Sequential High-Dose Treatment with Peripheral Blood Progenitor Cell Transplantation in Patients with Multiple Myeloma

Transcription

1 Sequential High-Dose Treatment with Peripheral Blood Progenitor Cell Transplantation in Patients with Multiple Myeloma Hartmut Goldschmidt, Ute Hegenbart, Marion Moos, Rita Eugenhart, Michael Wannenmacher;. Rainer Haas, Werner Hunstein Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany; Department of Radiology, University of Heidelberg, Heidelberg, Germany Key Words. Peripheral blood progenitor cell mobilization Multiple myeloma Peripheral blood progenitor cell transplantation Abstract. In June 1992, we started a dose-escalated cytotoxic therapy with peripheral blood progenitor cell (PBPC) transplantation in patients with chemosensitive multiple myeloma (MM). At the time of best response to conventional treatment, 70 patients received high-dose cyclophosphamide (HD-CY) or, in case of pre-existing heart disease, dose-escalated ifosfamide/mitoxantrone followed by filgrastim (R-metHuG-CSF, 300 pglday). PBPC collection was commenced when CD34 cells were detectable using direct immunofluorescence analysis. Fifty-four out of 70 patients were successfully harvested (2 2.5 x lo6 CD34 cellsfkg body weight [BW]) after the first cycle of HD chemotherapy. Conditioning therapy consisted of 140 mg/m2melphalan plus TBI (14.4 Gy hyperfractionated) or 200 mg/m melphalan in patients not eligible for TBI because of previous radiotherapy. To date, 56 patients have been transplanted. Autografts contained a median of 3.4 x 106 CD34 cells/kg BW. Following reinfusion of PBPC, rapid engraftment was achieved in 54 out of 56 patients with a median of 14 days (range 9-23) to reach 0.5 x 109fl neutrophils and 10 days (range 5-22) for an unsubstituted platelet count of > 20 x 1OY/I. One patient died of transplantation-related complications. Sequential HD treatment improved the remission status (European Bone Marrow Transplantation criteria) in 19 out of 46 patients (9 patients too early). Of note, in 11 patients the immunofixation became negative and a polyclonal immunoglobulin reconstitution was achieved. Our protocol provides an effective treatment strategy for patients with advanced MM combined with low treatment-related toxicity. Correspondence: Dr. Hartmut Goldschmidt, Department of Internal Medicine V, University of Heidelberg, Hospitalstr. 3, Heidelberg, Germany. Received August 2, 1995; accepted for publication August 2, OAlphaMed Press /95/$5.00/0 Introduction Multiple myeloma (MM) is a malignant disease of B cell origin and is characterized by the presence of monoclonal plasma cells in the bone marrow. The median time of survival has not significantly changed during the last 30 years [l]. A promising treatment approach to improve the survival for MM patients is based on reports of high complete remission (CR) rates after the administration of doseescalated alkylating agents. Dose escalation with melphalan was piloted by T. J. McElwain in the early 1980s [2]. This approach led to increased hematological toxicity and cytopenia-related deaths in up to 20% of patients. Cytokine administration after high-dose (HD) melphalan did not result in a significant reduction of infections and did not suppress the risk of toxic death [3]. At first, as a result of hematopoietic progenitor cell support after HD treatment, the duration of bone marrow aplasia was significantly shortened. The advantage of using peripheral blood progenitor cells (PBPC) in relation to autologous bone marrow (ABM) is the further reduction of treatment-induced neutropenia resulting in fewer cases of transplantrelated morbidity and possibly lower mortality [4]. An additional benefit of PBPC in comparison to ABM is the proposed low contamination of peripheral blood with tumor cells [5]. We therefore decided to use blood-derived hematopoietic progenitor cells for the hematological rescue in patients with MM following HD therapy. In this report, we summarize our experience with the first 70 patients treated with HD therapy. STEM CELLS 1995;13(suppl3):36-41

