Peripheral Blood Progenitor Cells Infusion Research Articles

Use of Romiplostim to Facilitate Platelet Engraftment in Allogeneic Hematopoietic Transplantation

Abstract 1947 Background:Thrombocytopenia requiring platelet transfusions is a constant in the hematopoietic transplantation (HT). In some situations, like the adult non-related donor and cord blood HT, the platelet engraftment is delayed for a long time. Hemorrhagic cystitis, venooclusive disease, graft-vs-host disease could to worse these procedures with a very high risk of bleeding and to increase the transplantation morbi-mortality. The agonists of thrombopoietin receptor (TRAs) have demonstrated to increase the platelet production in different pathological situations, like in the ITP and MDS patients. Thus, these new drugs could have a potential benefit in other clinical situations with low platelet production. Methods:We describe our experience in seven patients with Allogeneic HT using Romiplostim (NPlate®, Amgen Inc.), a parenteral TRA peptide, to accelerate the platelet engraftment or to increase the platelet level in the thrombocytopenia induced by HT conditioning or HT related complications. We have administrated Romiplostim in a compassionate basis (off-label). In all cases the drug was administered subcutaneously at a dose of 250 mcg. Most of the patients received only one dose, with the exception of patients #1 and 7, whom received two doses separated by seven days. The first case, a woman diagnosed as Acute Lymphoblastic Leukemia (ALL) with severe HLA platelet refractoriness acquired in the induction and consolidation chemotherapy treatments previous to HT, received two doses of 250 mcg of Romiplostim on days +4 and +12 after peripheral blood progenitor cells infusion from an HLA matched brother. Results:In the first case, a rapid and sustained platelet level increase was obtained, without platelet transfusional support. Encouraged by this successful result, we have used Romiplostim in six more patients with platelet refractoriness to platelet transfusions with or without bleeding. In all the patients the spleen was present. The patient #6, obtained a previous platelet engraftment that was loosed with the beginning of severe cGVHD. (see table) Conclusion:The use of Romiplostim could be very useful in HT complicated by severe platelet transfusions refractoriness. Our data encourages the realization of a randomized prospective study with this drug in HT.#Sex AgeDiagnosis DateBaseline plateletsHT type Rationale for NPlate@Platelets on day +14 after administrDate day 0 HTDays after day 0 (Date administration)DosesResponse1♀ALL6PBC HLA matched brother11416/Dec/2009+5 & +122Yes56August 2009PSR(21 & 28/Dec/2009)2♂CMML3Cord Blood (3°)323/Feb/2010+12 (12/Jul/2010)2 (†)NO*58March 2006SSR3♂ALL19PBC MRD13129/Jun/2010+82 (04/Jan/2011)1Yes35April 2010aGVHD Delayed platelet engraft4♂AML14Cord Blood SSR3419/Jan/2011+29 (18/Feb/2011)1Yes21March 20065♂ALL22ANR14509/Feb/2011+11 (20/Feb/2011)1Yes18April 2010SSR6♀NHL23Alog MDR PBSC18023/Feb/2010+363 (21/Feb/2011)1Yes34August 2007VOD + Pneumonia ICU Bleeding34August 2007VOD + Pneumonia ICU Bleeding18023/Feb/2010+363 (21/Feb/2011)1Yes7♂AML4Cord Blood12505/Apr/2011+8 & +142Yes*49July 2010VOD+Hemorrhagic cystitis+Sepsis Gram-SSR(14 & 19/Apr/2011)Abbreviations: ALL: Acute Lymphoblastic Leukemia; AML: Acute Myeloblastic Leukemia; aGVHD: Acute Graft-vs-host disease, cGVHD: Chronic Graft-vs-host disease; ANR: Adult non-related; CMML: Chronic Myelomonocytic Leukemia; ICU: Intensive Care Unit; MRD: “Mismatched Related Donor “: 1 locus; NHL: Non-Hodgkin Lymphoma; PBSC: Peripheral blood stem cell; PSR: Primary severe HLA platelet refractoriness; SRR: Secondary severe platelet refractoriness; † death. VOD: venooclusive disease; * Patient # 2 received platelet transfusional support every 12 hours from the Romiplostim administration, patient #7 a daily platelet transfusion until the day +14 post-day 0 and the rest without platelet transfusional support from Romiplostim administration day. Number of platelets x109/LGraphic evolution of platelet count over time is depicted in the next figure: [Display omitted] Days after Romiplostim administration. Number of platelets x109/L. Disclosures:Ojeda:Amgen Inc.: Consultancy, Honoraria. Off Label Use: Romiplostim (Nplate)is an agonist of thrombopoietin receptor (TRAs) that have demonstrated to increase the platelet production in different pathological situations, like in the ITP and MDS patients.

