1. Basics of Stem Cell Transplant Tamila Kindwall-Keller, D.O. August 18, 2008

2. Copyright ©2005 American Society of Hematology. Copyright restrictions may apply. Maslak, P. ASH Image Bank 2005;2005:101401 Figure 1. Scanning under low power reveals a heterogenous population of cells

3. Background First successful transplants—late 1960s First successful transplants—late 1960s 30,000-40,000 transplants performed yearly worldwide 30,000-40,000 transplants performed yearly worldwide >20,000 patients have survived >5 years >20,000 patients have survived >5 years Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

4. Background Hematopoietic stem cell transplantation Hematopoietic stem cell transplantation –Intravenous infusion of autologous or allogeneic stem cells Collected from bone marrow, peripheral blood or umbilical cord blood Collected from bone marrow, peripheral blood or umbilical cord blood –Re-establish hematopoietic function in patients with damaged/defective bone marrow or immune systems –Potentially curative for a wide variety of disorders Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

5. Graft Sources Allogeneic: from another person Allogeneic: from another person Syngeneic: from an identical twin Syngeneic: from an identical twin Autologous: from the patient Autologous: from the patient Choice of graft is based on disease type, patient condition, donor compatibility and health Choice of graft is based on disease type, patient condition, donor compatibility and health

6. Graft Sources Autologous Transplant Autologous Transplant –No evidence of disease in the blood or bone marrow –Transplant related mortality (TRM) lowest with autos (<5%) –Relapse rates are higher depending on the disease –Absence of graft versus tumor effects Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

7. Graft Sources Allogeneic Transplants Allogeneic Transplants –High TRM (30-50%) –Lower relapse rates due to graft versus tumor effects –Graft versus host effects Matched Related Donor (siblings) Matched Related Donor (siblings) –25% chance a sibling will be a match –The more siblings a patient has the better chance for a match Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

8. Graft Sources Alternative Donors Alternative Donors –Matched Unrelated Donors (MUD) NMDP NMDP Severe GVHD Severe GVHD Higher TRM Higher TRM –Haploidentical Donors From parent, child or sibling From parent, child or sibling Must have many stem cells to overcome risk of graft rejection Must have many stem cells to overcome risk of graft rejection Increased risk of GVHD Increased risk of GVHD Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

9. HLA Typing HLA typing became feasible in 1960s HLA typing became feasible in 1960s Linked on chromosome 6 Linked on chromosome 6 Inherited as haplotypes Inherited as haplotypes 1 in 4 chance a sibling will be identical 1 in 4 chance a sibling will be identical Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

10. HLA Matching 6/6, 8/8, or 10/10 6/6, 8/8, or 10/10 –HLA loci on chromosome 6 –HLA-A, HLA-B, HLA-C, HLA-DR, HLA-DQ, HLA-DP ABO incompatibility is not an exclusion ABO incompatibility is not an exclusion Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

11. Eligibility Age < 65 Age < 65 –Autologous, mini-allo Age < 55 Age < 55 –Myeloablative allogeneic Exclusions Exclusions –CHF, uncontrolled diabetes mellitus, active infections, renal insufficiency

12. Indications Autologous Transplant Multiple myeloma Multiple myeloma NHL NHL Hodgkin’s disease Hodgkin’s disease AML AML Neuroblastoma Neuroblastoma Ovarian cancer Ovarian cancer Germ-cell tumors Germ-cell tumors Autoimmune disorders Autoimmune disorders Amyloidosis Amyloidosis Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

13. Indications for Allogeneic Transplant AML AML ALL ALL CML CML MDS MDS MPD MPD NHL NHL Hodgkin’s Disease Hodgkin’s Disease CLL CLL Multiple myeloma Multiple myeloma Juvenile CML Juvenile CML Aplastic anemia Aplastic anemia PNH PNH Fanconi’s anemia Fanconi’s anemia Blackfan-Diamond Blackfan-Diamond Thalessemia major Thalessemia major Sickle cell anemia Sickle cell anemia SCID SCID Wiskott-Aldrich Wiskott-Aldrich Inborn errors of metabolism Inborn errors of metabolism Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

