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Bone Marrow Transplantation (2010) 45, 269–275 & 2010 Macmillan Publishers Limited All rights reserved 0268-3369/10 $32.00

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ORIGINAL ARTICLE

Mobilization of peripheral blood stem cells for autologous transplant in non-Hodgkin’s lymphoma and multiple myeloma patients by plerixafor and G-CSF and detection of tumor cell mobilization by PCR in multiple myeloma patients S Fruehauf 1,2, G Ehninger3, K Hu¨bel4, J Topaly1,2, H Goldschmidt2, AD Ho2, S Mu¨ller2, M Moos2, K Badel5 and G Calandra5 1 Center for Tumor Diagnostics and Therapy, Paracelsus Klinik, Osnabrueck, Germany; 2Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany; 3Department of Internal Medicine I, Division of Hematology and Oncology, Carl Gustav Carus University, Dresden, Germany; 4Department of Internal Medicine, University Hospital of Cologne, Cologne, Germany and 5Formerly AnorMED Inc., now Genzyme Corporation, Cambridge, MA, USA

This report describes the first investigational use of plerixafor in Europe and the determination of tumor cell mobilization by polymerase chain-reaction after plerixafor treatment in a subset of patients with multiple myeloma (MM). Thirty-five patients (31 MM and 4 NHL) received granulocyte colonystimulating factor (G-CSF) (10 lg/kg) each morning for 4 days. Starting the evening of Day 4, patients recieved plerixafor 0.24 mg/kg. Apheresis was initiated 10–11 h later, in the morning of Day 5. This regimen of G-CSF treatment each morning before apheresis and plerixafor treatment in the evening was repeated for up to 5 consecutive days. Mobilization with plerixafor and G-CSF resulted in a median 2.6-fold increase in peripheral blood (PB) CD34 þ cell count compared with before plerixafor treatment. All patients collected X2 106 CD34 þ cells/kg and 32 of 35 patients collected X5 106 CD34 þ cells/kg. After plerixafor treatment, 3 of 7 patients had a small increase and 4 of 7 patients had a small decrease in PB tumor cells. No G-CSF was given post transplant. The median number of days to polymorphonuclear leukocyte and platelet engraftment was 14.0 and 11.0, respectively. There were no reports of graft failure. Plerixafor was generally well tolerated. Mobilization of PB CD34 þ cells was consistent with previous clinical trials. The addition of plerixafor did not significantly increase the relative number of PB MM tumor cells. Bone Marrow Transplantation (2010) 45, 269–275; doi:10.1038/bmt.2009.142; published online 13 July 2009 Keywords: plerixafor; multiple myeloma; non-Hodgkin’s lymphoma; CD34 þ cells; mobilization; tumor cell contamination

Correspondence: Professor Dr S Fruehauf, Center for Tumor Diagnostics and Therapy, Paracelsus Klinik, Am Natruper Holz 69, 49076 Osnabruck, Germany. E-mail: [email protected] Received 30 October 2008; revised 19 May 2009; accepted 20 May 2009; published online 13 July 2009

Introduction Mobilized peripheral blood stem cells (PBSCs) have become the main source for autologous or allogeneic transplantation after myeloablative therapy in patients with hematolymphoid malignancies or solid tumors. Classical strategies for PBSC mobilization include administration of granulocyte colony-stimulating factor (G-CSF) alone or in combination with other cytokines or myelosuppressive chemotherapy.1 PBSC mobilization and collection have been optimized in numerous clinical trials,2 but a significant proportion of patients fail mobilization.3 In recent years, some of the underlying physiology of PBSCs has been elucidated, leading to the development of new mobilization strategies. Expression of the G-CSF receptor on stem cells is not required for mobilization. G-CSF or myelosuppressive therapy acts through secondary pathways, including the chemokine stromal-derived factor-1 and its receptor CXCR4. New chemokine receptor antagonists lead to a rapid and substantial PBSC mobilization. The most advanced data are available for plerixafor (AMD3100), which acts synergistically with G-CSF in normal donors and patients with MM and NHL.4 This CXCR4 antagonist seems to mobilize more primitive PBSCs with increased repopulation capacity when compared with G-CSF.5 Plerixafor þ G-CSF-mobilized PB progenitor cells express significantly higher amounts of genes that potentially promote superior engraftment after myeloablative therapy than G-CSF-mobilized CD34 þ PB progenitor cells.6 This report describes the first investigational use of plerixafor in Europe in an open-label, single-arm study conducted at three sites in Germany. The addition of plerixafor (0.24 mg/kg) to a standard G-CSF mobilization regimen was evaluated for safety and efficacy when used for the collection of PBSCs for autologous transplantation in patients with non-Hodgkin’s lymphoma (NHL) and multiple myeloma (MM). This is the first study that used a quantitative DNA amplification method to identify the

