Maria Laura Foddai

Autologous blood stem cell harvesting and transplantation in patients with advanced ovarian cancer

We investigated the feasibility of a programme of autologous blood stem cell (ABSC) harvesting and transplantation in 13 patients with advanced ovarian cancer, previously untreated by chemotherapy or radiotherapy and entering a phase II study of high‐dose cisplatin, etoposide and carboplatin with haematopoietic stem cell rescue. Prior to high‐dose treatment all patients underwent two courses of cisplatin and cyclophosphamide. An 8‐fold increase of the peripheral colony forming unit granulocytic‐macrophage (CFU‐GM) was observed during recovery from myelosuppression after the first chemotherapy course. The second course determined a 2·5‐fold increase of peripheral CFU‐GM. In 70% of enrolled patients (nine patients) we were able to perform ABSC harvesting by leukaphereses; in the apheresed patients we harvested an average of 20·8 × 104/kg CFU‐GM (range 10·9–37·0). Haematopoietic trilineage engraftment, established as the number of days necessary to reach white blood cells (WBC) >1·0 × 109/1, polymorphonuclear leucocytes (PMN) >0·5 × 109/1 and platelets (PLT) >50·109/1. occurred very promptly and was sustained in the same series after high‐dose cisplatin, carboplatin and etoposide, followed by autologous blood stem cell transplantation (ABSCT). In our experience we found a significant correlation (r = 0·77; P<0·05) between CFU‐GM infused dose and the engraftment speed of PMN. We conclude that the combination of cisplatin and cyclophosphamide is effective in mobilizing haematopoietic progenitors in the peripheral blood of patients with advanced ovarian cancer, previously untreated by chemora‐diotherapy. Moreover, ABSCT is capable of rapidly restoring the haematopoietic function after high‐dose treatment and for this reason it represents a particularly advisable therapeutic option for the treatment of solid tumours because these patients are commonly older than 50 and can be excluded from bone marrow transplantation.

Immunological reconstitution after high-dose chemotherapy and autologous blood stem cell transplantation for advanced ovarian cancer

We evaluated the immunological reconstitution of patients who underwent high-dose chemotherapy and autologous blood stem cell transplantation (ABSCT) for advanced ovarian cancer. Sixty days after transplantation a complete reconstitution of lymphocytes and of the CD3, CD4, CD8, CD19, and CD16/56 subsets was observed in this series. A significant increase in the count of interleukin-2 receptor expressing lymphocyte (CD25) was found on day +60 after transplantation compared to that obtained at diagnosis and before transplantation. A significantly higher lymphokine-activated killer (LAK) precursor activity was seen on day +60 compared to the values obtained at diagnosis and before transplantation while natural killer activity did not show any significant variation. We conclude that ABSCT gives prompt and complete immunohaematopoietic reconstitution after high-dose treatment. Moreover, our data support the feasibility of interleukin-2/LAK therapy as consolidative therapy after ABSCT.

High-dose carboplatin, etoposide and melphalan (CEM) with peripheral blood progenitor cell support as late intensification for high-risk cancer: non-haematological, haematological toxicities and role of growth factor administration.

The present report describes the non-haematological toxicity and the influence of growth factor administration on haematological toxicity and haematopoietic recovery observed after high-dose carboplatin (1200 mg m(-2)), etoposide (900 mg m(-2)) and melphalan (100 mg m(-2)) (CEM) followed by peripheral blood progenitor cell transplantation (PBPCT) in 40 patients with high-risk cancer during their first-line treatment. PBPCs were collected during the previous outpatient induction chemotherapy programme by leukaphereses. CEM administration with PBPCT was associated with low non-haematological toxicity and the only significant toxicity consisted of a reversible grade III/IV increase in liver enzymes in 32% of the patients. Haematopoietic recovery was very fast in all patients and the administration of granulocyte colony-stimulating factor (G-CSF) plus erythropoietin (EPO) or granulocyte-macrophage colony-stimulating factor (GM-CSF) plus EPO after PBPCT significantly reduced haematological toxicity, abrogated antibiotic administration during neutropenia and significantly reduced hospital stay and patients hospital charge compared with patients treated with PBPCT only. None of the patients died early of CEM plus PBPCT-related complications. Low non-haematological toxicity and accelerated haematopoietic recovery renders CEM with PBPC/growth factor support an acceptable therapeutic approach in an adjuvant or neoadjuvant setting.

