|
|
 Previous Article | Table of Contents | Next Article 
Blood, Vol. 93 No. 6 (March 15), 1999:
pp. 1858-1868
Multicenter Phase III Trial to Evaluate CD34+ Selected
Versus Unselected Autologous Peripheral Blood Progenitor Cell
Transplantation in Multiple Myeloma
By
Robert Vescio,
Gary Schiller,
A. Keith Stewart,
Oscar Ballester,
Stephen Noga,
Hope Rugo,
Cesar Freytes,
Edward Stadtmauer,
Stefano Tarantolo,
Firoozeh Sahebi,
Pat Stiff,
Jacinta Meharchard,
Robert Schlossman,
Randy Brown,
Heather Tully,
Mark Benyunes,
Cindy Jacobs,
Ronald Berenson,
John DiPersio,
Ken Anderson, and
James Berenson
From the West LA VAMC/University of California, Los
Angeles, Los Angeles, CA; The Toronto Hospital, Toronto, Ontario,
Canada; the University of South Florida, Miami, FL; Johns Hopkins
University, Baltimore, MD; the University of California, San Francisco,
San Francisco, CA; the University of Texas at San Antonio, San Antonio,
TX; the University of Pennsylvania, Philadelphia, PA; the University of
Nebraska, Omaha, NE; the Southern California Kaiser Permanente Medical
Group, Los Angeles, CA; Loyola University, Chicago, IL; the Washington
University School of Medicine, St Louis, MO; the Dana Farber Cancer
Institute, Boston, MA; and CellPro, Inc, Bothell, WA.
 |
ABSTRACT |
High-dose chemotherapy followed by autologous transplantation has
been shown to improve response rates and survival in multiple myeloma
and other malignancies. However, autografts frequently contain
detectable tumor cells. Enrichment for stem cells using anti-CD34
antibodies has been shown to reduce autograft tumor contamination in
phase I/II studies. To more definitively assess the safety and efficacy
of CD34 selection, a phase III study was completed in 131 multiple
myeloma patients randomized to receive an autologous transplant with
either CD34-selected or unselected peripheral blood progenitor cells
after myeloablative therapy. Tumor contamination in the autografts was
assessed by a quantitative polymerase chain reaction detection assay
using patient-specific, complementarity-determining region (CDR) Ig
gene primers before and after CD34 selection. A median 3.1 log
reduction in contaminating tumor cells was achieved in the CD34
selected product using the CEPRATE SC System (CellPro, Inc, Bothell,
WA). Successful neutrophil engraftment was achieved in all patients by
day 15 and no significant between-arm difference for time to platelet
engraftment occurred in patients who received an infused dose of at
least 2.0 × 106 CD34+ cells/kg. In
conclusion, this phase III trial demonstrates that CD34-selection of
peripheral blood progenitor cells significantly reduces tumor cell
contamination yet provides safe and rapid hematologic recovery for
patients receiving myeloablative therapy.
© 1999 by The American Society of Hematology.
| |
INTRODUCTION |
MULTIPLE MYELOMA is a fatal neoplasm in
which malignant plasma cells derived from a single transformed cell
(clone) accumulate in the bone marrow and produce an abundance of
monoclonal Ig. Although conventional therapy with oral melphalan and
prednisone has achieved remissions in approximately 40% of patients,
the disease remains incurable, with a median overall survival of 30 to
36 months.1-3 Attempts to improve overall survival have led to the evaluation of more aggressive, multiagent, conventional-dose chemotherapy regimens such as M2, VCMP, VBAP, and ABCM. Unfortunately, despite improved response rates, a meta-analysis of several prospective randomized trials showed no significant improvement in the survival of
patients treated with these multidrug regimens compared with standard
doses of melphalan and prednisone.4 Because the dose intensity of standard chemotherapy is often limited by hematologic toxicity, higher doses of chemotherapy followed by autologous bone
marrow transplantation have been attempted to improve upon myeloma cell
kill.5-8 High-dose melphalan followed by autologous bone
marrow transplantation was shown to improve response rates, disease-free survival, and overall survival in a randomized study when
compared with standard chemotherapy.9,10 However, the majority of myeloma patients treated with autologous bone marrow transplantation develop progressive disease within 3 years.
The use of peripheral blood progenitor cells (PBPCs) as the source of
hematopoietic stem cells has been evaluated as an alternative approach
to improve upon the efficacy of autologous transplantation in patients
with multiple myeloma.11-13 Several studies have
demonstrated that PBPCs can be used for autologous transplantation and
that restoration of hematopoiesis occurred more rapidly when compared with bone marrow stem cells.12,14-16 Furthermore, PBPCs can
be harvested without the use of general anesthesia. As a result, PBPCs
have become the preferred source for autografts in support of
myeloablative therapy.
Malignant cells have been detected in bone marrow harvests of patients
with multiple myeloma17,18 as well as in the peripheral blood and in the leukapheresis products.18-21 A recent
prospective study of 33 patients found an inverse correlation between
the monoclonal plasma cell concentration in leukapheresis or peripheral blood samples and disease-free survival.18 In this study,
the presence of  0.2 × 106 malignant plasma cells/L
was a significant predictor of early relapse. Because circulating tumor
cell numbers may simply reflect overall tumor burden, this finding does
not directly demonstrate that the reinfusion of circulating myeloma
cells contributed to disease recurrence. However, studies using gene
marking techniques and clonogenic tumor cell assays in other
malignancies suggest that tumor cells infused in an autologous graft
can contribute to relapse and affect overall outcome.22,23
Initial studies in patients with multiple myeloma evaluated ex vivo
purging of bone marrow harvests by incubation with cyclophosphamide derivatives or monoclonal B-cell antibodies.24-26 These
purging procedures substantially reduced autograft tumor burden yet
were associated with significant delays in engraftment. Because the malignant clone in myeloma does not express CD34,27 an
alternative approach for purging the autograft uses the positive
selection of stem cells using anti-CD34 antibodies. This method of
purging has the advantage of more widespread applicability among tumor types not expressing CD34 and eliminates the need to expose the autograft to potentially harmful agents.
Autologous transplantation using CD34-selected products can provide
effective hematopoietic support for patients receiving myeloablative
therapy.15,28,29 In a phase I/II study of 37 myeloma
patients, neutrophil engraftment (absolute neutrophil count
[ANC] >500/µL) and platelet (>20,000/µL)
engraftment were rapid (median of 12 days for both) provided that a
cell dose of at least 2 × 106 CD34+
cells/kg was reinfused. Tumor cell contamination was measured before
and after CD34 selection using a sensitive polymerase chain reaction
(PCR) assay based on the unique Ig heavy-chain variable region (VDJ)
sequence expressed by the myeloma cell clone. Tumor cells were detected
in 70% of the unmanipulated PBPC products. The CD34 selection using
the CEPRATE SC Stem Cell Concentration System (CellPro, Inc, Bothell,
WA) reduced the tumor cell contamination between 2.7 and 4.5 logs.15
A phase III, randomized study was conducted to more definitively
evaluate the tumor-purging capabilities of the CEPRATE SC System. Tumor
cell contamination of the autografts was quantified using a PCR-based
tumor detection assay.15,17 To determine the safety of CD34
selection using the CEPRATE SC System, hematologic recovery and
toxicity after autologous transplantation with either CD34 selected or
unselected PBPCs were compared.
| |
MATERIALS AND METHODS |
Study design.
From January 1995 to June 1996, 134 patients with multiple myeloma
between the ages of 18 and 70 years were enrolled in a phase III
open-label, randomized trial at 15 sites in North America, including
the University of California, Los Angeles (UCLA), The Toronto Hospital,
the Dana Farber Cancer Institute (DFCI), Washington University, the
University of South Florida, Johns Hopkins University, the University
of California, San Francisco (UCSF), the University of Texas at San
Antonio, the University of Pennsylvania, the Southern California Kaiser
Permanente Medical Group, the University of Nebraska, Baylor
University, the University of Arizona, and the University of
California, San Diego (UCSD). Data were analyzed as of January 1998. The study design was approved by the Institutional Review Boards of all
participating institutions and by the Food and Drug Administration
under an investigational device exemption (IDE). All patients gave
written informed consent to participate.