PBSC and tumor cell mobilization with plerixafor þ G-CSF S Fruehauf et al

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frequency of MM tumor cells in the PB of patients with MM after mobilization with G-CSF alone and again after the addition of plerixafor treatment. This is the first report to show that the addition of plerixafor does not seem to cause MM tumor cell contamination of the apheresis product.

Patients and methods Study design and patient population This was an open-label, single-arm study conducted at three sites in Germany. The study was conducted according to a protocol approved by all local ethics committees. All patients or patients’ designees signed an informed consent. The data were analyzed by the study-sponsored statistician and all investigators had access to the clinical trial data. This study is registered on clinicaltrials.gov, registration number NCT00322842. Principal inclusion criteria were: male and female patients from 18 to 70 years of age, with a diagnosis of NHL or MM and eligible for autologous transplantation; no more than three prior regimens of chemotherapy (rituximab was not considered chemotherapy); X4 weeks since the last cycle of chemotherapy; Eastern Cooperative Oncology Group performance status of 0 or 1; recovery from all acute toxic effects of prior chemotherapy; negative for HIV; and adequate hematologic, hepatic, renal and cardiac function parameters at screening. Principal exclusion criteria were: any comorbid condition which, in the view of the investigator, rendered the patient at high risk from treatment complications; failed previous stem cell collections; residual acute medical condition resulting from prior chemotherapy; brain metastases or carcinomatous meningitis; an acute infection; actual body weight exceeding 150% of ideal body weight; history of ventricular arrhythmias; and a history of paresthesias (Grade 2). In addition, patients who had deterioration of their clinical status or laboratory parameters between the time of enrollment and transplant (such that they no longer met entry criteria) might be removed from the study at the discretion of the investigators. PBSC mobilization and transplantation Patients initially received a mobilizing regimen of G-CSF (10 mg/kg subcutaneously) each morning for 4 days (Days 1–4), as per the standard of care. Starting the evening of Day 4, patients received plerixafor 0.24 mg/kg subcutaneously. Apheresis was initiated in the morning, 10–11 h after the evening dose of plerixafor. This regimen of G-CSF treatment each morning before apheresis and plerixafor treatment in the evening was repeated for up to 5 consecutive days. On each day of apheresis, the number of CD34 þ cells/ mL in the apheresis product was measured by flow cytometry by local and central (Esoterix) laboratories. The target cumulative yield of CD34 þ cells/kg was X5 106 and the minimum number of cells required for transplant was X2 106 CD34 þ cells/kg. The number of days required to collect the minimum and target numbers Bone Marrow Transplantation

of cells (up to 5 days) was recorded. The cell dose for transplantation was calculated on the basis of the patient’s actual body weight. After stem cell collection and before transplantation, patients underwent myeloablative chemotherapy. Efficacy was evaluated by the PB CD34 þ cell count (cells/ml), apheresis yield (CD34 þ cells/kg), number of days to PMN and PLT engraftment, and graft durability at 3, 6 and 12 months post transplantation. Safety was evaluated by the incidence of adverse events (AEs), serious adverse events (SAEs), clinical laboratory tests (chemistry, hematology including complete blood count with differential, urinalysis and coagulation), vital sign parameters and physical examination findings. AEs were recorded in three consecutive periods. Period 1 encompassed the period from G-CSF mobilization (Days 1–4), G-CSF plus plerixafor mobilization (Day 5 and up to Day 10), apheresis and rest before ablative treatment. Period 2 encompassed the period from transplantation to engraftment and Period 3 encompassed the period from engraftment to 12 months post transplant. In addition, tumor cell mobilization was evaluated in patients with MM.

