Transplant conditioning regimens

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Autologous (auto) stem cell transplant

BEAC

BEAC: BiCNU, Etoposide, Ara-C, Cyclophosphamide

Regimen

Autologous blood stem cells are infused on day 0.

• Carmustine (BiCNU) 300 mg/m2 IV on day -7
• Etoposide (Vepesid) 800 mg/m2 IV on days -6 to -3
• Cytarabine (Cytosar) 800 mg/m2 IV on days -6 to -3
• Cyclophosphamide (Cytoxan) 35 mg/kg IV on days -6 to -3

Supportive medications:

• Filgrastim (Neupogen) 5 mcg/kg SC daily starting on day +1, continued until there are 3 consecutive days with ANC ≥1000
• Prophylaxis against opportunistic infections and management of febrile neutropenia per "active protocols"

References

1. Jo JC, Kang BW, Jang G, Sym SJ, Lee SS, Koo JE, Kim JW, Kim S, Huh J, Suh C. BEAC or BEAM high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: comparative analysis of efficacy and toxicity. Ann Hematol. 2008 Jan;87(1):43-8. Epub 2007 Aug 21. link to original article contains protocol PubMed

BEAM

BEAM: BiCNU, Etoposide, Ara-C, Melphalan

Regimen #1, Jo, et al. 2008

Autologous blood stem cells are infused on day 0.

• Carmustine (BiCNU) 300 mg/m2 IV on day -6
• Etoposide (Vepesid) 200 mg/m2 IV on days -5 to -2
• Cytarabine (Cytosar) 400 mg/m2 IV on days -5 to -2
• Melphalan (Alkeran) 140 mg/m2 IV on day -1

Supportive medications:

• Filgrastim (Neupogen) 5 mcg/kg SC daily starting on day +1, continued until there are 3 consecutive days with ANC ≥1000
• Prophylaxis against opportunistic infections and management of febrile neutropenia per "active protocols"

Regimen #2, Stewart, et al. 2006

Autologous blood stem cells are infused on day 0.

• Carmustine (BiCNU) 300 mg/m2 IV on day -6
• Etoposide (Vepesid) 100 mg/m2 IV Q12H on days -5 to -2 (8 total doses)
• Cytarabine (Cytosar) 200 mg/m2 IV Q12H on days -5 to -2 (8 total doses)
• Melphalan (Alkeran) 140 mg/m2 IV on day -1

Supportive medications:

• Patients <70 kg: Filgrastim (Neupogen) 300 mcg SC daily starting on day +7 after stem cell transplant
• Patients >70 kg (reference did not clarify which dosage to use for patients who are exactly 70 kg): Filgrastim (Neupogen) 480 mcg SC daily starting on day +7 after stem cell transplant
• Trimethoprim/Sulfamethoxazole (Bactrim DS) (160/800 mg) PO BID on Monday and Thursdays, until 6 months after BEAM

While ANC <500

• Ciprofloxacin (Cipro) 500 mg PO BID
• Fluconazole (Diflucan) 100 mg PO daily or mycostatin 500,000 units swish & swallow QID
• Acyclovir (Zovirax) 400 mg PO TID

Regimen #3, Josting, et al. 2005

Paper did not specify which day peripheral blood stem cells were administered.

• Carmustine (BiCNU) 300 mg/m2 IV on day 1
• Etoposide (Vepesid) 150 mg/m2 IV Q12H on days 2-5 (8 total doses)
• Cytarabine (Cytosar) 200 mg/m2 IV Q12H on days 2-5 (8 total doses)
• Melphalan (Alkeran) 140 mg/m2 IV on day 1

Regimen #4, Gisselbrecht, et al. 2010

Autologous blood stem cells are infused on day 0, at least 24 hours after completion of BEAM.

