant neoplasms in patients who died were brain tumors in 3 patients; squamous-cell carcinoma of the oral cavity, larynx, esophagus, and anus in 5 patients; and secondary leukemia and neurofibrosarcoma in 1 patient each. The risk for death from all causes ( SE) was 7.9% 0.9% at 10 years and 12% 1.4% at 15 years after transplantation. Figure 1. Cumulative probability of developing a malignant neoplasm as a function of time after bone marrow transplantation. n Tumors New malignant disease was diagnosed in 53 patients. The most frequent tumors were carcinomas of the skin; basal-cell and squamous-cell carcinomas; tumors of the oral cavity; carcinomas of the uterus, including carcinoma in situ of the cervix; breast cancer; thyroid gland cancer; and brain tumors (Table 1). The actuarial risk for a malignant neoplasm was 3.5% 0.6% at 10 years and 11.5% 2.3% at 15 years (Figure 1). The overall incidence of malignant tumors is about fivefold greater than that in an age- and sex-matched population (Figure 2). This increase was more than 10-fold for cancer of the oral cavity, esophagus, or thyroid gland (Figure 3). Table 1. Malignant Neoplasms in Patients Who Survived 5 Years after Transplantation Figure 2. Cumulative number of malignant neoplasms after bone marrow transplantation as a function of age. Figure 3. Standardized incidence ratios of malignant neoplasms after bone marrow transplantation. circles Risk Factor Analysis The median age of donors and patients was 21 years (range, 1 to 51.9 years). Older age of the recipient at the time of transplantation was a risk factor for malignant neoplasm in female patients only (Table 2). Older age of the donor was also a risk factor for neoplasms in the recipient if the donor was female. Neoplasms were detected earlier in these recipients. The increased incidence of malignant neoplasms in recipients of allogeneic transplants compared with recipients of autologous and syngeneic transplants did not reach statistical significance. Only patients with extensive, chronic graft-versus-host disease had a significantly increased risk. Treatment of graft-versus-host disease with cyclosporine, azathioprine, and thalidomide significantly increased the risk for malignant neoplasms (Table 2). Variables with P values less than 0.2 in a log-rank test comparing time until tumor development were entered into a multivariate analysis using the Cox proportional-hazards model. Only patient age remained significant after adjustment for histocompatibility group and development of graft-versus-host disease (Table 3). Treatment of graft-versus-host disease with cyclosporine, thalidomide, or methotrexate was a significant risk factor (Table 3). Table 2. Malignant Neoplasm after Bone Marrow Transplantation: Univariate Analysis Table 3. Malignant Neoplasms after Bone Marrow Transplantation: Multivariate Analysis in Cox Proportional Hazards Model In the subgroup analysis, the effect of age on carcinogenesis was limited to female patients (Table 2), in part because of carcinomas of the breast and the uterus. However, the effect of age in female patients was still significant after malignant disease of the genital organs and breast was excluded from analysis (P=0.04). Neoplasms of the skin are frequent in patients who receive solid organ transplants (8). We also analyzed the risk factors in patients with tumors in organs other than skin. In these patients, chronic graft-versus-h

Health and Functional Status of Long-Term Survivors of Bone Marrow Transplantation

