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

Basics of Stem Cell Basics of Stem Cell TransplantTransplant

Tamila Kindwall-Keller, D.O.Tamila Kindwall-Keller, D.O.

August 18, 2008August 18, 2008

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

BackgroundBackground

First successful transplants—late First successful transplants—late 1960s1960s

30,000-40,000 transplants 30,000-40,000 transplants performed yearly worldwideperformed yearly worldwide

>20,000 patients have survived >20,000 patients have survived >5 years>5 years

Lazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3rd edition 2002:399-409

BackgroundBackground

Hematopoietic stem cell transplantationHematopoietic stem cell transplantation– Intravenous infusion of autologous or Intravenous infusion of autologous or

allogeneic stem cellsallogeneic stem cells Collected from bone marrow, peripheral blood or Collected from bone marrow, peripheral blood or

umbilical cord bloodumbilical cord blood

– Re-establish hematopoietic function in Re-establish hematopoietic function in patients with damaged/defective bone patients with damaged/defective bone marrow or immune systemsmarrow or immune systems

– Potentially curative for a wide variety of Potentially curative for a wide variety of disordersdisorders


Graft SourcesGraft Sources

Allogeneic: from another personAllogeneic: from another person Syngeneic: from an identical twinSyngeneic: from an identical twin Autologous: from the patientAutologous: from the patient

Choice of graft is based on Choice of graft is based on disease type, patient condition, disease type, patient condition, donor compatibility and healthdonor compatibility and health


Autologous TransplantAutologous Transplant– No evidence of disease in the blood No evidence of disease in the blood

or bone marrowor bone marrow– Transplant related mortality (TRM) Transplant related mortality (TRM)

lowest with autos (<5%)lowest with autos (<5%)– Relapse rates are higher depending Relapse rates are higher depending

on the diseaseon the disease– Absence of graft versus tumor effectsAbsence of graft versus tumor effects



Allogeneic TransplantsAllogeneic Transplants– High TRM (30-50%)High TRM (30-50%)– Lower relapse rates due to graft versus Lower relapse rates due to graft versus

tumor effectstumor effects– Graft versus host effectsGraft versus host effects

Matched Related Donor (siblings)Matched Related Donor (siblings)– 25% chance a sibling will be a match25% chance a sibling will be a match– The more siblings a patient has the better The more siblings a patient has the better

chance for a matchchance for a matchLazarus HM. Autologous and allogeneic transplantation procedures for hematologic malignancies. Manual of Clinical Hematology, 3rd edition 2002:399-409


Alternative DonorsAlternative Donors– Matched Unrelated Donors (MUD)Matched Unrelated Donors (MUD)

NMDPNMDP Severe GVHDSevere GVHD Higher TRMHigher TRM

– Haploidentical DonorsHaploidentical Donors From parent, child or siblingFrom parent, child or sibling Must have many stem cells to overcome risk of Must have many stem cells to overcome risk of

graft rejectiongraft rejection Increased risk of GVHDIncreased risk of GVHD


HLA TypingHLA Typing

HLA typing became feasible in HLA typing became feasible in 1960s1960s

Linked on chromosome 6Linked on chromosome 6 Inherited as haplotypesInherited as haplotypes 1 in 4 chance a sibling will be 1 in 4 chance a sibling will be

identicalidentical

Copelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813-1826.

HLA MatchingHLA Matching

6/6, 8/8, or 10/106/6, 8/8, or 10/10– HLA loci on chromosome 6HLA loci on chromosome 6– HLA-A, HLA-B, HLA-C, HLA-DR, HLA-HLA-A, HLA-B, HLA-C, HLA-DR, HLA-

