Median Yield Of CD34 Research Articles

Salvage treatment with plerixafor in poor mobilizing allogeneic stem cell donors: results of a prospective phase II-trial

We conducted a prospective clinical trial to investigate the safety and efficacy of plerixafor (P) in allogeneic peripheral blood stem cells (PBSC) donors with poor mobilization response to standard-dose granulocyte colony-stimulating factor (G-CSF), defined by <2 × 106 CD34 + cells/kg recipient body-weight (CD34+/kg RBW) after 1st apheresis. A single dose of 240 µg/kg P was injected subcutaneously at 10 p.m. on the day of the 1st apheresis. Thirty-seven allogeneic PBSC donors underwent study treatment. The median CD34+ count in peripheral blood was 15/µl on Day 1 after G-CSF alone, versus 44/µl on Day 2 after G-CSF plus P (p < 0.001). The median yield of CD34+ cells was 1.1 × 108 on Day 1 and 2.8 × 108 on Day 2. In contrast to a median yield of only 1.31 × 106 CD CD34+/kg RBW on Day 1, triggering study inclusion, a median of 3.74 × 106 CD CD34+/kg RBW were collected with G-CSF plus P on Day 2. Of 37 donors, 21 reached the target cell count of >4.5 × 106 CD34+/kg RBW (57%, 95%CI 40–73%). No donor experienced a severe adverse event requiring treatment. In conclusion, P might be considered on a case-by-case basis for healthy allogeneic donors with very poor stem cell mobilization success after G-CSF.

HIGH EFFICACY AND SAFETY OF VTD AS AN INDUCTION PROTOCOL IN NEWLY DIAGNOSED MM PATIENTS ELIGIBLE FOR HDT/AUTOSCT – A REPORT OF POLISH MULTIPLE MYELOMA STUDY GROUP

Introduction: Three drug bortezomib-based regimens are nowadays generally recommended standard induction therapy for transplant-eligible patients with newly diagnosed multiple myeloma (MM). The choice between different regimens depends on drug availability in particular countries, their toxicity profile and local preferences. Aims: The aim of this retrospective analysis was to evaluate the efficacy and safety of VTD regimen in newly diagnosed MM patients eligible for HDT/autoSCT in routine clinical practice. Methods: We collected the clinical data of 169 patients qualified to HDT/autoSCT treated with VTD as an induction regimen in 14 Polish hematology centers. VTD protocol recommended by Polish Multiple Myeloma Study Group was as follows: bortezomib: 1.3 mg/m2 (days 1, 4, 8, 11), thalidomide: 100–200 mg a day (days 1–21), dexamethasone 20 mg a day (days: 1, 2, 4, 5, 8, 9, 11, 12) or 40 mg a day (days 1–4), every 21 days. Adverse events (AEs) were graded according to CTCAE v4.0. The analysis involved also the impact of VTD regimen on efficiency of stem cells mobilization as well as high-dose therapy/autologous stem cell transplantation (HDT/autoSCT) procedure. Results: In the cohort of 169 patients, median age was 59 years (range 36–70). ISS stage 1 was found in 30.8% of patients, ISS 2 and 3 in 20.7% and 45.5%, respectively. Median number of VTD cycles was 5. In 81.6% of patients, bortezomib was administered subcutaneously. Thalidomide dose was 100 mg a day in 85.1% of patients. Bortezomib dose was reduced in 43 patients (25.4%) with peripheral polyneuropathy as the most common reason (75%). The most common grade 3/4 adverse event was polyneuropathy, observed in 20 patients (11.8%) and neutropenia, noted only in 5 patients (3%). Response rate ≥ PR was achieved in 95% of patients, including 5.6% of sCR, 27.1% of CR and 35.1% of VGPR. So far, stem cell mobilization was performed in 110 patients, most commonly used protocols were cyclophosphamide (42.9%) and cytosine arabinoside (36.2%). In 69.3% of patients, one apheresis allowed to obtain the number of stem cells sufficient for transplantation. Median yield of CD34+ cells was 11 × 106 /kg (max 55.7 × 106 /kg). HDT/autoSCT was performed so far in 89 patients with MEL 200 protocol as conditioning regimen in 77.6% of patients. Median number of transplanted CD34+ cells was 4.4 × 106 /kg. Median time to reach ANC count >0.5 G/L and PLT count >20 G/L was 11 days and 12 days, respectively. In the evaluation of response 100 days after HDT/autoSCT performed in 81 patients, sCR rate increased from 5.6% to 12.7% and CR from 27.1% to 36.7%. Conclusions: VTD regimen allowed allowed to achieve ≥PR in 95% of patients including ≥VGPR u 64.8% of patients as compared to 73.5% ≥ PR including 36% of ≥nCR achieved in patients treated with CTD in our previous study (Dmoszynska et al. Leuk Res 2010). In 96% of patients subsequently undergoing stem cell mobilization, sufficient numer of CD34+ cells was obtain during first procedure. HDT/autoSCT further increased response rate after VTD induction (≥CR up to 43.5%, ≥VGPR up to 83.5%). Keywords: autologous stem cell transplantation (ASCT); bortezomib; multiple myeloma (MM).

