Blood & Marrow Transplantation

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Kim Schmit-Pokorny, who will be talking with us about any and all questions you have regarding Blood and Marrow Transplantation. Welcome Kim!

 TeriNine 

I am curious about a allo a patient received from her 9 y/o brother (she is 25) She was told that because he is so young, she has had fewer gvh (Graft-vs- Host) issues. Why is this?

 TeriNine 

She has had virtually no gvh

 TeriNine 

And will be a year out May 20th.

 kschmit 

My understanding is that the younger you are, the fewer antibodies you have developed, and accept the graft better.

 kschmit 

However, it may be that the graft was really close. We have had some adults with virtually no GVHD.

 TeriNine 

They were a "perfect" match.

 kschmit 

Sometimes that is a good thing. However, there is some data (a slide I have seen several times regarding GVHD in different types of allos and syngeneic txplants) that shows "no gvhd" may also correlate with quicker relapse.

 kschmit 

And, patients who get gvhd, actually have a longer disease free survival.

 kschmit 

Have others experienced patients with no or minimal GVHD?

 kschmit 

Where is everyone from? Do you do transplants - and what type?

 steph199 

Fla. - no transplants at my Hosp. I'm just here to listen and learn…

 steph199 

…or read and learn.

 TeriNine 

Thank you, kschmit! I am from Vanderbilt University Medical Center, I am in inpatient Myelosuppression. We do allo/auto/cord

 kschmit 

That’s great! Lots to learn!

 aya.dilorenzo 

From MSKCC in NYC. We do auto & allo. We start seeing lots of DUCT recently.

 rhonda 

University of Iowa- auto/allo (MRD/MUD), NMA, and have just opened up a cord protocol.

 kschmit 

Could we define a few of the abbreviations - some people are not in transplant programs.

 kschmit 

Auto - autologous txplant - from self

 TeriNine 

Allo= Allogeneic

 rhonda 

MRD= Matched Related Donor, MUD= Matched Unrelated donor

 rhonda 

NMA= Non myeloablative regimen

 TeriNine 

Allo= Allogeneic (from another related or not)

 oncnurse 

What is DUCT?

 aya.dilorenzo 

Oh, sorry. I work at Memorial Sloan Kettering Cancer Center. DUCT=double umbilical cord transplant (sorry if I'm spelling wrong - I'm a little tired. just came home from night shift).

 oncnurse 

Wow, I’ve not heard of that acronym for double cord txplant!

 kschmit 

How are your DUCT's working? Very interesting concepts!

 kschmit 

Aya - great to have you after working all night!

 aya.dilorenzo 

We nurses really don't like cord transplant. Many patients develop lots of complications. Of course, many survive. Cancer-free. But they do get sick before engraftment.

 rhonda 

What is the average day for engraftment for the cords?

 aya.dilorenzo 

We recently had this young woman who became HHV6 active. She is currently at ICU.

 kschmit 

What sort of complications are you seeing - that are different or more extensive as compared to other txplants?

 TeriNine 

HHV6?

 rhonda 

Human Herpes Virus # 6

 TeriNine 

Thanks

 aya.dilorenzo 

Infection, pulmonary complications are common. Also, I know in theory that cord transplant should have less GVHD. I'm not sure if I agree with that. We have seen lots of GVHD in cord.

 kschmit 

I think - the engraftment is longer for cords than other txplants. Or any way our cords have been longer. However, we don't do many. Does any one else know the average day of engraftment? Is there an average day?

 rhonda 

How long does it take the patients to engraft after a DUCT?

 TeriNine 

Avascular necrosis of the in our first cord transplant.

 TeriNine 

(Hip)

 kschmit 

Dr. Michael Verneris spoke at the Tandem meetings several years ago on DUCT.

 kschmit 

He presented that the rate of chronic GVHD was no different between single or double cord txplants.

 kschmit 

He did find that pts who received a double cord had a lower rate of disease recurrence than single cords.

 aya.dilorenzo 

Re: engraftment. It depends on the type of transplant (I think). Myeloablative transplant usually takes 30days or so before pts engraft. But sooner in non-myeloablative ones. We had one pt who engrafted at Day 14 of DUCT. But he developed CMV (cytomegalovirus) activation and GVHD of gut. He is still at our unit on Day 60.

 kschmit 

Re: Dr. Verneris: He said a DUCT helped the patient to engraft faster than single.

 TeriNine 

Do they have an idea why?

 aya.dilorenzo 

We never do single cord at my institution.

 steph199 

Myeloblative transplant? Please explain that procedure?

 kschmit 

Of interest, Verneris said that DUCTs showed engraftment of a single cord unit (even though they received double). And, by day 21 the 2nd unit wasn't detected.

 aya.dilorenzo 

I was told by a RN (who works for MD Juliet Barker - a big DUCT MD) that two cords "compete" and that helps engraftment.

 kschmit 

That makes sense.

 rhonda 

That is interesting

 kschmit 

Myeloablative - the bone marrow/immune system is totally ablated/destroyed

 kschmit 

Non-myeloablative - the bone marrow/immune system is NOT totally destroyed

 kschmit 

Non-myeloablative = we are using the immune system to fight the cancer - Graft versus Leukemia or Lymphoma effect.

 kschmit 

Non- myeloablative are sometimes called "Mini -Allo" transplants. I don't think they are "mini - anything"! The patients still get pretty sick!

 aya.dilorenzo 

I’m really interested in what Seattle Cancer is doing to DUCT in order to have early engraftment. There was a session about it at the transplant conference. Anyone from Seattle?

