Chapter 31: Hematopoietic Cell Transplantation

Bone marrow transplantation was the original term used to describe the collection and transplantation of hematopoietic stem cells, but with the demonstration that peripheral blood and umbilical cord blood are also useful sources of stem cells, hematopoietic cell transplantation has become the preferred generic term for this process. The procedure is usually carried out for one of two purposes: (1) to replace an abnormal but nonmalignant lymphohematopoietic system with one from a normal donor or (2) to treat malignancy by allowing the administration of higher doses of myelosuppressive therapy than would otherwise be possible. The use of hematopoietic cell transplantation has been increasing, both because of its efficacy in selected diseases and because of increasing availability of donors. The Center for International Blood and Marrow Transplant Research (http://www.cibmtr.org) estimates that about 65,000 transplants are performed each year.

Several features of the hematopoietic stem cell make transplantation clinically feasible, including its remarkable regenerative capacity, its ability to home to the marrow space following intravenous injection, and the ability of the stem cell to be cryopreserved (Chap. 1). Transplantation of a single stem cell can replace the entire lymphohematopoietic system of an adult mouse. In humans, transplantation of a small percentage of a donor’s bone marrow volume regularly results in complete and sustained replacement of the recipient’s entire lymphohematopoietic system, including all red cells, granulocytes, B and T lymphocytes, and platelets, as well as cells comprising the fixed macrophage population, including Kupffer cells of the liver, pulmonary alveolar macrophages, osteoclasts, Langerhans cells of the skin, and brain microglial cells. The ability of the hematopoietic stem cell to home to the marrow following intravenous injection is mediated, in part, by an interaction between CXCL12, also known as stromal cell–derived factor 1, produced by marrow stromal cells and the alpha-chemokine receptor CXCR4 found on stem cells. Homing is also influenced by the interaction of cell-surface molecules, termed selectins, including E- and L-selectin, on bone marrow endothelial cells with ligands, termed integrins, such as VLA-4, on early hematopoietic cells. Human hematopoietic stem cells can survive freezing and thawing with little, if any, damage, making it possible to remove and store a portion of the patient’s own bone marrow for later reinfusion following treatment of the patient with high-dose myelotoxic therapy.

Hematopoietic cell transplantation can be described according to the relationship between the patient and the donor and by the anatomic source of stem cells. In ~1% of cases, patients have identical twins who can serve as donors. With the use of syngeneic donors, there is no risk of graft-versus-host disease (GVHD), which often complicates allogeneic transplantation, and unlike the use of autologous marrow, there is no risk that the stem cells are contaminated with tumor cells.

Allogeneic transplantation involves a donor and a recipient who are not genetically identical. Following allogeneic transplantation, immune cells transplanted with the stem cells or developing from them can react against the patient, causing GVHD. Alternatively, if the immunosuppressive preparative regimen used to treat the patient before transplant is inadequate, immunocompetent cells of the patient can cause graft rejection. The risks of these complications are greatly influenced by the degree of matching between donor and recipient for antigens encoded by genes of the major histocompatibility complex.

The human leukocyte antigen (HLA) molecules are responsible for binding antigenic proteins and presenting them to T cells. The antigens presented by HLA molecules may derive from exogenous sources (e.g., during active infections) or may be endogenous proteins. If individuals are not HLA-matched, T cells from one individual will react strongly to the mismatched HLA, or “major antigens,” of the second. Even if the individuals are HLA-matched, the T cells of the donor may react to differing endogenous or “minor antigens” presented by the HLA of the recipient. Reactions to minor antigens tend to be less vigorous. The genes of major relevance to transplantation include HLA-A, -B, -C, and -D; they are closely linked and therefore tend to be inherited as haplotypes, with only rare crossovers between them. Thus, the odds that any one full sibling will match a patient are one in four, and the probability that the patient has an HLA-identical sibling is 1 − (0.75)ⁿ, where n equals the number of siblings.

