Stem Cell Apheresis Research Articles

A Randomized Clinical Trial Comparing Cytokine Administration Sites for Mobilization of Peripheral Hematopoietic Progenitor Cells for Patients with Hematological Malignancies Undergoing Autologous Stem Cell Transplantation.

Abstract 4230 BackgroundThe optimal injection site for cytokine administration when used to mobilize peripheral blood stem cells for collection is unclear. There are known differences in the pharmacokinetics of subcutaneously injected drugs based upon site adiposity. We hypothesized that injection in lower adipose-tissue-containing sites in the extremities would result in a reduced reservoir effect leading to lower exposures of granulocyte colony stimulating factor (G-CSF) and therefore reduced stem cell collection following cytokine mobilization. MethodsWe completed a prospective single institution IRB-approved randomized study to determine the efficiency and tolerability of different injection sites among patients with multiple myeloma or lymphoma undergoing stem cell mobilization and apheresis. The primary end-points were the total number of CD34+ cells collected and the number of days of apheresis required to collect target numbers (5 × 10E6 CD34+ cells/kg for patients with lymphoma; 10 × 10E6 CD34+ cells/kg for patients with myeloma). Forty patients were randomized to receive cytokine injections in their abdomen (group A) or extremities (group B). Randomization was stratified based upon diagnosis (myeloma; N=29 vs. lymphoma; N=11), age (≤50; N=13 vs. >50; N=27), and mobilization strategy (cytokines alone; N=27 vs. chemomobilization; N=13). Both group A and B were balanced with respect to the stratification criteria. Filgrastim was planned at a dose of 10 ug/kg/day for patients undergoing chemomobilization or 15 ug/kg/day for patients undergoing cytokine-only mobilization. Actual mean cytokine doses were 11.78 ug/kg/day using chemomobilization and 12.96 ug/kg/day using cytokines alone due to rounding to nearest vial size. Patients recorded the injection site for G-CSF and symptoms daily. ResultsOf those enrolled, 90% were evaluable with 18 patients in each group. Four were deemed non-evaluable due to failure to proceed to the planned mobilization procedure (1 in group A and 2 in group B) or lack of consistent injection site (1 patient). In addition, one patient in group B received a non-protocol specified injection of plerixafor due to poor mobilization and collected a total of 13.62 × 10E6 CD34+ cells/kg in 2 days of apheresis. Among the 36 evaluable subjects, 1 subject in each group failed collection with a total of < 2.0 × 10E6 CD34+ cells/kg collected. Mean BMI at the time of mobilization was not different between groups A and B (27.25 ± 4.7 versus 29.39 ± 5.7, respectively; p=NS). Mean numbers of CD34+ cells (±SD) collected were not different between groups A and B (9.15 ± 4.7 versus 9.85 ± 5 × 106/kg, respectively; p=NS). The mode and median duration of apheresis was 2 days for both groups. Subjects from both groups reported similar toxicities of pain and discomfort at the injection site. ConclusionsBased upon the analysis, G-CSF administration site (extremities versus abdomen), does not affect the number of CD34+ cells collected by apheresis or the duration of apheresis needed to reach the target cell dose. Disclosures:Lonial:Celgene: Consultancy; Millennium: Consultancy, Research Funding; BMS: Consultancy; Novartis: Consultancy; Gloucester: Research Funding.

Older Age But Not Donor Health Impairs Allogeneic Granulocyte Colony-Stimulating Factor (G-CSF) Peripheral Blood Stem Cell Mobilization

We evaluated stem cell mobilization in 195 consecutive sibling donors who underwent a uniform mobilization regimen of granulocyte colony-stimulating factor (G-CSF) at 10 microg/kg/day divided into twice daily dosing. On day 5, peripheral blood (PB) CD34 cells/microL were measured immediately prior to peripheral blood stem cell (PBSC) apheresis. Failed mobilization was defined as <20 CD34 cells/microL on day 5. The median age was 52 years and 73 (37%) were 55 years or greater. Comorbid conditions by the Charlson Comorbidity Index (CCI) occurred in 13%, but only 3% had Karnofsky performance status (PS) <100%. Eight (4%) failed mobilization, defined as <20 CD34 cells/microL on day 5. Older age was associated with fewer CD34 cells/microL (P=.002). In addition, 6/73 (8.2%) older donors failed mobilization compared to 2/122 (1.6%) younger donors (P=.054). Comorbidity, sex, race, and donor weight did not influence mobilization. Although low PS was very uncommon, it was associated with reduced mobilization (P=.021), but not mobilization failure. A small fraction of older donors mobilize poorly, and this is not explained by standard measures of comorbidity or PS.

Leukocytapheresis: A procedure gaining ground?

