Autologous Peripheral Blood Progenitor Cell Research Articles

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.

Influence of harvest bacterial contamination on autologous peripheral blood progenitor cells post-transplant

Microbiological contamination of manipulated blood products, including hematopoietic progenitors obtained from peripheral blood, is an infrequent but persistent problem in transplant units. The relevance of such contamination in causing patient infection has been reported as insignificant, but the effect on the post-transplant course has not been well documented. We studied the incidence of bacterial contamination in autologous peripheral blood progenitor cell transplants in two of the bench processing steps, as well as the repercussions in the post-transplant course affecting incidence of infections, transfusion requirements and time to engraftment. A total of 365 aphereses performed on 152 patients were cryopreserved in 617 bags. In 31 of these bags (5.0%), bacterial cultures were positive for Coagulase-negative Staphylococcus (31.1%), S. epidermidis (21.9%), Corynebacterium sp. (6.3%), S. warneri (6.3%), Stenotrophomonas maltophilia (6.3%), Streptococcus sp. (9.4%), Viridans group Streptococcus (3.1%) and more than one bacteria (Coagulase-negative Staphylococcus plus Corynebacterium) (15.6%). Half of the bags were contaminated at the time of freezing and the others at the time of thawing. The 31 contaminated bags were infused into 17 patients. In five of these the same contaminating bacteria was found. No difference between the two groups of patients (contaminated and non-contaminated) was found on the day the fever started, length of fever, blood transfusion requirements and engraftment, but length of hospitalization was significantly greater in patients receiving contaminated transplants.

Phase I/II Trial of Bortezomib Maintenance Following Autolgous Peripheral Blood Progenitor Cell Transplantation as Treatment for Intermediate- and Advanced-Stage Multiple Myeloma.

Patients (median age 55 yrs, range 37 – 73 yrs) with chemotherapy-responsive, intermediate- and advanced-stage multiple myeloma were assigned to maintenance therapy with bortezomib beginning a minimum of three and a maximum of four months after the day of autologous peripheral blood progenitor cell transplantation following a standard preparative regimen of high-dose melphalan (200 mg/sq.m.). Eligibility for the initiation of maintenance therapy required post-transplant neutrophil and platelet recovery (defined as minimum ANC > 1000 mm−3 and untransfused platelet count of >30,000 mm−3). Cohorts of three patients each were entered at one of three dose levels of bortezomib (1.0, 1.3, and 1.6 mg/m2) given IV once weekly for 3 weeks followed by a one-week rest period constituting one treatment cycle for a total of eight treatment cycles. To-date, 17 patients were considered eligible for study treatment and 13 patients received at least one dose of maintenance therapy. Reasons for not proceeding to maintenance included one patient with an ANC < 1000 mm−3, one patient with a serum creatinine > 2mg/dl, and four additional patients unable to travel to the treatment center. The median time from diagnosis of myeloma to transplant was 8 months (range, 4 to 19 mos), and the median time from autologous transplant to the initiation of bortezomib maintenance was 4 mos. Protocol adherence was excellent with only one patient missing the final dose of treatment. After completion of the Phase I portion of the study, the dose-limiting toxicity was determined to be 1.6 mg/m2 based on grade 3 diarrhea in two patients after 2 and 3 cycles of treatment, respectively. All subsequent patients entered were treated at the maximum tolerated dose of 1.3 mg/m2. Other, non-dose-limiting toxicities included, fatigue (11 pts), anorexia (1 pt), nausea (6 pts), dizziness (3 pts), headache (4 pts), peripheral neuropathy (6 pts), thrombocytopenia (3 pts), neutropenia (1 pt), dry cough (2 pts), upper respiratory infection (3 pts), and Herpes zoster reactivation (3 pts). Disease assessment consisted of serum and urine protein electrophereses monthly for all patients, and bone marrow aspiration quarterly for those patients with nonsecretory myeloma; repeat bone surveys were required for all patients 3, 9, 15, and 21 months post transplant. While one patient required termination of study drug at the end of treatment cycle 8 due to unacceptable side effects, no patients required termination of study drug for disease progression. Six patients currently continue to be followed every three months for evidence of disease recurrence in the post-treatment period; others continue on treatment. This phase I/II trial demonstrates that bortezomib can be safely administered as a maintenance treatment following conventional autologous peripheral blood progenitor cell transplantation with a maximum tolerated dose of 1.3 mg/m2 given three times per month for eight months; treatment consolidated the remission achieved by autologous transplant as will be presented. Further study will determine the impact of bortezomib maintenance on recurrence.

