William Yk Hwang

Risk of hepatitis B reactivation and the role of novel agents and stem-cell transplantation in multiple myeloma patients with hepatitis B virus (HBV) infection

BACKGROUND The purpose of the study is to analyse the prevalence of hepatitis B virus (HBV) infection and its incidence of reactivation among multiple myeloma (MM) patients treated in the era of novel therapy in an endemic Asian setting. PATIENTS AND METHODS From 2000 to 2008, 273 patients with newly diagnosed MM were screened for the presence of hepatitis B virus surface antigen and HBV core antibody. HBV-infected patients were prospectively followed for reactivation with serial monitoring of serum alanine transferase and HBV DNA load. The patterns of HBV reactivation in relation to treatment received, exposure to high-dose therapy with autologous stem-cell transplantation (HDT/ASCT) and novel agents were studied. RESULTS The prevalence of HBV infection was 5.5%. Three cases of HBV reactivation despite lamivudine prophylaxis were reported. Two patients reactivated 3-5 months after HDT/ASCT while receiving thalidomide maintenance and one reactivated 3 years after HDT/ASCT and shortly after bortezomib salvage therapy. Emergence of a mutant HBV strain was documented in one patient. CONCLUSIONS Use of prophylaxis may reduce but will not preclude HBV reactivation. Highest risk occurs during immune reconstitution phase of HDT/ASCT. The role of immunomodulatory agents in HBV reactivation needs to be further elucidated. Separate HBV prophylaxis and surveillance guidelines ought to be developed for patients with MM.

Improving The Efficacy And Availability Of Stem Cell Transplant Therapies For Hematopoietic Stem Cell Transplantation

Over a million hematopoietic stem cell transplants (HSCTs) have been performed around the world for treatment of a range of cancers and hematological indications. A significant increase in transplants and transplant centers has been seen in many parts of the world, with the highest relative increase of transplant centers occurring in the Asia Pacific region, specifically in countries like China, India, Singapore and Thailand. The Bone Marrow Donors Worldwide (BMDW) register has grown to include over 20 million donors by 2013 with consequent greater ease in finding an unrelated donor for transplant. The availability of donors have been further enhanced through the use of alternate stem cell sources like cord blood and haploidentical donors. To protect donors while serving the needs of patients who are urgently seeking histocompatible donors in around the world, the World Marrow Donor Association (WMDA) has helped in establishing standards, accreditation, safety measures, shared processes and global monitoring systems for stem cell registries. Recent developments in pre-transplant preparative regimens as well as post-transplant care have made incremental but definite improvements in post-transplant survival. Graft engineering has also helped to facilitate the removal of cells which cause graft-versus-host disease (GVHD), the eradication of cells which might cause relapse, the expansion of donor cells when there is an inadequate cell dose, and the addition of selected cells to improve graft function with augmented anti-tumor or anti-infective properties. These advances help enhance the safety, efficacy and availability of HSCT, ensuring that this modality of treatment remains an important part of the continuum of care of patients of potentially fatal cancers and blood diseases.