Devita, Hellman, and Rosenberg's Cancer

LWBK1006-42 LWW-Govindan-Review December 12, 2011 20:38

534 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

preexisting CMV immunity to the recipient, compared with a CMV-na ̈ıve

donor.

Answer 42.17. The answer is E.

Mobilization and harvest of hematopoietic stem cells from peripheral

blood with G-CSF leads to significantly higher numbers of CD34+cells

and results in a shorter time to engraftment of both neutrophils and

platelets, compared with bone marrow. Despite significantly higher num-

bers of T cells, there was no evidence of a significant increase in the inci-

dence of acute GVHD in a randomized trial of peripheral blood mononu-

clear cell (PBMC) versus bone marrow, although a trend toward increased

chronic GVHD in PBMC recipients was observed.

Answer 42.18. The answer is B.

Because of its substantial treatment-related morbidity and mortality, allo-

geneic stem cell transplantation is generally reserved for patients with

hematologic malignancies with a low likelihood of cure with lower risk

alternatives, including conventional chemotherapy and/or autologous

HCT. Patients with AML with inversion 16 and translocation (8;22)

in remission have a favorable prognosis for cure with high-dose cytara-

bine consolidation and are generally only considered for allogeneic HCT

in the event of relapse. In contrast, patients with AML with high-risk

cytogenetics, including deletions of chromosomes 5 and 7, and com-

plex karyotypes, are rarely cured with conventional chemotherapy or

autologous HCT, and should be referred for consideration of allogeneic

HCT when in remission. Relapsed patients with intermediate-grade non-

Hodgkin’s lymphoma who respond to salvage chemotherapy may be

cured with autologous stem cell transplantation with a relatively low risk

of treatment-related morbidity and mortality. Because of the generally

indolent nature of CLL, initial remissions may persist for years. Although

potentially curative for CLL, the early mortality risk associated with allo-

geneic HCT is generally not justified in this scenario, although it may be

appropriate in selected patients with more advanced, multiply relapsed

disease.

Answer 42.19. The answer is D.

DLIs by design result in the infusion of large numbers of effector T cells

with the goal of augmenting an alloimmune response directed against

residual host-derived tumor cells. An unintended negative consequence,

however, is the simultaneous infusion of alloreactive T-cell clones directed

at normal tissue that may result in a significant flare in GVHD. In the case

of relapsed CML, a substantial percentage of host hematopoiesis may be

derived from the residual leukemic clone at relapse, in which case the

development of the desired GVL effect may be associated with transient

marrow aplasia. VOD is typically observed during the first 2 to 3 weeks

posttransplant and is thought to result from endothelial damage caused

by the conditioning regimen.