Patients and Methods:-Study Design:-Patients and Control:-The study was conducted in the bone marrow transplantation unit (department of clinical hematology at Ain Shams university hospital) during a period from June 2015 to August 2016.Participants were grouped into:-Group (1): included 100 patients with lymphoproliferative disorders who underwent BMT in our unit, 79 patients underwent autologus transplant and 21 underwent allogeneic transplant, 30 patients with NHL, 10 patients with HD, 39 patients with multiple myeloma and 21 patients with acute lymphoblastic leukemia.
Group (2) (healthy control group): included participants without known cardiovascular disease, hypertension or DM. They were matched 1:1 based on age, sex, blood pressure and surface area with the cases.Group (3) (positive control): 50 patients with lymphoproliferative disorders who received chemotherapy without undergoing BMT. They included 25 males and 25 females, 46% had MM, 42% had NHL and 12% had HD.Informed consents were obtained from all participants. The study was conducted in accordance with the stipulations of the local ethical and scientific committees of Ain Shams University and the procedures respected the ethical standards in Helsinki declaration of 1964.Methods:-All patients were subjected to full history and physical examination including the presence of B-symptoms like weight loss, fever, drenching sweats and pruritis, anemic manifestations or bleeding or the presence of bone fractures and the presence of lymphadenopathies or hepatosplenomegaly.To confirm the diagnosis of NHL and HD:-? Excision lymph node biopsy for fresh frozen and formaline-fixed samples for histopathological assessment.
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? Immunohistochemistry for B-cell markers like CD20,CD19,CD79a,CD10 and T-cell markers like CD3,CD4,CD8,CD7,CD5,CD2 , markers of immature lymphoblast like TdT, immunoglobulin Kappa and Lambda light chain restriction and for CD15 and CD30 for characterization of Reed-Sternberg cells.? Chest X-ray, contrast-enhanced CT scans of the neck, chest and pelviabdomen.? Baseline, interim and end of therapy PET was carried out whenever available for staging and response assessment.Bone marrow aspiration and trephine biopsy.? Cytogenetic analysis using conventional cytogenetics and FISH for certain specific chromosomal abnormalities.? Staging is carried out according to Ann-Arbor staging system Examination.? Cerebrospinal fluid and triple intrathecal chemotherapy prophylaxis was given to certain patients like: (1): patients with DLBCL with bone marrow, testicular, paranasal and epidural involvement.
(2): lymphoblastic lymphoma. (3): primary CNS lymphoma.? Upper GI endoscopy in those with suspected GI involvement eg. Mantle cell lymphoma.To confirm the diagnosis of multiple myeloma:-? Complete blood counts and serum chemistries especially for serum calcium, serum creatinine to detect CRAB features.? Detection of monoclonal M-protein in the serum and urine by serum protein electrophoresis.? Characterization of heavy and light chains in the serum and urine sample by immunofixation.
? Bone marrow aspiration and biopsy to evaluate the percentage of plasma cells.? Conventional chromosomal analysis and FISH for high-risk myeloma like t(4;14), (14;16) and 17p.? Skeletal survey for evaluation of lytic bone lesions using X-ray of spine, skull, pelvis, humerus and femur.
? MRI to evaluate symptomatic bony sites even if skeletal survey is negative or in case of spinal cord compression.? Serum free light chains and Kappa/Lambda ratio for the detection of stringent CR whenever possible.To confirm the diagnosis of acute lymphoblastic leukemia:-? Complete blood count and differential for the detection of peripheral blasts.? Bone marrow aspiration and trephine biopsy for the detection of the percentage of blast cells.? Immunophenotyping for lymphoid and myeloid markers.? Conventional cytogenetics and FISH for Philadelphia chromosome.? CT scans for the neck, chest and pelviabdomen.