Immune Mobilization of Autologous Peripheral Blood Progenitor Cells: IL-2 with GM-CSF and G-CSF Results in Effective Mobilization without Delay in Engraftment.

We initiated an immune mobilization trial in an attempt to mobilize cytotoxic effector cells, along with CD34+ hematopoietic progenitor cells. A Prospective Phase I trial was initiated using dose escalation of IL-2, in combination with GM-CSF and G-CSF. IL-2 began on Day 0 and continued as a daily SQ injection for 11 days. On Day 7, GM-CSF (7.5 mcg/kg/d) and G-CSF (5 mcg/kg/d) were initiated for 5 days (Days 7–11). On Day 11, leukapheresis was started if the peripheral blood CD34 + cell count was > 5 cells/mcl. The endpoint of collection was ≥ 3 × 106 CD34+ cells/kg. After collection, patients received melphalan (200 mg/m2) followed by infusion of cryopreserved stem cells. Post-transplant GM-CSF began on Day +5 and terminated once the ANC reached 5000 cells/mcl. To date, 9 patients have been treated (myeloma, n = 8; NHL, n = 1) and 7 patients are evaluable. Six patients received IL-2 at Dose Level 1 (6 × 105 IU/m2/d). The remaining 3 patients received IL-2 at Dose Level 2 (1 × 106 IU/m2/d). The MTD of IL-2 has not been reached. One patient (NHL) was removed from the study due to progressive disease. The remaining 8 patients completed the regimen. Toxicities have been mild and have included Grade 2 fever (n=1) on Dose Level 2. All patients were successfully mobilized. The median number of CD34+ cells/kg and MNC/kg collected were 3.4 × 106 (range 2.8 – 4.4 × 106/kg) and 9.5 × 108 (range 0.4 – 1.7 × 109), respectively. Two large volume leukaphereses were required (median; range 1 – 3). Following transplant, the ANC recovered on Day 13 (median; range: 10 – 14 d) and platelets recovered on Day 12 (median; range 0 – 13 d). These preliminary results demonstrate that immune mobilization and collection of an adequate number of hematopoietic progenitor cells is feasible without suppression of hematopoiesis. Toxicities are minimal but the MTD of IL-2 has not yet been reached. Post-transplant engraftment is not delayed. As patient accrual continues, we are currently evaluating the qualitative and quantitative components of the collected cells, including Th1 vs. Th2 cells and the types of dendritic cells mobilized.

AMD3100 with G-CSF for Autologous Peripheral Blood Progenitor Cell (PBPC) Mobilization in Non-Hodgkin's Lymphoma (NHL) and Multiple Myeloma (MM): Mobilization, Engraftment, and Pharmacokinetics (PK).

