Autologous Peripheral Blood Progenitor Cell Transplantation Research Articles

Alternative Schedule of Filgrastim after Autologous Transplantation: Less Dosing, Same Efficacy

Administration of colony-stimulating factors (CSF) after autologous peripheral-blood progenitor cell transplantation is the current standard of care, and G-CSF is usually given from day +5 or +7 until engraftment. Recent preliminary data in a non-transplant setting suggest that 2 doses of G-CSF may be equivalent to the standard schedule. In this pilot study, we evaluated the safety and efficacy of giving only 2 doses of filgrastim post-transplant (days +7 and +9) in non-myeloma pts; exclusion criteria were re-transplants and clinical instability at day +7. From July 07 to June 08, 19 consecutive pts were included (16 lymphomas, 3 acute leukaemias) and their outcome was compared to a historical control group of 42 similar pts transplanted from Jan 06 to Jun 07, who received filgrastim from d+7 until 1000 neutrophils/ul (4–18 days, median 9). There were no significant differences in primary endpoints: median time to neutrophil engraftment (500/ul reached on day +12 vs +11) rate of documented infections (with bacteremia in 23% of transplants in the study group vs 36% in the control group) and median length of hospitalisation (both 22 days). Median duration of intravenous antibiotics (11 vs 12 days) median time to platelet engraftment (20,000/ul reached on day +13 vs +14) incidence of grade 3/4 mucositis and transfusion requirements were also similar. There were no deaths at day +30 in the study group. In 2 of the 19 pts a secondary prescription of filgrastim was made (for 2 and 4 days). In this pilot study, reducing filgrastim administration to 2 doses seems possible without undue risks. If confirmed in a randomized trial, these findings could have a significant impact on the cost of transplantation.

Ex Vivo Graft Purging and Expansion of Autologous Mobilized Peripheral Blood Progenitor Cell (PBPC) Products from Patients with Multiple Myeloma (MM).

Introduction: Autologous PBPC transplantation has become the treatment of choice for selected MM patients. Autografts are often contaminated with MM cells which could be a source of post-transplant relapse. We elected to develop a graft manipulation procedure to purge tumor cells from the autograft without compromising its normal reconstituting activity. Previous studies have shown that bortezomib (Velcade, Millenium Pharmaceuticals, Inc., Cambridge, MA) can kill CD138+ MM cells, with little effect on CD138− B cells. However, the anti-CD20 monoclonal antibody, rituximab (Rituxan, Genentech, Inc., San Francisco, CA) has been shown to kill CD138− B cells, the putative MM “stem cells” population. Therefore we investigated whether an optimized combination of bortezomib and rituximab might effectively eradicate tumor cells from PBPC products. Previous studies1 have also suggested that tumor cells can also be selectively purged by ex vivo culture while expanding the normal hematopoietic progenitors. Thus, we incorporated an ex vivo culture step to optimize MM cell depletion and expansion of the reconstituting normal progenitors.Methods: CD138+ cells were depleted from the thawed PBPC of MM patients using the midiMACS device (Miltenyi Inc, Auburn, CA). The CD138− cells were treated for 24 hrs with 10 or 20 μg/ml rituximab followed by 20nM or 80nM bortezomib for 16hrs. Cells were then washed and ex vivo-expanded using an allogeneic normal marrow donor-derived mesenchymal stem cell (MSC) co-culture technique as previously reported.2 At the end of culture, cells were evaluated for total viable cells, expression of CD138, CD20, CD19, CD34, CD45 by flow cytometry and colony-forming cell (CFC) content in methylcellulose assays (StemCell Technologies, Vancouver, BC).Results: CD138+, CD138−/CD20+ or CD138−/CD20+/CD19+ cells were depleted in the MM PBPC products from patients when treated with bortezomib (20nM) and rituximab (20 μg/ml) followed by ex vivo culture.(Fig 1) Compared with input control, TNC increased by 6–72 fold and absolute numbers of CD34+ cells increased by approximately 3–9 fold. (See representative data Fig 2)Conclusion: Treating CD138-depleted MM PBPC products with bortezomib, rituximab and 2 weeks of ex vivo culture depleted CD138+ malignant plasma cells and CD138− B cells (MM “stem cells”). An estimated >4 log tumor depletion from a mobilized PBPC product was achieved, while the use of ex vivo expansion culture not only preserved but increased the number of normal hematopoietic progenitors. Further refinements of this procedure are in progress and will be tested clinically. [Display omitted] [Display omitted]

