Peripheral Blood Progenitor Cell Harvests Research Articles

Effectiveness of supplemental oral calcium drink in preventing citrate-related adverse effects in peripheral blood progenitor cell collection

Peripheral blood progenitor cells (PBPCs) are a predominant graft source in allogeneic hematopoietic cell transplantation. Citrate-induced hypocalcemia remains the most frequent side effect of PBPC apheresis. Although the method for preventing severe adverse events is established, more efficient prophylaxis is required so that volunteer donors can donate PBPCs without pain and anxiety. We studied 80 healthy donors who underwent PBPC harvest between February 2014 and June 2020. Of these, 23 donors who underwent apheresis between February 2014 and December 2015 received only the standard prophylaxis of intravenous calcium gluconate. Oral calcium drinks were provided to 57 donors who underwent apheresis from January 2016 to June 2020 to supplement intravenous calcium gluconate prophylaxis. The ionized calcium (ICa) levels at multiple time intervals and the hypocalcemic symptoms were evaluated. Oral supplementation with a calcium drink maintained significantly higher ICa levels. Analysis using the inverse probability weighted regression adjustment method suggested that calcium drinks reduced the frequency of citrate-related reactions by 39.2 %. Administering a prophylactic oral calcium drink before apheresis with intravenous administration of calcium gluconate is promising to further reduce citrate-induced hypocalcemia in volunteer donors.

Safety and Toxicity Profile of Pembrolizumab (PEM) in Combination with ICE Chemotherapy Followed By Autologous Stem Cell Transplantation for Relapsed/Refractory Classical Hodgkin Lymphoma: No Impairment in Stem Cell Mobilization or Engraftment

Background: Despite excellent outcomes in the front-line management of classical Hodgkin lymphoma (cHL), patients with relapsed or refractory disease typically undergo second-line cytotoxic chemotherapy before proceeding to consolidation with autologous hematopoietic stem cell transplant (autoHSCT). Pre-transplant F18-FDG-PET imaging is a well-established predictor of outcomes following autoHSCT; a complete metabolic response (CMR) to second-line therapy defined as a Deauville score 1-3 predicts a favorable outcome and is a requirement for transplant at many centers. The PD-1 pathway plays an important role in the pathogenesis of cHL and checkpoint inhibition with agents including PEM and nivolumab have shown efficacy as monotherapy in heavily pretreated disease. We hypothesized that the addition of PEM to ICE (ifosfamide, carboplatin, and etoposide) chemotherapy will increase the rate of CMR by PET-CT prior to autoHSCT without impairing the mobilization of peripheral blood progenitor cells (PBPC) or engraftment. Here we present interim safety and toxicity data from this ongoing trial (NCT03077828) including the yields of PBPC mobilization and engraftment. Methods: Enrollment criteria include patients age >18 years medically fit for autoHSCT with relapsed/refractory cHL and excludes those with prior PD-1 inhibitor exposure, CNS involvement, more than 2 prior regimens or history of autoimmune disease. Patients are treated with 2 cycles of PEM 200 mg IV on day 1 in combination with ICE chemotherapy (ifosfamide 5000 mg/m2 day 2 CIV over 24hr, carboplatin AUC 5 IV day 2, etoposide 100 mg/m2 IV days 1-3) on a Q21 day cycle. PBPC mobilization and harvest are performed per institutional protocol on recovery post-cycle #2. A cycle of PEM 200 mg IV is then administered as monotherapy followed by response assessment with PET-CT. Patients with Deauville scores ≤3 proceed to autoHSCT per institutional protocol. A third cycle of PEM+ICE is optional following the PET-CT assessment. Neither the conditioning regimen nor management during transplantation is dictated by the protocol. Results: As of July 2019, 23 of 40 planned patients have evaluable safety and toxicity data. One patient had inconclusive pathology and was removed from study after one cycle of PEM-ICE but is included for this report. The median age was 32 (range 19-62) and 17 of 23 patients were females (74%). 8 patients were refractory to first-line therapy, and 9 relapsed within one year of treatment. 19 patients had received ABVD. Following protocol directed therapy, all but one patient had successful mobilization and collection; one had a severe allergic reaction to filgrastim and underwent bone marrow harvest instead. 16 patients collected in a single day of apheresis; the remainder collected within 4 days. The median number of stem cells harvested was 12.6 x 106 CD34+ cells/kg (range 4.2 - 46.1 x 106/kg). 3 patients underwent the 3rd cycle of PEM + ICE chemotherapy. 3 patients had Deauville scores >3 on FDG-PET response assessment; two had biopsies showing only benign processes and proceeded to transplant. Following stem cell reinfusion, all patients successfully engrafted, with a median time to absolute neutrophil and platelet recovery of 11 days (range: 9 - 24) and 12 days (range: 9 - 23), respectively. The combination of PEM + ICE chemotherapy was well tolerated. There were no reports of pneumonitis, colitis, hepatitis, or endocrinopathies. The most common toxicities were cytopenias, mucositis, diarrhea and febrile neutropenia. A single death on protocol was deemed secondary to advanced cardiovascular disease discovered mid-treatment during the patient's pre-transplant assessment. There was no clinical evidence to suggest an inflammatory process resulting in the cardiac arrest. Conclusions: The combination of PEM with ICE chemotherapy in relapsed / refractory cHL appears tolerable and safe. We found no significant hindrance to peripheral blood stem cell harvest and PEM- related AEs were uncommon. Additionally, pre-treatment with a checkpoint inhibitor prior to autoHSCT appears safe thus far and does not appear to delay engraftment. Disclosures Casulo: Celgene: Research Funding; Gilead: Honoraria, Other: Travel, accommodation, expenses; Roche: Other: Travel, accommodation, expenses. Karmali:Takeda, BMS: Other: Research Funding to Institution; Gilead/Kite; Juno/Celgene: Consultancy, Speakers Bureau; Astrazeneca: Speakers Bureau. Pro:Celgene: Consultancy, Honoraria; Takeda: Consultancy, Honoraria, Other: Travel Expenses; Kyowa Hakka Kirin: Consultancy, Honoraria; Seattle Genetics: Consultancy, Honoraria, Other: Travel Expenses, Research Funding. Mehta:Millennium/Takeda, Celgene; stock in Celgene, Bristol-Myers Squibb and Bluebird: Speakers Bureau. Gordon:Bayer: Other: Advisory Board; Juno/Celgene: Other: Advisory Board, Research Funding; Gilead: Other: Advisory Board; Zylem LLC: Other: co-founder; research in nanoparticles in cancer. Winter:Merck: Consultancy, Research Funding.