High-dose sequential chemotherapy (HDSC) with peripheral blood progenitor cells (PBPC) support for high-risk breast cancer (BC)

11026 Background: Recent reports suggest that intensified adjuvant chemotherapy with stem cell support improve disease free (DFS) and overall survival (OS) in subgroups of patients with high risk BC. We retrospectively analyzed the efficacy, safety and feasibility of a program of HDSC with PBPC support (according to the Milan protocol, ASCO 2001) in patients with BC at high risk of recurrence Methods: Between February 1995 and January 2001, 201 non-consecutive patients with more than 3 positive axillary nodes at surgery, median age 46 (range 27–62), has been evaluated. Median number of involved nodes was 15 (range 3–48), 38% and 49% pts had ER and PgR negative tumors, respectively. Fourty-sevent percent of pts had tumors with a high proliferative activity. HDSC consisted of sequential administration of cyclosphosphamide 7 g/m2 (day 0) plus filgrastim 5 μg/kg s.c. daily and stem cell collection, methotrexate 8 g/m2 plus vincristine 2 mg/m2 (day +16), and two consecutive courses of epidoxorubicin 120 mg/m2 (days +23 and + 38) plus filgrastim 5 μg/kg s.c. daily. Myeloablative therapy (day +58) consisted of thiotepa 600 mg/m2 and melphalan 160 mg/m2 plus PBPCs and filgrastim 5 μg/kg s.c. daily. Results: Three pts discontinued the program permanently because of toxicity. A median of 9,35x106/kg (range 3.35–35.62) CD34+ cells was infused. Engraftment for neutrophils (> 500/μl) and platelets (> 20.000/μl) was observed a median of 9 days (range 7–17) and 10 days (range 7–18) after PBPC infusion, respectively. No treatment-related deaths were recorded. After a median follow-up of 79 months, 108 (54%) pts are disease- free. Ninety-three patients experienced disease recurrence [9/93 (10%) pts had loco regional disease recurrence and 84/93 (90%) pts distant recurrence], of whom 58/93 (63%) have died. Five-year DFS and OS from the start of treatment are 55% and 71%, respectively. No poor marrow function, myelodysplastic syndrome or secondary tumors were observed. In 2-sided log-rank tests, hormone-receptor status and the number of tumor-positive axillary lymph nodes were significant prognostic factors for DFS. Conclusions: Our results confirm that HDSC is a safe procedure and is associated with favorable outcome in patients with high-risk BC. No significant financial relationships to disclose.

