BlueCross and BlueShield of Montana Medical Policy/Codes
Stem-Cell Transplant for Primary Systemic Amyloidosis
Chapter: Medicine: Treatments
Current Effective Date: October 25, 2013
Original Effective Date: February 15, 2012
Publish Date: October 25, 2013
Revised Dates: September 27, 2013
Description

The primary amyloidoses comprise a group of diseases with an underlying clonal plasma cell dyscrasia. They are characterized by the extracellular deposition of pathologic, insoluble protein fibrils with a beta-pleated sheet configuration that exhibit a pathognomonic red-green birefringence when stained with Congo red dye and examined under polarized light. These diseases are classified on the basis of the type of amyloidogenic protein involved, as well as by the distribution of amyloid deposits.

In systemic amyloidosis, the unnatural protein is produced at a site that is remote from the site(s) of deposition, whereas in localized disease, the protein is produced at the site of deposition. Light-chain amyloidosis (AL), the most common type of systemic amyloidosis, has an incidence similar to that of Hodgkin’s lymphoma or chronic myelogenous leukemia, estimated at 5 to 12 people per million annually. The median age at diagnosis is approximately 60 years. The amyloidogenic protein in AL amyloidosis is an immunoglobulin light chain or light-chain fragment that is produced by a clonal population of plasma cells in the bone marrow. While the plasma cell burden in AL amyloidosis is typically low, ranging from 5–10%, this disease also may occur in association with multiple myeloma in 10–15% of patients. Deposition of AL amyloidogenic proteins causes organ dysfunction, most frequently in the kidneys, heart, and liver, although the central nervous system and brain may be affected.

Historically, this disease has had a poor prognosis, with a median survival from diagnosis of approximately 12 months, although outcomes have improved with the advent of combination chemotherapy with alkylating agents and autologous stem-cell support (AuSCS). Emerging approaches include the use of immunomodulating drugs such as thalidomide or lenalidomide, and the proteasome inhibitor bortezomib. Regardless of the approach chosen, treatment of AL amyloidosis is aimed at rapidly reducing the production of amyloidogenic monoclonal light chains by suppressing the underlying plasma cell dyscrasia, with supportive care to decrease symptoms and maintain organ function. The therapeutic index of any chemotherapy regimen is a key consideration in the context of underlying organ dysfunction.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Coverage of, evaluation for, and subsequent single treatment by stem-cell transplant (SCT) (using bone marrow, peripheral blood, or umbilical cord blood as a stem-cell source), derived from a specific donor category, and following a chemotherapy regimen for treatment of primary systemic amyloidosis are identified in the grids below.

NOTE: SCT may be known by different terminology and used interchangeably. Hereinafter, SCT will be known as stem-cell support (SCS) throughout the balance of this medical policy. 

Allogeneic

Is considered experimental, investigational and unproven for primary systemic amyloidosis.

Autologous

 

May be considered medically necessary to treat primary systemic amyloidosis.

Tandem or Triple Stem-Cell Support

Is considered experimental, investigational and unproven for primary systemic amyloidosis.

Donor Leukocyte Infusion

Is considered experimental, investigational and unproven for primary systemic amyloidosis.

Hematopoietic Progenitor Cell Boost (Stem-Cell Boost)

Is considered experimental, investigational and unproven for primary systemic amyloidosis.

Any use of short tandem repeat (STR) markers for the treatment of primary systemic amyloidosis is considered experimental, investigational and unproven.

Rationale

High-dose chemotherapy (HDC) followed by hematopoietic stem-cell (HSC) transplant (HSCT) or stem-cell support (SCS) (i.e., blood or marrow) transplant is an effective treatment modality for many patients with certain malignancies and non-malignancies. The rationale of this treatment approach is to provide a very dose-intensive treatment in order to eradicate malignant cells followed by rescue with peripheral blood, umbilical cord blood, or bone marrow stem-cells. 

Initially, this policy was based on a search of peer reviewed literature and included information on Waldenstrom Macroglobulinemia, which has been removed from this policy. The most recent update on primary amyloidosis was performed for the period of 2009 through 2013. Following is a summary of key references to date.

