Transfusion and Apheresis Science 48 (2013) 407–410

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Transfusion and Apheresis Science

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Which regimen is better for stem cell mobilization of lymphomapatients?

1473-0502/$ - see front matter � 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.transci.2013.04.027

⇑ Corresponding author. Address: Ankara Oncology Hospital, Hematol-ogy and Stem Cell Transplantation Clinic, Demetevler-Yenimahalle, 06200Ankara, Turkey. Tel.: +90 312 336 09 09x7402; fax: +90 312 335 38 18.

E-mail address: scivriz@hotmail.com (S.C. Bozdag).

Sinem Civriz Bozdag a,⇑, Emre Tekgündüz a, Gamze Durgun a, Abdurrahman Sarıca b,Itır S�irinoglu Demiriz a, S�erife Koçubaba a, Fevzi Altuntas� a,b

a Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkeyb Ankara Oncology Education and Research Hospital, Therapeutic Apheresis Center, Ankara, Turkey

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

Article history:

Although chemotherapy combined with G-CSF is an effective method for hematopoieticstem cell mobilization, standard chemotherapy protocol leading to best stem cell yield isnot defined. In our study, we aimed to assess the impact of chemotherapy choice on mobi-lization outcome in lymphoma patients. Patients were mobilized with cyclophosphamide(n:15), ASHAP (n:11) or VGEPP (n:12) protocols. Groups were similar according to collectedCD34+ cell count, total nucleated cell count and median apheresis days. Five out of fifteen(33%) patients could not be mobilized in Cy group but there was only one failed mobiliza-tion attempt in both salvage groups (9% with ASHAP vs 8% with VGEPP). In conclusion, weshowed that VGEPP and ASHAP are safe protocols in terms of stem cell mobilization andhave similar mobilization capacity as cyclophosphamide alone.

� 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Today, peripheral blood is the most commonly pre-ferred stem cell source for hematopoietic stem cell trans-plantation (HSCT) due to its faster engraftment kineticsand convenience. Collection of adequate numbers ofCD34+ cells is fundamental for engraftment after HSCT[2–4]. Initial mobilization attempts are mostly performedwith G-CSF alone or G-CSF after chemotherapy [5–7].Choice of mobilization regimen can differ according to pri-mary diagnosis of the patient, previous treatment modali-ties, chemotherapeutic agents and disease status [8].Mobilization failure rates with G-CSF based mobilizationregimens range from 5% to 30% [9,10]. In various studies,chemotherapy with G-CSF is found to be associated withhigher mobilization yield compared to G-CSF alone bothfor myeloma and lymphoma patients [11,12].

High dose chemotherapy and autologous HSCT (auto-HSCT) is a currently accepted treatment modality for trans-plant eligible relapse/refractory lymphoma patients[13,14]. In order to test the chemosensitivity and minimizethe disease burden, second line ‘salvage’ chemotherapyprotocols have been used before auto-HSCT. In terms of re-sponse rates none of these protocols have been found to besuperior to the others. There are few comparative studiesbetween these salvage regimens to evaluate their impacton mobilization yield [15–18]. Cyclophosphamide with/without etoposide is an alternative mobilization regimenfor lymphoma patients [19]. In our study, we aimed to as-sess the impact of chemotherapy choice on mobilizationoutcome. We compared cyclophosphamide with two dif-ferent salvage chemotherapies mainly used in our centerand summarize stem cell collection data of the threegroups.

2. Patients-methods

In this study, we retrospectively included 38 patientsundergoing to peripheral blood stem cell mobilization inAnkara Oncology Research and Training Hospital between

408 S.C. Bozdag et al. / Transfusion and Apheresis Science 48 (2013) 407–410

December 2009 and July 2011. Diagnosis of the patientswere non-Hodgkin lymphoma (n:17) and Hodgkin lym-phoma (n:21). All lymphoma patients had relapsed/refrac-tory disease and were chemosensitive to salvagetreatment. None of the lymphoma patients had bone mar-row infiltration before stem cell mobilization. G-CSF afterchemotherapy has been preferred as mobilization methodfor all patients. Patients were grouped according to mobi-lization protocol type; fifteen patients were mobilized withcyclophosphamide (Cy) 4 g/m2, the rest of the patientswere mobilized with salvage chemotherapy for lymphoma.All patients in Cy group received MESNA 4 g/m2 for theprevention of hemorrhagic cystitis. Salvage chemotherapywas either ASHAP (n:11) or VGEPP (n:12) chemotherapyprotocol.

