Search

Supplementary Figure 1: Consort flow diagram of patient flow through TT4 arms Supplementary Figure 2: Cumulative Incidence of Death and Post-Relapse Survival (P-values for S-TT4 vs L-TT4; TRM, p = 0.61; MRM, p = 0.70; OIM, p = 0.25). Supplementary Figure 3: Clinical outcomes according to the presence of PETidentified focal lesions (FL; =3) by TT4 arm Supplementary Figure 4: Ingenuity pathways identified a network of 8 interrelated genes.

Supplementary Table 1: Total Therapy 4 (TT4) protocol schema Supplementary Table 2: Adverse Events by Arm and Maximum NCI CTC Grade Supplementary Table 3: Top 51 gene probes distinguishing multiple myeloma with and without cytogenetic abnormalities (CA)

BACKGROUND Umbilical cord blood unit (CBU) volume is a predictor of its later clinical utility. Many studies suggest the need to increase the volume of CBU collected, but most obstetrical providers receive no formal collection training. STUDY DESIGN AND METHODS We designed and implemented an educational curriculum for obstetrics residents aimed at improving collection methods and increasing CBU volumes (CBUV). Residents were required to attend grand rounds and interactive didactic sessions on CBU collection followed by work with a simulated collection kit and then performed training collections under observation by a trained collector. Residents completed a self-assessment after each collection and received immediate personal feedback. Outside providers (non-UAMS physicians) received written instructional materials with the collection kits and had access to online training materials. They received feedback regarding their collection via standard mail. CBU donated to Cord Blood Bank of Arkansas for public use from 2014-2016 were analyzed. CBUV from residents were compared to those from outside providers. RESULTS After adjusting for maternal age and race, infant gender, gestational age, and birth weight, the least-squared mean CBUV was 92.1 mL for UAMS collections and 65.5 mL for outside provider collections. The improved CBUV of UAMS providers is statistically significant (p < 0.0001). CONCLUSION Our educational intervention was successful, and we believe that it can be replicated in other obstetrical residency programs. Cord blood collection education involving hands-on training with a model and immediate feedback improves CBUV, decreases kit waste, increases likelihood of CBU storage, and, therefore, inventory for transplantation.

PURPOSE We evaluated the Optia® continuous mononuclear collection (CMNC) system for hematopoietic progenitor cell-apheresis (HPC-A) collection (Terumo BCT, Lakewood, CO) compared to the COBE® Spectra (Terumo BCT, Lakewood, CO), including both large volume leukapheresis (LVL) and non-LVL collections. METHODS We performed a retrospective data analysis of all autologous HPC-A collections with the Optia® CMNC system (n = 93; LVL = 59, non-LVL = 34) since implementation at our institution and compared it with a similar number of concurrent collections utilizing the COBE® Spectra (n = 96; LVL = 68, non-LVL = 28). The population studied included multiple myeloma (62 patients/171 collections) and lymphoma (5 patients/18 collections). Mobilization was achieved using chemotherapy + G-CSF (n = 108), chemotherapy + G-CSF + plerixafor (n = 67), G-CSF alone (n = 10), or G-CSF + plerixafor (n = 4). Based on our minimum predicted collection formula and the collection goal, 7-30 L of whole blood was processed. Per protocol, a minimum of 2 days of collection was performed. RESULTS HPC-A collected on Optia® CMNC had lower %HCT than those collected on COBE® Spectra (3.7 versus 4.3%, P = .029). There were no statistically significant differences between the two devices for other variables examined, including preapheresis WBC count and CD34+ cell count, procedure time, whole blood volume processed, collection efficiency (CE2), % platelet loss and throughput. CE2 for both devices was higher when

Purpose: To determine whether a reduction in the intensity of Total Therapy (TT) reduces toxicity and maintains efficacy. Experimental Design: A total of 289 patients with gene expression profiling (GEP70)-defined low-risk multiple myeloma were randomized between a standard arm (TT4-S) and a light arm (TT4-L). TT4-L employed one instead of two inductions and consolidations. To compensate for potential loss of efficacy of TT4-L, bortezomib and thalidomide were added to fractionated melphalan 50 mg/m2/d for 4 days. Results: Grade ≥3 toxicities and treatment-related mortalities were not reduced in TT4-L. Complete response (CR) rates were virtually identical (P = 0.2; TT4-S, 59%; TT4-L, 61% at 2 years), although CR duration was superior with TT4-S (P = 0.05; TT4-S, 87%; TT4-L, 81% at 2 years). With a median follow-up of 4.5 years, there was no difference in overall survival (OS) and progression-free survival (PFS). Whereas metaphase cytogenetic abnormalities (CAs) tended to be an adverse feature in TT4-S, as with predecessor TT trials, the reverse applied to TT4-L. Employing historical TT3a as training and TT3b as test set, 51 gene probes (GEP51) significantly differentiated the presence and absence of CA (q < 0.0001), seven of which function in DNA replication, recombination, and repair. Applying the GEP51 model to clinical outcomes, OS and PFS were significantly inferior with GEP51/CA in TT4-S; such a difference was not observed in TT4-L. Conclusions: We identified a prognostic CA-linked GEP51 signature, the adversity of which could be overcome by potentially synergizing anti–multiple myeloma effects of melphalan and bortezomib. These exploratory findings require confirmation in a prospective randomized trial. Clin Cancer Res; 23(11); 2665–72. ©2016 AACR.

Background & Aim BACKGROUND AND AIM: Public cord blood banks have thresholds for accepting cord blood unit (CBU) collections for processing based on economic models developed using surrogate markers of suitability, i.e. volume and total nucleated cell count (TNCC). Only after processing has it been possible to look at CD34+ cell numbers and colony forming units (CFU). Since as few as 0.52 × 105 CD34+ cells can be expanded in vitro and used successfully for transplant, it is important to understand what is in the smaller collections that public bank guidelines currently prevent from being processed. Hybrid public/private cord blood banks permit economic support from the private bank to help support the public bank. They also offer an opportunity to evaluate products outside public banking thresholds because all collections are processed. AIM To present data from the first 72 private cord blood unit (CBU) collections processed for the Cord Blood Bank of Arkansas, showing the relationship between collection volume, TNCC and CD34+ cell numbers. Methods, Results & Conclusion METHODS: The CBBA is a hybrid bank, providing cord blood banking for public, private and research use. Parents are informed of the different options for banking available, document their informed consent, and then receive a collection kit to bring to the delivering obstetrician. Cord blood is collected with the placenta in utero using Pall model # 791-08 collection kits. Collections are processed within 72 h of collection at a central site with plasma and red cells removed. Pre-processing TNCC are performed with a Beckman Coulter Ac.T Diff2 cell counter and TNCC determined as follows: actual cord blood weight x WBC 103/100=TNCC. Flow cytometry is performed using the ISHAGE technique with a Beckman Coulter CytoFLOW. RESULTS Mean maternal age for CBU was 34y (range 26-45). Of 72 CBU donated (37 male, 35 female), delivery route was spontaneous vaginal for 50 (69.45%) and caesarian section for 22 (30.55%). Mean birth weight was 3341.5 g (median 3355; range 2296-4337). Mean gestational age was 38.92 weeks (median 39; range 36-41.14). CONCLUSION Data on hematopoietic potential of low volume/low TNCC products are currently available only from a hybrid or private bank. Here we show that CBU below threshold TNCC and volume for public banks can have a significant number of CD34+ cells available for expansion and use in transplant.

