自體造血幹細胞移植

Buzzwords → Dx

Process

1. Stem cell mobilization (G-CSF ± plerixafor) → apheresis collection.
2. Cryopreservation at –80 °C / liquid nitrogen.
3. Conditioning chemotherapy (e.g., melphalan 200 for MM; BEAM for lymphoma).
4. Stem cell infusion day 0.
5. Engraftment typically day +10 to +14 (faster than allo).
6. Supportive care during pancytopenia; G-CSF often used to accelerate.

Workup

• Disease assessment + remission depth.
• Cardiac (EF), pulmonary (DLCO), renal (eGFR), hepatic function.
• Performance status, comorbidity score.
• Infection screening.
• Stem cell mobilization assessment (hard-to-mobilize: prior chemo, prior radiation, lymphoma — plerixafor + G-CSF recommended).

Treatment Algorithm

flowchart TD
  A[Indication for auto-HCT] --> B[Mobilize stem cells<br>G-CSF ± plerixafor]
  B --> C[Apheresis collection<br>target ≥2 (preferred ≥5) × 10⁶ CD34+/kg]
  C --> D[Cryopreserve]
  D --> E[Conditioning chemo<br>disease-specific]
  E --> F[Reinfuse stem cells day 0]
  F --> G[Engraftment day +10 to +14]
  G --> H[Discharge typically day +14 to +21<br>monitor for late infections, organ toxicity]
  H --> I[Maintenance per disease<br>MM: lenalidomide<br>HL: BV AETHERA<br>Lymphoma: rituximab maintenance some indications]

Pearls / Pitfalls

• Auto vs allo HCT — auto has no GVHD or GVL effect; relies entirely on conditioning chemo. Lower TRM (~1–3 % vs ~10–25 % allo).
• Auto-HCT in MM is consolidation, not curative — followed by lenalidomide maintenance. Question is "early vs late" auto-HCT (early = post-induction; late = at first relapse). Most current evidence supports early.
• Auto-HCT in DLBCL — for late relapse (>12 mo) in chemo-sensitive disease. CAR-T (axi-cel ZUMA-7, liso-cel TRANSFORM) is now preferred for primary refractory or early relapse <12 mo.
• Auto-HCT in Hodgkin — standard 2L for chemo-sensitive R/R disease. Brentuximab maintenance post-auto in high-risk (AETHERA).
• PCNSL consolidation with BCNU/thiotepa-based auto-HCT is preferred over WBRT (better long-term cognition).
• AL Amyloidosis — auto-HCT in selected fit pts; Mayo cardiac stage IV (Eur IIIb) is excluded.
• Mobilization failure: prior alkylator exposure, lenalidomide, advanced age. Plerixafor (CXCR4 antagonist) + G-CSF rescues most.
• Engraftment syndrome: fever, rash, capillary leak around engraftment — supportive ± steroids; distinguishes from infection by lack of pathogen + temporal pattern.
• Late effects of auto-HCT: secondary MDS/AML (esp. with prior alkylator + auto-HCT), infertility, cardiotoxicity from anthracycline backbone, secondary cancers.
• No GVHD prophylaxis needed — patient's own cells.
• Vaccination resumption ~6–12 mo post-auto-HCT (faster immune reconstitution than allo).

Cross-references

• Allo-HCT — different indications
• MM — auto-HCT consolidation
• DLBCL — auto-HCT role declining vs CAR-T
• HL — 2L auto-HCT
• AL Amyloid — auto-HCT eligibility
• PCNSL consolidation

相關題目

• Q-145 — Auto-HCT in MM — conditioning regimen
• Q-146 — Auto-HCT — when to use vs CAR-T for DLBCL
• Q-147 — AL amyloid — auto-HCT eligibility

Sources