Granulocyte Colony-stimulating Factor Exposure Research Articles

Single Apheresis Session on the 4th Day of Granulocyte Colony-Stimulating Factor Administration Seems Convenient to Collect Enough Peripheral Blood Stem Cells from Healthy Donors

Background: To minimize adverse events of peripheral blood stem cell (PBSC) collection in healthy donors, it is reasonable to limit the total dose of granulocyte colony-stimulating factor (G-CSF) and/or the number of apheresis days without decreasing of PBSCs yield. Therefore, we have started to collect G-CSF induced PBSCs on day 4 instead of on day 5. So, we retrospectively aimed to investigate the results of this 4-day G-CSF administration. Study Design and Methods: Seventy-six healthy donors who performed on G-CSF induced PBSCs donation consecutively between January 2020 and July 2022 were included in this study. G-CSF (filgrastim) at 2 × 5 µg/kg/day subcutaneously was applied. Apheresis started on day 4. Results: Sixty-nine (90.8%) of 76 donors provided enough PBSCs on day 4 apheresis session. Younger age (p = 0.004), higher PB CD34+ cell count on the 4th day of G-CSF (p < 0.001), and male donor (p = 0.010) were correlated with increased amounts of PBSCs yield. Univariate and multivariate logistic regression analyses to predict very good mobilizers (collected PBSCs ≥8 × 106/kg after the first apheresis) were performed. In multivariate logistic regression analyses, male sex (p = 0.004), PB CD34+ cell count ≥100/µL on the 4th day of G-CSF (p < 0.001), and glomerular filtration rate ≥115 mL/min (p = 0.031) were found to be independent predicting factors to demonstrate very good mobilizer. Conclusion: It seems that starting the apheresis on the 4th day of G-CSF administration is effective and to provide minimal G-CSF exposure in healthy donors.

Is an earlier strategy for harvesting peripheral blood stem cells in healthy allogeneic donors feasible?

IntroductionPeripheral blood stem cells (PBSC) mobilization with granulocyte colony stimulating factor (G-CSF) for healthy donors is generally performed at 5th day. However, earlier collection is sometimes feasible, raising the question of whether to initiate apheresis early to limit further G-CSF exposure, while considering the risk of mobilization failure. In the current study, we examined the factors predicting successful 4th day collection and developed a model that can be used practically. Patients and methodsThe study was carried out by obtaining the data of PBSC mobilizations performed between January 2009 and September 2022 in our transplantation center. ResultsA total of 141 healthy donors with a median donor age of 32 (18–64) were included. Adequate mobilization was achieved in 115 (81.6 %) patients. Median peripheral CD34 + cell count was 69.4/μL in the adequate mobilization group and 46/μL in the mobilization failure group (p < 0001). Multivariate analysis revealed that donor/recipient weight ratio and the 4th day peripheral CD34 + cell count≥ 50/μL were independent markers for 4th day collection success. A predictive model of our center including these parameters was available with 0.765 sensitivity and 0.968 specificity [(AUC):0.948 (95 % CI, 0.90–0.99), p < 0.001]. ConclusionThe result of the current study shows that peripheral 4th day collection can be performed in selected donors, taking into account peripheral CD34+ cell count and donor/recipient weight ratio. In addition, using these indicators, new predictive models can be created that may assist clinicians in daily practice.

Abstract 6327: Impact of G-CSF on safety and efficacy of CAR T-cell therapy in non-Hodgkin lymphoma

Abstract Introduction: Chimeric antigen receptor T-cell (CAR-T) therapy is an established treatment modality for the management of refractory and/or relapsed non-Hodgkin lymphoma (NHL). Despite restrictions on granulocyte colony-stimulating factor (G-CSF) use in registration clinical trials due to potential worsening of cytokine release syndrome (CRS), G-CSF is often prescribed for neutrophil recovery post-CAR-T in clinical practice. We conducted a retrospective study to assess the association between G-CSF use and the safety and efficacy of CAR-T. Methods: Following Institutional Review Board approval, we retrospectively analyzed NHL patients receiving commercial CD19-targeted CAR-T across Mayo Clinic sites (Arizona, Florida, and Minnesota) between October 2017 and May 2023. Demographics, labs, and post CAR-T events were collected. Electronic medical records were reviewed for G-CSF exposure within Day 1 - 100 post-CAR T. Differences by G-CSF status were examined using a Chi-square test and Kruskal Wallis tests. Hazard ratios (HR) and 95% confidence intervals (CI) for overall survival (OS) were calculated using Cox model. Results: Among 270 CAR-T patients; 106 received G-CSF within 30 days and 164 did not. Median age was 56.9 with G-CSF and 58.3 without G-CSF. Most were male (75.2% G-CSF, 62.6% no G-CSF). Diffuse large B cell lymphoma was the predominant NHL subtype (67.0% G-CSF, 65.2% no G-CSF). G-CSF within 30 days was not associated with reduced incidence of neutropenic fever (11.7% G-CSF vs 9.9% no G-CSF, p = 0.6593) or documented infection (22.1% vs 18.3%, p = 0.4439). G-CSF correlated with decreased profound neutropenia duration (ANC &amp;lt; 100 μL, 0 vs 2 days, p &amp;lt; 0.0001) and incidence within 30 days ( 31.7% vs 60.4%, p &amp;lt; 0.0001) as well as incidence of protracted profound neutropenia (&amp;gt; 7 days, 3.8% vs 22.8%, p &amp;lt; 0.0001). G-CSF was associated with a higher incidence of cytopenias between days 30 -100: severe neutropenia (ANC &amp;lt; 500/uL, 28.8% vs 15.2%, p = 0.0075), severe anemia (Hb &amp;lt; 8 g/dL, 21% vs 9.7%, p = 0.0114), and severe thrombocytopenia (Plt &amp;lt; 50 g/L, 35.2% vs 20.9%, p = 0.0099). Logistic regression analysis showed that none of the examined covariates, including prior autologous stem cell transplant, ECOG PS score, and receipt of bridging therapy, were associated with severe neutropenia likelihood. G-CSF was associated with a higher CRS incidence (89.6% vs 79.9%, p = 0.0343), but grade 3 CRS or higher (4.7% vs 3.7%, p = 0.6675) was no different. No difference in complete response rates (66% vs 61.1%, p = 0.4707) or 2-year OS (p = 0.523) was observed between the 2 groups. Conclusion: G-CSF within 30 days was associated with reduced duration and incidence of profound neutropenia without a significant impact on incidence of neutropenic fever or documented infections. There was a signal of association between G-CSF and increased incidence of low-grade CRS and delayed cytopenias (day 30-100) that warrants confirmation in larger studies. Citation Format: Lay She Ng, Claire I. Yee, Radhika Bansal, Mohamed A. Kharfan-Dabaja, Grzegorz S. Nowakowski, Allison C. Rosenthal, Javier Munoz, Januario Castro, Wern Lynn Ng, Hemant S. Murthy, Yi Lin, Matthew R. Buras, Madiha Iqbal, Yucai Wang, Talal Hilal. Impact of G-CSF on safety and efficacy of CAR T-cell therapy in non-Hodgkin lymphoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6327.