Filgrastim Biossimilar para Mobilização de Células Progenitoras antes do Transplante Autólogo: Análise Retrospectiva de Pacientes com Mieloma Múltiplo e Linfomas

Introdução: O filgrastim, que desempenha um papel fundamental na coleta de células progenitoras de sangue periférico (CPSP), está disponível há quase 25 anos, e existem vários biossimilares de filgrastim sendo comercializados. Objetivo: Avaliar se um filgrastim biossimilar (Filgrastine®) foi associado com mobilização efetiva em pacientes submetidos à coleta de CPSP para transplante autólogo de medula óssea. Método: Foram revisados os prontuários de pacientes com mieloma múltiplo e linfomas tratados em três instituições no Brasil. O desfecho primário (taxa de sucesso de mobilização) foi a proporção de pacientes na população intenção de tratar (ITT), em que pelo menos 2 x 106 células CD34+/kg foram coletadas por leucaférese nos dias 5 e/ou 6. A população per protocolo (PP) foi composta por pacientes que receberam pelo menos quatro dias de Filgrastine e tiveram pelo menos uma contagem de CD34+ nos dias 5 ou 6. Resultados: A dose diária de Filgrastine (no D1, com pequenas alterações subsequentes) variou de 8,5 a 28,9 mcg/Kg nos 52pacientes na população ITT, com uma mediana de 13,8 mcg/Kg; 51 pacientes receberam pelo menos quatro doses. Uma média de 2,84±1,97 x 106 células CD34+/kg foram coletadas. A taxa de sucesso de mobilização foi de 53,9% (IC 95%, 39,5% a 67,8%) na população ITT e 62,2% (IC 95%, 46,5% a 76,2%) nos 45 pacientes da população PP. A mobilização foi considerada efetiva pelos pesquisadores em 80,8% dos pacientes da população ITT e 88,9% daqueles na população PP. Conclusão: Apesar de sua natureza observacional, este estudo sugere que Filgrastine esteja associado com as taxas de sucesso esperadas na coleta de CPSP para transplante autólogo de medula óssea.

Anticoagulation in large-volume leukapheresis: comparison between citrate- versus heparin-based anticoagulation on safety and CD34 + cell collection efficiency

Little is known of the effect of anticoagulation on peripheral blood progenitor cell (PBPC) harvest during large-volume leukapheresis (LVL). Because of the interaction of heparin with stromal cell-derived factor (SDF)-1α, it has been proposed that a heparin-based anticoagulation may result in an increased PBPC collection efficiency compared with standard citrate-based anticoagulation. We conducted a prospective randomized trial to address the effect of both anticoagulation regimes on safety, subjective comfort and CD34 (+) collection efficiency in 90 adult patients undergoing standardized LVL. Anticoagulation consisted of either citrate (group C) or a combination of heparin and low-dose citrate (group H). The overall incidence of adverse reactions (AR) during LVL was 17%. AR consisted only of citrate-related AR; no bleeding complications were observed. Determination of parameters of the acid-base balance revealed a higher frequency of metabolic alkalosis in group C. Analysis of serum SDF-1α revealed no differences in SDF-1α plasma levels. There were no differences in the CD34 (+) cell collection efficiency, resulting in the harvest of equal CD34 (+) cell yields independent of the anticoagulation used. Our data show no clinical relevant effect of a heparin containing anticoagulation in terms of an increased overall CD34 (+) cell collection during LVL, although this regime shows some benefits in terms of the incidence and subjective tolerance towards AR. Based on our results the decision between a citrate- and heparin-substituted anticoagulation for LVL should be driven by patient-related factors, and should concern potential contraindications of both methods.

Remobilization with High Dose Methotrexate and Cytarabine in Patients with Non-Hodgkin Lymphoma and Multiple Myeloma Previously Failing Mobilization with Chemotherapy and Cytokine Treatment

