CHAPTER 5 Sources and procurement of stem cells

Transcription

1 EBMT2008_1_21:EBMT :10 Pagina 112 * CHAPTER 5 Sources and procurement of stem cells J. Larghero, J. Garcia, E. Gluckman

2 EBMT2008_1_21:EBMT :10 Pagina 113 CHAPTER 5 Stem cell procurement 1. Introduction The source and procurement of haematopoietic stem cells (HSC) has varied and diversified over time. Nowadays, there are three possibilities: bone marrow (BM) HSC, granulocyte-colony stimulating factors (G-CSF) mobilised peripheral blood HSC and cord blood (CB). Each of them seems to give similar clinical results although the use varies according to age of the donor and the recipient, the indication and the preference of the centres and the donors. Usually BM collection is preferred in children, for adults it can be either BM or PBSC, CB depends on the availability of a suitable unit in banks and the absence of an HLA identical donor. 2. Use of different cell sources for HSCT in Europe An EBMT survey on HSC transplantation (HSCT) activity in 2005 reported that 24,168 first HSCT were performed in Europe by 597 centres (1). Among these transplants, 15,278 were autologous and 8,890 allogeneic. Of the 8,890 allo-hsct, 4,702 were provided by an HLA identical sibling donor, 514 by an HLA-mismatched family donor, and 57 by a homozygous (syngeneic) twin. An UD was used in 3617 patients (41%). The main indications were leukaemia (6,107 patients), lymphoproliferative diseases (1,520 patients), solid tumours (130 patients) and nonmalignant diseases (1,048 patients). The number of allo-hsct increased by 20% from 2004 to 2005, whereas numbers of auto-hsct remained stable (1). 3. Choice of stem cell source Traditionally, HSC were harvested from the iliac crests under general anaesthesia. Thereafter, mobilised PBSC have been increasingly used in both auto- and allo-hsct. Mobilisation of HSC in sufficient number in peripheral blood can be achieved by the classical administration of growth factor such as G-CSF (allo-hsct) and/or myelosuppressive chemotherapy (auto-hsct). In the 1990s, unmanipulated CB cells collected and cryopreserved at birth have been used both in related and unrelated HLA matched and mismatched allogeneic transplants in children, and more recently in adults. In 2005, the stem cell source for auto-hsct was from peripheral blood in 98% of the 15,278 transplants and from BM in 2%. In the allogeneic setting, BM was used in 2,331 of 8,890 transplants (21%) and PBSC in 74%, confirming the increasing use of this stem cell source. CB was used in 395 allogeneic HSCT compared to 281 in It has become evident that there are many differences, both quantitative and qualitative, between these cell sources (1). The main differences between cell sources are: HAEMATOPOIETIC STEM CELL TRANSPLANTATION 113

3 EBMT2008_1_21:EBMT :10 Pagina 114 Bone marrow G-CSF mobilised PBSC Cord blood Collection under general anaesthesia Limited number of haematopoietic stem cells Median number of nucleated cells: 2 x 10 8 /kg Median number of CD34+ cells: 2.8 x 10 6 /kg Median number of T-cells: 2.2 x 10 7 /kg Collection easy No requirement for general anaesthesia Side effects of G-CSF High number of cells Median number of nucleated cells: 9 x 10 8 /kg Median number of CD34+ cells: 7 x 10 6 /kg Median number of T-cells: 27 x 10 7 /kg Collection easy and harmless Immediate availability of cryopreserved units and lower risk of transmissible diseases Acceptable partial HLA mismatches Number of cells is the limiting factor Median number of nucleated cells: 0.3 x 10 8 /kg Median number of CD34+ cells: 0.2 x 10 6 /kg Median number of T-cells: 0.4 x 10 7 /kg 4. Donor work-up (2 5) (Tables 1 3) 4.1. Donor risk from the procedure The risks for the healthy donor must be minimised. A careful inquiry before donation must be performed. It is recommended that two separate physicians examine the donor prior to the procedure. Detailed information must be given and signed consent must be obtained from the donor and also from both parents in the case of donors under the age of legal consent. In some European countries, when the donor is <16 years old, the consent must be signed in front of a judge and both the family and the child must be seen by a committee of 3 independent experts. The presence of any risk from general anaesthesia for BM aspiration or from cardiac disease for PBSC collection is an absolute contraindication to the donation. The situation is of course completely different for CB, which represents a harmless and easily accessible source of haematopoietic stem cells without any risk to donors. 114 THE EBMT HANDBOOK 2008 REVISED EDITION

