Bone Marrow Transplantation (2004) 34, 693–702 & 2004 Nature Publishing Group All rights reserved 0268-3369/04 $30.00 www.nature.com/bmt

Post-transplant events Combined administration of alpha-erythropoietin and filgrastim can improve the outcome and cost balance of autologous stem cell transplantation in patients with lymphoproliferative disorders

A Olivieri1, I Scortechini1, D Capelli1, M Montanari1, M Lucesole1, G Gini1, M Troiani1, M Offidani1, A Poloni1, MC Masia1, GM Raggetti2 and P Leoni1

1Clinica di Ematologia, Universita` Politecnica delle Marche, Italy; and 2Facolta` di Economia e Commercio, Universita` Politecnica delle Marche, Italy

Summary: The use of growth factors (GFs) like G-CSF or GM-CSF for blood progenitor cell (BPC) mobilization (with or We compared the use of G-CSF plus EPOin a group of without chemotherapy) allows the collection of 32 multiple myeloma and lymphoma patients with large amounts of CD34 þ cells in about 85% of patients historical controls receiving G-CSF alone. Haemopoietic with lymphoma or MM. The most used GF both for reconstitution was significantly faster in patients receiving BPC mobilization and after transplantation is the human G-CSF þ EPO(group B), with a median time of 10 days G-CSF (filgrastim or lenograstim) at doses ranging to achieve an ANC count 40.5 Â 109/l, compared to 11 from 5 mg/kg, after chemotherapy, to 10–16 mg/kg as a days in the historical group (A). The median duration of single mobilizing agent.2–5 Although BPCs accelerate severe neutropenia (ANC count o100/ml) was signifi- engraftment kinetics compared to bone marrow (BM), the cantly shorter in group B compared to group A; platelet utility of addingGF after autotransplantation is still counts 420 Â 109 and 450 Â 109/l were achieved at days debated.5–10 þ 13 and þ 17, respectively in group B, compared to days Some reports concerningthe timingof G-CSF adminis- þ 14 and þ 24, respectively, in group A (P ¼ 0.015, tration after BPC reinfusion suggest no clear clinical benefit 0.002) patients. The transfusion requirement was reduced of early vs delayed administration.11,12 in group B, with 0 (0–6) RBC units and 1 (0–5) platelet Consequently, in many centers the administration of unit transfused in group B vs 2 RBC (0–9) and 2 platelet G-CSF after transplantation is not performed routinely units (0–8) in group A. Median days of fever, antibiotic when the stem cell source is mobilized BPC, especially when therapy and hospital stay were reduced in group B (9.5 the dose of CD34 þ cells reinfused is above the minimum days vs 22). The mean cost of autotransplantation per safe threshold required for a rapid engraftment. group A patient was 23 988 Euro, compared with 18 394 While the BPC dose needed to ensure quick, sustained Euro for a group B patient. Our study suggests that the and complete engraftment should not be less than 2 Â EPO þ G-CSF combination not only accelerates engraft- 106/kgCD34 þ cells,3,13 there is consensus that reinfusing ment kinetics, but can also improve the clinical course of a higher threshold (at least 5 Â 106/kg) of CD34 þ cells as ASCT. an optimal target to warrant a safe transplant procedure in Bone Marrow Transplantation (2004) 34, 693–702. at least more than 90% of patients minimizes the risks doi:10.1038/sj.bmt.1704643 of prolonged cytopenia and the costs of prolonged hospi- Published online 9 August 2004 talization and/or supportive care.14,15 Keywords: autologous transplantation; erythropoietin; Therefore, when the CD34 þ cell dose is optimal engraftment kinetics (45 Â 106/kg), the aplastic phase after HDT is unlikely to be further reduced. Moreover, the use of larger amounts of BPC is questionable and may increase the risks of 16,17 Autologous stem cell transplantation (ASCT) has comple- reinfusingmore clonogenictumor cells. tely replaced ABMT due to accelerated engraftment The possibility of further reducingthe aplastic phase kinetics and reduction of costs of the high-dose therapy after HDT has been explored by using ex vivo expansion (HDT).1 of haemopoietic stem cells, but this approach is time- consumingand very expensive. The ability of erythropoietin (EPO), associated with G-CSF, to reduce life-threateningneutropenia after chemo- Correspondence: Dr A Olivieri, Clinica di Ematologia, Ospedale therapy, has been recently suggested by a randomized study Torrette di Ancona, Via Conca 1 ZIP Code, 60020 Italy; of 50 patients with ovarian cancer,18 and before 1995 at E-mail: [email protected] Received 20 February 2004; accepted 30 May 2004 least three randomized studies evaluated the role of Published online 9 August 2004 EPO administration after ASCT, but none was able to Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 694 demonstrate accelerated reticulocyte recovery or a decrease patients with MM and two with NHL received a double in red blood cell (RBC) transfusions.19 autotransplant usingthe same regimen;consequently, the Altogether, attempts to further shorten or definitively total number of HDT procedures evaluated was 39. abrogate the aplastic phase after HDT were unable to To identify a control group, we reviewed the medical demonstrate additional significant benefits either in clinical records of all adults with MM and lymphoma autotrans- outcome and in cost–benefit. We therefore commenced a planted in our centre between January 1999 and November prospective pilot study to evaluate the early combined 2001. This control group of 33 patients (group A) was administration of EPO and G-CSF in patients with matched with the prospective group (group B) for the main lymphoma or myeloma after BPC reinfusion to further clinical characteristics, includingthe regimenand post- reduce the aplastic phase and the need for supportive care transplant patient care; those patients had received only after HDT. G-CSF (startingfrom day þ 5) without EPO, after HDT (Table 1). Eligibility criteria for transplantation were the same for Patients and methods all patients and were based on the evaluation of perfor- mance status, the accurate evaluation of organ reserve and, To reduce the aplastic phase and transfusional support in those aged over 60 years, a multidimensional geriatric after HDT, we tested the combined administration of assessment.20 alpha-EPO þ filgrastim (G-CSF) in a group of patients with The main protocol end points of the early combined lymphoproliferative disorders (lymphoma or MM), auto- administration of filgrastim plus EPO were: transplanted with BPC and high-dose regimens including high-dose melphalan (HDM). (1) duration of the aplastic phase after HDT; From December 2001, we consecutively enrolled 32 (2) the transfusion requirements, days of fever and days on patients with MM or lymphoma, who were candidates for antibiotic therapy. HDT after standard mobilization with chemotherapy followed by G-CSF. The median age was 56 years; 24 were The secondary end points were to compare the in- males and eight females; 14 had MM, 17 non-Hodgkin’s hospital days and the costs of the first 30 days after HDT in lymphoma (NHL) and one Hodgkin’s disease (HD); five the two groups.

