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Stem Cell Mobilization and Collection in Autologous Stem Cell Transplantation.

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Presentation on theme: "Stem Cell Mobilization and Collection in Autologous Stem Cell Transplantation."— Presentation transcript:

1 Stem Cell Mobilization and Collection in Autologous Stem Cell Transplantation

2 Activity Faculty Luciano J. Costa, MD, PhD Associate Professor of Medicine Department of Medicine and UAB-CCC Bone Marrow Transplantation and Cell Therapy Program School of Medicine University of Alabama at Birmingham Birmingham, AL

3 Learning Objectives Upon completion, participants should be able to:  Identify factors that place patients at risk of poor AHSC mobilization, thereby requiring guideline-recommended mobilization protocols  Apply guideline-based strategies that optimize first-attempt stem cell mobilization and collection in patients undergoing AHSC transplantation

4 Key Considerations in Mobilization for AHSC Transplant  Mobilization of AHSCs using chemotherapy, growth factors, and novel agents has increased the success rates of AHSC transplants  Risk factors for poor AHSC mobilization include prior chemotherapy, radiotherapy, age, low platelet count before mobilization, and diabetes  New guidelines exist to help optimize mobilization regimens and increase the success of AHSC transplant

5 Mobilization Regimens for AHSC Transplant  Chemomobilization –ICE (ifosfamide, carboplatin, etoposide) ± rituximab –DHAP (dexamethasone, cytarabine, cisplatin) ± rituximab –ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin) ± rituximab –Single-agent chemotherapy: cyclophosphamide, etoposide Child JA, et al. N Engl J Med. 2003;348: ; Hopman RK, et al. Blood Rev. 2014;28:31-40.

6  Cytokines – G-CSF – GM-CSF Mobilization Regimens for AHSC Transplant  Plerixafor –Approved by the FDA in 2008 in combination with G-CSF for AHSC mobilization in MM and NHL –Reversible CXCR4 antagonist Motabi IH, et al. Blood Rev. 2012;26:

7 Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: ; Costa LJ, et al. Bone Marrow Transplant. 2011;46: Mobilization Guidelines—Algorithm

8 Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: First-Line Mobilization Strategies: What Do the Guidelines Say? “For patients with MM:  Steady-state mobilization with G-CSF alone in doses of μg/kg/day is an option, but should be limited to patients with no more than 1 previous line of therapy, not previously treated with melphalan or > 4 cycles of lenalidomide; in such patients, PB CD34+ cell count monitoring with preemptive plerixafor will allow for successful collection in the vast majority of patients For patients with NHL:  Steady-state mobilization with G-CSF alone in doses of μg/kg/day, although associated with higher failure rates in some patient populations, may be an option owing to low toxicity and ease of scheduling; it should be limited to those at low risk for mobilization failure; again, PB CD34+ count monitoring with preemptive plerixafor will allow successful collection in the vast majority of patients  CM, either incorporated into the initial 3 to 6 cycles of planned chemotherapy or as part of a salvage regimen, is appropriate”

9 Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: ; Med-IQ In-Practice Research, Target vs. Ideal  Recommended target for stem cell collection is 3-5 x 10 6 cells/kg  Minimum recommended dose of AHSCs for transplant is 2 x 10 6 cells/kg  Ideal target numbers for AHSC transplant are less clear Practice Pearl: the ideal number of AHSCs varies among transplant centers

10  Prior chemotherapy with lenalidomide, melphalan, platinum- containing agents, alkylating agents, fludarabine, etc.  Previous radiotherapy  Age Motabi IF, et al. Blood Rev. 2012;26:267-78; Hopman RK, et al. Blood Rev. 2014;28:31-40; Fadini GP, et al. Diabetologia. 2007;50: ; Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: Risk Factors for Poor Mobilization  Low bone marrow reserve –Low cellularity –Low platelet count –Low PB CD34+ count  Comorbidities such as diabetes

11 Med-IQ In-Practice Research, Frontline Perspectives “So if someone had prior—especially pelvic—radiation, then I would consider that a risk factor. Multiple lines of prior chemotherapy, especially purine analogs like fludarabine. If they’ve had a lot of the alkylators over time. Our group found that diabetes seems to cause poor mobilization, too... [In] some of those, we might just do [plerixafor] from the get-go, plan on it, and not do the just-in-time where you add it in when you need to.” “[We] will add plerixafor if they have been heavily pretreated with chemo.”

12 Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: ; Med-IQ In-Practice Research, Mobilization Failure “Plerixafor has contributed almost 100% to increased success [of AHSC mobilization].” Practice Pearl: since the advent of plerixafor, mobilization failure is almost nonexistent in MM patients and has decreased greatly in NHL patients

13  Cytokines alone are insufficient  Remobilization with chemotherapy has historically been used  Obtaining cells from bone marrow is a rarely used option  Guidelines recommend using plerixafor (with either G-CSF or G-CSF + chemo) to remobilize  Remobilization with chemotherapy is an acceptable strategy Remobilization Giralt S, et al. Biol Blood Marrow Transplant. 2014;20:

14 Med-IQ In-Practice Research, Frontline Perspectives on Remobilization  One-half of specialists said that they use the same protocol that is used for initial mobilization  One-third use high-dose G-CSF plus planned plerixafor  Approximately 17% use chemomobilization

15 Giralt S, et al. Biol Blood Marrow Transplant. 2014;20: ; Med-IQ In-Practice Research, Frontline Perspectives “We follow the spirit of the guidelines.” Practice Pearl: to optimize the yield of HSCs, each transplant center should use a mobilization regimen based on algorithms developed at their own centers

16 Key Considerations in Mobilization for AHSC Transplant  Mobilization of AHSCs using chemotherapy, growth factors, and novel agents has increased the success rate of AHSC transplants  Risk factors for poor AHSC mobilization include prior chemotherapy, radiotherapy, age, low platelet count before mobilization, and diabetes  New guidelines exist to help optimize mobilization regimens and increase the success of AHSC transplant

17 Thank You To redeem credit, click the “Get Credit” button on the activity homepage: Please visit us online at for additional activities sponsored by Med-IQ. © 2015


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