4 EBMT2008_1_21:EBMT :10 Pagina 115 CHAPTER 5 Stem cell procurement Table 1: Potential transmission of donor diseases to recipients Transmission of Donor disease Infectious diseases Viruses HIV / Hepatitis B and C / HTLV-1 / CMV / EBV / Parvovirus B19 / West Nile virus Congenital disorders Bacteria Contaminants(a)/ Brucellosis Parasites Toxoplasmosis / Malaria / Leishmania / Babesia Fungi Prions Enzyme deficiencies Haemoglobinopathies Candida / Aspergillus Creutzfeld-Jakob disease(b) Gaucher s disease Thalassemia / Sickle cell anaemia Acquired disorders Autoimmune diseases Myasthenia gravis / Atopy / Lupus erythematosus / Thyrotoxicosis / Diabetes mellitus type I / Sarcoidosis / Coeliac disease / Autoimmune thrombocytopenia Haematological malignancies Non-haematological malignancies (c) AML / CML / T-cell lymphoma Small-cell lung cancer from renal transplantation / Glioblastoma multiforme from liver transplantation (a) Contamination rates of 1 in 3000 units in platelet concentrates. No information available on stem cell grafts. (b) No known cases in HSCT and blood transfusions. (c) Not reported in HSCT Table 2: Recommendations for donor work-up Test WMDA NMDP (a) JACIE (b) Proposal Medical history Physical examination Yes Infectious (including risk for infections), pregnancy, blood donation history Vaccination, travel, blood transfusion history, questions to identify persons at high risk of trasmitting infectious, inherited, haematological or immunological disease Family history, travel, vaccination, smoking, blood transfusion and donation, infectious, pregnancy, aller-gy, autoimmune, vaccination and tumour history Yes Yes Yes Particular attention to cardiovascular, bleeding and malignant diseases ECG Yes Yes Not specified Yes Chest X-ray Yes Yes Not specified Yes continue HAEMATOPOIETIC STEM CELL TRANSPLANTATION 115

