www.springerlink.com Chin J Cancer Res 23(1):49-53, 2011 49
Mobilization of Peripheral Blood Stem Cells Using Regimen Combining
Docetaxel with Granulocyte Colony-stimulating Factor
in Breast Cancer Patients
Jing Yu1, Jun Ren1*, Li-jun Di1, Guo-hong Song1, Yu-lin Zhu1, Jie Zhang1, Xu Liang1,
Li Che1, Han-fang Jiang1, Jun Jia1, Chun-rong Zhang2
Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), 1Department of Breast Oncology, 2Department
of Transfusion, Peking University School of Oncology, Beijing Cancer Hospital & Institute, Beijing 100142, China
© Chinese Anti-Cancer Association and Springer-Verlag Berlin Heidelberg 2011
Objective: To evaluate the effectiveness and safety of the mobilization of peripheral blood hematopoietic stem
cells by combining docetaxel with granulocyte colony-stimulating factor (G-CSF) in breast cancer patients.
Methods: A total of 57 breast cancer patients were treated with docetaxel 120 mg/m2. When the white blood
cell (WBC) count decreased to 1.0×109/L, patients were given G-CSF 5 μg/kg daily by subcutaneous injection until
the end of apheresis. Peripheral blood mononuclear cells (MNC) were isolated by Cobe Spectra Apheresis System.
The percentage of CD34+ cell was assayed by flow cytometry.
Results: At a median 6 of days (range 3-8) after the administration of docetaxel, the median WBC count
decreased to 1.08×109/L (range 0.20-2.31). The median duration of G-CSF mobilization was 3 days (range 2-7). The
MNC collection was conducted 8-12 days (median 10 days) after docetaxel treatment. The median MNC was
5.35×108/kg (range 0.59-14.07), the median CD34+ cell count was 2.43×106/kg (range 0.16-16.69). The CD34+ cell
count was higher than 1.00×106/kg in 47 of 57 cases (82.46%) and higher than 2.00×106/kg in 36 cases (63.16%).
The CD34+ cell count was higher than 2.00×106/kg in 27 collections (23.68%). The MNC count and the CD34+ cell
count were correlated with the bottom of WBC after docetaxel chemotherapy (r=0.364, 0.502, P=0.005, 0.000). The
CD34+ cell count was correlated with the MNC count (r=0.597, P=0.000). The mobilization and apheresis were well
tolerated in all patients. Mild perioral numbness and numbness of hand or feet were observed in 3 cases. No
serious adverse events were reported.
Conclusion: Mobilization of peripheral blood hematopoietic stem cell by combining docetaxel with G-CSF was
effective and safety in breast cancer patients.
Key words: Docetaxel; Granulocyte colony-stimulating factor (G-CSF); Mobilization; Stem cell
High-dose chemotherapy (HDC) with hematopoietic
stem cells support is regarded as an effective method to
improve survival in some human malignant diseases such
as leukemia, osteosarcoma, and germinal tumors. For breast
cancer, some randomized clinical trails revealed that
high-risk subgroups such as those with more than 10
positive lymph nodes, younger or premenopause and those
with triple negative (hormone receptor (ER, PR) negative
and Her2 negative) diseases, could benefit from high-dose
chemotherapy with improved progression–free survival
(PFS) and overall survival (OS)[1-3].
Received 2010−08−17; Accepted 2010−11−23
This work was supported by a grant from the Beijing Capital Development
Foundation for Medical Sciences (No. 2007-2053).
The Cancer and Leukemia Group B Trial 9741
demonstrated that the dosed-dense regimens significantly
prolonged both disease-free survival (DFS) and OS without
increasing toxicity. Multiple high-dose chemotherapy is
theoretically homologous as dose-dense chemotherapy but
with a much higher peak and a relative prolonged
intervention. Therefore we had developed a protocol
utilizing multiple cycles of HDC with the support of
peripheral blood hematopoietic stem cells (PBHSCs) for
patients with metastatic breast cancer (MBC).
