Implementation of a standardized oral care protocol for mucositis management resulted in a decreased incidence, duration and severity of mucositis, and also reduced the global negative impact of mucositis. Future studies may further evaluate the global impact by adjusting for confounding factors.

As cord blood (CB) lacks memory T- and B-cells, and recent decreases in herd immunity to vaccine preventable diseases in many developed countries have been documented, vaccine responses in CB transplantation (CBT) survivors are of great interest. We analyzed vaccine responses in double-unit CBT recipients transplanted for hematologic malignancies. In 103 vaccine eligible patients, graft-versus-host disease (GVHD) most commonly precluded vaccination. Sixty-five (63%) patients (engrafting units median HLA-allele match 5/8, range 2–7/8) received protein-conjugated vaccines, and 63 (median age 34 years, range 0.9–64) were evaluated for responses. Median vaccination time was 17 months (range 7–45) post-CBT. GVHD (n = 42) and prior rituximab (n = 13) delayed vaccination. Responses to Prevnar 7 and/or 13 vaccines (serotypes 14, 19f, 23f) were seen in children and adults (60% versus 49%, p = 0.555). Responses to tetanus, diphtheria, pertussis, H. influenzae, and polio were observed in children (86–100%) and adults (53–89%) even if patients had prior GVHD or rituximab. CD4+CD45RA+ and CD19+ cell recovery significantly influenced tetanus and polio responses. In a smaller cohort, responses were seen to measles (65%), mumps (50%), and rubella (100%) vaccines. No vaccine side-effects were identified and all vaccinated patients survive (median follow-up 57 months). While GVHD and rituximab can delay vaccination, CBT recipients (including adults and those with prior GVHD) have similar vaccine response rates to adult donor allograft recipients supporting vaccination in CBT recipients.

Cytomegalovirus (CMV) is associated with significant morbidity and mortality in allogeneic hematopoietic cell transplantation (HCT) patients. We evaluated the efficacy of letermovir as primary and secondary prophylaxis in 53 CMV-seropositive hematopoietic stem cell transplant recipients. 70% of patients were at high risk for CMV reactivation and disease (primarily ex vivo T-cell-depleted HCT [n = 18; 34%] or haploidentical T-replete HCT [n = 12; 23%]). This was a retrospective, single-center Patients were followed through September 2018. The primary outcome was the incidence of clinically significant CMV infection (CMV viremia requiring preemptive treatment or CMV disease). Primary letermovir prophylaxis started at a median of 7 days (range, 7-40) after allo-HCT. The median duration of primary letermovir prophylaxis was 116 days (range, 12-221). With primary prophylaxis in 39 patients, the observed CMV reactivation rate was 5.1%. Twenty-nine patients continued primary prophylaxis beyond 14 weeks with a reactivation rate of 3.4%. No recurrent reactivation was seen with secondary prophylaxis of an additional 14 patients. Our experience demonstrates the efficacy of letermovir in a real-world setting for CMV prevention for the first 14 weeks and continued efficacy when given longer than 14 weeks after allogeneic stem cell transplantation or as secondary prophylaxis.

These results highlight the high incidence of C. difficile infection in a subset of cancer patients at our institution. Although most patients presented with mild-moderate disease, severity of C. difficile infection in cancer patients may be underestimated due to the frequent presence of neutropenia. This study is the first analysis conducted, which directly compares outcomes of C. difficile infection after therapy with metronidazole, vancomycin, or combination therapy exclusively in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. We found no difference in treatment outcomes among metronidazole, vancomycin, or combination therapy. The recommendation from the literature to use metronidazole as the initial drug of choice for mild-moderate C. difficile infection is a reasonable option, although the rate of cure is low. This study highlights the critical need for better treatment options, due to suboptimal response rates to current therapy. Larger scale studies are needed to better understand the epidemiology and management of C. difficile infection in this patient population.

