Ramb - Suplemento 1 2016

uarte

when compared to chemotherapy. Moreover, G-CSF can be

administered at home, resulting in greater convenience for

patients. G-CSF also has a favorable toxicity profile, with

the most frequent adverse events being mild to moderate

musculoskeletal pain (usually controlled with conventio-

nal analgesics), as well as dysuria, fever, headache, nausea

and asymptomatic increase in alkaline phosphatase and

gamma-glutamyl transferase.

48,49

Retrospective and pros-

pective randomized studies suggest that the granulocyte-

-monocyte colony stimulating factor (GM-CSF) is less

effective than G-CSF in mobilizing hematopoietic proge-

nitor cells, either alone or in combination with chemothe-

rapy, with an additional less favorable profile of safety and

tolerability.

48,50

The combination of G-CSF and GM-CSF

did not result in significant clinical benefits in comparison

with isolated G-CSF.

Pegfilgrastim has not been widely

accepted by transplant centers, due to the fact that G-CSF

is easy to use and the accumulated experience using it, as

well as cost-related matters.

Recommendation:G-CSFcanbe usedalone tomobilize

hematopoietic progenitor cells at doses of 10 to 20 µg/kg,

divided into 2 to 4 equal daily applications, or with a

higher dose in the morning.

hemomobilization

The decision between mobilization with G-CSF alone

or a combination of chemotherapy and G-CSF should

take into account factors such as the remission status of

the underlying disease and the probability of poor mobi-

lization.

The combination of G-CSF with chemotherapy

accomplishes the double purpose of promoting both

the mobilization of hematopoietic progenitor cells and the

reduction of antitumor activity, with the latter effect being

demonstrated in cases of lymphoma and also of multiple

myeloma. Moreover, the combination of chemotherapy

and G-CSF has the advantage of resulting in the collection

of a higher number of CD34 + cells and requiring fewer

apheresis procedures, when compared with the isolated

use of G-CSF. In contrast, chemomobilization is associated

with lower predictability to the start of apheresis, as well

as the toxicity and complications from the chemotherapy

regimen used, including febrile neutropenia and need for

hospitalization.

10,42,50,52

Moreover, when the chemomobili-

zation is used as a cycle of part of the induction or rescue

therapy, additional expenses with the chemotherapy itself

and also hospitalization for treatment administration and

management of complications result in higher costs related

to the isolated use of G-CSF.

The combination of G-CSF with high-doses cyclo-

phosphamide was shown to improve the efficiency of col-

lection and increase the correlation between the CD34+

cell counts in peripheral blood and in the final collec-

tion.

8,49

Etoposide, in turn, has shown to be effective in

the treatment of Hodgkin’s and non-Hodgkin’s lymphoma;

thus, its inclusion in the mobilization regimens of patients

with these tumors has the advantage of providing treat-

ment during the mobilization phase

. The combination of

vinorelbine and G-CSF is an excellent alternative in com-

parison with G-CSF alone or in combination with cyclo-

phosphamide, showing a more favorable toxicity profile,

resulting in earlier collection and lower costs. Furthermore,

outpatient administration with one in bolus injection and

better predictability of apheresis improve patient comfort

and simplify the collection procedure, both in multiple

myeloma and in malignant lymphoma.

53-55

The use of several cytotoxic combination regimes

have also been described, including cisplatin, cytosine ara-

binoside, dexamethasone (DHAP); ifosfamide, carbopla-

tin and etoposide (ICE); etoposide, methylprednisolone,

cytarabine and cisplatin (ESHAP); cyclophosphamide,

mitoxantrone, dexamethasone (CMD); dexamethasone,

carmustine, etoposide, cytarabine, melphalan (Dexa-

BEAM); ifosfamide, epirubicin, etoposide (IEE); cyclo-

phosphamide and etoposide with or without cisplatin; and

etoposide and rituximab.

Recommendation: mobilization with chemotherapy

combined with G-CSF (beginning on the day after comple-

tion of chemotherapy) can be performed with cyclophos-

phamide 2 to 3 g/m

or vinorelbine 35 mg/m

in a single

dose

or etoposide 375 mg. The selection of other chemo-

mobilization regimens should preferably take into account

the sensitivity of the underlying malignancy to the different

cytotoxic agents.

obilization with

plerixafor

Plerixafor is a reversible antagonist of chemokine

receptor type 4 (CXCR4), which blocks the interaction

between the receptor and its ligand - the CXC chemo-

kine type 12 - and causes the release of CD34+ cells

from the bone marrow into blood circulation. The effi-

cacy and tolerability of the combination of Plerixafor

and G-CSF in promoting the mobilization of progeni-

tor cells in patients with previous failed mobilization

attempts has been demonstrated in several prospective

trials, with success rates ranging from 60 to 90%, even

among patients aged

≥

60 years.

Furthermore, the combination of Plerixafor and

G-CSF has also been successfully used in patients with

poor mobilization risk factors. Compared to chemomobili-

zation, the combination of Plerixafor and G-CSF provides

nais

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. 2016; 62 (

suppl

. 1):10-15