Mobilisation and collection of Peripheral Blood Stem Cells

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Mobilisation and collection of Peripheral Blood
Stem Cells

• N Milpied
• University and Hospital
• Bordeaux

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Principes
Intensification-autogreffe
Rechute
Seuil Clinique TEP ? Bio Mol ?
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Auto-SCT EBMT standard indications

• Allogeneic Autologous
• Sibling well-matched mm unrelated
• Disease Disease status donor unrelated
  gt1 ag mm related __________
• Diffuse large B-cell lymphoma CR1
  (intermediate/high IPI at dx) GNR/III GNR/III
  GNR/III CO/I
• Chemosensitive relapse CR2 CO/II CO/II
  GNR/III S/I
• Refractory D/II D/II
  GNR/III GNR/II
• Mantle cell lymphoma CR1 D/III D/III GNR/III
  S/II
• Chemosensitive relapse CR2
  D/II D/II GNR/III S/II
• Refractory D/II D/II GNR/III GNR/II
• Lymphoblastic lymphoma CR1
  CO/II CO/II GNR/III CO/II
• and Burkitts lymphoma Chemosensitive relapse
  CR2 CO/II CO/II GNR/III CO/II
• Refractory D/III D/III GNR/III GNR/II
• Follicular B-cell NHL CR1 (intermediate/high IPI
  at dx) GNR/III GNR/III GNR/III CO/I
• Chemosensitive relapse CR2
  CO/II CO/II D/III S/I
• Refractory CO/II CO/II D/II GNR/II
• T-cell NHL CR1 D/II D/II
  GNR/III D/II
• Chemosensitive relapse CR2 CO/II CO/II
  GNR/III D/II
• Refractory D/II D/II
  GNR/III GNR/II

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Caractéristiques des greffons
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Lancet 1996 347 353-57
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27 G-CSF (10 µg/Kg/day) x 6 days
Harvest (Day 5-7)
C H E M O T H E R A P Y
Reinfusion G-CSF
58 Pts
Hodgkins or High grade NHL
5 µg/Kg/day
31 Bone Marrow
Schmitz et al. Lancet 1996 347 353-57
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Results
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Marrow vs. PBSCT
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Déroulement
1- Chimiothérapies initiales 2- Mobilisation et
collecte CSP 3- Conditionnement (Effet
dose-intensité (BEAM, Mel200)) 4 - Greffe
Transfusion des CSP 5 - Reconstitution
hématologique Aplasie 10 à 15 jours
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PBSC Mobilization Regimens

• G-CSF only
• G-CSF chemotherapy
• G-CSF side effects
• Headache 75
• Bone pain 63
• Swelling 13- 20

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How do we mobilize stem cells ?
G-CSF
CD-34
Growth factor only
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Growth factor post chemo (Cy G-CSF)
G-CSF
CY
CD-34
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5
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10
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Chemo Growth factor
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G-CSF Stimulation How does it work ?
G-CSF
Stem Cells
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G-CSF Stimulation One Theory
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CD34 Cell
VLA-4
VCAM
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Elastase
CD34 Cell
G-CSF stimulates production of Neutrophils
Neutrophils Release Elastase
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Elastase
CD34 Cell
Elastase Digests VCAM molecule
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CD34 Cell
CD-34 Cells break free and circulate in PB
VLA-4
VCAM
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What is CD 34?

• 105-120 kDa transmembrane Glycoprotein

• Present in early hematopoietic cell precursors
• Present in 0.1 of peripheral mononuclear
  cells
• 1-4 human bone marrow cells

Probably an adhesion molecule.
From www. beckmancoulter.com
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When to collect ?
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Journal of Hematotherapy 745-52 (1998)
Mary Ann Liepert, Inc.
Evaluation of Mobilized CD-34 Cell Counts to
Guide Timing And Yield of Large-Scale Collection
by Leukopheresis
LENE MELDGAARD KNUDSEN, EVA GAARSDAL, LINDA
JENSEN KRISTEN NIKOLAISEN and HANS JOHNSEN

• G-CSF (10µg/kg/day)
• G-CSF HDCY (chemo)
• G-CSF CEF (chemo)
• G-CSF other chemo
• 3 None
• 3 No data