High-dose therapy and autologous stem cell transplantation (HDT-ASCT) can offer potential long-term remission or cure in patients with non-Hodgkin lymphoma (NHL). Limited experience is available on the safety and efficacy of HDT-ASCT in elderly patients. This is a single-center, retrospective study examining outcomes of HDT-ASCT for 202 NHL patients age 60 years and older between January 2001 and December 2012. Overall survival (OS) and progression-free survival (PFS) were analyzed according to age at HDT-ASCT, hematopoietic cell transplantation comorbidity index (HCT-CI), NHL histology, and remission status at the time of HDT-ASCT. The median age was 65 years (range 60–74) and the majority had either diffuse large B-cell lymphoma (DLBCL, n=73, 37%) or mantle cell lymphoma (MCL, n=69, 34%). One hundred and fifteen patients (57%) had high HCT-CI scores at the time of HDT-ASCT. With a median follow-up of 3.6 years (range 0.4–11.9 years) for survivors, PFS and OS at 3 years were 60% (95% CI: 53–68%) and 73% (95% CI: 67–80%), respectively. Transplant-related mortality (TRM) was 4% both at 100 days and at 1 year post HDT-ASCT. Age and HCT-CI score were not associated with OS or PFS, and high HCT-CI did not correlate with TRM. Seven patients (4%) developed secondary myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) at a median of 35 months (range 6–48) post HDT-ASCT. In this single-center cohort of elderly patients with NHL undergoing HDT-ASCT, this intervention is proved tolerable and effective, with results similar to historic controls in younger patients. Our data suggest that age alone should not preclude HDT-ASCT in elderly patients.

High-dose therapy and autologous stem cell transplantation (HDT-ASCT) with thiotepa, busulfan, cyclophosphamide (TBC) conditioning has emerged as an effective post-induction treatment strategy for patients with primary (PCNSL) or secondary central nervous system lymphoma (SCNSL), but it is associated with considerable toxicity and transplant-related mortality (TRM) in the modern era. Forty-three adult patients with chemosensitive PCNSL or SCNSL received TBC conditioned ASCT between 2006 and 2015. Twenty-eight of these patients received pharmacokinetically (PK)-targeted busulfan dosing. The median number of clinically relevant individual grade ≥3 non-hematologic toxicities per patient was 5. We found no association between pre-ASCT patient characteristics and > 5 observed grade ≥3 non-hematologic toxicities. Patients with elevated first-dose busulfan AUC levels did not experience more toxicity. Paradoxically, patients treated with >2 regimens prior to ASCT had lower first-dose busulfan AUC. With a median follow-up among survivors of 20 months, 1-year PFS and OS from the time of ASCT were 83% and 87%, respectively. While reaffirming the favorable progression-free and overall survival of TBC-conditioned ASCT for CNSL, this treatment strategy carries a large toxicity burden.

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Autoimmune hemolysis (AH) and immune thrombocytopenic purpura (ITP) are recognized complications after cord blood transplantation (CBT). We evaluated the incidence and characteristics of AH/ ITP after double-unit CBT in a day 100 landmark analysis of 152 patients (median age 36 years, range 0.9–70) transplanted for hematologic malignancies with myeloablative or non-myeloablative conditioning and calcineurin-inhibitor (CNI)/ mycophenolate mofetil. With a median 5.2 year (range 1.6–9.7) survivor follow-up, 10 patients developed autoimmune cytopenias (8 AH, 1 ITP, 1 both) at a median of 10.4 months (range 5.8–24.5) post-CBT for a 7% cumulative incidence 3 years after the day 100 landmark. Six patients presented with severe disease (hemoglobin ≤ 6 g/dl and/ or platelets < 20 × 109/L). All AH patients were direct anti-globulin test positive. All 10 cases developed during immunosuppression taper with 8 having prior acute graft-versus-host disease. All 10 patients received rituximab 2–18 days after diagnosis, and corticosteroids combined with rituximab within < 7 days was the most effective. No patient died of AH/ ITP. AH/ ITP occurs infrequently after CBT but may be life-threatening requiring emergency therapy. Rituximab combined with corticosteroids at diagnosis is warranted in patients with severe disease.