Bone Marrow Collection and Processing. Keith M. Sullivan, MD Duke University Medical Center November 15, 2008

Transcription

1 Bone Marrow Collection and Processing Keith M. Sullivan, MD Duke University Medical Center November 15, 2008

2 Bone Marrow : A Lab Overview (discussion points) Sources of Hematopoietic Stem Cells Collection Choices for Stem Cell Transplantation Processing Freezing and Shipping Quality Control

3 Sources of Stem Cells

4 The Hematopoietic Graft

5 Differences in Cell Transplants Allogeneic SCT graft-versus-tumor effect clean stem cells lower relapse rate transplant related mortality 15-30% Autologous SCT less morbidity (no graft-versus-host disease) no need for a donor older age limit transplant related mortality 2-5% Nonmyeloablative Allogeneic SCT less toxicity from the preparative regimen applicable to older patients and patients with comorbidities applicable to patients who have had prior autografts regimen mortality decreased, but SCT mortality still 15-20%

6 Comparing Stem Cell Sources Search Procurement Engraftment Cord Blood 1-2 Weeks 2 Days Slowest Marrow 3-4 Weeks 1 Week In Between PBSC 3-4 Weeks >1 Week Fastest

7 Engraftment after stem-cell infusion (IBMTR Database) Median Days to Granulocyte Count >0.5 x 10 9 /l Platelet Count >20 x 10 9 /l Autologous marrow (no GF *) Autologous marrow (with GF) Autologous PBSC (no GF) Autologous PBSC (with GF) Allogeneic marrow (no GF) Allogeneic PBSC (no GF) *GF, hematopoietic growth factor J. Cell. Mol. Med. 9:41, 2005

8 Collection of Stem Cells

9 Stem Cell Collection Bone marrow multiple aspirations at posterior iliac crest collect 10 ml/kg wash off red cells prior to freezing (deplete if ABO compatible) Peripheral blood mobilize with chemo, G-CSF, or both target at least 2 x 10 6 CD34+ cells/kg many mobilization regimens G-CSF dose at least 10ug/kg/day

10 Bone Marrow Harvest (iliac crests)

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12 Blood Stem Cell Pheresis

13 Complications of Stem Cell Donation (NMDP donors ) Hip or Back Pain Bone Marrow 82% Peripheral Blood --- Throat Pain (intubated) 33% --- Bone Pain 89% Pain Duration (weeks) 3 1 Serious Adverse Events 1.3% 0.6% Miller, et al Biol Blood Marrow Transplant 14:29,2008

14 Targets for Stem Cell Collection BONE MARROW Total Nucleated Cells (TNC) > 2.0 x 10 8 TNC/kg recipient wt. BLOOD CELL CD34 + cells Autologous > 2.0 x 10 6 CD 34/kg HLA ident sibling 2-5 x 10 6 CD34/kg Allogeneic NMA* x 10 6 CD34/kg * nonmyeloablative transplant

15 Choices for Stem Cell Transplant

16 Evolving Choices in SCT Cell Source: Bone Marrow Peripheral Blood Cord Blood Fetal Liver Donor Source: Matched Sibling Mismatched Sibling Matched Unrelated Mismatched Unrelated Autologous Regimen: Ablative Reduced Intensity Non-ablative

17 Human Leukocyte Antigens (HLA) Major Histocompatibility Complex

18 HLA-identical sibling donor selection Chromosome 6 Patient Healthy Siblings

19 Annual Numbers of Blood and Marrow Transplantations, ,000 Allogeneic 35,000 Autologous - Worldwide - Number of Transplants 30,000 25,000 20,000 15,000 10,000 5, Year SUM07_2.ppt

20 Transplants Indications for Hematopoietic Stem Cell Transplantation in North America ,500 5,000 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1, Allogeneic (Total N=7,880) Autologous (Total N=10,840) Multiple NHL AML Hodgkin ALL MDS/MPD CML Aplastic Other Leuk Other Non-Malig My eloma Disease Anemia Cancer Disease SUM07_8.ppt

21 100-day Mortality after Related Donor Transplantation with Reduced Intensity Conditioning, Mortality, % CR1 CR2 Not in Remission In Remission Other 10 0 AML NHL Multiple Myeloma

22 Growth in Cord Blood and Adult Donor Registries National Marrow Donor Program 2008

23 Changes in Cell Sources and Growth in Unrelated Donor Transplant Bone marrow Peripheral blood stem cells Cord blood National Marrow Donor Program 2008

24 Chimera: population of genetically distinct cells

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26 Processing of Stem Cells

27 Cell Recovery (%) after Processing Authors BM Separator NC MNC CFU-GM CD34 + Gonzales-Campos Fenwal CS 3000 Plus Zingsen Fresenius AS Schwella Fresenius AS Hester Fresenius AS Rick Fresenius AS Kanold COBE Spectra Davis COBE Davis COBE Spectra Angelini Fenwal CS 3000 Plus Rhodes Fenwal CS 3000 Plus Rhodes Fenwal CS 3000 Plus Gonzalez-Campos J Hemato Therapy Stem Cell Res 9:83, 2000