Assessment of tumor cell mobilization Tumor cell mobilization was evaluated from samples obtained from a sub-population of seven patients with MM, all from the Heidelberg center. Bone marrow puncture was performed at screening (before treatment with either G-CSF or plerixafor) to obtain the primer sequence for the polymerase chain-reaction (PCR) assay. In two additional patients, it was not possible to generate allele-specific oligonucleotide (ASO) primers from the bone marrow biopsies. PB samples were obtained at three time points: screening (before G-CSF and plerixafor treatment), preplerixafor (after G-CSF treatment and before the first plerixafor dose) and pre-apheresis (after G-CSF plus plerixafor treatment). The mobilization of tumor cells was evaluated by PCR as described earlier.7 Briefly, a fragment of three complementarity-determining regions (CDRs) was amplified by PCR from DNA extracted from bone marrow biopsy samples for each patient. The amplified CDR fragments were sequenced to ensure that the correct DNA fragment was amplified. In patients with MM, bone marrow samples contain a high proportion of malignant plasma cell clones; hence, the most frequently obtained sequence is the tumor sequence. For each patient, ASO primers were designed for the CDR2 region (forward) and the CDR3 region (reverse). These primers were used in a quantitative PCR to determine a count of the number of copies of DNA conforming to the ASO primers present in PB samples taken at three time points. The count of specific ASO PCR products obtained was used to determine the frequency of tumor genes with respect to the total DNA content. The MAXLIKE computer program (a gift of F. Cremer, Universita¨t Heidelberg, Heidelberg, Germany) was used to estimate the frequency of tumor cells, expressed as a share of total peripheral blood mononuclear cells (PBMCs).7


271 Table 1

Patient demographic and baseline disease characteristics

Parameter

Summary statistic

NHL N ¼ 4

MM N ¼ 31

All patients N ¼ 35

Gender Female Male

n (%) n (%)

3 (75.0) 1 (25.0)

12 (38.7) 19 (61.3)

15 (42.9) 20 (57.1)

Mean (s.d.) Median Min, Max

59.8 (8.1) 58.5 53.0, 69.0

58.8 (7.3) 61.0 41.0, 71.0

58.9 (7.3) 61.0 41.0, 71.0

Race/ethnic group Caucasian Other

n (%) n (%)

4 (100.0) 0

30 (96.8) 1 (3.2)

34 (97.1) 1 (2.9)

Disease stage at study entry I II III IV

n n n n

(%) (%) (%) (%)

0 1 (25.0) 1 (25.0) 2 (50.0)

0 5 (16.1) 26 (83.9) 0

0 6 (17.1) 27 (77.1) 2 (5.7)

33.3 (33.6) 23.0 6.0, 81.0

25.1 (39.5) 6.0 3.0, 159.0

26.1 (38.5) 6.0 3.0, 159.0

2 1.5 (2.1) 1.5 0.0, 3.0

6 7.5 (7.6) 6.5 0.0, 19.0

8 6.0 (7.1) 3.5 0.0, 19.0

Age (years)a

Time since confirmed diagnosis (months) Mean (s.d.) Median Min, Max Time since most recent progression/relapse (months) N Mean (s.d.) Median Min, Max a

Age is calculated as of the date of first study treatment.

Results A total of 35 patients (31 MM and 4 NHL) are described in this report. All 35 patients received plerixafor and were analyzed for safety and efficacy. Follow-up data recording graft durability to 12 months post transplant were available for 31 patients (29 MM and 2 NHL).

Patient demographics Patient demographics are shown in Table 1. The majority of patients were male (20 of 35) and Caucasian (34 of 35). The median age was 58.5 years in the NHL group and 61.0 years in the MM group. All patients had received prior cytoreductive chemotherapy (mean number of cycles: 7.6) and 10 patients had received prior radiotherapy: 1 (25.0%) in the NHL group and 9 (29.0%) in the MM group. Six patients with MM had prior melphalan treatment. Mobilization and apheresis yields As determined by the local laboratories, in the overall patient population, the median absolute PB CD34 þ cell count increased from 21.7 cells/ml at the time just before plerixafor administration to 69.2 cells/ml at the time just before first apheresis or 10–11 h after the first dose of plerixafor. In NHL patients, PB CD34 þ cells increased from 17.8 to 64.3 cells/ml, and in MM patients, PB CD34 þ cells increased from 26.5 to 71.0 cells/ml. Treatment with G-CSF plus plerixafor resulted in a median 2.6-fold increase in PB CD34 þ cell count from the time just before

