Peripheral Blood Stem Cells In Patients Research Articles

Outcomes after Bone Marrow Versus Peripheral Blood Stem Cell Matched Unrelated Donor Hematopoietic Stem Cell Transplantation

Background: Matched unrelated donors (MUD) have become an acceptable alternative donor for patients requiring potentially curative hematopoietic stem cell transplantation (HSCT) and lacking a matched sibling donor. Patients may undergo a bone marrow (BM) or peripheral blood stem cell (PBSC) graft, with previous studies showing similar survival outcomes. However, BM grafts have shown a lower incidence of chronic graft-versus-host disease (GVHD) but a higher relapse rate and slower engraftment. We aimed to compare the outcomes of BM versus PBSC in patients undergoing MUD HSCT. Methods: For this retrospective single-center study, we included all (n=276) adult MUD HSCT recipients at the University of Kansas Medical Center who had at least one year of follow-up (August 2016 to July 2021). We conducted a bivariate analysis using chi-squared and ANOVA tests. The Kaplan-Meier and regression analyses were also performed. Data analyses were conducted using SPSS version 28. Statistical significance was considered at p<0.05. Results: Our study included 276 MUD patients including 110 PBSC (40%) and 166 BM (60%) grafts. The median age was 55 (range 21-77) years, and 158 patients (57%) were males. Eighteen patients (6%) were ethnic minorities, and 89 (32%) patients had a Karnofsky performance status of ≥90%. 118 (43%) patients had a hematopoietic cell transplantation-specific comorbidity index of 3 or higher. Hematologic diseases included acute myeloid leukemia (n=119, 43%), myeloid disorders (n=77, 28%), acute lymphoblastic leukemia (ALL) (n=35, 13%), Lymphoma (n=15, 5%), and others (n=30, 11%). Sixty-two percent of patients were in complete remission at the time of transplantation, and patients not in remission included myelodysplastic syndrome, myelofibrosis, and lymphoma patients. Reduced-intensity conditioning (RIC, n=162, 58%) and myeloablative conditioning (MAC) (n=114, 41%) were used. The median follow-up was 55 (21-73) months. Overall survival (OS) was not reached in either BM or PBSC MUD HSCT group, while a median disease-free survival of 45 and 49 months was noted in PBSC and BM groups respectively (p=0.915). We observed similar rates of relapse (25% vs 27%, p=0.413), one-year overall survival (75% vs 72%, p=0.679), one-year disease-free survival (63% vs 62%, p=1.00), and one-year non-relapsed morality (NRM, 23% vs 21%, p=0.779) after PBSC or BM graft. Bone marrow graft recipients had delayed engraftment of neutrophils (20 days vs 16 days, p<0.001) and platelets (>20 K/uL: 24 days vs 16 days, p<0.001; >50 K/uL: 28 days vs 18 days, p=0.006) compared to PBSC recipients. Bone marrow graft recipients had similar rates of grade II-IV acute GVHD (50% vs 52%, p=0.714) and grade III-IV GVHD (12% vs 11%, p=0.847), but lower rates of 1-year chronic GVHD (39 % vs 55%, p=0.014) compared to PBSC recipients. In the subgroup analysis stratified by conditioning intensity, faster engraftment of neutrophils (median 16 vs 21 days, p<0.001) and platelets (>20 K/uL: 18 days vs 27 days, p<0.001; >50 K/uL: 18 days vs 33 days, p<0.001) was observed with PBSC as compared to BM graft in myeloablative transplant recipients, while there was no statistically significant association with the rates of acute or chronic GVHD, NRM, Relapse, DFS, and OS after a PBSC or BM graft. Among the RIC transplant recipients, faster neutrophil engraftment (mean 17 vs 20 days, p<0.001) and higher 1-year extensive chronic GVHD (52% vs 32%, p=0.015) were observed with PBSC compared to BM graft whereas no statistically significant difference was noted in platelet engraftment, acute GVHD, NRM, Relapse, DFS, and OS after a BM or PBSC graft. Conclusions: Allogeneic matched unrelated donor hematopoietic stem cell transplant recipients had similar rates of overall and disease-free survival, relapse, non-relapse mortality, and acute GVHD after a bone marrow or peripheral blood stem cell graft; however, delayed neutrophil and platelet engraftment with a lower incidence of chronic GVHD was noted after a bone marrow graft compared to peripheral blood stem cell graft.

Successful Mobilization of Autologous Hematopoietic Peripheral Blood Stem Cells after Salvage Chemotherapy in Patients with Low CD34 Blood Cell Counts

A major barrier for proceeding to autologous stem cell transplantation (ASCT) is an inability to mobilize and collect an adequate number of peripheral blood (PB) stem cells (PBSC) for the transplant graft. Plerixafor added to granulocyte colony stimulating factor (G-CSF) alone, without prior chemotherapy, significantly improves the mobilization of autologous PBSC in patients with non-Hodgkin lymphoma (NHL) and multiple myeloma (MM). However, the efficacy of plerixafor and the best timing to give the drug to poorly mobilizing patients with very low PB CD34+ cell counts after salvage chemotherapy and G-CSF are not well defined. We hypothesized that PBSC mobilization and collection might be improved in heavily treated patients who mobilized very poorly after salvage chemotherapy and G-CSF by alternating the days of plerixafor administration and leukapheresis. A day of rest between plerixafor doses, while continuing G-CSF, could allow time for some replenishment of the marrow stem/progenitor cell pool before the next mobilization. A retrospective review of collection results in poorly mobilizing patients at our center was undertaken. Three cohorts were identified: those who got every-other-day plerixafor and leukapheresis, those who got sequential plerixafor and leukapheresis and those who got risk adapted plerixafor. Overall, 69% of patients with NHL and MM with PB CD34+ cell counts <5/µL after salvage chemotherapy and G-CSF were ultimately able to collect adequate CD34+ cells to support ASCT using daily plerixafor and leukapheresis. On the alternating plerixafor and leukapheresis schedule, all 17 patients achieved the cumulative CD34+ cell product goals required for ASCT. This positive observation after salvage chemotherapy and G-CSF led to the incorporation at our center of an alternate-day schedule of plerixafor and leukapheresis into our real-time risk adapted strategy for poor mobilizers.© 2023 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Advantages of peripheral blood stem cells from unrelated donors versus bone marrow transplants in outcomes of adult acute myeloid leukemia patients

