Erin Medoff

Outpatient high-dose melphalan in multiple myeloma patients

BACKGROUND: The brief period of neutropenia and limited nonmarrow toxicity after high‐dose melphalan (HDM) provide a rationale for outpatient treatment.

Late Afternoon Dosing of Plerixafor for Stem Cell Mobilization: A Practical Solution

BACKGROUND Plerixafor was recently approved for stem cell mobilization in patients who have non-Hodgkin lymphoma or multiple myeloma. However, the use of late evening (10 PM) injections is inconvenient for patients and requires an after-hours infrastructure that may not be readily available. PATIENTS AND METHODS Based on an earlier study showing prolonged mobilization of stem cells in patients given plerixafor plus granulocyte colony-stimulating factor (G-CSF), we administered plerixafor at 5 PM and performed apheresis approximately 15 hours later. Plerixafor was administered primarily to patients who either had failed previous mobilization or were at risk for poor mobilization because of previous therapy, especially lenalidomide in patients who had multiple myeloma. RESULTS Of 48 patients, including 24 with myeloma and 24 with lymphoma, 47 had enough stem cells collected (> 2 × 10E6 CD34+ cells/kg) to proceed to transplant, including all 13 patients who had failed previous chemotherapy plus G-CSF mobilization and 18 patients treated with four cycles or more of lenalidomide. The day +1 post-plerixafor increment in circulating CD34+ cells was greatest in patients who had the highest preplerixafor CD34 count; however, in patients with preplerixafor CD34+ cell counts < 10/μL (and who typically mobilize poorly), 83% of patients had enough stem cells collected to proceed to transplant. CONCLUSION This study suggests that plerixafor is effective when given 15 hours before apheresis, even in a population at high risk for mobilization failure. A proposed cost-effective use of plerixafor is to administer it to patients who are inadequately mobilized with G-CSF alone or for salvage in patients who fail previous mobilization with chemotherapy plus G-CSF.

Sequential High-Dose Alkylating Therapy and Stem Cell Support for High-Risk Stage III Breast Cancer

Abstract:  Patients who receive neoadjuvant chemotherapy for locally advanced breast cancer and have four or more ipsilateral axillary lymph nodes involved at surgery are at high risk for recurrence, with a median time to relapse of 18 months. We offered such patients high‐dose chemotherapy with stem cell rescue. Patients received cyclophosphamide or paclitaxel and granulocyte colony‐stimulating factor (G‐CSF) to mobilize stem cells. Melphalan 140 mg/m2 was then given with stem cell rescue. Twenty‐four to 35 days later, thiotepa 900 mg/m2 was given with stem cell rescue. Patients with hormone receptor‐positive tumors received tamoxifen. We treated 14 patients in this fashion from 1995 to 1998. The mean age was 46.7 years. The majority of cancers were stage IIIB (79%). Thirteen women underwent mastectomy after anthracycline‐containing chemotherapy and 50% had more than seven positive lymph nodes. Hospitalization was principally for neutropenic fever. Other morbidities were pneumonitis, cardiomyopathy, and grade 3/4 white blood cell (WBC) toxicity. No patient died of a treatment‐related complication. Seven of 14 relapsed at 10, 12, <15, 15, 17, 21, and 36 months, with median follow‐up of 26.5 months. Time to relapse in this small series is only modestly improved over historical experience with standard‐dose adjuvant chemotherapy. Alternative strategies for treating locally advanced breast cancer should be pursued. 

Conviction in the face of affliction: a case series of Jehovah’s Witnesses with myeloid malignancies

Myeloid malignancies are challenging diseases to treat, and management of Jehovah’s Witnesses (JW) affected by them imposes additional complexities. More than 1.2 million JW lives in the USA, and based on a specific interpretation of several biblical verses, many JW believe that the receipt of blood products is directly against the will of God and thus forbidden irrespective of the clinical indication. Guidance for the receipt of specific fractions of plasma (e.g., cryoprecipitate, albumin, clotting factor concentrates) is unclear and as a result is left up to the individual to decide based on his or her own interpretation [1, 2]. Absence of treatment for the myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) will universally herald disease-related cytopenias and the need for blood product transfusion which if refused often will lead to death. Furthermore, standard therapies for these cancers are myelosuppressive and blood product transfusion is typically an integral component of the therapeutic approach. The optimal approach to such complex and delicate situation begins with respect for the autonomy of competent decision-makers, but also ideally uses therapies which might be less myelosuppressive, yet provide favorable, if not comparable, rates of response and cure. Because of this dilemma, there are no standardized approaches to the care of JW with AML or MDS and many patients will receive suboptimal care including omission of any active therapies.

Successful collection and engraftment of autologous peripheral blood progenitor cells in poorly mobilized patients receiving high-dose granulocyte colony-stimulating factor†

Background: Granulocyte Colony‐Stimulating Factor (G‐CSF) alone or in conjunction with chemotherapy is commonly used to mobilize hematopoietic progenitor cells (HPC) into peripheral blood for progenitor cell harvest for autologous HPC transplantation. However, in up to 30% of patients, HPC are not effectively mobilized. In this study, we report the efficacy and safety profiles of a mobilization strategy using high‐dose (up to 36 μg/kg) G‐CSF in poorly mobilized patients. Study Design and Methods: Retrospective medical record reviews were performed for 392 patients who underwent autologous peripheral blood progenitor cell collection. A total of 56 patients were given high‐dose G‐CSF due to very ineffective mobilization and 35 of these patients underwent autologous HPC transplantation. The efficacy of mobilization, apheresis collection, and infusion were reviewed and analyzed. Results: More than 2.5 × 106 CD34/Kg were collected in 88% of patients (49 of 56) who were placed on high‐dose G‐CSF due to very ineffective mobilization. Of the 35 patients who underwent HPC transplantation using the progenitor cells that were mobilized with high‐dose G‐CSF due to very ineffective mobilization, all had rapid and complete neutrophil and platelet engraftment comparable with good mobilizers. Conclusion: We conclude that collection of HPC using hyperstimulation with G‐CSF is an effective alternative approach for HPC harvest for poorly mobilized patients. J. Clin. Apheresis 27:235–241, 2012.