plerixafor administration to the time just before first apheresis, at approximately 10–11 h after the first plerixafor dose. The median fold increase in PB CD34 þ cell counts were the same for patients with NHL (2.6-fold) and MM (2.6-fold). There were patients with PB CD34 þ cell counts o20 cells/ml before plerixafor, the lowest being 2.6 cells/ml. Despite the low PB CD34 þ cell counts before plerixafor administration, all patients were successfully mobilized. As determined by the local laboratories, the median number of CD34 þ cells collected was 6.8 106 cells/kg overall; 6.4 106 cells/kg in patients with NHL and 6.8 106 cells/kg in patients with MM. All patients collected the minimum target collection of X2 106 CD34 þ cells/kg in a median of 1.0 day. The majority of patients (32 of 35 overall, 3 of 4 patients with NHL, and 29 of 31 patients with MM) met the target CD34 þ cell collection of X5 106 cells/kg in a median of 1.0 day overall (2.0 days NHL and 1.0 day MM). The central laboratory data were in accordance with the local laboratory data except that two patients did not reach the minimum target according to the central laboratory data. These patients collected 0.13 106 and 1.47 106 cells/kg based on central laboratory data; however, on the basis of the local laboratory data, the patients collected 2.60 106 and 6.15 106 cells/kg, respectively. The discrepancy between the central and local laboratory values could be due to sample degradation during shipment to the central laboratory. One MM patient inadvertently received double the normal dose of plerixafor and mobilized 6.44 106 CD34 þ cells/kg in 1 day. Bone Marrow Transplantation


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2.86 NA 4.02 4.36 0.67 1.22 NA Abbreviations: ND ¼ not done; NA ¼ not applicable; tp ¼ timepoint. a Negative fold change indicates a decrease.

3.52 103 1.07 105 4.44 106 8.30 106 2.87 104 1.53 105 2.08 106 3.94 103 1.02 105 3.90 105 8.16 106 2.65 104 2.64 105 1.08 105 1.38 103 ND 9.70 106 1.87 106 3.96 104 2.17 105 0.00 67 71 67 53 68 44 41 01–116 01–114 01–119 01–123 01–110 01–103 01–117

F M M F F M M

10.5 6.8 11.3 9.3 8.7 2.6 0.19

1 3 1 1 2 1 1

Pre-plerixafor (tp2) Screening (tp1)

Pre-apheresis (tp3)

Fold change in tumor cell frequency after G-CSF alonea (tp2/tp1) Frequency of tumor cells per total peripheral blood mononuclear cells Total number of days of apheresis Cell yield/ 106 CD34+ cells/kg Sex Age Patient

Apheresis yield and tumor cell mobilization (7 patients with MM)

Tumor cell mobilization Apheresis yields and relative tumor cell contamination from PB samples taken at three time points (screening, before plerixafor, after plerixafor) for the seven patients with MM are shown in Table 2. Three patients had Stage IIA disease and four patients had Stage IIIA disease. Age ranged from 41 to 71 years; 4 patients were male and 3 were female. A median of 8.7 106 (range, 0.19–11.3 106) CD34 þ cells/kg were collected from these 7 patients. One patient did not have tumor cells assessed from PB screening. The frequency of tumor cells per total PBMCs at screening was compared with the frequency at the preplerixafor time point to quantify tumor cell mobilization after mobilization with G-CSF alone. It was determined that with G-CSF alone, the frequency of tumor cells increased for 5 of 6 patients and the increase ranged from 2.86- to 4.36-fold. One patient showed a 0.67-fold decrease.

