Use of molecularly-cloned haematopoietic growth factors in persons exposed to acute high-dose, high-dose rate whole-body ionizing radiations.

Exposure to acute, high-dose, high dose-rate whole-body ionizing radiations damages the bone marrow resulting in rapid decreases in concentrations of blood cells, especially lymphocytes, granulocytes and platelets with associated risks of infection and bleeding. In several experimental models including non-human primate radiation exposure models giving molecularly cloned haematopoietic growth factor including granulocyte/macrophage colony-stimulating factor (G/M-CSF; sargramostim) and granulocyte colony-stimulating factor (G-CSF; filgrastim and pegylated G-CSF [peg-filgrastim]) accelerates bone marrow recovery and increases survival. Based on these data these molecules are US FDA approved for treating victims of radiation and nuclear incidents, accident and events such as nuclear terrorism and are included in the US National Strategic Stockpile. We discuss the immediate medical response to these events including how to estimate radiation dose and uniformity and which interventions are appropriate in different radiation exposures settings. We also discuss similarities and differences between molecularly cloned haematopoietic growth factors.

[Hematopoietic growth factors. Possibilities and limitations]. / Hämatopoetische Wachstumsfaktoren. Möglichkeiten und Grenzen.

The production of hematopoietic cells is under the tight control of distinct growth factors. As therapeutic agents, granulocyte colony-stimulating factor (G-CSF), erythropoietin (EPO), and thrombopoiesis-stimulating agents (TSA) are in routine clinical use. Granulocyte colony-stimulating factor is used to prevent febrile neutropenia or to increase dose-density in chemotherapy regimens. Despite a reduced duration of neutropenia, randomized controlled trials have documented only a modest clinical benefit. A clinical advantage of dose-dense chemotherapy has been shown only in specific chemotherapy regimens. Clinical practice guidelines recommend the use of G-CSF for patients with a high risk of adverse outcome of febrile neutropenia. Erythropoiesis-stimulating agents (ESAs) are used as an alternative to blood transfusion in patients with chemotherapy-induced anemia. However, recent meta-analyses of clinical studies suggest that their use was associated with an increased risk of all-cause mortality and serious adverse events. Thrombopoiesis-stimulating agents have been introduced recently into the market for patients with immune thrombocytopenic purpura. Prior to the use of TSA in other conditions such as chemotherapy-induced thrombocytopenia the lessons learned with G-CSF and ESAs should be taken into account.

Are guidelines on use of colony-stimulating factors in solid cancers flawed?

In cancer care in Australia, we are very reliant on an array of expensive pharmaceuticals. Our use of these treatments is often based on multinational or foreign clinical studies. Oncologists are, to varying degrees, reliant on how the studies are interpreted by the writers of journal editorials, clinical guidelines and opinion pieces. Therefore it is important that these guidelines are balanced and evidence based. We have examined in detail one of the most influential and wide ranging clinical guidelines used in oncology, The American Society of Clinical Oncology (ASCO) 2006 Update of Recommendations for the use of White Blood Cell Factors: An Evidence-Based Clinical Practice Guideline. We have discussed in detail some of the controversial recommendations in this guideline and have exposed what we believe are some flaws in these recommendations. We would urge that we continue to be rigorous in our oversight of international research agendas and international clinical guidelines in the future.

Administration of hematopoietic cytokines in the subacute phase after cerebral infarction is effective for functional recovery facilitating proliferation of intrinsic neural stem/progenitor cells and transition of bone marrow-derived neuronal cells.