With current techniques, the risk of graft rejection is 1–3%, and the risk of severe, life-threatening acute GVHD is ~15% following transplantation between HLA-identical siblings. The incidence of graft rejection and GVHD increases progressively with the use of family member donors mismatched for one, two, or three antigens. Although survival following a one-antigen mismatched transplant is not markedly altered, survival following two- or three-antigen mismatched transplants is significantly reduced. Since the formation of the National Marrow Donor Program and other registries, it has become possible to identify HLA-matched unrelated donors for many patients. The genes encoding HLA antigens are highly polymorphic, and thus the odds of any two unrelated individuals being HLA identical are extremely low, somewhat less than 1 in 10,000. However, by identifying and typing >20 million volunteer donors, HLA-matched donors can now be found for ~60% of patients for whom a search is initiated, with higher rates among whites and lower rates among minorities and patients of mixed race. It takes, on average, 3–4 months to complete a search and schedule and initiate an unrelated donor transplant. With improvements in HLA typing and supportive care measures, survival following matched unrelated donor transplantation is essentially the same as that seen with HLA-matched siblings.

Autologous transplantation involves the removal and storage of the patient’s own stem cells with subsequent reinfusion after the patient receives high-dose myeloablative therapy. Unlike allogeneic transplantation, there is no risk of GVHD or graft rejection with autologous transplantation. On the other hand, autologous transplantation lacks a graft-versus-tumor (GVT) effect, and the autologous stem cell product can be contaminated with tumor cells, which could lead to relapse. A variety of techniques have been developed to “purge” autologous products of tumor cells. Some use antibodies directed at tumor-associated antigens plus complement, antibodies linked to toxins, or antibodies conjugated to immunomagnetic beads. Another technique is positive selection of stem cells using antibodies to CD34, with subsequent column adherence or flow techniques to select normal stem cells while leaving tumor cells behind. All of these approaches can reduce the number of tumor cells from 1000- to 10,000-fold and are clinically feasible; however, no prospective randomized trials have yet shown that any of these approaches results in a decrease in relapse rates or improvements in disease-free or overall survival.

Bone marrow aspirated from the posterior and anterior iliac crests initially was the source of hematopoietic stem cells for transplantation. Typically, anywhere from 1.5 to 5 × 10⁸ nucleated marrow cells per kilogram are collected for allogeneic transplantation. Several studies have found improved survival in the settings of both matched sibling and unrelated transplantation by transplanting higher numbers of bone marrow cells.

Hematopoietic stem cells circulate in the peripheral blood but in very low concentrations. Following the administration of certain hematopoietic growth factors, including granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF), and during recovery from intensive chemotherapy, the concentration of hematopoietic progenitor cells in blood, as measured either by colony-forming units or expression of the CD34 antigen, increases markedly. This has made it possible to harvest adequate numbers of stem cells from the peripheral blood for transplantation. Donors are typically treated with 4 or 5 days of hematopoietic growth factor, following which stem cells are collected in one or two 4-h pheresis sessions. In the autologous setting, transplantation of >2.5 × 10⁶ CD34 cells per kilogram, a number that can be collected in most circumstances, leads to rapid and sustained engraftment in virtually all cases. In the 10–20% of patients who fail to mobilize sufficient CD34+ cells with growth factor alone, the addition of plerixafor, an antagonist of CXCR4, may be useful. Compared to the use of autologous marrow, use of peripheral blood stem cells results in more rapid hematopoietic recovery, with granulocytes recovering to 500/μL by day 12 and platelets recovering to 20,000/μL by day 14. Although this more rapid recovery diminishes the morbidity rate of transplantation, no studies show improved survival.

Hesitation in studying the use of peripheral blood stem cells for allogeneic transplantation occurred because peripheral blood stem cell products contain as much as 1 log more T cells than are contained in the typical marrow harvest; in animal models, the incidence of GVHD is related to the number of T cells transplanted. Nonetheless, clinical trials have shown that the use of growth factor–mobilized peripheral blood stem cells from HLA-matched family members leads to faster engraftment without an increase in acute GVHD. Chronic GVHD may be increased with peripheral blood stem cells, but in trials conducted so far, this has been more than balanced by reductions in relapse rates and nonrelapse mortality rates, with the use of peripheral blood stem cells resulting in improved overall survival. However, in the setting of matched unrelated donor transplantation, use of peripheral blood results in more chronic GVHD without a compensatory survival advantage, favoring the use of bone marrow in this setting.