Granulocyte-colony stimulating factor does not prevent in vitro cisplatin-induced germ cell reduction in immature human and mouse testis

BackgroundCurrently there are no established fertility preservation options for pre-pubertal boys facing cancer treatment. Granulocyte-colony stimulating factor (G-CSF) treatment has been proposed to be chemoprotective against spermatogonial cell loss in an alkylating chemotherapy model of busulfan treated adult mice. Having previously shown that exposure to the alkylating-like chemotherapy cisplatin resulted in a reduction in germ cell numbers in immature human testicular tissues, we here investigate whether G-CSF would prevent cisplatin-induced germ cell loss in immature human and mouse (fetal and pre-pubertal) testicular tissues.MethodsOrganotypic in vitro culture systems were utilised to determine the effects of clinically-relevant concentrations of G-CSF in cisplatin-exposed immature testicular tissues. Human fetal (n = 14 fetuses) and mouse pre-pubertal (n = 4 litters) testicular tissue pieces were cultured and exposed to cisplatin or vehicle control for 24 hrs and analysed at 72 and 240 hrs post-exposure. Combined G-CSF and cisplatin exposure groups explored varying concentrations and duration of G-CSF supplementation to the culture medium (including groups receiving G-CSF before, during and after cisplatin exposure). In addition, effects of G-CSF supplementation alone were investigated. Survival of total germ cell and sub-populations were identified by expression of AP2γ and MAGE-A4 for human gonocytes and (pre)spermatogonia, respectively, and MVH and PLZF, for mouse germ cells and putative spermatogonial stem cells (SSCs) respectively, were quantified.ResultsExposure to cisplatin resulted in a reduced germ cell number in human fetal and mouse pre-pubertal testicular tissues at 240 hrs post-exposure. Germ cell number was not preserved by combined exposure with G-CSF using any of the exposure regimens (prior to, during or after cisplatin exposure). Continuous supplementation with G-CSF alone for 14 days did not change the germ cell composition in either human or mouse immature testicular tissues.ConclusionsThis study demonstrates that exposure to G-CSF does not prevent cisplatin-induced germ cell loss in immature human and mouse testicular tissues in an in vitro system.

Identification of cancer chemotherapy regimens and patient cohorts in administrative claims: challenges, opportunities, and a proposed algorithm

BackgroundReal-world evidence is a valuable source of information in healthcare. This study describes the challenges and successes during algorithm development to identify cancer cohorts and multi-agent chemotherapy regimens from claims data to perform a comparative effectiveness analysis of granulocyte colony stimulating factor (G-CSF) use.MethodsUsing the Biologics and Biosimilars Collective Intelligence Consortium’s Distributed Research Network, we iteratively developed and tested a de novo algorithm to accurately identify patients by cancer diagnosis, then extract chemotherapy and G-CSF administrations for a retrospective study of prophylactic G-CSF.ResultsAfter identifying patients with cancer and subsequent chemotherapy exposures, we observed only 12% of patients with cancer received chemotherapy, which is fewer than expected based on prior analyses. Therefore, we reversed the initial inclusion criteria to identify chemotherapy receipt, then prior cancer diagnosis, which increased the number of patients from 2,814 to 3,645, or 68% of patients receiving chemotherapy had diagnoses of interest. Additionally, we excluded patients with cancer diagnoses that differed from those of interest in the 183 days before the index date of G-CSF receipt, including early-stage cancers without G-CSF or chemotherapy exposure. By removing this criterion, we retained 77 patients who were previously excluded. Finally, we incorporated a 5-day window to identify all chemotherapy drugs administered (excluding oral prednisone and methotrexate, as these medications may be used for other non-malignant conditions) as patients may fill oral prescriptions days to weeks prior to infusion. This increased the number of patients with chemotherapy exposures of interest to 6,010. The final cohort of included patients, based on G-CSF exposure, increased from 420 from the initial algorithm to 886 using the final algorithm.ConclusionsMedications used for multiple indications, sensitivity and specificity of administrative codes, and relative timing of medication exposure must all be evaluated to identify patient cohorts receiving chemotherapy from claims data.