Background aimsIn allogeneic stem cell transplantation, unrelated donors are chosen in cases where appropriate related donors are not available. Peripheral blood stem cells (PBSCs) are more often selected as a graft source than bone marrow (BM). However, the prognostic benefits of PBSCs versus BM transplants from unrelated donors have not been carefully examined in patients with acute myeloid leukemia (AML). This study compared outcomes of adult AML patients who underwent unrelated PBSC and BM transplantation, evaluating post-transplant complications, including engraftment, graft-versus-host disease (GVHD) and infections, and determined subgroups of patients who are most likely to benefit from unrelated PBSCs compared with BM transplants. MethodsThe authors analyzed 2962 adult AML patients who underwent unrelated PBSC or BM transplants between 2011 and 2018 (221 PBSC and 2741 BM) using the Japanese nationwide registry database, in which graft source selection is not skewed toward PBSCs. ResultsIn 49.7% of patients, disease status at transplantation was first complete remission (CR1). In 57.1% of cases, HLA-matched donors were selected. Myeloablative conditioning was performed in 75.1% of cases, and anti-thymocyte globulin (ATG) was added to conditioning in 10.5%. Multivariate analyses showed a trend toward favorable non-relapse mortality (NRM) in PBSC recipients compared with BM recipients (hazard ratio [HR], 0.731, P = 0.096), whereas overall survival (OS) (HR, 0.959, P = 0.230) and disease-free survival (DFS) (HR, 0.868, P = 0.221) were comparable between PBSC and BM recipients. Although the rate of chronic GVHD (cGVHD) was significantly higher in PBSC patients (HR, 1.367, P = 0.016), NRM was not increased, mainly as a result of significantly reduced risk of bacterial infections (HR, 0.618, P = 0.010), reflecting more prompt engraftments in PBSC recipients. Subgroup analyses revealed that PBSC transplantation was advantageous in patients transplanted at CR1 and in those without ATG use. PBSC recipients experienced significantly better OS and/or DFS compared with BM recipients in this patient group. ConclusionsThe authors' results confirmed the overall safety of unrelated PBSC transplantation for adult AML patients and suggested an advantage of PBSCs, especially for those in CR1. Further optimization of the prophylactic strategy for cGVHD is required to improve the overall outcome in transplantation from unrelated PBSC donors.

Non-cryopreserved hematopoietic stem cells in autograft patients with lymphoma: a matched-pair analysis comparing a single center experience with the use of cryopreserved stem cells reported to the European Society for Blood and Marrow Transplantation registry

Background aimsAround 50 000 autologous stem cell transplantations are done each year worldwide using cryopreserved peripheral blood stem cells (PBSCs). Cryopreservation is time-consuming and expensive. Since 2007, several retrospective studies have shown that PBSCs can be stored at 4°C for 2–3 days, allowing autologous stem cell transplantation in patients with multiple myeloma receiving high-dose melphalan. Data with non-cryopreserved PBSCs in patients autografted for lymphoma following longer pre-conditioning regimens are limited. In addition, no controlled comparison has been able to detect unforeseen differences. MethodsThe authors compared outcomes of 94 consecutive adult patients with lymphoma (66 with Hodgkin lymphoma) autografted in our department in Oran (Algeria) using PBSCs stored at 4°C, from 2009 to 2018, with patients receiving cryopreserved stem cells reported to the European Society for Blood and Marrow Transplantation registry. Patients autografted in Oran were matched with patients receiving cryopreserved PBSCs in the registry (four controls per patient in Oran). ResultsNeutrophil engraftment was significantly faster with cryopreserved PBSCs (P = 0.003). By day 10, only 17% of patients receiving non-cryopreserved PBSCs engrafted versus 48% for cryopreserved PBSCs. Likewise, platelet recovery to 20 000/mm3 was significantly faster in patients receiving cryopreserved PBSCs (P = 0.01). However, all patients in both groups had recovered by day 20. There were no significant differences in non-relapse mortality (9% versus 7%, P = 0.4), relapse incidence (22% versus 32%, P = 0.13), progression-free survival (70% versus 61%, P = 0.4) or overall survival (85% versus 75%, P = 0.3). ConclusionsThis analysis suggests that, in patients with lymphoma receiving pre-transplant regimens such as carmustine, etoposide, cytarabine and melphalan, PBSCs stored at 4°C for up to 6 days can be used safely in centers with no cryopreservation facility. However, the kinetics of hematopoietic recovery showed a significant, albeit small, delay in engraftment for both neutrophils and platelets, which favors the use of cryopreservation if available.

