Summary:Pulmonary complications develop in 30-60% of hematopoietic stem cell transplants (HSCT). The main, late onset, non-infectious complications include Bronchiolitis obliterans (BO), Bronchiolitis obliterans organizing pneumonia (BOOP), and idiopathic pneumonia syndrome (IPS). BO and BOOP occur almost exclusively in allogeneic HSCT, and have 61% and 21% mortality rates, respectively. BOOP responds favorably to corticosteroids. IPS has less than 15% 1-year survival. Bone Marrow Transplantation (2001) 28, 425-434. Keywords: pulmonary complications; Bronchiolitis obliterans; Bronchiolitis obliterans organizing pneumonia; interstitial pneumonia; hematopoietic stem cell transplantation Despite the success in treating otherwise fatal diseases, HSCT is associated with multiple complications. Pulmonary complications develop in 30-60% of HSCT recipients. 1,2 Factors that influence the development of pulmonary complications in HSCT include previous infections, pre-transplant conditioning regimen, current or prior immunosuppressant and radiation treatment, type of stem cell transplant (autologous vs allogeneic), use of prophylactic antibiotics, and time elapsed since transplant. With the use of prophylactic antibiotics, the spectrum of pulmonary complications following HSCT has changed increasingly from infectious to non-infectious etiologies. The times of onset and distinguishing features of the main non-infectious pulmonary complications are shown in Figure 1 and Table 1. This review will focus on the late-onset, non-infectious pulmonary complications in HSCT recipients. An algorithmic approach is outlined in Figure 2. Since most of the treatable pulmonary complications in HSCT recipients are diagnosed non-invasively and by bronchoscopy, we rarely subject our patients to surgical lung biopsy. However, in patients with suspected BOOP and when bronchoscopy is contraindicated or non-diagnostic, we occasionally resort to video-assisted thoracoscopic surgical lung biopsy. Abnormal lung functionRestrictive and obstructive ventilatory defects, and gas transfer abnormalities occur frequently in HSCT recipients. 3,4 In a study of 52 young, asymptomatic HSCT recipients, 38% had abnormalities in pulmonary function tests (PFT): 23% restrictive defect with or without impaired gas transfer and 15% isolated impaired gas transfer. 3 An abnormal pulmonary function test is a risk factor for pulmonary complications. 5-9 However, the role of PFT in identifying HSCT recipients at risk for pulmonary complications needs further investigation. The PFT findings in BO, BOOP, and delayed pulmonary toxicity syndrome are listed in Table 2. Bronchiolitis obliterans (BO)GVHD is a frequent complication of allogeneic HSCT. 10 The pulmonary morphological manifestations of GVHD include diffuse alveolar damage, lymphocytic bronchitis/ bronchiolitis with interstitial pneumonitis, BOOP, and BO. 11 BO is a nonspecific inflammatory injury affecting
Summary:This study investigated the response rate and toxicity of blood cell transplantation as treatment for primary amyloidosis (AL). Twenty-three patients had stem cells collected between November 1995 and September 1998. Conditioning included melphalan and total body irradiation in 16 and melphalan alone in 4. Three patients did not undergo stem cell infusion because of poor performance status. Two died of progressive amyloid at 1 and 3 months. One patient is alive on hemodialysis. Fourteen males and six females (median age, 57 years) underwent transplantation. Renal, cardiac (by echocardiography), peripheral neuropathy or liver amyloidosis occurred in 14, 12, 3, and 1, respectively. Echocardiography demonstrated an interventricular septal thickness у15 mm in six patients, five of whom died post transplantation. Three patients died of progressive amyloidosis at 7, 7, and 21 months. Thirteen patients are alive with a follow-up of 3 to 26 months. Twelve (60%) fulfilled the criteria of a hematologic or organ response. Severe gastrointestinal tract toxicity was seen in five (25%). We conclude that blood cell transplantation for amyloidosis had a much higher morbidity and mortality compared with transplantation for myeloma. The best results appear to occur in patients with nephrotic syndrome as the only manifestation of their disease. Bone Marrow Transplantation (2000) 26, 963-969.
Summary:Early absolute lymphocyte count (ALC) recovery at day 15 post-autologous stem cell transplantation (ASCT) is a powerful prognostic indicator for survival in multiple myeloma and non-Hodgkin's lymphoma. The relationship of ALC with clinical outcomes in metastatic breast cancer is unknown. We evaluated all 29 patients with metastatic breast cancer who underwent ASCT at the Mayo Clinic, Rochester, Minnesota, from 1994 to 1999. The ALC threshold was set at 500 cells/l on day 15 post-ASCT based on previous experience with hematologic malignancies. All patients were followed for a minimum of 2 years or until death, with a median follow-up for living patients of 2.25 years. Of the 29 patients, 17 have died with disease progression, two are alive and have progressed, and 10 are alive without progression. The median overall and progression-free survival times were significantly better for the 20 patients with ALC у500 cells/l compared with the nine patients with ALC Ͻ500 cells/l (not reached vs 14 months, P Ͻ 0.0001; 24 vs 7 months, P Ͻ 0.0015, respectively). In conclusion, ALC у500 cells/l on day 15 post-ASCT was associated with significantly better survival in patients with metastatic breast cancer, suggesting the importance of early immune recovery post-ASCT in these patients. Bone Marrow Transplantation (2001) 28, 865-871. Keywords: absolute lymphocyte count recovery; autologous stem cell transplantation; metastatic breast cancer Randomized studies between high-dose therapy (HDT) and conventional chemotherapy for metastatic breast cancer have shown no difference in survival. 1 The largest of the four metastatic breast cancer trials, the Philadelphia Intergroup study (PBT1), 2 entered a total of 535 patients. With a median follow-up of 37 months, there was no significant difference in the overall survival (OS) at 3 years (32% in the transplant group and 38% in the conventionalchemotherapy group, P = 0.23). There was also no significant difference in the median time to diverse progression (9.6 months for the transplant group and 9 months for conventional-dose chemotherapy, P = 0.31).High relapse rates post-ASCT have been attributed to the inability of HDT to eradicate minimal residual disease. Lower relapse rates observed after allogeneic bone marrow transplantation (ABMT) in malignant hematological conditions have been attributed to the adoptive graft-versustumor (GVT) immune response.3 Studies in ABMT have demonstrated that early absolute lymphocyte count (ALC) recovery post-ABMT is associated with prolonged survival. Using an ALC cut-off value of 200 cells/l at day 29 post-ABMT in 188 acute myelogenous leukemia (AML) patients, Powles et al 4 demonstrated a 3-year relapse probability of 42% for ALC Ͻ200 cells/l vs 16% for ALC 200 cells/l (P Ͻ 0.004). Pavletic et al 5 analyzed ALC in 41 patients post-ABMT (AML, chronic myelogenous leukemia, myelodysplastic syndrome, Hodgkin's disease, chronic lymphocytic leukemia). The OS at 1 year with an ALC at day 17 post-ABMT of у500 cells/l was 79% vs 19% for ALC Ͻ500 cel...
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