How we mobilize haemopoietic stem cells

Mobilization and collection of haemopoietic stem and progenitor cells (HSPC) is the cornerstone of autologous and allogeneic stem cell transplantation for a wide variety of haematological and some non-haematological malignancies. Centres providing this service face the challenge of optimizing the likelihood of successful collection of transplantable doses of cells, while maximizing the efficiency of the apheresis unit and minimizing the risk of toxicity as well as mobilization failure. Recent developments in the understanding of the molecular mechanisms of mobilization have led to the emergence of novel strategies for HSPC mobilization, which may assist in meeting these imperatives. The task for clinicians is how to incorporate the use of these strategies into practice, in the light of emerging evidence for efficacy and safety of these agents. Herein, the literature is reviewed, and a proposed algorithm for HSPC mobilization is presented.     

单个核细胞计数对异基因外周血干细胞移植后造血重建的预测研究

目的探讨单个核细胞(MNC)计数作为造血干(祖)细胞含量的独立指标预测异基因外周血干细胞移植(allo-PBSCT)后造血重建的可行性。方法将暨南大学附属第一医院血液科2000年1月至2008年12月120例allo-PBSCT患者分为MNC组(83例)和CD34+细胞组(37例),MNC组以≥4×108/kg为采集目标,CD34+细胞组以≥4×106/kgCD34+细胞为采集目标。比较两种计数指标对造血重建和供者采集次数的影响,并分析不同MNC剂量对造血重建的影响。结果MNC组受者输入MNC的中位数为6.81×108/kg,CD34+细胞组受者输入CD34+细胞的中位数为5.05×106/kg;两组造血重建率均为100%;两组中性粒细胞植活的中位时间均为移植后第11天(P0.05),血小板植活的中位时间均为移植后第12天(P0.05);两组供者1次采集率分别为100%和37.84%(P0.05);MNC组中HLA全相合与不全相合移植受者中性粒细胞植活的中位时间分别为移植后第11天和移植后第12天(P0.05),血小板植活的中位时间分别为移植后第12天和移植后第14天(P0.05);MNC剂量在(3～5.99)×108/kg递增时,剂量与造血重建呈正相关,而MNC剂量在达到6×108/kg后递增,则并未使植活时间随之进一步缩短。结论MNC计数单独作为造血干(祖)细胞含量的计数指标,不仅能可靠预示allo-PBSCT(包括HLA全相合与不全相合移植)后造血重建,其植活率和植活速度可与CD34+细胞相比拟,而且其供者1次采集率(100%)显著高于后者(37.84%),allo-PBSCT时MNC计数可取代CD34+细胞作为造血干(祖)细胞含量的独立指标。     

Purification and functional assessment of smooth muscle cells derived from mouse embryonic stem cells

Objective To obtain a pure population of smooth muscle cells (SMC) derived from mouse embryonic stem cells (ESC) and further assess their functions. Methods A vector, expressing both puromycin resistance gene (puro^r) and enhanced green fluorescent protein (EGFP) gene driven by smooth muscle 22α (SM22α) promoter, named pSM22α-puro^r-IRES2-EGFP was constructed and used to transfect ESC. Transgenic ESC (Tg-ESC) clones were selected by G418 and identified by PCR amplification of puro^rin vivo. After induction of SMC differentiation by all-trans retinoic acid, differentiated Tg-ESC were treated with 10 μg/mL puromycin for three days to obtain purified SMC (P-SMC). Percentage of EGFP+ cells in P-SMC was assessed by flow cytometer. Expressions of smooth muscle specific markers were detected by immunostaining and Western blotting. Proliferation, migration and contractility of P-SMC were analyzed by growth curve, trans-well migration assay, and carbachol treatment, respectively. Finally, both P-SMC and unpurified SMC (unP-SMC) were injected into syngeneic mouse to see teratoma development. Results Tg-ESC clone was successfully established and confirmed by PCR detection of puro^r+ percentage as high as 98.2% in contrast to 29.47% of unP-SMC. Compared with primary mouse vascular smooth muscle cells (VSMC), P-SMC displayed positive, but lowered expression of SMC-specific markers including SM α-actin and myosin heavy chain (SM-MHC) detected either, by immunostaining, or immunoblotting, accelerated proliferation, improved migration (99.33 ± 2.04 vs. 44.00 ± 2.08 migrated cells/field, P < 0.05), and decreased contractility in response to carbachol (7.75 ± 1.19 % vs. 16.50 ± 3.76 % in cell area reduction, P < 0.05). In vivo injection of unP-SMC developed apparent teratoma while P-SMC did not. Conclusions We obtained a pure population of ESC derived SMC with less mature (differentiated) phenotypes, which will be of great use in research of vascular diseases and in bio-engineered vascular grafts for regenerative medicine.     

