G-CSF-stimulated BM progenitor cells supplement suboptimal peripheral blood hematopoietic progenitor cell collections for auto transplantation

Salvage chemotherapy and autologous stem cell transplant in primary refractory diffuse large B-cell lymphoma: outcomes and prognostic factors

Patients with primary refractory diffuse large B-cell lymphoma (REF DLBCL: progression on or within 3 months of completion of primary therapy) sensitive to salvage chemotherapy undergo autologous stem cell transplant (ASCT). We conducted a retrospective review of 111 patients with REF DLBCL treated between 1999 and 2007. Primary treatment consisted of cyclophosphamide, adriamycin, vincristine and prednisone (CHOP; 66%) and rituximab with CHOP (R-CHOP; 33%); 14% received involved field radiation. The response rate (RR) to first salvage chemotherapy was 23% (RR by regimen: dexamethasone, cytosine arabinoside and cisplatin [DHAP] 15%, etoposide, Solu-Medrol, cytosine arabinoside and cisplatin [ESHAP] 36%, and gemcitabine, dexamethasone and cisplatin [GDP] 45%); 25% (n = 28) of patients underwent ASCT. With a median follow-up of 5.9 months (range 1-94), the median progression-free and overall survival from primary treatment failure was 3 and 10 months, respectively. Outcomes in patients with REF DLBCL after CHOP or R-CHOP appear equally poor. Second-generation platinum-containing regimens (ESHAP, GDP) may be superior to DHAP in this setting. Novel, prospectively evaluated treatment approaches should be pursued in REF DLBCL.

Hematologic recovery in patients who are treated with autologous stem cells transplantation taken from bone marrow after granulocyte-colony-stimulating factor stimulation

BACKGROUND

We sought to compare hematologic recovery between patients who did or did not receive granulocyte-colony-stimulating factor (G-CSF)-stimulated bone marrow (rich bone marrow [RBM]).

MATERIALS AND METHODS

The study subjects were 20 patients whose bone marrow was taken without prior stimulation with G-CSF and 15 patients in whom bone marrow was taken after previous G-CSF mobilization. The bone marrow harvest took place on the fifth day after G-CSF initiation. The bone marrow aliquot was 20 mL/kg.

RESULTS

The median value of nucleated cells obtained from patients without G-CSF preparation was 3.65×10(8)/kg. The median value of nucleated cells from RBM patients was 4.83×10(8)/kg. The median value of stem cells obtained from patients without G-CSF preparation was 0.96×10(6)/kg versus 1.9×10(6)/kg from RBM patients. The median time to recovery of the hematopoietic system based on an increase in PLT value>20 g/L was 12.6 days for RBM versus 18.8 days without G-CSF preparation. The median time to recovery of the hematopoietic system based on assessment of growth ANC>0.5 g/L was 13.0 days for RBM versus 17.8 days without G-CSF stimulation. Significantly higher values of nucleated cells and increased stem cells were observed among RBM patients compared with those whose bone marrow was harvested without any stimulation (P=.01). There was faster recovery of the hematopoietic system in cases where bone marrow was collected after G-CSF: PLT>20 g/L (P=.015) and ANC>0.5 g/L (P=.01). We also observed that the use of stimulated bone marrow shortened hospital stay after the administration of hematopoietic cells to 17.3 days compared with 23.1 days among patients receiving hematopoietic cells from nonstimulated bone marrow. The number of complications during transplantation was comparable in both cases, the most frequent ones being febrile neutropenia and grade III and IV mucositis.

CONCLUSION

RBM is a better method to obtain stem cells from bone marrow. Stimulated bone marrow shows faster engraftment compared with nonstimulated bone marrow helping patients who fail to generate are adequate number of stem cells from peripheral blood.

Assessing the charges associated with hematopoietic stem cell mobilization and remobilization in patients with lymphoma and multiple myeloma undergoing autologous hematopoietic peripheral blood stem cell transplantation

BACKGROUND

The purpose of this study was to perform a detailed analysis of the charges associated with chemomobilization and remobilization of autologous hematopoietic stem cells (HSCs) and to quantify medical costs and resource utilization associated with these procedures.

STUDY DESIGN AND METHODS

Patients with lymphoma underwent chemomobilization with ifosfamide and etoposide with or without rituximab (IE ± R). Patients with multiple myeloma (MM) received a modified hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone (hyper-CVAD) regimen after failing to mobilize with growth factors only.

RESULTS

Between January 2004 and October 2006, 98 patients with lymphoma underwent HSC mobilization with IE ± R. Mobilization with IE ± R was effective, with 90.8% of patients collecting at least 2 × 10(6) CD34+ cells/kg. The total charges for treatment were $27,996 and $37,667 for patients mobilized with IE and IE + R, respectively. Hospital readmission for complications occurred in 26.5% of patients, resulting in additional charges of $10,356. The preapheresis procedure charge was estimated to be $2522, the charge for a 2-day apheresis session was $5160, and the postapheresis phase resulted in charges of $8040. Our analysis determined that reducing apheresis by 1 day has the potential to save $6600. We also performed a retrospective analysis of 16 patients with MM remobilized with a modified hyper-CVAD regimen. Remobilization was successful, with 87.5% of patients. Our analysis determined that mobilization, preapheresis, apheresis, and postapheresis phase charges were $24,968, $2522, $6158, and $12,060, respectively.

CONCLUSIONS

Optimization of HSC mobilization regimens to reduce failure rates would not only benefit patients but also reduce the overall medical costs.

Mobilization strategies in hard-to-mobilize patients with lymphoid malignancies

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.