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Shaughnessy P, Chao N, Shapiro J, Walters K, McCarty J, Abhyankar S, Shayani S, Helmons P, Leather H, Pazzalia A, Pickard S. Pharmacoeconomics of hematopoietic stem cell mobilization: an overview of current evidence and gaps in the literature. Biol Blood Marrow Transplant 2013; 19:1301-9. [PMID: 23685251 DOI: 10.1016/j.bbmt.2013.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 05/08/2013] [Indexed: 12/22/2022]
Abstract
Adequate hematopoietic stem cell (HSC) mobilization and collection is required prior to proceeding with high dose chemotherapy and autologous hematopoietic stem cell transplant. Cytokines such as G-CSF, GM-CSF, and peg-filgrastim, alone or in combination with plerixafor, and after chemotherapy have been used to mobilize HSCs. Studies have shown that the efficiency of HSC mobilization and collection may vary when different methods of mobilization are used. No studies have shown that survival is significantly affected by the method of mobilization, but some studies have suggested that cost and resource utilization may be different between different mobilization techniques. After the FDA approval of plerixafor with G-CSF to mobilize HSCs many transplant centers became concerned about the cost of HSC mobilization. A panel of experts was convened ant this paper reviews the current literature on the pharmacoeconomics of HSC mobilization.
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Tanhehco YC, Vogl DT, Stadtmauer EA, O'Doherty U. The evolving role of plerixafor in hematopoietic progenitor cell mobilization. Transfusion 2013; 53:2314-26. [PMID: 23362980 DOI: 10.1111/trf.12102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 11/09/2012] [Accepted: 11/19/2012] [Indexed: 12/21/2022]
Abstract
The introduction of plerixafor as a peripheral blood stem cell mobilization agent has allowed more patients with multiple myeloma, non-Hodgkin's lymphoma, and Hodgkin's disease to mobilize sufficient hematopoietic progenitor cells (HPCs) to proceed to autologous transplantation. Because of the high cost of plerixafor, it is not routinely used in all patients undergoing HPC mobilization. If cost were not an issue, an argument could be made that plerixafor could be added to every mobilization regimen, but cost is an issue so in an attempt to be more cost-effective, many centers have limited plerixafor use to patients who have failed or who are predicted to fail collection of adequate numbers of cells by other methods. Additionally, plerixafor is now under investigation both for HPC collection of healthy donors for allogeneic stem cell transplantation and as an adjunct therapy (i.e., chemosensitizing agent) for acute leukemias. This article briefly reviews the role of plerixafor in autologous and allogeneic transplantation as well as its emerging role in the treatment of acute leukemias. Emphasis is placed on the choice of appropriate patients for plerixafor use to assure an adequate stem cell yield while maximizing the cost effectiveness of using plerixafor. The role of prophylactic collections and future areas of research are also presented.
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Affiliation(s)
- Yvette C Tanhehco
- Department of Pathology and Cell Biology, Columbia University, New York, New York; Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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53
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Maziarz RT, Nademanee AP, Micallef IN, Stiff PJ, Calandra G, Angell J, Dipersio JF, Bolwell BJ. Plerixafor plus granulocyte colony-stimulating factor improves the mobilization of hematopoietic stem cells in patients with non-Hodgkin lymphoma and low circulating peripheral blood CD34+ cells. Biol Blood Marrow Transplant 2013; 19:670-5. [PMID: 23333777 DOI: 10.1016/j.bbmt.2013.01.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 01/11/2013] [Indexed: 11/17/2022]
Abstract
Many institutions have adopted algorithms based on preapheresis circulating CD34+ cell counts to optimize the use of plerixafor. However, a circulating peripheral blood CD34+ cell threshold that predicts mobilization failure has not been defined. The superiority of plerixafor + granulocyte colony-stimulating factor (G-CSF) over placebo + G-CSF for hematopoietic stem cell mobilization and collection was shown for patients with non-Hodgkin lymphoma in a phase III, prospective, randomized, controlled study. The question remains as to which patients may benefit most from the use of plerixafor. In this post hoc retrospective analysis, mobilization outcomes were compared between the 2 treatment arms in patients stratified by peripheral blood CD34+ cell count (<5, 5 to 9, 10 to 14, 15 to 19, or ≥20 cells/μL) obtained before study treatment and apheresis. Compared with placebo plus G-CSF, plerixafor plus G-CSF significantly increased the peripheral blood CD34+ cells/μL over prior day levels in all 5 stratified groups. The probability of subsequent transplantation without a rescue mobilization was far greater in the plerixafor-treated patients for the lowest initial (day 4) peripheral blood CD34+ cells/μL groups (<5, 5 to 9, or 10 to 14). Engraftment and durability were the same for the 2 treatment groups for all strata, but the effect in the lower strata could be altered by the addition of cells from rescue mobilizations. These findings may provide insight into the optimal use of plerixafor in all patients undergoing stem cell mobilization.
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Affiliation(s)
- Richard T Maziarz
- Center for Hematologic Malignancies and Adult Blood & MarrowTransplant Program, Knight Cancer Institute, Oregon Health & Science University, Portland, OR 97239, USA.