BACKGROUND: Hematopoietic cytokines, granulocyte colony-stimulating factor (G-CSF), and stem cell factor (SCF) were reported to show a neuroprotective effect or to support neurogenesis. These cytokines also mobilize bone marrow (BM) cells into the brain, and the BM-derived cells differentiate into neuronal cells. We administered these hematopoietic cytokines after focal cerebral ischemia and assessed their effects and the therapeutic time window for neuronal regeneration. METHODS AND RESULTS: We induced permanent middle cerebral artery occlusion in mice whose BM had been replaced with BM cells from green fluorescent protein (GFP)-transgenic mice. The occluded mice were treated with G-CSF and SCF in the acute phase (days 1 to 10) or subacute phase (days 11 to 20), and the brain functions and histological changes were evaluated. Separately, we injected bromodeoxyuridine during cytokine treatment to assess cell kinetics in the brain. Six mice were prepared for each experimental group. Administration of G-CSF and SCF in the subacute phase effectively improved not only motor performance but also higher brain function, compared with acute-phase treatment. Acute-phase and subacute-phase treatments identically reduced the infarct volume relative to vehicle treatment. However, subacute-phase treatment significantly induced transition of BM-derived neuronal cells into the peri-infarct area and stimulated proliferation of intrinsic neural stem/progenitor cells in the neuroproliferative zone. CONCLUSIONS: Administration of G-CSF and SCF in the subacute phase after focal cerebral ischemia is effective for functional recovery, enhancing cytokine-induced generation of neuronal cells from both BM-derived cells and intrinsic neural stem/progenitor cells. Because G-CSF and SCF are available for clinical use, these findings suggest a new therapeutic strategy for stroke.

Hematopoietic growth factors in the treatment of acquired bone marrow failure states.

In severe aplastic anemia (SAA), the use of hematopoietic growth factors (HGFs) to support blood counts is of limited value, as predicted by in vitro studies and measurement of endogenous serum levels of hematopoietic growth factors (HGF), which are markedly elevated. Benefit is usually only seen in those with less severe disease who are unlikely to require HGFs in practice. HGFs administered alone play no role in the treatment of SAA. The main indication for using HGFs, most often granulocyte colony-stimulating factor (G-CSF), in SAA has been to determine whether they increase the response rate to immunosuppressive therapy (IST) and improve survival. While earlier neutrophil recovery occurs when G-CSF is administered with IST, studies to date show no significant advantage in hematologic response or overall survival. Conflicting results have been reported concerning whether G-CSF increases the known risk of myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) after IST; follow-up of at least 10 years is required, lacking in many clinical studies reported to date. In MDS, HGFs have been used to counteract the intramedullary apoptosis, which leads to ineffective hematopoiesis. In several uncontrolled and controlled studies, especially in low-risk MDS, high-dose erythropoietin (EPO) or its glycosylated derivative darbepoetin (DPO), alone or in combination with G-CSF, increased hemoglobin levels and diminished the need for red blood cell transfusions, in selected patients with prior transfusion frequency of less than 2 units per month and EPO levels below 500 IU/L. Quality-of-life measures were claimed to have improved, but the cost-effectiveness of this approach is debated, as is safety with regard to the risk of progression. G-CSF is used in supportive care of MDS to improve neutropenia during infectious complications, but to date there is no compelling evidence for a survival benefit or alteration of the course of the disease through the use of HGFs in MDS.

Reversible expansion of primate mast cell populations in vivo by stem cell factor.

Mast cell development in mice is critically regulated by stem cell factor (SCF), the term used here to designate a product of fibroblasts and other cell types that is a ligand for the tyrosine kinase receptor protein encoded by the proto-oncogene c-kit. However, the factors which regulate the size of mast cell populations in primates are poorly understood. Here we report that the subcutaneous administration of recombinant human SCF (rhSCF) to baboons (Papio cynocephalus) or cynomolgus monkeys (Macaca fascicularis) produced a striking expansion of mast cell populations in many anatomical sites, with numbers of mast cells in some organs of rhSCF-treated monkeys exceeding the corresponding values in control monkeys by more than 100-fold. Animals treated with rhSCF did not exhibit clinical evidence of mast cell activation, and discontinuation of treatment with rhSCF resulted in a rapid decline of mast cell numbers nearly to baseline levels. These findings are the first to demonstrate that a specific cytokine can regulate mast cell development in primates in vivo. They also provide the first evidence, in any mammalian species, to indicate that the cytokine-dependent expansion of tissue mast cell populations can be reversed when administration of the cytokine is discontinued.

Bone marrow transplantation in adults with thalassemia: Treatment and long-term follow-up.

