title: Veno-occlusive disease of the liver after busulfan, melphalan, and thiotepa conditioning therapy: incidence, risk factors, and outcome.
abstract: The purpose of this study was to determine the incidence of veno-occlusive disease (VOD) after a high-dose regimen of busulfan, melphalan, and thiotepa and the risk factors for a more severe outcome. We followed 253 consecutive patients with malignant disorders who received autologous transplants after stem cell harvest followed by 12 mg/kg busulfan, 100 mg/m2 melphalan, and 500 mg/m2 thiotepa. Diagnosis of VOD was based on weight gain, hepatomegaly, and jaundice. Risk factors for moderate or severe VOD were identified using logistic regression models. VOD occurred in 70 of 253 patients (28%), of whom 31 (12%) had moderate and 11 (4%) severe VOD. The median day of onset of hyperbilirubinemia was day 9, significantly later than the onset of jaundice after our cyclophosphamide-based regimens (p < 0.001). Resolution of weight gain and jaundice, followed by their reappearance several weeks later, occurred in 23 of 70 patients with VOD and was an adverse prognostic sign. Risk factors for moderate or severe VOD were a diagnosis of lymphoma or myeloma (odds ratio [OR] 2.65 compared with breast cancer), tumor involvement in the liver (OR 3.95), fever in the month before transplant (OR 3.32), and prior radiation therapy (OR 2.70). We conclude that VOD after busulfan, melphalan, and thiotepa was less frequent and less severe and developed later than VOD after our historical cyclophosphamide-based regimens. Significant risk factors included a diagnosis other than breast cancer, hepatic metastases, persistent fever, and prior radiation therapy. This study suggests that alkylating agents of comparable overall toxicity differ in their liver toxicity.
authors.affiliation: Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Lee
authors.forename: T
authors.initials: T
authors.lastname: Gooley
authors.forename: W
authors.initials: W
authors.lastname: Bensinger
authors.forename: K
authors.initials: K
authors.lastname: Schiffman
authors.forename: G B
authors.initials: GB
authors.lastname: McDonald
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D018906:Antineoplastic Agents, Alkylating / Q000008:administration & dosage / Q000009:adverse effects*; D002066:Busulfan / Q000008:administration & dosage / Q000009:adverse effects; D002648:Child; D002675:Child, Preschool; D003520:Cyclophosphamide / Q000009:adverse effects; D005260:Female; D019337:Hematologic Neoplasms / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation; D006504:Hepatic Veno-Occlusive Disease / Q000139:chemically induced* / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D015994:Incidence; D008107:Liver Diseases / Q000150:complications / Q000401:mortality; D008297:Male; D008558:Melphalan / Q000008:administration & dosage / Q000009:adverse effects; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000150:complications; D015999:Multivariate Analysis; D011878:Radiotherapy / Q000009:adverse effects; D012307:Risk Factors; D015996:Survival Rate; D013852:Thiotepa / Q000008:administration & dosage / Q000009:adverse effects; D019172:Transplantation Conditioning / Q000009:adverse effects*; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014916:Whole-Body Irradiation / Q000009:adverse effects
chemical_list: D018906:Antineoplastic Agents, Alkylating; D003520:Cyclophosphamide; D013852:Thiotepa; D002066:Busulfan; D008558:Melphalan