Leukemia, multiple myeloma and blood disorders
Physician-scientists at Johns Hopkins have developed a procedure called a half-matched bone marrow transplant that has been successful in “curing” patients of some cancers and blood disorders like sickle cell anemia. Rather than wiping out a patient’s immune system before transplanting donor bone marrow, doctors administer just enough chemotherapy to suppress the immune system, which keeps patients from rejecting the donated marrow without harming their organs. As a result, the side effects are much milder; only about half of patients may need to be admitted to the hospital. This procedure also greatly expands the potential donor pool, making more patients eligible for the transplant. Since developing the treatment more than a decade ago, Kimmel Cancer Center experts have performed more than 600 half-matched transplants for adult and pediatric leukemia and lymphoma. Johns Hopkins is currently the only center offering this type of transplantation for chronic leukemias, multiple myeloma and myeloproliferative disorders; other centers consider this treatment only for acute leukemias or lymphomas. Research results were reported in July 2011.
Making bone marrow transplant safe and available to all
For decades a serious complication known as graft versus host disease (GVHD) prevented bone marrow transplants from being performed on patients who did not have a donor with a nearly identically matching immune system, usually found in a brother or sister A large national registry matched some of these patients with unrelated donors, but most grew sicker and many died waiting for a match to be found. As a result, only about one-half of patients were candidates for the potentially curative therapy. Minorities suffered the most. African-American patients who did not have a match in their family, had less than a 10 percent chance of finding a donor in the unrelated registry.
Pioneering discoveries led by Kimmel Cancer Center investigators made it possible for almost any patient to receive a transplant. The research that led to this breakthrough focused on immune cells known as T cells and technologies to remove these cells from the donor marrow. Clinical studies showed that when the T cells were removed, patients did not get GVHD, but their cancers sometimes came back. It was one of the first observations of the immune system’s ability to kill cancer cells. The challenge was to remove a precise amount of T cells—small enough to avoid the most severe cases of GVHD yet a large enough number to allow the immune system to keep the cancer from coming back.
It turns out that the same drug used to treat patients before bone marrow transplant could be given post-transplant to limit GVHD without hampering the T cell’s ability to mop up any surviving cancer cells. This discovery led Kimmel Cancer Center experts to develop a new type of bone marrow transplant, known as a haploidentical or half-identical transplant.
This breakthrough approach developed at the Kimmel Cancer Center means that almost all parents, siblings, and children of patients—and sometimes even aunts and uncles, nieces and nephews, half-siblings, and grandparents or grandchildren—can safely serve as donors. Now, almost every patient who needs a bone marrow transplant can find a matching donor. Since developing the treatment more than a decade ago, Kimmel Cancer Center experts have performed more than 600 half-matched transplants for adult and pediatric leukemia and lymphoma.
These clinical studies have proven so successful, with safety and toxicity comparable to matched transplants, that the therapy is now used to treat chronic but debilitating noncancerous diseases of the blood in adults and children, such as sickle cell anemia and severe autoimmune disorders.
How it works
Three days after the transplant, a patient is given a high dose of a drug called cyclophosphamide, which “re-boots” the immune system. The cyclophosphamide spares the donor's stem cells and allows them to establish new blood cells and a new immune system. The budding immune system is re-trained to see the patient's body as friend, preventing the patient from rejecting the transplanted bone marrow. Doctors speculate the procedure works because with a higher level of mismatch between the donor and recipient, the immune system reacts more strongly against the cancer and lowers the chance of relapse, explains Dr. Ephraim Fuchs, associate professor of oncology, who helped develop the procedure.
Normally, doctors look for a donor who matches a patient's tissue type, specifically their human leukocyte antigen (HLA) tissue type. HLAs are proteins — or markers — found on most cells in the body. The immune system uses these markers to recognize cells that belong in the body versus those that do not. The closer the match between a patient's HLA markers and the donor’s, the better for the patient. In most cases of sickle cell disease, for example, doctors looked for a nearly full match prior to bone marrow transplantation. This was extremely difficult because in many cases, the person with the closest match, such as a sibling, may also have carried the sickle cell gene. The Hopkins procedure requires just a half-match, meaning that a patient’s parents or children could be suitable donors. With this option, doctors estimate that more than half of sickle cell patients, and nearly all patients with other blood cancers or autoimmune disorders, have potential matches.
Older age or match are not barriers
Kimmel Cancer Center researchers demonstrated that advanced age should no longer be a barrier to patients in need of bone marrow transplants. A study of 273 bone marrow transplants, in which a family member with partially-matched marrow was the donor, showed no difference in outcomes for patients aged 50 to 75, including graft-versus-host disease, mortality, and overall survival. As previously shown, the related haploidentical transplant did as well as matched donor transplants. These data demonstrate that bone marrow transplants are available to everyone in need regardless of match or age.