Bone marrow transplantation is used to treat patients who have life-threatening hematologic diseases [1, 2]. Many patients survive the acute complications of transplantation and remain free of their original disease for more than 5 years. However, information on the health and activity of surviving patients is sparse. Most studies of quality of life after bone marrow transplantation have involved a small number of patients and short observation times after transplantation [3-6, 7-11]. The assessment of late illness and death and the identification of the causes of and the risk factors for impaired health and reduced functional status may help to improve treatment strategies. Using data from centers that are collaborating in the European Group for Blood and Marrow Transplantation (EBMT), we conducted a retrospective, descriptive study on late death, health, and social reintegration of patients who had received allogeneic and syngeneic bone marrow transplants for hematologic disorders before 31 December 1985 and who had survived for at least 5 years. We evaluated variables associated with late illness and death and reduced participation in school or work. The patients primary disease, age, and sex and the availability of a donor were predetermined variables. However, evaluation of the variables related to the treatment strategy, such as the selection of the optimal time in the course of the disease for transplantation, the choice of the conditioning treatment (that is, with or without radiation), and the regimen used for prophylaxis of graft-versus-host disease, is of particular interest. Methods All European transplantation centers cooperating in the EBMT were asked to provide information on patients who had transplantation before 31 December 1985 and had survived for at least 5 years after receiving the graft. Data on 798 consecutive transplant recipients were reported from 43 centers in 13 European countries. The mean percentage (SD) of long-term survivors was 39.2% 8.8%. Selective reporting was excluded by scoring unique patient numbers that were previously reported to the EBMT registry in Leiden, the Netherlands. The data were validated at meetings of the EBMT Late Effects Working Party and through personal contact with the responsible persons at the centers. Clinical performance was assessed according to the latest Karnofsky score, and social activity was evaluated according to the patients ability to attend work or school full-time or part-time. Karnofsky scores were assigned in increments of 10%. Scores of 90% and 100% are compatible with normal activity; a score of 80% reflects special efforts to carry on normal activity; and scores of 70% or less reflect varying need for assistance with normal activity. For patients who died more than 5 years after transplantation, the causes of illness and death were reported. We considered the following factors as potential risk factors for impaired clinical and social performance and late death and entered them into a bivariate analysis: age and sex of the patient and donor; histocompatibility of the donor; primary disease and status at the time of transplantation; conditioning regimen, including details on radiation; method of prophylaxis of graft-versus-host disease; occurrence of acute and chronic graft-versus-host disease; development of secondary cancer; and recurrence of original disease. Patient Data Patient characteristics are summarized in Table 1. Patients younger than 18 years of age were classified as children (321 patients), and patients 18 years of age or older were classified as adults (477 patients). Most patients (n = 652) had transplantation for the treatment of leukemia. Early phases of disease were defined as first remission of acute leukemia or the chronic phase of chronic myelogenous leukemia; intermediate phases were acute leukemia in second remission or chronic myelogenous leukemia in the accelerated phase; and advanced phases were later remissions of or active acute leukemia and blastic transformation of chronic myelogenous leukemia. Donors were HLA-identical siblings for 775 patients, HLA-mismatched family members for 7 patients, and syngeneic twins for 16 patients. Table 1. Characteristics of Treated Patients* A total of 645 patients (80%) received total-body radiation; 434 patients were treated with single-dose total-body irradiation, and 211 patients received fractionated total-body irradiation. Thirty-four patients were conditioned by total lymphoid or thoracoabdominal radiation, and 89 patients were conditioned by chemotherapy only. For total lymphoid irradiation, the radiation field involved an inverted Y for the lower half of the body and a mantle field with shielding of the oropharynx. When thoracoabdominal irradiation was given to the trunk, the head and the limbs remained outside the field. Chemotherapy most frequently consisted of cyclophosphamide, either alone (50 mg/kg of body weight per day for 4 days) or in combination with radiation (60 mg/kg per day for 2 days or 50 mg/kg per day for 4 days). Other chemotherapy consisted of combination regimens, including cytosine-arabinoside (38 patients), melphalan (16 patients), busulfan (8 patients), daunomycin (13 patients), and the nitrosoureas bischlorethylnitrosourea or cyclohexylchlorethylnitrosourea (11 patients). In 30 patients, the type of conditioning procedure was not reported. The most frequently used methods of prophylaxis of graft-versus-host disease were methotrexate given after transplantation, cyclosporine, or the combination of cyclosporine and methotrexate. Eighty-three patients received prophylaxis with T-cell-depleted bone marrow or antithymocyte globulin. Data on the occurrence of graft-versus-host disease were reported for 655 recipients of allogeneic bone marrow. Acute graft-versus-host disease of grade II or higher developed in 23% of patients. Limited chronic graft-versus-host disease was seen in 182 patients (28%), and extended chronic graft-versus-host disease was seen in 92 patients (14%). Graft-versus-host disease had not developed in 381 patients (58%). Statistical Analysis Age and sex of the patients and donors, diagnosis and stage of the disease at the time of transplantation, conditioning regimen, method of prophylaxis of graft-versus-host disease, occurrence of acute and chronic graft-versus-host disease, development of secondary cancer, and recurrence of the original disease were assessed for their influence on late death, impaired clinical performance (Karnofsky score 80%), and return to social activity (full-time attendance at work or school). In a bivariate analysis, we used the Fisher exact test to compare proportions. Mortality was evaluated by comparing duration of survival using the log-rank test. A P value of 0.05 or less was considered statistically significant. Analyses were done using the Number Cruncher Statistical Systems (NCSS) statistical package (Dr. J.L. Hintze, Kaysville, Utah). Results Survival and Late Mortality The median duration of observation was 8.4 years (range, 5 to 19 years). Figure 1 shows the number of patients as a function of time since treatment; the cumulative overall mortality of the observed patients; and the expected mortality of a similar, unselected group of patients. Fifty-five patients died more than 5 years after bone marrow transplantation, and 743 patients are alive and evaluable for clinical performance and social activity. For 5-year survivors, the actuarial risk for death is 8% (95% CI, 6% to 11%) at 10 years (216 patients at risk) and 14% (CI, 8.1% to 19.9%) at 15 years (16 patients at risk). Figure 1. Mortality more than 5 years after bone marrow transplantation. The causes of death occurring more than 5 years after bone marrow transplantation are listed in Table 2. Leukemic relapse was the most common single cause of death and most frequently occurred in patients with chronic myelogenous leukemia (14%) and lymphoma (25%); it was also seen in 4% of patients with acute myelogenous leukemia and 4% of patients with acute lymphoblastic leukemia. Chronic graft-versus-host disease with and without infection and chronic lung disease were the second most frequent causes of death. Secondary cancer and transfusion-associated acquired immunodeficiency syndrome (AIDS) also contributed to mortality. Table 2. Causes of Death Occurring More Than 5 Years after Transplantation* The most important risk factor for survival after more than 5 years is recurrence of leukemia and lymphoma. Other statistically significant factors in the bivariate analysis were the development of secondary cancer, chronic graft-versus-host disease, stage of disease at the time of transplantation, and the use of radiation for conditioning treatment (Table 3). After patients with recurrent disease were excluded, extended chronic graft-versus-host disease, the development of secondary cancer, female sex of the donor, male sex of the patient, and the use of methotrexate were statistically significantly associated with late mortality (Table 3). Table 3. Risk Factors for Death More Than 5 Years after Allogeneic Bone Marrow Transplantation* Clinical Performance Information on Karnofsky scores was available for 647 patients. Patients with a Karnofsky score of 80% or less are considered to be unable to perform normally without special effort. Factors associated with clinical performance reduced to less than 100% were reported for 125 patients. After 15 patients who were living with recurrent disease were excluded, the major cause of illness was chronic graft-versus-host disease (Table 4). Pulmonary changes consisted of obliterative bronchiolitis, lung fibrosis, and recurrent infections, which were probably the sequelae of chronic graft-versus-host disease. Similarly, aseptic osteonecrosis and osteoporosis were associated with chronic graft-versus-host disease and its treatment with corticosteroids. Table 4. Causes of Reduced Performance Status in Pati