? CSF examination and triple intrathecal chemotherapy for prophylaxis and/or therapy in case of CNS involvement.Patients who underwent autologus transplant were subjected to:-? Complete blood count using (LH Beckman coulter).? Serum chemistries including liver and renal function tests (AU 680 chemistry autoanalayzer).? Viral markers for hepatitis B, hepatitis C and HIV using Rosh diagnostics and performed by copus instruments.? Polymerse chain reaction (PCR) for CMV using kits supplied by Qiagen and performed by rotor gene instrument for automated real time PCR.
? Serology for herpes simplex (HSV), Toxoplasma and Ebstein Bar virus (EBV).? Pulmonary function tests.? Renal scan.
? Electrocardiogram and echocardiography.? Mobilization was done using different regimens ranging from G-CSF alone to G-CSF and cyclophosphamide or other chemotherapeutic regimen depending on the specific disease.? Conditioning regimens: for patients with MM high dose melphalan 200mg/m2 on day -2, for patients with NHL and HD they received a conditioning regimens consisted of cyclophosphamide 60mg/kg/d -3 and -2, etoposide 15mg/kg/d -3 and -2, carboplatin 400mg/m2 -3 and -2.In addition, patients undergoing allogeneic transplant are subjected to:-? Donors received (after informed consent) 4 days of treatment with SC G-CSF (10ug/kg/d) before stem cells were collected.? Mononuclear cells were isolated using a Cobe Spectra separator (Lakewood, Co, USA).? The number of CD34 cells transfused was calculated using flowcytometric analysis.? GVHD prophylaxis consisted of cyclosporine and methotrexate.? Engraftment was defined as absolute neutrophilic count of more than 500 for three consecutive days.
? Chimerism analysis by variable number of tandem repeats (VNTR) was done at +28 and +56 after transplant.Conditioning regimen consisted of TBI 2.5GY days -7 to -4 /Cyclophosphamide 60mg/kg days -3 and -2, TBI 2.5 GY days -7 to -4 /etoposide 60mg/kg d-3, Fludarabine 30mg/m2 days -6 to -2 /oral Busulfan 1mg/kg/6hours days -6 to -3.
All patients in both autologus and allogeneic transplant were treated using the same anti-infectious and transfusion policy of our transplant center.Transthoracic echocardiography:-? All patients were evaluated during transplant in case of occurrence of any minor or major cardiac events according to the international guidelines recommended by ACC and AHA.? Transthoracic echocardiograph was done before transplant and 6 months after transplant.
? Transthoracic echocardiography was carried out using 2-4 MHz phased array transducer attached to a vivid S5 echocardiography machine by a cardiologist who was blinded to clinical details of each subject. Inter-observer variability was reduced by taking the mean of three reading during each echocardiography.? The following parameters were examined: left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD), intraventricular end-diastolic diameter (IVSDD), posterior wall end-diastolic diameter (PWEDD), right ventricular end-diastolic diameter (RVEDD), left atrium diameter (LA) and aorta diameter (Ao). The systolic function was determined by left ventricular ejection fraction (LVEF) using M-mode and modified Simpson’s formula. Left ventricular diastolic function was evaluated with pulsed Doppler and tissue Doppler imaging (TDI). The following parameters of the diastolic function of left ventricle were determined: early filling velocity E wave (E) and A wave (A) of mitral inflow, Doppler-derived mitral deceleration time of early filling (DT), isovolumetric relaxation time (IVRT) and early diastolic velocity of mitral annulus wave (E0).Statistical analysis:-? All analyses of the present study were done using SPSS version 17 software.? Statistical presentation and analysis of the present study was conducted, using the mean, standard deviation, student t-test, chi square.
? Data were expressed as mean value ± SD for continuous variables, and as percentages for categoric variables. In this study, statistical significance was established as follows: p?0.05 insignificant, p?0.05 significant, p?0.
01 highly significant.? Comparisons between continuous variables were performed using the paired t-test or unpaired t-test. For comparisons of categorical variables, frequency tables and chi-square tests were used.