sign in sign up
<<
Home , CEPP, Working Formulation

Bone Marrow Transplantation (2003) 32, 317–324 & 2003 Nature Publishing Group All rights reserved 0268-3369/03 $25.00 www.nature.com/bmt Second malignancies Secondary myelodysplastic syndrome and acute myelogenous are significant complications following autologous stem cell transplantation for

R Howe1, INM Micallef2, DJ Inwards2, SM Ansell2, GW Dewald3, A Dispenzieri2, DA Gastineau2, MA Gertz2, SM Geyer4, CA Hanson3, MQ Lacy2, A Tefferi2 and MR Litzow2

1Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester MN 55905, USA; 2Division of Hematology, Blood and Marrow Transplantation, Mayo Clinic, 200 First Street SW, Rochester MN 55905, USA; 3Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester MN 55905, USA; and 4Department of Biostatistics, Mayo Clinic, 200 First Street SW, Rochester MN 55905, USA

Summary: developing sMDS/AML after myeloablative conditioning and ASCT for lymphoma. Secondary myelodysplastic syndrome (sMDS) and acute Bone Marrow Transplantation (2003) 32, 317–324. myelogenous leukemia (AML) have been recognized with doi:10.1038/sj.bmt.1704124 increasing frequency following autologous stem cell Keywords: secondaryMDS; autologous stem cell trans- transplantation (ASCT). A retrospective analysis of 230 plantation; lymphoma consecutive patients with Hodgkin’s lymphoma (HL, 64) and non-Hodgkin’s lymphoma (NHL, 166) who under- went ASCT was conducted to assess the incidence and risk factors for the development of sMDS/AML. At a median follow up of 41 months (range 0.1–177 months), 10 of 230 patients (4.3%) developed sMDS/AML. The 5-year- Autologous stem cell transplantation (ASCT) is an actuarial incidence of sMDS/AML was 13.1% and 5- increasinglyimportant therapyfor patients with Hodgkin’s year cumulative incidence by competing risk analysis was lymphoma (HL) and non-Hodgkin’s lymphoma (NHL). 4.2%. The median time to development of sMDS/AML Long-term disease-free survival rates post ASCT now was 39.9 months from the time of ASCT (range 12.1–62.0 approach 50% or more in some settings, and these patients months). Complex karyotypes at diagnosis of sMDS/ maybe cured of their lymphoma. 1–3 Although recurrence of AML included structural anomalies and/or loss of disease remains the major cause of failure following ASCT chromosome 5 (eight patients), 7 (five patients), 17 (two with relapse rates approaching 40%, secondary myelodys- patients) and 20 (two patients). All patients subsequently plastic syndrome (sMDS) and acute myelogenous leukemia died, at a median of 6.8 months (range 0–39.9) from (AML) have been recognized with increasing frequency diagnosis of sMDS/AML. Fluorescent in situ hybridiza- post ASCT and are usuallyfatal. 4–8 The 5-year actuarial tion (FISH) analysis for À5/5q- and À7/7q- were normal incidence rates of approximately3–18% have been in all six patients whose pre-ASCT bone marrow was previouslyreported. 6,9–15 Factors shown to be associated available for testing. Five of the six had samples available with the development of sMDS and AML include older for testing at diagnosis of sMDS/AML and all had age,9,13,14,16 amount and type of chemotherapy received abnormal FISH results. By univariate statistical analysis, prior to transplantation,9,11,12,15,17–20 length of time between male gender (P ¼ 0.01), prior alkylating agents (mechlor- diagnosis of lymphoma and transplantation,11 prior radia- ethamine for HL, P ¼ 0.001 and cyclophosphamide for tion therapy,11,15 chemotherapyutilized for peripheral NHL, P ¼ 0.05) and the number of prior treatment blood stem cell mobilization,20 number,21 and regimens (P ¼ 0.04) were significantly associated with source5,10,22,23 of stem cells reinfused and the use of total the development of sMDS/AML. Given the relatively low bodyirradiation as part of the conditioning regi- incidence rate of sMDS/AML, these analyses are men.7,14,16,24 primarily exploratory in nature but provide some insight The primarygoals of this studywere to assess the into relevant risk factors and illustrate the risk of frequencyof sMDS/AML post ASCT in patients with HL and NHL at Mayo Clinic Rochester, to further define possible risk factors for sMDS/AML that maypredispose patients to developing this complication, and to describe Correspondence: Dr INM Micallef, Division of Hematology, Mayo the cytogenetic and FISH results on the bone marrow (BM) Clinic, 200 First Street SW, Rochester MN 55905, USA samples pre-ASCT and post-ASCT at diagnosis of sMDS/ Received 18 September 2002; accepted 29 January2003 AML. Secondary MDS/AML R Howe et al 318 Patients and methods done at day 100 and then yearly at Mayo Clinic. Reassessment included CBC, routine chemistryprofile Patients and CT scans. BM analysis was left to the discretion of the transplant physician. After day 100, patients returned The studypopulation consisted of 230 consecutive patients to their primaryhematologist for ongoing assessment; with HL (64) or NHL (166) who underwent high-dose however, yearly follow-up at Mayo Clinic Rochester was