Abstract P063: Risk factors beyond chemotherapy exposure for therapy-related myelodysplastic syndrome (tMDS) and Acute Myeloid Leukemia (tAML) development in lymphoma survivors: a 15-year SEER-Medicare analysis

Abstract Therapy-related Myeloid Neoplasms (tMNs) constitute 10-20% of newly diagnosed myeloid neoplasms and carry poor prognosis. tMNs develop in a small percentage of patients who receive chemoradiotherapy (CRT), thereby suggesting role of additional factors that may facilitate leukemic transformation. Clonal hematopoiesis (CH) represents a precursor state to overt myeloid neoplasm. CH surviving CRT/genotoxic stress may give rise to tMNs. Do factors beyond CRT aid in the clonal evolution and facilitate leukemia development? We hypothesized that CH-associated comorbidities (cardiovascular disease, infections, autoimmunity etc.) may facilitate CH’s evolution to tMN, beyond CRT. A population-based retrospective cohort study was conducted using cancer registries from the Surveillance, Epidemiology, and End Results (SEER) Program and Medicare claims database. Descriptive analyses included adults aged 66-84 who were diagnosed with first primary lymphoma (Diffuse Large B-Cell Lymphoma; DLBCL and Follicular Lymphoma; FL) during 2000 to 2014 (followed up through 2015), and survived at least 1 year, as reported to SEER. Chi-square tests were used to examine associations between comorbidity of interest/potential risk factors and tMDS/AML. Factors associated with tMDS/AML were then included in the multivariable logistic regression model with significance set at p&amp;lt;0.05. Among the 33,520 lymphoma patients (pts), 293 tMDS/AML cases were identified. tMDS/AML occurred more often after initial chemotherapy vs none (DLBCL-Odds Ratio; OR=1.87 95% CI=1.23-2.83; FL-OR=2.15 95% CI=1.29-3.61). Prior history of autoimmune conditions significantly increased the risk of subsequent tMDS/AML (DLBCL-OR=2.10 95% CI=1.51-2.91; FL-OR=3.46 95% CI=2.30-5.20). Though infection was not directly associated with increased risk, methods of infection prophylaxis often used in treatment of lymphomas, i.e., use of granulocyte colony-stimulating factor (GCSF) significantly increased the risk of subsequent tMDS/AML (DLBCL-OR=2.94 95% CI=2.03-4.26; FL-OR=3.97 95% CI=2.51-6.28). No other comorbidities of interest (hypertension, dyslipidemia, diabetes etc.) were associated with increased risk of subsequent tMDS/AML. Findings in our study suggest role of other mediators/selection pressures in clonal evolution/leukemic transformation of CH after CRT exposure. These factors include immunosuppressed state (as therapy for autoimmunity) and GCSF exposure, with former conceivably leading to clonal expansion via immune escape and latter via direct stimulation and clonal expansion. The findings warrant reconsideration and modifications to common clinical practices such as the use of GCSF during lymphoma treatment as primary prophylaxis to limit neutropenia. In addition, future research efforts should focus on replicating these findings at molecular level and designing CH screening strategies in pts with autoimmune conditions and those who receive GCSF. This knowledge may inform future clinical practice to avoid exposure in pts with underlying CH and thereby prevent future myeloid malignancy development. Citation Format: Abhay Singh, Megan M. Herr, Theresa E. Hahn, Swapna Thota. Risk factors beyond chemotherapy exposure for therapy-related myelodysplastic syndrome (tMDS) and Acute Myeloid Leukemia (tAML) development in lymphoma survivors: a 15-year SEER-Medicare analysis. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P063.

Effect of granulocyte colony-stimulating factor on toxicities after CAR T cell therapy for lymphoma and myeloma

Chimeric antigen receptor T cells (CAR T) are groundbreaking therapies but may cause significant toxicities including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and cytopenias. Granulocyte colony-stimulating factor (G-CSF) is often used to mitigate neutropenia after CAR T, but there is no consensus recommended strategy due to hypothesized, but largely unknown risks of exacerbating toxicities. To investigate the impact of G-CSF, we retrospectively analyzed 197 patients treated with anti-CD19 CAR T for lymphoma and 47 patients treated with anti-BCMA CAR T for multiple myeloma. In lymphoma, 140 patients (71%) received prophylactic G-CSF before CAR T (mostly pegylated G-CSF) and were compared with 57 patients (29%) treated with G-CSF after CAR T or not exposed. Prophylactic G-CSF was associated with faster neutrophil recovery (3 vs. 4 days, P < 0.01) but did not reduce recurrent neutropenia later. Prophylactic G-CSF was associated with increased grade ≥2 CRS (HR 2.15, 95% CI 1.11–4.18, P = 0.02), but not ICANS. In multiple myeloma, prophylactic G-CSF was not used; patients were stratified by early G-CSF exposure (≤2 days vs. ≥3 days after CAR T or no exposure), with no significant difference in toxicities. Future trials should clarify the optimal G-CSF strategy to improve outcomes after CAR T.

Headache in bone marrow donors and oncohematological patients, who taking granulocyte colony-stimulating factor: incidence and clinical features

The aim of the study was to assess the incidence and clinical features of headache associated with the use of granulocyte colony-stimulating factor (G-CSF) for stem cell mobilization or neutropenia treatment among oncohematological patients and bone marrow donors.Material and methods. A prospective observational uncontrolled study included 39 participants: 20 bone marrow donors (group 1) and 19 oncohematological patients (group 2). We evaluated the incidence and clinical features of headache after subcutaneous administration of G-CSF (filgrastim) at doses of 5 to 10 μg/kg for 2 to 5 days.Results. Headache occurred in bone marrow donors more often compared to patients with hematological malignancies (78.9% vs 35.0%; p = 0.006). There were no significant differences in the time of headache onset, its duration, intensity, features, and localization between two groups. Gender, age, dose of G-CSF, and duration of its use were not associated with headache development in both groups.Conclusion. Headache occurs more often in bone marrow donors than in patients with hematological malignancies. The phenotype of headache associated with G-CSF exposure is not drug-specific and requires further studies on its semiotics.

