Factors influencing collection of peripheral blood progenitor cells following high-dose cyclophosphamide and granulocyte colony-stimulating factor in patients with multiple myeloma

We treated 103 multiple myeloma (MM) patients with 7 g/m² cyclophosphamide (Cy) followed by 300 μg G-CSF/d to harvest peripheral blood progenitor cells (PBPC). PBPC autografts containing > 2.0 × 10⁶ CD34⁺ cells per kg body weight were obtained at the first attempt from 90/100 evaluable patients. The most significant factor predicting impairment of PBPC collection was the duration of previous melphalan treatment ( P  < 0.0001). In multivariate discriminate analysis, treatment with melphalan during the most recent chemotherapy cycles prior to mobilization ( P  = 0.0727) and previous radiotherapy ( P  = 0.0628) had a marginally significant negative influence on the efficacy of PBPC collection. We found no reduced functional capacity of CD34⁺ cells to restore haemopoiesis after myeloablative treatment related to the duration of melphalan exposure. At the time of best response to conventional treatment, a median paraprotein reduction of 21% was achieved following high-dose cyclophosphamide (HD-Cy). Two heavily pretreated patients died and one patient developed pulmonary toxicity W.H.O. grade IV following HD-Cy. Potential transplant candidates should undergo mobilization and harvesting of PBPC before melphalan-containing treatment. Combinations of haemopoietic growth factors and their dose modifications should be investigated to improve PBPC collection, to allow a dosage reduction of the mobilization chemotherapy.     

大剂量环磷酰胺联合粒细胞集落刺激因子动员多发性骨髓瘤造血干细胞的价值研究

目的研究大剂量环磷酰胺(HD-CTX)联合粒细胞集落刺激因子(G-CSF)在多发性骨髓瘤(MM)造血干细胞动员中的临床疗效和安全性。方法选择2006年6月至2010年9月中山大学附属第一医院血液科36例MM患者,全部患者接受HD-CTX联合G-CSF动员,CTX 3~5 g/m2,第1天,G-CSF300μg/d第2天起直到干细胞采集结束。结果 35例(97.2%)动员成功,其中31例第一次动员即成功,4例第二次动员成功。干细胞采集的中位时间为第11(9~13)天,22例(62.9%)患者采集1次,13例(37.1%)患者采集2次。采集的单个核细胞(MNC)数为(4.49±1.71)×108/kg,CD34+细胞数为(3.21±1.87)×106/kg。7例疗效在动员后得到进一步提高。动员的非血液系统副反应包括恶心、呕吐11例(26.8%)、腹痛腹泻5例(12.2%)、发热7例(17.1%)、骨痛4例(9.8%)等。只有1例因感染影响干细胞采集。结论 HD-CTX联合G-CSF是MM造血干细胞动员的安全有效的方法。     

Busulfan,cyclophosphamide, and etoposide as conditioning for autologous stem cell transplantation in multiple myeloma

Autologous stem cell transplantation (ASCT) has enabled the use of high-dose alkylating agents either as a single agent or in combination with other cytotoxic agents and/or total body irradiation (TBI) for the treatment of multiple myeloma. Despite improved complete remission rates, relapse and regimen-related toxicities remain challenging. In an effort to increase event-free survival and decrease the high incidence of regimen-related toxicity, we have studied the use of etoposide in combination with reduced-dose busulfan and cyclophosphamide as a conditioning regimen for ASCT in a group of 26 patients with advanced multiple myeloma. Median follow-up for the group was 30 months. There was no early treatment-related mortality. The main toxicity was mucositis. Otherwise, there was 1 case of reversible, clinically diagnosed hepatic veno-occlusive disease. Post-engraftment, 10 patients (38%) achieved CR, 15 (58%) patients achieved PR or SD, and 1 patient developed progressive disease (4%). Five patients in PR and 1 with progressive disease before transplant attained a CR post-transplant. The median times for event-free survival and overall survival after transplantation were 24 and 43 months, respectively. In conclusion, conditioning with busulfan, cyclophosphamide, and etoposide followed by ASCT is a safe regimen with comparable effectiveness to other previously used preparative regimens, thus providing another approach of non-TBI containing high-dose chemotherapy for patients with multiple myeloma.     

