Standard‐ versus high‐dose lenograstim in adults with hematologic malignancies for peripheral blood progenitor cell mobilization

BACKGROUND: The aim of this retrospective, multicenter study was to compare high‐ versus standard‐dose lenograstim after chemotherapy in collecting target dose of CD34+ peripheral blood progenitor cells (PBPCs) in adult candidates for autologous transplant. STUDY DESIGN AND METHODS: A total of 166 consecutive patients (28 acute leukemias [ALs], 77 lymphomas, 61 multiple myeloma [MM]) underwent 182 mobilization procedures. Only the first were analyzed. The CD34+ cell target was at least 2 × 10⁶, 4 × 10⁶, and 8 × 10⁶/kg and lenograstim started on days +19, +1, and +5 from the end of chemotherapy for AL, lymphomas, and MM, respectively. Eighty‐seven and 79 patients, respectively, received 5 and 10 µg/kg/day lenograstim subcutaneously (sc). An analysis to evaluate factors predicting satisfactory procedures and outcome of transplants performed with first‐mobilization‐procedure PBPCs was conducted. Most patients received 6 mg of pegfilgrastim or 5 µg/kg/day lenograstim sc after transplant. RESULTS: In multivariate analysis, high‐dose lenograstim (p = 0.053) in MM and male sex (p = 0.028) were positive predictive factors for reaching cell target. Fludarabine negatively influenced stimulation length (p = 0.002). Apheresis, CD34+ cells mobilized and collected, blood volume processed, side effects, transplants performed, and engraftment time were similar between lenograstim cohorts. Pegfilgrastim versus lenograstim delayed platelet (PLT) recovery times (13 days vs. 11 days, p = 0.036). CONCLUSIONS: High‐dose lenograstim more efficiently mobilized MM patients requiring the highest PBPC target but did not influence transplants performed and engraftment time. Male patients mobilized more efficiently. Fludarabine negatively influenced stimulation length. Finally, pegfilgrastim seems to delay PLT recovery.     

CD34+ cell dose requirements for rapid engraftment in a sequential high-dose chemotherapy regimen of paclitaxel, melphalan, and cyclophosphamide, thiotepa, and carboplatin (CTCb) with PBPC support in metastatic breast cancer

Sequential high-dose chemotherapy may increase the threshold dose of CD34+ cells necessary for rapid and successful hematologic recovery. There are limited data regarding the pharmacodynamics and threshold CD34+ cell dose required for engraftment following high-dose paclitaxel. To determine the dose of CD34+ PBPC sufficient for rapid engraftment, 65 women with metastatic breast cancer undergoing a sequential high-dose paclitaxel, melphalan, and cyclophosphamide, thiotepa, and carboplatin (CTCb) chemotherapy regimen were evaluated. The intertreatment interval was a median of 27 days. Paclitaxel was escalated from 400 to 825 mg/m2, infused continuously (CI) over 24 h on day -4 with PBPC reinfusion on day 0. Following marrow recovery, 90 mg/m2/day of melphalan was given over 30 min on days -2 and -1, with PBPC reinfusion on day 0. On recovery, patients received CTCb on days -7 to -3, with PBPC reinfusion on day 0. G-CSF was administered after each cycle until WBCC recovery. For paclitaxel, an ANC >0.5 x 10(9)/L occurred at a median of 6 days (range 0-7 days) after PBPC reinfusion. The median nadir platelet count was 63 x 10(9)/L (range 6 x 10(9)/L-176 x 10(9)/L). Eight patients (12%) had platelet nadir <20 x 10(9)/L, and all recovered their counts to >20 x 10(9)/L on day 7. There was no clinical difference in days to engraftment between women receiving <2 or > or =2 x 10(6) CD34+ PBPC/kg following paclitaxel. All patients recovered neutrophil and platelet counts within 7 days after reinfusion of > or =1 x 10(6) CD34+ cells/kg and G-CSF. The data suggest that a paclitaxel dose of 825 mg/m2 is not myeloablative. For melphalan, median days to ANC >0.5 x 10(9)/L was 10 days (range 9-15), and platelet recovery to >20 x 10(9)/L was 13 days (range 0-28) after PBPC reinfusion. Median time to engraftment was more rapid in patients receiving > or =2 x 10(6) CD34+/kg versus <2 x 10(6)CD34+/kg, for both neutrophils (11 days versus 10 days, p = 0.05) and platelets (14 days versus 12 days, p < 0.01). Ninety-eight percent of patients infused with > or =2 x 10(6) CD34+/kg engrafted within 21 days. Following CTCb in this sequential regimen, a dose of > or =2 x 10(6) CD34+ cells/kg provided for significantly more rapid neutrophil engraftment than <2 x 10(6) CD34+ cells/kg (9 days versus 10 days,p = 0.01), but a dose > or =3 X 10(6) CD34+ cells/kg is necessary for reliable, rapid, and sustained neutrophil and platelet engraftment by day 21.     