Conventional therapy for primary systemic amyloidosis usually combines oral melphalan with prednisone (MP), which has been shown to yield higher response rates and longer survival than colchicine or prior therapies. (1-3) Median survival after MP (approximately 18 months) is longer than for untreated patients or those given older therapies (10–14 months), but more effective regimens have been sought. Combination therapy with vincristine, doxorubicin, and dexamethasone (VAD), a well-established regimen for myeloma, has been investigated. (1, 2) However, because of its toxicity, VAD therapy usually is limited to patients without peripheral neuropathy or cardiomyopathy, both common complications of amyloidosis. Because conventional regimens rarely cure systemic amyloidosis, and because of the close biologic similarity to multiple myeloma, myeloablative chemotherapy with HSCT was investigated for this disease.

Autologous SCS (AuSCS)

Initial results of AuSCS in uncontrolled patient series were published in 1998. (4, 5) Clinical response rates (50% to 60%) were nearly twice those reported for conventional therapy, and 2-year survival reportedly ranged from 56% to 68%. (2, 6) However, procedure-related mortality rates of 15% to 43% were substantially higher than those observed in myeloma patients, usually in cases that involved more than 2 organ systems or had symptomatic cardiac involvement. (5, 7, 8)

A subsequent retrospective study analyzed outcomes of conventional therapy for primary amyloidosis in patients who would have been eligible for AuSCS. (6) Inclusion required age younger than 70 years, cardiac interventricular septal thickness less than 15, left ventricular ejection fraction (LVEF) more than 55%, serum creatinine less than 2 mg/dL, and direct bilirubin less than 2.0 mg/dL. Patients eligible for transplantation but managed conventionally reportedly had median survival of 42 months after conventional treatment, compared to median survival of only 18 months for all patients with primary amyloidosis. Survival of conventionally managed patients (n=229) at 24 months was 61%, which was similar to 56% - 65% survival at 24 months after AuSCS.

In the same report, survival of 39 patients given AuSCS at their institution was compared with survival of a matched cohort (n=78; 2 controls for each case) selected from their database of conventionally treated amyloidosis patients.(6) Factors used to match patients were limited to age (within 5 years), gender, and number of involved organs. They reported similar survival of cases and controls at 6 (85% versus 83%), 12 (77% versus 74%), and 24 months (68% and 60%, all respectively).

A follow-up report to the matched-pair analysis cited above included a larger group of cases (n=63) treated with AuSCS and used parameters measuring severity of organ involvement to select matched controls (n=63). (9) Factors used for matching were age, gender, time to presentation, LVEF, serum creatinine, cardiac septal thickness, nerve involvement, 24-hour urinary protein excretion, and serum alkaline phosphatase. At a median follow-up of 3.5 years from diagnosis for each group, 16 transplanted patients and 44 controls had died. Kaplan-Meier analysis showed significantly greater overall survival (OS) for those given autotransplants (p=0.004). The survival rates for the high dose and standard treatment groups at 1, 2, and 4 years were 89% and 71%; 81% and 55%; and 71% and 41%, respectively.

In addition to longer survival, evidence suggests improvement in symptoms for amyloidosis patients treated with AuSCS. In a large retrospective series of amyloidosis patients eligible for transplant (n=394), 63 patients declined treatment and 19 lost eligibility when they progressed before treatment started.(10) Estimated median survival for 312 patients who initiated stem-cell mobilization was 4.6 years, but median follow-up was not reported. Of 181 evaluable patients (alive and followed-up for 1 year or more), 40% achieved complete hematologic response, defined as no evidence of plasma cell dyscrasia at 1 year after transplant. The authors reported functional improvement in at least 1 affected organ for 44% of evaluable patients: 66% of 73 patients with complete hematologic response, and 30% of 108 patients with an incomplete or no hematologic response. Among 277 patients who completed the transplant protocol, 36 (13%) died of treatment-related toxicity before day 100 post-transplant, 21 (8%) died between day 100 and 1 year, and 39 were alive but had not reached 1 year since transplant. This series included all patients transplanted between July 1994 and June 2002, of which one-half (n=196) had 3 or more organs involved and 43% had some cardiac involvement. Median survival for those with cardiac involvement (n=137) was significantly shorter (1.6 vs. 6.4 years, respectively; p<0.001) than for those without cardiac involvement (n=175).