therapywith ASCT at MayoClinic Rochester, between continued indefinitely. Those who developed second April 1985 and December 1998, with follow-up through malignancies were identified either at Mayo Clinic July2002. Three patients received two transplants. One or bytheir referring physician.No patients were lost to patient was initiallydiagnosed with HL, underwent ASCT follow-up. 13 years later for relapsed disease and achieved a complete remission. At 18 months following the first ASCT, he relapsed with NHL and received a second ASCT; 2 months Diagnosis of sMDS and AML later, he developed AML. For the current study, this World Health Organization (WHO) criteria were used in patient was classified with a diagnosis of HL. The other two diagnosing sMDS and AML.25 All BM samples and blood patients who underwent second ASCT for disease relapse specimens were reviewed bya hematopathologist at Mayo did not develop sMDS or AML. The data for each of these Clinic, Rochester. Cytogenetic analysis was performed three patients are presented with respect to the first using standard G-banding techniques.26 Abnormal clones transplant only. were described using International System for Human Cytogenetic Nomenclature criteria.27 BM and peripheral blood stem cell collection BM was harvested under general anesthesia. Peripheral Fluorescent in situ hybridization (FISH) analysis blood stem cells (PBSC) were harvested after G-CSF priming. CD34 quantitation was routinelyperformed FISH analysis for À5 and/or 5qÀ (with probes for EGR1/ starting in May1997, using the standard method of D5S23/D5S721 from Vysis, Inc., Downers Grove, IL, ProCount byBecton Dickinson. No in vitro manipulation USA) and, À7 and/or 7qÀ (with probes for D7S522/ of the PBSC or BM harvests was done. Cells were D7Z1 from Vysis Inc., Downers Grove, IL) was performed cryopreserved and thawed immediately prior to use. on patients BM cells pre-ASCT in six patients and in five of Pretransplant cytogenetic analysis by G-banding was the six patients, at diagnosis of sMDS/AML. In all, 200 performed on BM specimens obtained as part of the interphase nuclei per patient were scored bytwo indepen- pretransplant testing and all were negative for chromosome dent observers to establish the percent abnormal cells. Prior abnormalities. Patients with abnormal karyotypes were to this study, the cutoff for normal values was calculated excluded from transplantation. from 20 known normal specimens, using the upper bound of a one-sided 95% confidence interval for observing the maximum false-positive nuclei for each signal pattern Myeloablative conditioning observed in a single specimen using the binomial distribu- Several conditioning regimens were used according to tion. The normal cutoff for 5qÀ, À5, 7qÀ and –7 were 6.0, protocols in place at the time of ASCT. A total of 99 4.0, 6.5 and 4.5%, respectively. patients received BEAC (BCNU (300 mg/m2 once), VP-16 2 (100 mg/m /dayb.i.d/  4 days), cytosine arabinoside Data analysis (100 mg/m2/dayb.i.d  4 days) and cyclophosphamide (35 mg/kg/day  4 days)); 69 patients received CBV (cyclo- The primaryend point of this studywas the incidence of phosphamide (1500 mg/m2/day  4 days), BCNU (300 mg/ sMDS/AML in post-ASCT lymphoma patients. The m2) and VP-16 (200 mg/m2/day  3 days)); and 58 patients variables analyzed as potential risk factors associated with received CyTBI (cyclophosphamide (60 mg/kg/day  2 the development of sMDS/AML included gender, age at days) and total body irradiation (1320 cGy in 6 fractions)). ASCT, lymphoma histological diagnosis (HL vs NHL), Additional protocols included: 6-thioguanine/VP-16/ prior radiation therapy, prior chemotherapy, prior sple- BCNU/Ara-C/total bodyirradiation (two patients), busul- nectomy, conditioning regimen (TBI vs non-TBI), platelet fan/cyclophosphamide (one patient), VP-16/thiotepa/cyclo- count prior to ASCT, time from lymphoma diagnosis to phosphamide (one patient). ASCT, stem cell source (BM vs peripheral blood) and the number of stem cells re-infused as measured bymono- Hospitalization and follow-up nuclear cells/kg. Since CD34 counting was not routinely performed until May1997, it was available in only41 Patients were treated in the Blood and Marrow Transplant patients (sMDS/AML n ¼ 2; non-MDS n ¼ 39) and there- Unit at Rochester Methodist Hospital, Mayo Clinic, fore it was not included in the statistical analysis. Patients Rochester MN, USA. All patients received standard with NHL were analyzed as a single group, as well as supportive care as per guidelines in place at the time. divided into histological subgroups byWorking Formula- Patients received G-CSF or GM-CSF post transplant to tion28 (low-grade NHL vs intermediate grade vs other facilitate neutrophil engraftment. Patients were followed (including angiocentric/angioblastic lymphoma, anaplastic dailyuntil adequate engraftment and until theywere well large cell, precursor B and immunoblastic, CNS T enough to be discharged home. Routine reassessment was cell lymphoma, lymphoblastic T cell, cutaneous T cell,