All patients had a diagnosis of multiple myeloma and were staged based
on the criteria developed by Durie and Salmon.30 Patients
were eligible for enrollment if they had evidence of one of the
following features at diagnosis or any time thereafter: (1)
intermediate to high M-component production rates (IgG 5 g/dL or IgA
3 g/dL or urine M-component 4 g/24 h); (2) more than one osteolytic
bone lesion, or radiographic evidence of diffuse osteoporosis; (3)
 -2 microglobulin 3 mg/L; and (4) nonsecretory myeloma if bone
marrow plasmacytosis was greater than 30%. Patients were required to
have stable or responsive disease after a minimum of three cycles of
chemotherapy. Patients who had received more than 3 months of
alkylator-based therapy and/or 6 months of any other prior
chemotherapy or disease progression at anytime were ineligible for
study entry. Patients who had a creatinine level 2 mg/dL, Karnofsky
performance status less than 70%, or other significant heart, lung, or
gastrointestinal dysfunction were ineligible. Randomization was
stratified by patient age (<55 or 55 years) and site.
Study schema.
Figure 1 shows a schema of the study.
Collection of autologous PBPCs occurred within 3 weeks of the
patient's evaluation for eligibility. The mobilization regimen
consisted of cyclophosphamide (2.5 g/m2) administered
intravenously on the first day of mobilization, prednisone (2 mg/kg/d)
administered orally on the first 4 days, and granulocyte
colony-stimulating factor (G-CSF; 10 µg/kg/d) administered
subcutaneously beginning on the second day and continuing until the
last day of leukapheresis.
View larger version (15K):
[in this window]
[in a new window]
| Fig 1.
Schema of study design. Eligible patients were
registered and PBPCs were mobilized. Before initiating
leukapheresis, patients were randomized to one of the two treatment
arms. All patients received high-dose chemotherapy followed by an
infusion of either CD34-selected or unselected PBPCs, with GM-CSF
administered posttransplant. The primary study period was completed at
6 months posttransplant with follow-up currently at 1 year
posttransplant. Additional follow-up is planned on a yearly basis.
|
|
Before leukapheresis, patients were randomized to receive CD34 selected
(the selected arm) or unselected PBPC (the unselected arm). After the
PBPC collection was completed, patients received a myeloablative
high-dose chemotherapy regimen consisting of busulfan and
cyclophosphamide. A total dosage of 14 mg/kg of busulfan (0.875 mg/kg
administered orally 4 times daily for 4 days on days  7 to
4) and 120 mg/kg of cyclophosphamide (60 mg/kg administered intravenously daily for 2 days on days 3 and 2) was
administered to all patients as in the previous phase I/II
study.15 Patients received the thawed CD34 selected or
unselected products 2 days after the last infusion of cyclophosphamide.
To speed hematologic recovery, granulocyte-macrophage
colony-stimulating factor (GM-CSF) at 250 µg/m2 (maximum
of 500 µg) was administered daily until the patient's ANC was at
least 1,000/µL for 2 consecutive days. Each site used its own
standardized supportive care protocols for patients on both arms of the study.
According to the protocol, the first 58 patients (28 selected arm and
30 unselected arm) began leukapheresis no sooner than day 15 of PBPC
mobilization and had to have a white blood cell (WBC) count
1,000/µL on two occasions more than 24 hours apart and a platelet
count 30,000/µL. The day 15 start date was chosen for scheduling
convenience and was based on successful stem cell collection in the
phase II protocol using this schema. Because of concerns that the peak
of circulating CD34+ cells was being missed before day 15, possibly because these patients were less heavily pretreated, the
remaining 76 patients (39 selected arm, 34 unselected arm, and 3 patients not randomized) began leukapheresis as soon as the hematologic
parameters outlined above were met. Leukapheresis was performed daily
until at least 5.0 × 108 total nucleated cells/kg
were obtained (minimum of 2 days). For patients randomized to receive a
CD34 selected autograft, there was an additional stopping criterion of
at least 4.0 × 106 nucleated cells/kg in the selected
product after processing on the CEPRATE SC System. This criterion was
based on the assumption that the selected product would contain at
least 50% CD34+ cells; thus, patients would receive an
infused CD34+ cell dose of at least 2 × 106 cells/kg.
Study endpoints.
There were two primary study endpoints. The primary efficacy endpoint
was a reduction of tumor cell contamination in the PBPC product after
processing with the CEPRATE SC System. Success was defined as greater
than a 2 log reduction in the number of contaminating tumor cells. The
primary safety endpoint was successful neutrophil engraftment (the
first day of two consecutive ANCs 500/µL after the nadir) on or
before day 14 after stem cell infusion. There were other secondary
endpoints, including the following: number of tumor cells infused;
infusion-related toxicities; time to neutrophil engraftment; time to
platelet engraftment (7 consecutive days of platelet transfusion
independence) and platelet recovery (platelet count 20 × 103/µL and platelet transfusion independence for at least
7 days); the number of patients with bleeding episodes, infections, and adverse events; days of hospitalization; number of red blood cell (RBC)
or platelet transfusions; and long-term engraftment and immune
reconstitution posttransplant. The rate of progression-free survival
was another secondary endpoint. Although the data are immature,
progression-free and overall survival at 1 year posttransplant is presented.
Leukapheresis, processing, and cryopreservation.
Autologous PBPCs were procured by continuous flow leukapheresis using a
Cobe Spectra (Cobe, Lakewood, CO). Blood volume processed per run was
10 L. Patients randomized to receive unselected PBPCs each had
individual leukapheresis products cryopreserved in 10% dimethyl
sulfoxide (DMSO) by control-rated freezing and stored in the vapor
phase of liquid nitrogen. Patients randomized to receive CD34-selected
PBPCs had each individual leukapheresis products selected using the
CEPRATE SC System, as previously described15 following the
manufacturer's protocol. The CD34-selected PBPCs were then
cryopreserved in 7.5% DMSO by control-rated freezing and stored in the
vapor phase of liquid nitrogen. For all patients receiving
CD34-selected PBPCs, the CD34-depleted fraction was cryopreserved for
backup in the event of graft failure.
Flow cytometry and colony-forming unit (CFU) analysis.
Samples were analyzed by Cytometry Associates, Inc (Brentwood, TN)
using fluorochrome-conjugated monoclonal antibodies and a flow
cytometer. Briefly, samples from the leukapheresis product, CD34-selected product, and the CD34-depleted product were incubated with anti-CD14 monoclonal antibody conjugated with fluorescein isothiocyanate (CD14-FITC) and with either anti-CD34 monoclonal antibody (CD34-PE) or an isotypic control (MsIgG-PE) conjugated with
phycoerythrin. In addition, the cells were stained with 7-Actinomycin D
(7-AAD) to assess viability. After acquisition of data from the flow
cytometer, the CD34+ cells were identified based on Boolean
gating of light scatter, viability, and absence of CD14 expression. The
percentage of positive CD34+ cells was calculated by
dividing the number of CD34+ events, derived from the above
gating strategy, by the total nucleated cells acquired and multiplying
this result by 100.
The culture and enumeration of CFU (including granulocyte-macrophage,
granulocyte-erythroid-monocyte-macrophage, and burst-forming unit-erythroid colonies) were performed by each site using standard media and procedures.29
Myeloma Ig gene identification.
