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Hemopoietic stem-cell harvesting and transplantation using G-CSF-primed BM: comparison with unprimed BM and G-CSF-primed PBSC
Cytotherapy (1999) Vol. 1, No. 5, 409–416
Hemopoietic stem-cell harvesting and transplantation using G-CSF-primed BM: comparison with unprimed BM and G-CSF-primed PBSC RM Lowenthal1, D Tuck1, E Tegg1, KA Marsden1, B Rees1, J Luck1, S Ragg1, N Parker1,2 and N Kotlovsky1 1
Clinical Haematology & Medical Oncology Unit, Royal Hobart Hospital, Hobart, Tasmania, Australia
2
Present address: Sullivan, Nicolaides & Partners, Immunology Dept, Brisbane, Queensland, Australia
Background
Consequently, larger numbers of cells were available for admin-
PBSC collected following G-CSF priming lead to more rapid
istration following transplantation with G-CSF-primed BM.
hemopoietic reconstitution (HR) after autologous transplantation
The results of HR after transplantation with G-CSF primed
than do unprimed BMstem cells. However, PBSC have a number
BM were intermediate between those of unprimed BM and
of disadvantages compared with BM cells, including the need for
PBSC. For example, platelet independence (unsupported platelet
an extended collection period and requirement for good venous
count 20 109/L) occurred after 22 days with unprimed
access.
BM, 14 days with G-CSF-printed BM and 10 days with PBSC (p for trend < 0.0001) and the mean number of days when
Methods
platelet transfusions were given was 10, 6 and 3 respectively
We retrospectively analysed our experience with an alternative
(p for trend < 0.005). These results reflected transplant cell
source of hemopoietic stem cells, G-CSF primed BM. Fortyfour
doses.
patients who underwent BM harvesting after 6 days’ administration of G-CSF, at a dose of 5 g/kg per day, were compared
Conclusion
with an equal number who underwent standard (unprimed) BM
G-CSF-primed BM is a valuable source of hemopoietic stem cells
harvesting. We also analysed HR after autologous transplantation
for autologous transplantation and a useful alternative to PBSC to
in 16 patients who received unprimed BM, 18 who received
certain circumstances.
G-CSF-primed BM and 14 who received PBSC. Keywords Results
stem cells, bone marrow transplantation, peripheral blood stem
G-CSF-primed BM was collected more quickly (p<0.00005) and
cells, G-CSF
yielded a larger number of cells (p<0.0001) than unprimed BM.
Introduction
recent years peripheral blood (PB) has become the preferred source, because studies have shown more favorable dynamics
Autologous hemopoietic stem-cell transplantation is now a
of hemopoietic reconstitution (HR) after transplantation.
commonplace medical procedure for treatment of a variety
With PBSC transplantation, neutrophils and platelets
of malignant and non-malignant haematological disorders
recover more quickly, and there is a shorter period of
and for intensification of treatment for certain solid tumors.
hospital stay, thus making use of PBS; safer and cheaper than
Stem cells originally were obtained from the BM, but in
using BM-derived stew cells [1,2].
Correspondence to: Professor Ray Lowenthal, Haematology/Oncology Unit, Royal Hobart Hospital, GPO Box 1061L Hobart, Tasmania, Australia, 7001 ß 1999 ISHAGE
409
410
RM Lowenthal et al.
However, the studies which have shown advantages for
harvesting during an overlapping time period. For this
PBSC over BM stem cells have actually compared growth-
comparison, 44 consecutive patients who had undergone
factor-primed PBSC with unprimed BM. (The growth
unprimed BM harvesting were chosen retrospectively from
factor most commonly used has been G-CSF.) An inter-
June 1997 to June 1992, except that patients with AML and
mediate potential source of stem cells has been less well-
CML were excluded, since none underwent G-CSF-primed
studied, namely growth-factor-primed BM. Despite its
harvesting, due to concerns about possible stimulation of
advantages, there are also disadvantages of PB compared
leukemic stem cells by G-CSF [5,6]. We then compared the
with BM: generally speaking PBSC collections take several
outcomes in those patients who subsequently underwent
days, whereas BM harvesting is a single procedure; the
autologous transplantation, by analysis of HR. By 31
collection process can be uncomfortable; there are difficul-
October, 1998 (close-out date), 16 of the 44 donors of
ties in collecting PBSC from young children or patients with
unprimed BM and 18 of the 44 donors of G-CSF-primed
poor venous access; and PBSC harvests occupy more room
BM had been transplanted. In a three-way comparison, we
in liquid nitrogen containers, where space is often at a
also compared the outcomes in these two groups of patients
premium.
with a contemporaneous group of 14 consecutive patients
Primed PBSC originate in the BM and in mice G-CSF
who were transplanted with autologous PBSC. (Of these,
printing greatly enhances the engraftment potential of BM
three had PBSC collected after priming with cyclopho-
stem cells [3], therefore we have explored the use of G-CSF-
sphamide only, four after the combination of cyclopho-
primed BM as a source of hemopoietic stem cells for
sphamide and G-CSF, and seven after G-CSF only.)
transplantation in humans. We introduced it as a method
Patients with myeloid leukernias were also excluded from
of overcoming the problem of inadequate stem-cell col-
the transplant analysis. All transplant recipients received
lection by standard methodology in patients who had
G-CSF 5 mg/kg per day subcutaneously from the day
undergone extensive prior therapy, and when this proved
of stem-cell reinfusion until recovery of neutrophils to
to be successful, we gradually extended its use to other
5 109/L.
patients.
This was a retrospective, uncontrolled analysis. The
We present a retrospective analysis of our experience
following data were collected: demographics (age, sex,
with G-CSF-primed BM harvesting and transplantation,
patient weight, diagnosis), harvest details [total WBC and
and compare it with our experience with unprimed BM
neutrophil counts immediately prior to harvest, procedure
harvesting and transplantation and with PBSC transplanta-
length in hours and minutes, number of cells collected
tion, in terms of numbers of cells collected and HR after
calculated per kg patient body weight, including total
transplantation.