Table 2

Safety assessment Overall, 24 of 35 (68.6%) patients experienced at least 1 AE (NHL 4 of 4 and MM 20 of 31). The most common AEs were anemia, thrombocytopenia, diarrhea, nausea, vomiting, herpes zoster, pneumonia, headache, hypokalemia and paresthesia. Two (5.7%) patients experienced AEs of severe intensity (not drug related) and 2 (5.7%) patients in the MM group experienced AEs considered life threatening (pneumonia requiring oxygen and sepsis) but not drug related. One patient with NHL died during the study period. The death was due to disease progression, not considered related to plerixafor, and occurred during the post transplant follow-up period. A total of 15 SAEs were reported for 8 patients, none of which were drug related. The majority of the SAEs reported occurred in Period 3. Only 1 SAE (type II diabetes mellitus) occurred during Period 1.

Fold change in tumor cell frequency after plerixafor + G-CSFa (tp3/tp2)

Transplant, engraftment and graft durability Thirty-three patients underwent transplantation; one patient refused transplantation and another withdrew from the study before transplantation. In the MM group, 15 patients underwent tandem transplants. Of a total of 48 transplants performed, 5 used 45 106 CD34 þ cells/kg, whereas the remaining used 42 106 CD34 þ cells/kg. None of the patients received G-CSF post transplantation. Engraftment of PMNs post transplant (second transplant in the case of tandem transplants) was assessed for 25 of 33 patients; data were missing in eight patients. The overall median number of days to PMN engraftment was 14.0 (19 days in patients with NHL and 14.0 days in patients with MM). Platelet engraftment was assessed in all 33 patients. The overall median number of days to PLT engraftment was 11.0 (17 days in patients with NHL and 11.0 in patients with MM). Graft durability up to 12 months post transplant was assessed for 31 of 33 patients. Of the two transplanted patients who were not assessed for graft durability, one died of disease progression and the other did not complete the 12-month follow-up visit. There were no reports of graft failure during the study.

0.89 1.05 0.11 1.02 1.08 0.58 0.19

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The frequency of tumor cells per total PBMCs preplerixafor was then compared with the frequency at the pre-apheresis time point to assess the effect of the addition of plerixafor treatment to G-CSF alone. At the preplerixafor time point, the frequency of tumor cells per total PBMCs was determined to be in the range of 8.16 10–6–3.94 10–3 tumor cells per total PBMCs. At the pre-apheresis time point after plerixafor treatment, mobilization of tumor cells was detected in the range of 2.08 10–6–3.52 10–3 tumor cells per total PBMCs. The frequency of tumor cells per total PBMCs after plerixafor treatment increased by 1.02–1.08-fold for 3 of 7 patients and decreased by 0.89–0.11-fold for 4 of 7 patients.

Discussion The results of the study indicated that the PB CD34 þ count increased from pre- to post-plerixafor treatment by an overall median of 2.6-fold. This was consistent with previous reports of mobilization with plerixafor plus G-CSF where a median increase of 2.6-fold increase in PB CD34 þ cells was observed.8 The generally accepted minimum number of cells for transplantation is X2 106 CD34 þ cells/kg, and the preferred number of cells for transplantation is generally X5 106 CD34 þ cells/kg.9 The median number of CD34 þ cells collected in this study after mobilization with plerixafor plus G-CSF was 6.8 106 cells/kg and all patients reached the minimum target CD34 þ cell collection of X2 106 cells/kg. The majority of patients (32 of 35, 91.4%) met the target CD34 þ cell collection of X5 106 cells/kg. The number of days from transplant to PMN engraftment is relatively consistent for patients with MM and NHL. Engraftment of PMNs usually occurs by 12 days post transplant, but may be as late as 21 days.10,11 The success rate of engraftment after autologous PBSC transplant was reported to be 490%.11 Thirty-three of the 35 patients who were treated with plerixafor plus G-CSF in this study underwent transplants and 15 patients with MM received tandem transplants. The time to PMN engraftment (median 14.0, maximum 74.0 days) and time to PLT engraftment (median 11.0 days, maximum 25.0 days) was consistent with that reported from the literature. It is important to note that in this study G-CSF was not administered post transplant and PMN engraftment was observed later than in previous trials of plerixafor where G-CSF was administered post transplant.12 G-CSF treatment has been shown to promote earlier engraftment of PMNs after autologous PBSC transplant.13,14 All patients assessed in this study had durable grafts at 12 months. There were no unexpected safety findings in this study and plerixafor seemed to be well tolerated. The spectrum of AEs observed in this study was similar to that observed previously where diarrhea, injection site erythema, and nausea/vomiting were the AEs most commonly associated with plerixafor.8,15 AEs including bone pain, fatigue, headache and nausea/ vomiting were consistent with the expected effects of plerixafor treatment, G-CSF treatment and apheresis. Tumor cells can be detected in the PB of patients with cancer and can contaminate stem cell products collected by