5 EBMT2008_1_21:EBMT :10 Pagina 116 Test WMDA NMDP (a) JACIE (b) Proposal Blood counts Blood group Full blood count and differential w. blood film Yes with antibody screen Complete blood count Not specified Complete blood count, manual differential on blood film ABO group and Rh type ABO Rh type and appropriate red cell compatibility with the recipient ABO group Rh type and appropriate red cell compatibility with the recipient Coagulation Yes No No PT, PTT, fibrinogen screen HLA-typing Yes Yes Yes A, B, C, DRB1, DQB1 Biochemical profile Infectious disease markers (within 30 days prior to collection) Pregnancy test (when indicated) Urea, electrolytes, creatinine, liver function tests, blood sugar Syphilis, HBsAg, HIV Ag + Ab, HB core Ag, HCV, HTLV-1, HSV, CMV, VZV, EBV serology Urea, electrolytes, creatinine, bilirubin, serum protein electrophoresis, Hb S for PBSC donors only HIV 1 and 2, HBV, HCV, HTLV 1 and 2, Treponema pallidum (syphilis), CMV Not specified in detail HIV 1 and 2, HBV, HCV, HTLV 1 and 2, Treponema pallidum and CMV Urea, electrolytes, creatinine, liver function tests (bilirubin, AST, ALT, AP, g-gt), LDH, blood sugar, protein electrophoresis, urine analysis HIV 1 and 2, HBV (HBs Ag, HBsAb, and HBcAb), HCV (HCVAb), HTLV type II, Treponema pallidum, CMV (IgG, IgM), Toxoplasmosis (IgG, IgM) and EBV Yes Yes Yes Gynaecological visit + pregnancy test + physical breast exam Other proposals: - Check for malignant diseases in donors >55 yrs (applies to related HSCT) Æ PSA in males, physical examination, occult blood in stool. BM aspiration if medical history or tests are abnormal. CT-chest scans in case of a long smoking history. - Congenital disorders Æ Testing for congenital disorders of planned recipient within family donors; testing for other congenital disorders of the family. (a) 18th Edition Standards/ September (b) Table 3: Donor selection in case of donors with abnormal findings Family Donors Abnormal finding Absolute contraindications Relative contraindications Specific consideration Infectious HIV HTLV-1 HBV, HCV, malaria within past 3 yrs, parvovirus B19 EBV, CMV, toxoplasmosis, Congenital Thalassaemia major Combined immune deficiency Congenital disease with severely reduced life expectancy Thalassaemia minor Gaucher s disease Targeted CB should be tested for congenital disease of planned recipient Malignancies Any malignancy except in situ cancer Skin cancer removed in toto continue 116 THE EBMT HANDBOOK 2008 REVISED EDITION

6 EBMT2008_1_21:EBMT :10 Pagina 117 CHAPTER 5 Stem cell procurement Family Donors Abnormal finding Absolute contraindications Relative contraindications Specific consideration Pregnancy Unrelated Donors (a) BM donation and G-CSF stimulated or unstimulated apheresis Infectious As for blood donation Parvovirus B19, if known after collection: Gram-positive or Gramnegative bacterial graft infection Congenital As for blood donation EBV, CMV, toxoplasmosis Malignancies Pregnancy Unrelated Cord Blood (b) Infectious Congenital Malignancies Any malignancy except in situ cancer Any donation As for blood donation. Gram-positive or Gramnegative contamination As for blood donation Exclude, if congenital diseases known in family Any, in child Skin cancer removed in toto EBV, CMV, toxoplasmosis (a) Not enough information is available for West Nile virus. Contamination of stem cell graft with epidermal bacteria might be a relative contraindication 4.2. Recipient risk from a particular donor (2) Potentially transmittable diseases from donors include infections, congenital disorders, and acquired diseases such as malignancies or autoimmune diseases. 5. Comparison of BMT and PBSCT (5 12) In 1995, 3 pivotal studies demonstrated the safety and feasibility of using G-CSF mobilised PB allografts (Table 4). Patients experienced prompt engraftment with an incidence of GvHD similar to that of BM recipients (Table 5). In addition, no serious short-term complications of G-CSF mobilised PB harvesting were observed in the donors. Direct comparison of PB and BM in allogeneic sibling donor transplantation has been reported in at least 8 randomised trials. Most of them did not show a benefit in overall HAEMATOPOIETIC STEM CELL TRANSPLANTATION 117