Current regular blood transfusion programs and chelation treatment have considerably improved survival of patients with thalassemia, which resulted in a larger proportion of adult patients. However, disease- and treatment-related complications in these patients progress over time, causing severe morbidity and shortened life expectancy. Stem cell transplantation still remains the only cure currently available for patients with thalassemia. This study updates transplant outcomes in 107 adult patients with median age of 22 years (range, 17-35 years) who received bone marrow transplantation (BMT) from human leukocyte antigen (HLA)-identical related donors between 1988 and 1996 (group A) and describes the results of BMT in 15 adult patients with median age of 21 years (range, 17-31 years) who were treated with a new treatment protocol (Protocol 26) between 1997 and 2003 (group B). The probability of survival, event-free survival, nonrejection mortality, and rejection for group A patients were 66%, 62%, 37%, and 4%, respectively, with a median follow-up of 12 years (range, 8.3-16.2 years). Group B patients treated with the new protocol had some improvement in thalassemia-free survival (67%) and lower transplant-related mortality (27%) than that of previous protocols. However, transplant-related mortality in these high-risk patients remains elevated. Current myeloablative BMT in adult patients is characterized by higher transplant-related toxicity due to an advanced phase of disease. Although this new approach to transplant adult patients with a reduced-dose intensity-conditioning regimen has improved thalassemia-free survival, transplant-related mortality in these high-risk patients remains elevated.

Evidence that ras and myc mediate the synergy between SCF or M-CSF and other haemopoietic growth factors.

We previously reported that M-CSF could mimic the synergistic effect of SCF upon myeloid FDC-P1 cells that were first infected with a c-fms retrovirus, which encodes the human M-CSFr. We now report that an M-CSFr with a mutation of its autophosphorylation site at position 809 was, in response to M-CSF, unable both to synergize with IL-3 or GM-CSF and to induce c-myc; whereas a mutant receptor with a deletion of its kinase insert was unaffected for these processes. The expression of an exogenous c-myc proto-oncogene or a 12H-ras oncogene lowered the requirement of FDC-P1 cells for IL-3 or GM-CSF, in a similar manner to M-CSF or SCF addition. Furthermore, the expression of either of these genes complemented the defective M-CSFr F809. These results strongly support a role for ras and myc in the synergistic action of M-CSF and, by implication, of SCF, which implies that these signalling intermediates are rate-limiting for the action of IL-3 and GM-CSF and possibly other haemopoietic growth factors.

Rat stem cell factor and IL-6 preferentially support the proliferation of c-kit-positive murine hemopoietic cells rather than their differentiation.

We have investigated the effect of stem cell factor (SCF) alone and in combination with interleukin-3 (IL-3) or interleukin-6 (IL-6) on the proliferation and maintenance of primitive hemopoietic progenitor cells. Results from liquid preculture of either unfractionated bone marrow cells or lineage (Lin)-c-kit+ cells indicates that the combination of SCF + IL-3 results in the greatest expansion of total nucleated cell numbers; however, the combination of SCF + IL-6 results in the greatest expansion of colony-forming cells in culture (CFU-C) and in spleen (CFU-S). Morphologic examination confirmed the increase in immature cells after culture with SCF + IL-6 and, therefore, this combination is deemed superior for the expansion of primitive cells in liquid culture. Reconstitution assays using congenic mice (Ly5) revealed that cultured cells in the presence of SCF + IL-6 contained stem cells that were capable of reconstituting the hemopoiesis in lethally irradiated mice. Although it remains unclear whether SCF + IL-6 directly supports the self-renewal of stem cells, SCF + IL-6 is a powerful tool for manipulating primitive hemopoietic cells in vitro.

The combined effects of interleukin-11, stem cell factor, and granulocyte colony-stimulating factor on newborn rat hematopoiesis: significant enhancement of the absolute neutrophil count.

