Nathalie Dhedin

Empirical versus Preemptive Antifungal Therapy for High-Risk, Febrile, Neutropenic Patients: A Randomized, Controlled Trial

BACKGROUND Empirical antifungal therapy is the standard of care for neutropenic patients with hematological malignancies who remain febrile despite broad-spectrum antibacterial treatment. Recent diagnostic improvements may ensure the early diagnosis of potentially invasive fungal disease. Reserving antifungals for this stage may achieve similar survival rates and reduce treatment toxicity and costs. METHODS In this multicenter, open-label, randomized noninferiority trial, we compared an empirical antifungal strategy with a preemptive one. Empirical treatment was defined as antibacterial treatment of patients who have persistent or recurrent fever. Preemptive treatment was defined as treatment of patients who have clinical, imaging, or galactomannan-antigen-assay evidence suggesting fungal disease. First-line antifungal treatment was amphotericin B deoxycholate (1 mg/kg/day) or liposomal amphotericin (3 mg/kg/day), depending on daily renal function. The primary efficacy outcome was the proportion of patients alive at 14 days after recovery from neutropenia. RESULTS The median duration of neutropenia (neutrophil count, <500 cells/mm3) for the 293 patients enrolled was 18 days (range, 5-69 days). By intention-to-treat analysis, survival was 97.3% with empirical treatment and 95.1% with preemptive treatment. The lower 95% confidence limit for the difference in mortality was -5.9%, which was within the noninferiority margin of -8%. Probable or proven invasive fungal infections were more common among patients who received preemptive treatment than among patients who received empirical treatment (13 of 143 vs. 4 of 150; P < .05), and most infections occurred during induction therapy (12 of 73 patients in the preemptive treatment group vs. 3 of 78 patients in the empirical treatment group were infected during induction therapy; P < .01). Preemptive treatment did not decrease nephrotoxicity but decreased costs of antifungal therapy by 35%. CONCLUSIONS Preemptive treatment increased the incidence of invasive fungal disease, without increasing mortality, and decreased the costs of antifungal drugs. Empirical treatment may provide better survival rates for patients receiving induction chemotherapy.

Comparison of serum galactomannan antigen detection and competitive polymerase chain reaction for diagnosing invasive aspergillosis.

To improve the diagnosis of invasive aspergillosis (IA), we retrospectively compared competitive polymerase chain reaction (PCR) and sandwich ELISA for detection of serum galactomannan (GM) antigen. We studied 281 serum samples collected weekly during the period at risk for IA from 41 selected hematology patients. Twenty-two patients had confirmed, probable, or suspected IA, according to clinical and mycologic data. Fifteen of them had positive GM titers (87 samples) and 12 had positive PCRs (20 samples). Nineteen of the 20 PCR-positive samples were also GM-positive. Of the 19 patients without IA (83 samples), one had 3 GM-false-positive samples. Neither test anticipated the initiation of antifungal therapy on the basis of clinical suspicion. Both tests were more likely to be positive before death. This study suggests that PCR on serum samples is not more sensitive than GM detection. However, PCR can improve the specificity of the GM test. Together, these noninvasive tests should improve the diagnosis of IA.

Identification of Prognostic Factors in 61 Patients With Posttransplantation Lymphoproliferative Disorders