Bone Marrow Transplantation Secondary MDS/AML R Howe et al 319 NK/T cell lymphoma)). In all, 15 of the 47 low-grade Cumulative Incidence and Actuarial NHL subsequentlytransformed to more aggressive histo- Incidence of sMDS/AML 100 logical grades, but were analyzed in the ‘low-grade’ NHL group. Patients with HL were analyzed only as a 80 single group because 56 of the 64 patients had HL. 60 Estimates of the exposure of patients to a given therapeutic agent were determined bysumming the total 40

number of cycles the patient received even when the Probability regimen doses differed. In all, 19 of the patients who did 20 not develop sMDS/AML had ambiguities in the total number of cycles given, and were not included in the 0 univariate analyses shown here. This exclusion probably 0 2 4 6 8 10 12 14 16 did not bias the results because these patients were few in Years of Follow-up number relative to the entire cohort (19 of 220 non-MDS MDS (CI) Death without MDS MDS (KM) patients), and when these 19 patients were included using estimates of the chemotherapytheyreceived, statistical Figure 1 Cumulative incidence and actuarial incidence of sMDS/AML. analysis was unchanged. The number of stem cells re- Cumulative incidence bycompeting risk analysis and actuarial incidence by reverse Kaplan–Meier estimate of sMDS/AML and the competing risk infused was reported separatelybased on source (PB vs of death without MDS for 230 patients after ASCT for HL and NHL. BM). Presence or absence of growth factor treatment was MDS (CI) ¼ cumulative incidence bycompeting risk analysis;MDS not evaluated as a risk factor, since it is routine practice for (KM) ¼ actuarial incidence byreverse Kaplan–Meier estimate. all patients to receive either G-CSF or GM-CSF following ASCT to facilitate neutrophil engraftment. Comparisons of categorical variables between those who was 4.3%, as determined bycompeting risk analysis did and did not develop sMDS/AML were done using (Figure 1). Fisher’s exact test. Comparisons of continuous variables Baseline clinical characteristics and details of the between these groups were conducted using two-tailed, diagnosis for the 10 patients who developed sMDS/AML two-sample t-tests or the nonparametric equivalent (Wil- are depicted in Table 1. Median age at ASCT was 49 years coxon rank-sum test). The associations of these variables (range 23–73). The median time from diagnosis to with the incidence of sMDS/AML were also explored using transplant was 35 months (range 15–151). Four patients logistic regression models. In addition to examining the received stem cells from BM and six from peripheral blood. incidence of sMDS/AML, we also summarized and Five patients had a prior diagnosis of NHL and five had evaluated the time from transplant to the development of HL. The median number of prior chemotherapyregimens sMDS/AML. The cumulative incidence of sMDS/AML prior to ASCT was 3 (range 2–4). All but one patients were was calculated using competing risk analysis, where death in complete remission of lymphoma at the time of sMDS/ was considered the competing risk. Patients who relapsed AML diagnosis. The histological diagnoses of sMDS were still considered to be at risk for sMDS/AML; included: refractory cytopenia with multilineage dysplasia therefore, relapse was not considered a competing risk. (RCMD) in four patients, atypical MDS with fibrosis Despite the potential for bias, the actuarial incidence rate in two patients and refractoryanemia with excess blasts of patients with sMDS/AML was calculated using the (RAEB) in two patients. One patient with RCMD reverse Kaplan–Meier estimate.29 This was done primarily subsequentlydeveloped AML-M4. Two patients developed to compare the results from this studyto those previously AML without an antecedent historyof sMDS. The median reported. time to development of sMDS/AML was 40 months (range Several factors were analyzed and statistical significance 12–63 months) following ASCT and a median of 75 months was determined if the P-value was p0.05. Given the (range 36-192 months) from original lymphoma diagnosis. exploratorynature of these analyses,multiple comparison All 10 patients died, where the time from diagnosis of corrections were not used. sMDS/AML to death ranged from 0.5 to 40 months (median 7 months). Treatment of sMDS/AML included an allogeneic transplant in one patient and supportive care in the remainder. Cytogenetic analysis at diagnosis of sMDS/ Results AML was available in eight of 10 patients; all eight patients Characteristics of secondary sMDS/AML or AML patients had at least three chromosome aberrations and four patients had X5 chromosome aberrations. Structural or Of the 230 patients who underwent high-dose chemo- numeric anomalies of chromosome five and seven were seen therapyand ASCT, 10 patients have developed sMDS in eight and five patients, respectively. No patients had or AML. The crude incidence rate of sMDS/AML was abnormalities of 11q23 or 21q22. 4.3% (10/230). At the time of these analyses, 97 patients were alive, with a median follow-up of 69 months (range FISH analysis 36–177 months). Of the 10 patients who developed sMDS/ AML, all have since died. The 5-year actuarial incidence BM samples from six patients, pre-ASCT had no evidence rate was 13.1% and the 5-year cumulative incidence rate of abnormal clones byconventional cytogeneticsor