apheresis or bone marrow harvest.16–18 Standard cancer treatments such as chemotherapy and radiation can induce significant mobilization of tumor cells and lead to increased metastases.19 Similarly, common methods used to mobilize stem cells such as chemotherapy and cytokines can also mobilize tumor cells and lead to significant contamination of stem cell products.19–21 We thus assessed the potential tumor cell mobilization effect of plerixafor by measuring the frequency of tumor cells compared with the total PMBCs. If plerixafor caused tumor cells to mobilize, the frequency of tumor cells per the total PBMCs would be expected to increase between the pre-plerixafor and pre-apheresis (post-plerixafor) time points. After treatment with plerixafor, the relative number of tumor cells per total PBMCs either decreased or increased only slightly (not clinically or statistically significant) over that seen with G-CSF alone. Therefore, consistent with previous reports, G-CSF can induce a small amount of tumor cell mobilization. However, the addition of plerixafor did not increase the percentage of tumor cells per total PBMCs, which indicates that plerixafor does not contribute significantly to the mobilization of MM tumor cells as measured in this study. Interestingly, the clinical effect of tumor cell contamination of the stem cell product and subsequent reinfusion of tumor cells into the recipient remain controversial. Though some studies have shown that tumor cell contamination may affect clinical outcome,22 many other studies have shown the opposite result with no effect on progression-free survival or overall survival.19,23–26 In some studies, the impact of contamination reached statistical significance only when the quantity of tumor in the stem cell product was very high.21 Most of these studies were performed in an uncontrolled or retrospective manner. Importantly, in two large, prospective, randomized controlled trials of tumor cell purging, despite large differences in the level of tumor cell contamination of the stem cell product, no effect on clinical outcome was observed.25,26 Collectively, the data presented in this manuscript and those from previous studies of plerixafor 27–31 suggest that the frontline use of plerixafor enhances CD34 þ stem cell mobilization, regardless of whether the patient was a ‘good’ or ‘poor’ mobilizer. Plerixafor increases the number of patients achieving both minimum and maximum CD34 þ cells/kg and does so in fewer apheresis sessions, allows for increased predictability of apheresis yield and timing, and enables more patients to proceed to transplant with prompt and durable engraftment. In conclusion, the first study of plerixafor conducted in Europe for mobilization of PB CD34 þ cells showed a similar efficacy and safety profile to previous clinical trials. Most importantly, this is the first study that showed that plerixafor did not increase tumor cell mobilization as measured by PCR in patients with MM.

Conflict of interest Gary Calandra was formerly an employee of AnorMed Incorporated, and is now a consultant for Genzyme Corporation. Dr Fruehauf received research funding and Bone Marrow Transplantation


274

honoraria from Genzyme Corporation. The other authors declare no conflict of interest. 14

Acknowledgements Funding Support: This study was formerly supported wholly by AnorMED, Inc., now Genzyme Corporation, Cambridge, MA, USA.