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Giebel S, Kruzel T, Czerw T, Sadus-Wojciechowska M, Najda J, Chmielowska E, Grosicki S, Jurczyszyn A, Pasiarski M, Nowara E, Glowala-Kosinka M, Chwieduk A, Mitrus I, Smagur A, Holowiecki J. Intermediate-dose Ara-C plus G-CSF for stem cell mobilization in patients with lymphoid malignancies, including predicted poor mobilizers. Bone Marrow Transplant 2013; 48:915-21. [DOI: 10.1038/bmt.2012.269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 11/06/2012] [Accepted: 11/28/2012] [Indexed: 11/09/2022]
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55
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Cost-Effectiveness Analysis of a Risk-Adapted Algorithm of Plerixafor Use for Autologous Peripheral Blood Stem Cell Mobilization. Biol Blood Marrow Transplant 2013; 19:87-93. [DOI: 10.1016/j.bbmt.2012.08.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 08/11/2012] [Indexed: 11/19/2022]
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56
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Systematic Review of Randomized Controlled Trials of Hematopoietic Stem Cell Mobilization Strategies for Autologous Transplantation for Hematologic Malignancies. Biol Blood Marrow Transplant 2012; 18:1191-203. [DOI: 10.1016/j.bbmt.2012.01.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 01/11/2012] [Indexed: 11/20/2022]
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57
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Piccirillo N, Vacca M, Lanti A, Ipsevich F, Maresca M, Fiorelli E, Bianchi M, Adorno G, Pierelli L, Majolino I, Leone G, Zini G. Poor mobilizer: a retrospective study on proven and predicted incidence according to GITMO criteria. Transfus Apher Sci 2012; 47:217-21. [PMID: 22784631 DOI: 10.1016/j.transci.2012.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The Italian Group for Bone Marrow Transplantation (Gruppo Italiano Trapianto di Midollo Osseo, GITMO) recently formalized criteria for a shared definition of poor mobilizer in order to facilitate randomized clinical trials and study comparison focusing on the efficacy of current mobilizing regimens. The availability of a standardized tool for poor mobilizer definition suggested us to retrospectively test GITMO criteria feasibility and applicability. Therefore we analyzed medical and laboratory records of adult patients affected by myeloma (MM) or lymphoma undergoing mobilization for autologous peripheral blood HSC collection from January 2010 to June 2011, at Servizio di Emotrasfusione, Istituto di Ematologia, Università Cattolica Del Sacro Cuore, Roma, UOC SIMT AO S. Camillo Forlanini Roma and SIMT Fondazione Policlinico Tor Vergata Roma. We collected data about 227 patients (134 male, 93 female) affected by MM (31.3%) NHL (58.6%) e HD (10.1%). Thirty-nine patients, 21 male and 18 female met proven poor mobilizer criteria definition resulting in a incidence of 17.2% (12.7% in MM, 21.8% in NHL and 4.3% in HD). Eleven patients, seven affected by lymphoma and four affected by myeloma, were defined predicted PM according to major criteria. Eight patients, seven affected by lymphoma and one affected by myeloma, were define predicted PM according to minor criteria. Sixteen out of 39 patients defined as poor mobilizer either according to major or minor criteria underwent collection procedures and eight (20.5%) achieved a cell dose ⩾2×10(6)/kg CD34(+) cells. GITMO criteria application was easy and resulted in poor mobilizer incidence comparable to current literature. Definitions of proven poor mobilizer and predicted poor mobilizer according to major criteria were very effective while minor criteria were less predictive. These results came from a retrospective analysis and therefore should be validated in future prospective trial. On the other hand these data could be an early overall view of the foreseeable future of peripheral blood stem cell collection. In conclusion we believe that these criteria will be able to better characterize poor mobilizer phenomenon and, consequently, to identify patients taking advantage from new mobilizing agents.
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Affiliation(s)
- Nicola Piccirillo
- Servizio di Emotrasfusione, Istituto di Ematologia, Università Cattolica del Sacro Cuore, Roma, Italy.
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Tsutsumi Y, Ogasawara R, Ito S, Sasaki J, Morita A, Senoo N, Murata N, Tanaka J, Asaka M, Imamura M. Retrospective analysis of an efficient peripheral blood stem cell collection and the relation between infused cell dose and clinical outcome in patients with malignant lymphoma and multiple myeloma. Int J Lab Hematol 2012; 34:403-9. [PMID: 22376221 DOI: 10.1111/j.1751-553x.2012.01410.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Etoposide (VP16) is a drug used not only for the treatment of lymphoma but also for the collection of peripheral blood stem cells (PBSCs). We analysed the efficacy and adverse effects of collecting PBSCs and the relation between the infused cell dose and the clinical outcome in lymphoid malignancies. METHOD Investigating 30 patients with non-Hodgkin's lymphoma, one patient with Hodgkin's lymphoma, and five patients with multiple myeloma, we compared the effects of several doses of etoposide with those of CHOP or CHOP-like treatments or salvage treatments. We also analysed the relation between the amount of CD34(+) cells collected (above or below 5.0 × 10(6) /kg/day) and prognosis of these patients. RESULTS We found the collected cell count to be highest in patients treated with 500 mg/m(2) of VP16 and lowest in those not treated with VP16 (P = 0.0073). A CD34(+) cell count above 100/μL on the collection day indicates that the target amount of CD34(+) cells (4.0 × 10(6) /kg) can be readily obtained and was reached most rapidly by the patients who had received 500 mg/m(2) of VP16 (P = 0.01). The longer duration of neutropenia in those patients (P = 0.000006) resulted in longer antibiotic treatment (P = 0.0052). Both progression-free survival (PFS) and overall survival (OS) were better for the patients who yielded more than 5.0 × 10(6) CD34(+) cells/kg/day (P = 0.087 for PFS and P < 0.033 for OS). CONCLUSION We show here that 3 days of VP16 at 500 mg/m(2) was useful for the collection of PBSCs and that patients who yielded more than 5.0 × 10(6) CD34(+) cells/kg/day survived longer than those who yielded less.