NON Cryopreserved Hematopoietic STEM CELLS to Autograft Patients with Lymphomas: A PAIR Matched Analysis Comparing a Single Center Experience to the Use of Cryopreserved STEM CELLS Reported to the EBMT Registry

Introduction: Around fifty thousand autologous stem cell transplantations are done each year worldwide, using cryopreserved peripheral blood stem cells (PBSC). Cryopreservation is time consuming and expensive. Since 2007, several retrospective studies have shown that PBSC can be stored at 4Dg C for two to three days, allowing autologous stem cell transplantation (ASCT) in patients with multiple myeloma receiving high dose melphalan. Data with non-cryopreserved PBSC in patients autografted for lymphoma following longer preconditioning regimens are limited. In addition, there has been no controlled comparison able to possibly detect unforeseen differences. Patients and methods: We compared outcomes of 94 consecutive adult patients with lymphomas (66 with Hodgkin Lymphoma) autografted in our department in Oran (Algeria), using PBSC stored at 4 dg C, from 2009 to 2018 with patients receiving cryopreserved stem cells reported to the EBMT registry. Patient's autografted in Oran were matched with patients receiving cryopreserved PBSC in the registry (4 controls per Oran Patient). Results: Neutrophil engraftment was significantly faster with cryopreserved PBSC (p= 0.003): by day 10, only 17% of patients receiving non-cryopreserved PBSC engrafted versus 48% for cryopreserved PBSC. Likewise, platelet recovery to 20 000/mm3 was significantly faster in patients receiving cryopreserved PBSC (p=0.01). However, all patients in both groups had recovered by day 20. There were no significant differences in Non Relapse Mortality (9% versus 7%; p=0.4), Relapse Incidence (22% versus 32%; p=0.13), Progression Free Survival (70% versus 61%; 0.4) or Overall Survival (85% versus 75%; p=0.3). Conclusion: This analysis suggests that, in patients with lymphomas receiving pretransplant regimens such as the BEAM, PBSC stored at 4dg C for up to six days can be used safely in centers with no cryopreservation facility. The kinetics of recovery of hematopoiesis however did show a significant, albeit small, delay of engraftment for both neutrophils and platelets, which favors the use of cryopreservation if available. Disclosures Blaise: Jazz Pharmaceuticals: Honoraria. Peggs:Autolus: Consultancy. Salles:Karyopharm: Consultancy; F. Hoffman-La Roche Ltd: Consultancy, Honoraria, Other; Bristol Myers Squibb: Consultancy, Other; Celgene: Consultancy, Honoraria, Other: Participation in educational events; Autolus: Consultancy; Abbvie: Consultancy, Honoraria, Other: Participation in educational events; Genmab: Consultancy; Novartis: Consultancy, Honoraria, Other; Kite: Consultancy, Honoraria, Other; Takeda: Consultancy, Honoraria, Other; Debiopharm: Consultancy; Amgen: Honoraria, Other: Participation in educational events; MorphoSys: Consultancy, Honoraria, Other; Gilead: Consultancy, Honoraria, Other: Participation in educational events; Janssen: Consultancy, Honoraria, Other: Participation in educational events; Epizyme: Consultancy. Milpied:Roche: Honoraria, Other: Travel support; Astellas: Honoraria; Sandoz: Honoraria, Other: consultancy or advisory role; Janssen: Honoraria; Gilead Sciences: Other: consultancy or advisory role; Celgene: Other: Travel support.

Plerixafor-aided Mobilization of Peripheral Blood Hematopoietic Stem Cells to Support Subsequent High-dose Chemotherapy After a Prior Autologous Transplant

BackgroundAn appreciable proportion of patients in need of salvage high-dose chemotherapy (HDC) and autologous peripheral blood stem cell (PBSC) transplantation (PBSCT) fail to mobilize adequate numbers of hematopoietic progenitors, and plerixafor is applied for that purpose. Limited data exist on remobilization of PBSCs in patients who have relapsed after prior HDC + PBSCT. Herein, we report on consecutive patients that had undergone successful prior single or tandem HDC for a variety of malignant neoplasms in our institution, and later required re-mobilization of PBSCs in order to support further HDC cycles. Patients and MethodsPlerixafor was administered in combination with granulocyte-colony stimulating factor alone, or after mobilizing chemotherapy. Five patients, 2 B-cell non-Hodgkin lymphomas, 1 multiple myeloma, 1 germ-cell tumor, and 1 Ewing sarcoma, having relapsed after prior HDC + PBSCT, were deemed candidates for further cycle(s) of PBSC-supported HDC. Plerixafor was applied in a “just-in-time” strategy after low CD34+ numbers were measured on the first day of anticipated hematopoietic stem cell collection (non-Hodgkin lymphoma, germ-cell tumor, and Ewing sarcoma), or pre-emptively in multiple myeloma. ResultsSuccessful collection of adequate PBSCs was achieved in all patients, from 1.8 to 3.8 × 106/kg after a median of 2 (range, 1-3) leukaphereses; 4 of 5 patients underwent subsequent HDC + PBSCT and engrafted after a median of 11 days (range, 9-55 days) and 25 days (range, 17-76 days) for neutrophils and platelets, respectively. ConclusionPlerixafor proved effective to mobilize adequate numbers of PBSCs in individual patients with relapsed malignancies after prior single or tandem HDC + PBSCT. These PBSCs could establish sustained multi-lineage hematopoietic engraftment without any sequelae.

Influence of Stem Cell Source on Outcomes of Allogeneic Reduced-Intensity Conditioning Therapy Transplants Using Haploidentical Related Donors

We compared outcomes for 2 retrospective cohorts of patients undergoing reduced-intensity conditioning (RIC) therapy transplants using haploidentical related donors and post-transplant prophylaxis against graft-versus-host disease (GVHD) with high-dose cyclophosphamide, tacrolimus, and mycophenolate. The first cohort of 13 was transplanted with bone marrow (BM) as the stem cell source, whereas the second cohort of 23 used peripheral blood stem cells (PBSCs) mobilized with granulocyte colony-stimulating factor. The BM cohort received a single 60-mg/kg dose of cyclophosphamide on day +3, whereas the PBSC cohort received 2 doses on days +3 and +4. Patients in the first cohort were slightly older and had a higher proportion of acute myeloid leukemia, but there were no differences in the distribution of Disease Risk Index scores between the 2 groups. Patients in the PBSC group received double the number of CD34+ cells in the stem cell graft. Times to neutrophil and platelet recovery were not different between the 2 groups. Three patients, all in the PBSC group, failed to engraft but recovered with autologous hemopoiesis and survived. The 6-month cumulative incidences of acute GVHD were 55.1% for BM and 48.5% for PBSCs (P = .651), whereas 24-month cumulative rates for chronic GHVD were 28.6% for BM and 32.3% for PBSCs (P = .685). Only 2 patients, both in the BM group, died of nonrelapse causes, both of second cancers. The 2-year cumulative incidences of relapse were 43.9% for BM and 23.5% for PBSCs (P = .286). Overall survival at 2 years was significantly better for PBSC patients (P = .028), at 83.4% versus 52.7% for BM. Relapse-free and event-free survival did not differ significantly between BM and PBSC groups. In this retrospective analysis, we conclude that the use of PBSCs for haploidentical RIC transplants is a feasible strategy, with equivalent rates of acute and chronic GVHD and risk of relapse and low nonrelapse mortality compared with BM.