nucleated cells (TNC), CFU-GM (colony-forming units granulocyte-macrophage) and CD34-positive cells] and rate
Patients and Methods
of HR following transplantation (see below). During the
We first carried out G-CSF-primed BM harvesting in June,
period of this study we changed our CFU-GM assay method
1994, on a patient with relapsed non-Hodgkin’s lymphoma
from using traditional soft agar [7] to methylcellulose with
(NHL), who had received extensive prior chemotherapy and
recombinant cytokines [8] (Methocult GFþ H4535, Stem-
in whom two previous attempts at stem-cell harvesting by
Cell Technologies Inc, Vancouver BC, Canada). Internal
standard methods (unprimed BM harvesting and G-CSF-
laboratory quality assurance demonstrated that the com-
primed PBSC harvesting) had yielded insufficient stem cells
mercial methylcellulose-based media gave a 10-fold greater
for safe transplantation. The patient subsequently went on to
plating efficiency than our original in-house soft agar
have a successful autologous transplant using the G-CSF-
method, so for comparison we have multiplied results of
primed BM [4]. By June 1997 we had performed 44 such
agar CFU-GM assays by 10 and ‘normalized’ results to the
harvests and at this time we adopted G-CSF-primed BM as
methylcellulose standard. CD34-positive cells were deter-
our standard source of blood stem cells. During the harvest,
mined by standard ISHAGE methodology [9]. Although
we aimed to collect 15 mL BM/kg body weight, or 1 L from
some laboratories have ceased using the CFU-GM assay for
an average-sized adult. Results of harvesting (that is, cell
validation of stem-cell collections, preferring CD34 assess-
yields) in the 44 patients were compared with those of a
ment, such assays are still recommended for assessment of
group of patients who underwent standard (unprimed) BM
adequacy of stem-cell collections [10] and were available for
G-CSF-primed bone marrow
411
all our patients, as were TNC counts. In contrast, the CD34
G.-CSF priming, the differences did not reach statistical
assay was introduced during the course of the present study
significance.
and was not available for all patients. We established a CFU-GM dose of 1 105/kg transplantation; all patients who were transplanted were
Transplantation: three-way comparison between unprimed BM, G-CSF-primed BM and G-CSF-primed PBSC
given at least this dose. HR was assessed by the number of
Table 2 shows the characteristics of the patients who
days following transplantation to reach a WBC count of 1.0,
underwent stem-cell transplantation. Only a minority of
a granulocyte count of 0.5 or a platelet count (unsupported)
those from whom stem cells were harvested and stored had
(methylcellulose standard) as the minimum acceptable for
9
of 20 or 50 10 /L, using the log-rank (Kaplan-Meier)
proceeded to transplantation by the cut-off date (16 of 44
method. We recorded the number of days in hospital, the
following unprimed and 18 of 44 following G-CSF-primed
number of days on which platelet transfusions were given
BM harvesting), because of our policy of cryopreserving cells
and the total number of RBC transfusions given, from Day
from patients at risk of relapse, as a form of ‘insurance’. As
0 (day of transplant) to Day 30. Our platelet transfusion
can be seen, the three transplanted groups were reasonably
policy was constant throughout the period of the study,
comparable in terms of ages and diagnoses. The most
namely, that patients were transfused routinely if the
common diagnosis was NHL (11, 11 and five patients in the
count was < 10 109/L, or if the count was < 20 109/L
unprimed BM transplant, G-CSF-primed BM transplant
and they were febrile (temperature 38.0 C), or at
and PBSC transplant groups respectively). The transplant
any level if they were bleeding and the bleeding was
cell dose was larger (by TNC and CFU-GM) for PBSC,
judged to be due to platelet deficiency or dysfunction.
compared with both of the other groups, and for the
Statistical
G-CSF-primed group compared with the unprimed group
calculations
were performed
using
Prism
(GraphPad Software, San Diego, California). Log-rank
(Table 2), reflecting the number of cells collected.
tests were used to compare time-dependent variables
Our criteria for carrying out G-CSF-primed BM
(namely, number of days for recovery of white cells,
harvesting changed during the course of this study (initially
neutrophils and platelets after transplantation). Patients
being restricted to patients from whom we anticipated poor
who died were censored on date of death. For all other
yields because of extensive prior chemotherapy, with criteria
analyses, the Mann–Whitney U test was used for two-group
being relaxed in later patients) we therefore compared the
comparisons and the Kruskall–Wallis test for comparisons
results of the first 22 and second 22 patients. There were no
among three groups.
statistically significant differences in patient demographics, cell yield or pre-transplant BM cellularity[11] between the
Results
two subgroups and no difference in the rate of HR following
Stem-cell harvesting: comparison between unprimed and G-CSF-primed BM
transplantation. However, survival following transplantation
Table 1 shows the characteristics of the two groups of 44
who were transplanted, compared with those of the second
patients and it can be seen that although this was not a
half ( p<0.05) (data not shown).
was poorer in those patients from the first half of the series
randomized comparison, they were comparable in terms of
Details of HR are given in Table 3 and Figures 1 and 2.
diagnoses and other demographics. The most common
It can be seen that there was no difference in the rate
single diagnosis was NHL (24 and 26 patients in the
of recovery of neutrophils to 0.5 109/L (Table 3 and
unprimed and G-CSF-primed groups, respectively). As
Figure 1), but that there was a significant difference between
would be expected, 6 days of G-CSF administration led to
the three groups in the rate of platelet recovery (Table 3 and
a highly significant increase in the total WBC and neutrophil
Figure 2). Platelet recovery to 20 109/L was more
counts on the day of harvesting ( p¼1016). Unexpectedly,
rapid after transplantation with G-CSF-primed than with
BM after G-CSF administration proved to be much easier to
unprimed BM (14 versus 22 days) and was even more
aspirate, leading to a saving of almost half an hour in harvest
rapid after PBSC transplantation (10 days; p for trend,
time ( p<0.00005). Significantly larger numbers of TNC
0.0001). Although none of the individual direct comparisons
were collected after G-CSF priming ( p<0.0001). Although
of HR after transplantation between unprimed and G-CSF-
more CFU-GM and CD34-positive cells were obtained after
primed BM yielded statistically significant differences, in
412
RM Lowenthal et al.
Table 1. Characteristics of patients undergoing BM harvesting and results of harvesting1 Stem-cell source n Age M:F Diagnoses LPD2 Solid tumors WBC3 109/L Neutrophil count3 l09/L Harvest time h:min TNC/kg 108 CD34/kg 106 CFU/kg 105
Unprimed BM
G-CSF-primed BM
44 43.5 (17–62) 22:22
44 48 (19–65) 17:27
35 9 5.25 (3–10.1) 3.5 (1.4–7.9) 1:35 (0:50–2:45) 1.15 (0.31–2.97) 0.32 (0.03–0.61) 3.6 (0.7–9.7)
32 12 26.1 (5.5–73.6) 21.7 (3.1–60.1) 1:08 (0:35–2:35) 3.1 (0.04–11.3) 0.79 (0.22–2.41) 5.2 (0–20.6)
P value
0.23 0.39 0.75
1016 1016 < 0.00005 < 0.0001 0.16 0.17
1
Results are shown as median (range) or, wbere appropriate, as numbers. LPD ¼ lymphoproliferative disorders (NHL, Hodgkin’s disease and ALL). 3 At time of harvest. 2
Table 2. Details of patients who underwent stem-cell transplantation
Stem-cell source
n Diagnosis: LPD1 Solid tumors Cell dose TNC/kg 108 2 CD34/kg 106 CFU/kg 105
Unprimed BM A
G-CSF primed BM B
PBSC
16
18
14
14 2
13 5
8 6
1.2 0.49
3.7 2.6 0.76 0.51 6.2 6.7
9.3 6.3 3.7 3.1 22.6 16.2
2.9 2.0
A versus B
P values A versus C B versus C
Trend
C
0.0002
0.0025
< 0.04
< 0.0001
< 0.0001 0.003 < 0.0001
< 0.0001 < 0.0001
Cell doses are shown as mean SD. 1 As defined in Table 1, but including two recipients of PBSC with multiple myeloma. 2 For unprimed BM, CD34 cell dose was available for only one patient, so no statistical analyses were possible.