It has been documented that the recovery of bone
marrow after chemotherapy-induced myelosuppression
typically produces an abundant release of progenitor cells
into the peripheral blood, and the magnitude of the increase
in circulating progenitor cells appears to correlate with the
intensity of the myelosuppression
chemotherapy. Chemotherapeutic agents utilized for
peripheral blood stem cell (PBSC) mobilization ideally
produce short-term marked myelosuppression while
50 Chin J Cancer Res 23(1):49-53, 2011 www.springerlink.com
sparing stem cells from severe toxicity. An optimal
chemotherapeutic mobilizing agent ideally should have
known antitumor activity with manageable toxicities.
Taxane including docetaxel has been shown to be an
effective PBSC mobilizer as a single agent or in combination
with cyclophosphamide, etoposide, and epirubicin[6, 7].
Docetaxel has been reported to have significant activity
against advanced breast cancer including anthracycline-
resistant breast cancer[8-10]. The dose-limiting toxicity of
docetaxel is grade 4 neutropenia, and the nonmyelocyte
toxicity is mild. Considering the facts that
cyclophosphamide, epirubicin, and paclitaxel have been
widely used in adjuvant chemotherapy and docetaxel is
superior to cyclophosphamide and other cytotoxic agents as
PBSC mobilizer, docetaxel is to be incorporated into our
subsequent high-dose regimen.
Because of these reasons above, in the study, we
investigated the effectiveness and safety of docetaxel and
granulocyte colony-stimulating factor (G-CSF) to mobilize
PBSC for MBC patients who were supposed to receive
MATERIALS AND METHODS
Eligible patients were 18-70 years old with histologically
and/or cytologically proven breast cancer. Patients were
required to have ECOG performance status of 2 or lower
and a life expectancy of over 6 month. Patients had received
chemotherapy, radiation therapy and surgery were also
eligible provided that the interventions at least 4 weeks
before PBSC mobilization. Adequate bone marrow (Blood
test: 4.0×109/L ≤ white blood cell (WBC) count ≤10.0×109/L,
95 g/L ≤ hemoglobin count ≤165 g/L, 75×109/L ≤ platelet
count ≤300×109/L), cardiac, pulmonary, renal, and hepatic
function were required. Patients at pregnant and lactating
were excluded. Patients with a history of myocardial
infarction, peripheral neuropathy, life-threatening hyper-
sensitivity to previous taxane, dysfunction of liver or kidney,
and impaired marrow were also excluded. All patients
provided written informed consents.
Protocol of Hematopoietic Stem Cell Mobilization
The mononuclear cells (MNC) were mobilized by
chemotherapy and G-CSF. Docetaxel (QILU Pharmaceutical
Co. Ltd. China) of 120 mg/m2 was administered with
premedicated dexamethasone 7.5 mg p.o. every 12 h ×6
doses starting 12 h prior to chemotherapy. When the WBC
count of peripheral blood decreased to about 1.0×109/L,
filgrastim (G-CSF, Chugai Pharmaceutical Co. Ltd. Japan) at
a dose of 5 µg⋅kg-1⋅d-1 were given subcutaneously until
leukapheresis was completed.
Patients had a routine complete blood count daily
following mobilization chemotherapy. Apheresis was
initiated when the WBC count increased to ≥8.0×109/L
using the COBE Spectra cell separator (COBE BCT,
Lakewood, Co., USA). Control vein catheterization with
double-lumen tube was inserted into the femoral vein. The
circulating blood volume was set at 8-12 L, dexamethasone
10 mg was given 2 h before cell separation. 10% calcium
gluconate 10 ml was intravenously given before and during
All collections were mixed with culture medium
containing DMSO (5%), human albumin (4%), and
hydroxyethyl starch (3%) (final concentration) and
cryopreserved at –80°C.
Assay of CD34+ Cells in MNC
The MNC count was tested routinely. The CD34+ cell
percentage was assayed by flow cytometry according to
standard ISHAGE program. CD34-PE/CD45-PC5 and
isotype IG1-PE/IG1-PC5 antibodies were purchased from
Immunotech Co. France.