PURPOSE Prognostic studies of posttransplantation lymphoproliferative disorders (PTLDs) are hindered by the small number of cases at each transplant center. We analyzed prognostic factors and long-term outcome according to clinical manifestations, pathologic features, and treatment and investigated the prognostic value of the non-Hodgkins lymphoma International Prognostic Index (IPI) in 61 patients with PTLD. PATIENTS AND METHODS We studied 61 patients in two institutions who developed PTLD and analyzed factors influencing the complete remission and survival rates. RESULTS In univariate analysis, factors predictive of failure to achieve complete remission were performance status (PS) > or = (P =.0001) and nondetection of Epstein-Barr virus (EBV) in the tumor (P =.01). Only a negative link with PS > or = 2 was observed in multivariate analysis. In univariate analysis, factors predictive of lower survival were PS > or = 2, the number of sites (one v > one), primary CNS localization, T-cell origin, monoclonality, nondetection of EBV, and treatment with chemotherapy. The IPI failed to identify a patient subgroup with better survival and was less predictive of the response rate than was a specific index using two risk factors (PS and number of involved sites), which defined three groups of patients: low-risk patients whose median survival time has not yet been reached, intermediate-risk patients with a median survival time of 34 months, and high-risk patients with a median survival time of 1 month. CONCLUSION PS and the number of involved sites defined three risk groups in our population. The value of these prognostic factors needs to be confirmed in larger cohorts of patients treated in prospective multicenter studies.

Development of a real-time polymerase chain reaction assay for the diagnosis of human herpesvirus-6 infection and application to bone marrow transplant patients.

A quantitative real-time PCR assay was developed for human herpesvirus-6 (HHV-6) genome based on TaqMan technology. After choosing a region of interest into the U65-U66 genes of HHV-6 genome, its nucleotide sequence was determined among four HHV-6 strains (one variant A and three variants B) to exclude a variability of sensitivity due to interstrain sequence differences. A plasmid containing HHV-6 target sequences identical to those of reference type viruses was constructed with the aim of standardisation. This HHV-6 genomic quantitation assay has a threshold sensitivity of ten copy equivalents (EqCop) per reaction. In order to test the feasibility of this assay directly on human samples, the technique was applied to the quantitation of HHV-6 genome in 30 blood samples from healthy subjects as well as 31 blood samples and three samples of cerebrospinal fluid (CSF) from 21 bone marrow transplant (BMT) recipients and four patients with a haematological disease but not treated by bone marrow transplantation. HHV-6 load ranged between 0.00015 and 0.0008 equivalent DNA copy number (EqCop) per 100 peripheral blood mononuclear cells (PBMCs) in healthy subjects whereas it ranged from <10 to 7500 EqCop per 100 PBMCs, and from <10 to 415,820 EqCop per 100 microl of whole CSF in patients. The efficacy of treatment with antiherpetic drug was associated with a decrease of the viral load in the CSF of one patient. This method leads to relevant results in term of range of quantitation, sensitivity, and safety against contamination by amplicons, and might constitute a useful tool for the follow-up of BMT recipients particularly in the presence of antiherpetic therapy.

CD4+CD25+ Regulatory T Cell Depletion Improves the Graft-Versus-Tumor Effect of Donor Lymphocytes After Allogeneic Hematopoietic Stem Cell Transplantation