A subsequent report based on the dataset from the large retrospective series outlined in the preceding paragraph provided an analysis of outcomes of risk-adjusted myeloablative melphalan and AuSCS in patients aged 65 years and older versus outcomes in those younger than 65 years, with up to 10 years of follow-up.(11) Patients younger than 65 years with LVEF of 45% or greater and adequate stem-cell yield (n=280; median age 55 years, range 29–64 years) received melphalan 200 mg/m2; those aged 65 years and older, those with reduced LVEF (40–45%), or those with lower stem-cell yield (n=65; median age 68 years, range 65–79 years) received risk-adjusted melphalan 140 mg/m2. No difference was observed in early treatment-related mortality (10.3% in patients 65 years or older vs. 13.4% in those younger than 65 years, p=0.665). A trend toward a lower rate of hematologic complete response (CR, defined as the absence of clonal plasma cells in the bone marrow by immunohistochemical staining and of monoclonal gammopathy by immunofixation electrophoresis of serum and urine) was observed in the older patients (27.6% for patients 65 years or older) versus 13.4% in those younger than 65 years (p=0.882). However, the median survival after AuSCS did not differ according to age (4.0 years for patients aged 65 years and older vs. 4.85 years for those younger than 65 years; log-rank p=0.28).

A registry analysis of 107 amyloidosis patients who received transplants between 1995 and 2001 at 48 centers included 37 (35%) patients who received a transplant for initial therapy of amyloidosis, while 27 (25%) received a transplant after 2 or more prior therapies.(12) With a median follow-up of 30 months after transplant, OS at 1 and 3 years was 66% (95% confidence interval [CI]: 56–75%) and 56% (95% CI: 45–66%), respectively. For those with no or 1 organ involved at transplant, survival at 1 year was 72% (95% CI: 61–82%), while for those with 2 or more organs involved, survival at 1 year was 54% (95% CI: 38–70%). Survival at 1 year also was greater for those without (69%; 95% CI: 58–79%) than with (56%; 95% CI: 37–74%) cardiac involvement. Treatment-related mortality at 30 days was 18% (95% CI: 11–26%), mostly among patients with cardiac and/or multiple organ involvement.

Long-term survival and outcomes were evaluated in a series of 80 patients with light-chain amyloidosis (AL) amyloidosis who were treated with myeloablative full-dose or risk-adjusted melphalan according to a risk-based protocol and underwent AuSCS. (13) All patients had a histologic diagnosis of amyloidosis with evidence of plasma cell dyscrasia and met eligibility criteria for AuSCS in clinical protocols. Patients (median age 56 years, range 29–71 years) received risk-adjusted melphalan 100 mg/m2 (n=37) or full-dose melphalan 200 mg/m2 (n=43) followed by AuSCS 24–72 hours after completion of the conditioning regimen. Treatment-related mortality was reported in 11 (14%) cases, 6 of whom had received risk-adjusted melphalan, while 5 received the full-dose regimen. Median survival for all 80 patients was 57 months; 18 (23%) were alive 10 or more years after undergoing AuSCS. Hematologic CR was assessed in 63 (79%) surviving patients at 1 year following treatment. Thirty-two of those patients (51%) achieved a hematologic CR; among those, median survival had not been reached at the time the report was prepared for publication. In contrast, the median survival for patients who failed to achieve a CR was 50 months, with a 6% estimated probability of survival at 10 years (p<.001 vs. patients with complete response).

In a series of 282 consecutive patients with AL amyloidosis who underwent AuSCS, investigators sought to determine whether or not a hematologic CR, as determined by normalization of serum and urine monoclonal protein levels, provides an adequate surrogate marker for OS. (14) All patients had AL histologically verified with Congo red tissue stain, and received risk-adjusted melphalan conditioning based on the presence of numbers of organs involved, creatinine level, age, and cardiac involvement. One third (n=93) of the patients received risk-adjusted melphalan (100 or 140 mg/m2) and 67% (n=189) received full-dose melphalan (200 mg/m2). The mortality at day 100 was 11%, with 28% of the cohort dead by the time this report was prepared. Ninety-three (33%) patients achieved a CR, 108 (38%) had a partial response (PR), and 36 (13%) had no response (NR) to AuSCS. Kaplan-Meier analysis showed that median survival was reached only in the NR group, compared with the CR and partial response (PR) groups after more than 80 months of follow-up (log-rank p<0.001 for NR vs. CR and PR). An analysis (landmark analysis) focused on patients who survived for at least 6 months after AuSCS included 86 patients in the CR group, 91 who had PR, and 36 NR patients. This analysis showed that the survival curve differences remained significant between response groups as in the overall cohort, with a median survival of 40 months reached only in the NR group.