Dysregulation of neonatal myelopoiesis and thrombopoiesis predisposes the newborn to develop neutropenia and/or thrombocytopenia during states of increased demand. We have previously examined the effects of granulocyte colony-stimulating factor (G-CSF) alone or in combination with either stem cell factor (SCF) or interleukin-11 (IL-11) on in vivo neonatal rat hematopoiesis. In this study, we determined the effect of the triple combination of IL-11, SCF, and G-CSF on newborn rat hematopoiesis. Newborn Sprague-Dawley rats (< or = 24 hours old) were administered intraperitoneal (IP) injections of 250 micrograms/kg IL-11, 100 micrograms/kg SCF, 5 micrograms/kg G-CSF, or various combinations or phosphate-buffered saline (PBS)/human serum albumin (HSA) x 14 d. Platelet and blood cell counts were obtained on days 1, 3, 6, 8, 10, and 13; on day 14 bone marrow neutrophil storage pool (BM NSP), neutrophil proliferative pool (NPP), colony-forming units-granulocyte/macrophage (CFU-GM), and CFU-GM proliferative rates were determined. The triple combination failed to significantly increase the circulating hematocrit over other combinations or placebo. The circulating platelet counts, however, significantly increased during each of the IL-11 treatment arms, but they were not enhanced by the addition of either SCF, G-CSF, or the combination. The triple combination of IL-11, SCF, and G-CSF induced the most significant increase in the circulating absolute neutrophil count (ANC) above any other combination or placebo. Circulating ANC increased 12-fold following the triple combination vs. PBS/HSA (day 14 ANC 16525 +/- 1340 vs. 1368 +/- 197) (p < 0.001). The triple combination of IL-11, SCF, and G-CSF also induced the most significant increase in the BM/CFU-GM proliferative rate and BM NPP, p < 0.002 and p < 0.008, respectively. The highest increase in CFU-GM colony formation, however, occurred with both early lineage CSFs, that is, IL-11 plus SCF, and it was not further enhanced by the addition of G-CSF. These data suggest that the combination of two early-lineage CSFs, IL-11 plus SCF and G-CSF, significantly induces newborn rat myelopoiesis and that IL-11 alone significantly induces newborn rat thrombopoiesis. These results may be helpful in the design of future therapies to treat and/or prevent cytopenias in the newborn.

Effects of mast cell growth factor, interleukin-3, and interleukin-6 on human primitive hematopoietic progenitors from bone marrow and cord blood.

Phycoerythrin (PE)-labeled murine monoclonal antibodies (MAB) to CD2, CD10, CD19, CD20, and CD33 were used as lineage markers, as were PE-labeled anti-DR MAB and fluorescein isothiocyanate (FITC)-conjugated MAB to CD34. One hundred CD34+Lin+DR+ or CD34+Lin-DR- cells were individually sorted and incubated without adherent cell layer in alpha-medium with or without cytokines such as 100 U/mL recombinant human interleukin-3 (rhIL-3), 100 U/mL rhIL-6, and/or 500 ng/mL mast cell growth factor (MGF). The incubated cells were harvested and cultured in medium containing methylcellulose every 2 weeks. The numbers of colonies from colony-forming units-granulocyte/macrophage (CFU-GM), burst-forming units-erythroid (BFU-E), and mixed colony-forming units (CFU-Mix) were scored on day 14. In the incubation, CD34+Lin-DR- cells from bone marrow and cord blood produced more CFU-GM and BFU-E, and for longer periods, than did CD34+Lin+DR+ cells. In addition, CD34+Lin-DR- from cord blood supplied more CFU-GM and BFU-E than did CD34+Lin-DR- from bone marrow. Although these data demonstrate that MGF, IL-3, and IL-6 synergistically stimulate the production of CFU-GM and BFU-E, this study indicates that CD34+Lin-DR- cells contain more primitive hematopoietic progenitors and that CD34+Lin-DR- cells are unable to maintain their self-renewal capacity in the presence of IL-3, IL-6, and MGF without adherent cell layer.

Mast cell growth factor (c-kit ligand) enhances cytokine stimulation of proliferation of the human factor-dependent cell line, M07e.