Table 1 Characteristics of patients

Prospective group (B) (day +1: G-CSF+EPO) Control group (A) (day +5: G-CSF) P

Transplant procedures 39 40 — Number of patients 32 33

Sex Male 24 18 0.1 Female 8 15

Diagnosis (transplant procedures) Non-Hodgkin lymphoma 17 (19 procedures) 18 Hodgkin disease 1 3 0.4 Multiple myeloma 14 (19 procedures) 12 (19 procedures)

Age Median 56 63 0.24 Range 23–74 20–71

CD 34+ cells  106/kg reinfused Median 7 5.9 0.27 Range 3.4–28.6 3.8–20.4

Conditioning regimen BEAMa 20 procedures 21 procedures 0.82 Melphalan 200 mg/m2 19 procedures 19 procedures

Pretransplant Performance Status (WHO) 0 34 procedures 29 procedures 1 3 procedures 9 procedures 0.6 2 2 procedures 2 procedures

Previous chemotherapy regimens Median 2 3 0.36 Range 2–5 2–6

aBCNU 300 mg/mq day À6, etoposyide 200 mg/mq and cytarabine 400 mg/mq from day À5toÀ2, melphalan 140 mg/mq day À1.

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 695 BPC mobilization, collection and cryopreservation B; in particular, the criteria for startingantibiotic therapy, transfusional support, fluid administration and discharge in All patients were mobilized with chemotherapy followed by group A did not differ from that in group B. G-CSF 5 mg/kg/day until the last leukapheresis; 14 patients with MM received cyclophosphamide 7 g/m2; the 18 patients with NHL and HD received DHAP chemotherapy Evaluation of engraftment kinetics and statistical analysis (cisplatin 100 mg/m2 on day 1, cytarabine 2 g/m2 on days All patients were monitored daily for the main clinical 2–3, dexamethasone 40 mgon days 1–4). parameters and blood count to evaluate the duration of The median number of CD34 þ cells collected was neutropenia (ANCo0.1  109 and 0.5  109/l) and the 7 106/kg(3.4–28.6) with a median number of two  platelet and neutrophil engraftment kinetics. Neutrophil leukaphereses; BPC were cryopreserved usingan uncon- engraftment was defined as the first day on which the trolled-rate freezing(URF) method as previously pub- absolute neutrophil count (ANC) exceeded 0.5  109/l for lished.21 two consecutive days. Platelet engraftment was defined as The patients of the control group received the same kind the first day on which the platelet count exceeded 20  109, of mobilization accordingto the diagnosisand the BPC and 50  109/l, unsupported by transfusion. Neutrophil cryopreservation was also performed usingthe URF nadir was defined as the first day on which ANC method. o0.5  109/l for two consecutive days. We conducted a matched pair analysis comparingthe HDT, PBSC reinfusion and patient care engraftment kinetics and the clinical outcome in the 39 HDT procedures performed usingthe combination All 32 patients received HDT regimens including HDM; in EPO þ G-CSF, with the 40 HDT procedures in the control all cases melphalan administration was preceded by group. The two series were homogeneous both for the Amifostine 750 mg/m2 intravenously (i.v.) to reduce non- clinical characteristics and for the number of CD34 þ cells haematologic toxicity as previously reported.22 As seven reinfused, as verified by usingthe w2, Fisher’s exact tests for patients received a double autotransplantation, the total discrete variables and the Mann–Whitney test for contin- number of HDT procedures was 39; the 14 patients with uous variables. MM received only melphalan 200 mg/m2 i.v. on day À1 for We evaluated the dose of CD34 þ cells reinfused, patient a total of 19 procedures; the 17 patients with NHL and the age, the HDT regimen, underlying disease, the number of patient with HD received the BEAM regimen for a total of previous chemotherapy regimens and the schedule of GF 20 procedures; the BEAM schedule consisted in the i.v. administration by the univariate and multivariate analyses administration of BCNU 300 mg/m2 on day À6; ARA-C of factors influencingneutrophils and platelet engraftment 400 mg/m2 and etoposide 200 mg/m2 on days À5, À4, À3, and duration of neutropenia. Probabilities of achieving À2 and melphalan 140 mg/m2 on day À1. ANC40.5  109/l, platelet count 420  109/l and 50  109/ On day 0, 24 h after the melphalan administration, l in the two groups (A and B) were calculated using the cryopreserved BPC were reinfused after thawingin a Kaplan–Meier method and compared by the log-rank test. waterbath at 371C, usinga central venous catheter. Factors significantly affecting haemopoietic recovery with All patients received G-CSF 5 mg/kg/day subcutaneously the univariate analysis were then included in the multi- (s.c.) from day þ 1 until the day after the achievement of variate analysis using the Cox logistic regression model. ANC41  109/l, combined with alpha-EPO 10 000 U/day Factors affectingthe duration of neutropenia (AN- s.c., from day þ 1 for 3 weeks. Co0.1  109/l) were also analysed with the ANOVA After BPC reinfusion, patients received mouth care with univariate test and those found to be significant were Clorhexidine and Fungilyn until PMN recovery; fluid afterwards evaluated in a multivariate linear regression administration and symptomatic therapy were adminis- model. tered at the discretion of the physician, but total parenteral We also compared the clinical course of transplantation nutrition was never administered; the antimicrobial pro- between the two groups evaluating: days of fever 4381C, phylaxis and febrile episode treatment were performed as days on intravenous antibiotic therapy, days of hospitaliza- described previously.22 tion from BPC reinfusion, number of RBCs and platelet Irradiated blood products were infused to maintain units transfused duringthe first 30 days after transplant haemoglobin and platelet levels above 8 g/dl and 10  109/l, and the analytical costs of HDT treatment until day þ 30. respectively. The univariate ANOVA test was performed to compare Discharge was planned when the following clinical transfusion requirements, duration of fever and days on criteria were satisfied: the patient is able to take oral antibiotic therapy; Fisher’s exact test was performed to therapy and to perform activities of daily living; absence of evaluate the incidence of infectious episodes in the two fever and no need of transfusional support for at least two groups. Data were analysed using statistical software consecutive days; no need of parenteral fluid administration (SPSS, Chicago, IL, USA). and an available caregiver. Patients from the control group (group A) received Cost analysis amifostine before HDM accordingto the same schedule used in patients of group B; also, the antimicrobial The cost analysis was performed evaluatingboth the prophylaxis and the clinical and nursingmanagementwere indirect cost of hospital stay not directly attributable to performed usingthe same policy used in patients of group the treatment (overall daily room cost) and the direct costs;