7 EBMT2008_1_21:EBMT :10 Pagina 118 Table 4: Collection protocols for PBSC allografts in 4 randomised trials Study Schmitz Blood 108: 4288, 2006 Couban BBMT 10: 624, 2004 Bensinger NEJM 344: 175, 2001 Blaise JCO 18: 537, 2000 G-CSF dose µg/kg Days G-CSF No of aphereses 10 6 /kg target CD34+ dose 10 6 /kg actual CD34+ dose (1-3) (1.5-68) (1-2) (0.7-32) (1-4) (1-30) (1-3) (1.5-19) 10 6 /kg T- cell dose 300 ( ) 370 ( ) 279 ( ) 356 ( ) Table 5: Neutrophil and platelet recovery and incidence of agvhd and cgvhd after allo-pbsct compared to allo-bmt in different randomised studies Reference Source n Neutrophils (median days) Platelets (median days) agvhd (%) Extensive cgvhd (%) Bensinger BM PBSC p=ns Blaise BM PBSC p=0.03 Schmitz BM PBSC p= p= Table 6: Relapse incidence (RI) and survival after allo-pbsct compared to allo- BMT in different randomised studies Reference Source n RI Survival Bensinger BM PBSC % 14% p= % 66% p= Early status: 72 vs. 75% p=ns - Advanced: 33 vs. 57% p=0.04 Blaise BM PBSC ns 65% 67% p=ns Schmitz BM PBSC ns ns 118 THE EBMT HANDBOOK 2008 REVISED EDITION

8 EBMT2008_1_21:EBMT :10 Pagina 119 CHAPTER 5 Stem cell procurement survival (OS). The incidence of agvhd was the same in all but one of the studies, but an increase (statistically significant or a trend) in the incidence of overall and extensive cgvhd was demonstrated in recipients of PB allografts (Table 6). The magnitude of this observation and its effect on relapse, OS and recipient quality of life is less clear. In unrelated transplant recipients, matched cohort comparisons of unrelated (UD) BMT and PBSCT reported faster haematological recovery among PB recipients with no difference in either acute or chronic GvHD. While results of randomised studies are pending, the use of PB allografts in UD HSCT has varied among transplant centres and countries. Some unrelated Donor Registries have permitted the collection of allografts from PB whereas others have not. Transplant centres may request a PB or a BM graft but the collection centre and wishes of the donor also determine which product is ultimately collected. Because of the absence of definitive data comparing both sources of cells, there is no indication to prefer either source of cells except perhaps in patients with advanced disease where chronic GvH and subsequent GvL might decrease relapse and improve OS or, in a situation where a high number of cells is necessary for engraftment, for example after non-myeloablative conditioning or if TCD is planned for a HLA mismatched transplant. 6. Cord blood collection and banking The first allogeneic CB transplantation (CBT) was successfully performed in 1988 in a child with Fanconi s anaemia; the CB donor was his HLA identical sister. Fifteen years later, this patient is doing well with full donor haematopoietic and lymphoid reconstitution. This first success showed that a single CB unit contained enough HSC to reconstitute definitely the host lympho-haematopoietic compartment, that a CB unit could be collected at birth without any harm to the new-born infant and finally that CB HSC could be cryopreserved and transplanted in a myeloablated host after thawing without losing their repopulating abilities. CB has many theoretical advantages due to the immaturity of newborn cells. HSC from CB are enriched in primitive haematopoietic stem cells, which are able to produce in vivo long-term repopulating SC. The properties of CB cells should compensate for the relatively low number of cells contained in a single CB unit and, through rapid expansion reconstitute myeloablated patients. In spite of the capacity of CB cell expansion, clinical results showed that haematopoietic recovery is delayed after CBT engraftment but improves if a higher number of nucleated and CD34+ cells are infused. In the long term, a higher frequency of reconstitution of early and committed haematopoietic progenitors was observed in children receiving a CBT compared to BMT suggesting that the delay in engraftment may reflect the difficulty HAEMATOPOIETIC STEM CELL TRANSPLANTATION 119