The Ig heavy chain variable region (VH) or light chain
(light chain only secreting tumors) variable region (VL)
sequence expressed by the myeloma clone was determined using a bone
marrow aspirate obtained from each patient at study entry, not at
diagnosis. When present, the predominant, appropriately sized PCR
product was excised from an agarose gel impregnated with ethidium
bromide, cloned, and sequenced by methods previously
described.15,17 A minimum of three identical clones of five
was required to assign an Ig sequence to the myeloma cell.
Assessment and quantification of tumor contamination.
Tumor contamination was determined using a PCR assay as previously
described in the phase I/II study.15,17 Briefly, DNA was
extracted from bone marrow and peripheral blood mononuclear cells,
unselected leukapheresis products, and CD34-selected and CD34-depleted
PBPCs products using standard techniques and quantitated using a
fluorometer (Hoeffer Scientific, San Francisco, CA). The VH
and VL myeloma gene sequences were compared (DNAsis;
Hitachi, San Bruno, CA) with known germline gene
segments.31,32 Patient-specific oligonucleotides (Operon,
Alameda, CA) were designed complementary to the most unique sequences
in the sense (CDR1 or CDR2) and antisense orientation (CDR3). PCR
conditions were optimized using the PCR Optimizer Kit (Invitrogen, San
Diego, CA) on bone marrow DNA diluted 100-fold with 0.6 µg of
placental DNA. Sixty cycles of amplification were performed with Taq
polymerase and Taq antibody.
To quantify the tumor cell contamination, multiple PCR reactions were
performed with sample DNA serially diluted in 0.5 log increments with
placental DNA. Five reactions were performed at each serial dilution
until PCR products were no longer detectable. Tumor contamination was
calculated by a Poisson distribution analysis of positive and negative
reactions at each serial dilution.15,17,33 Amplification of
tubes containing a diluted bone marrow specimen (positive), placental
DNA (negative), and water only (negative) using the patient-specific
primers served as controls for each assay. To reduce assay-to-assay
variability, the leukapheresis product and CD34-selected product
collected from the same patient were amplified simultaneously in the
same PCR machine. All PCR products were electrophoresed through
ethidium bromide-impregnated agarose gels, photographed, and scored in
triplicate by technicians blinded to sample identification.
The validation of the PCR tumor detection assay and statistical
derivation of the tumor cell contamination has been reported previously
in the phase I/II study.15,17
Immune reconstitution.
The process of enriching for stem cells by CD34 selection passively
removes lymphocytes from the PBPC collection and may potentially impact
immune reconstitution. To determine whether immune function was more
significantly impaired in those patients who received a CD34-selected
autograft, lymphocyte immunophenotyping and quantitative Ig levels were
performed at the premobilization, day-100, 6-month, and 1-year
posttransplant visits.
Statistical methods.
An intent-to-treat primary analysis of engraftment (safety) and tumor
purging (efficacy) was performed that included all eligible and
randomized patients. Patients who did not engraft their neutrophils (ANC 500) on or by day 14 after transplant and randomized patients not infused were considered engraftment failures. Comparisons between
the treatment arms in terms of the demographic, baseline, efficacy, and
safety data were performed using the two-sample t-test or
Wilcoxon rank sum test for continuous data and Fisher's Exact Test
(FET) for categorical data. Time to engraftment, survival time, and
progression-free survival time were calculated from the date of
transplant and summarized using Kaplan-Meier curves.34 The
treatment arms were compared using the Cox proportional hazards model.
Multiple regression with stepwise variable selection was used in the
analyses of factors influencing time to engraftment.
| |
RESULTS |
Patient demographics.
Between January 1995 and June 1996, 134 patients were enrolled at 15 sites throughout North America. Three patients were not randomized; one
patient elected to receive an allogeneic transplant, another patient
died before randomization, and the third developed disease progression
before randomization. There were 131 patients randomized in the
intent-to-treat population, and 130 patients underwent transplantation.
One patient had inadequate mobilization of stem cells and did not
proceed to transplant; this patient had been randomized on the trial
and is included in the primary analyses. The treatment arms were
similar at the time of the premobilization visit with respect to
performance and disease status, -2 microglobulin levels, and the
number of previous cycles of chemotherapy. There was a significantly
higher proportion of females in the selected arm (45% v 27%,
P = .030; Table 1). The only other
baseline characteristics that differed significantly between the
treatment arms were a lower median CD4/CD8 ratio, platelet, and WBC
counts (1.3 v 1.7, P = .032; 110 v
152 × 103/µL, P = .002; 15.9 v 26.2 × 103/µL, P = .042, respectively)
for patients in the selected arm at the time of randomization (Table 1
and see Table 6).
Stem cell collection and enrichment.
A median of two leukaphereses were required for both treatment arms to
reach the target of 5 × 108 nucleated cells/kg.
However, 18 of the 67 patients in the selected arm required an
additional leukapheresis to meet the second criterion of 4 × 106 nucleated cells/kg in the selected product.
Consequently, the mean number of leukaphereses required for patients in
the selected arm was 3.0 (range, 2 to 8) versus 2.3 for patients in the
unselected arm (range, 2 to 6; P = .002).
The median number of CD34+ cells in the leukapheresis
product before processing was 10.13 and 8.67 × 106/kg
for the selected and the unselected arms, respectively (P = .253). After enrichment, the median number of CD34+ cells
was 5.40 × 106/kg in the selected arm for a median
CD34+ cell yield of 52%. The median purity of
CD34+ cells was 0.9% before CD34 selection and 66.4%
after selection. As expected, the patients in the selected arm had
significantly fewer nucleated cells/kg (P < 0.001) and
CD34+ cells/kg (P = .012) infused than did the
patients in the unselected arm (Table 2).
The median number of CD34 cells in the cryopreserved backup stem cell
product (CD34-depleted product) was 2.78 × 106
CD34+ cells/kg.
There were no significant differences between the treatment arms in
terms of CFU/kg either before or after CD34 selection (P = .287). The median number of CFU per kilogram infused was 53.5 × 104/kg in the selected arm and 102.4 × 104/kg in the unselected arm.
Tumor purging efficacy of the CEPRATE SC System.
Bone marrow samples were obtained from every patient at the time of
study registration. A minimum of 3 months of prior chemotherapy was
required, potentially affecting the ability to identify the clonal Ig
sequences. A clonal Ig sequence was able to be identified and used in
the analysis for 47 patients: 28 (42%) in the selected arm and 19 (30%) in the unselected arm. A clonal Ig sequence was not identified
for 81 patients (36 in the selected arm and 45 in the unselected arm)
for the following reasons: normal SPEP and UPEP at study entry (22),
ineffective (19) or polyclonal (24) Ig gene amplification, and
inadequate (12) or unavailable (4) BM specimens. In addition, there
were 3 patients that had clonal Ig gene sequences identified who were
not included in the analyses: for 2 patients, PCR conditions could not
be adjusted to specifically amplify only the myeloma Ig gene product,
and 1 patient did not have samples obtained from leukapheresis products.
There were no detectable tumor cells in the initial leukapheresis PBPC
product of 4 patients in each treatment arm (14% in the selected arm
and 21% in the unselected arm; see Table 4). A median of 2.6 × 106 and 2.3 × 106 tumor cells was
detected in the initial leukapheresis product of patients in the
selected and unselected arms, respectively (Table 3). The primary efficacy endpoint of
the study was a greater than 2 log reduction in tumor cell
contamination after CD34 selection using the CEPRATE SC
System. This was evaluated in 24 patients in the selected arm for whom
a clonal Ig sequence could be identified and who had detectable tumor
cells in the PBPC product before CD34 selection
(Fig 2). Of the 24 patients with detectable
tumor cells in this PBPC product, 11 (46%) had no detectable tumor
cells in the CD34-selected product. To estimate the log depletion of tumor cells for these patients, the minimal detection limit was used
for the percentage of tumor cells, after CD34 selection in the
calculations. Thus, the mean and median log depletion of tumor cells
may be underestimated. A median 3.10 log (mean, 3.29 log) depletion of
tumor cells was achieved by the CEPRATE SC System in the selected arm
(range, 1.56 to 6.02 logs). Moreover, the number of tumor cells infused
was significantly lower in the selected arm (median, 0; range, 0 to 1.2 × 106) compared with the unselected arm (median, 2.3 × 106; range, 0 to 930 × 106; Table
3). Overall, the number of patients who received an autograft with no
detectable tumor cells was also significantly greater in the selected
arm (54% v 21%, P = .036;
Table 4).