Clinical side effects during peripheral blood progenitor cell infusion

There are several side effects which have been reported during the infusion of peripheral blood progenitor cells (PBPCs) either due to the infusion or the content of the infusate. We have evaluated the side effects detected during PBPCs infusion in 194 autologous and 25 allogeneic transplantations. In autologous cryopreserved PBPCs infusion, we detected a total of forty-nine (25.25%) side effect events during and after the infusion period. Forty-six (23.71%) of these side effects were detected during the infusion period including fifteen (7.73%) cardiac side effects, which required stopping the infusion, and thirty-one (15.97%) non-cardiac side effects, which did not require cessation of the infusion. Sinus bradycardia after a minimum of 45 min after completing the infusion was seen in three (1.54%) patients. The median volume, dimethyl sulfoxide (DMSO) and total nucleated cell (TNC) content of the product were found to be significantly higher in patients with side effects compared to the group without any side effects ( P < 0.05). The median volume and DMSO content were found to be significantly higher in patients with cardiac side effects compared to non-cardiac side effects ( P < 0.05). There was no cardiac side effects in patients treated with an infusate containing 100 × 10 9 L −1 leukocytes. We did not observe any infusion-related side effects in patients given allogeneic non-cryopreserved PBPCs. We have concluded that the volume, DMSO and TNC content of autologous cryopreserved PBPCs product are directly related to clinical side effects.

Outpatient high‐dose melphalan in multiple myeloma patients

The brief period of neutropenia and limited nonmarrow toxicity after high-dose melphalan (HDM) provide a rationale for outpatient treatment. Our experience with HDM (140-200 mg/m(2)) in 90 consecutive transplant episodes was retrospectively reviewed. Most patients were treated in an outpatient setting. Patients without a primary care provider (PCP) were electively admitted before the anticipated onset of neutropenia. Ceftriaxone was added to ciprofloxacin at the onset of neutropenia. All febrile patients were admitted. The median time from peripheral blood progenitor cell infusion to onset of neutropenia was 5 days (range, 4-6 days), and the mean duration of neutropenia was 5 days (range, 4-7 days). Thirty-eight transplants (42%) were performed entirely in the outpatient setting. The mean duration of hospitalization was 2.2 days in patients not electively admitted. The use of ceftriaxone was associated with a decreased risk for fever (39% vs. 79%) and reduced duration of hospitalization (1.6 days vs. 4.5 days) for nonelectively admitted patients. There was no treatment-related mortality. Ambulatory therapy with HDM is safe and can be achieved in a general outpatient setting. The predictable time to neutropenia allows even poor candidates for outpatient therapy to be admitted electively on Day +4. The apparent beneficial effect of ceftriaxone needs to be confirmed in randomized trials.

Large volume peripheral blood progenitor cell (PBPC) harvest in 27 pediatric solid tumor patients weighing less than 20 Kg

9061 While PBPC collection has become a safe and common procedure in adults, fewer reports exist about its efficacy and safety in low weight pediatric patients. PBPC harvest might be difficult in this patient population and extracorporeal separator line priming with red blood cells is usually required to improve hemodynamic stability and effectiveness of the collection. We present our experience in 27 children (11 females, 16 males) weighing less than 20 kg and autografted between May 2001 and December 2005. Median age and weight at the time of apheresis were 2.7 years (0.7 to 8) and 14.3 kg (9.7 to 20), respectively. Diagnosis were neuroblastoma in 15, brain tumor in 10, and others in 2. Harvest of PBPC started after mobilization with G-CSF 10 ug/kg/day SC for 4 days. A double lumen (Arrow 7Fr) central venous catheter was surgically placed under sedation in the OR. Collections were performed using a COBE Spectra separator primed with irradiated, white cell-depleted and CMV-negative packed red cells. A median of 2 (1 to 7) procedures were performed, resulting in the harvest of 12.9 (3.6–33.1) × 108/kg mononuclear cells and 4.98 (2.33–12.69) × 106/kg CD34 (+) cells. The apheresis were performed in the presence of the parents and did not require sedation. Only 1 patient had as side-effect perioral paresthesias with normal serum calcium. No patient had vasovagal reactions. A median platelet count reduction of 66% was observed, comparing pre and post apheresis values. All patients completed the procedure with a median of 71.800 platelets (25.000 to 152.000) and a median hemoglobin of 10.8 g/dl (8.2 to13.6). All children were successfully transplanted with myeloid engraftment (ANC &gt;500 × 109/L) at a median of 11 days (9 to 14) and independence from platelet transfusions (&gt; 20,000x × 109/L) at a median of 17 days (8 to 39) after PBPC infusion. Median of hospitalization days was 23 (18 to 42). We conclude that PBPC harvesting using large volume continuous flow cell separation was safe, even in this low-weight pediatric population. This procedure shortens the total number of apheresis, providing an adequate number of CD34 + cells, resulting in satisfactory hematological recovery and duration of hospitalization. No significant financial relationships to disclose.

