Hydroxyurée avant chimiothérapie intensive chez des patients atteints de leucémies aiguës myéloïdes hyperleucocytaires

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

CD34+ cell selection methods, quality controls and expected results: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)

CD34+ immunomagnetic positive selection allows for CD34+ hematopoietic progenitors separation from CD3+ lymphocytes subsets, usually from an apheresis product collected from a previously mobilized donor. This T-cell depleted stem cell graft is primarily intended for rare cases (around 2% of allotransplanted patients in France) of severe, persistent, symptomatic bi- or tri-cytopenia post-allotransplantation, in order to allow for hematologic reconstitution without increasing the risk of GvHD occurrence. Although semi-manual and complex, the process is of sufficient robustness to consistently generate a cellular product with distinctive features and specifications, based on iterative in-process quality controls, that are discussed within these guidelines

Procédé de préparation, contrôles de qualité et spécifications des immunosélections CD34+ : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC)

L’immunosélection CD34+ consiste à isoler, le plus fréquemment à partir d’un prélèvement d’aphérèse chez un donneur préalablement mobilisé, les progéniteurs hématopoïétiques CD34+ des autres cellules mononucléées et, notamment, des populations d’effecteurs immuns matures. Cette préparation de thérapie cellulaire est principalement destinée aux rares cas de bi- ou tri-cytopénies sévères symptomatiques persistantes post-allogreffe (environ 2 % des patients allogreffés en France), afin de permettre une reconstitution de l’hématopoïèse tout en limitant le risque de survenue de GvHD. Cette technique d’immunosélection, complexe mais robuste, conduit à l’obtention d’un produit cellulaire dont les caractéristiques et spécifications, basées sur des contrôles qualité mis en œuvre tout au long du procédé, font l’objet de ces recommandations

Vaccination of allogeneic haematopoietic stem cell transplant recipients: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC).

peer reviewedDuring immune reconstitution following allogeneic haematopoietic stem cell transplantation (allo-HSCT), (re)vaccination of allo-HSCT recipients is recommended. Herein, we propose an update of practical recommendations regarding vaccination of allo-HSCT recipients. These recommendations, based on data from the literature, national and international guidelines and the consensus of the participants when no formally proven data are available, were elaborated during the workshop of practice harmonization organized by the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) in Lille in September 2022

Real-life considerations on antifungal treatment combinations for the management of invasive mold infections after allogeneic cell transplantation

Background: Antifungal combination treatment is frequently administered for invasive mold infections (IMIs) after allogeneic hematopoietic cell transplantation (HCT). Here, we describe the indications, timing, and outcomes of combination antifungal therapy in post-HCT IMI. Methods: A single-center, 10-year, retrospective cohort study including all adult HCT recipients with proven/probable IMI between 1 January 2010 and 1 January 2020 was conducted. Results: During the study period, 515 patients underwent HCT, of whom 47 (9.1%) presented 48 IMI episodes (46 patients with one IMI episode and 1 patient with two separate IMI episodes): 33 invasive aspergillosis (IA) and 15 non-IA IMIs. Almost half (51%) of the patients received at least one course of an antifungal combination (median: 2/patient): 23 (49%), 20 (42%), and 4/47 (9%) patients received pure monotherapy, mixed monotherapy/combination, and pure combination treatment, respectively. Combination treatment was started at a median of 8 (IQR: 2, 19) days post-IMI diagnosis. Antifungal management was complex, with 163 treatment courses prescribed overall, 48/163 (29.4%) concerning antifungals in combination. The clinical reasons motivating the selection of initial combination antifungal therapy included severe IMI (18, 38%), lack of antifungal susceptibility data (14, 30%), lack of pathogen identification (5, 11%), and combination treatment until reaching a therapeutic azole serum level (6, 13%). The most common combination treatments were azole/liposomal amphotericin-B (28%) and liposomal amphotericin-B/echinocandin (21%). Combination treatment was administered cumulatively for a median duration of 28 days (IQR: 7, 47): 14 (IQR: 6, 50) days for IA and 28 (IQR: 21, 34) days for non-IA IMI (p = 0.18). Overall, 12-week mortality was 30%. Mortality was significantly higher among patients receiving ≥50% of treatment as combination (logrank = 0.04), especially those with non-IA IMI (logrank = 0.03). Conclusions: Combination antifungal treatment is frequently administered in allogeneic HCT recipients with IMI to improve clinical efficacy, albeit in an inconsistent and variable manner, suggesting a lack of relevant data and guidance, and an urgent need for new studies to improve therapeutic options.</p