Optimal timing of apheresis for the efficient mobilization of peripheral blood progenitor cells recruited by high-dose granulocyte colony-stimulating factor in healthy donors

Predictors of peripheral blood stem cell (PBSC) yield can potentially improve the comfort, safety, and efficacy of CD34+ cell collection from donors treated with recombinant human granulocyte colony-stimulating factor (G-CSF). We investigated 181 apheresis procedures on 109 healthy allogeneic donors to identify factors correlating with efficient PBSC collection. Apheresis started on Day 4 or 5 and continued up to Day 6 of G-CSF administration. CD34+ cell yields on Days 4 and 5 were comparable, and significantly higher than on Day 6. This suggests that starting apheresis on Day 4 rather than Day 5 may be preferable, to reduce G-CSF exposure and optimize yield, even if multi-day collection is required. More CD34+ cells were collected from male and cytomegalovirus (CMV)-seronegative donors than from female and CMV-seropositive donors, respectively. The yields of CD34+ cells were similarly high in both male and female donors aged 20–29 years; yields decreased in female donors in their thirties, and were comparably low in both male and female donors in their forties and thereafter. These findings should guide decision-making about when to begin apheresis, and encourage careful consideration of donor factors such as gender, age, and CMV serostatus when collecting PBSCs.

Donor Lymphocyte Infusion from G-CSF-Primed, Unmanipulated Whole Blood Is Safe and Improves Chimerism in HLA-Matched and Haploidentical Transplantation

Introduction: Donor lymphocyte infusion (DLI) is a useful therapy for mixed chimerism (MC) or measurable residual disease (MRD) after allogeneic hematopoietic cell transplantation (HSCT) in patients with malignancies, while it is less effective for overt relapse and is limited by graft-versus-host disease (GVHD). Multiple DLI products can be obtained from a single leukoapheresis without granulocyte-colony-stimulating factor (G-CSF) priming, while cryopreserving surplus is an alternative for peripheral blood grafts. The ideal DLI CD3+ cell dose remains undefined ranging from 1-500x106/kg. However, leukoapheresis and cryopreservation are not risk-free, they are expensive and their costs prohibitive for many patients in developing countries. Furthermore, T-cell doses present in standard whole blood units can reach ≥1x106/kg in healthy donors which can be further increased after G-CSF exposure. For these reasons we have used G-CSF-primed whole blood units (WB-DLI) in HLA-matched and haploidentical (Haplo) transplant recipients and report our single-center experience.Methods: Patients ≥16 years of age who received WB-DLI at any time after HLA-matched related or Haplo peripheral blood HSCT due to relapse, MRD, MC or poor graft function were included from 2016-2018. Donors were stimulated with filgrastim 5 μg/kg every 24 hours for 3 days prior to donation. Standard pre-transfusion testing included major/minor crossmatch and flow cytometry analysis for lymphocyte subset quantification. The blood draw was performed on day 4 with the aim to collect 450 mL of whole blood in a standard collection bag. For patients with major and bidirectional ABO mismatch who had not undergone group switch or had a mixed population in solid-phase typing, a reactive major crossmatch was considered an absolute contraindication, while a reactive minor crossmatch was not. WB-DLI was infused fresh on the day of collection without manipulation in an outpatient basis. For relapsed patients, concurrent chemotherapy was administered on a case-by-case basis. Disease evaluation after relapse was performed on day +30 after treatment, while chimerism analysis was performed on day +60 through standard methods. GVHD prophylaxis was performed with oral cyclosporine A or tacrolimus and gradually tapered in a 60-day window.Results: Fourteen patients received a single dose of WB-DLI, median age was 32 years (16-67), 50% were female. Most common diagnoses were acute lymphoblastic leukemia, (n=5) and acute myeloid leukemia (n=5), followed by myelodysplastic syndrome (n=2), non-Hodgkin lymphoma (n=1) and chronic myeloid leukemia (n=1). Nine patients received Haplo grafts, while 5 were HLA-matched. Three patients had previous GVHD inactive at the time of WB-DLI. Indication for WB-DLI was relapse for 6 patients, 3 had MRD while 5 remained in remission; one patient received WB-DLI due to poor graft function. Median chimerism at the time of WB-DLI was 72% (range 38-100%). A single infusion was administered in all cases. Median mononuclear cell count obtained was 32x10x6/kg (range, 9-74), while median CD3+ cell count was 6.7x106/Kg (range 5.2-19). No immediate, severe adverse effects were observed. Febrile non-hemolytic transfusion reaction was documented in 4 cases after completing the procedure. No complications were observed in n=4 ABO mismatch cases including (n=2) major and bidirectional patients. Overall 50% of patients responded. Chimerism was improved in 50%, with a median increase of 28% (range 9-53%). Median post-DLI chimerism was 92.5% (range 20-100). Regarding patients treated for relapse or MRD, 3/9 patients responded (33%). Overall 8/14 patients eventually relapsed (57%) with a 12-month progression free survival of 27.5%, lower in relapsed/MRD positive patients (Figure I) (log rank test p=0.02 and 0.04, respectively). Overall survival at 12 months was 61.2%. Three patients developed acute GVHD, two of them grade III/IV in a median of 13 days (range 7-38). Four patients died due to relapse. Median follow-up after WB-DLI was 5 months (range 0.6-20.1 months). The cost of obtaining and administering WB-DLI was $350 USD per dose.Conclusions: DLI obtained from unmanipulated, GCSF-primed whole-blood is a safe and affordable adoptive cell therapy. It is effective and improves mixed chimerism after HSCT, while it was less effective for overt relapse. DisclosuresGomez-Almaguer:AbbVie: Consultancy; Novartis: Consultancy.

Prolonged granulocyte colony stimulating factor use in glycogen storage disease type 1b associated with acute myeloid leukemia and with shortened telomere length

ABSTRACTGlycogen storage disease (GSD) type 1 is a rare autosomal recessive inherited condition. The 1b subtype comprises the minority of cases, with an estimated prevalence of 1 in 500,000 children. Patients with glycogen storage disease type 1b are often treated with granulocyte colony stimulating factor (G-CSF) for prolonged periods to improve symptoms of inflammatory bowel disease (IBD) and in the face of severe neutropenia to decrease risk of infection. Long-term G-CSF treatment may result in an increased risk of myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) possibly due to increased marrow stress resulting in telomere shortening. To our knowledge, there have been two published cases of AML in GSD type 1b patients following long-term G-CSF exposure. Here, we report two further cases of AML/MDS-related changes in patients GSD type 1b treated with G-CSF. One patient developed AML with complex karyotype after 20 years of G-CSF treatment. The second patient was found to have short telomeres after 10 years of G-CSF exposure, but no evidence of acute leukemia at present. The third patient developed AML/MDS after 25 years of G-CSF use, with short telomeres prior to bone marrow transplant. Together these cases suggest that GSD type 1b patients with prolonged G-CSF exposure may be at an increased risk of MDS/AML states associated with G-CSF-induced shortened telomeres. We recommend that any GSD1b patients with prolonged G-CSF should have routine telomere assessments with monitoring for MDS if telomere shortening is observed, and with particular attention warranted if there is unexplained loss of G-CSF responsiveness.

