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Four Days Tbo-Filgrastim Mobilization for Autologous Transplantation Demonstrates Similar CD34+ Yields and Less Use of Plerixafor
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Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Figure 1. NHL Disease status documentation screen.
lack of compliance, but even given this problem, internal audits results are much improved with fewer errors noted in these areas and an overall error rate <3%. Our plans for next-step programming will move to documentation of current disease status for the post-transplant period. This will help us better capture transplant outcomes and any relapses or progressions.
463 Four Days Tbo-Filgrastim Mobilization for Autologous Transplantation Demonstrates Similar CD34+ Yields and Less Use of Plerixafor Lisa Cantwell 1, Shahbaz Malik 2, Rose Duran 1, Keri Collins 1, Betsy Blunk 3, Aravind Ramakrishnan 2, Paul J. Shaughnessy 4. 1 Sarah Cannon Center for Blood Cancer and Oncology at St. David’s South Austin Medical, Austin, TX; 2 Blood and MarrowTransplant, Texas Transplant Institute at St. David’s South Austin Medical Center, Austin, TX; 3 Blood Cancer Network, Sarah Cannon, Denver, CO; 4 Adult Blood and Marrow Transplant, Texas Transplant Institute, San Antonio, TX Background: Standard protocol for autologous mobilization uses 5 days of colony stimulating factor followed by hematopoietic stem cell (HST) collection using various apheresis collection devices. This retrospective study evaluated whether Tbo-filgrastim mobilization over 4 days versus 5 days would yield adequate CD34+ cell counts and less use of Plerixafor. Methods: A retrospective analysis was performed on 86 patients who received Tbo-filgrastim mobilization and collection using the Spectra Optia®-mononuclear cell (MNC) collection process. Cohort A consisted of 36 consecutive patients (1/2016 – 8/2016) who were planned to receive 4 days of Tbofilgrastim followed by collection. Cohort B consisted of 50 consecutive patients (1/2015 – 12/2015) who were planned to receive 5 days of Tbo-filgrastim followed by collection. Pe-
ripheral blood (PB) CD34+ counts were checked on day 4 in both cohorts. Results: Day 4 PB CD34 counts were similar in both cohort A and B (17.0 and 17.4 cells/μl respectively). On Day 1 of collection, cohorts A and B had similar median WBC counts (44.2 and 44.5 μL respectively), and CD34+ product yields (4.9 X 106/kg and 4 X 106/kg respectively). Patients in Cohort A compared to Cohort B were able collect an adequate product CD34+ cell dose in 1 day 72% versus 36% (P = .002) of the time respectively. In turn, 42% of patients in Cohort A required Plerixafor while Cohort B required Plerixafor 58% of the time.
Table 1 Mobilization data Cohort A (n = 36) 1 total days of collection 2 total days of collection Received 5 Days Tbo-filgrastim (day 4) Received 6 Days Tbo-filgrastim (day 4 and day 5) Received Plerixafor Peripheral CD34 (cells/ul) Day 4 (Median) WBC Day 1 of collection (Median) PLT Day 1 of collection (Median) Peripheral CD34 (cells/ul) Day 1 of collection (Median) Liters Processed Day 1 of collection (Median) Product CD34 (10^6 cells/kg) Day 1 of collection (Median)
Cohort B (n = 50)
72% (26) 28% (10) 34% (11)
36% (18) 64% (32) 64% (32)
6% (2)
34% (17)
42% (15) 17.0 (1.2-95.8)
58% (29) 17.4 (.4-77.3)
44.2 (17.3-93.7)
44.5 (8-113.8)
153.5 (54-341)
191 (11-384)
62 (7.1-254.7)
44.5 (8.7-122.9)
15 (9.7-22)
15.7 (11.9-22.8)
4.9 (.8-22.4)
4 (1.0-9.3)
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Additionally, the numbers of liters processed was comparable in each cohort. Interestingly, platelet counts in Cohort A (153.5) showed a statistically significant difference (P = .925) from Cohort B platelet counts (191). Discussion: While the sample size is small, there was statistical significance in both the number of days to collect and the pre-collection platelet counts. This analysis demonstrates effective mobilization using 4 days of Tbo-filgrastim as it relates to CD34+ product yields, less use of Plerixafor and fewer days of collection. Future analysis will include additional factors such as age, disease mix, prior treatment, mobilization regimen, and financial impacts. (Table 1)
464 Influence of Donor Variables on CD34 Stem Cell Collection Yield Comparing Peripheral Blood Progenitor Cell and Bone Marrow Collection at a Single Institution Jordan Carter 1, Pooja Lothe 2, Meghan Stokley 3, Nick Onymeke 2, Edward Gracely 4, John McCormick 5, Maneesh Jain 2, Kristine Ward 2, David Topolsky 2, Pamela A. Crilley 2, Michael J. Styler 2. 