One randomized multicenter trial involving 8 centers from the Myelome Autogreffe (MAG) and Intergroupe Francophone du Myelome (IFM) Intergroup has been reported in which conventional chemotherapy with melphalan plus dexamethasone was compared with myeloablative melphalan followed by AuSCS in patients with AL amyloidosis.(15) Patients between 18 and 70 years of age had a histologic diagnosis of AL amyloidosis and either a complete hematologic response characterization of amyloid deposits or evidence of a monoclonal immunoglobulin protein in the serum or urine or a monoclonal staining pattern of bone marrow plasma cells and had received no more than 2 courses of any chemotherapy regimen. They were randomly allocated, stratified according to age (younger than 65 years or 65 years or older) and according to the affected organ system (cardiac, renal, neurological, or other). Of note, approximately two thirds of the patients had 2 or more organs affected. Patients in the melphalan plus dexamethasone group (n=50) received monthly courses of dose-adjusted (according to cytopenic status) oral melphalan, 10 mg/m2 of body-surface area, on days 1 to 4 plus oral dexamethasone, 40 mg/day on days 1 to 4, for up to 18 courses if no severe adverse events occurred. In the AuSCS patients (n=50), hematopoietic stem cells were obtained from peripheral blood with granulocyte colony-stimulating factor mobilization. Melphalan was administered intravenously on day 0, and stem cells were infused on day 2, with the dose reduced from 200 mg/m2 to 140 mg/m2 for patients aged 65 years or older and for those with an LVEF less than 30%, a calculated creatinine clearance less than 30 mL/min, or severe liver disease. According to intention-to-treat (ITT) analysis, the hematologic response rate did not differ between groups, with 12 CR (24%) and 14 PR (28%) in the melphalan plus dexamethasone recipients versus 11 CR (22%) and 7 PR (14%) in the autologous HSCT group (p=0.11). At publication of the study, the median follow-up for the entire cohort was 24 months, and for survivors it was 36 months; 20 patients in the melphalan-dexamethasone group had died versus 31 in the AuSCS group. Among 65 patients who could be evaluated, the ITT median survival for patients assigned to melphalan plus dexamethasone was 56.9 months, versus 22.2 months in the AuSCS group (p=0.04). Survival rates and duration were significantly better in responders (CR plus PR) compared to NR (p<0.0001). Analysis of patients who survived for at least 6 months and who received their assigned treatment, showed no significant difference in survival rates in patients assigned to melphalan plus dexamethasone compared to AuSCS, with neither group reaching median survival after 80 months (p=0.38).

These randomized trial data suggest that AuSCS may be no more efficacious than conventional chemotherapy in prolonging survival among patients with AL amyloidosis. However, the results are limited by the size of the study, a lack of assessor blinding or allocation concealment, and a large attrition post-randomization. Thus, among 50 patients assigned to AuSCS, 13 (26%) did not receive the planned treatment (1 declined, 2 had insufficient stem-cell harvest, 10 died before treatment), whereas 7 of 50 (14%) assigned to melphalan plus dexamethasone did not receive planned treatment (5 died before treatment, 1 did not tolerate treatment, 1 received incorrect treatment). Therefore, even though this was a randomized trial, the results are not sufficient to change the policy statement given the body of evidence available from other, albeit nonrandomized, studies.

A series of 421 consecutive patients treated with high-dose melphalan and AuSCS at a single referral center compared outcomes for patients with and without a CR. (16) Treatment-related mortality was about 11% overall (5.6% in the last 5 years). By intention-to-treat analysis, the CR rate was 34% and the median event-free survival (EFS) and OS were 2.6 and 6.3 years, respectively. Eighty-one patients died within the first year after SCS and were not evaluable for hematologic and organ response. Of 340 evaluable patients, 43% achieved CR and 78% of them experienced an organ response. For CR patients, median EFS and OS were 8.3 and 13.2 years, respectively. Among the 195 patients who did not obtain CR, 52% achieved an organ response, and their median EFS and OS were 2 and 5.9 years, respectively. Thus, treatment of selected AL patients with high-dose melphalan and AuSCS resulted in a high organ response rate and long OS, even for those patients who did not achieve CR. These results are compatible with others cited above.