Hepatosplenic gammadelta T-cell lymphoma in a 10-year-old boy successfully treated with hematopoietic stem cell transplantation

The authors report a 10-year-old boy with hepatosplenic gammadelta T-cell lymphoma, a rare form of lymphoma that is highly aggressive, exceedingly rare in children, and primarily seen in young men. Conventional multi-agent chemotherapy appears to be inadequate for cure. This is the first report with this type of lymphoma in a boy less than 15 years old treated with hematopoietic stem cell transplantation (HSCT).     

Antiangiogenic agents increase breast cancer stem cells via the generation of tumor hypoxia

Antiangiogenic therapy has been thought to hold significant potential for the treatment of cancer. However, the efficacy of such treatments, especially in breast cancer patients, has been called into question, as recent clinical trials reveal only limited effectiveness of antiangiogenic agents in prolonging patient survival. New research using preclinical models further suggests that antiangiogenic agents actually increase invasive and metastatic properties of breast cancer cells. We demonstrate that by generating intratumoral hypoxia in human breast cancer xenografts, the antiangiogenic agents sunitinib and bevacizumab increase the population of cancer stem cells. In vitro studies revealed that hypoxia-driven stem/progenitor cell enrichment is primarily mediated by hypoxia-inducible factor 1α. We further show that the Akt/β-catenin cancer stem cell regulatory pathway is activated in breast cancer cells under hypoxic conditions in vitro and in sunitinib-treated mouse xenografts. These studies demonstrate that hypoxia-driven cancer stem cell stimulation limits the effectiveness of antiangiogenic agents, and suggest that to improve patient outcome, these agents might have to be combined with cancer stem cell-targeting drugs.     

Ifosfamide,epirubicin, and etoposide (IEV) mobilize peripheral blood stem cells more efficiently than cyclophosphamide/etoposide

High-dose chemotherapy with autologous stem cell support is an effective treatment in advanced multiple myeloma. In this study, we compare chemotherapy with ifosfamide, epirubicin, and etoposide (IEV) or cyclophosphamide and etoposide (CE) in 47 patients with multiple myeloma with regard to stem cell mobilization, toxicity, and tumor response. The proportion of patients reaching the threshold of >6 × 10⁶ CD34⁺ cells/kg body weight was significantly higher in the IEV group (97% vs 71%), and more CD34⁺ cells (10 × 10⁶ vs 3.5 × 10⁶ cells/kg; p = 0.002) could be collected by the first leukapheresis associated with less leukaphereses needed. Non-hematopoietic side effects were mild with nausea being more frequent after IEV treatment (30% vs 7%). Grade 3/4 neutropenia (thrombocytopenia) occurred in 89 and 100% (55 and 44%) of the patients. There was one treatment-related death due to septic shock in the IEV group. Grade 3/4 anemia was more frequent in the IEV group (19% vs 0%). Forty-two percent (IEV) and 50% (CE) received inpatient treatment for neutropenic fever. In 20 and 7% of the patients, a partial response was observed after IEV and CE. However, the overall response rate (complete response and partial tumor response) after mobilization and tandem high-dose chemotherapy was 75% after IEV and 78% after CE and, thus, independent of the mobilization. In summary, both treatment protocols can readily be used for the mobilization of peripheral blood stem cells with comparable major toxicities and similar tumor response rates. However, the efficiency of the stem cell mobilization was significantly higher after IEV treatment.     

Hepatocyte growth factor mobilizes and recruits hematopoietic progenitor cells into liver through a stem cell factor‐mediated mechanism

