Ajuste de intensidad para el trasplante hematopoyético alogénico en leucemia aguda / Intensity adjustment of hematopoietic alogeneic transplantation in acute leukemia

Background: The intensity of conditioning chemotherapy and radiotherapy in hematopoietic stem cell transplantation (HSCT) varies according to several factors including the patient’s age, pre-existing conditions and performance status. Myeloablative conditioning (MA) increases transplant related mortality and reduces survival in older patients. Reduced intensity conditioning (RIC) is a good option for these patients. Aim: To report our experience with HSCT in patients of different ages with acute leukemia. Material and Methods: Retrospective analysis of 115 allogeneic HSCT performed in patients with acute myeloid or lymphoblastic leukemia. Results: We analyzed the cohort of patients in groups according to age at transplantation: younger than 40 years (n = 74), 41 to 50 years (n = 25) and older than 51 years of age (n = 16). Overall survival (OS), Disease free survival (DFS) and relapse at five years were similar in both groups of patients younger than 50 years (OS 40 and 44% respectively, DFS 38 and 42% respectively and relapse 40% and 34% respectively, p = NS). Patients over 51 years had a five years OS of 12%. However when we analyzed those patients by date and conditioning we found that patients who were treated with MA regimens in the first decade of the transplant program (before 2000) had lower OS compared to those treated after 2000 with RIC (five years OS 49% and 12% respectively, p < 0.01). No significant differences in terms of OS, recurrence or incidence of graft-versus-host disease were found when comparing groups under 40 years, between 41 and 50 years and older than 51 years treated only with RIC. Conclusions: RIC provides the possibility of HSCT in older patients with rates comparable to those obtained in younger patients successfully treated with MA conditioning.

Trasplante alogénico de precursores hematopoyéticos de sangre de cordón umbilical de donante no emparentado: primera experiencia, en tres casos, con donantes del banco público chileno de células de cordón / Allogenic hematopoietic stem cell transplantation with unrelated cord blood: Report of three cases from the Chilean cord blood bank

Public cord blood banks are a source of hematopoietic stem cells for patients with hematological diseases who lack a family donor and need allogeneic transplantation. In June 2007 we started a cord blood bank with units donated in three maternity wards in Santiago, Chile. We report the first three transplants done with cord blood units form this bank. Cord blood units were obtained by intrauterine collection at delivery. They were depleted of plasma and red cells and frozen in liquid nitrogen. Tests for total nucleated cells, CD34 cell content, viral serology, bacterial cultures and HLA A, B and DRB1 were done. Six hundred cord blood units were stored by March 2012. Three patients received allogeneic transplant with cord blood from our bank, two with high risk lymphoblastic leukemia and one with severe congenital anemia. They received conditioning regimens according to their disease and usual supportive care for unrelated donor transplantation until full hematopoietic and immune reconstitution was achieved. The three patients had early engraftment of neutrophils and platelets. The child corrected his anemia and the leukemia patients remain in complete remission. The post-transplant course was complicated with Epstein Barr virus, cytomegalovirus and BK virus infection. Two patients are fully functional 24 and 33 months after transplant, the third is still receiving immunosuppression.

Infección por Mycobacterium tuberculosis en una niña sometida a trasplante de progenitores hematopoyéticos / Mycobacterium tuberculosis infection in a pediatric patient who underwent a hematopoietic stem cell transplant

We report the case of a 10 year old girl with a relapsed acute lymphoblastic leukemia, who underwent a haploidentical hematopoietic stem cell transplant (HSCT), with grade II skin and digestive graft versus host disease, treated with corticosteroids and cyclosporine. On day + 54, she presented fever, with no other remarkable clinical findings. Imaging study showed the presence of lung and liver nodules, liver biopsy was performed. The study included histology, staining and culture for bacteria and fungi, and the preservation of a piece of tissue at -20°C for future prospective studies. Ziehl Nielsen stain was positive, and study for Mycobacterium infection was performed. Microbiological smears of tracheal and gastric aspirate, and bronchial fluid obtained by bronchoalveolar lavage (BAL) were positive. The final report confirmed Mycobacterium tuberculosis in gastric content, sputum, BAL and liver tissue, susceptible to rifampin, isoniazid, streptomycin and ethambutol, with determination of mutations for genes rpoβ and kat G (-). Tuberculosis (TB) diagnosis was confirmed. The girl received daily therapy for two months and then she continued on three times per week therapy for 9 months. Controlled by the transplant, infectious diseases and respiratory teams, the patient remained in good general condition, with radiologic resolution of pulmonary and liver involvement and negative smears. We conclude that Mycobacterium tuberculosis infection should be part of differential diagnosis of febrile illness in patients undergoing HSCT, and biopsy should be a standard practice of early diagnosis in these patients.