Bone Marrow Transplantation oeMro Transplantation Marrow Bone 320

Table 1 Clinical characteristics of patients with post-ASCT sMDS or sAML

# Age at Sex Lymphoma Interval from Prior chemotherapya Prior Conditioning Stem cell MDS/AML Chromosome deletions Total ASCT to MDS to ASCT diagnosis diagnosis to RT regimen source histology cytogenetic MDS death ASCT(years) abnormalities (years) (mos) 5 7 17 20 1 31 M LPHL 2.6 MOPP(6), ABVD(3), No Cy/TBI BM RCMD, X X X >5 3 12.8 DHAP(1) AML-M4 2 23 M NSHL 4.5 MOPP(2), ABVD(1), No CBV BM AML-M1 N/A 5 6.9 MOP/ABV(6), MOP/ABV(3) 3 39 M NSHL 12.6 MOPP/ABVD(10), Yes CBV BM AML- M2 X X >5 3.4 0.5 MDS/AML Secondary MOP/BAP(8), ABVD(4),

DHAP(2) Howe R 4 34 M NSHL 8.3 MOPP/ABV(6), Yes CBV PBSC RCMD X X X >5 1.9 7.4 MOPP/ABVD(8), DHAP(2) 5 55 M NSHL 5 MOPP/ABVD(8), Yes CBV BM RAEB X 5 1.5 30.5 al et MOP/ABV(6), ABV(2) 6 73 M DLCL 2 CHOP(6), CEPP(5), DHAP(1) No BEAC PBSC RCMD X 3 1 0.8 7 50 M SLL 3.3 CHOP(6), CHOP(3), Yes CBV BM MDS N/A 5.3 6.7 CHEP(4) w/fibrosis 8 58 M MCL 1.3 CHOP(6), Fludarabine(6) No BEAC PBSC RAEB X X 3 3.3 3.6 9 58 M MCL 1.4 CHOP(8), No Cy/TBI PBSC MDS X X X X >5 3 40.1 ProMACE/CytaBOM(4) w/fibrosis 10 49 M Angiocentric 1.6 ProMACE/CytoBOM(1), Yes Cy/TBI BM RCMD X 3 4 5.9 large T-cell CHOP(5), DHAP(2), NHL ProMACE/CytaBOM(5)

RT, Radiotherapy; LPHL, Lymphocyte predominant Hodgkin’s lymphoma; NSHL, nodular sclerosing Hodgkin’s lymphoma; DLCL, diffuse large-cell lymphoma, MCL, ; SLL, small lymphocytic lymphoma; NHL, non-Hodgkin’s lymphoma, MDS, myelodysplastic syndrome; RAEB, refractory anemia with excess blasts; AML, acute myelogenous leukemia; RCMD, refractorycytopenia with multilineage dysplasia, Cy/TBI, cyclophophamide/total body irradiation; CBV, BCNU/cyclophosphamide/VP-16; BEAC, BCNU/cyclophosphamide/cytosine arabinoside/VP-16; ASCT, autologous stem cell transplant; BM, bone marrow; PBSC, peripheral blood stem cell; CHOP, cyclophosphamide///prednisone; MOPP, mechlorethamine/vincristine/prednisone/procarbazine; ABVD, doxorubicin//vinblastine/dacarbazine; DHAP, dexamethasone/cytosine arabinoside (high dose)/cisplatin; ProMACE-CytaBOM, cyclophosphamide/doxorubicin/etoposide/prednisone/cytarabine/ bleomycin/methotrexate/vincristine; CEPP, cyclophosphamide/etoposide/procarbazine/prednisone; MOP-ABV, mechlorethamine/vincristine/procarbazine/doxorubicin/vinblastine/bleomycin; CHEP, cyclo- phosphamide/doxorubicin/etoposide/prednisone, mos, months; N/A, not available. a The Number in brackets, following each chemotherapyregimen, corresponds to the number of chemotherapycyclesthe patient received. Secondary MDS/AML R Howe et al 321 FISH studies. Five of the six patients tested pre- with a higher number of prior regimens were at greater risk ASCT had BM samples that were available for testing at (OR ¼ 1.64, 95% confidence interval: 1.02–2.65). Total the time of diagnosis of sMDS/AML and all five were reinfused stem cells among BM recipients was marginally abnormal byconventional cytogeneticand FISH studies lower in patients developing sMDS (OR ¼ 0.31, 95% (Table 3). confidence interval: 0.09–1.05; P ¼ 0.06); and similarly, borderline significant differences were found in the PBSC group in the number of reinfused PBSC between the Risk factors for development of sMDS or AML sMDS/AML and non-MDS groups (OR ¼ 1.16, 95% Table 2 compares clinical characteristics of those who did confidence interval: 1.002–1.33; P ¼ 0.05). None of the or did not develop sMDS/AML. The factors that were other clinical characteristics differed significantlybased on significantlyassociated with the development of sMDS/ incidence of sMDS/AML. Multivariate models were not AML were male gender (P ¼ 0.01) and number of prior evaluated given the low event incidence. chemotherapyregimens ( P ¼ 0.04). Statistical analysis To further define which drug might contribute to the using logistic regression yielded similar results. The number increased risk associated with prior chemotherapy, we of prior chemotherapyregimens was significantlyasso- determined the total number of cycles given of each ciated with sMDS/AML incidence (P ¼ 0.04), where those chemotherapeutic agent. We focused in particular on

Table 2 Clinical characteristics of all patients undergoing ASCT

Patient characteristics MDS/AML Non-MDS/AML Proba Total number of patients n=10 n=220 Male (number of patients, % of total) 10 (100%) 134 (60%) 0.01 Age in years (mean, s.d.) 47715 44715 0.66

