Four-step high-dose sequential chemotherapy with double hematopoietic progenitor-cell rescue for metastatic breast cancer.

PURPOSE: High-dose chemotherapy produces high complete remission (CR) rates and some survival advantage in patients with metastatic breast cancer (BC). A current issue is the possibility that these patients may have an even better prognosis with multiple high-dose treatments. In this study, we evaluated the feasibility of a four-step, high-dose sequential chemotherapy (HDSC) with double autologous hematopoietic progenitor-cell rescue. We also tested the hypothesis that peripheral-blood progenitor cells (PBPCs) harvested following a single recruitment with cyclophosphamide (CY) and granulocyte-macrophage colony-stimulating factor (GM-CSF) allow the safe administration of the whole HDSC with closely timed repeated courses of several non-cross-resistant agents. PATIENTS AND METHODS: The treatment plan included CY 7 g/m2, followed by GM-CSF 5 to 7 micrograms/kg/d administered by continuous intravenous (i.v.) infusion on days 2 to 14; PBPCs with or without bone marrow (BM) harvest; mitoxantrone (NOV) 60, 75, or 90 mg/m2 plus melphalan (L-PAM) 140 to 180 mg/m2 with hematopoietic rescue; methotrexate (MTX) 8 g/m2 plus vincristine (VCR) 1.4 mg/m2; and etoposide (VP-16) 1.5 g/m2 plus carboplatin (PP) 1.5 g/m2 with hematopoietic rescue. RESULTS: All 15 patients enrolled completed the entire treatment and there were no toxic deaths. Hematologic reconstitution was good at each step. The median number of days with an absolute neutrophil count (ANC) less than 100/microL and platelet count less than 20,000/microL were 8 and 3, respectively, after NOV plus L-PAM, and 7 and 4, respectively, after VP-16 plus PP. The main non-hematologic toxicity was mucositis, while organ toxicity was mild and reversible. CONCLUSION: This regimen is feasible, with acceptable toxicity. GM-CSF and PBPCs have a pivotal role, as they hasten hematologic reconstitution, abate toxicity, and allow rapid recycling.

Autografting followed by nonmyeloablative immunosuppressive chemotherapy and allogeneic peripheral-blood hematopoietic stem-cell transplantation as treatment of resistant Hodgkin's disease and non-Hodgkin's lymphoma.

PURPOSE: To investigate the use of a nonmyeloablative fludarabine-based immunosuppressive regimen to allow engraftment of HLA-sibling donors' mobilized stem cells and induction of a graft-versus-lymphoma effect for patients with advanced resistant Hodgkin's disease and non-Hodgkin's lymphoma. PATIENTS AND METHODS: Fifteen patients with Hodgkin's disease (n = 10) and non-Hodgkin's lymphoma (n = 5) were studied. All patients received cyclophosphamide and granulocyte colony-stimulating factor to mobilize autologous hematopoietic stem cells (HSCs). Subsequently, they received high-dose therapy with carmustine, etoposide, cytarabine, and melphalan and reinfusion of HSCs. At a median of 61 days after engraftment, patients were given fludarabine 30 mg/m(2) with cyclophosphamide 300 mg/m(2) daily for 3 days. Donor-mobilized HSC collections were prepared for fresh infusion and were not T-cell depleted. Methotrexate and cyclosporine were used to prevent graft rejection and as graft-versus-host disease (GVHD) prophylaxis. RESULTS: Combined treatment was well tolerated. After mini-allografting, hematologic recovery was prompt. Thirteen patients had 100% donor cell engraftment. Eleven patients achieved complete remission (CR) after the combined procedure. Nine patients, who were in partial remission after autografting, achieved CR after mini-allografting. Seven patients developed >/= grade 2 acute GVHD (aGVHD) and two developed extensive chronic GVHD (cGVHD). Three patients who received the highest number of donor lymphocyte infusions (DLIs) developed grade 3 GVHD (two patients) and extensive cGVHD (one patient). Ten patients are currently alive, and five are in continuous CR. Seven patients received DLI, with five CRs. Five patients died: one of progressive disease, two of progressive disease combined with aGVHD or cGVHD, one of extensive cGVHD, and one of infection. CONCLUSION: Fludarabine/cyclophosphamide was well tolerated and allowed consistent engraftment in lymphoma allografted patients. Response rates were high in this group of refractory and heavily pretreated patients. This dual procedure seems to be most promising in patients with end-stage malignant lymphomas.

