hematopoietic stem cell transplantation : an overview...hematopoietic stem cell transplantation : an...

Hematopoietic Stem Cell Transplantation : An Overview

Tracy Robinson, RN MN, CON(C) Clinical Nurse Specialist

Manitoba Blood and Marrow Transplant Program CancerCare Manitoba

DMM00_A2.ppt

Complications:

Blood & Marrow Changes:

BMT Process:

Supportive Therapy:

TIME LINE -

12

-

4

-

2

0 1 2 6 60 months

Marrow failure

Disease remission

Disease recurrenc

e

Continuous complete remission

(cure)

High-dose therapy

Primary diagnosis

and treatment

Relapse and

salvage therapy

Disease State:

Antibiotics

Nutrition

Antiemetic

s

Growth

factors

Red cell transfusions

Platelet transfusions

Donor search or obtain autologous stem cells

Chemo

XRT

PBSC/BM harvests in ABMT

Secondary tumors, cataracts, endocrine

changes, QoL

Acute and/or chronic GvHD

Viral infections CMV, VZV, PCP, IP, HSV

Bacterial

infections

mucositis

VOD

BM/SC re-

infusion

Marrow function

Immune function

eg: DHAP and GF and PBSC

Collect & freeze gcsf

Objectives

• Definition

• Indications for transplant

• Types of transplant

• Stages of BMT

• Cell sources

• Complications of BMT

What is a HSCT

– Stem cell rescue

Overview Blood and Marrow Transplantation

Red Blood Cells White Blood Cells Platelets

Stem Cell

Purpose

• Eradicate malignancy

• Reset immune system

• Facilitate hematopoeisis

Diseases Treatable by HSCT

Malignant Non Malignant

Leukemias and Lymphomas

Myelodysplastic syndromes

Multiple myeloma and other plasma cell disorders

Solid tumors

Severe aplastic anemia and other marrow failure states

Autoimmune diseases

Inherited metabolic disorders

Inherited immune system disorders

Sickle cell disease and thalassemia

MBMT Program Indication for Adult Transplants

1990-2012

0

50

100

150

200

250

Acute

Mye

loge

nous

Leu

kem

ia

Acute

Lym

phob

lastic L

euke

mia

Oth

er L

euke

mia

Mye

lody

splastic S

yndr

ome

Chr

onic M

yeloge

nous

Leu

kem

ia

Chr

onic L

ymph

ocytic L

euke

mia/P

LL

Non

-Hod

gkin's Lym

phom

a

Hod

gkin's

Lym

phom

a

Multip

le M

yeloma

Plasm

a Cell D

isor

der

Anem

ia/H

emog

lobino

path

y

Oth

er M

aligna

ncy

Non

-Maligna

nt D

isea

se

#

Transplants By Age Groups 1990-2012

17%

28%

34%

21%

0-17 years

18-40 years

41-55

>56 years

Graft Types

• Autologous

• Allogeneic related (MRD)

• Allogeneic unrelated (MUD)

• MMUD → Haploidentical

• Syngeneic

MBMT Program Total Transplants by Graft Type

1990-2013

571

320

252

8

0

100

200

300

400

500

600

# o

f T

ran

sp

lan

ts Autologous

Related Allogeneic

Unrelated Allogeneic

Syngeneic

Autologous HSCT Chemo to obtain disease control

Stem cell collection

Admission to hospital for transplant/Prep

regimen

Cells reinfused

Cells cryopreserved

Autologous HSCT

• Advantages

– Less risky (decreased TRM)

– Available donor

– No GVH

• Disadvantages

– Disease recurrence

– No GVL

– Not suitable for all diseases

– Cell collection

Allogeneic BMT

ImmunosuppressiveHigh dose therapy

Graft-versus-host disease prophylaxis

Donor

Recipient

Allogeneic BMT

• Advantages

– Uncontaminated cell sources

– Used for bone marrow failure or malignancies

– GVL effect

• Disadvantages

– Riskier transplant

– GHV effect

– Cost

– Donor availability

Haploidentical BMT

• Advantages

– Donor accessibility

• Disadvantages

– Riskier transplant

– To be determined

Stages of the BMT Process

Phase 1:The Preparative Regimen (Conditioning Regimen) (Day-xxx to Day-1)

A CONTINUUM OF CONDITIONING REGIMENS G

EN

ET

IC D

ISP

AR

ITY

CLL/AML/ALL auto LCL AML/ALL

auto MM

AGGRESSIVENESS OF MALIGNANCY

MUD

Matched

sibling

Myelosuppression

NMA01_27a.ppt

Immunosuppression

l Cy + TBI

l Flu Bu 12.8

l Mel/Etop Mel/TBI

l

Mel200 l

F+Cy

l Flu Bu6.4

Stages of the BMT Process

Phase 2: Hematopoietic Cell Infusion (Day 0)

MBMT Program

Allogeneic Cell Source 2011-2012

87%

9%4%

PBSC

BM

CB

9%

56%

35%

Adult Transplants Pediatric Transplants

The Cells

– Bone Marrow

• very rich

• spongy soft tissue found inside larger bones

• marrow removed in OR from iliac crests bilaterally with

needles and syringes

The Cells

– Peripheral Blood Stem Cells (PBSC)

• not as rich

• requires growth factors (G-CSF)

• apheresis procedure

• no anesthesia

• stem cells engraft faster

• GVHD

The Cells

– Umbilical Cord Blood Stem Cells

• rich source

• birth, collected, tissue-typed, processed and stored frozen

• first done 1988

• fixed amount cells»double cord (adult recipients)

• no access to donor

• unknown genetic disease

• Expensive!

Graft Versus Host Disease Prophylaxis

• MRD/MUD 10/10

– Immune suppression Day -2 and on

• Haplo

– Post transplant cyclophosphamide

– Day +7

Stages of the BMT Process

Phase 3: Recovery/Engraftment Period (Day +1 to +30)

Phase 4: Early Post BMT Period (Day +31- Day +100)

Early Complications

• Acute GVHD • Bacterial & Viral Infection • Stomatitis/Mucositis • Nausea & Vomiting • VOD/SOS • Pneumonitis & Pulmonary

Edema • Dysrrythmia • Renal insufficiency • Recurrence of disease

Stages of the BMT Process

• Phase 5: Late Post BMT Period (>Day +100)

Late Complications

GI/GU Musculoskeletal Dermatologic Hepatic Endocrine Sexual Relapse Psychosocial

Chronic GVHD

Infection

Neurologic

Ocular

Dental

Cardiac

Pulmonary

• The number of transplants performed annually worldwide is greater than 50,000

Causes of Death

after Transplants Done in

2009-2010

Autologous

Infection (7%)

Other (17%)

Organ Failure (3%)

New Malignancy (1%)

Primary Disease (72%)

Unrelated Donor

Infection (18%)

Other (18%)

Organ Failure (8%)

Primary Disease (37%)

New Malignancy (1%)

GVHD (18%)

Slide 18

HLA-identical Sibling

Infection (13%)

Other (16%)

Primary Disease (49%)

GVHD (16%)

Organ Failure (5%)

New Malignancy (1%)

SUM12_38.ppt

So Why Do We Do This?

One-Y

ear

Surv

ival, %

Slide 14

One-year Survival

by Year of Transplant, Donor and Age, Worldwide, 1997-2010

- In any remission, Acute Leukemia, CML or MDS-

SUM12_34.ppt

0

20

40

60

80

100

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

HLA-matched siblings, age <50 yrsUnrelated donor, age <50 yrsHLA-matched siblings, age >=50 yrsUnrelated donor, age >=50 yrs

Thank You