Immunological effects of donor lymphocyte infusion for treatment of recurrent malignancy after allogeneic hematopoietic cell transplantation can be enhanced by depleting T regulatory cells in the infused cells and in the recipient. Regulatory T Cells Interfere with Graft-Versus-Tumor Effects Patients search for organ donors who are close genetic matches to avoid immune reactions. But sometimes a little immune activation is a good thing. Hematopoietic stem cells in the form of bone marrow are often used to treat blood cancers, and the donated cells not only engraft in bone to provide a source of healthy blood cells but also contain T cells that attack and destroy any remaining cancerous cells. This graft-versus-tumor effect is also harnessed when such patients suffer a relapse and donor T cells are infused into the patient. These infusions often fail to quell the malignancy, however. The reason for failure, Maury et al. have now shown, is that the donor cells can often include regulatory T cells (Tregs), a class of T cells that dampens the immune response. Removing these cells before the infusion markedly improved the graft-versus-tumor effect and the patients’ survival. The beneficial graft-versus-tumor effect of transplantation can be accompanied by the not-so-desirable graft-versus-host disease. Like the transplanted T cells that perceive cancer cells as foreign, T cells can also attack the host’s skin, liver, intestinal lining, and other internal organs—a condition that is serious but can be treated. The authors of this study used the presence of graft-versus-host disease as a sign that there were active, functioning T cells that also provided graft-versus-tumor effects. They treated 17 patients with relapsed blood cancer who had previously received an infusion of lymphocytes and had neither clinical manifestations of graft-versus-host disease nor control of their malignancy. After receiving a new infusion of lymphocytes from which the Tregs had been removed, two of the patients developed graft-versus-host disease for the first time in their transplant history. Hypothesizing that this low rate of response was a result of Treg cells present in the recipient, they treated four of the patients who needed more infusions with the same Treg-depleted cells but now infused them immediately after recipient Tregs were eliminated with lymphopdepletive chemotherapy. These four patients, all of whom had Hodgkin’s lymphoma, reacted to the infused cells by developing graft-versus-host disease, a sign that the infused cells were likely attacking the tumor cells as well. When the whole group was assessed 1 year after treatment, the patients who had experienced a graft-versus-host reaction after cell infusion were found to have survived longer, likely a result of successful immune control of the cancer cells by the infused Treg-depleted lymphocytes. This preliminary study shows that depleting donor lymphocytes of inhibitory regulatory T cells can be a safe and effective way to free active T cells from inhibition so that they can fight cancer cells in the recipient. Further studies are needed, but this seemingly inappropriate encouragement of immune reactions in transplant recipients may prove a boon to patients with blood cancers. Donor T cells play a pivotal role in the graft-versus-tumor effect after allogeneic hematopoietic stem cell transplantation. Regulatory T cells (Tregs) may reduce alloreactivity, the major component of the graft-versus-tumor effect. In the setting of donor lymphocyte infusion after hematopoietic stem cell transplantation, we postulated that Treg depletion could improve alloreactivity and likewise the graft-versus-tumor effect of donor T cells. The safety and efficacy of Treg-depleted donor lymphocyte infusion was studied in 17 adult patients with malignancy relapse after hematopoietic stem cell transplantation. All but one had previously failed to respond to at least one standard donor lymphocyte infusion, and none had experienced graft-versus-host disease. Two of the 17 patients developed graft-versus-host disease after their first Treg-depleted donor lymphocyte infusion and experienced a long-term remission of their malignancy. Four of the 15 patients who did not respond after a first Treg-depleted donor lymphocyte infusion received a second Treg-depleted donor lymphocyte infusion combined with lymphodepleting chemotherapy aimed to also eliminate recipient Tregs. All four developed acute-like graft-versus-host disease that was associated with a partial or complete and durable remission. In the whole cohort, graft-versus-host disease induction through Treg depletion was associated with improved survival. These results suggest that Treg-depleted donor lymphocyte infusion is a safe, feasible approach that induces graft-versus-host or graft-versus-tumor effects in alloreactivity-resistant patients. In patients not responding to this approach, the combination of chemotherapy-induced lymphodepletion of the recipient synergizes with the effect of Treg-depleted donor lymphocyte infusion. These findings offer a rational therapeutic approach for cancer cellular immunotherapy.

High frequency of RUNX1 biallelic alteration in acute myeloid leukemia secondary to familial platelet disorder.

Familial platelet disorder (FPD), a rare autosomal dominant disorder characterized by quantitative and qualitative platelet abnormalities, is considered as a model of genetic predisposition to acute myeloid leukemia (AML). So far, monoallelic RUNX1 germline mutations have been found in 19 of 20 families with reported FPD, and the analysis of blast cells from only 5 patients at acute leukemia (AL) stage has shown no additional RUNX1 abnormality. Here, we performed RUNX1 analysis at constitutional and somatic levels in 8 persons with FPD who developed AL from 4 independent families. In addition to the germline RUNX1 mutation, we identified a second RUNX1 alteration in 6 AML cases (acquired point mutations in 4 cases and duplication of the altered RUNX1 allele associated with acquired trisomy 21 in 2 other cases). Although haploinsufficiency of RUNX1 causes FPD, our findings suggest that a second genetic event involving RUNX1 is often associated with progression to AML.