DQ, HLA-DPDQ, HLA-DP ABO incompatibility is not an ABO incompatibility is not an

exclusionexclusion


EligibilityEligibility

Age < 65Age < 65– Autologous, mini-alloAutologous, mini-allo

Age < 55Age < 55– Myeloablative allogeneicMyeloablative allogeneic

ExclusionsExclusions– CHF, uncontrolled diabetes mellitus, CHF, uncontrolled diabetes mellitus,

active infections, renal insufficiencyactive infections, renal insufficiency

Indications Autologous Indications Autologous TransplantTransplant Multiple myelomaMultiple myeloma NHLNHL Hodgkin’s diseaseHodgkin’s disease AMLAML NeuroblastomaNeuroblastoma Ovarian cancerOvarian cancer Germ-cell tumorsGerm-cell tumors

Autoimmune Autoimmune disordersdisorders

AmyloidosisAmyloidosis


Indications for Indications for Allogeneic TransplantAllogeneic Transplant AMLAML ALLALL CMLCML MDSMDS MPDMPD NHLNHL Hodgkin’s DiseaseHodgkin’s Disease CLLCLL Multiple myelomaMultiple myeloma Juvenile CMLJuvenile CML

Aplastic anemiaAplastic anemia PNHPNH Fanconi’s anemiaFanconi’s anemia Blackfan-DiamondBlackfan-Diamond Thalessemia majorThalessemia major Sickle cell anemiaSickle cell anemia SCIDSCID Wiskott-AldrichWiskott-Aldrich Inborn errors of Inborn errors of

metabolismmetabolismCopelan EA. Hematopoietic stem-cell transplantation. NEJM 2006;354:1813-1826.

Preparative RegimensPreparative Regimens

MyeloablativeMyeloablative– High doses of chemotherapy +/- High doses of chemotherapy +/-

radiationradiation– 3 goals3 goals

Eliminate malignancyEliminate malignancy Immunosuppression to allow Immunosuppression to allow

engraftmentengraftment Decrease graft versus host effectsDecrease graft versus host effects



Myeloablative Myeloablative RegimensRegimens Myeloablative RegimensMyeloablative Regimens

– Most common regimensMost common regimens Cyclophosphamide/TBICyclophosphamide/TBI Busulfan/CyclophosphamideBusulfan/Cyclophosphamide

Stem cells are essential to restore Stem cells are essential to restore marrow functionmarrow function



Myeloablative Myeloablative RegimensRegimens Therapy is based on diseaseTherapy is based on disease Other drugsOther drugs

– Etoposide, BCNU, cytarabine, Etoposide, BCNU, cytarabine, melphalanmelphalan

Graft versus leukemia effects in Graft versus leukemia effects in allogeneic donorsallogeneic donors



Preparative RegimensPreparative Regimens

Nonmyeloablative (Mini-allo)Nonmyeloablative (Mini-allo)– Sufficient immunosuppression to Sufficient immunosuppression to

allow donor cell engraftmentallow donor cell engraftment– Injury to organs less, fewer Injury to organs less, fewer

infections, fewer transfusionsinfections, fewer transfusions– Higher relapse ratesHigher relapse rates– May have mixed chimerismMay have mixed chimerism– Graft versus tumor effectsGraft versus tumor effects


Non-myeloablative Non-myeloablative ConditioningConditioning Alternative to conventional Alternative to conventional

myeloablative regimensmyeloablative regimens Older patients or patients with Older patients or patients with

comorbid conditionscomorbid conditions Therapeutic graft versus tumor Therapeutic graft versus tumor

effecteffect– Mediated by allogeneic T-cellsMediated by allogeneic T-cells– Donor T-cells eradicate the host’s Donor T-cells eradicate the host’s

malignant cellsmalignant cellsGeorges GE, Storb R. Review of “minitransplantation”: nonmyeloablative allogeneic hematopoietic stem cell transplantation. Int J Hematol. 2003;77:3-14.