Abstract 4402 BackgroundHigh-dose chemotherapy supported by autologous stem cell transplantation is a widely used therapeutic modality especially in patients with non-Hodgkin lymphomas (NHL) and multiple myeloma (MM). However, mobilization failure rates following first attempt are estimated to be between 5% and 30% and remobilization is required in those patients. Although plerixafor, a selective CXCR4 antagonist, is a promising agent for these purpose, mobilization with chemotherapeutic agents would be a hands-on option.°° Therefore we investigated the feasibility of high dose methotrexate and cytarabine with G-CSF as a remobilization regimen in those who failed a prior mobilization and collection with chemotherapy and G-CSF. Patients and methodsMobilization failure was defined as a collection of less than 5 × 106 CD34+ cells after 3–5 apheresis procedures. Methotrexate (3,500 mg/m2 in a 120 min infusion) on day 1 and cytarabine (3,000 mg/m2 infusion for 120 min) on day 4 and day 5 were followed by G-CSF. Supportive care and leucovorine rescue were done as standard protocol. Peripheral blood (PB) hematopoietic progenitor cells (HPCs) were counted with the Sysmex SE9000. PB progenitor cell harvest was initiated when HPC levels reached at least 5 per mm3. ResultsTotal 8 patients (6 NHL and 2 MM, median age: 55 years) who have failed in previous mobilization with conventional chemotherapy and G-CSF were tried again with high dose methotrexate, cytarabine and G-CSF. (table 1) Successful collection of CD34+ cells (> 5 × 106/kg) was achieved in six patients (75%). The total yield of CD34+ cells per kg of body weight harvested by 3 to 5 apheresis procedures was 6.28 × 106/kg (median; range, 1.53– 10.09 × 106/kg). (table 2) ConclusionHigh dose-MTX and cytarabine plus G-CSF may be a feasible chemotherapeutic regimen for stem cell mobilization in NHL and MM patients who have failed in previous mobilization with other type of chemotherapy and G-CSF.Table 1Patients characteristics and mobilization outcome (1st & 2nd °°mobilization)NAgeDiagnosisPrevious Treatmentprevious Mobilization regimen(1st)No. Of apheresis in 1st mobilizationTotal CD34+ yield (x106/kg ) in 1st mobilizationNo. Of apheresis in 2nd mobilizationTotal CD34+ yield (x106/kg ) in 2nd mobilizationCumulative CD34+ yield (x106/kg ) in 1st & 2nd mobilization148PTCLCHOP SMILESMILE44.0333.77.73257MZLRCVP ESHAPESHAP41.8845.337.21359MCLCHOP ESHAPESHAPHD Ara-C3,40.67, 1.5331.533.73454MMVAD PADCYC44.73410.0914.82564PTCLCHOP ESHAPESHAP20.647.017.61645DLBCLRCHOP ESHAPESHAP31.1257.738.85762MMVAD PADCYC43.7639.2112.97842EN NK/T cell lymphomaVIPDCYC53.1645.558.71Abbreviations: PTCL=Peripheral T-cell Lymphoma; MZL=Marginal Zone Lymphoma; MCL=Mantle Cell Lymphoma; MM=Multiple Myeloma; EN=extra nodal; DLBCL=Diffuse Large B-cell Lymphoma; CHOP=cyclophosphamide, doxorubicin, vincristine, prednisolone; SMILE=dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide; RCVP=rituximab, cyclophosphamide, vincristine, prednisolone; ESHAP=etoposide, methylprednisolone, cytarabine, cisplatin; VAD=vincristine, doxorubicin, dexamethasone; PAD=bortezomib, doxorubicin, dexamethasone; RCHOP=rituximab+CHOP; VIPD=etoposide, ifosfamide, cisplatin, dexamethasone; HD Ara-C=high dose cytarabine; CYC=cyclophosphamide; No.=number;Table 2Remobilization of CD34+ cells after HD-MTX and cytarabine plus G-CSFNApheresis 1Apheresis 2Apheresis 3Apheresis 4Apheresis 5Cumulative CD34+ yield (x106/kg)10.121.542.043.720.671.890.891.885.3330.290.760.481.5341.831.293.693.1810.0950.410.953.262.397.0160.390.471.871.543.467.7371.353.094.779.2181.121.272.021.145.55Median (range)0.54 (0.12−0.83)1.28 (0.47−3.09)2.03 (0.48−4.77)1.88 (1.14−3.18)3.46 (3.46)6.28 (1.53 – 10.09) Disclosures:No relevant conflicts of interest to declare.

The Era of High-Dose Chemotherapy for Breast Cancer: Revisiting a Troubled Quest

The Era of High-Dose Chemotherapy for Breast Cancer: Revisiting a Troubled Quest

Articular Cartilage Regeneration With Autologous Peripheral Blood Progenitor Cells and Hyaluronic Acid After Arthroscopic Subchondral Drilling: A Report of 5 Cases With Histology

The purpose of this study was to evaluate the quality of articular cartilage regeneration after arthroscopic subchondral drilling followed by postoperative intraarticular injections of autologous peripheral blood progenitor cells (PBPCs) in combination with hyaluronic acid (HA). Five patients underwent second-look arthroscopy with chondral core biopsy. These 5 patients are part of a larger pilot study in which 180 patients with International Cartilage Repair Society grade III and IV lesions of the knee joint underwent arthroscopic subchondral drilling followed by postoperative intra-articular injections. Continuous passive motion was used on the operated knee 2 hours per day for 4 weeks. Partial weight bearing was observed for the first 6 to 8 weeks. Autologous PBPCs were harvested 1 week after surgery. One week after surgery, 8 mL of the harvested PBPCs in combination with 2 mL of HA was injected intra-articularly into the operated knee. The remaining PBPCs were divided into vials and cryopreserved. A total of 5 weekly intra-articular injections were given. Second-look arthroscopy confirmed articular cartilage regeneration, and histologic sections showed features of hyaline cartilage. Apart from the minimal discomfort of PBPC harvesting and localized pain associated with the intra-articular injections, there were no other notable adverse reactions. Articular hyaline cartilage regeneration is possible with arthroscopic subchondral drilling followed by postoperative intraarticular injections of autologous PBPCs in combination with HA. Level IV, therapeutic case series.

Mobilization of hematopoietic progenitor cells with granulocyte colony stimulating factors for autologous transplant in hematologic malignancies

BackgroundIn 2006 the Hematology Service of Hospital Maciel published its experience with peripheral blood progenitor cell harvesting for autologous stem cell transplantation using Filgen JP (Clausen Filgrastim). After mobilization with a mean filgrastim dose of 78 mcg/Kg, 4.7 x 106 CD34+ cells/Kg were obtained by apheresis. Age above 50, multiple myeloma as underlying disease and a malignancy that was not in remission were identified as frequent characteristics among patients showing complex mobilization.ObjectiveThe aim of this study was to compare stem cell mobilization using different brands of filgrastim.MethodsOne hundred and fifty-seven mobilizations performed between 1997 and 2006 were analyzed. This retrospective analysis comparative two groups of patients: those mobilized with different brands of filgrastim (Group A) and those who received Filgen JP (Clausen Filgrastim) as mobilizing agent (Group B). A cluster analysis technique was used to identify four clusters of individuals with different behaviors differentiated by age, total dose of filgrastim required, number of apheresis and harvested CD34+ cells.ResultsThe mean total dose of filgrastim administered was 105 mcg/Kg, the median number of apheresis was 2 procedures and the mean number of harvested stem cells was 4.98 x 106 CD34+ cells/Kg. No significant differences were observed between Groups A and B regarding the number of apheresis, harvested CD34+ cells and number of mobilization failures, however the total dose of filgrastim was significantly lower in Group B.ConclusionsAmong other factors, the origin of the cytokine used as mobilizing agent is an element to be considered when evaluating CD34+ cell mobilization results.