Rituximab‐ESHAP as a mobilization regimen for relapsed or refractory B‐cell lymphomas: a comparison with ESHAP

It has previously been shown that ESHAP was an effective mobilization regimen for patients with pretreated lymphoma. To extend these observations, the efficacy and feasibility of rituximab plus ESHAP regimen in CD20+ B-cell NHL were assessed. The mobilization efficacy and engraftment characteristics were compared in the 22 patients who received the rituximab plus ESHAP (R-ESHAP) with 33 historical controls who received ESHAP. The two treatment groups were well matched in patient characteristics. In the R-ESHAP group, 62 pheresis procedures were performed. Apheresis procedures were started on median Day 16 (range, Days 13-18). The median number of collected CD34+ cells was 10.6 x 10(6) per kg (range, 4.9 x 10(6)-52.6 x 10(6)/kg). Nineteen (95%) patients achieved optimal peripheral blood hematopoietic progenitor cell (PBPC) collection, defined as at least 5 x 10(6) CD34+ cells per kg. There were no significant differences between the two groups with respect to mobilization efficacy. Sixteen patients in the R-ESHAP group (73%) underwent autologous peripheral blood progenitor cell transplantation (APBPCT). The median time to absolute neutrophil count at least 0.5 x 10(9) per L was 10 days (range, 8-17 days), and the median time to a platelet count of at least 20 x 10(9) per L was 12 days (range, 7-27 days). Lymphocyte recovery was slower in the R-ESHAP group, but the rate of infectious complications was similar in the two groups. In the R-ESHAP group, the 2-year overall survival and progression-free survival after APBPCT were 63.2 and 57.4 percent, respectively. Addition of rituximab to ESHAP chemotherapy did not have any adverse effects on PBPC mobilization. Further studies are needed, however, to determine whether addition of rituximab improves outcomes.

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

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. 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. 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. 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.

The platelet prophylactic transfusion trigger: when expectations meet reality

The platelet prophylactic transfusion trigger: when expectations meet reality

Long-Term Follow-Up of Patients with Non-Hodgkin Lymphoma Following Myeloablative Therapy and Autologous Transplantation of CD34+-Selected Peripheral Blood Progenitor Cells

Graft engineering by CD34(+) selection of peripheral blood progenitor cells (PBPC) has been used in non-Hodgkin lymphoma (NHL) with the aim to reduce relapse related to tumor cells within the graft. From September 1995 to January 2000, 39 patients with newly diagnosed (n = 31) or relapsed (n = 8) NHL were treated in our institution with myeloablative therapy followed by CD34(+) selected autologous PBPC transplantation. Thirty-one patients were diagnosed with follicular lymphoma, and eight patients with mantle-cell lymphoma. All patients had advanced disease (26% of patients stage III and 74% stage IV, Ann Arbor classification). Induction therapy resulted in a complete remission in 17 patients and a partial remission in 22 patients. PBPC were mobilized after cytotoxic chemotherapy with granulocyte colony-stimulating factor support. CD34(+) selection was performed using immunomagnetic beads (Baxter Isolex 300SA or 300i Magnetic Cell Separation System). Most patients (85%) received total body irradiation and high-dose cyclophosphamide as myeloablative regimen. Twelve patients also received rituximab 375 mg/m(2) before radiation and before the start of the cyclophosphamide treatment. The mean CD34(+) cell number for transplantation was 6.5 x 10(6) CD34(+) cells/kg of body weight. Platelet recovery (>20,000/microl median on day 13) and leukocyte recovery (>1,000/microl median on day 12) were within expected range. The estimated median follow-up was 47 months. The probabilities of freedom from progression, overall survival, and event-free survival 4 years after transplantation were 96%, 90%, and 87%, respectively, for patients with follicular lymphoma and 42%, 63%, and 33%, respectively, for patients with mantle-cell lymphoma. Risk factors for relapse were age and extranodal manifestation of disease. The rate of lethal infections in the 12-month follow-up period was 8%. We conclude that CD34(+) selection of autologous transplants following myeloablative therapy is feasible and results in long-term remission in the majority of patients, but the procedure is probably related to a higher rate of lethal infections.