Preceding chemotherapy, tumour load and age influence engraftment in multiple myeloma patients mobilized with granulocyte colony-stimulating factor alone

Haematopoietic growth factors, especially granulocyte colony-stimulating factor (G-CSF), are frequently utilized alone for peripheral blood stem cell (PBSC) procurement to avoid the morbidity associated with high-dose chemotherapy (HDT). Moreover, the cytotoxic agents used may not be the most optimal therapy for the malignancy. It also makes scheduling of apheresis easier. Factors having an impact on PBSC procurement and engraftment after HDT were analysed in 117 multiple myeloma patients mobilized with G-CSF (10-16 microg/kg, median 12 microg/kg) alone using Cox regression analysis. A median of 6.2 x 10(6) CD34 cells/kg (range 0.6-34.1) were procured during leukapheresis and a median of 2.5 x 10(6) CD34 cells was infused after the first HDT (range 0.3-23.9). The only factor significantly affecting optimal PBSC procurement was duration of preceding conventional chemotherapy (P = 0.002). Granulocyte recovery was prompt in almost all patients, 75% of whom attained a granulocyte count of 0.5 x 10(9)/l by day 13 (median 11, range 7-19). However, platelet recovery to both 20 x 10(9)/l (median 12 d, range 8-50+) and 50 x 10(9)/l (median 20 d, range 7-205+) varied widely. On univariate analysis, factors influencing platelet recovery were the number of CD34 cells/kg infused, age, beta(2)-microglobulin levels, response to preceding therapy, bone marrow plasmacytosis and duration of prior therapy. Factors attaining significance on multivariate analysis included number of CD34 cells/kg infused (P = 0.007), beta(2)-microglobulin levels (P = 0.0001), most probably representing disease load, and age (P = 0.002). Patients with high tumour burden, i.e. beta(2)-microglobulin levels > 2.5 mg/l, probably benefit from chemotherapy for mobilization both in terms of cytoreduction and adequate stem cell mobilization resulting in accelerated engraftment.     

Intensive chemotherapy with blood progenitor transplantation for primary resistant multiple myeloma

Summary. This study assessed the feasibility and effect of blood progenitors as the only source of haemopoietic support for myeloablative therapy for patients with primary resistant multiple myeloma and markedly infiltrated bone marrow. 17 patients with advanced, primary resistant myeloma received a priming regimen of cyclophosphamide (3 g/m²) and etoposide (900 mg/m²) with GM-CSF. During haematological recovery, at least 2 × 10⁶ CD34⁺ mononuclear cells/kg were collected from each patient with 4-12 leukaphereses. High-dose chemotherapy was then given which consisted of thiotepa (750 mg/m²), busulfan (10 mg/kg) and cyclophosphamide (120 mg/kg) followed by reinfusion of the blood progenitors. Haemopoietic reconstitution was rapid with recovery of granulocytes to >1.0 × 10⁹/1 after a median of 10 d and of platelets to 50 × 10⁹/1 after a median of 29 d. The myeloma responded in 10/17 patients for a projected median duration of at least 12 months. Survival was prolonged significantly in comparison with the outcome of control patients who did not receive intensive treatment. Blood progenitors, assessed from the number of CD34⁺ cells, produced early haemopoietic recovery after myeloablative therapy that induced sustained control of advanced and resistant multiple myeloma.     

Detection of monoclonal plasma cells in the peripheral blood stem cell harvests of patients with multiple myeloma

We evaluated the harvest product from 47 patients undergoing peripheral blood (BP) stem cell collections for monoclonal plasma cells (PC) using a sensitive immunofluorescence technique. 60% (28/47) had docu mented tumour cells in the apheresis product. The 32 patients in plateau had a mean of 1.62 x 10⁶ PC/1 v 74.64 x 10⁶ in 15 relapsed patients ( P < 0.01). 32% (6/19) of patients without any tumour cells in the initial sample had them detected on a subsequent apheresis sample. In four cases (all treated with GM-CSF) small numbers of tumour cells were detected initially but became undetectable on a subsequent sample.     