Mobilization and transplantation of Philadelphia-negative peripheral-blood progenitor cells early in chronic myelogenous leukemia.

PURPOSE: Mobilization of Philadelphia (Ph) chromosome-negative progenitors is now possible in many Ph1-positive chronic myelogenous leukemia (CML) patients who had received interferon alfa (IFN-alpha) with no cytogenetic response. In this pilot study, we used this approach in patients without prior IFN-alpha therapy to determine if the number and quality of mobilized progenitors would be increased and to evaluate the potential effect of these cells as autografts. PATIENTS AND METHODS: Twenty-two untreated patients were mobilized within 12 months of diagnosis. The treatment regimen consisted of the mini-ICE protocol. Beginning on day +8, granulocyte colony-stimulating factor (G-CSF) was used in all patients. Leukophoresis was performed as the patients were recovering from aplasia, when WBC count exceeded 0.8 x 10(9)/L. RESULTS: In 14 patients, (63%) the leukophoresis product was entirely Ph1-negative and in four patients the Ph1-positive cell rate was < or = 7%. Significant numbers of long-term culture-initiating cells (LTC-IC) and CD34+ Thy1+Lin- cells were found in most of the Ph1-negative collections that were tested. Twelve patients underwent autografting with their mobilized peripheral-blood progenitor cells (PBPC) (Ph1-negative collections, 10 patients; major cytogenetic response, two patients). All patients engrafted and are alive; six have Ph1-negative marrow 7 to 15 months after autografting. Posttransplant treatment was IFN-alpha combined with interleukin (IL)-2 because of the recent demonstration of synergistic activity in augmenting cytolytic activity. CONCLUSION: Intensive chemotherapy given in early chronic phase of CML is well tolerated and results in high numbers of circulating Ph1-negative precursor cells.

Therapy of acute phase chronic myelogenous leukemia with intensive chemotherapy, blood cell autotransplant and cyclosporine A.

The expansion of the Philadelphia (Ph) chromosome positive clone in chronic myeloid leukemia (CML) may depend on its capacity to suppress the proliferation of Ph-negative stem cells, but this proliferative advantage might, in certain circumstances, be reversible. Various lines of evidence suggest that Ph-negative cells, albeit in a suppressed state, must still be present. As recently suggested, the expansion of 'putative' normal Ph-negative hemopoietic stem cells might have, in certain circumstances, a proliferative advantage over the Ph clone in CML. This suggests that the treatment of CML with intensive chemotherapy might allow the collection of Ph-negative hemopoietic cells in the early phase of recovery. Eight patients with acute phase chronic myelogenous leukemia (AP-CML) were treated with idarubicin, intermediate dose cytarabine and etoposide. During recovery from bone marrow aplasia, when the white blood cell count reached 0.3-1 x 10(-9), blood cells were collected with 2-5 (median 3) consecutive leukapheresis. In 5/8 patients, these peripheral cells were Ph-negative at the cytogenetic analysis. Moreover, in one case the polymerase chain reaction analysis performed to detect the presence of minimal residual disease in the cells collected by leukapheresis was negative, further confirming that this approach may induce a very high degree of suppression of the Ph-positive clones. After complete recovery, these five patients were subsequently treated with high-dose etoposide, cyclophosphamide and total body radiation (10 Gy, single dose) followed by reinfusion of Ph-negative peripheral blood stem cells. All these patients received cyclosporine A post-autotransplant in an attempt to induce acute graft-versus-host-disease. Three of 5 patients remain in clinical and cytogenetic remission 5-15 months post-transplant. It is concluded that Ph-negative peripheral blood stem cells can be recovered from patients with AP-CML and used successfully to restore Ph-negative hemopoiesis after high dose therapy.