2 Goldschmidt et a1 37 Materials and Methods Patients Seventy patients with chemosensitive MM were enrolled into this study. According to the classification of Salmon and Durie [6], 3 patients (pts.) had stage I, 13 pts. stage I1 and 54 pts. stage I11 MM. There were 44 males and 26 females with a median age of 51 years (range 30-65). The disease status at the time of best response to conventional therapy was as follows (European Bone Marrow Transplantation group criteria): 10 pts. had achieved CR, 54 pts. partial remission (PR) and 6 pts. minimal response (MR). Patient characteristics are shown in Table I. Cytokine-supported HD chemotherapy served as consolidation or salvage therapy and was found to be effective for progenitor cell mobilization. Independent of disease status, patients received HD cyclophosphamide (HD-CY, 66 pts.) or in case of pre-existing heart disease (4 pts.), dose-escalated ifosfamide (4 g/m2 on days 1 and 2) and mitoxantrone (5 mg/m2 on days 2 and 3). First, we treated 16 pts. with 4 g/m2 CY. To optimize PBPC mobilization, we increased the CY dose to 7 g/m2 for the following pts. G-CSF administration at a dosage of 300 pg/d S.C. was started 24 h after the end of chemotherapy and continued until the last leukapheresis day. The blood-derived progenitor cells were harvested during the rebound phase of marrow recovery as soon as a distinct population of CD34' cells could be identified by direct immunofluorescence analysis. The study was performed under the ethical guidelines of the Joint Committee of Clinical Investigation of the University of Heidelberg. Informed consent was obtained from each patient. The cutoff date of this report is June 15, Collection of PBPCs and Cryopreservation Harvesting was performed with a Fenwal CS 3000 (Baxter Deutschland, Munchen, Germany). For each leukapheresis, 10 L blood were processed at a flow rate of 50 to 70 ml/min. The apheresis product of a 50 ml cell suspension was mixed with the same volume of minimal essential medium (MEM) containing 20% dimethylsulfoxide (DMSO; Merck, Darmstadt, Germany). The final 100 ml cell suspension was transferred into freezing bags (Delmed, New Brunswick, NJ), and frozen to -100 C using a computer-controlled cryopreservation device (Cryoson BV-6; Cryoson Deutschland, Germany). The frozen cells were transferred into liquid-phase nitrogen and stored at -196 C. Clonogenic Assay for Hematopoietic Progenitor Cells The concentration of hematopoietic progenitor cells in each single leukapheresis product and in the peripheral blood was assessed using a semisolid clonogenic culture assay (Terry Fox Laboratories, Vancouver, Canada) as previously described [7]. Immunofluorescence Staining and Flow Cytometry For immunofluorescence analysis, 20 pl of whole blood or 1 x 1 O6 mononuclear cells were Table I. Patient characteristics of 70 patients with cheinosensitive multiple myeloma Age in years* MaleslFemales Paraprotein Disease status prior to mobilization Stage No. of prev. therapy cycles* Prev. radiation Duration of previous alkylating therapy in months* * median (range) G A BJ D asecretory C RIP RIM R I/II/III 51 (30-65) /54 6 (3-27) 37 5 (0-35)

3 38 PBPC Transplantation in Multiple Myeloma incubated for 30 min at 4 C with the fluorescein isothiocyanate (F1TC)-conjugated monoclonal antibody HPCA-2 (anti-cd34) (Becton Dickinson, Heidelberg, Germany). The cells were analyzed using a Becton Dickinson FACScan as previously described [7]. Pretransplantation Conditioning Regimen and Intensive Care Post-Transplantation The pretransplantation conditioning therapy in 38 pts. consisted of TBI (14.4 Gy, hyperfractionated over 4 days) and 140 mg/m2 melphalan, whereas 18 pts. were treated with 200 mg/m2 melphalan because of previous radiotherapy of the spine. The patients received prophylactic bowel decontamination and antibiotic combination therapy was administered for fever > 38.5"C while amphotericin-b was added in case of documented fungal infection or persistent fever. A platelet count greater than 20 x 10y/l was maintained by HLA-A/Bmatched platelet transfusions, and packed red blood cells were given when the hemoglobin level was less than 8 g/dl. Results PBPC Mobilization The patients presented in this study differ with respect to previous chemo- or radiotherapy and to the disease status after conventional therapy. In 52 out of 66 pts. treated with HD-CY followed by filgrastim, a first mobilization cycle was sufficient to mobilize x lo6 CD34' cells/kg BW. To evaluate the impact of increasing the CY dosage, we compared the results of PBPC mobilization after 4 or 7 g/m2 CY in 32 pts. Both patient groups (16 pts. in each group) were comparable with regard to disease stage, number of previous therapies, the duration of previous therapy with alkylating agents and the degree of bone marrow infiltration prior to mobilization therapy. As a result of the higher CD34' cell peak values in the peripheral blood following cytokine supported HD-CY (47.86 versus CD34' celldpl), the number of CD34' cells/kg BW per leukapheresis was significantly increased after 7 g/m2 CY (Fig. 1). The increased hematological toxicity following 7 g/m2 CY (median 7 versus 3.5 days neutrophils < 0.5 x 10y/l) was not associated with a significant difference in the rate of fever or septicemia between both groups. The nonhematological toxicity was similar in both treatment groups and did not exceed World Health Organization (WHO)-grade I11 [S]. Analyzing favorable factors for PBPC mobilization, we found that successfully harvested patients were pretreated less with alkylating agents (5 versus 9 months). Neither post-hd-cy nor post-dose-escalated ifosfamide/mitoxantrone chemotherapyinduced cardiac damage was observed in electrocardiogram or echocardiogram. High-Dose Therapy with PBPC Support Fifty-six pts. have been transplanted. Thirtyone pts. received TBI (hyperfractionated, 14.4 Gy over 4 days) followed by 140 mg/m2 melphalan while 18 pts. were treated with 200 mg/m2 melphalan alone because of previous irradiation. Following HD conditioning therapy, PBPC were reinfused without additional bone marrow or growth factor support. The autografts contained between 1.5 x 10h and 12.4 x lo6 CD34' celldkg (median 3.4). No significant difference was found in the speed of reconstitution between patients regarding the conditioning regimen. The median time to reach a neutrophil count of 0.5 x 109/1 was 14 days with a range from 9 to 23 days. Platelets recovered rapidly in 54 out of 56 pts. reaching an unsupported number of greater than 20 x 10y/l between 5 and 22 days (median 10) post-transplantation. p f. ; s/m2 7 m2 Fig. 1. Amount of CD34' cells per kg BW in leukapheresis products. 4 g/m2 versus 7 g/m2 cyclophosphamide chemotherapy.