Purified donor NK-lymphocyte infusion to consolidate engraftment after haploidentical stem cell transplantation.

This pilot study tested feasibility of natural killer cell purification and infusion (NK-DLI) in patients after haploidentical hematopoietic stem cell transplantation (HSCT). The aim was to obtain ⩾1.0 × 107/kg CD56+/CD3− NK cells and <1.0 × 105/kg CD3+ T cells. Mononuclear cells were collected by 10 l leukapheresis. A two-step ex vivo procedure was used to purify NK cells, using an immunomagnetic T-cell depletion, followed by NK-cell enrichment. Five patients with high-risk myeloid malignancies were included, presenting 3–12 months after a haploidentical HSCT with mixed chimerism (3), impending graft failure (1) or early relapse (1). The purified product contained a median of 1.61 × 107/kg (range 0.21–2.2) NK cells and 0.29 × 105/kg (0.11–1.1) T cells. A purity of NK cells of 97% (78–99), a recovery of 35.5% (13–75), and a T-cell depletion of 3.55 log (2.9–4.5) was achieved. Infusions were well tolerated and none of the patients developed graft-versus-host disease. We observed an increase in donor chimerism in 2/5, stable mixed chimerism, decreasing chimerism and relapse of AML in one patient each. Selection of NK-DLI is technically feasible. NK cells are well tolerated when used as adoptive immunotherapy in recipients of haploidentical HSCT.

The EBMT activity survey: 1990-2010

A total of 654 centers from 48 countries were contacted for the 2010 survey. In all, 634 centers reported a total of 33 362 hematopoietic SCT (HSCT) with 30 012 patients receiving their first transplant (12 276 allogeneic (41%) and 17 736 autologous (59%)). Main indications were leukemias: 9355 (31%; 93% allogeneic), lymphoid neoplasias specifically Non Hodgkin’s lymphoma, Hodgkin’s lymphoma and plasma cell disorders: 17 362 (58%; 12% allogeneic), solid tumors: 1585 (5%; 6% allogeneic) and non-malignant disorders: 1609 (6%; 88% allogeneic). There were more unrelated donors than HLA-identical sibling donors (53% versus 41%); the proportion of peripheral blood as stem cell source was 99% for autologous and 71% for allogeneic HSCT. Cord blood was primarily used in allogeneic transplants (6% of total) with three autologous cord blood HSCT being reported. The number of transplants has increased by 19% since 2005 (allogeneic 37% and autologous 9%) and continued to increase by about 1100 HSCT per year since 2000. Patterns of increase were distinct and different. The data show the development of transplantation in Europe since 1990, with the number of patients receiving a HSCT increasing from 4200 to over 30 000 annually. The most impressive trend seen is the steady increase of unrelated donor transplantation, in parallel to the availability of unrelated donors through donor registries.

Clonal analysis of TET2 and JAK2 mutations suggests that TET2 can be a late event in the progression of myeloproliferative neoplasms.

Somatic mutations in TET2 occur in patients with myeloproliferative neoplasms and other hematologic malignancies. It has been suggested that TET2 is a tumor suppressor gene and mutations in TET2 precede the acquisition of JAK2-V617F. To examine the order of events, we performed colony assays and genotyped TET2 and JAK2 in individual colonies. In 4 of 8 myeloproliferative neoplasm patients, we found that some colonies with mutated TET2 carried wild-type JAK2, whereas others were JAK2-V617F positive, indicating that TET2 occurred before JAK2-V617F. One of these patients carried a germline TET2 mutation. However, in 2 other patients, we obtained data compatible with the opposite order of events, with JAK2 exon 12 mutation preceding TET2 mutation in one case. Finally, in 2 of 8 patients, the TET2 and JAK2-V617F mutations defined 2 separate clones. The lack of a strict temporal order of occurrence makes it unlikely that mutations in TET2 represent a predisposing event for acquiring mutations in JAK2.