Liz Higgins - Haematology Association of Ireland

AutologousPeripheral
Blood Stem Cell Harvest.
Liz Higgins
BMT Co-ordinator
St James’s Hospital, Dublin

National BMT/PBSCT
Unit
Allogenic
Autologous PBSCT –
GUH
SVH
Shared Care SJH - AMNCH,
Beaumont, Mater hospitals.

PBSCH
2008 71
2009 75
2010 54 to date

TEAM
Referring Consultant
Referring CNS
Apheresis Team
Cryobiology Team
CNM
Stem cell Transplant Co-Ordinators

PBSCT
PBSCT involves eliminating an
individual’s bone marrow stem cells.
They are then replaced with bone
marrow stem cells either from another
individual or with a previously
harvested portion of the individuals
own bone marrow or peripheral blood
stem cells.

Reasons for PBSCT
Defective marrow function e.G. Aplastic
anaemia, myelodysplasia, severe combined immune
deficiency, sickle cell disease, and other benign
inherited disorders
Diseased marrow function e.G. Acute and
chronic leukaemia
To facilitate high dose therapy in
other malignant conditions e.G.
Lymphoma, testicular cancer, Multiple Myeloma.

Cancers treated by
Autologous PBSCT
Hodgkin,s disease
Non Hodgkin's Lymphoma
Chronic Myeloid Leukaemia
Acute Myeloid Leukaemia
Acute Lymphocytic Leukaemia
Multiple Myeloma
Testicular CA
Ewing's Sarcoma.

Stem Cell
Red Cell or White Cell or
Platelet
Once the ‘decision’ is made it is
probably irreversible

Sources of Bone Marrow
Stem Cells
Bone marrow (BM) - aspirated from
the posterior iliac crests under GA,
usually 800-1200mls in volume
Peripheral blood stem cells
(PBSC) - following the administration
of growth colony stimulating factor (G-
CSF) + / - Chemotherapy

Autologous rescue involves two
processes.
PBSCH/ BMH
PBSCT/ BMT

PBSCH
COMMISSION DIRECTIVE 2006/17/EC
of 8 February 2006
implementing Directive 2004/23/EC of
the European Parliament and of the
Council as regards
certain technical requirements for the
donation, procurement and testing of
human tissues and cells

Storage
Liquid Nitrogen
Stored in Vapour phase
- 190 C
15 Years

PBSC Mobilisation
Initial Review
FBC
RLB Profile
Coagulation
Blood group
G&H
Disease markers
Virology – Hepatitis
B,C; HIV 1&2; HTLV
1&2; Syphilis
Consider venous
access –
peripheral/central
Medical assessment
Nursing Assessment
Counselling
CXR/ ECG/ ECHO
Consent
Correspondence

Mobilisation Regimens
G-CSF 10mcg/kg X 4 days
IEV
ICE
Cyclophosphamide 2grms / M 2
Ivac
Dhap
ESHAP
Taxol / Ifos x 2
VIDE

Cyclophosphamide
2g/m 2
Chemo on Monday
Commence G-CSF (10mcg/Kg
Tuesday)
CD34 Count from day 8
Leucapheresis day 8-10

GSCF ( Neupogen)
10Mcg / kg Round up.
Commence on Saturday.
CD34 Count Tuesday +/- Gcsf
PBSCH

ICE
Etoposide 10mg/m 2 Day 1,2,3.,
Carboplatin AUC 5 Day 2, Ifosfamide
5000mg/m 2 24 hour infusion Day 2
Neupogen 5 mcg/kg commence day 6
Commence ICE on Thursday
PBSCH 12-14 days Post
Usually Wed for harvest

IEV / DHAP/ IVAC
Wednesday
PBSCH day 12-14

Eshap
Commence Tuesday
Day 12-14

Aphoresis
Pending Peripheral CD34 Count x
10 3 /ml
(EDTA sample in lab for 8am)
Monitored daily
1-3 Days
4-5 Hours
Inpatient or Transfer as day patient

Apheresis guidelines

Pre harvest procedure
Neutropenic
Antibiotic therapy
Throbcytopenia
Platelet count > 30 for procedure
Anaemia.
HB > 8 for procedure
Anticoagulation Therapy
Drugs

COBE

Failure to Mobilise.
2009 11 Patients failed to mobilise.

Autologous HSCT in
multiple myeloma and lymphoma
It is generally accepted that patients must collect a minimum of 2 x 10 6
CD34+ cells/kg during apheresis to proceed with high dose
chemotherapy and stem cell rescue.
Patients who fail to collect this number of cells are usually considered
mobilisation failures
Current clinical practice involves remobilizing these patients with
existing G-CSF or chemotherapy plus G-CSF regimens
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Risk factors for
poor or failed mobilisation
Advanced age
Bone marrow involvement by tumour
Extensive radiation to marrow sites
Extensive prior therapy
Mobilisation with G-CSF alone
Previous treatment with alkylating agents
Prior fludarabine or lenalidomide treatment
General physical status
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Indication
Plerixafor is indicated in combination with G-CSF to
enhance mobilisation of haematopoietic stem cells to the
peripheral blood for collection and subsequent autologous
transplantation in patients with lymphoma and multiple
myeloma whose cells mobilise poorly

Plerixafor: a first in class
stem cell mobilising agent
Structural formula of plerixafor 16
Plerixafor is a first in class CXCR4 antagonist that mobilises stem
cells from the bone marrow, increasing their number in peripheral
blood
Its mode of action is to block the chemokine receptor 4 (CXCR4, found
on stems cells), preventing binding.
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Mechanism of action of Plerixafor
Plerixafor blocks the CXCR4–SDF-1α interaction, releasing stem cells from
the bone marrow into the circulating blood.
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The recommended dose of Plerixafor is 0.24mg/kg body weight/day. It should
be administered by subcutaneous injection at a time that will allow an interval
between dosing and the initiation of apheresis that is a minimum of 10 hours
and a maximum of 11 hours.
Gcsf at part of standard care – administered in the morning , and on the days of
apheresis, at least one hour prior to the initiation of apheresis.
Plerixafor 10pm
Gcsf 7am
Apheresis 8.30am
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Plerixafor increases predictability of
apheresis yield and timing
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Numbers
14 patients
7 MM
7 Lymphoma
3 failures ( Lymphoma Pts)