Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize ...hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.
Abstract HNC is the 11th most frequent carcinoma with a world-wide yearly incidence exceeding over half a million cases 1 , a 10:1 male gender predilection and country specific variability 2 . The ...principal risk factors are tobacco and alcohol use and, in a growing population without these exposures, HPV infection. While much progress has been made in understanding the molecular basis of cancer, the 5-year mortality of head and neck cancer has remained approximately 50%. To this date we have not been able to translate as much of our basic science knowledge into significant disease altering therapeutic strategies in terms of local, loco-regional, functional and overall survival. Challenges remain in all aspects of head and neck cancer management: prevention, diagnosis, surgical and non-surgical treatment.
At Hiwa Cancer Hospital (Sulaymaniyah, Iraqi Kurdistan) after the center was started by a cooperative project in June 2016, autologous transplantation was developed.
To develop the project, the ...capacity-building approach was adopted, with on-site training and coaching of personnel, educational meetings, lectures, on-the-job training, and the implementation of quality management planning.
Here, we report initial results of peripheral-blood stem-cell mobilization and collection of the first 27 patients (age 12 to 61 years; 19 males and 8 females; multiple myeloma, n = 10; plasma cell leukemia, n = 1; Hodgkin lymphoma, n = 12; non-Hodgkin lymphoma, n = 3; and acute myeloid leukemia, n = 1). Only three (11.5%) of 26 patients experienced a failure of mobilization. A median of 6.1 × 10
/kg CD34-positive cells per patient were collected (range, 2.4 to 20.8), with two apheretic runs. Twenty-four patients underwent autologous transplantation. All but one transplantation engrafted fully and steadily, with 0.5 and 1.0 × 10
/L polymorphonucleates on day 10.5 (range, 8 to 12) and day 11 (range, 9 to 15), respectively, and with 20 and 50 × 10
/L platelets on day 13 (range, 10 to 17) and day 17 (range, 2 to 44), respectively. More than 95% of patients are projected to survive 1 year after autograft.
These data are the result of an Italian effort to establish in Iraqi Kurdistan a leading center for hemopoietic stem-cell transplantation. The capacity building approach was used, with on-site training and coaching as instruments for the development of provider ability and problem solving. With future limitations for immigration, this method will be helpful, especially in the field of high-technology medicine.
Abstract 2257
Autologous Stem Cell Transplantation (ASCT) is an effective anti-tumor strategy in multiple myeloma (MM) and lymphoma patients. However, a significant proportion of patients cannot ...mobilize a sufficient number of CD34+cells to proceed to transplantation. Plerixafor addition to G-CSF significantly increases the proportion of lymphoma and MM patients, mobilizing ≥2×10106 /kg CD 34+ cells, considered the minimum dose safe for ASCT; however there are very few data about the use of Plerixafor after mobilizing chemotherapy (CHT).
We report here 39 MM or lymphoma patients, candidate for ASCT, who received Plerixafor to collect peripheral blood stem cells (PBSC) after CHT, followed by granulocyte colony-stimulating factor (G-CSF); 17 were affected by non-Hodgkin Lymphoma, 16 by MM and 6 by Hodgkin's Lymphoma; 21 were male and 18 female and the median age was 58 years (20-72). In this population the PBSC collection was planned after disease-specific chemotherapy, followed by G-CSF. These patients were considered poor mobilizers (PM), and therefore eligible for Plerixafor addition, according to the following criteria: ì-previous failure of at least one mobilization attempt (proved PM); ìì- presence of factors predicting unsuccessful harvest (predicted PM), such as: advanced disease, extensive Bone Marrow involvement, previous treatment with extensive radiotherapy or previous prolonged treatment with stem cell poisons (Fludarabine, Alkylating agents, Lenalidomide); ììì- CD34+ cells count <10 cells/μL in Peripheral Blood (PB), during the recovery phase after CHT plus G-CSF for at least 7 consecutive days (probable PM). All patients had advanced disease and the median number of previous CHT regimens was 2 (range:1-4); 24 failed at least one mobilization attempt (proven PM); 5 had been considered predicted PM, according to disease status and/or previous treatment; 10 patients have been considered “probable PM”, due to the persistently low CD34+ cell count after G-CSF for at least 7 consecutive days. Retrospectively only 10 out of the 39 mobilized patients reached a CD34+ cell count ≥10/mcl in PB, before receiving Plerixafor. Plerixafor (0.24 mg/Kg), was administered subcutaneously for up to 3 consecutive days (median 2 days; range: 1–3), while continuing G-CSF, 9–11 hours before the planned leukapheresis. G-CSF was administered starting 48–96 hrs after the end of the mobilizing CHT. In all cases the mobilizing CHT was part of a disease-specific protocol: 13 patients received high-intermediate-dose Cytoxan (3-7 g/m2), 13 DHAP, 5 high-dose VP16 (2 g/m2), 4 HyperC-VAD and 4 other CHT (Dexa-BEAM, DCEP, IVAC, High-dose ARA-C).
Plerixafor administration was safe and no significant adverse events were recorded. Following Plerixafor we observed a 3,3 median fold-increase (range 0–20) of the circulating CD34+ cells, (median CD34+ peak: 31; range: 0–202/mcl) as compared to the day before Plerixafor (median CD 34+ peak: 5; range 0–32/mcl). In 30/39 patients we collected ≥2×106 CD34+ cells/Kg (median 3.7×106 /kg; range 0–15) after 1–3 leukaphereses (median 2). Twenty-five patients have been transplanted with Plerixafor-mobilized PBSCs, 24 of them showing a rapid and durable hematological recovery. The median time to reach PMN recovery (PMN≥500/mcl) was 13 days (9-23); median days to reach unsupported Platelet count ≥20.000/mcl and ≥50.000/mcl were 15 (89-88) and 22 (15-180) respectively. At present 22 patients are alive and maintain stable engraftment after ASCT; 1 died before engraftment while 2 died of disease progression. Our results suggest that “on-demand” addition of Plerixafor to G-CSF after disease-oriented-CHT is safe and may allow a satisfactory harvest in lymphoma and MM patients, considered to be proven or predicted PM, but still eligible for ASCT.