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Affiliation(s)
- Y Tsutsumi
- Department of Hematology, Hakodate Municipal Hospital, Hakodate, Japan.
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Unsuccessful stem cell remobilization for autologous transplantation is predicted by renal impairment and a stem cell yield ≤ 0.5 X 10(6) CD34+ cells/kg at first mobilization. Bone Marrow Transplant 2012; 47:1372-3. [PMID: 22343671 DOI: 10.1038/bmt.2012.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Attolico I, Pavone V, Ostuni A, Rossini B, Musso M, Crescimanno A, Martino M, Iacopino P, Milone G, Tedeschi P, Coluzzi S, Nuccorini R, Pascale S, Di Nardo E, Olivieri A. Plerixafor Added to Chemotherapy Plus G-CSF Is Safe and Allows Adequate PBSC Collection in Predicted Poor Mobilizer Patients with Multiple Myeloma or Lymphoma. Biol Blood Marrow Transplant 2012; 18:241-9. [DOI: 10.1016/j.bbmt.2011.07.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 07/20/2011] [Indexed: 01/09/2023]
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Abstract
This review evaluates the latest information on the mobilisation of haemopoietic stem cells for transplantation, with the focus on what is the current best practice and how new understanding of the bone marrow stem cell niche provides new insights into optimising mobilisation regimens. The review then looks at the mobilisation of mesenchymal stromal cells, immune cells as well as malignant cells and what clinical implications there are.
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Long-Term Outcome after Autologous Stem Cell Transplantation with Adequate Peripheral Blood Stem Cell Mobilization Using Plerixafor and G-CSF in Poor Mobilizer Lymphoma and Myeloma Patients. Adv Hematol 2011; 2011:517561. [PMID: 22190942 PMCID: PMC3235426 DOI: 10.1155/2011/517561] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 09/26/2011] [Accepted: 10/11/2011] [Indexed: 12/29/2022] Open
Abstract
Poor peripheral blood stem cell (PBSC) mobilization predicts worse outcome for myeloma and lymphoma patients post autologous stem cell transplant (ASCT). We hypothesize that PBSC harvest using plerixafor and G-CSF in poor mobilizers may improve long-term outcome. We retrospectively analyzed the data on patients who had second PBSC mobilization using plerixafor and G-CSF as a rescue. Nine lymphoma and 8 multiple myeloma (MM) patients received the drug. A control group of 25 MM and lymphoma patients who were good mobilizers with G-CSF only was used for comparison. Sixteen of the 17 poor mobilizers proceeded to ASCT, and one MM patient had tandem transplants. Length of hospital stay, infection incidence, granulocyte engraftment, and long-term hematopoietic recovery were not significantly different between the two groups. In conclusion, all poor mobilizers were able to obtain adequate stem cells transplant dose and had similar transplant course and long-term outcome to that of the control good mobilizers group.
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63
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Hübel K, Fresen MM, Apperley JF, Basak GW, Douglas KW, Gabriel IH, Geraldes C, Jaksic O, Koristek Z, Kröger N, Lanza F, Lemoli RM, Mikala G, Selleslag D, Worel N, Mohty M, Duarte RF. European data on stem cell mobilization with plerixafor in non-Hodgkin's lymphoma, Hodgkin's lymphoma and multiple myeloma patients. A subgroup analysis of the European Consortium of stem cell mobilization. Bone Marrow Transplant 2011; 47:1046-50. [PMID: 22080971 DOI: 10.1038/bmt.2011.216] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The effectiveness of the novel hematopoietic stem cell mobilizing agent plerixafor was evaluated in nationwide compassionate use programs in 13 European countries. A total of 580 poor mobilizers with non-Hodgkin's lymphoma (NHL), Hodgkin's lymphoma (HL) and multiple myeloma (MM) were enrolled. All patients received plerixafor plus granulocyte CSF with or without chemotherapy. Overall, the collection yield was significantly higher in MM patients (>2.0 × 10(6) CD34+ cells/kg: 81.6%; >5.0 × 10(6) CD34+ cells/kg: 32.0%) than in NHL patients (>2.0 × 10(6) CD34+ cells/kg: 64.8%; >5.0 × 10(6) CD34+ cells/kg: 12.6%; P<0.0001) and also significantly higher in HL patients (>2.0 × 10(6) CD34+ cells/kg: 81.5%; >5.0 × 10(6) CD34+ cells/kg: 22.2%) than in NHL patients (P=0.013). In a subgroup analysis, there were no significant differences in mobilization success comparing patients with diffuse large B-cell lymphoma, follicular lymphoma and mantle cell lymphoma. Our data emphasize the role of plerixafor in poor mobilizers, but further strategies to improve the apheresis yield especially in patients with NHL are required.
