?Preengraftment — less than three weeks
?Immediate postengraftment — three weeks to three months
?Late postengraftment — more than three months

Unfortunately, infection is reported as the primary cause of death in 8% of autologous HCT patients and 17% to 20% of allogeneic HCT recipients. Many of these are CMV or varicelaa-zoster viral infections and may be prevented with drugs such as Acyclovir. High-dose intravenous acyclovir (500 mg/m2 3 times daily, from day < 5 until day > 30) followed by oral acyclovir (800 mg 4 times daily for 6 months) has been found to effectively reduce the incidence of CMV disease (52%–59% vs. 61%–75%) and increase overall patient survival. However, it is expensive and has side effects. The Infectious Diseases Society of America (IDSA) issued clinical practice guidelines for preventing opportunistic infections among HCT recipients, published in Biol Blood Marrow Transpant ; 2009 ; 15 : 1143 -1238. IDSA does not recommend open ended acyclovir prophylaxis. It says: “Acyclovir prophylaxis should be offered to all HSV-seropositive allogeneic recipients to prevent HSV reactivation during the early posttransplant
period (AI). The standard approach is to begin acyclovir prophylaxis at the start of the conditioning therapy and continue until engraftment occurs or until mucositis resolves, whichever is longer, or approximately 30 days after HCT.” It does appears from its discussion in this section that there may be a benefit for a longer patients who are seronegative positive for CMV or VZV but the guideline does not define how long and does not specifically recommend it.  NCCN does recommend a year of prophylaxis in CMV or VZV infected patients but otherwise only for 30 days.  The American Society of Bone Marrow Transplantation and CDC take the same position in an identical language to the ISDA.  

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Inoperable medulloblastomas are often treated with chemotherapy but there is no randomized prospective evidence to support this. This is especially so in adults, in whom this disease is less common than in children and in whom it appears to behave distinctly differently. 30% of medulloblastoma cases occur in adults.

Autologous transplantation of relapsed disease has support from case reports, case series and small prospective trials. What to do if the disease returns after an autologous transplant? We don’t know. There are but a few case reports of allogeneic transplantation for medulloblastoma, some of them from the older literature. I am not aware of any cases of allogeneic stem cell being used after failure of autologous stem cell transplantation that have been reported.

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Three randomized controlled trials (RCTs) that compared outcomes of hematopoietic sibling stem cell transplantation(SCT) to outcomes with conventional-dose chemotherapy in children with ALL did not demonstrate superiority of transplantation in all comers but did suggest that those at high risk for relapse or those in relapse who were able to obtain another remission, did better. The literature in general shows promising results for allogeneic SCT in patients in first complete response at high risk for recurrence, and in patients in second or greater remission. This conclusion is further supported by an evidence-based systematic review of the literature sponsored by the American Society for Blood and Marrow Transplantation (ASBMT)(Hahn et al). Outcomes following matched unrelated donor and umbilical cord blood transplants have improved significantly over the past decade and may offer outcome similar to that obtained with matched sibling donor transplants.

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Regarding dose, please look at the professional version. How long should Neupogen be used? It is recommended that NEUPOGEN® (filgrastim) be given for at least 4 days before the first leukapheresis procedure and continued until the last leukapheresis. The FDA says, “Although the optimal duration of NEUPOGEN® (filgrastim) administration and leukapheresis schedule have not been established‚ administration of NEUPOGEN® (filgrastim) for 6 to 7 days with leukaphereses on days 5‚ 6‚ and 7 was found to be safe and effective (see Clinical Experience for schedules used in clinical trials). Neutrophil counts should be monitored after 4 days of NEUPOGEN® (filgrastim) ‚ and NEUPOGEN® (filgrastim) dose modification should be considered for those patients who develop a WBC count > 100‚000/mm3.” In none of the studies listed in the Clinical Experience section, was Neupogen used for 14 days for stem cell mobilization.

Clinical studies have used longer administrations than the FDA recommends, for example, Ria et al, used a 12 day schedule. Nevertheless, the FDA approved dose and schedule are the most common and there is little evidence to prefer a longer schedule.

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