• Carmustine (BiCNU) 300 mg/m2 IV on day -6
• Etoposide (Vepesid) 200 mg/m2 IV on days -5 to -2
• Cytarabine (Cytosar) 200 mg/m2 IV on days -5 to -2
• Melphalan (Alkeran) 140 mg/m2 IV on day -1

References

1. Josting A, Sieniawski M, Glossmann JP, Staak O, Nogova L, Peters N, Mapara M, Dörken B, Ko Y, Metzner B, Kisro J, Diehl V, Engert A. High-dose sequential chemotherapy followed by autologous stem cell transplantation in relapsed and refractory aggressive non-Hodgkin's lymphoma: results of a multicenter phase II study. Ann Oncol. 2005 Aug;16(8):1359-65. Epub 2005 Jun 6. link to original article contains protocol PubMed
2. Stewart DA, Bahlis N, Valentine K, Balogh A, Savoie L, Morris DG, Jones A, Brown C, Russell JA. Upfront double high-dose chemotherapy with DICEP followed by BEAM and autologous stem cell transplantation for poor-prognosis aggressive non-Hodgkin lymphoma. Blood. 2006 Jun 15;107(12):4623-7. Epub 2006 Feb 7. link to original article contains protocol PubMed content property of HemOnc.org
3. Jo JC, Kang BW, Jang G, Sym SJ, Lee SS, Koo JE, Kim JW, Kim S, Huh J, Suh C. BEAC or BEAM high-dose chemotherapy followed by autologous stem cell transplantation in non-Hodgkin's lymphoma patients: comparative analysis of efficacy and toxicity. Ann Hematol. 2008 Jan;87(1):43-8. Epub 2007 Aug 21. link to original article contains protocol PubMed
4. Gisselbrecht C, Glass B, Mounier N, Singh Gill D, Linch DC, Trneny M, Bosly A, Ketterer N, Shpilberg O, Hagberg H, Ma D, Brière J, Moskowitz CH, Schmitz N. Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin Oncol. 2010 Sep 20;28(27):4184-90. doi: 10.1200/JCO.2010.28.1618. Epub 2010 Jul 26. Erratum in: J Clin Oncol. 2012 May 20;30(15):1896. link to original article contains verified protocol PubMed

C-VAMP -> high-dose Melphalan (Alkeran)

C-VAMP: Cyclophosphamide, Vincristine, Adriamycin, MethylPrednisolone

Regimen - multiple myeloma high-dose therapy

Induction therapy

• Doxorubicin (Adriamycin) 9 mg/m2/day IV continuous infusion over 4 days (total dose per cycle: 36 mg/m2) on days 1-4
• Vincristine (Oncovin) 0.4 mg IV once daily on days 1-4 (total dose per cycle: 1.6 mg)
• Methylprednisolone (Solumedrol) 1000 mg/m2 (maximum dose per cycle of 1500 mg) PO/IV once daily on days 1-5
• Cyclophosphamide (Cytoxan) 500 mg IV once daily on days 1, 8, 15
  • Cyclophosphamide was omitted in patients with a serum creatinine >3.4 mg/dL

21-day cycles, given until maximal response was achieved. A minimum of 3 cycles given before stem cell harvest.

• Stem cell mobilization was performed with administration of Cyclophosphamide (Cytoxan) 2000-4000 mg/m2 IV with hydration and G-CSF on days 5-12

Melphalan (Alkeran) & transplant

• Melphalan (Alkeran) 200 mg/m2 IV (no additional details given)
• Peripheral blood stem cells infused on day 0, 24 hours after melphalan
• Methylprednisolone (Solumedrol) 1500 mg IV once daily on days 0-3

An alternative to the above melphalan option was:

• Bone marrow autograft
• Total body irradiation (TBI)
• Melphalan (Alkeran) 140 mg/m2 IV (no additional details given)
• Methylprednisolone (Solumedrol) 1500 mg IV once daily on days 0-3

Interferon alfa maintenance therapy

• Interferon alfa-2a (Roferon-A) 3 million units SC three times per week

References

1. Child JA, Morgan GJ, Davies FE, Owen RG, Bell SE, Hawkins K, Brown J, Drayson MT, Selby PJ; Medical Research Council Adult Leukaemia Working Party. High-dose chemotherapy with hematopoietic stem-cell rescue for multiple myeloma. N Engl J Med. 2003 May 8;348(19):1875-83. link to original article contains verified protocol PubMed

Cyclophosphamide (Cytoxan), Etoposide (Vepesid), TBI

Regimen

Autologous hematopoetic stem cell transplant on day 0.

