Fludarabine-Melphalan-Campath, Followed by Unmanipulated Peripheral-Blood Haematopoietic Stem Cells, Can Still Cure Lymphoma.

Background: The second decade of this millennium was characterized by a widespread availability of chimeric antigen receptor T-cell (CAR-T) therapies to treat relapsed and refractory lymphomas. As expected, the role and indication of allogeneic haematopoietic stem cell transplant (allo-HSCT) in the management of lymphoma changed. Currently, a non-neglectable proportion of patients will be considered candidate for an allo-HSCT, and the debate of which transplant platform should be offered is still active. Objectives: to report the outcome of patients affected with relapsed/refractory lymphoma and transplanted following reduced intensity conditioning at King's College Hospital, London, between January 2009 and April 2021. Methods: Conditioning was with 150mg/m2 of fludarabine and melphalan of 140mg/m2. The graft was unmanipulated G-CSF mobilized peripheral blood haematopoietic stem cells (PBSC). Graft-versus-host disease (GVHD) prophylaxis consisted of pre-transplant Campath at the total dose of 60 mg in unrelated donors and 30 mg in fully matched sibling donors and ciclosporin. Results: One-year and five years OS were 87% and 79.9%, respectively, and median OS was not reached. The cumulative incidence of relapse was 16%. The incidence of acute GVHD was 48% (only grade I/II); no cases of grade III/IV were diagnosed. Chronic GVHD occurred in 39% of patients. TRM was 12%, with no cases developed within day 100 and 18 months after the procedure. Conclusions: The outcomes of heavily pretreated lymphoma patients are favorable, with median OS and survival not reached after a median of 49 months. In conclusion, even if some lymphoma subgroups cannot be treated (yet) with advanced cellular therapies, this study confirms the role of allo-HSCT as a safe and curative strategy.

Hematopoietic stem cell transplantation in Saudi Arabia between 1984 and 2016: Experience from four leading tertiary care hematopoietic stem cell transplantation centers.

Saudi Arabia is the largest of the Arabian Gulf countries with a total population of 33.41 million as of 2017. This report summarizes the experience from four leading tertiary care hematopoietic stem cell transplantation (HSCT) centers in Saudi Arabia representing more than 90% of all HSCTs performed in the country. Between 1984 and 2016, a total of 6,184 HSCTs were performed. Of these, 3,586 HSCTs were performed in adults and 2,598 HSCTs were performed in pediatric patients. Malignancy was the main indication for transplantation (47%). While most transplants were performed from an identical sibling donor, HSCTs from cord blood, unrelated and, more recently, haploidentical donors have also been performed. Relative shortage of HSCT bed capacity is perceived to be a limiting factor in Saudi Arabia. Lately, more HSCT centers are emerging with rapid growth, which may significantly improve the access to HSCT in the country in the near future.

Virtual Management of Patients With Cancer During the COVID-19 Pandemic: Web-Based Questionnaire Study.

