Cost of autologous peripheral blood stem cell transplantation: the Norwegian experience from a multicenter cost study.

High-dose therapy with autologous blood progenitor cell support is now routinely used for patients with certain malignant lymphomas and multiple myeloma. We performed a prospective cost analysis of the mobilization, harvesting and cryopreservation phases and the high-dose therapy with stem cell reinfusion and hospitalization phases. In total, 40 consecutive patients were studied at four different university hospitals between 1999 and 2001. Data on direct costs were obtained on a daily basis. Data on indirect costs were allocated to the specific patient based on estimates of relevant department costs (ie the service department's costs), and by means of predefined allocation keys. All cost data were calculated at 2001 prices. The mean total costs for the two phases were US$ 32,160 (range US$ 19,092-50,550). The mean total length of hospital stay for two phases was 31 days (range 27-37). A large part of the actual cost in the harvest phase was attributed to stem cell mobilization, including growth factors, harvesting and cryopreservation. In the high-dose chemotherapy phase, the most significant part of the costs was nursing staff. Average total costs were considerably higher than actual DRG-based reimbursement from the government, indicating that the treatment of these patients was heavily subsidized by the basic hospital grants.

No benefit from adding GM-CSF to induction chemotherapy in transforming myelodysplastic syndromes: better outcome in patients with less proliferative disease.

In this prospective randomized multicenter trial 93 patients, median age 72 years, with RAEB-t (n=25) and myelodysplastic syndrome (MDS)-AML (n=68) were allocated to a standard induction chemotherapy regimen (TAD 2+7) with or without addition of granulocyte-macrophage-CSF (GM-CSF). The overall complete remission (CR) rate was 43% with no difference between the arms. Median survival times for all patients, CR patients, and non-CR patients were 280, 550, and 100 days, respectively, with no difference between the arms. Response rates were significantly better in patients with serum lactate dehydrogenase (S-LDH) levels

[High dose therapy with autologous stem cell support--finally a progress in myelomatosis]. / Høydosebehandling med autolog stamcellestøtte--endelig et fremskritt ved myelomatose.

BACKGROUND: Since the introduction of the simple cyclic oral treatment with melphalan and prednisone in the late 1960s, there has been no substantial improvement in the therapy of multiple myeloma. In 1994, the Nordic Myeloma Study Group initiated a population-based, prospective study to evaluate the impact on survival of high dose chemotherapy in newly diagnosed, symptomatic patients under 60 years of age, compared to a conventionally treated control group. MATERIAL AND METHODS: 274 patients were treated according to a specified high dose protocol and compared to 274 patients from previous population-based trials fulfilling the same eligibility criteria. RESULTS: Median survival was 44 months in the control group and 62 months in the intensive treatment group (risk ratio 1.65; 95% CI = 1.28-2.14, P = 0.0001). A study of health-related quality of life (HRQoL) which was integrated in the trial showed a moderately reduced HRQoL associated with the intensive treatment phase, but no statistically significant difference beyond the first year of follow-up. In a cost-utility analysis of the trial, the cost per (quality-adjusted life years) was estimated at USD 26,000. INTERPRETATION: The incremental cost of the treatment is within what is usually thought to be acceptable limits. Further improvement of the results and reduction of stay in hospital would give an even more favourable cost-utility ratio.

[Alexander Pushkin's duel--biographic and medical aspects]. / Aleksander Pusjkins duell--biografiske og medisinske aspekter.

The great Russian poet Aleksandr Pushkin (1799-1837) died 46 hours after being wounded by a pistol shot in a duel. The bullet penetrated the right pelvic bone, continued through the lower abdomen, and crushed the right part of the sacral bone. Biographical events leading to the duel are presented in the article, which also reviews articles in Russian medical journals describing the extent of the trauma and discussing the treatment possibilities at the time of the duel as well as present-day treatment. It is concluded that death was caused by peritonitis and that only modern extensive abdominal and orthopaedic surgery combined with antibiotic treatment could have saved the poet's life.

[Chronic myeloid leukemia in health regions 1, 3, 4 and 5 during the period 1990-96]. / Kronisk myelogen leukemi i helseregion 1, 3, 4 og 5 i perioden 1990-96.

The aim of the present investigation was to obtain information about treatment, clinical course and outcome for all patients with chronic myeloid leukaemia through a six-year period in a defined part of Norway. A total number of 141 patients fulfilled the diagnostic criteria. This is equivalent to 0.9 patients per 100,000 per year. The median age was 62 years. More than 70% of the patients were primarily treated with hydroxyurea, either alone or combined with interferon. 40 out of 57 patients younger than 55 years underwent allogeneic stem cell transplantation. Median survival for all patients was 36 months with an estimated five-year survival rate of 33%. Patients older than 55 years had a median survival of 30 months with 16% alive after five years. The five-year survival rate for patients younger than 55 years was 56%, for transplanted patients 72%. 60 of 84 patients older than 55 years have died after 4 1/2 years median observation time. Two thirds of those died of leukaemia; one third of other causes. 23 of 57 patients younger than 55 years have died. 11 of them had had transplantations and most of them died from transplantation-related causes, while leukaemia was the dominating cause of death in the others.