Peripheral Blood Stem Cell Mobilization and Engraftment after Autologous Stem Cell Transplantation with Biosimilar rhG-CSF

Biosimilar versions of filgrastim [recombinant human granulocyte colony-stimulating factor (rhG-CSF)] are now widely available. To date, biosimilar rhG-CSF has demonstrated a comparable quality, safety and efficacy profile to the originator product (filgrastim [Neupogen(®)], Amgen Inc., CA, USA) in the prevention and management of neutropenia. Biosimilar rhG-CSFs have also been used to induce peripheral blood stem cell (PBSC) mobilization in patients undergoing autologous stem cell transplantation (AHSCT). The authors have examined the effectiveness of a biosimilar rhG-CSF (Zarzio(®), Sandoz Biopharmaceuticals, Holzkirchen, Germany) in two retrospective studies across two medical centers in Hungary. In Study 1, 70 patients with hematological malignancies scheduled to undergo AHSCT received chemotherapy followed by biosimilar rhG-CSF (2 × 5 μg) for facilitating neutrophil, leukocyte, and platelet engraftment. In study 2, 40 additional patients with lymphoid malignancies and planned AHSCT received chemotherapy followed by biosimilar rhG-CSF for PBSC mobilization. The effectiveness of treatment was assessed by the average yield of cluster of differentiation (CD) 34+ cells and the number of leukaphereses required. In Study 1 (patients undergoing AHSCT), the median age was 56 years and most patients were male (60%). The conditioning regimens were mainly high-dose melphalan (n = 41) and carmustine (BiCNU(®), Bristol-Myers Squibb, NJ, USA), etoposide, cytarabine and melphalan BEAM (n = 21). Median times to absolute neutrophil and leukocyte engraftment were 9 (range 8-11 days) and 10 (8-12) days, respectively. Median time to platelet engraftment was 10.5 days (7-19 days). In Study 2, the patients' median age was 54 years and the majority (57.5%) were female. The median time interval between day 1 of mobilizing chemotherapy and first leukapheresis was 12 (9-27) days. In the autologous PBSC grafts, the median number of CD34+ cells harvested was 5.2 × 10(6)/kg (2.22-57.07 × 10(6)/kg). The median yield of CD34+ cells per leukapheresis product was 2.47 × 10(6)/kg. In total, 58 leukaphereses were performed in 40 successfully harvested patients. In line with previous studies with originator rhG-CSF, the findings of this study indicate that biosimilar rhG-CSF following AHSCT is effective and generally well tolerated in the engraftment setting. In addition, biosimilar rhG-CSF is comparable to the originator rhG-CSF in terms of kinetics of PBSC mobilization and yield of CD34+ cells. In conclusion, the authors have demonstrated that the use of biosimilar rhG-CSF is effective and safe in autologous PBSC mobilization and engraftment after AHSCT.

Factors Influencing Peripheral Blood Progenitor Cell Yield After 2nd Mobilization With G-CSF In Allogeneic Donors

Purpose2nd collection of Peripheral Blood Progenitor Cells (PBPC) from the same donor is increasingly required for the treatment of complications after allogeneic transplantation, but information regarding the efficacy of this procedure is still limited. MethodsWithin our program 212 allogeneic donors underwent a 2nd cycle of G-CSF-application and PBPC leukapheresis between 1996 and 2012. Demographical data and details of donation are shown in table 1. G-CSF (lenograstim) was administered at a median daily dose of 7.5µg/kg for 4.5d; leukapheresis was performed on day 5 and 6, if necessary. Peripheral CD 34+ counts and leukapheresis yields after both mobilization cycles were compared. The influence of age, sex, BMI, G-CSF schedule and the interval between the donations on the efficacy of the 2nd PBPC mobilization were analyzed, too.Table 1Characteristics of PBPC donors with 2 mobilization cyclesGender145 male (68.4 %);67 female (31.6%)Age, years (mean, min-max)37 (1-70)Relationship to the recipient171 unrelated (80.7%)41 related (19.3%)Body Mass Index (mean, min-max)24.8 (17.2-43.2)Schedule of G-CSF-application29 single dose174 devided doseInterval between 1st and 2nd mobilization, months (mean, min-max)7.3 (0.6-105.0) ResultsMedian CD 34+ counts in peripheral blood were 53.2/µl at day 5 of 1st mobilization compared to 49.5/µl at day 5 of 2nd mobilization. Between 1st and 2nd donation, the median yield of CD 34+ cells/kg recipient b.w. decreased from 7.3 x 106 to 6.6 x 106 (p = 0.026, see table 2). The number of aphereses necessary in both donation episodes did not differ in the majority of donors (n=175; 82.5%). A strong correlation was observed between the amount of CD 34+ cells per recipient b.w. after the 1st and 2nd PBPC donation (r=0.89). The majority (65.4%, n=17) of donors with poor mobilization (<3 x 106 CD 34+ cells/kg recipient b.w.) after the 1st leukapheresis reached similar low CD 34+ counts after the 2nd mobilization. The interval between both mobilization cycles did not affect the results of the 2nd donation. According to an adjusted model, the other variables (age, sex, BMI and G-CSF-schedule) had no additional influence on mobilization efficacy in the 2nd cycle of G-CSF application.Table 2Comparison of the results of the first and second PBPC mobilization (median values and range)Parameter1stMobilization2ndMobilizationpCD 34+ concentration in peripheral blood on day 5 of G-CSF application53.2/µl (9-243)49.5/µl (6-207)0.099Yield of CD 34+ cells/ kg recipient weight (in 1 or 2 leukaphereses)7.3 x106 (1.3-68.6)6.6 x106 (0.9-65.1)0.026Donors with 2 leukaphereses60430.068 ConclusionsIn the largest group of healthy donors reported so far, we could demonstrate a slight reduction (about 10%) of PBPC yield after the 2nd mobilization that might not be clinically significant. Demographic variables affected the results of both mobilization episodes in the same way and the interval between them was of no significance. Our data support the assumption, that stem cell mobilization is probably determined by genetic factors and the outcome of a 2nd donation can easily be predicted by the results of the 1st one. Disclosures:No relevant conflicts of interest to declare.