Background: AMD3100 potentiates the effect of G-CSF (Filgrastim) to mobilize hematopoietic PBPCs from the bone marrow into peripheral blood (PB) and may decrease the number of aphereses required to collect sufficient PBPCs for transplantation.Methods: Mobilization treatment consisted of subcutaneous G-CSF 10 ug/kg given in the morning on 5 consecutive days and a single dose of AMD3100 240 ug/kg in the evening of day 4, 10 – 11 hours prior to leukapheresis. These doses of G-CSF and AMD3100 were continued for up to 4 additional days in order to reach the target of ≥ 5 × 10^6 CD34+ cells/kg. Blood samples for FACS analysis of CD34+ cells were obtained immediately prior to dosing with AMD3100 and pre-apheresis the next morning. PK parameters were determined from samples obtained immediately prior to dosing, 0.25, 0.5, 1, 2, 4, 6 and 8 hours after the injection of AMD3100, and just prior to apheresis.Clinical Results: Nineteen pts have thus far been enrolled, 11 MM and 8 relapsed NHL. AMD3100 was well tolerated. Mobilization characteristics are summarized in table 1; 100% of MM pts and 63% of NHL pts reached the target of 5 × 10^6 CD34+ cells/kg; all collected > 2 ×10^6 CD34+ cells/kg. For apheresis day 1, AMD3100 increased absolute CD34+ counts ≥ 2-fold in 100% of pts; the median increase for MM pts was 3-fold (range: 2–7.7 fold) or an absolute increase of 108 CD34+ cells/uL (range: 40–166), whereas the median increase for NHL pts was 2.7-fold (range: 2.2–3.7 fold) or an absolute increase of 35.5 CD34+ cells/uL (range: 11–99). Among the relapsed NHL pts, who were characterized by lower pre-AMD3100 CD34+ counts, 4 had increase in PB CD34+ cells/ul from < 20 to > 20 and one other increased from 6 to 17. Of the 17 pts who have subsequently been transplanted; median time to engraftment of neutrophils >0.5 ×10^9/L and platelets >20 ×10^9/L was 11 and 18 days, respectively.PK Results: PK determinations for AMD3100 were completed in a subset of patients (4 MM; 3 NHL) using plasma samples obtained after the first dose. AMD3100 was rapidly absorbed following subcutaneous injection with a median tmax of 30 (range, 15–60) minutes and Cmax of 0.84 (range, 0.77–1.03) ug/ml. Plasma concentrations declined in a bi-exponential manner, with a median elimination half-life of 4.6 (range, 2.71–5.32) hours. The median AUC 0-infinity was 4410 (range, 2682–5165) ug-hr/ml. AMD3100 pharmacokinetics were consistent with results previously obtained in studies conducted using healthy volunteers in the absence of G-CSF.Conclusions:AMD3100 was generally safe and well tolerated in both groups.PK in the cancer patients was similar to that in previously studied healthy volunteers.AMD3100 increased PBPC mobilization following 4 days of G-CSF, and resulted in collecting large numbers of PBPCs in MM patients and facilitated adequate PBPC collections for poor mobilizers within the relapsed NHL group.Table 1:Mobilization characteristicsNo. of ptsNo. apheresis days (range)Median CD34+ cells collected (×10^6/kg)>2×10^6/kg collected on day 1>5×10^6/kg collected on day 1MM111 (1–2)13.1 (5.8–19.7)100%82%NHL82 (1–5)5.6 (2.8–10.6)88%50%All191 (1–5)9.0 (2.8–19.7)95%68%

Evaluation of Single-Dose Palifermin To Reduce Oral Mucositis (OM) in Fractionated Total Body Irradiation (fTBI) and High Dose (HD) Chemotherapy with Autologous Peripheral Blood Progenitor Cell (PBPC) Transplantation.

For some patients (pts) with hematologic malignancies (HM) undergoing PBPC transplantation, the approved regimen of 3 daily doses of palifermin 60 μg/kg prior to myeloablative conditioning therapy may be inconvenient. This study was initially developed to demonstrate the non-inferiority of various collapsed pre-conditioning dosing regimens (180 μg/kg) in reducing the incidence of severe OM (WHO grade 3 or 4) induced by fTBI and HD chemotherapy in pts with HM undergoing PBPC transplantation. The study was stopped early because of slower than expected accrual.Methods: Pts were 18 to 74 years old with HM, a Karnofsky performance score ≥70%, and eligible for fTBI (12 Gy) followed by optional VP-16 (60 mg/kg) and cyclophosphamide (100 mg/kg), and autologous PBPC support. Pts were randomized (1:1:1:1) to receive palifermin 60 μg/kg administered once daily for 3 days prior to the start of fTBI (Arm A) versus palifermin 180 μg/kg administered once only on day -1 (Arm B); day -2 (Arm C); or day -3 (Arm D) prior to the start of fTBI and stratified by VP-16 use and by the number of days of TBI fractions. All pts received palifermin 60 μg/kg for 3 days post transplant (days 0, 1, 2). Results are summarized as point estimates. Efficacy was analyzed for all evaluable patients as randomized; sensitivity analyses were done for all evaluable patients as treated.Results: Of the 47 pts randomized, 1 pt was excluded from analyses due to delayed informed consent. The primary efficacy endpoint, incidence of severe OM, is summarized in Table 1. The overall incidence of severe OM for all pts was 61% (28/46), with a mean duration (SD) of 4.3 days (4.4). Severe OM incidences were 82% (9/11) in Arm A and 54% (19/35) in the combined collapsed dose groups (Arms B+C+D). Severe OM rates were 60% (6/10), 31% (4/13), and 75% (9/12) in Arms B, C and D, respectively. A similar distribution of the incidence of severe OM was seen in the sensitivity analysis (Table 1). All arms had a similar incidence of adverse events.Conclusion: The overall incidence and duration of severe OM observed in this trial was consistent with the efficacy data of palifermin demonstrated in the pivotal randomized phase 3 trial (Spielberger et al, NEJM 351:10–17, 2004). The collapsed dosing regimen (180 μg/kg) was well tolerated, and the efficacy of palifermin in the collapsed dose arms is similar to Arm A, possibly allowing for increased patient and caregiver convenience. The small sample sizes limit the ability to compare the individual collapsed dose arms; however, the timing of palifermin collapsed dose administration may have an impact on the efficacy of OM reduction.Incidence of Severe OMAnalysis SubsetaArm AArm BArm CArm DPrimary9/11 (82%)6/10 (60%)4/13 (31%)9/12 (75%)Sensitivity7/10 (70%)8/11 (73%)5/13 (38%)8/12 (67%)aPrimary: Analyzed according to randomized treatment assignment. Sensitivity: Analyzed according to actual treamtent received

