Autologous hematopoietic cell transplantation for multiple myeloma patients with renal insufficiency: a center for international blood and marrow transplant research analysis.

Autologous hematopoietic cell transplantation (AHCT) in multiple myeloma (MM) patients with renal insufficiency (RI) is controversial. Patients who underwent AHCT for MM between 2008 and 2013 were identified (N=1492) and grouped as normal/mild (⩾60 mL/min), N=1240, moderate (30-59), N=185 and severe RI (<30), N=67 based on Modification of Diet in Renal Disease. Multivariate analyses of non-relapse mortality (NRM), relapse, PFS and overall survival (OS) were performed. Of the 67 patients with severe RI, 35 were on dialysis prior to AHCT. Patients received melphalan 200 mg/m2 (Mel 200) in 92% (normal/mild), 75% (moderate) and 33% (severe) RI; remainder received 140 mg/m2 (Mel 140). Thirty four of 35 patients with severe RI achieved post-AHCT dialysis independence. The 5-year PFS for normal, moderate and severe RI was 35 (95% CI, 31-38)%, 40 (31-49)% and 27 (15-40)%, respectively, (P=0.42); 5-year OS for normal, moderate and severe RI was 68 (65-71)%, 68 (60-76)% and 60 (46-74)%, respectively, (P=0.69). With moderate RI, 5-year PFS for high-dose melphalan 140 mg/m2 was 18 (6-35)% and for Mel 200 was 46 (36-57)% (P=0.009). With severe RI, 5-year PFS Mel 140 was 25 (11-41) % and for Mel 200 was 32 (11-58)% (P=0.37). We conclude that AHCT is safe and effective in patients with MM with RI.

B-cell activating factor (BAFF) plasma level at the time of chronic GvHD diagnosis is a potential predictor of non-relapse mortality.

Biological markers for risk stratification of chronic GvHD (cGvHD) could improve the care of patients undergoing allogeneic hematopoietic stem cell transplantation. Increased plasma levels of B-cell activating factor (BAFF), chemokine (C-X-C motif) ligand 9 (CXCL9) and elafin have been associated with the diagnosis, but not with outcome in patients with cGvHD. We evaluated the association between levels of these soluble proteins, measured by ELISA at the time of cGvHD diagnosis and before the initiation of therapy, with non-relapse-mortality (NRM). Based on the log-transformed values, factor levels were divided into tertiles defined respectively as low, intermediate, and high levels. On univariable analysis, BAFF levels were significantly associated with NRM, whereas CXCL9 and elafin levels were not. Both low (⩽2.3 ng/mL, hazard ratio (HR)=5.8, P=0.03) and high (>5.7 ng/mL, HR=5.4, P=0.03) BAFF levels were associated with a significantly higher NRM compared with intermediate BAFF level. The significant effect of high or low BAFF levels persisted in multivariable analysis. A subset of cGvHD patients had persistently low BAFF levels. In conclusion, our data show that BAFF levels at the time of cGvHD diagnosis are associated with NRM, and also are potentially useful for risk stratification. These results warrant confirmation in larger studies.

Simultaneous presentation of acute monoblastic leukemia and mantle cell lymphoma: case report and review of the literature.

This paper reports a 73-year old woman with simultaneous presentation of acute monoblastic leukemia (acute myeloid leukemia (AML), French-American-British (FAB) type M5a) and mantle cell lymphoma. The patient presented with wasting, generalized lymphadenopathy, an extensive infiltrative rash and pancytopenia. Bone marrow and lymph node histopatholology showed extensive infiltration by leukemic monoblasts. Marrow cytogenetics revealed a complex karyotype, including t(8;16)(p11;p13). Flow cytometric immunophenotyping of peripheral blood, lymph node and bone marrow demonstrated two populations, expressing CD5, CD19, CD20 and CD22 and CD45, HLA-DR, CD13, CD33, CD14 and CD38, respectively. A focus of abnormal lymphocytes in the lymph node biopsy demonstrated BCL1 expression and t(11;14)(p11;p13) by fluorescence in situ hybridization and immunoglobulin heavy chain gene rearrangement by the polymerase chain reaction. The patient received infusional cytarabine, daunorubicin and etoposide chemotherapy, with complete remission of both the AML and the mantle cell leukemia. To the authors' knowledge, this is the first report of simultaneous presentations of AML, FAB M5a and mantle cell lymphoma. The case is discussed and the literature is reviewed.

Outcomes of primary hepatocellular carcinoma treatment: an 8-year experience with 368 patients in Thailand.

