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The authors examined data from 166 children who received autologous peripheral blood progenitor cell (PBPC) transplantation to ascertain the incidence of early transplant-related mortality (TRM) and the contributing risk factors. Eleven patients (6.6%) (6 boys, 5 girls) died within 180 days following PBPC infusion. The median age was 4 years (range 2–17). The overall probability of TRM was 6.9 ± 2% at day +180. On univariate analysis, the status of disease at transplantation (complete remission vs. not in complete remission) was identified as the only pretransplant significant predicting factor for TRM (14% of patients who were not in complete remission died within 180 days after PBPC infusion, whereas only 2% of patients in complete remission died) (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01–1.26, P= 0.01). Age, gender, conditioning, and number of CD34+ cells infused were not significantly associated with TRM. In the postinfusion phase, patients who developed multiorgan dysfunction during the neutropenic period, especially when the lung was the first failing organ (RR 16.1, 95% CI 7.16–36.18, P= 0.0001), and those with engraftment syndrome (RR 2.81, 95% CI 1.49–5.24, P= 0.001) had an increased risk for TRM. On multivariate analysis, development of engraftment syndrome was the only significant variable that influenced TRM. In conclusion, the authors found for the first time that engraftment syndrome emerges as the main cause of TRM after autologous PBPC transplantation in children with malignancies.

Secondary acute leukemia (SAL) after treatment of osteosarcoma has been seldom reported in children. Two main mechanisms that can induce SAL have been described. The authors describe two patients who developed SAL after treatment with multiagent therapy. The first patient developed a secondary acute leukemia after treatment with alkylating agents and platinum compounds. The second patient had the clinical and molecular features of a secondary acute leukemia due to topoisomerase II inhibitors. The authors also discuss the data regarding cisplatin-associated SAL. Different molecular and pathogenic agents may be implicated in the development of second malignant neoplasms in long-term survivors of osteosarcomas.