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2.03.11	Quimioterapia en dosis altas con la ayuda de células madres hematopoyéticas en Cáncer de Mama
SecciónMedicina	Fecha Original: 15 de diciembre de 2005
SubsecciónOncología	Fecha Revisión8 de agosto de 2017
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Definición

El uso de quimioterapia en dosis altas (HDC) y trasplante de células madres hematopoyéticas (HSCT), en lugar de la dosis estándar de quimioterapia, se usa en un intento de prolongar la sobre vida en mujeres en alto riesgo de cáncer de mama metastatico y no metastatico.
TRASFONDO
Trasplante de Células Madres Hematopoyéticas (HSCT)
Se refiere a un procedimiento en el cual células madres hematopoyéticas son inyectadas para restaurar la función de la medula ósea en pacientes que reciben quimioterapia con drogas citotóxicas a la medula ósea. Estas células madres se obtienen de un recipiente (HSCT autólogo) o de un donante (HSCT alogeneico). Estas células pueden obtenerse de la medula ósea, sangre periférica o sangre del cordón umbilical inmediatamente luego del parto. Aunque la sangre del cordón es una fuente alogenéica, estas células madres son antigénicamente “ignorantes” y por lo tanto están asociadas a una incidencia de rechazo muy baja.
La compatibilidad inmunológica entre las células madres infundidas y el recipiente no es un problema mayor en los trasplantes autólogos de HSCT. Sin embargo esta compatibilidad inmunológica entre donante y paciente es un factor crítico cuando se trata de trasplante alogenéicos (HSCT). La compatibilidad se establece tipificando los antígenos de leucocitos humanos (HLA) usando células, serología o técnicas moleculares. HLA se refiere al tipo de tejido según expresado en el Loci en la clasificación I y clasificación II del cromosoma 6.
Condicionamiento Convencional para HSCT
El éxito del trasplante autólogo de HSCT consiste en la habilidad de la quimioterapia citotóxica de erradicar, con o sin radiación, células cancerosas de la sangre y de la medula ósea. Esto permite que luego la medula ósea se repoble presumiblemente con células madres normales obtenidas del paciente previo a la ablación de la medula ósea. Como consecuencia, el trasplante autólogo de HSCT se realiza como una terapia de consolidación cuando la condición del paciente está en completa remisión. Pacientes a los cuales se le realiza trasplante autólogos de HSCT están o son susceptibles a toxicidades asociadas y a infecciones oportunísticas previo al trasplante.
El trasplante alogeneico (Convencional o Clásico) consiste en la administración de agentes citotoxicos (ej. Ciclofosfamide, Busulfan) con o sin irradiación total al cuerpo en dosis lo suficientemente alta para destruir la capacidad hematopoyética en el paciente. El efecto beneficioso de este procedimiento se debe a una erradicación inicial de las células malignas y el efecto subsiguiente de injerto versus células malignas (efecto similar al injerto Vs Huésped). Este efecto se considera ser potencialmente curativo.
Condicionamiento de Intensidad Reducida para HSCT Alogenéicos
El acondicionamiento de intensidad reducida (RIC) se refiere al uso de pre trasplante de dosis más bajas y menos intensas de regímenes de drogas citotóxicas o radiación que las usadas en el tratamiento tradicional preparativo mielo ablativo. La meta de RIC es reducir la carga de enfermedad y minimizar tanto como sea posible la morbilidad asociada y la mortalidad en el periodo durante el cual se obtiene el beneficio del efecto de GVM del trasplante.
HSCT en Tumores Sólidos de Adultos
HSCT es un tratamiento establecido para ciertas malignidades hematológicas sin embargo su uso en tumores sólidos en adultos, continua siendo generalmente experimental.
Política
El trasplante hematopoyético de células madre Individual o en tándem no se considera para pago para tratar cualquier etapa del cáncer de mama.
El trasplante hematopoyético alogénico de células madres no se considera para pago para el tratamiento de cualquiera de las etapas del cáncer de mama.
Códigos