View larger version (30K):
[in this window]
[in a new window]
| Fig 2.
Depletion of tumor cells from first
leukapheresis. Tumor contamination was determined in the PBPC product
before and after CD34 selection. The number of tumor cells was
calculated as the product of the total number of nucleated cells and
the percentage of tumor cells detected. The figure represents the log
number of tumor cells detected in the 24 of 28 patients (86%) in the
CD34-selected arm with detectable tumor cells in the first
leukapheresis. For those products purged below the detection level of
the assay, the line intersects 0 on the x-axis (no detectable tumor
cells). Only 2 of the 24 patients had their autografts purged of tumor
cells by less than 2 logs (dashed lines).
|
|
Hematologic recovery and toxicity.
Successful neutrophil engraftment (ANC 500/µL) by day 14 was
achieved by 63 of 67 patients (94%) in the selected arm and all 64 patients in the unselected arm. Three of the 4 patients in the selected
arm who did not achieve neutrophil engraftment by day 14 engrafted on
day 15. The fourth patient was not transplanted because of an
inadequate stem cell collection but was included in the intent-to-treat
analysis as an engraftment failure. The median time to neutrophil
engraftment was 12 days for both arms (Table 5).
Secondary safety endpoints assessed the times to platelet engraftment
and recovery as well as RBC and platelet transfusions. Although all
patients achieved platelet engraftment, the times to platelet
engraftment and recovery were statistically significantly longer in the
selected arm (median of 11 days for both platelet engraftment and
recovery) than in the unselected arm (median of 9 and 10 days for
platelet engraftment and recovery, respectively; P = .003 and
P = .004; Table 5). In addition, the number of platelet transfusion events per patient was significantly greater in the selected arm (median, 3; range, 0 to 26) than in the unselected arm
(median, 2; range, 0 to 24; P = .011; Table 5). The median number of RBC transfusions was comparable for both arms (median, 4 U;
P = .21; Table 5).
Multiple regression analysis of factors potentially influencing the
time to platelet engraftment and recovery showed that the number of
CD34+ cells per kilogram in the infused product and the
platelet count at the time of randomization had significant
(P  .01) effects on both platelet engraftment and
recovery. Additionally, the WBC count at the premobilization visit had
a significant (P = .048) effect on time to platelet
engraftment. Both platelet count and WBC count at randomization were
significantly lower in the selected arm compared with the unselected
arm. When the 108 patients (55 in the selected arm and 53 in the
unselected arm) who received a dose of at least 2.0 × 106 CD34+ cells/kg (target dose suggested by
protocol and based on the phase I/II study15) were
compared, there were no significant differences between the arms in
time to platelet engraftment (Fig 3), time
to platelet recovery, or number of platelet transfusion events.
View larger version (21K):
[in this window]
[in a new window]
| Fig 3.
Kaplan-Meier probability of achieving
platelet engraftment for the patients who received at least 2 × 106 CD34+ cells/kg in the infused product. Of
the 130 patients infused, the number of CD34+ cells per
kilogram was not assessed in 5 patients and were less than 2 × 106 CD34+ cells/kg for 17 patients.
For the remaining 108 patients with at least 2 × 106
CD34+ cells/kg infused, probabilities of the time to
achieve platelet engraftment (transfusion independence) were the same
for the unselected arm (n = 53) and the selected arm (n = 55).
Similar results occurred for the probabilities of the time to achieve
platelet recovery.
|
|
Adverse events.
The percentage of patients with at least one episode of hypertension
during the 24-hour posttransplant period was significantly higher in
the unselected arm (53%) than in the selected arm (33%; P = .023). The percentage of patients with at least one episode of
bradycardia during the 24-hour posttransplant period was higher in the
unselected arm (9%) compared with the selected arm (2%; P = .060). Other than these two specific events, the incidence of adverse
events was similar between the arms. No significant differences were
detected between the treatment arms for days of posttransplant
hospitalization, percentage of patients rehospitalized, days of
rehospitalization, the percentage of patients with at least one
bleeding event, or number of bleeding events (Table 5). One patient in
the CD34-selected arm received the backup CD34-depleted product on day
119 posttransplant due to a failure to achieve platelet recovery,
although the patient was platelet transfusion independent. In
retrospect, this patient was ineligible for the study due to
progressive disease before mobilization and received an autograft
containing only 1.7 × 106 CD34+ cells/kg.
The platelet count remained less than 20 × 103/µL
after receipt of the CD34-depleted product.
Immune reconstitution/infections/hospital days.
Patients randomized to the selected arm had a significantly lower
baseline CD4/CD8 ratio and this difference persisted posttransplant at
the day-100, 6-month, and 1-year time points
(Table 6). Although the CD4 lymphocyte
count was not significantly different at baseline, it was significantly
lower in the selected arm at the day-100 and 6-month visits (211 v 298 cells/µL, P = .003; and 261 v 314 cells/µL, P = .018, respectively). By the 1-year visit there
was no significant difference in the median CD4+ lymphocyte
count between the arms. The median CD3+, CD8+,
CD56+, and CD19+ lymphocyte counts were not
significantly different between the arms at more than one of the
evaluation time points. There was no significant difference between the
selected arm and the unselected arm with respect to IgA, IgM, or IgG
levels by the day-100, 6-month, or 1-year visits.
There were no significant differences between the treatment arms in the
number of patients with infections or the type of infections during the
transplant (day 0 to 100) or posttransplant (after day 100) periods and
neither were there differences in days of hospitalization (Table 5).
Clinical response, progression-free survival, and overall survival.
Disease status and survival were assessed at the day-100, 6-month, and
1-year follow-up visits. The percentage of patients in complete
remission (CR), defined by a lack of detectable monoclonal protein on
serum and urine immunoelectrophoresis and less than 5% plasma cells
within the bone marrow, was 28% at 1 year. At study enrollment, twice
as many patients in CR were randomized to receive an unselected
transplant (16% v 8%; P = .17). This ratio persisted
throughout the study with CR rates two to three times as high for
patients receiving an unselected product (arm B). The CR rates at day
100, 6 months, and 1 year were 11%, 14%, and 18% for patients on arm
A, versus 29%, 35%, and 38% for patients on arm B, respectively,
with only the first two time points being statistically significant.
There were 2 transplant-related deaths before day 100 in the unselected
arm (infection on day 14 and veno-occlusive disease [VOD] on day 68 posttransplant) and none in the selected arm. At 1 year, 19 of 66 patients (29%) in the selected arm and 21 of 64 patients (33%) in the
unselected arm had progressed or died. Although these data remain
immature, there is no apparent difference between the two treatment
arms with respect to progression-free survival
(Fig 4) and overall survival at 1 year
posttransplant.
View larger version (21K):
[in this window]
[in a new window]
| Fig 4.