every case the results favored the primed BM and log-rank
on which platelet transfusions were given and number of
tests for trend confirmed the intermediate position of
RBC transfusions given. The number of days spent in
G-CSF-primed BM between that of unprimed BM and
hospital was intermediate for G-CSF-primed BM trans-
PBSC. Furthermore, if a single unique case is excluded from
plantation, compared with the other two groups ( p for trend
the primed group (a patient who failed to achieve platelet
< 0.05).
independence due to resistant lymphoma, identified by BM biopsy on Day 62; there were no such cases in either of the
Discussion
other groups), there was a significant advantage for primed
Compared with unprimed BM, collection of G-CSF-primed
over unprimed BM in number of days to achieve a platelet
BM was performed more quickly and significantly greater
count of 20 109/L ( p ¼ 0.006).
numbers of cells (TNC) were collected. When used as the
Similarly, there were advantages for PBSC over the
stem-cell source for transplantation, we found the effects of
other two stem-cell sources, in terms of numbers of days
G-CSF-primed BM to be intermediate between those of
G-CSF-primed bone marrow
413
Table 3. Hemopoietic reconstitution after transplantation: three-way comparison1
Stem-cell source
n Number of days for recovery of: Neutrophils to 0.5 109/L WCC to 1 109/L Platelets to 20 109/L Platelets to 50 109/L Days with platelet support Number of RBC transfusions Hospital days Day 0–Day 30
A versus B
P values A versus C B versus C
Unprimed BM A
G-CSF primed BM B
PBSC
Trend
16
18
14
14 (9–26)
12 (9–21)
11 (9–28)
0.11
0.30
0.75
0.26
14 (10–26)
13 (9–21)
10 (9–26)
0.14
< 0.07
0.28
0.09
22 (11–58)
14 (7–65þ)
10 (8–14)
< 0.09
< 0.0001
< 0.007
0.0001
37 (22–72)
23 (15–103)
16 (11–20)
0.58
< 0.0001
< 0.0001
< 0.0001
9.7 7.7
6.2 þ4.1
3.2 2.7
0.11
< 0.01
< 0.05
< 0.005
11.8 12.3
9.4 6.5
4.6 2.8
0.49
< 0.05
< 0.05
< 0.05
17.5 6.3
15.4 6.4
12.5 4.6
0.36
< 0.05
0.17
< 0.05
C
1
Results are shown as median (range), or mean SD.
Figure 1. Hemopoietic recovery after transplantation: recovery of
Figure 2. Hemopoietic recovery after transplantation: recovery of
neutrophils to 0.5 10 /L.
platelets to 20 109/L.
unprimed BM and G-CSF-primed PB, in terms of rate of
were given (mean 3.2, 6.2 and 9.7 days respectively, p for
platelet recovery, number of transfusions given and number
trend < 0.005).
9
of days in hospital. For example, the group given PBSC had 9
Increasing cells doses (measured bv TNC, CD34-
recovery of platelets to 20 10 /L in 10 days, compared with
positive cells and CFU-GM) were administered from the
14 days for the G-CSF-primed BM and 22 days for the
three stem-cell sources, namely unprimed BM, G-CSF-
unprimed BM ( p for trend 0.0001), with a consequent
primed BM and PBSC respectively (Table 2), reflecting
reduction in the number of days when platelet transfusions
numbers of cells collected. In another recent study, speed of
414
RM Lowenthal et al.
HR after stem-cell transplantation was shown to correlate
harvest, or both, or where we predicted a high likelihood of
with dose of infused TNC, of infused CD34-positive cells
failure (for example, because of extensive prior chemother-
and of infused CFU-GM, with dose of CFU-GM the only
apy [25]). In support of the notion that the early patients
significant factor in the multivariate analysis [12]. Thus,
subjected to G-CSF-primed BM harvesting were an
CFU-GM dose may be the most reliable indicator of
unfavorable group, we found survival following transplanta-
potential for hemopoietic recovery after transplantation.
tion to be poorer in those patients from the first half of
Our findings are consistent with those of that study. All our
the series who were transplanted, compared with those
transplant recipients received at least the minimum safe
from the second half. Thus, while the advantages we found
number of cells according to CFU-GM criteria.
for G-CSF-primed BM harvesting over unprimed harvest-
It is clear that growth-factor priming is greatly advanta-
ing were modest, a controlled comparison might well show
geous in the PB setting, compared both with unprimed
greater benefit for G-CSF priming, as already reported by
PB [13] and with unprimed BM [1,14]. G-CSF-primed
others [l5].
BM harvesting and transplantation have been less well
Furthermore, although we did not collect data on the
studied. Most published studies of growth factor-primed
number of chemotherapy regimens administered prior to
BM have concluded that BM stem cells, when collected
stem-cell collection, it is likely to have been less on average
following cytokine priming, lead to a similarly rapid HR,
for patients with solid tumors since, in general, there are
compared with cytokine-primed PBSC [15–19]. However,
fewer treatment options available for solid tumors than for
one small study showed a slower rate of platelet recovery
lymphomas. HR after PBSC may be slower in patients who
with G-CSF-primed BM compared with G-CSF-primed
have had a large number of prior chemotherapeutic regimens
PBSC [20], a result similar to ours. In a comparison of
[26]. Whether HR after transplantation varies depending on
G-CSF-primed with unprimed BM, Stoppa et al. [21]
diagnosis per se is contentious [12]. Compared with patients
showed faster neutrophil recovery after priming, whereas
treated with G-CSF-primed BMT, a higher proportion of
another study, while showing that growth factors expanded
PBSC transplants had a solid tumor diagnosis. This is
BM myelopoiesis, failed to show any speeding-up of myeloid
another reason why, in this uncontrolled study, the results
recovery after transplantation compared with historical
are unlikely to favor the group treated with primed BM.
controls [22]. However, it is of interest that in that study
Although use of unprimed BM has fallen into disfavor,
[22] G-CSF was given for 10 days prior to BM harvesting.