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References 1 Fruehauf S, Seeger T. New strategies for mobilization of hematopoietic stem cells. Future Oncol 2005; 1: 375–383. 2 Fruehauf S, Klaus J, Huesing J, Veldwijk MR, Buss EC, Topaly J et al. Efficient mobilization of peripheral blood stem cells following CAD chemotherapy and a single dose of pegylated G-CSF in patients with multiple myeloma. Bone Marrow Transplant 2007; 39: 743–750. 3 Fruehauf S, Seggewiss R. It’s moving day: factors affecting peripheral blood stem cell mobilization and strategies for improvement [corrected]. Br J Haematol 2003; 122: 360–375. 4 Liles W, Rodger E, Broxmeyer H, Dehner C, Badel K, Calandra G et al. Augmented mobilization and collection of CD34+ hematopoietic cells from normal human volunteers stimulated with granulocyte-colony-stimulating factor by single-dose administration of AMD3100, a CXCR4 antagonist. Transfusion 2005; 45: 295–300. 5 Broxmeyer H, Orschell C, Clapp D, Hangoc G, Cooper S, Plett P et al. Rapid mobilization of murine and human hematopoietic stem and progenitor cells with AMD3100, a CXCR4 antagonist. J Exp Med 2005; 201: 1307–1318. 6 Fruehauf S, Seeger T, Maier P, Li L, Weinhardt S, Laufs S et al. The CXCR4 antagonist AMD3100 releases a subset of G-CSF-primed peripheral blood progenitor cells with specific gene expression characteristics. Exp Hematol 2006; 34: 1052–1059. 7 Cremer FW, Kiel K, Wallmeier M, Goldschmidt H, Moos M. A quantitative PCR assay for the detection of low amounts of malignant cells in multiple myeloma. Ann Oncol 1997; 8: 633–636. 8 Flomenberg N, Devine S, Dipersio J, Liesveld J, McCarty J, Rowley S et al. The use of AMD3100 plus G-CSF for autologous hematopoietic progenitor cell mobilization is superior to G-CSF alone. Blood 2005; 106: 1867–1874. 9 Jillella A, Ustun C. What is the optimum number of CD34+ peripheral blood stem cells for an autologous transplant? Stem Cells Dev 2004; 13: 598–606. 10 Tricot G, Jagannath S, Vesole D, Nelson J, Tindle S, Miller L et al. Peripheral blood stem cell transplants for multiple myeloma: identification of favorable variables for rapid engraftment in 225 patients. Blood 1995; 85: 588–596. 11 Gazitt Y, Freytes CO, Callander N, Tsai T-W, Alsina M, Anderson J et al. Successful PBSC mobilization with high-dose G-CSF for patients failing a first round of mobilization. J Hematother 1999; 8: 173–183. 12 Flomenberg N, Comenzo R, Badel K, Calandra G. Single agent AMD3100 mobilization of peripheral blood progenitor cells for autologous transplantation in patients with multiple myeloma (MM). ASH Annual Meeting Abstracts 2006; 108: 3381. 13 Linch D, Donald W, Milligan D, Winfield S, Kelsey S, Johnson T et al. G-CSF after peripheral blood stem cell transplantation in lymphoma patients significantly accelerated Bone Marrow Transplantation