Predictive algorithms for hematopoietic progenitor cell (HPC) collection are useful tools to increase efficiency of the collection, of the workflow in both the collection center and processing laboratory, and to facilitate concurrent quality assurance. Once established within a center, their use can also decrease costs by decreasing the number of days of growth factor used for mobilization and by decreasing the number of collection days or length of a collection, leading to a decrease in number of blood products transfused during collection since platelet loss can be minimized. Many approaches to predictive algorithms have been tried, and this chapter presents an overview of their history as well as a useful general strategy for current practice.

Umbilical cord blood unit (CBU) volume is a predictor of its later clinical utility. Many studies suggest the need to increase the volume of CBU collected, but most obstetrical providers receive no formal collection training.We designed and implemented an educational curriculum for obstetrics residents aimed at improving collection methods and increasing CBU volumes (CBUV). Residents were required to attend grand rounds and interactive didactic sessions on CBU collection followed by work with a simulated collection kit and then performed training collections under observation by a trained collector. Residents completed a self-assessment after each collection and received immediate personal feedback. Outside providers (non-UAMS physicians) received written instructional materials with the collection kits and had access to online training materials. They received feedback regarding their collection via standard mail. CBU donated to Cord Blood Bank of Arkansas for public use from 2014-2016 were analyzed. CBUV from residents were compared to those from outside providers.After adjusting for maternal age and race, infant gender, gestational age, and birth weight, the least-squared mean CBUV was 92.1 mL for UAMS collections and 65.5 mL for outside provider collections. The improved CBUV of UAMS providers is statistically significant (p 0.0001).Our educational intervention was successful, and we believe that it can be replicated in other obstetrical residency programs. Cord blood collection education involving hands-on training with a model and immediate feedback improves CBUV, decreases kit waste, increases likelihood of CBU storage, and, therefore, inventory for transplantation.

ADAMTS13 testing plays a critical role in confirming the clinical diagnosis of acquired idiopathic thrombotic thrombocytopenic purpura (TTP) and distinguishing it from other forms of thrombotic microangiopathies (TMA). Serial measurements of ADAMTS13 activity and inhibitor levels are also helpful in determining response to treatment and/or subsequent relapses. Numerous ADAMTS13 assays have been developed recently, including some with rapid turnaround times. Despite the good inter-assay correlation of different ADAMTS13 methodologies in published case studies, discrepancies have been shown to occur. Here we present a case where discrepant results were obtained using two different assays, posing a clinical treatment dilemma.

Uncovering the cellular and molecular mechanisms by which hematopoietic stem cell (HSC) self-renewal is regulated can lead to the development of new strategies for promoting ex vivo HSC expansion. Here, we report the discovery that alternative (M2)-polarized macrophages (M2-MΦs) promote, but classical (M1)-polarized macrophages (M1-MΦs) inhibit, the self-renewal and expansion of HSCs from mouse bone marrow (BM) in vitro. The opposite effects of M1-MΦs and M2-MΦs on mouse BM HSCs were attributed to their differential expression of nitric oxide synthase 2 (NOS2) and arginase 1 (Arg1), because genetic knockout of Nos2 and Arg1 or inhibition of these enzymes with a specific inhibitor abrogated the differential effects of M1-MΦs and M2-MΦs. The opposite effects of M1-MΦs and M2-MΦs on HSCs from human umbilical cord blood (hUCB) were also observed when hUCB CD34+ cells were cocultured with M1-MΦs and M2-MΦs generated from hUCB CD34- cells. Importantly, coculture of hUCB CD34+ cells with human M2-MΦs for 8 days resulted in 28.7- and 6.6-fold increases in the number of CD34+ cells and long-term SCID mice-repopulating cells, respectively, compared with uncultured hUCB CD34+ cells. Our findings could lead to the development of new strategies to promote ex vivo hUCB HSC expansion to improve the clinical utility and outcome of hUCB HSC transplantation and may provide new insights into the pathogenesis of hematological dysfunctions associated with infection and inflammation that can lead to differential macrophage polarization.

Clots may be seen during hematopoietic progenitor cell (HPC) collection or on product arrival to the cell therapy processing laboratory. We have always given one 81 mg acetylsalicylic acid (ASA) when clotting is seen during collection if there is no allergy, but hypothesized that the incidence of clotting would decrease if ASA was given to all autologous collectors with a platelet count of ≥80×10Autologous HPC were collected using the Spectra Optia instrument or Cobe Spectra instrument (Terumo BCTA total of 2574 HPC products were collected between September 2010 and August 2013; clotting was observed in 66 HPC products (66/2574; 2.56%). A total of 1906 HPC products were collected between November 2013 and October 2016; clotting was observed in 24 HPC products (24/1906; 1.25%). Thus an overall reduction was seen in incidence of clotting between groups 1 and 2 (2.56% versus 1.25;We observed an overall reduction in the incidence of clotting in our HPC products after initiating pre-emptive ASA usage (2.56% versus 1.25%

Platelet refractoriness or lack of platelet increase after platelet transfusion is seen in patients receiving chronic platelet transfusion support. Antibodies may develop against human platelet antigens (HPA) and/or against HLA class I antigens. Crossmatch (XM) compatible platelets or HLA-identical or HLA-compatible platelets are typically used to manage transfusion refractoriness. We aimed to determine if percent calculated Panel Reactive Antibody (% cPRA) against class I HLA antigens could predict percent positive platelet XM when looking for compatible transfusion products.A retrospective review of all platelet XM performed at our institution between 2008-2012 was performed, and patient characteristics recorded. For each patient, the percentage of all positive platelet XM performed was calculated and compared with the corresponding % cPRA levels against class I HLA antigens.Mean and median % positive platelet XM for all 50 patients tested in the period 2008-2012 were 61% and 60% (range 0-100%), respectively. Mean and median % cPRA levels were 66% and 68% (range 0-100%), respectively. No correlation was seen between age, sex, race, or diagnosis and positive platelet XM results.The results of our study indicate that the % cPRA correlates well with the % positive platelet XM. Thus, a higher % cPRA alerts the blood bank that additional platelets will be required for XM and/or that it would be beneficial to request HLA-identical or compatible units.