Myeloablative Conditioning of Patients with Myelofibrosis with Myeloid Metaplasia Using i.v. Treosulfan and Autologous Peripheral Blood Progenitor Cell Transplantation (PBPCT) with High Doses of CD34+ Cells Results in Hematologic Responses - 32 Months Follow-Up of Three Patients and Short-Term Results of a New Study.

Myelofibrosis with myeloid metaplasia (MMM) is a chronic myeloproliferative disorder. Myeloablation with high-dose treosulfan and autologous PBPCT provides a palliative approach. A minimum of 5 x 106 CD34+ cells/kg was collected in all patients after G-CSF-priming (16 μg/kg/d for 4 days). Myeloablation consisted of treosulfan (total dose 42 g/m2). To date we have transplanted 3 patients, all female on an individual basis. We observed a prolonged time to reconstitution of leucocytes > 1/nl post transplantation of 28 days (#1, #2) and 38 days (#3). The observation period post transplantation is 32 months now. Patient #1, who required erythrocyte transfusions twice weekly pretransplant received her last erythrocyte transfusion on day 56; her last Hb-value is 9.5 g/dl. The second patient (#2) recovered to platelet counts higher than pre transplantation (58/nl) at 3 months (143/nl) and had 125/nl at last follow-up. Pat. #3 showed a marked reduction of max. spleen size and a rise in Hb from 9 g/dl to 12 g/dl after 12 months, the last Hb value at 26 months was 7.6 g/dl and she received about 3 erythrocyte transfusions per month again. She then underwent allogeneic transplantation from her sister and is currently alive and well. Three male patients were treated in a new one-armed, multicenter study applying the aforementioned protocol. In two patients we observed again a prolonged reconstitution period of 28 (S1) and 44 (S2) days. In one patient (S1) leukocytosis and thrombocytosis resolved while transfusion dependent anemia persisted. In the second patient (S2) transfusion dependent anemia persisted. He received a backup transplantation but still remains transfusion-dependent. Patient S3 had a critical thrombocytopenia of 16/nl before transplantation and proved to be refractory to thrombocyte transfusions post-transplantation. He developed cerebral hemorrhage and died. The conditioning regimen was well tolerated and despite the prolonged aplasia period neutropenic fever was rare (median 1 day, range 0–6 days). The overall response rate was 60%, the mortality rate was 17% which is both compatible with previous data of autologous transplantation in MMM patients undergoing busulfan conditioning. This multicenter study is continuing to recruit patients (http://leukaemie.krebsinfo.de/kn_home/Studien/studie_101.html ).

Reticulated platelets: a reliable measure to reduce prophylactic platelet transfusions after intensive chemotherapy

Reticulated platelets (RPs) are the youngest circulating platelets (PLTs). The aim of our study was to predict PLT recovery with RP percentage (RP%) and therefore to identify PLT transfusions that could be avoided after autologous peripheral blood progenitor cell (PBPC) transplantation. With a whole-blood dual-labeling flow cytometric method, RP% was prospectively assessed in 47 patients who received myeloablative chemotherapy followed by autologous PBPC transplantation. Retrospective analysis of RP evolution identified three time points: nadir of the RP% (NRP), imminent PLT recovery (IPR) corresponding to an RP% of greater than 7 percent, and PLT transfusion autonomy (PTA). Median occurrences of NRP, IPR, and PTA were on Days +5, +8, and +12 after transplantation, respectively. The RP% value at NRP (4%) was significantly lower compared to the IPR (15%) and PTA (14%). Thirty patients (64%) achieved PTA within 4 days after IPR. On Day +8, if RP% was greater than 7 percent, positive and negative predictive values for PTA within 4 days, specificity, and sensitivity were 79, 63, 66, and 76 percent, respectively. Fever between IPR and PTA was the only factor found to negatively influence PLT recovery (p = 0.02). All patients required at least one PLT transfusion. Among patients with rapid PLT recovery (IPR-PTA interval < 4 days; n = 30), half of them received one PLT transfusion after RP increase, which could be avoided. These encouraging results may allow us to reduce the prophylactic PLT transfusion according to patients RP% increase.