Granular lymphocyte proliferative disorder after autologous peripheral blood stem cell transplantation for multiple myeloma

A 57-yr-old woman with multiple myeloma underwent tandem autologous peripheral blood stem cell transplantation (APBSCT). Fever, anemia, and thrombocytopenia, followed by the proliferation of granular lymphocytes in the peripheral blood occurred, after a second APBSCT. Clonal rearrangement of the T-cell receptor was detected using Southern blot analysis of peripheral blood samples. Granular lymphocyte proliferative disorders (GLPD) were diagnosed. After steroid therapy, the symptoms resolved. Lymphocytosis did not recur after the discontinuation of steroids. There have been a few reports of GLPD after solid organ and allogeneic hematopoietic stem cell transplantations. We report a first case of GLPD after APBSCT.     

The endogenous granulocyte colony-stimulating factor response following autologous peripheral blood stem cell transplantation is impaired in patients with myeloma

Granulocyte colony-stimulating factor (G-CSF) levels were studied in 23 patients (10 myeloma, 13 relapsed Hodgkin's disease, non-Hodgkin's lymphoma or germ cell tumours), post autologous peripheral blood stem cell transplantation (PBSCT). The two groups had similar previous chemotherapy and numbers of CD34+ cells transplanted. All patients received G-CSF by injection starting 8 d post transplantation. Twenty out of 23 patients showed raised endogenous levels of G-CSF before cytokine administration. Myeloma patients showed significantly lower levels of endogenous G-CSF than the other patients (0.767 versus 3.262 ng/ml, P < 0.05). Further rises in G-CSF levels were seen following the administration of exogenous G-CSF which then fell, despite ongoing administration of G-CSF, as neutrophil recovery occurred.     

Multiple myeloma related cells in patients undergoing autologous peripheral blood stem cell transplantation

A high incidence of oligoclonal serum M-components is observed in multiple myeloma (MM) patients treated with autologous stem cell transplantation (ASCT). To determine whether these M-components are produced by myeloma clonally related cells or caused by an aberrant B-cell regeneration we analysed by semi-nested ASO-RT-PCR and DNA sequencing the immunoglobulin (Ig) variable genes (VH) obtained from bone marrow samples obtained before and after transplantation and peripheral blood stem cell (PBSC) samples from seven patients. Myeloma clonally related cells are identifiable by the expression of variant Ig heavy chain isotypes and were detected in two patients at presentation. No myeloma clonally related cells were found in post-transplantation samples (n = 7) in spite of the appearance of new serum M-components. However, in two cases we amplified sequences from post-transplantation bone marrow cells that were able to bind to the B-cell clone-specific CDR3 oligonucleotides but showed no further similarity regarding the VDJ rearrangement. These data indicate that serum oligoclonality post-transplantation is not caused by myeloma clonally related B cells but rather by the regenerating B-cell compartment.     

Haematopoietic stem cell mobilization with plerixafor and G-CSF in patients with multiple myeloma transplanted with autologous stem cells

A proportion of patients with multiple myeloma (MM) who have already undergone autologous stem cell transplantation (autoSCT) might benefit from a further transplantation. For this, they might need to undergo another round of stem cell mobilization. We analyzed retrospectively the outcomes of stem cell mobilization with plerixafor and granulocyte colony-stimulating factor (G-CSF) in a group of 30 patients who had undergone autoSCT previously, and in 46 other patients. The previously transplanted patients were significantly different from the remaining patients with respect to the intensity and number of previous therapies. We observed that the median peripheral blood concentration of CD34+ cells after the first administration of plerixafor was lower in previously transplanted (19 cells/μL) than in other patients (30 cells/μL, P < 0.05). Despite a comparable number of apheresis sessions being performed, the median total yield of CD34+ cells was significantly lower in the previously transplanted than in the remaining patients (2.8 × 10(6) cells/kg vs. 4.2 × 10(6) cells/kg, P < 0.05). However, successful collection of at least 2.0 × 10(6) CD34+ cells/kg was achieved finally in a similar proportion of previously transplanted and other patients (70% vs. 82.6%). Our data suggest that stem cell mobilization with plerixafor and G-CSF might overcome the negative effect of prognostic factors for poor stem cell mobilization in patients with MM who have undergone autoSCT previously.     