High-dose Chemotherapy with Autologous Peripheral Stem Cell Support in Advanced Ovarian Cancer

Twenty patients with advanced (stage III-IV), previously untreated ovarian carcinoma were treated by: (a) induction chemotherapy (40 mg/m2 cisplatin, days 1-4; 1.5 g/m2 cyclophosphamide, day 4; every 4 weeks for two cycles) followed by (b) intensification chemotherapy (100 mg/m2 cisplatin, day 1; 650 mg/m2 etoposide, day 2; 1.8 g/m2 carboplatin, day 3). Eligibility criteria further included: age less than 55 years, moderately good to poor tumour grade, macroscopic (> 0.5 cm) residual tumour. Autologous peripheral stem cells were recruited after the induction cycles and, to ensure haematological support, autologous bone marrow harvesting was routinely performed in the first 14 cases. Haematological support consisted of autologous peripheral stem cells and autologous bone marrow transplant in 16 and four patients, respectively. All patients are evaluable for toxicity and 19 for pathological response, one being dead of systemic mycosis 35 days after the autologous bone marrow transplant. Severe extra-haematological toxicities were the following: gastrointestinal (100%), neurological (10%), hepatic (10%). Pathological response was detected in 84% of cases (CR 37%, microscopic PR 26%, macroscopic PR 21%). Median follow-up times of 48 and 41 months have been reached respectively from enrolment and second-look. Four-year 62% overall and 57% progression-free survivals have been reached. Ten patients are still alive with NED (six of seven with CR, three of five with microscopic PR, and one of four with macroscopic PR). Autologous peripheral stem cell transplant significantly reduced the duration of aplasia compared with autologous bone marrow transplant, and toxicity was proved to be manageable in those patients undergoing autologous peripheral stem cell transplant. The prolonged disease-free survival in patients showing CR and microscopic PR suggests that further investigation on this new approach is worthwhile.

The combination of erythropoietin and granulocyte colony-stimulating factor increases the rate of haemopoietic recovery with clinical benefit after peripheral blood progenitor cell transplantation

In order to investigate the effects of erythropoietin (EPO) plus granulocyte colony‐stimulating factor (G‐CSF) administration after peripheral blood progenitor cell transplantation (PBPCT) we performed a phase I/II study in patients with high‐risk cancer. 15 consecutive patients were treated with recombinant human G‐CSF (rhG‐CSF) at the dose of 5 μg/kg subcutaneously (s.c.) every 24 h until day +12 and with recombinant human EPO (rhEPO) at the dose of 150 IU/kg s.c. every 48 h until day +11 following PBPCT. Their haemopoietic recovery was compared to that obtained in eight historic control patients who did not receive any cytokines after PBPCT. No side‐effects were observed during EPO plus G‐CSF treatment and the treatment was not discontinued in any of the patients before completion of the treatment plan. The administration of EPO plus G‐CSF after PBPCT produced a significant increase in the rate of white blood cell (WBC) (P = 0.0005), polymorphonuclear leucocyte (PMN) (P = 0.0005) and platelet (PLT) (P = 0.0105) recovery compared to the control group. The acceleration in haemopoietic recovery observed in the EPO plus G‐CSF‐treated patients produced a significant reduction of the days with WBC < 1×109/l (P = 0.0009), PMN  < 0.2×109/l (P = 0.0030) and PMN < 0.5×109/l (P = 0.0006). EPO plus G‐CSF‐treated patients required a significantly lower number of single donor PLT transfusions (P = 0.0142) and did not experience neutropenic fever, but historic control patients experienced fever > 38°C for a median period of 4 d (0–12) with a median period of parenteral antibiotic administration of 7.5 d (0–17). The length of the hospital stay was significantly shorter in the study group than in the historic control group (P = 0.0264). In conclusion, we can confirm that EPO plus G‐CSF treatment is feasible and potentiates the haemopoietic recovery after PBPCT, thus simplifying the clinical management of cancer patients who undergo high‐dose chemotherapy.