Statistical analyses were carried out using SPSS
software Version 15.0. Date expressed by median and range
of relevant data collected cells. Linear relationships between
patients’ age, the WBC count at the bottom after docetaxel
treatment, the WBC count and the ratio of lymphocytes plus
monocytes (L+M) cells at the first collection day and the
total number of collected MNC and CD34+ cells were
assessed using Spearman correlation. The nonparametric
Mann-Whitney U test was used to compare the data with or
without visceral metastasis, bone metastasis, previous
chemotherapy cycles, radiotherapy and hormonal treatment
on acquisition of MNC and CD34+ cells. A P value of less
than 0.05 was regarded as statistically significant.
A total of 57 patients with histologically and/or
cytologically proven breast cancer were enrolled from April
2005 to May 2010. All patients agreed to accept high-dose
chemotherapy with the support of peripheral blood stem
cells and written consents were signed. All patients were
female. The median age was 48 years (range 28 to 67 years).
The pathological diagnoses were infiltrating ductal
carcinoma for 49 cases, invasive lobular carcinoma for 3
cases, simple carcinoma for 3 cases, medullary carcinoma for
one case and one case by fine needle aspiration cytology
diagnosis of breast cancer.
The high-dose chemotherapy was administrated as
adjuvant chemotherapy for 3 patients and relapse treatment
for the other 54 patients. The mobilization chemotherapy,
docetaxel treatment was used as first-line treatment in 23
cases, second-line treatment in 15 cases, third line treatment
in 8 cases, and more than third line treatment in 10 cases. A
total of 35 cases received previous endocrine therapy and 33
patients received previous radiation treatment.
Quality of Apheresis
In 57 breast cancer patients, the median dose of
docetaxel was 200 mg (range 160-200 mg). At a median of 6
days (range 3-8), the mean white blood cells count was
decreased to median 1.08×109/L (range 0.20-2.31). The
median duration of G-CSF was 3 days (range 2-7) and the
peripheral blood stem cell collection was started on median
10 days (range 8-12) after docetaxel mobilization. Totalled
www.springerlink.com Chin J Cancer Res 23(1):49-53, 2011 51
114 collections were performed in 57 patients. Before the
first time blood cell separation, the median WBC count was
13.33×109/L (range 5.27-37.80), the median L+M ratio was
27.4% (range 3.10-88.00) and the median L+M count was
3.28×109/L (range 0.60-13.90).
The median MNC count was 5.35×108/kg (range
0.59-14.07) and the median CD34+ cells count was
2.43×106/kg (range 0.16-16.69) in 57 patients (Table 1). The
CD34+ cell counts were less than 1.00×106/kg (median
0.68×106/kg) in 10 cases (17.54%) and more than
1.00×106/kg in the other 47 patients (82.46%) among which
CD34+ cell counts were more than 2.00×106/kg in 36 cases
(63.16%). The CD34+ cells counts were more than
2.00×106/kg at single collection in 27 collections (23.68%)
Factors Affecting Apheresis
The factors that could affect the quality of apheresis
were analyzed and summarized in Table 3. Patients’ age,
WBC count and the ratio of L+M cells at the first collection
day had no relation with the number of collected MNC and
CD34+ cells. The total number of collected MNC and CD34+
cells was correlated with the WBC count at the bottom after
docetaxel treatment (correlation coefficient, r=0.364, 0.502,
P=0.005, 0.000), meanwhile the total number of collected
CD34+ cells also had relation with the amount of collected
MNC (r=0.597, P=0.000) and was positively correlated.