9 EBMT2008_1_21:EBMT :10 Pagina 120 of CB progenitors to reprogram themselves toward differentiation. The second advantage of CBT relates to the immaturity of the immune system at birth. This property should decrease the alloreactive potential of lymphocytes and as a consequence reduce the incidence and severity of GvHD after an HLA matched or mismatched transplant. These properties should lead to less stringent criteria for HLA donor recipient selection (Table 7). Recent studies have shown that the cell dose is the most important factor for donor selection: a minimum cell dose of 3 x 10 7 nucleated cells/kg is required for successful engraftment. More recently the use of two CB units seems to improve the engraftment rate. Table 7: Advantages and disadvantages in the search and identification process of BM and CB unrelated donor Information on A+B+DRB1(DNA) type Median search time Donors identified but not available Rare haplotypes represented (a) Major limiting factors to graft acquisition Ease of arranging date of cell infusion Potential for second HSC graft or DLI Potential - for viral transmission - for congenital diseases Risk to donor Bone marrow 16 56% 3 6 months 30% 2% HLA match Difficult Yes Yes No Yes Cord blood 50 80% <1month < 1% 29% Cell dose Easy No from the same donor No Yes No (a) Data of the ethnic distribution of CB (n=4577) and BM donors registered (n=68487) in the British Bone marrow Registry (Cristina Navarrete, personal communication) 7. Cord blood banking for unrelated CBT In order to organise the development of CB banks, Netcord, an International Foundation promoting high quality cord blood banking, currently includes more than twenty experienced large CB banks in the USA, Europe, Japan and Australia. Netcord has developed a detailed set of standards for CB banking, the third edition of which has been recently released. These include respective national and international regulatory aspects and, with the collaboration of the Foundation for Accreditation of Hemopoietic Cell Therapy (FAHCT) (USA), an international accreditation program was started in 2002, with more than 15 accredited CBBs up to date. Furthermore, a joint allocation system employing most recent Internet technology has been implemented to facilitate the rapid allocation of CB units 120 THE EBMT HANDBOOK 2008 REVISED EDITION

10 EBMT2008_1_21:EBMT :10 Pagina 121 CHAPTER 5 Stem cell procurement according to histocompatibility and number of nucleated cells within an average time of 48 hours. The number of CB transplants from UD has increased dramatically, and more than 5,800 patients have undergone CBT from UD thus far ( Practical aspects of cord blood banking Informed consent CB is a discarded product that, up to some years ago, could be used without permission; however, today it is considered a transplantable product (cells, tissue or pharmaceutical drug according to the regulations in different countries) and informed consent must be obtained for its donation and for carrying out tests on the mother and the CB. Careful questioning about medical history allows the opportunity of excluding donors who have a high risk of transmitting any infectious or genetic diseases. The families must be informed about the genetic and infectious tests performed Collection techniques Two techniques are used to collect CB: - One is collection in the delivery room while the placenta is still in utero, and - The other is collection of the CB in an adjacent room after the delivery. In the first instance, the collection can be done in the delivery room by an obstetrician or a midwife. The advantage of this procedure is that the volume of cells collected is usually higher if the cord is clamped early and the collection is begun immediately; however, this can disrupt the normal process of delivery and is not always feasible. The collection of CB after delivery is easier and it can be performed by designated personnel; however, fewer cells may be collected and there may be an increase in the risk of bacterial contamination or clotting Infectious disease testing Tests for syphilis and for viral infections (including those for HIV, HBV and HCV, and CMV) are performed on the mother s blood. In some countries, the mother is also tested for HTLV-I/II and toxoplasmosis or other transmissible diseases according to local prevalence. Most often, virology tests are not performed immediately; rather, a separate frozen aliquot is kept so that these tests can be performed before a transplant procedure. CB should be quarantined until a confirmatory test is performed on the mother 3 6 months after delivery. This should decrease the risk of virus transmission considerably. These risk estimates may be higher in CB donors because, unlike regular whole blood HAEMATOPOIETIC STEM CELL TRANSPLANTATION 121

