Go to:
		Diagnosis
		Side Effects of Treatment
		Catheters
		Surgery
		Radiotherapy
		Blood Counts and Transfusions
		Scans
		Bone Marrow Transplants
		Finishing the Treatment
		Relapse

Bone marrow transplantation

Bone marrow transplantation started at Sydney Children's Hospital in May 1975. Bone marrow was collected from another person (called an allogeneic transplant). In the 1980's the use of a patient's own bone marrow (an autologous transplant) commenced. The important cell in a bone marrow transplant is the stem cell which is able to replace and produce white cells, red cells and platelets lifelong. Blood collected from a vein also contains stem cells as does blood collected from the placenta at birth. Thus, marrow stem cells for transplant can be collected from the bone marrow (bone marrow transplant), peripheral blood (peripheral blood stem cell transplant) and cord blood (cord blood transplant).

Aim of a Transplant:

1. Malignancy - the aim is to give megadose therapy (high dose chemotherapy with or without radiotherapy) to attempt to kill all cancer cells at one go. This treatment is given over 6-8 days. Because normal bone marrow cells have similar sensitivity to cancer cells, the bone marrow is destroyed in the process of trying to kill all the cancer. A bone marrow transplant is necessary as a rescue.
2. Aplastic Anaemia - the aim is to give back normal healthy functioning bone marrow to replace the failed bone marrow.
3. Genetic Diseases (e.g. thalassaemia, immune deficiency) - the diseased bone marrow or immune system needs to be destroyed.

An important aim with the conditioning therapy is to dampen the immunity to decrease and hopefully prevent the risk of the marrow transplant being rejected.

What is involved for the Donor?

Allogeneic or Autologous Bone Marrow: The donor is admitted the day before collection, goes to the operating theatre the next morning, and under a general anaesthetic, marrow is collected from the hips usually at the back. Marrow cells are bathed in blood in a honeycomb of bony spaces. Marrow is collected using a needle which needs to be inserted into each of these bony spaces. The procedure takes 1-1½ hours. Only a small amount of all of the bone marrow (which in children is present in virtually all bones in the body) is removed. The bone and marrow return to normal over 2-3 months. There is some discomfort in the hips after waking from anaesthetic and this is relieved with analgesia. The donor is discharged the following day and after discharge there are no restrictions (except for contact sport for 4 or 5 days).

Peripheral Blood Stem Cells: These are collected on 2 or 3 consecutive days using a special central line. The procedure is undertaken in the Day Only Ward using a cell separator machine. The machine removes the stem cells from the blood and returns the blood back to the child. The procedure takes between 4-5 hours. Tests are undertaken on the collected cells to determine when an adequate number have been collected.

Choice of type of transplant: Autologous transplants are routinely undertaken in the treatment of Acute Myeloid Leukaemia.

Peripheral blood stem cell transplants (or autologous) are undertaken for the treatment of solid tumours (eg. Neuroblastoma, Brain Tumours, Wilms' Tumour, Rhabdomyosarcoma, Ewings Sarcoma). The timing of transplant will vary with the disease and in some settings may be undertaken once the disease is under control and in other settings undertaken only after recurrence of disease.

For all other diseases and settings, an allogeneic transplant is the treatment of choice. The best donor is a histocompatible (matched) brother or sister. 30% of children needing a transplant have such a donor. When there is no such donor, the alternatives considered are searching the immediate and extended family to see if there is a matched or partially mismatched family member. The possibility of finding such a donor is approximately 4%. Unrelated Bone Marrow Donor Registries can be searched to identify a matched unrelated donor. The possibility of finding such a donor is approximately 20%. Recently, we commenced searching the Unrelated Cord Blood Banks. It is not clear yet what the potential is to find a donor in these Banks.

Conditioning: To prepare a child for transplant, we give what is called conditioning therapy. This always involves chemotherapy and sometimes radiotherapy as well. The conditioning therapy consists of much larger doses than would normally be able to be given. The aim is to kill the remaining cancer cells and in the process the patient's bone marrow and immunity are also killed. Thus, in undertaking the transplant the marrow and the immunity are replaced.

The conditioning therapy is also given to prevent rejection.

Isolation: The child needs to be isolated for the duration of the conditioning therapy and for a period of 6-8 weeks minimum after transplant. The length of this isolation may vary particularly if graft versus host disease develops. While in isolation in hospital, the child may be visited by immediate family and 2 other relatives or friends. After discharge from hospital, the child must not return to school or public crowded places until the isolation period is over.

The marrow transplant: Whatever type of transplant is being given, the marrow cells are infused into the central line. There is usually no reaction from this. Indeed the transplant day is an anti-climax because there is nothing much to it. If the marrow is being given fresh, then it is brought from the operating theatre and transfused like a normal blood transfusion. If the stem cells have been frozen, then they are thawed in the transplant room, drawn up into a syringe and injected into the central line. A substance used to protect the cells while they are being frozen (DMSO) has a strong smell and after being injected, it is breathed out through the lungs.

What does engraftment mean? The transplanted marrow cells circulate in the blood for some hours and gradually home in on the marrow cavity inside the bones. Once they have settled in, marrow production starts again and once a critical mass of marrow cells has been reached, the white cell count starts to rise. This occurs usually between 10 and 21 days post transplant.

Complications after transplant (early): There are 4 main complications after transplant. The marrow may not engraft or be rejected, the marrow cells may cause graft versus host disease, bacterial or fungal infection may develop during the period of lack of white cell production, and viral infections may occur while the immunity is recovering. The potential chance of each of these problems occurring depends on the type of transplant being undertaken.

When can the patient go home? Once a child is free of fever, antibiotics have been stopped, eating and drinking have returned, discharge can occur. In autologous and matched sibling transplants, this would normally occur around 20-30 days after transplant. After discharge, treatment with drugs to prevent graft versus host disease or antibiotics to prevent infection are given for a period of time which varies depending on the type of transplant. No further treatment is required or helpful for the cancer.

Long term complications (years later):
Some long term complications can occur and depend on the conditioning therapy and whether or not graft versus host disease occurs. Cataracts and growth failure are potential complications of radiation and infertility is a potential complication of both radiotherapy and chemotherapy.

Useful Links

Australian Cord Blood Bank
The Australian Cord Blood Bank (ACBB) was established at the Sydney Children's Hospital in 1995 and forms part of a national network of cord blood banks in Melbourne, Sydney and Brisbane. It collects and banks cord blood from voluntary donors, anonymously, for use by any patients, Australian or overseas, needing a stem cell transplant.
http://www.sch.edu.au/departments/acbb/default.asp

Bone Marrow Transplant 
If you or someone you love is about to undergo a bone marrow, peripheral blood stem cell or cord blood transplant and is interested in being matched with survivors who are willing to provide emotional support 
http://www.bmtinfonet.org/services.html

International Bone Marrow Transplant
The International Bone Marrow Transplant Registry (IBMTR) and the Autologous Blood and Marrow Transplant Registry (ABMTR) are voluntary organizations of basic and clinical scientists collaborating in an effort to address important issues in blood and marrow transplantation. We are not a donor registry - we do not find donors for patients needing transplants. What we do is gather information on results of blood and marrow transplants. This information is used to guide clinical decisions and identify ways to improve transplant outcomes. 
www.ibmtr.org

National Bone Marrow Transplant Link (USA)
This non-profit organization seeks to help patients and families of those considering bone marrow transplants. Its Web site includes online guides about bone marrow transplants and about stem cell transplants for breast cancer, FAQs of interest to transplant recipients and their families, and information about donating marrow. 
http://comnet.org/nbmtlink 

Home