G-CSF-primed BM would seem to be a legitimate alter-
The optimum number of days of administration of G-CSF
native to PBSC. From the point of view of cell collection,
prior to harvesting of BM stem cells is not known, but 10
while PBSC harvesting avoids the need for an anesthetic,
days may well be too long; it may well be less even than the 6
patients are subjected to some discomfort, having to be
days that we used [16], since PBSC traditionally are collected
attached to a cell separator for several hours over a number
after 5–7 days G-CSF administration [23] and PBSC
of days. In contrast, BM harvesting is a single procedure.
originate in the BM.
PBSC collections are not without risk: although rare, there
Our failure to demonstrate a difference in the rate of
are reports of splenic rupture occurring during the collection
neutrophil recovery between the three groups may be
program [27,28], possibly a complication of leukapheresis-
merely a function of the small numbers in the study.
induced thrombocytopenia and/or the higher doses of G-
Alternatively, it may be due to our routine use of post-
CSF used. Furthermore, economic analyses that have shown
transplant G-CSF, which has been shown in several studies
cost-benefit for PBSC: transplantation over unprimed BM
to shorten time to neutrophil recovery following stem-cell
transplantation [14,29] are premised on the significantly
transplantation [12,24].
slower HR of unprimed BM transplantation, compared with
Although this was not a controlled study, the patients
PBSC transplantation, whereas HR after G-CSF-primed
subjected to primed and unprimed BM harvests were similar
BM transplantation is only marginally slower than that after
in demographic characteristics (Table 1). On the other hand,
PBSC transplantation, as we have shown. They also do not
in many ways the comparison was biased against the primed
take into account the reduced need for storage space in
harvests as, in the early part of the study, we restricted the
liquid nitrogen containers following the single BM collec-
technique of G-CSF BM priming to patients who had
tion. Such containers are bulky and expensive devices, and
already failed either an unprimed BM harvest or a PBSC
space is often at a premium.
G-CSF-primed bone marrow
There are differences in the phenotype of BM and PB
415
Acknowledgements
cells [30], one of particular note being the presence of larger
We thank Drs Michael Beamish, David Boodle, Roger
numbers of T cells in PB collections. This has raised
Kimber, Kim Rooney and Rosemary Young for patient
concerns in the allogeneic setting of increased risks of
referrals and Dr Brett Daniels for statistical assistance.
GvHD, if PBSC are used instead of BM, and has stimulated interest in the use of growth-factor-primed BM for
References
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1
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13 Nademanee A, Sniecinski I, Schmidt GM et al. High-dose therapy followed by autologous peripheral-blood stem-cell transplantation for patients with Hodgkin’s disease and nonHodgkin’s lymphoma using unprimed and granulocyte colonystimulating factor-mobilized peripheral-blood stem cells. J Clin Oncol 1994;12:2176–86. 14 Ager S, Scott MA, Mahendra P et al. Peripheral blood stem cell transplantation after high-dose therapy in patients with malignant lymphoma: a retrospective comparison with autologous bone marrow transplantation. Bone Marrow Transplant 1995; 16:79–83. 15 Janssen WE, SmileeRC:, Elfenbein GJ. A prospective randomized trial comparing blood- and marrow-derived stem cells for hematopoietic replacement following high-dose chemotherapy. J Hematotherapy 1995;4:139–40. 16 Dicke KA, Hood DL, Ameson M et al. Effects of short-term in vivo administration of G-CSF on bone marrow prior to harvesting. Exp Hematol 1997;25:34–8. 17 Weisdorf D, Miller J, Verfaillie C et al. Cytokine-primed bone marrow stern cells vs. peripheral blood stem cells for autologous transplantation: a randomized comparison of GMCSF vs. G-CSF. Biol Blood Marrow Transplant 1997;3:217–23. 18 Damiani D, Fanin R, Silvestri F et al. Randomized trial of autologous filgrastim-primed bone marrow, transplantation versus filgrastim-mobilized peripheral blood stem cell transplantation in lymphoma patients. Blood 1997;90:36–42. 19 Janssen WE. Mobilization of peripheral blood stem cells for autologous transplantation. Methods, mechanisms, and role in accelerating hematopoietic recovery. Ann N Y Acad Sci 1995;770: 116–29. 20 Knudsen LM, Hansen SW, Daugard G et al. Comparison of rhG-CSF primed bone marrow and blood stem cell autografts: an analysis of engraftment in malignant Iymphomas and solid tumours. Eur J Haematol 1998;61:229–34. 21 Stoppa AM, Blaise D, Viens P et al. Phase I study of in vivo lenograstim (rHuG-CSF) for stein cell collection demonstrates improved neutrophil recovery after autologous bone marrow, transplantation. Bone Marrow Transplant 1994;13:541–7. 22 Hansen PB, Knudsen H, Gaarsdal E et al. Short-term in vivo priming of bone marrow haematopoiesis with rhG-CSF, rhGM-CSF or rhIL-3 before marrow harvest expands myelopoiesis but does not improve engraftment capability. Bone Marrow Transplant 1995;16:373–9. 23 Sheridan WP, Begley CG, Juttner CA et al. Effect of peripheralblood progenitor cells mobilised by filgrastim (G-CSF) on platelet recovery after high-dose chemotherapy. Lancet 1992; 339:640–4. 24 Klumpp TR, Mangan KF, Goldberg SL, et al. Granulocyte colony-stimulating factor accelerates neutrophil engraftment following peripheral-blood stem cell transplantation: a prospective, randomizcd trial. J Clin Oncol 1995;13:1323–7. 25 Brugger W, Bross K, Frisch J et al. Mobilization of peripheral blood progenitor cells by sequential administration of interleukin-3 and granulocyte-macrophage colony-stimulating factor following polychemotherapy with etoposide, ifosfamide, and cisplatin. Blood 1992; 79:1193–200. 26 Spitzer G, Adkins DR. Persistent problems of neutropenia and thrombocytopenia with peripheral blood stem cell transplantation. J Hematother 1994;3:193–8.
