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 3AE5-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 2AE03/1000 and 8AE63/1000 transplantations respectively (P ¼ 0AE001). A higher incidence of late IPI was observed after BMT than after PBSCT (10AE99 versus 3AE23/1000; P < 0AE01) and after allogeneic versus autologous SCT (12AE20 versus 4AE60/1000; P < 0AE01). There was a higher estimated incidence of IPI in allogeneic patients with than in those without graft-versus-host disease (GVHD) (18AE85 versus 8AE25/1000; P ¼ 0AE015). 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 posttransplantation, requires preventive approaches, mainly effective immunization.

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A systematic review of radiation therapy trials in several tumour types was carried out by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for evaluation of the scientific literature are described separately (Acta Oncol 2003; 42: 357-365). This synthesis of the literature on radiation therapy for Hodgkin's lymphoma (HL) is based on data from 12 randomized trials and 2 meta-analyses. Data from 3 prospective studies, 29 retrospective studies and 58 other articles were also used. In total, 58 scientific articles are included, involving 27,280 patients. The results were compared with those of a similar overview from 1996 including 38,362 patients. The conclusions reached can be summarized thus: Solid scientific documentation shows that in patients with HL more than 80% in the early stages and 60-70% of younger patients in advanced stages of disease are now cured by the development of radiotherapy and combination chemotherapy. Long-term follow-up shows that after 15 to 20 years the mortality from HL in early and intermediate stages is exceeded by other causes of death, mostly secondary malignancies and cardiac deaths, especially myocardial infarction. Convincing data show that radiotherapy plays a major role in the development of solid cancers and cardiovascular disease, but no randomized trials have been performed. During the past decade increasing awareness of fatal long-term sequelae has fundamentally changed treatment strategies in early and intermediate stages. A thorough long-term follow-up is essential to evaluate the effects of the modifications of the therapy. In early stages of disease extended field irradiation is now replaced by short periods of chemotherapy followed by limited radiotherapy to decrease late sequelae. This approach is strongly supported by early reports from randomized trials. Final results cannot be fully evaluated for many years. The optimal radiation dose and volume after chemotherapy are not defined or if irradiation is needed at all. Several studies are under way. In intermediate stages two recently reported randomized trials indicate that combined modality therapy is preferable and that involved field could replace extended field irradiation. It is still too early to draw any firm conclusions. In advanced stages, there is no evidence of any survival benefit from additional radiotherapy. The role of radiotherapy in the case of residual tumour and bulky disease still remains controversial. There is no scientific support for improved survival with radiotherapy in conjunction with high-dose chemotherapy with stem-cell support. Radiotherapy as salvage treatment might be an alternative in late limited nodal recurrence after initial chemotherapy. However, the body of knowledge is small. The role of radiotherapy in the treatment of HL is decreasing.

Twenty-five patients (21-45 years old) treated for Hodgkin's disease with mantle radiotherapy but no chemotherapy underwent cardiac testing with myocardial scintigraphy during exercise, Echo-Doppler cardiography and CT-examination, 10-20 years after treatment. Four of twenty-six (15%) young patients had serious cardiac complications after mantle therapy, and reduced systolic and/or diastolic function; and minor valvular disturbances were often found. One 36-year-old female died of myocardial infarction 4 years after therapy, one 39-year-old male had two non-lethal infarctions after 14 years, one 36-year-old male with no symptoms had severe reversible ischemia and three proximal coronary artery stenoses, and one 32-year-old female with constrictive pericarditis had pericardeictomy 14 years after therapy. In 23/24 patients the pericardial thickness was normal and no pericardial effusion was found. 23/24 patients had normal working capacity, but myocardial scintigraphy was normal in only 9 patients. 11/25 patients had reduced systolic function and in 12/24 patients the diastolic function was reduced. 11/25 patients had abnormal valvular or subvalvular structures. Valvular stenosis was not found but aortic, mitral and tricuspidal regurgitations were found in 1/25, 9/25 and 22/25, respectively. In all but two cases the regurgitations were mild. We conclude that mediastinal irradiation must be considered a risk factor for cardiac disease. It may be advisable to reduce other risk factors in these patients.

Background. Splenectomy is accompanied by a lifelong risk of overwhelming postsplenectomy infection (OPSI), mainly caused by polysaccharide (PS) encapsulated bacteria such as Streptococcus pneumoniae. Despite extensive prophylactic efforts the mortality and morbidity rates remain high. The present study was based on a strategy with a predefined vaccination algorithm including repeated 23-valent pneumococcal vaccinations and monitoring of pneumococcal antibody levels. The antibody levels of splenectomized Hodgkin's lymphoma (HL) patients were compared with those patients splenectomized due to immune-mediated cytopenias [autoimmune haemolytic anaemia (AIHA) and immune thrombocytopenic purpura (ITP)] and also individuals who were splenectomized because of trauma (TRAUMA).