Upload
indonesian-journal-of-cancer
View
214
Download
0
Embed Size (px)
Citation preview
8/8/2019 Bone Marrow Tranplantation
1/32
Bone marrowtranplantation
Nanis Sacharina
A week-observation in
Centro Trapianti di Midollo Osseo,Ospedale Microcitemico,
Cagliari, 7-16 Dec 2005
8/8/2019 Bone Marrow Tranplantation
2/32
Ospedale Microcitemico
8/8/2019 Bone Marrow Tranplantation
3/32
History team workStart in 1993
1 BMT unit, outpatient clinic
7 doctors, 10 nurses (+ 2 nurses for clinic)molecular laboratory:
3 doctors
1 biologist
2 technicians
Every day meeting
8/8/2019 Bone Marrow Tranplantation
4/32
Meeting
8/8/2019 Bone Marrow Tranplantation
5/32
IndicationThalassemia (110 patients)
leukemia
solid tumor
SCID
aplastic anemia
8/8/2019 Bone Marrow Tranplantation
6/32
Survival rate
Familial donor
43 patients (1-15 yo), 120 months follow-up
Disease free survival rate: 95% 2 deaths
32 patients (16-34 yo), 120 months follow-up
Disease free survival rate 88%
Non familial donor17 patients
Disease free survival rate : 65%
CTMO, Ospedale Microcitemico, Cagliari
8/8/2019 Bone Marrow Tranplantation
7/32
Survival rate (Thalassemia)36 class 1 and 2 thalassemic patients, 72 mo
follow-up
Survival rate 96%Thalasemia free survival rate 85%
Class 1: 100%, class 2: 75%
35 class 3 patients, 12 years follow-upthalasemia free survival rate 50%
8/8/2019 Bone Marrow Tranplantation
8/32
Risk classes in thalassemic
patients at the time of BMT
Risk factors class I class II class IIIHepatomegaly < 2
Only one or a
combination of
two risk factors
out of three
2
Portal fibrosis No Yes
Iron chelation regular Irregular
8/8/2019 Bone Marrow Tranplantation
9/32
Umbilical cordGraft failure 21%
Long period of aplasia
Thalassemia: 7/33 failed
Sickle cell 1/ 11 failed
8/8/2019 Bone Marrow Tranplantation
10/32
ProtocolHLA typing:
Class I: A, B, C
Class II: DQ, DR, DP
Parents/ patients agreement
Informed consent
Several work-up and laboratory test
8/8/2019 Bone Marrow Tranplantation
11/32
List serologically-identifiable HLAs
Locus A Locus B Locus C Locus DR Locus DQ
1 5: 51, 52 w1 1: 103 1: 5, 6
2: 203, 210 7 W2 2: 15, 16
3 8 w3,: w9, w10 3: 17, 18 2
9: 23, 24, 2403 12: 44, 45
13
W4 4 3: 7, 8, 9
10: 25, 26, 34, 66
11:
19: 29, 30, 31, 32,
33, 74
28: 68, 69
36
43
80
14: 64, 65
15: 62, 63, 75, 76,
77
16: 38, 39
17: 57, 58
18
21: 49, 50, 4005
22: 54, 55, 56
etc
W5
W6
W7
w8
5: 11, 13
6: 13, 14, 1403,
1404
7
8
9
10
51
52
53
4
8/8/2019 Bone Marrow Tranplantation
12/32
Compatibility and incompatibility
Full compatibility = full-house/ zero mismatch:
the best!
Donor: A26 A32 B38 B55 DR1 DR4
Receiver: A26 A32 B38 B55 DR1 DR4
Poor compatibility
Donor: A26 A32 B38 B55 DR1 DR4
Receiver: A1 A32 B17 B35 DR9 DR7
8/8/2019 Bone Marrow Tranplantation
13/32
Laboratory (donor and recipient)
Mixed lymphocyte culture
DNA extraction
4 ml of serumfT3-fT4-TSH
Lymphocyte subset
tuberculine test
Ig-C3-C4Liver and renal function test
VNTR
8/8/2019 Bone Marrow Tranplantation
14/32
LaboratoryAnti toxoplasma-CMV
antibody
anti EBV
anti herpes simplex
and zooster
anti HCV-HCV RNA
markers HBV
anti HIV
VDRL
Anti platelet antibody
ferritine
nasal and pharyngeal
culture
rectal/ preputium/
perineal swab-culture
urine culture
PT, PTTElectrophoresis Hb,
protein
8/8/2019 Bone Marrow Tranplantation
15/32
Work-upECG-cardiology consultation
echocardiography
Chest X-ray
bone age (> 2 yo)
spirometry (age 7)
8/8/2019 Bone Marrow Tranplantation
16/32
Donor preparationErythropoetin
Iron
Folic acid
Blood predeposit prevent random
transfusion
8/8/2019 Bone Marrow Tranplantation
17/32
BMT unit
2
1
3
4
kitchen
Nurse station
Doctor station
bagno
Mini lab
8/8/2019 Bone Marrow Tranplantation
18/32
Patients room
bathroom
Parents room Patients room
cupboard
8/8/2019 Bone Marrow Tranplantation
19/32
8/8/2019 Bone Marrow Tranplantation
20/32
Fausto with us
8/8/2019 Bone Marrow Tranplantation
21/32
Patients room
8/8/2019 Bone Marrow Tranplantation
22/32
Patients room
8/8/2019 Bone Marrow Tranplantation
23/32
BMT Protocol (thalassemia)Vena central catheter insertion undergeneral anesthesia (7 days before day -10),
day careadmission to the BMT unit on day -10
suppress the defected marrow and preventGvHD
hydration and alkalinitation start 12 hoursbefore administration of busulfan
8/8/2019 Bone Marrow Tranplantation
24/32
Bone marrow suppressionBusulfan 4 days: 14 mg/kg
hydration 3 L/m2 until day -1
alkalinisation: NaHCO3
KCl
Furosemid
carbamazepine
Co-trimoxazole
CPA/ endoxan 4 days: 200 mg/kgmesna
hydration
8/8/2019 Bone Marrow Tranplantation
25/32
Other drugsColimicin
neomicin
nistatin
azyclovir
ondansetron
chlorpheniramin
8/8/2019 Bone Marrow Tranplantation
26/32
GvHD preventionCyclosporin A
Methylprednisolone
ranitidine
Methotrexate if necessary
8/8/2019 Bone Marrow Tranplantation
27/32
MonitoringEvery day
CBC
blood gas analysis, electrolyte (duringalkalinisation)
balance diuresis
8/8/2019 Bone Marrow Tranplantation
28/32
Bone marrow harvesting &
retransfusionUnder general anesthesia
Operating room
20 ml/ kg recipient, nucleated cells 3.5-4 x108/ kg
BM retransfusion as soon as possible
depends on ABO compatibility:plasma removal: minor
red blood cell removal: major
8/8/2019 Bone Marrow Tranplantation
29/32
After BMTGrafted or not?
VNTR: before BMT and > +10 day
Usually take 12-20 ( to 30) days
Complication
Infection: special concern of IgG EBV and
CMV positive reactivation?
Acute GvHD (familial donor 20%, non familial
60%)
8/8/2019 Bone Marrow Tranplantation
30/32
Discharge criteriaGood condition overall
No infection, GvHD
Laboratory normal
8/8/2019 Bone Marrow Tranplantation
31/32
Follow-up after dischargeFirst year: monthly
Afterwards: 2 monthly
Infection
Chronic GvHD
8/8/2019 Bone Marrow Tranplantation
32/32
Chronic GvHD