Intermediate doses of cytarabine plus granulocyte-colony-stimulating factor as an effective and safe regimen for hematopoietic stem cell collection in lymphoma patients with prior mobilization failure

Evaluation of efficacy and safety in the use of cytarabine for mobilization of hematopoietic stem cells in a reference hospital in northeastern Brazil

Autologous hematopoietic stem cell transplantation (Auto-HSCT) is widely used in the treatment of patients with hematological neoplasms. Since these cells circulate in small quantities in the periphery, the use of regimens that promote their mobilization is essential. In this study, we retrospectively evaluated the efficacy and safety of using intermediate doses of cytarabine (1.6 g/m²) + filgrastim (10 mcg/kg/day) in the mobilization of stem cells in 157 patients treated by the Unified Health System at the Hematology and Bone Marrow Transplant Service of the Hospital Real Português de Beneficência, in Recife, Pernambuco. The sample included patients with multiple myeloma (MM) (58.6 %), lymphomas (29.9 %), and other neoplasms (11.5 %). The target of 2.0 × 10 6 CD34+ cells/kg was achieved by 148 (94.3 %) patients, in most cases (84.1 %) in a single apheresis and the median number of cells collected was 9.5 × 10 6 CD34+ cells/kg. No episode of febrile neutropenia was observed, however, 79 patients (50.3 %) required platelet transfusion (no cases attributed to bleeding). The median engraftment time was 11 days. Given these results, we suggest that the use of intermediate doses of cytarabine, combined with filgrastim, is safe and effective in mobilizing hematopoietic stem cells (HSCs).

Efficacy and safety of stem cell mobilization with etoposide +cytarabine plus G-CSF in poor mobilizers with relapsed or refractory lymphoma

Background

Autologous stem cell transplantation (ASCT) is a potentially curative strategy for relapse or refractory(r/r) aggressive lymphoma. However, a proportion of lymphoma patients who are at high risk of mobilization failure fail to mobilize stem cells and cannot proceed to ASCT. The aim of this study is to explore the efficacy and safety of Etoposide combined with Cytarabine (EA) plus G-CSF mobilization in poor mobilizers (PMs) with r/r aggressive lymphoma.

Methods

This retrospective study analyzed the outcomes of chemo-mobilization based on EA (Etoposide 0.1 g/m2, qd d1~3; AraC 0.5 g/m2, q12h d1~3) in 98 patients with r/r aggressive lymphoma. Of these, 39 patients met the criteria for predicted PMs as proposed by the Gruppo Italiano Trapianto di Midollo Osseo working group.

Results

Of the 39 PMs, 38(97.4%) patents harvested adequate mobilization (≥2×106 CD34+ cells/kg), while 31(79.5%) patients achieved optimal mobilization (≥5×106 CD34+ cells/kg). Overall, the mean number of CD34+ cells/kg collected was 17.99(range: 1.08~83.07) ×106 with an average of 1.4 apheresis sessions, and the number was 15.86(range: 0.37~83.07) ×106 for the first apheresis, respectively. A single apheresis procedure was sufficient to reach the target yield of adequate mobilization in 35(89.7%) PMs, while 76.9% of PMs achieved optimal collection within two apheresis sessions. We observed acceptable hematological toxicity and antibiotic usage exposure in 26 patients with a mean duration of 3.6 days. No grade 4 infection or mobilization-related mortality was recorded. Most patients underwent ASCT and achieved successful hematopoietic recovery with prompt engraftment duration, except for one NK/T-cell lymphoma patient who succumbed to severe septicemia after receiving conditioning chemotherapy.

Conclusion

Our findings indicate that EA plus G-CSF is an effective and tolerable CD34+ stem cell mobilization strategy for patients with r/r lymphoma, including those predicted to be PMs. This regimen could be an option for patients with r/r lymphoma, particularly those undergoing mobilization for salvage ASCT therapy.

Higher efficacy of intermediate dose cytarabine + G-CSF compared to cyclophosphamide + G-CSF in hematopoietic stem cell mobilization in patients with multiple myeloma

BACKGROUND

There are several regimens used in hematopoietic stem cell (HSC) mobilization in multiple myeloma (MM). Cyclophosphamide (Cy) is one of the most commonly used agents, although it does not always result in collecting adequate number of CD34+ cells. Recently, cytarabine (Ara-C) has been proposed as potentially efficient and safe option.