Umbilical cord blood contains a high concentration of hematopoietic progenitor cells, allowing for its use as a source of stem cells for transplantation. Cord blood transplantation from family members has been explored in the setting where the immediate need for transplantation precludes waiting the 9 or so months generally required for the baby to mature to the point of donating marrow. Use of cord blood results in slower engraftment and peripheral count recovery than seen with marrow but a lower incidence of GVHD, perhaps reflecting the low number of T cells in cord blood. Multiple cord blood banks have been developed to harvest and store cord blood for possible transplantation to unrelated patients from material that would otherwise be discarded. Currently more than 500,000 units are cryopreserved and available for use. The advantages of unrelated cord blood are rapid availability and decreased immune reactivity allowing for the use of partially matched units, which is of particular importance for those without matched unrelated donors. The risks of graft failure and transplant-related mortality are related to the dose of cord blood cells per kilogram, which previously limited the application of single cord blood transplantation to pediatric and smaller adult patients. Subsequent trials have found that the use of double cord transplants diminishes the risk of graft failure and early mortality even though only one of the donors ultimately engrafts. Survival rates are now similar with unrelated donor and cord blood transplantation.

The treatment regimen administered to patients immediately preceding transplantation is designed to eradicate the patient’s underlying disease and, in the setting of allogeneic transplantation, immunosuppress the patient adequately to prevent rejection of the transplanted marrow. The appropriate regimen therefore depends on the disease setting and source of marrow. For example, when transplantation is performed to treat severe combined immunodeficiency and the donor is a histocompatible sibling, no treatment is needed because no host cells require eradication and the patient is already too immunoincompetent to reject the transplanted marrow. For aplastic anemia, there is no large population of cells to eradicate, and high-dose cyclophosphamide plus antithymocyte globulin are sufficient to immunosuppress the patient adequately to accept the marrow graft. In the setting of thalassemia and sickle cell anemia, high-dose busulfan is frequently added to cyclophosphamide in order to eradicate hyperplastic host hematopoiesis. A variety of different regimens have been developed to treat malignant diseases. Most of these regimens include agents that have high activity against the tumor in question at conventional doses and have myelosuppression as their predominant dose-limiting toxicity. Therefore, these regimens commonly include busulfan, cyclophosphamide, melphalan, thiotepa, carmustine, etoposide, and total-body irradiation in various combinations.

Although high-dose treatment regimens have typically been used in transplantation, the understanding that much of the antitumor effect of transplantation derives from an immunologically mediated GVT response has led investigators to ask if reduced-intensity conditioning regimens might be effective and more tolerable. Evidence for a GVT effect comes from studies showing that posttransplant relapse rates are lowest in patients who develop acute and chronic GVHD, higher in those without GVHD, and higher still in recipients of T cell–depleted allogeneic or syngeneic marrow. The demonstration that complete remissions can be obtained in many patients who have relapsed after transplant by simply administering viable lymphocytes from the original donor further strengthens the argument for a potent GVT effect. Accordingly, a variety of reduced-intensity regimens have been studied, ranging from the very minimum required to achieve engraftment (e.g., fludarabine plus 200 cGy total-body irradiation) to regimens of more immediate intensity (e.g., fludarabine plus melphalan). Studies to date document that engraftment can be readily achieved with less toxicity than seen with conventional transplantation. Furthermore, the severity of acute GVHD appears to be somewhat decreased. Complete sustained responses have been documented in many patients, particularly those with more indolent hematologic malignancies. In general, relapse rates are higher following reduced-intensity conditioning, but transplant-related mortality is lower, favoring the use of reduced-intensity conditioning in older patients and those with significant comorbidities. High-dose regimens are favored in younger, fitter patients.

THE TRANSPLANT PROCEDURE

Marrow is usually collected from the donor’s posterior and sometimes anterior iliac crests, with the donor under general or spinal anesthesia. Typically, 10–15 mL/kg of marrow is aspirated, placed in heparinized media, and filtered through 0.3- and 0.2-mm screens to remove fat and bony spicules. The collected marrow may undergo further processing depending on the clinical situation, such as the removal of red cells to prevent hemolysis in ABO-incompatible transplants, the removal of donor T cells to prevent GVHD, or attempts to remove possible contaminating tumor cells in autologous transplantation. Marrow donation is safe, with only very rare complications reported.