CPT	Description
38204	Management of recipient hematopoietic cell donor search and cell acquisition
38205	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection, allogeneic
38206	Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection, autologous
38208	Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor
38209	Transplant preparation of hematopoietic progenitor cells;thawing of previously frozen harvest, with washing, per donor
38210	Transplant preparation of hematopoietic progenitor cells;specific cell depletion with harvest, T cell depletion
38211	Transplant preparation of hematopoietic progenitor cells;tumor cell depletion
38212	Transplant preparation of hematopoietic progenitor cells;red blood cell removal
38213	Transplant preparation of hematopoietic progenitor cells;platelet depletion
38214	Transplant preparation of hematopoietic progenitor cells;plasma (volume) depletion
38215	Transplant preparation of hematopoietic progenitor cells;cell concentration in plasma, mononuclear, or buffy coat layer
38220	Bone marrow; aspiration only
38221	Bone marrow; biopsy, needle or trocar
38230	Bone marrow harvesting for transplantation; allogeneic
38232	Bone marrow harvesting for transplantation; autologous
38240	Bone marrow or blood-derived peripheral stem-cell transplantation; allogeneic
38241	Bone marrow or blood-derived peripheral stem-cell transplantation; autologous
38242	Allogeneic donor lymphocyte infusions

ICD-9 Procedure	Description
41.01	Autologous bone marrow transplant without purging
41.02	Allogeneic bone marrow transplant with purging
41.03	Allogeneic bone marrow transplant without purging
41.04	Autologous hematopoietic stem-cell transplant without purging
41.05	Allogeneic hematopoietic stem-cell transplant without purging
41.07	Autologous hematopoietic stem-cell transplant with purging
41.08	Allogeneic hematopoietic stem-cell transplant with purging
41.09	Autologous bone marrow transplant with purging
41.91	Aspiration of bone marrow from donor for transplant
99.79	Other therapeutic apheresis (includes harvest of stem cells)

ICD-9 Diagnosis	Description
174.0-174.9	Malignant neoplasm of the female breast (code range)
175.0-175.9	Malignant neoplasm of male breast (code range)

ICD-10-CM (Effective date 10/01/15)	Description
	Not medically necessary or investigational for all relevant diagnoses
C50.111	Malignant neoplasm of central portion of right female breast
C50.112	Malignant neoplasm of central portion of left female breast
C50.121	Malignant neoplasm of central portion of right male breast
C50.122	Malignant neoplasm of central portion of left male breast
C50.211	Malignant neoplasm of upper-inner quadrant of right female breast
C50.212	Malignant neoplasm of upper-inner quadrant of left female breast
C50.221	Malignant neoplasm of upper-inner quadrant of right male breast
C50.222	Malignant neoplasm of upper-inner quadrant of left male breast
C50.311	Malignant neoplasm of lower-inner quadrant of right female breast
C50.312	Malignant neoplasm of lower-inner quadrant of left female breast
C50.321	Malignant neoplasm of lower-inner quadrant of right male breast
C50.322	Malignant neoplasm of lower-inner quadrant of left male breast
C50.411	Malignant neoplasm of upper-outer quadrant of right female breast
C50.412	Malignant neoplasm of upper-outer quadrant of left female breast
C50.421	Malignant neoplasm of upper-outer quadrant of right male breast
C50.422	Malignant neoplasm of upper-outer quadrant of left male breast
C50.511	Malignant neoplasm of lower-outer quadrant of right female breast
C50.512	Malignant neoplasm of lower-outer quadrant of left female breast
C50.521	Malignant neoplasm of lower-outer quadrant of right male breast
C50.522	Malignant neoplasm of lower-outer quadrant of left male breast
C50.611	Malignant neoplasm of axillary tail of right female breast
C50.612	Malignant neoplasm of axillary tail of left female breast
C50.621	Malignant neoplasm of axillary tail of right male breast
C50.622	Malignant neoplasm of axillary tail of left male breast
C50.811	Malignant neoplasm of overlapping sites of right female breast
C50.812	Malignant neoplasm of overlapping sites of left female breast
C50.821	Malignant neoplasm of overlapping sites of right male breast
C50.822	Malignant neoplasm of overlapping sites of left male breast
C50.911	Malignant neoplasm of unspecified site of right female breast
C50.912	Malignant neoplasm of unspecified site of left female breast
C50.921	Malignant neoplasm of unspecified site of right male breast
C50.922	Malignant neoplasm of unspecified site of left male breast
C79.81	Secondary malignant neoplasm of breast