Salvage Treatment of Refractory HSV Oral Lesions with Pritelivir in Allogeneic Hematopoietic Cell Transplant Recipients

We present two allogeneic hematopoietic cell transplantation recipients (HCTr) treated with pritelivir for acyclovir-resistant/refractory (r/r) HSV infection based on the expanded access program of the pritelivir manufacturer. Outpatient treatment with pritelivir was administered, with partial response by week 1 of treatment and complete response by week 4 of treatment in both patients. No adverse events were noted. Pritelivir appears to be an effective and safe option for the management of acyclovir-r/r HSV infections in highly immunocompromised patients in an outpatient setting

Successful treatment of central nervous system lymphoproliferative disorder in a kidney-pancreas and stem cell transplanted patient using intrathecal rituximab

Central nervous system lymphoproliferative disorder (CNS-PTLD) after organ transplant is a unique clinicopathological entity and is associated with poor survival rates. When the CNS is involved, intravenous rituximab might not be the treatment of choice, due to its poor CNS penetration. However, intrathecal (IT) administration of rituximab has shown to be safe and efficient in small studies and in case series. We report here the case of a patient with late development of CNS-PTLD after kidney-pancreas transplantation who achieved complete remission after surgical resection and four cycles of IT rituximab and we provide a review of the literature for this treatment option

Real-world experience of sorafenib maintenance after allogeneic hematopoietic stem cell transplantation for FLT3-ITD AML reveals high rates of toxicity-related treatment interruption

Sorafenib significantly improves survival of FLT3-ITD mutated AML patients when used as a post-allogeneic HSCT maintenance. Importantly, clinical trials reported a low rate of toxicities requiring sorafenib discontinuation. The aim of our analysis was to evaluate the real-world experience in patients treated with post-allogeneic HSCT sorafenib maintenance therapy for FLT3-ITD AML with a particular focus on tolerability and toxicity-related treatment interruption. We conducted a single-center retrospective study on 30 FLT3-ITD AML patients undergoing allogeneic HSCT in complete remission between 2017 and 2020 and who received sorafenib maintenance. 26 patients (87%) experienced toxicities leading to dose reduction (n=9) or direct interruption (n=17). Average time on sorafenib was 125 days (range 1-765). Most common toxicities were skin, gastrointestinal, and hematologic. Among patients who had a dose reduction, 4 eventually interrupted the drug and 5 were able to continue. Among patients who interrupted sorafenib because of toxicities, 7 were re-challenged with good tolerance in 3 cases. Overall, 18 patients (60% of the entire cohort) definitively discontinued sorafenib because of toxicities. 14 patients were thereafter switched to midostaurin. Importantly, with a median follow-up of 12 months, the median overall survival was not reached suggesting a positive impact of sorafenib maintenance despite the high rates of treatment interruption. In conclusion, our real-world analysis reveals high rates of toxicity-related interruption of sorafenib maintenance after allogeneic HSCT. Interestingly, our results suggest the feasibility of re-challenging with sorafenib and/or of switching to other maintenance approaches in case of intolerance

When and how do we stop antifungal treatment for an invasive mould infection in allogeneic haematopoietic cell transplant recipients?