Intensive conventional chemotherapy can lead to a precocious overshoot of cytogenetically normal blood stem cells (BSC) in chronic myeloid leukemia and acute lymphoblastic leukemia.

Forty patients with Ph-positive blastic phase (BP) (28 patients) or chronic phase (CP)-CML (3 patients) and relapsed adult acute lymphoblastic leukemia (ALL) (9 patients) with cytogenetical translocations [t(8;14):2 patients; t(4;8):2 patients; t(4;11):3 patients; t(9;22):2 patients], received an intensive conventional chemotherapy. During early recovery from marrow aplasia, when WBC reached 0.3-1.5 x 10--9/L, peripheral blood stem cells (BSC) were collected by 4-8 leukapheresis consecutively. BSC collected from the 2/3 patients with CP-CML resulted Ph-negative and PCR negative. In 8 out of 26 BP-CML patients, BSC resulted Ph-negative and in two cases PCR negative. Of the nine ALL patients, 6 patients lost the cytogenetic translocations, one patient died during aplasia, two patients did not have cytogenetic modifications and died in few weeks of leukemia and one patient out of six responding patients relapsed before transplant. After complete recovery, 15 patients (BP-CML:8 patients; CP-CML:2 patients; ALL:5 patients) were subsequently given high-dose therapy (VP-16 +/- Cy+TBI in single dose) followed by reinfusion of "normal" BSC. Both the patients in CP-CML and 5/5 patients with ALL maintain clinical and cytogenetic remission; all the patients transplanted in BP-CML relapsed 5-18 months post-transplant. It is concluded that intensive conventional chemotherapy employed in CML and ALL can lead to a precocious overshoot of cytogenetically normal BSC.

Multicomponent collection as of 2005.

Multicomponent apheresis (MCA) begun in Genoa in 1985 in autologous terms. Named "sequestration" it was the preoperative collection of autologous components (RBC-plasma-platelets) using the same apparatus and harness ready for intraoperative blood salvage. In 1986 the technique was applied to donor platelet apheresis with the goal of reducing the costs of platelet collection and concurrently reducing the risks of viral disease transmission to haematological patients who did receive, in the same transfusion event, the necessary blood components obtained from the same donor. The results of this application were maximized by the so called aggressive MCA by which in selected donors, it is possible to collect 2 units of platelets along with 1 or 2 units of PRBCs. These applications were made possible by the development of the concept of dry-platelet collection according to which platelets are collected in only 20-25 mL of plasma and subsequently resuspended in non-plasma solutions such as T-Sol. A last development of MCC is for RBC apheresis, with the collection of 1-2 units of RBC independently of platelet collection. This is going to be the first step of apheresis as the unique modality of collecting blood leaving the bags to history of blood transfusion. Interestingly it took 15 years to MCC to be rediscovered and appreciated worldwide both for its intrinsic cost saving capabilities offered along with an increasing safety for patients. In terms of donor acceptance it is our experience that, since 1989 no donor has refused MCC, consisting at least in the concurrent collection of plasma along with platelets, but also RBC and or a second unit of platelets.

Rheotherapy for vascular disorders.

Patients with vascular disorders are seldom offered apheresis in he management of their symptoms. In this article we review the different apheretical techniques used in these situations.

Hypertriglyceridemia: apheretic treatment.