Mobilization of Hematopoietic Stem Cells by a Bendamustine-Containing Regimen in Hodgkin's Lymphoma

AbstractAbstract 1914 Introduction:Bendamustine has demonstrated efficacy as single agent in several lymphoproliferative disorders, including Hodgkin's lymphoma (HL). Despite the wide use of this compound, alone or in combination, there are no published data regarding its mobilizing activity. In 2011, we started a phase II open-label prospective study with Bendamustine, Gemcitabine and Vinorelbine (BeGEV) to evaluate the efficacy of this induction regimen before high dose chemotherapy plus autologus stem cell transplant (ASCT). One of the study objectives was to detect the role of Bendamustine as part of a mobilizing regimen for peripheral blood stem cell (PBSC) collection. Methods:Between August 2011 and July 2012, 16 consecutive patients with relapsed/refractory HL were enrolled in a Phase II open-label prospective study with BeGEV followed by ASCT. The treatment schedule was: Bendamustine (90mg/sqm, days 2–3), Gemcitabine (800mg/sqm, day 1 and 4) and Vinorelbine (25mg/sqm, day 1) plus G-CSF 10mcg/Kg beginning on day 7 continued daily until the target yield would be reached. PBSC collection was planned starting from cycle 1 or from cycle 3 in case of bone marrow involvement. Three million CD34+/Kg were considered as the minimum cell dose established for a safety rescue. Other than successful rate of harvest, we evaluated the absolute number of collected CD34+ cells/Kg, the number of procedures performed per cycle, preleukapheresis circulating CD34+ cells/mcL, white blood cells (WBC) count and the day of first collection. Adverse events were also recorded. All patients provided written informed consent at the time of study inclusion. Results:Of the 16 patients enrolled, 14 already underwent leukapheresis.All patients were able to mobilize readily and all achieved the primary end point with at least 3.6 × 10>6 CD34+/Kg collected in a single cycle. The median yield of CD 34+/Kg collected was 7.8 × 10>6 CD34+/Kg (range, 3.6–15) after a median of 1 procedure (range, 1–2). The median preleukapheresis circulating CD34+/mcL and WBC count/mcL were 76/mcL (range, 25–201) and 21750/mcL (range, 11200–87080), respectively. The median day of first collection was 12 (range, 9–15). Six pts underwent leukapheresis at cycle 1, 7 pts at cycle 2 (6 pts due to logistic reasons,1 to Cytomegalovirus reactivation). One pt underwent leukapheresis at cycle 3 for personal reasons obtaining the highest yield (15×10>6 CD34+/Kg). Hematologic and non-hematologic side effects were acceptable and no toxic deaths occurred. One patient developed blood-pressure decrement during the apheresis but she was able to complete the procedure without sequelae. To date, 6 patients (43%) underwent ASCT with prompt engraftment. Data about neutrophils and platelets engraftment will be presented in the final analysis. Comparison with historical IGEV published data (Magagnoli et al, BMT 2007) is reported in Table 1. Conclusions:This is the first prospective study evaluating Bendamustine as mobilizing agent in resistant HL pts before ASCT. Despite the small sample, our results show that BeGEV regimen, combined with G-CSF support, can be successfully and safely used to mobilize PBSC. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Mobilization and Harvesting of Peripheral Blood Stem Cells in Pediatric Patients With Solid Tumors

Survival of patients with high-risk pediatric solid tumors has improved with the introduction of a high-dose chemotherapy regimen and autologous stem cell rescue. Here, we present our data regarding the evaluation of the efficacy and safety of hematopoietic stem cell mobilization and harvesting in children with solid tumors. From November 2002 to March 2010, 85 children underwent autologous peripheral blood stem cell collection; 35 (41.1%) of them weighed less than 20 kg and were diagnosed with neuroblastoma, Wilms' tumor, medulloblastoma, yolk sac sarcoma, or non-Hodgkin's lymphoma. The mobilization regimens included disease-specific chemotherapy plus granulocyte colony-stimulating factor in most of the patients. The median age and weight at the time of apheresis was 36 months and 13.5 kg, respectively. Large-volume leukapheresis was performed with the aim of reducing the psychological and financial impact of leukapheresis by reducing the number of procedures while collecting a large number of cells. The median number of mobilization and leukapheresis procedures per case was one. The pre-apheresis CD34+ cell count ranged from 2 to 845 µL, with a median of 24 µL. A median of four patient blood volumes was processed per procedure, lasting 279 min (range, 113-420 min). A radial catheter was used for harvesting in 35 procedures (71.4%). The median yield of CD34+ cells was 6.6×10(6) /kg per patient. The targeted dose of 5×10(6) /kg CD34+ cells was realized in 80% of patients. The tolerance of peripheral blood stem cell collection in our patients was good. In conclusion, the collection of peripheral blood stem cells is an effective and safe procedure, even when conducted on the youngest children.

