We report 40 patients (pts) with AML who underwent autologous HSCT in first (CR1) or second (CR2) remission from 2002 to 2007. Twenty one were male and nineteen were female with a mean age of 52.8 (range 35–66) years. Patients enrolled in clinical trials are not included in this analysis. Using CALGB (Byrd) criteria, 6 had favorable cytogenetic risk (all in CR2), 26 had intermediate risk, including 22 with normal karyotypes (20 in CR1 and 2 in CR2), and 8 had unfavorable cytogenetics (7 in CR1 and 1 in CR2), including two patients with t(9;22). One pt had Ph+ AML and one CML with myeloid blast crisis. One patient had AML transformed from myelodysplastic syndrome (MDS). Four patients had AML with multi-lineage dysplasia (MLD). Nine patients were in CR2. Thirty-five patients had intensification / mobilization with high dose VP16/ARAC, four with high dose ARAC and one patient had a bone marrow harvest. Thirty-six patients received Busulfan (0.8mg/kg x 16 doses) and VP-16 (60mg/kg) as their preparative regimen. Four received Busulfan (0.8 mg/kg x 16 doses) and Cytoxan (120 mg/kg). One hundred day transplant related mortality was 2.5%. Mean overall survival was 20.9 months. Mean disease free survival was 36.7 months with a range of 10–76 months. One year overall survival was 63%, with a one year disease free survival of 40%. Four of six pts with favorable cytogenetics are alive in CR more than 24 months after autologous transplant. Two patients with t(9;22) are on imatinib maintenance in CR 12 and 42 months post transplant. One patient with APL developed a secondary MDS with a monosomy 7. No patients with prior MDS or MLD were alive after 12 months. Five patients who relapsed after autologous HSCT went on to receive reduced intensity allogeneic transplantation with a 100 day mortality of 0%. We conclude that autologous HSCT should be considered an effective and safe post-remission consolidation therapy for pts with intermediate risk AML in CR1 and for pts with favorable cytogenetics in CR2. Patients with MLD and prior MDS do poorly. Prior autologous HSCT does not increase the 100 day mortality with reduced intensity allogeneic transplantation. Further studies are necessary, continuing to focus on risk-adapted therapy and assessing quality of life endpoints. We report 40 patients (pts) with AML who underwent autologous HSCT in first (CR1) or second (CR2) remission from 2002 to 2007. Twenty one were male and nineteen were female with a mean age of 52.8 (range 35–66) years. Patients enrolled in clinical trials are not included in this analysis. Using CALGB (Byrd) criteria, 6 had favorable cytogenetic risk (all in CR2), 26 had intermediate risk, including 22 with normal karyotypes (20 in CR1 and 2 in CR2), and 8 had unfavorable cytogenetics (7 in CR1 and 1 in CR2), including two patients with t(9;22). One pt had Ph+ AML and one CML with myeloid blast crisis. One patient had AML transformed from myelodysplastic syndrome (MDS). Four patients had AML with multi-lineage dysplasia (MLD). Nine patients were in CR2. Thirty-five patients had intensification / mobilization with high dose VP16/ARAC, four with high dose ARAC and one patient had a bone marrow harvest. Thirty-six patients received Busulfan (0.8mg/kg x 16 doses) and VP-16 (60mg/kg) as their preparative regimen. Four received Busulfan (0.8 mg/kg x 16 doses) and Cytoxan (120 mg/kg). One hundred day transplant related mortality was 2.5%. Mean overall survival was 20.9 months. Mean disease free survival was 36.7 months with a range of 10–76 months. One year overall survival was 63%, with a one year disease free survival of 40%. Four of six pts with favorable cytogenetics are alive in CR more than 24 months after autologous transplant. Two patients with t(9;22) are on imatinib maintenance in CR 12 and 42 months post transplant. One patient with APL developed a secondary MDS with a monosomy 7. No patients with prior MDS or MLD were alive after 12 months. Five patients who relapsed after autologous HSCT went on to receive reduced intensity allogeneic transplantation with a 100 day mortality of 0%. We conclude that autologous HSCT should be considered an effective and safe post-remission consolidation therapy for pts with intermediate risk AML in CR1 and for pts with favorable cytogenetics in CR2. Patients with MLD and prior MDS do poorly. Prior autologous HSCT does not increase the 100 day mortality with reduced intensity allogeneic transplantation. Further studies are necessary, continuing to focus on risk-adapted therapy and assessing quality of life endpoints.

