- Email: [email protected]
Stem cell collection and transplant in myeloma patients following lenalidomide or bortezomib based induction therapy
19th Annual ISCT Meeting
Donor Lymphocyte Infusions (DLI) are frequently used to enhance donor engraftment or treat relapse following allogeneic stem cell transplant. DLI can be collected unprimed (without prior G-CSF administration to donors) or as part of a hemopoietic stem cell collection following administration of G-CSF to the donor. We determined the factors that influence post-thaw viable CD3+ recovery of DLI cryopreserved during 2006 to 2011. DLI harvests were obtained from 42 related donors and 31 unrelated donors. G-CSF primed collections contained a higher percentage of granulocytes, a lower number of platelets and were cryopreserved at a higher cell concentration. Although recovery of total nucleated cells was improved after thawing of G-CSF primed products (100 v 88%, P<0.001), recovery of viable CD3+ cells was reduced (62% for unprimed collections compared with 49% for G-CSF primed, P<0.001; viable CD3+ counts 76.8 v 43.1 106/kg respectively, P<0.001). Multivariate analysis showed that the factors that significantly affected viable CD3+ recovery were: 1) harvest type: GCSF primed compared to unprimed: P<0.001; 2) Time to cryopreservation P¼0.002 for <10 hours compared to 10-24 hours and >24 hours. These 2 factors have been noted previously by our laboratory as also affecting viable CD34+ recovery. One factor that showed weak correlation with viable CD3+ recovery was the cryopreserved cell concentration for the unprimed (r2 ¼ 0.2, P¼0.0095), but not for G-CSF primed collections (r2 ¼0.015, P¼0.48). In conclusion, achieving adequate viable T cell doses for DLI infusions requires cryopreservation of over 108/kg CD3+ cells. Our lab makes allowance for thawing losses of around 30% to 50% when freezing DLIs. We have demonstrated that using G-CSF primed stem cell products and/or delaying time to cryopreservation can reduce viable T cell numbers upon thawing and may limit DLI doses available for infusion, particularly unrelated collections from overseas. 78 STEM CELL COLLECTION AND TRANSPLANT IN MYELOMA PATIENTS FOLLOWING LENALIDOMIDE OR BORTEZOMIB BASED INDUCTION THERAPY A Khot, K Stokes, T Joyce, C Coulson, P Gambell, M Darby, D Ritchie, M Prince, S Harrison Peter MacCallum Cancer Centre, East Melbourne, Australia Newer agents such as lenalidomide, an immunomodulatory drug and bortezomib, a proteasome inhibitor, have been introduced into myeloma front-line therapy, and are associated with improved rates and depth of response. Reports suggest a reduced capacity to collect adequate numbers of stem cells following lenalidomide based induction with GCSF only. We compare the outcomes of patients mobilised with cyclophosphamide and GCSF following lenalidomide or bortezomib based induction in our institution. Induction regimens were; lenalidomide 15-25 mg d1-21, dexamethasone 20 mg weekly 4, for 4 weekly cycles; or Bortezomib 1.3 mg/m2 SC on Days 1,4,8, and 11, cyclophosphamide 300 mg/m2 orally on Days 1, 8, and 15, and dexamethasone 20 mg orally on Days 1,2,4,5,8,9,11, and 12. The mobilization regimen for both cohorts was cyclophosphamide 2-4 gm/m2 followed by GCSF 10 mcg/kg from d+1. Cells were collected using either Cobe SpectraÒ or Sectra OptiaÒ apheresis devices and collections commenced when the CD34+ count in peripheral blood was 5 cells/ml. The target was 6-10106 CD34+ cells/kg to allow sufficient cells for 2 transplant procedures as per local protocol. 37 patients were collected following lenalidomide and 12 after bortezomib induction. There were no differences in the median number of stem cells collected (11.41 [range 2.91-40.6] vs 9.46106/kg [3.4-29.13]) following lenalidomide or bortezomib, or in the median number of collection days (3 [1-6] vs 2.5 [1-7]). 36 patients have undergone HSCT following lenalidomide and 8 after bortezomib induction. There were no differences in the median number of days to neutrophil (12 vs 11.5) or platelet (11 vs 11) engraftment following lenalidomide or bortezomib induction therapies. Our data suggest no difference in the ability to mobilise adequate numbers of HSCT following 4 cycles of lenalidomide or bortezomib based induction. To date, stem cell function appears similar in terms of platelet and neutrophil engraftment. These data will be updated. 79 THE RED CELL CONTENT OF APHERESIS PRODUCTS IS ROUTINELY OVERESTIMATED MJ Watts1, C Balsa1, A Pizzey2, S Ings1, A Antonio1 1 University College London Hospitals, London, United Kingdom, 2University College London, London, United Kingdom
S25
Following a series of severe and life-threatening reactions after the infusion of red cell replete cord blood units reported to the WMDA (BB-IND #7555) the red cell content of all products must be specified (JACIEv5.2 standard B.7.4.1). We routinely estimate the red cell volume of apheresis harvests as ‘Product Volume (ml) Blood Analyser HCT’ (Sysmex KX21). The RBC and MCV of impedance counters, though reliable for cord blood samples are known to be spuriously increased by high white cell counts such as in apheresis products. We used a Glycophorin A monoclonal antibody and quantitative flow cytometry to measure a ‘flow-RBC’ which when multiplied by the pre-harvest blood MCV gave a ‘flow-HCT’ without white cell interference. The flow-RBC was precise (CV<5%), consistently 4% higher than the KX21 RBC in 12 mobilised and 4 steady-state blood samples tested though highly correlated (R2¼0.97). Conversely, the flow-RBC, flow-HCT
Figure 1. Higher red cell product volume using a standard hematology analyser (KX21) compared to flow cytometric red cell assessment for different apheresis harvest types (n¼22).