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 696 the costs not directly attributable to the treatment, but not The median duration of in-hospital stay was 18 days involvingpatient care (work time lost by patient, caregiver (4–23) overall, and 12 days from day 0 (2–28). and productivity losses due to morbidity) were not considered. Comparison of the engraftment kinetics and clinical The overall daily room cost in the Transplant Unit and outcome in the two groups the direct costs were estimated by the Health Management Office of Ancona University (directed by Professor GM Haemopoietic reconstitution (Table 2) was significantly Raggetti) in collaboration with the Cost Data Management faster in patients receivingthe combination of G- of the Azienda Ospedaliera Umberto I Ancona; the costs of CSF þ EPO (group B), with 10 days to achieve ANC resources employed and the professional fees were derived 40.5 Â 109/l, compared to 11 days in group A; the platelet from our hospital analytic accountingsystem; the drug count 420 Â 109/l, 450 Â 109/l and 4150 Â 109/l (in the costs were obtained from wholesale price lists applied to the absence of platelet transfusions) were achieved in a median Azienda Ospedaliera Umberto I Ancona Pharmacy (as the of þ 13, þ 17 and þ 23 days, respectively, in group B, cost analysis was a secondary end point of this work, we compared with þ 14, þ 24 and þ 50 days, respectively, in omitted the detailed procedures of the economic evalua- group A patients. tion: manuscript in preparation). Moreover, the early combination of G-CSF þ EPO The direct costs were subdivided into four main significantly increased the percentage of patients who categories: quickly achieved safety levels of platelets and neutrophils: in group B, 90% of patients achieved ANC 40.5 Â 109/l at (1) Drugs: all drugs used during the transplant procedure day þ 11, platelet count 420 Â 109/l (without transfusions) were considered, includingconditioning,Amifostine, at day þ 14 and platelet count 450 Â 109/l at day þ 22, G-CSF, EPO, blood transfusions, antibiotics, antie- while 90% of patients in group A achieved ANC metics, fluids etc.; 40.5 Â 109/l at day þ 14, platelet count 420 Â 109/l at (2) equipment and supplies; day þ 25 and platelet count 450 Â 109/l at day þ 37 (3) staff (medical and nursing); (Figures 1 and 2). (4) diagnostics: imaging and laboratory investigations. Finally, the median duration of neutropenia was significantly shorter in group B, with only 3 (range 0–6) In summary, the overall estimated costs of the transplant days on ANC o0.1 Â 109/l and 5 (range 1–9) days on ANC procedure in the two groups of patients included all the o0.5 Â 109/l compared to 5 (range 1–22) days and 7 (range hospital overheads, medical and nursingstaff and the room 3–23) days, respectively, observed in group A. cost calculated from the day of admission in hospital until As the acceleration of neutrophil engraftment in group B the day þ 30 after BPC reinfusion (includingthe costs due consisted of only 24 h (median), and even though this to a second readmission in the Transplant Unit). Table 2 Engraftment kinetics in the two groups of patients

Group B (day Group A (day P Results +1: G- +5: G-CSF) CSF+EPO) All 65 patients of the two groups, receiving the 79 HDT procedures, had complete and sustained engraftment. No Transplant procedures 39 40 — toxic deaths were observed duringthe first 30 days after Days to ANC 40.5 Â 109/l autotransplantation and nonhaematologic toxicity was Mediana 10 11 0.0009 absent or mild, consistingmainly of mucositis and CI (95%) 10–10 10–12 diarrhoea (only 12.5% of patients had grade 3–4 WHO 9 degree of toxicity) or neutropenic fever (in 33% of Days to platelets 420 Â 10 /l Mediana 13 14 0.015 patients). CI (95%) 12–14 12–16 No relevant (grade 3–4 WHO) cardiac, hepatic, neuro- logical, metabolic or renal toxicities were observed and only Days to platelets 450 Â 109/l a one patient (in group A) died within day þ 90 of sepsis, Median 17 24 0.002 with an overall transplant-related mortality (TRM) of CI (95%) 15–19 7–41 1.27%; in summary, we did not observe any substantial Days to platelets differences between the two groups concerning major 4150 Â 109/l nonhaematologic toxicities. Mediana 23 50 0.05 Overall, haemopoietic reconstitution in the 79 proce- CI (95%) 16–30 1–99 dures was characterized by 10 (4–25) days to achieve ANC Days on ANC 0.1 Â 109/l 9 9 o 40.5 Â 10 /l, 13 days (7–30) for platelet count 420 Â 10 /l, Median 3 5 o0.0001 19 days (11–60) to achieve PLT 450 Â 109/l and 25 days Range 0–6 1–22 (14–190) for PLT 4150 Â 109/l. Days on ANC o0.5 Â 109/l Patients needed a median of 1 RBC unit (0–8) and 1 Median 5 7 0.001 platelet unit (0–9); the median duration of fever 4381C was Range 1–9 3–23 only 1 day (0–9) and the median number of days on antibiotic therapy was 0 (0–17). aKaplan–Meier median.