Patients with extremely high triglyceride levels and associated lipemia are at high risk for acute pancreatitis. Two factors can increase triglyceride-rich lipoproteins; one is overproduction and other is a defect in clearance. Either mechanism can cause hypertriglyceridemia and both may exist simultaneously. Causes can be either primary or secondary. Plasmapheresis is efficacious for severe Hypertriglyceridemia in patients who have not responded to previous therapies. We have treated 15 cases of hypertriglyceridemia complicating the course of patients receiving Cyclosporin A after bone marrow transplantation. Five patients were treated with plasmapheresis, the other ten with cascade filtration. The removal rate for triglycerides was 58.0% for patients treated by cascade filtration and 63.5% for patients treated by plasmapheresis. The removal rates for triglycerides were low possibly as a consequence of early saturation of the filter.

Allogeneic bone marrow or peripheral blood cell transplants in adults with hematologic malignancies: a single-center experience.

This is a retrospective study of 97 patients who received either allogeneic bone marrow transplant (BMT) (n=52) or peripheral blood cell transplant (PBCT) (n=45) at our institution from human leukocyte antigen (HLA)-identical sibling donors between January 1994 and January 1997. The two groups were comparable with respect to diagnosis, age, sex, interval from diagnosis, and disease phase. They were prepared with cyclophosphamide (CY) and fractionated total-body irradiation (TBI) (n=51) or CY and thiotepa (n=46). Graft-vs.-host disease (GVHD) prophylaxis consisted of cyclosporin A and methotrexate. Patients who received PBCT exhibited faster neutrophil engraftment (day 14 vs. day 16, p = 0.002) than those in the BMT group, as well as higher platelet counts on day 20 (32x10(9)/kg vs. 21x10(9)/kg, p = 0.001), but graft function as assessed by platelet counts on days 50, 100, and thereafter was comparable. The number of days spent in the hospital, days on intravenous antibiotics, and days of fever were lower in the PBCT group, but not significantly. Acute GVHD, chronic GVHD, and cytomegalovirus infections were comparable between the two groups. The overall actuarial 3-year transplant-related mortality (TRM) rate for BMT vs. PBCT patients was 20 vs. 33% (p = 0.1), the survival rate was 53 vs. 48% (p = 0.3), and the relapse rate was 42 vs. 43% (p = 0.8). For patients in first complete remission, these figures were TRM 12 vs. 22% (p = 0.2), survival rate 75 vs. 70% (p = 0.4) and relapse rate 31 vs. 9% (p = 0.4), respectively, for the BMT and PBCT groups. These data suggest that the short-term outcome of allogeneic PBCT is not significantly different from that of allogeneic BMT in patients with hematologic malignancies. Long-term results are not available at present.

Donor lymphocyte infusions (DLI) in patients with chronic myeloid leukemia following allogeneic bone marrow transplantation.

Donor lymphocyte infusions (DLI) were given between June 1990 and March 1996 to 18 patients with chronic myeloid leukemia (CML) for the treatment of cytogenetic (n = 6) or hematologic relapse (n = 12) following an allogeneic bone marrow transplant (BMT). Patients were divided in two groups: patients in group A (n = 8) received a large dose of donor lymphocytes (> or = 1 x 10(8)/kg), whereas patients in group B (n = 10) received escalating numbers of cells (2 x 10(5) up to 2 x 10(8)/kg). The median number of DLI in group A was 2 (range 1-3); the median number of infusions in group B was 7 (range 3-9). Acute GVHD occurred in 12 patients (grades I-III) and was a major cause of death in two. The risk of developing GVHD correlated with the number of cells infused: 37%, 14%, 5% and 0% for DLI with cells > or = 1 x 10(8), 2 x 10(7)/kg, 2 x 10(6)/kg, and 2 x 10(5)/kg, respectively (P = 0.01). Median transaminase levels were found to be significantly increased in patients with, as compared to patients without, acute GVHD (GPT 412 vs 28 IU/l; P = 0.03). Severe aplasia occurred in four and was a contributing cause of death in two patients. Overall, four patients died as a consequence of DLI and all received > 1 x 10(8)/kg cells: the actuarial risk was 38% in group A and 14% in group B (P = 0.1). There were 10 complete and three partial cytogenetic responses: the actuarial probability at 5 years of being Ph negative was 69%: it was 46% for group A and 85% for group B (P = 0.1). The longest patient is now 6 years post-DLI, Ph negative, BCR-ABL negative. The actuarial 3 year survival is 38% in group A and 86% in group B (P = 0.06). The study confirms that DLI post-BMT is not innocuous and that there is a definite long-lasting antileukemic effect in patients with CML. It also suggests that: (1) the risk of developing GVHD correlates with the number of infused cells; (2) that significant elevations of serum GPT levels are associated with GVHD; and (3) that the use of escalating doses of cells may allow the identification of side-effects and discontinuation of infusions before life-threatening GVHD has developed.