Effective Primary Mobilization of Autologous Peripheral Blood Stem Cells with Granulocyte Colony-Stimulating Factor and Plerixafor in Lenalidomide-Treated Patients with Multiple Myeloma

AbstractAbstract 2254 Background:Lenalidomide (LEN) is extensively used in combination with dexamethasone (DEX), with or without bortezomib (BOR), for initial treatment of multiple myeloma (MM). However, several studies have shown that previous exposure to LEN is associated with impaired collection of autologous peripheral blood stem cells (PBSCs) after mobilization with either granulocyte-colony stimulating factor (G-CSF) or chemotherapy plus G-CSF. The effects of previous exposure to LEN on the collection of autologous PBSCs after mobilization with G-CSF plus plerixafor (PLX; Mozobil®) are not well described. Methods:We evaluated the outcomes of autologous PBSC mobilization and collection in 15 consecutive patients (pts) with MM who received previous treatment with at least 2 21-day cycles of LEN in combination with either DEX (10 pts) or DEX and BOR (5 pts) and who underwent initial autologous PBSC mobilization with G-CSF (10 micrograms/kg/dose subcutaneously daily × 4 days) and PLX (0.24 mg/kg/dose subcutaneously, after fourth dose of G-CSF), with additional doses of G-CSF and PLX for subsequent apheresis sessions. Results:Median age of pts was 58 yr (range, 35–67). Patients received a median of 5 cycles (range, 2–12) of LEN. The median number of apheresis sessions was 1 (range, 1–2). The median level of CD34+ cells in the peripheral blood at day 1 of apheresis was 84.36 per microliter (range, 12.46–167.37), and the median yield of CD34+ cells was 6.52 × 106/kg (range, 1.43–17.11) after day 1 of apheresis and 7.46 × 106/kg (range, 2.32–17.11) after day 2 of apheresis. No LEN-treated pts failed mobilization (defined as collection of less than 2 × 106 CD34+ cells/kg). Eleven pts (73.3%) collected at least 6 × 106/kg CD34+ cells (i.e., sufficient for 2 transplants) after 1 or 2 aphereses, with 8 pts (53.3%) reaching that target after 1 apheresis. Of the 4 pts (26.7%) in whom fewer than 6 × 106/kg CD34+ cells were collected after 2 aphereses, 3 pts collected at least 4 × 106 CD34+ cells/kg, and only 1 pt (who received only 2 cycles of LEN) collected 2.32 × 106/kg CD34+ cells. The number of cycles of LEN did not correlate with concentration of CD34+ cells in peripheral blood on day 1 of apheresis (r2=0.099), yield of CD34+ cells on day 1 of apheresis (r2=0.108), or total yield of CD34+ cells after 2 days of apheresis (r2=0.067). Pts who received 4 or fewer cycles of LEN had higher median circulating CD34+ cells on apheresis day 1, higher median CD34+ cell yield with day 1 apheresis and higher total CD34+ cell yield after 2 aphereses than pts who received more than 4 cycles of LEN (Table). Five of 6 pts who received 4 or fewer cycles of LEN collected at least 6 × 106 CD34+ cells/kg after 1 apheresis, compared with 3 of 9 pts who received more than 4 cycles. However, none of these differences were statistically significant (Table). Conclusions:Previous treatment with LEN does not impair collection of autologous PBSCs after initial mobilization with G-CSF and PLX. However, there was a trend to more robust autologous PBSC collections and decreased need for second aphereses in pts who received fewer cycles of LEN. These findings are consistent with the recommendation of the International Myeloma Working Group to collect autologous PBSCs from MM pts after 4 or fewer cycles of LEN-containing regimens. As mobilization with G-CSF with or without chemotherapy leads to inconsistent autologous PBSC collection in LEN-treated MM pts, our experience supports the use of G-CSF plus PLX as an upfront mobilization strategy for these pts. Disclosures:No relevant conflicts of interest to declare.

