H. Grant Prentice

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

A randomized controlled trial of itraconazole versus fluconazole for the prevention of fungal infections in patients with haematological malignancies

Fluconazole is widely used as antifungal prophylaxis but it is ineffective against Aspergillus. Itraconazole has a broader spectrum of activity but the capsules give erratic bioavailability in neutropenic patients. We compared itraconazole oral solution (which has an improved pharmacokinetic profile) with fluconazole for antifungal prophylaxis.

Minimal Residual Disease Tests Provide an Independent Predictor of Clinical Outcome in Adult Acute Lymphoblastic Leukemia

PURPOSE Investigation of minimal residual disease (MRD) in childhood acute lymphoblastic leukemia (ALL) using molecular markers has proven superior to other standard criteria (age, sex, and WBC) in distinguishing patients at high, intermediate, and low risk of relapse. The aim of our study was to determine whether MRD investigation is valuable in predicting outcome in Philadelphia-negative adult patients with ALL. PATIENTS AND METHODS MRD was assessed in 85 adult patients with B-lineage ALL by semiquantitative immunoglobulin H gene analysis on bone marrow samples collected during four time bands in the first 24 months of treatment. Fifty patients received chemotherapy only and 35 patients received allogeneic (n = 19) or autologous (n = 16) bone marrow transplantation (BMT) in first clinical remission. The relationship between MRD status and clinical outcome was investigated and compared with age, sex, immunophenotype, and presenting WBC count. RESULTS Fishers exact test established a statistically significant concordance between MRD results and clinical outcome at all times. Disease-free survival (DFS) rates for MRD-positive and -negative patients and log-rank testing established that MRD positivity was associated with increased relapse rates at all times (P <.05) but was most significant at 3 to 5 months after induction and beyond. MRD status after allogeneic BMT rather than before was found to be an important predictor of outcome in 19 adult patients with ALL tested. In patients receiving autologous BMT (n = 16), the MRD status before BMT was more significant (P =.005). CONCLUSION The association of MRD test results and DFS was independent of and greater than other standard predictors of outcome and is therefore important in determining treatment for individual patients.

Cytomegalovirus-Specific Cellular Immune Responses and Viremia in Recipients of Allogeneic Stem Cell Transplants

The immune suppression inherent in allogeneic stem cell transplantation (SCT) offers a favorable environment for infection by opportunistic agents, such as human cytomegalovirus (CMV). Despite the application of potent antiviral prophylaxis, patients remain at risk for CMV infection until adequate immunity is restored. CMV-specific CD8(+) T cell counts were monitored, using HLA-A2 tetrameric complexes, to establish the level of immune response to the viral phosphoprotein UL83 in patients after allogeneic SCT. Correlating this with viral replication and clinical status shows that the level of tetramer-positive T cells provides an assessment of CMV immune reconstitution after stem cell transplantation. Most patients with seropositive donors did reconstitute long-term CMV immunity, unless prolonged immunosuppression to control graft-versus-host disease was induced. Together with polymerase chain reaction testing, this technique provides measurable parameters that can be a guide to therapeutic decision making and can form the basis of CMV immunotherapy.

Early and late invasive pneumococcal infection following stem cell transplantation: a European Bone Marrow Transplantation survey

Summary.  Streptococcus pneumoniae (S. pneumoniae) may cause severe and lethal infections months and years following stem cell transplantation (SCT). In a prospective survey over a 3·5‐year period, we assessed the incidence, risk factors and outcome for invasive pneumococcal infection (IPI) following SCT. Fifty‐one episodes of IPI were reported: 43 episodes after bone marrow transplantation (BMT) and 8 after peripheral blood stem cell transplantation (PBSCT); 35 after allogeneic SCT and 16 after autologous SCT. Seven IPI episodes, all bacteraemias, were defined as early, occurring 1–35 d (median 3 d) post transplantation. Forty‐four episodes were defined as late (≥ 100 d post SCT), occurring 4 months to 10 years (median 17 months) post transplantation. The incidences of early and late IPI were 2·03/1000 and 8·63/1000 transplantations respectively (P = 0·001). A higher incidence of late IPI was observed after BMT than after PBSCT (10·99 versus 3·23/1000; P < 0·01) and after allogeneic versus autologous SCT (12·20 versus 4·60/1000; P < 0·01). There was a higher estimated incidence of IPI in allogeneic patients with than in those without graft‐versus‐host disease (GVHD) (18·85 versus 8·25/1000; P = 0·015). The mortality rate was 20%, including 2/7 of early and 8/44 of late IPI. S. pneumoniae is a rare but important complication during the aplastic phase after SCT. In conclusion, S. pneumoniae is a significant cause of morbidity late post‐transplantation, especially in allogeneic patients, and particularly those with GVHD. The high IPI mortality rate, both early and late post‐transplantation, requires preventive approaches, mainly effective immunization.