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 697 Group B (d. +1: G-CSF+EPO) Group B (d. +1: G-CSF+EPO) Group A (d. +5: G-CSF) Group A (d. +5: G-CSF)

1.0 1.0 0.9 0.9 0.8 0.8 0.7 0.7 0.6 0.6 0.5 (1) 0.5 0.4 0.4 P = 0.0009 % of patients (2) % of patients 0.3 0.3 0.2 0.2 0.1 0.1 0.0 0.0 0 4 8 12 16 20 24 28 0 5 10 15 20 25 Days Days Figure 3 Kinetics of neutropenia in the two groups of patients: Figure 1 Probability of achievingANC 40.5 Â 109/l in the two groups of probability of neutrophil nadir (ANC o0.5 Â 109/l) (1) and to achieve patients. ANC o 0.5 Â 109/l (2) after HDT.

Group B (d. +1: G-CSF+EPO) Table 3 Comparison of clinical course and supportive care in the Group A (d. +5: G-CSF) two groups of patients 1.0 Group B (day +1: Group A (day P 0.9 G-CSF+EPO) +5: G-CSF)

0.8 Units of RBCs transfused 0.7 Median 0 2 0.001 Range 0–6 0–8 0.6 Units of platelets transfused 0.5 Median 1 2 0.0001 Range 0–5 0–9 0.4 % of patients 0.3 P = 0.002 Incidence of febrile episodes No. (%) 13/38 (34.2) 26/39 (66.7) 0.006 0.2 Febrile days (4381C) 0.1 Median 0 1 0.01 Range 0–8 0–9 0 5 1 1 2 2 3 3 4 4 5 5 6 Days Days on antibiotic therapy Median 0 1 0.01 Figure 2 Probability of achievingplatelet count 450 Â 10 Â 109/l in the Range 0–8 0–9 two groups of patients. difference was statistically significant, this could not 0 (0–8). Moreover, the transfusion requirement was almost completely explain the substantial difference between the abolished in group B, with 0 RBC units transfused (0–6) vs 2 duration of neutropenia in the two groups; therefore, the (range 0–8) in group A, and only 1 platelet unit transfused in combination of two factors probably contributed to group B (range 0–5) vs 2 (range 0–9) in group A. significantly shorten the neutropenia in patients of group Consequently, this led to a significant reduction in days B: the acceleration of neutrophil recovery and the delay of of hospitalization with a median of 9.5 days (4–27), neutrophil nadir (days to ANC o0.5 Â 109/l) after HDT, compared with 22 (15–43) in the control group of patients even though this delay was not statistically significant when receivingonly G-CSF. considered alone (Figure 3). The univariate analysis performed in the 79 HDT Finally, the clinical outcome (Table 3) was significantly procedures identified the combination of G-CSF þ EPO better in patients receivingthe combination EPO plus G- as the only significant factor (Po0.0001) influencingthe CSF both in terms of days of fever and days on antibiotic duration of neutropenia, while CD34 þ cell dose, age, type therapy; patients receivingthe combination EPO þ G-CSF of HDT regimen, diagnosis and number of previous experienced a median of 0 days of febrile neutropenia (0–8) chemotherapy regimens were not statistically significant and the median number of days of i.v. antibiotic therapy was (data not shown).

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 698 The multivariate analysis (Table 4) confirmed this finding statistical differences concerningthe diagnosisdistribution with a median duration of severe neutropenia (ANC and the type of HDT between the two groups of patients, o0.1  109/l) of 3 days (CI 2.8–3.8) in group B, compared and the median number of CD34 þ cells  106/kgreinfused to 5 days (CI 4.6–7.1) in group A (CR 2.53; CI 1.7–3.9; was not statistically different between patients with Po0.0001). lymphoma and those with MM (data not shown). The multivariate analysis selected two parameters able to predict a faster engraftment: the combination of G- Cost–benefit analysis CSF þ EPO and the type of HDT, while all other factors were not significant; the hazard ratio for a faster achieve- The mean estimated cost of the entire autotransplantation ment of ANC 40.5  109/l and a platelet count 420  procedure in patients of group A was 23 988 Euro; the 109/l, in patients receivingthe combination G-CSF þ EPO, mean cost of the same procedure in patients of group B was were, respectively, 1.8 and 1.72. 18 394 Euro. Also, the type of HDT significantly influenced only the As the costs of the transplant procedure were calculated PMN engraftment kinetics, but not the platelet engraft- startingfrom the day of the hospital admission until day ment; lymphoma patients receivingthe BEAM regimen þ 30 post reinfusion, the additional costs due to subse- achieved the ANC 40.5  109/l significantly faster (med- quent hospitalizations needed after discharge (within day ian: 10 days; 95% CI: 10–10) than those (with MM) þ 30) were also considered. receivingMelphalan 200 mg/m 2 (median: 11 days; 95% CI: Table 5 shows the costs distribution in the two groups 10–12) (P ¼ 0.0003). As previously shown, there were no accordingto the categoriesanalysed (direct costs or indirect

Table 4 Multivariate analysis of factors influencingthe neutrophils and platelets engraftmentand the duration of neutropenia

Relative hazard P Relative hazard P Regression coefficient P (days to ANC (days to platelets (days on ANC 40.5 Â 109/l) 420 Â 109/l) o0.1 Â 109/l)

Group A (G-CSF) 1 0.01 1 0.03 Group B (G-CSF+EPO) 1.8 (95% CI: 1.72 (95% CI: À2.53 (95% CI: o0.0001 1.14–2.96) 1.1–2.8) À1.17 to À3.9)

Conditioning regimen HDMa 1 BEAM 1.62 (95% CI: 0.05 b — b — 1.1–2.6)

CD34+ cell  106/kg o5 vs 45; o7 vs X7 b NS b NS Age o60 years vs 460 years b NS b NS Diagnosis bb Lymphoma vs Myeloma NS NS Previous chemotherapy o2 vs 42 b NS b NS

aHigh-dose melphalan (200 mg/m2). bThe variable did not enter the multivariate analysis.