Allogeneic SCS (AlloSCS)

Data on the use of AlloSCS to treat AL amyloidosis are sparse, with no systematic evaluation in a clinical trial. (17) Concerns about the use of AlloSCS include high treatment-related mortality (more than 40%), morbidity secondary to graft-versus-host (GVH) disease (GVHD), and questions about the efficacy of a proposed graft-versus-malignancy (GVM) effect on low-grade plasma cell dyscrasias.

Clinical Guidelines

National Comprehensive Cancer Network Guidelines

The 2013 National Comprehensive Cancer Network (NCCN) guidelines include AuSCS as primary therapy for systemic amyloidosis; however, they caution that the optimal therapy is not established and that such treatment would best be performed in a clinical trial. (21)

National Cancer Institute Physician Data Query (PDQ®) Database

A search of the National Cancer Institute clinical trials PDQ database identified one active Phase III study. It compares hematologic response rate in patients with primary systemic amyloidosis treated with conventional chemotherapy comprising low-dose melphalan and dexamethasone versus high-dose melphalan followed by AuSCS and compares the toxicity of these regimens in these patients. The study was listed as MAYO-MC0482 MAYO-IRB-1691-05, MC0482, NCT00477971: Phase III Randomized Study of Low-Dose Melphalan and Dexamethasone Versus High-Dose Melphalan Followed By Autologous Hematopoietic Stem Cell Transplantation in Patients With Primary Systemic Amyloidosis.

Additional Infusion Treatments for Primary Amyloidosis

Tandem or triple stem-cell transplant and donor leukocyte infusion (DLI) for primary amyloidosis are considered experimental, investigational, and unproven due to lack of adequate evidence of safety and effectiveness documented in published, peer-reviewed medical literature.

As with DLI, hematopoietic progenitor cell (HPC) boost has a positive response rate for relapse following AlloSCS. (25) The boost of stem-cells, a second dose, may be helpful to reduce the graft failure process, avoiding the risk of serious bleeding and/or infection. However, the data is insufficient for the use of HPC Boost following AlloSCS for treatment of non-hematological malignancies to lessen post-transplant graft failures. (22, 23, 24, 25)

Short Tandem Repeat (STR) Markers

Following SCS therapy, it is important to determine whether the new blood forming system is of the donor or the recipient, based upon the proportion of donor and recipient cells. The characteristics of the engraftment are analyzed, which is called chimerism analysis. Using STR marker assay to characterize the hematological course and to evaluate the usefulness of the blood forming system (particularly for hematological malignancies, myelodysplastic/myeloproliferative processes, or certain genetic or metabolic disorders) has been tested initially after the SCS, when the patient is declared as disease-free, and at the point of the confirmed stable engraftment of only the donor pattern of the blood forming system. (26, 27) Without further randomized trials using STR markers prior to or post SCS therapy for treatment of primary systemic amyloidosis, the data is insufficient to determine the outcome/effect of stem-cell engraftment. (29, 30, 31, 32, 33, 34)

Summary

Chemotherapy for the treatment of AL amyloidosis was introduced in 1972 in the form of MP. (3) Median survival with this regimen was typically 12 to 18 months, with therapy remaining unchanged until the introduction of AuSCS. The use of AuSCS for AL amyloidosis rapidly eradicates the amyloidogenic light chain produced by the clonal plasma cell populations, which is the proximal cause of pathology and subsequent death. This has extended survival rates to a reported 53% at 10 years in patients with a CR to treatment. (13) Transplant-related mortality rates have declined, from as high as 40% to 7% in current studies. (18) Therefore, AuSCS is an important option for patients who are deemed eligible, and it is considered medically necessary. Data on the use of AlloSCS are sparse and it remains experimental, investigational and unproven.