Acquired idiopathic thrombotic thrombocytopenic purpura is a life-threatening disease with a mortality of up to 90%, if not promptly recognized and treated. We report a 64-year-old woman with this condition who presented with left-sided weakness and seizure-like activity preceded by headache and easy bruising. She did not achieve optimal response to plasma exchange, corticosteroids, rituximab, and vincristine. We initiated treatment with eculizumab, following which she had durable remission that continued for 30 months after discontinuation of the drug. We later found that our patient has homozygous deletion in two closely related genes, complement factor H-related 1 and complement factor H-related 3.

Introduction Chronic graft-versus-host disease (cGVHD) is the leading cause of allogeneic hematopoietic stem cell transplantation (alloHSCT) related mortality and morbidity with limited understanding of its pathophysiology. The Cyclex ImmuKnow (IK) test, quantitatively measures the intracellular adenosine triphosphate levels in stimulated T cells. The IK test was FDA approved in 2002 as a functional measure of cell-mediated immunity (CMI) in the immunosuppressed population demonstrating predictive value in acute GVHD but its role in cGVHD is unclear. Methods We conducted a retrospective analysis of the role of IK in 8 alloHSCT. Four patients had a diagnosis of AML, two each had ALL and AA/MDS. All patients had IK drawn at initial diagnosis of cGVHD; five developed refractory cGVHD requiring photopheresis and had IK drawn during the period of ECP. The IK assay results were stratified as: low (0-225 ng/ml), normal (225-525 ng/ml) and high (>525 ng/ml). Results Of the 8 patients with cGVHD, at the time of diagnosis 6 had low IK, 1 was normal, and 1 was high. All of them were on two or more immune suppressive agents (IST) during the time of assay measurement. Post ECP levels did not vary significantly compared to pre-ECP levels except for one patient (Patient 3, Fig. 1) with high IK level (737 ng/ml) at diagnosis of cGVHD and subsequently had significant drop in her IK level after ECP (256 ng/ml at 60 days and 158 ng/ml at 140 days from the start of photopheresis). Discussion The IK values did not correlate with degree of chronic GVHD or its response to treatment with IST and ECP although it should be noted that cGVHD remained stable in all but one patient during the period of IK measurement. Nonetheless, in one patient with increased IK levels at the diagnosis of cGVHD IK decreased over time with slow improvement in her cGVHD, suggesting that levels might show some correlation with the treatment in responding patients. Longitudinal measurements over time may help to adjust IST, and further studies with standardized timing seem warranted.

Thrombotic thrombocytopenic purpura (TTP) results from a congenital or acquired deficiency of the von Willebrand factor (vWF)-cleaving protease ADAMTS13. The disease can be fatal and hence treatment should be initiated promptly. Therapeutic plasma exchange (TPE) remains the standard treatment along with adjunct therapies including steroids and immunosuppressive drugs. Addition of rituximab to TPE has been shown to be beneficial in refractory/relapsing TTP; however, TPE results in removal of rituximab from the circulation requiring more frequent dosing of rituximab to achieve a favorable outcome. The intermediate-purity plasma-derived Factor VIII concentrate (FVIII) Koate® contains the highest amount of ADAMTS13 activity yet reported and has been used successfully in treating congenital TTP. Here we report our experience with addition of this FVIII concentrate to rituximab, corticosteroids and TPE in three TTP patients with an ADAMTS13 inhibitor to permit withholding TPE for 48 h after rituximab infusion.

Introduction: Thrombocytopenia has been reported to predict for poor mobilization and apheresis collection of HPC (Morris CL et al., Br J Haematol 2003; 120(3): 413-23). Collection of HPC in lymphoma and myeloma patients often fails as the result of damage to the marrow following multiple cycles of chemotherapy, which may also result in persistent thrombocytopenia. Plerixafor reduces but does not eliminate collection failures due to poor mobilization. Eltrombopag is an FDA-approved drug for immune thrombocytopenia that has also been shown to be effective in improving all lineages in aplastic anemia. Eltrombopag has recently been shown in a dose-finding pilot study to improve HPC collection in myeloma patients. Here we report its addition to other standard measures to prevent failure to achieve the desired collection goal in myeloma (MM) and non-Hodgkin lymphoma (NHL) patients. Methods: We used our previously validated minimum daily predictive formula (Rosenbaum et al., Cytotherapy, 2012; 14: 461-466) to identify thrombocytopenic patients with predicted poor collections of CD34+ cells. These patients had predictions for collection of of Results: Six non-Hispanic white patients (pts) were identified who met study criteria: median age was 63 years (range 50-72), 3 male/3 female, 3 MM/3 NHL. All were heavily pretreated with chemotherapy: NHL patients had 2, 3 and 2 prior lines of therapy while MM patients had 5, 9 and 14 lines respectively. The median time from start of eltrombopag to start of collection was 11.5 days (range 4-19). The dose of eltrombopag was 50 mg daily (4 pts) and 2 pts needed dose escalation to 100 mg daily for successful collection. The median peak daily CD34 + cells from peripheral blood during collection was 10.75/uL (range 2.1-31.4). The mean predicted minimum daily CD 34 + cell collection totaled 4.7x 106 (range 3.6 - 6.8x106) and mean total CD 34+ cells actually collected was 6.28x106 (range 3.9-10.7x106). The median days needed for collection was 4 days (range 2-5). Six patients continued to transplant, with regimens of melphalan (MEL) 140 mg/m2 (1 MM), PACMED (1 MM), BEAM (MEL100 mg/m2, 1 MM) and BEAM (3 NHL). The median number of CD34+ cells/kg infused for transplant was 3.15 (range 1.6-4.3x106; mean 3.15). Mean day of WBC engraftment post-transplant was day 12 (range 9-17). Mean day of platelet (PLT) engraftment was day 22 (range 11-27) for 3 pts. Of the other 3, 1 had not engrafted at the time of data collection with a follow up of 19 days and 2 had PLT engraftment complicated by viral reactivation, of whom 1 was given a boost. Conclusions: Eltrombopag can be used successfully in NHL as well as MM patients, together with G-CSF and plerixafor, for mobilization and collection of HPC in heavily pretreated pts who are persistently thrombocytopenic prior to starting mobilization and who are predicted to be poor mobilizers. WBC engraftment after auto HPCT was not delayed relative to our historical data, but PLT engraftment was delayed in some cases, which is not uncommon in this patient population where extensive previous therapy has damaged the stem cell niche. Disclosures van Rhee: Takeda: Consultancy; Sanofi Genzyme: Consultancy; Castleman Disease Collaborative Network: Consultancy; EUSA: Consultancy; Adicet Bio: Consultancy; Kite Pharma: Consultancy; Karyopharm Therapeutics: Consultancy. OffLabel Disclosure: Eltrombopag is FDA approved for immune thrombocytopenia. In this study, it was used for thrombocytopenia thought due to previous chemotherapy

Mobilization regimens for CD34+ cells have generally been judged successful based on the number of cells collected without evaluating mobilization separately from collection. Using retrospective data for patients who collected CD34+ cells on Total Therapy protocols 3a/3b (VTD-PACE) and Total Therapy 4/5 using a novel regimen that added low dose melphalan to VTD-PACE (MVTD-PACE), we analyzed mobilization and collection variables separately. A significant difference favoring MVDT-PACE was found in mean CD34+ cells/µL on day 2 of collection and in mean ratio of CD34+ cells/µL on day 2 to day 1. However, because apheresis variables and growth factor dose during collection were manipulated to optimize individual collections, the two regimens were not significantly different when the mean total CD34+ cells ×10(6) /kg collected was compared. Thus, when evaluating a chemotherapy regimen or new growth factor for mobilization, it is important to realize that total CD34+ cells collected is dependent on both mobilization and collection variables.