CD34+-selected peripheral blood progenitor cell transplantation in patients with multiple myeloma: tumour cell contamination and outcome

Thirty-six patients with multiple myeloma (23 PR1, nine PR2, four stable disease) were entered into a pilot study evaluating the use of CD34+-selected peripheral blood progenitor cell transplantation (PBPCT) following high-dose melphalan alone or high-dose melphalan and total body irradiation. Peripheral blood progenitor cells (PBPCs) were mobilized with cyclophosphamide and granulocyte colony stimulating factor (G-CSF). CD34+ selection using the Cellpro Ceprate-SC system was performed in 22 cases with an adequate yield in 20. 10 patients failed to mobilize sufficient cells to permit selection and in four cases selection was not performed for other reasons. 16 patients therefore received unselected PBPC. Tumour cell contamination was evaluated by IgH gene fingerprinting (fpPCR). Harvested PBPC were fpPCR positive in 13/20 CD34+-selected cases and remained positive after selection in seven. Harvested PBPC were studied in 9/16 patients receiving unselected cells; fpPCR was positive in five and negative in four. There was no difference in event-free survival (EFS) between the CD34+-selected group and the unselected group (median 21 and 26 months, respectively, P=ns). The CD34+-selection process therefore reduced contamination but did not eliminate it completely, and in this small non-randomized study there was no apparent clinical benefit of CD34+ selection.     

Pegfilgrastim effectively mobilizes PBSC in a poor mobilizer multiple myeloma patient

Studies performed on mice and healthy human volunteers have shown that a single dose of pegfilgrastim (Peg-GCSF) is effective in stimulating peripheral blood stem cells (PBSC) mobilization. This prompted us to try the stimulation with pegfilgrastim in a patient previously non-mobilizing with a combination of chemotherapy and filgrastim. In December 2003, a 65-yr-old man was diagnosed as having stage III A IgG/k multiple myeloma. He received three courses of polichemotherapy (DC-IE) obtaining a stable response. Afterwards, the patient was treated with high-dose cyclophosphamide (CPM; 7 g/sqm) plus daily 10 mcg/kg filgrastim in order to mobilize PBSC, without success. After 2 months off therapy, the disease progressed and the patient received alternate cycles VAD (vincristine, dexamethasone, adriblastine)/high-dose dexamethasone. A second attempt to mobilize PBSC, using daily 10 mcg/kg filgrastim after the second and third VAD cycle, failed. In a further attempt to mobilize PBSC, we administered a single dose of 12 mg pegfilgrastim on day 5 after a fourth VAD course. Daily evaluation of circulatory CD34+ cells was started from day 8 after the end of chemotherapy. On day +10 postchemotherapy the CD34+ cell count was 24/microL and two aphaeresis were performed, harvesting 1.6 x 10(6) and 0.89 x 10(6) CD34+ cells/kg respectively (total 2.49 x 10(6) cells/kg). The only side effect was moderate skeletal pain. The patient underwent successful transplantation. The median times necessary to recover 0.5 x 10(9) PMN/L and 20 x 10(9) platelets/L after PBSC reinfusion were 9 and 12 d respectively. The patient did not need red blood cell or platelet transfusions. He experienced a sustained engraftment and maintains complete remission 9 months after the reinfusion. In conclusion, a single dose of pegfilgrastim was able to mobilize a sufficient number of CD34+ in a multiple myeloma patient not responsive to two previous attempts with high or standard dose chemotherapy followed by filgrastim. This approach, if confirmed on larger series and other diseases, could open new opportunities in stem cell mobilization for poor or non-mobilizers.     

