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Saving lives: Bone marrow transplantation

Post by on Saturday, October 9, 2021

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Hematopoietic stem cell transplant, also known as Bone marrow transplant is transforming medicine and with it the lives of increasing numbers of patients with life threatening illnesses are saved daily. It is the only curative treatment available in many cancers after failure of chemotherapy and in many non-cancerous conditions.
The first successful bone marrow transplant was performed by Dr Donall E. Thomas, an American medical Oncologist in 1956 in a case of Acute Leukemia (a type of blood cancer). This landmark therapeutic procedure won the Nobel Prize for Medicine in 1990 to Dr Thomas who is considered the father of hematopoietic stem cell transplant (HSCT).
Bone marrow transplant, a groundbreaking form of treatment, has contributed to the successful treatment of multiple diseases, be it cancers or non-cancerous diseases. The indication for HSCT is ever increasing and the world has witnessed a plethora of HSCT being conducted at present in comparison to the past.
Nearly 60,000 stem cell transplants are performed globally every year. The procedure involves the intravenous infusion of hematopoietic stem cells in order to reestablish blood cell production in patients whose bone marrow or immune system is damaged or defective.
Over the past half a century, this technique has been used with increasing frequency to treat numerous malignant and nonmalignant diseases. The cancers form the main indication for HSCT world over. Among cancers, it is indicated for multiple Myeloma, non-Hodgkin’s Lymphoma, Hodgkin’s Lymphoma, different types of blood cancers like AML, ALL, CLL, CML in blast crisis etc, germ cell tumors, Neuroblastoma to name a few.
Among the non-cancerous conditions it is the treatment of choice for every Aplastic anemia, Thalassemia, Sickle cell anemia, Autoimmune diseases, various immunodeficiency disorders like SCID and some neurological illnesses.
Stem cells are the actual building blocks of the blood and immune system and they have incredible capabilities. They can heal and repair cells and tissues, help rebuild the blood and immune system and even transform themselves into other types of cells in order to replace cancer cells or damaged cells.
These stem cells are housed in the bone marrow and in very small numbers in peripheral blood. One of the richest sources is umbilical cord blood, taken at birth and stored in special blood banks.
Bone marrow transplant can be Autologous transplant where patients own stem cell are used after the underlying disease is controlled, Allogeneic transplant where stem cells are obtained from a healthy related or unrelated donor or Cord blood transplant where stem cell are obtained from stored umbilical cord blood at birth and they are stored in special cord blood banks.
Undergoing a successful bone marrow transplant is a five-stage process.
1.     Assessment of the patient and donor. Physical examination to assess the recipient's health status.
2.     Harvesting: It is the process of obtaining stem cells to be used in the transplant from bone marrow or more commonly from peripheral blood by special apheresis machines by using very specialized collection kits.
3.     Conditioning: preparing the body for transplant. It is usually the process of giving very high doses of chemotherapy or radiotherapy to destroy the body’s immune and blood cells.
4.     Transplanting the stem cells. The stem cells collected earlier are stored in special conditions in blood bank and are infused back to the patient after ablating the patient’s own reserves. These stem cells then mobilize to bone marrow and start replicating and replacing the normal blood and immune system forming cells.
5.     Recovery period: This is a very critical period of the whole procedure were most of the complications associated with the procedure can happen like Febrile Neutropenia, Sepsis, Graft Versus Host Disease (GVHD), Veno Occlusive Disease (VOD), Engraftment Syndrome, Graft Failure etc. The transplant physician and the whole team needs to be vigilant to address the complications for the successful outcome of the transplant.
Bone marrow has been the traditional source of hematopoietic stem cells for use in autologous and allogeneic transplantations. However, peripheral blood has replaced bone marrow as a source of these cells for most autologous transplantations and a significant proportion of allogeneic transplantations.  
Advantages of peripheral blood stem cell transplantation (PBSCT) include the nonsurgical method of collection and the far larger number of stem cells that can be collected with apheresis. 
Peripheral blood stem cell transplantation (PBSCT) is associated with higher graft-versus-tumor or graft-versus-leukemia effect and decreased relapse rates. The PBSC transplant is also associated with rapid engraftment (because a higher number of committed progenitor cells are collected), which translates into decreased mortality and early hospital discharges.
The disadvantage with PBSCT is the increased incidence of GVHD. However, the bone marrow stem cell transplant is considered superior to PBSCT for nonmalignant conditions (hemoglobinopathies like thalassemia, severe aplastic anemia etc.), in which rapid engraftment is not crucial and a graft-versus-tumor effect is not required.
Hematopoietic Stem Cell Transplant is a rapidly increasing health facility in India. However, there is a huge disparity between the need and the actual transplants performed in India annually. It is estimated that in India nearly 80,000 to 1 lakh transplants are needed annually but only under 2000 transplants are performed annually in India.
The scenario is similar in other countries with limited resources. Establishing a HSCT unit in a resource limited setting remains a challenge.  Social and economic distribution are quite variable in India.  Even the increased number of HSCT units in India is falling short for these needs. To address this issue the Indian Council of Medical Research (ICMR) has issued a guideline, directives for minimum standards required to run a HSCT unit.
At SKIMS Srinagar, a lead was taken by the Department of Medical Oncology way back in early 2010 to start a bone marrow transplant facility to offer this unmet medical need to the local population. A dedicated unit has been functional in the Department of medical Oncology and Stem Cell Transplant since then.
Till date the department has successfully performed more than 71 Stem Cell Transplants/Bone Marrow Transplants in patients of different cancers like multiple Myeloma, Non-Hodgkin’s Lymphomas, Hodgkin’s Lymphoma, Acute Leukemias, Neuroblastoma etc. Both autologous and allogeneic Transplants are performed in the Department with satisfied results. The stem cell transplant unit of Department of Medical Oncology at SKIMS is a recognized centre and is registered under Indian Society for Blood and Marrow Transplant (ISBMT) and Asia Pacific Society for Blood & Marrow Transplant (APBMT), a rare feat achieved by SKIMS Deemed University.
There is some lack of awareness about the procedure and unfounded myths about transplant in common people. The need is to aware the general public about this facility available at SKIMS.
The SKIMS needs a separate and fully equipped unit for the bone marrow transplant under the Medical Oncology in State Cancer Institute with adequate manpower in the form of doctors, nurses, technicians and laboratory persons besides providing the facility for HLA matching, Cryopreservation, liquid nitrogen and other requirements.
The State Cancer Institute, a centrally funded project by the government of India for SKIMS, has a separate BMT Unit under the Department of Medical Oncology with a fixed budgetary allocation.
With the provision of a full Hematopoietic stem cell transplant unit under the department of Medical Oncology in the Centrally funded State Cancer Institute for SKIMS, the unmet needs of the local population will be addressed to a large extent in future.
About the Author
Dr. Mir Mohammad Hussain (DM Medical Oncology) is Assistant Professor, Medical Oncology & Stem Cell Transplant Unit, SKIMS, Srinagar.

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