Recurrent seizure and sustained encephalopathy associated with dimethylsulfoxide-preserved stem cell infusion

We report the case of a patient who received two infusions of dimethylsulfoxide (DMSO) cryopreserved autologous peripheral blood progenitor cells (PBPCs) after myeloablative chemotherapy for a relapsing lymphoma. A 49-year-old man presented an episode of tonic-clonic seizure over a few minutes after the start of each infusion and developed a profound and sustained but reversible encephalopathy with coma after the second infusion. The patient's neurological condition correlated well with the electrophysiological findings (electroencephalogram and multimodality evoked potentials) and, to a lesser extent, with the radiological abnormalities (magnetic resonance imaging). Severe but reversible neurological complications may occur with the infusion of PBPCs cryopreserved with DMSO.

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

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

BEAC or BEAM for High-dose Therapy in Patients with Non-Hodgkin's Lymphoma? A Single Centre Analysis on Toxicity and Efficacy

High-dose chemotherapy supported by autologous stem cell transplantation is widely used in patients with non-Hodgkin's lymphoma (NHL). Limited data is available on the comparative toxicity and efficacy of various high-dose regimens applied in NHL. We therefore analysed regimen-related toxicity and outcome in 71 consecutive NHL patients who received either BEAC (N=36) or BEAM (N=35) supported by peripheral blood progenitor cell infusion plus granulocyte colony-stimulating factor. The patients who received BEAM had significantly more often WHO grade >2 mucositis (63 vs. 28%, P=0.009) and diarrhoea grade >2 (29 vs. 8%, P=0.062). Septicaemia also tended to be more frequent and the peak CRP value was higher in the BEAM group (140 vs. 113 mg/l, P=0.034). Transplant-related mortality (<100 d) was 3 and 9% in the BEAC and BEAM groups, respectively. No significant differences were observed in overall survival or progression free survival between these two groups. While BEAC and BEAM appears to have equal antitumour efficacy in patients with NHL, BEAM seems to be more toxic to the gastrointestinal tract. However, randomised studies are needed for more definitive conclusions on the relative merits of various high-dose regimens in patients with NHL.

High-dose samarium-153 ethylene diamine tetramethylene phosphonate: low toxicity of skeletal irradiation in patients with osteosarcoma and bone metastases.

Samarium-153 ethylene diamine tetramethylene phosphonate ((153)Sm-EDTMP), a bone-seeking radiopharmaceutical, provides therapeutic irradiation to osteoblastic bone metastases. Because the dose-limiting toxicity of (153)Sm-EDTMP is thrombocytopenia, a dose-escalation trial using peripheral-blood progenitor cells (PBPCs) or marrow support was conducted to treat metastatic bone cancer. Patients with locally recurrent or metastatic osteosarcoma or skeletal metastases avid on bone scan were treated with 1, 3, 4.5, 6, 12, 19, or 30 mCi/kg of (153)Sm-EDTMP. Thirty patients were treated with (153)Sm-EDTMP. Transient symptoms of hypocalcemia were seen at 30 mCi/kg. Estimates of radioisotope bound to bone surfaces and marrow radiation dose were linear with injected amount of (153)Sm-EDTMP. Cytopenias also occurred in all subjects and were dose-related. At day +13 after (153)Sm-EDTMP, residual whole-body radioactivity was 1% to 65% of whole-body radioactivity considered safe for PBPC infusion, 3.6 mCi. After PBPC or marrow infusion on day +14 after (153)Sm-EDTMP, recovery of hematopoiesis was problematic in two patients at the 30 mCi/kg dose infused with less than 2 x 10(6) CD34(+)/kg on day +14, but not in other patients. Reduction or elimination of opiates for pain was seen in all patients. Patients had no adverse changes in appetite or performance status. (153)Sm-EDTMP with PBPC support can provide bone-specific therapeutic irradiation (estimates of 39 to 241 Gy). Hematologic toxicity at 30 mCi (153)Sm-EDTMP/kg requires PBPC grafts with more than 2 x 10(6) CD34(+)/kg to overcome myeloablative effects of skeletal irradiation. Nonhematologic side effects are minimal.