According to the clinical characteristics of patients
before mobilization, compared the data with or without
visceral metastasis, bone metastasis, previous cycles of
chemotherapy, radiation therapy and hormonal treatment
Table 1. Collection results of 57 breast cancer patients
Collection day 1
MNC cells (×108/kg)
CD34+ cells ratio (%)
CD34+ cells (×106/kg)
MNC: mononuclear cell
Collection day 2
1.14 (0.05-10.82) 2.43 (0.16-16.69)
Table 2. Collected CD34+ cells results of 57 breast cancer patients
Collection times (cases)
1.00 ≤ − < 2.00
Cases (%) Median (range)
1.48 ( 1.00-1.99)
Table 3. Factors affecting apheresis
Total number of MNC
Total number of CD34+ cells
WBC count nadir
WBC count at the first collection day
MNC: mononuclear cell; L: lymphocyte; M: monocyte
Table 4. The impact of clinical features of 57 cases of breast cancer patients on the acquisition of MNC and CD34+ cells
MNC cells (×108/kg)
No 25 6.22 (2.50-14.07)
Yes 32 5.24 (0.59-12.93)
No 29 6.20 (2.28-14.07)
Yes 28 5.24 (0.59-12.93)
Previous cycles of chemotherapy
≤ 6 28 6.27 (2.28-14.07)
> 6 29 5.21 (0.59-10.82)
No 24 6.21 (1.91-14.07)
Yes 33 5.20 (0.59-12.28)
No 22 5.98 (2.28-14.07)
Yes 35 5.27 (0.59-12.93)
CD34+ cells (×106/kg)
P value P value
52 Chin J Cancer Res 23(1):49-53, 2011 www.springerlink.com
on acquisition of MNC and CD34+ cells, the results were not
statistically significant. The results are shown in Table 4.
The G-CSF mobilization and cell separation of
peripheral blood stem cells were well tolerated. During and
after the cell collection, no body weight loss, painful venous
catheter, bleeding, and thrombosis were observed. Three
patients had experienced mild perioral numbness and
numbness of hand and foot. The symptom was slight and
disappeared after treatment with calcium gluconate.
Hematopoietic stem cells consist of 0.1%-1% bone
marrow and CD34+ is popularly used as cell marker to
identify these subsets from other blood cells. The percentage
of CD34+ cells is 0.01%-0.1% in peripheral blood
mononuclear cells. To fulfill successful peripheral derived
hematopoietic stem cell transplantation requires
administrating effective mobilizor to increase the percentage
of CD34+ cells in peripheral blood. Combining
chemotherapy and G-CSF is currently being considered the
best program for HSC mobilization.
G-CSF is a popular used cytokine in clinic to treat
neutropenia and leucopenia caused by chemotherapy. It has
been proved that G-CSF administration for 4 to 5 days could
dramatically increase the number of peripheral blood
progenitor cells to 40 to 80 times[13, 14]. Imamura et al.
found that G-CSF could induce CD34+ CD10+
CD19-Lin-cells and CD34+ CD10+ CD19+ Lin- cells to
differentiate into B cells and natural killer cells. G-CSF could
not only stimulate the proliferation of colony-forming unit
in bone marrow but also mobilize mature cells releasing
from bone marrow to peripheral blood. For the
myelosuppression induced by chemotherapy, G-CSF could
promote the release of large number of progenitor cells from
bone marrow into circulation and effectively increase the
number of the peripheral blood stem/progenitor cells.
The effects of G-CSF are dose-dependent and at dosage of
up to 10-16 μg⋅kg-1⋅d-1 the effects reach to maximum.
G-CSF could synergize with chemotherapy in mobilizing
hematopoietic stem cells. The yield of CD34+ cells is 10 to 30
times of that without mobilization.
An ideal mobilization chemotherapy regimen for
metastatic breast cancer patients who previously received
adjuvant chemotherapy should not only mobilize large
numbers of CD34+ cells into the circulation but also had
antitumor activity to control tumor growth during this
phase. Therefore, the selection of an appropriate
mobilization agent for MBC patients should take into
consideration both the following conditioning regiment and
prior drug exposure. With the increased use of
cyclophosphamide and anthracycline-containing regimens
in the adjuvant treatment, the choice of mobilization
regimen for patients supposed to receive multiple HDC
with PBSC support for MBC is somewhat limited.
Docetaxel demonstrates significant antitumor activity
with limited toxicity in breast cancer patients including
heavily pretreated patients[8-10]. Similar to paclitaxel,
docetaxel does not cause significant hematological toxicity
and is not known to be damaging to stem cells[6, 18]. A
number of clinical trails has suggested that as second-line
treatment, docetaxel has a clinical response rate of 27% to
48% and a median progression-free time of 4 to 6 months for
MBC patients[8-10, 19]. The dose-limiting toxicity of docetaxel
is grade 4 neutropenia and the non-myeloid toxicity such as
congestive heart-failure， hepatitis, peripheral neuritis etc are
tolerable. The myelosuppression of docetaxel is short and
recovers rapidly[6, 18].