In the hemato-oncologic practice, leukocytapheresis is known both for therapeutic procedures like blastapheresis but also for preparative purposes. Examples of the latter are a. patient and donor stem cell apheresis after G-CSF mobilization and b. procurement of donor lymphocytes that in the post allogeneic stem cell transplantation can help the transplanted patient to attain full donor chimerism or to eradicate his/her (minimal) residual disease. Leukocytapheresis can also be adapted to collect therapeutic quantities of donor granulocytes. Although, not yet evidence based, donor granulocytes have been described to be of help in preventing reactivation of or cure severe -often fungalinfections in granulocytopenic patients. Much broader use of leukocytapheresis-isolated leukocytes (subsets) from the peripheral blood, however, seems heralded by the promise of immunomodulatory cell therapy to attenuate autoimmunity, to generate tolerance for organ and hematopoietic stem cell transplants and to induce new or stronger immunity against cancer or pathogens. In this respect, leukocytapheresis using closed system tubing sets is the most practical method to isolate GMP-grade buffy coats. These buffy coats namely are the raw material for subsequent elutriation or immunoadsorption (CliniMacs) mediated enrichment or depletion to prepare cell products such as regulatory T-cells (via CD25 and CD4 positivity), natural killer cells (via CD56 positivity and CD3 a/o CD19 negativity) and monocytes (via CD14 positivity). Leukocytapheresis, elutriation and immunoadsorp-

B152 First Analysis of HOVON-65/GMMG-HD4 Randomized Phase III Trial Comparing Bortezomib, Doxorubicin, Dexamethasone (PAD) vs. VAD as Induction Treatment Prior to High-dose Melphalan (HDM) in Patients with Newly Diagnosed Multiple Myeloma (MM)

The randomized, open-label, phase III trial HOVON-65/GMMG-HD4 was designed to evaluate the efficacy of bortezomib prior to HDM for response and progression-free survival (PFS) in patients with newly diagnosed MM. The trial was performed in 75 referral centers in the Netherlands and Belgium (HOVON group) and Germany (GMMG group). Patients with Salmon & Durie (SD) stage II or III, age 18-65 years inclusive, were randomly assigned to 3 cycles of VAD (vincristine 0.4 mg, adriamycine 9 mg/m2 days 1-4, dexamethasone 40 mg days 1-4, 9-12, and 17-20) or PAD (bortezomib 1.3 mg/m2 days 1,4,8,11, adriamycine 9 mg/m2 days 1-4, dexamethasone 40 mg days 1-4, 9-12, and 17-20). No thrombosis prophylaxis was given. Stem cells were mobilized using the CAD regimen, including cyclophosphamide 1000 mg/m2 iv day 1, and G-CSF. After induction therapy, all patients were to receive 1 or 2 cycles of high-dose melphalan (HDM) 200 mg/m2 with autologous stem cell rescue followed by maintenance with thalidomide 50 mg daily (VAD arm) or bortezomib, 1.3 mg/m2 once every 2 weeks (PAD arm) for 2 years. Between May 4, 2005 and May 16, 2008, 833 patients were randomized. After the trial was closed, we here report the planned interim analysis data on response after induction and HDM-1 of the initial 300 (150 per arm) randomized patients. The 2 randomization arms were equal for SD stage of disease, ISS stage, and distribution of chromosomal abnormalities. 137 patients (91%) completed PAD or 136 (91%) completed VAD and 132 patients (88%) in each arm completed HDM-1. Full dose bortezomib could be administered in 95% (PAD1), 89% (PAD2) and 85% (PAD3) of patients. Successful stem cell apheresis was achieved in all 137 PAD treated patients who received CAD mobilization . Peripheral polyneuropathy CTC grade 3-4 during PAD vs VAD was 16% vs 6%, while DVT/pulmonary embolism was diagnosed in 3% during VAD and 4% during PAD. Responses were assessed according to EBMT criteria including VGPR and nCR after PAD/VAD, after HDM-1 and best response on protocol treatment. Complete Response (CR/nCR), Very Good Partial Response (VGPR) and Partial Response (PR) in both arms were compared by logistic regression (table 1). Deletion of chromosome 13q or presence of t(4;14) did not have a significant impact on VGPR or (n)CR. We conclude that PAD induces significantly more PR+VGPR+(n)CR as compared with VAD, and that this effect is sustained after HDM-1.

Efficient mobilization of PBSC with vinorelbine/G-CSF in patients with malignant lymphoma

High-dose chemotherapy (HDT) and hematopoietic SCT are effective in patients with relapsing or refractory malignant lymphoma. Collection of sufficient numbers of stem cells is a prerequisite for such a therapy. In a pilot trial, we evaluated the feasibility of stem cell mobilization with vinorelbine/G-CSF in patients with lymphoma, a regimen allowing precise timing and harvesting of sufficient stem cells in myeloma patients. Forty-five patients with lymphoma received vinorelbine 35 mg/m(2) i.v. on day 1 and G-CSF 10 microg/kg/day s.c., divided in two daily doses from day 4 until collection. Stem cell collection was successfully performed in 43 patients (96%) with a median of 3.6 x 10(6) CD34(+) cells/kg (range: 1.4-16) in the collected product. In 28 patients (62%), the first stem cell apheresis was performed on day 8, and for 28 patients a sufficient stem cell yield was reached with one apheresis only. All 43 patients underwent high-dose chemotherapy with BEAM and auto-SCT with hematological recovery on time and without unexpected toxicity. In conclusion, vinorelbine/G-CSF allows accurate timing and safe harvesting of sufficient stem cells in patients with malignant lymphoma.