• Cyclophosphamide (Cytoxan) 100 mg/kg IV over 1 to 2 hours once on day -2
• Etoposide (Vepesid) 60 mg/kg IV over 4 hours once on day -4
• Total body irradiation (TBI) with 150 cGy fractions given twice per day (fractions are at least 5 hours apart) x 8 fractions (total dose: 1200 cGy) over 4 days on days -8 to -5, with lung shielding for the final 600 Gy
  • Note: Table 1 of Stiff, et al. 1998 lists the dosage of each fraction as being 120 cGy, in contrast to the body text under "treatment regimen" saying each fraction is 150 cGy. It is believed that the 150 cGy dose is correct since 8 fractions of this results in the correct total dose of 1200 cGy.

Supportive medications:

• Diphenhydramine (Benadryl) 25 mg (route not specified) once 2 hours before etoposide to prevent allergic reaction
• Hydrocortisone (Cortef) 100 mg (route not specified) once 2 hours before etoposide to prevent allergic reaction
• "Continuous bladder irrigation and vigorous hydration were used" to protect against hemorrhagic cystitis

References

1. Stiff PJ, Dahlberg S, Forman SJ, McCall AR, Horning SJ, Nademanee AP, Blume KG, LeBlanc M, Fisher RI. Autologous bone marrow transplantation for patients with relapsed or refractory diffuse aggressive non-Hodgkin's lymphoma: value of augmented preparative regimens--a Southwest Oncology Group trial. J Clin Oncol. 1998 Jan;16(1):48-55. link to original article contains verified protocol PubMed

High-dose Melphalan (Alkeran)

Regimen - immunoglobulin light-chain (AL) amyloidosis

Eligibility criteria: Biopsy-proven amyloid disease and ≥1 major organ involved, evidence of plasma cell dyscrasia, no heart failure or arrhythmia that cannot be medically managed, cardiac ejection fraction ≥40%, no pleural effusions, supine systolic blood pressure ≥90 mmHg, O2 saturation ≥95% on room air, lung diffusing capacity ≥50% predicted, SWOG performance status ≤2 unless due to neuropathy.

• Patients who fulfilled all of these criteria--≤65 years old, cardiac ejection fraction ≥45%, and ≥2.5 x 10⁶ CD34+ cells/kg collected--received Melphalan (Alkeran) 200 mg/m2 total dose IV divided over two consecutive days
• Patients with at least one of these criteria-->65 years old, cardiac ejection fraction 40-44%, or with 2.0-2.5 x 10⁶ CD34+ cells/kg collected received Melphalan (Alkeran) 140 mg/m2 total dose IV divided over two consecutive days
• Autologous stem cell infusion occurs 24-72 hours after the last dose of melphalan

References

1. Skinner M, Sanchorawala V, Seldin DC, Dember LM, Falk RH, Berk JL, Anderson JJ, O'Hara C, Finn KT, Libbey CA, Wiesman J, Quillen K, Swan N, Wright DG. High-dose melphalan and autologous stem-cell transplantation in patients with AL amyloidosis: an 8-year study. Ann Intern Med. 2004 Jan 20;140(2):85-93. link to original article contains verified protocol PubMed

TAM6

Regimen

• Total body irradiation (TBI) with a total dose of 10 Gy over 3 days using twice per day fractions
• Cytarabine (Cytosar) 1500 mg/m2 IV Q12H x 2 days (total of 4 total doses)
• Melphalan (Alkeran) 140 mg/m2 IV

Peripheral stem cells are infused on day 0

Supportive medications: "Antimicrobial prophylaxis and use of G-CSF or erythropoietin were permitted according to physician decision."