Should Immunoglobulin therapy be used in allogeneic stem-cell transplantation? A randomized, double-blind, dose effect, placebo-controlled, multicenter trial

Context No placebo-controlled trials have evaluated potential benefits of immunoglobulin in patients undergoing hematopoietic stem-cell transplantation. Contribution This multicenter randomized, double-blind trial involved 200 recipients of HLA-matched sibling transplants. At 6 months, the benefit of prophylactic immunoglobulin (given weekly from day 7 to day 100) compared with placebo was not significant for the following outcomes: number of infections, interstitial pneumonia, graft-versus-host disease, and transplantation-related mortality. Implications Prophylactic immunoglobulin is not indicated for patients undergoing allogeneic hematopoietic stem-cell transplantation from HLA-identical siblings. The Editors Despite controversy about the benefit of immunoglobulin in stem-cell transplantation, this agent has been given as part of most transplantation protocols for more than 20 years. Several large controlled series showed that immunoglobulin prevented infection (1, 2), especially cytomegalovirus infection (3), interstitial pneumonia (3, 4), and graft-versus-host disease (2, 3, 5); patients older than 20 years of age experienced the most benefit (1, 6). However, because of different products (hyperimmune or polyvalent immunoglobulins), schedules, dosing regimens, and patient samples, it has been difficult to definitively conclude that immunoglobulin is beneficial for transplant recipients. The varying conclusions of two large meta-analyses (6, 7) have encouraged new trials to better define the optimal dose and duration of immunoglobulin therapy and its value. Immunoglobulin exposes patients to the potential transmission of new pathogens. It is very expensive in high doses and is not always well tolerated. Although immunoglobulin is still widely used, strong evidence supporting its use is lacking. None of the early trials, which led to the approval of immunoglobulin in most countries, were placebo controlled, and two recent trials comparing doses did not include a control group (8, 9). In addition, effective agents are now available to prevent and treat most of the infections that led to the original use of prophylactic immunoglobulin. To re-evaluate the benefit of immunoglobulin in allogeneic stem-cell transplantation using current protocols, we conducted a randomized, double-blind, dose effect, placebo-controlled study limited to recipients of transplants from an HLA-identical sibling. To our knowledge, this is the first placebo-controlled study evaluating immunoglobulin in this population. We assessed the value of immunoglobulin, given from day 7 to day 100, in the prophylaxis of transplantation-related complications. Methods Study Design We designed the study as a multi-institutional trial involving 19 centers of the Socit Franaise de Greffe de Molle in France (Figure 1). Patients were recruited at a visit 14 to 28 days before transplantation. They were randomly assigned to receive 16 weekly doses, from day 7 to day 100, of placebo (group 1) or polyvalent immunoglobulin at 50 mg/kg of body weight (group 2), 250 mg/kg (group 3), or 500 mg/kg (group 4); the proportion of patients in each group was equal. Day 0 was the day of transplantation. Randomization was centralized; stratified by center, age, and disease status; and performed 14 to 28 days before transplantation. The ethical committee of Hpital Piti-Salptrire, Paris, approved the protocol, and all patients gave informed consent. Data were collected prospectively and verified on site with the original charts. Figure 1. Flow diagram of the trial. Randomization We used a randomization procedure with random permuted blocks to ensure the same number of patients at certain equally spaced points in the sequence of patient assignments in each center. The physicians responsible for recruitment in each center did not know the block size. Each sequence was computer generated. Eligibility Criteria We used the following inclusion criteria: age older than 2 years, first-time recipient of an allogeneic stem-cell transplant from an HLA-identical sibling, and no plans for T-cell depletion. Exclusion criteria were as follows: a syngeneic, unrelated, or haplo-mismatched donor; nonmyeloablative conditioning; previous autologous transplants conditioned with total-body irradiation or busulfan and cyclophosphamide; active infection; presence of hypogammaglobulinemia (<4 g/L) at time of randomization; or presence of HIV. Immunoglobulin and Placebo Administration Immunoglobulin was provided from unselected, commercially available lots [Sandoglobulin, Novartis Pharma, Rueil-Malmaison]. The placebo was a 5% dextrose solution. We maintained blinding during the study by using two procedures: 1) The immunoglobulin was prepared by the pharmacist and delivered to the clinical unit in bottles with special plastic covers [a small vertical slit allowed the nurse to watch the level of infusion without