In Vitro Culture during Retroviral Transduction Improves Thymic Repopulation and Output after TBI and Autologous PBPC Transplantation in Rhesus Macaques.

We recently completed a longitudinal study over 12 months on T-cell immune reconstitution after total body irradiation and autologous transplantation of peripheral blood progenitor cells in 3–5 year old rhesus macaques. The focus of the study was to evaluate the source of T-cell recovery using three different sources of cells for transplantation. The starting number of CD34+ cells contained within the graft was adjusted to be the same for each of the three groups: unselected peripheral blood progenitor cells (PBPC) (n=3) vs. CD34+ selected mobilized PBPC (n=4) vs. CD34+ selected cells cultured for 4 days in vitro (Flt-3L/MDGF/SCF/retronectin) and retrovirally-transduced (n=3). Peripheral blood and lymph nodes were collected for phenotypic and TREC analysis. There was a trend for animals receiving cultured and transduced CD34+ cells to attain higher absolute naive and memory CD4+ T-cell, CD20+ B-cell and CD16+ NK-cell numbers in the first months after transplantation compared to the two other groups. There were no differences for numbers of CD8+ T-cells, monocytes or dendritic cells. The absolute TREC amount per μl blood of the CD4+ T-cells in the group that received selected-transduced cells was significantly higher than in the group that received unselected cells (p=0.0166) and for CD8+ cells significantly higher than for selected cells (p=0.0464). There was significantly less peripheral T-cell expansion as measured by Ki-67 expression in the selected-transduced group compared to the two other groups: At 1 month after transplantation the mean Ki-67 expression level for CD8+ cells in peripheral blood was 33.9% in the selected vs. 23.3% in the unselected vs. 8% in the selected-transduced group. Histology at 12 months revealed striking differences in the thymus between the 3 groups, while other organs (lymph nodes, spleen, tonsils and Peyer's patches) showed no remarkable differences. In the CD34+ selected-transduced group the thymus showed preserved lobular architecture with well defined cortical and medullary areas, compared to atrophy with fat replacement, decreased thickness of the cortex, and cystic changes of the thymic epithelium in the CD34+ selected and unselected groups. The degree of atrophy was more pronounced in the latter group. This study demonstrates an enhanced ability of in vitro expanded and retrovirally transduced cells to repopulate the thymus compared to non-manipulated CD34+ selected cells. In vitro expansion and transduction may promote development of T-cell and NK-cells as has been described earlier for fetal thymic organ culture of cord blood CD34+ cells as well as in the SCID-hu mouse model. Our observation of an acceleration of T-cell and NK cell immune reconstitution following in vitro culture contrasts with limited prior clinical trial experiences describing poor repopulating potential of cultured progenitor cells. Our data suggest that in vitro culture and retroviral gene transfer per se does not induce an intrinsic differentation defect. Future studies are planned to examine mechanisms behind the improved repopulation ability of selected-transduced progenitor cells, which has important implications for gene therapy trials, and suggests that cultured cells may be useful for a number of clinical applications.

Engraftment syndrome emerges as the main cause of transplant-related mortality in pediatric patients receiving autologous peripheral blood progenitor cell transplantation.

The authors examined data from 166 children who received autologous peripheral blood progenitor cell (PBPC) transplantation to ascertain the incidence of early transplant-related mortality (TRM) and the contributing risk factors. Eleven patients (6.6%) (6 boys, 5 girls) died within 180 days following PBPC infusion. The median age was 4 years (range 2-17). The overall probability of TRM was 6.9 +/- 2% at day +180. On univariate analysis, the status of disease at transplantation (complete remission vs. not in complete remission) was identified as the only pretransplant significant predicting factor for TRM (14% of patients who were not in complete remission died within 180 days after PBPC infusion, whereas only 2% of patients in complete remission died) (relative risk [RR] 1.13, 95% confidence interval [CI] 1.01-1.26, P = 0.01). Age, gender, conditioning, and number of CD34+ cells infused were not significantly associated with TRM. In the postinfusion phase, patients who developed multiorgan dysfunction during the neutropenic period, especially when the lung was the first failing organ (RR 16.1, 95% CI 7.16-36.18, P = 0.0001), and those with engraftment syndrome (RR 2.81, 95% CI 1.49-5.24, P = 0.001) had an increased risk for TRM. On multivariate analysis, development of engraftment syndrome was the only significant variable that influenced TRM. In conclusion, the authors found for the first time that engraftment syndrome emerges as the main cause of TRM after autologous PBPC transplantation in children with malignancies.

