Use In Hematopoietic Stem Cell Transplantation

The PARMA trial clearly showed that high-dose chemotherapy and autologous hematopoietic stem cell transplantation is the optimal treatment for patients with relapsed chemotherapy-sensitive NHL (33). PBPCs collected with HGFs have now supplanted the use of bone marrow progenitors for use in autologous rescue after high-dose chemotherapy (34). Optimal use of HGFs in the mobilization of patients with lymphoma continues to be determined (35-39). Separate studies by Watts and colleagues (38) and Pavone and colleagues (39) found that lymphoma-specific salvage chemotherapy (ESHAP [etoposide, solumedrol, cytarabine, and cisplatin] or DHAP [cisplatin, cytara-bine, and dexamethasone]) followed by rHuG-CSF resulted in PBPC collections similar to those achieved with high-dose cyclophosphamide and rHuG-CSF. When rHuG-CSF and rHuGM-CSF have been compared, there has been no difference in the quality of the harvests, although patients receiving rHuG-CSF for mobilization after cyclophos-phamide had a shorter interval to harvest but a relative delay in platelet recovery (35,36). Interestingly, a randomized trial in patients with lymphoma at the New England Medical Center showed that rHuG-CSF alone is adequate for mobilization, eliminating the need for high-dose cyclophosphamide (37). Patients who received only rHuG-CSF collected a lower total number of CD34+ cells/kg, but this did not translate into a significantly longer time to engraftment. Clearly, the optimal role of HGFs in the mobilization of lymphoma patients remains undefined.

The use of HGFs in the post-transplant setting has been studied. Three randomized studies have shown benefit for the addition of rHuG-CSF after high-dose chemotherapy and autologous PBPC transplant (40-42). Linch et al. (41) reported that the use of rHuG-CSF beginning on d +1 resulted in a significantly shorter duration of neutropenia with shorter hospitalizations than controls. Lee and colleagues (40) found similar results and concluded that health care costs were reduced by approx 22% in patients receiving rHuG-CSF support post transplant. These cost savings were not seen in a similar study from Spain, although the relatively shorter time to engraftment associated with rHuG-CSF was confirmed (42). HGFs have been shown to shorten the duration of neutropenia in the setting of allogeneic stem cell transplant without affecting rates of acute graft-vs-host-disease (GvHD), 100-d transplant-related mortality, or disease-free survival (43-45). The use of HGFs after autologous and allogeneic hematopoietic stem cell transplant clearly shortens the duration of neutropenia, but whether or not this translates into financial savings remains controversial.

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