Peripheral blood stem cells are collected by leukapheresis after the donor has been treated with hematopoietic growth factors or, in the setting of autologous transplantation, sometimes after treatment with a combination of chemotherapy and growth factors. Stem cells for transplantation are infused through a large-bore central venous catheter. Such infusions are usually well tolerated, although occasionally patients develop fever, cough, or shortness of breath. These symptoms typically resolve with slowing of the infusion. When the stem cell product has been cryopreserved using dimethyl sulfoxide, patients more often experience short-lived nausea or vomiting due to the odor and taste of the cryoprotectant.

ENGRAFTMENT

Peripheral blood counts usually reach their nadir several days to a week after transplant as a consequence of the preparative regimen; then cells produced by the transplanted stem cells begin to appear in the peripheral blood. The rate of recovery depends on the source of stem cells, the use of posttransplant growth factors, and the form of GVHD prophylaxis used. If marrow is the source of stem cells, recovery to 100 granulocytes/μL occurs on average by day 16 and to 500/μL by day 22. Use of G-CSF–mobilized peripheral blood stem cells speeds the rate of recovery by ~1 week when compared to marrow, whereas engraftment following cord blood transplantation is typically delayed by ~1 week compared to marrow. Use of a myeloid growth factor (G-CSF or GM-CSF) after transplant can accelerate recovery by 3–5 days, whereas use of methotrexate to prevent GVHD delays engraftment by a similar period. Following allogeneic transplantation, engraftment can be documented using fluorescence in situ hybridization of sex chromosomes if donor and recipient are sex-mismatched or by analysis of a variable number of tandem repeats or short tandem repeat polymorphisms after DNA amplification.

COMPLICATIONS FOLLOWING HEMATOPOIETIC CELL TRANSPLANT

Early direct chemoradiotoxicities

The transplant preparative regimen may cause a spectrum of acute toxicities that vary according to intensity of the regimen and the specific agents used, but frequently results in nausea, vomiting, and mild skin erythema (Fig. 31-1). Regimens that include high-dose cyclophosphamide can result in hemorrhagic cystitis, which can usually be prevented by bladder irrigation or with the sulfhydryl compound mercaptoethanesulfonate (MESNA); rarely, acute hemorrhagic carditis is seen. Most high-dose preparative regimens will result in oral mucositis, which typically develops 5–7 days after transplant and often requires narcotic analgesia. Use of a patient-controlled analgesic pump provides the greatest patient satisfaction and results in a lower cumulative dose of narcotic. Keratinocyte growth factor (palifermin) can shorten the duration of mucositis by several days following autologous transplantation. Patients begin losing their hair 5–6 days after transplant and by 1 week are usually profoundly pancytopenic.

Depending on the intensity of the conditioning regimen, 3–10% of patients will develop sinusoidal obstruction syndrome (SOS) of the liver (formerly called venoocclusive disease), a syndrome that results from direct cytotoxic injury to hepatic-venular and sinusoidal endothelium, with subsequent deposition of fibrin and the development of a local hypercoagulable state. This chain of events leads to the clinical symptoms of tender hepatomegaly, ascites, jaundice, and fluid retention. These symptoms can develop any time during the first month after transplant, with the peak incidence at day 16. Predisposing factors include prior exposure to intensive chemotherapy, pretransplant hepatitis of any cause, and use of more intense conditioning regimens. The mortality rate of sinusoidal obstruction syndrome is ~30%, with progressive hepatic failure culminating in a terminal hepatorenal syndrome. Both thrombolytic and antithrombotic agents, such as tissue plasminogen activator, heparin, and prostaglandin E, have been studied as therapy, but none has proven of consistent major benefit in controlled trials, and all have significant toxicity. Studies with defibrotide, a polydeoxyribonucleotide, seem encouraging.

Although most pneumonias developing early after transplant are caused by infectious agents, in ~5% of patients a diffuse interstitial pneumonia will develop that is thought to be the result of direct toxicity of high-dose preparative regimens. Bronchoalveolar lavage usually shows alveolar hemorrhage, and biopsies are typically characterized by diffuse alveolar damage, although some cases may have a more clearly interstitial pattern. High-dose glucocorticoids or antitumor necrosis factor therapies are sometimes used as treatment, although randomized trials testing their utility have not been reported.