Panel reactive antibody (PRA) reduction protocols are used to decrease anti-HLA antibodies with concomitant PRA monitoring as a measure of successful treatment prior to organ and haploidentical blood and marrow transplant (BMT). We hypothesized that the more sensitive flow cytometry (FC) based assays for PRA [FlowPRAA female patient with myelodysplastic syndrome and a high HLA class I PRA [90% PRA and cPRA by complement-dependent cytotoxicity (CDC) assay and Flow PRA] required allogeneic BMT. Baseline HLA Class I and class II antigen typing was performed and a matched sibling donor was identified. Although baseline anti-HLA class I and class II antibodies measured by FC and CDC revealed no donor specific antibodies (DSA), the decision was made to attempt antibody desensitization to facilitate platelet transfusion during BMT. FC and CDC assays were performed to determine anti-HLA class I antibodies and cPRA/%PRA prior to starting desensitization and at the end of desensitization. Over the course of desensitization and BMT, a total of 194 apheresis platelet units underwent cross-match (XM) using Capture-PHigh PRA by FC or CDC assays correlates with a high % of XM-positive (incompatible) platelet units. When the CDC PRA fell to 2% after desensitization, platelet XM incompatibility fell from 100% to 63% positive (incompatible). When the FC PRA fell to 5% the positive platelet XM fell to 5%.Antibody desensitization facilitated platelet transfusion. PRA determination by FC appeared better correlated than determination by CDC with the ability to find XM-compatible platelets.

The ability to predict how many CD34(+) cells a donor will collect on a given day is vital for efficient leukapheresis.We validated a formula to predict daily CD34(+) cell collections by leukapheresis, calculated as follows: (peripheral blood CD34(+) cells/L) × (adjusted collection efficiency of 30%)/body weight (kg), multiplied by the number of liters processed. This validation was performed from 234 donors undergoing 30 L large volume leukapheresis (LVL) and 162 donors undergoing smaller collections (non-LVL). The LVL group consisted of 811 collection events (625 multiple myeloma, 186 non-myeloma). The non-LVL group consisted of 224 collection events (196 multiple myeloma, 28 non-myeloma). All predicted and observed CD34(+) cell collection numbers were plotted (predicted versus observed) and assessed using linear regression analyses. Linear correlation coefficients (r-values), slopes and intercepts of the regression lines were evaluated.Predicted versus observed data points across all quantities of CD34(+) cells/kg collected by both LVL and non-LVL had strong r-values of 0.947 and 0.913, respectively, demonstrating near perfect positive linear correlations. Data for LVL collections subgrouped by number of cells collected (poor, intermediate and good), mobilization regimen, collection day and diagnosis were analyzed the same way and showed consistent findings.We have validated a formula with a strong ability to predict collection of CD34(+) cells/kg that would allow for individualization of collection for any donor once the peripheral blood CD34(+) cell count and optimal goal of collection were known; to date this has not been published by other groups.

BACKGROUND: Washed or volume-reduced platelets (PLTs) are occasionally requested for patients with a history of allergic or anaphylactic transfusion reactions. However, conclusive data are not available as to which method is more suitable. STUDY DESIGN AND METHODS: A direct comparison of saline-washed and volume-reduced PLTs was performed by splitting 11 units of 6-day-old apheresis PLT units. PLT activation, aggregation, plasma protein, and PLT count were determined before and after each procedure. To assess whether washing using neutral, calcium-free Ringer's acetate (NRA) would better preserve PLT function, 8 additional units of apheresis PLTs were split and were washed in saline or NRA. RESULTS: Saline washing resulted in significantly increased number of activated, P-selectin-expressing PLTs compared to volume reduction (24.2% vs. 10.3%, p = 0.001). Aggregation was also significantly reduced (-40.6% vs. -0.8%, p = 0.004). Plasma protein removal was significantly better for saline-washed than volume-reduced PLTs (96% vs. 51.1%, p < 0.001). PLT recovery was not significantly different for saline-washed versus volume-reduced PLTs (70.5% vs. 80.7%, p = 0.079). There was no difference between washing in saline or NRA with regard to PLT activation and loss of aggregation. CONCLUSIONS: PLT washing with saline or NRA significantly increases PLT activation and decreases PLT aggregability. On the other hand, volume reduction does not adequately remove plasma proteins. Therefore, PLT washing should be reserved for patients with a history of severe allergic or anaphylactic transfusion reactions. We suggest that fresher PLTs be selected to improve the functionality of washed PLTs.

Vaccination with idiotype (Id) protein-pulsed dendritic cells (DCs) has been explored in multiple myeloma and the results have been disappointing. To improve the efficacy of DC vaccination in myeloma, we investigated the use of Id- and keyhole limpet haemocyanin (KLH)-pulsed, CD40 ligand-matured DCs administered intranodally. Nine patients with smoldering or stable myeloma without treatment were enrolled and DC vaccines were administered at weekly intervals for a total of 4 doses. Following vaccination, all patients mounted Id-specific γinterferon T-cell response. Interleukin-4 response was elicited in 2, and skin delayed-type hypersensitivity reaction occurred in 7 patients. More importantly, Id-specific cytotoxic T-cell responses were also detected in 5 patients. Most if not all patients mounted a positive T-cell response to KLH following vaccination. At one-year follow-up, 6 of the 9 patients had stable disease, while 3 patients had slowly progressive disease even during the vaccination period. At 5-year follow-up, 4 of the 6 patients continued with stable disease. No major side effects were noted. In summary, intranodal administration of Id-pulsed CD40 ligand-matured DCs was able to induce Id-specific T and B-cell responses in patients. Current efforts are geared towards breaking tumour-mediated immune suppression and improving clinical efficacy of this immunotherapy.

