Effective mobilization with etoposide and cyclophosphamide for collection of peripheral blood stem cell in patients with multiple myeloma

Purpose: To evaluate the efficacy and toxicity of etoposide and cyclophosphamide for mobilization peripheral stem cells in multiple myeloma patients. Methods: We retrospectively analyzed 46 patients with multiple myeloma who underwent peripheral blood stem cell collection for upfront autologous hematopoietic stem cell transplantation in the First Affiliated Hospital of Xi’an Jiaotong University between January 2010 and July 2019. The mobilization protocols included cyclophosphamide 2.0 g/m2 with G-CSF (CTX group) before January 2015, and two-days of 5 mg/kg.d etoposide and 1.0 g/m2.d cyclophosphamide with G-CSF (EC group) after January 2015. Results: The success rate of harvest (≥2×106 cells/kg) during the first mobilization attempt was 82.1% in the EC group and 50.0% in the CTX group, and the rate of adequate harvest (≥4×106 cells/kg) was 57.1% in the EC group and 15.8% in the CTX group. After the second mobilization, a sufficient number of CD34+/kg cells for an auto-HSCT was obtained for all patients in the EC group and the majority (68.4%) of patients in CTX group. There was no significant difference of non-hematological adverse events between two groups. The mean neutrophil engraftment time was 11.22±1.56 days and 9.89±2.81days for the CTX and EC groups, respectively (P>0.05). Platelet engraftments were significantly faster in the EC group than the CTX group (P0.05). Conclusion: The etoposide and cyclophosphamide regimen could be an effective and safe method for mobilization in patients with multiple myeloma.

Allogeneic Stem Cell Transplantation for Adult T-Cell Leukemia/Lymphoma—Romanian Experience

Adult T-cell leukemia/lymphoma (ATLL) is a rare and aggressive mature T-cell malignancy caused by the human T lymphoma virus I (HTLV-I) affecting 3–5% of HTLV-1 carriers and is usually diagnosed in endemic regions. Romania is a region with high prevalence of HTLV-1 infection and ATLL and with low median age at diagnosis for aggressive types. We performed a retrospective analysis of post-transplant outcome in the first Romanian patients with ATLL receiving hematopoietic stem cell allotransplant. The study population included eight patients (three males, five females), with median age of 39.5 (range 26–57), with acute (one case) and lymphoma type (seven cases) that received peripheral stem cells (PBSC) from matched related (MRD) and unrelated donors (MUD) after reduced intensity conditioning. Graft versus host disease (GVHD) developed in six patients. Relapse occurred in four cases (50%) at a median time of 5-months post-transplant. Six patients died: four cases with disease-related deaths and two patients with GVHD-related deaths. The median survival post-transplant was 19.5 months (range 2.3–44.2 months). The post-transplant survival at 1-year was 62.5%, at 2-years 50%, and at 3-years 37.5%. In our opinion allogeneic transplant improves outcome in aggressive type ATLL.

Feasibility of Peripheral Blood Stem Cell Collection from Heterozygoussickle Cell Trait Donors

Introduction Allogeneic haematopoietic stem cell transplantation (HSCT) is currently the only curative treatment for sickle cell disease (SCD) offered to patients with a fully matched sibling (MSD) or matched unrelated donor (MUD). With a MSD/MUD donor availability of below 20% a haploidentical HSCT from a family donor either with post-transplant cyclophosphamide (post-cy) or with a TCRαß/CD19 depleted graft (T-haplo) is an increasingly successful alternative for the majority of patients. In contrast to post-cy where mostly bone marrow is used, T-haploHSCT requires the generation of a G-CSF stimulated peripheral stem cell grafts. Almost uniformly haploidentical relatives of SCD patients are heterozygous carriers of SC trait. For these donors with a genetically heterozygous sickle trait, G-SCF represents a major safety concern with regard to triggering a sickle cell crisis. Therefore, the use of sickle trait donors is prohibited or not recommended in several countries, and guidelines are currently not available due to lack of evidence. Methods Haploidentical related donors with heterozygousSCD (group S, n=13) as well as healthy donors (group O, n=9) were stimulated with G-CSF. In all donors a similar mobilizations schedule using G-CSF was applied. All donors were applied 10µg/kg body weight (Neupogen®or Granocyte®) sub cutaneous daily with first apheresis on day 5 and day 6 when necessary. The amount of mobilized CD34+ cells were assessed after mobilization. In addition, the harvested stem cell preparations were analysed for CD34 content after apheresis and patients monitored for potential serious adverse effects (AE) during and after the apheresis. Results Mobilization was tolerated well with only mild and typical AE related to apheresis procedure such as citrate reactions, joint pain, ostealgia and headache, observed equally in both groups. In most of the donors (n=13/13 and 8/9), we were able to collect a sufficient amount of CD34+peripheral stem cells (mean of 16.3 and 8.2 x 10^6/kg in group S and O, respectively). We observed slight increases in LDH and reticulocyte counts in few donors also without significant differences between both groups. In particular, there were no severe neurologic side effects and no problems like sickle cell crisis despite mean pre-apheresis hemoglobin concentrations of 14.1 (range 11.9-17.5) g/dL in group S. Conclusions Collectively, these data indicate that in the absence of a MSD or MUD donor, haploidentical family donors with heterozygoussickle cell trait provide a safe and effective alternative for collection of peripheral CD34+stem cells for a T-haplo HSCT. Disclosures No relevant conflicts of interest to declare.