Risk Factors for the Development of Secondary Malignancy After High-Dose Chemotherapy and Autograft, With or Without Rituximab: A 20-Year Retrospective Follow-Up Study in Patients With Lymphoma

High-dose chemotherapy with peripheral blood progenitor cell (PBPC) autograft is effective in high-risk lymphoma, particularly with the addition of rituximab; however, it is associated with risk of secondary malignancy. These issues have been addressed in a series of 1,347 patients with lymphoma treated with a high-dose sequential (HDS) program. A total of 1,024 patients with B-cell lymphoma, 234 patients with Hodgkin's lymphoma, and 89 patients with T-cell lymphoma were treated with HDS between 1985 and 2005 at 11 Gruppo Italiano Terapie Innovative Linfomi centers. HDS was given as salvage treatment to 707 patients (52%); 655 patients (49%) received a modified HDS, with high-dose cytarabine and two consecutive PBPC harvests. Rituximab-supplemented HDS was given to 523 patients (39%). At a median follow-up of 7 years, the median overall survival (OS) was 16.2 years; in B-cell lymphoma the OS was significantly superior with rituximab HDS compared to HDS alone. The cumulative incidence at 5 and 10 years of secondary myelodysplasia/acute leukemia (sMDS/AL) were 3.09% and 4.52%, respectively, that of solid tumors were 2.54% and 6.79%, respectively. Factors associated with sMDS/AL were male sex and use of the second harvest PBPC for the graft; factors found to be associated with solid tumor were advanced age, post-HDS radiotherapy, and rituximab addition to HDS. Despite the increased risk of solid tumors, rituximab addition to HDS was still associated with survival advantages. This analysis has relevant implications for the design and use of intensive chemoimmunotherapy with autograft. In addition, it offers useful insights toward the understanding and prevention of tumor development.

Influence of Prior Lenalidomide Exposure On Peripheral Blood Progenitor Cell Mobilization for Autologous Stem Cell Transplant in 144 Consecutive Patients with Multiple Myeloma.

Abstract 3223Poster Board III-160There are concerns that prolonged exposure to lenalidomide (len) impairs the peripheral blood progenitor cell (PBPC) yield in patients (pts) undergoing autologous peripheral blood stem cell transplant (ASCT) for multiple myeloma. To evaluate the effect of len on PBPC yield, we retrospectively analyzed 144 consecutive pts undergoing PBPC harvest prior to ASCT for multiple myeloma between July 1, 2007 and June 30, 2009. Exclusion criteria included prior ASCT or prior treatment with an alkylating agent. Of the evaluable patients, 67 pts received at least one cycle of len as part of their pre-harvest therapy (median # of cycles 4 (range 1-28)) and 63 received non-len containing regimens. Median age for all pts was 57 years and was similar between the two groups.Initial PBPC harvest was unsuccessful (defined as collection of <2.5 × 106 CD34+ cells/kg) in 6 of 52 (11.5%) G-CSF mobilized pts who had prior len exposure, compared to 4 of 49 (8.2%) non-len exposed pts mobilized with G-CSF (p = NS). One pt in each group underwent ASCT after collection of <2.5 × 106 CD34+ cells/kg and both engrafted normally. One other cyclophosphamide/G-CSF mobilized and len exposed pt failed initial harvest as well. Of the 11 total pts in whom initial PBPC harvest failed, a second attempt was successful in 10 (3 G-CSF/GM-CSF; 6 plerixafor/G-CSF; 1 cyclophosphamide/G-CSF) and not attempted in 1.The median number of PBPCs harvested in len exposed pts mobilized with G-CSF alone was 6.36 × 106 CD34+ cells/kg (range 2.1-20.62), compared to 8.22 × 106 CD34+ cells/kg (range 2.29-46.1) in non-len exposed pts mobilized with G-CSF alone (p=0.001 by Mann-Whitney test). Len treated pts required more apheresis sessions for adequate PBPC harvest (1.89 days vs 1.57 days (p<0.05)) than non-len treated pts when G-CSF was used alone as the mobilizing agent. Eleven (24%) of the len treated pts and 6 (13%) of the non-len treated pts were not able to collect ≥ 5.0 × 106 CD34+ cells/kg with G-CSF alone (p=0.42). Among 10 G-CSF mobilized pts who received >6 cycles (median # of cycles 11, range 7-28) of len prior to PBPC harvest, the median PBPC yield was 6.44 × 106 CD34+ cells/kg collected over a median of 2 days. Seven of the 10 collected enough PBPCs for two transplants. One pt receiving 7 cycles of len failed initial PBPC harvest with G-CSF alone and subsequently successfully harvested with plerixafor/G-CSF.Nineteen pts were initially mobilized for PBPC harvest with cyclophosphamide/G-CSF. Nine had prior len exposure (median # of cycles 4 (range 3-8)) and the PBPC yield for each pt was well above that required for tandem ASCT. There was no difference in the number of days to harvest between the len treated and non-len treated pts and most harvested in 1 apheresis attempt. One patient with 4 cycles of prior len therapy did not collect an adequate number of PBPCs but subsequently successfully harvested enough PBPCs for 2 ASCTs with plerixafor/G-CSF.In summary, most pts treated with len containing regimens prior to PBPC harvest were able to collect adequate numbers of PBPCs for tandem ASCT with G-CSF mobilization. All len treated pts in our series who failed G-CSF mobilization and underwent a second attempt at PBPC harvest using plerixafor/G-CSF or cyclophosphamide/G-CSF as the mobilizing agent were able to successfully harvest adequate numbers of PBPCs for ASCT. In this retrospective review, the difference in PBPC yield between len treated and non-len treated pts did not impact the ability to proceed to ASCT. DisclosuresOff Label Use: Cyclophosphamide for stem cell mobilization. Zonder:Millennium: Research Funding; Amgen, Pfizer, Cephalon: Consultancy; Millennium, Celgene: Speakers Bureau. Abidi:Millennium: Speakers Bureau; Amgen, Merck: Research Funding; Genzyme, Millennium: Consultancy.

BIOEQUIVALENCE of a BIOSIMILAR FILGRASTIM and REFERENCE FILGRASTIM: IMPACT ON the MOBILIZATION of CD34+ PERIPHERAL BLOOD PROGENITOR CELLS in a RANDOMIZED, PHASE I STUDY.

