DONATEHEMATOLOGY ONCOLOGY & BONE MARROW SERVICES
Overview
Hematopoietic Stem Cell (HSCT) / Bone Marrow Transplantation (BMT) is a lifesaving treatment for variety of diseases including Blood Cancers like Leukemia, Lymphoma, Myeloma etc, as well as benign disorders like Aplastic Anemia and Thalassaemia.
Bone Marrow Transplant Program started in RGCI&RC in 2001 and since then approximately 1000 transplants have been performed, placing RGCI&RC among leading transplant centers in India. At present, on an average, we perform 125 transplants per year.
As of now, Rajiv Gandhi Cancer Institute has a 21 bedded bone marrow transplant unit equipped with HEPA filters and a dedicated team of renowned hematologists and bone marrow transplant specialists along with a team of nursing staff trained and experienced in bone marrow transplantation. We have a dedicated hemato-pathology lab, molecular laboratory and round the clock blood bank services to support diagnostic and blood component needs of patients undergoing BMT.
Transplant is an expensive treatment and requires lot of resources but at RGCIRC, the cost of a transplant has been affordable as compared to other private sector hospitals and comparable to some of government hospital.
Diseases for which a Bone Marrow Transplant is Recommended
Transplant for Non-Malignant Conditions
- Aplastic Anemia and other bone marrow failure syndromes: These diseases are characterized by failure of bone marrow to produce adequate blood components to meet needs of patients and is a life threatening disease. Such patients have low hemoglobin, leucocytes and platelets in blood and usually require blood and platelet transfusions. An Allogeneic stem cell transplantation in a timely manner may be life saving for such patients.
- Thalassemia Major: This is a genetic disorder where a child survives on regular blood transfusion since infancy due to a genetic defect of hemoglobin. This is a life threatening disorder without adequate blood transfusion and iron chelation therapy. An Allogeneic stem cell transplantation early in life can cure most of thalassemia patients.
- Sickle Cell Anemia: this too is a genetic disorder of hemoglobin which causes painful episodes, stroke and organ failure along with anemia. An Allogeneic stem cell transplantation can cure most of such patients.
- Hemophagocytic Syndrome: This is a catastrophic disease which can be rapidly life threatening and can be cured with An Allogeneic stem cell transplantation
- There are many other disorders where a stem cell transplantation can be life saving like inborn errors of metabolism, congenital immunodeficiency disorders etc.
Transplant for Malignant (Cancer) Conditions
- Multiple Myeloma (MM): This is a cancer of plasma cells and can cause anemia, kidney dysfunction, bone disease, infections and can be life threatening if not treated early. Treatment of Multiple Myeloma includes chemotherapy as well as Autologous Stem Cell Transplantation. Autosomal stem cell transplantation can improve chances of survival of such patients.
- Hodgkins & Non-Hodgkins Lymphoma: These are a group of blood cancers arising from lymphocytes and can affect any organ of body. Treatment of most of lymphomas includes chemotherapy. Few high risk lymphomas or relapsed lymphoma patients are treated with Autologous or Allogeneic Stem Cell Transplantation. Many of such patients can be cured with Stem cell transplantation
- Acute Myeloid Leukemia (AML): This is an aggressive blood cancer and is life threatening disease. Treatment of intermediate to high risk AML requires intensive chemotherapy as well as Allogeneic Stem Cell Transplantation to achieve cure.
- Acute Lymphoblastic Leukemia (ALL): This too is an aggressive and life threatening blood cancer and is mostly treated with chemotherapy. Few of high risk ALL patients and those who have a relapse of ALL despite chemotherapy require Allogeneic stem cell transplantation to achieve cure.
- Chronic Myeloid Leukemia (CML): CML is mostly treated with targeted drugs. Only few patients who do not achieve a good response to targeted drugs are treated with Allogeneic Stem Cell Transplantation to achieve cure.
- Myelofibrosis, Myelodysplastic syndrome (MDS), Chronic Myelo-Monocytic Leukemia (CMML) and other similar blood cancers: Such blood cancers are treated with Allogeneic stem cell transplantation to achieve cure. Certain patients may require a course of chemotherapy prior to transplant.
- Neuroblastoma: This is a disease of childhood and mostly requires chemotherapy and Autologous Stem Cell Transplantation.
