ABSTRACT
BACKGROUND: Respiratory syncytial virus (RSV) is a frequent cause of respiratory viral infections, increasing the morbidity and mortality in allogeneic haematopoietic stem cell transplantation (HSCT) recipients. Little is known about the best management strategy in this immunocompromised group and there are very few data on oral ribavirin treatment. AIM: To evaluate the effectiveness of oral ribavirin in allogeneic HSCT patients with RSV infection. METHODS: Twenty-three RSV cases treated with oral ribavirin were analysed retrospectively. RSV diagnosis was established by polymerase chain reaction assay. Oral ribavirin was initiated at 15 mg/kg/day in three divided doses for 10 days, with no subsequent dose escalation, as per centre policy. FINDINGS: At diagnosis, seven patients presented with lower respiratory tract infection (RTI), whereas 16 had upper RTI. Oral ribavirin was well tolerated with minor adverse effects. The median treatment duration was 10 days (range: 5-47). After a median follow-up of 17 months (range: 4-48), 17 patients are alive. We recorded one RSV-related and five non-related deaths. CONCLUSION: To our knowledge, this is the largest single centre study yet performed on adult allogeneic HSCT recipients with RSV infection treated with oral ribavirin. Prompt initiation of treatment is essential and may avoid hospital admission. Our experience supports the use of oral ribavirin, but large prospective studies are needed to determine the optimal therapy in this patient group.
Subject(s)
Antiviral Agents/administration & dosage , Hematopoietic Stem Cell Transplantation/adverse effects , Respiratory Syncytial Virus Infections/drug therapy , Ribavirin/administration & dosage , Transplant Recipients , Transplantation, Homologous/adverse effects , Administration, Oral , Adult , Aged , Female , Humans , Male , Middle Aged , Retrospective Studies , Survival Analysis , Treatment Outcome , Young AdultABSTRACT
DLIs are frequently used following haematopoietic SCT (HSCT) in patients with risk of relapse but data on GVHD following DLI are scarce. We report on 68 patients who received DLI following HSCT. Most patients developed GVHD following DLI (71%), which was acute in 22 patients (32%) almost half of whom had grade III-IV acute GVHD (aGVHD). Thirty patients (44%) developed cGVHD which followed aGVHD in four patients and was graded severe in nine patients. Corticosteroids were the most common first-line therapy for both acute and chronic GVHD. A wide range of second/third-line agents included cyclosporin, mycophenolate, tacrolimus, imatinib, infliximab and ECP. Relapse of initial malignancy occurred in 37%. Relapse was significantly less frequent in those receiving pre-emptive DLI. Relapse rates were also lower in those with GVHD (31%) than those without GVHD (50%), but this did not reach statistical significance. At 55 months post DLI, 34% of patients had died most commonly from relapse and 22% had on-going GVHD. Although GVHD was an important cause of morbidity post DLI (71%), only 6% died from GVHD. Although most patients develop GVHD post DLI and may require consecutive therapies, mortality from GVHD is infrequent. DLI remains an important option for relapse post transplant and manipulation of the GVT effect needs to be optimised to induce remission without morbidity from GVHD.
Subject(s)
Graft vs Host Disease , Hematopoietic Stem Cell Transplantation , Immunosuppressive Agents/administration & dosage , Lymphocyte Transfusion , Adult , Aged , Allografts , Disease-Free Survival , Female , Graft vs Host Disease/mortality , Graft vs Host Disease/prevention & control , Hematologic Neoplasms/mortality , Hematologic Neoplasms/therapy , Humans , Living Donors , Male , Middle Aged , Survival Rate , United Kingdom/epidemiologyABSTRACT
The presence of minimal residual disease (MRD) by multiparametric flow cytometry (MFC) has been associated with adverse outcomes in AML patients treated with chemotherapy alone, but its impact in the setting of allogeneic hematopoietic SCT (HSCT) is less clear. We studied 88 patients who underwent myeloablative (MA) or reduced-intensity conditioned allogeneic HSCT for AML in first or subsequent remission at our center. MRD status was determined using three-color MFC on pre-HSCT BM aspirates, and patients were stratified by MRD status into MRD-negative, low-level MRD-positive (<1%) or high-level MRD-positive groups (1-4.9%). Two-year survival estimates in these groups were 66.8%, 51% and 30%, respectively (P=0.012), and 2-year estimates of relapse were 7.6, 37 and 70% (P<0.001). Pre-HSCT MRD was related to disease characteristics including secondary AML (P=0.002) and primary induction failure (P=0.005), but, despite these strong correlations, MRD remained independently associated with poorer survival in multivariate analysis (hazard ratio, 1.92; P=0.014). Pre-HSCT MRD is associated with adverse clinical outcomes in AML patients undergoing reduced-intensity or MA HSCT in first or subsequent remission and should be integrated into transplant strategies for patients with AML.