In vitro collection and posttransfusion engraftment characteristics of MNCs obtained by using a new separator for autologous PBPC transplantation

BACKGROUND: A clinical study was performed to evaluate the peripheral blood progenitor cell (PBPC) collection, transfusion, and engraftment characteristics associated with use of a blood cell separator (Amicus, Baxter Healthcare). STUDY DESIGN AND METHODS: Oncology patients (n = 31) scheduled for an autologous PBPC transplant following myeloablative therapy were studied. PBPCs were mobilized by a variety of chemotherapeutic regimens and the use of G-CSF. As no prior studies evaluated whether PBPCs collected on the Amicus separator would be viable after transfusion, to ensure patient safety, PBPCs were first collected on another cell separator (CS-3000 Plus, Baxter) and stored as backup. The day after the CS-3000 Plus collections were completed, PBPC collections intended for transfusion were performed using the Amicus instrument. For each transplant, >2.5 x 10(6) CD34+ PBPCs per kg of body weight were transfused. RESULTS: Clinical data collected on the donors immediately before and after PBPC collection with the Amicus device were comparable to donor data similarly obtained for the CS-3000 Plus collections. While the number of CD34+ cells and the RBC volume in the collected products were equivalent for the two devices, the platelet content of the Amicus collections was significantly lower than that of the CS-3000 Plus collections (4.35 x 10(10) platelets/bag vs. 6.61 x 10(10) platelets/bag, p<0.05). Collection efficiencies for CD34+ cells were 64 +/- 23 percent for the Amicus device and 43 +/- 14 percent for the CS-3000 Plus device (p<0.05). The mean time to engraftment for cells collected via the Amicus device was 8.7 +/- 0.7 days for >500 PMNs per microL and 9.7 +/- 1.5 days to attain a platelet count of >20,000 per microL-equivalent to data in the literature. No CS-3000 Plus backup cells were transfused and no serious adverse events attributable to the Amicus device were encountered. CONCLUSIONS: The mean Amicus CD34+ cell collection efficiency was better (p<0.05) than that of the CS-3000 Plus collection. Short-term engraftment was durable. The PBPCs collected with the Amicus separator are safe and effective for use for autologous transplant patients requiring PBPC rescue from high-dose myeloablative chemotherapy.     

Peripheral blood stem cell transplantation: Impact on procedure load and workload in an apheresis unit

Peripheral blood stem cells (PBSC) reinfusion appears to hasten hematologic reconstitution following myeloablative therapy. While procurement of PBSC adds apheresis procedures, rapid engraftment could decrease the demand for platelet transfusions. To determine the impact of PBSC collection on workload in our apheresis unit, we studied 3 consecutive groups of patients with metastatic breast cancer given comparable high-dose chemotherapy and autologous bone marrow transplant, with or without PBSC or granulocyte-colony stimulating factor (G-CSF). Forty-one transplants were performed with bone marrow cells only: 31 patients (Group A) did not receive G-CSF, while the following 10 patients (group B) received daily G-CSF until neutrophil engraftment. Bone marrow cells and PBSC were used for the most recent 11 transplants (group C), followed by daily G-CSF until engraftment. PBSC were mobilized with cyclophosphamide (4 g/m²) and etoposide (1 g/m²), followed by G-CSF, 8 μg/kg/day. PBSC collection was carried out on a Fenwal CS3000 + cell collector, using modified procedure 1, to obtain a minimum of 5 × 10⁸ mononuclear cells/kg. The times to neutrophil count over 500/μL, platelet count over 20,000/μL, and discharge from the hospital after transplant were significantly shorter for patients in group C (medians of 8, 8, and 21 days, respectively) compared to group A (medians of 14, 14, and 29 days; P = 0.001) or group B (medians of 11, 24, and 32 days; P < 0.001). The number of single-donor platelet equivalents transfused (1 SDE = 1 unit of single-donor platelets or 8 pooled random-donor platelets) was significantly decreased in group C (median = 4) compared to group A (median = 19) and group B (median = 11; P = 0.001 for both comparisons). The total apheresis procedure load (the sum of SDE and PBSC collection for each transplant) was significantly decreased in group C (median = 6) compared to groups A and B combined (median = 14; P = 0.001). The apheresis unit workload assessing apheresis durations per patient, calculated as 2 × SDE + 4 × PBSC, was also significantly reduced in group C (median = 16) compared to groups A and B (median = 28; P = 0.002). Thus, PBSC were advantageous in terms of faster engraftment, reduced platelet transfusions, and shorter hospitalization, while decreasing both procedure load and net workload per patient in the apheresis unit. © 1992 Wiley-Liss, Inc.     