Docetaxel either single or in combination with
cyclophosphamide or anthracycline has been reported to
successfully mobilize CD34+ cells from peripheral blood[20-22].
Prince et al. prospectively evaluated docetaxel (100
mg/m2) with G-CSF (10 μg/kg S.C., daily) for mobilization
efficiency in 26 patients with breast cancer. The median
PBSC CD34+ cell content ranged from 1.2 to 5.9×106/kg per
day during days 7 to 11 with a median CD34+ content of
3.4×106/kg (range 0.07–15.6) for total 72 PBSC collections.
Fifteen patients obtained a peripheral blood progenitor cell
(PBPC) collection exceeding 5×106/kg on a single day of
collection. Twenty-two patients subsequently received
repetitive high-dose therapy
transplantation with 57 cycles of HDT having been
delivered. The median time to reach absolute neutrophil
count (ANC) at >0.5×109/L and 1.0×109/L was 10 days and
11 days respectively. The median time for platelets to reach
greater than 20×109/L, 50×109/L and 100×109/L was 13
days, 17 days and 23 days respectively. Laport et al.
explored docetaxel as a peripheral blood stem cell
mobilizing agent in 33 women with stage III-IV ovarian
carcinoma (n=10) or stage II-IV breast cancer (n=23) who
were in preparation for high-dose chemotherapy. The
median number of prior regimens received before
mobilization was two (range 1–3). The docetaxel was
administered followed by G-CSF (10 μg/kg/day) starting 4
days after docetaxel administration. Thirty two (97%)
patients began leukapheresis within 7–9 days after receiving
docetaxel and 27 (82%) ≥2.0×106/kg CD34+ cells were
collected. None of the patients experienced neutropenic
fever or required blood or platelet transfusion support.
In our study, PBSCs were mobilized by docetaxel at 120
mg/m2 followed by 5 μg/kg/day G-CSF subcutaneous
injection when the white blood cell count decreased to
1.0×109/L in 57 metastatic breast cancer patients. At a
median 6 days (range 3-8) after the administration of
docetaxel, the G-CSF was given and the median duration
was 3 days (range 2-7) and the peripheral blood stem cell
collection was started on median 10 days (range 8-12) after
docetaxel mobilization. The median collected MNC count
was 5.35×108/kg (range 0.59-14.07) and the median CD34+
cell count was 2.43×106/kg (range 0.16-16.69). The CD34+
cell counts were more than 1.00×106/kg in the other 47
patients (82.46%) among whom CD34+ cell counts were
more than 2.00×106/kg in 36 cases (63.16%). The CD34+ cell
counts were more than 2.00×106/kg at single collection in 27
collections (23.68%). These results are similar to previous
reports[20-22]. The total number of collected MNC and CD34+
cells had correlated with the WBC count at the bottom after
docetaxel treatment (P=0.005, 0.000). This suggests that
(HDT) and PBSC
www.springerlink.com Chin J Cancer Res 23(1):49-53, 2011 53 Download full-text
chemotherapy mobilization plan should be performed for
bone marrow suppression, it helps to collect more cells.
According to the clinical characteristics of patients before
mobilization, the acquisitions of MNC and CD34+ cells with
or without visceral metastasis, bone metastasis, previous
cycles of chemotherapy, radiation therapy and hormonal
treatment on were compared. Though the results were not
statistically significant, we still have to take into account the
decreases of bone marrow function in advanced breast
cancer patients who experienced multiple courses of
treatment, so the number of collected CD34+ cells will be
affected. We should choose the right time and mobilization
program, to collect more CD34+ cells, in order to facilitate
patient’s follow-up treatment. The mobilization was well
tolerated with no serious adverse events.
Our data demonstrate that docetaxel is an appropriate
choice to mobilize PBSCs for patients with breast cancer
who have been previously exposed to anthracyclines or
cyclophosphamide. Notably, no patient experienced febrile
neutropenia or required platelet transfusions. We conclude
that docetaxel with G-CSF could effectively mobilize PBSC
without serious adverse events.
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