ICD-10-CM Termination date 10/01/2015	Description
C50.019	Malignant neoplasm of nipple and areola, unspecified female breast
C50.029	Malignant neoplasm of nipple and areola, unspecified male breast
C50.119	Malignant neoplasm of central portion of unspecified female breast
C50.129	Malignant neoplasm of central portion of unspecified male breast
C50.219	Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.229	Malignant neoplasm of upper-inner quadrant of unspecified male breast
C50.319	Malignant neoplasm of lower-inner quadrant of unspecified female breast
C50.329	Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50419	Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.429	Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.519	Malignant neoplasm of lower-outer quadrant of unspecified female breast
C50.529	Malignant neoplasm of lower-outer quadrant of unspecified male breast
C50.619	Malignant neoplasm of axillary tail of unspecified female breast
C50.629	Malignant neoplasm of axillary tail of unspecified male breast
C50.819	Malignant neoplasm of overlapping sites of unspecified female breast
C50.829	Malignant neoplasm of overlapping sites of unspecified male breast
C50.919	Malignant neoplasm of unspecified site of unspecified female breast
C50.929	Malignant neoplasm of unspecified site of unspecified male breast

ICD-10-PCS (effective 10/1/15)	Description
	ICD-10-PCS codes are only used for inpatient services.
30230G0, 30233G0	Transfusion of autologous bone marrow into peripheral vein, code by approach
30230G1, 30233G1	Transfusion of nonautologous bone marrow into peripheral vein, code by approach
30240G0, 30243G0	Transfusion of autologous bone marrow into central vein, code by approach
30240G1, 30243G1	Transfusion of nonautologous bone marrow into central vein, code by approach
30250G0, 30253G0	Transfusion of autologous bone marrow into peripheral artery, code by approach
30250G1, 30253G1	Transfusion of nonautologous bone marrow into peripheral artery, code by approach
30260G0, 30263G0	Transfusion of autologous bone marrow into central artery, code by approach
30260G1, 30263G1	Transfusion of nonautologous bone marrow into central artery, code by approach
3E03005, 3E03305	Introduction of other antineoplastic into peripheral vein, code by approach
3E04005, 3E04305	Introduction of other antineoplastic into central vein, code by approach
3E05005, 3E05305	Introduction of other antineoplastic into peripheral artery, code by approach
3E06005, 3E06305	Introduction of other antineoplastic into central artery, code by approach
30230AZ, 30233AZ	Transfusion of stem cells, embryonic into peripheral vein, code by approach
30230Y0, 30233Y0	Transfusion of autologous stem cells, hematopoietic into peripheral vein, code by approach
30240AZ, 0243AZ	Transfusion of stem cells, embryonic into central vein, code by approach
30240Y0, 30243Y0	Transfusion of autologous stem cells, hematopoietic into central vein, code by approach
30250Y0, 30253Y0	Transfusion of autologous stem cells, hematopoietic into peripheral artery, code by approach
30260Y0, 30263Y0	Transfusion of autologous stem cells, hematopoietic into central artery, code by approach
30230Y1, 30233Y1	Transfusion of nonautologous stem cells, hematopoietic into peripheral vein, code by approach
30240Y1, 30243Y1	Transfusion of nonautologous stem cells, hematopoietic into central vein, code by approach
30250Y1, 30253Y1	Transfusion of nonautologous stem cells, hematopoietic into peripheral artery, code by approach
30260Y1, 30263Y1	Transfusion of nonautologous stem cells, hematopoietic into central artery, code by approach
079T00Z, 079T30Z, 079T40Z	Drainage of bone marrow with drainage device, code by approach
079T0ZZ, 079T4ZZ	Drainage of bone marrow, code by approach
07DQ0ZZ, 07DQ3ZZ	Extraction of sternum bone marrow, code by approach
07DR0ZZ, 07DR3ZZ	Extraction of iliac bone marrow, code by approach
07DS0ZZ, 07DS3ZZ	Extraction of vertebral bone marrow, code by approach
6A550ZT, 6A551ZT	Pheresis of cord blood stem cells, code for single or multiple
6A550ZV, 6A551ZV	Pheresis of hematopoietic stem cells, code for single or multiple

Limitación
Según las establecidas en la póliza.
___________________________ ____________________________________
Ángela Hernández, MD Benjamín Santiago, MD
Director Médico Asociado VP Manejo Médico
Rev. 08/08/2017
05/18/16
02/12/2015
2/20/2014
02/07/13
03/15/12
06/26/09 (iCES)
07/09/07

Referencias

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3. Leonard RC, Lind M, Twelves C et al. Conventional adjuvant chemotherapy versus single-cycle, autograft-supported, high-dose, late-intensification chemotherapy in high-risk breast cancer patients: a randomized trial. J Natl Cancer Inst 2004; 96(14):1076-83.

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17. Wang J, Zhang Q, Zhou R et al. High-dose chemotherapy followed by autologous stem cell transplantation as a first-line therapy for high-risk primary breast cancer: a meta-analysis. PLoS One 2012; 7(3):e33388.

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