Abstract 4564 BackgroundGranulocyte colony-stimulating factor (G-CSF) stimulates the proliferation and differentiation of hematopoietic stem and progenitor cells. Recombinant human G-CSF (filgrastim) was developed by Amgen to enhance mobilization of peripheral blood progenitor cells (PBPCs) prior to autologous or allogeneic hematopoietic stem/progenitor cell transplantation. After the patent expiry of Amgen filgrastim (Neupogen®), Hospira developed a biosimilar filgrastim. Preclinical and phase I studies supported the bioequivalence of Hospira filgrastim and Amgen filgrastim in terms of their physicochemical, pharmacokinetic and pharmacodynamic characteristics (Skrlin A, et al. EHA 2009, Abstract 0568; Waller CF, et al. EHA 2009, Abstract 0562). Here we compare the impact of Hospira filgrastim and Amgen filgrastim on CD34+ PBPC mobilization in a randomized, double-blind phase I study. AimTo demonstrate the bioequivalence of Hospira filgrastim and Amgen filgrastim with respect to the mobilization of CD34+ PBPCs. MethodsHealthy, male or female volunteers aged 18–50 years were enrolled at Charles River Clinical Services, Edinburgh, UK, between 2 November 2006 and 24 January 2007. Using a computer-generated randomization list, volunteers were first randomized to 5μg/kg or 10μg/kg dose groups, before further randomization to order of agent administration. Subcutaneous injections of Hospira filgrastim or Amgen filgrastim were administered under double-blind conditions on five consecutive days (days 1–5), with crossover to the alternative agent after a washout period of ≥13 days. Blood samples were taken at day 1 (pre dose), day 3 (6 hours [h] post dose), day 5 (6 h post dose), day 7 (48 h post dose) and day 10 (120 h post dose). Mean CD34+ cell counts were evaluated by flow cytometry and bioequivalence was assessed using a mixed effects analysis of variance model. Bioequivalence was concluded if the 90% confidence intervals (CI) for the ratio of ‘test' (Hospira filgrastim) to ‘reference' (Amgen filgrastim) mean CD34+ cell counts at day 5 were completely within the conventional bioequivalence limits of 0.80–1.25. ResultsTwenty-four volunteers were randomized to the 5μg/kg group and 26 to the 10μg/kg group. At both doses, CD34+ cell counts were similar with Hospira filgrastim and Amgen filgrastim across all time points. Regardless of agent or dose, mean CD34+ cell count at day 1 was 2.2–2.8 cells/μl, increasing to a maximum count at day 5. In the 5μg/kg group, mean CD34+ cell count at day 5 (n=24) was 47.2 cells/μl (95% CI: 36.1, 61.7) with Hospira filgrastim and 46.0 cells/μl (95% CI: 33.6, 63.0) with Amgen filgrastim. In the 10μg/kg group, mean CD34+ cell count at day 5 (n=23) was 81.9 cells/μl (95% CI: 64.5, 104.0) with Hospira filgrastim and 77.5 cells/μl (95% CI: 59.4, 101.3) with Amgen filgrastim (Figure 1). At both doses, 90% CIs for the ratios of test to reference mean CD34+ cell counts at day 5 were within the predefined range required to demonstrate bioequivalence. The incidence of adverse events (AEs) was slightly lower with Hospira filgrastim than with Amgen filgrastim at both doses (5μg/kg, 79 vs 83%; 10μg/kg, 77 vs 92%). The most frequently reported AEs of any severity (mild/moderate/severe) with each agent at each dose were back pain (38–62%) and headache (44–58%), which could be treated with standard analgesics. ConclusionsHospira filgrastim and Amgen filgrastim are similar in their ability to stimulate mobilization of CD34+ PBPCs. These data add to a growing body of evidence in support of the bioequivalence of these agents. Hospira filgrastim may provide a useful alternative to Amgen filgrastim as a growth factor to support PBPC mobilization and transplantation. The bioequivalence of these agents may enable Hospira filgrastim to be used without the need to adapt PBPC harvesting protocols. The continued clinical development of Hospira filgrastim is warranted. AcknowledgmentsMedical writing support provided by Hannah FitzGibbon (GeoMed) with financial support from Hospira. [Display omitted] Disclosures:Bronchud:Hospira UK Ltd: Consultancy. Waller:Hospira UK Ltd: Consultancy. Off Label Use: Hospira filgrastim is a biosimilar filgrastim that is in clinical development for the treatment of neutropenia associated with cytotoxic chemotherapy.. Mair:Charles River Clinical Services: Employment. Challand:Hospira UK Ltd: Employment.

Brazilian experience using high dose sequential chemotherapy followed by autologous hematopoietic stem cell transplantation for malignant lymphomas

ObjectiveTo evaluate the use of high-dose sequential chemotherapy in a Brazilian population.MethodsHigh-dose cyclophosphamide followed by autologous hematopoietic stem cell transplantation is an effective and feasible therapy for refractory/relapsed lymphomas; this regimen has never before been evaluated in a Brazilian population. All patients (106 with high-grade non-Hodgkin lymphoma and 77 with Hodgkin's lymphoma) submitted to this treatment between 1998 and 2006 were analyzed. Chemotherapy consisted of the sequential administration of high-dose cyclophosphamide (4 or 7 g/m2) and granulocyte-colony stimulating factor (300 µg/day), followed by peripheral blood progenitor cell harvesting, administration of etoposide (2g/m2) and methotrexate (8 g/m2 only for Hodgkin's lymphoma) and autologous hematopoietic stem cell transplantation.ResultsAt diagnosis, non-Hodgkin lymphoma patients had a median age of 45 (range: 8-65) years old, 78% had diffuse large B-cell lymphoma and 83% had stage III/IV disease. The Hodgkin's lymphoma patients had a median age of 23 (range: 7-68) years old, 64.9% had the nodular sclerosis subtype and 65% had stage III/IV disease. Nine Hodgkin's lymphoma patients (13%) and 10 (9%) non-Hodgkin lymphoma patients had some kind of cardiac toxicity. The overall survival, disease-free survival and progression-free survival in Hodgkin's lymphoma were 29%, 59% and 26%, respectively. In non-Hodgkin lymphoma, these values were 40%, 49% and 31%, respectively. High-dose cyclophosphamide-related mortality was 10% for Hodgkin's lymphoma and 5% for non-Hodgkin lymphoma patients. High-dose cyclophosphamide dosing had no impact on toxicity or survival for both groups.ConclusionsDespite a greater prevalence of poor prognostic factors, our results are comparable to the literature. The incidence of secondary neoplasias is noteworthy. Our study suggests that this approach is efficient and feasible, regardless of toxicity-related mortality.