Plerixafor as preemptive strategy results in high success rates in autologous stem cell mobilization failure

Plerixafor in combination with granulocyte‐colony stimulating factor (G‐CSF) is approved for autologous stem cell mobilization in poor mobilizing patients with multiple myeloma or malignant lymphoma. The purpose of this study was to evaluate efficacy and safety of plerixafor in an immediate rescue approach, administrated subsequently to G‐CSF alone or chemotherapy and G‐CSF in patients at risk for mobilization failure. Eighty‐five patients mobilized with G‐CSF alone or chemotherapy were included. Primary endpoint was the efficacy of the immediate rescue approach of plerixafor to achieve ≥2.0 × 10⁶ CD34⁺ cells/kg for a single or ≥5 × 10⁶ CD34⁺ cells/kg for a double transplantation and potential differences between G‐CSF and chemotherapy‐based mobilization. Secondary objectives included comparison of stem cell graft composition including CD34⁺ cell and lymphocyte subsets with regard to the mobilization regimen applied. No significant adverse events were recorded. A median 3.9‐fold increase in CD34⁺ cells following plerixafor was observed, resulting in 97% patients achieving at least ≥2 × 10⁶ CD34+ cells/kg. Significantly more differentiated granulocyte and monocyte forming myeloid progenitors were collected after chemomobilization whereas more CD19⁺ and natural killer cells were collected after G‐CSF. Fifty‐two patients underwent transplantation showing rapid and durable engraftment, irrespectively of the stem cell mobilization regimen used. The addition of plerixafor in an immediate rescue model is efficient and safe after both, G‐CSF and chemomobilization and results in extremely high success rates. Whether the differences in graft composition have a clinical impact on engraftment kinetics, immunologic recovery, and graft durability have to be analysed in larger prospective studies.     

The apheresis content analysis in Allo-HSCT represents reliable influential factors on graft-versus-host disease and overall survival

BackgroundHematopoietic stem cell transplantation (HSCT) is an established treatment for hematologic malignancies. However the post-HSCT outcome can be affected by multiple pre-transplant, transplant, and post-transplant factors. The cellular content of graft could be possible factors influencing the graft-versus-host disease (GVHD) and overall survival (OS) as transplantation outcomes.PurposeThe aim of this study was to assess the impact of infused CD34+ cells, CD3+ cells, and MNC count on the patients’ survival and incidence of graft-versus-host disease (GVHD).Material and methodsWe analyzed 87 patients with hematological malignancies who underwent allogeneic hematopoietic stem cell transplantation at the Taleghani Stem Cell Transplantation and Cell therapy center, Tehran, Iran from January 2016 to December 2018. Patients were conditioned with either myeloablative conditioning regimen or reduced-intensity regimen.ResultA CD34⁺ cell dose < 4.35 × 10⁶/kg and CD3⁺ cell dose < 365 × 10⁶/kg was associated with higher survival and lower acute and chronic GVHD incidence, although their association was not statistically significant. Moreover, there was a significant association between MNC count < 6.15 × 10⁸/kg and acute GVHD incidence.ConclusionGraft cell dose, lower than the cut-off level, could lead to better outcomes after allogeneic transplantation. However, this study showed that future investigations are required in a larger population of patients in order to determine the exact effect of allogeneic graft cell dose on transplantation outcome.     

Factors influencing haematological recovery after allogeneic bone marrow transplantation in leukaemia patients treated with methotrexate-containing GVHD prophylaxis

 In the present single institution study of 66 leukaemia patients (28 AML, 23 ALL, 15 CML), the factors influencing haematological recovery after allogeneic bone marrow transplantation (alloBMT) were analysed retrospectively to identify the optimal conditions required for rapid haematological recovery after alloBMT. All patients received GVHD prophylaxis with cyclosporine A plus methotrexate. The mean number of days required to achieve a neutrophil count ≥0.5×10⁹/l after alloBMT was 17 (range 9–27), 19 patients (28.8%) had rapid neutrophil recovery within 15 days after alloBMT. Haematological recovery was more rapid in the 38 patients without GVHD or with only grade I GVHD. Also, 50% and 40% of patients receiving 10 (n=18) or 5 (n=20) μg/kg G-CSF per day, respectively, had rapid neutrophil recovery within 15 days after alloBMT, as against only 7.1% of patients not receiving G-CSF after the transplant (n=28);P<0.001. The neutrophil recovery was similar in patients receiving either fresh or cryopreserved allografts and either a TBI-containing or a busulfan-containing conditioning regimen. A significant correlation was found between the neutrophil recovery and either the MNCs or CFU-GM contents of the allografts. The mean number of days required for neutrophil recovery was only 16 (range 9–24) in patients receiving allografts containing >1×10⁵ CFU-GM/kg (n=28), as against 19 (range 13–27) in patients receiving allografts containing ≤1×10⁵ CFU-GM/kg (n=35). Three patients receiving allografts containing <0.5×10⁵ CFU-GM/kg had primary neutrophil engraftment failure. The mean number of days required to achieve a platelet count ≥20×10⁹/l was 21 (range 11–50), and 30 patients (46.9%) had platelet recovery within 20 days after alloBMT. The platelet recovery after alloBMT was not affected by the type of leukaemia, conditioning regimen, or G-CSF administration. The mean number of days required for platelet recovery after alloBMT was 20 in patients receiving allografts containing >1.0×10⁵ BFU-E/kg (n=35), as against 23 days in patients receiving allografts containing ≤1.0×10⁵ BFU-E/kg (n=24). Seven patients receiving allografts containing <0.5×10⁵ BFU-E/kg had primary platelet engraftment failure. The present study has identified the high number of progenitor cells in the allografts infused and the daily administration of G-CSF posttransplant as the optimal combination for rapid neutrophil recovery after alloBMT. More significantly, the number of BFU-E in allografts was the most significant determining factor in platelet recovery after alloBMT. The development of GVHD of grade II or more during the first weeks after alloBMT was associated with slower haematological recovery, a longer period of fever during neutropenia and longer hospitalization.     

