Stem Cell Procurement And Mobilization

1. “Anyone can give up, it’s the easiest thing in the world to do. But to hold it together when everyone else would understand if you fell apart, that’s true strength”

2. Stem Cell Procurement And Mobilization Judith Davis, RN Transplant Coordinator Bone Marrow Transplant Program

3. Sources of stem cells • Case Report • Mobilization schedule for autologous donor

4. Stem Cell Sources • Bone Marrow Harvest (BM) • Peripheral Blood Stem Cell (PBSC) • Umbilical Cord Blood

5. Which is best? • Multi-center study recently completed by NMDP comparing PBSC to BM. − # days to engraftment • Amount of Graft Vs. Host disease (GVHD) • Disease recurrence. • Results pending

6. Who Decides? • Decision regarding source: • Related donors = physician decides (at our center last year in adults 100% PBSC) • Unrelated donors = physician requests product but donor can decide to accommodate that request or not.

7. Bone Marrow Harvest • Used to be standard procedure for harvesting stem cells • Requires general anesthesia • Multiple needle punctures into the Posterior iliac crest to extract liquid bone marrow • Amount harvested depends on size of recipient, usually no more than 2% of donor marrow. • Used mostly with pediatric population rarely for adult donors.

8. Umbilical Cord Blood • Advantages: • Rich source of haemopoeitic stem and progenitor cells. • Contains more naive T-cells than bone marrow which allows for a greater mis- match without increased risk of GVHD • No risk to donors • Decreased risk of infection • Easily obtained

9. Umbilical Cord Blood • Disadvantages • Definitive number of cells. Can not request more from donor • Longer time to engraftment. • Often time total cell count (TCN) not enough for adult.

10. Obtaining Cord Blood • Unsuccessful unrelated search. • Search Cord Blood Banks through the NMDP. • Often times request 2 cords to increase TNC. • Usually attempt to find 5/6 HLA match cords. • Cords shipped to our facility once patient is ready for transplant, but before prep regimen is started (if shipped and not used cannot be returned and we incur expense)

12. Peripheral Blood Stem Cells • Most frequent way for obtaining stem cells. • Does not require general anesthesis • Decrease risk to donor • Quicker time to engraftment than BM.

13. Related donors • Initial visit to Bone Marrow Transplant Clinic for testing to determine eligibility. • Starting on Friday donor begins Growth Colony Stimulating Factor (GCSF) 10 mcg/kg sub-q daily. • Saturday and Sunday GCSF injection. • Monday begin PBSC. • Usually collect enough in one day, sometimes requires another collection.

14. Medications Growth Colony Stimulating Factor • Most commonly used agent to mobilize stem cells. • Hormone that stimulates the bone marrow to produce hematopoietic cells. • Side Effects: • Bone pain • Headache • Nausea • Local reaction at injection site

15. Medications Plerixafor • Given with GCSF, binds with protein on the surface of the stem cell disrupting the bond that normally keeps the stem cell anchored in the bone marrow. • .24 mg/kg sub-q at 9:00 PM • Side effects – generally well tolerated. • Diarrhea • nausea • tiredness, • Injection site reactions • Headache • Joint pain • dizziness

16. Transplant Journey

17. Mobilization Schedule Schedule for ____________________ MR#________________. Friday August 28th, 2009 In preparation for your catheter placement you will need to not eat or drink after midnight. Start: levaquin 500 mg tablet daily bactrim DS 1 tablet daily Continue both until admission for transplant. Also start OTC tums 2 tabs 3X/day continue these until apheresis is complete. 9:00 AM Bone Marrow Transplant Clinic – North Hospital 7th floor Neupogen injections Levaquin, Tums, and Bactrim 10:00 AM Registration for Catheter Placment Gateway Building 1st Floor After you finish with regirstration you will be directed to Main Hospital 3rd floor Radiology Department for the catheter placment

18. Saturday August 29th, 2009 10:00 AM Bone Marrow Transplant Clinic North Hospital 7th floor Neupogen injections Levaquin, Tums and Bactrim Sunday August 30th, 2009 10:00 AM Bone Marrow Transplant Clinic Neupogen injections, Levaquin, Tums, Bactrim

19. Monday August 31st, 2009 8:00 AM Bone Marrow Transplant Clinic –North Hospital 7th floor Neupogen injections Levaquin, Tums, Bactrim Following your injection this morning if your counts are adequate you will be directed to the Apheresis Unit, Gateway Building 6th floor to begin the stem cell collection. The labs take approximately 2 hours to result. If your counts are not adequate with neupogen alone we will add **mozobil injection that evening. You will be advised of your lab results and the plan. If you come back that night for mozobil Tuesday morning you will go directly to the apheresis unit at 8:00 AM. Apheresis takes 3-5 hours. Please eat breakfast before the procedure. If you start mozobil these injections will be continued each night along with apheresis the following morning until we have collected an adequate number of cells for transplant. 9:00 PM North Hospital 10th floor Inpatient Bone Marrow Transplant Unit **Mozobil injection

20. Tuesday September 1st, 2009 8:00 AM Gateway 6 Apheresis Unit to begin collecting stem cells Lab work Neupogen injections Tums, Bactrim, and Levaquin 8:00PM North Hospital 10th floor Inpatient Bone Marrow Transplant Unit Mozobil injection This will continue daily until we have collected enough stem cells

21. Goals for collection • Single Transplant 5 X 10(6) stem cells • Tandem Transplant 10 X 10(6) stem cells • This is counted daily at the end of collection which will determine if the patient continues with apheresis the next day.

22. “To get through the hardest journey we need take only one step at a time, but we must keep on stepping”