PBPC collections: Management, techniques and risks

We evaluated the efficiency, safety and risks of three techniques which were used for autologous PBPC collections: (a) large-volume leukapheresis (LVL), (b) standard collections, and (c) a new modified technique which was named as “Mixed” collections. In spite of the fact that the standard and LVL collection techniques are used routinely, there may occur special conditions in which the procedures cannot be recommended. Some patients may suffer from serious clinical complications and they cannot tolerate either standard procedures with administration of higher doses of ACD-A, or the high extent of procedure in the course of LVL. We tried to find the safe and efficient collection technique which could help this group of patients to overcome their problems. The “Mixed” collection technique could be such a choice. The numbers of 136 autologous PBPC collections were performed in 98 patients who suffered from hemato-oncological diseases. We evaluated the results of (a) 93 LVL (more than 3 TBV, total blood volumes of the patients were processed; anticoagulation: ACD-A and Heparin), (b) 16 Standard procedures (less than 3 TBV were processed; anticoagulation: ACD-A), and (c) 27 “Mixed” collections (less than 3 TBV of patients were processed; anticoagulation: ACD-A+ Heparin). Collections were performed by the use of separator Cobe Spectra, Caridian. In patients (a) with a good effect of mobilization (precollection CD 34+ cells in blood higher than 20 × 10 3/mL) we prepared almost the same median dose of CD 34+ cells from the standard and “Mixed” collections, 3.8 and 4 × 10 6/kg, respectively. In LVL the median yield of CD 34+ cells was 8.2 × 10 6/kg. In patients (b) who were mobilized weakly (precollection CD 34+ cells in blood lower than 20 × 10 3/mL), LVL enabled to prepare 1.5 × 10 6 of CD 34+/kg from one collection, while the median yield of CD 34+ cells from the standard and “Mixed” collections was 0.9 and 1.2 × 10 6/kg. All the standard, LVL and “Mixed” procedures were tolerated well without any serious adverse reactions. We detected 22 adverse reactions, but only three reactions were associated directly with the procedure. Mild hypocalcemia (2) and hypotensive reaction (1) were transient and treated efficiently. Procedures could continue and were finished according to the planned programme. Other reactions were related either to the insufficient function of central venous catheter or to the poor clinical condition of the patients. LVL enabled to get a higher yield of CD 34+ cells than the Standard and “Mixed” collections in well mobilized patients as well as in weakly mobilized patients. We observed the similar efficiency in standard and “Mixed” collections in well mobilized and weakly mobilized patients. We can recommend LVL in all patients who can tolerate it due to a greater chance of collecting higher yields of progenitor cells. In the weakly mobilized patients LVL offers a greater chance of collecting at least a minimum amount of CD 34+ cells needed for transplantation. “Mixed” collections may be used as an alternative technique under the circumstances in which standard or LVL cannot be recommended – like in patients who do not tolerate a high amount of citrate or a high extent of the procedure, e.g. patients with cardiac arrhytmia, impaired liver or renal function or unstable vital signs.

Mobilization of Allogeneic Peripheral Blood Stem Cells in Family Donors with Single-Dose Pegfilgrastim.

Abstract 2148Poster Board II-125 Introduction:The standard procedure for obtaining peripheral blood stem cells (PBSC) is donor mobilization with G-CSF. Pegfilgrastim is a covalently bound conjugate of filgrastim and monomethoxypolyethylene glycol with longer half-life elimination due to decreased plasma clearance and could represent an alternative approach for PBSC mobilization in healthy donors. Design and Methods:From July 2006 till August 2009 28 related healthy donors (50% male, 50% female) were treated with single dose of 12 mg pegfilgrastim for mobilization of allogeneic PBSC. The harvests were performed as large-volume, continuous-flow collections using a Cobe Spectra blood cell separator on day 4 and if necessary on day 5 of the mobilization regimen. In case of inadequate CD34+ counts (less than 4×106/kg body weight of recipient on day 5), stimulation was continued with filgrastim. In addition, the serum level of filgrastim was determined twice daily. Results:We present the results of 27 donors (the results of the 28th donor are still pending). In all 27 cases the harvests were successful. In 22 out of 27 donors (82%) only a single apheresis was needed to reach the target. Two of the donors required additional treatment with non-pegylated filgrastim.The maximal concentration of circulating CD34+ cells was achieved on day 4 (median 74.3/μl; range 24.6-136.6). The median yield of CD34+ cells was 5.9×106/kg of the recipients body weight (range 3-14.5), and the median CD3+ count was 9.1×108/kg of the recipient body weight (range 1.4-6.2). Serum filgrastim level peak was on day 2 of the mobilization regimen with a median level of 226 ng/ml (range 35 to 1123 ng/ml), thus preceding the increase of CD34+ cells in blood. The main adverse events were WHO grade 1 and included headaches, bone pain and transient elevations of alkaline phosphatase and lactate dehydrogenase. Conclusion:PBSC mobilization with a single dose of pegfilgrastim is feasible for healthy donors. The graft composition was comparable to that obtained with the conventional regimen of short-term G-CSF. Long-term follow-up of healthy donors treated with pegfilgrastim should be further investigated. Disclosures:No relevant conflicts of interest to declare.

Successful Stem Cell Remobilization Using Plerixafor (Mozobil) Plus Granulocyte Colony-Stimulating Factor in Patients with Non-Hodgkin Lymphoma: Results from the Plerixafor NHL Phase 3 Study Rescue Protocol

In a phase 3 multicenter, randomized, double-blinded, placebo-controlled study of 298 patients with non-Hodgkin lymphoma (NHL), granulocyte colony-stimulating factor (G-CSF) plus plerixafor increased the proportion of patients who mobilized >or=5 x 10(6) CD34(+) hematopoietic stem cells (HSCs)/kg compared with placebo plus G-CSF (P < .001). Patients in either study arm who failed mobilization (< 0.8 x 10(6) CD34(+) cells/kg in 2 collections or <2 x 10(6) CD34(+) cells/kg in 4 collections) were eligible to enter the opened-label rescue protocol. Following a 7-day minimum rest period, these patients received G-CSF (10 microg/kg/day) for 4 days, followed by daily plerixafor (0.24 mg/kg) plus G-CSF and apheresis for up to 4 days. Of the 68 patients failing initial mobilization (plerixafor, n = 11; placebo, n = 57), 62 patients (91%) entered the rescue procedure (plerixafor, n = 10; placebo, n = 52). Four of 10 patients (40%) from the plerixafor group and 33 of 52 (63%) from the placebo group mobilized sufficient CD34(+) cells (>or= 2 x 10(6) cells/kg) for transplantation from the rescue mobilization alone (P = .11). Engraftment of neutrophils (11 days) and platelets (20 days) was similar to that in patients who did not fail initial mobilization, and all patients had durable grafts at the 12-month follow-up. Common plerixafor-related adverse events (AEs) included mild gastrointestinal (GI) effects and injection site reactions. There were no drug-related serious AEs. These data support that plerixafor plus G-CSF can safely and effectively remobilize patients with NHL who have failed previous mobilization.

