Transfusion and Apheresis Science xxx (2013) xxx–xxx

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Transfus ion and Apher esis Science

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Predicting the successful peripheral blood stem cell harvesting

1473-0502/$ - see front matter � 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.transci.2013.04.028

⇑ Corresponding author. Address: Ankara Oncology Hospital Hematol- ogy and Stem Cell Transplantation Clinic Demetevler-Yenimahalle, 06200 Ankara, Turkey. Tel.: +90 312 336 09 09x7271; fax: +90 312 335 38 18.

E-mail address: dritir@hotmail.com (I.S�irinog ˘lu Demiriz).

Please cite this article in press as: Demiriz IS� et al. Predict ing the successful peripher al bloo d stem cell harvestin g. Transf Aph (2013), http ://dx.doi.org/10.1016/ j.transc i.2013.04.0 28

Itır S�irinog ˘lu Demiriz ⇑, Sinem Civriz Bozdag ˘, Emre Tekgündüz, Bilge Ugur, Gamze Durgun,S�erife Koçubaba, Fevzi Altuntas �Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey

a r t i c l e i n f o a b s t r a c t

Article history:Available online xxxx

Several previously defined factors affect ing the mobilization success include age, prior che- motherapy lines, exposure to myelot oxic agents, extended field radiotherapy and bone marrow infiltration with the primary disease. The purpose of this study was to retrospec- tively analyze the influence of the predictive factors for a successful peripheral stem cell mobilization. We enrolled a total of 145 patients into the study (non-Hodgkin lymphoma (n: 40), Hodgkin lymphoma (n: 36), myeloma (n: 64), solid tumors (n:5)) who received autologous stem cell transplantation between 2009 and 2012. In multivariate analysis only platelet count was found to be related with mobilization outcome (p < 0.05). Knowing pre- dictive factors for successful mobilization may be useful to define the best timing for mobi- lization and the most appropriate mobilizing agents for proper patient population.

� 2013 Elsevier Ltd. All rights reserved.

1. Introductio n

Autologous stem cell transplanta tion (ASCT) after high- dose chemotherapy is a treatment modality which has the potential of improving remission rates and prolonging sur- vival in various hematological disorders [1]. In the previous decades, bone marrow was the main source of hematopoi- etic stem cells, but today peripheral blood derived progen- itor cells are preferred for nearly all patients undergoing ASCT. The use of peripheral blood has advantages both for the donor and recipient. Avoidanc e of general anesthe- sia, comfort during collection, outpatient mobilization,acceptable toxicity profile for donors and faster engraft- ment kinetics are the main advantag es of peripheral blood as stem cell source [2].

Although granulocyte colony-stim ulating factors (G-CSF) either alone or in combination with chemothera pyor plerixafo r are established, widely used methods for stem cell mobilization, in 15–30% of patients mobilization failure still remains to be a problem [3,4]. Previously

defined factors directly related to increased risk of mobili- zation failure are high numbers of prior chemoth erapy lines, exposure to alkylating agents, lenalidomide or flu-darabine, extended field radiotherapy to marrow contain- ing sites, bone marrow infiltration with the primary disease and advanced age [1,5,7,9–12]. Iron overload, ele- vated serum ferritin levels, remission status of the disease and type of mobilization regimens has also been evaluated as risk factors [13–16]. All well-known and newer factors that have impact on mobilization success, may be useful to define the best timing and mobilizin g agents for proper patient population. The purpose of this study was to retro- spectively analyze the influence of the predictive factors for a successful mobilization. We aimed to identify the im- pact of new parameters on mobilization failure like lipid profile, CRP, ferritin levels in addition to previously definedones.

2. Patients and method

This study is a single-center retrospective review of 145 patients who were treated with high dose chemoth erapy followed with ASCT for both hematologi cal malignancie sand solid tumors in Ankara Oncology Research and Train- ing Hospital, Hematology and Stem Cell Transplanta tion

eres Sci

Table 1Demographic characteri stics of study cohort.

Gender (male/female) 101/44 Age (median/range) 48 (16–71)

DiseaseMultiple myeloma 64Non-Hodgkin lymphoma 40Hodgkin lymphoma 36Solid tumors 5

Disease status before mobilization CR 93VGPR/PR 36Refractory 16

Prior radiotherapy Yes/no 20/125

Prior chemotherapy including alkylating agents/fludarabine/lenalidomide

Yes/no 53/92

Median number of chemotherapy cycles before mobilization (median/range)

4.51

Number of chemotherapy lines before mobilization

1 38P2 107

Platelet count before mobilization (median/range) (�103/mm3)

165 (104–498)

Table 2Characteristics of stem cell collection.