27 Becker PS, Wagle M, Matou S et al. Spontaneous splenic rupture following administration of granulocyte colony-stimulating factor (G-CSF): occurrence in an allogeneic donor of peripheral blood stem cells. Biol Blood Marrow Transplant 1997;3:45–9. 28 Falzetti F, Aversa F, Minelli O, Tabilio A. Spontaneous rupture of spleen during peripheral blood stem-cell mobilisation in a healthy donor. Lancet 1999;353:555. 29 Duncan N, Hewetson M, Powles R et al. An economic evaluation of peripheral blood stem cell transplantation as an alternative to autologous bone marrow, transplantation in multiple myeloma. Bone Marrow Transplant 1996;18:1175–8. 30 To LB, Haylock DN, Dowse T et al. A comparative study of the phenotype and proliferative capacity of peripheral blood (PB) CD34þ cells mobilized by four different protocols and those of steady-phase PB and bone marrow CD34þ cells. Blood 1994;84: 2930–9. 31 Meisenberg B, Frakes L, Brehm T et al. Use of G-CSF given to allogeneic donors to improve CD34 yields in bone marrow collections and hasten engraftment. Blood 1996;299(Suppl 1): Abstract No. 1599. 32 Isola LM, Scigliano E, Skerrett D et al. A pilot study of allogeneic bone marrow transplantation using related donors stimulated with G-CSF. Bone Marrow Transplant 1997;20:1033–7. 33 Ringden O, Remberger M, Runde V et al. Peripheral blood stem cell transplantation from unrelated donors: a comparison with marrow transplantation. Blood 1999;94:455–64. 34 Appelbaum FR. Choosing the source of stem cells for allogeneic transplantation: no longer a peripheral issue. Blood 1999;94:381–3. 35 Elmaagacli AH, Beelen DW, Opalka B et al. The risk of residual molecular and cytogenetic disease in patients with Philadelphia-chromosome positive first chronic phase chronic myelogenous leukemia is reduced after transplantation of allogeneic peripheral blood stem cells compared with bone marrow. Blood 1999;94:384–9. 36 Marmont AM. Stem cell transplantation for severe autoimmune diseases: progress and problems. Haematologica 1998;83:733–43. 37 Potter M, Black C, Bone marrow transplantation for autoimmune diseases. Br Med J 1999;318:750–1. 38 Andre M, Henry-Amar M, Blaise D et al. Treatment-related deaths and second cancer risk after autologous stem-cell transplantation for Hodgkin’s disease. Blood 1998;92:1933–40. 39 Voso MT, Murea S, Goldschmidt H et al. High-dose therapy with peripheral blood stem cell transplantation results in a significant reduction of the haemopoietic progenitor cell compartment. Br J Hemantol 1996;94:759–66. 40 Dhodapkar M, Goldberg SL, Tefferi A, Gertz MA. Reversible encephalopathy after cryopreserved peripheral blood stem cell infusion. Am J Hematol 1994;45:187–8. 41 Zambelli A, Poggi G, Da Prada G et al. Clinical toxicity of cryopreserved circulating progenitor cells infusion. Anticancer Res 1998;18:4705–8. 42 Verdeguer A, Bermudez M, De la Rubia J et al. Allogeneic PBPC transplantation in children. Cytotherapy 1999;1:195–201. 43 Nussbaumer W, Scho¨nitzer D, Trieb T et al. Peripheral blood stem cell (PBSC) collection in extremely low-weight infants. Bone Marrow Transplant 1996;15–7.
Hemopoietic stem-cell harvesting and transplantation using G-CSF-primed BM: comparison with unprimed BM and G-CSF-primed PBSC RM Lowenthal1, D Tuck1, E Tegg1, KA Marsden1, B Rees1, J Luck1, S Ragg1, N Parker1,2 and N Kotlovsky1 1
Clinical Haematology & Medical Oncology Unit, Royal Hobart Hospital, Hobart, Tasmania, Australia
2
Present address: Sullivan, Nicolaides & Partners, Immunology Dept, Brisbane, Queensland, Australia
Background
Consequently, larger numbers of cells were available for admin-
PBSC collected following G-CSF priming lead to more rapid
istration following transplantation with G-CSF-primed BM.
hemopoietic reconstitution (HR) after autologous transplantation
The results of HR after transplantation with G-CSF primed
than do unprimed BMstem cells. However, PBSC have a number
BM were intermediate between those of unprimed BM and
of disadvantages compared with BM cells, including the need for
PBSC. For example, platelet independence (unsupported platelet
an extended collection period and requirement for good venous
count 20 109/L) occurred after 22 days with unprimed
access.
BM, 14 days with G-CSF-printed BM and 10 days with PBSC (p for trend < 0.0001) and the mean number of days when
Methods
platelet transfusions were given was 10, 6 and 3 respectively
We retrospectively analysed our experience with an alternative
(p for trend < 0.005). These results reflected transplant cell
source of hemopoietic stem cells, G-CSF primed BM. Fortyfour
doses.
patients who underwent BM harvesting after 6 days’ administration of G-CSF, at a dose of 5 g/kg per day, were compared
Conclusion
with an equal number who underwent standard (unprimed) BM
G-CSF-primed BM is a valuable source of hemopoietic stem cells
harvesting. We also analysed HR after autologous transplantation
for autologous transplantation and a useful alternative to PBSC to
in 16 patients who received unprimed BM, 18 who received
certain circumstances.
G-CSF-primed BM and 14 who received PBSC. Keywords Results
stem cells, bone marrow transplantation, peripheral blood stem
G-CSF-primed BM was collected more quickly (p<0.00005) and
cells, G-CSF
yielded a larger number of cells (p<0.0001) than unprimed BM.
Introduction
recent years peripheral blood (PB) has become the preferred source, because studies have shown more favorable dynamics
Autologous hemopoietic stem-cell transplantation is now a
of hemopoietic reconstitution (HR) after transplantation.
commonplace medical procedure for treatment of a variety
With PBSC transplantation, neutrophils and platelets
of malignant and non-malignant haematological disorders
recover more quickly, and there is a shorter period of
and for intensification of treatment for certain solid tumors.
hospital stay, thus making use of PBS; safer and cheaper than
Stem cells originally were obtained from the BM, but in
using BM-derived stew cells [1,2].
Correspondence to: Professor Ray Lowenthal, Haematology/Oncology Unit, Royal Hobart Hospital, GPO Box 1061L Hobart, Tasmania, Australia, 7001 ß 1999 ISHAGE
409
410
RM Lowenthal et al.