Bone Marrow/ Stem Cell transplants being regularly conducted at RGCI&RC are:
- Autologous stem cell transplant (ASCT): here the Stem Cells are collected from patients own blood. As mentioned above, ASCT is a treatment for patients with Multiple Myeloma, Lymphomas and Neuroblastoma mostly.
- Allogeneic stem cell transplant: Here the stem cells are collected from a healthy donor. The donor is usually a family member who has HLA (Tissue antigens) matching with the patient. Depending upon relationship to patient and degree of HLA match, there can be different donor types:
- Fully HLA matched related (family) donor
- Fully HLA matched unrelated donor
- Half match related donor (Haplo-identical donor)
Whom to Contact
Transplant coordinator- +91-11-47022261, 47022279, 9654846677
Room Number 3259, 2nd Floor- D Block,
Rajiv Gandhi Cancer Institute & Research Centre,
Sector-5, Rohini, Delhi, India, 110085
Our team at RGCIRC has wide experience in performing HLA Matched Related Donor (MRD), Match Unrelated Donor (MUD) and Haploidentical donor (half match) transplants in various disorders. We are amongst the few centers in India offering Matched Unrelated Donor (MUD) transplants from national and international registries to our patients.
What Is Bone Marrow 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), Thalassemia or Immunological causes (Aplastic Anemia) then deficiency of formed components of blood sets in, 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 Hematopoietic Stem Cells.
Why You Need Bone Marrow Transplant?
There are some diseases like Thalassemia, in which conventional treatment options are mainly supportive blood / component transfusions requiring multiple blood donors and frequent hospitalization, ultimately resulting in iron overload, organ toxicities, growth failure 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 Anti-leukemia Therapy and is a curative option. In leukemia chemotherapy dictum is higher the dose, better the disease control. Very high doses of Chemotherapy cannot 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 pre-collected stem cells (Autologous) 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. With advancements in learning and refining of conditioning regimen, including reduction of doses of chemotherapy and more reliance on graft vs tumor effect, the benefits of transplant have been extended to elderly population as well.
Sources of Hematopoietic Stem Cells
- 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, with donor being discharged on next day Bone Marrow stem cells are preferred in diseases like Thalassemia 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.
- Peripheral Blood: Stem cells can also be collected from larger veins of body using apheresis technique on a cell separator machine after giving growth factor injections for 4-5 days. It is a very safe and reliable procedure taking only a few hours and does not require Anesthesia. Stem cells can be collected even difficult to mobilize patients with plerixafor and G CSF support. In comparison to Bone Marrow graft, the recovery is earlier by 5-7 days with peripheral blood stem cell graft. This type of transplant is preferred for Leukemia, Myeloma and Lymphomas.
- 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.
Autologous Versus Allogenic Transplant
A Transplant Process includes following phases- Stem Cell Collection from donor or patient, Conditioning with chemo-radiotherapy for the patient, stem Cell Infusion, pre-engraftment bone marrow suppression and post engraftment follow up. Average time taken prior to engraftment ranges from 3-4 weeks in the BMT unit. 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 one year post transplant, patient’s immune system recovers and most of the medicines can be stopped.
- Stem Cell Collection: Stem Cells are collected from donors’ blood (in allogeneic 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.
- Conditioning: Conditioning is the name given to high dose Chemotherapy or Radiotherapy to destroy or suppress patients existing Bone Marrow and provide immunosuppresion 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.
- 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 cells. Time taken for blood production is called engraftment period. Before engraftment patient’s blood counts are markedly depressed for around 10-20 days, chances of infections are highs so patients are kept in strict isolation and hepa-filtered 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 versus 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. Sometimes 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 is temporary as hairs come back within 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 to maintain an acceptable platelet count. Once engraftment occurs, the platelet production starts and bleeding risk disappears.
Fertility – Temporary or permanent sterility may occur in almost all adult / adolescent male and female patients 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. This can be treated with immunosuppressive therapies with good results.
Relapse – Even though transplant is performed with curative intent, some patients with very aggressive disease may relapse. The risk of relapse decreases significantly after 2 years post transplant. Monitoring the patient regularly for relapse and early intervention with chemotherapy, decreasing immune suppression or donor lymphocyte infusion can be used to salvage relapse in many patients.