Polyclonal Long-Term MFGS-gp91phox Marking in Rhesus Macaques after Nonmyeloablative Transplantation with Transduced Autologous Peripheral Blood Progenitor Cells

We have recently reported that the RD114-pseudotyped MFGS-gp91phox vector achieves unprecedented levels of correction of the NADPH-oxidase gp91phox (approved gene symbol CYBB) defect in CD34+ cells from patients with X-linked chronic granulomatous disease in the NOD/SCID mouse model. Considering clinical use of this vector, we transplanted autologous mobilized peripheral blood CD34+ progenitor cells, transduced with the RD114-MFGS-gp91phox vector, into two healthy rhesus macaques following nonmyeloablative conditioning. The moderately high levels of in vivo marking seen in the first months following transduction decreased and stabilized at about 8 months posttransplant. Marking for both healthy animals after 15 months was 0.3 to 1.3 vector copies per 100 cells in lymphocytes, neutrophils, and monocytes. Vector insertion analyses performed by linear amplification-mediated PCR and sequencing identified 32 and 45 separate insertion sites in the animals. Identical insertion sites were found in myeloid cells and lymphocytes, demonstrating the successful transduction of lymphomyeloid progenitors. Some inserts landed in the vicinity of genes controlling cell cycle and proliferation. Statistical analyses of insertion sites 1 year posttransplant suggest a high diversity of insertion sites despite low marking.

Progenitor cell recruitment during individualized high‐flow, very‐large‐volume apheresis for autologous transplantation improves collection efficiency

Individual adaptation of processed patient's blood volume (PBV) should reduce number and/or duration of autologous peripheral blood progenitor cell (PBPC) collections. The durations of leukapheresis procedures were adapted by means of an interim analysis of harvested CD34+ cells to obtain the intended yield of CD34+ within as few and/or short as possible leukapheresis procedures. Absolute efficiency (AE; CD34+/kg body weight) and relative efficiency (RE; total CD34+ yield of single apheresis/total number of preapheresis CD34+) were calculated, assuming an intraapheresis recruitment if RE was greater than 1, and a yield prediction models for adults was generated. A total of 196 adults required a total of 266 PBPC collections. The median AE was 7.99 x 10(6), and the median RE was 1.76. The prediction model for AE showed a satisfactory predictive value for preapheresis CD34+ only. The prediction model for RE also showed a low predictive value (R2 = 0.36). Twenty-eight children underwent 44 PBPC collections. The median AE was 12.13 x 10(6), and the median RE was 1.62. Major complications comprised bleeding episodes related to central venous catheters (n = 4) and severe thrombocytopenia of less than 10 x 10(9) per L (n = 16). A CD34+ interim analysis is a suitable tool for individual adaptation of the duration of leukapheresis. During leukapheresis, a substantial recruitment of CD34+ was observed, resulting in a RE of greater than 1 in more than 75 percent of patients. The upper limit of processed PBV showing an intraapheresis CD34+ recruitment is higher than in a standard large-volume leukapheresis. Therefore, a reduction of individually needed PBPC collections by means of a further escalation of the processed PBV seems possible.

