Bone Marrow Transplant in India

Bone Marrow Transplantation


Overview

Hematopoietic Stem Cell (HSCT) / Bone Marrow Transplantation (BMT) is a life saving treatment for variety of diseases including Blood Cancers like Leukemia, Lymphoma, Myeloma etc, as well as benign disorders like Aplastic Anemia and Thalassaemia.

Transplant at RGCI & RC

Rajiv Gandhi Cancer Institute has a 4 bedded, HEPA filtered transplant unit and a dedicated team of renowned transplant specialists and Hemato - Oncologists. Bone Marrow Transplant Programme started in RGCI & RC in 2001 and since then more than 200 transplants have been performed placing RGCI & RC among leading transplant centres in India. Transplant is an expensive treatment, requires lot of resources but in RGCI & RC cost of a transplant has been very affordable as compared to other private sector hospitals. A large chunk of our patients come from neighboring countries and overall our results of transplant have been at par with international standards.  Diseases for which transplant has been done includes -

Transplant for non-malignant conditions
  • Aplastic Anemia
  • Thalassaemia Major

Transplant for malignant conditions
  • Multiple Myeloma (MM)
  • Non-hodgkins and  Hodgkin’s lymphoma
  • Acute Myeloid Leukemia (AML)
  • Acute Lymphoblastic Leukemia (ALL)
  • Chronic Myeloid Leukemia (CML)

Whom to contact

Transplant coordinator- +91-11-47022261


Transplant procedure

1) What is a transplant?

Bone Marrow is the tissue inside the bones, which contains blood forming cells, known as  Hematopoietic Stem Cells (HSC). If this Bone Marrow malfunctions due to reasons like cancer (Leukemia) or Immunological causes (Aplastic Anemia) then deficiency of formed components of blood, resulting in weakness, infections and bleeding ultimately leading to death. Bone Marrow or Hematopoietic Stem cell transplant is a procedure in which Diseased Marrow is replaced by Healthy Marrow or Hematopoitic Stem Cells.

2) Why transplant?

There are some diseases like Aplastic Anemia or Thalassamia, in which conventional  treatment options are mainly supportive blood / component transfusions requiring multiple blood donors and frequent hospitalization, ultimately results in iron overload and viral (HIV, Hepatitis B, Hepatitis C) infections. Allogenic Bone Marrow / Stem cell is the only curative treatment available for these patients. Similarly treatment of Leukemia consisted of Chemotherapy but the allogenic transplant remains the most potent Antileukemia Therapy and is a curative option. In Leukemia Chemotherapy dictum is higher the dose, better the disease control. Very high doses of Chemotherapy can not be given due to lethal toxicity of Bone Marrow failure. During transplant a very high dose of Chemotherapy is given to eradicate the diseased Bone Marrow but it is followed by infusion of donor’s hematopoietic stem cells (allogenic transplant ) or patients own precollected stem cells to restore blood production. The effectiveness of transplant depends upon high dose Chemotherapy given and  graft versus Leukemia / Lymphoma effect, which is seen in allogenic transplant in which donors stem cell destroys cancer cells which escapes killing by Chemotherapy.

3) Sources of hematopoietic stem cells

3.1) Bone Marrow

Stem cells from Bone Marrow are collected by using aspiration needles from the iliac crest (hip bone). It is carried out under general Anesthesia, is safe and painless. Bone Marrow stem cells are preferred in diseases like Thalassaemia or Aplastic Anemia. With Bone Marrow as a graft source, recovery period is delayed as compared with peripheral blood stem cells but the risk of graft versus host disease is less.

3.2) Peripheral Blood

Stem cells can also be collected from larger veins of body using a cell separator machine after giving growth factor injections for 3-4 days. It is a very safe and reliable procedure taking only a few hours and does not require Anesthesia. In comparison to Bone Marrow recovery is earlier by 5-7 days. This type of transplant is preferred for Leukemia, Myeloma and Lymphomas.

3.3) Cord Blood

Blood collected from placenta after birth is a rich source of Hematopoietic Stem Cells, can also be used for allogenic stem cell transplants. Problem is low volume and cell dose resulting in delayed recovery / engraftment failure.