Mobilization of hemopoietic stem cells with high‐dose methotrexate plus granulocyte–colony‐stimulating factor in patients with primary central nervous system lymphoma

High-dose therapy with autologous stem cell support after standard dose induction is a promising approach for therapy of primary central nervous system lymphoma (PCNSL). High-dose methotrexate (HD-MTX) is a standard drug for induction of PCNSL; however, data about the capacity of HD-MTX plus granulocyte-colony-stimulating factor (G-CSF) to mobilize hemopoietic progenitors are lacking. This investigation describes the data from stem cell mobilization and apheresis procedures after one or two cycles of HD-MTX for induction of PCNSL within the East German Study Group for Haematology and Oncology 053 trial. Eligible patients proceeded to high-dose busulfan/thiotepa after induction therapy and mobilization. Data were available from nine patients with a median age of 58 years. The maximal CD34+ cell count per microL of blood after the first course of HD-MTX was 13.89 (median). Determination was repeated in six patients after the second course with a significantly higher median CD34+ cell count of 33.69 per microL. Five patients required two apheresis procedures and in four patients a single procedure was sufficient. The total yield of CD34+ cells per kg of body weight harvested by one or two leukapheresis procedures was 6.60 x 10(6) (median; range, 2.68 x 10(6)-15.80 x 10(6)). The yield of CD34+ cells exceeded the commonly accepted lower threshold of 3 x 10(6) cells per kg of body weight in eight of nine cases. Even in the ninth, hemopoietic recovery after stem cell reinfusion was rapid and safe. HD-MTX plus G-CSF is a powerful combination for stem cell mobilization in patients with PCNSL and permits safe conduction of time-condensed and dose-intense protocols with high-dose therapy followed by stem cell reinfusion after HD-MTX induction.

Phase II Study of GM-CSF, IL-2 and Rituximab Immunomodulation Following Autologous Stem Cell Transplantation in Patients with Relapsed or Refractory Lymphomas

A fraction of patients with relapsed/refractory lymphomas can achieve durable remission after autologous stem cell transplantation (ASCT). Nevertheless, relapse following ASCT remains as high as 60%, mostly related to persistent minimal residual disease (MRD) or malignant graft contamination. Post-transplantation rituximab has been proposed as a way to eradicate MRD, but its efficacy in this setting has not been proven, and may be limited due to decreased antibody-dependent cellular cytotoxicity (ADCC) during the immediate post-transplant period. GM-CSF and IL-2 might individually enhance the efficacy of rituximab by upregulating immunologic effectors. We hypothesized that given together, rituximab, GM-CSF and IL-2 would act synergistically to augment eradication of MRD, and improve event-free survival in relapsed/refractory lymphomas. The treatment regimen was as follows:following mobilization chemotherapy, patients received GM-CSF 200 mg/m2/day starting day +4 and G-CSF 10 mg/kg/day starting day +9 until completion of stem cell apheresis;following BEAM (BCNU, etoposide, ara-C, melphalan) conditioning and ASCT, GM-CSF 250 mg/m2/day was started day +1 until an absolute neutrophil count of >1500 cells/mL;starting between days +30 and +120, patients received 1 dose of rituximab 375 mg/m2 (cycle 1). This was followed by 3 cycles of GM-CSF 250 mg/day SQ days 1–5, IL-2 1.5 MIU/m2/day SQ days 6–12 and rituximab 375 mg/m2 IV day 9, repeated every 21 days.RESULTS: Between December 2001 and March 2008, 46 patients with relapsed or refractory lymphomas were enrolled. Histologic subtypes included diffuse large B-cell lymphoma (27), follicular lymphoma (3), mantle cell lymphoma (1), marginal zone lymphoma (1), small lymphocytic lymphoma (1) and Hodgkin disease (9). The median age was 50 years (range 21–68 years). Median number of regimens before salvage was 1 (range 1–4). Fifty-seven percent of patients enrolled had prior exposure to rituximab. Four patients (9%) failed mobilization. Two patients did not receive ASCT because of active disease, and another had an anaphylactic reaction to GM-CSF. Disease status prior to ASCT was complete remission (CR) (28), partial remission (PR) (7), stable disease (SD) (3) and even progressive disease (PD) (1). Overall, there were 39 patients eligible for post-ASCT immunotherapy. Ten patients (26%) did not initiate post-transplant immunotherapy due to depression, insurance rejection, cardiomyopathy, endocarditis, persistent neutropenia and autologous graft-versus-host disease. Among the 29 patients who underwent immunotherapy, 9 completed 1–2 cycles and 20 completed 3–4 cycles. Reasons for premature cessation of immunotherapy included intolerance, persistent cytopenias, chest pain, pleural effusion and infection. Main reported hematological toxicities were grade 3–4 neutropenia (12) and grade 3 thrombocytopenia (1). No increase in NK or T cells during therapy occurred. With a median follow-up of 33 months, the estimated 5 year overall survival (OS) for patients receiving 3–4 cycles is 62% and the estimated 5 year event-free survival (EFS) is 55%. When compared to patients who received no immunotherapy or 1–2 cycles, OS was similar, with a non-significant trend in improved EFS for patients receiving 3–4 cycles of immunotherapy.CONCLUSION: post-ASCT immunomodulation with rituximab, IL-2 and GM-CSF may be an effective approach to eradicate minimal residual disease following ASCT. In selected patients, it is well tolerated. Doses and schedules of this regimen need to be further investigated to determine maximal efficacy.

