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  • br Hematopoietic cell transplantation HCT is generally recom

    2019-05-15


    Hematopoietic cell transplantation HCT is generally recommended for AML patients with intermediate or high risk cytogenetics, when the aim of treatment is curative. However, elderly patients are seldom offered a transplant mainly due to concerns regarding toxicity, despite the fact that the main reason for death after HCT in the older adult is not toxicity but relapse [52]. Fortunately, there has been a steady increase in the number of HCTs in this patient group in the past decade [53] as a consequence of the introduction of less intensive conditioning regimes, which have significantly reduced toxicity whilst maintaining successful engraftment. Nevertheless, nowadays only about 8% of elderly patients with AML undergo HCT each year in the US [36], even though they constitute more than 50% of the new AML cases. Outcome analysis in this population indicates that those who are submitted to HCT have a relatively favorable outcome, with almost 40% 3-year relapse-free and overall survival [54]. It is therefore essential to identify those patients whose prostaglandin receptor and disease characteristics make them the best candidates for transplant. Beyond chronological age [55], factors that predict OS and relapse are high risk AML (cytogenetics, gene mutations), higher HCT-CI scores, patient CMV status and greater HLA disparity, while the impact of donor age is still disputed, especially in the context of reduced-intensity conditioning regimes. In addition, poor performance status and active infections are associated with poorer outcomes and these patients should not be transplanted, unless their condition improves. Similarly, patients who have active disease at the time of HCT are very unlikely to maintain remission long term, and should be rather rescued with chemotherapy and transplanted when in CR. Patients with favorable prognostic disease, especially those with CBF mutations and no additional poor risk cytogenetic or molecular markers, do well with consolidation chemotherapy and do not benefit from transplant in first remission. Therefore all elderly patients with good performance status (ECOG PS 0-1) and with any disease risk other than the good prognostic group should be considered for HCT, depending on their HCT-CI [56] and EBMT [57] risk score (Table 6). The role of geriatric assessment in identifying patient vulnerabilities before HCT is still in the beginning, but gait speed, instrumental activities of daily living and cognition evaluation, among other clinical parameters, seem to be useful for this purpose [58]. The analysis of the impact of HCT on the quality-of-life of the older adults is also very much in its infancy. Lastly, it should be emphasized that HCT candidates must be identified at diagnosis and this option discussed upfront with the patient as some elderly patients may not agree on an aggressive treatment course.
    Social issues Social and family support is critical in patients dependent for basic activities of daily life, but also for those dependent only for instrumental activities or even in the independent ones (limited budget, frequent hospital visits, unexpected medical complications, less prone to visit the Emergency Department) [59]. Such a support may modulate the type and intensity of the treatment to be given, even in the best developed countries, and becomes critical when welfare state is less than optimal.
    Conclusion
    Disclosures
    Introduction The increased incidence of second primary solid tumors and hematological malignancies have been reported in the setting of Non-Hodgkin lymphoma (NHL) [1,2]. The observed rates of renal cell carcinoma (RCC) developing in the NHL patients was 1.86-fold greater, and conversely, NHL developing in RCC patients was 2.67-times higher than that the expected rates in the general population [3]. There appears to be an association between lymphoid malignancies and RCC that cannot be explained by chance alone. This co-existence should be attributed to prior treatment modalities such as alkylating agents, long-term survival of elderly patients, close monitorization of NHL with imaging studies, immunosuppression due to underlying lymphoproliferative disorder, genetic alterations predisposing to both malignancies, environmental factors, and viral aetiology [1,2,4]. However, the exact mechanism has not been clarified yet.