Mycophenolate mofetil for the treatment of refractory auto‐immune haemolytic anaemia and auto‐immune thrombocytopenia purpura

Summary.  The treatment of both auto‐immune haemolytic anaemia (AIHA) and auto‐immune thromobocytopenic purpura (AITP) remains unsatisfactory in those refractory to first‐line management. Mycophenolate mofetil (MMF) is an immunosuppressive agent originally used to prevent acute rejection of solid organ transplants and used more recently in the management of auto‐immune conditions. We report its use in four patients with AIHA and six patients with AITP. All four patients with AIHA and five of the six patients with AITP showed a complete or good partial response to treatment with MMF, confirming a possible role in the treatment of these conditions.

Evidence that continued remission in patients treated for acute leukaemia is dependent upon autologous natural killer cells.

Summary. Although it has been known for more than 40 years that allogeneic immune responses cure leukaemias after bone marrow transplantation, autologous leukaemia‐specific immunity remains controversial and its impact upon survival has not been established. Here we have tested 25 patients with de novo acute leukaemias, while in remission at completion of their anti‐leukaemia therapy, for evidence of autologous cytolytic immunity to their leukaemic cells taken and cryopreserved at disease presentation. We have measured this degree of cell‐mediated cytotoxicity in vitro and termed it ‘leukaemia cytolytic activity’ (LCA). Patients whose disease ultimately relapsed had significantly lower LCA than those who remained in remission beyond 2 years (P < 0·001); the absence of LCA when in remission predicted subsequent relapse within 2 years with a sensitivity of 100% and specificity of 77%. LCA was mediated in vitro by CD56+/CD8α+/CD3– natural killer cells. We propose that it is this immune response, rather than the chemotherapy per se, which is responsible for continued remission and that measurement of LCA in patients at completion of therapy may be used as an indicator of risk of subsequent relapse. Patients lacking this response will require further treatment, either with an allogeneic donor transplant or an alternative immunotherapeutic strategy.

Lipid-based amphotericin B: a review of the last 10 years of use.

The last decade has been remarkable for the dramatic increase in the prevalence of serious fungal infections in patients with haematological disorders and neutropenic cancer patients. The mortality rate of deep-seated infection has been in excess of 90% and there is no doubt that this is one of the greatest challenges currently facing haematologists and oncologists. The development of the lipid-based drugs - liposomal amphotericin (AmBisome(R)), amphotericin B lipid complex, ABLC (Abelcet(R)), amphotericin B colloidal dispersion, Amphocil (ABCD(R)), has meant that doses of amphotericin B can be safely escalated for the first time whilst the problems of nephrotoxicity, infusion related reactions (including chills, rigors, fevers and hypoxia) can be reduced. These toxicities are variably reduced with AmBisome more than Abelcet and more than Amphocil and there is little information from randomised trials other than for AmBisome. AmBisome used in the setting of persistent fever and neutropenia not responding after 3-4 days of intravenous antibiotics, is associated with less breakthrough systemic fungal infections. There is also much less need for premedication, including steroids, compared with amphotericin B and Abelcet. The use of intermittent doses of Ambisome given prophylactically is now being explored. A new and exciting era of antifungal therapy is opening up with new compounds, such as itraconazole voriconazole, posaconazole and echinocandins, being investigated and for the first time, we also have options for combination therapy and prophylaxis.