First Analysis of HOVON-65/GMMG-HD4 Randomized Phase III Trial Comparing Bortezomib, Adriamycine, Dexamethasone (PAD) Vs VAD as Induction Treatment Prior to High Dose Melphalan (HDM) in Patients with Newly Diagnosed Multiple Myeloma (MM)

The randomized, open-label, phase III trial HOVON-65/GMMG-HD4 was designed to evaluate the efficacy of bortezomib prior to HDM for response and progression-free survival (PFS) in patients with newly diagnosed MM. The trial was performed in 75 referral centers in the Netherlands and Belgium (HOVON group) and Germany (GMMG group). Patients with Salmon & Durie (SD) stage II or III, age 18–65 years inclusive, were randomly assigned to 3 cycles of VAD (vincristine 0.4 mg, adriamycine 9 mg/m2 days 1–4, dexamethasone 40 mg days 1–4, 9–12, and 17–20) or PAD (bortezomib 1.3 mg/m2 days 1,4,8,11, adriamycine 9 mg/m2 days 1–4, dexamethasone 40 mg days 1–4, 9–12, and 17–20). No thrombosis prophylaxis was given. Stem cells were mobilized using the CAD regimen, including cyclophosphamide 1000 mg/m2 iv day 1, and G-CSF. After induction therapy, all patients were to receive 1 or 2 cycles of high-dose melphalan (HDM) 200 mg/m2 with autologous stem cell rescue followed by maintenance with thalidomide 50 mg daily (VAD arm) or bortezomib, 1.3 mg/m2 once every 2 weeks (PAD arm) for 2 years. Between May 4, 2005 and May 16, 2008, 833 patients were randomized. After the trial was closed, we here report the planned interim analysis data on response after induction and HDM-1 of the initial 150 (75 per arm) randomized patients. The data of the initial 300 registered patients (150 per arm) will be available by November 1, 2008 and presented. The 2 randomization arms were equal for SD stage of disease, ISS stage, and distribution of chromosomal abnormalities. 134 patients (89%) completed PAD/VAD and 130 patients (87%) completed HDM-1, with no difference between the treatment arms. Full dose bortezomib could be administered in 95 % (PAD1), 79 % (PAD2) and 85 % (PAD3) of patients. Successful stem cell apheresis was achieved in all 132 patients who received CAD. Adverse events CTC grade 2–4 during PAD vs VAD included neurologic or polyneuropathy (PNP) 38% vs 21 %, constitutional symptoms 30 % vs 24 %. PNP of CTC grade 1–4 was more frequent in the PAD arm (p=0.01), while DVT/pulmonary embolism was diagnosed in 10 % during VAD and 6 % during PAD. Responses were assessed according to EBMT criteria including VGPR after PAD/VAD, after HDM-1 and best response on protocol treatment. Complete Response (CR), Very Good Partial Response (VGPR) and Partial Response (PR) in both arms were compared by logistic regression (table 1)Response ITT (%)PADVADp-valuePAD+ HDM-1VAD+ HDM-1p-valueCR500.061540.05≥VGPR41170.00159470.14≥PR80640.0392770.01The (preliminary) overall complete response rate including maintenance was 27 % (PAD arm) and 5% (VAD arm) (p=0.001). Deletion of chromosome 13q did not have a significant impact on response. We conclude that PAD induces significantly more PR+VGPR+CR as compared with VAD, and that this effect is sustained after HDM-1. This trial was supported by the Dutch Cancer Foundation (EudraCT nr 2004-000944-26), the German Federal Ministry of Education and Research and a grant from Johnson and Johnson

Factors influencing catheter-related infections in the Dutch multicenter study on high-dose chemotherapy followed by peripheral SCT in high-risk breast cancer patients