28 Bone Marrow Volume & RBC Depletion* Variable Volume (ml) Hct (%) RBCs (ml) RBCs (ml)/kg wt Initial Bone Marrow ( ) (16-43) ( ) ( ) After processing (57-300) (0-9) ( ) ( ) RBCs depletion (%) ( ) Data are reported as mean + SD (range). Cobe Spectra selection Larghero, et al Transfusion 46:398,2006

29 Fenwall CS 3000 Cell Separator (bone marrow bag on right)

30 Continuous Flow Centrifugal Drive

31 Container RBCs and Granulocytes

32 Container of Mononuclear Cells

33 Sponsored by: National Institutes of Health (NIH) through its Division of Allergy, Immunology and Transplantation (DAIT) in the National Institute of Allergy and Infectious Diseases (NIAID)

34 CD-34 Cell Selection Rationale Disease effectors include mature lymphocytes Avoid introducing autoreactive cells collected CD34 expressed on immature hematopoietic cells CD34 selection can efficiently remove large numbers of mature blood cells Purified progenitor cells can reestablish hematopoiesis and ultimately generate new immune cells Drawbacks Nonselectively immunosuppressive Need larger number of CD34+ cells because of losses during processing FDA oversight and manufacturing requirements

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36 Isolex Technology: Two-step Cell Capture 1. Sensitize CD34 + Progenitor/Stem Cells 2. Dynal Bead Labeling. Mouse anti-cd34 Antibody Paramagnetic Bead Stem Cell Sheep anti-mouse Antibody

37 Paramagnetic Cell Selection S Apheresis Containing CD34+ Stem Cells Anti-CD34 MoAb S Paramagnetic bead Anti-Mouse Ig 2 nd antibody Magnet S S S S S S S S S S S Purified CD34+Stem Cells Stem Cell Release S S S

38 Benchmarks for CD34 Isolation (SCOT Study) Post Isolex sep. CD34 + cell count CD34 + recovery CD34 + purity Log T cell depletion T cell content Stem Cell Product target > 2.5 CD34 + x 10 6 cells/kg > 40% > 70% > 3.0% < 30%

39 Freezing and Shipping

40 Cryopreservation of Bone Marrow

41 Berz, et al Am J Hematol 82:463, 2007

42 Shipping Unfrozen Cell Products If > 1 PBSC collection, store first at the collection center at 2-8 o C overnight Ship in container meeting NMDP standards at 2-8 o C in liquid state. Infuse within 72 hours of collection

43 Quality Control

44 Incidence of microbe contamination (735 grafts) Incidence Type of graft Peripheral blood HPCs BM harvest Umbilical cord blood Total Number 21/532 8/177 4/26 33/735 Percent Kamble, et al Transfusion 45:874, 2005

45 Microbial contamination of HPC grafts: clinical relevance* Study author Total # harvest Contaminate harvests Potentially pathogenic Iatrogenic sepsis Webb 2, (3.2) 5 (0.18) 2 (0.07) Schwella (4.4) 1 (0.34) 0 Prince 1, (3.2) 5 (0.3) 0 Attarian 1,263 3 (0.2) 0 0 Jestice ( (1.5) 0 Nasser 1, (0.6) 2 (0.1) 0 Espinosa 1,040 3 (0.2) 0 NA** Padley (2.4) 1 (0.1) 0 Schwella (26.3) 13 (5.4) 0 Rowley (22) 0 0 Lazarus (6.7) 1 (0.5) 1 (0.5) Cohen (7.0) 2 (0.8) 0 Total 10, (3.0) 30 (0.27) 3 (0.27) *Data are reported as number (%). **All contaminants discarded. Kamble, et al Transfusion 45:874,2005

46 Billing Codes for Cell Processing Old Code Title RVU New Code Title RVU HCPCS G-Code Cryopreservation, freezing * Cryopreservation and storage; bone marrow Peripheral blood progenitor cells 0.89 G Thawing and expansion of frozen cells, each aliquot * Transplantation preparation for hematopoietic progenitor cells; thawing of a previously cryopreserved progenitor cell 0.56 G Thawing of a previously cryopreserved progenitor cell harvest with wash 0.24 G Modification, treatment, and processing of bone marrow or blood-derived stem cell specimens for transplantation * Specific cell depletion within a harvest; T-cell depletion 1.57 G Tumor purging 1.42 G Red cell removal 0.94 G Platelet depletion G Plasma volume depletion 0.81 G Cell concentration of plasma mononuclear buffy coat layer 0.94 G0267

47 Which is Better: Blood or Bone Marrow? Peripheral Blood Bone Marrow Donor Collection Convenient, less pain Surgical procedure Cell Content Cell Dose Greater CD34 + cells and total cells Greater number T-cells More GVL? More chronic GVHD Collection varies: patient/recipient size Greater TNC Faster engraftment Better survival CTN Protocol PBSCT vs BMT #0201 enrolling unrelated donors Target 5-10 x 10 6 CD34/kg recipient wt. Target 4 x 10 8 TNC/kg Volume < 20 ml/kg

48 Marrow Transplant: Back to the Future What is the best hematopoietic stem cell source for patients? Can we engineer: cellular contents donor chimerism Can we better safeguard the product

49 Acknowledgments

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51 Duke BMT Represented on Gokyo Ri (~20,000 feet)