seeing the bubbles of the immunoglobulin infusion] and 2) the final volume and flow rate of each infusion were adapted, according to manufacturer recommendations, to the highest immunoglobulin dose (500 mg/kg). The recommended flow rate was 0.5 mL/kg per hour during the initial 30 minutes of administration, and then, if tolerated, 4 mL/kg per hour. End Points The principal end point was the cumulative incidence of infection during the 6 months after transplantation. Secondary end points were time to first infection, occurrence and severity of acute or chronic graft-versus-host disease, occurrence and grade of veno-occlusive disease, interstitial pneumonia, treatment-related mortality at 6 months, overall survival at 2 years, and side effects. Concomitant Treatment, Anti-Infectious Prophylaxis, and Supportive Care All patients received prophylaxis against graft-versus-host disease with methotrexate (15 mg/m2 on day 1 and 10 mg/m2 on days 3 and 6) and cyclosporine (2 mg/kg per day from the day before transplantation) to at least day 100. No patient received prophylactic steroids. All patients were housed in high-efficiency particulate air-filtered or laminar airflow rooms. Intestinal decontamination, according to French practices, was performed with nonabsorbable antibiotics (mostly oral colimycin and gentamicin) and antifungal drugs (oral polyenes) during the neutropenic phase. Prophylactic acyclovir was allowed if all patients included in a given center received the same prophylactic strategy. All patients received leukodepleted and irradiated blood products and Pneumocystis carinii prophylaxis until at least day 100. Patients did not receive prophylactic growth factors or anticytomegalovirus drugs. All patients, except those who were seronegative for cytomegalovirus with seronegative donors, were screened weekly for cytomegalovirus (using pp65 antigenemia detection or polymerase chain reaction) until day 100. Preemptive treatment with ganciclovir or foscarnet for at least 14 days was begun on the basis of one positive test result for pp65 antigenemia or two consecutive positive polymerase chain reaction results within 7 days. Definitions Acute graft-versus-host disease was diagnosed and graded (from 0 to IV), according to standard criteria, on the presence and severity of skin, liver, and intestinal tract injury (10). Chronic graft-versus-host disease was graded as absent, limited, or extensive according to the criteria of Shulman and colleagues (11). Veno-occlusive disease was diagnosed by different criteria depending on whether it occurred before or after day 20; the criteria were those of Shulman and colleagues (12). Criteria for veno-occlusive disease occurring before day 20 were the presence of at least two of the three following manifestations: serum bilirubin level of 34.2 mol/L or greater ( 2.0 mg/dL), painful hepatomegaly, or abrupt weight gain of 5% or more above baseline body weight. Criteria for veno-occlusive disease occurring after day 20 were based on histologic evidence obtained at liver biopsy. The severity of veno-occlusive disease was also graded: grade 1, spontaneous resolution of liver symptoms; grade 2 (moderate), resolution of symptoms with specific treatments; or grade 3 (severe), no resolution before day 100 or death, whichever occurred first (12). Cytomegalovirus infection and disease were defined according to the criteria of the Multidisciplinary International Workshop (13). Bacteremia was defined by fever associated with at least one positive blood culture, except for coagulase-negative staphylococci, for which two positive blood cultures from two different sites were required. The diagnosis of bacterial pneumonia required 103 or more colony-forming units/mL in a protected bronchial sample or 104 or more colony-forming units/mL in bronchoalveolar lavage fluid. A definitive diagnosis of Aspergillus pneumonia was made if Aspergillus species were isolated from bronchoalveolar lavage fluid or from a lung biopsy specimen; the diagnosis was considered probable if an air-crescent sign or characteristic fungus ball was present or results of a serum galactomannane test were positive. Interstitial pneumonia was defined by the presence of nonbacterial, nonfungal pneumonitis and hypoxemia of 75 mm Hg or less while breathing room air. If no cause of infection was identified on at least one bronchoalveolar lavage or lung biopsy (which included stains for P. carinii and viral tests), the diagnosis was idiopathic pneumonia. The severity of infection was graded as follows: Grade 1 infections were all episodes treated at home or all episodes of fever of unknown origin in neutropenic patients receiving broad-spectrum antibiotics; grade 3 infections had an expected death rate greater than 60% (based on data in the literature) and included infections associated with Aspergillus, fungemia, and cytomegalovirus disease and any type of pneumonia with a Pao 2 less than 65 mm Hg; and grade 2 infections were all others (usually requiring treatment in a hematology ward). One author, who