[Empirical antibiotic treatment of patients with acute myelogenous leukemia]. / Empirisk antibiotikabehandling hos pasienter med akutt myelogen leukemi.

All febrile episodes (a total of 276) which occurred in 85 patients with acute myelogenous leukaemia treated in four Norwegian centres during the period 1990-1994 were studied retrospectively in order to assess the efficacy of antibiotic treatment. 72% of these episodes were initially treated with benzyl penicillin and aminoglycoside (standard treatment), while alternative empirical treatment was given in the remaining cases. The treatment was successful in 94% of the febrile episodes initially treated with standard treatment and in 96% of the episodes which received alternative antibiotics. For both types of treatment, a change to second line antibiotic regimen was made for various reasons in a majority of cases. The combination benzyl penicillin and aminoglycoside seems to be a safe empirical treatment for febrile neutropenia in patients with acute myelogenous leukaemia in our treatment centres, provided that the treatment is modified in patients with unsatisfactory clinical response.

Treatment of anemia in myelodysplastic syndromes with granulocyte colony-stimulating factor plus erythropoietin: results from a randomized phase II study and long-term follow-up of 71 patients.

Treatment with erythropoietin (epo) may improve the anemia of myelodysplastic syndromes (MDS) in approximately 20% of patients. Previous studies have suggested that treatment with the combination of granulocyte colony-stimulating factor (G-CSF) and epo may increase this response rate. In the present phase II study, patients with MDS and anemia were randomized to treatment with G-CSF + epo according to one of two alternatives; arm A starting with G-CSF for 4 weeks followed by the combination for 12 weeks, and arm B starting with epo for 8 weeks followed by the combination for 10 weeks. Fifty evaluable patients (10 refractory anemia [RA], 13 refractory anemia with ring sideroblasts [RARS], and 27 refractory anemia with excess blasts [RAEB]) were included in the study, three were evaluable only for epo as monotherapy and 47 for the combined treatment. The overall response rate to G-CSF + epo was 38%, which is identical to that in our previous study. The response rates for patients with RA, RARS, and RAEB were 20%, 46%, and 37%, respectively. Response rates were identical in the two treatment groups indicating that an initial treatment with G-CSF was not neccessary for a response to the combination. Nine patients in arm B showed a response to the combined treatment, but only three of these responded to epo alone. This suggests a synergistic effect in vivo by G-CSF + epo. A long-term follow-up was made on 71 evaluable patients from both the present and the preceding Scandinavian study on G-CSF + epo. Median survival was 26 months, and the overall risk of leukemic transformation during a median follow-up of 43 months was 28%. Twenty patients entered long-term maintenance treatment and showed a median duration of response of 24 months. The international prognostic scoring system (IPSS) was effective to predict survival, leukemic transformation, and to a lesser extent, duration of response, but had no impact on primary response rates.

Survival in 86 patients, aged 15-60, with primary acute myelogenous leukemia, treated with a common program in the Norwegian health regions I, III, IV and V in the period 1990-1995.

Eighty-six patients between 15 and 60 yr with primary acute myelogenous leukemia in health regions I, III, IV and V in Norway were treated according to a common protocol from 21 January 1990 until 1 September 1995 (until 1 January 1993 for health region IV). Seventy-one percent of the patients reached complete remission (CR) and went on to receive consolidation treatment. In addition to chemotherapy, 18 patients under the age of 52, i.e. 28% of all patients in this age group, received allogeneic bone marrow transplantation. A follow-up analysis was performed by 1 September 1996. The median overall survival was 15 months, estimated 3-yr survival 30% and estimated survival at 5 yr was 26%. The median duration of 1st CR was 19 months, and the leukemia-free survival at 3 yr was 29%. At follow-up 26/86 patients were alive, 18 in 1st CR (4 after BMT) and 8 in 2nd CR (5 after BMT in 2nd, 1 after BMT in early 1st relapse). These results are comparable to many previously published studies, but may be inferior to the results obtained with more intensive consolidation treatment, including high dose Ara C.

[High dose therapy with autologous stem cell support in malignant disorders. Excerpt from the statement by the advisory group of the State Health Services]. / Høydosebehandling med autolog stamcellestøtte ved maligne lidelser. Utdrag fra innstilling fra rådgivende gruppe nedsatt av Statens helsetilsyn.

