Plerixafor-augmented peripheral blood stem cell mobilization in AL amyloidosis with cardiac involvement: a case series

Abstract

Nearly half of AL amyloidosis patients have cardiac involvement, an independent predictor of poor prognosis. High-dose melphalan and autologous stem-cell transplantation (HDM/SCT) can induce complete hematologic responses and prolong survival in AL amyloidosis. Granulocyte colony-stimulating factor (G-CSF)-induced mobilization of peripheral blood stem cell (PBSC) in AL amyloidosis patients is associated with volume overload, arrhythmias and capillary leak syndrome. Plerixafor has a different mechanism of action and has non-overlapping toxicities with G-CSF. We describe our experience in five patients with AL amyloidosis and cardiac involvement who received plerixafor with G-CSF for PBSC mobilization. Median age was 56 years; two patients had undergone heart transplantation within the year prior to HDM/SCT. Three patients received plerixafor after an initial trial of mobilization with G-CSF alone. No patient had any significant toxicities during mobilization and PBSC collection. The median total yield of PBSCs collected was 5.9 × 10(6) CD34+ cells/kg; the median number of leukapheresis days was 2. Neutrophil engraftment after HDM/SCT occurred at a median of nine days, platelet engraftment at a median of 13 days. Plerixafor was effective and well tolerated when used upfront or as rescue for PBSC mobilization in AL amyloidosis patients with cardiac involvement.

An updated single center experience with plerixafor and granulocyte colony‐stimulating factor for stem cell mobilization in light chain amyloidosis

“…In a phase II study, plerixafor combined with G‐CSF was shown to be efficient for CD34 mobilization and allowed for fewer apheresis sessions in patients with lymphoma and multiple myeloma . Several other small case series have highlighted the safety and efficacy of plerixafor‐based stem cell mobilization in AL amyloid patients . Our center adopted a combined G‐CSF/plerixafor‐based stem cell mobilization in patients with AL amyloidosis with the goal of reducing G‐CSF and enhancing CE in AL amyloidosis.…”

“…In terms of post-autoHCT outcomes, the median time to neutrophil recovery was 14 days (range 9-21) and the median time to platelet engraftment was 14 days (range [9][10][11][12][13][14][15][16][17][18][19]. Day 100 transplant-related mortality was 0.…”

“…13 Several other small case series have highlighted the safety and efficacy of plerixafor-based stem cell mobilization in AL amyloid patients. 14,15 Our center adopted a combined G-CSF/plerixafor-based stem cell mobilization in patients with AL amyloidosis with the goal of reducing G-CSF and enhancing CE in AL amyloidosis. Earlier, we published our experience comparing outcomes of patients mobilized with G-CSF/plerixafor versus G-CSF alone in AL amyloidosis.…”

Continuation of clozapine during chemotherapy and a stem cell transplant

“…In patients with AL amyloidosis, G-CSF-induced stem cell mobilisation is associated with volume overload, arrhythmias, and capillary leak syndrome. 15 The risk is therefore significant and can occur in patients without amyloidosis with cardiac involvement.…”

High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation in AL Amyloidosis

“…The recommended optimal dose of CD34+ cells in AL patients is at least 5 × 10 6 CD34+ cells/kg [21]. Plerixafor, CXCR4 receptor antagonist, as a stem cell mobilization regimen along with an abbreviated dose of G-CSF can be beneficial in patients with fluid overload to reduce the dose of G-CSF and reduce the risk of capillary leak syndrome and also reduce the number of leukapheresis session needed for optimal stem cell collection yield [22, 23].…”