 kschmit 

Non-myeloablative does allow us to transplant older or sicker patients - who otherwise wouldn't be eligible for a "full" allo transplant.

 kschmit 

When Dr. Verneris spoke at Tandem, he was from the Univ of Minnesota.

 kschmit 

I missed the presentation from Seattle on DUCT.

 aya.dilorenzo 

It seems like lymphoma pts get non-myeloablative. Is it because lymphoma requires graft-vs-leukemia effect? Does anyone know?

 kschmit 

We do both auto, myeloablative allo, and non-myeloablative on our lymphoma patients. Many of the Mantle cell lymphomas have an allo. Depending on age/co-morbidities get either myeloablative or non-myeloablative.

 kschmit 

For the non-myeloablative to work (for the graft vs. tumor effect to work), the disease has to be somewhat slower growing.

 kschmit 

If the disease is growing to fast - there is no time for the graft vs tumor effect to happen.

 kschmit 

Another part of allo transplants (either non- myelo or myelo) is the use of donor lymphocytes (sometimes called DLI). The donor lymphocytes are given after transplant - usually weeks - or even months to cause a graft vs tumor effect.

 aya.dilorenzo 

We do have many lymphoma pts getting auto. Some come back to us for allo transplant after auto. But they usually get non-myeloablative. I can't think of one lymphoma pt who got myeloablative... (but I could be wrong).

 aya.dilorenzo 

DLI is usually done as outpatient at my institution. I don't know much about it. Can someone explain how that works?

 kschmit 

We have done the same - auto - then allo. Here the type of allo depends on age, and co-morbidities.

 kschmit 

DLI = Donor lymphocyte or leukocyte infusion.

 kschmit 

DLI is collected from the allo donor (possibly at the same time as the hematopoietic stem cells are collected - or the donor may be called back).

 kschmit 

When a patient is showing signs of relapse or progression - DLI may be given to try to promote the graft vs leuk/lymphoma effect.

 aya.dilorenzo 

Can DLI cause gvhd?

 kschmit 

Yes - DLI can cause GVHD. And, if a patient has some GVHD, it can make it worse.

 kschmit 

We don't have a standard dose of DLI to give - it all depends on the patient and how much GVHD (Graft-versus Host Disease) the patient has.

 kschmit 

Sometimes we have given several different 'doses' of DLI over several months - to try to stimulate the graft vs leuk/lymphoma effect.

 aya.dilorenzo 

Thank you.

 TeriNine 

How often do you see GVH with DLI?

 kschmit 

It depends - we are actually trying to 'give' a little GVHD to the patient - to stimulate the graft vs leuk/lymphoma effect. Going back to that slide I mentioned before - that shows patients who have more GVHD, and both acute and chronic gvhd - have better disease free survival. I will try to find the slide.

 oncnurse 

Kim, what kind of infusion issues have you seen? Are they correlated to the type of transplants you do?

 kschmit 

Some side effects of infusion - some that are possibly related to the cryopreservation DMSO are nausea, vomiting, diarrhea, bad taste or smell (like garlic).

 kschmit 

Also, patients can have an allergic or anaphylactic reaction to the DMSO. We have also seen facial or whole body flushing and abdominal cramping possibly from the DMSO.

 kschmit 

So, products that are infused fresh (mostly allo donors - related or unrelated) wouldn't have the DMSO side effects.

 kschmit 

Other side effects: increased creatinine, hemoglobinuria, could be related to the breakdown of red blood cells.

 kschmit 

The patients usually receive a lot of fluid - both the cells and hydration - so there is the possibility of fluid overload, pulmonary and heart issues with that.

 kschmit 

Also, the frozen products are infused somewhat cold yet - so some patients get chills or even a fever.

 kschmit 

It is probably best to infuse fresh - however hard to do with an auto transplant.

 kschmit 

Though, I have heard of centers collecting and storing a fresh auto product for several days (while the chemo is being infused) and then giving the fresh auto product. I can't say which center - don't remember.

 kschmit 

Any other experiences in infusion?

 aya.dilorenzo 

Is chemo given before DLI?

 kschmit 

We have done both - give chemo before DLI - to try to decrease the leuk/lymphoma. And, also given DLI just by itself.

 kschmit 

Lots of variation with DLI - I think we still have lots to learn!

 aya.dilorenzo 

I’ve heard about giving some kind of cells to patients with viral infections (eg. CMV). Is it a type of DLI?

 kschmit 

There is a study developing a CMV vaccine.

 kschmit 

I think the donor is vaccinated - and then the cells are collected. Is this what you mean? I don't know too much about the study?

 kschmit 

We tried to participate - but it was hard to convince donors!

 Laurl at ONS 

It’s about five minutes before the end of our chat- please don’t stop asking questions! However, when you can, please take a moment after the chat to cut and paste this URL into a browser window and take our very brief survey- we’d love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsSWPsXYTYUsPsP

 aya.dilorenzo 

I'm not sure what I meant... I think someone mentioned at the conference. I can imagine how hard it would be to convince donors. But if it works, it'll be great. We've seen lots of CMV reactivation recently (not sure why...).

 steph199 

Thanks for all the good information.

 kschmit 

Any last questions? Thanks to everyone for joining!!

 TeriNine 

Thank you!

 Laurl at ONS 

Thank you Kim for a great discussion- and thanks to all for participating!

 aya.dilorenzo 

Thank you!

 Laurl at ONS 

The last of this series is on Monday - please tell your coworkers about it!

 kschmit 

Bye everyone!

 TeriNine 

Bye!

 Laurl at ONS 

Have a great day!

 TeriNine 

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