Autologous peripheral blood progenitor cell transplantation

Harvesting of autologous peripheral blood stem cells (PBSCs) has been facilitated by using currently available, efficient apheresis technology at the time of rebound from chemotherapy while patients are receiving recombinant growth factors, i.e., granulocyte (G) or granulocyte-macrophage (GM) colony stimulating factor (CSF). Ideally pheresis should be done before patients have had extensive stem cell toxins, i.e., alkylating agents or nitrosoureas. This strategy has facilitated the use of high dose chemoradiotherapy given as a single regimen or in a divided dose for patients with solid tumors or hematologic malignancies and results in more rapid engraftment than bone marrow transplantation (BMT). Although mere are no assays which measure repopulating stem cells, enumeration of CD34⁺ cells within PBSCs is a direct and rapid assay which provides an index of both early and late long-term reconstitutive capacity, since it correlates with colony-forming unit (CFU)-GMs, as well as pre-progenitor or delta assays and long-term culture-initiating cells (LTC-IC). A threshold of ≥2 × 10⁶ CD34⁺ cells/kg recipient body weight has been reported to be required for engraftment, but may vary depending upon the clinical setting. Strategies for mobilization of normal PBSCs also increase tumor cell contamination within PB in the setting of both hematologic malignancies and solid tumors, but the significance of these tumor cells in terms of patient outcome is unclear. Recently isolation of CD34⁺ cells from PBSCs has been done using magnetic beads or immunoabsorption on columns or rigid plates in order to enrich for normal hematopoietic progenitors and potentially decrease tumor cell contamination. As for other cellular blood components, standards have been developed to assure efficient collection and processing, thawing, and reinfusion, and to maintain optimal PBPC viability. Finally, future directions of clinical research include expansion of hematopoietic progenitor cells ex vivo; use of umbilical cord or placenta as rich sources of progenitor cells; syngeneic hematopoietic stem cell transplantation; related and unrelated allogeneic hematopoietic stem cell transplantation; treatment of infections, i.e., Epstein Barr virus, or tumor relapse after allogeneic BMT using donor PBSC infusions; and gene therapy approaches.     

CD41+ and CD42+ hematopoietic progenitor cells may predict platelet engraftment after allogeneic peripheral blood stem cell transplantation

The objective of this study was to quantify subpopulations of CD34+ cells such as CD41+ and CD42+ cells that might represent megakaryocyte (MK) precursors in peripheral blood stem cell (PBSC) collections of normal, recombinant human granulocyte‐colony stimulating factor (rhG‐CSF) primed donors and to determine whether there is a statistical association between the dose infused megakaryocytic precursors and the time course of the platelet recovery following an allogeneic PBSC transplantation. Twenty‐six patients with various hematologic malignancies transplanted from their HLA identical siblings between July 1997 and December 1999 were used. All patients except one with severe aplastic anemia who had cyclophosphamide (CY) alone received busulfan‐CY as preparative regimen and cyclosporine‐methotrexate for GVHD prophylaxis. Normal healthy donors were given rhG‐CSF 10 μg/kg/day subcutaneously twice daily and PBSCs were collected on days 5 and 6. The median number of infused CD34+, CD41+ and CD42+ cells were 6.61 × 10⁶/kg (range 1.47–21.41), 54.85 × 10⁴/kg (5.38–204.19), and 49.86 × 10⁴/kg (6.82–430.10), respectively. Median days of ANC 0.5 × 10⁹/L and platelet 20 × 10⁹/L were 11.5 (range 9–15) and 13 (8–33), respectively. In this study, the number of CD41+ and CD42+ cells infused much better correlated than the number of CD34+ cells infused with the time to platelet recovery of 20 × 10⁹/L in 26 patients receiving an allogeneic match sibling PBSC transplantation (r = ?0.727 and P < 0.001 for CD41+ cells, r = ?0.806 and P < 0.001 for CD42+ cells, r = ?0.336 and P > 0.05 for CD34+ cells). There was an inverse correlation between the number of infused CD41+ and CD42+ cells and duration of platelet engraftment. Therefore, as the number of CD41+ and CD42+ cells increased, duration of platelet engraftment (time to reach platelet count of ≥ 20 × 10⁹/L) shortened significantly. Based on this data we may conclude that flow cytometric measurement of CD41+ and CD42+ progenitor cells may provide an accurate indication of platelet reconstitutive capacity of the allogeneic PBSC transplant. J. Clin. Apheresis. 16:67–73, 2001. © 2001 Wiley‐Liss, Inc.     