Lenograstim

Lenograstim (Granocyte®, Neutrogin®, Myelostim®) is a glycosylated recombinant human granulocyte colony-stimulating factor. This article reviews the pharmacological properties, therapeutic efficacy and tolerability of lenograstim, mainly focusing on its use in chemotherapy-induced neutropenia, acceleration of neutrophil recovery following haematopoietic stem cell transplantation (HSCT), and peripheral blood stem cell (PBSC) mobilization in patients with cancer and healthy donors. In randomized, multicentre trials in patients with solid tumours, lymphoma or multiple myeloma, the durations of chemotherapy-induced neutropenia, hospitalization for infection and intravenous antibacterial therapy were significantly shorter in patients receiving lenograstim prophylaxis than in those receiving placebo. The time to neutrophil recovery was also significantly shorter in patients with acute myeloid leukaemia or acute lymphoblastic leukaemia who received lenograstim than in those who received placebo or no treatment, according to the results of randomized, multicentre trials. In addition, lenograstim prophylaxis facilitated the administration of dose-intense or dose-dense chemotherapy regimens, with improved clinical outcomes seen in some trials. In patients with cancer undergoing HSCT, lenograstim accelerated neutrophil recovery post-HSCT and shortened the duration of hospitalization, according to the results of randomized, multicentre trials. Lenograstim effectively mobilized PBSCs in patients with cancer, demonstrating generally similar efficacy to filgrastim or molgramostim in five randomized trials (although lower dosages of lenograstim than filgrastim were administered in four of the trials). Lenograstim also provided effective PBSC mobilization in healthy donors and was more effective than filgrastim when both drugs were administered at a dosage of 10 μg/kg/day. The efficacy and safety of lenograstim for PBSC mobilization in healthy donors was supported by the results of a prospective, longer-term study involving almost 4000 healthy donors. Lenograstim was generally well tolerated across a variety of treatment settings, including PBSC mobilization in healthy donors, with bone pain being one of the most commonly reported adverse events. In conclusion, lenograstim remains an important option for use in chemotherapy-induced neutropenia, acceleration of neutrophil recovery following HSCT, and PBSC mobilization.

A Comparison of Stem Cell Source in Recipients of T-Cell Depleted Myeloablative Transplants for Leukaemia: No Difference in Mortality Using BM or PBSC.

The use of GSCF-mobilised Peripheral Blood Stem Cells (PBSC) for unrelated donor (UD) transplantation has increased dramatically since 2000. The association of PBSC with more rapid engraftment and with an increase in chronic Graft versus Host Disease (GvHD), compared to bone marrow (BM) has been reported in a number of studies. More recently the use of PBSC has been associated with an increase in transplant related mortality (TRM) and decrease in survival (OS) in T-cell replete transplants. We sought to analyse the impact of PBSC compared to BM in a cohort of UD transplant recipients, where T-cell depleting agents (in-vivo campath in >90%) were included in the transplant conditioning. The study included 145 patients transplanted between January 2000 and March 2006: CML- 35 in 1CP; acute leukaemia (AML in 61, ALL in 49)-110 in CR1 or 2. All had myeloablative conditioning regimens and received grafts with 9–10/10 matched HLA alleles. 86 patients received BM and 59 PBSC. There were no associations between the stem cell source and any transplant variable (including disease and stage). There was a trend to an increased use of PBSC in patients with a single antigen mismatch (p=0.052). All evaluable patients achieved neutrophil engraftment, with a significantly faster time to engraft in recipients of PBSC compared to BM (16 vs 20 days; p=0.0003). The incidence of acute GvHD was 46% (grade I in 50%, II in 41%, III in 8%, IV in 2%). This was significantly higher in recipients of PBSC (60%) compared to BM (36%; p=0.006), however there was no increase in either II/IV (p=0.69) or III/IV (p=0.18) disease in PBSC recipients. In univariate analysis, the presence of a single HLA mismatch (p=0.026) was the only other variable to be associated with an increase in acute GvHD. In a logistic regression model including both these variables, the use of PBSC remained significantly associated with an increase in aGvHD (OR=2.3; 95% CI 1.1,4.7;p=0.020). The TRM was 14%, 27% and 39% at 100 days, 1 and 5 years respectively. At none of these time points was the stem cell source associated with a significant difference in TRM. The 5-year incidence of chronic GvHD was 58% (BM 55%, PBSC 60%; NS), extensive disease in one third, and of relapse was 61% (BM 60%, PBSC 62%; NS). The 5-years OS was 41% with a median follow-up of 3.4 years (0.5–7.1). This was 44% using PBSC and 40% using BM (NS). In conclusion, although we observed an increase in acute GVHD with PBSC this was only of grade 1 disease. We found no association between the use of PBSC and an increased risk of chronic GVHD or of a worse transplant outcome, when compared to BM, in recipients of T-cell depleted myeloablative transplants for leukaemia.

