On the basis of the data suggesting that adolescents and young adult patients with acute lymphoblastic leukemia (ALL) have improved outcomes when treated on pediatric protocols, we assessed the feasibility of treating adult patients aged 18–50 years with ALL with the DFCI Pediatric ALL Consortium regimen utilizing a 30-week course of pharmacokinetically dose-adjusted E. coli L-asparaginase during consolidation. Between 2002 and 2008, 92 eligible patients aged 18–50 years were enrolled at 13 participating centers. Seventy-eight patients (85%) achieved a complete remission (CR) after 1 month of intensive induction therapy. With a median follow-up of 4.5 years, the 4-year disease-free survival (DFS) for the patients achieving a CR was 69% (95% confidence interval (CI) 56–78%) and the 4-year overall survival (OS) for all eligible patients was 67% (95% CI 56–76%). The 4-year DFS for the 64 patients who achieved a CR and were Philadelphia chromosome negative (Ph−) was 71% (95% CI 58–81%), and for all 74 Ph− patients the 4-year OS was 70% (95% CI 58–79%). We conclude that a pediatric-like treatment strategy for young adults with de novo ALL is feasible, associated with tolerable toxicity, and results in improved outcomes compared with historical regimens in young adult patients with ALL.

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Specialized health services, such as blood and marrow transplantation (BMT), are usually based in large urban centers. Previous research has suggested that rural patients undergoing BMT have a higher risk of death. We performed a cohort study using data from both the Manitoba BMT Program and the provincial Cancer Registry to determine whether patients from the rural areas would have inferior survival after BMT and whether rural patients have reduced access to BMT. A total of 463 adult Manitobans, who underwent BMT between January 1990 and December 2006, were assessed. We analyzed area of residence (rural vs urban), disease and BMT characteristics, and calculated the OS. Patients undergoing autologous and allogeneic transplants were analyzed separately. When adjusted for gender, age at BMT and year of BMT, area of residence was not a significant predictor of mortality. A relative survival analysis was also conducted, and area of residence was again not a significant predictor of mortality. To measure access to BMT in urban vs rural patients, we evaluated all patients with newly diagnosed Hodgkin's Lymphoma (HL) during this same period. Of 432 Manitobans diagnosed with HL, 182 (42%) were rural and 250 (58%) were urban. In contrast, 69% of patients undergoing transplant for HL were urban. In conclusion, using population-based data from a Canadian province, we were unable to show a survival disadvantage for rural patients after controlling for other variables. BMT utilization in rural populations deserves further study.

Central nervous system (CNS) myeloma is a rare phenomenon, especially so after high-dose therapy (HDT) and stem cell transplantation. We describe a case of isolated CNS relapse of myeloma post autologous transplantation that followed a prolonged progression-free interval. Issues regarding the pathophysiology and management of this unusual complication are discussed.

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Patient 1 is a 67-year-old woman with unexplained normocytic anaemia on routine blood tests. Her white blood cell (WBC) count is 9 × 10 9 /L (normal range 4.5-11 × 10 9 /L; normal WBC count differential), Hb 10 g/dL (normal range 14-18 g/dL), mean corpuscular volume 90 fl (normo cytic) and platelet count 560 × 10 9 /L (normal range 150-450 × 10 9 /L). Electrolytes, renal and liver function are within normal limits. C-reactive protein is elevated (30 mg/L; normal <5 mg/L), total protein 96 g/L (normal range 60-80 g/L) and quantitative immuno globulins demonstrate an IgG of 24 g/L (normal range 6.9-16.2 g/L), with normal IgM and IgA levels. This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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