14. Preparative Regimens Myeloablative Myeloablative –High doses of chemotherapy +/- radiation –3 goals Eliminate malignancy Eliminate malignancy Immunosuppression to allow engraftment Immunosuppression to allow engraftment Decrease graft versus host effects Decrease graft versus host effects Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

15. Myeloablative Regimens Myeloablative Regimens Myeloablative Regimens –Most common regimens Cyclophosphamide/TBI Cyclophosphamide/TBI Busulfan/Cyclophosphamide Busulfan/Cyclophosphamide Stem cells are essential to restore marrow function Stem cells are essential to restore marrow function Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

16. Myeloablative Regimens Therapy is based on disease Therapy is based on disease Other drugs Other drugs –Etoposide, BCNU, cytarabine, melphalan Graft versus leukemia effects in allogeneic donors Graft versus leukemia effects in allogeneic donors Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826. Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

17. Preparative Regimens Nonmyeloablative (Mini-allo) Nonmyeloablative (Mini-allo) –Sufficient immunosuppression to allow donor cell engraftment –Injury to organs less, fewer infections, fewer transfusions –Higher relapse rates –May have mixed chimerism –Graft versus tumor effects Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

18. Non-myeloablative Conditioning Alternative to conventional myeloablative regimens Alternative to conventional myeloablative regimens Older patients or patients with comorbid conditions Older patients or patients with comorbid conditions Therapeutic graft versus tumor effect Therapeutic graft versus tumor effect –Mediated by allogeneic T-cells –Donor T-cells eradicate the host’s malignant cells Georges GE, Storb R. Review of “minitransplantation”: nonmyeloablative allogeneic hematopoietic stem cell transplantation. Int J Hematol. 2003;77:3- 14.

19. Non-myeloablative Regimens Nonmyeloablative Regimens Nonmyeloablative Regimens –Usually fludarabine based –ATG is added –May be combined with other drugs Busulfan, cyclophosphamide, melphalan Busulfan, cyclophosphamide, melphalan Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

20. Non-myeloablative Regimens Better for slow growing cancers Better for slow growing cancers –CLL, NHL Graft eradicates the cancer not the chemo Graft eradicates the cancer not the chemo High relapse rates High relapse rates Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

21. Reduced Intensity Conditioning Regimens Advantages Advantages –Reduction in mortality –Reduction in non-relapse mortality –Reduced PRBC and platelet transfusions –Duration of neutropenia reduced –Reduced numbers of bacteremias –Able to give to heavily pretreated patients Sandmaier BM, Mackinnon S, Childs RW. Reduced intensity conditioning for allogeneic hematopoietic stem cell transplanation: Current perspectives. Biol Blood Marrow Transplant. 2007;13:87-97.

22. Reduced Intensity Conditioning Regimens Reduced GVHD compared to myeloablative Reduced GVHD compared to myeloablative Late onset acute GVHD occurring beyond day 100 Late onset acute GVHD occurring beyond day 100 Sandmaier BM, Mackinnon S, Childs RW. Reduced intensity conditioning for allogeneic hematopoietic stem cell transplanation: Current perspectives. Biol Blood Marrow Transplant. 2007;13:87-97.

23. Principals of Conditioning Donor Lymphocyte Infusions (DLI) Donor Lymphocyte Infusions (DLI) –T cells and NK cells –Additional anticancer effects –Preventing relapse or eliminating active disease CML and multiple myeloma CML and multiple myeloma Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

24. Umbilical Cord Blood 1 st UCB transplant 16 years ago 1 st UCB transplant 16 years ago –Child with Fanconi’s anemia Cell dose is given per recipient weight Cell dose is given per recipient weight –Lower patient weights the high the cell dose –2 x 10 7 nucleated cells/kg –1.7 x 10 7 CD 34+ cells/kg 4/6 match UCB with sufficient cells has a similar outcome to a matched or one antigen mismatched MUD 4/6 match UCB with sufficient cells has a similar outcome to a matched or one antigen mismatched MUD Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

25. Umbilical Cord Blood Umbilical Cord Blood Umbilical Cord Blood –Cryopreserved –Small number of stem cells –Higher incidence of engraftment failure Using more than one unit in adults Using more than one unit in adults –Lower risk of GVHD –Degree of matching not as stringent Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

26. Umbilical Cord Blood Lower GVHD Lower GVHD TRM not different than MUD TRM not different than MUD Can be used with myeloablative or nonmyeloablative conditioning (on a clinical trial) Can be used with myeloablative or nonmyeloablative conditioning (on a clinical trial) Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.