Factors predicting response and graft-versus-host disease after donor lymphocyte infusions: a study on 593 infusions.

In the present study, we analyze factors predicting graft-versus-host disease (GvHD) and response after donor lymphocyte infusions (DLI). A total of 100 patients received 593 DLI between June 1990 and December 2000 in a bulk dose (n=14) or in escalating dose infusions (n=86). Patients were analyzed after stratification for type of relapse: (1). molecular relapse (n=6), (2). cytogenetic relapse (n=20), (3). chronic phase of chronic myeloid leukemia (CML) or complete remission of other disease post chemotherapy (n=24), (4). CML in accelerated/blastic phase (n=14), (5). resistant disease not responding to chemotherapy (n=36). The proportion of responders to DLI in these five groups was 100, 90, 75, 36 and 0% (P<0.0001). Factors predicting response by multivariate analysis were type of relapse (P<0.0001), post-DLI GvHD (P=0.005), pancytopenia (P=0.008), and a diagnosis of CML (P=0.04). Acute GvHD (grades II-IV) occurred in 21 patients (21%), and correlated in multivariate analysis with pancytopenia and less than four DLI. Other predictors of GvHD were the number of CD3+cells/infusion and serum levels of gamma-glutamyl transferase (gammaGT). The actuarial probability of treatment-related mortality was 9% for HLA identical siblings and 44% for alternative donor transplants (P=0.006). Response to DLI is predicted by tumor burden and is associated with GvHD and pancytopenia.

High-dose chemo-radiotherapy followed by autologous Philadelphia chromosome-negative blood progenitor cell transplantation in patients with chronic myelogenous leukemia.

Twenty-three patients with chronic myelogenous leukemia in early chronic phase (ECP) and not previously treated with alpha-interferon (IFN-alpha) (10 patients), in ECP but pretreated with IFN-alpha (<12 months) (seven patients) and in late chronic phase (LCP) pretreated with IFN-alpha (>12 months) (six patients) underwent autografting with Philadelphia (Ph) chromosome-negative blood progenitor cells (BPCs) (20 patients), or partially/totally Ph-positive BPCs (three patients), previously mobilized during the early phase of recovery after aplasia induced by intensive chemotherapy. The conditioning regimen consisted of high-dose chemotherapy alone or followed by total body irradiation (TBI). Recombinant G-CSF was given after BPCs infusion on day +8. All patients in ECP not pretreated with IFN-alpha are alive and five of them are Ph-negative in the marrow after autografting. Six of seven patients autografted with Ph-negative BPCs in the group of ECP pretreated with IFN-alpha (<12 months) are alive and two of them are still Ph-negative in the marrow. In the same group, the only patient transplanted with partially Ph-positive BPCs, died of blastic transformation 2 months after reinfusion. Three patients (two patients autografted with Ph-negative BPCs and one patient with Ph-positive BPC) in the group of LCP pretreated with IFN-alpha >12 months are alive but Ph-positive after autografting. The other three patients of the same group died of procedure-related toxicity (two patients) and blastic transformation (one patient). Seventeen patients (10/10 ECP not pretreated with IFN-alpha; 5/7 ECP pretreated with IFN-alpha and 2/6 LCP pretreated with IFN-alpha) of 23 autografted patients were treated with IFN-alpha +/- IL-2. Toxicities after autografting were mostly related to myelosuppression, particularly thrombocytopenia. All patients of the two groups pretreated with IFN-alpha developed febrile episodes during the aplastic phase following BPCs reinfusion. No patient autografted in ECP and those not pretreated with IFN-alpha developed febrile episodes. This is also probably due to the use of i.v. antibiotic and antimicotic prophylaxis when neutrophils were < or = 1 x 10(9)/l after autografting. Greater toxicity was observed in patients pretreated with IFN-alpha, being lethal in two cases in LCF. In conclusion, the "in vivo' manipulation approach employed in our institution is a safe procedure and it results in a high collection of Ph-negative cells in the blood if the cells are harvested: (1) in early chronic phase; (2) in early phase of recovery after chemotherapy-inducing aplasia; (3) in patients not extensively pretreated with IFN-alpha. The data presented here have shown encouraging trends in chronic phase of CML and offer new perspective for patients without an HLA-identical donor or for patients who do not respond to IFN-alpha.