Kaplan-Meier probability of progression-free survival
based on data as of January 1998. The probabilities of the time to
progression as of 1 year posttransplant were the same for patients on
the unselected arm and the selected arm.
|
|
| |
DISCUSSION |
This study represents the first controlled, randomized phase III trial
comparing the use of CD34-selected versus unselected peripheral blood
autografts for transplantation in patients undergoing high-dose
chemotherapy. Because autografts collected from patients with multiple
myeloma,8,15,17,20 breast cancer35,
non-Hodgkin's lymphoma,27 and other malignancies have been
found to contain malignant cells, methods to remove these undesirable
cells have been developed in the hope that such a step could improve
patient outcome. Although the contribution of these contaminating cells remains to be definitively determined, recent studies suggest that
these cells may promote disease relapse. In one study, bone marrow
autograft cells collected from patients with acute myeloid leukemia
(AML) undergoing high-dose chemotherapy were marked with the neomycin resistance gene. Of the 12 patients assessed, 4 subsequently relapsed and the neomycin resistance gene was detectable
within the leukemic cells in 3 of these patients (neomycin gene
presence was indeterminate in the fourth patient).22
Studies completed by Sharp et al23
demonstrated an increased relapse rate for those patients reinfused
with morphologically appearing normal bone marrow but containing
clonogenic lymphoma cells after in vitro culture.29
Finally, relapse rates for non-Hodgkin's lymphoma patients were
significantly higher for those patients with autografts incompletely
purged by the use of anti-B-cell antibodies and
complement.24,36 Whereas the results obtained from the
latter study could be explained by an inherent property of the
malignancy that made tumor purging less effective or simply reflect
total body tumor burden, the study of AML patients convincingly
demonstrates that malignant cells within the autograft can survive and
grow within a patient after reinfusion.
Our study of 131 randomized patients with multiple myeloma demonstrated
that the CEPRATE SC System effectively purged the autografts without
compromising hematopoietic recovery after myeloablative therapy. For
patients randomized to the selected arm, the median number of tumor
cells in the autograft was 3.3 logs lower than the median for their
counterparts in the unselected arm. In addition, the true efficiency of
the purging procedure is underestimated, because the CD34-selected
products without detectable tumor cells were assumed to have tumor cell
contamination at the lower limit of detection for the assay. In fact,
in the majority of patients, the autografts had no detectable tumor
cells after CD34 selection (Table 4).
The purging efficiency reported in this study is similar to results
reported in the published literature of multiple myeloma patients
receiving a CD34-selected autograft using the CEPRATE SC
System.15,28,37-40 In the studies that quantified the level of tumor cell depletion, a greater than 2.5 log depletion of tumor cells was commonly observed.15,28,40 Similar studies
evaluating the results of tumor cell depletion using the CEPRATE SC
System for patients with non-Hodgkin's lymphoma and breast cancer
yielded comparable results.35,41-43
Whereas phase II studies evaluating tumor cell purging methods that
treated the autografts with either antibody plus complement or
cyclophosphamide derivatives have demonstrated equally efficient purging, these procedures appear to substantially prolong engraftment times. In contrast, CD34 selection of the autograft using the CEPRATE
SC System appears safe. The median time to neutrophil engraftment was
12 days for patients in both arms of this study and all patients who
received a transplant in the trial achieved an ANC of 500 by day 15. These results are consistent with other large studies of autologous
PBPC transplantation whereby 97% to 100% of patients achieved
neutrophil engraftment after treatment with either unselected
PBPCs44-46 or CD34-selected PBPCs.37,47-49 Furthermore, the median 12-day engraftment is comparable to previous studies using the CEPRATE SC System.47-50
Median times to platelet engraftment and recovery were slightly
prolonged for patients receiving a CD34-selected transplant. Although
this 1- to 2-day difference was statistically significant, there was no
clinical impact as measured by an increased incidence of bleeding
events or RBC transfusions in the patients who received a CD34-selected
autograft. Additional analyses determined that two factors influenced
the posttransplant platelet engraftment and recovery time: the platelet
count at the time of randomization (immediately before leukapheresis)
and the infused cell dose of CD34+ cells. Patients
receiving a cell dose less than 2 × 106
CD34+ cells/kg (n = 11 in each arm) were at increased risk
for a delay in time to platelet engraftment and recovery, regardless of
treatment arm. However, there was no significant delay in the time to
platelet engraftment and recovery for patients in the selected arm who received at least 2 × 106 CD34 + cells/kg (Fig 3).
These results suggest that CD34+ cell dose, and not
processing with the CEPRATE SC System, was the main factor influencing
time to platelet engraftment. Furthermore, these results are consistent
with other studies reporting threshold doses of CD34+ cells
required for rapid platelet engraftment,44-48 including the
phase I/II study in multiple myeloma that established a threshold dose
of 2 × 106 CD34+ cells/kg.15
We were unable to establish a minimum CD34+ cell dose that
affected neutrophil engraftment, because all transplanted patients had
neutrophil engraftment by day 15 postinfusion. Furthermore, there was
no indication that there were significant decreases in time to
neutrophil engraftment in patients receiving CD34+ cell
doses greater than 2 × 106/kg.
Recently, there has been a concern regarding a potential detrimental
effect of CD34 selection on the recovery of immune function. The
clinical manifestation of delayed recovery of immune function is an
increase in the incidence of infections. Despite the presumptive median
2.6 log elimination of lymphocytes by the CEPRATE SC System, there were
no significant differences in the incidence or type of infections
between the patients who received a CD34-selected autograft compared
with patients who received an unselected graft. Additional clinical
parameters evaluated in the study supported the safety of CD34
selection with the CEPRATE SC System. These results are in contrast to
a recently published report using a different CD34 selection method in
which patients had delayed engraftment and immune
reconstitution.51 Furthermore, patients receiving a
CD34-selected graft demonstrated a significantly lower incidence of
diastolic hypertension in the 24 hours after transplantation that
likely resulted from the reduced cell debris and quantity of DMSO
contained within the selected autograft and subsequently reinfused to
the patient.
In summary, this study showed that CD34 selection effi-ciently purged
contaminating tumor cells from peripheral blood autografts in patients
with multiple myeloma without adversely affecting the ability of the
hematopoietic stem cells to restore hematopoiesis. In particular, when
at least 2 × 106 CD34+ cells/kg were
infused, times to neutrophil and platelet engraftment were not
significantly affected by the selection procedure. Patients receiving a
CD34-selected autograft also had a lower incidence of toxicities
associated with the autograft infusion and had no greater incidence of
infections or bleeding events when compared with patients receiving an
unselected autograft.
Further follow-up of the patients enrolled and transplanted on this
trial will be required to determine whether tumor purging by CD34
selection will have a significant effect on progression-free and
overall survival for multiple myeloma patients, although this study may
not be sufficiently powered to detect a small but still clinically
relevant difference. In the absence of larger randomized phase III
trials, tumor purging, as a component of a combined treatment strategy,
may be a more important issue to be addressed in clinical studies. To
that end, the CEPRATE SC System can provide efficient tumor removal
without compromising hematopoietic recovery.
| |
ACKNOWLEDGMENT |
The authors thank Drs Mike White, Monica Krieger, and Amy Sing for
their editorial contributions and Donna Speron for her assistance in
the preparation of this manuscript.
| |
FOOTNOTES |
Submitted June 11, 1998; accepted October 30, 1998.
Supported in part by a grant from CellPro, Inc (Bothell, WA).
The publication costs of this
article were defrayed in part by
page charge payment. This article
must therefore be hereby marked
"advertisement"
in accordance with 18 U.S.C. section
1734 solely to indicate this fact.
Address reprint requests to Robert Vescio, MD, University of
California, Los Angeles, 111-H West LA VAMC, 11301 Wilshire Blvd, Los
Angeles, CA 90073.
| |
REFERENCES |
1.
Kyle RA:
Newer approaches to the management of multiple myeloma.
Cancer
72:3489, 1993[Medline]
[Order article via Infotrieve]
2.
Alexanian R, Dimopoulous M:
The treatment of multiple myeloma.