BACKGROUND AND AIMS: Primary hepatocellular carcinoma (HCC) is common in Thailand and its prognosis is extremely poor. Hepatic resection and liver transplantation are modes of curative therapy and various therapies have been developed to treat inoperable HCC. This study was performed to determine the outcome of therapy and to identify prognostic factors for survival among Thai patients with HCC. METHODS: Three hundred and sixty-eight patients with tissue-proven or serodiagnosed HCC were studied. Differences in laboratory investigations, patient survival, treatment outcomes and prognostic factors were analysed. The Kaplan-Meier method and the log-rank test were used to calculate and compare survival of patients receiving different therapies. RESULTS: Of the 368 patients 317 were males (86.1%, M: F ratio 6.2:1). The median age of all patients was 52 years range (2-85 years). Fifty-nine patients were specifically treated and 209 were conservatively treated. Among those tested, 70% had hepatitis B virus-related HCC. The overall median survival (range) after diagnosis and that of the treated and untreated patients were 5.6 (0-92.1), 9.0 (0-92.1) and 2.3 (0-25.9) months, respectively. More than 50% of the Okuda I patients survived beyond 30 months. The Okuda II and III patients had a median survival (range) of 5.7 (0.1-75.2) and 1.6 (0.1-25.9) months, respectively. Those patients treated by surgery, transcatheter oil chemoembolization and systemic chemotherapy had a better survival rate than did the conservatively managed patients. Surgery was found to be a better treatment than systemic chemotherapy. However, no differences between other pairs of treatment groups were identified. Subgroup analysis of the Okuda II group patients revealed the same results. Independent predictors of death were multiple lesions, advanced Okuda stage and treatment modality. CONCLUSION: Despite various kinds of therapy, the treatment outcomes for Thai HCC patients remain poor and largely depend on the disease extent and treatment received. Most Thai HCC patients are at an advanced stage at diagnosis. Thai patients who received disease-specific treatment other than intraarterial chemotherapy had a better survival rate than did supportive treatment patients.

Natural history of untreated primary hepatocellular carcinoma: a retrospective study of 157 patients.

Primary hepatocellular carcinoma (HCC) is a common malignancy with a dismal prognosis; new modalities of treatment as alternatives to surgery have been developed for unresectable patients. The authors obtain baseline data for the natural history of HCC so that the efficacy of new treatments may be evaluated. A retrospective study of 157 untreated patients with tissue-proven or serodiagnosed HCC was conducted. Clinical characteristics including laboratory investigation, treatment received, survival from the time of diagnosis, and prognostic factors were evaluated. There were 129 men and 28 women (ratio, 4.6:1). Median age was 50.9 years (range, 14.1-85.3 years). The most common symptoms and signs were weight loss (68.2%), abdominal fullness (62.5%), abdominal pain (51.6%), hepatomegaly (73.7%), ascites (45.2%), and jaundice (40.6%). Eighteen percent had extrahepatic metastases of which the lungs were the most common site. Seventy percent were hepatitis B virus related. Overall median survival was 8.7 weeks after the time of diagnosis. Survivals by stages were: TNM II, 16.6 weeks; TNM III, 7.3 weeks; TNM IVA, 9.7 weeks; TNM IVB, 7.6 weeks; Okuda II, 10.7 weeks; and Okuda III, 7.3 weeks. Multivariate analysis revealed serum total bilirubin and albumin as independent prognostic factors of survival. Common causes of death were upper gastrointestinal hemorrhage (34.1%), cancer-related causes (cachexia, HCC rupture, metastatic disease, 31.8%), and hepatic failure (25.0%). Patients with HCC were diagnosed at late stages of their disease and the advanced nature of the tumor precluded effective therapy. Earlier tumor detection at a time when patients are better candidates for treatment may be aided by an active surveillance program of high risk groups.

Ruptured primary hepatocellular carcinoma at Chulalongkorn University Hospital: a retrospective study of 32 cases.

Rupture of Primary hepatocellular carcinoma (HCC) is relatively common in high incidence areas including Thailand. There have been attempts to establish a standard treatment to manage this phenomenon. We retrospectively reviewed the records of patients with HCC from January 1989 to June 1997, and ten per cent (32/306) had tumor rupture during the course of the disease. Overall median survival of the patients with tumor rupture was 2.7 months [95% confidence interval (CI), 0-5.9 months] that was not significantly different from that of the patients without rupture (median 6.6 months; 95% CI, 4.0-9.1 months) (P = 0.4605). Among the ruptured group, the patients treated with surgical intervention survived longer than those receiving supportive care alone (median = 15.5 months; 95% CI, 8.7-22.2 months and median = 0.4 months; 95% CI, 0.2-0.5 months, P = 0.0027). The resectional and non-resectional surgical subgroups also had better survival than the supportive group (P = 0.0300 and P = 0.0209, respectively). In conclusion, surgical intervention, if applicable, should be performed in managing ruptured HCC.