Bortezomib Plus Melphalan and Prednisone as Induction Prior to Transplant or as Frontline Therapy for Non-Transplant Candidates in Patients with Previously Untreated Multiple Myeloma.

High-dose therapy plus autologous stem cell transplant (ASCT) is the standard of care for patients with multiple myeloma (MM) aged ≤65 years. Melphalan–prednisone (MP)-based therapy is the standard for non-ASCT candidates but is not typically used for transplant-eligible patients as prolonged therapy with melphalan can adversely affect stem cell collection. The phase 3 VISTA study demonstrated the superior efficacy of bortezomib plus MP (VMP) versus MP in previously untreated MM patients ineligible for ASCT. In this phase 2 study, we evaluated the efficacy of a shorter course of VMP on a different treatment schedule as induction therapy prior to ASCT or as frontline therapy in non- ASCT candidates. Patients aged ≥18 years with previously untreated MM received up to six 28-day cycles of bortezomib 1.3 mg/m2 IV, days 1, 4, 8, and 11, plus oral melphalan 6 mg/m2 and oral prednisone 60 mg/m2, days 1–7. After 2–6 cycles, ASCT-eligible patients could proceed to stem cell mobilization (G-CSF 10 mg/kg/day ± GM-CSF 250 mg/m2/ day or cyclophosphamide 4 g/m2 + GM-CSF) and conditioning with melphalan 200 mg/ m2 (140 mg/m2 if aged >65 years). Response was assessed every two cycles and post- ASCT by International Uniform Response Criteria. The primary end point was complete response (CR) rate to VMP. A total of 45 patients were enrolled; 27 were male. Median age was 63 years (range 33–75). MM subtype was 67% IgG, 16% IgA, and 9% each κ- and λ- light-chain; 37% of patients had ISS Stage III MM, 22% had ECOG performance status >1, and 70% had ≥40% plasma cells in bone marrow. In total, 20 patients proceeded to ASCT. Median duration of VMP was 4 cycles in both non-ASCT (range 1–6) and ASCT (range 2–6) patients. Response rate (best response) to VMP was 95% (42 of 44 evaluable patients), including 9% stringent CR (sCR), 9% CR (18% ≥CR [95% CI: 7%, 30%]), 27% very good partial response (VGPR), and 50% partial response (PR). Best response was achieved after cycle 2 in 10 patients, cycle 4 in 25 patients, and cycle 6 in 7 patients. All 20 ASCT patients had successful stem cell mobilization; median yield of CD34+ cells/ kg was 5.6 x 106 (range 2.3–12.2 x 106), in a median of 2 collection days. Post-transplant responses were 10% sCR, 20% CR, 55% VGPR, and 5% PR; the remaining 2 patients need further follow-up for response assessment. Response improved post-VMP to post-ASCT in 10 patients (6 PR to VGPR, 2 PR to CR, 2 VGPR to CR). After median follow-up of 14.0 months (range 7.4–47.7) and 14.6 months (range 8.2–42.9) in non-ASCT and ASCT patients, respectively, both median time to progression and progression-free survival were 19.8 months (95% CI: 14.3 months, not estimable [NE]) in non-ASCT patients and 27.9 months (95% CI: 14.6 months, NE) in ASCT patients. A total of 7 patients (5 non- ASCT, 2 ASCT) have died; 1-year survival rate was 82% (95% CI: 59%, 93%) in non- ASCT patients and 95% (95% CI: 69%, 99%) in ASCT patients. Most common grade 3/4 adverse events in all 45 patients during VMP therapy included peripheral neuropathy (24%), thrombocytopenia (20%), neutropenia (18%), and infection (9%). Only 1 patient had deep-vein thrombosis. In conclusion, VMP represents a highly effective therapy for previously untreated MM, with 45% of patients achieving VGPR or better, including 18% sCR/CR. Toxicities were predictable and generally manageable. Short-course VMP therapy did not negatively impact stem cell mobilization, supporting its use as induction therapy prior to ASCT. Very high post-transplant response rates were seen, with 85% of patients achieving ≥VGPR, including 30% sCR/CR. Since achievement of CR/VGPR is associated with improved long-term outcomes in MM, the preliminary outcome data presented here appear promising; however, longer follow-up is required.

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.

Unrelated-Donor PBSC Collection Facilitated by the NMPD, 1999–2005: Efficacy and Toxicities, Serious Unexpected Events, and Outcomes of Standard vs. Large Volume Collections.

