33 Stem Cell Transplantation

Brian Hess and Rizwan Romee

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 33.1 The curative potential of allogeneic stem cell transplantation (allogeneic SCT) may be derived from which of the following?

A. High-dose chemotherapy

B. Graft-versus-leukemia (GVL) effect

C. Graft-versus-host effect

D. A and B

Question 33.2 The allogeneic SCT conditioning regimen serves to achieve which of the following?

A. Provide immunosuppression to prevent rejection

B. Provide immunosuppression to prevent graft-versus-host disease (GVHD)

C. Eradicate malignant cells

D. A and C

Question 33.3 A 54-year-old male is diagnosed with AML with complex cytogenetics. After achieving complete remission with standard 7+3 chemotherapy he is evaluated for allogeneic SCT from his HLA-matched brother. Which of the following regimens is considered myeloablative for his upcoming transplant?

A. Cyclophosphamide 60 mg/kg/d intravenously (IV) × 2 days plus 1,200 cGy total body irradiation (TBI)

B. Cyclophosphamide 60 mg/kg/d IV × 2 days plus busulfan 3.2 mg/kg/d IV × 4 days

C. Fludarabine 30 mg/m² × 3 days plus 200 cGy TBI

D. A and B

Question 33.4 Which conditioning regimen leads to improved disease-free survival in chronic myeloid leukemia (CML)?

A. Cyclophosphamide 60 mg/kg/d IV × 2 days plus busulfan 3.2 mg/kg/d IV × 4 days

B. 1,200 cGy TBI and cyclophosphamide 60 mg/kg/d IV × 2 days

C. Chemotherapy and radiation-based conditioning are equivalent

D. Fludarabine 30 mg/kg/d IV × 5 plus busulfan 3.2 mg/kg/d IV × 2 plus ATG 2.5 mg/kg/d IV × 4

Question 33.5 Which of the following drugs used in the conditioning regimens for stem cell transplant (SCT) is the most common cause of acute cardiac toxicity?

A. Cytarabine

B. Fludarabine

C. Cyclophosphamide

D. Busulfan

Question 33.6 A 64-year-old female is diagnosed with multiple myeloma. She has experienced a very good partial response after four cycles of induction therapy but her creatinine remains elevated at 3.9 g/dL and her creatinine clearance remains less than 15 mL/min. What is the most appropriate management in regards to her conditioning regimen for upcoming autologous stem cell transplant?

A. Melphalan 200 mg/m²

B. Dose reduce melphalan to 140 mg/m²

C. Dose reduce melphalan to 100 mg/m²

D. Her elevated creatinine is a contraindication to autologous transplant

Question 33.7 The GVL effect after transplant is most pronounced in which of the following malignancies?

A. Acute myelogenous leukemia (AML)

B. Acute lymphoblastic leukemia (ALL)

C. Chronic-phase CML

D. Accelerated-phase CML

Question 33.8 Which of the following increases the risk of relapse after allogenic stem cell transplantation?

A. Human leukocyte antigen (HLA)-mismatched transplant

B. CD34 cell dose >2 × 10⁶ but <5 × 10⁶/kg recipient body weight

C. Acute and chronic GVHD

D. Use of T-cell–depleted graft

Question 33.9 Which of the following therapies in a patient with multiple myeloma would potentially hinder stem cell mobilization and collection for future autologous stem cell transplant?

A. Melphalan

B. Long-term use of lenalidomide

C. Velcade

D. A and B

Question 33.10 Sinusoidal obstruction syndrome (SOS) of the liver is associated with which of the following factors?

A. TBI 12 Gy conditioning

B. Oral busulfan conditioning

C. Advanced age

D. All of the above

Question 33.11 Which of the following factors is associated with increased risk of engraftment failure in allogeneic stem cell transplantation?

A. T-cell depletion of the product

B. Less than 1 × 10⁶ CD34+ cells/kg recipient body weight

C. HLA-mismatched stem cell donor

D. All of the above

Question 33.12 In which setting is the risk of CMV reactivation the highest after allogeneic SCT?

A. CMV-positive donor to a CMV-negative recipient

B. CMV-negative donor to a CMV-positive recipient

C. CMV-negative donor to a CMV-negative recipient

D. CMV-positive donor to a CMV-positive recipient

Question 33.13 Peripheral blood mobilized stem cell allografts, compared with bone marrow, are associated with which of the following?

A. Shorter period of neutropenia

B. Shorter period to platelet recovery

C. Equivalent T-cell numbers

D. Equivalent incidence of acute GVHD

E. A, B, and D

Question 33.14 For which of the following patients with an HLA-matched donor is allogeneic SCT most appropriate?

A. A 35-year-old man with AML with inversion 16 in CR1 after 7+3

B. A 40-year-old woman with AML and complex cytogenetics in first clinical remission (CR)

C. A 48-year-old woman with diffuse large B-cell lymphoma with chemosensitive relapse after initial remission of 18 months

D. A 55-year-old man with RAI stage III chronic lymphocytic leukemia (CLL) in first remission

Question 33.15 Which of the following are potential complications of donor lymphocyte infusion (DLI)?

A. Bone marrow aplasia

B. GVHD flare

C. SOS

D. A and B

Question 33.16 Factors that influence the choice of conditioning regimen in allogeneic stem cell transplantation include:

A. Underlying malignancy and prior treatment.

B. Patient age and comorbidity.

C. Donor:recipient HLA compatibility.

D. All of the above.

Question 33.17 Late complications after allogeneic SCT include:

A. Skeletal complications, including osteoporosis and avascular necrosis.

B. Secondary malignancies.

C. Endocrine failure.

D. All of the above.

Question 33.18 What is the most common cause of late hemorrhagic cystitis in patients undergoing allogeneic SCT?

A. Cyclophosphamide

B. BK virus

C. EBV

D. CMV

Question 33.19 Autologous stem cell transplantation is indicated in certain situations for which of the following solid tumors?

A. Testicular cancer

B. Neuroblastoma

C. Breast cancer

D. A and B

Question 33.20 Graft manipulation ex vivo to purge contaminating tumor cells is a strategy that has been successful in reducing the rate of relapse after autologous stem cell transplantation.

A. True

B. False

Question 33.21 Which of the following should be considered for autologous stem cell transplant?

A. DLBCL that has relapsed after first-line R-CHOP chemotherapy

B. Follicular lymphoma that has relapsed after first-line Bendamustine and Rituxan

C. ALK-positive T-cell lymphoma in first remission

D. Nodal Marginal zone lymphoma that has progressed after a 6-month period of observation

Question 33.22 A mismatch of which of the following HLA genes would NOT adversely influence the outcome in an HLA mismatched unrelated donor allogeneic SCT?

A. HLA-A

B. HLA-B

C. HLA-C

D. HLA-DQB1

E. HLA-DRB1

Question 33.23 Which of the following cells present in the stem cell graft are thought to play a major role in mediating GVL effect seen in allogeneic stem cell transplants?

A. Donor T lymphocytes

B. Donor B cells

C. Donor NK cells

D. A and C

Question 33.24 A 42- year-old male is undergoing transplant for relapsed AML. He has no matched related or unrelated donors available and thus he is undergoing referral for a haploidentical transplant from his brother. Which of the following would be appropriate in order to decrease the likelihood of acute GVHD in this setting?

A. Post transplant Cytoxan 50 mg/m² on day +3 and day +4

B. Reduce dose of calcineurin inhibitor started on day 0

C. Reduced intensity conditioning

D. Posttransplant Rituximab 375 mg/m² on day +4

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