References

1. Delarue R, Haioun C, Ribrag V, Brice P, Delmer A, Tilly H, Salles G, Van Hoof A, Casasnovas O, Brousse N, Lefrere F, Hermine O; for the Groupe d'Etude des Lymphomes de l'Adulte (GELA). CHOP and DHAP plus rituximab followed by autologous stem cell transplantation in mantle cell lymphoma: a phase 2 study from the Groupe d'Etude des Lymphomes de l'Adulte. Blood. 2013 Jan 3;121(1):48-53. Epub 2012 Jun 20. link to original article contains verified protocol PubMed

VMCP & BVAP -> high-dose Melphalan (Alkeran)

VMCP: Vincristine, Melphalan, Cyclophosphamide, Prednisone
BVAP: BiCNU, Vincristine, Adriamycin, Prednisone

Regimen - multiple myeloma high-dose therapy

VMCP induction therapy

• Vincristine (Oncovin) 1 mg IV once on day 1
• Melphalan (Alkeran) 5 mg/m2 PO once daily on days 1-4
• Cyclophosphamide (Cytoxan) 110 mg/m2 PO once daily on days 1-4
• Prednisone (Sterapred) 60 mg/m2 PO once daily on days 1-4

21-day cycles x 2-3 cycles, given in an alternating fashion with BVAP

BVAP induction therapy

• Vincristine (Oncovin) 1 mg IV once on day 1
• Carmustine (BiCNU) 30 mg/m2 IV once on day 1
• Doxorubicin (Adriamycin) 30 mg/m2 IV once on day 1
• Prednisone (Sterapred) 60 mg/m2 PO once daily on days 1-4

21-day cycles x 2-3 cycles, given in an alternating fashion with VMCP

VMCP and BVAP are given in an alternating fashion x a total of 4-6 cycles; patients with a WHO performance status <3, creatinine <1.7 mg/dL (150 μmol/L), and bone marrow (collected after cycle 4) with greater than 200 million nucleated cells/kg would proceed to melphalan, total body irradiation (TBI), and transplant:

Melphalan (Alkeran), TBI, and transplant

• Melphalan (Alkeran) 140 mg/m2 IV (no other details given about its administration)
• Total body irradiation (TBI) with a total dose of 8 Gy given over 4 days in 4 fractions, without lung shielding
• Autologous hematopoietic stem cell transplant after melphalan and TBI
• Interferon alfa treatment started after transplant when ANC >1500/mm3 and platelets >75,000/mm3

References

1. Attal M, Harousseau JL, Stoppa AM, Sotto JJ, Fuzibet JG, Rossi JF, Casassus P, Maisonneuve H, Facon T, Ifrah N, Payen C, Bataille R. A prospective, randomized trial of autologous bone marrow transplantation and chemotherapy in multiple myeloma. Intergroupe Français du Myélome. N Engl J Med. 1996 Jul 11;335(2):91-7. link to original article contains verified protocol PubMed

Allogeneic (allo) stem cell transplant

BEAM

BEAM: BiCNU, Etoposide, Ara-C, Melphalan

Regimen

Day 0 is the day of transplantation.

• Carmustine (BiCNU) 300 mg/m2 IV on day -6
• Etoposide (Vepesid) 200 mg/m2 IV BID on days -5 to -2
• Cytarabine (Cytosar) 200 mg/m2 IV BID on days -5 to -2
• Melphalan (Alkeran) 140 mg/m2 IV on day -1

Supportive medications:

• Filgrastim (Neupogen) 5 mcg/kg SC daily, starting on day +7 and continued until engraftment
• GVHD prophylaxis with tacrolimus and methotrexate
• "Prophylactic antibiotics"

References

1. Przepiorka D, van Besien K, Khouri I, Hagemeister F, Samuels B, Folloder J, Ueno NT, Molldrem J, Mehra R, Körbling M, Giralt S, Gajewski J, Donato M, Cleary K, Claxton D, Braunschweig I, Andersson B, Anderlini P, Champlin R. Carmustine, etoposide, cytarabine and melphalan as a preparative regimen for allogeneic transplantation for high-risk malignant lymphoma. Ann Oncol. 1999 May;10(5):527-32. link to original article contains protocol PubMed

Busulfan & Cyclophosphamide (BuCy)

Regimen

Day 0 is the day of transplantation.