Neutropenia following high-dose chemotherapy leads to a high incidence of infectious complications, of which central venous catheter-related infections predominate. Catheter-related infections and associated risk factors in 392 patients participating in a randomized adjuvant breast cancer trial and assigned to receive high-dose chemotherapy and peripheral stem-cell reinfusion were evaluated. Median catheter dwell time was 25 days (range 1-141). Catheter-related infections were seen in 28.3% of patients (11 infections per 1000 catheter-days). Coagulase-negative staphylococci were found in 104 of 186 positive blood cultures (56%). No systemic fungal infections occurred. Cox regression analysis showed that duration of neutropenia >10 days (P=0.04), using the catheter for both stem-cell apheresis and high-dose chemotherapy (P= <0.01), and use of total parenteral nutrition (TPN, P=0.04) were predictive for catheter-related infections. In conclusion, a high incidence of catheter-related infections after high-dose chemotherapy was seen related to duration of neutropenia, use of the catheter for both stem-cell apheresis and high-dose chemotherapy, and use of TPN. Selective use and choice of catheters could lead to a substantial reduction of catheter-related infectious complications.

Correlation between serum lactate dehydrogenase and stem cell mobilization

After observing a correlation between elevated serum lactate dehydrogenase (LDH) levels and good stem cell collections, retrospective data from 540 donors undergoing 650 stem cell apheresis procedures (87% autologous, 13% allogeneic) were studied to determine the correlation between preapheresis LDH levels and the absolute peripheral blood CD34+ cell count (PBCD34). PBCD34 (1-1611/mul; median 40) correlated modestly with leukocytes (0.5-118.2 x 10(9)/l; median 30.2) (r=0.16; P=0.00005) and poorly with platelets (16-660 x 10(9)/l; median 131) (r=0.02; P=0.69). The correlation between LDH (64-1664 IU/l; median 310) and PBCD34 was very strong (r=0.54; P<10(-48)). In multivariate regression analysis, serum LDH was the only factor correlating significantly with PBCD34. The correlation between serum LDH and PBCD34 was strong on the first day of collection (n=517; r=0.53; P<10(-37)), weakened on the second day (n=74; r=0.37; P=0.0009) and disappeared beyond day 2 (n=59; r=0.09; P=0.49). PBCD34 was significantly higher (median 53 versus median 11; P<0.00001) when LDH was elevated (n=511) compared to when LDH was normal (n=139). The relationship between serum LDH and PBCD34 was strong for autologous (r=0.54) as well as for allogeneic (r=0.41) collections. Our data suggest that it is reasonable to assume good stem cell mobilization and start apheresis if the LDH is elevated.

Use of totally implantable catheters for peripheral blood stem cell apheresis

Collection of PBSC by leukapheresis requires one venous access (VA) for inflow and one for outflow. The use of implantable venous access devices (IVAD) has never been reported in this setting. We retrospectively analyzed the use of IVAD for performing apheresis. The study was conducted between January 2000 and June 2005 on 64 patients (41 children) requiring intensification for treatment of a solid tumor. Mean body weight was 26 kg (range 8-91 kg) for a median age of 8.5 years (range 0.7-66 years). A total of 121 aphereses were performed (mean 1.89 apheresis/patient). The second VA was in a cubital vein in 84 procedures and was a temporary central VA in 31. Mean duration of apheresis was 3 h (range 30-274 min). Mean flow rate was 41.3 ml/min (range 12-85 ml/min). Mean collection rate was 59.2% for CD34+ cells and 70% for mononuclear cells. The total number of CD34+ cells collected was 2.5 x 10(6)/kg per apheresis, and 5.9 x 10(6)/kg per patient. Several complications occurred: one catheter-related sepsis (0.86%), four catheter occlusions (3.47%) and eight hemodynamic instabilities related to extracorporeal volume. Weight <10 kg is a risk factor for complication (P=0.0006). IVAD are effective and safe for PBSC collection. Placement of a second central VA (requiring general anesthesia for children) could be avoided.

Peripheral Blood Stem Cell Transplantation in Children with Thalassemia.