A Mobilizing Regimen of AMD3100 and G-CSF Increases Stem Cell Collection in Patients with Hodgkin's Disease, and PK Is Similar to That of Non-Cancer Patients.

For patients undergoing autologous peripheral blood stem cell transplantation (PBSCT), the number of CD34+ cells collected is a reliable predictor of neutrophil and platelet engraftment after transplantation, with doses > 5 x 106 CD34+ cells/kg associated with faster count recovery. Unfortunately, collection of an adequate number of peripheral blood stem cells (PBSCs) can be difficult in Hodgkin's disease (HD) patients. AMD3100 reversibly inhibits the binding of stromal cell-derived factor 1 (SDF-1), constitutively expressed on bone marrow stromal cells, to its receptor CXCR4, expressed on CD34+ cells. AMD3100 combined with G-CSF has been shown to improve PBSC collection compared to mobilization with G-CSF alone in patients with multiple myeloma or non-Hodgkin's lymphoma (Blood 2005; 106:1867). This study was undertaken to determine whether a mobilization regimen of AMD3100 + G-CSF can safely and effectively mobilize PBSCs in patients with HD who are undergoing autologous PBSCT. Results were compared to a historical control group comprised of 98 consecutive HD patients who underwent G-CSF-alone mobilization at our institution. Patients were followed post-transplant to evaluate engraftment timing and durability. Pharmacokinetic (PK) determinations were completed in a subset of patients (n=6) following the first dose of AMD3100. To date, 19 patients with relapsed (17) or refractory (2) HD have been mobilized with G-CSF (10 ug/kg/d) + AMD3100 (240 ug/kg/d sc at 10 p.m. beginning on day 4). Apheresis was performed 11 hours after each AMD3100 dose. The first dose of AMD3100 produced a median (range) 3.0 (1.9–12) fold increase in the number of circulating CD34+ cells. Twelve patients (63%) achieved a collection of ≥ 5 x 106 CD34+ cells/kg, a significantly higher proportion than historical controls (15%, p=0.049). Eighteen patients (95%) mobilized with AMD3100 + G-CSF collected > 2 x 106 CD34+ cells/kg (range, 0.9–9.6 x 106 CD34+ cells/kg), compared to 78% of controls (p=0.116). The median (range) number of apheresis procedures performed per patient was 2 (1–5). The median collection in the first two days of pheresis was 5.0 x 106 CD34+ cells/kg, which is significantly better than historical controls, who collected a median 3.0 x 106 CD34+ cells/kg in the first two days of pheresis (p=0.002). No grade II-IV adverse events were ascribed to AMD3100. Eighteen patients were transplanted with G-CSF + AMD3100 mobilized cells. All had prompt and stable engraftment, with median neutrophil recovery at day +9 (8–11) and median platelet recovery at day +15 (9–20). PK studies demonstrated that AMD3100 was rapidly absorbed following subcutanetous injection, with a median (range) Cmax of 0.87 (0.66–1.16) ug/ml. Plasma concentrations declined in a bi-exponential manner, with a median elimination half-life of 3.7 (2.4–4.0) hours. The median AUC0–infinity was 3,749 (2,808–4,761) ug-hr/ml. AMD3100 pharmacokinetics in this patient population are consistent with results previously obtained from healthy volunteers in the absence of G-CSF. We conclude that AMD3100 + G-CSF is a well-tolerated and effective mobilization regimen in patients with HD. For these patients, AMD3100 + G-CSF can improve the number of PBSCs collected and decrease the number of days of pheresis.

Mobilization, harvesting, and selection of peripheral blood stem cells in patients with autoimmune diseases undergoing non-myeloablative autologous hematopoietic stem cell transplantation

We have studied the properties of peripheral blood stem cell (PBSC) mobilization, harvesting, and selection in 128 patients with severe autoimmune diseases undergoing non-myeloablative autologous hematopoietic stem cell transplantation (HSCT). Fifty patients had a diagnosis of systemic lupus erythematosus (SLE), 43—multiple sclerosis (MS), 15—Crohn’s disease (CD), 8—scleroderma (Scl), and 12—others. Female/male ratio and mean age (range) were 90/38 patients, and 34 (14–59) years old, respectively. Mobilization regimen included cyclophosphamide 2g/m2 and G-CSF 5–10 mcg/kg/day. Baxter CS300 was used for stem cell collection in 41 patients, Spectra in 78 patients, and in 9 patients both apheresis machines were utilized. The mean number of aphereses was 1.8 (range 1–10). Patients with SLE required the largest number of apheresis sessions (mean 2.4), compared to patients with CD (mean 1.9), Scl (mean 1.4), MS (mean 1.3). Five patients additionally required bone marrow harvest for collection of adequate numbers of stem cells. One patient failed to reach CD34+ cell number of 1.0 × 106/kg, and therefore did not proceed to HSCT. The mean number of CD34+ cells in each apheresis unit was 6.07 ± 6.96 × 106/kg (the highest of 9.22 ± 8.52 × 106/kg was attained in patients with MS and the lowest of 3.93 ± 4.48 × 106/kg, in patients with SLE). Ninety-eight patients underwent stem cell selection with CEPRATE SC (n = 18), Isolex 300iv1.12 (N = 2) or Isolex 300iv2.5 (N = 78) stem cell concentrator. The mean purity of selected products was 74.3%; mean recovery of CD34+ cells was 61.2%. T cell reduction by average of 3.7 logs was achieved. The mean number of infused CD34+ cells was 7.24 ± 5.5 × 106/kg. We observed a moderate positive correlation between peripheral blood (PB) CD34+ cells/ul and PB WBC/ul (R = 0.34, P < .05), PB platelets/ul (R = 0.51, P < .05) and a strong positive correlation between PB CD34+ cells/ul and the number of CD34+ cells/kg/apheresis (R = 0.67, P < .05). A weak positive correlation was seen between the number of infused CD34+cells/kg and faster WBC engraftment (ANC > 500) and platelet engraftment (platelet count > 20 K). There was no observed toxicity except for 1 patient with SLE who died of disseminated mucormycosis 1 week after stem cell collection. Mobilization, harvesting, and selection of PBSC in patients with severe autoimmune diseases undergoing non-myeloablative autologous HSCT are safe and efficient.