11 EBMT2008_1_21:EBMT :10 Pagina 122 donors, CB donors are recruited only once. Bacterial infection is also a major issue, but it seems that the incidence of bacterial contamination diminishes with the expertise of the staff in charge of the collection. In all cases, a bacterial culture for anaerobic and aerobic bacteria must be performed Genetic disease testing The decision to perform tests for genetic diseases should be directed by the family medical history, its ethnic background and the follow-up of the donor. Tests on cord blood are expensive and there is no real consensus on the type and number of tests that should be performed. There are also some concerns about notifying the family of the test results HLA typing HLA typing is performed on an aliquot of CB. In collaboration with the Eurobank project, Eurocord/Netcord collects DNA from the donor and recipient to perform molecular typing for HLA-C, -DQB1, -DPB1, some HLA-A and -B antigens, and other markers. Some banks type routinely the mother for HLA in order to have information on the haplotype and to control the accuracy of CB typing Cell processing Because of the small volume of CB collected, which usually ranges from ml, there is some concern that any attempt at cell manipulation and concentration may result in a considerable cell loss that could impair engraftment. Many banks, specially the larger ones, use advanced GMP procedures for CB volume reduction, freezing and storage, which have minimised cell loss. The thawing technique is well established and aims at removing red residual cells and cryoprotectants. Evaluation of HSC content is very important. Several studies have shown that the number of nucleated cells infused correlates with engraftment. A correlation has also been demonstrated between placental weight, time of clamping, speed of processing, volume collected, and progenitor cell content. Quantification of the cellular content of cord blood is not always easy. Most studies refer to nucleated or mononuclear cells infused per kilogram of body weight before and after thawing of cells. Enumeration of CD34+ cells by flow cytometric analysis is performed routinely by most laboratories, but these results are not always comparable. Others count the number of CFU-GM in clonogenic assays. There is a large variation of methodology among laboratories, which explains why quantification has been a problem. In the European study, a correlation was found between the number of nucleated cells infused and engraftment, but this correlation was not found when the number of CD34+ cells and CFU-GM were evaluated. 122 THE EBMT HANDBOOK 2008 REVISED EDITION

12 EBMT2008_1_21:EBMT :10 Pagina 123 CHAPTER 5 Stem cell procurement Ethical and legal aspects CB can be collected for infusion into an unrelated or a related recipient and, more hypothetically, for autologous use. For unrelated CBT, the mother must be aware that the donation is anonymous and free, and that there will be no guarantee that it will be possible to retrieve the cord blood if it is needed later for family or autologous use. 8. Comparison of UD CBT and UD BMT 8.1. Children with acute leukaemia In 2001, a comparison between UD CBT and UD BMT was carried out by Eurocord and EBMT in 515 children with AL, transplanted either with an UD CBT (n=99) or an UD BMT (n=416) (13). Recipients of CB were younger and had more pre-transplant adverse disease factors. Most of the BM donors were HLA matched or had a maximum of 1 HLA difference while most of the CB donors had 2 to 3 HLA differences. The median number of nucleated cells infused was 4 x 10 8 /kg in UD BMT and 0.38 x 10 8 /kg in UD CBT. In unrelated BMT, 262 children received an unmanipulated BMT and 180 a TCD BMT using Campath-1M as the most frequent mean of TCD. The median followup was 29 months. During the first 100 days after HSCT, while unmanipulated and TCD BMT did not differ in haematopoietic recovery and TRM, the main findings that emerged from these adjusted comparisons were the poor results of CBT in relation to neutrophil and platelet recovery and early TRM. In contrast CBT and TCD BMT gave less agvhd than the unmanipulated BMT group. Finally the unmanipulated BMT and CBT groups had less leukaemic relapse than the T-cell depleted group. In the long term, the unmanipulated BMT group had more cgvhd than the TCD BMT and the CBT groups. Furthermore, while the outcome of the 3 groups were comparable in terms of long term relapse, mortality after day 100 was increased in the TCD BMT group, mainly because of the occurrence during the first 100 days after BMT of early relapse, GvHD and lack of engraftment. In summary, the main differences in adjusted outcomes between the three unrelated transplant groups appeared in the first 100 days post transplant but without giving an advantage to any group. Indeed, the delay of engraftment and increased TRM observed after UD CBT must be balanced against the higher risk of agvhd after unmanipulated UD BMT and to the higher risk of relapse after TCD. In contrast, after day 100 posttransplant, the 3 groups achieved similar results in terms of relapse but cgvhd occurred more frequently with unmanipulated UD BMT and death with TCD UD BMT. Recently, these results have been reinforced by the report of CIBMTR and New York cord blood bank, comparing the outcomes of 503 children with acute leukaemia transplanted with UD mismatched CB with 282 UD BM recipients (of which 116 were HAEMATOPOIETIC STEM CELL TRANSPLANTATION 123