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Affiliation(s)
- K Hübel
- Department of Internal Medicine I, University Hospital of Cologne, Cologne, Germany
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64
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Hübel K, Fresen MM, Salwender H, Basara N, Beier R, Theurich S, Christopeit M, Bogner C, Galm O, Hartwig R, Heits F, Lordick F, Rösler W, Wehler D, Zander AR, Albert MH, Dressler S, Ebinger M, Frickhofen N, Hertenstein B, Kiehl M, Liebler S, von Lilienfeld-Toal M, Weidmann E, Weigelt C, Lange F, Kröger N. Plerixafor with and without chemotherapy in poor mobilizers: results from the German compassionate use program. Bone Marrow Transplant 2011; 46:1045-52. [PMID: 20972470 DOI: 10.1038/bmt.2010.249] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 06/28/2010] [Accepted: 08/23/2010] [Indexed: 11/09/2022]
Abstract
The CXCR4-inhibitor plerixafor mobilizes hematopoietic stem cells amplifying the effects of granulocyte-CSF (G-CSF). Before approval plerixafor was used in a compassionate use program (CUP) for patients who failed a previous mobilization. In the German CUP 60 patients from 23 centers (median age 56.5 years (2-75)) were given 240 μg/kg plerixafor SC 9-11 h before apheresis. A total of 78.3% (47/60) received G-CSF for 4 days before plerixafor administration; 76.6% of those (36/47) yielded at least 2.0 × 10(6) CD34(+) cells/μL. The median cell yield was 3.35 × 10(6) CD34+ cells/kg (0-29.53). Nine patients received plerixafor alone or with G-CSF for less than 4 days mobilizing a median of 3.30 × 10(6) CD34+ cells/kg (1.6-5.6). There was no significant difference between G-CSF application for 4 days and for a shorter period of time (P=0.157). A total of 47 patients received plerixafor plus G-CSF combined with chemotherapy yielding a median of 3.28 × 10(6) CD34+ cells/kg (0-24.79). In all, 40 of 60 patients (66.7%) proceeded to transplantation, and achieved a timely and stable engraftment. Side effects were rare and manageable. In conclusion, mobilization with plerixafor in poor mobilizers is safe and results in a sufficient stem cell harvest in the majority of patients.
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Affiliation(s)
- K Hübel
- University Hospital of Cologne, Cologne, Germany.
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Basak GW, Jaksic O, Koristek Z, Mikala G, Mayer J, Masszi T, Labar B, Wiktor-Jedrzejczak W. Identification of prognostic factors for plerixafor-based hematopoietic stem cell mobilization. Am J Hematol 2011; 86:550-3. [PMID: 21674573 DOI: 10.1002/ajh.22038] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 03/18/2011] [Indexed: 11/05/2022]
Abstract
The introduction of plerixafor has enabled successful collection of stem cells in the majority of patients with lymphoma or myeloma in whom previous attempts at mobilization have failed. However, a proportion of patients have been shown to be resistant to this mobilization regimen. To identify the factors that impair stem cell mobilization and collection with plerixafor, we reviewed the data for 197 patients who had undergone mobilization with plerixafor and granulocyte-colony stimulating factor in Central Europe. Predictors of mobilization failure were evaluated using logistic regression analysis. Among the 197 patients mobilized, the target of ≥2.0 × 10(6) CD34+ cells/kg was collected from 133 (67.5%). Our analysis revealed that previous treatment with lenalidomide, bortezomib, melphalan, radiotherapy, or autologous stem cell transplantation and regimen of plerixafor use in combination with chemotherapy had no significant effect on the efficiency of collection. In contrast, an age ≥65 years (odds ratio 0.331, 95% CI: 0.112-0.977, P < 0.05), a diagnosis of non-Hodgkin's lymphoma (odds ratio 0.277, 95% CI: 0.124-0.622, P < 0.01), and treatment with ≥ four chemotherapy regimens (odds ratio 0.366, 95% CI: 0.167-0.799, P < 0.05) were associated significantly with failed mobilization. The rate of successful mobilizations was decreased in patients treated with purine analogues (odds ratio 0.323, 95% CI: 0.096-1.094, P = 0.07) but increased in female patients (odds ratio 1.961, CI: 0.943-4.080, P = 0.07). Patients who are characterized by the above negative features could benefit potentially from further improvement in the mobilization strategy.
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Affiliation(s)
- Grzegorz W Basak
- Department of Hematology, Oncology and Internal Diseases, The Medical University of Warsaw, Poland.