However, the studies which have shown advantages for
harvesting during an overlapping time period. For this
PBSC over BM stem cells have actually compared growth-
comparison, 44 consecutive patients who had undergone
factor-primed PBSC with unprimed BM. (The growth
unprimed BM harvesting were chosen retrospectively from
factor most commonly used has been G-CSF.) An inter-
June 1997 to June 1992, except that patients with AML and
mediate potential source of stem cells has been less well-
CML were excluded, since none underwent G-CSF-primed
studied, namely growth-factor-primed BM. Despite its
harvesting, due to concerns about possible stimulation of
advantages, there are also disadvantages of PB compared
leukemic stem cells by G-CSF [5,6]. We then compared the
with BM: generally speaking PBSC collections take several
outcomes in those patients who subsequently underwent
days, whereas BM harvesting is a single procedure; the
autologous transplantation, by analysis of HR. By 31
collection process can be uncomfortable; there are difficul-
October, 1998 (close-out date), 16 of the 44 donors of
ties in collecting PBSC from young children or patients with
unprimed BM and 18 of the 44 donors of G-CSF-primed
poor venous access; and PBSC harvests occupy more room
BM had been transplanted. In a three-way comparison, we
in liquid nitrogen containers, where space is often at a
also compared the outcomes in these two groups of patients
premium.
with a contemporaneous group of 14 consecutive patients
Primed PBSC originate in the BM and in mice G-CSF
who were transplanted with autologous PBSC. (Of these,
printing greatly enhances the engraftment potential of BM
three had PBSC collected after priming with cyclopho-
stem cells [3], therefore we have explored the use of G-CSF-
sphamide only, four after the combination of cyclopho-
primed BM as a source of hemopoietic stem cells for
sphamide and G-CSF, and seven after G-CSF only.)
transplantation in humans. We introduced it as a method
Patients with myeloid leukernias were also excluded from
of overcoming the problem of inadequate stem-cell col-
the transplant analysis. All transplant recipients received
lection by standard methodology in patients who had
G-CSF 5 mg/kg per day subcutaneously from the day
undergone extensive prior therapy, and when this proved
of stem-cell reinfusion until recovery of neutrophils to
to be successful, we gradually extended its use to other
5 109/L.
patients.
This was a retrospective, uncontrolled analysis. The
We present a retrospective analysis of our experience
following data were collected: demographics (age, sex,
with G-CSF-primed BM harvesting and transplantation,
patient weight, diagnosis), harvest details [total WBC and
and compare it with our experience with unprimed BM
neutrophil counts immediately prior to harvest, procedure
harvesting and transplantation and with PBSC transplanta-
length in hours and minutes, number of cells collected
tion, in terms of numbers of cells collected and HR after
calculated per kg patient body weight, including total
transplantation.
nucleated cells (TNC), CFU-GM (colony-forming units granulocyte-macrophage) and CD34-positive cells] and rate
Patients and Methods
of HR following transplantation (see below). During the
We first carried out G-CSF-primed BM harvesting in June,
period of this study we changed our CFU-GM assay method
1994, on a patient with relapsed non-Hodgkin’s lymphoma
from using traditional soft agar [7] to methylcellulose with
(NHL), who had received extensive prior chemotherapy and
recombinant cytokines [8] (Methocult GFþ H4535, Stem-
in whom two previous attempts at stem-cell harvesting by
Cell Technologies Inc, Vancouver BC, Canada). Internal
standard methods (unprimed BM harvesting and G-CSF-
laboratory quality assurance demonstrated that the com-
primed PBSC harvesting) had yielded insufficient stem cells
mercial methylcellulose-based media gave a 10-fold greater
for safe transplantation. The patient subsequently went on to
plating efficiency than our original in-house soft agar
have a successful autologous transplant using the G-CSF-
method, so for comparison we have multiplied results of
primed BM [4]. By June 1997 we had performed 44 such
agar CFU-GM assays by 10 and ‘normalized’ results to the
harvests and at this time we adopted G-CSF-primed BM as
methylcellulose standard. CD34-positive cells were deter-
our standard source of blood stem cells. During the harvest,
mined by standard ISHAGE methodology [9]. Although
we aimed to collect 15 mL BM/kg body weight, or 1 L from
some laboratories have ceased using the CFU-GM assay for
an average-sized adult. Results of harvesting (that is, cell
validation of stem-cell collections, preferring CD34 assess-
yields) in the 44 patients were compared with those of a
ment, such assays are still recommended for assessment of
group of patients who underwent standard (unprimed) BM
adequacy of stem-cell collections [10] and were available for
G-CSF-primed bone marrow
411
all our patients, as were TNC counts. In contrast, the CD34
G.-CSF priming, the differences did not reach statistical
assay was introduced during the course of the present study
significance.
and was not available for all patients. We established a CFU-GM dose of 1 105/kg transplantation; all patients who were transplanted were
Transplantation: three-way comparison between unprimed BM, G-CSF-primed BM and G-CSF-primed PBSC
given at least this dose. HR was assessed by the number of
Table 2 shows the characteristics of the patients who
days following transplantation to reach a WBC count of 1.0,
underwent stem-cell transplantation. Only a minority of
a granulocyte count of 0.5 or a platelet count (unsupported)
those from whom stem cells were harvested and stored had
(methylcellulose standard) as the minimum acceptable for
9
of 20 or 50 10 /L, using the log-rank (Kaplan-Meier)
proceeded to transplantation by the cut-off date (16 of 44
method. We recorded the number of days in hospital, the
following unprimed and 18 of 44 following G-CSF-primed
number of days on which platelet transfusions were given
BM harvesting), because of our policy of cryopreserving cells
and the total number of RBC transfusions given, from Day
from patients at risk of relapse, as a form of ‘insurance’. As
0 (day of transplant) to Day 30. Our platelet transfusion
can be seen, the three transplanted groups were reasonably
policy was constant throughout the period of the study,
comparable in terms of ages and diagnoses. The most
namely, that patients were transfused routinely if the
common diagnosis was NHL (11, 11 and five patients in the
count was < 10 109/L, or if the count was < 20 109/L
unprimed BM transplant, G-CSF-primed BM transplant
and they were febrile (temperature 38.0 C), or at
and PBSC transplant groups respectively). The transplant
any level if they were bleeding and the bleeding was
cell dose was larger (by TNC and CFU-GM) for PBSC,
judged to be due to platelet deficiency or dysfunction.
compared with both of the other groups, and for the
Statistical
G-CSF-primed group compared with the unprimed group
calculations
were performed
using
Prism
(GraphPad Software, San Diego, California). Log-rank
(Table 2), reflecting the number of cells collected.
tests were used to compare time-dependent variables
Our criteria for carrying out G-CSF-primed BM
(namely, number of days for recovery of white cells,
harvesting changed during the course of this study (initially
neutrophils and platelets after transplantation). Patients
being restricted to patients from whom we anticipated poor
who died were censored on date of death. For all other
yields because of extensive prior chemotherapy, with criteria
analyses, the Mann–Whitney U test was used for two-group
being relaxed in later patients) we therefore compared the
comparisons and the Kruskall–Wallis test for comparisons
results of the first 22 and second 22 patients. There were no
among three groups.
statistically significant differences in patient demographics, cell yield or pre-transplant BM cellularity[11] between the
Results
two subgroups and no difference in the rate of HR following
Stem-cell harvesting: comparison between unprimed and G-CSF-primed BM
transplantation. However, survival following transplantation
Table 1 shows the characteristics of the two groups of 44
who were transplanted, compared with those of the second
patients and it can be seen that although this was not a
half ( p<0.05) (data not shown).
was poorer in those patients from the first half of the series
randomized comparison, they were comparable in terms of
Details of HR are given in Table 3 and Figures 1 and 2.