ASHAP protocol consisted, cisplatin 25 mg/m2 D1-4,doxorubicin 10 mg/m2 D1-4, cytarabine 2 g/m2 D5, meth-ylprednisolone 500 mg D1-5 [20]. VGEPP protocol wasmodified from the previously reported protocol [21]. Che-motherapy consisted gemcitabine 800 mg/m2 D1 and D8,vinorelbine 25 mg/m2 D1 and D8, procarbazine 100 mg/m2 D1-7, methylprednisolone 60 mg/m2 D1-15. Filgrastimor lenograstim was given for mobilization at a dose of10 lg/kg/day. Enumeration of CD34+ cells in the peripheralblood was assessed when blood leukocyte count exceeded1000/mm3. Apheresis was performed when the peripheralCD34+ cell count was >20/ll by Fresenius cell separator.Total nucleated and CD34+ cell count of the apheresisproduct was evaluated with flow cytometry.

Mobilization failure was defined as collected CD34+ cellcount of less than 2 � 106/kg in two consecutive days.Optimum mobilization was defined as collection of5 � 106/kg CD34+ in one apheresis procedure. Apheresisproducts have been cryopreserved with 10% dimethylsulf-oxide and stored at �196 �C. Neutrophil engraftment was

Table 1Demographics features of patients.

CY (n:15)

DiagnosisNHL 8HL 7

GenderF/M 1/14

AgeMedian(range) 47(28–58)

Stage of lymphoma pts. I/II/III/IV 0/3/8/4

Previous CT line 2/3 (n) 10/5Number of mobilization attempt 1/2/3 7/8/0

Table 2Apheresis collection data of the patients.

Cy (n:15)

CD34+ cell count (�106/kg) 4.5(2.6–17.6)TNC count (�108/kg) 20(6.1–28)Procedure per patient (n) 2(1–2)CD34> 5 � 106/kg in one apheresis 2Mobilization failure 5

defined as the first of 3 consecutive days with absoluteneutrophil count P500/mm3 without growth factor sup-port, and platelet engraftment as the first of 7 consecutivedays with platelet count P20,000/mm3 withouttransfusions.

2.1. Statistical analysis

Descriptive statistics are presented as median andrange. Comparisons of continuous variables between thethree cohorts were performed using the nonparametrictest of Kruskal–Wallis. Proportions were compared utiliz-ing chi-square test. p < 0.05 was considered to be statisti-cally significant.

3. Results

Demographic features of both groups are summarizedin Table 1. Seven out of thirty eight patients could not bemobilized successfully (18%). Median collected CD34+ celland total nucleated cell count (TNC) of all patients were5.1(2.5–51) � 106/kg and 9.9(3.4–28.1) � 108/kg, respec-tively. Median apheresis procedure number was 2 [1–3].Cyclophosphamide was the second line mobilization regi-men for a significantly higher number of patients(p:0.02). In the VGEPP group, more patients received thisprotocol as their first line mobilization regimen comparedto ASHAP protocol (p:0.05). Apheresis collection data of thethree groups are summarized in Table 2. Groups were sim-ilar according to collected CD34+ cell count, TNC count andapheresis procedure per patient. The number of patientswith collected CD34+ cell count of more than 5 � 106/kgin one apheresis procedure, were also similar betweenthe groups. Five out of fifteen (33%) patients could not bemobilized in Cy group but there was only one patient with

ASHAP (n:11) VGEPP (n:12) P

5 4 0.5826 8

4/7 4/8 0.135

45(18–59) 0.473

3/2/4/2 1/3/6/2 0.482

8/3 6/6 0.4955/5/1 11/1/0 0.057

ASHAP (n:11) VGEPP (n:12) P

5.5(2.5–51) 4.7(3.7–13.8) 0.5826.3(3.4–20) 13(3.5–27) 0.2661(1–3) 2(1–2) 0.1164 1 0.1801 1 0.160

S.C. Bozdag et al. / Transfusion and Apheresis Science 48 (2013) 407–410 409

failed mobilization in both salvage groups (9% with ASHAPvs 8% with VGEPP). Later, all of these patients were mobi-lized successfully with plerixafor combined with G-CSF.