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66
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Khera N, Jinneman J, Storer BE, Heimfeld S, O'Meara MM, Chauncey TR, Lee SJ, Linenberger M. Limiting the daily total nucleated cell dose of cryopreserved peripheral blood stem cell products for autologous transplantation improves infusion-related safety with no adverse impact on hematopoietic engraftment. Biol Blood Marrow Transplant 2011; 18:220-8. [PMID: 21703976 DOI: 10.1016/j.bbmt.2011.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 06/02/2011] [Indexed: 10/18/2022]
Abstract
Cryopreserved peripheral blood stem cell (PBSC) products can induce a number of infusion-related adverse reactions, including life-threatening cardiac, neurologic, and other end-organ complications. Preliminary analyses suggested limiting the daily total nucleated cell dose infused might decrease the incidence of these adverse effects. A policy change implemented in December 2007, limiting the total nucleated cell (TNC) dose to <1.63 × 10(9) TNC/kg/day, allowed us to assess the impact of this intervention on infusion-related safety, infusion schedules, engraftment, and costs in cohorts of patients undergoing autologous stem cell transplants (ASCTs) 2 years before (325 ASCTs in 288 patients) and 2 years after the policy change (519 ASCTs in 479 patients). The percentage of autologous transplant patients requiring multiple day infusions increased from 6% to 24%. Concurrently, the incidence of infusion-related grade 3-5 severe infusion-related adverse events (SAEs) decreased significantly, from 4% (13 of 325) prepolicy change to 0.6% (3 of 519) postpolicy change (P < .0004). Multiday infusions were not associated with increased time to neutrophil or platelet engraftment or the costs of transplantation. We conclude that limiting the daily TNC dose improved the safety of this procedure without compromising engraftment or increasing the costs of the procedure.
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Affiliation(s)
- Nandita Khera
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. North, Seattle, WA 98109, USA.
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Proposed definition of 'poor mobilizer' in lymphoma and multiple myeloma: an analytic hierarchy process by ad hoc working group Gruppo ItalianoTrapianto di Midollo Osseo. Bone Marrow Transplant 2011; 47:342-51. [PMID: 21625224 PMCID: PMC3296914 DOI: 10.1038/bmt.2011.82] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Many lymphoma and myeloma patients fail to undergo ASCT owing to poor mobilization. Identification of poor mobilizers (PMs) would provide a tool for early intervention with new mobilization agents. The Gruppo italianoTrapianto di Midollo Osseo working group proposed a definition of PMs applicable to clinical trials and clinical practice. The analytic hierarchy process, a method for group decision making, was used in setting prioritized criteria. Lymphoma or myeloma patients were defined as ‘proven PM' when: (1) after adequate mobilization (G-CSF 10 μg/kg if used alone or ⩾5 μg/kg after chemotherapy) circulating CD34+ cell peak is <20/μL up to 6 days after mobilization with G-CSF or up to 20 days after chemotherapy and G-CSF or (2) they yielded <2.0 × 106 CD34+ cells per kg in ⩽3 apheresis. Patients were defined as predicted PMs if: (1) they failed a previous collection attempt (not otherwise specified); (2) they previously received extensive radiotherapy or full courses of therapy affecting SC mobilization; and (3) they met two of the following criteria: advanced disease (⩾2 lines of chemotherapy), refractory disease, extensive BM involvement or cellularity <30% at the time of mobilization; age ⩾65 years. This definition of proven and predicted PMs should be validated in clinical trials and common clinical practice.
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Mohty M, Ho AD. In and out of the niche: perspectives in mobilization of hematopoietic stem cells. Exp Hematol 2011; 39:723-9. [PMID: 21624427 DOI: 10.1016/j.exphem.2011.05.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 04/23/2011] [Accepted: 05/02/2011] [Indexed: 01/01/2023]
Abstract
Several stem cell mobilization strategies have been employed in the past 2 decades, including chemotherapy, hematopoietic growth factors, and chemotherapy plus growth factors. Granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage CSF are standard agents approved for peripheral blood stem cell mobilization since the early 1990s. Between 5% and 20% of patients, however, fail to mobilize a sufficient numbers of peripheral blood stem cells in response to G-CSF with or without chemotherapy. Recent advances in defining the basic mechanisms regulating the interactions between hematopoietic stem cells and their marrow niche had led to the discovery that CXCR4 and stromal-cell-derived factor 1α axis play a significant role. Plerixafor, an antagonist of the CXCR4-stromal-cell-derived factor 1α axis has been shown to result in a significant mobilization of hematopoietic stem cells. Numerous clinical trials have demonstrated that the combination of G-CSF and AMD3100 (G+A) resulted in a significant increase in CD34(+) cell yield as compared to the administration of G-CSF alone. In particular, the progenitors mobilized have been shown to comprise a significantly higher proportion of primitive and possibly more potent CD34(+)/CD38(-) subpopulation. Transplantation of PBSC mobilized by G+A administration have led to a rapid and sustained neutrophil and platelet engraftment. Another prospective role of this new class of agents might lie in the mobilization of dormant leukemia stem cells that are well protected by the niche. The future role of CXCR4 antagonists in treatment of hematologic malignancies includes mobilization of hematopoietic stem cells for transplantation and mobilization of leukemia-initiating cells for long-term cure.
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Affiliation(s)
- Mohamad Mohty
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Nantes, France.