Pituitary Apoplexy (PA) is an uncommon neurologic event that results from sudden hemorrhage or infarction of the pituitary gland. Most of these events occur in patients with undiagnosed pituitary adenoma. There are various precipitating causes. We report a case of PA precipitated by thrombocytopenia during autologous stem cell transplantation. The patient is a 48M with history of stage II multiple myeloma initially treated with lenalidomide and dexamethasone. The patient then proceeded to Auto PSCT. His preparative regimen consisted of melphalan 200 mg/m2. Initial lab values showed a platelet count of 429K/ul. The patient became febrile on Day 4 and was started on broad spectrum antibiotics. Voriconazole replaced fluconazole when fevers persisted. On Day 7, the patient complained of blurry vision. This was the first day plts were below 10K/ul. A possible culprit was voriconazole and it was discontinued. The patient complained his peripheral vision was particularly compromised, and bitemporal hemianopsia was confirmed. CT of the brain revealed a 2.3 × 2.5 cm hemorrhagic pituitary mass. Platelets were transfused to keep plts above 75K/ul. Hydrocortisone was begun, as was desmopressin, for developing diabetes insipidus. MRI confirmed a large suprasellar mass consisitent with a pituitary macroadenoma that contained hemorrhage. The incidence of PA with pituitary adenoma is variable, but has been reported to be as high as 27.7%. Many patients have nonfunctional adenomas or are asymptomatic prior to the event. Clinical symptoms of PA are also variable but the most common symptoms include headache, nausea, and visual deficits. As in most cases, our patient had an undiagnosed pituitary adenoma and was asymptomatic. The thrombocytopenia and immunocomprimise of PSCT can make the pituitary vulnerable to hemorrhage and abscess, both reported causes of apoplexy. Surgical management can be delayed by pancytopenia or other complications of PSCT. Transsphenoidal surgery has been shown to be more successful in improving vision if performed within 8 days of diagnosis. Emergent surgery is indicated for deteriorating vision, hemiparesis, or altered consciousness, while those with stable or resolving visual field deficits can be managed conservatively. Our patient was managed conservatively until engraftment. Transsphenoidal surgery was then performed, 9 days after diagnosis. At six months follow-up, his visual deficits had resolved but he continued to have diabetes insipidus.

Autologous stem cell transplantation has become the gold standard for treatment of patients with multiple myeloma under the age of 65, and improves survival for these patients. It is evident that all patients will progress after transplantation. At this time it is not clear what is the best induction regimen prior to high dose chemotherapy and ASCT. Thalidomide has been proven to impact on plasma cell growth through multiple mechanisms. At our institution we used thalidomide (50-100 mg) after ASCT as a maintenance program along with a bisphosphonate (Zometa or Aredia). We reviewed 68 myeloma patientswho were transplanted at our facility between 2001 and 2005. 30 patients were placed on a thalidomide maintenance program. Patients received various cytoreductive regimens prior to stemcell collection. 27 patients who received thalidomide were in partial remission prior to ASCT; 3 patients were in complete remission and none were refractory. Of the 38 patients who did not receive maintenance 35 were in partial remission, 2 were in complete remission and 1 was refractory. All patients except 2 received a preparative regimen including melphalan 200 mg per meter squared. 24 patients received thalidomide maintenance with 100 mg daily and 6 patients received 50 mg daily. The dose given depended on prior tolerability of the drug and history. Thalidomide was started between 120 and 150 days post ASCT. Patients needed to have an ANC above 1000 and platelets above 100 as well as resolution of transplant related toxicities. 13 patients needed a decrease in thalidomide because of neuropathy. One of these 13 patients also suffered from decreased GI motility and bezoar. The average time to progression was 32.5 months in the thalidomide group and 19 months in the patients who did not receive the drug. Patients who received thalidomide after transplant had improved median time to progression (36 months) compared to patients who did not receive thalidomide (15 months). Low dose thalidomide maintenance in combination with bisphosphonates seemed to improve progression free survival in myeloma patients after stem cell transplantation.