4 Goldschmidt et al s 60--.ii J E 40~- 3 E a Granulocytes > 0.5lnl _ I b Q a? Ew-tfres Survival I 0-1 I Days Tme in Months Fig. 2. Cumulative frequency of hematological reconstitution after autologous peripheral blood progenitor cell transplantation. The hematological reconstitution is shown as cumulative frequency in Figure 2. One patient died of multiorgan failure 20 days post-transplantation. HD therapy with PBPC support improved the remission state in 19 out of 46 eligible pts. (9 pts. too early [Fig. 31). Of note, the immunofixation became negative in 11 pts. and a polyclonal immunoglobulin reconstitution was achieved after sequential HD treatment. Nine pts. relapsed between 3 and 12 months post-autografting. In this group, IgA-subtype, hypercalcemia and stage 111 MM were observed more frequently. The median values of p-2- microglobulin prior to transplantation did not differ between patients relapsed or in remission. Chemotherapy High-dose High-dose qclophmphamide or melphalan +I- TBI ifoslamidelmitarantrone Fig. 3. Changes of the remission state in the course of sequential HD treatment in 46 patients with multiple myeloma. Fig. 4. Probability of event-free and overall survival after HD chemotherapy with peripheral blood progenitor cell transplantation in 54 patients with multiple myeloma. With a median follow-up of 12 months (range 1-36) 52 pts. are alive. Forty-six pts. are in remission or have a stable disease. This can be translated into a probability of overall survival of 82% after two years (Fig. 4). Discussion In this report we present data of 70 pts. with chemosensitive MM who underwent consolidation or salvage HD therapy after conventional treatment. A sufficient autograft containing x lo6 CD34' cells/kg BW was harvested in 57 out of 70 pts. (81 %) after the first cytokine-supported HD treatment cycle. Using a second mobilization cycle, the number of autografts increased to 60 (86%). Fermand et al. [9] have shown that CHOP-like chemotherapy without cytokine support is successful only in 57% of MM patients in mobilizing PBPC. Kotasek et al. reported that increasing CY from 4 to 7 g/m2 resulted in a doubling of the colony forming units-granulocytemacrophage (CFU-GM) harvested. Patients who received cytokine support after HD-CY had significantly higher CFU-GM peak values than patients treated without hematopoietic growth factors [lo]. We found that 7 g/m2 CY followed by filgrastim are significantly more effective for PBPC mobilization compared to 4 g/m2, whereas the toxicity of the higher dosage did not

