Safety and survival outcomes for bloodless transplantation in patients with myeloma

Abstract

High‐dose therapy (HDT) and autologous stem cell transplantation (ASCT) are established components in the treatment of multiple myeloma; however, undergoing transplantation usually requires hematopoietic support, which poses a challenge among patients who are unwilling to receive blood products. Most transplant centers decline HDT/ASCT to these patients because of safety concerns. Here, the authors’ institutional data on safety, engraftment parameters, and survival outcomes after bloodless ASCT (BL‐ASCT) are examined among patients with myeloma. This retrospective case‐control study included patients who underwent BL‐ASCT and Transfusion‐supported ASCT (TS‐ASCT) at Emory University Hospital between August 2006 and August 2016. In total, 24 patients who underwent BL‐ASCT and 70 who underwent TS‐ASCT were included. The median time for neutrophil engraftment, platelet engraftment and the median length of hospital stay all were equivalent for both groups. There were no transplant‐related cardiovascular complications or mortality in either the BL‐ASCT group or the TS‐ASCT group. The median progression‐free survival was 36 months and 44 months in the BL‐ASCT and TS‐ASCT groups, respectively (P = .277), and the median OS was not reached in either group at a median follow‐up of 59 months after ASCT (P = .627). There was no transplant‐related mortality at the 100‐day or 1‐year mark in either group. BL‐ASCT is safe and feasible; transplant‐related mortality, cardiovascular and hematologic complications are similar to those associated with TS‐ASCT. Furthermore, BL‐ASCT can yield similar engraftment and survival parameters comparable to those observed with TS‐ASCT.

Safety of bloodless autologous stem cell transplantation in Jehovah's Witness patients

“…The second patient with higher grade bleeding had multiple medical issues requiring ICU transfer. Joseph et al reported no bleeding-associated mortality in their series of 24 BL-ASCT cases, while Ballen et al reports two cases of high-grade bleeding in 26 BL-ASCT patients [7,14]. Based on our data, bleeding risk appears to be clinically acceptable to perform BL-ASCT transplants.…”

“…This study supports the concept that BL-ASCT can be performed safely without significantly increased risk of TRM. In our study, there were only 2 cases of TRM out of 70 transplant cases with overall BL-ASCT TRM at 2.9%, which is <8% TRM in bloodless transplants reported by Ballen et al and comparable with 2-4% TRM in TS-ASCT [2,7,14,15]. Joseph et al reported the lowest 0% TRM in BL-ASCT for multiple myeloma [7].…”

“…It is important to point out that at our institution as well as in all published BL-ASCT protocols, aminocaproic acid was administered to patients undergoing BL-ASCT when the platelet level decreased below 10 × 10 9 /L. Platelet threshold for the initiation of aminocaproic acid as well as aminocaproic acid dose vary between institutions [7,8,10,13,14]. There are no studies comparing the incidence and severity of bleeding with or without aminocaproic acid in the setting of BL-ASCT.…”

“…Most institutions recommend red cell transfusion for hemoglobin levels < 7 g/dL, and platelet transfusion for platelet counts < 10 × 10 9 /L. On average, an ASCT recipient receives 1-2 units of PRBCs and 2 units of platelet transfusions in the posttransplant course [7,8]. Platelet and red cell posttransplant transfusion requirement may depend on institutional protocol, pretransplant hemoglobin and platelet counts [9,10].…”

“…This may be due to perceived risks of increased risk of adverse events, such as bleeding and cardiovascular complications, and/or due to the lack of experience with bloodless transplants. Nevertheless, there is now a growing body of evidence that with appropriate supportive care, bloodless autologous stem cell transplants (BL-ASCT) can be as safe and effective as ASCT with transfusion support (TS-ASCT) [7,8,13,14]. In this study we describe our center's experience with 70 BL-ASCT cases with regards to their engraftment outcomes, complications, mortality, and survival data.…”