Late direct chemoradiotoxicities

Late complications of the preparative regimen include decreased growth velocity in children and delayed development of secondary sex characteristics. These complications can be partly ameliorated with the use of appropriate growth and sex hormone replacement. Most men become azoospermic, and most postpubertal women will develop ovarian failure, which should be treated. However, pregnancy is possible after transplantation, and patients should be counseled accordingly. Thyroid dysfunction, usually well compensated, is sometimes seen. Cataracts develop in 10–20% of patients and are most common in patients treated with total-body irradiation and those who receive glucocorticoid therapy after transplant for treatment of GVHD. Aseptic necrosis of the femoral head is seen in 10% of patients and is particularly frequent in those receiving chronic glucocorticoid therapy. Both acute and late chemoradiotoxicities (except those due to glucocorticoids and other agents used to treat GVHD) are considerably less frequent in recipients of reduced-intensity compared to high-dose preparative regimens.

Graft failure

Although complete and sustained engraftment is usually seen after transplant, occasionally marrow function either does not return or, after a brief period of engraftment, is lost. Graft failure after autologous transplantation can be the result of inadequate numbers of stem cells being transplanted, damage during ex vivo treatment or storage, or exposure of the patient to myelotoxic agents after transplant. Infections with cytomegalovirus (CMV) or human herpesvirus type 6 have also been associated with loss of marrow function. Graft failure after allogeneic transplantation can also be due to immunologic rejection of the graft by immunocompetent host cells. Immunologically based graft rejection is more common following use of less immunosuppressive preparative regimens, in recipients of T cell–depleted stem cell products, and in patients receiving grafts from HLA-mismatched donors or cord blood.

Treatment of graft failure usually involves removing all potentially myelotoxic agents from the patient’s regimen and attempting a short trial of a myeloid growth factor. Persistence of lymphocytes of host origin in allogeneic transplant recipients with graft failure indicates immunologic rejection. Reinfusion of donor stem cells in such patients is usually unsuccessful unless preceded by a second immunosuppressive preparative regimen. Standard high-dose preparative regimens are generally tolerated poorly if administered within 100 days of a first transplant because of cumulative toxicities. However, use of regimens combining, for example, fludarabine plus low-dose total-body irradiation, or cyclophosphamide plus antithymocyte globulin, has been effective in some cases.

Graft-versus-host disease

GVHD is the result of allogeneic T cells that are transferred with the donor’s stem cell inoculum reacting with antigenic targets on host cells. Acute GVHD usually occurs within the first 3 months after transplant with a peak onset around 4 weeks and is characterized by an erythematous maculopapular rash; by persistent anorexia or diarrhea, or both; and by liver disease with increased serum levels of bilirubin, alanine and aspartate aminotransferase, and alkaline phosphatase. Because many conditions can mimic acute GVHD, the diagnosis usually requires skin, liver, or endoscopic biopsy for confirmation. In all these organs, endothelial damage and lymphocytic infiltrates are seen. In skin, the epidermis and hair follicles are damaged; in liver, the small bile ducts show segmental disruption; and in intestines, destruction of the crypts and mucosal ulceration may be noted. A commonly used rating system for acute GVHD is shown in Table 31-1. Grade I acute GVHD is of little clinical significance, does not affect the likelihood of survival, and does not require treatment. In contrast, grades II to IV GVHD are associated with significant symptoms and a poorer probability of survival, and they require aggressive therapy. The incidence of acute GVHD is higher in recipients of stem cells from mismatched or unrelated donors, in older patients, and in patients unable to receive full doses of drugs used to prevent the disease.

One general approach to the prevention of GVHD is the administration of immunosuppressive drugs early after transplant. Combinations of methotrexate and either cyclosporine or tacrolimus are among the most effective and widely used regimens. Prednisone, anti–T cell antibodies, mycophenolate mofetil, sirolimus, and other immunosuppressive agents have also been or are being studied in various combinations. A second general approach to GVHD prevention is removal of T cells from the stem cell inoculum. While effective in preventing GVHD, T cell depletion has been associated with an increased incidence of graft failure, infectious complications, and tumor recurrence after transplant; as yet, it is unsettled whether T cell depletion improves cure rates in any specific setting.

Despite prophylaxis, significant acute GVHD will develop in ~30% of recipients of stem cells from matched siblings and in as many as 60% of those receiving stem cells from unrelated donors. The disease is usually treated with glucocorticoids, additional immunosuppressants, or monoclonal antibodies targeted against T cells or T cell subsets.