Efficacy of single‐dose pegfilgrastim after chemotherapy for the mobilization of autologous peripheral blood stem cells in patients with malignant lymphoma or multiple myeloma

A single injection of pegfilgrastim has been shown to be equivalent to daily filgrastim in enhancing neutrophil recovery after chemotherapy, whereas the experiences with pegfilgrastim in mobilization of peripheral blood progenitor cells (PBPCs) are limited. Forty unselected patients with lymphoma or multiple myeloma were treated with different chemotherapy regimens followed by 6 mg of pegfilgrastim for mobilization of autologous PBPCs. Patients with an inadequate mobilization (blood CD34+ cells <or= 10/microL after nadir) were given additional daily doses of 10 microg per kg unconjugated filgrastim. A median blood CD34+ peak concentration of 81 per microL (range, 10-565/microL) was found in 30 patients, who had only received pegfilgrastim, compared to 13 per microL (median, range 4-71/microL; p < 0.001) in 10 poor mobilizing patients with additional filgrastim. The median yield of CD34+ cells was 9.8 x 10(6) per kg (range, 1.5-88.1) after pegfilgrastim only versus 2.5 x 10(6) (range, 1.7-7.0) in poor mobilizers. Patients who needed additional cytokine administration were those with a more extensive previous antineoplastic treatment and mobilizing regimens containing PBPC toxic agents. The results confirm the efficacy and feasibility of PBPC mobilization with chemotherapy and single-dose pegfilgrastim in patients with lymphoproliferative malignacies. In less heavily pretreated patients, 6 mg of pegfilgrastim after chemotherapy induced an adequate mobilization, whereas dose and schedule in patients after numerous cytotoxic regimens need further investigation.

Single versus sequential high-dose chemotherapy (HDCT) in patients with relapsed or refractory germ-cell tumors (GCT)

4511 Background: Patients (pts) with relapsed or refractory GCT may be cured by HDCT. It is unknown whether single or sequential HDCT is superior. Methods: Between 11/99 and 11/04, 216 pts with relapsed or refractory GTC were treated in a prospective, randomized, multicenter phase III trial with either one cycle of cisplatin 100 mg/m2, etoposide 375 mg/m2 and ifosfamide 6 g/m2 (VIP) plus three cycles of high-dose carboplatin 1500 mg/m2 and etoposide 1500 mg/m2 (CE, arm A) or three cycles of VIP plus one cycle of high-dose carboplatin 2200 mg/m2, etoposide 1800 mg/m2 and cyclophosphamide 6400 mg/m2 (CEC, arm B) followed by reinfusion of autologous peripheral blood progenitor cells. Primary study endpoint was the event-free survival (EFS) one year after randomization. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and toxicities. An event was defined as any deviation from the planned treatment, relapse, progression or death from any cause. The planned study size was 230 pts to detect a difference of 15% with an alpha error of 5% and a power of 80%. Results: The study was stopped after recruitment of 216 pts due to excess treatment-related mortality in arm B: 111 pts were randomized in arm A and 105 pts in arm B. Due to non-GCT histologies at review 5/216 pts had to be excluded from further analysis. With a median follow-up of 36 months, 109/211 (52%) evaluable pts are still alive and 91/211 (43%) are progression-free. At one year EFS; PFS and OS are 40%, 55% and 80% in arm A as compared to 37%, 49% and 61% in arm B. Treatment-related deaths mainly due to sepsis and cardiac toxicity were less frequent in arm A (4/111 pts, 4%) as compared to arm B (15/105 pts, 14%) (p = 0.01). Severe non-hematologic organ toxicities were also less frequent in arm A. Conclusions: Treatment with sequential high-dose carboplatin and etoposide is at least as effective but less toxic than single HDCT with carboplatin, etoposide and cyclophosphamide. No significant financial relationships to disclose.