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Basak GW, Jaksic O, Koristek Z, Mikala G, Basic-Kinda S, Mayer J, Masszi T, Giebel S, Labar B, Wiktor-Jedrzejczak W. Haematopoietic stem cell mobilization with plerixafor and G-CSF in patients with multiple myeloma transplanted with autologous stem cells. Eur J Haematol 2011; 86:488-95. [DOI: 10.1111/j.1600-0609.2011.01605.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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70
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Moreb JS. Plerixafor in non-Hodgkin’s lymphoma and multiple myeloma patients undergoing autologous stem cell transplantation. Oncol Rev 2011. [DOI: 10.1007/s12156-010-0062-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Pelus LM, Farag SS. Increased mobilization and yield of stem cells using plerixafor in combination with granulocyte-colony stimulating factor for the treatment of non-Hodgkin's lymphoma and multiple myeloma. STEM CELLS AND CLONING-ADVANCES AND APPLICATIONS 2011; 4:11-22. [PMID: 24198526 PMCID: PMC3781755 DOI: 10.2147/sccaa.s6713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Multiple myeloma and non-Hodgkin’s lymphoma remain the most common indications for high-dose chemotherapy and autologous peripheral blood stem cell rescue. While a CD34+ cell dose of 1 × 106/kg is considered the minimum required for engraftment, higher CD34+ doses correlate with improved outcome. Numerous studies, however, support targeting a minimum CD34+ cell dose of 2.0 × 106/kg, and an “optimal” dose of 4 to 6 × 106/kg for a single transplant. Unfortunately, up to 40% of patients fail to mobilize an optimal CD34+ cell dose using myeloid growth factors alone. Plerixafor is a novel reversible inhibitor of CXCR4 that significantly increases the mobilization and collection of higher numbers of hematopoietic progenitor cells. Two randomized multi-center clinical trials in patients with non-Hodgkin’s lymphoma and multiple myeloma have demonstrated that the addition of plerixafor to granulocyte-colony stimulating factor increases the mobilization and yield of CD34+ cells in fewer apheresis days, which results in durable engraftment. This review summarizes the pharmacology and evidence for the clinical efficacy of plerixafor in mobilizing hematopoietic stem and progenitor cells, and discusses potential ways to utilize plerixafor in a cost-effective manner in patients with these diseases.
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Affiliation(s)
- Louis M Pelus
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana
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The role of plerixafor in optimizing peripheral blood stem cell mobilization for autologous stem cell transplantation. Leukemia 2011; 25:1-6. [PMID: 21224858 DOI: 10.1038/leu.2010.224] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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73
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Eide MB, Lauritzsen GF, Kvalheim G, Kolstad A, Fagerli UM, Maisenhölder M, Østenstad B, Fluge Ø, Delabie J, Aarset H, Liestøl K, Holte H. High dose chemotherapy with autologous stem cell support for patients with histologically transformed B-cell non-Hodgkin lymphomas. A Norwegian multi centre phase II study. Br J Haematol 2011; 152:600-10. [DOI: 10.1111/j.1365-2141.2010.08519.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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74
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Jantunen E, Fruehauf S. Importance of blood graft characteristics in auto-SCT: implications for optimizing mobilization regimens. Bone Marrow Transplant 2011; 46:627-35. [DOI: 10.1038/bmt.2010.320] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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75
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Jantunen E, Kvalheim G. Mobilization strategies in hard-to-mobilize patients with lymphoid malignancies. Eur J Haematol 2010; 85:463-71. [PMID: 20738393 DOI: 10.1111/j.1600-0609.2010.01520.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Depending on definitions and patient characteristics, 5-40% of patients with lymphoid malignancies are hard-to-mobilize. Several premobilization factors such as previous chemotherapy (CT), disease, marrow infiltration and platelet count at the time of mobilization influence the efficacy of CD34(+) cell mobilization. In general, however, prediction of hard-to-mobilize patient is difficult. Postmobilization factors especially low blood CD34(+) counts are important in clinical practice as we have now ways to enhance mobilization at this point. Plerixafor combined with granulocyte-colony stimulating factor (G-CSF) has significantly increased efficacy of remobilization in patients who have failed a previous mobilization attempt with a success rate of about 70%. Addition of plerixafor to G-CSF or more recently to a mobilization regimen consisting of CT + G-CSF is promising as blood CD34(+) counts can be increased three to fivefold to facilitate effective collection with less aphaeresis sessions. As plerixafor is expensive, development of practical algorithms for its use is important to make blood stem cell mobilization and collection more efficient in a cost-effective way. This review attempts to summarize current treatment strategies in hard-to-mobilize patients with lymphoid malignancies.
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Affiliation(s)
- Esa Jantunen
- University of Eastern Finland/Institute of Clinical Medicine, Kuopio, Finland.
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77
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Worel N, Rosskopf K, Neumeister P, Kasparu H, Nachbaur D, Russ G, Namberger K, Witt V, Schloegl E, Zojer N, Linkesch W, Kalhs P, Greinix HT. Plerixafor and granulocyte-colony-stimulating factor (G-CSF) in patients with lymphoma and multiple myeloma previously failing mobilization with G-CSF with or without chemotherapy for autologous hematopoietic stem cell mobilization: the Austrian experienc. Transfusion 2010; 51:968-75. [DOI: 10.1111/j.1537-2995.2010.02896.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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78
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Kim JE, Yoo C, Kim S, Lee DH, Kim SW, Lee JS, Suh C. Optimal timing of G-CSF administration for effective autologous stem cell collection. Bone Marrow Transplant 2010; 46:806-12. [PMID: 20697366 DOI: 10.1038/bmt.2010.194] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The best time of G-CSF administration for PBPC collection remains to be defined. We aimed to identify optimal G-CSF administration timing for efficient autologous stem cell collection. A total of 262 lymphoma or multiple myeloma patients, who underwent PBPC collection from January 2000 to March 2008, were included. PBPCs were mobilized with chemotherapy followed by lenograstim at 10 μg/kg/day. Patients received lenograstim at 2000 hours, about half a day before leukapheresis (PM group) before November 2004, and at 0600 hours, 3 h before apheresis (AM group) subsequently. In the AM group, the median number of total collected CD34+ cells/kg was greater over a shorter duration of apheresis, and the median number of collected CD34+ cells/kg at first leukapheresis was larger. Stem cell collection efficacy (ratio of total collected CD34+ cells/kg per number of leukapheresis procedures) was higher, and proportion of patients who yielded an optimum harvest was larger. The statistically significant between-group difference was observed only in patients with high-dose CY chemotherapy for stem cell mobilization in subgroup analysis. The present study showed that G-CSF injection 3 h before apheresis improved the efficacy of autologous stem cell collection.
