Here’s What’s Coming

~When bone marrow transplant is used for up-front therapy of AML (meaning in the initial treatment plan as opposed to after a relapse), it is ideally given after 3 cycles of chemotherapy.  The patient receives chemotherapy and waits for the effects of the chemotherapy to recover before starting the bone marrow transplant (typically takes 4-6 weeks after starting the 3rd course of chemotherapy to be ready to start the bone marrow transplant).  All of this timing depends on how well the leukemia responded to treatment, if there is still detectable disease, certain genetic changes in the leukemia cells, and any complications of therapy up until this point.

Bone marrow transplant is actually an antiquated term for the procedure – we now call it hematopoetic stem cell transplant.(  I don’t see anything poetic about this.)< Me, inserting my opinion about that new terminology. The reason for this is we can get the stem cells from several different sources — from the bone marrow of a donor, from the peripheral blood of a donor, or from the national cord blood bank.  The goal of the transplant is to use very high doses of chemotherapy to completely wipe out the bone marrow (blood factory and source of the leukemia), so high that his own blood factory can’t recover on its own (different than the chemotherapy he has been getting up until now).  Then we ‘rescue’ the bone marrow by infusing a donor’s stem cells, which find their way into the patient’s bone marrow and start to grow there.

When trying to find a bone marrow donor, we try to ‘match’ them to the patient as closely as we can.  Sometimes it can be difficult to find an exact match, and then in those situations we start to look at less well-matched donors.  Everybody has a donor available, but the goal is to find the best possible match.  At our hospital we do haplo-identical transplants (half-matched transplants, typically using the patients mom as the donor) when there is no better option available.  The reason that we want the best possible match is to minimize a potentially life-threatening complication of the transplant called graft-versus-host disease (GVHD).  GVHD happens when the new cells that are transplanted into the patient realize that they are in a foreign place, and start to attack the patient’s organs (skin, liver, lungs, gut).  A little bit of GVHD is actually a good thing, because we think that there also is a graft-versus-leukemia effect (the new cells also recognize any lingering leukemia cells as foreign and attack them).  Patients die from severe GVHD.

I always encourage families that I take care of to get another opinion if they want one.  Parents have to live with the consequences of the medical care/decisions made for their child, regardless of the outcome, for the rest of their lives.  Second opinions can be in person, or patient materials can be sent to another institution for review by physicians.