Telomere length predicts neutrophil recovery in the absence of G-CSF after autologous peripheral blood stem cell transplantation.

Haemopoietic regeneration after autologous peripheral blood progenitor cell (PBPC) transplantation can be delayed in some patients despite adequate infusion of CD34(+) cells. This suggests variability in the proliferation potential of the implanted cells, a capacity that may be predicted by their telomere length. To test this theory, telomere length was measured on stored apheresis samples from 36 patients aged 46.6+/-11.1 years, who had undergone successful autologous PBPC transplantation with a median of 5.6 x 10(6)/kg (1.3 x 10(6)-36.1 x 10(6)/kg) CD34(+) cells. The mean PBPC telomere length for the cohort was 9.4+/-2.3 kbp. For patients who did not receive G-CSF post transplantation (n=7), days to absolute neutrophil recovery (ANC), >/=0.1, 0.5 and 1.0 x 10(9) cells/l, were significantly inversely correlated with telomere length of the infused PBPC (r=-0.88, -0.81, -0.77, respectively; P<0.05,). However, no correlation was found for patients who received G-CSF from day 1 post transplantation (n=20). These data suggest that for transplantation with sufficient CD34(+) cells, neutrophil recovery is less efficient in patients receiving infusions of cells with short telomeres, but this deficiency can be corrected with adequate post transplantation administration of G-CSF. Bone Marrow Transplantation (2004) 34, 439-445. doi:10.1038/sj.bmt.1704607 Published online 19 July 2004

Effect of cumulative etoposide doses on the outcome of autologous peripheral-blood progenitor-cell transplantation for lymphoma.

Studies evaluating the effects of previous chemotherapy on stem-cell yield and hematological recovery after autologous peripheral-blood progenitor-cell transplantation (PBPCT) have shown conflicting results. We have retrospectively analyzed 103 consecutive lymphoma patients treated with the BEAM regimen and autologous PBPCT. The impact of the different chemotherapeutic drugs (cumulative doses) on stem-cell yield and transplant-related toxicity was investigated. Highly significant differences in platelet recovery (>20 x 10(9)/l) were observed between patients receiving less or more than 750 mg/m(2) of etoposide before transplant (15 vs 29 days, P=0.001), and between patients receiving less or more than 1.2 x 10(6)/kg CD34(+) cells (27 vs 14 days, P<0.001). Differences in neutrophil engraftment between groups were not clinically significant. Pre-transplant cumulative doses of etoposide >750 mg/m(2) were associated with low CD34(+) cell collections on multivariate analysis. The actuarial incidence of transplant-related mortality (TRM) was 14% at 5 years. Pre-transplant cumulative doses of etoposide >350 mg/m(2) and previous administration of procarbazine were found to be independent prognostic factors for TRM.

Recombinant human thrombopoietin augments mobilization of peripheral blood progenitor cells for autologous transplantation