5 40 PBPC Transplantation in Multiple Myeloma exceed WHO-grade 111. We prefer, therefore, the 7 glm' CY dosage followed by cytokine administration for the mobilization of PBPC in pretreated MM patients. In agreement with Tricot et al. [l I], we also observed that a longer duration of previous therapy with alkylating agents has a negative influence on the probability of successful PBPC mobilization in MM patients. As a result of the amount of autografted cells, a rapid hematological reconstitution was observed in 54 out of 56 pts. transplanted. A fast bone marrow recovery is the main factor in reducing the risk of bleeding or infectious complications after PBPC transplantation. Dose limitations are now implied by organ impairment (i.e., toxic heart failure, severe mucositis) instead of hematological toxicity. The improvement of remission state in the course of sequential HD treatment in 19 out of 46 pts. and the treatment-related mortality of 2% in our study are in agreement with other trials [12, 131. Nine pts. relapsed between 3 and 12 months post-transplantation, eight of them had stage 111 MM. Other factors for an increased relapse risk were IgA-subtype and hypercalcemia at the time of diagnosis. The lack of a plateau in the survival curve in most autologous transplantation trials demonstrates either the inability of HD regimens to eradicate the tumor clone or an induction of the relapse by tumor cell reinfusion. Tumor cell removal from autologous grafts may be accomplished by negative selection of tumor cells and by positive selection of hematopoietic stem cells. Results of patient-specific CDR3- polymerase chain reaction assays show that the CD34' progenitor cell is probably not involved in the malignant clone and that a CD34' selection is effective to reduce the tumor content in PBPC autografts [ 141. Multicenter studies to evaluate the efficacy and the impact of CD34' enrichment in autografts have recently been started in the U.S. andeurope [15]. Up to now, the role of HD treatment for the long-term prognosis of patients with MM is not fully evaluated. Although the randomized French myeloma trial showed a significant survival advantage for patients following autologous transplantation [ 161, further randomized prospective studies are required to evaluate the role of blood progenitor cell transplantation after HD treatment in MM. Therefore, patients younger than 65 years should be treated preferentially in prospective randomized trials. Acknowledgments The authors thank the nursing staff of the Department of Internal Medicine V and the Department of Radiology for their outstanding care of these patients, and Margit Pforsich, Usclzi Birkenstock, Eike John, Kivsten Flentje. Evi Holdermann and Magdalenu Volk for their excellent technical assistance. We are indebted to Professor Rother (Institute for Immunology and Serology at the University of Heidelberg) and his colleagues for providing the RBC and HLA-matched platelet transfusions. References 1 Alexanian R, Dimopoulos M. The treatment of multiple myeloma. N Engl J Med 1994;330: McElwain TJ, Powles RL. High dose intravenous melphalan for plasma cell leukemia and myeloma. Lancet 1983;2: Harrousseau JL, Fiere D, Bezwoda WR et al. GM-CSF instead of autologous stem cell transplantation after high dose melphalan (HDM) in multiple myeloma (MM). Blood 1994;84:181a. 4 Jagannath S, Vesole DH, Tricot G et al. Hemopoietic stem cell transplants for multiple myeloma. Oncology 1994;8: Bird JM, Bloxham D, Samson D et al. Molecular detection of clonally rearranged cells in peripheral blood progenitor cell harvests from multiple myeloma patients. Br J Hematol 1994;88: Durie B, Salmon S. A clinical staging system for multiple myeloma. Cancer 1975;36: Haas R, Mohle R, Fruhauf S et al. Patient characteristics associated with successful mobilizing and autografting of peripheral blood progenitor cells in malignant lymphoma. Blood 1994;83: WHO Handbook for Reporting Results of Cancer Treatment. Geneva: WHO Offset Publications, Fermand J-P, Chevret S, Ravaud P et al. Highdose chemoradiotherapy and autologous blood stem cell transplantation in multiple myeloma: results of a phase I1 trial involving 63 patients. Blood 1993;82: Kotasek D, Shepherd KM, Sage RE et al. Factors affecting blood stem cell collections following high-dose cyclophosphamide mobilization in lymphoma, myeloma and solid tumors. Bone Marrow Transplant 1992;9:11-17.

6 Goldschmidt et al Tricot G, Jagannath S, Vesole D et al. Peripheral blood stem cell transplants for multiple myeloma: identification of favorable variables for rapid engraftment in 225 patients. Blood 1995;85: Harrousseau JL, Attal M, Divine M et al. Autologous stem cell transplantation after first remission induction treatment in multiple myeloma: a report of the French Registry on autologous transplantation in multiple myeloma. Blood 1995 $ Vesole DH, Barlogie 3, Jagannath S et al. Highdose therapy for refractory multiple myeloma: improved prognosis with better supportive care and double transplants. Blood 1994;84: Vescio RA, Hong CH, Cao J et al. The hematopoietic stem cell antigen, CD34, is not expressed on the malignant cells in multiple myeloma. Blood 1994;84: Pic0 JL. A randomized multicentric phase I11 trial to evaluate hematological recovery and tumor cell contamination after CD34' selection of peripheral blood progenitor cells with the CEPRATEO SC in patients with multiple myeloma. EBMT Study, CellPro Europe Protocol EU Attal M, Harousseau JL, Stoppa AM et al. High dose therapy in multiple myeloma: a prospective randomized study of the "Intergroup Francais Du Myelome" (IFM). Bone Marrow Transplant 1995; 15:s 12a.