Between 1999 and 2005 the NMDP conducted a prospective trial assessing the safety and efficacy of PBSC collection in >5000 healthy unrelated donors. Donors ranged in age from 18–60 and were mobilized with 10 ug/kg/d G-CSF on days 1–5 with collection on day 5 alone or days 5 and 6. 2400 donor collections (1999–2003) were analyzed in detail for efficacy and toxicity and 5334 collections (1999-June 2005) were reviewed for serious unexpected events. 90% of subjects underwent collection using peripheral access, with 10% requiring central catheter placement. Female donors required central access more frequently than males (20% vs 4%, p<0.001). G-CSF induced bone pain peaked on days 4–5 and was present in greater than 80% of donors, although severe bone pain occurred in at most 5% (Table 1). Grade 3–4 CALGB toxicities occurred in 136 donors (6%) and unexpected serious adverse events occurred in 30 (0.6%, Table 2). Median yield of CD34+ cells for the cohort was 27 x 106 cells/L processed (n=1776, range 0.7–236) on day +5 of G-CSF and 24 x 106 cells/L processed (n=1285, range 1–133) on day +6. Median CD34+ cell dose/kg recipient weight collected was 5 x 106/kg (n=1040, range 0.1–110) on day +5 of G-CSF and 3 x 106/kg (n=751, range 0.1–29) on day +6. Inadequate collections were rare with 5% and 6% of donors yielding <2 or ≥2 but <3 x 106 CD34+ cells/kg recipient weight, respectively (n=1001). The risk of toxicity was the same for standard (≤12L), intermediate (>12≤16L), and large (>16L) volume collections. Importantly, as volumes of apheresis in a single day increased, the yield of CD34+ cells/L processed was unchanged (median yield 27, 26, 28, and 29 x 106/L processed for <12L, ≥12<16L, ≥16<20L, ≥20L); day 5 collection, p =0.4). This resulted in similar outcomes measured in CD34 cells/kg recipient weight for large volume single day collections compared to standard volume 2 day collections. Platelet counts fell more with large compared to standard volume apheresis (change in platelets −83 vs −105 x 109/L, p<0.001), however, the drop in platelets over the course of 2 standard volume procedures was greater than a single large volume procedure (−131 vs −107 x 109/L, p<0.001). In summary, this large prospective trial shows that unrelated donor PBSC collection yields adequate CD34+ cell numbers with low, but measurable rates of significant toxicity. Single-day large vs two-day standard volume procedures resulted in similar cell yields without evidence of increased toxicity. With this data, centers can now more appropriately counsel unrelated adult donors regarding risks of PBSC donation. Large volume, single day collection is a safe and effective resource-sparing alternative to standard volume procedures.Table 2Unexpected Serious Adverse Events (N=30/5334, 0.6%)EventNausea, Vomiting, HeadacheBleeding/ThrombocytopeniaCitrate ToxicitySevere chest/back painOther: hypotension/ syncope/ rash/ viral illnessN123/343/11/1/1/1Table 1Acute G-CSF ToxicitiesG-CSF Day+12+3+4+5+6Any Bone Pain (n=2396)7%50%78%83%82%64%Severe Bone Pain (n=2277)2%<1%3%4%5%3%Grade 3–4 CALGB Toxicity* (n=2386)<1%<1%1%2%2%2%*136/2386 donors experienced the following grade 3–4 toxicities: 89 insomnia, 82 headache, 29 fatigue, 19 nausea, 10 vomiting, 10 anorexia, 8 flu symptoms, 2 myalgias, and 1 skin rash. 80 donors had 1 grade 3–4 toxicity, 26 had 2, 13 had 3, 9 had 4, 5 had 5, and 3 had 6.

PBPC collection techniques: standard versus large volume leukapheresis (LVL) in donors and in patients

Transplantations of autologous and allogeneic peripheral blood progenitor cells (PBPC) are able to assure a complete hematopoietic and immunologic reconstitution in patients. PBPC are collected by leukapheresis technique after prior mobilization therapy, but procedures and results remain still highly variable and are poorly characterized. An optimum regimen for PBPC collections has not yet been recommended, but 2–3 total blood volumes (TBV) of the donor or patient are regarded as a standard. Another promising technique is large volume leukapheresis (LVL) with processing of 3–6 TBV of donor or patient. The aim of this paper is to find the most efficient and safe collection technique for an individual donor or patient and, consequently minimize the number of procedures required. Finding the optimal collection procedure would be helpful while considering which method would be preferred in an individual donor or patient with respect to the result of mobilization, health state and required yield of CD 34+ cells for transplantation. We evaluated the results in a total of 134 standard and LVL procedures, which were performed in 21 well mobilized donors (Group I), in 65 well mobilized patients (Group II), and in 14 weakly mobilized patients (Group III) with hemato-oncological diseases. A precollection concentration of CD 34+ cells in peripheral blood higher than 20 × 10 3/mL was considered to be the criterion for efficient mobilization. Such levels of concentration indicating the start of PBPC collections could be easily reached in Group I of donors and Group II of well mobilized patients. Heavily pretreated patients at advanced stages of disease (Group III) did not respond to mobilization sufficiently and had a concentration of CD 34+ cells lower than 20 × 10 3/mL. LVL technique made it possible to obtain higher numbers of CD 34+ cells than in the standard collection in well mobilized donors (Group I), well mobilized patients (Group II), and even in weakly mobilized patients in Group III. In donors and well mobilized patients (Group I and Group II) it was possible to collect sufficient amounts of CD 34+ cells for allogeneic or for autologous transplantation from one LVL collection. The median yield of CD 34+ cells from one LVL collection was 5.5 × 10 6/kg b.w. in donors, and 6.0 × 10 6/kg b.w. in well mobilized patients. Due to the linear dependence of the yield of collected CD 34+ cells on the concentration of CD 34+ cells in blood, it can be used as a simple prediction of the success of collection in Group II (correlation coefficient 0.93 for standard procedures, and correlation coefficient 0.88 for LVL). In Group III of weakly mobilized patients the standard collections were usually ineffective and the relationship between the yield of CD 34+ cells/kg in the product and the precollection concentration of CD 34+ cells was much less significant (correlation coefficient 0.56 for standard procedures and correlation coefficient 0.66 for LVL). The median of CD 34+ cells collected from one standard procedure was only 0.7 × 10 6/kg but using LVL the median increased to 1.4 × 10 6/kg. Our results prove that the yield of CD 34+ cells in the product can be enhanced by large volume leukapheresis (LVL). Based on the results obtained, we recommend LVL in all donors and patients who can tolerate it due to a greater chance of collecting higher yields of progenitor cells while minimizing adverse reactions. LVL procedures should also be preferred in weakly mobilized patients where it is not possible to collect sufficient amounts of CD 34+ cells for transplantation using the standard regime. In weakly mobilized patients LVL provides a greater chance to at least collect a minimum amount of CD 34+ cells necessary. LVL should be used in circumstances where extremely high doses of CD 34+ cells has to be prepared, e.g. planned “tandem” transplantations or manipulations with a graft in which a significant loss of cells is expected.