Table 5 Analysis of the cost of BPC transplantation procedure in the two group of patients

Group A (day +5: G-CSF) Group B (day +1: G-CSF+EPO)

Direct costs 12 948 Euro 10 714 Euro Drugs (total) 3173 3914 G-CSF 440 (median 8 days) 720 (median 13 days) EPO — 1424 (median 20 days) Conditioninga 885 885 PLT transfusions 938 (median 2 units) 469 (median 1 unit) RBC transfusions 310 (median 2 units) — Others (antibiotics, antiemetics) 600 416 Equipment/materials 1656 1152 Staff (medical and nursing) 6348 4416 Diagnostic (laboratory and radiology) 1771 1232

Indirect costs 11 040 Euro 7680 Euro Room daily cost 480 Euro 480 Euro Days of hospitalisationb 23 16 days

Total 23 988 Euro 18 394 Euro

aMean cost of HDT with HDM alone or BEAM. bTotal median number of days in-hospital until day +30 (includingreadmissions).

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 699 costs) duringthe different phases of the transplant Some in vivo data suggest synergy in the combination of procedure; the cost savingin patients receivingthe G-CSF plus EPO, both for BPC mobilization,27,28 and for combination of EPO þ G-CSF was achieved not only by treatment of myelodysplastic syndromes.29 More recently, reducingthe hospital stay (mean indirect costs re- the study of Pierelli,18 demonstrated that this cytokine duction ¼ 3360 Euro), but also by reducingthe direct costs combination could also be synergistic in accelerating PMN (mean direct costs saving ¼ 2234 Euro). recovery after nonmyeloablative chemotherapy. Overall, these data strongly suggest a clinically relevant multilineage effect of this cytokine combination. Discussion On the other hand, the role of EPO after autologous stem cell transplantation has been investigated in at least In the last 10 years, the extensive use of mobilized BPC and four randomized trials, but only two evaluated the the improvement of the supportive care have strongly combination of EPO þ G-CSF;19 Link reported the larger reduced the mortality and the morbidity of ASCT, even experience on 114 patients randomized to receive EPO vs though a small but not negligible TRM (around 2–3%) is placebo startingthe day of transplantation until RBC still reported in patients with solid tumours.23 recovery, but patients of the two groups did not receive G- The growing number of HDT procedures in Western CSF; furthermore, the study end points were the reticulo- countries generated several problems related to the cost– cyte recovery and the time to RBC transfusion indepen- benefit balance and quality of life of candidates for this dence, but not the duration of the aplastic phase.30–32 procedure; some experience supports the use of outpatient Chao randomized a small group of 35 patients to receive HDT even though the careful selection of patients fit for G-CSF alone vs the combination with EPO, but in this this approach is mandatory; nevertheless, in this setting protocol EPO was started 4 weeks before transplant and as well, the duration of severe neutropenia (ANC o0.5 Â resumed on day þ 1 after marrow infusion; no benefit in 109/l) is still consistent (approximately 7 days). terms of RBC transfusion requirement was observed in In this setting, an original approach has been proposed patients receivingthis cytokine combination, but only by Morabito et al,24 the so-called mixed Inpatient–Out- patients receivingbone marrow entered in this study. 33 patient Model; this approach has been tested in 44 patients Vannucchi34 compared three small groups of patients with MM, conditioned with HDM (and receivingEPO randomized to receive after transplantation the combina- after BPC reinfusion) and the authors showed, in a tion EPO þ G-CSF, only G-CSF or neither of these historical comparison of 35 patients with MM, receiving cytokines; patients receivingEPO þ G-CSF and G-CSF the same treatment in hospital, a significant improvement had significantly fewer units transfused than controls while of the quality of life without increasingthe morbidity and the platelet and myeloid recovery were comparable in the mortality in the outpatient setting. two groups receiving G-CSF alone or combined with EPO. Our experience suggests that the early combined admin- Besides the small number of patients enrolled (10 for each istration of EPO þ G-CSF not only accelerates engraftment group), this study shows other important limits: all patients and reduces the duration of neutropenia, but also received BM instead of BPC (like the previous studies) and significantly improves clinical outcome after HDT. This the kind of conditioningwas not homogeneousin the three translated into significant cost reduction and in the future groups (six of 10 patients given EPO þ G-CSF received TBI could make outpatient transplant programs feasible and vs zero of 10 in the control group). cost-effective for the majority of patients with MM and A summary of the main experience with G-CSF after NHL, who usually receive regimens including HDM. autotransplantation (with different timingof administra- The role of G-CSF after ASCT has been previously tion) with or without EPO is reported in Table 6. investigated by several authors; however, it is still unclear if In our study, 79 consecutive ASCT procedures were the acceleration of neutrophil recovery translates into performed in two groups of patients with lymphoprolifera- clinical and economical benefits.11,12,25 tive disorders, receivingthe same HDT regimen(HDM In the study published by Cortellazzo,26 a homogeneous 200 mg/m2 in myeloma patients and BEAM in lymphoma population of lymphoma patients receivingthe same kind patients). of conditioningand reinfused with an optimal CD34 þ cell The two groups of patients were matched for all clinical dose was randomized to receive G-CSF vs placebo from characteristics, the CD34 þ cell dose and for their manage- day þ 1 to stable engraftment: while only a trend in favour ment duringHDT procedure: the criteria for transfusional of G-CSF group was observed for the engraftment kinetics, support, antimicrobial prophylaxis and treatment of febrile no clinical benefit was observed in terms of days of neutropenia. hospitalization, days with fever, days on antibiotic therapy The main modification in our policy for lymphoma and or transfusion requirement. myeloma patients receivingHDT since 1999 to 2002 was Recently, Hornedo23 reported a randomised trial of 216 the introduction of the association G-CSF þ EPO after patients receivingHDT for breast cancer and receivingG- BPC reinfusion, although we cannot exclude the possibility CSF from the day of infusion or 5 days later; patients that some minor changes in the discharge policy may occur. receivingG-CSF from the day of reinfusion had faster In our opinion, the learningcurve effect in the ASCT neutrophil engraftment, but this did not translate into a settinginduced several temporal changes,especially during reduction of hospitalization time. The authors’ conclusions the first 10 years (1988–1998) after the introduction of GFs, are that the gold standard after HDT remains late G-CSF which seem less important afterwards (indeed we did administration, at least in patients with breast cancer. not observe a further improvement of TRM which is still

