ATRA plus arsenic trioxide is at least not inferior and may be superior to ATRA plus chemotherapy in the treatment of patients with low-to-intermediate-risk APL. (Funded by Associazione Italiana contro le Leucemie and others; ClinicalTrials.gov number, NCT00482833.).

Autologous HSCT suggest positive early results in the management of progressive MS and is feasible. These multicentre data suggest an association with significant mortality risks especially in some patient groups and are being utilised in the planning of future trials to reduce transplant related mortality.

Sixty thalassemia patients (median age, 7 years; range, 1-37) underwent allogeneic hematopoietic stem cell transplantation (HSCT) after a preparation combining thiotepa, treosulfan, and fludarabine. Before HSCT, 27 children were assigned to risk class 1 of the Pesaro classification, 17 to class 2, and 4 to class 3; 12 patients were adults. Twenty patients were transplanted from an HLA-identical sibling and 40 from an unrelated donor. The cumulative incidence of graft failure and transplantation-related mortality was 9% and 7%, respectively. Eight patients experienced grade II-IV acute GVHD, the cumulative incidence being 14%. Among 56 patients at risk, 1 developed limited chronic GVHD. With a median follow-up of 36 months (range, 4-72), the 5-year probability of survival and thalassemiafree survival are 93% and 84%, respectively. Neither the class of risk nor the donor used influenced outcome. This treosulfan-based preparation proved to be safe and effective for thalassemia patients given allogeneic HSCT. (Blood. 2012;120(2):473-476) IntroductionAllogeneic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment able to render patients with thalassemia major (TM) transfusion independent. 1-5 However, the clinical outcome after HSCT in children with TM who belong to class 3 of the Pesaro classification and in adults with poor performance status and/or organ dysfunction is still unsatisfactory because of the high risk of life-threatening complications or graft failure. [1][2][3][4][5] Treosulfan-based conditioning regimens have been shown initially to be safe and effective in adults with hematologic malignancies not eligible for conventional preparations. 6-9 These results have been confirmed recently in pediatric patients with high-risk hematologic malignancies receiving a treosulfan-based preparative regimen before second or third HSCT. 10 Moreover, a treosulfanbased conditioning regimen proved to be valuable in children with primary immunodeficiencies. 11 We reported recently preliminary, encouraging results on the use of a thiotepa/treosulfan/fludarabine myeloablative regimen in a cohort of 20 patients with TM. In particular, we found a high probability of cure of the disease in the absence of major transplantation-related complications in adults and in patients with poor performance status. 12 In the present study, we report the final results on the safety and efficacy of this regimen in a large cohort of TM patients. Details on patient, donor, and transplantation characteristics are reported in Table 1. Before transplantation, pediatric patients were assigned to 1 of the 3 classes of risk using the Pesaro classification. 1 Among 48 children, 27 were assigned to class 1, 17 to class 2, and 4 to class 3; the remaining 12 patients were adults. Twenty patients were transplanted from an HLA-identical sibling (matched family donor [MFD]) and the remaining 40 from an unrelated donor (UD). In the MFD cohort, the donor was always an HLA-identical sibling, and 11 patients received...

Bone marrow transplantation (BMT) remains the only potentially curative treatment for patients with thalassemia major. However, most candidates for BMT do not have a suitable family donor. In order to evaluate whether BMT from an HLA-matched unrelated volunteer donor can offer a probability of cure comparable to that obtained when the donor is a compatible sibling, we carried out a study involving 68 thalassemia patients transplanted in six Italian BMT Centers. Thirty-three males and 35 females (age range, 2-37 years; median age, 15) were transplanted from unrelated volunteer donors, all selected using high-resolution molecular typing of both HLA class I and II loci. Fourteen patients were classified in risk class 1; 16 in risk class 2; and 38 in risk class III of the Pesaro classification system. Nine patients (13%) had either primary or secondary graft failure. Fourteen patients (20%) died from transplant-related causes. Grade II-IV acute graft-versus-host disease (GVHD) developed in 24 cases (40%), and chronic GVHD in 10 cases (18%). Overall survival (OS) in the cohort of 68 patients was 79.3% (CI 67-88%), whereas the Kaplan-Meier estimates of disease-free survival (DFS) with transfusion independence was 65.8% (CI 54-77%). In the group of 30 thalassemic patients in risk classes 1 and 2, the probability of OS and DFS were 96.7% (CI 90-100%) and 80.0% (CI 65-94%), respectively, whereas in the 38 patients in class 3 OS was 65.2% (CI 49-80%) and DFS was 54.5% (CI 38-70%). These data show that when donor selection is based on stringent compatibility criteria, the results of unrelated transplantation in thalassemia patients are comparable to those obtained when the donor is a compatible sibling.