13 EBMT2008_1_21:EBMT :10 Pagina 124 8/8 antigen HLA matched) (14). While they showed that TRM was increased in children receiving a low CB cell dose (less than 3 x 10 7 /kg) and one HLA-mismatched CB, or two HLA-mismatched CBT independently of cell dose, this study also demonstrated that leukaemia-free survival (LFS) was not statistically different from one or two HLA-mismatched CBT compared with a HLA-allele-matched UD BMT. These results justify the simultaneous search of UD CB donors and UD BM in children with AL. The decision to perform CBT will be based on the cell content of the graft the number of HLA disparities and the urgency of the transplant Adults with acute leukaemia (14, 15) In 2004, two groups reported the transplant outcomes of adults with leukaemia transplanted with either UD CB or UD BM (15, 16). In both studies, CB recipients were younger and had more advanced disease at the time of transplantation. In the study comparing CB with HLA-matched UD BM, multivariate analysis showed lower acute GvHD grade II after CB transplantation but delayed neutrophil recovery. The 2-yrs cumulative incidence of cgvhd, TRM, leukaemia relapse, and the 2-yrs probability of OS and LFS were not significantly different. The second report compared transplant outcomes between patients receiving UD CB (one or two mismatch) with patients grafted with UD BM (HLA-matched or one mismatch). UD CB and mismatched BM transplantation were associated with a higher risk of cgvhd and agvhd, respectively. Interestingly, the incidence of TRM, treatment failure, and overall mortality were similar in patients who received mismatched BM or mismatched CB transplants. These data suggest that, despite increased HLA disparity, CB from UD offers comparable results to matched UD BM in adults with AL leading to the conclusion that the donor search process for BM and CB from UD should be started simultaneously in adults especially in patients with AL where the time factor is very important. 9. Algorithm for donor search High resolution HLA typing of patient and family No donor: Alternative donor search BM donor registries HLA identical A, B, C, DR, DQ 10 /10 or 9/10 Transplant Cord blood banks Cell dose >2 x 10 8 /kg 1 or 2 HLA mismatches A, B, DR Transplant 124 THE EBMT HANDBOOK 2008 REVISED EDITION