Total therapy 3 incorporated bortezomib into a melphalan-based tandem transplant regimen for 303 newly diagnosed patients with myeloma. Induction chemotherapy prior to and consolidation chemotherapy after transplants each consisted of two cycles of VTD-PACE (bortezomib, thalidomide, dexamethasone and 4-d continuous infusions of cis-platin, doxorubicin, cyclophosphamide, etoposide); 3-year maintenance comprised monthly cycles of VTD in the first and TD in the remaining years. The median age was 59 years (age >64 years, 28%). A minimum of 20 x 10(6) CD34 cells/kg was collected in 87% of patients; 83% completed both transplants, and only 5% suffered a treatment-related death. At 24 months, 83% had achieved near-complete remission, which was sustained in 88% at 2 years from its onset. With a median follow-up of 20 months, 2-year estimates of event-free and overall survival were 84% and 86% respectively. The 44 patients who experienced an event more often had a high-risk gene array profile, cytogenetic abnormalities and indicators of high lactate dehydrogenase, beta-2-microglobulin, creatinine and International Staging System stage. Toxicities of grade > 2 included thrombo-embolic events in 27% and peripheral neuropathy in 12%. Results of this phase-2 study demonstrated that bortezomib could be safely combined with multi-agent chemotherapy, effecting near-complete remission status and 2-year survival rates in more than 80% of patients.

Summary Prognostic models for multiple myeloma have been fraught with tremendous heterogeneity in outcome among subgroups. In the context of Total Therapy 2, a tandem transplant trial for newly diagnosed myeloma, comprehensive information was available in 220 patients on standard prognostic factors (SPF), magnetic resonance imaging (MRI)-defined focal lesions, cytogenetic abnormalities (CA), fluorescence-in-situ-hybridisation (FISH)-derived amplification of chromosome 1q21 (amp1q21) and deletion of 13q14, as well as gene expression profiling (GEP). Five multivariate analysis-based survival models were derived, utilising SPF only (model 1), with progressive addition of CA (model 2), MRI (model 3), FISH (model 4) and GEP (model 5). The R 2 value, a measure of accounting for clinical outcome variability, increased progressively from 18% in model 1 to 38% in model 5. The hazard ratio for overall survival was highest for GEP (3AE07, P

Many SCD patients receive chronic transfusions for prevention or treatment of disease related complications. Complications of the chronic transfusion noted in these patients include allergic reactions, transfusion transmitted infections, iron overload, and alloantibody formation. Even though hemoglobin (Hb) variants are prevalent in the general population, reports of transfusion-acquired Hb variants are rare. We performed a retrospective analysis on all SCD patients who underwent red cell exchange (RBCEx) transfusions at our institution during 2011-2013 to identify the presence of Hb variants acquired as a result of RBCEx.We found 66 occurrences of acquired Hb variants in 30 SCD patients during the period examined. The most commonly acquired Hb variant was Hemoglobin C (HbC) (64/66 occurrences). More than half of the patients (19/30) acquired HbC on multiple occasions (2-6 times). One patient acquired HbJ and another patient acquired HbD/G in addition to HbC. The segments from donor units were available in some of these cases and hemoglobin electrophoresis (HBE) was performed to confirm the presence of the variant Hb in the donor segments corresponding to that seen on the post-RBCEx sample.Heterozygous donors are asymptomatic and show no abnormalities during donor screening. Since HBE is not routinely performed on the donor specimen, it may go unrecognized until the post-transfusion recipient results pose diagnostic difficulties. There are no definitive guidelines on deferring these donors; hence one should be cognizant of these findings to prevent misdiagnosis. In a population where HbS negative blood is routinely requested, the effect of other Hb variants remains unknown. None of the patients in our study showed any adverse events due to the acquired Hb variants; however, this is of special concern in the pediatric population where a single RBC unit can contribute a significant portion of the exchanged blood volume. Additionally, donor centers may need mechanisms to confirm the findings and counsel the donors as needed.

To molecularly define high-risk disease, we performed microarray analysis on tumor cells from 532 newly diagnosed patients with multiple myeloma (MM) treated on 2 separate protocols. Using log-rank tests of expression quartiles, 70 genes, 30% mapping to chromosome 1 (P < .001), were linked to early disease-related death. Importantly, most up-regulated genes mapped to chromosome 1q, and down-regulated genes mapped to chromosome 1p. The ratio of mean expression levels of up-regulated to down-regulated genes defined a high-risk score present in 13% of patients with shorter durations of complete remission, event-free survival, and overall survival (training set: hazard ratio [HR], 5.16; P < .001; test cohort: HR, 4.75; P < .001). The high-risk score also was an independent predictor of outcome endpoints in multivariate analysis (P < .001) that included the International Staging System and high-risk translocations. In a comparison of paired baseline and relapse samples, the high-risk score frequency rose to 76% at relapse and predicted short postrelapse survival (P < .05). Multivariate discriminant analysis revealed that a 17-gene subset could predict outcome as well as the 70-gene model. Our data suggest that altered transcriptional regulation of genes mapping to chromosome 1 may contribute to disease progression, and that expression profiling can be used to identify high-risk disease and guide therapeutic interventions.

The duration of neutropenia (absolute neutrophil count (ANC)or = 100/microl) identifies cancer patients at risk for infection. A test that precedes ANCor = 100/microl would be of clinical value. The immature reticulocyte fraction (IRF) reflects erythroid engraftment and hence a recovering marrow. We evaluated the IRF as predictor of marrow recovery among 90 myeloma patients undergoing their first and second (75 patients) melphalan-based autologous stem cell transplantation (Mel-ASCT). The time to IRF doubling (IRF-D) preceded ANCor = 100/microl in 99% of patients after the first Mel-ASCT by (mean+/-s.d.) 4.23+/-1.96 days and in 97% of the patients after the second Mel-ASCT by 4.11+/-1.95 days. We validated these findings in a group of 117 myeloma patients and 99 patients with various disorders undergoing ASCT with different conditioning regimens. We also compared the time to hypophosphatemia and to absolute monocyte countor = 100/microl to the time to ANCor = 100/microl. These markers were reached prior to this ANC end point in 55 and 25% of patients but were almost always preceded by IRF-D. We conclude that the IRF-D is a simple, inexpensive and widely available test that can predict marrow recovery several days before ANCor = 100/microl.

Although hematopoietic progenitor/stem cells (HPC) have been used for autologous transplants for approximately 25 years, it is only recently that we have begun to finally understand the factors which play important roles in causing these cells to leave their marrow niches and circulate in the blood. Still less is understood about factors important in homing of these cells from the blood to the marrow, and their re-engraftment there. Nonetheless, a significant amount of clinical information exists on how to make these cells leave the marrow in order to facilitate their collection from the blood for use as a transplant graft. This review provides an overview of what is currently known about the factors influencing mobilization of HPC from the marrow into the blood. Further, it suggests how this knowledge may be used to individually optimize collection of HPC. It is particularly important to optimize collection in the older myeloma patient, where it has traditionally been difficult to collect adequate numbers of cells for the tandem transplant now thought to provide the best hope for long-term survival in this disease.