Chronic GVHD occurs most commonly between 3 months and 2 years after allogeneic transplant, developing in 20–50% of recipients. The disease is more common in older patients, in recipients of mismatched or unrelated stem cells, and in those with a preceding episode of acute GVHD. The disease resembles an autoimmune disorder with malar rash, sicca syndrome, arthritis, obliterative bronchiolitis, and bile duct degeneration and cholestasis. Single-agent prednisone or cyclosporine is standard treatment at present, although trials of other agents are under way. Mortality rates from chronic GVHD average around 15%, but range from 5–50% depending on severity. In most patients, chronic GVHD resolves, but it may require 1–3 years of immunosuppressive treatment before these agents can be withdrawn without the disease recurring. Because patients with chronic GVHD are susceptible to significant infection, they should receive prophylactic trimethoprim-sulfamethoxazole, and all suspected infections should be investigated and treated aggressively.

Although onset before or after 3 months after transplant is often used to discriminate between acute and chronic GVHD, occasional patients will develop signs and symptoms of acute GVHD after 3 months (late-onset acute GVHD), whereas others will exhibit signs and symptoms of both acute and chronic GVHD (overlap syndrome). There are as yet no data to suggest that these patients should be treated differently than those with classic acute or chronic GVHD.

From 3–5% of patients will develop an autoimmune disorder following allogeneic HCT, most commonly autoimmune hemolytic anemia or idiopathic thrombocytopenic purpura. Unrelated donor source and chronic GVHD are risk factors, but autoimmune disorders have been reported in patients with no obvious GVHD. Treatment is with prednisone, cyclosporine, or rituximab.

Infection

Posttransplant patients, particularly recipients of allogeneic transplantation, require unique approaches to the problem of infection. Early after transplantation, patients are profoundly neutropenic, and because the risk of bacterial infection is so great, most centers initiate antibiotic treatment once the granulocyte count falls to <500/μL. Fluconazole prophylaxis at a dose of 200–400 mg/d reduces the risk of candidal infections. Patients seropositive for herpes simplex should receive acyclovir prophylaxis. One approach to infection prophylaxis is shown in Table 31-2. Despite these prophylactic measures, most patients will develop fever and signs of infection after transplant. The management of patients who become febrile despite bacterial and fungal prophylaxis is a difficult challenge and is guided by individual aspects of the patient and by the institution’s experience.

Once patients engraft, the incidence of bacterial infection diminishes; however, patients, particularly allogeneic transplant recipients, remain at significant risk of infection. During the period from engraftment until about 3 months after transplant, the most common causes of infection are gram-positive bacteria, fungi (particularly Aspergillus), and viruses including CMV. CMV infection, which in the past was frequently seen and often fatal, can be prevented in seronegative patients transplanted from seronegative donors by the use of either seronegative blood products or products from which the white blood cells have been removed. In seropositive patients or patients transplanted from seropositive donors, the use of ganciclovir, either as prophylaxis beginning at the time of engraftment or initiated when CMV first reactivates as evidenced by development of antigenemia or viremia, can significantly reduce the risk of CMV disease. Foscarnet is effective for some patients who develop CMV antigenemia or infection despite the use of ganciclovir or who cannot tolerate the drug.

Pneumocystis jiroveci pneumonia, once seen in 5–10% of patients, can be prevented by treating patients with oral trimethoprim-sulfamethoxazole for 1 week before transplant and resuming the treatment once patients have engrafted.

The risk of infection diminishes considerably beyond 3 months after transplant unless chronic GVHD develops, requiring continuous immunosuppression. Most transplant centers recommend continuing trimethoprim-sulfamethoxazole prophylaxis while patients are receiving any immunosuppressive drugs and also recommend careful monitoring for late CMV reactivation. In addition, many centers recommend prophylaxis against varicella-zoster, using acyclovir for 1 year after transplant. Patients should be revaccinated against tetanus, diphtheria, Haemophilus influenzae, polio, and pneumococcal pneumonia starting at 12 months after transplant and against measles, mumps, and rubella (MMR), varicella-zoster virus, and possibly pertussis at 24 months.

TREATMENT

TREATMENT