Peripheral blood progenitor cell collection without close monitoring of peripheral blood CD34+ cells: A feasible strategy for multiple myeloma or pre-treated Non-Hodgkin’s Lymphoma patients mobilized with low-dose cyclophosphamide plus G-CSF

Background Daily monitoring of peripheral blood CD34+ cells may not be necessary for all patients with hematologic malignancies for adequate peripheral blood progenitor cells (PBPC) mobilization and harvesting. We therefore designed a regimen for PBPC mobilization in patients with multiple myeloma or pre-treated Non-Hodgkin’s lymphoma based on a combination of low-dose cyclophosphamide (Cy) plus granulocyte colony-stimulating factor (G-CSF) without daily monitoring of peripheral blood CD34+ cells. Study design and methods A prospective study was performed on patients with multiple myeloma ( n = 22) or pre-treated Non-Hodgkin’s lymphoma ( n = 17) whose PBPC were harvested according to the following regimen: 1.5 g/m 2 Cy at day 1, 12 μg/kg/day G-CSF from day +7 to +11 avoiding daily monitoring of peripheral blood CD34+ cells and two consecutive leukapheresis at days +12 and +13. The optimum threshold of 2 × 10 6 CD34+ cells per kg was established. Results The proportion of patients with higher CD34+ cell yield after two leukapheresis was similar: multiple myeloma (16/22–72.7%) and Non-Hodgkin’s lymphoma (12/17–70.6%). Exposure to radiotherapy and greater than two prior chemotherapy regimens were significantly associated with lower yield in multiple myeloma ( p = 0.002) and Non-Hodgkin’s lymphoma patients ( p = 0.002), respectively. Conclusion Our data suggested that adequate yields of CD34+ cells may be achieved in multiple myeloma or pre-treated Non-Hodgkin’s lymphoma mobilized with low-dose Cy plus G-CSF regardless of the daily monitoring of peripheral blood CD34+ cells.

Peripheral Blood Progenitor Cell Collection in Low-Weight Infants (36 patients; 69 Large Volume Leukapheresis Procedures)

Peripheral blood progenitor cells (PBPC) have increasingly become the preferred source of stem cells for autologous transplantation due to their easier accessibility, rapid engraftment and higher safety. The harvest of PBPC in paediatric patients assumes critical importance, particularly in low-weight infants, in whom optimizing the procedure allows the collection of sufficient number of cells, with a reduced number of leukapheresis. The published data of these low-weight patients are scarce, and very likely the accumulation of cases will contribute to optimize the procedure.In this single centre study we retrospectively analyzed data of 69 large volume leukapheresis (LVL) from 36 low weight (< 20Kg) paediatric patients between January 1998 and April 2008. Primary diagnosis included several malignancies: neuroblastomas (21 cases), meduloblastomas (4 cases), acute leukaemia (4 cases), retinoblastoma (2 cases) and other 5 cases with various solid tumours. All the LVL procedures underwent with a continuous flow blood separator (COBE Spectra) after priming the extracorporeal line with red blood cells and acid-citrate-dextrose (ACD) was used as the anticoagulant.Mean body weight was 15,78kg (ranging 9–19Kg), and a median age of 44 months (ranging 7–88 months). Blood withdrawn at a mean rate of 33,8 mL/min (standard deviation [SD] 8,0), through central vein catheters and using 4 volemias (one case with 3), lasting a mean 133,43 minutes/procedure (ranging 212–101 min). A mean of 4881,78 ml of blood was processed (ranging 2101–7327mL).Leukapheresis was performed on the fifth day of G-CSF stimulation in most of the procedures (66,7%), while 21 patients were submitted to stimulation for a longer period (18,8% with 6 days, 7,2% with 7 days and 4,3% with eight). The mean G-CSF dose used was 203,06 μg/d (ranging 105–400 μg/d).The mean number of CD34+ cells in peripherical blood, before leukapheresis, was 20,4 ×106 cells (ranging 1–216 ×106 cells), while the PBPC collection yielded 2,73 ×106 CD34+/Kg (ranging 0,1–28,94 ×106 CD34+/Kg).The majority of LVL procedures (53,6%) were initiated with a peripherical blood CD34+ count inferior to 15×106 cells. Only 33,3% of each LVL procedure harvest sufficient PBPC (> 2,5 ×106 CD34+/Kg), most of which from patients with peripherical blood CD34+ count superior to 15×106 cells (59,4%). There is a significant correlation between peripherical blood CD34+ count, before leukapheresis, and collected PBPC CD34+ (Pearson chi-square 18,212; p<0,01).Every patient underwent a mean of 1,9 apheresis procedures (range 1–5), 20 patients required only a single apheresis to collect the minimum requirement of CD34+/Kg, 6 patients underwent leukapheresis on two consecutive days, while 7 patients required a second course of mobilization with G-CSF in the following month, to achieve the necessary amount of CD34+ cells.The leucocyte count variation during the procedure was + 8,12 cells/μL (18,37 [SD 9,0]–26,49 cells/μL [SD 28,6]); the platelet (plt) count variation was negative 63,78 ×103 plt/μL (145 [SD 78,5]–81,53×103 plt/μL [SD 39,47]); the haemoglobin count variation was negative 1,45 g/dL (9,79 [SD 1,35]–8,34 g/dL [SD 1,49]). There were no significant differences between heart rate (105,86 [SD 22,9]–113,31 bpm [SD 22,5]) and systolic blood pressure before and after the procedure (114,28 [SD 12,54]–108,38 mmHg [SD 15,72]).There were adverse events in 14,5% of LVL procedures, most of them related with symptomatic hypocalcaemia (6 cases), corrected with calcium injection. Two cases of catheter malfunctioning were reported, one of them associated with haemodinamic instability. There was also a case of high blood pressure peak with no haemodinamic instability and another case with vomiting. All these patients underwent PBPC collection, in the following days.Twenty five percent of the cases needed transfusion support, with 9 cases requiring blood transfusion, and 8 cases requiring platelet transfusion (platelet count fell below 50×103 plt/μL).Nineteen patients underwent autologous transplantation, using the collected cells. There were no incidents regarding the storage of the PBPC.In conclusion, harvesting PBPC in small children is effective and safe, as this data shows. Future publications will allow to gather the necessary experience in order to optimize this procedure.