Lymphoma subtype (number of patients, % of total) 0.15 5 (50%) 59 (27%) Non-Hodgkin lymphoma 5 (50%) 161 (73%)

Non-Hodgkin lymphoma subtype (n=166) n=5 n=161 0.3 Low-grade NHLb 3 (60%) 47 (29%) Intermediate-grade NHL 1 (20%) 80 (50%) Other NHL 1 (20%) 34 (21%)

Prior splenectomy(number of patients, % of total) 3 (30%) 30 (14%) 0.16 Prior radiation (number of patients, % of total) 5 (50%) 87 (40%) 0.53

Number of prior chemotherapy episodes 0.04 1 0 (0%) 39 (18%) 2 3 (30%) 100 (45%) 3 3 (30%) 56 (25%) X4 4 (40%) 25 (11%)

Disease status (number of patients, % of total) 0.75 1st remission 1 (10%) 40 (18%) X2nd remission 9 (90%) 162 (74%) Refractory0 (0%) 19 (97%)

Stem cell source (number of patients, % of total) 1 BM 6 (60%) 121 (55%) PB 4 (40%) 94 (42%) Both 0 (0%) 5 (2%) BM stem cells (total nucleated cells  108/kg, mean, s.d.) n=132 1.770.8 2.370.9 0.09 PB stem cells (total nucleated cell  108/kg, mean, s.d.), n=103 14.4712.4 9.173.9 0.3

Conditioning (number of patients, % of total) 0.33 TBI 3 (30%) 57 (27%) Non-TBI 7 (70%) 163 (74%)

Pre-ASCT platelet count  109/l (mean, s.d.) 2327136 1997119 0.41 Diagnosis-to-ASCT in mos (median, range) 35 (15–151) 21 (3–245) 0.08 ASCT to last follow-up in mos (median, range) 33 (12–63) 42 (0.1–177) 0.97 Diagnosis to last follow-up in mos (median, range) 75 (36–192) 172 (7–1267) 0.54

MDS, myelodysplastic syndrome; AML, acute myelogenous leukemia; BM, bone marrow; PB, peripheral blood; mos, months; Cy/TBI, cyclophosphamide/ total body irradiation; CBV, BCNU/cyclophosphamide/VP-16; BEAC, BCNU/cyclophosphamide/cytosine arabinoside/VP-16; Prob, Probability; SD, standard deviation; NHL, non-Hodgkin lymphoma; ASCT, autologous stem cell transplantation. aStatistical tests were performed as described in Materials and methods. Probabilityvalues are given. bMantle cell NHL is included in the low-grade category.

Bone Marrow Transplantation Secondary MDS/AML R Howe et al 322 Table 3 Pre- and post-ASCT FISH analysis

Patient Pre-ASCT Post-ASCT MDS/sAML # Karyotype FISH results (%) Karyotype FISH results (%)

À55qÀÀ77qÀÀ55qÀÀ77qÀ 2 46,XY[20] 0.5 1.0 0.0 0.0 N/A 4 46,XY[30] 0.0 0.5 0.0 1.0 45,XY,À5, À7, À13,add(14)(p11.2)+mar,+r[20] 1.5 73.0 1.0 60.0 6 46,XY[20] 0.0 1.0 0.0 3.0 45–46,XY, À5, À6,+1–2mar[cp18]/46,XY[2] 0.5 61.0 0.0 4.0 8 46,XY[30] 0.5 0.0 0.0 2.0 45,XY,del(5)(q15q33), À7[19]/46,XY[1] 0.5 70.0 72.5 0.0 9 46,XY[40] 2.0 0.0 0.0 1.5 45,XYt(2;6)(q32;p11.2),del(5)(q13q33), 0.5 25.0 0.0 1.5 del(17)(p11.2p13), À20[cp12]/46,XY[8] 10 46,XY[20] 0.0 0.5 0.0 2.5 45,XY, À7inv(10)(q11.2q24)[20] 0.0 2.0 80.5 0.5

Normal cutoffs: À5=4.0%; 5qÀ=6.0%; À7=4.5%; 7qÀ=6.5%.