Fourteen out of fifteen patients in Cy group, nine out oftwelve patients in VGEPP group and eight out of eleven pa-tients in ASHAP group received auto-HSCT. Two patientsdied due to sepsis during transplantation in VGEPP group,one in the aplasia period and the other following neutro-phil engraftment. Only one patient died during aplasia per-iod in Cy group. Median neutrophil engraftment days forCy, ASHAP, VGEPP groups were 12(10–15), 11(8–14),10(9–12) respectively. We did not find a significant differ-ence in terms of neutrophil engraftment kinetics (p:0.07).Median platelet engraftment days for Cy, ASHAP, VGEPPgroups were 15(9–17), 12(9–16) and 9(9–14), respectively.Although VGEPP group had earlier platelet engraftment, itwas statistically insignificant (p:0.07).

4. Discussion

Despite the improvement in outcomes of lymphoma pa-tients, treatment of relapsed/refractory disease still re-mains a major challenge. High dose therapy followed byauto-HSCT has been established as standard therapy fortransplant eligible relapsed/refractory lymphoma patients.Response to salvage regimen can predict posttransplanta-tion outcome of these patients. Optimum salvage regimenmust not have a negative impact on mobilization capacitywhile achieving disease control [13–18]. Mobilizationsuccess was reported to be 86–99% with different salvageregimens for relapsed/refractory Hodgkin lymphomapatients in previous studies [17,18]. In diffuse large B celllymphoma (DLBCL) patients, similar mobilization failurerates of 10% were observed after both RICE (rituximab,ifosphamide, etoposide, carboplatin) and RDHAP (ritux-imab, cisplatin, cytarabine, dexamethasone) regimens[16]. IEV (ifosphamide, etoposide, carboplatin) was com-pared with one of the most commonly used salvage regi-mens (ICE) and found to be superior in mobilizingcapacity [22]. In our study, two different regimens, ASHAP[20] and VGEPP [21], has been preferred as salvage andmobilization regimens. Gemcitabine either in combinationwith platinum based or ifosphamide, vinorelbine chemo-therapies were found to be safe for mobilization [23–25].Suyani et al., reported 83% mobilization success with gem-citabine, vinorelbine combination chemotherapy [25].VGEPP protocol shows promising results as salvage ther-apy but its influence on the mobilization capacity has tobe assessed [21]. ASHAP protocol is also a feasible, welltolerated and effective salvage treatment but its role onmobilization yield is a question to be answered also [20].So in our study, we retrospectively included these twogroups and compared outcomes both with each otherand cyclophosphamide group. Over 90% of patients couldbe mobilized with both salvage protocols which is in linewith previous reports.

Although cyclophosphamide plus etoposide was foundto be superior in achieving target stem cell yield withminimum apheresis procedure, potential contribution ofetoposide to myelodysplasia/acute leukemia after auto-

HSCT can be a reason for its less usage [26]. In our study,we treated our patients with 4 g/m2 cyclophosphamidealone. Comparative studies between high dose cyclophos-phamide and salvage chemotherapies has also been re-ported previously. Pavone et al., randomly assignedmobilizing chemotherapy regimens as DHAP (cisplatin,cytarabine, dexamethasone) vs. cyclophosphamide andcould not find statistical difference in terms of TNC,CD34+ cells and CFU-GM collected between the two treat-ment schedules [27]. In contradictory with these results,Lee et al., reported better mobilization outcome withESHAP (etoposide, cisplatin, cytarabine, steroid) chemo-therapy compared to high dose cyclophosphamide. Totalcollected CD34+ cells and apheresis day 1 CD34+ cells weresignificantly higher in ESHAP group [28]. In our study,while mobilization failure rates were 8% and 9% in salvagegroups, it was over 30% in cyclophosphamide group. It ispossible that we could not find a statistical significanceas a consequence of low patient numbers included. Besidescyclophosphamide has been used as second line mobilizingregimen in a higher number of patients. Pusic et al,reported 48% mobilization failure rate with G-CSF pluschemotherapy as remobilizing regimen [29].

We also assesed the impact of mobilization regimen onengraftment kinetics after auto-HSCT. Milone et al, showedthat patients mobilized with CY plus G-CSF required moretime for engraftment of platelets and neutrophils com-pared with G-CSF alone [30]. In another study, no engraft-ment delay was observed between these two mobilizationprotocols [29]. Posttransplant hematological recovery dataafter salvage chemotherapies were also shown in differentstudies [31]. Todd et al., observed no engraftment failureand median neutrophil engraftment day as 14 with inter-mediate dose gemcitabine–cisplatin combination [32]. Inour study, there was no significant difference betweenthe three groups in terms of neutrophil and plateletengraftment.

In conclusion, we showed that salvage regimens, VGEPPand ASHAP are effective protocols in terms of stem cellmobilization and have similar mobilization capacity ascyclophosphamide.