Although improvements in conventional treatment have enhanced the prognosis of thalassaemia, stem cell transplantation remains the only cure. Studies have shown that peripheral blood stem cell transplantation (PBSCT) results in rapid hematological and immunological recovery but increased risk for graft versus host disease (GVHD). We report the PBSCT experience of Akdeniz University School of Medicine Pediatric Hematology&Oncology department concerning 54 patients with beta-thalessemia. Median age was 6 years (1–18 years), 26 were girls, 28 were boys. Thirteen were Class I, twenty-two were Class II, nineteen were Class III according to Pesaro criteria. 12 patients were given BU+CY and 39 BU+CY plus ATG as conditioning regimen. Three Class III patients were conditioned with Pesaro protocol 26. BU dosage was 16 mg/kg for Class I and Class II patients followed by CY 200 mg/kg totally. Class III patients received 14 mg/kg BU and 160 mg/kg CY. All patients received MTX (+1, +3, +6) and CsA for GVHD prophylaxis. All of the donors were HLA identical (51 sibling, 3 parents). Median age of the donors was 7 years (range: 2–40 years). G-CSF was given for 5 days with the dosage of 5 μgr/kg/day to child and 10 μgr/kg/day to adult donors for peripheral blood stem cell mobilization. Stem cell apheresis was performed on fifth day, but continued to day 7 if adequate cell count was not achieved. In older children and parents if appropriate, antecubital veins were used for harvesting but for younger donors, femoral dual lumen catheters were emplaced. Fresenius AS. TEC204 or Haemonetics MCS+ cell separators were used for apheresis. The median apheresis count was 1 (range 1–3). Median transfused MNC and CD34 cell counts were 10.1×108/kg (range:5.3–27.7×108/kg) and 4,65×106/kg (range:1.1–29.4×106 /kg) respectively. Median neutrophil and platelet engraftment times were day 14 and day 15, respectively. Grade II–IV acute GVHD were observed in five patients, chronic GVHD were in four of two were extensive. One patient died on posttransplant day 32 because of acute GVHD. Death because of chronic GVHD was not observed. At a median follow-up of 26 months (1–92 months), overall survival for the whole group is 92.6 % and evet-free survival is %80.4. Autologous reconstitution developed in six patients and graft failure in two.

Overnight storage of autologous stem cell apheresis products before cryopreservation does not adversely impact early or long-term engraftment following transplantation

To reduce costs and avoid inconvenient overtime work, our institution changed policy in September 2000 so that autologous stem cell apheresis products were stored overnight before cryopreservation rather than immediately processed. This retrospective review was conducted to evaluate the possible impact of this policy change on hematopoietic engraftment following autologous stem cell transplantation (ASCT). In total, 229 consecutive lymphoma patients who underwent a single, unpurged ASCT in Calgary between January 1995 and November 2003 were evaluated. Of these patients, 131 patients' autografts underwent immediate processing and cryopreservation before September 2000, and 98 patients' autografts underwent next-day cryopreservation after overnight storage following this date. Results of univariate and multivariate analyses demonstrated no adverse effect of overnight storage before cryopreservation on the number of days to initial engraftment of platelets or neutrophils, on the proportion of patients with low blood counts 6 months post-ASCT, or on lymphoma relapse rates or overall survival post-ASCT. These data suggest that overnight storage of the autograft before cryopreservation does not adversely affect graft viability or influence long-term disease status, and support the continued use of overnight storage of stem cells before cryopreservation as a convenient, cost reduction measure.

Accurate prediction of autologous stem cell apheresis yields using a double variable‐dependent method assures systematic efficiency control of continuous flow collection procedures

Stem cell collection is a standard procedure for the procurement of autologous grafts to rescue myelosuppression induced by high-dose treatments. Accurate prediction of collection yields may contribute to optimize planning and quality control of collection. Data of 313 autologous haematopoietic stem cell (AHSC) evaluable collections performed in 208 patients with haematologic and non-haematologic neoplasms from seven centres were prospectively analysed to test the accuracy of yield predictions generated by a formula that required the input of peripheral blood (PB) CD34+ cell precount and desired PB volume to be processed. Data were matched in a standard linear regression, in a zero-point regression analysis and tested for prediction accuracy. Further 165 AHSC collections were analysed on a single-centre basis, using yield predictions as reference standards. Analysis showed high levels of correlation between measured collection yields (my) and predictions (py) (R = 0.85; P = 0.000000) as well as high degree of prediction accuracy (my vs. py at paired t-test: P = 0.114781; median my/py ratio = 1.23). Analysis of additional 165 AHSC collections on a single-centre basis showed that the analysed centres had 70% or more measured yields comprising the 0.6-1.8 interval of the my/py ratio. The observance of the 'efficiency' my/py interval assured collection quality control in these centres confirming the reliability of the method. This prediction method generates accurate and immediate yield predictions allowing collection planning and rapid efficiency control. As a consequence of our study, four centres out of seven use the described method to plan both leukapheresis number and single-procedure blood processing volume while the remaining three centres plan leukapheresis number on the basis of our predictions, maintaining a fixed single-procedure 200 ml/kg blood volume processing, according to their centre AHSC collection policy.

The new WAA apheresis registry

The WAA (World Apheresis Association) registry for apheresis has been developed to enable registration through internet by centers all around the world. It is of no charge for the registering centers. The new version is available at the site www.iml.umu.se/medicin. Until now more than 5700 treatments have been registered from centers in 6 countries. It allows registration of acute or chronic therapeutic apheresis and also collection of stem cells, cellapheresis, photopheresis and various adsorption technologies. Registration includes diagnoses, access, anticoagulation, replacement fluids, mode of treatment, volumes processed, techniques used and adverse events that develop. Analyses of data enables improvement of quality of apheresis. The new registry enables you to change data that were wrongly entered as well as add data that was missed when you firstly entered the file. We cordially invite all of you to join the registration procedure.