• Busulfan (Myleran) 3.2 mg/kg IV once daily on days -7 to -4
• Cyclophosphamide (Cytoxan) 60 mg/kg IV once daily on days -3 and -2

Supportive medications:

• "Cyclosporine alone or cyclosporine plus methotrexate according to the discretion of the attending physician"
• Filgrastim (Neupogen) 450 mcg SC once daily, starting on day +5 and continued until ANC >3,000

References

1. Lee JH, Joo YD, Kim H, Ryoo HM, Kim MK, Lee GW, Lee JH, Lee WS, Park JH, Bae SH, Hyun MS, Kim DY, Kim SD, Min YJ, Lee KH. Randomized trial of myeloablative conditioning regimens: busulfan plus cyclophosphamide versus busulfan plus fludarabine. J Clin Oncol. 2013 Feb 20;31(6):701-9. doi:10.1200/JCO.2011.40.2362. Epub 2012 Nov 5. link to original article contains verified protocol PubMed

Busulfan & Fludarabine (Flu/Bu; BuFlu)

Regimen #1, Russell, et al. 2002 (Flu/Bu)

Day 0 is the day of transplantation.

• Fludarabine (Fludara) 50 mg/m2 IV daily on days -6 to -2
• Busulfan (Myleran) 3.2 mg/kg (ideal body weight) IV daily over 3 hours on days -5 to -2

Supportive medications:

• Phenytoin (Dilantin) "loading" PO/IV, dosed to maintain therapeutic levels of 40-80 umol/L on days -5 to -2
• Ciprofloxacin (Cipro) 500 mg PO BID as prophylaxis
• Trimethoprim/Sulfamethoxazole (Bactrim DS) (dose not specified in reference, but assume 160/800 mg dose) PO 2 times a week as PCP prophylaxis
• No routine fungal prophylaxis
• No routine use of growth factors
• CMV negative blood

Acute GVHD prophylaxis:

• Antithymocyte globulin (Thymoglobulin, rabbit ATG) 0.5 mg/kg IV on day -2; 2 mg/kg/day IV on days -1 and 0 (total dose of 4.5 mg/kg)
• Cyclosporine modified (Neoral) or Cyclosporine non-modified (Sandimmune) PO/IV BID, with doses adjusted to maintain cyclosporine levels of 150-400 umol/L
• Methotrexate (MTX) 15 mg/m2 once on day 1; 10 mg/m2 once daily on days 3, 6, 11
• Folinic acid (Leucovorin) 5 mg started 24 hours after each dose of methotrexate and continued Q6H until 12 hours before the next dose of methotrexate

Regimen #2, Lee, et al. 2013 (BuFlu)

Day 0 is the day of transplantation.

• Busulfan (Myleran) 3.2 mg/kg IV once daily on days -7 to -4
• Fludarabine (Fludara) 30 mg/m2 IV once daily on days -6 to -2

Supportive medications:

• "Cyclosporine alone or cyclosporine plus methotrexate according to the discretion of the attending physician"
• Filgrastim (Neupogen) 450 mcg SC daily, starting on day +5 and continued until ANC >3,000

References

1. Russell JA, Tran HT, Quinlan D, Chaudhry A, Duggan P, Brown C, Stewart D, Ruether JD, Morris D, Glick S, Gyonyor E, Andersson BS. Once-daily intravenous busulfan given with fludarabine as conditioning for allogeneic stem cell transplantation: study of pharmacokinetics and early clinical outcomes. Biol Blood Marrow Transplant. 2002;8(9):468-76. link to original article contains verified protocol PubMed
2. Lee JH, Joo YD, Kim H, Ryoo HM, Kim MK, Lee GW, Lee JH, Lee WS, Park JH, Bae SH, Hyun MS, Kim DY, Kim SD, Min YJ, Lee KH. Randomized trial of myeloablative conditioning regimens: busulfan plus cyclophosphamide versus busulfan plus fludarabine. J Clin Oncol. 2013 Feb 20;31(6):701-9. doi:10.1200/JCO.2011.40.2362. Epub 2012 Nov 5. link to original article contains verified protocol PubMed

Fludarabine and Low-dose TBI

Regimen

Day 0 is the day of transplantation.