alkylating agents and etoposide.6,23 Of the 64 patients including mechlorethamine and chlorambucil as an im- with HL, all five who developed sMDS/AML, and 48 of portant risk factor of sMDS/AML. There was also, an the 59 who did not develop sMDS/AML received apparent association between sMDS/AML and high-dose mechlorethamine, as present in MOPP. The number of TBI (413.2 Gy); however, this regimen was infrequently cycles of mechlorethamine was significantly higher in HL used and thus therefore needs to be confirmed. The data on patients developing sMDS/AML (median 14, range 6–18) TBI as a risk factor for sMDS/AML are conflicting.14,16,24 compared to HL patients without sMDS/AML (median 6, We did not observe differences in the incidence of sMDS/ range 0–12, P ¼ 0.001). In contrast, there were no AML in patients who received TBI-containing conditioning significant differences in the number of procarbazine or regimens compared to non-TBI-containing conditioning cisplatin cycles between those HL patients who developed regimens. Total chemotherapycyclesprior to transplant sMDS/AML and those without sMDS/AML (data not was significantlyhigher in those patients developing sMDS/ shown). AML. In agreement with Metayer et al,24 as well as Among patients with NHL, all five who developed others,12,30 we found that the total number of cycles of sMDS/AML and 160 of the 161 who did not develop mechlorethamine in MOPP regimens prior to ASCT was sMDS/AML received cyclophosphamide. The number of significantlyhigher in HL patients with sMDS/AML. We cyclophosphamide cycles was higher in patients developing also observed that among NHL patients, total prior cycles sMDS/AML (median 11, range 6–13) than among those with cyclophosphamide was higher in sMDS/AML pa- without sMDS/AML (median 8, range 0–23, P ¼ 0.05). No tients, although this finding onlyapproached borderline significant differences were observed in the total number of statistical significance. Alkylator therapy is a known risk etoposide or cisplatin cycles received between the NHL factor for sMDS/AML in the nontransplant setting; the 5- patients who developed sMDS/AML and those without year estimated risk of sMDS/AML after long-term sMDS/AML. Fludarabine was used in too few patients to alkylator therapy or low-dose radiation is 7%.31,32 Second- assess its influence. aryMDS/AML usuallyoccurs in patients receiving long- term alkylator therapy such as continuous chlorambucil. The association of prior cyclophosphamide (pre-ASCT) Discussion with the incidence of sMDS/AML post ASCT has not been seen in other studies and therefore needs to be confirmed. SecondaryMDS/AML remain important complications Other factors including patient age,9,13,14,16 number,21 or post ASCT. In this retrospective series, the crude, 5-year source10,13,20,23 of stem cells infused, pretransplant platelet actuarial and 5-year cumulative incidence rates of sMDS or levels11 or splenectomy23 have been observed in some, but AML were 4, 13, and 4%, respectively, with a median time not all studies. In this study, we did not see associations to diagnosis of approximately3 yearsafter transplant. with sMDS/AML and anyof these risk factors. Owing to The 5-year actuarial incidence by Kaplan–Meier of 13% the relativelylow incidence rate of sMDS/AML, the is within the range (3–18%) reported in other nonsignificant results could potentiallybe because of a studies.6,9–16,18–23 We have shown the incidence byboth lack of power to detect all but verylarge differences in these Kaplan–Meier actuarial incidence and bycompeting risk variables between those who do and do not develop sMDS/ analysis since both of these methods have been used in AML. Larger, confirmatorystudies maybe required to prior reports. The Kaplan–Meier actuarial incidence over- fullyevaluate and determine significant risk factors for estimates the cumulative incidence as it does not take into sMDS/AML. account the competing risk of death in this patient group. One surprising result was that all patients who developed There appears as yet to be no consensus on which risk sMDS/AML were male. It is unclear whyall the sMDS/ factors are important for the development of sMDS/AML, AML patients in this studywere male. Conceivably, but exposure to prior chemotherapyhas been a consistent hormonal effects could influence hematopoiesis to enhance finding.9,11,12,18,20,24 This was confirmed in a recent large myelodysplasia or transformation in males, or inhibit this multicenter case–control studybyMetayer et al24 who process in females. However, there have been no consistent identified type and intensity of pretransplant chemotherapy prior associations of gender with development of sMDS or