Non-myeloablative Non-myeloablative RegimensRegimens Nonmyeloablative RegimensNonmyeloablative Regimens

– Usually fludarabine basedUsually fludarabine based– ATG is addedATG is added– May be combined with other drugsMay be combined with other drugs

Busulfan, cyclophosphamide, melphalanBusulfan, cyclophosphamide, melphalan


Non-myeloablative Non-myeloablative RegimensRegimens Better for slow growing cancersBetter for slow growing cancers

– CLL, NHLCLL, NHL Graft eradicates the cancer not Graft eradicates the cancer not

the chemothe chemo High relapse ratesHigh relapse rates


Reduced Intensity Reduced Intensity Conditioning RegimensConditioning Regimens AdvantagesAdvantages

– Reduction in mortalityReduction in mortality– Reduction in non-relapse mortalityReduction in non-relapse mortality– Reduced PRBC and platelet Reduced PRBC and platelet

transfusionstransfusions– Duration of neutropenia reducedDuration of neutropenia reduced– Reduced numbers of bacteremiasReduced numbers of bacteremias– Able to give to heavily pretreated Able to give to heavily pretreated

patients 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.

Reduced Intensity Reduced Intensity Conditioning RegimensConditioning Regimens Reduced GVHD compared to Reduced GVHD compared to

myeloablativemyeloablative Late onset acute GVHD occurring Late onset acute GVHD occurring

beyond day 100beyond 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.

Principals of Principals of ConditioningConditioning Donor Lymphocyte Infusions (DLI)Donor Lymphocyte Infusions (DLI)

– T cells and NK cellsT cells and NK cells– Additional anticancer effectsAdditional anticancer effects– Preventing relapse or eliminating Preventing relapse or eliminating

active diseaseactive disease CML and multiple myelomaCML and multiple myeloma


Umbilical Cord BloodUmbilical Cord Blood

11stst UCB transplant 16 years ago UCB transplant 16 years ago – Child with Fanconi’s anemiaChild with Fanconi’s anemia

Cell dose is given per recipient weightCell dose is given per recipient weight– Lower patient weights the high the cell Lower patient weights the high the cell

dosedose– 2 x 102 x 1077 nucleated cells/kg nucleated cells/kg– 1.7 x 101.7 x 1077 CD 34+ cells/kg CD 34+ cells/kg

4/6 match UCB with sufficient cells has 4/6 match UCB with sufficient cells has a similar outcome to a matched or one a similar outcome to a matched or one antigen mismatched MUDantigen mismatched MUD

Chao NJ, Emerson SG, Weinberg KI. Stem cell transplantation (Cord Blood Transplants). Am Soc Hematol Ed Book. 2004:354-371.


Umbilical Cord BloodUmbilical Cord Blood– CryopreservedCryopreserved– Small number of stem cellsSmall number of stem cells– Higher incidence of engraftment Higher incidence of engraftment

failurefailure Using more than one unit in adultsUsing more than one unit in adults

– Lower risk of GVHDLower risk of GVHD– Degree of matching not as stringentDegree of matching not as stringent



Lower GVHDLower GVHD TRM not different than MUDTRM not different than MUD Can be used with myeloablative Can be used with myeloablative

or nonmyeloablative conditioning or nonmyeloablative conditioning (on a clinical trial)(on a clinical trial)


Haploidentical Haploidentical TransplantsTransplants Parent, sibling or childParent, sibling or child High rate of engraftment failureHigh rate of engraftment failure GVHDGVHD


Collection of Stem Collection of Stem CellsCells Bone Marrow HarvestBone Marrow Harvest

– General anesthesiaGeneral anesthesia– Equivalent of 50-100 bone marrow Equivalent of 50-100 bone marrow

biopsiesbiopsies– Used much less oftenUsed much less often– 2 deaths in 8000 collections2 deaths in 8000 collections



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

Collection of Stem Collection of Stem CellsCells Stem Cell Collection (mobilization)Stem Cell Collection (mobilization)