Evaluation of dosed red blood cell units collected with Gambro BCT--TRIMA.

The increasing need of collecting high quality blood components and of improving the overall productivity of a blood centre requires the utilisation of a new innovative process that combines high speed collection with an automated process and blood component tailoring to fit individual patient requirements. We collected dosed Red Blood Cell (dRBC) units on 64 donors, eligible as regular donors on the Gambro BCT TRIMA using the dRBC collection protocol. The collection target was set to 180 ml packed Red Blood Cells (pRBCs) in 225 ml total collection volume (n = 7), or 300 ml pRBCs in 375 ml total collection volume (n = 33) or 360 ml in 450 ml (n = 24), depending on donor's hematological profile and blood volemia. Saline was infused as the replacement fluid at a 120%) collection:infusion ratio. Donor per cent hematocrit was (mean +/- S.D.) 43.7 +/- 4.0% and TBV = 4.99 +/- 0.69 1. The procedures yielded 100 +/- 6% of predicted yield, with a hematocrit of 78.2 +/- 6.6% in 29 +/- 3 min. Hb content was 99.9 +/- 21.8 in all procedures, or 61.5-94.4-118.6 g in the three groups, respectively. After the addition of the SAG-M storage solution, the hematocrit was 56.3 +/- 6.2%. No adverse reactions have been reported by the donors and all pPRBC units were transfused to patients without any transfusion reaction being reported by clinicians. The dRBC protocol is well tolerated by donors without any side effects, other than normal effects of regular blood donation. Higher pRBC productivity can be reached with a safe and automated process in conjunction with a high and consistent product quality easily matching the donor collection criteria and pRBC unit standards. Tailoring of pRBC units can result in an improved patient transfusion support.

Cellular contamination of plasma collected with various apheresis systems.

Efforts to improve the purity of blood products have mainly focused on reducing white blood cell (WBC) levels in cellular blood products. Relatively little attention has been given to the cellular purity of plasma. We evaluated plasma units collected on six apheresis systems: Dideco Excel, Haemonetics-MCS+, Fresenius-AS-Tech 204, Baxter-Amicus, Gambro BCT COBE Spectra and Gambro BCT-Trima. Collected plasma volumes averaged 300-350 ml for the various systems. Plasma samples were analyzed for platelet (PLT) content (Technicon H3, Bayer) and residual WBC (Imagn 2000). Results are given below. Platelet levels were consistently low for MCS+, COBE Spectra and Trima (all <50 x 10(3) microl(-1)), and were highest with AS204. Residual WBC levels were relatively low in all systems except MCS+. Extremely low levels were observed in Trima plasma. All of the Trima and Spectra units contained <1 x 10(6) WBC per product. With Excel, AS-Tech 204 and Amicus, 1 to 2 units were found to have >1 x 10(6) WBC, while almost all units from MCS+ exceeded this limit. Different levels of plasma purity were obtained with different apheresis systems. The Gambro BCT COBE Spectra and Trima systems were found to achieve consistently low levels of both platelets and WBC.