AIMS

Since the data regarding Ara-C in HSC mobilization is limited, the aim of our study was to compare retrospectively the efficiency and toxicity of G-CSF combined with either Ara-C or Cy in MM patients.

MATERIALS & METHODS

Of a total of 89 patients, 43 received low or intermediate doses of Cy, and 46 were treated with 800 mg/m² /day of Ara-C administered for two days.

RESULTS

The mean peak of CD34+ cells/ul in peripheral blood was 132 (range, 84-202) in Ara-C and 51 (range, 29-69) in Cy cohort (p < 0.001). The median number of collected CD34+ cells (×106/kg) was 10.3 (range, 4.2-17.9) vs 4.5 (range, 2.7-8.9), respectively (p < 0.001). Mobilization failure was observed in one patient in Ara-C cohort (2%) and in 8 patients treated with Cy (19%) (p = 0.013). In the Ara-C group 98% of patients obtained more than 4×106 CD34+ cells/kg required for tandem transplantation. Moreover, we observed a trend toward increased paraprotein levels measured at transplant compared to before HSC mobilization in Ara-C cohort and significantly higher transfusion rates in that group.

CONCLUSION

Our findings confirm higher HSC mobilization efficacy of Ara-C compared to Cy in MM patients. However, lower transfusions rate and better disease control of Cy may justify its use in some cases.

A retrospective study of autologous stem cell mobilization by G-CSF in combination with chemotherapy in patients with multiple myeloma and lymphoma

Factors affecting peripheral blood hematopoietic stem cell (PBSC) mobilization and collection were investigated in patients with multiple myeloma (MM) and lymphoma who were undergoing chemotherapy. Clinical data from 128 patients, including 53 MM and 75 malignant lymphoma (7 Hodgkin's lymphoma and 68 non-Hodgkin's lymphoma) cases were retrospectively analyzed. Autologous PBSCs were mobilized using granulocyte-colony stimulating factor (G-CSF) during chemotherapy, and collected using a continuous flow cell separation instrument. The yields of CD34+ cells per kilogram of patient body weight <2.0×10⁶/kg, >2.0×10⁶/kg or >5.0×10⁶/kg were defined as a failure, a success or ideal mobilization, respectively. In MM and lymphoma patients, the success rates of CD34+ cell acquisition were 73.6 (39/53) and 58.7% (44/75), the ideal rates were 43.4 (23/53) and 30.7% (23/75), and the failure rates were 26.4 (14/53) and 41.3% (31/75), respectively. Univariate and multivariate statistical analysis revealed that negative factors for PBSC mobilization in patients with MM were lenalidomide treatment, multiple chemotherapies, incomplete disease remission and low-level blood hemoglobin; in patients with lymphoma, the negative factors were the histological disease type, incomplete disease remission, being beyond the first-line of previous chemotherapy, multiple chemotherapies, chemotherapy with the HyperCVAD-B mobilization scheme, high-dose MTX/Ara-c (methotrexate/cytarabine) treatment, prolonged administration of G-CSF and low-hematocrit levels. In the present study, different factors influencing PBSC mobilization and collection in MM and lymphoma cases were identified. PBSC mobilization yielded sufficient CD34+ cell counts both in MM and lymphoma patients; however, the failure rates were relatively high.

Intermediate-dose cytarabine plus G-CSF as mobilization regimen for newly diagnosed multiple myeloma and heavily pre-treated patients with hematological and non-hematological malignancies

BACKGROUND

Intermediate-dose cytarabine plus G-CSF has recently emerged as safe and effective mobilization regimen for heavily pre-treated patients with lymphoid malignancies. We prospectively tested this regimen in patients referred to our center in order to collect enough stem cells for hematopoietic rescue in autologous transplantation (auto-HSCT).

STUDY DESIGN AND METHODS

cytarabine (1.6 g/m²) plus G-CSF (outpatient administration) was performed in 81 consecutive patients who underwent auto-HSCT. For analyses purposes patients were divided into Group A, consisted of 48 patients with newly diagnosed multiple myeloma (MM) and Group B with 33 heavily pre-treated patients (13 Hodgkin´s lymphoma, 7 non-Hodgkin´s lymphoma, 7 MM, 4 germ cell tumor, 2 non-promyelocytic acute myeloid leukemia).