1 Internal Medicine, Drexel University College of Medicine, Philadelphia, PA; 2 Hematology / Oncology, Drexel University College of Medicine, Philadelphia, PA; 3 Hematology / Oncology, Hahnemann University Hospital, Philadelphia, PA; 4 Family, Community, and Preventive Medicine, Drexel University College of Medicine, Philadephia, PA; 5 Drexel University College of Medicine, Philadelphia, PA Background: Studies have looked at donor characteristics and their effects on CD34 stem cell yields by peripheral apheresis or bone marrow (BM) harvesting with varying results. Recent studies have found a negative association between older age, female gender, lower BMI, and tobacco use on CD34 count in apheresis donors (Teipel, Transfusion2015; Bertani, Transfusion 2014). There have been variable results among studies looking at BM collection regarding tobacco use, BMI, gender, and older age (Anthias, Transfusion 2016). Additionally, few studies have compared both methods together or at a single center, with previous literature suggesting variability between centers may have impacted prior BM results. Our study compares donor variables between apheresis and BM collection at a single center. Methods: Retrospective analysis of donors over 18 years old who underwent BM or apheresis between 2010-2016 at Hahnemann University Hospital for allogeneic transplantation were included in the study. Donor characteristics including CD34 yield, collection volume, gender, smoking status, alcohol use, and weight were recorded. Results were analyzed using multivariate linear regression analysis. An uncorrected chi-square test was used to determine any differences in variable distribution between the groups. Results:177 donors were included in the apheresis cohort, 123 males and 47 females. In the BM cohort, there were 46 donors, 28 males and 18 females. Multivariate linear regression analysis of the apheresis cohort demonstrated a negative correlation with age (P = .023), female gender (P = .017), smoking (P = .255), and a positive correlation with alcohol use (P = .089) and weight (P = .016). In the BM cohort, multivariate linear regression analysis demonstrated a negative correlation with age (P = .052) and smoking (P = .593), while a positive correlation was seen with female gender (P = .001), weight (P = .007), and alcohol (P = .591). There was no difference in distribution of variables between the two groups
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in terms of gender (P = .15), smoking status (P = .22), alcohol use (P = .94), or age (P = .82). Conclusion: Female gender correlated with a statistically significant decrease in the CD34 yield in apheresis donors, but the opposite trend was noted in BM donors. While these findings agree with prior studies of apheresis donors, a positive correlation has not been previously reported in female BM donors. Results for weight in both cohorts and older age in the apheresis group were statistically significant and agreed with prior studies. Smoking showed no statistical correlation in either group in contrast to past research. While not significant, social alcohol use correlated with a higher CD34 count in both groups. Despite being a known cause of myelosuppression, this was not the case among the donors in our study, possibly due a lack of chronic alcohol use history.
465 Preemptive Ordering of Tacrolimus in Adult Stem Cell Transplant (SCT) Patients to Streamline Discharge Richard Creger 1,2, Bernadette McQuigg 3, Brooke Nutter 3, Christina Reeber 3, Brenda Cooper 1,2, Paolo Caimi 1,2. 1 Division of Hematology & Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; 2 Case Western Reserve University, Cleveland, OH; 3 Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH Monitoring and maintenance of tacrolimus concentrations are essential for the management of allogeneic stem cell transplant (SCT) patients. Tacrolimus dosages frequently change prior to discharge. Insurance coverage and prior authorization may also change prior to dispensing. Changes in prescription coverage can result in extended length of stay (LOS) and decreased patient satisfaction. A multidisciplinary, three-staged approach was implemented to streamline tacrolimus discharge prescription ordering, improve patient satisfaction and reduce LOS. The first stage occurs at the initial transplant workup. The insurance company is contacted for authorization information and prescription coverage for both tacrolimus .5 and 1 mg capsules. The second stage occurs 10 days prior to the expected discharge. At this point, a prescription is submitted to the patient’s designated pharmacy. 24 – 48 hours after submission, the pharmacy is contacted to check availability of tacrolumus. If problems occur related to prior authorization, they are readdressed. Patients are given prescriptions for both .5 and 1 mg tacrolimus capsules providing flexibility in dosing to the discharging team. The last stage occurs at discharge, the patient’s family provides the tacrolimus for visual confirmation. Patients are also given a patient information (PI) sheet that describes the importance of tacrolimus, blood level monitoring and clear instructions on timing and required dosing. As the patient’s dose changes in the ambulatory setting, the PI sheet is updated and provided to the patient. This process has resulted in significant decreases in discharge delays. This system was implemented in 2015. Prior to its implementation, on average 2 – 4 patients per month experienced a delay in discharge secondary to tacrolimus prescription approval, extending LOS 2-4 days every month. After 18 months of using this approach, no delays secondary to prescription coverage have occurred, it has simplified dosing changes in the outpatient setting, has increased efficiency and improved patient satisfaction.