Multigene Measurable Residual Disease Assessment Improves Acute Myeloid Leukemia Relapse Risk Stratification in Autologous Hematopoietic Cell Transplantation

We report here the largest study to date of adult patients with acute myeloid leukemia (AML) tested for measurable residual disease (MRD) at the time of autologous hematopoietic cell transplantation (auto-HCT). Seventy-two adult patients who underwent transplantation between 2004 and 2013 at a single academic medical center (University of California San Francisco) were eligible for this retrospective study based on availability of cryopreserved granulocyte colony–stimulating factor (GCSF)–mobilized autologous peripheral blood progenitor cell (PBPC) leukapheresis specimens (“autografts”). Autograft MRD was assessed by molecular methods (real-time quantitative PCR [RQ-PCR] for Wilms tumor 1 (WT1) alone or a multigene panel) and by multiparameter flow cytometry (MPFC). WT1 RQ-PCR testing of the autograft had low sensitivity for relapse prediction (14%) and a negative predictive value of 51%. MPFC failed to identify MRD in any of 34 autografts tested. Combinations of molecular MRD assays, however, improved prediction of post–auto-HCT relapse. In multivariate analysis of clinical variables, including age, gender, race, cytogenetic risk category, and CD34+ cell dose, only autograft multigene MRD as assessed by RQ-PCR was statistically significantly associated with relapse. One year after transplantation, only 28% patients with detectable autograft MRD were relapse free, compared with 67% in the MRD-negative cohort. Multigene MRD, while an improvement on other methods tested, was however suboptimal for relapse prediction in unselected patients, with specificity of 83% and sensitivity of 46%. In patients with known chromosomal abnormalities or mutations, however, better predictive value was observed with no relapses observed in MRD-negative patients in the first year after auto-HCT compared with 83% incidence of relapse in the MRD-positive patients (hazard ratio, 12.45; P = .0016). In summary, increased personalization of MRD monitoring by use of a multigene panel improved the ability to risk stratify patients for post–auto-HCT relapse. WT1 RQ-PCR and flow cytometric assessment for AML MRD in autograft samples had limited value for predicting relapse after auto-HCT. We demonstrate that cryopreserved autograft material presents unique challenges for AML MRD testing because of the masking effects of previous GCSF exposure on gene expression and flow cytometry signatures. In the absence of information regarding diagnostic characteristics, sources other than GCSF-stimulated PBSC leukapheresis specimens should be considered as alternatives for MRD testing in AML patients undergoing auto-HCT.

Immunomodulation Induced by Stem Cell Mobilization and Harvesting in Healthy Donors: Increased Systemic Osteopontin Levels after Treatment with Granulocyte Colony-Stimulating Factor.

Peripheral blood stem cells from healthy donors mobilized by granulocyte colony-stimulating factor (G-CSF) and harvested by leukapheresis are commonly used for allogeneic stem cell transplantation. The frequency of severe graft versus host disease is similar for patients receiving peripheral blood and bone marrow allografts, even though the blood grafts contain more T cells, indicating mobilization-related immunoregulatory effects. The regulatory phosphoprotein osteopontin was quantified in plasma samples from healthy donors before G-CSF treatment, after four days of treatment immediately before and after leukapheresis, and 18–24 h after apheresis. Myeloma patients received chemotherapy, combined with G-CSF, for stem cell mobilization and plasma samples were prepared immediately before, immediately after, and 18–24 h after leukapheresis. G-CSF treatment of healthy stem cell donors increased plasma osteopontin levels, and a further increase was seen immediately after leukapheresis. The pre-apheresis levels were also increased in myeloma patients compared to healthy individuals. Finally, in vivo G-CSF exposure did not alter T cell expression of osteopontin ligand CD44, and in vitro osteopontin exposure induced only small increases in anti-CD3- and anti-CD28-stimulated T cell proliferation. G-CSF treatment, followed by leukapheresis, can increase systemic osteopontin levels, and this effect may contribute to the immunomodulatory effects of G-CSF treatment.

Impact of G-CSF for Outcomes of Non-M3 AML Patients Who Were Treated By Anthracycline-Based Induction (7+3 regimen) Chemotherapies