Predictors for Successful Mobilization of Peripheral Blood Progenitor Cells with ESHAP+G-CSF in Patients with Pretreated Non-Hodgkin's Lymphoma

ESHAP (etoposide/methylprednisolone/cytarabine/cisplatin) plus granulocyte-colony stimulating factor (G-CSF) is an effective regimen of therapy for advanced non-Hodgkin's lymphoma (NHL) and peripheral blood progenitor cell (PBPC) mobilization. However, the timing of PBPC harvest following immobilization and factors to predict optimal PBPC yield remain to be explored. We herein analyzed the factors potentially correlated to optimal PBPC mobilization. Twenty patients with pretreated advanced NHL were recruited and mobilized with ESHAP + G-CSF followed by 2 leukaphereses, which were initiated once the white blood cell count (WBC) in peripheral blood exceeded 10 x 10(9)/L. Total CD34+ cells collected by 2 leukaphereses were > 2 x 10(6)/kg body weight in 16 patients; between 1.0 and 2.0 x 10(6)/kg in another 3, and < 1 x 10(6)/kg in the remaining 1 patient. The pre-leukapheresis peripheral blood CD34+ cell counts, available for 28 leukaphereses, correlated linearly with the CD34+ cell yields (r2 = 0.870, p < 0.001). The CD34+ cell yield with pre-leukapheresis peripheral blood CD34+ cell count > or = 50 x 10(6)/L was higher than that with < 50 x 10(6)/L (5.60 +/- 4.32 vs. 0.96 +/- 0.56 x 10(6)/kg/leukapheresis; p = 0.004). Other factors predictive of favorable PBPC yield included preceding chemotherapy cycles < 6 and peripheral blood WBC > 3,500/microL on the day of mobilization chemotherapy (p = 0.032 and 0.013, respectively). The pre-leukapheresis peripheral blood CD34+ cell count correlates well with PBPC yields. Less than 6 chemotherapy cycles before mobilization and adequate peripheral blood WBC before mobilization chemotherapy also predict a favorable PBPC yield.

Factors Associated with Successful Mobilization of Progenitor Hematopoietic Stem Cells Among Patients with Lymphoid Malignancies

PurposeThis study's main aim was to assess the effect of 2 mobilization regimens (granulocyte colony-stimulating factor [G-CSF] and chemotherapy vs. G-CSF alone) on the yield of CD34+ cells in the apheresis components of patients with lymphoid malignancy. We also sought to identify possible predictors of CD34+ cell yield in the apheresis components. Patients and MethodsCD34+ cells were mobilized and harvested from 89 patients with non-Hodgkin lymphoma (n = 62) or Hodgkin disease (n = 27). Forty-one patients (46.1%) were mobilized with G-CSF, and 48 (53.9%) were mobilized with chemotherapy and G-CSF. Univariate and multivariate analyses were used to examine potential predictors of the CD34+ cell yield (collection of > 2.7 > 106 cells/kg), such as the number of peripheral CD34+ cells, age, sex, diagnosis, disease stage, weight, bone marrow status at baseline, mononuclear cells, white blood cells, and platelet counts. ResultsThe median patient age was 41 years (range, 12-66 years), and the median patient weight was 72 kg (range, 44-123 kg). Mobilization of peripheral blood progenitor cells (PBPCs) was superior when using chemotherapy and G-CSF versus G-CSF alone (3.6 > 106 cells/kg vs. 2.2 > 106 cells/kg; P = .001). CD34+ cell counts and platelet counts in the peripheral blood significantly correlated with CD34+ yield (P < .01 and P = .009, respectively). The yield was also significantly affected by weight, diagnosis, mobilization regimen, and baseline bone marrow status (P = .021, P = .05, P = .002, and P = .043, respectively). ConclusionMany factors influence harvesting of PBPCs, including diagnosis, bone marrow status at baseline, patient weight, and the type of mobilization regimen. The number of CD34+ cells in the peripheral blood can be used to predict the timing of apheresis and optimize yield.

Platelet count is a sensitive predictor of autologous peripheral blood progenitor cell collection yield in previously treated plasma cell disease patients

It is often a clinical dilemma to determine when to collect autologous peripheral blood progenitor cells (PBPCs) in patients who received prior chemotherapy. It is also challenging to predict if the collected cells will be enough for one or two transplants. A total of 103 PBPC donors were followed to evaluate factors that predict poor autologous PBPC collection. The donors were categorized into three groups: plasma cell disorders (PCDs), lymphomas, and normal allogeneic donors. Our evaluation showed that platelet (PLT) count before growth factor administration significantly correlated with total CD34+ cell yield (Spearman r = 0.38, p < 0.001). Further analysis showed this correlation was only significant in plasma cell disease patients who received prior chemotherapy (Spearman r = 0.5, p = 0.008). Baseline PLT counts did not correlate with PBPC collection yield in untreated PCD, lymphoma, and normal allogeneic donors. In addition, daily PLT count during PBPC harvest correlated with CD34+ cell yield for that day (Spearman r = 0.41, p < 0.001). With a multiple linear regression model (adjusted R(2) = 0.31, AIC = 63.1), it has been determined that the baseline PLT count significantly correlates with total CD34+ cell yield in treated PCD patients. Baseline PLT count is a sensitive indicator of autologous PBPC mobilization in PCD patients who received prior chemotherapy. This finding may be considered before growth factor administration to determine the optimal period to mobilize treated PCD patients and to predict if enough cells can be collected for one or two transplants.