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

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

Thiotepa and fludarabine (TT-FLUDA) as conditioning regimen in poor candidates for conventional allogeneic hemopoietic stem cell transplant.

Standard conditioning for allogeneic bone marrow transplantation induces high transplant-related mortality (TRM) in patients with a poor performance status. Less intensive regimens have been tested to reduce the TRM; our purpose was to evaluate the feasibility and tolerability of a new combination: thiotepa and fludarabine (TT-FLUDA). Six patients received 5 mg thiotepa/kg daily from day -8 to -7 and 25 mg fludarabine/m2 daily from day -6 to -2 followed by an allogeneic peripheral blood progenitor cell infusion; three of these patients with signs of overt leukemia received 18 mg idarubicin/m2 i.v. at day -12. Graft-versus-host-disease (GVHD) prophylaxis was performed i.v. with 1 mg cyclosporine A/kg per day from day -5 to the day of marrow engraftment, then 6 mg/kg per day orally up to day +100, and 10 mg methotrexate/m2 at day +1, and 8 mg/m2 at days +3, +6, and +11. Chimerism was studied with fluorescent in situ hybridization for sex chromosomes (XY-FISH) and minisatellite polymerase chain reaction (PCR) at days +30, +100, +180, and +360. Engraftment was achieved in all cases with complete donor chimerism in all but one patient who had refractory acute leukemia. No major toxicity was noticed; only one patient died at day +51 of acute GVHD because of early cyclosporine A discontinuation. One patient with refractory non-Hodgkin's lymphoma (NHL) had a testicular relapse at day +180. Three patients (one with mantle cell lymphoma, two with acute myeloid leukemia) are still in continuous complete remission (CR) with complete donor chimerism at days +180, +210, and +450, respectively. TT-FLUDA seems to be well tolerated, allowing engraftment and stable donor chimerism in patients who are poor candidates for conventional conditioning regimens.

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

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

Progress in clinical application of use of progenitor cells expanded with hematopoietic growth factors.

The ability to isolate and expand the cells capable of reconstituting hematopoiesis and immunity holds great promise to improve the outcomes of patients treated with autologous and allogeneic transplantation. The morbidity caused by prolonged neutropenia resulting from myeloablative therapy in the transplant setting leaves patients at risk to develop serious infections. Peripheral blood progenitor cells (PBPC) have supplanted bone marrow in autologous and allogeneic transplantation as a source of hematopoietic reconstitution mainly because of a reduction in the duration of neutropenia. Regardless, neutrophil recovery times continue to range between 7 to 10 days and platelet recovery times range between 12 to 24 days, after infusion of PBPC. Thus, ex vivo culture of PBPC has been evaluated for the purpose of providing a larger number of hematopoietic cells intended to accelerate the rate of recovery after myeloablative therapy. Moreover, expansion of alternative hematopoietic stem cell sources, including umbilical cord blood, has been tested in clinical trials.