Cord blood (CB) stem cells for wound repair. Preliminary report of 2 cases.

In 2 patients, to promote skin wound/lesion repair we used fibrin-platelet glue combined with HLA compatible (2 mismatches accepted) buffy coats containing CD 34+ cord blood cells. The fibrin platelet glue was prepared with autologous apheresis platelets and cryoprecipitate. The original product was divided into 3 and 4 aliquots respectively for a correspondent number of applications. At each application, the margins of the lesion were infiltrated with 3 ml of cord blood buffy coat, containing 30 x 10(3) CD 34+ cells. No graft versus tissue reaction was seen in our patients in a follow-up of 3-7 months. The level of improvement, scored arbitrarily from 0 to 4, was 3 and 4, respectively. Our conclusion is that the use of cord blood cells along with fibrin platelet glue is of clinical interest.

Double plateletpheresis (DPA) and tailored RBC collection with the Excel-Pro: preliminary results.

The Dideco Excel-Pro is frequently used for double plateletpheresis (DPA) when the platelet precount exceeds 280 x 10(3)/l. Platelets are collected as "dry platelets" and the resuspension solution is added when the procedure is over. Even when DPA is carried out the product volume prior to resuspension may be as low as 60 ml. As a result, a third product may be collected along with platelets. Our priority is to collect RBCs and, depending on the donor's BW, tailored RBC collections are carried out. This means that from 400 to 480 ml of PRBC (70% hct) are collected from donors whose BW exceeds 75 kg. The results of the last 27 DPA/tailored PRBC collections are: Donors gender and BW (kg), 19M/8F: 88.4 +/- 7.3 Hemoglobin (g/dl): 15.4 +/- 1.3 Platelet precount (x 10(3)/microl): 308 +/- 45 Volume of blood processed (1): 5.5 Procedure time (min): 81 +/- 3 Platelet yield (x 10(11)): 6.8 +/- 0.6 Avg Hemoglobin content of PBRC (g): 102.6 +/- 12.3 WBC contamination of the platelets: 6.8 +/ -10(5).

The MCS + revision A2 for highly efficient PBSC collection.

Autologous PBSC transplantation is an integral component of the management of hemato-oncology patients. In order to reduce the number of sessions needed to collect the desired number of repopulating cells there has been significant research activity in developing progressively more and more effective technologies and techniques. Recently our group has been involved in the rejuvenation of the MCS + apparatus for both platelet and PBSC collection. The so called "version A2 protocol" is aimed at collecting PBSC in a very efficient way. This protocol is characterized by high blood flow rates both in the collection and reinfusion (80 ml/min) recirculation (56 ml/min) and collection phases (30 ml/min). Only one recirculation is carried out every 5 cycles and only from 5 to 7 are carried out for a single procedure. Twenty-seven collections were carried out of which 25 were evaluable in terms of PBSC efficiency. These averaged 68.8% in an average procedure time of 3.5-5 h for processing an average of 7,052 ml of blood. The RBC contamination was reduced to approximately 5.02 g of hemoglobin and the average volume of the product to 177 ml. If these results are confirmed, the gap between CFC and DFC PBSC is progressively closing.

Nine years of cascade filtration for thrombotic thrombocytopenic purpura.