This study assessed the ability of various schedules of recombinant human thrombopoietin (rhTPO) to enhance mobilization of peripheral blood progenitor cells (PBPCs) in 134 patients with cancer undergoing high-dose chemotherapy and autologous PBPC transplantation. Patients received the study drug on days 1, 3, and 5 before initiation of granulocyte colony-stimulating factor (G-CSF) 10 μg/kg/day on day 5 and pheresis starting on day 9. Randomly assigned treatments on days 1, 3, and 5 were: group 1 (n=27) placebo, placebo, rhTPO 1.5 μg/kg; group 2 (n=27) rhTPO 1.5 μg/kg, placebo, placebo; groups 3 (n=28) and 4 (n=22) rhTPO 0.5 μg/kg on all 3 treatment days; and group 5 (n=30) placebo on all 3 treatment days. After high-dose chemotherapy and PBPC transplantation, groups 1 through 4 received rhTPO 1.5 μg/kg days 0, +2, +4, and +6 with either G-CSF 5 μg/kg/day (groups 1-3) or granulocyte-macrophage colony-stimulating factor 250 μg/m 2/day (group 4). Group 5 received placebo plus G-CSF 5 μg/kg/day. The addition of rhTPO to G-CSF increased median CD34 + cell yield/pheresis in cohorts in which rhTPO was started before day 5, with higher yields in groups 2 (2.67 × 10 6/kg) and groups 3 and 4 (3.10 × 10 6/kg) than in group 1 (1.86 × 10 6/kg) or group 5 (1.65 × 10 6/kg) ( P=.006 across groups). Comparing rhTPO to placebo, higher percentages of patients achieved the minimum yield of CD34 + ≥2 × 10 6/kg (92% v 75%; P=.050) as well as the target yield of CD34 + ≥5 × 10 6/kg (73% v 46%; P=.041). rhTPO-treated patients required fewer phereses to achieve minimum ( P=.011) and target ( P=.015) CD34 + cell values. rhTPO given after transplantation did not speed platelet recovery. No neutralizing antibodies were observed. We conclude that rhTPO can safely enhance mobilization of PBPC, reduce the number of leukapheresis, and allow more patients to meet minimal cell yield requirements to receive high-dose chemotherapy with PBPC transplantation.

Engraftment syndrome in children undergoing autologous peripheral blood progenitor cell transplantation.

There is limited experience on engraftment syndrome (ES) in children. The present study analyzes the characteristics of ES in pediatric patients undergoing autologous peripheral blood progenitor cells transplantation (PBPCT). From 1993 to 2001, 30 of 156 patients (19.2%) who underwent PBPCT developed ES (skin rash which involved more than 27% of the body surface and temperature >38.3 degrees C with no compatible infectious disease etiology, during neutrophil recovery). Of the 30 patients who developed ES, 20 (66%) developed hypoxia and/or pulmonary infiltrates, seven (23%) had hepatic dysfunction, six (20%) developed renal insufficiency, 16 (53%) showed weight gain and three (10%) experienced transient encephalopathy. Multivariate analysis showed that the only positive predictive factor for developing ES was mobilization with high-dose G-CSF (12 microg/kg twice daily) (RR 3.88, CI 95% 1.73-8.67; P < 0.0005). The overall transplant-related mortality (TRM) was 8.33% and this was significantly higher in the patients who developed ES than in those who did not (23% vs 4.76%; P < 0.0001). We also found a higher morbidity in patients who developed ES, expressed as a statistically significant increase in supportive care (transfusion requirement, parenteral nutrition) and increase in the length of hospital stay. In summary, we have found ES to be the most important cause of morbidity and mortality in children undergoing autologous PBPCT.

High-dose cyclophosphamide followed by autologous peripheral blood progenitor cell transplantation improves the salvage treatment for persistent or sensitive relapsed malignant lymphoma.

Trials have demonstrated that high-dose escalation followed by autologous transplantation can promote better long-term survival as salvage treatment in malignant lymphomas. The aim of the present nonrandomized clinical trial was to demonstrate the role of high-dose cyclophosphamide (HDCY) in reducing tumor burden and also to determine the effectiveness of HDCY followed by etoposide (VP-16) and methotrexate (MTX) in Hodgkin's disease plus high-dose therapy with peripheral blood progenitor cell (PBPC) transplantation as salvage treatment. From 1998 to 2000, 33 patients with a median age of 33 years (13-65) affected by aggressive non-Hodgkin's lymphoma (NHL) (60.6%) or persistent or relapsed Hodgkin's disease (39.4%) were enrolled and treated using high dose escalation (HDCY + HDVP-16 plus HDMTX in Hodgkin's disease) followed by autologous PBPC transplantation. On an "intention to treat" basis, 33 patients with malignant lymphomas were evaluated. The overall median follow-up was 400 days (40-1233). Thirty-one patients underwent autografting and received a median of 6.19 x 10(6)/kg (1.07-29.3) CD34+ cells. Patients who were chemosensitive to HDCY (N = 22) and patients who were chemoresistant (N = 11) presented an overall survival of 96 and 15%, respectively (P<0.0001). Overall survival was 92% for chemosensitive patients and 0% for patients who were still chemoresistant before transplantation (P<0.0001). Toxicity-related mortality was 12% (four patients), related to HDCY in two cases and to transplant in the other two. HDCY + HDVP-16 plus HDMTX in only Hodgkin's disease followed by autologous PBPC proved to be effective and safe as salvage treatment for chemosensitive patients affected by aggressive NHL and Hodgkin's disease, with acceptable mortality rates related to sequential treatment.

