Hematopoietic transplant- focus on boards

 Pearls in Stem cell transplant for the boards

Reference ASH

Know the indications for  :

1. Allo SCT

AML: CR1 for intermediate or poor risk, CR2 for favorable risk, primary refractory, MDS or t-AML

ALL: Ph+ in CR1, any relapse, failure to achieve MRD neg after first induction, in AYA if high risk features such as iAMP 21 ( intrachromosomal amplification of chromosome 21), B cell with poor risk, 11 q 23

MDS: Intermediate or high risk, transfusion dependence, refractory cytopenias, moderate or severe fibrosis, therapy associated, adverse cytogenetics

CML: T3151 mutation, refractory or intolerant, accelerated or blast crisis

MF- DIPSS 2 or higher, DIPSS1 with other poor risk features, transfusion dependence, possibly triple neg MF

CLL: Richter's, second or higher progression

2. Auto transplant

a. Multiple myeloma

b. Chemosensitive Relapsed Hodgkin and NHL

c. Mantle cell

d. Autoimmune disease

e. Relapsed germ cell

f. T cell lymphoma ( not supported by phase 3 trials, but done in practice as for Mantle cell)

TYPES of transplant and stem cell sources

Auto

Allo- sibling donor

Haplo identical ( alternative donor)

MUD 10/10

Cord blood ( alternative donor)

Syngeneic - identical twin ( do not use when you want GVL effect, e.g AML)

Why syngeneic is not used in AML: We want the GVL effect, and you do not get that with an identical twin.

Stem cell sources

a. Umbilical- low risk of GVHD, prolonged time to engraftment

b. bone marrow: inconvenient to donors, no difference in survival compared to peripheral blood, less GVHD compared to peripheral SCT

c. Peripheral blood: higher CD 34 and T lymphocytes, so faster engraftment but higher GVHD

Preference of donors:

First: sibling, then second would  be fully matched unrelated

Third- haplo, cord

Finally unmatched unrelated

HLA matching is important

Gender Female donor to male recipient higher GVHD because Y chromosome acts as a minor antigen

Biggest risk for GVHD: HLA mismatch

Calcineurin associated TMA- stop the drug

Calcineurin associated PRES ( altered mentation) in the peri transplant period- stop the drug

Hepatic VOD- defibrotide

GVHD rx in steroid refractory

Acute- Jakafi

Chronic- Ibrutinib, Belumosidil

Idiopathic pneumonia syndrome- steroids, etanercept