Retrospective Outcome Data for Hematopoietic Stem Cell Transplantation in Patients with Concurrent Coronary Artery Disease

Hematopoietic stem cell transplantation (HSCT) represents an extended period of physiologic stress. It is unknown whether patients with pre-existing coronary artery disease (CAD) may be poor transplant candidates. There are no data analyzing the risk of transplantation in this population. Sixty-nine patients with CAD who underwent 72 transplantations, autologous and allogeneic, were identified retrospectively. Fifty-five percent of these patients had prior percutaneous coronary intervention, 42% had verifiable history of myocardial infarction, and 23% had prior coronary artery bypass grafting. Outcomes were compared to 1109 patients without established CAD who underwent 1183 transplants during the same time period. Cancer diagnoses in the 2 groups were similar, predominantly lymphoma, multiple myeloma, and leukemia. There was no significant difference between the CAD group and the control group with respect to type of transplant (autologous 68% versus 64%, P = .612, myeloablative 86% versus 85%, P = .867). Treatment-related mortality was no different in the CAD group versus the control group (5.6% versus 4.9%, P = .777), nor were there differences in mortality at 1 year (15.3% versus 16.6%, P = .871), urgent intensive care unit admission (11.1% versus 9.9%, P = .686), or length of stay (25.5 days versus 28.4 days, P = .195). These findings suggest many patients with underlying coronary artery disease may be safely managed through hematopoietic stem cell transplantation

Toxicities of high-dose chemotherapy and autologous hematopoietic cell transplantation in older patients with lymphoma

High-dose chemotherapy and autologous hematopoietic cell transplantation is an effective consolidation therapy in lymphoma; however, its use in elderly patients has been limited because of concerns for greater toxicity in this group. We investigated the toxicities of carmustine, etoposide, cytarabine, and melphalan (BEAM) and autologous hematopoietic cell transplantation (AHCT) in 346 patients in 2 age groups: 279 patients aged 60 to 69 years and 67 patients aged ≥70 years. The majority developed severe toxicities; the most common were febrile neutropenia, gastrointestinal, infections, and cardiovascular. Older patients were at higher risk for grade ≥3 cardiovascular toxicities (hazard ratio [HR], 3.36; 95% confidence interval [CI], 2.25-5.00; P < .001) and skin toxicities (HR, 2.45; 95% CI, 1.08-5.54, P = .032). In the older group, nonrelapse mortality at 100 days and at 2 years was 2.99% (95% CI, 0.55-9.32) and 6.2% (95% CI, 1.97-13.95), respectively, vs 1.79% (95% CI, 0.68-3.92) and 2.91% (95% CI, 1.37-5.42), respectively, in the younger group. When adjusting for the number of grade ≥3 toxicities within the first 100 days, older patients had a 1.71-fold (95% CI, 1.08-2.71) increased risk for progression or death relative to younger patients. Although BEAM followed by AHCT is effective, it is associated with significant organ toxicities, especially in patients aged ≥70 years. Interventions to mitigate toxicities while maintaining efficacy are much needed

Graded Cardiac Response Criteria for Patients With Systemic Light Chain Amyloidosis

PURPOSE: Binary cardiac response assessment using cardiac biomarkers is prognostic in light chain amyloidosis. Previous studies suggested four-level cardiac responses using N-terminal prohormone of brain natiuretic peptide improves prognostic prediction. This study was designed to validate graded cardiac response criteria using N-terminal prohormone of brain natiuretic peptide/brain natiuretic peptide. PATIENTS AND METHODS: This retrospective, multicenter study included patients with light chain amyloidosis who achieved at least a hematologic partial response (PR) and were evaluable for cardiac response. Four response criteria were tested on the basis of natriuretic peptide response depth: cardiac complete response (CarCR), cardiac very good partial response (CarVGPR), cardiac PR (CarPR), and cardiac no response (CarNR). Response was classified as best response and at fixed time points (6, 12, and 24 months from therapy initiation). The study primary outcome was overall survival. RESULTS: 651 patients were included. Best CarCR, CarVGPR, CarPR, and CarNR were achieved in 16%, 26.4%, 22.9%, and 34.7% of patients, respectively. Patients in cardiac stage II were more likely to achieve CarCR than patients in cardiac stage IIIA and IIIB (22% v 13.5% v 3.2%; P < .001). A deeper cardiac response was associated with a longer survival (5-year overall survival 93%, 79%, 65%, and 33% for CarCR, CarVGPR, CarPR, and CarNR, respectively; P < .001). Fixed time-point analyses and time-varying covariates Cox regression analysis, to minimize survivorship bias, affirmed the independent survival advantage of deeper cardiac responses. Four-level response performed better than two-level response as early as 12 months from therapy initiation. CONCLUSION: Graded cardiac response criteria allow better assessment of cardiac improvement compared with the traditional binary response system. The study re-emphasizes the importance of early diagnosis, which increases the likelihood of deep cardiac responses