Aims: Although bone marrow cells are reported to migrate to the liver under circumstances of severe liver injury, the bone marrow cell type and the mechanisms in this process, remain to be clarified. We examined the involvement of hepatocyte growth factor (HGF) in this process and the cell type of migrated hematopoietic cells by HGF. Methods: The CD34⁺ cells and colony forming cells in the peripheral blood were examined in HGF transgenic, recombinant HGF‐administered, and HGF‐expressing adenovirus‐administered mice. The cell type mobilized by HGF was examined by the percentages of donor cells in the peripheral blood of the recipient mice transplanted with Lin^‐c‐kit⁺Sca‐1⁺CD34⁺ cells and those with Lin^‐c‐kit⁺Sca‐1⁺CD34^‐ cells. Expression of stem cell factor (SCF) was examined after the addition of HGF in MS‐5 stromal cells. The numbers of the cells which were mobilized from bone marrow and recruited into liver by HGF were assessed using green fluorescence fluorescent (GFP)‐chimera mice. Results: Mobilized CD34+ cells and colony forming cells in the peripheral blood were increased by HGF treatment. The cells mobilized by HGF were mostly Lin^‐c‐kit⁺Sca‐1⁺CD34⁺ cells. Recruitment of bone marrow cells into liver was not suppressed in MMP‐9‐/‐ mice. Expression of SCF was induced by HGF in MS‐5 stromal cells. However, expression of CXCR4, SDF‐1, MMP‐9 or VCAM‐1 was not changed. The numbers of GFP‐positive cells in liver 1 month after treatment by HGF was greater than that by G‐CSF. Conclusion: The results of the present study suggest that HGF mobilizes and recruits hematopoietic progenitor cells from bone marrow into the liver through SCF‐mediated mechanism.     

Cotransplantation of HLA-identical mesenchymal stem cells and hematopoietic stem cells in Chinese patients with hematologic diseases

Mesenchymal stem cells (MSCs) may be employed to support hematopoietic reconstitution and mitigate graft-vs.-host disease (GVHD) in transplantation of hematopoietic stem cells (HSCs). The aim of this study was to explore the feasibility and safety of cotransplantation culture-expanded MSCs and HSCs from the same human leukocyte antigen (HLA)-identical sibling donor in Chinese patients with hematologic diseases. Bone marrow mononuclear cells from healthy donors were cultured and expanded ex vivo. Immunophenotype, adipogenic and osteogenic differentiation potential, and karyotype of the harvested MSCs were detected on those who had been cotransplanted with HSCs and MSCs from the same donor. Hematopoietic reconstitutions, complications, and clinical outcomes were observed after cotransplantation in these patients. (1.77 ± 0.40) × 10⁶/kg (donor’s weight) MSCs were successfully expanded from 23.6 ± 5.96 ml of bone marrow samples. They had normal karyotypes with bi-lineages differentiation potential, and were CD73, CD90, and CD105 positive. Twelve patients underwent cotransplantation with no observable adverse response during and after the infusion of MSCs. Hematopoietic reconstitutions were rapid. Two patients developed grade II–IV acute GVHD, and two extensive chronic GVHD. Four patients suffered from cytomegalovirus infection but were cured eventually. Up to now, seven patients have been followed as long as 29–57 months and five patients died. It is concluded that MSCs can be expanded effectively by culture and it is safe and feasible to cotransplant patients with allogenic culture-expanded MSCs and HSCs.     

Association of functional polymorphisms of the transforming growth factor B1 gene with survival and graft-versus-host disease after unrelated donor hematopoietic stem cell transplantation

Background

Many genetic factors play major roles in the outcome of hematopoietic stem cell transplants from unrelated donors. Transforming growth factor β1 is a member of a highly pleiotrophic family of growth factors involved in the regulation of numerous immunomodulatory processes.

Design and Methods

We investigated the impact of single nucleotide polymorphisms at codons 10 and 25 of TGFB1, the gene encoding for transforming growth factor β1, on outcomes in 427 mye-loablative-conditioned transplanted patients. In addition, transforming growth factor β1 plasma levels were measured in 263 patients and 327 donors.

Results

Patients homozygous for the single nucleotide polymorphism at codon 10 had increased non-relapse mortality (at 3 years: 46.8% versus 29.4%, P=0.014) and reduced overall survival (at 5 years 29.3% versus 42.2%, P=0.013); the differences remained statistically significant in multivariate analysis. Donor genotype alone had no impact, although multiple single nucleotide polymorphisms within the pair were significantly associated with higher non-relapse mortality (at 3 years: 44% versus 29%, P=0.021) and decreased overall survival (at 5 years: 33.8% versus 41.9%, P=0.033). In the 10/10 HLA matched transplants (n=280), recipients of non-wild type grafts tended to have a higher incidence of acute graft-versus-host disease grades II-IV (P=0.052). In multivariate analysis, when analyzed with patients’ genotype, the incidences of both overall and grades II-IV acute graft-versus-host disease were increased (P=0.025 and P=0.009, respectively) in non-wild-type pairs.