Adoptive immunotherapy with cytokine-induced killer cells generated with a new good manufacturing practice-grade protocol

BACKGROUND AIMS We have recently shown that thymoglobulin (TG) efficiently expands cytokine-induced killer (CIK) cells in combination with interferon (IFN)-γ and interleukin (IL)-2 (ITG2 protocol). It is presently unknown whether the infusion of autologous immune effector cells generated by TG, IFN-γ and IL-2 is feasible and safe. METHODS Five patients with advanced and/or refractory solid tumors were enrolled in the present phase I/II study. Peripheral blood mononuclear cells (PBMC) collected by leukapheresis were stimulated under good manufacturing practice (GMP)-conditions with IFN-γ, followed by TG and IL-2. After 2-3 weeks in culture, a median of 4.65 × 10(6) immune effector cells per kilogram of recipients body weight was obtained and infused intravenously. The median time from enrollment into the study to infusion of the expanded CIK cells was 30 days. RESULTS ITG2 efficiently expanded immune effector cells that comprised both conventional natural killer (NK) cells and CD3(+) CD16(+) CD56(+) CIK cells. One patient with advanced melanoma died because of disease progression before the infusion of CIK cells. The target dose of at least 2.5 × 10(6) CIK cells/kg of recipients body weight was reached in four out of five evaluable patients. CIK cells were administered intravenously without any measurable toxicity. In vitro, CIK cells exerted lytic activity against cervical cancer cells. The median survival was 4.5 months (range 1-13) from the first infusion of CIK cells. CONCLUSIONS This study has highlighted the feasibility and safety of the administration of CIK cells generated with the ITG2 protocol. Whether CIK cells can help control disease burden in patients with advanced malignancies will be determined in future clinical trials.

Very high-dose chemotherapy with autologous peripheral stem cell support in advanced ovarian cancer

20 patients with stage III-IV ovarian cancer were submitted to induction chemotherapy (ICT) (40 mg/m2 cisplatin, days 1-4; 1.5 g/m2 cyclophosphamide, day 4; every 4 weeks for 2 cycles) followed by intensified CT (100 mg/m2 cisplatin, day 1; 650 mg/m2 etoposide, day 2; 1.8 g/m2 carboplatin by 24 h infusion, day 3). Haematological support consisted of autologous peripheral stem cells (APSC) and bone marrow (ABM) transplant (T) in 16 and 4 patients, respectively. All patients were evaluable for toxicity and 19 for pathological response (PR), one patient dying of systemic mycosis after ABMT. Severe (grade 3-4) non-haematological toxic effects were gastrointestinal (100%), neurological (10%) and hepatic (10%). PR was observed in 84% of patients (complete response 37%, partial response with microscopic residual disease 26%, partial response with macroscopic residual disease 21%). Five year overall survival was 60% and progression-free survival was 51% with 9 patients still disease-free (DFS). APSCT significantly reduced the duration of aplasia compared with ABMT, and toxicity was acceptable in those patients undergoing APSCT. The prolonged DFS in patients showing PCR suggests that this new approach may have a therapeutic impact.

Evaluation of a new protocol for peripheral blood stem cell collection with the Fresenius AS 104 cell separator.