4) Autologous Versus Allogenic Transplant

Autologous Transplant involves using a patients own Hematopoietic Stem Cells. It is usually done for multiple Myeloma, Relapsed Lymphoma and Acute Myeloid Leukemia. In this procedure a patient’s stem cells are first collected once his disease is in a fair degree of control and then a very high dose of Chemotherapy is given to eradicate existing Bone Marrow followed by reinfusion of  collected stem cells to reestablish blood formation.
In Allogenic Transplant Stem cells are collected from a healthy donor who is HLA antigen matched to the patient. This healthy donor is usually a sibling (related donor) or can be found from international donor registry (unrelated donor) or obtained from umbilical cord blood. At present in India there is no national HLA registry exists.

5) Transplant Process

A Transplant Process includes three steps- Stem Cell Collection, Conditioning, Stem Cell Infusion & Engraftment. Average time taken for transplant ranges from 3-4 weeks after that patient is discharged home on oral medications to prevent graft versus host disease and infections. Patients need to be in close regular follow up for first 3- 6 months of transplant and advised to stay near the transplant centre. By the one year post transplant patient’s immune system recovers and most of the medicines can be stopped.

5.1) Stem Cell Collection

Stem Cells are collected from donors blood (in allogenic transplant) by cell separator machine or Bone Marrow aspiration. In Autologous transplant Stem Cells are collected by cell separator machine from patients own blood. Hence, it can be done only after disease has been brought under control by using standard treatment.

5.2 ) Conditioning

Conditioning is the name given to high dose Chemotherapy or Radiotherapy to destroy or suppress patients existing Bone Marrow so that donor Stem Cell can home in Bone Marrow and start functioning. Drugs used in conditioning differs by the underlying condition for which transplant is being done.

5.3) Stem Cell Infusion & Engraftment

After conditioning Blood Stem Cells or Bone Marrow are given to the patient through veins, just like Blood Transfusion. These stem cells then reach to Bone Marrow, home there and start producing blood. Time taken for blood production is called engraftment period. Before engraftment patients blood counts are markedly depressed for around 7-10 days, chances of infections are highs so patients are kept in strict isolation rooms. During this time patient will need close monitoring of blood counts and regular blood/platelet transfusions.

Side Effects

Side effects of transplant are due to Chemotherapy / Radiotherapy used in conditioning which is seen both in Autologous and Allogenic Transplants or Immunological Reaction known as graft vesus host disease seen in Allogenic Transplants.

Nausea, Vomiting, Loss of Appetite- Usually it is for short period, lasting for few days. With the availability of modern drugs it can be prevented and controlled to great extent.
Mouth ulcers - usually mild, lasting for few days and not requires specific treatment other than pain control but some times it can be severe enough to forbid drinking / swallowing in that case patients are given nutrition through veins.

Hair Loss- High dose chemotherapy / radiotherapy used in conditioning results in universal hair loss but it should not be worrisome as hairs come back with in few months after transplant. 

Fever - Patients are prone to infections due to markedly low white blood cell counts before engraftment. To prevent infections patient are kept in strict isolation rooms with filtered air till their blood counts improve.

Bleeding - Platelets are the blood component which prevents bleeding and their count decreased after conditioning, resulting in risk of bleeding in skin, mouth, nose or other sites. To prevent bleeding, platelets are transfused every other day or earlier to maintain an acceptable platelet count. Once engraftment occurs, the  platelet production starts and bleeding risk disappears.

Fertility- In almost all adult / adolescent male and female patients, sterility occurs after transplant due to side effects of chemotherapy / radiotherapy although ability to have sex is not affected by transplant.  It is advisable for males patients, who plan to have family to have their sperm stored for future use.

Graft Versus Host Disease- Once engraftment occurs, one side effect which is seen in Allogenic Transplant is Graft Versus Host Disease (GVHD). It refers to reaction mounted by donor’s blood cell to patient’s body. It occurs in spite of patient and donor being HLA matched hence medicines are given to prevent it from occurring. It is usually mild, affects skin (rashes), liver (jaundice) or intestines (loose motions, pain abdomen) but can be serious and life threatening in a fraction of patients. Once GVHD occurs, it does not mean that transplant has failed. In fact a mild degree of GVHD may be helpful in better control of the cancers as these donor cells which are reactive against patients normal tissues also acts against cancer cells and destroys them.

 

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