and resulting product RBC volume were all lower than by KX21 HCT in all 22 apheresis products tested. The median (range) of harvest RBC volume was only 1.9 (0.2-5.4) ml by flow-HCT but 4.2 (1.7-12.2) ml using the KX21 HCT and the greatest discrepancies seen in the allogeneic products where the ratio of WBC:flow-RBC was twice that of the autologous products (median ratio 2.3:1 versus 1.1:1 respectively). Haematology analyser HCT calculation represents a maximum red cell volume but may significantly overestimate and exceed defined infusion limits. To confirm this or to validate apheresis machines and other processing procedures, red cell flow cytometry can provide a more accurate measurement.
80 RETROSPECTIVE ASSESSMENT OF THE POTENTIAL IMPACTS BONE MARROW PRODUCT QUALITY HAS ON UTILIZATION OF BONE MARROW AS A CELL SOURCE FOR TRANSPLANT NL Prokopishyn Calgary Laboratory Services, Calgary, AB, Canada Bone marrow (BM) was the original source of hematopoietic stem/progenitor cells (HSCs) used in allogeneic transplants. With the advent of G-CSF mobilization of
Donor Lymphocyte Infusions (DLI) are frequently used to enhance donor engraftment or treat relapse following allogeneic stem cell transplant. DLI can be collected unprimed (without prior G-CSF administration to donors) or as part of a hemopoietic stem cell collection following administration of G-CSF to the donor. We determined the factors that influence post-thaw viable CD3+ recovery of DLI cryopreserved during 2006 to 2011. DLI harvests were obtained from 42 related donors and 31 unrelated donors. G-CSF primed collections contained a higher percentage of granulocytes, a lower number of platelets and were cryopreserved at a higher cell concentration. Although recovery of total nucleated cells was improved after thawing of G-CSF primed products (100 v 88%, P<0.001), recovery of viable CD3+ cells was reduced (62% for unprimed collections compared with 49% for G-CSF primed, P<0.001; viable CD3+ counts 76.8 v 43.1 106/kg respectively, P<0.001). Multivariate analysis showed that the factors that significantly affected viable CD3+ recovery were: 1) harvest type: GCSF primed compared to unprimed: P<0.001; 2) Time to cryopreservation P¼0.002 for <10 hours compared to 10-24 hours and >24 hours. These 2 factors have been noted previously by our laboratory as also affecting viable CD34+ recovery. One factor that showed weak correlation with viable CD3+ recovery was the cryopreserved cell concentration for the unprimed (r2 ¼ 0.2, P¼0.0095), but not for G-CSF primed collections (r2 ¼0.015, P¼0.48). In conclusion, achieving adequate viable T cell doses for DLI infusions requires cryopreservation of over 108/kg CD3+ cells. Our lab makes allowance for thawing losses of around 30% to 50% when freezing DLIs. We have demonstrated that using G-CSF primed stem cell products and/or delaying time to cryopreservation can reduce viable T cell numbers upon thawing and may limit DLI doses available for infusion, particularly unrelated collections from overseas. 78 STEM CELL COLLECTION AND TRANSPLANT IN MYELOMA PATIENTS FOLLOWING LENALIDOMIDE OR BORTEZOMIB BASED INDUCTION THERAPY A Khot, K Stokes, T Joyce, C Coulson, P Gambell, M Darby, D Ritchie, M Prince, S Harrison Peter MacCallum Cancer Centre, East Melbourne, Australia Newer agents such as lenalidomide, an immunomodulatory drug and bortezomib, a proteasome inhibitor, have been introduced into myeloma front-line therapy, and are associated with improved rates and depth of response. Reports suggest a reduced capacity to collect adequate numbers of stem cells following lenalidomide based induction with GCSF only. We compare the outcomes of patients mobilised with cyclophosphamide and GCSF following lenalidomide or bortezomib based induction in our institution. Induction regimens were; lenalidomide 15-25 mg d1-21, dexamethasone 