The use of myeloma Ag-loaded mature DC vaccines, cryopreserved in single-use aliquots, is an attractive immunotherapeutic strategy. In this study we investigated the retention of phenotype, viability and potency of DC vaccines after freezing and thawing.Plastic-adherent monocytes, derived from a steady-state leukapheresis, were cultured in serum-free media containing GM-CSF and IL-4. DC were loaded on day 6 with myeloma lysate (ML) or idiotype (Id) Ag and keyhole limpet hemocyanin (KLH), induced to mature on day 7 with CD40-ligand and cryopreserved on day 9. Seventeen clinical-scale cultures were evaluated for DC yield, recovery and immunophenotype after potency was validated with allogeneic mixed lymphocyte culture and Ag presentation assays.We produced 88 individual vaccines from 17 clinical-scale cultures. Median DC yield at harvest was 131 x 10(6) (range 37-375 x 10(6)) and median recovery of viable DC after thawing was 69% (range 11-100%). We confirmed viability (7AAD-), phenotype (CD14-, CD83+/CD40+, CD83+/CD80+, CD83+/CD86+, CD83+/CD54+, HLA-DR++) and the ability of the DC to present Ag and stimulate allogeneic T cells post-thawing.We have validated a serum-free culture system for the production of DC. Cryopreservation did not interfere with DC activity, allowed time for rigorous quality control (QC) and flexible scheduling of intranodal vaccination, and reduced the time to prepare multiple vaccines.

We have investigated the interaction between tumor cells and specific cells in their microenvironment using myeloma as a model. The role of myeloma-induced osteoclastogenesis in the disease was studied ex vivo. Myeloma plasma cells freshly purified from patients’ bone marrow attracted committed osteoclast (OC) precursors (n = 9; P < 0.01) and in 22 experiments directly induced their differentiation to multinucleated, bone-resorbing OCs (P < 0.00002) in a receptor activator of nuclear factor-κB ligand-mediated mechanism that was inhibited by the receptor activator of nuclear factor-κB (RANK-Fc) in 13 experiments by 71 ± 12% (P < 0.008). In contrast, myeloma cells did not induce differentiation of peripheral blood mononuclear cells. Myeloma plasma cells cocultured with OCs retained their viability and proliferative activity for >13 weeks. After 14 days in coculture, the plasma cells from 29 patients had higher viability (P < 2 × 10−6), fewer apoptotic cells (P < 4 × 10−15), and a higher bromodeoxyuridine labeling index (P < 0.0006) than controls. Physical contact between OCs and myeloma cells was required for these effects to take place. No differences were observed between OCs from healthy donors and those from myeloma patients. Blocking interleukin 6 activity, while reducing survival of myeloma cells, had no effect on their proliferative activity. These results support data obtained from animal models and clinical observations on the essential role of the microenvironment in tumor sustenance and progression.

Purpose: To improve outcome in previously treated patients (at least two cycles of standard therapy) with multiple myeloma, thalidomide was combined with cytotoxic chemotherapy as induction therapy. Patients and Methods: The regimen consisted of 4-days of oral dexamethasone, daily thalidomide, and 4 days of continuous-infusion cisplatin, doxorubicin, cyclophosphamide, and etoposide (DTPACE). Response to two cycles of DTPACE for induction was evaluated in 236 patients. Before being treated with DTPACE, 148 patients (63%) had shown progressive disease while receiving standard chemotherapy, and 55 patients (23%) had chromosome 13 abnormalities. Results: The partial remission rate (PR) after two cycles of DTPACE was 32%, with 16% attaining a complete remission (CR) or near-CR (nCR; defined as only immunofixation electrophoresis–positive). Patients with high lactate dehydrogenase (LDH; n = 98) showed a better response than those with normal LDH (n = 138): PR or better, 43% v 27% (P = .01); CR + nCR, 25% v 11% (P = .01). Patients with chromosome 13 abnormalities (n = 55) responded equally well as the other patients (n = 181): PR or better, 35% v 33% (P = .84); CR + nCR, 17% v 15% (P = .73). Patients who received 100% dose of DTPACE for two cycles (n = 115) achieved higher response rates than those with less than 100% dose (n = 121): PR or better, 49% v 17% (P < .0001); CR + nCR, 27% v 6% (P < .0001). Conclusion: Combination therapy of oral dexamethasone and thalidomide with infusional chemotherapy is effective as induction therapy before autotransplantation, especially in patients with high-risk features.

Background: Sweet syndrome (SS), a paraneoplastic syndrome characterized by fever, neutrophilia, multiple erythematous painful plaques, and a dense dermal neutrophilic infiltration, has a known association with hematologic malignancies such as acute myelogenous leukemia. However, no clear association with multiple myeloma (MM) has been reported. Materials and methods: Pathology reports of the 2357 patients with multiple myeloma at the University of Arkansas for Medical Sciences were reviewed to retrieve cases who had developed SS. Cytogenetic studies and immunoglobulin secretory status were retrieved. Five cases of SS in MM and 25 cases of SS in patients without MM underwent syndecan-1 immunohistochemistry. Observations: Six cases of SS occurring in the setting of MM showed a predominance in patients secreting IgG paraprotein. Five of the six patients received granulocyte-colony stimulating factor while the sixth received granulocyte-monocyte-colony stimulating factor. Fifty percent showed a non-specific cytogenetic anomaly. Conclusions: There is no specific cytogenetic anomaly associated with SS in the setting of MM. This paraneoplastic syndrome may be secondary to elevated levels of granulocyte colony stimulating factor (G-CSF), possibly with a component of enhanced sensitivity to endogenous G-CSF. The immunoglobulin secretory status parallels that seen in MM with cutaneous involvement, but IgG secretors may be at an increased risk of developing SS compared with their counterparts who secrete other immunoglobulins.

Summary. The mobilization of peripheral blood stem cells was studied in 984 multiple myeloma patients, including 106 patients aged ≥ 70 years. Increasing age correlated inversely with CD34+ yield (P 12 months prior therapy and premobilization platelet count

Successful blood and marrow transplant (BMT), both autologous and allogeneic, requires the infusion of a sufficient number of hematopoietic progenitor/stem cells (HPCs) capable of homing to the marrow cavity and regenerating a full array of hematopoietic cell lineages in a timely fashion. At present, the most commonly used surrogate marker for HPCs is the cell surface marker CD34, identified in the clinical laboratory by flow cytometry. Clinical studies have shown that infusion of at least 2 × 106 CD34+ cells/kg recipient body weight results in reliable engraftment as measured by recovery of adequate neutrophil and platelet counts approximately 14 days after transplant. Recruitment of HPCs from the marrow into the blood is termed mobilization, or, more commonly, stem cell mobilization. In Section I, Dr. Tsvee Lapidot and colleagues review the wide range of factors influencing stem cell mobilization. Our current understanding focuses on chemokines, proteolytic enzymes, adhesion molecules, cytokines and stromal cell-stem cell interactions. On the basis of this understanding, new approaches to mobilization have been designed and are now starting to undergo clinical testing. In Section II, Dr. Michele Cottler-Fox describes factors predicting the ability to mobilize the older patient with myeloma. In addition, clinical approaches to improving collection by individualizing the timing of apheresis and adjusting the volume of blood processed to achieve a desired product are discussed. Key to this process is the daily enumeration of blood CD34+ cells. Newer methods of enumerating and mobilizing autologous blood HPCs are discussed. In Section III, Dr. John DiPersio and colleagues provide data on clinical results of mobilizing allogeneic donors with G-CSF, GM-CSF and the combination of both as relates to the number and type of cells collected by apheresis. Newer methods of stem cell mobilization as well as the relationship of graft composition on immune reconstitution and GVHD are discussed.