RESULTS

In the Group A, circulating CD34+ cells/μL was significantly higher, 90% started stem cell harvest on day 14, 98% collected ≥5.0 × 10⁶ CD34+cells/kg and a single apheresis was sufficient in 92% of the cases. In the Group B, 85% started leukapheresis on day 14, 88% collected ≥2.0 × 10⁶ CD34+cells/kg which was achieved with a single apheresis in 82% of the cases; a higher proportion of the patients (63.6% versus 33.3%) required platelet transfusions. Both groups exhibited few adverse events and the time to neutrophil and platelet recovery was similar between groups.

CONCLUSION

Intermediate-dose cytarabine plus G-CSF mobilization is effective even for heavily pre-treated patients. The outpatient administration of G-CSF, the reliable prediction of the day to begin harvesting, the optimal CD34+ cell yield obtained with a single apheresis and the fewer occurrences of adverse events denoted the benefits of this regimen.

Etoposide + Granulocyte Colony-Stimulating Factor and Optional Plerixafor in Patients Who Failed Chemomobilization with or without Plerixafor

We conducted a retrospective study of 62 patients undergoing etoposide (2 g/m²) + granulocyte colony-stimulating factor (G-CSF; 10 patients also received additional plerixafor) as a salvage stem cell mobilization regimen after previous unsuccessful chemomobilization with or without plerixafor. The median peak CD34⁺ values after etoposide + G-CSF ± plerixafor was 54.07 CD34⁺/μL compared with 9.6 CD34⁺/μL after previous mobilization attempts (P < .001). The median yield was 6.33 × 10⁶ CD34⁺ cells/kg per 2 apheresis. Etoposide + G-CSF ± plerixafor mobilization regimen resulted in 91.53% successful mobilizations and 89.83% of patients proceeding to autologous stem cell transplantation. All 7 patients who had previously failed plerixafor-based mobilization attempts were successfully mobilized with etoposide + G-CSF ± plerixafor and proceeded to autologous stem cell transplantation. The most common grades 3 to 4 adverse events of etoposide + G-CSF ± plerixafor were febrile neutropenia (69.35%), mucositis (51.62%), and bacteremia (20.97%). No fatal outcomes were observed. Rates of 12-month overall survival and progression-free survival were 88.71% and 70.97%, respectively. Etoposide + G-CSF ± plerixafor is an effective regimen for salvage stem cell mobilization also in patients who failed plerixafor, with most patients undergoing autologous stem cell transplantation. The adverse event rate may warrant a decrease in the dose of etoposide.

Effective chemomobilization with etoposide and cytarabine (EC regimen) in lymphoma patients: a single-center, retrospective, observational study

Objective

Autologous stem cell transplantation is an important strategy for patients with relapsed or refractory lymphoma. Although various regimens for peripheral blood stem cell collection have been used, the optimal regimen has not yet been established. We aimed to evaluate the mobilization efficacy and safety of the regimen consisted of etoposide and cytarabine (EC regimen).

Methods

We retrospectively analyzed the clinical data of 46 lymphoma patients who received peripheral blood stem cell mobilization with the EC regimen [etoposide (100 mg/m2/day, days 1-4) and cytarabine (100 mg/m2/day, days 1-4)] at Toyohashi municipal hospital from 2004 to 2013.

Results

The median age of the patients was 55 years. The most common underlying diseases were diffuse large B-cell lymphoma (46%) and follicular lymphoma (26%). Three-quarters of patients were in their second complete or partial remission. The median total number of collected CD34+ cells was 10.6 × 106 kg-1. Forty-two patients (91%) yielded at least 2 × 106 kg-1 CD34+ cells within a median of 2 apheresis days, and 33 patients (72%) achieved it with only one apheresis. Successful mobilization was observed in five of six patients who failed to mobilize previously. Although febrile neutropenia occurred in 22 patients (48%), no fatal infection was observed.

Conclusion

The EC regimen was highly effective in lymphoma patients, including patients who mobilized poorly with other regimens.