Prolonged CD4 depletion after sequential autologous peripheral blood progenitor cell infusions in children and young adults

Administration of mobilized peripheral blood progenitor cells (PBPCs) after high-dose chemotherapy rapidly restores multilineage hematopoiesis, but the ability of such products to restore lymphocyte populations remains unclear. In this report, we evaluated immune reconstitution in a series of patients treated with sequential cycles of high-dose chemotherapy, followed by autologous PBPC infusions (median CD34+ cell dose 7.2 × 106 cells/kg [range 2-29.3]). Although patients experienced rapid reconstitution of B cells and CD8+ T cells, we observed CD4 depletion and diminished immune responsiveness in all patients for several months after completion of therapy. Mature CD4+ T cells contained within the grafts did not appear to contribute substantially to immune reconstitution because CD4 counts did not differ between recipients of unmanipulated T-cell replete infusions versus CD34 selected, T-cell–depleted infusions. Rather, at 12 months after therapy, total CD4 count was inversely proportional to age (ρ = −0.78,P = .04), but showed no relationship to CD34 cell dose (ρ = −0.42, P = .26), suggesting that age-related changes within the host are largely responsible for the limited immune reconstitution observed. These results demonstrate that in the autologous setting, the infusion of large numbers of PBPCs is not sufficient to restore T-cell immune competence and emphasize that specific approaches to enhance immune reconstitution are necessary if immune-based therapy is to be used to eradicate minimal residual disease after autologous PBPC transplantation.

Prolonged CD4 depletion after sequential autologous peripheral blood progenitor cell infusions in children and young adults

AbstractAdministration of mobilized peripheral blood progenitor cells (PBPCs) after high-dose chemotherapy rapidly restores multilineage hematopoiesis, but the ability of such products to restore lymphocyte populations remains unclear. In this report, we evaluated immune reconstitution in a series of patients treated with sequential cycles of high-dose chemotherapy, followed by autologous PBPC infusions (median CD34+ cell dose 7.2 × 106 cells/kg [range 2-29.3]). Although patients experienced rapid reconstitution of B cells and CD8+ T cells, we observed CD4 depletion and diminished immune responsiveness in all patients for several months after completion of therapy. Mature CD4+ T cells contained within the grafts did not appear to contribute substantially to immune reconstitution because CD4 counts did not differ between recipients of unmanipulated T-cell replete infusions versus CD34 selected, T-cell–depleted infusions. Rather, at 12 months after therapy, total CD4 count was inversely proportional to age (ρ = −0.78,P = .04), but showed no relationship to CD34 cell dose (ρ = −0.42, P = .26), suggesting that age-related changes within the host are largely responsible for the limited immune reconstitution observed. These results demonstrate that in the autologous setting, the infusion of large numbers of PBPCs is not sufficient to restore T-cell immune competence and emphasize that specific approaches to enhance immune reconstitution are necessary if immune-based therapy is to be used to eradicate minimal residual disease after autologous PBPC transplantation.

High-dose BEAM chemotherapy with autologous peripheral blood progenitor-cell transplantation for unselected patients with primary refractory or relapsed Hodgkin's disease

The use of autologous peripheral blood progenitor cells (PBPC) expedites hematologic recovery and reduces the costs of transplantation in comparison with autologous bone marrow; however, its efficacy in patients with Hodgkin's disease has been questioned. We evaluated the results of autologous PBPC transplantation in a population of unselected and uniformly treated patients with primary refractory or relapsed Hodgkin's disease. Forty consecutive adult patients with primary refractory (n = 7) or relapsed (n = 33) Hodgkin's disease received high-dose BEAM (BCNU, etoposide, ara-C, and melphalan) followed by autologous PBPC infusion. Twenty-four patients (60%) received high-dose BEAM as outpatients. Consolidative radiation therapy was administered to 14 patients (35%). Thirty-seven patients (92%) achieved a post transplant complete response. The 3-year progression-free survival (PFS) was 69%, and the 3-year overall survival (OS) was 77%, with a median follow-up of surviving patients of 28 months. Severe non-hematologic toxicities included gastrointestinal side effects (diarrhea 17%, mucositis 25%), and interstitial pneumonitis (15%). One patient died of acute transplant-related complications (mortality rate 2.5%). Strong predictors of poor PFS were chemoresistant versus chemosensitive/untested disease (actuarial PFS 89% versus 22%, P = 0.0000) and stage IIB-IV versus I-IIA at relapse/progression (86%, versus 46%, P = 0.005). All five patients with elevated lactate dehydrogenase at the time of transplantation died of their disease. There was a trend toward worse PFS for patients receiving a higher number of CD34+ cells (> or = 11 x 10(6) per kg). High-dose BEAM chemotherapy with autologous PBPC transplantation is associated with low mortality and results in satisfactory PFS for patients with primary refractory or relapsed Hodgkin's disease. The subset of patients with progressive disease at the time of transplantation performs poorly and may benefit from alternative strategies.