BACKGROUND: During the coronavirus disease (COVID-19) pandemic, patients with cancer in rural settings and distant geographical areas will be affected the most by curfews. Virtual management (telemedicine) has been shown to reduce health costs and improve access to care. OBJECTIVE: The aim of this survey is to understand oncologists' awareness of and views on virtual management, challenges, and preferences, as well as their priorities regarding the prescribing of anticancer treatments during the COVID-19 pandemic. METHODS: We created a self-administrated electronic survey about the virtual management of patients with cancer during the COVID-19 pandemic. We evaluated its clinical sensibility and pilot tested the instrument. We surveyed practicing oncologists in Gulf and Arab countries using snowball sampling via emails and social media networks. Reminders were sent 1 and 2 weeks later using SurveyMonkey. RESULTS: We received 222 responses from validated oncologists from April 2-22, 2020. An awareness of virtual clinics, virtual multidisciplinary teams, and virtual prescriptions was reported by 182 (82%), 175 (79%), and 166 (75%) respondents, respectively. Reported challenges associated with virtual management were the lack of physical exam (n=134, 60%), patients' awareness and access (n=131, 59%), the lack of physical attendance of patients (n=93, 42%), information technology (IT) support (n=82, 37%), and the safety of virtual management (n=78, 35%). Overall, 111 (50%) and 107 (48%) oncologists did not prefer the virtual prescription of chemotherapy and novel immunotherapy, respectively. However, 188 (85%), 165 (74%), and 127 (57%) oncologists preferred the virtual prescription of hormonal therapy, bone modifying agents, and targeted therapy, respectively. In total, 184 (83%), 183 (83%), and 176 (80%) oncologists preferred to continue neoadjuvant, adjuvant, and perioperative treatments, respectively. Overall, 118 (53%) respondents preferred to continue first-line palliative treatment, in contrast to 68 (30%) and 47 (21%) respondents indicating a preference to interrupt second- and third-line palliative treatment, respectively. For administration of virtual prescriptions, all respondents preferred the oral route and 118 (53%) preferred the subcutaneous route. In contrast, 193 (87%) did not prefer the intravenous route for virtual prescriptions. Overall, 102 (46%) oncologists responded that they would "definitely" prefer to manage patients with cancer virtually. CONCLUSIONS: Oncologists have a high level of awareness of virtual management. Although their survey responses indicated that second- and third-line palliative treatments should be interrupted, they stated that neoadjuvant, adjuvant, perioperative, and first-line palliative treatments should continue. Our results confirm that oncologists' views on the priority of anticancer treatments are consistent with the evolving literature during the COVID-19 pandemic. Challenges to virtual management should be addressed to improve the care of patients with cancer.

AML in Saudi Arabia: Analysis According to the European LeukaemiaNet 2017 Cytogenetic Classification.

INTRODUCTION: To the best of our knowledge, few studies have addressed the prognosis of patients with acute myeloid leukemia (AML) in Saudi Arabia. The present study retrospectively analyzed the prognostic factors in patients with de novo AML at a single institution owing to the observation of some differences with the reported data from the Western world. PATIENTS AND METHODS: Patients with de novo AML who had been referred to King Abdulla Medical City were included. All patients had undergone bone marrow aspiration, biopsy, flow cytometry, cytogenetics (conventional and fluorescence in situ hybridization panel performed at Mayo Clinic), molecular tests, and other routine tests. RESULTS: The data from 170 patients were reviewed. Of the 170 patients, 26 had had acute promyelocytic leukemia, 16 with AML had received less intensive therapy, 119 had received intensive induction, and 8 had refused treatment. The present analysis was limited to the 119 patients who had received intensive induction therapy. For the major cytogenetic categories, 17 of 27 patients with core binding factor leukemia (62.9%) were reassigned to the intermediate (n = 10; 37%) or unfavorable (n = 7; 25.9%) risk group according to the FLT3-ITD and NPM results. Of the 50 cases of normal cytogenetic findings, 2 (4%) were considered unfavorable, 12 (24%), favorable, 30 intermediate (60%), and 6 (12%) unknown. The median leukemia-free survival was 21.5 months. The median overall survival was 16.4 ± 2.2 months, with a 3-year survival rate of 37.2%. Multivariate Cox regression analysis revealed that the cytogenetics results (P = .002) and the presence of FLT-3 (P = .03) were independent prognostic factors for relapse-free survival. Performance status, response, relapse, and cytogenetics findings were independent prognostic factors for survival. CONCLUSIONS: The results from the present study revealed some differences in patient age and cytogenetic risk groups for patients with AML in our region and those in the Western world, including a younger median age, relevance of core binding factor leukemia, and a greater incidence of monosomies.

Upfront treatment of elderly myeloma patients: an overview and update.