Allogeneic bone marrow transplantation (BMT) from a genotypically identical family donor is an accepted therapeutic option for homozygous beta-thalassemia. However, only a minority of patients have access to this curative procedure. The aim of this study is to explore the feasibility of matched unrelated transplants in thalassemia and the possibility of reducing the risk of immunologic complications through careful selection of donor/ recipient pairs. Since November 1992, 32 patients (age range, 2-28 years) have been enrolled. There were 4 patients assigned to risk-class I, 11 to risk-class II, and 17 to risk-class III of the Pesaro classification. Extended haplotype analysis and family segregation studies were employed for identification of suitable donors. Of the 32 donor/recipient pairs, 24 were identical for HLA-A, B, C, DRB1, DRB3, DRB4, DRB5, DQA1, and DQB1 loci; 7 pairs were identical for 2 extended haplotypes, and 15 pairs shared one extended haplotype. Grade II-IV acute graft-versus-host disease (GVHD) developed in 11 cases (41%) and chronic GVHD in 6 (25%) out of 24 patients at risk. There are 22 patients (69%) who are alive and transfusionindependent after a median follow-up of 30 months (range, 7-109 months). There were 6 patients (19%) who engrafted and subsequently died from transplant-related complications. In 4 cases (12.5%) graft rejection was observed within 30 days and it was followed by autologous IntroductionAllogeneic bone marrow transplantation (BMT) from a genotypically identical family donor has radically changed the prognosis of patients with homozygous beta-thalassemia. For young patients at an early stage of disease, the reported percentage of thalassemiafree survival and the mortality risk were 91% and 8%, respectively. 1,2 Transplantation performed on older, heavily iron-loaded patients, in particular those with liver abnormalities, has a lesssatisfactory outcome, the probability of thalassemia-free survival and mortality being 51% and 32%, respectively. 3 The probability of finding an HLA-identical donor within the family is less than 30% in western countries. 4 For the remaining 70% of patients with thalassemia, there was until recently no option other than treatment based on chronic transfusion and ironchelating therapy. Although optimization of protocols for transfusion and chelation has dramatically improved the life expectancy of these patients, complications of iron overload cannot be completely avoided. 5,6 Full compliance with a chronic transfusion regimen and a daily, lifelong injective chelation therapy has been shown to be difficult to maintain with advancing age. 7 Multiple endocrine dysfunctions, myocardiopathy, progressive liver fibrosis, and consequences of posttransfusion viral infections affect the quality of life and increase the mortality risk with age. [7][8][9] During the past 10 years, BMT from unrelated donors has been increasingly employed for hematologic malignancies and lifethreatening inborn errors. [10][11][12] At first, results were characterized by el...

No abstract

The success of allogeneic hematopoietic stem cell transplantation (HSCT) from matched unrelated donors (UDs) for ␤-thalassemia may be hampered by the occurrence of graft rejection. Here, we show that the rate of this complication can be reduced by selecting 5-loci HLAmatched donors without nonpermissive mismatches at HLA-DPB1, defined according to an algorithm previously described and based on principles of central T-cell tolerance. Seventy-two consecutive patients and their UDs, prospectively selected for matching at the allelic level for HLA-A, -B, -C, -DRB, and -DQB1 loci, were enrolled in the analysis. These pairs were either DPB1 matched/permissively mismatched (n ‫؍‬ 45, control group) or had at least one nonpermissive DPB1 mismatch in the host-versus-graft (HvG; n ‫؍‬ 17) or in the graft-versus-host (GvH; n ‫؍‬ 10) direction. In multivariate analysis, the risk of rejection was significantly increased in the group with HvG disparity (RR ‫؍‬ 7.42; 95% CI ‫؍‬ 1.29-42.68; P ‫؍‬ .02) as compared to the control group. A lower, statistically significant, probability of thalassemia-free survival was found in patients belonging to the HvG group as compared to controls (RR ‫؍‬ 5.15; 95% CI ‫؍‬ 1.58-16.82; P ‫؍‬ .01). These data suggest that in patients with thalassemia, the incidence of graft failure after HSCT may be reduced by appropriate selection of UDs, with such selection taking into account the functional rules of immunogenetics.

BackgroundThalassemia is a common disorder worldwide with a predominant incidence in Mediterranean countries, North Africa, the Middle East, India, Central Asia, and Southeast Asia. Whilst substantial progress has been made towards the improvement of Health related quality of life (HRQoL) in western countries, scarce evidence-based data exists on HRQol of thalassemia children and adolescents living in developing countries.MethodsWe studied 60 thalassemia children from Middle Eastern countries with a median age of 10 years (range 5 to 17 years). HRQoL was assessed with the Pediatric Quality of Life Inventory (PedsQL) 4.0. The Questionnaire was completed at baseline by all patients and their parents. The agreement between child-self and parent-proxy HRQoL reports and the relationship between HRQoL profiles and socio-demographic and clinical factors were investigated.ResultsThe scores of parents were generally lower than those of their children for Emotional Functioning (mean 75 vs 85; p = 0.002), Psychosocial Health Summary (mean 70.3 vs 79.1; p = 0.015) and the Total Summary Score (mean 74.3 vs 77.7 p = 0.047). HRQoL was not associated with ferritin levels, hepatomegaly or frequency of transfusions or iron chelation therapy. Multivariate analysis showed that a delayed start of iron chelation had a negative impact on total PedsQL scores of both children (p = 0.046) and their parents (p = 0.007).ConclusionsThe PedsQL 4.0 is a useful tool for the measurement of HRQoL in pediatric thalassemia patients. This study shows that delayed start of iron chelation has a negative impact on children’s HRQoL.