The effect of hematopoietic progenitor cells’ temperature on cardiac arrhythmias in patients given peripheral blood progenitor cells

Background Infusion of cryopreserved and non-cryopreserved hematopoietic progenitor cells (HPC) is associated with a broad variety of symptoms. In this study, we have investigated infusion-related toxicity regarding temperature of cryopreserved autologous peripheral blood progenitor cells (PBPCs) transplanted in 31 and allogeneic non-cryopreserved PBPCs in 4 patients receiving high dose chemotherapy and stem cells transplantation for hematological malignancies. Study design and method A 24 h ECG-Holter recording system was used to obtain cardiac arrhythmias. Two milliliters HPC were collected from entrance site of venous access to evaluate the temperature of infused HPC. Results We have detected arrhythmias in 17 (48.58%) of our patients before, during and after infusion. Median temperature of the infusat was 21 °C (18–28.2). Arrhythmias during infusion were detected in 8 (22.85%) patients. The temperatures of infused HPCs were not statistically different in group with and without arrhythmias as 22 °C and 21 °C, respectively ( P > 0.05). And also, volume, contents [dimethylsulphoxide (DMSO), red blood cells (RBC), platelet (PLT), and total nucleated cell (TNC)] of product, and rate of infusion speed did not have any effect on arrhythmias. Conclusion As a result of this study, we have concluded that the temperature of HPC does not cause any systemic hypothermia and does not have any relation to arrhythmias detected during infusion.

Fixed‐dose single agent pegfilgrastim for peripheral blood progenitor cell mobilisation in patients with multiple myeloma

High-dose chemotherapy and autologous peripheral blood progenitor cell transplantation is an effective treatment for multiple myeloma. Progenitor cells are generally mobilised into the peripheral blood by administration of filgrastim. Pegfilgrastim is a covalent conjugate of filgrastim with a longer half-life. The results of a phase II study of pegfilgrastim, administered as a single injection to mobilise autologous peripheral blood progenitor cells in patients with multiple myeloma, is reported. All patients (n = 19) received 12 mg of pegfilgrastim. Leukaphaeresis was started when the peripheral blood CD34(+) count was >0.015 x 10(9)/l. Daily, leukaphaeresis was performed until the target progenitor cell dose was obtained. The median number of leukaphaeresis procedures required to collect the target CD34(+) cell dose was 2 (range 1-5). A median of 8.4 x 10(6) CD34(+) cells/kg (range 4.1-15.8) was collected. The most common toxicity was bone pain/myalgia. Sustained haematological recovery occurred in all the patients who underwent high-dose chemotherapy followed by autologous peripheral blood progenitor cell transplantation with pegfilgrastim-mobilised cells. A single fixed dose of pegfilgrastim was effective in mobilising adequate peripheral blood progenitor cells in patients with multiple myeloma. The efficacy and toxicity profile was similar to that described with filgrastim treatment.

A randomized phase III comparative trial of immediate consolidation with high-dose chemotherapy and autologous peripheral blood progenitor cell support compared to observation with delayed consolidation in women with metastatic breast cancer and only bone metastases following intensive induction chemotherapy

The prognosis for patients with metastatic breast cancer remains poor. Metastatic breast cancer confined to the bones may have a better prognosis, especially hormone receptor-positive disease. We performed a prospective, randomized clinical trial to compare immediate consolidation with high-dose chemotherapy and hematopoietic support versus observation with high-dose consolidation at the time of disease progression in women with metastatic breast cancer and only bone metastases. The patients received chemotherapy with doxorubicin, 5-fluorouracil and methotrexate before randomization. In all, 85 patients were enrolled and 69 were randomized. The median follow-up is 8.1 years from randomization. The median event-free survival (EFS) for the immediate transplant arm is 12 months and for the observation arm is 4.3 months (P<0.0001). The median overall survival for the immediate transplant arm is 2.97 years and for the observation arm 1.81 years, a difference that is not statistically significant. Immediate high-dose chemotherapy and radiation therapy as consolidation offers a clinically and statistically significant improvement in EFS compared with radiation therapy alone following induction chemotherapy for women with metastatic breast cancer confined to the bones.

Pegfilgrastim compared with Filgrastim after autologous hematopoietic peripheral blood stem cell transplantation