Transplant Outcome of Unrelated Hematopoietic Stem Cell Transplantation (HSCT) after Myelo-Ablative or Reduced Intensity Conditioning (RIC) for Chronic Lymphocytic Leukemia(CLL). A Study of EBMT Registry.

Place of allogeneic HSCT in the therapeutical strategy of CLL remains still controversial and unrelated allogeneic transplantation has to be better explored. This retrospective analysis concerned 214 patients (164 males and 50 females) who underwent allogeneic HSCT for CLL from unrelated donors (150 males and 64 females) and who were reported on EBMT registry. The median age was 49 years. Fifty two patients received bone marrow (BM) and 162 peripheral blood stem cells (PBSC) from 48 HLA mismatched and 166 HLA matched unrelated donors. Sex mismatch and ABO incompatibility were found in 33% and 52% of cases respectively. On 194 evaluated patients for conditioning, 80 received a myelo-ablative regimen, 114 a reduced intensity conditioning and a Total Boby Irradiation was performed in 70 cases. After transplant, 72 patients (37%) developed an acute GVHD grade II-IV (36% in BM patients and 37% in PBSC patients; 49% in myelo-ablative group and 28% in RIC group). On evaluated patients, a chronic GVHD was present in 61% of the patients (50% in BM patients and 67% in PBSC patients, 66% in myelo-ablative group and 63% in RIC group). With a median follow-up of 20 months, we found no significant difference for 3-year probability of Overall Survival between myelo-ablative group (59%, 46–76) and RIC group (48%, 37–63). No significant difference was observed when comparing BM and PBSC patients whatever the conditioning they received. OS was significantly better in HLA matched compared to HLA mismatched patients in RIC population (51% vs 36%, p=0.01) but not in myelo-ablative population. In multivariate analysis (table 1) studying pre and post transplantation factors, a significant impact of 2 variables, age and aGVHD (grade III-IV vs 0-I), was shown on OS for the global population, myelo-ablative and RIC groups. Other variables influenced also significantly the OS: HLA matching (global and RIC populations), sex matching (myelo-ablative and RIC), TBI (myelo-ablative group). Concerning BM and PBSC groups, we demonstrated the influence of age and aGVHD. In conclusion, besides the known influence of severe aGVHD on survival, this study points out the importance of age and HLA matching in allogeneic unrelated HSCT transplantation setting for CLL. No difference was found regarding conditioning regimen and further studies are needed to determine the most adequate regimen for this disease.Multivariate analysesVariablesOS (HR)pGlobal populationAge1.04 (1-1.07)0.05HLA matching: yes vs no0.44 (0.22-0.89)0.02aGVHD grade III-IV vs 0-I1.37 (1.1-1.74)0.01Myelo-ablative groupAge1.07 (1-1.13)0.04Sex Mismatch: F to M vs F to F6.26 (1.53-25.6)0.01TBI: yes vs no16.3 (3.26-80.2)0.0006aGVHD grade III-IV vs 0-I1.9 (1.18-3.06)0.008RIC groupAge1.05 (1-1.1)0.05HLA matching: yes vs no0.28 (0.1-0.76)0.01Sex Mismatch M to F vs F to F0.63 (0.42-0.96)0.03aGVHD grade III-IV vs 0-I1.66 (1.16-2.39)0.005BM groupAge1.12 (1-1.24)0.03aGVHD grade III-IV vs 0-I1.88 (1-1.36)0.05PBSC groupaGVHD grade III-IV vs 0-I1.38 (1.02-1.86)0.03

The Mobilisation of Peripheral Blood Stemcells in Patients with High Risk or Relapsed Non-Hodgkin Lymphoma Does Not Lead to the Presence of Detectable Tumour Cells in the Stem Cell Harvest.

Consolidation treatment with high dose chemotherapy in combination with an autologous peripheral blood stem celll transplant. is widely used in patients with high risk non-Hodgkin lymphoma (NHL). Also this treatment has its place in patients with relapsed intermediate lymphoma. Earlier studies in patients with breast cancer or multiple myeloma showed evidence for (minimal) tumour contamination in the graft that might lead to the occurence of relapse. For patients with NHL this is less clear. For the present analysis 60 patients (pts) were included: 18 pts with primary high risk NHL, 6 patients with mantle cell lymphoma, and 36 pts with primary refractory or relapsed intermediate NHL. Patients with high risk NHL were treated with induction chemotherapy according to the Hovon-27 or Hovon-40 protocol(www.hovon.nl). Two patients (1 pt with T-Lymphoblastair lymphoma, 1 pt with Burkitt Lymphoma ) received intensive induction chemotherapy according to our leukemia protocols. Stem cells were collected as early as possible, provided the peripheral blood and bone marrow showed no histological evidence of NHL and < 20% lymfocytes. In the patients with mantle cell lymphoma stem cells were collected during the induction chemotherapy (Hovon-45 protocol:www.hovon.nl), irrespective of their presence in the bone marrow. The patients with primary refractory or relapsed intermediate NHL received reinduction chemotherapy with DHAP (Dexamethason, Cytarabin, Cisplatin) or EMP (Etopside, Mitoxantrone, Prednisone). After two or three courses peripheral blood stem cells were mobilised with G-CSF (Neupogen, Amgen) 10 μg/kg sc daily starting day 5 and harvested for autologous stem cell transplant. Before the start of mobilisation patients were required to be responsive to the induction chemotherapy and to have a bone marrow without histological and immunological detectable tumour cells. In all patients a sample of the first day stem cell collection was analyzed with the use of three or four colour Flowcytometry. The sensitivity of the assay was 1/ 104–105 lymphoma cells. Only in 3 pts tumour cells were found at a level > 0.05 %. Interestingly two patients had a primary diagnosis of diffuse large B-cell lymphoma T-cell/ histiocyte rich variant. Both pts relapsed: one within 6 months and the other one within 12 months.The third patient suffered from a anaplastic large cell T-cell lymphoma and relapsed after 15 months. In all other patients no lymphoma cells were detectable in the stemcell harvest at a minimum level of <0.02%. Follow up showed a relapse within 12 months in 16 of 36 patients with relapse or primary refractory NHL (44%) and 6 of 24 patients with high risk NHL (25%). In conclusion, in the vast majority of the above patients, no circulating lymphoma cells were detectable with the use of flowcytometry in the stemcell harvest. Therefore we conclude that with the present techniques and sensitivity immunological analysis of the graft does not give additional information and therefore is not necessary in this patient group. Provided the bone marrow before collection is free of lymphoma cells, we feel that the currently used mobilisation regimen is safe in these patients and does not lead to the presence of detectable tumour cells in the collected stemcells.