Total number of apheresis sessions 101 Number of patients with final CD34 +

cell > 2 � 106/kg achieved 92

With 1 apheresis session 84With 2 apheresis sessions 7With >2 apheresis sessions 1

Median peripheral blood CD34 + cell count at 1st apheresis day

45(12–146)/mm3

Median apheresis number per patient (range) 2(1–3)Median product CD34 + cell � 106/kg (range) 5.3(2–21)

2 I.S�irinog ˘lu Demiriz et al. / Transfusion and Apheresis Science xxx (2013) xxx–xxx

Clinic between 2009 and 2012. Patient demographics are summarized in Table 1. According to our institutiona l pol- icy initial mobilization attempt was performed with 10 lg/kg/d G-CSF alone in patients with low tumor burden. Pa- tients who needed salvage chemotherapy received G-CSF (10 lg/kg/d) in combinati on with chemotherapy. For poor mobilizers in G-CSF alone group, chemotherapy followed by G-CSF was preferred as second line mobilization regi- men. Chemotherapy was either high dose cyclophospha- mide or salvage chemoth erapies according to primary disease of the patients. Chemotherapy regimens that were used in first line and salvage settings according to primary disease type and chemosensi tivity of the tumor were asfollows: ASHAP (n:25), ICE (n:15), DHAP (n:22), VCD (n:21), VAD (n: 53), VD (n:21), hyper-CVA D (n:11), ViGEPP (n:7), VTD-PAC E (n:3) and CODOX-M/I VAC (n:2). Only 20patients had received involved field RT but none of our pa- tients were treated with extended field RT. For patients who received only G-CSF for mobilization stem cell apher- esis began on the fifth day of G-CSF administration . On the other hand in patients who were mobilized with G-CSF plus chemotherapy enumerati on of CD34 + cells in the peripheral blood was assessed when blood leukocyte count exceeds 1000/mm 3 and apheresis was performed when the peripheral CD34 + cell count was >20/mm 3. Total nucleated and CD34 + cell count of the apheresis product was mea- sured with flow cytometry.

The definition of successful and adequate PBSC proce- dure was accepted as collecting at least 2 � 106/kg CD34 +-

cells. We used following criteria for defining mobilization failure:

(1) CD34 +cell count <10/mm 3 for two sequential days.(2) CD34 + cell count 10–20/mm3 at first assessme nt but

do not increase to >20/mm 3 on the following day.

Please cite this article in press as: Demiriz IS� et al. Predictin g the suc(2013), http ://dx.doi.org/10.1016/ j.transc i.2013.04.0 28

(3) Failure to harvest the minimum threshold CD34 + cellcounts in two sequential days.

2.1. Statistical analysis

Descriptive parameters were given as median and range. Categorical variables were compare d with chi- square test. Mann Whitney U test was used for continuo usparameters. Correlation analyses were performed with Pearson correlation analysis. Log rank logistic regression analyses have been used for multivariate analysis.p < 0.05 was defined as statistical ly significant.

3. Results

One hundred and 33 patients (91%) received G-CSF alone (5 lg/kg twice daily), 12 patients (9%) received che- motherapy plus G-CSF as first line mobilization regimen.Fifty-three patients out of 145 (36%) could not be mobi- lized successfully . Among patients with mobilization fail- ure only one patient was in the chemotherapy plus G-CSF group and the rest 52 patients were in G-CSF alone group.Mobilization failure rates in patients receiving G-CSF alone and G-CSF plus chemoth erapy were 39% and 8%,respectively .

The characteristics of apheresis procedures are summa- rized in Table 2. As expected peripheral blood CD34 + cellcount was correlate d with apheresis product CD34 + cellcount (p < 0.05). The frequenc y of mobilization failure was significantly lower in myeloma patients compared toothers (p < 0.05). On univariat e analysis it was found that patients in mobilization failure group received higher number of prior chemoth erapy lines and were also more frequently treated with agents known to be associated with stem cell toxicity like fludarabine, alkylatin g agents and lenalidom ide (p < 0.05). Platelet counts at first day ofapheresis were found to be significantly lower in mobiliza- tion failure group (p < 0.05). Age, gender, previous radio- therapy, myelofibrosis, remission status were not found to be associated with mobilization failure. LDH, ferritin,CRP, LDL, trigliseride levels were not different between pa- tients who could be mobilized successfully and not. Inmultivariate analysis only platelet count was found to berelated with mobilization outcome (p < 0.05).

c essful peripheral bloo d stem cell harvesting. Transf Aph eres Sci

Table 3Effect of different parameters on mobilization success.

Parameters Successful mobilization

Failed mobilization

p

Age 51 (17–81) 48 (16–71) P = 0.233 Platelet count 191 (27–458) 93 (105–406) P < 0.05 LDH 382 (122–2043) 326 (105–1242) P = 0.407 Ferritin 206 (2–2486) 266 (12–3800) P = 0.302 CRP 5 (2–175) 5 (3–176) P = 0.443 LDL 124 (36–257) 126 (32–191) P = 0.88 TG 157 (42–601) 141 (19–715) P = 0.812

