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Majority of patients receiving initial therapy with lenalidomide-based regimens can be successfully mobilized with appropriate mobilization strategies

Leukemia volume 26, pages 1119–1122 (2012)Cite this article

High-dose therapy and autologous stem cell transplantation (ASCT) remains an integral component of myeloma therapy.1 The traditional approach in patients considered eligible for ASCT consists of initial therapy with 4–6 cycles of a non-alkylator-containing regimen, followed by ASCT. Until the advent of novel agents like thalidomide, lenalidomide or bortezomib, VAD (vincristine, adriamycin, dexamethasone) or single-agent dexamethasone were the used induction regimens, neither of which had any impact on peripheral blood stem cell (PBSC) mobilization. The combination of lenalidomide and dexamethasone (Len–Dex) results in high-response rates in newly diagnosed myeloma2 and has become a commonly used initial therapy. Previous studies suggested that lenalidomide therapy could result in suboptimal PBSC collection.3, 4, 5, 6 The results vary significantly across different studies; likely reflective of treatment duration, age, mobilization regimens and collection targets.7, 8, 9 We retrospectively examined the results of the PBSC collection in a large cohort of patients receiving initial therapy with Len–Dex to clearly define the problem, the risk factors and alternative approaches to mobilization.

The study included 224 patients undergoing PBSC collection between July 2004 and December 2009, following Len–Dex induction. PBSC were collected using granulocyte colony-stimulating factor (G-CSF) or G-CSF plus cyclophosphamide (CTX), or G-CSF plus plerixafor as previously described.3 Among these, 48 patients were included in the previous report demonstrating the impact of lenalidomide on mobilization.3 G-CSF was administered subcutaneously (10 μg/kg) daily, followed by a peripheral blood CD34 (PB-CD34) count on day 4 (days counted from first day of G-CSF). If the PB-CD34 count is ⩾10/μl, patients initiate collection the next day (day 5); otherwise, it is rechecked and apheresis initiated once they reach the threshold. Patients failing to reach the PB-CD34 threshold by day 5 typically had G-CSF increased to 16 μg/kg twice daily. CTX 1.5 g/m2 was given on 2 consecutive days in those with high-residual tumor burden, followed by G-CSF until collection was completed. Plerixafor was used either as part of upfront mobilization trials or as per the risk adapted algorithm we developed (February 2009–November 2009). For patients with PB-CD34 <10/μl on day 4, it was measured again on day 5; if it was still <10/μl, plerixafor (0.24 mg/kg subcutaneously) was administered on day 5 evening and apheresis was commenced the following day. In addition, if daily collection yield was <0.5 × 106 CD34 per kg, plerixafor was added. G-CSF and plerixafor continued daily until apheresis was complete. The collection target was 2 (minimum) to 4 (ideal) million CD34 cells per kg per planned transplant. The study was conducted with the approval of the Institutional Review Board. Several parameters were used to compare efficacy of PBSC collection: total CD34 yield, number of collections, number of collection days, average CD34 collection per day, total CD34 yield on day 1, percentage of target CD34 collected, percentage of patients who failed to collect ⩾2 million and/or ⩾4 million CD 34 cells per kg.

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Acknowledgements

This study was supported in part by CA90628 (SKK) and the Hematologic Malignancies Program (Mayo Clinic).

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Authors and Affiliations

  1. Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA

    S Sinha, M A Gertz, M Q Lacy, A Dispenzieri, S R Hayman, F K Buadi, D Dingli, I N Micallef, W J Hogan, D A Gastineau, S V Rajkumar & S K Kumar

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  1. S Sinha
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  2. M A Gertz
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Correspondence to S K Kumar.

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Competing interests

MAG received Honoraria from Celgene, Millenium, Neotope Eisai Inc., Lilly Research Laboratories, Optum Health Education, Research to Practice, Physician's Education Resource and Amgen Inc. MQL received research funding from Celgene. AD received research funding from Celgene and binding site. INM is on the advisory board of Genzyme. SKK received research funding from Celgene, Genzyme, Millenium, Novartis, Bayer, Merck and Cephalon and is on the advisory board of Genzyme. SS, SRH, FKB, DD, WJH, DAG and SVR declare no conflict of interest.

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Sinha, S., Gertz, M., Lacy, M. et al. Majority of patients receiving initial therapy with lenalidomide-based regimens can be successfully mobilized with appropriate mobilization strategies. Leukemia 26, 1119–1122 (2012). https://doi.org/10.1038/leu.2011.308

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