In order to assess the effect of Pegfilgrastim on the duration of neutropenia and clinical outcome of patients after autologous peripheral blood stem cell (PBSC) transplantation, we compared 20 consecutive patients with lymphoma or multiple myeloma receiving a single 6-mg dose of Pegfilgrastim on day 1 posttransplant to an historical control group of 60 patients receiving daily Filgrastim 5 microg/kg starting on day 1 posttransplant. The duration of neutropenia was similar in the Pegfilgrastim group compared with the control group. There were no differences in time to neutrophil, erythroid, or platelet engraftment nor in the incidence of fever and infections. The duration of antibiotic therapy, transfusion support, and time to hospital discharge were similar in the two groups. However, after initial hematopoietic reconstitution, we observed significantly higher values of lymphocytes (e.g., 1,660+/-1,000 versus 970+/-460 on day 80, p=0.0002), neutrophils (e.g., 3,880+/-2,030 versus 2,420+/-1,500 on day 25, p=0.0004), reticulocytes (e.g., 148,160+/-90,590 versus 87,140+/-65,920 on day 25, p<0.0001), and platelets (e.g., 210,700+/-116,090 versus 150,240+/-58,230 on day 55, p=0.0052) up to day 100 in the Pegfilgrastim group compared with the Filgrastim group. These observations had no impact on clinical outcome of the patients after day 30 due to the low incidence of infectious events after engraftment in autologous PBSC transplantation. We conclude that the effect of Pegfilgrastim administrated on day 1 posttransplant is comparable to that of daily Filgrastim on initial hematopoietic reconstitution. The possibly superior effect of Pegfilgrastim on cell counts we observed after initial engraftment should be further tested in a prospective randomized trial.

Long-Term Follow-Up of Patients with Breast Cancer Transplanted with AutologousEx VivoExpanded Peripheral Blood Progenitor Cells

Ex vivo expanded peripheral blood progenitor cells (PBPC) have been shown to provide rapid neutrophil engraftment, and in some patients, to eliminate neutropenia after transplantation to support high-dose chemotherapy. However, the effect of expansion culture on stem cell content and potential loss of stem cells caused by induction of differentiation remains a concern. We have transplanted 21 patients with breast cancer with expanded autologous PBPC, with 11 patients receiving expanded PBPC as their sole hematopoietic cell source. In these studies, the CD34+ cells were selected and cultured for 10 days in defined media containing 100 ng/mL each of recombinant human stem cell factor (rhSCF), recombinant human granulocyte colony stimulating factor (rhG-CSF), and recombinant human megakaryocyte growth and developmental factor (rhMGDF) in 1-liter Teflon bags at 20,000 to 50,000 cells/mL. After culture the cells were washed and reinfused after high-dose chemotherapy followed by daily administration of rhG-CSF. Engraftment of neutrophils (absolute neutrophil count [ANC] > 500/µL) occurred in a median of 8 days (range, 4 to 16), with 7 patients engrafting neutrophils in 8 days or less. Of the 11 patients transplanted with only expanded cells, 9 remained alive at more than 24 months, and all had durable engraftment; neutrophil and platelet levels remained stable. At 5 years posttransplant 7 of 11 (64%) patients are alive with no evidence of disease, 2 of 11 (18%) patients have relapsed, and 2 of 11 (18%) patients have died as a result of progressive disease. Late graft failure did not occur in any patients. Because the chemotherapy regimens were myeloablative but may not be stem cell ablative, it is possible that the long-term cell production in these patients resulted from endogenous recovery of stem cells. This study suggests that it is feasible to transplant patients with ex vivo expanded PBPC as the sole autologous hematopoietic support. The expanded products provide (1) rapid neutrophil engraftment, (2) sufficient progenitor cells to bridge the time until stem cells repopulate the hematopoietic system, and (3) possibly sufficient stem cells to enable long-term cell production.

In Vitro Culture During Retroviral Transduction Improves Thymic Repopulation and Output After Total Body Irradiation and Autologous Peripheral Blood Progenitor Cell Transplantation in Rhesus Macaques

Immunodeficiency after peripheral blood progenitor cell (PBPC) transplantation may be influenced by graft composition, underlying disease, and/or pre-treatment. These factors are difficult to study independently in humans. Ex vivo culture and genetic manipulation of PBPC grafts may also affect immune reconstitution, with relevance to gene therapy applications. We directly compared the effects of three clinically relevant autologous graft compositions on immune reconstitution after myeloblative total body irradiation in rhesus macaques, the first time these studies have been performed in a large animal model with direct clinical relevance. Animals received CD34(+) cell dose-matched grafts of either peripheral blood mononuclear cells, purified CD34(+) PBPCs, or purified CD34(+) PBPCs expanded in vitro and retrovirally transduced. We evaluated the reconstitution of T, B, natural killer, dendritic cells, and monocytes in blood and lymph nodes for up to 1 year post-transplantation. Animals receiving selected-transduced CD34(+) cells had the fastest recovery of T-cell numbers, along with the highest T-cell-receptor gene rearrangement excision circles levels, the fewest proliferating Ki-67(+) T-cells in the blood, and the best-preserved thymic architecture. Selected-transduced CD34(+) cells may therefore repopulate the thymus more efficiently and promote a higher output of naïve T-cells. These results have implications for the design of gene therapy trials, as well as for the use of expanded PBPCs for improved T-cell immune reconstitution after transplantation.