Engraftment after autologous hematopoietic stem cell transplantation in patients mobilized with Plerixafor: A retrospective,multicenter study of a large series of patients

Plerixafor (PLX) appears to effectively enhance hematopoietic stem-cell mobilization prior to autologous hematopoietic stem cell transplantation (auto-HCT). However, the quality of engraftment following auto-HCT has been little explored. Here, engraftment following auto-HCT was assessed in patients mobilized with PLX through a retrospective, multicenter study of 285 consecutive patients. Information on early and 100-day post-transplant engraftment was gathered from the 245 patients that underwent auto-HCT. The median number of PLX days to reach the stem cell collection goal (≥2 × 10⁶ CD34⁺ cells/kg) was 1 (range 1–4) and the median PLX administration time before apheresis was 11 h (range 1–18). The median number of apheresis sessions to achieve the collection goal was 2 (range 1–5) and the mean number of CD34⁺ cells collected was 2.95 × 10⁶/kg (range 0–30.5). PLX administration was safe, with only 2 mild and transient gastrointestinal adverse events reported. The median time to achieve an absolute neutrophil count (ANC) >500/μL was 11 days (range 3–31) and the median time to platelet recovery >20 × 10³/μL was 13 days (range 5–69). At 100 days after auto-HCT, the platelet count was 137 × 10⁹/L (range 7–340), the ANC was 2.3 × 10⁹/L (range 0.1–13.0), and the hemoglobin concentration was 123 g/L (range 79–165). PLX use allowed auto-HCT to be performed in a high percentage of poorly mobilized patients, resulting in optimal medium-term engraftment in the majority of patients in whom mobilization failed, in this case mainly due to suboptimal peripheral blood CD34⁺ cell concentration on day +4 or low CD34⁺ cell yield on apheresis.     

CD133+ cell content does not influence recovery time after hematopoietic stem cell transplantation

BACKGROUND: Infusion of an adequate dose of CD34+ mononuclear hematopoietic stem cells (HSCs) is the single most important variable to assure success in hematopoietic grafting. CD133+ HSCs constitute the CD34+ subgroup with higher differentiation potential. The number of granulocyte–colony‐stimulating factor (G‐CSF)‐mobilized CD133+ HSCs administered during hematopoietic grafting and its relationship with the number of days needed to regain hematopoiesis was determined. STUDY DESIGN AND METHODS: Thirty‐eight patients with malignant hematologic diseases who received an autologous (n = 15) or allogeneic (n = 23) HSC transplant were prospectively evaluated. G‐CSF was administered for 5 days at 10 µg/kg/day. Hematopoietic progenitors were recovered from peripheral blood on day 5 by leukopheresis. CD34+ and CD133+/CD34+ cell populations were quantified by flow cytometry; the number of days to hematologic recovery was documented. RESULTS: A median dose of 4.56 × 10⁶/kg CD34+ HSCs (range, 1.35 × 10⁶‐14.6 × 10⁶) was recovered and transplanted; of these grafted cells, a median 3.25 × 10⁶ were also CD133+ (range, 1.25 × 10⁶‐14.3 × 10⁶). In the autologous group, the median number of days to reach a platelet (PLT) count of 20 × 10⁹/L or greater was 12, and 15 days to obtain a neutrophil count of 0.5 × 10⁹/L or greater; in the allogeneic group 13 and 16 days, respectively, were required (p > 0.05). A median 76.5% of G‐CSF–mobilized CD34+ HSCs coexpressed the CD133+ antigen (range, 23.1‐97.9). CONCLUSIONS: A higher number of CD133+/CD34+ HSCs in the graft was not clearly associated with a shorter neutrophil or PLT recovery time in either allogeneic or autologous recipients.     

Prediction of engraftment after autologous peripheral blood progenitor cell transplantation: CD34, colony‐forming unit–granulocyte‐macrophage,or both?