Based on a search of scientific literature in the MedLine database through March 2013, HPC boost to reduce the graft failure process and STR markers to monitor engraftment chimerism for the treatment of primary systemic amyloidosis are considered experimental, investigational, and unproven due to the lack of adequate evidence of safety and effectiveness documented in published, peer-reviewed medical literature.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

Rationale for Benefit Administration
 
ICD-9 Codes

41.00, 41.01, 41.02, 41.03, 41.04, 41.05, 41.06, 41.07, 41.08, 41.09, 41.91, 99.25, 99.74, 99.79, 277.30-277.39 

ICD-10 Codes

E85.0-E85.9, 30243G0, 30243X0, 30243Y0, 07DQ0ZZ, 07DQ3ZZ, 07DR0ZZ, 07DR3ZZ, 07DS0ZZ, 07DS3ZZ 

Procedural Codes: 36511, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38220, 38221, 38230, 38232, 38240, 38241, 38242, 38243, 81265, 81266, 81267, 81268, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 86805, 86806, 86807, 86808, 86812, 86813, 86816, 86817, 86821, 86822, 86825, 86826, 86828, 86829, 86830, 86831, 86832, 86833, 86834, 86835, 86849, 86950, 86985, 88240, 88241, S2140, S2142, S2150
References
  1. Gertz MA, Lacy MQ, Dispenzieri A. Amyloidosis: recognition, confirmation, prognosis, and therapy. Mayo Clin Proc 1999; 74(5):490-4.
  2. Comenzo RL, Gertz MA. Autologous stem cell transplantation for primary systemic amyloidosis. Blood 2002; 99(12):4276-82.
  3. Jones NF, Hilton PJ, Tighe JR et al. Treatment of "primary" renal amyloidosis with melphalan. Lancet 1972; 2(7778):616-9.
  4. Comenzo RL, Vosburgh E, Falk RH et al. Dose-intensive melphalan with blood stem-cell support for the treatment of AL (amyloid light-chain) amyloidosis: survival and responses in 25 patients. Blood 1998; 91(10):3662-70.
  5. Moreau P, Leblond V, Bourquelot P et al. Prognostic factors for survival and response after high-dose therapy and autologous stem cell transplantation in systemic AL amyloidosis: a report on 21 patients. Br J Haematol 1998; 101(4):766-9.
  6. Dispenzieri A, Lacy MQ, Kyle RA et al. Eligibility for hematopoietic stem-cell transplantation for primary systemic amyloidosis is a favorable prognostic factor for survival. J Clin Oncol 2001; 19(14):3350-6.
  7. Gertz MA, Lacy MQ, Dispenzieri A. Myeloablative chemotherapy with stem cell rescue for the treatment of primary systemic amyloidosis: a status report. Bone Marrow Transplant 2000; 25(5):465-70.
  8. Saba N, Sutton D, Ross H et al. High treatment-related mortality in cardiac amyloid patients undergoing autologous stem cell transplant. Bone Marrow Transplant 1999; 24(8):853-5.
  9. Dispenzieri A, Kyle RA, Lacy MQ et al. Superior survival in primary systemic amyloidosis patients undergoing peripheral blood stem cell transplantation: a case-control study. Blood 2004; 103(10):3960-3.
  10. Skinner M, Sanchorawala V, Seldin DC et al. High-dose melphalan and autologous stem-cell transplantation in patients with AL amyloidosis: an 8-year study. Ann Intern Med 2004; 140(2):85-93.
  11. Seldin DC, Anderson JJ, Skinner M et al. Successful treatment of AL amyloidosis with high-dose melphalan and autologous stem cell transplantation in patients over age 65. Blood 2006; 108(12):3945-7.
  12. Vesole DH, Perez WS, Akasheh M et al. High-dose therapy and autologous hematopoietic stem cell transplantation for patients with primary systemic amyloidosis: a Center for International Blood and Marrow Transplant Research Study. Mayo Clin Proc 2006; 81(7):880-8.
  13. Sanchorawala V, Skinner M, Quillen K et al. Long-term outcome of patients with AL amyloidosis treated with high-dose melphalan and stem-cell transplantation. Blood 2007; 110(10):3561-3.
  14. Gertz MA, Lacy MQ, Dispenzieri A et al. Effect of hematologic response on outcome of patients undergoing transplantation for primary amyloidosis: importance of achieving a complete response. Haematologica 2007; 92(10):1415-8.
  15. Jaccard A, Moreau P, Leblond V et al. High-dose melphalan versus melphalan plus dexamethasone for AL amyloidosis. N Engl J Med 2007; 357(11):1083-93.