Bone marrow transplantation depleted of T cells followed by repletion with incremental doses of donor lymphocytes for relapsing patients with chronic myeloid leukemia: a therapeutic strategy.

For patients with chronic myeloid leukemia (CML), long-term survival after stem cell transplantation requires adequate control of graft-versus-host disease (GVHD) and disease recurrence. Relapsing patients respond to donor lymphocyte infusion (DLI) but develop life-threatening complications. Patients with CML in first chronic phase received bone marrow (n = 14) or peripheral blood progenitor cell transplants (n = 4) from HLA-identical siblings. GVHD prophylaxis was by ex vivo T-cell depletion with CAMPATH 1G. If disease recurred, donors' mononuclear cells were collected by apheresis, the CD3 samples commencing at 10(6)/kg were aliquoted at half-log increment intervals, cryopreserved, and infused until disease clearance. Eighteen patients (median age: 32.5 years) received transplants. All engrafted without procedure-related mortality. Fourteen patients relapsed, and 13 entered the DLI program. Two developed extensive GVHD after single schedule infusions ranging from 89x10(6) to 670x10(6) mononuclear cells/kg, and one survives in complete remission (CR). The rest, treated with incremental dose DLI, experienced no acute toxicities. One, who had developed grade III steroid-responsive GVHD, died in CR2 from opportunistic infections. Steroids reversed limited cutaneous GVHD and elevated liver enzymes in five patients. Three others developed pancytopenia, and two restored blood counts only after donor peripheral blood progenitor cell infusions. Molecular CR2 was established in 12/13 patients, occurring in 10/11 (91%) on the incremental program at a median accumulation of 67 (range: 5-166) x10(6) CD3 cells/kg. Sixteen of 18 (89%) survive at median of 854.5 days from bone marrow transplantation, 4 in CR1 and 10 in CR2 at a median disease-free survival (for remission 2) duration of 341 days. The median combined disease-free survival of the 14 patients in CR 1+2 is 660 days, with 99% average performance status. Escalating DLI leads to safe new molecular CR in most CML relapse patients. These results raise the possibility of using "safe" transplantation programs of T-cell depletion, that include graded DLI as prevention against disease recurrence.

Innovations in allogeneic stem-cell transplantation

Allogeneic bone marrow transplantation (BMT) is associated with prolonged periods of neutropenia and thrombocytopenia, which can lead to severe infections and bleeding complications. Transplantation-related side effects might be ameliorated by use of cytokine-mobilized peripheral blood progenitor cells (PBPC) instead of bone marrow. We have studied PBPC mobilization and transplantation in more than 150 patients with high-risk hematologic malignancies. Normal donors can be sufficiently mobilized with granulocyte colony-stimulating factor (G-CSF), with 91% of G-CSF-stimulated normal donors producing more than 2 × 10 6 CD34 + cells/kg by a single apheresis. The combination of G-CSF plus granulocyte-macrophage colony-stimulating factor (GM-CSF) was more effective than mobilization with G-CSF alone. A clear relationship was seen between numbers of resting CD34 + cells premobilization and numbers of PBPC collected by apheresis, indicating that resting CD34 + cells might be used to predict mobilization results and identify donors who could benefit from more effective mobilization regimens. Transplantation of G-CSF-mobilized PBPC was associated with a more rapid engraftment than that observed for BMT. While engraftment was safe and acute graft-versus-host disease (aGvHD) rates were not increased over BMT, chronic GvHD rates were higher after PBPC transplantation. An additional PBPC infusion on day +3 resulted in a further shortening of neutropenia and thrombocytopenia. Incorporation of these innovative approaches with “minimal” conditioning regimens has resulted in near-complete elimination of fever, neutropenia, thrombocytopenia, and the need for antibiotics and RBC and platelet transfusions after allogeneic transplantation.