Murine mast cell growth factor (muMGF), a c-kit ligand, has additive to greater-than-additive effects on in vitro colony formation of murine and human myeloid progenitor cells stimulated with erythropoietin, granulocyte-macrophage colony-stimulating factor (GM-CSF), and/or interleukin (IL)-3. To confirm direct-acting effects on responding cells, MGF was assessed alone and in combination with other cytokines for effects on the proliferation of the human factor-dependent cell line, M07e. Proliferation was assayed in liquid culture by [3H]thymidine uptake and in semisolid medium by colony formation. Purified recombinant (r) muMGF (25-50 ng/ml) by itself had proliferative activity but less than r human (hu) GM-CSF. In combination with rhuGM-CSF (250 U/ml) or IL-3 (500 U/ml), rmuMGF (25 ng/ml) enhanced [3H]thymidine uptake two- to sevenfold greater than the sum of the effects of each factor alone. Similar enhancement was seen in the number and size of colonies formed. When MGF was used in combination with rhuIL-4 (500-1000 U/ml), rhuIL-6 (5 ng/ml), rhuIL-9 (5-10 U/ml), or rhu interferon gamma (IFN-gamma; 250-500 U/ml) (factors that alone stimulate little proliferation), [3H]thymidine uptake and colony formation were respectively increased 2- to 11- and 3- to 55-fold over the sum of each of the effects of the factors alone. Exposure of 5 x 10(5) cells/ml to 50 ng/ml MGF for 24 h, a time during which synergism is noted with MGF plus either GM-CSF or IL-3, did not change GM-CSF or IL-3 receptor binding affinity or the number of binding sites. Exposure of cells to MGF for 48 h did not alter subsequent GM-CSF- or IL-3-stimulated proliferation. The results suggest that M07e cells will be useful as a model for the analysis of intracellular biochemical mechanisms of the direct-acting proliferative and synergistic effects of MGF.

Cytokine-mediated expansion of 5-FU-resistant peripheral blood stem cells.

We evaluated the expansion capacity of untreated and 5-fluorouracil (5-FU)-resistant peripheral blood stem cells (PBSC) after 7-day incubation with interleukin-1 (IL-1) plus IL-3 plus stem cell factor (SCF) or with medium alone. We found a significant increase in the proportion of CD34+ cells in the PBSC fraction resistant to 25 micrograms/mL 5-FU after 7-day incubation with IL-1 plus IL-3 plus SCF as compared with the untreated fraction (p = 0.011). We also showed that 5-FU-resistant PBSC have a greater capacity for expansion of IL-1/IL-3/SCF-responsive immature progenitors (p = 0.05), amplification of IL-3 plus GM-CSF responsive progenitors (p = 0.01), and production of committed single growth factor-responsive (granulocyte-macrophage colony-stimulating factor [GM-CSF]) precursors (p = 0.01) than the untreated PBSC. The expansion of all types of progenitors and CD34+ cells was only observed after 7-day incubation with IL-1 plus IL-3 plus SCF. These results suggest that PBSC contain a primitive stem cell population with an enhanced expansion capacity that is identified by 5-FU resistance. As these cells can be expanded in vitro, they may then be suitable for a number of clinical applications.

Synergistic effect of stem cell factor with interleukin-3 or granulocyte-macrophage colony-stimulating factor on the proliferation of murine primitive hematopoietic progenitors.

We examined the effect of recombinant murine stem cell factor (SCF) on murine primitive hematopoietic stem cells in vivo. Marrow cells from 5-fluorouracil (5-FU)-treated male CBA/J mice were transplanted into lethally irradiated female littermates. Immediately after marrow transplant, the mice received SCF, interleukin-3 (IL-3), and granulocyte-macrophage colony-stimulating factor (GM-CSF) alone or in combination daily for 6 days. Day-12 colony-forming units-spleen (CFU-S) and marrow-derived colony-forming units-granulocyte/macrophage (CFU-GM) were assessed. Bone marrow cells from primary transplant recipients were transplanted into a secondary group of lethally irradiated mice, and the number of spleen colonies arising after 12 days' engraftment was determined as pre-CFU-S. SCF alone did not increase spleen colony formation in either primary or secondary recipients. In contrast, treatment of primary recipients with SCF and GM-CSF or IL-3 or with all three cytokines resulted in a synergistic increase of CFU-S in secondary recipients, indicating increased pre-CFU-S levels. The cytokine combinations also produced synergistic increases of CFU-GM in primary recipient marrow. Evaluation of spleen colonies in secondary recipients by PCR amplification of the Y-chromosome sex-determining region indicated that about 80% were of donor (male) origin. We conclude that SCF with IL-3 and/or GM-CSF increases pre-CFU-S proliferation.