Bone Marrow Transplantation oeMro Transplantation Marrow Bone 700

Table 6 Main clinical trials evaluatingthe role of G-CSF and EPO after ASCT rtrpitnadto oGCFatratlgu transplantation autologous after G-CSF to addition Erythropoietin Reference Kind of study Kind of cytokine PTS treated (no/diagnosis/SC Engraft kinetics Comment source)

Miller19 Randomized Arm A: EPO (200 U/kg/d) 50 (hematol. malignancies/BM) No statistical difference No improvement in RBC Arm B: placebo transfusion requirement Khwaja12 Retrospective Group A: G-CSF 17 (malignant lymphomas/BM) Significantly improved in group A Cost saving with delayed G-CSF Historical group: no GFs Link32 Randomized Arm A: EPO (150 U/kg/d) 114 (hematol. malignancies/BPC) No statistical difference No improvement of red blood Arm B: placebo cells requirement Chao33 Randomized Arm A: Epo (600 U/kg  3/w)+G-CSF 35 (lymphoma/BM) No statistical difference No improvement in red blood Arm B: placebo+G-CSF cells or platelets requirement Spitzer6 Randomized Arm A:G-CFS (7.5 mg/kg/d) and GM- 37 (miscellaneous/BM and BPC) Significantly improved in the group Shorter hospitalization in the CSF (2.5 mg/kg/d) receivingGFs GFs group; no difference in

Arm B: no GFs clinical outcome and transfusion Olivieri A requirement Shimazaki10 Prospettico G-CSF (50 mg/m2) 20 (hematol. malignancies/BPC) Significantly improved in the group Reduced antibiotic use in the