Highly activated/expanded natural killer (NK) cells can be generated by stimulation with the human leukocyte antigen-deficient cell line K562, genetically modified to express 41BB-ligand and membrane-bound interleukin (IL)15. We tested the safety, persistence, and activity of expanded NK cells generated from myeloma patients (auto-NK) or haploidentical family donors (allo-NK) in heavily pretreated patients with high-risk relapsing myeloma. The preparative regimen comprised bortezomib only or bortezomib and immunosuppression with cyclophosphamide, dexamethasone, and fludarabine. NK cells were shipped overnight either cryopreserved or fresh. In 8 patients, up to 1×10⁸ NK cells/kg were infused on day 0 and followed by daily administrations of IL2. Significant in vivo expansion was observed only in the 5 patients receiving fresh products, peaking at or near day 7, with the highest NK-cell counts in 2 subjects who received cells produced in a high concentration of IL2 (500 U/mL). Seven days after infusion, donor NK cells comprised90% of circulating leukocytes in fresh allo-NK cell recipients, and cytolytic activity against allogeneic myeloma targets was retained in vitro. Among the 7 evaluable patients, there were no serious adverse events that could be related to NK-cell infusion. One patient had a partial response and in another the tempo of disease progression decreased; neither patient required further therapy for 6 months. In the 5 remaining patients, disease progression was not affected by NK-cell infusion. In conclusion, infusion of large numbers of expanded NK cells was feasible and safe; infusing fresh cells was critical to their expansion in vivo.

Disease relapse occurs in 50% or more of patients who are autografted for relapsed or refractory lymphoma (NHL) or Hodgkin's disease (HD). The administration of non-cross-resistant therapies during the post-transplant phase could possibly control residual disease and delay or prevent its progression. To test this approach, 55 patients with relapsed/refractory or high-risk NHL or relapsed/refractory HD were enrolled in the following protocol: stem cell mobilization: cyclophosphamide (4.5 g/m2) + etoposide (2.0 g/m2) followed by GM-CSF or G-CSF; high-dose therapy: gemcitabine (1.0 g/m2) on day −5, BCNU (300 mg/m2) + gemcitabine (1.0 g/m2) on day −2, melphalan (140 mg/m2) on day −1, blood stem cell infusion on day 0; post-transplant immunotherapy (B cell NHL): rituxan (375 mg/m2) weekly for 4 weeks + GM-CSF (250 μg thrice weekly) (weeks 4–8); post-transplant involved-field radiotherapy (HD): 30–40 Gy to pre-transplant areas of disease (weeks 4–8); post-transplant consolidation chemotherapy (all patients): dexamethasone (40 mg daily)/cyclophosphamide (300 mg/m2/day)/etoposide (30 mg/m2/day)/cisplatin (15 mg/m2/day) by continuous intravenous infusion for 4 days + gemcitabine (1.0 g/m2, day 3) (months 3 + 9) alternating with dexamethasone/paclitaxel (135 mg/m2)/cisplatin (75 mg/m2) (months 6 + 12). Of the 33 patients with B cell lymphoma, 14 had primary refractory disease (42%), 12 had relapsed disease (36%) and seven had high-risk disease in first CR (21%). For the entire group, the 2-year Kaplan–Meier event-free survival (EFS) and overall survival (OS) were 30% and 35%, respectively, while six of 33 patients (18%) died before day 100 from transplant-related complications. The rituxan/GM-CSF phase was well-tolerated by the 26 patients who were treated and led to radiographic responses in seven patients; an eighth patient with a blastic variant of mantle-cell lymphoma had clearance of marrow involvement after rituxan/GM-CSF. Of the 22 patients with relapsed/refractory HD (21 patients) or high-risk T cell lymphoblastic lymphoma (one patient), the 2-year Kaplan–Meier EFS and OS were 70% and 85%, respectively, while two of 22 patients (9%) died before day 100 from transplant-related complications. Eight patients received involved field radiation and seven had radiographic responses within the treatment fields. A total of 72 courses of post-transplant consolidation chemotherapy were administered to 26 of the 55 total patients. Transient grade 3–4 myelosuppression was common and one patient died from neutropenic sepsis, but no patients required an infusion of backup stem cells. After adjustment for known prognostic factors, the EFS for the cohort of HD patients was significantly better than the EFS for an historical cohort of HD patients autografted after BEAC (BCNU/etoposide/cytarabine/cyclophosphamide) without consolidation chemotherapy (P = 0.015). In conclusion, post-transplant consolidation therapy is feasible and well-tolerated for patients autografted for aggressive NHL and HD and may be associated with improved progression-free survival particularly for patients with HD. Bone Marrow Transplantation (2002) 29, 303–312. doi:10.1038/sj.bmt.1703363

BACKGROUND: Blood group incompatibility does not appear to affect the overall outcome in patients undergoing myeloablative conditioning before allogeneic BMT. Data on ABO-mismatched transplantation in the nonmyeloablative setting are limited. STUDY DESIGN AND METHODS: A retrospective analysis of the effects of ABO mismatches in multiple myeloma patients who received a nonmyeloablative conditioning regimen was conducted. RESULTS: Three of 27 patients received a minor ABO-mismatched graft, all with evidence of hemolysis before converting to donor ABO group on Days 10, 15, and 6. Six patients received a major ABO-mismatched graft; of these, three developed GVHD of more than grade 2 and subsequently converted to the ABO blood group of the donor on Days 38, 33, and 43. Of the three patients without GVHD, one rejected the allograft and had autologous reconstitution. One remained a mixed chimera to Day 100 despite three donor lymphocyte infusions, and one developed pure RBC aplasia. None of the ABO-matched patients rejected the graft, whether they developed GVHD or not. RBC transfusions were significantly higher in the major and minor ABO-mismatched patients than in the ABO-matched patients, with medians of 12 units (range, 2-35), 13 units (range, 5-18), and 4 units (range, 2-15), respectively (p = 0.02). ABO-matched patients had a similar incidence of GVHD, with 5 of 9 ABO-mismatched patients (56%) having more than grade 2 versus 10 of 18 (56%). Four of 9 ABO-mismatched patients (44%) were mixed chimeras up to Day 100 versus 2 of 18 ABO-matched patients (11%), and the difference was significant (p = 0.01). CONCLUSION: Patients with ABO mismatch had problems with engraftment, including graft rejection, pure RBC aplasia, and mixed-lineage chimerism. RBC transfusions were significantly higher in the ABO-mismatched recipients. GVHD may play a role in engraftment, possibly by facilitating the disappearance of native ABO antibodies via graft-versus-plasma cell effect. A prospective study to evaluate the effects of ABO mismatch on engraftment in the nonmyeloablative setting is needed.