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4. Discussion

Mobiliza tion can be defined as iatrogenic augmentati onof hematopoieti c stem cell recirculati on. It has been shown that minimum 2 � 106/kg CD34 + cells has to be collected inorder to achieve engraftmen t in the post-trans plantation period [17,18]. In previous studies it was clear that the peripheral blood CD34 + cell count on the day of apheresis significantly correlated to the CD34 + cell content of the harvested product [5,19–21]. We also showed the positive correlation between peripher al blood and product CD34 +

cell count.One of the major predictive factors for optimum mobi-

lization is the choice of mobilization regimen. The optimal mobilization regimen should have the anti-neop lastic activity, but also has to provide a time prediction to start apheresis procedure with higher efficacy for mobilizing the stem cells [6]. Unfortunate ly, mobilization failure still remains to be a problem and with G-CSF based regimens 5–40% of the patients cannot be mobilized successfully [8,18]. It has been shown previously that mobilization yield can be higher with chemoth erapy followed by G-CSF compared with G-CSF alone [22–25]. In our study pop- ulation mobilization failure rate was found to be 36% fol- lowing first line mobilization, which is in line with previous experiences. But we should bear in mind that 91% of our patients received G-CSF alone in first mobiliza- tion attempt and only one patient in chemotherapy plus G-CSF group could not be mobilized successfu lly. Pusic et al.[26] had summari zed mobilization data of 1040 lym- phoma/mye loma patients and found similar mobilization failure rates with G-CSF and G-CSF/chemoth erapy regi- mens (18.8% vs. 18.6%, respectivel y). In their study, regard- less of mobilization regimen used, myeloma patients had the highest total CD34 + cell yield and required less apher- esis to collect P2 � 106 CD34+cells/kg.

We also observed higher mobilization success in myelo- ma patients compared to lymphoma/sol id tumor patients [27]. IMWG recomme nds starting mobilization with G-CSF alone among patients undergoing initial therapy with thalidomide /bortezomib in combination with dexamet ha- sone or among those treated with lenalidomide/d exameth- asone who have received fewer than four cycles of therapy and younger than 65 years. The great majority of our mye- loma patients were treated with bortezomib based regi- mens and only three patients received lenalidomide including therapy. The latter group had only two cycles of lenalidomide.

Duration and the number of prior alkylating agent exposure has been found to be highly predictiv e for mobi- lization failure [17,26,28–33]. Although in univariat e anal- ysis, exposure to myelotoxic treatments (alkylating agents,fludarabine and lenalidom ide) were found to be related with mobilization success, we could not show its impact in multivariate analysis. Numbers of previous chemother- apy lines were found to be a predictive factor for mobiliza- tion in univariat e analysis. Our 107 patients received median P2 lines and 4.5 cycles of chemothera py. In con- tradictory to univariate analysis, we did not prove its influ-ence on mobilization yield in multivari ate analysis. On the

Please cite this article in press as: Demiriz IS� et al. Predict ing the suc(2013), http ://dx.doi.org/10.1016/ j.transc i.2013.04.0 28

other hand extended field radiotherapy was also reported to be associate d with mobilization failure [30,31]. Wecould not show the impact of radiotherapy on mobilization success. This can be a conseque nce of both the small num- ber of patients receiving RT and the involved field radio- therapy usage in treatment protocols for all of our patients. The rational for the discordance of our univariate and multivariate analysis with the previous literature may be the fewer number of patients in our study.

The effect of age on stem cell mobilization is a debate.Although most of the previous reports are consistent with poor mobilization capacity for elderly, there are also a few studies showing similar outcomes [34,35]. We did not findage differenc e between patients accordin g to mobilization failure.

In our study, only paramete r that is predictive for mobi- lization failure both in univariate and multivariate analysis is platelet count. Rising platelet numbers were found to becorrelated with higher mobilization yield in previous stud- ies [36]. We observed that a platelet count above 150.000/ mm3 are related with successful mobilizati on (Table 3).

The importance of iron overload as an independen tprognostic factor on transplant outcome has been proven in several studies [13–16]. However the role of higher fer- ritin levels on mobilization outcome is not clear. Park et al.[16], reported that serum ferritin levels were notably high- er in the poor mobilizers compared with the good mobiliz- ers and they showed transfusion associate d iron overload as a predictive factor for mobilizati on success. In our study,we did not find impact of ferritin in multivari ate analysis.We did not analyze transfusion requiremen t due to the lack of data in some patients. CRP, LDL and triglyceride lev- els might have a negative impact on mobilizati on but inour study both univariat e and multivari ate analysis re- vealed that this relation has not been significant. The pre- dictive value of these newer factors has to be studied inlarger and homogenous populations.

In summary , data presented in our study indicate that prolonged exposure to alkylatin g agents, lower platelet counts; more chemothera py lines before mobilization are adverse factors for sufficient stem cell mobilization in uni- variate analysis. On the other hand, CT plus G-CSF as the mobilization regimen refers to higher successful mobiliza- tion rates. In multivariate analysis, only platelet count ispredictive of mobilizati on failure. Identification of novel risk factors of poor mobilizers in all patients is very impor- tant for clinical response and therapeutic decisions .

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c essful peripheral bloo d stem cell harvesting. Transf Aph eres Sci