Vs no GFs receivingG-CSF GFs group al et Vey25 Retrospective Group A: G-CSF from d +1 78 (NHL,HD,breast cancer,ovarian Significantly improved in the groups No difference in clinical Group B: G-CSF from d +6 cancer/BM) A and B; no difference between A outcome and cost saving Group C: no GFs and B between the two groups Cortellazzo26 Randomized Group A: G-CSF 40 (NHL/BPC) No statistical difference No difference in clinical Group B: no G-CSF outcome or platelet transfusion requirement Klumpp8 Randomized G-CSF 41 (miscellaneous/BPC with or Significantly improved in the group Shorter hospitalization and Vs no GFs without BM) receivingG-CSF significant reduction of antibiotics in the GFs group Vannucchi34 Randomized Arm A: G-CSFfrom d+1 30 (HD,NHL,ALL/BM) No statistical difference between No transfusional benefits Arm B: G-CSF plus EPO (150 U/kg) group receiving G-CSF and group from d+1 receivimgG-CSF+EPO; Arm C: no GFs significantly improved reticulocyte kinetics in arm B Hornedo23 Randomized Arm A: G-CSF from d 0 241 (breast cancer/BPC) Significantly improved in the two Shorter hospitalization in arms Arm B: G-CSF from d+5 arms receivingG-CSF; no difference A and B; no difference between Arm C: no GFs between arm A and arm B A and B; arm C closed due to delayed engraftment Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 701 2–3%). Our data are derived from a matched-historical expansion of autologous CD34 þ cells; all patients comparison and should be confirmed in a randomized experienced an impressive reduction of neutropenia with study or by increasingthe number of patients autotrans- only 2 days of severe neutropenia (ANC o0.5 Â 109/l) and planted in the two groups in a prospective fashion. only 1 day of platelets o20 Â 109/l; the transfusion Multivariate analysis confirmed that, in this homoge- requirement was also reduced but not abrogated, with a neous settingof patients receivingan optimal dose of median of 1 (0–9) platelet transfusions and 0 (0–3) of RBC CD34 þ cells, the only two factors able to significantly transfusions. accelerate engraftment and reduce the aplastic phase were Bertolini et al36 previously published a limited experience the EPO þ G-CSF combination and the BEAM regimen. of megakaryocytic precursor generation in an ‘ex vivo’ We can exclude that the type of conditioningcould be system, to use for platelet support duringthe aplasia post- responsible for the different engraftment kinetics between auto-PBSC transplantation: 10 cancer patients received the two groups: indeed there was no difference in the escalating doses of autologous megakaryocytic progenitors distribution of diagnosis between the two groups and generated by ex vivo liquid culture, but only two of the 10 finally BEAM only influenced the kinetics of ANC patients receivingthe expanded cells did not need platelet engraftment and not platelet engraftment.The clinical transfusions. More recently, Blair et al37 evaluated the ‘ex benefits of the early combination of EPO þ G-CSF mainly vivo’ expansion of megakaryocyte progenitors and obtained consisted in the abolition of RBC transfusions, in the promisingresults. Unfortunately, all these approaches are reduction of febrile neutropenia with reduced parenteral time-consuming, very expensive and require sophisticated antibiotic need and, most importantly, these observations devices for large-scale CD34 þ cell selection, GMP- suggest a substantial improvement in the safety of the HDT approved systems for cell expansion in bags and at least 1 procedure. week of ‘ex vivo’ culture before clinical use. Indeed, 90% of patients in group B achieved ANC Our approach seems feasible in the majority of patients 40.5 Â 109/l at day þ 11 with only 3.3 days of severe who are candidates for HDT, and in centres without neutropenia, compared to 5.8 days of severe neutropenia facilities for the conventional outpatient management of in patients of group A who achieved ANC 40.5 Â 109/l patients. (in 90% of cases) at day þ 14. Until now, we have only preliminary data concerningthe The reduction of the aplastic phase was the main end impact of this combination on the quality of life, but our point of our study and these results strongly suggest a experience suggests that this simple approach could synergistic effect of EPO þ G-CSF, even though a larger effectively make the outpatient ASCT a feasible and cost- number of patients should be treated with this combination effective procedure in a large number of patients. Indeed, to confirm these data; as well, the consequent reduction of we have initiated up a prospective trial to evaluate this days of hospitalization that we observed need to be approach for the outpatient management of ASCT. prospectively confirmed in a multicentre experience. It should be stressed that the reduction of days of hospitaliza- tion in group B was not a cosmetic effect, but this advantage was maintained even considering the additional Acknowledgements days of re-hospitalization duringthe first 30 days after This work has been supported by Associazione Italiana contro le ASCT (16 vs 23 days). Leucemie-Sez. di Ancona (AIL). In the Freeman study,1 a detailed cost analysis was conducted in a large number of patients receiving autotransplantation for NHL from 1989 until 1995. Many factors contributed to a significant cost decrease: the shift References from BM harvest to BPC mobilization, the use of different kinds of HDT regimens (including or not TBI in many 1 Freeman MB, Vose J, Bennett C et al. Costs of care for high- patients) and the use of different techniques of BPC dose therapy and autologous transplantation for non-Hodg- collection. The main cost savingwas achieved after 1992, kin’s lymphoma: results from the University of Nebraska Medical Center 1989 through 1995. Bone Marrow Transplant and this probably reflects improvements in ABMT 1999; 24: 679–684. technology and patient care; also, the duration of hospital 2 Gianni AM, Siena S, Bregni M et al. Granulocyte-macrophage stay decreased from a mean of 42.5 to 11.9 days by 1995, colony-stimulatingfactor to harvest circulatinghaemopoietic but it was not specified if the duration of hospitalization stem cells for autotransplantation. Lancet 1989; 2: 580–585. included also the conditioningor it was computed by day 0. 3 Weaver CH, Birch R, Greco FA et al. Mobilization and In our experience, the mean cost savingfor each harvestingof peripheral blood stem cells: randomized evalua- transplant procedure by usingthe combination of G-CSF tions of different doses of filgrastim. Br J Haematol 1998; 100: þ EPO was 24% despite the more extensive use of 338–347. expensive drugs such as EPO in group B, which were 4 Waller CF, Bertz H, Wenger MK et al. Mobilization of largely counterbalanced by reductions in hospitalization, peripheral blood progenitor cells for allogeneic transplanta- tion: efficacy and toxicity of a high-dose rhG-CSF regimen. transfusional support and the workingtime of the medical Bone Marrow Transplant 1996; 18: 279–283. and nursingstaff. 5 Sheridan WP, Begley CG, Juttner CA et al. Effect of 35 Recently, Reiffers reported preliminary data in 27 peripheral-blood progenitor cells mobilised by filgrastim (G- patients with MM, suggesting the possibility of abrogating CSF) on platelet recovery after high-dose chemotherapy. postmyeloablative chemotherapy neutropenia by ex vivo Lancet 1992; 339: 640–644.