INTRODUCTION: Multiple myeloma is primarily a disease of older age, with a median age of 70 years at diagnosis. Management of the disease in this diverse population is challenging, in the face of comorbidities and frailties. Areas covered: This review discusses the management challenges of elderly myeloma patients in view of the current evidence and propose for performing a formal objective assessment of the functional status to guide choice of treatment. Expert commentary: The approval of many antimyeloma medications with various mechanisms of action in the past two decades had sparked the debate about choosing the best combination, duration of therapy, role of transplant and the possibility to cure myeloma after being changed to a chronic disease. Indeed, among these debates are the choice of treatment for the elderly population and approaches that might help in clinical decision making particularly with the encouraging response and survival results of newer therapies. In this population, a balance between efficacy and toxicity is required to achieve prolongation of survival while maintaining the quality of life. Objective assessment of functional status might help in this task. Prospective randomized trials specifically addressing the needs for this population is certainly required to allow for more informed treatment decisions.

The Dana Farber consortium protocol (DFCP) vs. classic Hyper-CVAD for treatment of acute lymphoblastic leukemia in patients <50 Y. Single institution experience.

BACKGROUND: The use of intensive pediatric protocols for the treatment of ALL is being extended to older adults. AIM OF THE STUDY: Analysis of the efficacy and toxicity results of pediatric DFCP vs. classic Hyper-CVAD protocol for the treatment of patients with ALL < 50 Y. PATIENTS AND METHODS: A retrospective single center comparative analysis of DFCP & classic Hyper-CVAD for first line treatment of patients with ALL < 50 Y. RESULTS: 73 patients were included, 43 received DFCP and 30 received Hyper-CVAD protocol. CR rate was 90.7% for DFCP vs. 83.7 for Hyper-CVAD (p 0.7). 3 Y Leukemia free survival was 57.4% (70.9% for DFCP vs. 41.6% Hyper-CVAD P 0.1) while 3Y OS was 62.6%% for the whole group, 72.6% DFCP vs. 48.5% Hyper-CVAD, P 0.04. Those with age <21 Y, had significantly longer 3 Y LFS and OS (P 0.04, 0.02, respectively). TOXICITY: pancreatitis occurred in 5 patients with DFCP and it was related to Asparginase and in 1 patient on Hyper-CVAD related to gall stones. Osteonecrosis affected 5 patients on DFCP. IN CONCLUSION: pediatric protocols are feasible in patients younger than 50 Y and they are more active than classic adult protocols. Although modifications of adult protocols may improve their results, this had to be investigated in randomized controlled trials.

The Dana Farber Consortium Protocol for the Treatment of Adolescents and Young Adults With Acute Lymphoblastic Leukemia: A Single Institution Experience in Saudi Arabia.

BACKGROUND: Recent retrospective analyses and phase II trials have shown differential outcomes in adolescents and young adults when treated with pediatric compared with adult protocols. The aim of this study was to evaluate the efficacy and toxicity of the Dana Farber Consortium Protocol (DFCP) in Saudi young adults diagnosed with de novo acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS: In this retrospective study we included 38 patients with de novo ALL who presented to King Abdulla Medical City in the period from June 2010 to March 2015 and received the DFCP (Princess Margret modified version). RESULTS: A total of 38 patients were included with a median age of 19 years. Two patients died during induction treatment, and 35 of 38 patients achieved complete remission (92.1%). With a median follow-up period of 22 months, at 1 and 3 years, leukemia-free survival was 80% and 68%, respectively, and overall survival was 88% and 72%, respectively. Age younger than 21 years showed a significant association with longer survival. Toxicities included febrile neutropenia in all patients during induction, typhilitis in 8/38 (21%), pneumonia in 10/38 (26%), and pancreatitis in 5/38 patients (13%), 3/38 (7.8%) during induction and 2/38 (5.2%) during intensification. Osteonecrosis affected 3/38 patients (7.8%), and was detected during screening in 2/38 (5.2%) of these patients. There were no fractures or surgical interventions, and no venous thromboembolism was recorded. CONCLUSION: Although it might be feasible to use pediatric-inspired protocols in this age group, toxicity cannot be overlooked, and the application of these protocols might require modification of drug doses or schedules relative to those used for younger children. Moreover, additional surveillance and supportive measures should be implemented to maximize benefits while minimizing toxicity.