Clinical and economic comparison of allogeneic peripheral blood progenitor cell and bone marrow transplantation for acute lymphoblastic leukemia in children

Abstract

Summary:There is limited experience in the use of peripheral blood progenitor cells (PBPC) for allogeneic transplantation in children. In the present study we compared engraftment kinetics, incidence of acute and chronic graft-versus-host disease (GVHD) and the outcome and economic costs of allogeneic PBPCT vs BMT in children with ALL in a single institution. All children were transplanted in complete remission (CR) with a similar conditioning regimen and the same GVHD prophylaxis. Patients undergoing PBPCT achieved myeloid and platelet engraftment before patients undergoing BMT (P Ͻ 0.001). Platelet recovery was faster for the PBPCT group (P Ͻ 0.014 for 50 × 10 9 /l and P Ͻ 0.039 for 100 × 10 9 /l). Incidence and severity of acute and chronic GVHD were similar in both groups (acute grade 1-2: 9/13 for PBPCT vs 9/11 for BMT; chronic GVHD: 5/12 for PBPCT vs 3/8 for BMT). Hospital stay was shorter for the PBPCT than for the BMT group (28.8 days vs 42.9 days, respectively) and the PBPCT group used less clinical resources, resulting in overall lower cost for PBPCT (US $14 046) compared to BMT (US $19840). There was no statistically significant difference in DFS between PBPCT and BMT (68.4% vs 50%, respectively). Bone Marrow Transplantation (2000) 26, 269-273.

Allogeneic peripheral blood stem cell transplantation (PBSCT) from HLA-identical sibling donors in children with hematological diseases: a single center pilot study

“…In a previous publication we found a similar incidence and severity of chronic GVHD in a group of patients receiving PBSCT and a historical group given a BMT, 57 as also reported by Li et al 18 The higher rate of chronic GVHD which has been found in some studies associated with this procedure is of concern, but despite differences in the incidence of GVHD, reported EFS and OS after PBSCT are similar in all the previous studies. 18,20,21,57 PBSCT can provide important advantages for the recipient, especially in the early post-transplant period, accelerating bone marrow recovery and decreasing toxic effects of the transplant. Also, G-CSF mobilization and collection can be easily performed and well tolerated in healthy children without major complications, yielding enough numbers of progenitor cells and avoiding the risks and discomfort associated with bone marrow harvesting.…”

“…18,20,21 Similarly, in a study performed recently at our institution, the outcome of a group of pediatric patients which underwent allogeneic BMT for the treatment of ALL and a similar group of patients which received allogeneic PBSCT was compared and significantly faster engraftment was found in the PBSCT group. 57 An inverse correlation between the CD34 + cell dose given, the post-transplant administration of MTX and the kinetics of engraftment has been noted by others. 10 In our series such a correlation was not statistically proven, probably due to the small size of our patient population.…”

“…[58][59][60][61] This effect could constitute an additional advantage of PBSC grafts; however, most clinical studies have failed to find a clear correlation between allo-PBSCT and reduced risk of disease recurrence. [5][6][7][8][9][10][11][12][13][14][15][16] While the reported incidence of acute GVHD with PBSCT is similar or lower compared to BMT, 18,20,21,57 several authors have found an increased rate of chronic GVHD after allo-PBSCT. 8,9,12-14, 21 Levine et al 21 found an increased rate of chronic GVHD of up to 75% at 1 year after PBSCT in pediatric patients.…”

Matched-pair analysis comparing allogeneic PBPCT and BMT from HLA-identical relatives in childhood acute lymphoblastic leukemia

“…Because of this, longer follow-up is necessary to address this controversial issue. However, despite differences in cGVHD incidences there is no reported negative influence on event-free survival in pediatric series, 15,34,35,37 which implies a similar TRM and a similar relapse incidence. One could expect a lower probability of leukemia relapse in PBPCT patients because of a cGVHD-related graft-versus-leukemia effect.…”

Differences between graft product and donor side effects following bone marrow or stem cell donation

“…27 The relative merits of allogeneic PBSC or BM transplantation also encompass economic, psychosocial, and ethical concerns that were not investigated in the present study. Economic analyses have shown the overall costs associated with the two procedures, from the start of donor mobilization or bone marrow harvest to 100 days post transplantation, to be approximately equivalent in Canada 28 and for PBSC transplantation to be cheaper than BM transplantation by approximately 20% in the US 29 and approximately 30% in Spain 30 . In a recent US National Marrow Donor Program survey, 31 donors with experience of both procedures reported that they had found BM donation physically more difficult and more time consuming, and expressed a preference for PBSC donation.…”