Bone Marrow Transplantation Erythropoietin addition to G-CSF after autologous transplantation A Olivieri et al 702 6 Spitzer G, Adkins DR, Spencer V et al. Randomized study of peripheral blood progenitor cell autotransplant: a retrospective growth factors post-peripheral blood stem cell transplant: study. Br J Haematol 2000; 110: 300–307. neutrophil recovery is improved with modest clinical benefit. 23 Hornedo J, Sola C, Solano C et al. The role of granulocyte J Clin Oncol 1994; 12: 661–670. colony-stimulatingfactor (G-CSF) in the post-transplant 7 Weaver CH, Hazelton B, Birch R et al. An analysis of period. Bone Marrow Transplant 2002; 29: 737–743. engraftment kinetic as a function of the CD34 content of 24 Morabito F, Martino M, Stelitano C et al. Feasibility of a peripheral blood peripheral cell collections in 692 patients after mixed inpatient-outpatient model of peripheral blood stem cell the administration of myeloablative chemotherapy. Blood transplantation for multiple myeloma. Haematologica 2002; 1995; 10: 3961–3969. 87: 1192–1199. 8 Klumpp TR, Mangan KF, Goldberg SL et al. Granulocyte 25 Vey N, Molnar S, Faucher C et al. Delayed administration of colony-stimulatingfactors accelerates neutrophil engraftment granulocyte colony-stimulating factor after autologous bone followingperipheral-blood stem-cell transplantation: a pro- marrow transplantation: effect on granulocyte recovery. Bone spective, randomized trial. J Clin Oncol 1995; 13: 1323–1327. Marrow Transplant 1994; 14: 779–782. 9 McQuaker IG, Hunter AE, Pacey S et al. Low dose Filgastrim 26 Cortellazzo S, Viero P, Bellavita P et al. Granulocyte colony- significantly enhances neutrophil recovery following autolo- stimulatingfactor followingperipheral-blood progenitor-cell gous peripheral-blood stem-cell transplantation in patients transplant in non-Hodgkin’s lymphoma. J Clin Oncol 1995; 4: with lymphoproliferative disorders: evidence for clinical and 935–941. economical benefit. J Clin Oncol 1997; 15: 451–457. 27 Kessinger A, Sharp G. Mobilization of hematopoietic 10 Shimazaki C, Oku N, Uchiyama H et al. Effect of granulocyte progenitor cells with epoetin alfa. Semin Haematol 1996; 33 colony-stimulatingfactor on hematopoietic recovery after (Suppl 1): 10–15. peripheral blood progenitor cell transplantation. Bone Marrow 28 Olivieri A, Offidani M, Cantori I et al. Addition of Transplant 1994; 13: 271–275. erythropoietin to granulocyte colony-stimulating factor after 11 Gomez AT, Jimenez MA, Alvarez MA et al. Optimal timingof primingchemotherapy enhances hemopoietic progenitormo- granulocyte colony-stimulating factors (G-CSF) administra- bilization. Bone Marrow Transplant 1995; 16: 765–770. tion after bone marrow transplantation: a prospective rando- 29 Hellstrom-Lindberg E, Ahlgren T, Beguin Y et al. Treatment mized study. Ann Hematol 1995; 71: 65–70. of anemia in myelodysplastic syndromes with granulocyte 12 Khwaja A, Mills W, Leverdige AH et al. Efficacy of delayed colony-stimulatingfactor plus erythropoietin: results from a granulocyte colony-stimulating factor after autologous BMT. randomized phase II study and long-term follow-up of 71 Bone Marrow Transplant 1993; 11: 479–482. patients. Blood 1998; 92: 68–75. 13 Olivieri A, Offidani M, Montanari M et al. Factors affecting 30 Casadevall N, Durieux P, Dubois S et al. Effects of hemopoietic recovery after high-dose therapy and autologous erythropoietin (rHuEpo) plus granulocyte colony stimulating peripheral blood progenitor cell transplantation: a single factor (rHuG-CSF) for the treatment of myelodysplastic center experience. Haematologica 1998; 83: 329–337. syndromes (MDS) on anemia, costs and quality of life: a 14 Linch Dc, Watts MJ, Sullivan AM et al. Progenitor-cell randomized controlled trial. Blood 2004; (Epub ahead of mobilization after low-dose cyclophosphamide and granulo- print). cyte colony-stimulatingfactor: an analysis of progenitor-cell 31 Thompson JA, Gilliland DG, Prchal JT, et al, and the GM/ quantity and quality and factors predictingfor these para- EPO MDS Study Group. Effect of recombinant human meters in 101 pretreated patients with malignant lymphoma. erythropoietin combined with granulocyte/macrophage col- J Clin Oncol 1997; 2: 535–546. ony-stimulatingfactor in the treatment of patient with 15 Bensinger W, Appelbaum F, Rowley S et al. Factors that myelodisplastic syndrome. Blood 2000; 95: 1175–1179. influence collection and engraftment of autologous peripheral- 32 Link H, Boogaerts M, Fause AA et al. A controlled trial of blood stem cells. J Clin Oncol 1995; 13: 2547–2555. recombinant human erythropoietin after bone marrow trans- 16 Shpall E, Jones RB. Release of tumor cells from bone marrow. plantation. Blood 1994; 84: 3327. Blood 1994; 83: 623–625. 33 Chao N, Schriber JR, LongGD et al. A randomized study of 17 Brugger W, Bross KJ, Glatt M et al. Mobilization of tumor erythropoietin and granulocyte colony-stimulating factor (G- cells and hematopoietic progenitor cells into peripheral blood CSF) versus placebo and G-CSF for patients with Hodgkin’s of patients with solid tumors. Blood 1994; 83: 636. and non-Hodgkin’s lymphoma undergoing autologous bone 18 Pierelli L, Perillo A, Greggi S et al. Erythropoietin addition to marrow transplantation. Blood 1994; 83: 2823. granulocyte colony-stimulating factor abrogates life-threaten- 34 Vannucchi AM, Bosi A, Ieri A et al. Combination therapy with ingneutropenia and increases peripheral-blood progenitor-cell G-CSF and erythropoietin after autologous bone marrow mobilization after epirubicin, paclitaxel, and cisplatin combi- transplantation for lymphoid malignancies: a randomized trial. nation chemotherapy: results of a randomised comparison. Bone Marrow Transplant 1996; 17: 527–531. J Clin Oncol 1999; 17: 1288. 35 Reiffers J, Cailliot C, Dazey B et al. Abrogation of 19 Miller CB, Lazarus HM. Erythropoietin in stem cell trans- post-myeloablative chemotherapy neutropenia by ex-vivo plantation. Bone Marrow Transplant 2001; 27: 1011–1016. expanded autologous CD34-positive cells. Lancet 1999; 354: 20 Balducci L, Extern M. Management of cancer in the older 1092–1093. person: a pratical approach. Oncologist 2000; 5: 224–236. 36 Bertolini F, Battaglia M, Pedrazzoli P et al. Megakaryocytic 21 Montanari M, Capelli D, Poloni A et al. Long-term progenitors can be generated ex vivo and safely administered to hematologic reconstitution after autologous peripheral blood autologous peripheral blood progenitor cell transplant reci- progenitor cell transplantation: a comparison between con- pients. Blood 1997; 89: 2679–2688. trolled-rate freezingand uncontrolled-rate freezingat 80 37 Blair A, Baker CL, Pamphilon DH et al. Ex vivo expansion of degrees C. Transfusion 2003; 43: 42–49. megakaryocyte progenitor cells from normal bone marrow and 22 Capelli D, Santini G, De Souza C et al. Amifostine can reduce peripheral blood and from patients with haematological mucosal damage after high-dose melphalan conditioning for malignancies. Br J Haematol 2002; 116: 912–919.

Bone Marrow Transplantation