N Engl J Med
330:484, 1994[Free Full Text]
3. Imamura Y, Takagi T, Yawata Y, Nishinarita S, Kosaka M, Mikuni C,
Takatsuki K, Sezaki T, Mori M: Combination chemotherapy with MCNU,
vindesine, melphalan, and prednisolone (MCNU-VMP therapy) in induction
therapy for multiple myeloma. Int J Hematol 59:1994
4.
Gregory WM, Richards MA, Malpas JS:
Combination chemotherapy versus melphalan and prednisolone in the treatment of multiple myeloma: An overview of published trials.
J Clin Oncol
10:334, 1992[Abstract]
5.
Jagannath S, Vesole DH, Tricot G, Crowley J, Salmon SE, Barlogie B:
Hematopoietic stem cell transplantations for multiple myeloma.
Oncology
8:89, 1994[Medline]
[Order article via Infotrieve]
6.
Harousseau JL, Milpied N, Laporte JP, Collombat P, Facon T, Tigaud JD, Cassassus P, Gilhot F, Ifrah N, Gandhour C:
Double-intensive therapy in high-risk multiple myeloma.
Blood
79:2827, 1992[Abstract/Free Full Text]
7.
Bjorkstrand B, Ljungman P, Brandt TL, Brunet S, Carlson K, Cavo M, Fassas A, Ferrant A, Goldstone AH, DeLaurenzi A, Prentice HG, Remes K, Samson D, Verdonck LF, Gahrton G:
Autologous stem cell transplantation (ASCT) in multiple myeloma. A study of the Europeon BMT registry.
Blood
84:535a, 1994 (abstr, suppl 1)
8.
Fermand JP, Chevret S, Ravaud P, Divine M, Leblond V, Dreyfus F, Mariette X, Brouet JC:
High-dose chemoradiotherapy and autologous blood stem cell transplantation in multiple myeloma: Results of phase II trial involving 63 patients.
Blood
82:2005, 1993[Abstract/Free Full Text]
9.
Attal M, Huguert F, Schlaifer D, Payen C, Laroche M, Fournie B, Mazieres B, Pris J, Laurent G:
Intensive combined therapy for previously untreated aggressive myeloma.
Blood
79:1130, 1992[Abstract/Free Full Text]
10.
Attal M, Harousseau JL, Stoppa AM, Sotto JJ, Fuzibet JG, Rossi JF, Cassassus P, Maisonneuve H, Facon T, Ifrah N, Payen C, Bataille R:
A prospective, randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma patients.
N Engl J Med
335:91, 1996[Abstract/Free Full Text]
11.
Marit G, Faberes C, Pico JL, Boiron JM, Bourhis JH, Brault P, Bernard P, Foures C, Cony-Makhoul, Puntous M, Vezon G, Broustet A, Girualt D, Reiffers J:
Autologous peripheral-blood progenitor cell support following high-dose chemotherapy or chemoradiotherapy in patients with high-risk multiple myeloma.
J Clin Oncol
14:1306, 1996[Abstract/Free Full Text]
12.
Dimopoulous M, Alexanian R, Przepiorka D, Hester J, Andersson B, Giralt S, Mehra R, vanBesien K, Delasalle KB, Reading C, Deissseroth AB, Champlin RE:
Thiotepa, busulfan, and cyclosphosphamide: A new preparative regimen for autologous marrow or blood stem cell transplantation in high-risk multiple myeloma.
Blood
82:2324, 1993[Abstract/Free Full Text]
13.
Jagannath S, Vesole DH, Glenn L, Crowley J, Barlogie B:
Low-risk intensive therapy for multiple myeloma with combined autologous bone and blood stem cell support.
Blood
80:1666, 1992[Abstract/Free Full Text]
14.
Schiller G, Nimer S, Vescio R, Lieb G, Lee M, Gajewski J, Territo M, Berenson J:
Phase I-II study of busulfan and cyclophosphamide conditioning for transplantation in advanced multiple myeloma.
Bone Marrow Transplant
14:131, 1994[Medline]
[Order article via Infotrieve]
15.
Schiller G, Vescio R, Freytes C, Spitzer G, Sahebi F, Lee M, Wu CH, Cao J, Lee JC, Hong CH, Lichtenstein A, Lill M, Hall J, Berenson R, Berenson J:
Transplantation of CD34+ peripheral blood progenitor cells after high-dose chemotherapy for patients with advanced multiple myeloma.
Blood
36:390, 1995[Abstract/Free Full Text]
16.
Korbling M, Przepiorka D, Huh YO, Engel H, vanBesien K, Giralt B, Andersson B, Kleine HD, Seong D, Deisseroth AB, Andreef M, Champlin R:
Allogenic blood stem cell transplantation for refractory leukemia and lymphoma: Potential advantage of blood over marrow allografts.
Blood
85:1659, 1995[Abstract/Free Full Text]
17.
Vescio R, Han EJ, Schiller GJ, Lee JC, Wu CH, Cao J, Shin J, Kim A, Lichtenstein AK, Berenson JR:
Quantitative comparison of multiple myeloma tumor contamination in bone marrow harvest and leukapheresis autografts.
Bone Marrow Transplant
18:103, 1996[Medline]
[Order article via Infotrieve]
18.
Gertz MA, Witzig TE, Pineda AA, Greipp P, Kyle RA, Litzow MR:
Monoclonal plasma cells in the blood stem cell harvest from patients with multiple myeloma are associated with shortened relapse-free survival after transplantation.
Bone Marrow Transplant
337:19, 1997
19.
Berenson J, Wong R, Kim K, Brown N, Lichtenstein A:
Evidence for peripheral blood B lymphocyte but not T lymphocyte involvement in multiple myeloma.
Blood
70:1550, 1987[Abstract/Free Full Text]
20.
Billadeau D, Quam L, Thomas W, Kay N, Greipp P, Kyle R, Oken MM, VanNess B:
Detection and quantitation of malignant cells in the peripheral blood of multiple myeloma patients.
Blood
80:1818, 1992[Abstract/Free Full Text]
21.
Pilarski LM, Jensen GS:
Monoclonal circulating B cells in multiple myeloma. A continously differentiating, possibly invasive, population as defined by expression of CD45 isoforms and adhesion molecules.
Hematol Oncol Clin North Am
6:297, 1992[Medline]
[Order article via Infotrieve]
22.
Brenner MK, Rill DR, Moen RC, Krance RA, Mirro J Jr, Anderson WF, Ihle JN:
Gene-marking to trace origin of relapse after autologous bone-marrow transplantation.
Lancet
341:85, 1993[Medline]
[Order article via Infotrieve]
23.
Sharp JG, Kessinger A, Mann S, Crouse DA, Armitage JO, Bierman P, Weisenburger DD:
Outcome of high-dose therapy and autologous transplantation in non-Hodgkin's lymphoma based on the presence of tumor in the marrow or infused hematopoietic harvest.
J Clin Oncol
14:214, 1996[Abstract]
24.
Gribben JG, Freedman AS, Neuberg D, Roy DC, Blake KW, Woo SD, Grossbard ML, Rabinowe SN, Coral F, Freeman GJ, Ritz J, Nadler LM:
Immunologic purging of marrow assessed by PCR before autologous bone marrow transplantation for B-cell lymphoma.
N Engl J Med
325:1525, 1991[Abstract]
25.
Anderson KC, Barut BA, Ritz J, Freedman AS, Takvorian T, Rabinowe SN, Soiffer R, Heflin L, Coral F, Dear K, Mauch P, Nadler LM:
Monoclonal antibody-purged autologous bone marrow transplantation therapy for multiple myeloma.
Blood
77:712, 1991[Abstract/Free Full Text]
26.
Reece DE, Barnett MJ, Connors JM, Klingemann H, O'Reilly SE, Shepherd JD, Sutherland HJ, Phillips GL:
Treatment of multiple myeloma with intensive chemotherapy followed by autologous BMT using bone marrow purged with 4-hydroperoxyclophosphamide.