RHuG‐CSF Increases the Platelet‐Neutrophil Complex Formation and Neutrophil Adhesion Molecule Expression in Volunteer Granulocyte and Stem Cell Apheresis Donors

Several reports have shown that granulocyte colony-stimulating factor (G-CSF) administration induces a transient, mild hypercoagulable state, which might predispose certain donors to thrombotic complications. In the present study, changes in the expression of neutrophil adhesion molecules (CD11b/CD18, CD62L) and platelet-neutrophil complex formation following rHuG-CSF administration were investigated in normal granulocyte and stem cell donors. For granulocyte apheresis (N = 10), rHuG-CSF (5 microg/kg) was given subcutaneously every 12 h three times and apheresis was carried out two hours after the last dose. For stem cell apheresis (N = 8), rHuG-CSF (10 microg/kg/day) was given subcutaneously for 5 days and apheresis was carried out when peripheral CD34+ cell counts exceeded 20 cell/microL. Expression of neutrophil adhesion molecules (CD11b/CD18, CD62L) and platelet-neutrophil complex formation following rHuG-CSF administration were investigated in donors by a flow cytometric method. A significant increase in neutrophil counts (P < 0.001), and decreases in platelet counts (P < 0.01) and hemoglobin levels (P < 0.01) occurred following G-CSF administration. The expression of CD11b/CD18 significantly increased (P < 0.001) over pretreatment values with G-CSF administration and returned to baseline 1 week after stopping the drug. In contrast, CD62L expression was decreased (P < 0.01) with G-CSF and returned to normal after cessation of the drug. rHuG-CSF caused more than a two-fold increase (from 0.3 to 7.0 x 10(9)/L) in circulating platelet-neutrophil complexes (P < 0.01), which returned to normal after 1 week. Although clinical significance of these laboratory changes is not clear, the occurrence of neutrophil activation and increased platelet-neutrophil complex formation might predispose certain donors or patients to thrombotic complications following G-CSF administration.

Does mRNA level of microsomal carnitine palmitoyltransferase predict yield of peripheral blood stem cell apheresis?

Transplantation of autologous hematopoietic stem cells is a well established therapeutic procedure. Despite advances in efficacy of the stem cell mobilization and apheresis process until now a predictive factor for the expected stem cell yield before initiation of mobilization therapy could not be identified. The main objective of our study was to evaluate alterations in enzymes involved in fatty acid metabolism on the level of gene expression in mononuclear cells, as changes in relative mRNA levels of these enzymes could represent the hematopoietic regenerative potential. Data of 23 consecutive patients with different lymphoid malignancies undergoing stem cell mobilization were analyzed. Our results show that mRNA levels of microsomal carnitine palmitoyltransferase in peripheral blood mononuclear cells quantified before application of mobilization therapy correlate positively with the amount of CD34 positive cells in peripheral blood before first apheresis, in the first apheresis product and in the total harvest outcome. The association of enzymes involved in fatty acid metabolism with hematoopoiesis was further confirmed in healthy subjects on altitude-adaptation training and in proliferating or differentiating HL60 cells. This gives evidence for a possible predictive value of such analyzes though further data of a larger sample are to be collected to confirm our observations.