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Affiliation(s)
- J E Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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79
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Wuchter P, Ran D, Bruckner T, Schmitt T, Witzens-Harig M, Neben K, Goldschmidt H, Ho AD. Poor Mobilization of Hematopoietic Stem Cells—Definitions, Incidence, Risk Factors, and Impact on Outcome of Autologous Transplantation. Biol Blood Marrow Transplant 2010; 16:490-9. [DOI: 10.1016/j.bbmt.2009.11.012] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 11/11/2009] [Indexed: 12/21/2022]
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80
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Hosing C, Saliba RM, Ahlawat S, Körbling M, Kebriaei P, Alousi A, De Lima M, Okoroji JG, McMannis J, Qazilbash M, Anderlini P, Giralt S, Champlin RE, Khouri I, Popat U. Poor hematopoietic stem cell mobilizers: a single institution study of incidence and risk factors in patients with recurrent or relapsed lymphoma. Am J Hematol 2009; 84:335-7. [PMID: 19384931 DOI: 10.1002/ajh.21400] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The purpose of this retrospective study was to determine the incidence and predictive factors if any, of mobilization failure in lymphoma patients referred for autologous stem cell transplantation. A total of 588 lymphoma patients were referred for transplant consultation from January 2003 to December 2004. Predictors of mobilization failure were evaluated using logistic regression analysis including diagnosis, mobilization regimen, age, sex, type and number of prior chemotherapies, bone marrow cellularity, platelet count, white count, prior bone marrow involvement with malignancy, and prior radiation therapy. Two hundred and six patients were eligible for transplantation and underwent stem cell mobilization. Twenty-nine (14%) patients failed to mobilize adequate stem cells after the first attempt. For the entire group age (>or=60 versus <60 years), diagnosis (Hodgkin's versus non-Hodgkin's lymphoma), use of cytokines alone, platelet count <150 x 10(9)/L, and bone marrow cellularity <30% were significant predictors for mobilization failure on univariate analysis. In view of small number of patients multivariate analysis was not possible. However, a low platelet count (150 x 10(9)/L) was the only significant predictor when the analysis was restricted to non-Hodgkin's lymphoma patients who were mobilized with chemotherapy. Mobilization failure rates are higher in patients with non-Hodgkin's lymphoma compared with those with Hodgkin's lymphoma. In the subset of patients who undergo chemomobilization for non-Hodgkin's lymphoma platelet count at the time of mobilization is a predictor of mobilization failure.
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Affiliation(s)
- Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Bensinger W, DiPersio JF, McCarty JM. Improving stem cell mobilization strategies: future directions. Bone Marrow Transplant 2009; 43:181-95. [DOI: 10.1038/bmt.2008.410] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mendrone A, Arrais CA, Saboya R, Chamone DDAF, Dulley FL. Factors affecting hematopoietic progenitor cell mobilization: An analysis of 307 patients. Transfus Apher Sci 2008; 39:187-92. [DOI: 10.1016/j.transci.2008.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Park IH, Kim Y, Kim JS, Cheong JW, Song JW, Min YH. Transfusion-associated iron overload as a predictive factor for poor stem cell mobilization in patients with haematological malignancies. Transfus Med 2008; 18:97-103. [DOI: 10.1111/j.1365-3148.2008.00849.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Wang S, Nademanee A, Qian D, Dagis A, Park HS, Fridey J, Smith E, Snyder D, Somlo G, Stein A, Rosenthal J, Falk P, Kogut N, Palmer J, Gaal K, Kim Y, Bhatia R, Yuan S, Kay C, Weiss L, Forman S. Peripheral blood hematopoietic stem cell mobilization and collection efficacy is not an independent prognostic factor for autologous stem cell transplantation. Transfusion 2007; 47:2207-16. [PMID: 17714420 DOI: 10.1111/j.1537-2995.2007.01448.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The successful mobilization and collection of hematopoietic stem cells are dependent on a number of clinical factors such as previous chemotherapy and disease stage. The aim of this retrospective study was to determine whether the effectiveness of mobilization and collection is an independent prognostic factor for autologous stem cell transplantation outcome. STUDY DESIGN AND METHODS A total of 358 patients who received transplants from January 2003 to December 2004 (201 male and 157 female patients, ages from 2.7 to 77.3 years with median of 53 years of age) underwent autologous hematopoietic stem cell collection after mobilization with granulocyte-colony-stimulating factor (G-CSF) or G-CSF plus chemotherapy priming. This retrospective study included patients with diagnoses of acute myelogenous leukemia, non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma, and solid tumors. All patients underwent stem cell collection until a target or a minimum CD34+ cell dose was reached. Correlations were performed between stem cell mobilization and/or collection efficacy and transplantation outcomes. RESULTS In general, both larger reinfused CD34+ cell dose and shorter number of days for the stem cell count to reach the minimum of 2 x 10(6) per kg CD34+ cells do not foster quicker engraftment. Reinfused CD34+ cell dose of less than 12 x 10(6) and number of days stem cell collection to reach this minimum CD34+ cell dose did not independently affect the overall survival (OS) or disease-free survival (DFS). CONCLUSION The effectiveness of hematopoietic stem cell mobilization and collection as defined as number of days to reach a CD34+ cell dose of 2 x 10(6) per kg should not be used independently to forecast posttransplantation prognosis, engraftment, DFS, and OS.