No relevant conflicts of interest to declare.
We describe the entire process leading to the start-up of a hematopoietic stem cell transplantation center at the Hiwa Cancer Hospital, in the city of Sulaymaniyah, Kurdistan Iraqi Region. This ...capacity building project was funded by the Italian Development Cooperation Agency and implemented with the support of the volunteer work of Italian professionals, either physicians, nurses, biologists and technicians. The intervention started in April 2016, was based exclusively on training and coaching on site, that represent a significant innovative approach, and led to a first autologous transplant in June 2016 and to the first allogeneic transplant in October. At the time of reporting, 9 months from the initiation of the project, 18 patients have been transplanted, 15 with an autologous and 3 with an allogeneic graft. The center at the HCH represents the first transplantation center in Kurdistan and the second in wide Iraq. We conclude that international development cooperation may play an important role also in the field of high-technology medicine, and contribute to improved local centers capabilities through country to country scientific exchanges. The methodology to realize this project is innovative, since HSCT experts are brought as volunteers to the center(s) to be started, while traditionally it is the opposite, i.e. the local professionals to be trained are brought to the specialized center(s).
The PLASMIC score for the prediction of a likelihood of a severe ADAMTS13 deficiency represents a valid pre-test diagnostic tool to identify patients with thrombotic thrombocytopenic purpura.
To assess the impact of margin status on disease-free survival, overall survival, and organ preservation in early glottic cancer treated by endoscopic laser surgery.
Prospective nonrandomized study.
...Tertiary referral center.
A total of 274 patients with untreated (possibly biopsied) cTis, cT1a/b, cT2, cN0 glottic cancer; adequate exposure of the glottic region; no contraindications to general anesthesia; and the ability to give informed consent.
European Laryngological Society laser cordectomy. Patients with negative margins (>1 mm) were followed, patients with close margins (< or =1 mm) or 1 positive margin (tumor on margin) had another operation, and patients with more than 1 positive margin had postoperative radiotherapy. Median follow-up was 58 months.
Eight-year disease-free survival, 5-year overall survival, and organ preservation rate.
Margins were negative in 180 patients, close in 40, and positive in 54. A second laser resection was performed in 36 of 94 patients with close or positive margins. Radiotherapy was administered to 36 patients. Patients with close or positive margins who did not undergo further treatment had a greater recurrence risk (hazard ratio, 2.53; 95% confidence interval, 0.97-6.59, P = .06) than did those with negative margins, mainly owing to relapses in 5 of the 8 protocol breakers with positive margins not treated further. Eight-year relapse-free survival was 88.2%, 5-year overall survival was 90.9%, and the larynx was preserved in 97.1%.
Laser removal of early glottic cancer is oncologically adequate with margins greater than 1 mm from the tumor edge. Positive margins require further treatment; close margins may require further treatment depending on tumor characteristics.
Current medical practice for determining hemoglobin concentration (which is especially important for anemic patients in need of blood transfusion) involves frequent blood tests. In this work, we ...propose an alternative, non-invasive approach to hemoglobin estimation, based on image analysis of a specific conjunctival region. Our ultimate goal is to develop an easy-to-use wearable device that patients themselves can employ at home to autonomously assess their need of blood transfusion. In this paper, we detail the prototype of our device and the methodology for extracting key information from the color values of the acquired image. Tests conducted on 77 anemic and healthy patients show significant correlation between the real hemoglobin value obtained through blood sampling and the value estimated by our algorithm. A prototypical binary classification algorithm for assessing the need of blood transfusion yielded good results in terms of accuracy, specificity and sensitivity, thus making it possible to avoid a significant number of blood tests.
We evaluated the safety and efficacy of plerixafor, subsequent to disease-specific chemotherapy followed by granulocyte-colony stimulating factor (G-CSF), in 37 multiple myeloma (MM) or lymphoma ...patients, who were candidates for autologous stem cell transplantation (ASCT) predicted as poor mobilizers (PMs). Patients were identified as predicted PMs according to the history of a previously failed mobilization attempt or the presence of ≥1 factors predicting an unsuccessful harvest, such as advanced disease, prior extensive radiotherapy, or prolonged treatment, with stem cell poisons, advanced age, or extensive bone marrow involvement. Plerixafor (0.24 mg/kg) was administered subcutaneously for up to 3 consecutive days while continuing G-CSF for 9 to 11 hours before the planned apheresis. Plerixafor administration was safe and no significant adverse events were recorded. We observed a median 4-fold increase (range: 1.4-32) in the number of circulating CD34+ cells following plerixafor compared with baseline CD34+ cell concentration (from a median of 5 cells/μL, range: 1-32, to a median of 32 cells/μL, range: 6-201). Twenty-seven of the 37 patients (14 of 17 with MM and 13 of 20 with lymphoma) had ≥2×106 CD34+ cells/kg collected in 1-3 apheretic procedures. Of the 27 patients rescued with plerixafor, 24 (13 MM, 11 lymphoma) have been transplanted with plerixafor-mobilized peripheral blood stem cells, showing a rapid and durable hematologic recovery. Our results suggest that the addition of plerixafor to G-CSF after disease-oriented chemotherapy is safe and allows for a satisfactory harvest in order to perform a safe ASCT, in a relevant proportion of lymphoma and MM patients considered to be PMs.
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