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Figure 1. NHL Disease status documentation screen.
lack of compliance, but even given this problem, internal audits results are much improved with fewer errors noted in these areas and an overall error rate <3%. Our plans for next-step programming will move to documentation of current disease status for the post-transplant period. This will help us better capture transplant outcomes and any relapses or progressions.
463 Four Days Tbo-Filgrastim Mobilization for Autologous Transplantation Demonstrates Similar CD34+ Yields and Less Use of Plerixafor Lisa Cantwell 1, Shahbaz Malik 2, Rose Duran 1, Keri Collins 1, Betsy Blunk 3, Aravind Ramakrishnan 2, Paul J. Shaughnessy 4. 1 Sarah Cannon Center for Blood Cancer and Oncology at St. David’s South Austin Medical, Austin, TX; 2 Blood and MarrowTransplant, Texas Transplant Institute at St. David’s South Austin Medical Center, Austin, TX; 3 Blood Cancer Network, Sarah Cannon, Denver, CO; 4 Adult Blood and Marrow Transplant, Texas Transplant Institute, San Antonio, TX Background: Standard protocol for autologous mobilization uses 5 days of colony stimulating factor followed by hematopoietic stem cell (HST) collection using various apheresis collection devices. This retrospective study evaluated whether Tbo-filgrastim mobilization over 4 days versus 5 days would yield adequate CD34+ cell counts and less use of Plerixafor. Methods: A retrospective analysis was performed on 86 patients who received Tbo-filgrastim mobilization and collection using the Spectra Optia®-mononuclear cell (MNC) collection process. Cohort A consisted of 36 consecutive patients (1/2016 – 8/2016) who were planned to receive 4 days of Tbofilgrastim followed by collection. Cohort B consisted of 50 consecutive patients (1/2015 – 12/2015) who were planned to receive 5 days of Tbo-filgrastim followed by collection. Pe-
ripheral blood (PB) CD34+ counts were checked on day 4 in both cohorts. Results: Day 4 PB CD34 counts were similar in both cohort A and B (17.0 and 17.4 cells/μl respectively). On Day 1 of collection, cohorts A and B had similar median WBC counts (44.2 and 44.5 μL respectively), and CD34+ product yields (4.9 X 106/kg and 4 X 106/kg respectively). Patients in Cohort A compared to Cohort B were able collect an adequate product CD34+ cell dose in 1 day 72% versus 36% (P = .002) of the time respectively. In turn, 42% of patients in Cohort A required Plerixafor while Cohort B required Plerixafor 58% of the time.
Table 1 Mobilization data Cohort A (n = 36) 1 total days of collection 2 total days of collection Received 5 Days Tbo-filgrastim (day 4) Received 6 Days Tbo-filgrastim (day 4 and day 5) Received Plerixafor Peripheral CD34 (cells/ul) Day 4 (Median) WBC Day 1 of collection (Median) PLT Day 1 of collection (Median) Peripheral CD34 (cells/ul) Day 1 of collection (Median) Liters Processed Day 1 of collection (Median) Product CD34 (10^6 cells/kg) Day 1 of collection (Median)
Cohort B (n = 50)
72% (26) 28% (10) 34% (11)
36% (18) 64% (32) 64% (32)
6% (2)
34% (17)
42% (15) 17.0 (1.2-95.8)
58% (29) 17.4 (.4-77.3)
44.2 (17.3-93.7)
44.5 (8-113.8)
153.5 (54-341)
191 (11-384)
62 (7.1-254.7)
44.5 (8.7-122.9)
15 (9.7-22)
15.7 (11.9-22.8)
4.9 (.8-22.4)
4 (1.0-9.3)
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
Additionally, the numbers of liters processed was comparable in each cohort. Interestingly, platelet counts in Cohort A (153.5) showed a statistically significant difference (P = .925) from Cohort B platelet counts (191). Discussion: While the sample size is small, there was statistical significance in both the number of days to collect and the pre-collection platelet counts. This analysis demonstrates effective mobilization using 4 days of Tbo-filgrastim as it relates to CD34+ product yields, less use of Plerixafor and fewer days of collection. Future analysis will include additional factors such as age, disease mix, prior treatment, mobilization regimen, and financial impacts. (Table 1)
464 Influence of Donor Variables on CD34 Stem Cell Collection Yield Comparing Peripheral Blood Progenitor Cell and Bone Marrow Collection at a Single Institution Jordan Carter 1, Pooja Lothe 2, Meghan Stokley 3, Nick Onymeke 2, Edward Gracely 4, John McCormick 5, Maneesh Jain 2, Kristine Ward 2, David Topolsky 2, Pamela A. Crilley 2, Michael J. Styler 2. 