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Affiliation(s)
- Shirong Wang
- Department of Transfusion Medicine, Division of Pathology, City of Hope National Medical Center, Duarte, California 91010, USA.
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Tomblyn M, Burns LJ, Blazar B, Wagner J, Lee C, Rogers T, McGlave P, Miller JS, Weisdorf DJ. Difficult stem cell mobilization despite adequate CD34+ cell dose predicts shortened progression free and overall survival after autologous HSCT for lymphoma. Bone Marrow Transplant 2007; 40:111-8. [PMID: 17530003 DOI: 10.1038/sj.bmt.1705708] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Hematopoietic growth factors alone or in combination with myelosuppressive chemotherapy are used to mobilize peripheral blood stem cells for autologous transplantation. To identify characteristics of successful mobilization with granulocyte colony-stimulating factor (G-CSF) alone and to study the impact of immediate chemotherapy mobilization following G-CSF mobilization, we treated 175 chemotherapy sensitive lymphoma patients with G-CSF (G) mobilization and leukapheresis followed by chemotherapy plus G-CSF (CG) mobilization and leukapheresis and then autologous transplantation. Patients with stage I/II disease at diagnosis and < or =5 years from diagnosis were more likely to mobilize successfully with G-CSF alone (G). CG mobilization led to superior stem cell yields compared to the preceding mobilization with G (median 2.37 vs 1.37 ( x 10(6)CD34+ cells/kg); P<0.0001). Patients (n=58, 33%) with successful G-CSF mobilization (> or =2 x 10(6) CD34+ cells/kg) had quicker platelet recovery and improved progression free and overall survival compared to patients who had adequate collection only after chemotherapy mobilization or to those who failed to collect an adequate graft with either type of mobilization. The poor clinical outcome of patients with difficult mobilization using either method identifies them as a high-risk group who might benefit from alternative therapies.
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Affiliation(s)
- M Tomblyn
- Blood and Marrow Transplant Program, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Shimoni A, Zwas ST, Oksman Y, Hardan I, Shem-Tov N, Yerushalmi R, Avigdor A, Ben-Bassat I, Nagler A. Yttrium-90-ibritumomab tiuxetan (Zevalin) combined with high-dose BEAM chemotherapy and autologous stem cell transplantation for chemo-refractory aggressive non-Hodgkin's lymphoma. Exp Hematol 2007; 35:534-40. [PMID: 17379063 DOI: 10.1016/j.exphem.2007.01.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 12/19/2006] [Accepted: 01/18/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the safety and outcome following standard-dose ibritumomab tiuxetan followed by BEAM high-dose chemotherapy and autologous stem cell transplantation (ASCT) in patients with chemo-refractory aggressive non-Hodgkin's lymphoma. PATIENTS AND METHODS The study included 23 patients, median age 55 years (range, 35-66) with chemo-refractory lymphoma, either primary refractory (n = 11) or in refractory relapse (n = 12). Rituximab 250 mg/m(2) followed by ibritumomab tiuxetan 0.4 mCi/kg were given on day -14 and high-dose BEAM chemotherapy started on day -6. RESULTS All patients engrafted. Twenty-one patients are evaluable for response; 11 achieved CR, 9 achieved PR, 5 of whom converted to CR with additional radiation therapy (overall CR rate 76%). With a median follow-up of 17 months (range, 4-27) 16 patients are alive and 12 are progression-free. The estimated 2-year overall and progression-free survival are 67% (95% CI, 46-87%) and 52% (95% CI, 31-72%), respectively. The day-100 rate of treatment-related mortality was 9% (95% CI, 2-33%) and the 2-year cumulative incidence of relapse was 31% (95% CI, 17-57%). Extensive prior therapy (>3 lines), high LDH and IPI score at ASCT, bulky disease, and progression during last chemotherapy were risk factors for reduced survival. CONCLUSION Ibritumomab tiuxetan-BEAM and ASCT is relatively safe and may improve outcome in patients with refractory lymphoma. Although excess nonrelapse mortality can not be ruled out, relapse rate was relatively low, resulting in improved outcome. Standard-risk patients with chemo-sensitive disease may also benefit from ibritumomab tiuxetan-BEAM and ASCT. This hypothesis merits further study in larger-scale prospective randomized studies.
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Affiliation(s)
- Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Israel.
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Current Awareness in Hematological Oncology. Hematol Oncol 2006. [DOI: 10.1002/hon.755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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