References

[1] Champlin RE, Schmitz N, Horowitz MM, et al. Blood stem cellscompared with bone marrow as a source of hematopoietic cells forallogeneic transplantation. Blood 2000;95(12):3702–9.

[2] Allan DS, Keeney M, Howson-Jan K, Popma J, Weir K, Bhatia M, et al.Number of viable CD34(+) cells reinfused predicts engraftment inautologous hematopoietic stem cell transplantation. BMT2002;29(12):967–79.

[3] Siena S, Schiavo R, Pedrazzoli P, Carlo-Stella C. Therapeutic relevanceof CD34 cell dose in blood stem cell transplantation for cancertherapy. J Clin Oncol 2000;18:1360–77.

[4] Shpall EJ, Champlin R, Glaspy JA. Effect of CD34+ peripheral bloodprogenitor cell dose on hematopoietic recovery. Biol Blood MarrowTransplant 1998;4(2):84–92.

[5] Dazzi C, Cariello A, Rosti G, et al. Is there any difference in PBPCmobilization between cyclophosphamide plus G-CSF and G-CSFalone in patients with non-Hodgkin’s lymphoma? Leuk Lymphoma2000;39(3–4):301–10.

[6] To LB, Shepperd KM, Haylock DN, et al. Single high doses ofcyclophosphamide enable the collection of high numbers ofhemopoietic stem cells from the peripheral blood. Exp Hematol1990;18:442–7.

410 S.C. Bozdag et al. / Transfusion and Apheresis Science 48 (2013) 407–410

[7] Goldschmidt H, Hegenbart U, Haas R, et al. Mobilization of peripheralblood progenitor cells with high-dose cyclophosphamide (4 or 7 g/m2) and granulocyte colony-stimulating factor in patients withmultiple myeloma. Bone Marrow Transplant 1996;17:691–7.

[8] Ikeda K, Kozuka T, Harada M. Factors for PBPC collection efficiencyand collection predictors. Transfusion Apheresis Sci2004;31:245–59.

[9] Dreger P, Kloss M, Petersen B, et al. Autologous progenitor celltransplantation: prior exposure to stem cell-toxic drugs determinesyield and engraftment of peripheral blood progenitor cell but not ofbone marrow grafts. Blood 1995;86:3970–8.

[10] Tarella C, Di Nicola M, Caracciolo D, et al. High-dose ara-C withautologous peripheral blood progenitor cell support induces amarked progenitor cell mobilization: an indication for patients atrisk for low mobilization. Bone Marrow Transplant 2002;30:725–32.

[11] Milone G, Leotta S, Indelicato F, Mercurio S, Moschetti G, DiRaimondo F, et al. G-CSF alone vs cyclophosphamide plus G-CSF inPBPC mobilization of patients with lymphoma: results depend ondegree of previous pretreatment. Bone Marrow Transplant2003;31:747–54.

[12] Gertz MA, Kumar SK, Lacy MQ, Dispenzieri A, Hayman SR, Buadi FK,et al. Comparison of high-dose CY and growth factor with growthfactor alone for mobilization of stem cells for transplantation inpatients with multiple myeloma. BMT 2009;43:619–25.

[13] Philip T, Guglielmi C, Hagenbeek A, et al. Autologous bone marrowtransplantation as compared with salvage chemotherapy in relapsesof chemotherapy-sensitive non-Hodgkin’s lymphoma. N Engl J Med1995;333:1540–5.

[14] Brice P. Managing relapsed and refractory Hodgkin lymphoma. BJH2008;141:3–13.

[15] Gisselbrecht C. Is there any role for transplantation in the rituximabera for diffuse large B-cell lymphoma? ASH Educ Book2012;1:410–6.

[16] Gisselbrecht C, Glass B, Mounier N, Gill D, Linch DC, Trneny M, et al.Salvage regimens with autologous transplantation for relapsed largeB-cell lymphoma in the rituximab era. JCO 2010;28:4184–90.

[17] Mendler J, Friedberg J. Salvage therapy in Hodgkin’s lymphoma. TheOncologist 2009;14(4):425–32.

[18] Colpo A, Hochberg E, Chen Y. Current status of autologous stem celltransplantation in relapsed and refractory Hodgkin’s lymphoma. TheOncologist 2012;17:80–90.