BACKGROUND: The rate of hematologic recovery after peripheral blood progenitor cell (PBPC) transplantation is influenced by the dose of progenitor cells. Enumeration of cells that express CD34+ on their surface is the most frequently used method to determine progenitor cell dose. In vitro growth of myeloid progenitor cells (colony-forming unit-granulocyte-macrophage [CFU-GM]) requires more time and resources, but may add predictive information. STUDY DESIGN AND METHODS: A series of 323 patients, who underwent autologous PBPC transplantation for multiple myeloma, malignant lymphoma, or locally advanced breast cancer, were studied for the effect of CD34+ dose and CFU-GM dose on hematologic recovery. Measures for engraftment were days to absolute granulocyte and platelet (PLT) counts to greater than 500 per muL and than 20 x 10(9) per L, respectively, and number of PLT transfusions and red cell units required. RESULTS: The CD34+ dose had a median of 8.4 x 10(6) per kg, and the CFU-GM dose a median of 84.9 x 10(4) per kg. The CD34+ and CFU-GM doses showed significant correlation (R = 0.63; p < 0.0001) but a wide variation in the ratio of CD34+ and CFU-GM. Both CD34+ and CFU-GM doses had significant correlation with the measures of engraftment, but for all measures the relationship of CD34+ was stronger. Multivariate analysis and subgroup analysis of patients receiving CD34+ doses of less than 5 x 10(6) per kg also did not reveal an independent predictive value for CFU-GM. CONCLUSION: For prediction of hematologic recovery after autologous PBPC transplantation, determination of CFU-GM dose does not add to the predictive value of the CD34+ dose.     

Hematologic recovery after autologous PBPC transplantation: importance of the number of postthaw CD34+ cells

BACKGROUND: The implementation of a quality-assurance program is a major requirement to ensure quality and safety of the final PBPC components intended for clinical use. It is not clear whether the quantification of CFU-GM and CD34+ cells should be done on fresh components and after cryopreservation, which better represents the actual composition of the graft. STUDY DESIGN AND METHODS: Correlation between prefreeze and postthaw MNCs, CD34+ cells, and CFU-GM collected from 126 patients undergoing BMT (n=43) or PBPC (n =83) transplantation were evaluated. The statistical incidence of prefreeze and postthaw parameters as well as patient characteristics and conditioning regimens on hematologic recovery were analyzed. RESULTS: By multivariate analysis, prefreeze and postthaw CD34+ cells were the only two variables significantly and independently correlated to hematologic recovery. Low prefreeze and postthaw CD34+ cell numbers associated to a low CD34+ yield characterize PBPC grafts from patients who have the slowest hematologic recovery. The postthaw PBPC CD34+ cell number can be estimated before conditioning regimen by thawing a small aliquot of the graft. CONCLUSION: In association to prefreeze CD34+ cell number and to CD34+ yield, postthaw CD34+ cell number may be useful in monitoring cell loss during processing and identifying patients at risk of slow PBPC engraftment.     

Factors influencing collection and engraftment of CD34+ cells in patients with breast cancer following high-dose chemotherapy and autologous peripheral blood progenitor cell transplantation

Although autologous PBPC transplantation is being used increasingly for the treatment of breast cancer, there are few data on factors influencing mobilization and engraftment in these patients. We have analyzed these factors in 70 patients with advanced or metastatic breast cancer undergoing autologous PBPC transplantation. All patients were mobilized after stimulation with G-CSF, and a median of 3.16 x 10(6)/kg CD34+ cells (range 0.75-23.33) were infused. All patients received conditioning with a combination of cyclophosphamide, thiotepa, and carboplatin, and postinfusion G-CSF was administered to 60 patients. The median times to reach 0.5 x 10(9)/L and 1 x 10(9)/L neutrophils were 10 and 11 days, respectively. The median times to obtain 20 x 10(9)/L and 50 x 10(9)/L platelets were 12 and 18 days, respectively. An analysis of factors that influence CD34+ cell collection was performed by linear regression. Previous radiation therapy and increasing age were associated with lower numbers of CD34+ cells collected. Those variables that could influence the tempo of engraftment were examined by multivariate analysis using Cox regression models. The number of CD34+ cells infused was found to influence both neutrophil and platelet recovery. The use of G-CSF after transplant, accelerated neutrophil recovery, and having more than six cycles of previous chemotherapy was an unfavorable factor for recovering >50 x 10(9)/L platelets.     

Peripheral blood progenitor cell collection without close monitoring of peripheral blood CD34+ cells: A feasible strategy for multiple myeloma or pre-treated Non-Hodgkin’s Lymphoma patients mobilized with low-dose cyclophosphamide plus G-CSF

BackgroundDaily monitoring of peripheral blood CD34+ cells may not be necessary for all patients with hematologic malignancies for adequate peripheral blood progenitor cells (PBPC) mobilization and harvesting. We therefore designed a regimen for PBPC mobilization in patients with multiple myeloma or pre-treated Non-Hodgkin’s lymphoma based on a combination of low-dose cyclophosphamide (Cy) plus granulocyte colony-stimulating factor (G-CSF) without daily monitoring of peripheral blood CD34+ cells.Study design and methodsA prospective study was performed on patients with multiple myeloma (n = 22) or pre-treated Non-Hodgkin’s lymphoma (n = 17) whose PBPC were harvested according to the following regimen: 1.5 g/m² Cy at day 1, 12 μg/kg/day G-CSF from day +7 to +11 avoiding daily monitoring of peripheral blood CD34+ cells and two consecutive leukapheresis at days +12 and +13. The optimum threshold of 2 × 10⁶ CD34+ cells per kg was established.ResultsThe proportion of patients with higher CD34+ cell yield after two leukapheresis was similar: multiple myeloma (16/22–72.7%) and Non-Hodgkin’s lymphoma (12/17–70.6%). Exposure to radiotherapy and greater than two prior chemotherapy regimens were significantly associated with lower yield in multiple myeloma (p = 0.002) and Non-Hodgkin’s lymphoma patients (p = 0.002), respectively.ConclusionOur data suggested that adequate yields of CD34+ cells may be achieved in multiple myeloma or pre-treated Non-Hodgkin’s lymphoma mobilized with low-dose Cy plus G-CSF regardless of the daily monitoring of peripheral blood CD34+ cells.     

