Pocket Oncology (Pocket Notebook Series), 1st Ed.

AUTOLOGOUS STEM CELL TRANSPLANTATION

Amanda L. Olson and Craig Sauter

Description

• HDC/radiation followed by infusion of autologous multipotent hematopoietic stem cells.

• Tx of hematologic malignancies using HDC/radiation followed by ASCR to reconstitute the BM.

Indications

Pretransplant Evaluation

To establish extent of disease & assess pt comorbidities, includes the following.

• Hx: PS, prior Rx, drug allergies, prior infxn, & social support

• Physical exam: Oral cavity/skin for nidus for infxn, CNS exam, & assessment of lymphadenopathy

• Labs: CBC, chemistries w/liver & renal function, 24-h urine collection for measurement of Cr clearance

• CXR or CT chest

• ECG & a study of cardiac function (ECHO or MUGA)

• PFT including DLCO

• Disease-specific restaging studies including

BM aspiration/bx

CT or combined CT/PET in pts w/certain lymphomas

SPEP & UPEP w/immunofixation, serum FLC assay & skeletal assessment in pts w/myeloma

Stem Cell Source

• Stem cells should be collected prior to exposure to an alkylating agent such as oral melphalan, nitrogen mustard or purine analog & fludarabine as these agents are stem cell toxic

• Collection may be done by BM harvesting or peripheral blood stem cell apheresis following tx w/G-CSF

• Harvested cells are cryopreserved until time of transplant

Conditioning Regimens

• Chemotherapy or radiation given prior to transplant to eradicate disease.

• All conditioning regimens are ablative, as the therapeutic response following ASCT depends on the HDC/radiation.

• Melphalan-based regimens are commonly used for the tx of plasma cell dyscrasias & lymphoma (commonly treated w/BEAM: BCNU, Etoposide, Ara-C, Melphalan).

Engraftment

• Expansion of the HSC in the BM w/c results in normalization of blood counts & immune recovery

• Time to engraftment varies based on conditioning regimen, stem cell graft, & characteristics

• BM graft & lower cell dose generally result in longer time for engraftment

Transplant Complications and Outcomes

• Major complications are tox from preparative regimen, infxn, VOD, mucositis, development of new malignancies, & relapse

• Cardiac & pulm tox are most common

• Relapse: In addition to close clinical & lab follow-up BM aspiration/bx is generally at routine intervals post-transplant to r/o relapsed disease

Post-Transplant Maintenance Therapy

• Post-transplant maintenance chemotherapy or radiation may be given for selected diseases eg, lenalidomide or bortezomib for MM

• Post-transplant maintenance rituximab does not show benefit based on randomized phase III data (CORAL, Ann Oncol 2006;Suppl 4:iv31)

Prognosis

• Prognosis varies & is dependent upon a number of factors including

disease type

stage

stem cell source

HLA-matched status

conditioning regimen

• Mortality for SCT can be estimated using the HCT-CI