Bone Marrow Transplantation Secondary MDS/AML R Howe et al 323 AML, and this suggests that the association observed in ASCT FISH analysis is more sensitive in detecting this studymayhave been bychance alone. abnormal clones; thus, we are still unable to predict The consistent association in the literature between accuratelywhich patients will develop this serious and sMDS/AML and prior chemotherapyargues for pretrans- usuallyfatal complication. plant mutagenesis as at least one necessaryevent. This possibilityis supported bythe recent finding of multiple chromosome aberrations, byFISH analysis,present prior Acknowledgements to transplantation in samples previouslyconsidered to be normal byless-sensitive techniques. 33–36 In the studyfrom We thank Nathan Foster for help with the statistical analysis, St Bartholomew’s Hospital, manyof the aberrations found Stephanie Brockman for the FISH analysis and Alisa Marx- at diagnosis of sMDS/AML were detected pre-ASCT by hausen for secretarial assistance. FISH analysis, implying that a necessary event had already taken place prior to transplantation.34 In contrast to these studies, we found no –5/5qÀ or –7/7qÀ abnormalities by References either cytogenetic or FISH analysis among pretransplant et al samples from six of the patients. However, pretransplant 1 Yuen AR, Rosenberg SA, Hoppe RT . Comparison between conventional salvage therapyand high-dose therapy samples from four of the patients were unavailable, and with autografting for recurrent or refractoryHodgkin’s hence we maynot be able to generalize these findings to all disease. Blood 1997; 89: 814–822. our patients with sMDS/AML. The equivalent sensitivity 2 Philip T, Armitage JO, Spitzer G et al. High-dose therapyand of conventional cytogenetics and FISH is similar to studies autologous bone marrow transplantation after failure of done in de novo MDS. Ketterling et al37 tested 32 conventional chemotherapyin adults with intermediate-grade cytogenetically normal patients with primary MDS by or high-grade non-Hodgkin’s lymphoma. N Engl J Med 1987; FISH panel testing and byM-FISH. Onlyone of 32 316: 1493–1498. patients had 13qÀ, while the remaining 31 were normal, 3 Freedman AS, Takvorian T, Anderson KC et al. Autologous suggesting limited utilityin FISH testing over standard bone marrow transplantation in B-cell non-Hodgkin’s lym- cytogenetics. Differences in FISH strategy and normal phoma: verylow treatment-related mortalityin 100 patients in sensitive relapse. J Clin Oncol 1990; 8: 784–791. cutoff values mayaccount for the discrepancybetween the 4 Rohatiner A. Myelodysplasia and acute myelogenous leuke- results in this present studyand the previous reports. In mia after myeloablative therapy with autologous stem-cell addition, it is not clear whether mutational events, even transplantation. J Clin Oncol 1994; 12: 2521–2523. when identified pre-ASCT, are both necessaryand suffi- 5 Armitage JO. Myelodysplasia and acute leukemia after cient, or whether additional events are required post-ASCT autologous bone marrow transplantation. J Clin Oncol 2000; for the development of sMDS/AML. 18: 945–946. It is possible that secondaryevents, perhaps influencing 6 Pedersen-Bjergaard J, Andersen MK, Christiansen DH. proliferation or differentiation of a damaged clone, could Therapy-related acute myeloid leukemia and myelodysplasia contribute to tumorigenesis, for example, byimpeding after high-dose chemotherapyand autologous stem cell Blood adaptive DNA repair mechanisms. Such secondaryevents transplantation. 2000; 95: 3273–3279. 7 Stone RM. Myelodysplastic syndrome after autologous could occur either prior to, at, or following transplantation. transplantation for lymphoma: the price of progress. Blood The fact that the time interval from transplant to sMDS/ 1994; 83: 3437–3440. AML is sometimes onlya few months could be used as an 8 Deeg HJ, Socie G. Malignancies after hematopoietic stem cell argument against an obligatorypost-transplant event. transplantation: manyquestions, some answers. Blood 1998; However, the median time to development of sMDS/ 91: 1833–1844. AML is usuallyin the range of 3–5 years,suggesting that it 9 Micallef IN, Lillington DM, Apostolidis J et al. Therapy- is at least somewhat related to the transplant itself. Several related myelodysplasia and secondary acute myelogenous studies have implicated factors at the time of the transplant, leukemia after high-dose therapywith autologous hemato- such as total bodyirradiation, 14,16,24 use of etoposide for poietic progenitor-cell support for lymphoid malignancies. J Clin Oncol 2000; 18: 947–955. mobilization,20 stem cell source,10,13,20,23 or number of stem 21 10 Miller JS, Arthur DC, Litz CE et al. Myelodysplastic cells transplanted (this studyand ) in the development of syndrome after autologous bone marrow transplantation: an sMDS/AML. This could result in either new mutations or additional late complication of curative cancer therapy. Blood greater proliferative stress of previouslydamaged stem cells 1994; 83: 3780–3786. during transplantation. In contrast, a large cooperative 11 Stone RM, Neuberg D, Soiffer R et al. Myelodysplastic studyfound that risk was virtuallyall associated with prior syndrome as a late complication following autologous bone chemotherapy, and not with the transplant procedure, marrow transplantation for non-Hodgkin’s lymphoma. J Clin although patients were conditioned byBEAM and not Oncol 1994; 12: 2535–2542. TBI.18 Given a likelymulti-step mechanism for pathogen- 12 Pedersen-Bjergaard J, Pedersen M, Myhre J, Geisler C. High esis, as well as numerous patterns of chromosome aberra- risk of therapy-related leukemia after BEAM chemotherapy tions in sMDS/AML, it is not surprising that there have and autologous stem cell transplantation for previouslytreated is mainly related to primary chemotherapy and not been inconsistencies in risk factors associated with the to the BEAM-transplantation procedure. Leukemia 1997; 11: development of sMDS/AML from studyto study. 1654–1660. In summary, our results confirm the significant risk of 13 Bhatia S, RamsayNK, Steinbuch M et al. Malignant developing either sMDS/AML following myeloablative neoplasms following bone marrow transplantation. Blood conditioning and ASCT. It remains unclear whether pre- 1996; 87: 3633–3639.