14 EBMT2008_1_21:EBMT :10 Pagina 125 CHAPTER 5 Stem cell procurement 10. HSC and regenerative medicine The need for an alternative source of pluripotent stem cells for tissue engineering that does not require the use of human embryos or therapeutic cloning has resulted in increased interest in the use of adult stem cells, although they are likely more limited in potential. However, stem cells (haematopoietic, mesenchymal, endothelial, etc.) isolated from either BM or CB represent an ethically uncontroversial source of cells for clinical applications. The experimental and first clinical data reported with such stem cells herald new applications in cellular therapy and tissue regeneration, ranging from neurodegenerative, muscular, brain or bone diseases to myocardial infarction, liver cirrhosis, or vascular disorders. References 1. Gratwohl A, Baldomero H, Frauendorfer K, et al. Results of the EBMT activity survey 2005 on haematopoietic stem cell transplantation: Focus on increasing use of unrelated donors. Bone Marrow Transplant 2007; 39: Niederwieser D, Gentilini C, Hegenbart U, et al. Transmission of donor illness by stem cell transplantation: Should screening be different in older donors? Bone Marrow Transplant 2004; 34: Cleaver SA, Warren P, Kern M, et al. Donor work-up and transport of bone marrowrecommendations and requirements for a standardized practice throughout the world from the Donor Registries and Quality Assurance Working Groups of the World Marrow Donor Association (WMDA). Bone Marrow Transplant 1997; 20: Favre G, Beksac M, Bacigalupo A, et al. for the European Group for Blood and Marrow Transplantation (EBMT). Differences between graft product and donor side effects following bone marrow or stem cell donation. Bone Marrow Transplant 2003; 32: Couban S, Barnett M. The source of cells for allografting. Biol Blood Marrow Transplant 2003; 9: Champlin RE, Schmitz N, Horowitz MM, et al. Blood stem cells compared with bone marrow as a source of hematopoietic cells for allogeneic transplantation. Blood 2000; 95: Bensinger WI, Martin PJ, Storer B, et al. Transplantation of bone marrow as compared with peripheral blood from HLA identical relatives in patients with hematologic cancers. N Engl J Med 2001; 344: Blaise D, Kuentz M, Fournier C, et al. Randomized trial of bone marrow versus lenogastrimprimed blood cell allogeneic transplantation in patients with early stage leukemia: A report from the Société Française de Greffe de Moelle. J Clin Oncol 2000; 18: Gorin NC, Labopin M, Rocha V, et al. for the Acute Leukemia Working Party (ALWP) of the European Cooperative group for Blood and Marrow Transplantation (EBMT). Marrow versus peripheral blood for geno-identical allogeneic stem cell transplantation in acute myelocytic leukemia: Influence of dose and stem cell source shows better outcome with rich marrow. Blood 2003; 102: HAEMATOPOIETIC STEM CELL TRANSPLANTATION 125

15 EBMT2008_1_21:EBMT :10 Pagina Ringden O, Remberger M, Runde V. Peripheral blood stem cell transplantation from unrelated donors: A comparison with marrow transplantation. Blood 1999; 94: Remberger M, Ringden O, Blau IW, et al. No difference in graft versus host disease, relapse and survival comparing peripheral blood stem cells to bone marrow using unrelated donors. Blood 2001; 98: Ringden O, Labopin M, Bacigalupo A, et al. Transplantation of peripheral blood stem cells as compared with bone marrow from HLA identical siblings in adult patients with acute myeloid leukemia and acute lymphoblastic leukemia. J Clin Oncol 2002; 20: Rocha V, Cornish J, Sievers EL, et al. Comparison of outcome of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood 2001; 97: Eapen M, Rubinstein P, Zhang MJ, et al. Outcomes of transplantation of unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: A comparison study. Lancet 2007; 369: Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of cord blood or bone marrow from unrelated donors in adults with leukaemia. N Engl J Med 2004; 351: Rocha V, Labopin M, Sanz G, et al. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukaemia. N Engl J Med 2004; 351: Mutiple Choice Questionnaire To find the correct answer, go to 1. Compared to allogeneic bone marrow cells, peripheral blood HSC give: a) Less GvHD b) Accelerated neutrophil recovery c) Higher relapse rate d) Better overall survival The best criterion for cord blood search is: a) Number of nucleated cell dose >3 x 10 7 /kg b) ABO compatibility c) HLA identity determined by allele typing d) Donor sex THE EBMT HANDBOOK 2008 REVISED EDITION

16 EBMT2008_1_21:EBMT :10 Pagina 127 CHAPTER 5 Stem cell procurement 3. Quality of unrelated matched HSCT collection relies on which of the following criteria? a) Total volume b) Number of CD34 cells/kg c) Number of viable cells d) Number of CFU-GM Which of the following viral infections in the unrelated donor does contraindicate the use of the donor? a) HIV b) CMV c) Hepatitis B d) Hepatitis C The main complication of collection of PBSC is: a) Hypotension b) Bleeding c) Flu like symptoms due to G-CSF d) Infection HAEMATOPOIETIC STEM CELL TRANSPLANTATION 127