Se presenta el caso clínico de una niña de 10 años, con una leucemia linfoblástica aguda en recaída, sometida a un trasplante de progenitores hematopoyéticos (TPH) haploidéntico, con enfermedad injerto contra hospedero cutánea y digestiva grado II, en tratamiento con corti-costeroides y ciclosporina, que presentó el día +54 posttrasplante fiebre y compromiso de estado general. Dentro del estudio de su cuadro febril se practicaron imágenes que mostraron presencia de nódulos pulmonares y hepáticos. Se realizó una biopsia hepática cuyo estudio incluyó histología, tinciones y cultivo para bacterias y hongos. La tinción de Ziehl Nielsen de tejido hepático, así como las baciloscopias de contenido gástrico, aspirado traqueal y de fluido bronquial obtenido por lavado broncoalveolar (LBA) fueron positivas. El informe definitivo de cultivo confirmó Mycobacterium tuberculosis en contenido gástrico, esputo, LBA y tejido hepático, sensible a rifampicina, isoniazida, estreptomicina y etambutol, con determinación de mutaciones de genes rpoβ y kat G (-). Se confirmó el diagnóstico de tuberculosis, por lo que recibió tratamiento diario con cuatro fármacos por dos meses y luego terapia trisemanal con rifampicina, isoniazida y etambutol por nueve meses. Controlada por los equipos de trasplante, infectología y broncopulmonar, la paciente se mantiene actualmente en buenas condiciones generales, con imágenes con resolución del compromiso hepático y pulmonar y baciloscopias negativas. La infección por M. tuberculosis debe formar parte del diagnóstico diferencial de los cuadros febriles en los pacientes sometidos a TPH, y la toma de biopsia debe ser una práctica habitual y precoz en el enfrentamiento diagnóstico de estos pacientes.

Linfoma linfoblástico tipo Burkitt dos ovários / Burkitt's lymphoblastic lymphoma of the ovaries

Os autores realatam um caso de comprometimento bilateral dos ovários por linfoma linfoblástico tipo Burkitt em uma paciente de 14 anos. De acordo com a revisao bibliográfica o ovário é o segundo sítio mais comum de linfoma de Burkitt depois da mandíbula.

Bone marrow transplantation in Ramathibodi Hospital: progress report.

Bone marrow transplantation has become the accepted treatment for several hematologic disorders. We have done 3 autologous and 6 allogeneic bone marrow transplantations at Ramathibodi Hospital since July 1989 in patients with acute lymphoblastic leukemia, acute non-lymphocytic leukemia, chronic myeloid leukemia, non-Hodgkin's lymphoma and severe aplastic anemia. Only one patient with aplastic anemia had late graft rejection, but the rest of them engrafted and did well during the median follow up period of 317 days (range: 39 to 962 days) post transplantation. None of the allogeneic BMT had graft-versus-host disease. We use cyclosporin and short course methotrexate for post transplantation immunosuppression.

Abdomen agudo como forma de presentación de leucemia aguda / Acute abdomen as the first sympton of acute leukemia

Dentro de la sintomatología inicial, el dolor abdominal está presente aproximadamente en casi un 7 por ciento de los pacientes con leucemia. Es poco frecuente que el comienzo de la enfermedad presente un cuadro de apendicitis aguda. Se describen 2 pacientes, una niña de 9 años con leucemia mieloide aguda que se trató médicamente y un varón de 3 años con leucemia linfoide aguda que requirió intervención quirúrgica hallándose una apendicitis gangrenosa retrocecal. Sugerimos, como conclusiones, que ante un síndrome de fosa ilíaca derecha con marcada leucopenia y neutropenia se tenga en cuenta el diagnóstico de esta enfermedad hematológica y que una vez hecho éste, si la conducta quirúrgica está indicada, se lleve a cabo sin demora, en beneficio del pronóstico de estos enfermos.