Conclusions

We conclude that increasing numbers of single nucleotide polymorphisms in codon 10 of TGFB1 in patients and donors are associated with a worse outcome following hematopoietic stem cell transplantation from unrelated donors.     

8-bromo-7-methoxychrysin inhibits properties of liver cancer stem cells via downregulation of β-catenin

AIM:To evaluate whether 8-bromo-7-methoxychrysin(BrMC),a synthetic analogue of chrysin,inhibits the properties of cancer stem cells derived from the human liver cancer MHCC97 cell line and to determine the potential mechanisms.METHODS:CD133+cells were sorted from the MHCC97 cell line by magnetic activated cell sorting,and amplified in stem cell-conditioned medium to obtain the enriched CD133+sphere forming cells(SFCs).The stem cell properties of CD133+SFCs were validated by the tumorsphere formation assay in vitro and the xenograft nude mouse model in vivo,and termed liver cancer stem cells(LCSCs).The effects of BrMC on LCSCs in vitro were evaluated by MTT assay,tumorsphere formation assay and transwell chamber assay.The effects of BrMC on LCSCs in vivo were determined using a primary and secondary xenograft model in Balb/c-nu mice.Expressions of the stem cell markers,epithelialmesenchymal transition(EMT)markers andβ-catenin protein were analyzed by western blotting or immunohistochemical analysis.RESULTS:CD133+SFCs exhibited stem-like cell properties of tumorsphere formation and tumorigenesis capacity in contrast to the parental MHCC97 cells.We found that BrMC preferentially inhibited proliferation and self-renewal of LCSCs(P<0.05).Furthermore,BrMC significantly suppressed EMT and invasion of LCSCs.Moreover,BrMC could efficaciously eliminate LCSCs in vivo.Interestingly,we showed that BrMC decreased the expression ofβ-catenin in LCSCs.Silencing ofβ-catenin by small interfering RNA could synergize the inhibition of self-renewal of LCSCs induced by BrMC,while Wnt3a treatment antagonized the inhibitory effects of BrMC.CONCLUSION:BrMC can inhibit the functions and characteristics of LCSCs derived from the liver cancer MHCC97 cell line through downregulation ofβ-catenin expression.     

低浓度二甲基亚砜冻存外周血造血干细胞的效果

目的:观察外周血造血干细胞(PBSC)用低浓度二甲基亚砜(DMSO)和羟乙基淀粉(HES)在-80℃条件下冷冻保存的效果。方法:49例次患者的PBSC在冻存后3、6个月及1年进行复苏,分别取样进行有核细胞(NC)计数、锥虫蓝拒染率测定、CD34 细胞阳性率分析和粒-巨噬细胞集落生成单位(CFU-GM)检测。结果:PB-SC在-80℃冰箱中冻存3个月和6个月的NC、CD34 细胞、CFU-GM回收率的差异均无统计学意义(均P>0.05),NC活细胞比率差异也无统计学意义(P>0.05)。PBSC冻存1年NC、CD34 细胞、CFU-GM集落回收率及活细胞比率均有显著性下降(均P<0.01)。结论:应用低浓度DMSO在-80℃冻存PBSC3个月和6个月的细胞能得到较好保存,1年后的冻存效果显著下降。     

Autologous hematopoietic stem cell transplantation in patients with refractory Crohn's disease

BACKGROUND & AIMS: Crohn's disease (CD) is an immunologically mediated inflammatory disease of the gastrointestinal tract. Due to a high morbidity and/or an increase in mortality in refractory cases, a new treatment approach is needed. In theory, maximum immune ablation by autologous hematopoietic stem cell transplantation (HSCT) can induce a remission. METHODS: We conducted a phase 1 HSCT study in 12 patients with refractory CD. Candidates were younger than 60 years of age with a Crohn's Disease Activity Index (CDAI) of 250-400 despite conventional therapies including infliximab. Peripheral blood stem cells were mobilized with cyclophosphamide and granulocyte colony-stimulating factor and CD34 + enriched. The immune ablative (conditioning) regimen consisted of 200 mg/kg cyclophosphamide and 90 mg/kg equine antithymocyte globulin. RESULTS: The procedure was well tolerated with anticipated cytopenias, neutropenic fever, and disease-related fever, diarrhea, anorexia, nausea, and vomiting. The median days for neutrophil and platelet engraftment were 9.5 (range, 8-11) and 9 (range, 9-18), respectively. The initial median CDAI was 291 (range, 250-358). Symptoms and CDAI improved before hospital discharge, whereas radiographic and colonoscopy findings improved gradually over months to years following HSCT. Eleven of 12 patients entered a sustained remission defined by a CDAI < or =150. After a median follow-up of 18.5 months (range, 7-37 months), only one patient has developed a recurrence of active CD, which occurred 15 months after HSCT. CONCLUSIONS: Autologous HSCT may be performed safely and has a marked salutary effect on CD activity. A randomized study will be needed to confirm the efficacy of this therapy.     