Hydroxyurea-induced HbF production in anemic primates: augmentation by erythropoietin, hematopoietic growth factors, and sodium butyrate.

Hydroxyurea, a cell-cycle-specific cytotoxic agent, has been shown to increase fetal hemoglobin (HbF) production. This property makes it an attractive drug for treatment of sickle cell disease and severe beta thalassemia. Its potential efficacy is limited because of a variable and often suboptimal response. Combinations of hydroxyurea and other drugs may induce more clinically significant increases in HbF. We have utilized chronically phlebotomized rhesus monkeys, treated with oral hydroxyurea, to investigate the capacity of several other agents to further augment HbF synthesis. Recombinant human erythropoietin, in super-pharmacologic doses, increased F-reticulocyte production when given on a weekly sequential schedule (3 of 7 days) with hydroxyurea (4 of 7 days), but it was less effective on an alternate day schedule when hydroxyurea was given daily. Neither recombinant human interleukin 3 (IL-3) nor recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF), when infused individually, increased F-reticulocytes in animals receiving daily hydroxyurea. Sequential, overlapping infusions of IL-3 and GM-CSF produced a small but statistically significant increase in F-reticulocytes in one of two hydroxyurea-treated animals. Infusions of sodium butyrate produced a substantial augmentation in F-reticulocyte production in animals chronically treated with hydroxyurea. Thus, our studies have identified several agents that may prove useful in combination with hydroxyurea to achieve clinically beneficial levels of HbF.

Filgrastim, lenograstim and pegfilgrastim in the mobilization of peripheral blood progenitor cells in patients with lymphoproliferative malignancies.

Patients with lymphoproliferative disorders, candidate to autologous stem cell transplantation (ASCT), require mobilization with chemotherapy and granulocyte colony -stimulating factor (G-CSF). This study looked for differences in hematopoietic peripheral stem cells (HPSCs) mobilization in response to the three available G-CSFs, namely lenograstim, filgrastim, and pegfilgrastim. Between 2000 and 2012, 146 patients (66 M and 80 F) who underwent ASCT for multiple myeloma, non-Hodgkin's lymphoma or Hodgkin's lymphoma were studied. All patients received induction therapy and then a mobilization regimen with cyclophosphamide plus lenograstim, or filgrastim, or pegfilgrastim. From days 12 to 14, HPSCs were collected by two to three daily leukaphereses. Our results show that high-dose cyclophosphamide plus lenograstim achieved adequate mobilization and the collection target more quickly and with fewer leukaphereses as compared to filgrastim and pegfilgrastim. No differences between the three regimens were observed regarding toxicity and days to WBC and platelet recovery. Thus, lenograstim may represent the ideal G-CSF for PBSC mobilization in patients with lymphoproliferative diseases. Further studies are needed to confirm these results and better understand the biological bases of these differences.

Hematopoietic growth factors. Defining the appropriate clinical role in multimodality cancer therapy.

Laboratory investigations have begun to elucidate the regulatory molecules that control the processes of blood cell growth and differentiation. Recombinant human colony-stimulating factors are examples of biotechnology-produced molecules that have epitomized the translation of such basic scientific investigation into therapeutic advances. Small cell lung cancer, a malignancy that is overall highly sensitive to aggressive myelosuppressive chemotherapy at initial presentation, has been used as a clinical model in which the activity of human colony-stimulating factors has been tested. In this article, the clinical applications of hematopoietic growth factors are reviewed in brief. The appropriate clinical use of these agents may allow novel therapeutic strategies to be developed in a research setting. Similarly, these agents have the potential to improve supportive care and improve certain clinical outcomes in the non-research clinical care of patients. Issues of cost of treatment are raised by these agents, but the true clinical value of hematopoietic growth factors needs to be studied more rigorously, with emphasis on quality of life and redistribution of care costs outside of hospitals before definitive statements can be made.