Immune reconstitution after autologous peripheral blood progenitor cell transplantation: effect of interleukin-15 on T-cell survival and effector functions.

The aim of this study was to evaluate the occurrence of T-cell spontaneous apoptosis (A(spont)) and its modulation in vitro by the interleukin-2 receptor (IL-2R) gamma-chain (gammac)-signaling cytokine IL-15 in patients transplanted with autologous peripheral blood progenitor cells (PBPC) for hematologic malignancies. Patients were examined on days 30-60, 60-90, and 90-120 after PBPC infusion. Dissipation of mitochondrial transmembrane potential, a hallmark of T-cell apoptosis, has been detected using the fluorescent probe 3,3'-dihexyloxacarbocyanine iodide, after short-term T-cell culture in the absence or presence of exogenous cytokines. Expression of Bcl-2 family members has been studied by flow cytometry and reverse transcriptase polymerase chain reaction. T-cell proliferative responses to recall antigens have been estimated in autologous mixed leukocyte cultures. A(spont) was seen in 45% +/- 6% of CD4(+) and 55% +/- 6% of CD8(+) T cells cultured in the absence of cytokines. Of interest, IL-15 and, to a lesser extent, its structural cousin IL-2 counteracted T-cell A(spont) by inhibiting the processing of caspase-3 and up-regulating Bcl-2 mRNA and protein levels. Cell division tracking confirmed that IL-15 did not rescue T cells from A(spont) by promoting proliferation but rather acted as a genuine survival factor. Addition of a gammac-blocking antibody to cytokine-conditioned cultures abrogated both apoptosis inhibition and Bcl-2 induction by IL-15, suggesting involvement of the IL-2Rgammac signal transduction pathway. Whereas cytokine-unprimed posttransplant T cells mounted inadequate responses to recall antigens, T cells conditioned with IL-15 expanded vigorously, indicating restoration of antigen-specific proliferation. T cells recovering after autologous PBPC transplantation are highly susceptible to spontaneous apoptosis in vitro. This phenomenon can be counteracted by the gammac-signaling cytokine IL-15. These findings suggest that IL-15 might be a promising immunomodulating agent to improve postgrafting T-cell function.

Consolidation treatment with autologous peripheral blood progenitor cell transplantation in acute myeloid leukemia: a single center experience.

Several trials have suggested that intensive post-remission therapy may prolong the duration of complete remission (CR) in acute myeloid leukemia (AML). The purpose of this study was to evaluate the feasibility and the efficacy of high-dose cytarabine (HiDAC) consolidation chemotherapy followed by high-dose therapy and autologous infusion of peripheral blood progenitor cells (PBPC) mobilized by G-CSF in adult patients with AML in first CR. Fifteen consecutive AML patients underwent HiDAC consolidation chemotherapy, used as a method of in vivo purging, followed by G-CSF for the purpose of autologous PBPC collection. Eleven patients collected a median of 6.9x10(8)/kg peripheral blood mononuclear cells (MNC) (range 2.9-23) and a median of 6.67x10(6)/kg CD34+ cells (range 1.8-33.5) with a median of two aphereses (range 1-3). Two patients did not mobilize and two obtained an inadequate number of progenitor cells. The 11 patients with adequate collections received myeloablative chemotherapy followed by the infusion of PBPC. The median number of days to recover neutrophils and platelets was 12 and 13, respectively. After a median follow-up of 28.7 months (range 17.2-43.4), five out of 11 patients who underwent PBPC transplantation are still in CR, five have died in first relapse and one is alive in CR after relapse treated with salvage therapy and second PBPC infusion. These results demonstrate that HiDAC consolidation chemotherapy followed by autologous PBPC transplantation is a feasible procedure with minimal toxicity. Randomized studies should be performed to evaluate whether this form of consolidation may produce a significant improvement in leukemia-free survival.