diagnoses and other demographics. The most common
It can be seen that there was no difference in the rate
single diagnosis was NHL (24 and 26 patients in the
of recovery of neutrophils to 0.5 109/L (Table 3 and
unprimed and G-CSF-primed groups, respectively). As
Figure 1), but that there was a significant difference between
would be expected, 6 days of G-CSF administration led to
the three groups in the rate of platelet recovery (Table 3 and
a highly significant increase in the total WBC and neutrophil
Figure 2). Platelet recovery to 20 109/L was more
counts on the day of harvesting ( p¼1016). Unexpectedly,
rapid after transplantation with G-CSF-primed than with
BM after G-CSF administration proved to be much easier to
unprimed BM (14 versus 22 days) and was even more
aspirate, leading to a saving of almost half an hour in harvest
rapid after PBSC transplantation (10 days; p for trend,
time ( p<0.00005). Significantly larger numbers of TNC
0.0001). Although none of the individual direct comparisons
were collected after G-CSF priming ( p<0.0001). Although
of HR after transplantation between unprimed and G-CSF-
more CFU-GM and CD34-positive cells were obtained after
primed BM yielded statistically significant differences, in
412
RM Lowenthal et al.
Table 1. Characteristics of patients undergoing BM harvesting and results of harvesting1 Stem-cell source n Age M:F Diagnoses LPD2 Solid tumors WBC3 109/L Neutrophil count3 l09/L Harvest time h:min TNC/kg 108 CD34/kg 106 CFU/kg 105
Unprimed BM
G-CSF-primed BM
44 43.5 (17–62) 22:22
44 48 (19–65) 17:27
35 9 5.25 (3–10.1) 3.5 (1.4–7.9) 1:35 (0:50–2:45) 1.15 (0.31–2.97) 0.32 (0.03–0.61) 3.6 (0.7–9.7)
32 12 26.1 (5.5–73.6) 21.7 (3.1–60.1) 1:08 (0:35–2:35) 3.1 (0.04–11.3) 0.79 (0.22–2.41) 5.2 (0–20.6)
P value
0.23 0.39 0.75
1016 1016 < 0.00005 < 0.0001 0.16 0.17
1
Results are shown as median (range) or, wbere appropriate, as numbers. LPD ¼ lymphoproliferative disorders (NHL, Hodgkin’s disease and ALL). 3 At time of harvest. 2
Table 2. Details of patients who underwent stem-cell transplantation
Stem-cell source
n Diagnosis: LPD1 Solid tumors Cell dose TNC/kg 108 2 CD34/kg 106 CFU/kg 105
Unprimed BM A
G-CSF primed BM B
PBSC
16
18
14
14 2
13 5
8 6
1.2 0.49
3.7 2.6 0.76 0.51 6.2 6.7
9.3 6.3 3.7 3.1 22.6 16.2
2.9 2.0
A versus B
P values A versus C B versus C
Trend
C
0.0002
0.0025
< 0.04
< 0.0001
< 0.0001 0.003 < 0.0001
< 0.0001 < 0.0001
Cell doses are shown as mean SD. 1 As defined in Table 1, but including two recipients of PBSC with multiple myeloma. 2 For unprimed BM, CD34 cell dose was available for only one patient, so no statistical analyses were possible.
every case the results favored the primed BM and log-rank
on which platelet transfusions were given and number of
tests for trend confirmed the intermediate position of
RBC transfusions given. The number of days spent in
G-CSF-primed BM between that of unprimed BM and
hospital was intermediate for G-CSF-primed BM trans-
PBSC. Furthermore, if a single unique case is excluded from
plantation, compared with the other two groups ( p for trend
the primed group (a patient who failed to achieve platelet
< 0.05).
independence due to resistant lymphoma, identified by BM biopsy on Day 62; there were no such cases in either of the
Discussion
other groups), there was a significant advantage for primed
Compared with unprimed BM, collection of G-CSF-primed
over unprimed BM in number of days to achieve a platelet
BM was performed more quickly and significantly greater
count of 20 109/L ( p ¼ 0.006).
numbers of cells (TNC) were collected. When used as the
Similarly, there were advantages for PBSC over the
stem-cell source for transplantation, we found the effects of
other two stem-cell sources, in terms of numbers of days
G-CSF-primed BM to be intermediate between those of
G-CSF-primed bone marrow
413
Table 3. Hemopoietic reconstitution after transplantation: three-way comparison1
Stem-cell source
n Number of days for recovery of: Neutrophils to 0.5 109/L WCC to 1 109/L Platelets to 20 109/L Platelets to 50 109/L Days with platelet support Number of RBC transfusions Hospital days Day 0–Day 30
A versus B
P values A versus C B versus C
Unprimed BM A
G-CSF primed BM B
PBSC
Trend
16
18
14
14 (9–26)
12 (9–21)
11 (9–28)
0.11
0.30
0.75
0.26
14 (10–26)
13 (9–21)
10 (9–26)
0.14
< 0.07
0.28
0.09
22 (11–58)
14 (7–65þ)
10 (8–14)
< 0.09
< 0.0001
< 0.007
0.0001
37 (22–72)
23 (15–103)
16 (11–20)
0.58
< 0.0001
< 0.0001
< 0.0001
9.7 7.7
6.2 þ4.1
3.2 2.7
0.11
< 0.01
< 0.05
< 0.005
11.8 12.3
9.4 6.5
4.6 2.8
0.49
< 0.05
< 0.05
< 0.05
17.5 6.3
15.4 6.4
12.5 4.6
0.36
< 0.05
0.17
< 0.05
C
1
Results are shown as median (range), or mean SD.
Figure 1. Hemopoietic recovery after transplantation: recovery of
Figure 2. Hemopoietic recovery after transplantation: recovery of
neutrophils to 0.5 10 /L.
platelets to 20 109/L.
unprimed BM and G-CSF-primed PB, in terms of rate of
were given (mean 3.2, 6.2 and 9.7 days respectively, p for
platelet recovery, number of transfusions given and number
trend < 0.005).
9
of days in hospital. For example, the group given PBSC had 9
Increasing cells doses (measured bv TNC, CD34-
recovery of platelets to 20 10 /L in 10 days, compared with
positive cells and CFU-GM) were administered from the
14 days for the G-CSF-primed BM and 22 days for the
three stem-cell sources, namely unprimed BM, G-CSF-
unprimed BM ( p for trend 0.0001), with a consequent
primed BM and PBSC respectively (Table 2), reflecting
reduction in the number of days when platelet transfusions
numbers of cells collected. In another recent study, speed of
414
RM Lowenthal et al.
