BLOOD AND MARROW STEM CELL TRANSPLANTATION

What is a Stem Cell Transplant and What Can They Treat?

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 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.

How Do Stem Cell Transplants Work ?

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. Patients need to be in close regular follow up for first 3-6 months of transplant and advised to stay near the transplant centre.

Diseases for which a Bone Marrow Transplant is Recommended

Transplant for non-malignant conditions

Aplastic Anemia and other bone marrow failure syndromes

Thalassemia Major

Sickle Cell Anemia

Hemophagocytic Syndrome

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)

Hodgkins & Non-Hodgkins Lymphoma

Acute Myeloid Leukemia (AML)

Acute Lymphoblastic Leukemia (ALL)

Chronic Myeloid Leukemia (CML)

Myelofibrosis, Myelodysplastic syndrome (MDS), Chronic Myelo-Monocytic Leukemia (CMML) and other similar blood cancers

Neuroblastoma

Bone Marrow/ Stem Cell transplants being regularly conducted at RGCIRC 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:

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

Autologous Transplant involves using a patient’s own Hematopoietic Stem Cells. It is usually done for multiple Myeloma, Relapsed Hodgkin and Non Hodgkin Lymphoma and T Lymphoma. In this procedure a patient’s stem cells are first collected after achieving at least partial response in disease and then a very high dose of Chemotherapy is given to eradicate existing disease followed by reinfusion of collected stem cells to reestablish blood formation. In Allogenic Transplant Stem cells are collected from a healthy donor. This healthy donor is usually a sibling (related donor fully matched or haploidentical) or can be found from international donor registry (unrelated donor) or obtained from umbilical cord blood. Voluntary donor registries from India like DATRI are very active and have provided donors for multiple transplants.

Bone Marrow Transplant Procedure

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.

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.

Whom to Contact

Transplant coordinator- +91-11-47022261, 47022279
Room Number 3259, 2nd Floor- D Block,
Rajiv Gandhi Cancer Institute & Research Centre,
D – 18, Sector – 5, Rohini, Delhi – 110085

Why to Choose RGCIRC for A Bone Marrow Transplant?

Bone Marrow Transplant Program started in RGCIRC in 2001 and since then approximately 1000 transplants have been performed, placing RGCIRC among leading transplant centers in India. At present, on an average, we perform 125 transplants per year.
As of now, Rajiv Gandhi Cancer Institute & Research Centre 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.
RGCIRC doctors and care teams never stop improving the care we deliver. Researchers who specialize in stem cell transplantation always work to reduce the complications of transplants.