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The Nuts and Bolts of Bone Marrow Transplants
 
Bone marrow transplantation (BMT) is a relatively new medical procedure being used totreat diseases once thought incurable. Since its first successful use in 1968, BMTs havebeen used to treat patients diagnosed with leukemia, aplastic anemia, lymphomas such asHodgkin's disease, multiple myeloma, immune deficiency disorders and some solidtumors such as breast and ovarian cancer.In 1991, more than 7,500 people underwent BMTs nationwide. Although BMTs nowsave thousands of lives each year, 70 percent of those needing a BMT using donormarrow are unable to have one because a suitable bone marrow donor cannot be found.
WHAT IS BONE MARROW?
Bone marrow is a spongy tissue found inside bones. The bone marrow in the breast bone,skull, hips, ribs and spine contains stem cells that produce the body's blood cells. Theseblood cells include white blood cells (leukocytes), which fight infection; red blood cells(erythrocytes), which carry oxygen to and remove waste products from organs andtissues; and platelets, which enable the blood to dot
WHY TRANSPLANT?
In patients with leukemia, aplastic anemia, and some immune deficiency diseases, thestem cells in the bone marrow malfunction, producing an excessive number of defectiveor immature blood cells (in the case of leukemia) or low blood cell counts (in the case of aplastic anemia). The immature or defective blood cells interfere with the production of normal blood cells, accumulate in the bloodstream and may invade other tissues.Large doses of chemotherapy and/or radiation are required to destroy the abnormal stemcells and abnormal blood cells. These therapies, however, not only kill the abnormal cellsbut can destroy normal cells found in the bone marrow as well. Similarly, aggressivechemotherapy used to treat some lymphomas and other cancers can destroy healthy bonemarrow. A bone marrow transplant enables physicians to treat these diseases withaggressive chemotherapy and/or radiation by allowing replacement of the diseased ordamaged bone marrow after the chemotherapy/radiation treatment.While bone marrow transplants do not provide 100 percent assurance that the disease willnot recur, a transplant can increase the likelihood of a cure or at least prolong the periodof disease-free survival for many patients.
TYPES OF TRANSPLANTS
 
In a bone marrow transplant, the patient's diseased bone marrow is destroyed and healthymarrow is infused into the patient's blood-stream. In a successful transplant, the new bonemarrow migrates to the cavities of the large bones, engrafts and begins producing normalblood cells.If bone marrow from a donor is used, the transplant is called an "allogeneic" BMT, or"syngeneic" BMT if the donor is an identical twin. In an allogeneic BMT, the new bonemarrow infused into the patient must match the genetic makeup of the patient's ownmarrow as perfectly as possible. Special blood tests are conducted to determine whetheror not the donor's bone marrow matches the patient's. If the donor's bone marrow is not agood genetic match, it will perceive the patient's body as foreign material to be attackedand destroyed. This condition is known as graft-versus-host disease (GVHD) and can belife-threatening. Alternatively, the patient's immune system may destroy the new bonemarrow. This is called graft rejection.There is a 35 percent chance that a patient will have a sibling whose bone marrow is aperfect match. If the patient has no matched sibling, a donor may be located in one of theinternational bone marrow donor registries, or a mis-matched or autologous transplantmay be considered.In some cases, patients may be their own bone marrow donors. This is called anautologous BMT and is possible if the disease afflicting the bone marrow is in remissionor if the condition being treated does not involve the bone marrow (e.g. breast cancer,ovarian cancer, Hodgkin's disease, non-Hodgkin's lymphoma, and brain tumors). Thebone marrow is extracted from the patient prior to transplant and may be "purged" toremove lingering malignant cells (if the disease has afflicted the bone marrow).
PREPARING FOR THE TRANSPLANT
A successful transplant requires the patient be healthy enough to undergo the rigors of thetransplant procedure. Age, general physical condition, the patient's diagnosis and thestage of the disease are all considered by the physician when determining whether aperson should undergo a transplant.Prior to a bone marrow transplant, a battery of tests is carried out to ensure the patient isphysically capable of undergoing a transplant. Tests of the patient's heart, lung, kidneyand other vital organ functions are also used to develop a patient "baseline" against whichpost-transplant tests can be compared to determine if any body functions have beenimpaired. The pre-transplant tests are usually done on an outpatient basis.A successful bone marrow transplant requires an expert medical team - doctors, nurses,and other support staff - who are experienced in bone marrow transplants, can promptlyrecognize problems and emerging side effects, and know how to react swiftly andproperly if problems do arise. A good bone marrow transplant program will alsorecognize the importance of providing patients and their families with emotional and
 
psychological support before, during and after the transplant, and will make personal andother support systems readily available to families for this purpose.
BONE MARROW HARVEST
Regardless of whether the patient or a donor provides the bone marrow used in thetransplant, the procedure used to collect the marrow - the bone marrow harvest - is thesame. The bone marrow harvest takes place in a hospital operating room, usually undergeneral anesthesia. It involves little risk and minimal discomfort.While the patient is under anesthesia, a needle is inserted into the cavity of the rear hipbone or "iliac crest" where a large quantity of bone marrow is located. The bone marrowa thick, red liquid - is extracted with a needle and syringe. Several skin punctures on eachhip and multiple bone punctures are usually required to extract the requisite amount of bone marrow. There are no surgical incisions or stitches involved - only skin punctureswhere the needle was inserted.The amount of bone marrow harvested depends on the size of the patient and theconcentration of bone marrow cells in the donor's blood. Usually one to two quarts of marrow and blood are harvested. While this may sound like a lot, it really only representsabout 2% of a person's bone marrow, which the body replaces in four weeks.When the anesthesia wears off, the donor may feel some discomfort at the harvest site.The pain will be similar to that associated with a hard fall on the ice and can usually becontrolled with Tylenol. Donors who are not also the BMT patient are usually dischargedafter an overnight stay and can fully resume normal activities in a few days.For autologous transplants, the harvested bone marrow will be frozen (cryopreserved)and stored at a temperature between -80 and -196 degrees centigrade until the day of transplant. It may first be "purged" to remove residual cancerous cells that can't be easilyidentified under the microscope (see page 30).
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