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