The role of the nurse practitioner caring for blood marrow transplant patients in the after hours oncology clinic

Purpose: Caring for bone marrow transplant (BMT) patients in an outpatient clinical setting is very challenging. The patients are usually very sick with multiple complaints that require frequent and timely interventions. Over the years the treatment of BMT patients has changed. One major change, the Autologous Peripheral Blood Progenitor Cell Transplant, has gone from being a hospital procedure, to a common outpatient clinic procedure. This has created a need to extend the Ambulatory Clinic hours to accommodate the growing patient population.

Cryopreserving Human Peripheral Blood Progenitor Cells

High-dose chemotherapy followed by autologous peripheral blood progenitor cell (PBPC) transplantation is used in the treatment of chemosensitive malignancies. Cryopreservation of PBPC in 10% dimethyl sulfoxide (DMSO) has been the standard procedure in most institutions. Infusion of PBPC cryopreserved with DMSO can be associated with toxic reactions such as vomiting, cardiac dysfunction, anaphylaxia and acute renal failure. The grade of toxicity experienced by patients is related to the amount of DMSO present in the PBPC. Cryopreservation with lower DMSO concentrations would be expected to reduce the toxicity. In recent studies done with PBPC cells cryopreserved with 5%, 4% and 2% DMSO, using 10% DMSO as a reference control, CD34+ cells were investigated for preservation of viability, apoptosis, and necrosis. Also preservation of mature colony-forming (CFU) cells, specifically mature myeloid, erythroid progenitors, CFU-megakaryocytes and long-term culture-initiating cells (LTC-ICs) were investigated, using 5% and 10% DMSO as cryoprotectant. All samples were frozen in a rate-controlled programmed freezer and stored in the vapor phase of liquid nitrogen until used. 5% DMSO is the optimal concentration for cryopreserving human PBPC in vitro. Consequently, some hospitals have started using 5% DMSO as cryoprotectant for the autologous PBPC as a standard procedure.

Gonadotropin‐releasing hormone analogues added to adjuvant chemotherapy protect ovarian function and improve clinical outcomes in young women with early breast carcinoma

The objective of the current study was a retrospective evaluation of 100 consecutive premenopausal women with high-risk, early breast carcinoma who received a gonadotropin-releasing hormone (Gn-RH) analogue as ovarian protection during adjuvant chemotherapy. After surgery, patients received a Gn-RH analogue and adjuvant chemotherapy, which was tailored to their peculiar biologic features. The median patient age was 43 years (range, 27-50 yrs). Fifty-two women had positive estrogen receptor (ER) status, and 48 women had negative ER status. There were 64 women with Stage II breast carcinoma and 36 women with UICC Stage III breast carcinoma. All patients had their serum estradiol suppressed to values<40 pg/mL. The chemotherapy regimens administered included cyclophosphamide, methotrexate, and 5-fluorouracil (n=26 patients) and anthracycline-based regimens (n=74 patients, including 9 patients who had >10 positive axillary lymph nodes, who also received high-dose chemotherapy with autologous peripheral blood progenitor cell transplantation). Patients with positive c-erb-2 status also received a taxane. Eighty patients received radiation therapy. During therapy with the Gn-RH analogue, patients who had a positive ER status after chemotherapy received an aromatase inhibitor. After a median follow-up of 75 months, normal menses were resumed by all patients younger than age 40 years and by 56% of patients older than age 40 years. Three pregnancies were observed that resulted in two normal deliveries and one voluntary abortion. The projected recurrence-free survival rates at 5 years and 10 years were 84% and 76%, respectively; and the projected overall survival rates at 5 years and 10 years were 96% and 91%, respectively. The current data showed that, in premenopausal women with early breast carcinoma, the addition of a Gn-RH analogue to adjuvant therapy and temporary total estrogen suppression in patients with ER-positive disease was tolerated well, protected long-term ovarian function, and appeared to improve the expected clinical outcome.