Granulocyte colony-stimulating factor (G-CSF) has been known to reduce the duration of neutropenia and the incidence of infection-related death in patients with solid cancer who were treated by cytotoxic chemotherapies. A few randomized trials addressed these benefits in patients with non-M3 acute myelogenous leukemia (AML). However, long-term effects of G-CSF exposure in these patients were not reported. We analyzed the impact of G-CSF for outcomes of non-M3 AML patients who were treated by anthracycline-based induction and high-dose cytarabine consolidation chemotherapies.The patients enrolled in the Korea University AML registry from September 2002 to December 2014 were analyzed. AML patients who were treated by anthracycline-based inducton (7+3 regimen) and high-dose cytarabine consolidation (cytarabine 3g/m2 q 12 hours on D1, 3, 5) chemotherapies were included for this analysis. Patients with acute promyelocytic leukemia were excluded. The enrolled patients were classified into 3 subgroups based on G-CSF administration strategies during induction chemotherapies; 1) patients without G-CSF exposure during induction (no G-CSF group), 2) patients with G-CSF administration which was initiated immediately after development of neutropenia (absolute neutrophil counts < 1000) but before development of febrile neutropenia (preemptive group), 3) patients with G-CSF administration which was initiated after development of febrile neutropenia (therapeutic group).285 patients were included in this analysis. The median follow-up duration was 18 months. The number of no G-CSF, preemptive and therapeutic group were 83, 70, and 132, respectively. The impacts of G-CSF administration strategies for treatment outcomes were summarized in table 1. The incidence and duration of chemotherapy-induced febrile neutropenia (CIFN) was not statistically different in no G-CSF group and preemptive group (p=0.700 and p=0.103, respectively). According to the median duration of neutropenia, preemptive G-CSF group (20.5 days) showed marginal benefit compared to the other groups (24 days in no G-CSF group and 23 days in therapeutic group) (p=0.052). The median time to ANC recovery (>1000) was significantly shorter in preemptive group (23 days) and therapeutic group (23 days) compared to no G-CSF group (27 days) (p<0.001). Infection-related mortality was significantly lower in preemptive group (2.9%) compared to no G-CSF group (9.6%) and therapeutic group (15.9%) (p=0.020). Complete remission rate and cumulative incidence of relapse were not significantly different between groups (p=0.151 and p=0.423, respectively). In multivariate analysis for incidence of CIFN, quinolone prophylaxis was independently significant factor for reducing the incidence of CIFN (HR 0.222, 95% confidence interval 0.054-0.911, p=0.037). In multivariate analysis for infection-related death, young age (°Â60) and preemptive group were independently significant factors for reducing the development of infection-related death (HR 0.284, 95% confidence interval 0.120-0.676, p=0.004 and HR 0.108, confidence interval 0.012-0.934, p=0.043 respectively). According to the survival, there were no significant differences among groups in overall survival and relapse free survival (figure 1).Preemptive G-CSF administration during induction treatments in non-M3 AML patients was considered to be effective in reducing infection-related deaths without affecting remission, relapse and overall survival. Because quinolone prophylaxis was showed to be effective in reducing the incidence of CIFN, combination of preemptive G-CSF administration and quinolone prophylaxis might be considered to provide synergistic benefit in non-M3 patients with intensive chemotherapy. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Collection of peripheral blood progenitor cells on Day 4 is feasible and effective while reducing granulocyte–colony‐stimulating factor exposure to healthy donors

Peripheral blood progenitor cells (PBPCs) are the most common stem cell source for allogeneic transplantations. Analysis of our collection data obtained with a Spectra Optia device (Terumo) for apheresis demonstrated collection efficacies (CEs) exceeding our internal target levels of 5 × 10(6) CD34+ cells/kg body weight of the recipient when collected on Day 5. We thus aimed to investigate whether collection on Day 4 would lead to adequate amounts of PBPCs while minimizing granulocyte-colony-stimulating factor (G-CSF) exposure in healthy donors. We compared feasibility and effectiveness of Day 5 versus Day 4 collections with data obtained from 23 and 18 allogeneic procedures, respectively. Both groups were comparable with regard to donor and collection characteristics. Product characteristics as well as platelet loss, CE, throughput, and collection rate did not differ between both protocols. A higher contamination with white blood cells (WBCs; ×10(9) /L) was observed in products collected on Day 5 compared to Day 4 (231 [range, 181-299] vs. 203 [range, 165-239]; p = 0.004). A second apheresis procedure was required in three of 23 patients and three of 18 patients, respectively (p = 0.6) to obtain the required PBPC dose. PBPC apheresis on Day 4 seems as feasible and effective as collection on Day 5. Collection on Day 4 produces lower WBC content in the product and allows a reduction in G-CSF exposure to healthy donors.

Granulocyte-Colony Stimulating Factor (G-CSF) in Secondary Prophylaxis for Advanced-Stage Hodgkin Lymphoma Treated with ABVD Chemotherapy: A Cost-Effectiveness Analysis

Background: G-CSF is commonly administered to patients with advanced-stage Hodgkin Lymphoma (HL) with severe neutropenia during therapy, although such an approach does not appear to provide a survival benefit. Although the therapy may reduce episodes of febrile neutropenia, any benefit might be offset by increased costs and the potential for increased bleomycin lung toxicity with G-CSF exposure, suggested in prior studies (Martin et al., JCO 2005). As an alternative to secondary prophylaxis, single institution studies have suggested that ABVD chemotherapy can be administered without G-CSF support, treatment delays, or dose reductions. The relative costs and benefits of such an approach compared to routine use of G-CSF is unknown.Methods: We constructed a Markov decision-analytic model to compare the strategy of secondary prophylaxis with G-CSF to a strategy of “no G-CSF” in response to therapy-related severe neutropenia for a cohort of 40 year-old patients with clinical stage IIB to IV HL treated with 8 cycles of ABVD. A 2-year time horizon was simulated. Baseline probability estimates and utilities were derived from a systematic review of relevant published studies. Direct medical costs were obtained from publicly available administrative databases or from the literature and applied to the health states. All costs and benefits were discounted by 3%. A Canadian public health payer’s perspective was considered and costs were presented in 2013 Canadian dollars. Key variables were subjected to sensitivity analyses.Results: The quality-adjusted life years (QALYs) attained with the G-CSF and “no G-CSF” strategies were 1.403 and 1.416, respectively, for a net expected benefit of 0.013 QALYs associated with omitting G-CSF. Costs for the strategies with and without G-CSF were $38,971 and $33,982, respectively, with a cost savings of $4,989 when G-CSF is omitted. In the base case analysis, the “no G-CSF” strategy was associated with both cost savings and improved quality-adjusted outcomes compared to secondary prophylaxis; therefore, the “no G-CSF” approach was dominant. This analysis was robust to one-way sensitivity analyses involving all key variables; the “no-GCSF” strategy remained dominant even when the cost of G-CSF was zero (Figure 1). In probabilistic sensitivity analysis (1000 simulations), the “no-G-CSF” strategy remained dominant in all pairwise simulations compared to an approach with G-CSF for secondary prophylaxis (Figure 2).Conclusions: For patients with severe neutropenia during ABVD chemotherapy for advanced-stage HL, a strategy without G-CSF support, treatment delay or dose reduction is associated with improved quality-adjusted outcomes and cost savings and is the preferred approach. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Enhancement in cognitive function recovery by granulocyte-colony stimulating factor in a rodent model of traumatic brain injury

