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Hematopoietic stem cell transplant > HSCT > Flashcards

HSCT Flashcards

1
Q

What are indications for HSCT in AML?

A 
- CR1: HR patients
Therapy-related AML
MDS-related AML
Primary induction failure
Cytogenetics: 7-, del5q, abn (3q)
Molecular: FLT3-ITD
IR disease with positive MRD after Course 1
- Relapsed AML
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2
Q

Risk factors for acute GVHD (5)

A
  • Related vs unrelated donor
  • Degree of HLA mismatch
  • Source of stem cells
  • Donor sex (female sex associated with more GVHD, proportional to parity)
  • TBI-based conditioning
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3
Q

Risk factors for chronic GVHD (5)

A
  • Degree of HLA-mismatch
  • Increasing donor age
  • Donor sex (female associated with more GVHD)
  • TBI-based conditioning
  • Previous aGVHD
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4
Q

Risk factors of graft rejection (5)

A
  • Degree of mismatch
  • Low cell dose
  • Use of T-cell depletion for GVHD prophylaxis
  • Underlying conditions: SAA, storage disorders, osteopetrosis (hostile BM)
  • (+)ve crossmatch for antidonor lymphocytic Ab
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5
Q

Definition graft rejection

A

Failure to recover hematopoetic function of stem cell graft (usually caused by recipient T-lymphs)

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6
Q

Risk factors for VOD (6)

A
  • Liver radiation
  • Pre-treatment with busulfan, dactinomycin, gemtuzumab
  • Prior intensive chemotherapy
  • Prior TPN (>30 days)
  • Prior iron overload
  • Transplant from unrelated donor
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7
Q

Clinical criteria for the diagnosis of VOD

A

Modified Seattle criteria: otherwise unexplained occurrence of two or more of the following events within 20 days of HCT
●Serum total bilirubin concentration greater than 2 mg/dL (>34.2 micromoles/L)
●Hepatomegaly or right upper quadrant pain
●Sudden weight gain due to fluid accumulation (>2 % of baseline weight)

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8
Q

How to make the diagnosis of VOD?

A

Often relies on clinical criteria

Doppler US: reversal of flow in portal vein, elevation of mean hepatic arterial resistive index

Diagnosis gold standard= hepatic biopsy, but rarely feasible

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9
Q

List 5 factors impacting the speed of immune reconstitution post-HSCT

A
  1. Source of stem cell
  2. Intensity of conditioning used: Myeloablative < RIC < non-myeloablative
  3. Presence of GVHD
  4. Presence of infections
  5. Age of recipient
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10
Q

Name factors associated with late MDS following autologous HSCT

A
  • Use of etoposide
  • Use of TBI-containing regimen
  • Amount of chemotherapy received pre-HSCT
  • Interval between diagnosis and HSCT
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11
Q

What is the typical time to engrafment in…
… Autologous HSCT?
… Allogeneic HSCT?

A

7-14 days (autologous)

14-28 days (allogeneic)

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12
Q

Criteria to consider when selecting a donor (6) for allogeneic HSCT?

A 
#1: HLA mismatch
Source of stem cell
Donor/recipient size mismatch
Age and sex of donor
Viral infections: CMV status
ABO type
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13
Q

Number of cells required for transplant using CURD

A

TNC: > 3*10^7 cells/kg

CD34+: >3-5*10^6 cells/kg

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14
Q

Degree of match in HSCT:

  • What means 6/6?
  • What means 8/8?
  • What means 10/10?
A

6: HLA-A, -B, HLA-DR
8: HLA-A, -B, -C, HLA-DR
10: HLA-A, -B, -C, HLA-DR, -DQ

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15
Q

What degree of HLA match is required for a CURD or for a matched sibling donor?

A
  • HLA-A and HLA-B: antigen level
  • HLA-C: optional (often correlates with HLA-B)
  • HLA-DRB1: allele level
  • HLA-DQ and HLA-DP: optional
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16
Q

What degree of HLA match is required if stem cells come from a unrelated donor, or a related donor (not sibling)?