New biomedical knowledge may improve the diagnostic procedures and treatment provided by the Health Services, but at additional cost. In a social democratic health care system, the hospital budgets have no room for expensive, new procedures or treatments, unless these are funded through extra allocation from the central authorities. High dose therapy with autologous stem cell support in malignant disorders is an example of a new and promising, but rather expensive treatment, but its role in cancer therapy has yet to be established. The indications for testing high dose therapy with autologous stem cell support in various malignancies are discussed, with emphasis on the principles for deciding which categories of disease should have priority. The authors suggest some malignant disorders for which high dose therapy with stem cell support should be explored versus conventional treatment in randomised prospective trials.

[Idiopathic hypereosinophilic syndrome. Two patients with multiple organ damage]. / Idiopatisk hypereosinofilt syndrom. To pasienter med affeksjon av flere organer.

The idiopathic hypereosinophilic syndrome is a disorder characterized by sustained overproduction of eosinophils with undetectable etiology in addition to specific organ damage. Multiple organ systems may be involved in this condition, including the heart, lungs, skin and nervous system. The most important cause of mortality is myocardial involvement combined with valvular insufficiency. However, the prognosis for these patients has been to a large extent improved by greater awareness of this condition, combined with better surgical techniques. We describe two cases that illustrate the complex clinical situations that may be encountered in these patients.

A combination of granulocyte colony-stimulating factor and erythropoietin may synergistically improve the anaemia in patients with myelodysplastic syndromes.

In an attempt to obtain a synergistic effect on the hemoglobin levels in anaemic patients with myelodysplastic syndromes (MDS), granulocyte colony-stimulating factor (G-CSF) and erythropoietin (epo) were combined in a clinical phase II trial. Twenty-two patients with MDS were included in the study. G-CSF was given alone for six weeks and then in combination with epo for the following twelve weeks. Eight (38%) of 21 evaluable patients showed a significant increase in hemoglobin. One patient with a previous response and subsequent failure to epo alone improved after the addition of G-CSF. Responses were more frequent in patients with less advanced pancytopenia, lower endogenous levels of serum-epo and in those with ring sideroblasts in the bone marrow. The response frequency of 38% is higher than in any study of epo as monotherapy. Moreover, patients with ring sideroblasts, who respond poorly to epo alone, showed a response rate of 60%. Our findings suggest a synergistic in vivo effect of granulocyte-CSF and erythropoietin in patients with myelodysplastic syndromes.

[Immunomodulating treatment of severe aplastic anemia in adults]. / Immunmodulerende behandling av alvorlig aplastisk anemi hos voksne.

Immune modulating therapy has greatly improved the prognosis in aplastic anaemia, but the response to treatment varies considerably. We describe eight patients who were treated for severe aplastic anaemia. Antithymocyte globulin was given as first line treatment, followed by cyklosporine A if the patient failed to respond. Seven patients entered complete remission, but two of these relapsed later. Both developed paroxysmal nocturnal haemoglobinuria. One patient failed to respond to therapy. She died of bone marrow failure and haemochromatosis 12 months after start of therapy. Immune modulating therapy is discussed in relation to bone marrow transplantation, which is the alternative therapy for younger patients.

Interleukin-2 receptor levels in non-Hodgkin's lymphoma. Correlation to histological degree of malignancy and presence of constitutional symptoms.

Serum interleukin-2 receptor (Il-2R) levels were measured in 28 untreated patients with stage III or IV non-Hodgkin's lymphoma (low grade lymphoma: n = 11, high grade lymphoma: n = 17). Markedly higher levels of Il-2R were found in these patients compared to an age- and sex-matched control group. Significant differences were also found between the high grade group and the low grade group, and between patients with and without constitutional (B) symptoms. It has previously been shown that Il-2R levels vary according to tumor burden in patients with non-Hodgkin's lymphoma. Our data indicate that histological degree of malignancy as well as presence or absence of B symptoms may also influence Il-2R levels in these patients. All three parameters should therefore be taken into account when the clinical significance of Il-2R levels is evaluated.

Non-caseating granulomas in patients with hematologic malignancies. A report of three cases.

Sarcoidosis or sarcoid-like lesions occurred in three patients with hematologic malignancies. In one patient, an overlap syndrome sarcoidosis/polycythemia vera was the most probable diagnosis. In the other two cases, the granulomas were probably secondary to myelofibrosis and Waldenström's disease, respectively. Recent epidemiological studies have failed to show a causal relationship between sarcoidosis and malignancy. The co-existence of sarcoidosis and malignancy is probably fortuitous, but non-caseating granulomas may occur secondary to malignant diseases.