Traumatic brain injury (TBI) is characterized by neuronal damage and commonly, secondary cell death, leading to functional and neurological dysfunction. Despite the recent focus of TBI research on developing therapies, affective therapeutic strategies targeting neuronal death associated with TBI remain underexplored. This study explored the efficacy of granulocyte-colony stimulating factor (G-CSF) as an intervention for improving cognitive deficits commonly associated with TBI. Although G-CSF has been studied with histological techniques, to date, its effects on functional outcome remain unknown. To this end, we used a closed head injury (CHI) model in Wistar rats that were randomly assigned to one of four groups (untreated TBI, G-CSF treated TBI, G-CSF treated Control, Control). The treatment groups were administered subcutaneous injections of G-CSF 30min (120μg/kg) and 12h (60μg/kg) post-trauma. The Morris Water Maze test was used to measure any treatment-associated changes in cognitive deficits observed in TBI animals at days 2–6 post-injury. Our findings demonstrate a significant improvement in cognitive performance in the G-CSF treated TBI animals within a week of injury, compared to untreated TBI, indicative of immediate and beneficial effect of G-CSF on cognitive performance post CHI. Our model suggests that early G-CSF exposure may be a promising therapeutic approach in recovery of cognitive deficits due to TBI.

PREGNANCY OUTCOME In GENETIC Subtypes of CONGENITAL Neutropenia

Abstract 4722Severe congenital neutropenia (CN) comprises a heterogeneous group of disorders with a common hematological and clinical phenotype characterized by a maturation arrest of myelopoiesis at the level of the promyelocyte / myelocyte stage with peripheral blood absolute neutrophil counts (ANC) below 0.5 ′ 109/l and early onset of bacterial infections. Current data on the molecular causes have demonstrated that CN is a multigene disorder with more than 10 genes described to date. Genetic analyses in autosomal dominant and sporadic cases of CN indicate that the majority of these cases are attributable to mutations in the elastase 2 (ELANE) gene encoding neutrophil elastase. However, mutations in the ELANE gene do not discriminate between patients with CN and patients with cyclic neutropenia (CyN). Since 1987, recombinant human Granulocyte-Colony stimulating factor (G-CSF) is available for the treatment of CN. Independent of the genetic subtype, more than 90% of patients respond well to G-CSF with sustained increase of absolute neutrophil counts and prolonged life expectancy. Since our first patients have reached adulthood the desire for parenthood arises. To-date there is only limited data on the infectious risk for affected mothers and their children due to G-CSF treatment during pregnancy.In this study we assessed the outcome of pregnancies reported to the SCNIR in Europe since 1994 with regard to:1.The neutropenia status in newborns of mothers and fathers with different genetic CN subtypes as an indicator for inheritance.2.The impact of G-CSF treatment on maternal and newborn complications in women of all neutropenia subtypes with or without G-CSF treatment during pregnancy.Since 1994 the SCNIR has collected long-term follow-up data of 510 patients with severe chronic neutropenia subtypes. 3 patients are diagnosed with congenital (71 ELANE-CN, 31 HAX1, 9 GC6PC3, 47 SDS, 117 unknown, 45 other), 66 with cyclic and 82 with idiopathic neutropenia. Adulthood was reached by 144 out of 304 CN patients. These include 38 ELANE-CN patients (male:14, female:24) and 11 ELA-CyN patients (male: 5, female:6).A total of 20 pregnancies in 12 mothers and 13 newborns by 7 fathers with different genetic subtypes of CN have been reported. Among them are pregnancies of 11 women with ELANE-CN, 8 with ELANE-CyN, 1 with SDS, 13 with an unknown genetic origin of CN (n=9) or CyN (n=4). No pregnancies were reported in patients with HAX1 or G6PC3 although 7 of these patients have reached adulthood.Data on neutropenia status was documented in 24 out of 31 live births. Neutropenia in newborns was diagnosed in 16 out of 30 live births from parents with genetic subtypes of CN. In 8 of the 16 affected newborns neutropenia was related to ELANE mutations. One mother registered with SDS delivered a healthy child.During pregnancy 17 women received G-CSF treatment (CN=11, CyN=4, IDN=2). Regardless of any cytokine treatment no major infectious complications were reported in our cohort. 24 of 31 reported pregnancies resulted in life births. 5 spontaneous terminations occurred in women with respectively without exposure to G-CSF. In addition, 2 still births were reported in women with idiopathic neutropenia, but G-CSF exposure remains unknown. Conclusion:The proportion of newborns with congenital neutropenia indicates the pattern of inheritance by their parents and reveals the need for genetic counseling. However, the acceptance of having affected children may reflect the high quality of life due to G-CSF treatment in affected parents. G-CSF treatment during pregnancy is well tolerated. In terms of G-CSF treatment, no differences in infectious complications during pregnancy in women with or without G-CSF administration were reported in our cohort. Interestingly, the proportion of women receiving G-CSF during pregnancy is highest among the CN subtype indicating the severe clinical phenotype. We therefore recommend the application of G-CSF in patients with severe chronic neutropenia during pregnancy. Disclosures:No relevant conflicts of interest to declare.

Barth Syndrome and Severe Chronic Neutropenia.