A
  • HLA-A, -B, -C, HLA-DR: allele level

- HLA-DQ, HLA-DP: optional

17
Q

Indications for HSCT in CML (3)

A
  • Resistance or failure of TKIs
  • Good donor, with strong family preference
  • Advanced phase (i.e. blasts 10-19%)
18
Q

Indications for HSCT in Hodking lymphoma

A
  • Autologous, for relapsed of resistant disease

- Allo can salvage failure after autologous HSCT

19
Q

Indications for HSCT in non-Hodgkin lymphoma

A
  • LLy: same as ALL
  • Relapsed disease; autologous HSCT usually tried first, allo can be used if resistance or relapse after autologous HSCT
    (especially useful for ALCL)
20
Q

HSCT is a part of treatment of which solid tumors?

A
  • High risk neuroblastoma (CR1)
  • HR germ cell tumor (CR2)
  • HR retinoblastoma
  • Controversial: Ewing, relapsed HR Wilms, RMS
21
Q

HSCT is a part of treatment of which brain tumors?

A
  • Medulloblastoma

- Relapsed CNS germ cell tumors

22
Q

Steps required for donor of HSCT

A
  1. Verify consent
  2. Absence of other health conditions (e.g. asthma) posing a risk to the donor during procedure
  3. Screening for infectious diseases (similar to transfusion)
23
Q

Antibiotic prophylaxis in HSCT?

A

Recommended for pre-engraftment

Quinolones for all recipients of HSCT

24
Q

What specific infection has been associated with TBI?

A

Pneumococcal sepsis (late post-engraftment))

25
Q

Recommended fungal prophylaxis in HSCT

A

Azole: fluconazole, voriconazole;

to be given in initial neutropenic phase and in case of severe GVHD

26
Q

What coverage is provided by fluconazole?

A

Covers: Candida spp, cryptococcus

Doesn’t cover: candida krusei, glabrata, aspergillus

27
Q

What is the recommended regimen for fungal infections in a patient post-HSCT?

A

Empiric treatment (prolonged fever): caspofungin, amphotericin B
Invasive aspergillosis: voriconazole;
Consider combination therapy if sever sepsis, CNS involvement, resp failure

28
Q

Describe pre-emptive therapy for CMV

A
  • Monitoring 2X/week of CMV PCR; treat prophylactically if asymptomatic increase in levels
  • Antiviral options includes
    • Ganciclovir
    • Foscarnet
29
Q

What is the treatment of a symptomatic CMV infection post-transplant?

A 
1st line:
- Ganciclovir and IVIG if pneumonia
- Ganciclovir or foscarnet for other sites
2nd line:
- Ganciclovir AND foscarnet
- Cidofovir
30
Q

What treatment options are available for increase in viral load of EBV (before development of EBV-PTLD)?

A
  1. Reduction of immunosuppression
  2. Rituximab
  3. Donor cytotoxic lymphocytes
31
Q

What antiviral can be used for a HHV6 infection?

A

Ganciclovir

Foscarnet

32
Q

Bronchiolitis obliterans following HSCT:

  • Symptoms?
  • Diagnostic work up?
A
  • Persistent, dry cough; decreased exercice tolerance

- Chest CT-scan, pulmonary function tests

33
Q

Name 5 risk factors associated with transplant associated thrombotic microangiopathy?

A
  1. Calcineurin inhibitors
  2. Sirolimus
  3. High dose busulfan
  4. TBI
  5. Infections
34
Q

Name 4 laboratory features of TA-TMA

A
  • CBC: anemia, thrombocytopenia
  • Smear: schistocytes
  • Biochemistry: elevated bilirubin, elevated creatinine, elevated LDH, decreased haptoglobin
35
Q

Work up of suspected PLTD?

A
  • EBV PCR in serum
  • PET-scan
  • Biopsy (especially if unclear diagnosis, or suspected malignancy relapse)

Hematopoietic stem cell transplant (2 decks)

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