Unmanipulated HLA-mismatched/haploidentical peripheral blood stem cell transplantation for high-risk hematologic malignancies

BACKGROUND: Haploidentical hematopoietic stem cell transplantation (HSCT) has been increasingly applied in high‐risk hematologic patients due to the absence of HLA‐matched donors. The aim of this study was to investigate the efficacy and safety of unmanipulated haploidentical allogeneic peripheral blood stem cells transplantation (PBSCT) for hematologic malignancies. STUDY DESIGN AND METHODS: Patients who underwent unmanipulated HLA‐mismatched/haploidentical PBSCT from July 2007 to March 2010 with high‐risk hematologic malignancies were enrolled for retrospective analysis. RESULTS: Twenty‐one patients with high‐risk hematologic malignancies underwent unmanipulated HLA‐mismatched/haploidentical PBSCT with myeloablative conditioning. The numbers of CD34+ cells infused at transplantation were 4.81 (range, 2.61‐11.47) × 10⁶/kg. Patients achieved myeloid and platelet engraftment at a median of 16.5 and 20 days, respectively. The cumulative incidence of acute graft‐versus‐host disease (GVHD) on Day 100 was 52.7 ± 10.7%, and the 2‐year cumulative incidence of chronic GVHD was 39.5 ± 10.6%. The cumulative incidences of cytomegalovirus antigenemia and hemorrhagic cystitis within 100 days after PBSCT were 59.5 ± 16.7 and 34.8 ± 13.3%, respectively. One hundred‐day transplantation‐related mortality (TRM) rate and the 2‐year cumulative TRM rate were 14.3 and 20.5 ± 7.8%, respectively. The 2‐year cumulative overall survival was 62.1 ± 11.4% and the probability of disease‐free survival at 2 years was 55.6 ± 10.7% with a 16‐month median follow‐up. CONCLUSION: Unmanipulated PBSCT is a promising protocol in HLA‐mismatched/haploidentical transplant settings.     

Allogeneic transplantation combining mobilized blood and bone marrow in patients with refractory hematologic malignancies

BACKGROUND: Mobilized blood stem cells have been used successfully in autologous transplant recipients to reduce the complications of pancytopenia due to dose-intensive chemotherapy. Reports of cytokine- mobilized blood progenitor cells in allogeneic transplant recipients are rare. STUDY DESIGN AND METHODS: This is a pilot trial of six patients. Patients with advanced hematologic malignancy received bone marrow (median total 2.6 × 10(8) mononuclear cells/kg) followed by four daily transfusions of blood (median total 9.5 × 10(8) mononuclear cells/kg) from HLA-matched sibling donors who were mobilized with recombinant human granulocyte-colony-stimulating factor (5 micrograms/kg/day subcutaneously for 5 days). All patients received cyclosporine and prednisone for graft-versus-host disease (GVHD) prophylaxis. RESULTS: An absolute neutrophil count greater than 500 per mm3 was achieved on Day 12, and platelet transfusion independence was achieved on Day 16. The median day of hospital discharge was Day 23 after transplant. All patients achieved 100-percent donor cell engraftment. Acute > or = Grade III GVHD did not develop in any patients, but all patients developed Grade I (n = 4) or Grade II (n = 2) acute GVHD. Chronic extensive GVHD developed in four of six patients. One patient died of pneumonia 263 days after transplant while undergoing immune-suppressive therapy for chronic GVHD. CONCLUSION: The transfusion of blood stem cells in patients undergoing allogeneic bone marrow transplant is well tolerated soon after transplant, but the development of chronic GVHD may limit the general usage of unmanipulated blood stem cells.     