Patients with aaIPI 2-3 Diffuse Large B-Cell Lymphoma Achieve 75% Long-Term Survival Following First-Line Rituximab-Supplemented High-Dose Sequential Chemotherapy and Autograft: Final Results of the Prospective Phase II GITIL (Gruppo Italiano Terapie Innovative nei Linfomi) Trial.

Background The outcome of Diffuse Large B Cell Lymphoma (DLB-CL) has been definitely improved by the addition of the anti-CD20 rituximab to conventional chemotherapy. However, despite the advantages offered by rituximab, results are still disappointing in patients presenting with adverse prognostic factors. For these patients, rituximab-supplemented intensive programs with autograft might represent a suitable option. Thus, a prospective multicenter study has been performed using first-line the Rituximab-supplemented high-dose sequential chemotherapy program delivered with multiple autologous peripheral blood progenitor cell (PBPC) support (R-HDS-maps regimen), in DLB-CL patients with score 2 or 3 according to the age-adjusted International Prognostic Index (aaIPI). Preliminary results have been already reported (ASH 2005; Leukemia 2007, 21: 1802). Updated results after a prolonged follow-up are here presented.Methods. R-HDS-maps includes:i.3 APO courses;ii.sequential administration of hd-cyclophosphamide (CY), hd-Ara-C, both supplemented with Rituximab, hd-etoposide/Cisplatin, with PBPC harvests following hd-CY and hd-Ara-C;iii.hd-Mitoxantrone/L-Pam + 2 further Rituximab doses;iv.involved-field radiotherapy.PBPC rescue was scheduled following Ara-C, etoposide/Cisplatin and Mitoxantrone/L-Pam. Six GITIL Centers participated in the multicenter study, with patients enrolled between November 1999 and September 2004.Results. Overall, 112 consecutive patients (74 score 2, 38 score 3) entered the study protocol. There were 5 early toxic deaths (3 sepsis, 1 pneumonia, 1 JC-virus leucoencephalopathy) + one late toxic death due to pneumonia, at 10 mos.; two more patients died for secondary myelodysplastic syndrome at 3.4 and 3.6 yrs. As reported in Figures 1–2, at a median follow-up of 59 mos., 86 patients (77%) are alive; 79 (70%) are in continuous CR, with a 5-yr event-free survival (EFS) projections of 69%; no significant differences in OS and EFS between subgroups with Germinal-Center and Activated B-cell phenotype were observed.Conclusions. R-HDS-maps regimen:i.is feasible in a multicenter setting, with a toxicity similar to that of other dose-intense/high-dose regimens;ii.offers prolonged survival to most patients with aaIPI 2–3 DLB-CL.Its comparative efficacy versus R-CHOP-14 is being tested in an ongoing GITIL phase III study. [Display omitted] [Display omitted]

Prolonged survival in poor-risk diffuse large B-cell lymphoma following front-line treatment with rituximab-supplemented, early-intensified chemotherapy with multiple autologous hematopoietic stem cell support: a multicenter study by GITIL (Gruppo Italiano Terapie Innovative nei Linfomi)

A prospective multicenter program was performed to evaluate the combination of rituximab and high-dose (hd) sequential chemotherapy delivered with multiple autologous peripheral blood progenitor cell (PBPC) support (R-HDS-maps regimen) in previously untreated patients with diffuse large B-cell lymphoma (DLB-CL) and age-adjusted International Prognostic Score (aaIPI) score 2-3. R-HDS-maps includes: (i) three APO courses; (ii) sequential administration of hd-cyclophosphamide (CY), hd-Ara-C, both supplemented with rituximab, hd-etoposide/cisplatin, PBPC harvests, following hd-CY and hd-Ara-C; (iii) hd-mitoxantrone (hd-Mito)/L-Pam + 2 further rituximab doses; (iv) involved-field radiotherapy. PBPC rescue was scheduled following Ara-C, etoposide/cisplatin and Mito/L-Pam. Between 1999 and 2004, 112 consecutive patients aged <65 years (74 score 2, 38 score 3) entered the study protocol. There were five early and two late toxic deaths. Overall 90 patients (80%) reached clinical remission (CR); at a median 48 months follow-up, 87 (78%) patients are alive, 82 (73%) in continuous CR, with 4 year overall survival (OS) and event-free survival (EFS) projections of 76% (CI 68-85%) and 73% (CI 64-81%), respectively. There were no significant differences in OS and EFS between subgroups with Germinal-Center and Activated B-cell phenotype. Thus, life expectancy of younger patients with aaIPI 2-3 DLB-CL is improved with the early administration of rituximab-supplemented intensive chemotherapy compared with the poor outcome following conventional chemotherapy.

Low doses of GM-CSF (molgramostim) and G-CSF (filgrastim) after cyclophosphamide (4 g/m2) enhance the peripheral blood progenitor cell harvest: results of two randomized studies including 120 patients

The use of a combination of G-CSF and GM-CSF versus G-CSF alone, after cyclophosphamide (4 g/m2) was compared in two randomized phase III studies, including 120 patients. In study A, 60 patients received 5 x 2 microg/kg/day of G-CSF and GM-CSF compared to 5 mug/kg/day of G-CSF. In study B, 60 patients received 2.5 x 2 microg/kg/day G-CSF and GM-CSF compared to G-CSF alone (5 microg/kg/day). With the aim to collect at least 5 x 10(6)/kg CD34 cells in a maximum of three large volume leukapherises (LK), 123 LK were performed in study A, showing a significantly higher number of patients reaching 10 x 10(6)/kg CD34 cells (21/29 in G+GM-CSF arm vs 11/27 in G-CSF arm, P=0.00006). In study B, 109 LK were performed, with similar results (10/27 vs 15/26, P=0.003). In both the study, the total harvest of CD34 cells/kg was twofold higher in G-CSF plus GM-CSF group (18.3 x 10(6) in study A and 15.85 x 10(6) in study B) than in G-CSF group (9 x 10(6) in study A and 8.1 x 10(6) in study B), a significant difference only seen in multiple myeloma, with no significant difference in terms of mobilized myeloma cells between G-CSF and GM-CSF groups.