Hematopoietic stem cell transplantation in the era of tyrosine kinase inhibitors.

Until the 1990 s, the treatment of chronic myeloid leukemia (CML) recognized hematopoietic stem cell transplantation as the best treatment for those patients with an available donor. With the advent of imatinib in 2001, this paradigm changed dramatically as this drug provided outstanding and durable rates of hematologic, cytogenetic, and molecular responses. As a consequence it became the gold standard first-line treatment for most patients. However, after almost a decade of its use, it is clear that although very effective, imatinib cannot cure CML as transplantation has already proven so. Furthermore, the new non-myeloablative regimens and the improvements in survival after allogeneic transplant, especially in the field of unrelated transplants, offer this option to a broader population of patients with CML. This adds to the old question of whom to transplant, when and how to proceed with the allograft. This article reviews the current role of transplantation in the era of tyrosine kinase inhibitors and will try to elucidate its role in the frontline setting as well as after first- and second-line kinase inhibitors failure.

Efficacy of extended thrombo-prophylaxis in major abdominal surgery: what does the evidence show? A meta-analysis.

Venous thromboembolism (VTE) is a frequent complication following major abdominal surgery. The use of low-molecular-weight heparins (LMWH) to prevent thrombotic events in these patients is a common and well documented practice. However, there is some controversy surrounding the duration of the prophylaxis, as it has been suggested that the risk persists for several weeks after surgery. The objective of this meta-analysis is to systematically review the clinical studies that compared safety and efficacy of extended use of LMWH (for three to four weeks after surgery) versus conventional in-hospital prophylaxis. An electronic data base search was performed. Only randomized, controlled studies were eligible. Data on the incidence of deep vein thrombosis (DVT), VTE and bleeding were extracted. Only three studies fulfilled the inclusion criteria. The indication for surgery was neoplastic disease in 70.6% (780/1104) of patients. The administration of extended LMWH prophylaxis significantly reduced the incidence of VTE, 5.93% (23/388) versus 13.6% (55/405), RR 0.44 (CI 95% 0.28 - 0.7); DVT 5.93% (23/388) versus 12.9% (52/402), RR 0.46 (CI 95% 0.29 - 0.74); proximal DVT 1% (4/388) versus 4.72% (19/402), RR 0.24 (CI 95% 0.09 - 0.67). We found no significant difference in major or minor bleeding between the two groups: 3.85% (21/545) in the extended thrombo-prophylaxis (ETP) group versus 3.48% (19/559) in the conventional prophylaxis group; RR 1.12 (CI 95% 0.61 - 2.06). There was no heterogeneity between the studies. We conclude that ETP with LMWH should be considered as a safe and useful strategy to prevent VTE in high-risk major abdominal surgery.