130 patients
PBSC (10 L) began when PB CD-34 Cells ? 20 x103
/ml
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CD34 cells Peripheral counts vs product
collected
CD34 x 106/Kg
R0.87
CD34 x 103/ml blood
CD34 x 103/ml blood
CD34 Cells in Peripheral Blood and Product
collected on Day 1
CD34 Cells in Peripheral Blood on day before and
Product collected on Day 1
From Meldgard et al,Journal of Hematotherapy
745-52 (1998)
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Correlation between WBC count and CD34 cells
harvested on day 1
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How many CD 34 cells to collect and for what ?
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What is your preferred (target) number of CD34
cells (x106/kg) for a single auto-SCT at your
center?
NHL
Myeloma
PREDICT Investigators Meeting Amsterdam, 13
November 2008
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CD34 Cells

• Number of cells correlates with engraftment
• Number or cells correlates with speed of
  engraftment
• 2 x 106 / Kg (ideal body weight) is considered
  sufficient
• 4 to 5 x 106 / Kg ( more acceptable dose for
  engraftment)
• gt5 x 106 / Kg ( gives more rapid engraftment
  and lower incidence of graft failure
• Further increases, decrease the time to platelet
  engraftment

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How often are these numbers harvested ?
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High variability in published lymphoma
mobilisation failure rates (11-53)
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Variations in defining mobilisation failure

• Significant variation both in definition of
  mobilization failure and mobilization practice
  lead to large variations in reported failure
  rates
• Patients with a peripheral blood (PB) CD34 count
  below 10 cells/µl usually do not go to apheresis
  and are often not counted as failures
• Successful mobilisation may include patients
  transplanted with pooled cells from prior
  mobilizations
• Target cell numbers may be defined differently
  (e.g. optimal numbers vs. minimal, as well as
  numerical differences)

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Differences in clinical practice affect failure
rates

• G-CSF doses and schedules
• Doses and regimens of chemotherapy during
  chemo-mobilisation
• Blood volumes processed
• Maximal numbers of apheresis sessions allowed
• Extent of disease at time of mobilisation
• Hematology parameters used as surrogate markers
  to initiate apheresis (e.g. some centres use
  CD34 cell count, some use WBC)

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Number of mobilization attempts by histological
categories
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Number of mobilization attempts by age (n3972)
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Who will be poor or will fail mobilization?

• Pre-treatment
• Age
• Radiotherapy/Mel/ Nitrosureas, Fludarabine
  lenalidomide
• anti-CD20?
• Marrow involvement
• Disease
• Many issues unknown

Failed Mobilizers
Predicted Poor Mobilizers
Slow Mobilizers
Frontline with G-CSF Alone
Frontline with G-CSF Chemotherapy or Replace
Chemo
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Solutions for poor mobilisers?
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• Endoxan G-CSF
• G-CSF SCF
• Bone Marrow harvest
• G-CSF Plerixafor

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Plerixafor Mozobil AMD3100

• First in class hematopoietic stem cell
  mobilisation agent
• Unlike G-CSF, Mozobil is not a growth factor
• Reversibly binds the CXCR4 receptor and blocks
  SDF-1 interaction

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Fig 1. Study treatment
DiPersio, J. F. et al. J Clin Oncol 274767-4773
2009
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Fig 3. (A) Kaplan-Meier estimate of proportion of
patients reaching gt 5 x 106 CD34 cells/kg
DiPersio, J. F. et al. J Clin Oncol 274767-4773
2009
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Plerixafor as part of an ideal stem cell
mobilization regimen
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Collecte de CSP par cytaphérèses

• Thrombopénies
• Hypocalcémies / Hypomagnésémies
• Hypotensions (très rares)
• Allergies
• Problèmes mécaniques de CEC
• Incidents de voie dabord
• Hématomes
• Importance de laccès veineux

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Manipulation du greffon

• 1) Congélation obligatoire (DMSO 10)
• Protègent les membranes et évite la
  cristallisation
• Ralentissent les échanges deau
• Réduisent la concentration intracellulaire des
  électrolytes
• 2) Stockage en cuve azote surveillée
• 3) Décongélation du greffon
• Lavage du DMSO (sinon troubles rythme cardiaque,
  malaises,céphalées, épilepsie, HTA,
  nausées-vomissements)
• Prémédication lors de la réinfusion / surveillance

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Concluding remarks

• G-CSF /- Chimio most often efficient.
• Close monitoring of circulating CD34 cells
  allows for precise time to harvest.
• 2x10e6 CD 34 cells/kg injected is enough to
  achieve a good engraftment.
• Poor mobilisation cannot be completely predicted
• Use of Perixafor with G-CSF either systematically
  after a 1st failure or upon low PB CD 34 cells
  count on scheduled apheresis day may overcome
  poor mobilisation in 60 of the cases

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Thank you