Maximizing hematopoietic progenitor cell collections by apheresis

The timing of the initiation of peripheral blood stem cell collection or apheresis varies considerably among oncologists and institutions. Some physicians may choose to initiate apheresis based on the peripheral white blood cell count (WBC), number of days post chemotherapy, or number of days post initiation of high dose growth factor administration. At Kosair Children’s Hospital, it was noted that the timing of the initiation of apheresis was very subjective, which led to inconsistent and at times unsuccessful collections. Some children were harvested over many days with poor CD34+ collections and other children needed only 1 day to obtain an adequate product yield. We began collecting data on all the apheresis patients, which included the performance of a peripheral CD34+ count and a CBC prior to every apheresis collection. The results demonstrated that when a donor’s circulating CD34+ cells/ul were below 4.5 cells/ul, the product yield was found to be unacceptable (below 1 × 106CD34+ cells/kg). When a donor’s circulating CD34+ cells/ul fell between 4.5 cells/ul and 9.0 cells/ul, the product yield did not consistently contain adequate cells for transplant, and apheresis was left to the transplant physician’s discretion. When the donor’s circulating cell count/ul was 9.0 cells/ul and greater, the CD34+ collection was always adequate (>1 × 106CD34+ cells/kg), and the donor should undergo apheresis that day. Changes were made in our decision process for initiating apheresis. Now, all donors undergo peripheral CD34+ testing with a CBC, and they are not evaluated for apheresis until the absolute CD34+ cells/ul are above 4.5 cells/ul. Since implementation, our patients have received a more cost-effective stem cell collection, and one that is also less time consuming for the staff, institution, and above all the family. This poster presentation will: (1) Demonstrate the correlation between the CD34+ count and the WBC in relation to the amount of stem cells collected. (2) Illustrate the improvement in stem cell collections as seen in the CD34+ cell count of the products and the reduction in the number of days required to collect a sufficient quantity of stem cells. The timing of the initiation of peripheral blood stem cell collection or apheresis varies considerably among oncologists and institutions. Some physicians may choose to initiate apheresis based on the peripheral white blood cell count (WBC), number of days post chemotherapy, or number of days post initiation of high dose growth factor administration. At Kosair Children’s Hospital, it was noted that the timing of the initiation of apheresis was very subjective, which led to inconsistent and at times unsuccessful collections. Some children were harvested over many days with poor CD34+ collections and other children needed only 1 day to obtain an adequate product yield. We began collecting data on all the apheresis patients, which included the performance of a peripheral CD34+ count and a CBC prior to every apheresis collection. The results demonstrated that when a donor’s circulating CD34+ cells/ul were below 4.5 cells/ul, the product yield was found to be unacceptable (below 1 × 106CD34+ cells/kg). When a donor’s circulating CD34+ cells/ul fell between 4.5 cells/ul and 9.0 cells/ul, the product yield did not consistently contain adequate cells for transplant, and apheresis was left to the transplant physician’s discretion. When the donor’s circulating cell count/ul was 9.0 cells/ul and greater, the CD34+ collection was always adequate (>1 × 106CD34+ cells/kg), and the donor should undergo apheresis that day. Changes were made in our decision process for initiating apheresis. Now, all donors undergo peripheral CD34+ testing with a CBC, and they are not evaluated for apheresis until the absolute CD34+ cells/ul are above 4.5 cells/ul. Since implementation, our patients have received a more cost-effective stem cell collection, and one that is also less time consuming for the staff, institution, and above all the family. This poster presentation will: (1) Demonstrate the correlation between the CD34+ count and the WBC in relation to the amount of stem cells collected. (2) Illustrate the improvement in stem cell collections as seen in the CD34+ cell count of the products and the reduction in the number of days required to collect a sufficient quantity of stem cells.

Quo vadis haemapheresis: Current developments in haemapheresis

The techniques of haemapheresis originated in the development of centrifugal devices separating cells from plasma and later on plasma from cells. Subsequently membrane filtration was developed allowing for plasma—cell separation. The unspecificity of therapeutic plasma exchange led to the development of secondary plasma separation technologies being specific, semi-selective or selective such as adsorption, filtration or precipitation. In contrast on-line differential separation of cells is still under development. Whereas erythrocytapheresis, granulocytapheresis, lymphocytapheresis and stem cell apheresis are technically advanced, monocytapheresis may need further improvement. Also, indications such as erythrocytapheresis for the treatment of polycythaemia vera or photopheresis though being clinically effective and of considerable importance for an appropriate disease control are to some extent under debate as being either too costly or without sufficient understanding of the mechanism. Other forms of cell therapy are under development. Rheohaemapheresis as the most advanced technology of extracorporeal haemorheotherapy is a rapidly developing approach contributing to the treatment of microcirculatory diseases and tissue repair. Whereas the control of a considerable number of (auto-) antibody mediated diseases is beyond discussion, the indication of apheresis therapy for immune complex mediated diseases is quite often still under debate. Detoxification for artificial liver support advanced considerably during the last years, whereas conclusions on the efficacy of septicaemia treatment are debatable indeed. LDL-apheresis initiated in 1981 as immune apheresis is well established since 24 years, other semi-selective or unspecific procedures, allowing for the elimination of LDL-cholesterol among other plasma components are also being used. Correspondingly Lp(a) apheresis is available as a specific, highly efficient elimination procedure superior to techniques which also eliminate Lp(a). Quality control systems, more economical technologies as for instance by increasing automation, influencing the over-interpretation of evidence based medicine especially in patients with rare diseases without treatment alternative, more insight into the need of controlled clinical trials or alternatively improved diagnostic procedures are among others tools ways to expand the application of haemapheresis so far applied in cardiology, dermatology, haematology, immunology, nephrology, neurology, ophthalmology, otology, paediatrics, rheumatology, surgery and transfusion medicine.

Comparison of flow cytometry vs. a haematology cell analyser‐based method to guide the optimal time‐point for peripheral blood stem cell apheresis

For timing the onset of apheresis, parameters obtained by flow cytometry and by a haematological cell analyser were compared. Haematopoietic cell counts (n = 159) were performed by two different methods; CD34 analyses by flow cytometry, immature myeloid information (IMI) and human progenitor cell counts (HPC) by a haematological cell analyser. Comparing the IMI total results with CD34+ analyses (n = 159) revealed a correlation of r = 0.46 (P < 0.05). Similar results were obtained for HPC (r = 0.44; P < 0.05). The haematology analyser-based method does not allow the precise determination of absolute haematopoietic stem cell numbers and is thus not able to replace flow cytometry for the monitoring of peripheral blood stem cell counts.