LDH elevation after autologous stem cell transplantation.

We have anecdotally noted that serum LDH values rise after the infusion of autologous peripheral blood progenitor cells (PBPCs), presumably the result of cellular lysis. To further study this issue, we retrospectively reviewed 203 consecutive patients undergoing autologous PBPC transplant from August 1996 to December 1997. 194 patients were evaluable, having documented LDH values on day -1 to day +5 post-transplant. All patients received cytokine mobilization for PBPC collection, and 99% received a chemotherapy-only preparative regimen. 99% of patients had a rise in serum LDH after PBPC infusion. 76% had a normal LDH prior to PBPC infusion that became abnormally high after infusion; 22% began with an abnormally high value that became higher with the infusion of PBPCs. The LDH rose at least 50% in 91% of patients. 92% of the patients had their peak LDH value occur on day +1 post-transplant. The total dose of CD34+ cells infused negatively correlated with peak percentage change of LDH (P = 0.0007). This result was initially perplexing, as we believed that a higher number of infused cells would correlate with a higher LDH value as a result of in vivo cellular lysis. However, the total number of CD34+ cells also negatively correlated with the number of phereses required to collect our threshold of 2.0 x 10(6) CD34+ cells/kg (P = 0.0001). After adjusting for CD34+ cell dose, we found that the number of phereses correlated highly with a peak percentage of change of LDH (P = 0.001). We conclude that the serum LDH increases universally after autologous PBPC infusion, peaking on day +1. We believe that this rise in serum LDH is a result of cell lysis that occurs ex vivo, and correlates with the number of pheresis procedures required to collect an adequate number of CD34+ cells. This may be a result of increasing red blood cell contamination with more phereses, and resultant RBC hemolysis.

Adverse events occurring during bone marrow or peripheral blood progenitor cell infusion: analysis of 126 cases.

Bone marrow (BM) and/or peripheral blood progenitor cells (PBPC) given after high-dose chemo-radiotherapy are commonly cryopreserved. Re-infusion of the thawed product can cause cardiovascular and other complications. We compared two groups of adult patients receiving autologous BM or PBPC transplant to assess the incidence of adverse events occurring during infusion. Fifty-one patients received BM, and 75 PBPC. The two groups were comparable in respect of age, total volume infused, quantity of dimethylsulfoxide (DMSO) and number of polymorphonuclear neutrophils. Patients receiving PBPC had a higher number of nucleated cells per kg of body weight; those in the BM group received a significantly greater quantity of red cells. Non-cardiovascular complications occurred in 19% and 8% of patients rescued by BM and PBPC respectively. The incidence of hypertension was 21% in the BM and 36% in the PBPC group. Asymptomatic hypotension was more frequent in PBPC patients (P<0.001). Bradyarrhythmia was noticed in two of 75 PBPC patients and in 14 of 51 BM patients (P<0.001). In the former group one patient had heart block; he died of renal failure 10 days later. Bradycardia and hemoglobinuria were more common in patients receiving BM where a higher concentration of red cells was present (P<0.001). Since bradyarrhythmias may be a life-threatening complication we advise continuous careful monitoring during infusion of thawed BM. The strong correlation between bradycardia and red blood cell contamination suggests the use of purified products with a very low red cell content.