We validated the correlation of aldehyde dehydrogenase ALDH(br) cells with total and viable CD34(+) cells in fresh and thawed hematopoietic progenitor cell (HPC) products, and looked for a correlation with time to white blood cell (WBC) and platelet engraftment after autologous transplantation, using simple linear regression analyzes. We found a significant correlation between pre-freeze ALDH(br) cell numbers and pre-freeze total CD34(+) (P0.001), viable CD34(+) (P0.001) and post-thaw viable CD34(+) (P0.001) cell numbers. We suggest that ALDH(br) may be substituted for CD34(+) cell numbers when evaluating HPC. As post-thaw viability testing apparently adds no significant information, we suggest that it may not be necessary. Finally, neither marker correlated with time to engraftment in our patients, supporting previous data suggesting the existence of a threshold dose for timely engraftment around 2.5 × 10(6) cells/kg.

We report on three patients with multiple myeloma who developed drug-induced pneumonitis 1-2(1/2) months following maintenance (post autologous transplantation) chemotherapy with CDEP (cyclophosphamide, dexamethasone, etoposide, cisplatin) and 6-20 months after exposure to carmustine (BCNU) 300 mg/m(2), used in combination with melphalan 140 mg/m(2), as pre-transplant conditioning regimen. All patients had either a proven (two) or suspected (one) fungal pneumonia and were treated with liposomal amphotericin B. Dyspnea, fever and cough were the prominent clinical symptoms, while air-space disease with ground glass appearance was seen radiographically. Histologic features typical for drug-induced lung injury were detected. All patients had a dramatic, clinical and radiographic response to a brief course of corticosteroids. Although CDEP-induced pneumonitis appears to be a rare complication, its early recognition and prompt treatment, as well as its possible association with preceding fungal infection may have important clinical implications.

In a retrospective study, we examined the association between cytomegalovirus (CMV) infection and non-neutropenic fever immediately following autologous peripheral blood stem cell transplantation for a variety of haematological malignancies and solid tumours. Sixty non-neutropenic febrile episodes (41 in CMV-seropositive and 19 in CMV-seronegative patients) were evaluated. CMV reactivation, documented by CMV antigenaemia, was detected in 16 out of 41 (39%) seropositive patients compared with 0 out of 19 seronegative patients. In 12 of these 16 patients, CMV infection was considered the sole cause of fever. Thirteen patients had maximum antigenaemia levels > 5 cells/slide. Specific antiviral treatment led to the resolution of the fever in all, but two, patients, who developed fatal CMV pneumonia. Patients with multiple myeloma and lymphoma, possibly owing to a combination of disease-related characteristics and prior immunosuppressive treatment, had high rates of CMV reactivation and may require more frequent diagnostic evaluation and prompt therapeutic intervention.

Adenoviruses are increasingly recognized as a significant cause of morbidity and mortality in immunocompromised patients. We report on a patient who, approximately 4 weeks after allogeneic stem cell transplantation, developed fever, new liver lesions and thrombotic microangiopathy. Adenovirus type 2 was isolated from blood and urine samples. Liver biopsy showed parenchymal necrosis with intranuclear viral inclusion bodies. Immunohistochemistry was positive for adenovirus. In addition, on electron microscopy the morphologic pattern was highly suggestive of adenovirus. The patient died on post-transplant day 40. The relatively early post-transplant presentation of disseminated adenoviral disease and its possible association with a TTP-like picture are rather unusual after allogeneic transplantation.

We carried out a retrospective analysis of viability by diagnosis and dimethyl sulfoxide (DMSO) concentration in patients who had undergone autologous transplants using hematopoietic progenitor cells (HPC) after long-term storage (up to 17.8 years).Viability was tested using flow cytometry for HPC that were harvested and preserved using a controlled rate freezer and 5% or 10% DMSO with human serum albumin, then stored in liquid nitrogen. Data from 262 samples were analyzed (249 myeloma patients and 13 other diagnoses): 100 consecutively thawed samples with a storage time of1 year (all 10% DMSO), 50 consecutive samples stored for 1-4.9 years (10% DMSO), 50 samples stored for 5-9 years (5% DMSO) and all samples stored and used for transplant after9 years (60 samples, 5% DMSO; two samples, 10% DMSO).No statistically significant difference in viability between the 5% DMSO and 10% DMSO groups was observed (P = 0.08), so the 1-4.9 years and 5-9 years were combined and the three groups (1 year, 1-9 years and9 years) were compared using an anova test. There was no difference in viability based on cryostorage period (P = 0.23) or between myeloma and other diagnoses (P = 0.45). No difference was seen in time to White blood cell (WBC) engraftment (P = 0.10) or to platelet engraftment between groups (P = 0.52).These data suggest that long-term storage in 5% DMSO and human serum albumin is safe.

Immunosuppressive therapy, routinely given after allogeneic transplantation to modulate graft-versus-host disease (GVHD) may have an adverse effect on the graft-versus-tumour (GVT) effect. Twelve patients with high-risk haematological malignancies were given cyclophosphamide, total body irradiation and antithymocyte globulin followed by peripheral blood stem cell grafts from HLA-identical siblings without prophylactic immunosuppression. At the earliest clinical evidence of GVHD, patients were treated with high-dose solumedrol and tacrolimus. Prompt haematological recovery [absolute neutrophil count (ANC) > 1.0 x 109/l] was observed (median time 9 d). All patients developed grade III-IV GVHD (median onset 9 d), involving the skin (11), intestine (five) and liver (three). Of nine evaluable patients, seven developed chronic GVHD [extensive (six), limited (one)]. Six patients died 1-6.5 months after transplantation. Three patients died from treatment-related complications, two from acute GVHD and one from relapsing disease. The remaining six patients are alive 5-26 months after transplantation, five in complete remission and one myeloma patient in very good partial remission. In conclusion, omission of post-transplantation GVHD prophylaxis is feasible, does not lead to graft failure or a high incidence of uncontrollable GVHD and appears to be associated with encouraging clinical responses in a group of patients with high-risk disease features.