Background: Limited data exist to describe end-of-treatment (EOT) parameters of antifungal therapy for invasive mould infections (IMI). Methods: In a 10-year cohort of consecutive adult allogeneic haematopoietic cell transplant recipients with proven/probable IMI, we describe treatment duration and patient profile at EOT. Results: There were 61 patients with 66 proven/probable IMI identified: 47/66 (71%) invasive aspergillosis (IA), 11/66 (17%) mucormycosis, and 8/66 (12%) other-IMI. Excluding 5 (8%) patients lost to follow-up, treatment was prematurely discontinued due to death or palliative care in 29/56 (51.8%) patients. Antifungal treatment was completed in 27 (48.2%) patients, for a median duration of 280 days (IQR: 110, 809): 258 (IQR: 110, 1905) and 307.5 (99, 809) days in IA and non-IA IMI, respectively. Treatment was continued after 90 and 180 days in 43/56 (76.8%) and 30/56 (53.6%) patients, respectively. At EOT, most patients were not neutropenic (ANC: 2.12 G/L, IQR: 0.04, 5.3), with CD4+ counts at 99 cells/μl (IQR: 0, 759) and immunoglobulins at 5.6 g/L (IQR: 2.3, 10.6). Most patients (16/27, 59.3%) were not receiving steroids at EOT, while 14/27 (53.9%) were on another type of immunosuppression. Amongst 15 patients with imaging at EOT, 12 (80%) had complete/partial radiologic response. Any chart documentation or an infectious disease consultation on treatment discontinuation was observed in 12/56 (21%) and 11/56 (20%) patients, respectively. Conclusions: Long treatment courses are observed in patients with IMI, due to prolonged immunosuppression. Although immune reconstitution and radiological response were frequently observed at EOT, consistent documentation of treatment discontinuation based on well-defined parameters is lacking.</p

Successful Treatment of Saksenaea sp. Osteomyelitis by Conservative Surgery and Intradiaphyseal Incorporation of Amphotericin B Cement Beads

International audienceOsteoarticular mucormycosis cases are quite rare and challenging infections that are mostly due to direct inoculation during traumatic injury among immu-nocompetent patients. Classic management includes a combination of aggressive surgical debridement, which may lead to amputation, and long-term systemic lipo-somal amphotericin B therapy. This article describes the successful treatment of Sak-senaea sp. osteomyelitis in a patient with diabetes mellitus, using a combination of systemic antifungal therapy and conservative surgery with insertion of amphotericin-impregnated cement beads. KEYWORDS Mucorales, amphotericin B, antifungal agents, osteomyelitis M ucorales osteomyelitis still presents diagnostic and therapeutic challenges and is associated with high mortality rates despite a combined therapeutic strategy involving antifungal treatment and surgery (1). Members of the order Mucorales are present in soil and plant debris and could be responsible for osteoarticular mucormy-cosis as a consequence of contamination through disrupted cutaneous barriers after traumatic injury (2). Surgical management is classically aggressive and complicated, with poor functional outcomes or even amputation. We report the first successful conservative orthopedic treatment of Saksenaea sp. osteomyelitis in a patient with diabetes mellitus, using in situ amphotericin-impregnated cement beads in combination with systemic posaconazole therapy. A 63-year-old man was admitted for a painful and swollen right ankle. He had well-controlled diabetes mellitus, hypertension, and degenerative arthritis. He lived in France and had never travelled overseas. Seven years earlier, he had suffered ankle trauma due to a rockfall and developed a necrotic subcutaneous abscess and a diaphyseal periosteal reaction seen on X-ray films. He underwent surgical drainage of the abscess; the sample cultures remained sterile and the surgical wound outcome was marked by a purple painless cutaneous infiltration. Seven years after the first operation, the patient's ankle became painful again and a bone biopsy was performed, which revealed no microorganisms in cultures. Empirical broad-spectrum antibiotherapy was initiated, without efficacy. Lower leg pain, erythema, and edema worsened and a satellite, 4-cm, right inguinal area of lymphadenopathy appeared. The patient was afebrile and had moderate biological inflammatory syndrome (C-reactive protein level, 50 mg/liter). Magnetic resonance imaging (MRI) showed decreased signal intensity on Citation Parize P, Mamez A-C, Garcia-Hermoso D, Dumaine V, Poirée S, Kauffmann-Lacroix C, Jullien V, Lortholary O, Lanternier F. 2019. Successful treatment of Saksenaea sp. osteomyelitis by conservative surgery and intradiaphyseal incorporation of amphotericin B cement beads