In this report we analyzed sixty leukapheresis procedures on 35 patients with a new protocol for the Fresenius AS 104. Yields and efficiencies for MNC, CD 34+ cells, and CFU‐GM indicate that the new protocol is able to collect large quantities of hemopoietic progenitors. Procedures were performed processing 8.69 ± 2.8 liters of whole blood per apheresis and modifying 3 parameters: spillover‐volume 7 ml, buffy‐coat volume 11.5 ml, centrifuge speed 1,500 rpm; blood flow rate was 50 ml/min and the anticoagulant ratio was 1:12. No side effects were observed during apheresis procedures except for transient paresthesia episodes promptly resolved with the administration of calcium gluconate. Yields show a high capacity of the new program to collect on average MNC 17.28 ± 10.85 × 109, CD 34+ 471 ± 553.5 × 106 and CFU‐GM 1278.7 ± 1346.3 × 104 per procedure. Separator collection efficiency on average was 49.91 ± 23.28% for MNC, 55.1 ± 35.66% for CFU‐GM, and 62.97 ± 23.09% for CD 34+ cells. Particularly interesting are results for MNC yields and CD 34+ efficiency; these results make the new program advantageous or similar to the most progressive blood cell separators and capable to collect a sufficient number of progenitor cells for a graft with a mean of 1.80 ± 0.98 procedures per patient. J. Clin. Apheresis 12:82–86, 1997.

Biosimilar filgrastim (Zarzio(®)) vs. lenograstim (Myelostim(®)) for peripheral blood stem cell mobilization in adult patients with lymphoma and myeloma: a single center experience.

1 Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, 2 Immuno-Transfusional Medicine, Leukapheresis and Cellular Therapy Unit, S. Camillo-Forlanini Hospital, 3 Immuno-Transfusional Medicine Unit, Regina Elena National Cancer Institute, 4 Scientifi c Direction, Regina Elena National Cancer Institute, and 5 Intensive Care and Pain Therapy Unit, Regina Elena National Cancer Institute, Rome, Italy

161 O - Very high-dose chemotherapy (VHDCT) with ematologic support in previously untreated advanced ovarian cancer (OVCA): preliminary results of a phase I-II study

Two consecutive trials were conducted to evaluate a VHDCT programme with autologous bone marrow (ABM) or perlpheral stem cell (APSC) support in previously untreated OVCA patients (Pts) with macroscopic (0.5–2cm) residual tumor. Fifthy-one pts (median age 44; stage IIIC 78%) underwent: Induction chemotherapy (Indct) (2–4 cycles of a cisplatin and cyclophosphamide combination +/- G-CSF) with ABM and/or APSC hsrvestlng (H) foflowed by intensification (Int) CT (one course of a platinum, etoposide combination +/- L-PAM, +/-G-CSF&EPO) In the absence of clinical progression. 2nd-look laparotomy was performed in complete responders. 42 (82%) and 39 (76%) pts are evaluable for toxicity and pathological response (PR), respectively while 6 pts are still on treatment, 3 progressed when on treatment, 2 are awaiting 2nd look. One toxic death occurred due to systemic mycosis in a pt undergoing ABM transplantation (T). The number of leukaphereses required for adequate APSCH decreased after G-CSF Incorporation. Duration of BM aplasia progressively decressed lor pts receiving ABMT. APSCT and APSCT + G-cSF & EPO, respectively. 90% pR (CR 44%, PR 41% of which 36% microscopic) was revealed at 2nd-1ook. A median follow up of 28 (2–79) months has been reached from diagnosis. Only 2 of the 19 pathologically complete responders (6 with a > 5 year follow-up from 2nd-look) have so far relapsed without further therapy. Treatment proved to be feasible with acceptable toxicity when APSCT + G-CSF & EPO were used. The disease-free Interval would seem to be longer than expected in this pt subset. These data, if confirmed after a prolonged observation, warrants further investigation (in a randomized setting) on the possible therapeutic impact of this new approach on chemosensitive tumors.