HR after stem-cell transplantation was shown to correlate
harvest, or both, or where we predicted a high likelihood of
with dose of infused TNC, of infused CD34-positive cells
failure (for example, because of extensive prior chemother-
and of infused CFU-GM, with dose of CFU-GM the only
apy [25]). In support of the notion that the early patients
significant factor in the multivariate analysis [12]. Thus,
subjected to G-CSF-primed BM harvesting were an
CFU-GM dose may be the most reliable indicator of
unfavorable group, we found survival following transplanta-
potential for hemopoietic recovery after transplantation.
tion to be poorer in those patients from the first half of
Our findings are consistent with those of that study. All our
the series who were transplanted, compared with those
transplant recipients received at least the minimum safe
from the second half. Thus, while the advantages we found
number of cells according to CFU-GM criteria.
for G-CSF-primed BM harvesting over unprimed harvest-
It is clear that growth-factor priming is greatly advanta-
ing were modest, a controlled comparison might well show
geous in the PB setting, compared both with unprimed
greater benefit for G-CSF priming, as already reported by
PB [13] and with unprimed BM [1,14]. G-CSF-primed
others [l5].
BM harvesting and transplantation have been less well
Furthermore, although we did not collect data on the
studied. Most published studies of growth factor-primed
number of chemotherapy regimens administered prior to
BM have concluded that BM stem cells, when collected
stem-cell collection, it is likely to have been less on average
following cytokine priming, lead to a similarly rapid HR,
for patients with solid tumors since, in general, there are
compared with cytokine-primed PBSC [15–19]. However,
fewer treatment options available for solid tumors than for
one small study showed a slower rate of platelet recovery
lymphomas. HR after PBSC may be slower in patients who
with G-CSF-primed BM compared with G-CSF-primed
have had a large number of prior chemotherapeutic regimens
PBSC [20], a result similar to ours. In a comparison of
[26]. Whether HR after transplantation varies depending on
G-CSF-primed with unprimed BM, Stoppa et al. [21]
diagnosis per se is contentious [12]. Compared with patients
showed faster neutrophil recovery after priming, whereas
treated with G-CSF-primed BMT, a higher proportion of
another study, while showing that growth factors expanded
PBSC transplants had a solid tumor diagnosis. This is
BM myelopoiesis, failed to show any speeding-up of myeloid
another reason why, in this uncontrolled study, the results
recovery after transplantation compared with historical
are unlikely to favor the group treated with primed BM.
controls [22]. However, it is of interest that in that study
Although use of unprimed BM has fallen into disfavor,
[22] G-CSF was given for 10 days prior to BM harvesting.
G-CSF-primed BM would seem to be a legitimate alter-
The optimum number of days of administration of G-CSF
native to PBSC. From the point of view of cell collection,
prior to harvesting of BM stem cells is not known, but 10
while PBSC harvesting avoids the need for an anesthetic,
days may well be too long; it may well be less even than the 6
patients are subjected to some discomfort, having to be
days that we used [16], since PBSC traditionally are collected
attached to a cell separator for several hours over a number
after 5–7 days G-CSF administration [23] and PBSC
of days. In contrast, BM harvesting is a single procedure.
originate in the BM.
PBSC collections are not without risk: although rare, there
Our failure to demonstrate a difference in the rate of
are reports of splenic rupture occurring during the collection
neutrophil recovery between the three groups may be
program [27,28], possibly a complication of leukapheresis-
merely a function of the small numbers in the study.
induced thrombocytopenia and/or the higher doses of G-
Alternatively, it may be due to our routine use of post-
CSF used. Furthermore, economic analyses that have shown
transplant G-CSF, which has been shown in several studies
cost-benefit for PBSC: transplantation over unprimed BM
to shorten time to neutrophil recovery following stem-cell
transplantation [14,29] are premised on the significantly
transplantation [12,24].
slower HR of unprimed BM transplantation, compared with
Although this was not a controlled study, the patients
PBSC transplantation, whereas HR after G-CSF-primed
subjected to primed and unprimed BM harvests were similar
BM transplantation is only marginally slower than that after
in demographic characteristics (Table 1). On the other hand,
PBSC transplantation, as we have shown. They also do not
in many ways the comparison was biased against the primed
take into account the reduced need for storage space in
harvests as, in the early part of the study, we restricted the
liquid nitrogen containers following the single BM collec-
technique of G-CSF BM priming to patients who had
tion. Such containers are bulky and expensive devices, and
already failed either an unprimed BM harvest or a PBSC
space is often at a premium.
G-CSF-primed bone marrow
There are differences in the phenotype of BM and PB
415
Acknowledgements
cells [30], one of particular note being the presence of larger
We thank Drs Michael Beamish, David Boodle, Roger
numbers of T cells in PB collections. This has raised
Kimber, Kim Rooney and Rosemary Young for patient
concerns in the allogeneic setting of increased risks of
referrals and Dr Brett Daniels for statistical assistance.
GvHD, if PBSC are used instead of BM, and has stimulated interest in the use of growth-factor-primed BM for
References
allogeneic transplantation [31,32], although preliminary
1
reports do not so far bear out the concern about high rates of GvHD after allogeneic PBSC transplantation [33]. On the other hand, because GvHD may be associated with a graftversus-tumor effect, in the allogeneic setting there may be special advantages for PBSC for certain diagnoses [34,35]. In contrast, the presence of large numbers of T cells in autologous PBSC grafts may be disadvantageous in transplantation for autoimmune disease [36,37], currently an experimental procedure, where T cells are thought to have a role in the disease process. In this special situation, there may be theoretical advantages to the use of BM stem cells, with their lower number of T cells. There are a number of other possible disadvantages in the use of PB, as opposed to BM stem cells. One recent report suggests that PBSC transplantation may carry an increased risk of the development of second tumors [38]. Concern has been expressed that PBSC transplants may be associated with long-term impairment of the hemopoietic system [39]. The larger volume of material infused for PBSC transplantation requires the administration of larger amounts of the potentially-toxic cryoprotective agent dimethyl sulphoxide [40,41]. Although PBSC harvesting has been performed successfully on small children and infants [42,43], BM harvesting is a technically simpler method of collecting hemopoietic stem cells from such patients. If good venous access is not available a venous access device will have to be inserted, with attendant risks of infection and thrombosis. Our finding that speed of HR after G-CSF-primed BMT is intermediate between that of unprimed BMT and of PBSC transplantation probably reflects transplant-cell dose which, in turn, reflects numbers of cells collected. Even if so, the advantages of G-CSF-primed BM, in terms of ease of collection and storage, and its fairly minor disadvantages compared with PBSC in the rate of HR after transplantation, may allow blood stem-cell collection to be made available to patients who otherwise would be denied it. G-CSF-primed BM is a valuable source of hemopoietic stem cells and an alternative to PBSC that has advantages in certain circumstances.
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