Tempo of hematologic recovery correlates with peripheral blood CD34+ cell level in patients undergoing stem cell mobilization

This study was undertaken to evaluate the relationship between the time to recovery of peripheral blood counts and CD34+ cells in the peripheral blood (PB) and apheresis collections of patients undergoing intensive chemotherapy followed by rhG-CSF. Twenty-three patients with a median age of 42 years (range 17–64) with malignancies underwent peripheral blood stem cell (PBSC) collection after cyclophosphamide (CY) 4 g/m2 and etoposide (600 mg/m2) followed by rhG-CSF (10 μg/kg/day). The WBC, platelet counts, CD34+ cell counts per ml of PB, and CD34+ cells in apheresis products were followed in all patients. The relationship of the time to recovery of WBC >1,000/μl, >3,000/μl, >10,000/μl and platelets >20,000/μl and 50,000/μl was compared to the average daily CD34+ cells/ml in each patient using the Spearman Correlation test. The tempo of recovery of WBC and platelets were highly correlated with the average CD34+ cell count in blood. In order to derive some useful guidelines for the timing of apheresis, the patients were divided into two groups, early recover (ER) and late recover (LR) based on the median time (day 10) to reach WBC count greater than 1,000/μl. ER patients had an average daily PB CD34+ cell count of 9.04 × 104/ml (range 0.44–17.5) and a median yield of CD34+ cells of 10.43 × 106/kg (range 0.60–25.95) compared to LR patients, who had 1.87 × 104/ml (range 0.32–5.44) in the PB (P = .001) and a yield 3.20 × 106/kg CD34+ cells (range 0.037–9.39) (P = .001). Patients recovering their WBC to 1,000/ml within 10 days of completing this regimen may undergo PBSC collection and achieve minimum-target cell doses of >2.5 × 106 CD34+ cells/kg—100% of the time. J. Clin. Apheresis 13:1–6, 1998. © 1998 Wiley-Liss, Inc.

Peripheral-blood stem-cell collections after paclitaxel, cyclophosphamide, and recombinant human granulocyte colony-stimulating factor in patients with breast and ovarian cancer.

Here we evaluate Taxol (paclitaxel; Bristol-Myers Squibb, Princeton, NJ) and cyclophosphamide (CY) with recombinant human granulocyte colony-stimulating factor (rhG-CSF) for mobilization of peripheral-blood stem cells (PBSCs) for autologous stem-cell transplantation in patients with breast and ovarian cancer. PBSCs were collected from 17 patients with breast (n = 11), ovarian (n = 5), and gastric (n = 1) cancer after administration of Taxol (170 mg/m2 x 1) and CY (4 g/m2 x 1) followed by rhG-CSF (10 micrograms/kg/d). PBSC collections after Taxol and CY were compared with PBSC collections from nine patients with stage IV breast (n = 8) or stage III ovarian (n = 1) cancer who had received CY (4 g/m2 x 1) followed by rhG-CSF (16 micrograms/kg/d) for mobilization. Mean WBC and platelet counts on the first day of apheresis were 6.3 x 10(9)/L (range, 1.9 to 22.1) and 35 x 10(9)/L (range, 19 to 77), respectively. The median numbers of CD34+ cells, peripheral-blood mononuclear cells (PBMNC), and peripheral-blood total nucleated cells (PBTNC) collected were 13.02 x 10(6)/kg (range, 5.4 to 57.8; mean, 16.02), 6.86 x 10(8)/kg (range, 1.9 to 51.2), and 17.41 x 10(8)/kg (range, 2.4 to 106.6), respectively. In the comparison group, the median yield of CD34+ cells was 6.39 x 10(6)/kg (range, 0.2 to 28; mean, 10.01; P = .01). The mean daily yield of CD34+ cells/kg/collection was 3.5 (range, 0.8 to 28.9) after Taxol and CY, as compared with 1.3 (range, 0.1 to 7.0) for patients who received CY alone (P = .01). All patients who received CY and Taxol reached a target level of 5 x 10(6) CD34+ cells/kg, as compared with five of nine patients (55.5%) who received CY alone (P = .03). These data suggest that Taxol and CY followed by rhG-CSF mobilizes PBSCs in patients with advanced breast and ovarian cancer more effectively than this regimen without Taxol.