Stem Cell Transplantation

AUTOLOGOUS STEM CELL TRANSPLANTATION

Amanda L. Olson

Craig Sauter

Description

HDC/radiation followed by infusion of autologous multipotent hematopoietic stem cells.
Tx of hematologic malignancies using HDC/radiation followed by ASCR to reconstitute the BM.

Indications

Disease	Details
Multiple myeloma (MM)	Consolidation Rx following initial response to chemotherapy or for the tx of relapsed or refractory disease (NEJM 2007;356:1110).
Hodgkin lymphoma (HL)	Tx of chemotherapy-sensitive relapsed disease. Curative intent (Lancet 2002;359:2065)
DLBCL	Tx of chemotherapy-sensitive relapsed disease. Curative intent (Parma Trial, NEJM 1995;333:1540)
Follicular lymphoma	Tx of chemotherapy-sensitive early relapsed disease or disease that has progressed to a clinically aggressive histology (eg, DLBCL).
Peripheral T cell lymphoma	Consolidation Rx in first complete remission or for the tx of chemotherapy-sensitive relapsed disease.
Mantle cell lymphoma	Consolidation Rx in first complete remission or for the tx of chemotherapy-sensitive relapsed disease.
Acute myeloid leukemia	Postremission Rx in pts in first remission. No survival benefit to consolidation chemotherapy alone.
Ig light chain (AL) amyloidosis	Consolidation Rx following initial response to chemotherapy or for the tx of relapsed disease.
Waldenström macroglobulinemia (WM)	Tx of chemotherapy-sensitive early relapsed disease

Pretransplant Evaluation

To establish extent of disease & assess pt comorbidities, includes the following.

Hx: PS, prior Rx, drug allergies, prior infxn, & social support
Physical exam: Oral cavity/skin for nidus for infxn, CNS exam, & assessment of lymphadenopathy
Labs: CBC, chemistries w/liver & renal function, 24-h urine collection for measurement of Cr clearance
CXR or CT chest
ECG & a study of cardiac function (ECHO or MUGA)
PFT including DL_CO
Disease-specific restaging studies including
- BM aspiration/bx
- CT or combined CT/PET in pts w/certain lymphomas
- SPEP & UPEP w/immunofixation, serum FLC assay & skeletal assessment in pts w/myeloma

Stem Cell Source

Stem cells should be collected prior to exposure to an alkylating agent such as oral melphalan, nitrogen mustard or purine analog & fludarabine as these agents are stem cell toxic
Collection may be done by BM harvesting or peripheral blood stem cell apheresis following tx w/G-CSF
Harvested cells are cryopreserved until time of transplant

Conditioning Regimens

Chemotherapy or radiation given prior to transplant to eradicate disease.
All conditioning regimens are ablative, as the therapeutic response following ASCT depends on the HDC/radiation.
Melphalan-based regimens are commonly used for the tx of plasma cell dyscrasias & lymphoma (commonly treated w/BEAM: BCNU, Etoposide, Ara-C, Melphalan).

Engraftment

Expansion of the HSC in the BM w/c results in normalization of blood counts & immune recovery
Time to engraftment varies based on conditioning regimen, stem cell graft, & characteristics
BM graft & lower cell dose generally result in longer time for engraftment