Overview Of Blood and Marrow Transplantation AAMDS Conference Moncton, New Brunswick October 15, 2016 Stephen Couban Division of Hematology Dalhousie University and Nova Scotia Health Authority
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Overview Of Blood and Marrow Transplantation
AAMDS Conference Moncton, New Brunswick
October 15, 2016 Stephen Couban
Division of Hematology Dalhousie University and Nova Scotia Health Authority
Disclosures: Stephen Couban
Research support NCIC CTG, NIH, Terry Fox Research Institute, Genzyme-Sanofi, CIHR
Employee Nil
Consultant Lundbeck (Arsenic trioxide)
Stockholder Nil
Speaker bureau Nil
Scientific advisory board
Novartis, BMS, Genzyme, Roche, Celgene, GSK, Schering, Otsuka, Lundbeck
• All photographs of patients are used with their permission
Objectives:
• Describe the different types of bone marrow and peripheral blood transplant
• Review transplant eligibility criteria
– Which patients benefit from a transplant?
• Describe major diseases for which transplant is undertaken
• Explain graft vs host disease and the graft versus tumour effect
Goals of BMT
• Cancer therapy – Often with the intent to cure the disease
• Marrow replacement – Aplastic anemia, thalassemia, sickle cell disease
• Developmental – Connective tissue diseases: scleroderma – Multiple sclerosis – Brain tumours – (Breast Cancer)
Stem Cell Source
Autologous
Syngeneic Allogeneic
Related Donor
(family)
Unrelated Donor (MUD)
(volunteer)
Types of Transplant
Stem Cell Source
Autologous
Syngeneic Allogeneic
Myeloablative
Related Donor
Unrelated Donor
Non Myeloablative
Reduced Intensity
“Mini-Transplant”
Related Donor
Unrelated Donor
Types of Transplant
Other Types of Transplant • Cord blood transplants • Haplo-identical transplants
Key Points
1. Many types of blood and marrow transplant – Different risks and benefits
2. Different terms to describe similar types of transplant – Non-myeloablative transplant or reduced intensity transplant or “mini
transplant” – Stem cell transplant or autologous transplant or peripheral blood
transplant.
3. Key distinction: autologous vs allogeneic
Autologous Transplant
Stem Cell Source
Autologous
Syngeneic Allogeneic
Related Donor
Unrelated Donor
(MUD)
Autologous Transplant
• Age – 70 years old or younger
• Evidence of benefit
• Performance State – vital organ function (heart, lungs, liver, kidneys)
• Chemosensitivity
Autologous Indications: 2016
• Myeloma
– Novel therapies
• Relapsed Lymphoma
– Hodgkin, Non-hodgkin’s lymphoma
• Acute leukemia
• Solid tumours – Germ cell tumour
– (breast cancer)
Autologous Transplant: Stages
1. Pre-transplant chemotherapy
2. Harvest
3. Conditioning
4. Infusion
5. Recovery
1. Pre-Transplant Chemotherapy
•Demonstrate chemosensitivity •Reduce the amount of cancer cells in the patient
2. Harvest: Source of Cells
Autologous Transplant
Bone Marrow Peripheral Blood
“stem cells”
Bone Marrow Harvest
• Advantages
– No further chemotherapy
– No growth factors
– One day
• Disadvantages
– General anesthetic
– Large volume
Peripheral Blood Harvest • Advantages
– No general anesthetic
– Small volume
– Recovery of counts
• Disadvantages
– Chemotherapy
– Growth factors
– Apheresis
3. Conditioning
Standard
Chemo Conditioning
Chemotherapy Radiation
(TBI)
4+5. Infusion to Count Recovery
Engraftment
•Infection •Bleeding •Organ Dysfunction •ICU
Late Effects
• Organ Damage: pulmonary, cardiac, renal
• Second Cancers
• Hormonal issues • Underactive thyroid, osteoporosis
• Infertility
• Cataracts
•Relapse
Unrelated Donor
Infection (19%)
Other (20%)
Organ toxicity (10%) Relapse (33%)
IPn (5%)
GVHD (13%)
SUM09_19.ppt
Slide 18
HLA-identical Sibling
Infection (16%)
Other (19%)
Organ toxicity (9%) Relapse (42%)
IPn (2%)
GVHD (12%)
Causes of Death after Autologous Transplantation
Relapse is the single most
common cause of death after autologous transplant
Autologous
Infection (6%)
Other (14%)
Organ toxicity (5%) Relapse (73%)
IPn (1%)
Myeloma
Breast Cancer
High Dose Chemotherapy Standard Therapy
Allogeneic Transplant
Types of Transplant
Autologous Syngeneic
Allogeneic
Related Donor
(Sibling)
Unrelated Donor
(MUD)
(Volunteer)
Types of Transplant
Donor Type
Autologous Syngeneic Allogeneic
Related Non-
Myeloablative
Unrelated
Myeloablative
Myeloablative
Non-Myeloablative
RICT
RICT Graft
Source
Marrow
Peripheral Blood
Cord
Tra
nspla
nts
SUM11_41.ppt
Slide 3
Transplant Activity in the U.S. 1980-2010
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
'80 '81 '82 '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03'04' '05 '06 '07 '08 '09 '10
Autologous
Related Donor
Unrelated Donor
Allogeneic Transplant
• Age –55 years old or younger(myeloablative)
–< 65 years old or younger (non-myeloablative)
• Performance State –end organ function
• (Chemosensitivity)
Allogeneic Indications
• Leukemia –Acute leukemia, MDS > CML, CLL
• Lymphoma – Indolent lymphomas
• Myeloma – Uncommon in 2015
• Bone marrow failure: aplastic anemia • Diseased bone marrow
Allogeneic: The Match Each child inherits one set of HLA antigens
from each parent
1 2 3 4
1 3 1 4 2 3 Here, none of the siblings are a match
Allogeneic: The Match
1 2 3 4
1 3 1 4 1 3 Bill Bob Tanya
Bill and Tanya are a match
Parents/children are rarely a match for each other
Graft versus Host Disease
Reverse of graft rejection
Immune attack of donor cells against the recipient
Acute Graft versus Host Disease (aGvHD)
• Skin: Rash
• Liver: Inflammation
• Gut: Diarrhea
• Skin – Scleroderma
• GI tract – Small, dry mouth – Strictures – Chronic diarrhea
• Liver • Eyes
– Sicca syndrome – Corneal ulceration
• Nervous System – Peripheral
neuropathy
• Lungs – Bronchiolitis
obliterans – (BOOP)
• Muscles and Joints – Lupus-like syndrome – Myositis
Chronic Graft versus Host Disease (cGvHD)
• The Immune Effect in Allogeneic Transplant
– A double-edged sword
– Graft vs host disease
– Graft vs tumour effect
• No benefit of GvHD in aplastic anemia
• Significant benefit in MDS
Conclusions
• Autologous Transplant
– Identifying which patients will benefit
• cure (lymphoma)
• disease control (myeloma)
– Transplant schema
– Indications
– Risks and complications
Conclusions
• Allogeneic Transplant
– Identifying which patients will benefit
• current challenge of CML
– Transplant schema
– Indications
– Complications
– Immune effect
Patient Flow
BMT Referral ASSESSMENT: BMT Coordinator
Physician Dentist
Social Work
Other Professionals
Chemotherapy
Response?
Stem Cell Collection
Pre-Transplant Work-up Transplant
Post-Transplant Follow-up
Related Documents