Thrombotic thrombocytopenic purpura (TTP) continues to attract physicians' attention because of its unpredictable course and underlying pathogenetic mechanisms. It is also attractive because of its optimal response to therapeutic plasma exchange (PE) even in the most severe cases. The usual approach to its treatment is conventional PE with plasma substitution and only recently fresh frozen plasma (FFP) has been substituted by cryodepleted or virally inactivated plasma with clinical results that are, if not better, at least comparable with the ones attained when FFP is employed. Nonetheless, no consensus exists regarding the optimal PE fluid and this is not of marginal interest as even after PE treatment mortality is still from 15 to 20%. On the contrary, some consensus exists on the pathogenetic relevance of the exceedingly large Von Willebrand (vWF) multimers whose presence parallels the clinical course and appears to be determined by the abnormalities in the production or function and survival of vWF-cleaving proteases which is auto-antibody mediated. In both cases plasmapheresis without plasma infusion is relatively ineffective, perhaps because it does not increase protease activity. Paradoxically, cascade filtration (CF) can produce the same favorable results without replacing any protease activity. As with CF, the replacement is the autologous plasma with approximately 20% levels of vWF, fibrinogen, fibronectin, IgM and circulating immune complexes and 75% of albumin, IgGs, AT III and proteins whose molecular weight exceeds 250-300000 Da. Our experience with CF for TTP began in 1994. Since then, 16 patients have undergone CF combined with decreasing amounts of FFP supplementation and since 1998 without any allogeneic FFP supplementation in 9 cases. Twenty-four patients (96%) treated with no or minimal amounts of FFP survived but four (16%) experienced from one to four recurrences associated with cutaneous, paradental, cholecystic and vaginal infections. Only one patient died (5%) after the second CF procedure. There were no untoward effects related to the procedure itself and up to 18 procedures in one patient were carried out over 16 months, 10 with the patient in her sixth month of pregnancy and four in the post partum period in preparation for a splenectomy. Remission was achieved after an average number of treatments (10.7 +/- 6.8); a result that compares favorably with those of our historical control group of 47 cases (14 +/- 13). The patient's exposure to allogenic plasma which was 10.8 +/- 4.6 plasma U/session was reduced to 0 in 10 patients, to 1.4 +/- 1.2 and 4.4 +/- 2.3 plasma U/session, respectively, for seven and nine patients receiving PE + CF and CF with same plasma supplementation as described in our previous article. Based on our experience, we believe CF is presently the optimal treatment for patients with classic, sporadic TTP.

Defective function of granulocytes in patients with cancer.

Mobilization of granulocytes into a serum-filled chamber, histochemical nitroblue tetrazolium (NBT) reduction tests, and phagocytosis were performed in 11 patients with solid tumors treated with surgical excision and chemotherapy and in 22 untreated or surgically treated patients. The results revealed a decreased mobilization (p less than 0.001) and an impaired capability of neutrophils to reduce NBT after stimulation (p less than 0.05) in both groups of patients. The decrease in the values in the stimulated reduction of NBT was more pronounced in untreated patients than in treated ones. At the same time the phagocytic activity of neutrophils on Candida albicans, which was decreased (p less than 0.01) in untreated patients, was normal in those who had been treated with chemotherapy. There were no distinctive correlations between circulating immune complexes and granulocyte function. We propose that this newly demonstrated defect in neutrophil mobilization and low median C. albicans-stimulated NBT reduction contributes more in the evolution of the tumor than in the pathogenesis of infections and that chemotherapy seems to restore a better granulocyte function.

Rheopheresis for sudden hearing loss (SHL).

Rheopheresis has met an increasing interest and application in different disease conditions affecting microcirculation. Its last applications are for the management of Macular and Cochlear disorders. The sudden hearing loss syndrome is a condition that affects 20 out of 100,000 persons per year, reduces the patient's social interaction and quality of life. It is associated with vascular and coagulation risk factors and it is considered as a result of local hypoperfusion secondary both to inflammatory and dysimmune conditions determining inadequate NO release and endothelial dysfunction. Rheopheresis treatment is a new approach which brings to satisfactory clinical results. Cascade filtration, heparin induced lipid precipitation and conventional plasma exchange are equally effective, and only 2 sessions are required for producing long lasting benefits. Our experience is with 60 patients, 90% of which getting from partial to complete recovery after treatment as measured by pure tone audiometry.