Outcome after autologous stem cell transplantation for multiple myeloma in patients with preceding plasma cell disorders

A third of patients with multiple myeloma (MM) have a preceding diagnosis of plasma cell proliferative disorder (PCPD), mostly monoclonal gammopathy of undetermined significance (MGUS), smoldering MM (SMM) or plasmacytoma. While autologous stem cell transplantation (SCT) improves survival in MM, it is not clear if patients with preceding PCPD have a different outcome. We identified 151 patients with preceding PCPD from among 804 patients undergoing SCT, and their outcomes were compared. The response rates, including complete responses, were similar between the groups. Patients with a preceding diagnosis of MGUS had longer time to progression (TTP; 27·5 months vs. 17·2 months, P  = 0·01), and longer overall survival (OS) from transplant (80·2 months vs. 48·3 months, P  = 0·03) compared to those with de novo myeloma. However no differences were seen among those with a preceding diagnosis of SMM or plasmacytoma in terms of TTP or OS from transplant when compared to those with de novo myeloma. Multivariate analysis indicated that the presence of MGUS prior to myeloma was prognostic for post-transplant relapse independent of other known risk factors. Patients with pre-existing MGUS prior to myeloma diagnosis have a better outcome following HDT, reflecting more indolent disease and a favourable biology than those presenting with de novo myeloma.     

Peripheral blood progenitor cell collections in multiple myeloma: predictors and management of inadequate collections

Thirty-seven patients with previously treated multiple myeloma (MM) underwent peripheral blood progenitor cell (PBPC) collection following high-dose cyclophosphamide and GM-CSF or sequential IL-3 and GM-CSF. Patients with an inadequate collection were considered for a second or third collection. 25 patients underwent subsequent autotransplant. The only variable predictive of CFU-GM yield was the extent of prior melphalan therapy. All repeat collections were unsuccessful and patients infused with an autograft obtained from multiple sets of collections had a high incidence of delayed engraftment. We conclude that melphalan should be avoided or PBPC collection performed early in the disease course in patients who are potential transplant candidates.     

骨髓瘤肾病患者自体外周血干细胞移植治疗临床分析

目的:探讨骨髓瘤肾脏累及患者进行自体外周血干细胞移植(APBSCT)治疗的疗效和安全性。方法:首诊为多发性骨髓瘤(MM)肾病的男性患者4例,年龄35~53岁,进行常规血生化,血、尿免疫蛋白电泳和骨髓穿刺检查,3例行肾脏活组织检查(活检),常规化学治疗(化疗)后均行大剂量化疗(HDT)联合APBSCT。结果:4例患者中IgG型2例,IgD及无分泌型各1例;ⅡA期2例,ⅢA期1例,ⅢB期1例;确诊时均有蛋白尿(1.51～5.70 g),急性肾损伤(AKI)2例,慢性肾脏病(CKD)Ⅱ期、CKDⅤ期各1例。肾穿刺3例中1例弥漫间质炎细胞浸润,1例为轻链沉淀肾病(LCDD),另1例为管型肾病;1例未肾活检,临床推测MM管型肾病可能。移植前常规化疗4~6疗程。3例轻、中度肾功能受累者APBSCT治疗后1例再次发生AKI,但短时间恢复,长期随访尿蛋白基本转阴性,肾功能稳定无进展;1例移植后1年转变为浆细胞白血病死亡,2例MM完全缓解(CR)。1例严重肾功能受累(CKDⅤ期)者移植后因感染性休克死亡。结论:HDT联合APBSCT是治疗MM的有效方法。APBSCT治疗对轻、中度肾功能受累MM肾病患者的肾功能无明显影响,疗效满意。严重肾功能衰竭患者中进行该治疗尚需进一步探讨。     

自体外周造血干细胞移植治疗21例多发性骨髓瘤的临床疗效及预后因素评价

目的:评价自体外周造血干细胞移植(APBSCT)治疗21例多发性骨髓瘤(MM)患者的临床疗效以及影响预后的相关因素.方法:21例MM患者中有2例患者复发后行2次APBSCT,因此共行APBSCT 23例次.5例患者在诱导治疗时采用硼替佐米(万坷)联合方案,其他患者多数采用长春新碱、阿霉素加地塞米松(VAD)方案诱导治疗...     