It is estimated that 80% of patients who undergo high-dose chemotherapy plus or minus radiotherapy prior to transplantation develop mucositis. Mucositis is a painful complication, which can lead to poor nutrition, increased use of narcotics, dehydration, greater risk for infection and bacteremia, as well as altered quality of life. Patients can have oral ulceration, epigastric discomfort, diarrhea, rectal irritation, and bleeding. It is likely that the complications of mucositis can contribute to increased lenght of stay during stem cell transplantation.The purpose of this study is to compare patients who received Kepivance(palifermin) as part of their treatment with patients that did not receive this medication during autologous stem cell transplantation. We performed a retrospective analysis of 70 patients; 20 prior to the institution of Kepivance(palifermin), and 50 patients after. The preparative regimens include Melphalan, Busulfan & Etoposide, Cytoxan, BCNU, Etoposide, and Busulfan & Cytoxan.The average length of stay for non-Kepivance patients was 32.3 days compared to 28 days in patients who received the drug. The severity of both oral and GI mucositis appeared to be less. 85% of non-Kepivance patients experienced diarrhea or rectal irritation, versus 52% with Kepivance. Neutropenic fever was noted in 95% of patients that did not receive the drug and 76% of the patients that did. There was a trend torward earlier engraftment in the Kepivance group.Kepivance seems to have had a positive effect on our patients. This updated study suggests an improvement in mucositis symptoms with the use of Kepivance(palifermin). It appears that mucositis and its treatment contribute to the length of stay and costs of stem cell transplantation. Qualtiy of life for these patients can be greatly improved if mucositis is reduced during the course of stem cell transplantation. It is estimated that 80% of patients who undergo high-dose chemotherapy plus or minus radiotherapy prior to transplantation develop mucositis. Mucositis is a painful complication, which can lead to poor nutrition, increased use of narcotics, dehydration, greater risk for infection and bacteremia, as well as altered quality of life. Patients can have oral ulceration, epigastric discomfort, diarrhea, rectal irritation, and bleeding. It is likely that the complications of mucositis can contribute to increased lenght of stay during stem cell transplantation. The purpose of this study is to compare patients who received Kepivance(palifermin) as part of their treatment with patients that did not receive this medication during autologous stem cell transplantation. We performed a retrospective analysis of 70 patients; 20 prior to the institution of Kepivance(palifermin), and 50 patients after. The preparative regimens include Melphalan, Busulfan & Etoposide, Cytoxan, BCNU, Etoposide, and Busulfan & Cytoxan. The average length of stay for non-Kepivance patients was 32.3 days compared to 28 days in patients who received the drug. The severity of both oral and GI mucositis appeared to be less. 85% of non-Kepivance patients experienced diarrhea or rectal irritation, versus 52% with Kepivance. Neutropenic fever was noted in 95% of patients that did not receive the drug and 76% of the patients that did. There was a trend torward earlier engraftment in the Kepivance group. Kepivance seems to have had a positive effect on our patients. This updated study suggests an improvement in mucositis symptoms with the use of Kepivance(palifermin). It appears that mucositis and its treatment contribute to the length of stay and costs of stem cell transplantation. Qualtiy of life for these patients can be greatly improved if mucositis is reduced during the course of stem cell transplantation.