Successful peripheral blood stem cell mobilisation with filgrastim in patients with chronic myeloid leukaemia achieving complete cytogenetic response with imatinib, without increasing disease burden as measured by quantitative real-time PCR.

Imatinib mesylate (Glivec) is a selective inhibitor of bcr-abl tyrosine kinase, the product of the Philadelphia chromosome, which is the hallmark of chronic myeloid leukaemia (CML). With imatinib, complete cytogenetic response (CCR) can be achieved in over 70% of newly diagnosed patients with CML. However, the optimal long-term management of patients who achieve CCR after imatinib is unknown. With longer follow-up, it is anticipated that some patients are likely to progress and become candidates for autologous transplantation. We studied filgrastim (r-metHuG-CSF) mobilisation of peripheral blood stem cells (PBSC) in 32 patients who have achieved CCR with imatinib. Our data demonstrate that (1) the target CD34(+) cell yields of >/=2.0 x 10(6)/kg were attained with filgrastim 10 microg/kg/day, in 9/18 (50%) of patients during uninterrupted imatinib therapy, and in 10/14 (70%) when imatinib was temporarily withheld. The median CD34(+) cell yield per aphaeresis was 0.70 x 10(6)/kg (range 0.14-2.18) and 2.90 x 10(6)/kg (range 0.15-8.71) in the two groups, respectively (P&<0.005). (2) The cell yields did not correlate with the duration of imatinib administration. (3) There was no impact of the mobilisation procedure on the level of leukaemia as measured by serial blood bcr-abl levels using real-time quantitative PCR with either protocol. (4) bcr-abl remained detectable at low levels in the harvests in most but not all patients. In conclusion, filgrastim can safely be used to mobilise PBSC in patients who have achieved CCR with imatinib, but CD34(+) cell yields are significantly improved when imatinib is temporarily withheld.

Mobilization of dendritic cells from patients with breast cancer into peripheral blood stem cell leukapheresis samples using Flt-3-Ligand and G-CSF or GM-CSF.

Treatment with myeloablative chemotherapy and autologous peripheral blood stem cell (PBSC) transplantation followed by vaccination with autologous dendritic cells (DCs) treated with tumor antigens is a promising therapeutic strategy for several types of cancer. Obtaining sufficient numbers of both PBSCs and DCs is central to this approach. Previously, it has been shown that administration of Flt-3-Ligand (FL) combined with either G-CSF or GM-CSF mobilizes large numbers of PBSCs in patients with cancer. In the current study, we sought to determine whether these same cytokines could simultaneously mobilize DCs into the PBSC leukapheresis collection. DCs were analysed in PBSC leukapheresis samples obtained from five patients with high-risk breast cancer who received G-CSF alone as priming prior to leukapheresis, four patients who received FL+G-CSF and five patients who received FL+GM-CSF. DCs were defined as cells with a lin(dim/-) HLA-DR+ CD11c+ phenotype. The proportions of DCs in the FL+G-CSF and FL+GM-CSF samples were significantly higher than in pre-mobilization peripheral blood and G-CSF leukapheresis samples. The mean yield of DCs/kg in the FL+GM-CSF samples was also significantly higher than the mean yield of DCs in the G-CSF samples. The FL+G-CSF and FL+GM-CSF mobilized DCs were immature by morphologic and phenotypic criteria but stimulated allogeneic T-cells at levels similar to DCs generated in culture from PBMCs. Overnight culture?of the immature DCs obtained from patients receiving either FL+G-CSF or FL+GM-CSF in TNF-alpha?resulted in the generation of mature DCs. In summary, administration of FL in combination with GM-CSF and G-CSF to patients with breast cancer can mobilize large numbers of immature DCs into PBSC leukapheresis collections.

Allogeneic transplantation using peripheral blood stem cells

Over the past 9 years there has been a remarkable increase in the use of peripheral blood stem cells (PBSC) for allogeneic transplantation, primarily for matched sibling transplants but also increasingly for unrelated donor transplantation. In 1999 over 50% of all sibling transplants and over 25% of unrelated donor transplants reported to the European Group for Blood and Marrow Transplantation (EBMT) used PBSC. The major reason for this increasing use of PBSC relates to the rapid haemopoietic recovery seen which mirrors the advantages of using PBSC in autologous transplantation. This improvement in engraftment is a consequence of the larger number of stem cells that can be collected from G-CSF-mobilized peripheral blood compared to bone marrow. Evidence from randomized trials now shows a survival advantage for the use of PBSC in patients with advanced leukaemia. The reason for this improved survival appears primarily to relate to a reduced risk of transplant-related mortality and, possibly, a reduced risk of relapse, However, these randomized studies have also confirmed that there is an increased risk of chronic graft-versus-host disease associated with PBSC transplantation and further follow-up is required to determine the long-term impact on outcome.