Bone Marrow Transplant
11:139, 1993[Medline]
[Order article via Infotrieve]
27.
Vescio R, Hong C, Cao J:
The hematopoietic stem cell antigen, is not expressed on the malignant cells in multiple myeloma.
Blood
84:3283, 1994[Abstract/Free Full Text]
28.
Lemoli RM, Fortuna A, Motta MR, Rizzi S, Amabile M, Fogli M, Cavo M, Tura S:
Transplantation of enriched CD34+ cells provides indirect purging of circulating tumor cells in multiple myeloma (MM) patients.
Blood
84:399a, 1994 (abstr, suppl 1)
29.
Shpall EJ, LeMaistre CF, Holland K, Ball E, Jones RB, Saral R, Jacobs C, Heimfeld S, Berenson R, Champlin R:
A prospective randomized trial of buffy coat versus CD34-selected autologous bone marrow support in high-risk breast cancer patients receiving high-dose chemotherapy.
Blood
90:4313, 1997[Abstract/Free Full Text]
30.
Durie BGM, Salmon SE:
A clinical staging system for multiple myeloma: Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival.
Cancer
36:842, 1975[Medline]
[Order article via Infotrieve]
31.
Tomlinson IM, Walter G, Marks JD, Llewelyn MB, Winter G:
The repertoire of human germline VH sequence reveals about fifty groups of VH segments with different hypervulable loops.
J Mol Biol
227:776, 1992[Medline]
[Order article via Infotrieve]
32.
Kabat EA, Wu TT, Reid-Miller M, Perry HM, Gottesman KS:
Sequence of Proteins of Immunological Interest. Bethesda, MD, National Institutes of Health, 1987.
33.
Molesh DA, Hall JM:
Quantitative analysis of CD34+ stem cells using RT-PCR on whole cells.
PCR Methods Appl
3:278, 1994[Medline]
[Order article via Infotrieve]
34.
Kaplan EL, Meier P:
Nonparametric estimations from incomplete observations.
J Am Stat Assoc
53:457, 1958
35.
Franklin WA, Shpall EJ, Archer P, Johnson CS, Garza-William S, Hami L, Bitter MA, Bast RC, Jones RB:
Immunocytochemical detection of breast cancer cells in marrow and peripheral blood of patients undergoing high dose chemotherapy with autologous stem cell support.
Breast Cancer Res Treat
41:1, 1996[Medline]
[Order article via Infotrieve]
36.
Gribben JG, Saporito L, Barber M, Blake KW, Edwards RM, Griffin JD, Freedman AS, Nadler LM:
Bone marrows of non-Hodgkin's lymphoma patients with a bcl-2 translocation can be purged of polymerase chain reaction-detectable lymphoma cells using monoclonal antibodies and immunomagnetic bead depletion.
Blood
80:1083, 1992[Abstract/Free Full Text]
37.
Owen RG, Haynes AP, Evans PA, Johnson RJ, Rawstron AC, McQuaker G, Smith GM, Galvin MC, Barnard DL, Russell NH, Child JA, Morgan GJ:
Detection of clonal immunoglobulin gene rearrangements in the peripheral blood progenitor cells of patient with multiple myeloma: The potential role of purging with CD34+ positive selection.
J Clin Pathol
49:M112, 1996
38.
Johnson RJ, Owen RG, Smith GM, Child JA, Galvin M, Newton LJ, Rawstron A, Major K, Woodhead V, Robinson F, Jack A, Morgan GJ:
Peripheral blood stem cell transplantation in myeloma using CD34+ selected cells.
Bone Marrow Transplant
17:723, 1996[Medline]
[Order article via Infotrieve]
39.
Pico JL, Bourhis JH, Bennaceur AL, Beaujean F, Bayle C, Ibrahim A, Girinski T, Hayat M, Dighiero G, Tchernia G:
Engraftment of CD34+ peripheral blood progenitor cells into multiple myeloma patients following total body irradiation.
Nouv Rev Franc Hematol
37:381, 1995
40.
Rossi JF, Legouffe E, Fegueux N, Sun RX, Exbravat C, Latry P, Polge G, deVoos J, Capdevila V, Lu ZY, Klein B:
Autologous transplantation (AT) of CD34+ peripheral blood progenitor cells (PBPC) after double (D) high-dose chemotherapy (HDC) in multiple myeloma (MM) is followed by severe immunodeficiency (ID) and high production of interleukin-6 (IL-6) related-C reactive protein (CRP) requiring additive immunotherapy.
Blood
88:142a, 1996 (abstr, suppl 1)
41.
Gorin NC, Lopez M, Laporte JP, Quittet P, Lesage S, Lemoine F, Berenson RJ, Isnard F, Grande M, Stachowiak J, Labopin M, Fouillard L, Morel P, Jouet J, Noel-Walter M, Detourmignies L, Aoudjhane M, Bauters F, Najman A, Douay L:
Preparation and successful engraftment of purified CD34+ bone marrow progenitor cells in patients with non-Hodgkin's lymphoma.
Blood
85:1647, 1995[Abstract/Free Full Text]
42. Bachier C, Giles RE, Ellerson D, Hanania EG, Garcia-Sanchez F,
Haley T, Andreef M, Cabanillas F, Champlin R, Berenson R, Heimfeld S,
Deisseroth AB: Stem cell (SC) transplant and retroviral transduction of
hematopoietic cells in patients with follicular non-Hodgkin's lymphoma
(FNHL). Proc Am Soc Clin Oncol 16:1997 (abstr)
43.
Vogel W, Behringer D, Scheding S, Kanz L, Brugger W:
Ex vivo expansion of CD34+ peripheral blood progenitor cells: Implications for the expansion of contaminating epithelial tumor cells.
Blood
88:2707, 1996[Abstract/Free Full Text]
44.
Bensinger W, Applebaum F, Rowley S, Storb R, Sanders J, Lilleby K, Gooley T, Demirer T, Schiffman K, Weaver C, Clift R, Chauncey T, Klarnet J, Montgomery P, Petersdorf S, Weiden R, Witherspoon R, Buckner CD:
Factors influencing collection and engraftment of autologous peripheral blood stem cells.
J Clin Oncol
13:2547, 1995[Abstract]
45.
Tricot G, Jagannath S, Vesole DH, Nelson J, Tindle S, Miller L, Cheson B, Crowley J, Barlogie B:
Peripheral blood stem cell transplants for multiple myeloma: Identification of favorable variables for rapid engraftment in 225 patients.
Blood
85:588, 1995[Abstract/Free Full Text]
46.
Weaver CH, Hazelton B, Birch R, Palmer P, Allen C, Schwartzberg L, West W:
An analysis of engraftment kinetics as a function of the CD34 content of peripheral blood progenitor cell collections in 692 patients after the administration of myeloabalative chemotherapy.
Blood
86:3961, 1995[Abstract/Free Full Text]
47.
Brugger W, Henschler R, Heimfeld S, Berenson RJ, Mertelsmann R, Kanz L:
Positively selected autologous blood CD34+ cells and unseparated peripheral blood progenitor cells mediate identical hematopoietic engraftment after high-dose VP16, ifosfamide, carboplatin, and epirubicin.
Blood
84:1421, 1994[Abstract/Free Full Text]
48.
Somlo G, Sniecinski I, Odom-Maryon T, Nowicki B, Chow W, Hamasaki V, Leong L, Margolin K, Morgan R Jr., Raschko J, Shibata S, Tetef M, Molina A, Berenson RJ, Forman SJ, Doroshow JH:
Effects of CD34+ selection and various schedules of stem cell reinfusion and granulocyte colony-stimulating factor priming on hematopoietic recovery after high-dose chemotherapy for breast cancer.
Blood
89:1521, 1997[Abstract/Free Full Text]
49.