Prognostic importance of the axillary lymph node ratio in autologous transplantation for high-risk stage II/III breast cancer.

The role of autologous peripheral blood progenitor cell (PBPC) transplantation for high-risk stage II/III breast cancer remains controversial. New prognostic indicators defining subsets of patients who may benefit from autologous PBPC transplantation would be clinically useful. The axillary lymph node ratio, defined by the total number of axillary nodes involved with cancer divided by the number of axillary nodes surgically sampled, has been reported to be of potential prognostic importance in transplantation for high-risk, stage II/III breast cancer. We therefore retrospectively reviewed 111 women with high-risk, stage II/III breast cancer with at least four positive axillary lymph nodes undergoing autologous PBPC transplantation from 1991 to June 1999. None of the patients had received prior radiotherapy and all had completed one, and only one, course of at least three cycles of adjuvant chemotherapy. The median number of axillary nodes sampled was 20 (range 6-40) and the median number of positive axillary nodes was 12 (range 4-35). The median node ratio, dividing the number of positive nodes by the number of sampled nodes, was 0.68. Event-free survival was strongly influenced by node ratio. Patients having a node ratio of < 0.7 had a 5-year event-free survival of 68%, vs those with a node ratio of > or = 0.7 with a 5-year event-free survival of 46% (P = 0.03). Forty percent of patients with a high node ratio have relapsed vs 20% with a low node ratio (P = 0.02). Multivariate analysis revealed that positive estrogen receptor status and a node ratio of < 0.7 were independent factors related to better event-free survival (P = 0.0001 and P = 0.004, respectively). We conclude that patients having a node ratio of < 0.7 have a significantly better prognosis following autologous PBPC transplantation than do patients with a ratio > or = 0.7.

Factors affecting hematopoietic recovery after autologous peripheral blood progenitor-cell transplantation in aggressive non-Hodgkin's lymphoma: a prospective study of 123 patients

Factors affecting hematopoietic recovery after autologous peripheral blood progenitor-cell transplantation in aggressive non-Hodgkin's lymphoma: a prospective study of 123 patients

Autologous Peripheral Blood Progenitor Cell Transplantation for Transformed Diffuse Large-Cell Lymphoma

The outcome of patients with transformed diffuse large-cell lymphoma is poor. High-dose chemotherapy and autologous peripheral blood progenitor cell (PBPC) transplantation is the treatment of choice for patients with relapsed nontransformed diffuse large-cell lymphoma. The role of transplantation for transformed lymphoma is poorly studied. We retrospectively reviewed 118 consecutive diffuse large-cell lymphoma patients undergoing autologous PBPC transplantation from 1994 through 1999 and compared 18 transformed diffuse largecell lymphoma patients with 100 nontransformed patients. The transformed patients were more likely to be older (median age, 52 years vs. 45 years, P = 0.03), had a longer time from diagnosis to transplant (median, 35 months vs. 10 months; P < 0.0001), were more likely to have bone marrow involvement at diagnosis (61% vs. 15%, P = 0.0001), and were more likely to have had 2 or more courses of prior chemotherapy (94% vs. 71%, P = 0.04) than were nontransformed patients. Ninety-nine percent of patients received high-dose busulfan/cyclophosphamide/etoposide as the transplant preparative regimen. Event-free survival and overall survival were similar in the two treatment groups. Four-year overall survival was 53% in the nontransformed group versus 61% in the transformed group; 4-year event-free survival was 37% in the nontransformed group versus 38% in the transformed group. We concluded that autologous PBPC transplantation is a viable and potentially effective treatment option for patients who have transformed diffuse large-cell lymphoma.