16

17

18

19

20

21

22

23

24

25

26

neutrophil recovery and shortened time in hospital: results of a randomized BNLI trial. Br J Haematol 1997; 99: 933–938. McQuaker IG, Hunter AE, Pacey S, Haynes AP, Iqbal A, Russell NH. Low-dose filgrastim significantly enhances neutrophil recovery following autologous peripheral-blood stemcell transplantation in patients with lymphoproliferative disorders: evidence for clinical and economic benefit. J Clin Oncol 1997; 15: 451–457. Calandra G, McCarty J, McGuirk J, Tricot G, Crocker SA, Badel K et al. AMD3100 plus G-CSF can successfully mobilize CD34+ cells from non-Hodgkin’s lymphoma, Hodgkin’s disease and multiple myeloma patients previously failing mobilization with chemotherapy and/or cytokine treatment: compassionate use data. Bone Marrow Transplant 2007; 41: 331–338. Billadeau D, Quam L, Thomas W, Kay N, Greipp P, Kyle R et al. Detection and quantitation of malignant cells in the peripheral blood of multiple myeloma patients. Blood 1992; 80: 1818–1824. Haas R, Moos M, Karcher A, Mohle R, Witt B, Goldschmidt H et al. Sequential high-dose therapy with peripheral-blood progenitor-cell support in low-grade non-Hodgkin’s lymphoma. J Clin Oncol 1994; 12: 1685–1692. Pantel K, Brakenhoff RH, Brandt B. Detection, clinical relevance and specific biological properties of disseminating tumour cells. Nature Rev 2008; 8: 329–340. Biswas S, Guix M, Rinehart C, Dugger TC, Chytil A, Moses HL et al. Inhibition of TGF-beta with neutralizing antibodies prevents radiation-induced acceleration of metastatic cancer progression. J Clin Invest 2007; 117: 1305–1313. Anagnostopoulos A, Aleman A, Yang Y, Donato M, Weber D, Champlin R et al. Outcomes of autologous stem cell transplantation in patients with multiple myeloma who received dexamethasone-based nonmyelosuppressive induction therapy. Bone Marrow Transplant 2004; 33: 623–628. Kopp HG, Yildirim S, Weisel KC, Kanz L, Vogel W. Contamination of autologous peripheral blood progenitor cell grafts predicts overall survival after high-dose chemotherapy in multiple myeloma. J Cancer Res Clin Oncol 2008; 135: 637–642. Gertz MA, Witzig TE, Pineda AA, Greipp PR, Kyle RA, Litzow MR. Monoclonal plasma cells in the blood stem cell harvest from patients with multiple myeloma are associated with shortened relapse-free survival after transplantation. Bone Marrow Transplant 1997; 19: 337–342. Blystad AK, Delabie J, Kvaloy S, Holte H, Valerhaugen H, Ikonomou I et al. Infused CD34 cell dose, but not tumour cell content of peripheral blood progenitor cell grafts, predicts clinical outcome in patients with diffuse large B-cell lymphoma and follicular lymphoma grade 3 treated with high-dose therapy. Br J Haematol 2004; 125: 605–612. Ho J, Yang L, Banihashemi B, Martin L, Halpenny M, Atkins H et al. Contaminating tumour cells in autologous PBSC grafts do not influence survival or relapse following transplant for multiple myeloma or B-cell non-Hodgkin’s lymphoma. Bone Marrow Transplant 2009; 43: 223–228. Stewart AK, Vescio R, Schiller G, Ballester O, Noga S, Rugo H et al. Purging of autologous peripheral-blood stem cells using CD34 selection does not improve overall or progressionfree survival after high-dose chemotherapy for multiple myeloma: results of a multicenter randomized controlled trial. J Clin Oncol 2001; 19: 3771–3779. Bourhis JH, Bouko Y, Koscielny S, Bakkus M, Greinix H, Derigs G et al. Relapse risk after autologous transplantation in patients with newly diagnosed myeloma is not related with infused tumor cell load and the outcome is not improved by


275 CD34+ cell selection: long term follow-up of an EBMT phase III randomized study. Haematologica 2007; 92: 1083–1090. 27 DiPersio J, Stadtmauer EA, Nademanee AP, Stiff P, Micallef I, Angell J et al. A phase III, multicenter, randomized, doubleblind, placebo-controlled, comparative trial of AMD3100 (plerixafor)+G-CSF vs. G-CSF+placebo for mobilization in multiple myeloma (MM) patients for autologous hematopoietic stem cell (aHSC) transplantation. Blood (ASH Annual Meeting Abstracts) 2007; 110: 445. 28 DiPersio JF, Micallef I, Stiff PJ, Bolwell BJ, Maziarz RT, Angell J et al. A phase III, multicenter, randomized, doubleblind, placebo controlled, comparative trial of AMD3100 (plerixafor)+G-CSF vs. placebo+G-CSF in non-Hodgkin’s lymphoma (NHL) patients for autologous hematopoietic stem cell (aHSC) transplantation. ASH Annual Meeting Abstracts 2007; 110: 601.

29 DiPersio JF, Micallef INM, Stiff PJ, Bolwell BJ, Maziarz RT, Bridger G et al. Months report from the phase 3 study of plerixafor+G-CSF vs. placebo+G-CSF for mobilization of hematopoietic stem cell for autologous transplant in patients with NHL. Blood (ASH Annual Meeting Abstracts) 2008; 112: 1136. 30 DiPersio JF, Stadtmauer EA, Nademanee AP, Micallef INM, Stiff PJ, Bridger G et al. 12 months report from a phase 3 study of plerixafor+G-CSF vs. placebo+G-CSF for mobilization of hematopoietic stem cell for autologous transplant in patients with multiple myeloma. Blood (ASH Annual Meeting Abstracts) 2008; 112: 3312. 31 Flomenberg N, Devine SM, Dipersio JF, Liesveld JL, McCarty JM, Rowley SD et al. The use of AMD3100 plus G-CSF for autologous hematopoietic progenitor cell mobilization is superior to G-CSF alone. Blood 2005; 106: 1867–1874.

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