Heterogeneous in nature the management of leukemia, lymphoma and multiple myeloma all present complex clinical problems, requiring an ever evolving multidisciplinary approach to diagnosis and treatment. Recognizing that patient quality of life and survival are significantly improved when these cancers are detected early and treated appropriately.
In the late 1990s, the use of reduced-intensity conditioning regimen (RIC) was a major paradigm shift in the field of stem cell transplantation. The main idea was to harness the graft-versus-tumor (GVT) effect to achieve the ultimate goal of cure without the need for toxic myeloablative therapy. It became clear that engraftment after RIC can result in mixed donor chimerism adequate to correct the medical problem without subjecting the patient to short- and long-term toxicities associated with myeloablative transplantation regimens.
This issue of Grand Rounds in Hematology covers a number of diverse topics related to the diagnosis and treatment of and T-cell lymphomas and highlights an evening educational session at the 2009 American Society of Hematology meeting in San Francisco. Several key opinion leaders in the field gathered to present their thoughts on a number of topics, including the pathophysiology of T-cell lymphoproliferative disorders, current treatment options for patients with peripheral T-cell lymphomas (PTCL), treatment strategies for patients with cutaneous T-cell lymphomas (Mycosis fungoides and Sézary syndrome), an overview of the biology and treatment options for extranodal gastric marginal zone lymphomas of mucosalassociated lymphoid tissue (MALT), and fi nally approaches to the treatment of primary central nervous system lymphomas (PCNSL).
The management of multiple myeloma has changed dramatically over the past 2 decades. Testing of new treatment options continues at a rapid pace. The advances have resulted in improved survival rates not only in clinical trial participants, but these benefits have been applied to general practice and survival rates are improving in population-based studies as well. Although cure largely remains beyond a realistic prospect, durable control of disease is achievable in the majority of patients.
Although the myelodysplastic syndromes (MDS) are not curable without hematopoietic cell transplant (HCT), advances in non-transplant therapies today offer considerable benefit to our patients. Over the years, prognostic algorithms have been developed and validated and these are useful guides to allow us to more accurately predict the likely trajectory of disease progression in a group of syndromes that have a notorious heterogeneity.
The alloreactive potency of the hematopoietic stem cell graft provides powerful anticancer activity. Unfortunately, the potential for harm (by graft-versus-host disease [GVHD]) is often as strong as the potential for good. The measures used to control GVHD, such as steroids and antithymocyte globulin, often seem like elephant guns causing similar harmful effects (toxicity and vulnerability for infection) as the GVHD itself, and they rob much of the anticancer effects of the donor graft. GVHD is indeed the thorniest problem of allogeneic hematopoietic cell transplantation (HCT).
The content of this continuing medical education (CME) activity is derived from a symposium, “The Promise of Epigenetic Therapy,” presented at the 48th Annual Meeting of the American Society of Hematology.