Results of autologous stem cell transplant in multiple myeloma patients with renal failure

Data are presented on 81 multiple myeloma (MM) patients with renal failure (creatinine > 176.8 micromol/l) at the time of autologous stem cell transplantation (auto-SCT), including 38 patients on dialysis. The median age was 53 years (range: 29-69) and 26% had received more than 12 months of prior chemotherapy. CD34+ cells were mobilized with granulocyte colony-stimulating factor (G-CSF) alone (n = 51) or chemotherapy plus G-CSF (n = 27), yielding medians of 10 and 16 x 106 CD34+ cells/kg respectively (P = 0.003). Sixty patients (27 on dialysis) received melphalan 200 mg/m2 (MEL-200). Because of excessive toxicity, the subsequent 21 patients (11 on dialysis) received MEL 140 mg/m2 (MEL-140). Thirty-one patients (38%) completed tandem auto-SCT, including 11 on dialysis. Treatment-related mortality (TRM) was 6% and 13% after the first and second auto-SCT. Median times to absolute neutrophil count (ANC) > 0.5 x 109/l and to platelets > 50 x 109/l were 11 and 41 d respectively. Non-haematological toxicities included mucositis, pneumonitis, dysrhythmias and encephalopathy. At a median follow up of 31 months, 30 patients have died. Complete remission (CR) was achieved in 21 patients (26%) after first SCT and 31 patients (38%) after tandem SCT. Two patients discontinued dialysis after SCT. Median durations of complete remission (CR) and overall survival (OS) have not been reached; probabilities of event-free survival (EFS) and OS at 3 years were 48% and 55% respectively. Dialysis dependence and MEL dose did not affect EFS or OS. Sensitive disease prior to SCT, normal albumin level and younger age were independent prognostic factors for better OS. In conclusion, renal failure had no impact on the quality of stem cell collections and did not affect engraftment. MEL-140 had an acceptable toxicity and appeared equally effective as MEL-200. In the setting of renal failure, the role of auto-SCT early in the disease course and benefits of tandem SCT require further evaluation.     

Retrospective analysis of an efficient peripheral blood stem cell collection and the relation between infused cell dose and clinical outcome in patients with malignant lymphoma and multiple myeloma

Introduction: Etoposide (VP16) is a drug used not only for the treatment of lymphoma but also for the collection of peripheral blood stem cells (PBSCs). We analysed the efficacy and adverse effects of collecting PBSCs and the relation between the infused cell dose and the clinical outcome in lymphoid malignancies. Method: Investigating 30 patients with non‐Hodgkin’s lymphoma, one patient with Hodgkin’s lymphoma, and five patients with multiple myeloma, we compared the effects of several doses of etoposide with those of CHOP or CHOP‐like treatments or salvage treatments. We also analysed the relation between the amount of CD34⁺ cells collected (above or below 5.0 × 10⁶/kg/day) and prognosis of these patients. Results: We found the collected cell count to be highest in patients treated with 500 mg/m² of VP16 and lowest in those not treated with VP16 (P = 0.0073). A CD34⁺ cell count above 100/μL on the collection day indicates that the target amount of CD34⁺ cells (4.0 × 10⁶/kg) can be readily obtained and was reached most rapidly by the patients who had received 500 mg/m² of VP16 (P = 0.01). The longer duration of neutropenia in those patients (P = 0.000006) resulted in longer antibiotic treatment (P = 0.0052). Both progression‐free survival (PFS) and overall survival (OS) were better for the patients who yielded more than 5.0 × 10⁶ CD34⁺ cells/kg/day (P = 0.087 for PFS and P < 0.033 for OS). Conclusion: We show here that 3 days of VP16 at 500 mg/m² was useful for the collection of PBSCs and that patients who yielded more than 5.0 × 10⁶ CD34⁺ cells/kg/day survived longer than those who yielded less.