Lenograstim versus filgrastim in mobilization before autologous hematopoietic stem cell transplantation in patients with multiple myeloma and lymphoma - Single center experience

ObjectivePeripheral blood stem cell transplantation is frequently used in the treatment of various hematological malignancies after intensive chemotherapy. The primary aim of our study is to compare the amount of collected CD34+ cells and engraftment times in patients mobilized with filgrastim or lenograstim.Material and MethodsDemographic and clinical data of multiple myeloma (MM) and lymphoma patients who underwent autologous transplantation and mobilized with G-CSF (filgrastim or lenograstim) without chemotherapy were collected retrospectively.ResultsOne hundred eleven MM and 58 lymphoma patients were included in the study. When mobilization with filgrastim and lenograstim was compared in MM patients, there was no significant difference in neutrophil and thrombocyte engraftment times of lenograstim and filgrastim groups (p = 0.931 p = 0.135, respectively). Similarly, the median number of CD34+ cells collected in patients receiving filgrastim and lenograstim was very similar (4.2 × 10⁶/kg vs 4.3 × 10⁶/kg, p = 0.977). When compared with patients who received lenalidomide before transplantation and patients who did not receive lenalidomide, the CD34+ counts of the two groups were similar. However, neutrophil and platelet engraftment times in the group not receiving lenalidomide tended to be shorter (p = 0.095 and p = 0.12, respectively). When lymphoma patients mobilized with filgrastim and lenograstim were compared, neutrophil engraftment time (p = 0.498), thrombocyte engraftment time (p = 0.184), collected CD34+ cell counts (p = 0.179) and mobilization success (p = 0.161) of the groups mobilized with filgrastim and lenograstim were similar.ConclusionThe superiority of the two agents to each other could not be demonstrated. Multi-center prospective studies with larger numbers of patients are needed.     

A prospective clinical trial evaluating the safety and efficacy of the combination of rituximab and plerixafor as a mobilization regimen for patients with lymphoma

BACKGROUND: Previous reports suggested that rituximab may impair stem cell collection and posttransplant engraftment in lymphoma patients undergoing autologous hematopoietic progenitor cell transplantation. STUDY DESIGN AND METHODS: A prospective biologic allocation study examined the effect of adding rituximab to a mobilization regimen of plerixafor and granulocyte–colony‐stimulating factor (G‐CSF) for patients with CD20+ lymphoma compared with CD20? lymphoma patients mobilized without rituximab. The primary endpoint was safety of the rituximab‐containing regimen; secondary endpoints compared the efficiency of stem cell collection, posttransplant engraftment, graft characteristics, mobilization kinetics, immune reconstitution, and engraftment durability between the cohorts of patients with CD20+ and CD20? lymphoma. RESULTS: Fifteen subjects assigned to each treatment arm were accrued. Both mobilization regimens had similar toxicities. The median number of CD34+ cells collected (7.4 × 10⁶/kg vs. 6.4 × 10⁶/kg) and the median numbers of days of apheresis needed to collect stem cells were not different between the CD20+ and CD20? cohorts. No significant differences in neutrophil engraftment (median, 13.5 days vs. 13 days) or platelet engraftment (22 vs. 21 days) or in graft durability were seen comparing patients with CD20+ versus CD20? lymphoma. There were no significant differences in the kinetics of blood T‐cell or natural killer–cell reconstitution comparing the two groups. B‐cell reconstitution was delayed in the CD20+ lymphoma group, but this did not translate into a significant increase in infectious complications. CONCLUSION: Rituximab can be safely added to the combination of plerixafor and G‐CSF as a mobilization strategy without excess toxicity or posttransplant engraftment delays for patients with chemosensitive lymphoma undergoing autologous hematopoietic progenitor cell transplantation.     

Mobilization and collection of peripheral blood progenitor cells for transplantation.

Bone marrow transplantation gradually expanded as a treatment modality for various malignant and non malignant disease conditions. Since the discoveries of the potential of Peripheral Blood Progenitor Cells (PBPC) in the hematopoietic reconstitution mid 1980s and early 1990s PBPC gradually replaced bone marrow as the preferred source of stem cells. The introduction of hematopoietic cytokines that can mobilize large number of progenitors into circulation accelerated PBPC usage. Technological advancements in the apheresis instrumentation greatly helped in the conversion from marrow to PBPC. PBPC collection is less painful, less expensive and transplant with PBPC results in faster hematological recovery than with marrow. Almost all of the autologous transplants are currently performed with PBPC and a similar trend is seen with the allogeneic transplants. The progenitor cell mobilization regimen for autologous patients can be cytokines alone or cytokines combined with chemotherapy. In the majority of the patients the required minimal cell dose of 2.5-5.0 x 10(6)/kg CD34+ cells can be collected in one or two apheresis collections. A few of autologous transplant patients who mobilize poorly require several collections. Allogeneic donors are generally mobilized with daily subcutaneous injections of G-CSF 10 microg/kg for 5 days. The PBPC are collected in one or two apheresis procedures. The side effects of G-CSF are generally mild to moderate; however rare serious reactions including rupture of the spleen have been reported. The collection of PBPC in pediatric patients poses additional challenges yet an adequate dose of cells can be collected with the available apheresis instrumentation. The apheresis collection procedures are safe with no serious adverse consequences. Future scientific advancements may expand the use of PBPC for other clinical application in addition to the current use for hematological reconstitution.