Increased levels of megakaryocyte progenitors in peripheral blood mobilised by chemotherapy and/or haemopoietic growth factor protocols.

We have quantitated colony-forming unit megakaryocyte, (CFU-Mk), burst-forming unit megakaryocyte, (BFU-Mk), colony-forming unit granulocyte-macrophage (CFU-GM), and CD34+ cells in 98 mobilised PB samples from 53 patients mobilised by one of six protocols, including myelosuppressive chemotherapy alone (n = 22), or in combination with recombinant haemopoietic growth factors (n = 32), and growth factors alone (n = 17) or in combination (n = 27). The frequency of megakaryocyte progenitors (total Mk = CFU-Mk + BFU-Mk) in mobilised PB (mean 356, range 0-3240/10(6)) was similar to that in steady-state BM (mean 429, range 0-3315/10(6) n = 45). The levels of total Mk in mobilised PB (mean 1509, range 0-36 099/ml) showed a mean 75-fold increase compared with steady state PB (mean 20, range 0-86/ml, n = 15). In mobilised PB the levels of CFU-Mk were significantly correlated with levels of BFU-Mk (rs = 0.71, P < 0.0001) and the levels of megakaryocyte progenitors correlated significantly with those of myeloid progenitors (rs = 0.59, P < 0.0001) and CD34+ cells (rs = 0.69, P < 0.0001). The mobilisation of megakaryocyte progenitors into the circulation in response to high-dose chemotherapy and/or haemopoietic growth factors contributes to an understanding of the rapid platelet recovery following PBSC transplantation and suggests that the measurement of megakaryocyte progenitors may be a useful indicator for platelet reconstitutive capacity.

The role of cytokines following bone marrow transplantation: indications and controversies.

The use of cytokines following bone marrow transplantation has become an area of increasing controversy with specific regard to indication, efficacy and cost. This review will attempt to summarize cytokine data in both adult and pediatric transplantation. Indications for cytokines following transplantation will be presented, as well as suggestions for specific issues that should be addressed in future clinical trials.

Collection of more hematopoietic progenitor cells with large volume leukapheresis in patients with multiple myeloma.

Reinfusion of mobilized peripheral blood stem cells (PBSC) after high dose chemotherapy accelerates hematopoietic recovery. Because of the relatively low content of hematopoietic progenitors in the peripheral blood even after mobilization, multiple leukapheresis procedures are necessary to reach the required target number of CD34 cells to ensure prompt engraftment post-transplantation. Our previous studies have shown that the highest proportions of hematopoietic progenitors cells (CD34) are collected during the first three days of apheresis, whereas peak levels of myeloma cells are observed during subsequent days. Therefore, large volume leukapheresis (LVL), defined as processing of greater than 3 blood volumes or a total of at least 15 liters, was explored in 23 myeloma patients, undergoing 91 procedures; 14 patients were mobilized with high dose cyclophosphamide (6g/m2) and hematopoietic growth factors and 9 with G-CSF only. CD34 yields were measured separately for the first and last two hours of collection. We observed no decrease in CD34 cells/kg during the last two hours of collection and when the LVL collections were compared to historical matched controls, mobilized with the same regimen, the median quantity of CD34 cells/kg/liter collected remained equivalent during all days of apheresis. When compared to G-CSF only, mobilization with high dose cyclophosphamide appeared to result in superior hematopoietic stem cell collections. Interestingly, the G-CSF group experienced a progressive decrease in platelets during consecutive days of LVL, while the opposite was seen in the cyclophosphamide group. LVL procedures were not associated with a higher complication rate than standard volume apheresis. We conclude that LVL procedures allow collection of more CD34 cell per session while not jeopardizing progenitor cell collections during subsequent sessions. Since more CD34 cells are collected, fewer days are required to attain the optimal target of progenitor cells. This should result in PBSC grafts with less tumor contamination.