Transplantation for myeloid neoplasms with antecedent solid tumor.

BACKGROUND: Definitive treatment of acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and myeloproliferative neoplasm (MPN) involves allogeneic hematopoietic stem cell transplantation (allo-HSCT), either with myeloablative (MAC) or reduced-intensity conditioning (RIC). These diseases may arise in patients with a prior solid tumor. The impact of antecedent solid tumor on transplantation decision-making and outcomes is not well defined. METHODS: The authors performed a retrospective cohort study to address this question. A total of 1193 patients who underwent allo-HSCT for AML, MDS, or MPN between January 1, 2010 and December 31, 2018 were included, 102 of whom had a history of prior solid tumor. RESULTS: Patients with prior solid tumor were older (median age, 62.5 vs. 54.9 years; p < .00001) and more frequently were conditioned with RIC (52.5% vs. 27.2%; p < .00001). A higher incidence of acute graft-versus-host disease was observed in patients with prior solid tumor (73.5% vs 66.4%; adjusted odds ratio, 1.65; 95% confidence interval, 1.03-2.65; p = .037), yet overall survival and relapse did not significantly differ. Cytogenetic risk was the dominant risk factor for survival. CONCLUSIONS: Analysis by the authors suggests that patients with antecedent solid tumor and respective therapy can be transplanted successfully. Although selection bias is likely to be a factor, the results are encouraging for patients who come to transplantation after surviving a prior cancer.

Safety of bedside lumbar puncture in adult patients with thrombocytopenia.

The risk of lumbar puncture (LP) hemorrhagic complications is believed to be exacerbated by thrombocytopenia, yet evaluations in clinical practice are lacking. We conducted a retrospective cohort study to examine the risk of traumatic tap (TT) and significant hemorrhagic complications in thrombocytopenic patients undergoing bedside LP. Two hundred sixty-two adult patients undergoing initial bedside LP were analyzed. Overall, we observed 37 TTs (14.1%, 95% CI 10.0 to 18.3%). TTs occurred in 11 of 78 LPs performed on patients with thrombocytopenia, compared with 26 of 184 LPs among patients with a normal platelet count (14.1% vs 14.1%; p > 0.99) and 6 of 19 LPs among patients with severe thrombocytopenia compared with 31 of 243 among those without (31.6% vs 12.8%; p = 0.04). For patients with severe thrombocytopenia, the relative risk of TT was 2.5 (95% CI 1.2 to 5.2; p = 0.02). Stratifying this group by operator experience, a higher incidence of TTs was observed in LPs performed by trainees (57.1% vs 15.8%; p = 0.02), an effect which did not reach significance in LPs performed by dedicated procedural operators (16.7% vs 10.8%; p = 0.63). The presence of other bleeding risk factors was not found to be statistically associated with the incidence of TT. There were no significant hemorrhagic complications. TTs occurred significantly more frequently among patients with severe thrombocytopenia, an effect modulated by operator experience. For patients in this higher risk group, LPs should be performed by the most skilled operators available.

Autoimmune- and complement-mediated hematologic condition recrudescence following SARS-CoV-2 vaccination.

A variety of autoimmune disorders have been reported after viral illnesses and specific vaccinations. Cases of de novo immune thrombocytopenia (ITP) have been reported after SARS-CoV-2 vaccination, although its effect on preexisting ITP has not been well characterized. In addition, although COVID-19 has been associated with complement dysregulation, the effect of SARS-CoV-2 vaccination on preexisting complementopathies is poorly understood. We sought to better understand SARS-CoV-2 vaccine-induced recurrence of autoimmune- and complement-mediated hematologic conditions. Three illustrative cases were identified at the University of Washington Medical Center and the Seattle Cancer Care Alliance from January through March 2021. We describe the recrudescence of 2 autoimmune conditions (ITP and acquired von Willebrand Disease [AvWD]/acquired hemophilia A) and 1 complementopathy (paroxysmal nocturnal hemoglobinuria [PNH]). We report the first known case of AvWD/acquired hemophilia A, and describe the first PNH exacerbation in the absence of complement inhibition after SARS-CoV-2 vaccination. Although SARS-CoV-2 vaccine-induced ITP is a known concern, our case clearly depicts how thrombocytopenia in the setting of preexisting ITP can sequentially worsen with each vaccine dose. Based on our experiences and these examples, we provide considerations for how to monitor and assess risk in patients with underlying autoimmune- and complement-mediated hematologic conditions.

A review of thrombotic microangiopathies in multiple myeloma.

Patients with multiple myeloma (MM) are susceptible to developing thrombotic microangiopathies (TMAs), an etiologically diverse group of syndromes which include atypical hemolytic uremic syndrome (aHUS) and thrombotic thrombocytopenic purpura (TTP). The TMAs are characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA), and are associated with a high mortality risk and irreversible end-organ damage when treatment is delayed. In MM patients, TMAs may be triggered by specific chemotherapies, bone marrow transplantation (BMT), and progression of underlying disease. Because many characteristics of TMAs overlap with sequelae of MM and its treatments, diagnosis requires a high index of suspicion. Furthermore, our understanding of optimal treatments for these entities is rapidly evolving and clinical practice guidelines do not yet exist. Historically, consideration of a diagnosis of TMA has prompted initiation of therapeutic plasma exchange. In this review, we present an overview of the MM-related TMAs, an approach to workup and diagnosis, and argue for initial empiric MM-related TMA treatment with eculizumab rather than plasma exchange.