Practical Aspects of Hematologic Stem Cell Harvesting and Mobilization

Published on 04/03/2015 by admin

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Chapter 45 Practical Aspects of Hematologic Stem Cell Harvesting and Mobilization

Scott D. Rowley, Michele L. Donato

Choice of Hematologic Stem Cell Product for Transplantation

Virtually all patients undergoing autologous HSC transplantation will have PBSC as the source of HSC, based on the following advantages: ease of collection, greater quantities of HSC (resulting in faster hematologic recovery and shorter and less costly hospital stays), and potentially lower risks for tumor cell contamination of the graft.

The allogeneic donor has a wider range of options, including marrow, PBSC, or UCB products from HLA-compatible or partially compatible related or unrelated donors. The transplant recipient may request a source of cells, but the donor has the right to decide about the method of donation. PBSC products have the greatest quantity of HSC and will result in faster hematologic recovery compared with marrow or UCB transplants. In some reports, PBSC transplantation also results in a survival advantage. However, PBSC transplantation is also associated with a higher risk for difficult-to-control chronic GVHD and may not be appropriate for use in patients who would not benefit from a robust GVL effect, such as those treated for nonmalignant diseases. Umbilical cord blood has the advantage of being immediately available, reducing the time to transplantation. Targeted collection of UCB products from ethnic populations not well represented in donor registries will facilitate treatment of ethnic minority patients. The relative immature immunity of the cord blood donor allows use of HLA mismatched products without an undue increase in GVHD risk. Infusion of two cord blood units may achieve a greater graft-versus-tumor effect, even though one unit will be rejected. The much smaller quantity of HSC in the cord blood product results in slower hematologic recovery, and the adult patient, in particular, may be at greater risk for posttransplant infections because of the relative immature immune system of the donor.

Table 45-1 Randomized Studies Comparing Marrow and PBSC as HSC Sources*

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ANC, Absolute neutrophil count; BM, bone marrow, G-BM, granulocyte colony-stimulated bone marrow; NS, not significant; PBSC, peripheral blood stem cell.

* Shown are number of patients enrolled in each arm of the study, quantity of CD34+ cells × 106/kg (CFU-GM × 104/kg for reports by Beyer and Hartmann), days after transplantation to achieve a peripheral blood absolute neutrophil count >500/µL and platelet count >20,000/µL (25,000/µL for report by Blaise and 30,000/µL for report by Hartmann), and percentage of patients developing acute graft-versus-host disease.

Evaluation of the Marrow or Peripheral Blood Stem Cell Donor

HSC transplantation involves the infusion of a “blood product,” and all donors must be evaluated for risks for disease transmission as per the current criteria for blood donation. Exemptions from criteria that specifically address the risk for disease transmission are permissible, if the risks of excluding an otherwise appropriate donor outweigh the risks for disease transmission to the transplant recipient, who may not have an alternate donor. Informed consent must be obtained for the evaluation and collection procedures. Informed consent also must be specifically obtained for the release of protected donor health information to the transplant recipient, allowing proper informed consent for the transplant to be obtained. Minors and donors not competent to provide consent must be represented by a third party not involved in the care of the recipient. Ideally, similar courtesy will be provided to the adult donor. Donors must also be evaluated for health issues that would increase the risks resulting from the collection procedures. For marrow donors, this includes the risks of anesthesia; for PBSC donors, evaluation should include the risks of mobilization medications and apheresis.

The donor collection facility’s standard operating procedures for evaluation of HSC donors must meet FACT/JACIE or AABB guidelines and FDA (or other regulatory agency) standards, and include policies and procedures for the following:

• Education of donor, including education regarding procedures, risks, alternatives, and possible future collections

• Medical history, including special attention to history of autoimmune disorders, arthritis, cardiac and vascular diseases, and history of cancer

• History of high-risk behaviors, such as recent tattoos, body piercing, sexual practices, and travel

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