Ford Patricia A, Grant Shakira J, Mick Rosemarie, Keck Gina
All authors: Pennsylvania Hospital, University of Pennsylvania Health System.
J Clin Oncol. 2015 May 20;33(15):1674-9. doi: 10.1200/JCO.2014.57.9912. Epub 2015 Apr 13.
Autologous stem-cell transplantation (ASCT) has shown to provide curative benefit in patients with relapsed lymphoma and multiple myeloma (MM), often requiring hematopoietic support until marrow engraftment. Because of Jehovah's Witnesses' (JW) refusal of blood products, treatment challenges arise. This study represents 125 JWs with lymphoma (n = 55), MM (n = 68), or amyloidosis (n = 2), treated with high-dose chemotherapy (HDC) and ASCT without transfusions.
Priming with intravenous iron and erythropoietin occurred to increase hemoglobin (Hb) pretransplantation. Cytokine mobilization of stem-cells was used. Delay to HDC was done to allow Hb and platelets to approach 11 g/dL and 100 × 10(3)/μL, respectively. Patients with MM received a standard dose of melphalan 200 mg/m(2), with dose reduction for severe kidney dysfunction. Patients with lymphoma received carmustine 300 mg/m(2), cyclophosphamide 1,500 mg/m(2) on days 2 through 5 (total 6 g/m(2)), and etoposide 700 mg/m(2) per day on days 2 through 4 (total 2,100 mg/m(2)). Post-transplantation, a combination of granulocyte colony-stimulating factor, erythropoietin, aminocaproic acid, and phytonadione was administered.
There were two major and 15 minor bleeding complications, none occurring at platelets less than 5.0 × 10(3)/μL, with six (4.8%) treatment-related mortalities. The median decrease in Hb was 5.0 g/dL, with median Hb nadir of 7.0 g/dL. The median number of days with platelet count less than 10 × 10(3)/μL was 3, with median platelet nadir of 5.0 × 10(3)/μL. Cardiac complications occurred in 40 patients (32%).
ASCT can safely be performed without transfusion support. A platelet transfusion trigger of ≤ 5 × 10(3)/μL may be appropriate in select patients. Pharmacotherapy and cardiac monitoring are effective in the management of cardiac complications.
自体干细胞移植（ASCT）已显示对复发淋巴瘤和多发性骨髓瘤（MM）患者具有治愈益处，通常需要造血支持直至骨髓植入。由于耶和华见证会（JW）拒绝使用血液制品，治疗面临挑战。本研究纳入了125例患有淋巴瘤（n = 55）、MM（n = 68）或淀粉样变性（n = 2）的耶和华见证会信徒，他们接受了大剂量化疗（HDC）和无输血的ASCT治疗。
在移植前通过静脉注射铁剂和促红细胞生成素进行预处理以提高血红蛋白（Hb）水平。采用细胞因子动员干细胞。延迟进行HDC以使Hb和血小板分别达到11 g/dL和100×10³/μL。MM患者接受标准剂量的美法仑200 mg/m²，严重肾功能不全者剂量减半。淋巴瘤患者接受卡莫司汀300 mg/m²、环磷酰胺在第2至5天为1500 mg/m²（总量6 g/m²）以及依托泊苷在第2至4天每天700 mg/m²（总量2100 mg/m²）。移植后，给予粒细胞集落刺激因子、促红细胞生成素、氨基己酸和维生素K的联合治疗。
发生了2例严重出血并发症和15例轻微出血并发症，血小板计数低于5.0×10³/μL时未发生出血并发症，有6例（4.8%）与治疗相关的死亡。Hb的中位数下降为5.0 g/dL，Hb最低点中位数为7.0 g/dL。血小板计数低于10×10³/μL的天数中位数为3天，血小板最低点中位数为5.0×10³/μL。40例患者（32%）发生心脏并发症。
不给予输血支持也可安全地进行ASCT。对于部分患者，血小板输注阈值≤5×10³/μL可能是合适的。药物治疗和心脏监测对心脏并发症的处理有效。