自体造血干细胞移植治疗1型糖尿病的疗效和安全性评价

目的 对初发的新诊断1型自身免疫性糖尿病患者施行自体外周造血干细胞移植术,评估该治疗方式的安全性和有效性.方法 共有18例患者符合入选条件,获得知情同意后接受移植治疗.利用环磷酰胺和粒细胞集落刺激因子促进外周造血干细胞产生,干细胞富集后采集冷冻保存.通过环磷酰胺和抗胸腺球蛋白获取免疫抑制,于上述两种给药后即行干细胞回输.术前后监测血糖、血清C肽、HbA1C、谷氨酸脱羧酶抗体(GAD-Ab)水平和记录不良事件,对干细胞移植的疗效和安全性进行评估.结果 18例患者(6例男性,12例女性2)平均年龄(18.8±4.4)岁,平均随访天数(414±150)d.67%(12/18)患者术后停用胰岛素,最短在术后2周,最长在术后6个月.12例中有4例因上感等原因出现血糖上升而重新使用胰岛素.目前有44.4%(8/18)患者完全脱离胰岛素治疗,其余患者胰岛素用量的减量幅度平均为67.3%±22.4%.18例患者的GAD-Ab水平明显下降,转阴率33.3%(6/18).空腹C肽和餐后2 h C肽水平在术后明显上升,C肽曲线下面积(AUCC)上升更为显著,且可维持1年.在移植治疗过程中,所有患者均出现不同程度的胃肠道反应,脱发,发热,骨髓抑制等不良反应,有5例患者接受了成份血输注.未观察到明显的心、肝、肾等脏器功能受损.不良反应在干细胞回输后的2～4周逐步消失,粒细胞减少的恢复最为缓慢.结论 自体造血干细胞移植治疗有胰岛功能残存的初发1型糖尿病患者有一定的疗效,安全性较高,临床可行性强.对其治疗机制还有待进一步研究.     

CD226 is expressed on the megakaryocytic lineage from hematopoietic stem cells/progenitor cells and involved in its polyploidization

OBJECTIVES: In this study, we examined the expression of CD226 on megakaryocytic, granulocytic and erythroid lineage from hematopoietic stem cells/progenitor cells in adult and fetus and its potential role in megakaryocytic maturation. METHODS: CD34(+) cells from adult and fetus were induced to differentiate toward the megakaryocytic lineage by thrombopoietin (TPO) and the granulocytic lineage by granulocyte colony-stimulating factor (G-CSF), respectively. Mononuclear cells from fetal liver and CD34(+) cells from adult were induced to differentiate toward erythroid-lineage by erythropoiesis (EPO). We investigated the expression of CD226 and lymphocyte function associated antigen-1 (LFA-1) (CD11a) during hemopoiesis. We also studied the effect of CD226 monoclonal antibody (MoAb) and LFA-1 MoAb on megakaryocyte with antibody cross-liking technique. RESULTS: CD34(+) cells from adult and fetus and TPO-induced CD41(+) cells all expressed CD226 molecule. CD226 was not expressed on erythroid progenitor cells and erythroblasts and most cells of granulocytic lineage although G-CSF induced a significant increase of the expression of CD226 on CD34(+) cells in early period of time. CD226 MoAb acts on megakaryocytes by inducing intracellular calcium mobilization. The expression of LFA-1 decreased significantly at late stage of differentiation and maturation of fetal megakaryocytes whereas the expression of LFA-1 on adult megakaryocytes retained at a high level. CD226 MoAb in combination with LFA-1 MoAb shifted the ploidy of generated megakaryocytes from adult-derived CD34(+) cells to higher classes significantly although CD226 and LFA-1 MoAb slightly increased the ploidy of the generated megakaryocytes individually. CD226 MoAb or LFA-1 MoAb or CD226 MoAb plus LFA-1 MoAbs did not increase the ploidy of the generated megakaryocytes from fetus-derived CD34(+) cells. CONCLUSION: CD226 molecules play an important role in maturation of the megakaryocytes in combination with LFA-1.     

