Summary:Our goal was to compare direct and indirect medical costs and quality of life associated with inpatient vs outpatient autologous hematopoietic stem cell transplantation (AuHSCT). Twenty-one sequential outpatients and 26 inpatients were enrolled on this prospective trial. All candidates for AuHSCT were screened for eligibility for outpatient transplantation. Patients with either breast cancer or hematologic malignancy, insurance coverage for the outpatient procedure, one to three caregivers available to provide 24 h coverage, and no significant comorbidities were eligible to participate. Patients without caregivers or insurance coverage for outpatient transplant were accrued to the study in a consecutive manner as inpatient controls, based on willingness to participate in the quality of life portion of the study and to permit review of their hospital and billing records. Approximately half of all 139 prospective outpatient candidates were ineligible because they lacked a caregiver. Most commonly, the patient without a caregiver was single or widowed or their family and friends were needed to provide childcare. Most caregivers were college educated from families with incomes greater than $80 000. Indirect costs to the caregivers totaled a median of $2520 (range $684-$4508), with the majority attributed to lost 'opportunity costs'. Overall, there were significant differences in the total costs of treatment for inpatient vs outpatient AuHSCT ($40 985 vs $29 210, P Ͻ 0.01)). In general, no significant differences were detected between inpatient and outpatient scores on quality of life measures. Although significant cost savings were associated with outpatient transplantation, this approach was applicable to only half of our otherwise eligible candidates because of a lack of caregivers. The financial burden associated with the caretaking role may underlie this finding.

Summary:One hundred and seventy-seven large-volume leukapheresis procedures performed on 91 patients over a 15 month period were reviewed to see if the pre-apheresis hematocrit (Hct) affected the CD34 ؉ cell collection efficiency (CE) of the Fenwal CS 3000 Plus cell separator. The Hct was 0.174-0.461 (median 0.317), and the peripheral blood CD34 ؉ cell count 2-2487 per l (median 21). The total CD34 ؉ cell quantity collected was 3.0-2677.2 ؋ 10 6 (median 113.0). Based on the number of CD34 ؉ cells contained in the blood volume processed (23.3-37303.2 ؋ 10 6 ; median 318.0), the CE was 1.7-87.5% (median 30.3). No correlation was found between the Hct and CE (r 2 ‫؍‬ 0.0034; P ‫؍‬ 0.44) or the total CD34 ؉ cell quantity collected (r 2 ‫؍‬ 0.0040; P ‫؍‬ 0.40). CEs for Hct Ͻ0.25 (median CE 36%), Hct 0.25-0.299 (median CE 30%) and Hct 0.30 (median CE 30%) were comparable. As expected, highly significant correlations were seen between the CD34 ؉ cell quantities collected and quantities processed (r 2 ‫؍‬ 0.59; P Ͻ 10 ؊6 ) as well as the peripheral blood CD34 ؉ cell counts (r 2 ‫؍‬ 0.60; P Ͻ 10 ؊6 ). We conclude that the minimum acceptable Hct or hemoglobin level for leukapheresis should be dictated by clinical circumstances because it does not affect stem cell collection. Bone Marrow Transplantation (2001) 28, 597-601. Keywords: apheresis; CD34 ϩ cells; cell separator; collection efficiency, FAHCT; hematocrit; leukapheresis Peripheral blood has essentially replaced bone marrow as the source of hematopoietic stem cells for transplantation because of faster hematopoietic 1 and immune 2 recovery, and lower treatment-related mortality 3 and relapse rates. 2 The factors identified as important in determining CD34 ϩ cell yields have been studied extensively. [4][5][6][7] These include

No abstract

Summary:Eleven patients with hematologic malignancies and two with aplastic anemia were treated using unmanipulated marrow and immunoselected CD34 ؉ blood cells. Donors began G-CSF (10 g/kg) injections 1 day after undergoing bone marrow harvest. Blood stem cells were collected on day 5 of G-CSF. Peripheral blood lymphocytes were depleted via CD34-positive selection. If, after marrow and blood harvest, less than 2.0 ؋ 10 6 CD34 cells/kg were mobilized, leukapheresis was repeated on day 6. Median time to an absolute neutrophil count greater than 500 l was day 10; transfusion-independent platelet count greater than 20 000/ l was day 13; average hospital discharge was day 14; and average inpatient hospital charges were 101 870 US dollars. Acute GVHD grade II occurred in five of 13 patients. No patient developed grade III or IV acute GVHD. At a median follow-up of 10 months, no patient has developed extensive chronic GVHD. Allografts of unmanipulated bone marrow supplemented with G-CSF-mobilized and CD34 immunoselected blood cells may prevent an increased risk of GVHD while preserving the rapid engraftment kinetics of peripheral blood. Supplementation of marrow with CD34 enriched blood cells appears to result in rapid engraftment, early hospital discharge, lower inpatient charges, decreased regimen-related toxicity, and no apparent increase in GVHD.

Summary:Patients with recurrent leukemia after an allogeneic hematopoietic stem cell transplant may be treated with donor lymphocyte infusions (DLI). The transfusion of lymphocytes from the original hematopoietic stem cell donor induces remission in approximately one third of relapsed AML cases and 80% of relapsed CML. DLI may be complicated by delayed and sometimes lethal graft-versus-host disease (GVHD). In an attempt to avoid this complication, several centers have initiated DLI trials in which the infused lymphocytes carry a suicide gene, herpes simplex thymidine kinase (HStk), which confers sensitivity to ganciclovir (GCV). In the event of severe GVHD, administration of GCV should terminate or ameliorate GVHD. Keywords: donor lymphocyte infusions; retroviral vector; gene therapy In 1990, Kolb et al 1 reported that infusion of lymphocytes from the original bone marrow donor could re-induce remission in patients who relapse after an allogeneic transplant. Subsequently, use of unmanipulated and HStk modified DLI are being evaluated by several investigators. Lymphocytes are generally collected from the peripheral blood of the donor by lymphopheresis, purified by FicollHypaque density gradient centrifugation, and infused as fresh cells into the recipient. Although the effect of cryopreservation on anti-leukemic efficacy is unknown, cells may also be cryopreserved, thawed, and infused at a later date. In general, between 10 6 and 5 × 10 8 T cells per kilogram recipient weight are infused at one time or at intervals of several days to weeks.The optimal dose of donor lymphocytes remains unclear. 22 Although it seems intuitive that larger numbers of infused lymphocytes are more likely to reinduce remission, in an EBMT analysis of 258 patients treated with DLI, patients receiving more than 3.0 × 10 8 mononuclear cells/kg had a lower response rate than those receiving less than 3.0 × 10 8 /kg. 23 This may imply a response plateau or be artifactual since DLI are often given in increments and