Risk Factors of BK Virus Cystitis in Haematopoietic Stem Cell Transplantation-a Retrospective Monocentric Study

Background: BK virus (BKV) is a human polyomavirus. Reactivation occurs during deep immunosuppression as in hematopoietic stem cell transplantation (HSCT) and renal transplantation, leading to hemorrhagic cystitis (HC) and nephropathy respectively. In HSCT, systematic PCR for BKV in urine is positive for 50 to 100% of patients (pts), but only 5 to 40% develop a BKV HC. Thus, BKV PCR is usefull to confirm a diagnostic of BKV HC but not to predict its occurrence. Several risk factors to develop BKV HC have been studied, especially mismatched HLA and haploidentical HSCT. Objectives: The aim of this retrospective study was to ascertain the risk factors to develop BKV HC. Methods: A retrospective study was performed by considering data from Grenoble University Hospital in the national retrospective register ProMISe, from the SFGM-TC. The period of the study covered from January 2014 to January 2018. PCR BKV in urine was performed when pts presented hematuria grade 2 or higher with clinical symptoms of cystitis. Viral nucleic acid was extracted from the urine samples with the EasyMag platform (Biomérieux) and the qPCR with BK Virus R-GENE®kit (ARGENE) on a LightCycler 480 (ROCHE). BKV HC is defined by the association of clinical symptoms of cystitis, haematuria grade 2 or higher and a BKV viruria >7 log10 copies/mL. Univariable and multivariable logistic regression model were used to identify risk factors for BK cystitis. Results: 188 HSCT were performed during the study period. After exclusion of 13 pts for early mortality (<30 days) and 4 for engraftment failure, 171 pts were finally considered for analysis, from whom 43 (25.1%) developed a BKV HC. The median age of patients presenting with BKV HC was 44 years (23-62) and males represented 67.4 %. Acute leukemia was the most common indication of HSCT (74.4%), followed by myelodysplastic syndromes (9.3%), lymphoma (6.9%), myeloproliferative neoplasms (4.7%) and aplastic anemia (4.7%). In most cases, pts were not in complete response at transplant (51.2%). First autologous or allogenic HSCT had previously been performed for 30.2% of pts. The majority of pts had a transplant with peripheral stem cells as graft source (76.6%), and had a transplant with mismatched HLA (9/10, n=9, 20.9%) or haploidentical donors (n=13, 30.2%). Twenty-nine pts (67.4%) received reduced-intensity conditioning and twenty-two pts (51.2%) received cyclophosphamide post allograft to prevent Graft Versus Host Disease (GVHD). BKV HC prophylaxis relied on hyperhydratation and mesna during the conditioning regimen. The median time to develop HC was 42 days post-transplantation (30-55) mainly with a grade 3 HC (53.5%). The median viruria was 9 log (9-10). Cidofovir was administered as curative treatment to 20 pts (46.5%) and 25 pts (58%) needed bladder irrigation and forced diuresis. The median level of platelets at diagnosis was 58 G/L (29-123). At diagnosis of BKV HC, 32.6% of pts presented a bacterial cystitis and 62.8% an acute renal failure. Allogenic HSCT was complicated by an acute GVHD in 88.4% of pts and 69.8% were treated by corticosteroids. CMV reactivation was observed in 39.5% of pts, and HHV6 in 18.6%. In univariate analysis, post-transplant cyclophosphamide (p<0.001), age below 40 years (p<0.001), history of previous auto or allograft (p=0.007), allograft with mismatched HLA (9/10 and haploidentical) (p<0.001), use of peripheral stem cells (p=0.047), engraftment of platelets >100 days (p=0.016), acute GVHD (p=0.007), corticotherapy (p<0.001), co-infection by HHV6 (p=0.006), association to bacterial cystitis (p=0.002), acute renal failure (p=0.009) and platelets below 50G/L (p<0.001) were significantly associated with increased risk of BKV HC. After logistic regression, the risk factors associated with BKV HC were reduced to: exposition post-transplantation to cyclophosphamide (OR 4.1, 1.5-10.7, p=0.004), age below 40 years (OR 4.1, 1.6-10.9, p=0.004), corticosteroids therapy (OR 3.9, 1.6-9.5, p=0.033), acute renal failure (OR 3.8, 1.5-9.6, p=0.0056), bacterial cystitis (OR 3.3, 1.2-8.7, p=0.0175), and platelets below 50G/L (OR 3.8, 1.382-10.486, p=0.097). Conclusion: BKV HC was observed in 25.1% of patients. Exposition to cyclophosphamide, young age, corticosteroids therapy and bacterial cystitis are potential risk factors of BKV HC. Surprisingly, young age was not expected as risk factor. Disclosures No relevant conflicts of interest to declare.