20 mg weekly 4, for 4 weekly cycles; or Bortezomib 1.3 mg/m2 SC on Days 1,4,8, and 11, cyclophosphamide 300 mg/m2 orally on Days 1, 8, and 15, and dexamethasone 20 mg orally on Days 1,2,4,5,8,9,11, and 12. The mobilization regimen for both cohorts was cyclophosphamide 2-4 gm/m2 followed by GCSF 10 mcg/kg from d+1. Cells were collected using either Cobe SpectraÒ or Sectra OptiaÒ apheresis devices and collections commenced when the CD34+ count in peripheral blood was 5 cells/ml. The target was 6-10106 CD34+ cells/kg to allow sufficient cells for 2 transplant procedures as per local protocol. 37 patients were collected following lenalidomide and 12 after bortezomib induction. There were no differences in the median number of stem cells collected (11.41 [range 2.91-40.6] vs 9.46106/kg [3.4-29.13]) following lenalidomide or bortezomib, or in the median number of collection days (3 [1-6] vs 2.5 [1-7]). 36 patients have undergone HSCT following lenalidomide and 8 after bortezomib induction. There were no differences in the median number of days to neutrophil (12 vs 11.5) or platelet (11 vs 11) engraftment following lenalidomide or bortezomib induction therapies. Our data suggest no difference in the ability to mobilise adequate numbers of HSCT following 4 cycles of lenalidomide or bortezomib based induction. To date, stem cell function appears similar in terms of platelet and neutrophil engraftment. These data will be updated. 79 THE RED CELL CONTENT OF APHERESIS PRODUCTS IS ROUTINELY OVERESTIMATED MJ Watts1, C Balsa1, A Pizzey2, S Ings1, A Antonio1 1 University College London Hospitals, London, United Kingdom, 2University College London, London, United Kingdom
S25
Following a series of severe and life-threatening reactions after the infusion of red cell replete cord blood units reported to the WMDA (BB-IND #7555) the red cell content of all products must be specified (JACIEv5.2 standard B.7.4.1). We routinely estimate the red cell volume of apheresis harvests as ‘Product Volume (ml) Blood Analyser HCT’ (Sysmex KX21). The RBC and MCV of impedance counters, though reliable for cord blood samples are known to be spuriously increased by high white cell counts such as in apheresis products. We used a Glycophorin A monoclonal antibody and quantitative flow cytometry to measure a ‘flow-RBC’ which when multiplied by the pre-harvest blood MCV gave a ‘flow-HCT’ without white cell interference. The flow-RBC was precise (CV<5%), consistently 4% higher than the KX21 RBC in 12 mobilised and 4 steady-state blood samples tested though highly correlated (R2¼0.97). Conversely, the flow-RBC, flow-HCT
Figure 1. Higher red cell product volume using a standard hematology analyser (KX21) compared to flow cytometric red cell assessment for different apheresis harvest types (n¼22).
and resulting product RBC volume were all lower than by KX21 HCT in all 22 apheresis products tested. The median (range) of harvest RBC volume was only 1.9 (0.2-5.4) ml by flow-HCT but 4.2 (1.7-12.2) ml using the KX21 HCT and the greatest discrepancies seen in the allogeneic products where the ratio of WBC:flow-RBC was twice that of the autologous products (median ratio 2.3:1 versus 1.1:1 respectively). Haematology analyser HCT calculation represents a maximum red cell volume but may significantly overestimate and exceed defined infusion limits. To confirm this or to validate apheresis machines and other processing procedures, red cell flow cytometry can provide a more accurate measurement.
80 RETROSPECTIVE ASSESSMENT OF THE POTENTIAL IMPACTS BONE MARROW PRODUCT QUALITY HAS ON UTILIZATION OF BONE MARROW AS A CELL SOURCE FOR TRANSPLANT NL Prokopishyn Calgary Laboratory Services, Calgary, AB, Canada Bone marrow (BM) was the original source of hematopoietic stem/progenitor cells (HSCs) used in allogeneic transplants. With the advent of G-CSF mobilization of