Autologous Stem Cell Transplantation And Subsequent Growth Factor Support

Randomized trials of G-CSF versus control following autologous peripheral blood and stem cell transplantation have documented a benefit from prescribing G-CSF, in terms of decreased duration of neutropenia and hospitalization. In general, patients treated with autologous transplantation do experience shortened periods of neutropenia and reduced duration of hospi-talization after receiving filgrastim ranging from 5 to 30 ^g/kg per day, or two different dose schedules of lenograstim.45-48 As illustrated by the wide range of prescribed doses of G-CSF and lenograstim, the optimal dose and timing/duration of administration is still unclear in the postautologous recovery phase.47 A non-randomized study suggested a benefit in terms of decreased duration of hospitalization, neutrophil recovery, and cost savings, when G-CSF was initiated on the day immediately after peripheral blood progenitor cell reinfusion, in comparison to starting this therapy 4 days later.49 These findings have not been supported in other randomized studies regardless of whether administration of G-CSF began on day 1 versus 7, or 3 versus 5 days after reinfusion of stem cells.5051

Not all growth factors are created equal: GM-CSF support following reinfusion of primed peripheral blood progenitor cells did not result in any benefit in one placebo-controlled trial.52

Myeloablative therapy will induce severe anemia necessitating transfusion of virtually all patients undergoing autologous transplantation. Earlier data suggested that administration of erythropoietin, when given both prior to ablative therapy and when resumed subsequently on day 1, failed to decrease the number of red blood cell transfusions in comparison to placebo.53 Recently, the effects of erythropoietin, administered at a dose of 500 units/kg per week starting from day 30 after transplantation, to a cohort of patients treated for malignant lymphoma or myeloma were assessed. In a retrospective analysis, mean hemoglobin levels were substantially better: only 2 of 41 patients in the treatment group versus 12 of 45 patients in a previously treated "control" group without erythropoietin support experienced hemoglobin levels less than 9 g/dL.54 The potential benefit of such delayed administration, as well as pilot data demonstrating a protective effect in multiple myeloma patients in whom erythropoietin is provided prior to the second phase of a tandem transplant, needs to be confirmed in a prospective randomized fashion.55 The effect of erythropoietin has also been evaluated in patients with lymphomas undergoing intense salvage therapy followed by consolidation. When epoetin beta was prescribed at a dose of 10,000 IE thrice a week during the entire course of two cycles of DHAP (dexamethasone, ARA-C, and cisplatin), followed by further intensification and peripheral blood progenitor cell collection and BEAM (carmustine, etoposide, melphalan, and ARA-C) therapy, the number of red cell transfusion required (4.5 vs 8.3) and mean hemoglobin levels during the course of therapy were all favorably affected by growth factor therapy.5

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