27. Haploidentical Transplants Parent, sibling or child Parent, sibling or child High rate of engraftment failure High rate of engraftment failure GVHD GVHD Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

28. Collection of Stem Cells Bone Marrow Harvest Bone Marrow Harvest –General anesthesia –Equivalent of 50-100 bone marrow biopsies –Used much less often –2 deaths in 8000 collections Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

29. Copyright ©2005 American Society of Hematology. Copyright restrictions may apply. Maslak, P. ASH Image Bank 2005;2005:101279 Figure 2. The posterior iliac crests (arrows) are common sites for bone marrow aspiration and biopsy

30. Collection of Stem Cells Stem Cell Collection (mobilization) Stem Cell Collection (mobilization) –Stem cells circulate in the blood –Identified by CD34+ by flow cytometry –Filgrastim, sargramostim, AMD 3100 –Stem cells are collected through an apheresis catheter –More cells are collected –Higher chronic GVHD than bone marrow harvest –More rapid marrow recovery Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

31. Infusion of Stem Cells Stem cells may be infused fresh within a few hours of collection Stem cells may be infused fresh within a few hours of collection May be frozen using DMSO May be frozen using DMSO –Creamed corn or garlic smell Umbilical cord blood is obtained from one of the umbilical cord veins and frozen with an anticoagulant and nutrient media Umbilical cord blood is obtained from one of the umbilical cord veins and frozen with an anticoagulant and nutrient media Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

32. Stem Cell Manipulation ABO incompatible ABO incompatible –Removal of isoagglutinins or RBCs T-cell depletion T-cell depletion –Reduce incidence of GVHD –Increased graft failure –Increased relapse rates In vitro purging In vitro purging –Removal of tumor cells –Positive selection of CD34+ cells Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

33. Complications Early Early –Mucositis –Sinusoidal obstructive syndrome (VOD) Fluid retention, jaundice, hepatomegaly Fluid retention, jaundice, hepatomegaly –Transplant related infections Damage to mouth, gut and skin Damage to mouth, gut and skin Prolonged neutropenia Prolonged neutropenia Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

34. Complications Early Early –Pancytopenia PRBC and platelet transfusions PRBC and platelet transfusions Broad spectrum antimicrobials Broad spectrum antimicrobials Antifungals if prolonged fevers 3-5 days Antifungals if prolonged fevers 3-5 days Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

35. Complications Early Early –Graft Versus Host Disease Acute GVHD to day 100 Acute GVHD to day 100 –Skin, GI tract, liver Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409 Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

36. Complications Early Early –Graft Rejection Host versus graft Host versus graft Drug injury to marrow Drug injury to marrow Viral infections: CMV, HHV-6 & 8 Viral infections: CMV, HHV-6 & 8 –Interstitial Pneumonitis Diffuse alveolar hemorrhage Diffuse alveolar hemorrhage Too few donor stem cells Too few donor stem cells ARDS often caused by CMV ARDS often caused by CMV Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409

37. Complications Delayed Delayed –Chronic GVHD Scleroderma or Sjogrens syndrome Scleroderma or Sjogrens syndrome Bronchiolitis Bronchiolitis Keratoconjunctivitis Keratoconjunctivitis Malabsorption Malabsorption Cholestasis Cholestasis Esophageal stricture Esophageal stricture Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813- 1826.

38. Late Complications Secondary Tumors Secondary Tumors –Acute leukemias, solid tumors, MDS –Months to years after transplant –Increased incidence with TBI Late Infections Late Infections –Bacterial, viral fungal –Months after transplant –Associated with GVHD –Need repeat vaccinations Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, flu Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, flu Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3 rd edition 2002:399-409