– Stem cells circulate in the bloodStem cells circulate in the blood– Identified by CD34+ by flow cytometryIdentified by CD34+ by flow cytometry– Filgrastim, sargramostim, AMD 3100Filgrastim, sargramostim, AMD 3100– Stem cells are collected through an Stem cells are collected through an

apheresis catheterapheresis catheter– More cells are collectedMore cells are collected– Higher chronic GVHD than bone marrow Higher chronic GVHD than bone marrow

harvestharvest– More rapid marrow recoveryMore rapid marrow recoveryLazarus HM. Autologous and allogeneic transplantation procedures

for hematologic malignancies. Manual of Clinical Hematology, 3rd edition 2002:399-409

Infusion of Stem CellsInfusion of Stem Cells

Stem cells may be infused fresh Stem cells may be infused fresh within a few hours of collectionwithin a few hours of collection

May be frozen using DMSOMay be frozen using DMSO– Creamed corn or garlic smellCreamed corn or garlic smell

Umbilical cord blood is obtained Umbilical cord blood is obtained from one of the umbilical cord from one of the umbilical cord veins and frozen with an veins and frozen with an anticoagulant and nutrient mediaanticoagulant and nutrient media


Stem Cell ManipulationStem Cell Manipulation

ABO incompatibleABO incompatible– Removal of isoagglutinins or RBCsRemoval of isoagglutinins or RBCs

T-cell depletionT-cell depletion– Reduce incidence of GVHDReduce incidence of GVHD– Increased graft failureIncreased graft failure– Increased relapse ratesIncreased relapse rates

In vitro purgingIn vitro purging– Removal of tumor cellsRemoval of tumor cells– Positive selection of CD34+ cellsPositive selection of CD34+ cells


ComplicationsComplications

EarlyEarly– MucositisMucositis– Sinusoidal obstructive syndrome Sinusoidal obstructive syndrome

(VOD)(VOD) Fluid retention, jaundice, hepatomegalyFluid retention, jaundice, hepatomegaly

– Transplant related infectionsTransplant related infections Damage to mouth, gut and skinDamage to mouth, gut and skin Prolonged neutropeniaProlonged neutropenia



EarlyEarly– PancytopeniaPancytopenia

PRBC and platelet transfusionsPRBC and platelet transfusions Broad spectrum antimicrobialsBroad spectrum antimicrobials Antifungals if prolonged fevers 3-5 daysAntifungals if prolonged fevers 3-5 days



EarlyEarly– Graft Versus Host DiseaseGraft Versus Host Disease

Acute GVHD to day 100Acute GVHD to day 100– Skin, GI tract, liverSkin, GI tract, liver




EarlyEarly– Graft RejectionGraft Rejection

Host versus graftHost versus graft Drug injury to marrowDrug injury to marrow Viral infections: CMV, HHV-6 & 8Viral infections: CMV, HHV-6 & 8

– Interstitial PneumonitisInterstitial Pneumonitis Diffuse alveolar hemorrhageDiffuse alveolar hemorrhage Too few donor stem cellsToo few donor stem cells ARDS often caused by CMVARDS often caused by CMV



DelayedDelayed– Chronic GVHDChronic GVHD

Scleroderma or Sjogrens syndromeScleroderma or Sjogrens syndrome BronchiolitisBronchiolitis KeratoconjunctivitisKeratoconjunctivitis MalabsorptionMalabsorption CholestasisCholestasis Esophageal strictureEsophageal stricture


Late ComplicationsLate Complications

Secondary TumorsSecondary Tumors– Acute leukemias, solid tumors, MDSAcute leukemias, solid tumors, MDS– Months to years after transplantMonths to years after transplant– Increased incidence with TBIIncreased incidence with TBI

Late InfectionsLate Infections– Bacterial, viral fungalBacterial, viral fungal– Months after transplantMonths after transplant– Associated with GVHDAssociated with GVHD– Need repeat vaccinationsNeed repeat vaccinations

Pneumovax, Hep B, Hemophilus influenza b, Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, flupoliovirus, diphtheria/tetanus, flu


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