AbstractAbstract 3787Barth syndrome is an X-linked recessive genetic condition characterized by neutropenia, cardiomyopathy, growth delay, muscle weakness, and 3-methylglutaconic aciduria (an increase in organic acid caused by abnormal mitochondria). Its clinical manifestations are variable and can include fatigue, hypotonia, and dilated cardiomyopathy. Symptoms usually appear at birth or within the first few months of life. Mutations in the tafazzin (TAZ) gene cause Barth syndrome.The Severe Chronic Neutropenia International Registry (SCNIR) is building a base of information about the natural history and response to granulocyte colony stimulating factor (G-CSF) treatment for patients with Barth syndrome and other causes of chronic neutropenia. Through the SCNIR, we follow the clinical course and treatment of seven male subjects (median age 17 years, range: 6–28 years) with Barth syndrome observed for up to 11 years (median 9, range 3–11). Six of these seven subjects were neutropenic prior to G-CSF treatment, the median absolute neutrophil count (ANC) was 0.293 × 109/L (range 0 – 1.260). The seventh subject was not consistently neutropenic, median ANC 2.107 × 109/L (range 0.779 – 3.520).Sixteen bone marrow evaluations were performed on four of the seven subjects. Four of 16 bone marrows were prior to G-CSF exposure (3 subjects). Two of three subjects manifest eosinophilia in the marrow but not in the blood. Marrow exams for two of the three subjects' evaluations were read as normocellular marrow, and one of the three was read as hypocellular with a decrease in cells of the myeloid series. Twelve of the 16 bone marrow evaluations were performed in two subjects who were receiving G-CSF. One of the four subjects had bone marrow evaluations both before and after G-CSF exposure. His pre G-CSF evaluations displayed hypocellular bone marrow, and his post G-CSF evaluations showed normocellular bone marrow and eosinophilia. None of the marrow evaluations before or on G-CSF suggested myelodysplasia or showed evidence of acute myeloid leukemia.The six neutropenic subjects have all received G-CSF for a median of 96 months (range 28 – 137) at a median dose of 1.57 mcg/kg/day (range 0.43 to 2.18). The total G-CSF exposure for all six subjects is 507 months. The median ANC of the six subjects prior to G-CSF treatment was 0.293 × 109/L (range 0–1.260). The median ANC on G-CSF was 2.056 × 109/L (range 1.640–3.403).Prior to receiving G-CSF, three of the seven subjects reported mouth ulcers. Two of seven subjects reported skin infections, including one subject who reported infections around the G-tube used to maintain his nutritional status. One of seven subjects reported an episode of bacteremia. Of the six subjects who received G-CSF, three reported a reduced number of mouth ulcers and two of six reported reduced skin infections (G-tube, port-a-cath). None of the subjects experienced unusual side effects or clinically significant complications associated with G-CSF therapy.These data indicate that patients with Barth syndrome and neutropenia have ulcers and patterns of infections similar to other patients with chronic neutropenia. They are responsive to G-CSF treatment and it appears to be safe and effective to reduce their predisposition to bacterial infections. Disclosures:Dale:Amgen: Consultancy, Research Funding.

Neutrophil Elastase Mutations and the Risk of Leukemia In Patients with Cyclic and Congenital Neutropenia.

AbstractAbstract 3786Mutations in the gene for neutrophil elastase (ELANE) are the cause for the majority of cases of cyclic and congenital neutropenia. More than 50 different mutations of ELANE have been identified in patients with these disorders. It is not known whether specific ELANE mutations predispose patients to the risk of myelodysplasia (MDS) and acute myeloid leukemia (AML).We have investigated the relationships of ELANE mutations to the risk of MDS/AML in a population of 208 patients with cyclic (N=92) and congenital neutropenia (N=116) having ELANE mutations and receiving granulocyte colony-stimulating factor (G-CSF) therapy for up to 22 years. In the congenital group there were 52 different mutations occurring with increasing frequency from exon 1 (2 mutations) to exon 5 (17 different mutations). In the cyclic group there was a narrower spectrum of mutations; these mutations clustered in exon 4, intron 4 and exon 5. There were 13 different mutations in this group. Mutations P110L, S97L, R191Q, and splice site mutations in intron 4: +5 SD G>A, and +1 SD G>T were observed both in patients with the cyclic and congenital neutropenia.Sixteen congenital neutropenic patients developed MDS/AML. There were 15 different mutations associated with these transformations. There are also 15 congenital patients who have not evolved to develop leukemia who have the same mutations as in the MDS/AML group. In three families with autosomal dominant congenital neutropenia attributed to ELANE mutations, one affected member has developed AML the other has not. The pairs are: father no, daughter yes; father yes, daughter no; and one identical twin yes, other twin no. One patient with a clinical diagnosis of cyclic neutropenia who had received long term immunosuppressive therapy also developed MDS and had a stem cell transplant. There were no MDS/AML transformations in the other 91 cyclic patients. For the overall population of cyclic and congenital patients, missense mutations in ELANE were most commonly found. In the 16 congenital neutropenia patients evolving to MDS/AML by category the mutations were: missense (8), deletion (2) termination (4) intronic (2), a pattern similar to those of the congenital patients who have not evolved to develop MDS/AML: missense (79) deletion (7) termination (8) intronic (6).The 16 patients with congenital neutropenia who developed MDS/AML were treated with G-CSF for a median of 8.6 years (range 3.3 – 15.2). The mean of the median G-CSF dose for patients with MDS/AML transformation was 14.6 mcg/kg/day (range 2–43 mcg/kg/day) and the mean of the median dose of G-CSF for the population not developing MDS/AML was 13.7 mcg/kg/day (range 0–183 mcg/kg/day) (p=0.89). However, a higher proportion of the AML group (69%) were receiving G-CSF at > 8mcg/kg than the non MDS/AML group (40%). The median duration of G-CSF treatment was significantly less (p=0.009) in the MDS/AML group than the group not developing MDS/AML. The mean cumulative G-CSF exposure was not significantly different (p=0.54) for the two groups.These data indicate that there are no specific ELANE mutations or specific types of ELANE mutations predisposing patients with congenital neutropenia to development of MDS or AML. The data confirm previous reports that patients requiring higher daily doses of G-CSF may be at somewhat greater risk of MDS/AML, but there is no distinct dose predicting risk and no association with total G-CSF exposure and the risk of MDS/AML. The specific cause for the high risk of MDS and AML in congenital neutropenia remains unknown. Disclosures:Dale:Amgen: Consultancy, Research Funding.