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In general the adult guidelines are applicable to children but additional considerations (aggressive or very progressive childhood neoplasms, specific indications, neonatal use, congenital disorders) must be taken into account.

Summary:The role of support measures in the Intensive Care Unit for bone marrow transplant recipients has been controversial. Data from 176 pediatric bone marrow transplants were retrospectively analyzed to ascertain the probability, causes, risk factors and survival for lifethreatening complications requiring intensive care. Ninety-two patients underwent allogeneic BMT and 84 autologous BMT between January 1991 and December 1995. Thirty-one ICU admissions were recorded. The most frequent causes were acute respiratory failure (n = 15, mostly interstitial pneumopathies), septic shock (n = 5) neurological disorders (n = 5) and heart failure (n = 2). The cumulative incidence of an ICU admission at 20 months post-transplant in patients with an allogeneic BMT was 25.7% (CI: 16.4-35.1), compared with 10.8% (CI: 4.2-17.5) in those with an autologous graft (P = 0.04). ICU admission frequency was maximum during the first 2 months post-transplant. All complications in patients with autologous transplants appeared during the first 5 months post-transplant. Among patients with allogeneic grafts, four were later admitted to the ICU, at 7, 9, 12 and 20 months post-transplant, respectively. The main risk factor for ICU admission was acute GVHD grades III-IV. No differences were found between patients with allogeneic transplants with GVHD grades 0-II and those undergoing autologous transplant. In contrast, differences were highly significant between patients undergoing allogeneic transplants with GVHD grades III-IV and those with GVHD grades 0-II or autologous transplants. No differences were observed between allogeneic and autologous transplants in terms of causes for ICU admission, duration of stay, hours on mechanical ventilation, hours on inotropic drug therapy and numbers of organs failing. Neither were differences found in ICU discharge survival between patients with allogeneic (50%, CI: 29.1-70.9) and autologous (66.7%, CI: 29.9-89.1) transplants. ICU discharge survival in patients admitted for lung disease was 28.6% (CI: 12.1-65.6) but 76.5% (CI: 41.9-87.8) in patients admitted for other causes (P = 0.007). ICU Although a complication requiring admission to the ICU is, as confirmed by multivariate analysis, an unfavorable factor in long-term survival of transplanted patients, it must be emphasized that three of every 10 patients admitted to the ICU were alive and well at 3 years. Intensive care support in these patients can be life-saving.

Our study reflects the difficulties in the completion of a therapeutic strategy that include BMT and suggests that intensification before BMT may be useful in the setting of ABMT, but this approach was associated with a high mortality rate in allo-BMT patients.

Summary:Herein we describe our experience with 75 consecutive autologous BM transplants for patients with high-risk ALL, with special attention to the clinical impact of BM purging. Fifty-two patients received purged BM using monoclonal antibody (MoAb) cocktails and complement, and 23 patients received untreated BM. The distribution of prognostic factors was similar in both groups. Hemopoietic reconstitution was adequate and did not differ in the two groups. Transplant-related mortality was 9.6% and 13% in 'purged' and 'unpurged' groups. Median follow up was 11 months (2-71) and overall actuarial probability of disease-free survival (DFS) at 5 years was 40% (53% relapse probability). We found a beneficial effect of purging in patients over 15 years of age and in patients needing more than 1 month to reach CR1. Patients in CR1 receiving purged marrow had a longer DFS and a lower relapse probability (52% vs 12%, P = 0.02 and 35% vs 86%, P = 0.005, respectively) which were related to the efficacy of the purging procedure (more or less than one log of depletion). In further CR, no advantage of purging has been found. Our data strongly suggest the clinical relevance of BM purging in autologous BMT in high-risk ALL patients and support the need for prospective randomized studies. Keywords: autologous BMT; acute lymphocytic leukemia; bone marrow purging Therapy for acute leukemia has become more and more efficient during the past decade. Most children with acute lymphoblastic leukemia (ALL) can be cured with current chemotherapy strategies. 1-3 Similarly, the majority of patients with acute myeloid leukemia (AML), regardless of their age, can achieve a complete remission (CR) using combined chemotherapy with anthracyclines, cytosine arab- inoside, etoposide, carboplatinum and other drugs in different combinations. [4][5][6] However, many of these AML patients and high-risk ALL patients will never be cured with chemotherapy due to the high incidence of relapse. 5,6 Bone marrow transplantation (BMT) technologies have improved significantly over the past 15-20 years and now constitute a regular therapeutic approach for poor-risk ALL patients. 7,8 Although allogeneic BMT is currently curative for approximately 50% of the patients, [8][9][10][11][12] unfortunately, this kind of transplant can only be applied to those patients having an HLA-identical donor, either family related or unrelated. The probability of finding an HLA-matched donor in a family with at least two children is 25-30%, and unrelated donors can be found for 50% of patients who do not have a family donor. Also the probability of being in CR rapidly decreases during the first 4 to 5 months, which is the median time necessary for a successful search for an unrelated donor. Thus 40-50% of patients will not be eligible for this potentially curative therapeutic option.Autologous BMT is an alternative to allogeneic BMT for many of these patients. 13,14 There are at least two factors that make autologous BMT less likely to be curative when compared to allogeneic t...