1 Internal Medicine, Drexel University College of Medicine, Philadelphia, PA; 2 Hematology / Oncology, Drexel University College of Medicine, Philadelphia, PA; 3 Hematology / Oncology, Hahnemann University Hospital, Philadelphia, PA; 4 Family, Community, and Preventive Medicine, Drexel University College of Medicine, Philadephia, PA; 5 Drexel University College of Medicine, Philadelphia, PA Background: Studies have looked at donor characteristics and their effects on CD34 stem cell yields by peripheral apheresis or bone marrow (BM) harvesting with varying results. Recent studies have found a negative association between older age, female gender, lower BMI, and tobacco use on CD34 count in apheresis donors (Teipel, Transfusion2015; Bertani, Transfusion 2014). There have been variable results among studies looking at BM collection regarding tobacco use, BMI, gender, and older age (Anthias, Transfusion 2016). Additionally, few studies have compared both methods together or at a single center, with previous literature suggesting variability between centers may have impacted prior BM results. Our study compares donor variables between apheresis and BM collection at a single center. Methods: Retrospective analysis of donors over 18 years old who underwent BM or apheresis between 2010-2016 at Hahnemann University Hospital for allogeneic transplantation were included in the study. Donor characteristics including CD34 yield, collection volume, gender, smoking status, alcohol use, and weight were recorded. Results were analyzed using multivariate linear regression analysis. An uncorrected chi-square test was used to determine any differences in variable distribution between the groups. Results:177 donors were included in the apheresis cohort, 123 males and 47 females. In the BM cohort, there were 46 donors, 28 males and 18 females. Multivariate linear regression analysis of the apheresis cohort demonstrated a negative correlation with age (P = .023), female gender (P = .017), smoking (P = .255), and a positive correlation with alcohol use (P = .089) and weight (P = .016). In the BM cohort, multivariate linear regression analysis demonstrated a negative correlation with age (P = .052) and smoking (P = .593), while a positive correlation was seen with female gender (P = .001), weight (P = .007), and alcohol (P = .591). There was no difference in distribution of variables between the two groups
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in terms of gender (P = .15), smoking status (P = .22), alcohol use (P = .94), or age (P = .82). Conclusion: Female gender correlated with a statistically significant decrease in the CD34 yield in apheresis donors, but the opposite trend was noted in BM donors. While these findings agree with prior studies of apheresis donors, a positive correlation has not been previously reported in female BM donors. Results for weight in both cohorts and older age in the apheresis group were statistically significant and agreed with prior studies. Smoking showed no statistical correlation in either group in contrast to past research. While not significant, social alcohol use correlated with a higher CD34 count in both groups. Despite being a known cause of myelosuppression, this was not the case among the donors in our study, possibly due a lack of chronic alcohol use history.
465 Preemptive Ordering of Tacrolimus in Adult Stem Cell Transplant (SCT) Patients to Streamline Discharge Richard Creger 1,2, Bernadette McQuigg 3, Brooke Nutter 3, Christina Reeber 3, Brenda Cooper 1,2, Paolo Caimi 1,2. 1 Division of Hematology & Oncology, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; 2 Case Western Reserve University, Cleveland, OH; 3 Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH Monitoring and maintenance of tacrolimus concentrations are essential for the management of allogeneic stem cell transplant (SCT) patients. Tacrolimus dosages frequently change prior to discharge. Insurance coverage and prior authorization may also change prior to dispensing. Changes in prescription coverage can result in extended length of stay (LOS) and decreased patient satisfaction. A multidisciplinary, three-staged approach was implemented to streamline tacrolimus discharge prescription ordering, improve patient satisfaction and reduce LOS. The first stage occurs at the initial transplant workup. The insurance company is contacted for authorization information and prescription coverage for both tacrolimus .5 and 1 mg capsules. The second stage occurs 10 days prior to the expected discharge. At this point, a prescription is submitted to the patient’s designated pharmacy. 24 – 48 hours after submission, the pharmacy is contacted to check availability of tacrolumus. If problems occur related to prior authorization, they are readdressed. Patients are given prescriptions for both .5 and 1 mg tacrolimus capsules providing flexibility in dosing to the discharging team. The last stage occurs at discharge, the patient’s family provides the tacrolimus for visual confirmation. Patients are also given a patient information (PI) sheet that describes the importance of tacrolimus, blood level monitoring and clear instructions on timing and required dosing. As the patient’s dose changes in the ambulatory setting, the PI sheet is updated and provided to the patient. This process has resulted in significant decreases in discharge delays. This system was implemented in 2015. Prior to its implementation, on average 2 – 4 patients per month experienced a delay in discharge secondary to tacrolimus prescription approval, extending LOS 2-4 days every month. After 18 months of using this approach, no delays secondary to prescription coverage have occurred, it has simplified dosing changes in the outpatient setting, has increased efficiency and improved patient satisfaction.