Bone Marrow Transplantation Secondary MDS/AML R Howe et al 324 14 Darrington DL, Vose JM, Anderson JR et al. Incidence and 25 Harris NL, Jaffe ES, Diebold J et al. World Health characterization of secondary myelodysplastic syndrome and Organization classification of neoplastic diseases of the acute myelogenous leukemia following high-dose chemora- hematopoietic and lymphoid tissues: report of the Clinical diotherapyand autologous stem-cell transplantation for AdvisoryCommittee Meeting–Airlie House, Virginia, Novem- lymphoid malignancies. J Clin Oncol 1994; 12: 2527–2534. ber 1997. J Clin Oncol 1999; 17: 3835–3849. 15 Wheeler C, Khurshid A, Ibrahim J et al. Low incidence of 26 RooneyDE, Czepulkdowski BH (eds). Human Cytogenetics: post-transplant myelodysplasia/acute leukemia (MDS/AML) a practical approach. Volume II, Malignancy and Acquired in NHL patients autotransplanted after cyclophosphamide, Abnormalities. Oxford UniversityPress: NY, New York, 1992. carmustine and etoposide (CBV). Blood 1997; 90: 385b. 27 Mitelman F (ed.) An International System for Human 16 Milligan DW, Ruiz De Elvira MC, Kolb HJ et al. Secondary Cytogenetic Nomenclature. Karger: Basel, Switzerland, 1995. leukaemia and myelodysplasia after autografting for lympho- 28 National Cancer Institute sponsored studyof classifications of ma: results from the EBMT. EBMT Lymphoma and Late non-Hodgkin’s lymphomas: summary and description of a Effects Working Parties. European Group for Blood and working formulation for clinical usage. The Non-Hodgkin’s Marrow Transplantation. Br J Haematol 1999; 106: 1020– Lymphoma Pathologic Classification Project. Cancer 1982; 49: 1026. 2112–2135. 17 Sobecks RM, Le Beau MM, Anastasi J, Williams SF. 29 Kaplan FL, Meier P. Non-parametric estimation from Myelodysplasia and acute leukemia following high-dose incomplete observations. J Am Stat Assoc 1958; 52: 457–481. chemotherapyand autologous bone marrow or peripheral 30 Pedersen-Bjergaard J, Specht L, Larsen SO et al. Risk of blood stem cell transplantation. Bone Marrow Transplant 1999; therapy-related leukaemia and preleukaemia after Hodgkin’s 23: 1161–1165. disease. Relation to age, cumulative dose of alkylating agents, 18 Harrison CN, GregoryW, Hudson GV et al. High-dose and time from chemotherapy. Lancet 1987; 2: 83–88. BEAM chemotherapywith autologous haemopoietic stem cell 31 Greene MH, Young RC, Merrill JM, DeVita VT. Evidence of transplantation for Hodgkin’s disease is unlikelyto be a treatment dose response in acute nonlymphocytic associated with a major increased risk of secondaryMDS/ which occur after therapyof non-Hodgkin’s lymphoma. AML. Br J Cancer 1999; 81: 476–483. Cancer Res 1983; 43: 1891–1898. 19 Govindarajan R, Jagannath S, Flick JT et al. Preceding 32 Pedersen-Bjergaard J, Ersboll J, Sorensen HM et al. Risk of standard therapyis the likelycause of MDS after auto- acute nonlymphocytic leukemia and preleukemia in patients transplants for multiple myeloma. Br J Haematol 1996; 95: treated with cyclophosphamide for non-Hodgkin’s lympho- 349–353. mas. Comparison with results obtained in patients treated for 20 Krishnan A, Bhatia S, Slovak ML et al. Predictors of therapy- Hodgkin’s disease and ovarian carcinoma with other alkylat- related leukemia and myelodysplasia following autologous ing agents. Ann Intern Med 1985; 103: 195–200. transplantation for lymphoma: an assessment of risk factors. 33 Abruzzese E, Radford JE, Miller JS et al. Detection of Blood 2000; 95: 1588–1593. abnormal pretransplant clones in progenitor cells of patients 21 Friedberg JW, Neuberg D, Stone RM et al. Outcome in who developed myelodysplasia after autologous transplanta- patients with myelodysplastic syndrome after autologous bone tion. Blood 1999; 94: 1814–1819. marrow transplantation for non-Hodgkin’s lymphoma. J Clin 34 Lillington DM, Micallef IN, Carpenter E et al. Detection of Oncol 1999; 17: 3128–3135. chromosome abnormalities pre-high-dose treatment in patients 22 Traweek ST, Slovak ML, Nademanee AP et al. Clonal developing therapy-related myelodysplasia and secondary karyotypic hematopoietic cell abnormalities occurring after acute myelogenous leukemia after treatment for non-Hodg- autologous bone marrow transplantation for Hodgkin’s kin’s lymphoma. J Clin Oncol 2001; 19: 2472–2481. disease and non-Hodgkin’s lymphoma. Blood 1994; 84: 35 Amigo ML, del Canizo MC, Hernandez JM et al. Clonal 957–963. myelodysplastic cells present in apheresis product before 23 Andre M, Henry-Amar M, Blaise D et al. Treatment-related transplantation. Leukemia 1998; 12: 1497–1499. deaths and second cancer risk after autologous stem-cell 36 Gilliland DG, Gribben JG. Evaluation of the risk of therapy- transplantation for Hodgkin’s disease. Blood 1998; 92: 1933– related MDS/AML after autologous stem cell transplantation. 1940. Biol Blood Marrow Transplant 2002; 8: 9–16. 24 Metayer C, Curtis RE, Vose J et al. Myelodysplastic syndrome 37 Ketterling RP, Wyatt WA, VanWier SA et al. Primary and acute myeloid leukemia after autotransplantation for myelodysplastic syndrome with normal cytogenetics: utility lymphoma: a multicenter case–control study. Blood 2002; of ’FISH panel testing’ and M-FISH. Leuk Res 2002; 26: 10: 10. 235–240.

Bone Marrow Transplantation