[19] Mollee P, Pereira D, Nagy T, Song K, Saragosa R, Keating A, et al.Cyclophosphamide, etoposide and G-CSF to mobilize peripheralblood stem cells for autologous stem cell transplantation in patientswith lymphoma. BMT 2002;30(5):273–8.

[20] Nückel H, Dürig J, Dührsen U. Salvage chemotherapy according tothe ASHAP protocol: a single-center study of 24 patients withrelapsed or refractory aggressive non-Hodgkin’s lymphomas. AnnHematol 2003;82:481–6.

[21] Di Renzo N, Brugiatelli M, Montanini A, Vigliotti ML, Cervetti G,Liberati AM, et al. Vinorelbine, gemcitabine, procarbazine andprednisone (ViGePP) as salvage therapy in relapsed or refractoryaggressive non-Hodgkin’s lymphoma (NHL): results of a phase II

study conducted by the Gruppo Italiano per lo Studio dei Linfomi.Leuk Lymphoma 2006;47(3):473–9.

[22] Fox CP, McMillan AK, Bishton MJ, Haynes AP, Russell NH. IVE(ifosfamide, epirubicin and etoposide) is a more effective stem cellmobilisation regimen than ICE (ifosphamide, carboplatin andetoposide) in the context of salvage therapy for lymphoma. Br JHaematol 2008;141(2):244–8.

[23] Crump M, Baetz T, Couban S, Belch A, Marcellus D, Howson-Jan K,et al. Gemcitabine, dexamethasone, and cisplatin in patients withrecurrent or refractory aggressive histology B-cell non-Hodgkinlymphoma: a phase II study by the National Cancer Institute ofCanada Clinical Trials Group (NCIC-CTG). Cancer2004;101(8):1835–42.

[24] Santoro A, Magagnoli M, Spina M, Pinotti G, Siracusano L, Michieli M,et al. Ifosfamide, gemcitabine, and vinorelbine: a new inductionregimen for refractory and relapsed Hodgkin’s lymphoma.Haematologica 2007;92(1):35–41.

[25] Suyanı E, Sucak GT, Akı S�Z, Yegin ZA, Özkurt ZN, Yagcı M.Gemcitabine and vinorelbine combination is effective in both as asalvage and mobilization regimen in relapsed or refractory Hodgkinlymphoma prior to ASCT. Ann Hematol 2011;90(6):685–91.

[26] Krishnan A, Bhatia S, Slovak ML, Arber DA, Niland JC, Nademanee A,et al. Predictors of therapy-related leukemia and myelodysplasiafollowing autologous transplantation for lymphoma: an assessmentof risk factors. Blood 2000;95(5):1588–93.

[27] Pavone V, Gaudio F, Guarini A, Perrone T, Zonno A, Curci P, et al.Mobilization of peripheral blood stem cells with high-dosecyclophosphamide or the DHAP regimen plus G-CSF in non-Hodgkin’s lymphoma. Bone Marrow Transplant 2002;29(4):285–90.

[28] Lee JL, Kim S, Kim SW, Kim EK, Kim SB, Kang YK, et al. Suh CESHAPplus G-CSF as an effective peripheral blood progenitor cellmobilization regimen in pretreated non-Hodgkin’s lymphoma:comparison with high-dose cyclophosphamide plus G-CSF. BoneMarrow Transplant 2005;35(5):449–54.

[29] Pusic I, Jiang SY, Landua S, Uy GL, Rettig MP, Cashen AF, et al. Impactof mobilization and remobilization strategies on achieving sufficientstem cell yields for autologous transplantation. Biol Blood MarrowTransplant 2008;14(9):1045–56.

[30] Milone G, Leotta S, Indelicato F, Mercurio S, Moschetti G, DiRaimondo F, et al. G-CSF alone vs cyclophosphamide plus G-CSF inPBPC mobilization of patients with lymphoma: results depend ondegree of previous pretreatment. Bone Marrow Transplant2003;31(9):747–54.

[31] McQuaker I, Haynes AP, Stainer C, Byrne JL, Russell NH. Mobilisationof peripheral blood stem cells with IVE and G-CSF improves CD341cell yields and engraftment in patients with non-Hodgkin’slymphomas and Hodgkin’s disease. Bone Marrow Transplant1999;24:715–22.

[32] Todd T, Raj S, Camilleri D, Stafford G, Bulusu R, Follows G, et al.Intermediate dose gemcitabine–cisplatin combinationchemotherapy without treatment delay for cytopenia followed byautografting – a new standard of care in relapsed or refractoryHodgkin lymphoma? Ann Hematol 2009;88(11):1107–12.