Thrombotic thrombocytopenic purpura after allogeneic stem cell transplantation: a survey of the European Group for Blood and Marrow Transplantation (EBMT)

Summary. A survey was carried out among the European Group for Blood and Marrow Transplantation (EBMT) centres to determine the incidence, risk factors, treatment and outcome of thrombotic thrombocytopenic purpura (TTP) following allogeneic haematopoietic stem cell transplantation. TTP was defined as the simultaneous occurrence of red cell fragmentation, laboratory findings of haemolysis, red cell transfusion requirement and de novo or persistant thrombocytopenia caused by consumption, in the absence of disseminated intravascular coagulation. Forty‐five centres reported all patients (n = 406) transplanted between July and December 1996. Twenty‐three patients developed TTP; the risk of developing TTP was 6·7% at 2 years (95% CI: 4·1% to 9·3%). The median time of onset was 44 d (range 13–319) post transplantation. Significant risk factors for the development of TTP were female gender (P = 0·005) and an unrelated donor (P = 0·046). To treat TTP, cyclosporin administration was discontinued in 10 cases, plasma exchanges were performed in five cases and 12 patients received plasma infusions without plasma exchange. TTP resolved in 13 of the 23 patients (57%). The only factor predictive of resolution of TTP was the absence of nephropathy. Seven patients (30%) were alive at follow‐up of 38–45 months from the onset of TTP. Sixteen patients died; the causes were multiple, only three patients had TTP as a central factor. The median time to death was 41 d (range 1–762 d) from the onset of TTP. TTP is a relatively frequent complication of allogeneic stem cell transplantation and it is associated with high mortality, though death is usually caused by multiple factors.

Allogeneic stem cell transplantation in the myelodysplastic syndromes: interim results of outcome following reduced-intensity conditioning compared with standard preparative regimens

Summary. Conventional allogeneic stem cell transplantation (SCT) for myelodysplastic syndrome (MDS) is associated with excessive procedure‐related mortality. The outcome following volunteer‐unrelated donor (VUD) or sibling allogeneic SCT was therefore evaluated in 23 MDS patients conditioned with reduced‐intensity regimens (fludarabine/busulphan/Campath‐1H) because of advanced age (48 vs 37 years, P = 0·002) and/or co‐morbidity (19 vs 3, P < 0·0001) which precluded conventional transplantation, and compared with 29 treated with standard protocols [busulphan/cyclophosphamide (Bu/Cy); Bu/Cy/total‐body irradiation/Campath‐1G]. Graft‐versus‐host disease (GVHD) prophylaxis comprised of cyclosporine/methotrexate. One hundred per cent donor engraftment (variable number tandem repeat analysis/cytogenetics/fluorescence in situ hybridization) was achieved in 18/19 (95%) evaluable patients receiving reduced‐intensity regimens, although six (32%) have subsequently shown mixed chimaerism. Reduced‐intensity conditioning was associated with significantly reduced duration of aplasia, less mucositis, fever, antibiotic, analgesia, parenteral nutrition use, less acute and chronic GVHD, and lower early procedure‐related mortality [two (9%) vs nine (31%), P < 0·05]. Six patients relapsed (two standard, four reduced‐intensity) and two (reduced‐intensity) experienced late graft failure. The 2 year actuarial overall/disease‐free survival (OS/DFS) was 48/39% in the reduced‐intensity arm and 44/44% in the standard group. The 2 year non‐relapse mortality was 31% and 50% respectively. In VUD recipients, OS was superior in the reduced‐intensity arm (49%vs 34%). Predictors of DFS included good/intermediate‐risk karyotype, low/intermediate‐1 International Prognostic Scoring system score, human leucocyte antigen compatibility and attainment of complete remission. Our data demonstrates that VUD or sibling allogeneic SCT following reduced‐intensity conditioning is feasible in high‐risk MDS patients considered unsuitable for standard transplantation and is associated with comparable 3·5 year DFS to those receiving conventional regimens.