Allogeneic blood and bone-marrow stem-cell transplantation in haematological malignant diseases: a randomised trial

Autologous transplantation with peripheral blood stem cells (PBSC) results in faster haematopoietic-cell repopulation than with bone marrow. We prospectively compared bone marrow and PBSC for allogeneic transplantation. Adult HLA-identical sibling donors provided bone marrow and lenograstim-mobilised PBSC. 39 patients with malignant haematological disorders were infused with either bone marrow (n=19) or PBSC (n=20) after standard conditioning regimens in a double-blind, randomised fashion. The identity of the infused products for all patients remained masked until 1 year after the last patient had received transplantation. The PBSC group had significantly faster neutrophil recovery to 0.5x10(9)/L (median 17.5 vs 23 days, p=0.002), and platelet recovery to 20x10(9)/L (median 11 vs 18 days, p<0.0001) and to 50x10(9)/L (median 20.5 vs 27 days, p=0.02) than the bone-marrow group. PBSC patients were discharged from hospital earlier than were bone-marrow patients (median 26 vs 31 days, p=0.01). At 4 weeks after transplantation, absolute lymphocytes (0.48 vs 0.63, p=0.08) and CD25 cells (0.04 vs 0.08, p=0.007) were higher in the PBSC group, and the proportion of patients with absolute lymphopenia (74% vs 33%, p=0.03) and CD4 lymphopenia (59% vs 24%, p=0.05) was significantly higher in the bone-marrow group. There was no significant difference in the occurrence of acute or chronic graft-versus-host disease and overall survival. The probability of relapse was significantly higher in the bone-marrow group than in the PBSC group (p=0.01); all five relapses occurred among bone-marrow recipients. Our small study indicates that PBSCs are better than bone marrow for allogeneic transplantation from HLA-identical siblings in terms of faster haematopoietic and immune recovery, and have the potential to reduce disease recurrence.

Cd 34+ Cells and Clonogenicity of Peripheral Blood Stem Cells During Chemotherapy Treatment in Association with Granulocyte Colony Stimulating Factor in Osteosarcoma

The introduction of aggressive chemotherapy in the treatment of osteosarcoma has improved the long-term outcome for these patients. With the increasing aggressiveness of chemotherapy protocols, hematopoietic growth factors have emerged as useful adjuncts involving, in some cases, rescue by peripheral blood stem cell (PBSC) infusion to assist faster recovery and maintain relative dose intensity. To evaluate the number of PBSCs needed, we analyzed the number of CD34+ cells and hematopoietic progenitor cells in the peripheral blood of 16 patients with osteoblastic, condroblastic and fibroblastic osteosarcoma enrolled in an Istituto Ortopedico Rizzoli-Scandinavian Sarcoma Group (IOR-SSG) pilot study, consisting of two cycles of preoperative high dose chemotherapy. The blood samples were studied at different times. The CD34+ cells were analyzed by flow cytometry and the hematopoietic progenitor cells were analyzed by tissue culture clonogenic assay. In comparing the two courses of chemotherapy, we observed that modification of the mean values of WBC, CD34+ and CFU-GM were very similar. The second course of chemotherapy seemed to induce greater hematological toxicity. All three parameters showed good correlation. The results demonstrated that the best time to collect PBSC by means of leukapheresis is post G-CSF used as rescue after ifosfamide treatment.We verified the ability of G-CSF to mobilize PBSCs in patients with osteosarcoma through cytofluorimetric analysis of CD34+ cells and their clonogenic capability. Moreover, during this preoperative treatment, we identified the best time to collect a sufficient number of PBSCs, that is after 9-10 days of G-CSF treatment following the first cycle of ifosfamide.

Factors that influence the collection and engraftment of allogeneic peripheral-blood stem cells in patients with hematologic malignancies.

To determine the number of CD34+ cells associated with a high probability of rapid engraftment after allogeneic peripheral-blood stem-cell (PBSC) transplant, and to examine the relationship between certain donor characteristics and the effectiveness of PBSC mobilization. Between December 1994 and July 1996, we treated 47 patients who had resistant hematologic neoplasms with myeloablative therapy followed by transplantation of allogeneic PBSC collected from histocompatible siblings after mobilization with granulocyte colony-stimulating factor (G-CSF). Expression of CD34 was determined by flow cytometry. Engraftment was rapid and similar to that observed following autologous PBSC transplant, with an absolute neutrophil count (ANC) greater than 500/microL and platelet count greater than 20,000/microL on median days +9 and +11, respectively. The pace of hematologic recovery correlated with the number of hematopoietic progenitors transplanted, so that patients who received greater than 5 x 10(6) CD34+ cells/kg recipient weight had a 95% likelihood of neutrophil and platelet recovery by day +15. Baseline (precytokine) CD34+ cells per milliliter of donor peripheral blood and total G-CSF dose (donor weight x 10 micrograms/kg) correlated with the number of CD34+ cells collected (R2 = .24 and P = .0009, and R2 = .24 and P < .0001, respectively). Donor age and sex did not effect mobilization. Following allogeneic PBSC transplant, patients who received greater than 5 x 10(6) CD34+ cells/ kg recipient weight had a high probability of rapid engraftment. Donors with low baseline levels of circulating progenitors (< 2,000 CD34+ cells/mL blood) and those who received lower total doses of G-CSF were less likely to be effectively mobilized. For donors with low baseline CD34+ counts, higher doses of G-CSF might improve mobilization. Baseline CD34+ counts and total G-CSF dose accounted for less than half of the variation in CD34+ cells collected, which indicates that other, as yet unidentified, factors play an important role in determining the effectiveness of mobilization.

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.