More effective therapeutic strategies are required for patients with poor-prognosis systemic sclerosis (SSc). A phase 2 single-arm study of high-dose immunosuppressive therapy (HDIT) and autologous CD34-selected hematopoietic cell transplantation (HCT) was conducted in 34 patients with diffuse cutaneous SSc. HDIT included total body irradiation (800 cGy) with lung shielding, cyclophosphamide (120 mg/kg), and equine antithymocyte globulin (90 mg/kg). Neutrophil and platelet counts were recovered by 9 (range, 7 to 13) and 11 (range, 7 to 25) days after HCT, respectively. Seventeen of 27 (63%) evaluable patients who survived at least 1 year after HDIT had sustained responses at a median follow-up of 4 (range, 1 to 8) years. There was a major improvement in skin (modified Rodnan skin score, ؊22.08; P < .001) and overall function (modified Health Assessment Questionnaire Disability Index, ؊1.03; P < .001) at final evaluation. Importantly, for the first time, biopsies confirmed a statistically significant decrease of dermal fibrosis compared with baseline (P < .001). Lung, heart, and kidney func-

Summary:Allogeneic hematopoietic cell transplantation is followed by humoral immunodeficiency. We evaluated whether antibody levels can be improved by recipient vaccination on day À1 and 50 and whether the levels can be further improved by donor vaccination on day À20. A total of 85 patients were randomized or assigned to one of the following strategies of immunization with Streptococcus pneumoniae polysaccharides, Haemophilus influenzae polysaccharide-protein conjugate, tetanus toxoid (protein recall antigen) and hepatitis B surface antigen (protein neo-antigen): (1) donor on day À20, recipient on days À1, þ 50 and þ 365 (D À20 R À1,50,365 ); (2) donor nil, recipient on days À1, þ 50 and þ 365 (D N R À1,50,365 ); or (3) donor nil, recipient on day þ 365 (D N R 365 ). For H. influenzae and tetanus, IgG levels after grafting were the highest in the D À20 R À1,50,365 patients, intermediate in the D N R À1,50,365 patients and the lowest in the D N R 365 patients. For S. pneumoniae and hepatitis B, antibody levels appeared to be similar in all three patient groups. The results suggest that for polysaccharide-protein conjugate antigens or protein recall antigens, recipient immunization on days À1 and 50 improves antibody levels and that donor vaccination on day À20 further improves the levels. In contrast, neither recipient immunization on days À1 and 50 nor donor immunization on day À20 appears to be efficacious for polysaccharide antigens and poorly immunogenic protein neo-antigens. 3-6 Antibody levels can be improved either by the administration of immunoglobulin or by vaccination. The administration of immunoglobulin may decrease the rates of some infections at the time of immunoglobulin administration, but may hamper reconstitution of antibody immunity and thus increase infection rates after the immunoglobulin has been discontinued. 6 The vaccination can improve pathogen-specific immunity both at the time of vaccination as well as years after vaccination. However, vaccination during the first year after transplantation leads to only minor increases in specific antibody levels. Moderate to marked increases in specific antibody levels during the first year after transplant were achieved when both the donor and the recipient were immunized 7-10 days before transplantation and the recipient was boosted at 3 and 6 months after transplantation. 7,8 Presumably this happened because large numbers of antigen-specific lymphocytes were generated in the donors and because these lymphocytes (transferred with the graft) or their progeny proliferated and differentiated upon encounter with the antigen injected to the recipient 7-10 days before transplant and at 3 and 6 months after transplant.We set out to compare the following three vaccination strategies: (1) donor vaccination on day À20 (20 days before transplant) with recipient vaccination on days À1, þ 50 and þ 365 (D À20 R À1,50,365 ); (2) no donor vaccination and recipient vaccination on days À1, þ 50 and þ 365 (D N R À1,50,365 ) and (3) a conventional strategy of no don...

Cardio-oncology is a multidisciplinary field focusing on the management and prevention of cardiovascular complications in cancer patients and survivors. While the initial focus of this specialty was on heart failure associated with anthracycline use, novel anticancer agents are increasingly utilized and are associated with many other cardiotoxicities including hypertension, arrhythmias and vascular disease. Since its inception, the field has developed at a rapid pace with the establishment of programs at many major academic institutions and community practices. Given the complexities of this patient population, it is important for providers to possess knowledge of not only cardiovascular disease but also cancer subtypes and their specific therapeutics. Developing a cardio-oncology program at a stand-alone cancer center can present unique opportunities and challenges when compared to those affiliated with other institutions including resource allocation, cardiovascular testing availability and provider education. In this review, we present our experiences establishing the cardio-oncology program at Moffitt Cancer Center and provide guidance to those individuals interested in developing a program at a similar independent cancer institution.