• Fludarabine (Fludara) 30 mg/m2 IV daily on days -4 to -2
• Total body irradiation (TBI) 2 Gy at a rate of 0.07-0.20 Gy/min on day 0

Supportive medications for GVHD prophylaxis:

• "Postgrafting immunosuppression consisted of cyclosporine or tacrolimus combined with mycophenolate mofetil," further details not specified

References

1. Gyurkocza B, Storb R, Storer BE, Chauncey TR, Lange T, Shizuru JA, Langston AA, Pulsipher MA, Bredeson CN, Maziarz RT, Bruno B, Petersen FB, Maris MB, Agura E, Yeager A, Bethge W, Sahebi F, Appelbaum FR, Maloney DG, Sandmaier BM. Nonmyeloablative allogeneic hematopoietic cell transplantation in patients with acute myeloid leukemia. J Clin Oncol. 2010 Jun 10;28(17):2859-67. doi:10.1200/JCO.2009.27.1460. Epub 2010 May 3. link to original article contains verified protocol PubMed

Fludarabine, Cyclophosphamide, & TBI for dUCB or haploidentical transplant

dUCB: double Umbilical Cord Blood

Regimen #1, Brunstein et al. 2011 - dUCB transplantation

Day 0 is the day of transplantation.

• Fludarabine (Fludara) 40 mg/m2 IV once daily on days -6 to -2 (total dose: 200 mg/m2)
• Cyclophosphamide (Cytoxan) 50 mg/kg IV once on day -6
• Total body irradiation (TBI) 2 Gy once on day -1

Supportive medications:

• Mesna (Mesnex) (dose/route/schedule not specified) and "vigorous IV hydration for uroprotection."

GVHD Prophylaxis

• Mycophenolate mofetil (CellCept) 1000 mg (route not specified) Q8H for patients >50 kg, starting on day -3 "and continuing until day +30 or 7 days after engraftment, whichever was later"
  • Patients <50 kg received Mycophenolate mofetil (CellCept) 15 mg/kg (route not specified) Q8H, starting on day -3 "and continuing until day +30 or 7 days after engraftment, whichever was later"
• Cyclosporine A (Neoral vs. Sandimmune not specified, route not specified) with a goal trough of 200 to 400 ng/mL (starting date not specified) until day +100. Patients without GVHD had their dose tapered by 10% each week starting on day +101, with discontinuation of cyclosporine A around day +180 to +200.
• Tacrolimus (Prograf) (route not specified) with a goal trough level of 5 to 10 ng/mL could be substituted for cyclosporine.
• Filgrastim (Neupogen) 5 μg/kg SC once daily, starting on day +1, continued until ANC ≥2000/μL for 3 consecutive days

Regimen #2, Brunstein et al. 2011 - Haploidentical

Day 0 is the day of transplantation.

• Fludarabine (Fludara) 30 mg/m2 IV once daily on days -6 to -2 (total dose: 150 mg/m2)
• Cyclophosphamide (Cytoxan) 14.5 mg/kg IV on days -6 and -5
• Total body irradiation (TBI) 2 Gy once on day -1

Supportive medications:

• Mesna (Mesnex) (dose/route/schedule not specified) and "vigorous IV hydration for uroprotection."

GVHD Prophylaxis

• Cyclophosphamide (Cytoxan) 50 mg/kg IBW IV over 1 to 2 hours once daily on days +3 (60 to 72 hours after marrow infusion) and +4
• Mycophenolate mofetil (CellCept) 15 mg/kg (maximum daily dose of 3000 mg; route not specified) Q8H, starting on day +5, continued until day +35 or longer at physician discretion if active GVHD was present
• Tacrolimus (Prograf) (route not specified) with a goal trough level of 5 to 10 ng/mL, starting on day +5, continued until day +180
• Filgrastim (Neupogen) 5 μg/kg SC once daily, starting on day +5, continued until ANC ≥1000/μL for 3 consecutive days

References

1. Brunstein CG, Fuchs EJ, Carter SL, Karanes C, Costa LJ, Wu J, Devine SM, Wingard JR, Aljitawi OS, Cutler CS, Jagasia MH, Ballen KK, Eapen M, O'Donnell PV;Blood and Marrow Transplant Clinical Trials Network. Alternative donor transplantation after reduced intensity conditioning: results of parallel phase 2 trials using partially HLA-mismatched related bone marrow or unrelated double umbilical cord blood grafts. Blood. 2011 Jul 14;118(2):282-8. link to original article contains verified protocol PubMed