  16. Cibeira MT, Sanchorawala V, Seldin DC et al. Outcome of AL amyloidosis after high-dose melphalan and autologous stem cell transplantation: long-term results in a series of 421 patients. Blood 2011; 118(16):4346-52.
  17. Wechalekar AD, Hawkins PN, Gillmore JD. Perspectives in treatment of AL amyloidosis. Br J Haematol 2008; 140(4):365-77.
  18. Gertz MA, Lacy MQ, Dispenzieri A et al. Trends in day 100 and 2-year survival after auto-SCT for AL amyloidosis: outcomes before and after 2006. Bone Marrow Transplant 2011; 46(7):970-5.
  19. Comenzo RL. Who knows how to treat systemic light chain amyloidosis? Oncology (Williston Park) 2011; 25(7):626, 28-9, 32-3.
  20. Gertz MA. Immunoglobulin light chain amyloidosis: 2011 update on diagnosis, risk-stratification, and management. Am J Hematol 2011; 86(2):180-6.
  21. NCCN – National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Multiple Myeloma (V.1.2013). Available at http://wwwnccn.org (accessed on 2012 November 30).
  22. ACS – Stem Cell Transplant (Peripheral Blood, Bone Marrow, and Cord Blood Transplants) (2013). American Cancer Society. Available at http://www.cancer.org (accessed – 2013 April 15).
  23. Slatter, M.A., Bhattacharya, A., et al. Outcome of boost hematopoietic stem cell transplant for decreased donor chimerism or grapft dysfunction in primary immunodeficiency. Bone Marrow Transplantation (2005) 35:683-9.
  24. Larocca, A., Piaggio, G., et al. A boost of CD35+-selected peripheral blood cells without further conditioning in patients with poor graft function following allogeneic stem cell transplantation. The Hematology Journal (2006) 91(7):935-40.
  25. NIH – Marrsson, J., Ringden, O., et al. Graft failure after allogeneic hematopoietic cell transplantation. Biology and Blood Marrow Transplant (2008 January) 14(Supplement 1):165-70. National Institutes of Health Public Access. Available at http://www.nih.gov (accessed – 2013 April 15).
  26. Borrill, V., Schlaphoff, T., et al. The use of short tandem repeat polymorphisms for monitoring chimerism follow bone marrow transplantation: a short report. Hematology (2008 August) 13(4):210-4.
  27. Crow, J., Youens, K., et al. Donor cell leukemia in umbilical cord blood transplant patients: a case study and literature review highlighting the importance of molecular engraftment analysis. Journal of Molecular Diagnostics (2010 July) 12(4):530-7.
  28. Park, M., Koh, K.N., et al. Clinical implications of chimerism after allogeneic hematopoietic stem-cell transplantation in children with non-malignant diseases. Korean Journal of Hematology (2011 December) 46(4):258-64.
  29. Odriozola, A., Riancho, J.A., et al. Evaluation of the sensitivity of two recently developed STR multiplexes for the analysis of chimerism after hematopoietic stem-cell transplantation. International Journal of Immunogenetics (2013 April) 40(2):88-92.
  30. Lawler, M., Crampe, M., et al. The EuroChimerism concept for standardized approach to chimerism analysis after allogeneic stem-cell transplantation. Leukemia (2012 August) 26(8):1821-8.
  31. Tilanus, M.G. Short tandem repeat markers in diagnostics: what’s in a repeat? Leukemia (2006 August) 20(8):1353-55. Available at http://www.nature.com (accessed – 2013 April 22).
  32. High-Dose Chemotherapy plus Hematopoietic Stem-Cell Support to Treat Primary Amyloidosis. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 February) Therapy 8.01.42.
  33. Donor Leukocyte Infusion for Malignancies A Treated with an Allogeneic Stem-Cell Transplant. BCBSA Medical Policy Reference Manual (2012 May) Medicine: 2.03.03.
History
August 2011 New Policy for BCBSMT. Codes already sent with other Hematopoietic Stem-Cell Transplant policies.
October 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis" to "Stem-Cell Transplant for Primary Systemic Amyloidosis".
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Stem-Cell Transplant for Primary Systemic Amyloidosis