Allogeneic bone marrow transplantation in aggressive non-Hodgkin's lymphoma (excluding Burkitt and lymphoblastic lymphoma): a series of 73 patients from the SFGM database

The place of allogeneic bone marrow transplantation (BMT) in the treatment of aggressive non‐Hodgkins lymphoma (NHL) remains controversial. We conducted a retrospective study of French experience in allografting NHL between 1984 and 1994. To improve the homogeneity of the study population, cases of low‐grade, Burkitt and lymphoblastic NHL were excluded. 73 patients were included in the analysis. Median age at transplantation was 35 years (range 9–61 years); 64 patients were in stage IV and 45 had bone marrow involvement at diagnosis. At the time of transplantation, 46 patients had sensitive disease (25 in complete remission; CR).

Romiplostim safety and efficacy for immune thrombocytopenia in clinical practice: 2-year results of 72 adults in a romiplostim compassionate-use program

Romiplostim, a thrombopoietic agent with demonstrated efficacy against immune thrombocytopenia (ITP) in prospective controlled studies, was recently licensed for adults with chronic ITP. Only France has allowed romiplostim compassionate use since January 2008. ITP patients could receive romiplostim when they failed to respond to successive corticosteroids, intravenous immunoglobulins, rituximab, and splenectomy, or when splenectomy was not indicated. We included the first 80 patients enrolled in this program with at least 2 years of follow-up. Primary platelet response (platelet count ≥ 50 × 10(9)/L and double baseline) was observed in 74% of all patients. Long-term responses (2 years) were observed in 47 (65%) patients, 37 (79%) had sustained platelet responses with a median platelet count of 106 × 10(9)/L (interquartile range, 75-167 × 10(9)/L), and 10 (21%) were still taking romiplostim, despite a median platelet count of 38 × 10(9)/L (interquartile range, 35-44 × 10(9)/L), but with clinical benefit (lower dose and/or fewer concomitant treatment(s) and/or diminished bleeding signs). A high bleeding score and use of concomitant ITP therapy were baseline factors predicting romiplostim failure. The most frequently reported adverse events were: arthralgias (26%), fatigue (13%), and nausea (7%). Our results confirmed that romiplostim use in clinical practice is effective and safe for severe chronic ITP. This trial was registered at www.clinicaltrials.gov as #NCT01013181.

Successsful Voriconazole Treatment of Disseminated Fusarium Infection in an Immunocompromised Patient

Fusarium infection is known to cause major morbidity and mortality in immunocompromised hosts. We report the successful treatment of disseminated Fusarium infection with skin manifestations in a severely neutropenic, immunocompromised host with voriconazole, a new second-generation triazole. Voriconazole might be an alternative therapy for patients with neutropenia who have fusariosis that is refractory or unresponsive to amphotericin B or its liposomal formulation.