Schiller G, Vescio R, Freytes C, Spitzer G, Lee M, Wu CH, Cao J, Lee JC, Lichtenstein A, Lill M, Berenson RJ, Berenson J:
Long-term outcome of high-dose chemotherapy and autologus CD34 selected peripheral blood progenitor cell transplantation for patients with advanced multiple myeloma.
Bone Marrow Transplant
21:141, 1998[Medline]
[Order article via Infotrieve]
50.
Watts MJ, Sullivan AM, Ings SJ, Leverett D, Peniket AJ, Perry AR, Williams CD, Devereux S:
Evaluation of clinical scale CD34+ cell purification: Experience of 71 immunoaffinity column procedures.
Bone Marrow Transplant
20:157, 1997[Medline]
[Order article via Infotrieve]
51.
Tricot G, Gazitt Y, Leemhuis T, Jagannath S, Desikan KR, Siegel D, Fassas A, Tindle S, Nelson J, Juttner C, Tsukamoto A, Hallagan J, Atkinson K, Reading C, Hoffman R, Barlogie B:
Collection, tumor contamination, and engraftment kinetics of highly purified hematopoietic progenitor cells to support high dose therapy in multiple myeloma.
Blood
91:4489, 1998[Abstract/Free Full Text]
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
D. R. Sutherland and M. Keeney
Re: Selection of Stem Cells by Using Antibodies That Target Different CD34 Epitopes Yields Different Patterns of T-Cell Differentiation
Stem Cells,
September 1, 2007;
25(9):
2385 - 2386.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J.-H. Bourhis, Y. Bouko, S. Koscielny, M. Bakkus, H. Greinix, G. Derigs, G. Salles, W. Feremans, J. Apperley, D. Samson, et al.
Relapse risk after autologous transplantation in patients with newly diagnosed myeloma is not related with infused tumor cell load and the outcome is not improved by CD34+ cell selection: long term follow-up of an EBMT phase III randomized study
Haematologica,
August 1, 2007;
92(8):
1083 - 1090.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Witzens-Harig, C. Heilmann, M. Hensel, M. Kornacker, A. Benner, R. Haas, S. Fruehauf, and A. D. Ho
Long-Term Follow-Up of Patients with Non-Hodgkin Lymphoma Following Myeloablative Therapy and Autologous Transplantation of CD34+-Selected Peripheral Blood Progenitor Cells
Stem Cells,
January 1, 2007;
25(1):
228 - 235.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Craiu, Y. Saito, A. Limon, H. M. Eppich, D. P. Olson, N. Rodrigues, G. B. Adams, D. Dombkowski, P. Richardson, R. Schlossman, et al.
Flowing cells through pulsed electric fields efficiently purges stem cell preparations of contaminating myeloma cells while preserving stem cell function
Blood,
March 1, 2005;
105(5):
2235 - 2238.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Blade, D. H. Vesole, and M. Gertz
Transplantation for multiple myeloma: who, when, how often?
Blood,
November 15, 2003;
102(10):
3469 - 3477.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Zhou, Y. Zhang, C. Martinez, N. Kalakonda, S. D. Nimer, and R. L. Comenzo
Melphalan-mobilized blood stem cell components contain minimal clonotypic myeloma cell contamination
Blood,
July 15, 2003;
102(2):
477 - 479.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Damiani, R. Stocchi, P. Masolini, A. Michelutti, A. Geromin, A. Sperotto, C. Skert, M. Michieli, M. Baccarani, and R. Fanin
CD34+-selected versus unmanipulated autologous stem cell transplantation in multiple myeloma: impact on dendritic and immune recovery and on complications due to infection
Ann. Onc.,
March 1, 2003;
14(3):
475 - 480.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Malphettes, G. Carcelain, P. Saint-Mezard, V. Leblond, H. K. Altes, J.-P. Marolleau, P. Debre, J.-C. Brouet, J.-P. Fermand, and B. Autran
Evidence for naive T-cell repopulation despite thymus irradiation after autologous transplantation in adults with multiple myeloma: role of ex vivo CD34+ selection and age
Blood,
March 1, 2003;
101(5):
1891 - 1897.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. M. Pilarski and A. R. Belch
Clonotypic Myeloma Cells Able to Xenograft Myeloma to Nonobese Diabetic Severe Combined Immunodeficient Mice Copurify with CD34+ Hematopoietic Progenitors
Clin. Cancer Res.,
October 1, 2002;
8(10):
3198 - 3204.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. K. Stewart, R. Vescio, G. Schiller, O. Ballester, S. Noga, H. Rugo, C. Freytes, E. Stadtmauer, S. Tarantolo, F. Sahebi, et al.
Purging of Autologous Peripheral-Blood Stem Cells Using CD34 Selection Does Not Improve Overall or Progression-Free Survival After High-Dose Chemotherapy for Multiple Myeloma: Results of a Multicenter Randomized Controlled Trial
J. Clin. Oncol.,
September 1, 2001;
19(17):
3771 - 3779.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Mohr, F. Dalmis, E. Hilgenfeld, E. Oelmann, M. Zühlsdorf, K. Kratz-Albers, A. Nolte, C. Schmitmann, D. Önaldi-Mohr, U. Cassens, et al.
Simultaneous Immunomagnetic CD34+ Cell Selection and B-Cell Depletion in Peripheral Blood Progenitor Cell Samples of Patients Suffering from B-Cell Non-Hodgkin's Lymphoma
Clin. Cancer Res.,
January 1, 2001;
7(1):
51 - 57.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
W. S. Dalton, P. L. Bergsagel, W. M. Kuehl, K. C. Anderson, and J. L. Harousseau
Multiple Myeloma
Hematology,
January 1, 2001;
2001(1):
157 - 177.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. J. Schiller, R. Vescio, and J. Berenson
Cytomegalovirus infection following transplantation of autologous CD34-selected progenitor cells
Blood,
August 1, 2000;
96(3):
1194 - 1194.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. M. Lemoli, G. Martinelli, E. Zamagni, M. R. Motta, S. Rizzi, C. Terragna, R. Rondelli, S. Ronconi, A. Curti, F. Bonifazi, et al.
Engraftment, clinical, and molecular follow-up of patients with multiple myeloma who were reinfused with highly purified CD34+ cells to support single or tandem high-dose chemotherapy
Blood,
April 1, 2000;
95(7):
2234 - 2239.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. Vogel, S. Scheding, L. Kanz, and W. Brugger
Clinical Applications of CD34+ Peripheral Blood Progenitor Cells (PBPC)
Stem Cells,
March 1, 2000;
18(2):
87 - 92.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
K. C. Anderson, R. A. Kyle, W. S. Dalton, T. Landowski, K. Shain, R. Jove, L. Hazlehurst, and J. Berenson
Multiple Myeloma: New Insights and Therapeutic Approaches
Hematology,
January 1, 2000;
2000(1):
147 - 165.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Holmberg, M. Boeckh, H. Hooper, W. Leisenring, S. Rowley, S. Heimfeld, O. Press, D. G. Maloney, P. McSweeney, L. Corey, et al.
Increased Incidence of Cytomegalovirus Disease After Autologous CD34-Selected Peripheral Blood Stem Cell Transplantation
Blood,
December 15, 1999;
94(12):
4029 - 4035.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. H. Moskowitz, J. R. Bertino, J. R. Glassman, E. E. Hedrick, S. Hunte, N. Coady-Lyons, D. B. Agus, A. Goy, J. Jurcic, A. Noy, et al.
Ifosfamide, Carboplatin, and Etoposide: A Highly Effective Cytoreduction and Peripheral-Blood Progenitor-Cell Mobilization Regimen for Transplant-Eligible Patients With Non-Hodgkin's Lymphoma
J. Clin. Oncol.,
December 1, 1999;
17(12):
3776 - 3785.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
TOP
ABSTRACT
INTRODUCTION