Sca-1 expression identifies stem cells in the proximal region of prostatic ducts with high capacity to reconstitute prostatic tissue

We previously showed that prostatic stem cells are concentrated in the proximal regions of prostatic ducts. We now report that these stem cells can be purified from isolated proximal duct regions by virtue of their high expression of the cell surface protein stem cell antigen 1 (Sca-1). In an in vivo prostate reconstitution assay, the purified Sca-1-expressing cell population isolated from the proximal region of ducts was more effective in generating prostatic tissue than a comparable population of Sca-1-depleted cells (203.0 +/- 83.1 mg vs. 11.9 +/- 9.2 mg) or a population of Sca-1-expressing cells isolated from the remaining regions of ducts (transit-amplifying cells) (31.9 +/- 24.1 mg). Almost all of the proliferative capacity of the proximal duct Sca-1-expressing cell population resides within the fraction of cells that express high levels of Sca-1 (top one-third), with the proximal region of prostatic ducts containing 7.2-fold more Sca-1(high) cells than the remaining regions. More than 60% of the high-expressing cells coexpress alpha6 integrin and the anti-apoptotic factor Bcl-2, markers that are also characteristic of stem cells of other origins. Further stratification of the phenotype of the stem cells may enable the development of rational therapies for treating prostate cancer and benign prostatic hyperplasia.     

NK T cells provide lipid antigen-specific cognate help for B cells

The mechanisms of T cell help for production of antilipid antibodies are largely unknown. This study shows that invariant NK T cells (iNK T cells) and B cells cooperate in a model of antilipid antigen-specific antibody responses. We use a model haptenated lipid molecule, 4-hydroxy-3-nitrophenyl-alphaGalactosylCeramide (NP-alphaGalCer), to demonstrate that iNK T cells provide cognate help to lipid-antigen-presenting B cells. B cells proliferate and IgG anti-NP is produced from in vivo-immunized mice and in vitro cocultures of B and NK T cells after exposure to NP-alphaGalCer, but not closely related control glycolipids. This B cell response is absent in CD1d(-/-) and Jalpha18(-/-) mice but not CD4(-/-) mice. The antibody response to NP-alphaGalCer is dominated by the IgM, IgG3, and IgG2c isotypes, and marginal zone B cells stimulate better in vitro lipid antigen-driven proliferation than follicular B cells, suggesting an important role for this B cell subset. iNK T cell help for B cells is shown to involve cognate help from CD1d-instructed lipid-specific iNK T cells, with help provided via CD40L, B7-1/B7-2, and IFN-gamma, but not IL-4. This model provides evidence of iNK T cell help for antilipid antibody production, an important aspect of infections, autoimmune diseases, and vaccine development. Our findings also now allow prediction of those microbial antigens that would be expected to elicit cognate iNKT cell help for antibody production, namely those that can stimulate iNKT cells and at the same time have a polar moiety that can be recognized by antibodies.     

Persistent poor long-term prognosis of allogeneic hematopoietic stem cell transplant recipients surviving invasive aspergillosis

Background Voriconazole treatment increases early survival of allogeneic hematopoietic stem cell transplant recipients with invasive aspergillosis. We investigated whether this survival advantage translates into an increased long-term survival. DESIGN AND METHODS: This retrospective study involved all patients with an invasive aspergillosis diagnosis transplanted between September 1997 and December 2008, at the Saint-Louis Hospital, Paris, France. The primary end point was survival up to 36 months. Survival analysis before and after 12 weeks, as well as cumulative incidence analysis in a competing risk framework, were used to assess the effect of voriconazole treatment and other factors on mortality. RESULTS: Among 87 patients, 42 received first-line voriconazole and 45 received another antifungal agent. Median survival time was 2.6 months and survival rate at 36 months was 18%. Overall, there was a significant difference in the survival rates of the two groups. Specifically, there was a dramatic difference in survival rates up to ten months post-aspergillosis diagnosis but no significant difference after this time. Over the first 36 months as a whole, no significant difference in survival rate was observed between the two groups. First-line voriconazole significantly reduced aspergillosis-attributable mortality. However, first-line voriconazole patients experienced a significantly higher probability of death from a non-aspergillosis-attributable cause. Conclusions Although the prognosis for invasive aspergillosis after stem cell transplantation has dramatically improved with the use of voriconazole, this major advance in care does not translate into increased long-term survival for these severely immunocompromised patients.