Time Dependent Decrease in Efficacy of Second G-CSF Mobilization in Healthy Unrelated Donors

Abstract Introduction: Graft failure or a second allogeneic hematopoietic stem cell transplantation or HLA haplotypes leading to donor requests for two patients are reasons for a second collection of peripheral stem cells of the same donor. Few reports about second stimulation showed conflicting results. Higher G-CSF doses or the addition of plerixafor has been described either in autologous or allogenic settings. In order to get more information about second stimulation with G-CSF, we pooled the data from three collection centers in Germany. Donors and Methods: The collection centers of Dresden, Hameln and Cologne performed between December 1991 and May 2015 18,124 collections of peripheral stem cells. We identified 351 of donors who donated twice. All collections were performed after G-CSF stimulation (Lenograstim) of 7.5 to 10 µg / kg body weight. The same apheresis machine was used in 80 % of donors. Besides Spectra and Optia from Terumo ComTec machines from Fresenius were used. We compared leukocytes, platelets, hemoglobin and CD 34 positive cells in the blood before apheresis, yield of stem cells, and blood volume processed as endpoint of interest. There are differences in the number of donor results since the reported data in the first years were incomplete. We created 4 groups of donors depending on the interval between the two donations (Group A: interval <= 90 days, group B 91 to 180 days, group C 181 to 360 days, group D > 360 days). The minimum difference between two apheresis was 20 days, the maximum 4,436 days. The data of the donors were analyzed using NCSS as statistical program. To determine significance in the data paired t tests were performed. Results: Platelet counts, hemoglobin and erythrocyte counts at the time of apheresis was similar at first and second time point of collection. CD34-positive cells in the blood on the 1st day of apheresis were significantly higher with 77.9/µl at 1st apheresis compared to 67.9/µl at 2nd apheresis. Leukocyte counts were also higher at first donation date (42,954/µl compared to 40,330/µl). Considering the product, total collected CD34 pos. cells were lower at 2nd apheresis (617 * 106 compared to 566 * 106) but there was no significant difference in the CD34 pos. cells per kg BW of the patient which might be due to the observation that the body weight of the patients were lower at 2nd transplantation. We were interested in the time-dependence of the second mobilization capacity. The details are shown in the table. Leukocyte counts in the blood remained lower after 2nd G-CSF stimulation even after more than one year. In contrast, CD34 stimulation returned to values measured at the first stem cell collection. To achieve the requested amount of CD 34 pos. cells a higher blood volume had to be processed if the two collections are less than 6 months apart. Discussion: Our data are in accordance with earlier observations showing that at a second stimulation with G-CSF is less affective. The data of 351 donors indicate that this difference lasts for up to 1 year for stimulation of CD34 pos. cells. Only for leukocytes, there is still a significant difference also if restimulated after more than 1 year . In contrast, this decreased restimulation of stem cells has no important clinical effect on the possibility to get suffient numbers of stem cells for a transplantation. A second treatment of a donor at least with 7.5 to 10 µg G-CSF/kg body weight does not harm the donor since baseline hematologic parameters were the same at time of medical assessment. Table 1. CD 34 pos. cells/µl (blood) Leukocytes/µl (blood) Total CD 34 pos. cell in the product (*10^6) CD 34 pos. cells / BW patient (*10^6) Processed blood volume of the donor (l) Interval between 2 collections < =90 days 1st apheresis 77.0* (69) 42,772* (69) 598* (71) 8.5 (70) 13.8* (55) 2nd apheresis 59.2* 38,612* 558* 8.06 16.1* Interval between 2 collections 91 - 180 days 1st apheresis 76.6* (94) 42,872* (95) 567* (95) 7.27 (95) 14.4* (80) 2nd apheresis 64.7* 40,886* 517* 7.22 15.6* Interval between 2 collections 181 - 360 days 1st apheresis 81.3* (85) 43,643* (86) 654* (87) 9.33 (86) 14.6 (79) 2nd apheresis 77.6* 41,388* 572* 8.68 14.9 Interval between 2 collections > 360 days 1st apheresis 76.8 (98) 42,557* (98) 646 (98) 9.66 (98) 15.5 (89) 2nd apheresis 73.2 40,071* 615 10.33 14.9 *Difference significant (p<0.01) in paired t-test, in brackets number of donors Disclosures Schetelig: GSK and Sanofi: Research Funding; Janssen, Sanofi and Neovii: Membership on an entity's Board of Directors or advisory committees. Ehninger:Cellex GmbH: Equity Ownership.