Subject(s)
Hematopoietic Stem Cell Transplantation/methods , Leukemia, Myeloid, Acute/diagnosis , Leukemia, Myeloid, Acute/therapy , Neoplasm, Residual/diagnosis , Transplantation Conditioning/methods , Adolescent , Adult , Aged , Flow Cytometry , Hematopoietic Stem Cell Transplantation/mortality , Humans , Leukemia, Myeloid, Acute/mortality , Middle Aged , Multivariate Analysis , Myeloablative Agonists/therapeutic use , Neoplasm, Residual/mortality , Predictive Value of Tests , Prognosis , Recurrence , Retrospective Studies , Survival Analysis , Transplantation, Homologous , Young AdultABSTRACT
There are few prospective studies evaluating the role of extracorporeal photopheresis (ECP) in chronic GVHD (cGVHD) and only occasional reports of the effect of ECP on patients' quality of life (QoL). We report a single-centre prospective study of patients undergoing fortnightly ECP for moderate or severe cGVHD. Response was assessed after 6 months of treatment using NIH scoring criteria and reduction in immunosuppression. QoL assessments were undertaken at baseline and at 6 months using the chronic GVHD symptom scale (cGVHD SS) and dermatology life quality index (DLQI). An intention-to-treat analysis showed that 19/38 (50%) of patients had a complete or partial response. Twenty-seven out of 38 patients completed 6 months of ECP treatment and 70% (19/27) had a complete or partial response. Eighty per cent of patients who completed 6 months of ECP treatment had a reduction in immunosuppression dose. A subset of patients completed QoL questionnaires. Seventeen out of 18 patients (94%) showed an improvement in scores. The mean cGVHD SS and mean DLQI score were both significantly lower after 6 months of ECP (22 compared with 36, P=0.012 and 3.4 compared with 6.9, P=0.009, respectively). This study confirms that ECP can lead to objective clinical responses and, in addition, may lead to an improvement in QoL in cGVHD.
Subject(s)
Graft vs Host Disease/therapy , Immunotherapy/methods , Photopheresis/methods , Quality of Life , Skin/immunology , Adolescent , Adult , Aged , Chronic Disease , Drug Resistance/immunology , Female , Graft vs Host Disease/immunology , Humans , Immunosuppressive Agents/therapeutic use , Male , Middle Aged , Prospective Studies , Steroids/therapeutic use , Surveys and Questionnaires , Survival Rate , Treatment Outcome , Young AdultABSTRACT
Extracorporeal photopheresis (ECP) has become a recognised treatment for steroid-refractory chronic GVHD (cGVHD), but the optimal frequency and duration of treatment are yet to be established. We report on 82 consecutive patients with mucocutaneous cGVHD who received a bimonthly regimen of ECP treatment for two consecutive days, which could be subsequently tapered to a monthly regimen depending on response. Patients were steroid-refractory, steroid-dependent or steroid-intolerant, and 29 (35%) had multiorgan involvement. The median duration of treatment was 330 days (42-987). The median number of ECP cycles was 15 (1.5-32). Response was assessed by clinical assessment and reduction in immunosuppression after 6 months. 69/82 (84%) had completed 6 months of ECP and 65/69 (94%) had ≥ 50% improvement in symptoms and signs of cGVHD. A total of 77% of patients who completed 6 months of ECP had a reduction in immunosuppression dose and 80% had decreased their steroid dose (27.5% stopped, 30% had ≥ 75% reduction, 17.5% had ≥ 50% reduction and 25% had <50% reduction). OS at 3 years from the start of ECP was 69%. This study reports the largest series of patients receiving bimonthly ECP treatment for cGVHD, and confirms that ECP allows successful reduction of immunosuppression.
Subject(s)
Graft vs Host Disease/therapy , Photopheresis/methods , Skin Diseases/therapy , Adolescent , Adult , Aged , Chronic Disease , Female , Hematologic Neoplasms/therapy , Humans , Male , Middle Aged , Time FactorsABSTRACT
Empirical antifungal therapy is frequently used in allogeneic transplant patients who have persistent febrile neutropenia and can be associated with high cost, toxicity and breakthrough infections. There are limited reports of strategies for early diagnosis of invasive fungal infection (IFI) and, to our knowledge, no reports of treatment strategies based only on high-resolution computerized tomography (HRCT) scans. We used an early treatment strategy for IFI in 99 consecutive patients undergoing allogeneic transplantation. Patients received caspofungin if they had antibiotic-resistant neutropenic fever for more than 72 h and a positive HRCT scan. Fifty-three of 99 patients (54%) had antibiotic-resistant neutropenic fever at 72 h and would have received parenteral antifungal treatment if an empirical approach had been used. The HRCT-based strategy reduced the use of parenteral antifungal agents to 17/99 patients (17%), a 68% reduction. No subsequent diagnoses of IFI occurred within 100 days in patients with a negative HRCT. Only one patient died from IFI within 100 days. These data suggest that this non-empirical strategy may be feasible and that caspofungin may be effective in this setting. A randomized controlled trial is warranted to further assess these results.
Subject(s)
Antifungal Agents/administration & dosage , Echinocandins/administration & dosage , Hematopoietic Stem Cell Transplantation , Mycoses/diagnostic imaging , Mycoses/drug therapy , Mycoses/mortality , Tomography, X-Ray Computed/methods , Adolescent , Adult , Aged , Caspofungin , Female , Hematologic Neoplasms/diagnostic imaging , Hematologic Neoplasms/mortality , Hematologic Neoplasms/therapy , Humans , Lipopeptides , Male , Middle Aged , Mycoses/etiology , Time Factors , Transplantation, HomologousABSTRACT
Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH. The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient, support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Burnout describes the end result of stress in the professional life of a physician or caregiver and combines emotional exhaustion, depersonalization and low personal accomplishment. This problem is common in health care workers in every specialty and may affect not only personal satisfaction, but also the quality of care delivered to patients. Burnout is particularly relevant in oncology where caregivers work closely with patients who have life-threatening illnesses and therapy often has only a limited impact. Burnout was discussed in the rounds with an emphasis on factors which precipitate or prevent stress among health care workers. Presentations were made by Dr. Canellos of the Dana Farber Cancer Institute, and Dr. Picard of the Institute for Health Professions. Staff discussed the main issues contributing to burnout including the health care system, lack of time and inadequate training. They considered preventative measures including psychological support of the health care team, communication and management skills, and effective coping mechanisms.