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50 TH Anniversary Lay Brochure
50 TH Anniversary Lay Brochure
Years
in Hematology
We hope this brochure strengthens your understanding of blood diseases and their
treatments and enhances your appreciation for the importance of scientific research.
We welcome you to share it with anyone who has an interest in learning more about
hematology – patients, students, doctors, and others. For additional copies, please contact
ash@hematology.org.
Sincerely,
o Antithrombotic Therapy 28
chapter 1: red blood cells
R e d B l o o d C e l l , th e d e l i v e r e r :
picks up oxygen in the lungs and delivers it throughout
the body where it is exchanged for carbon dioxide,
which is then returned and expelled through the lungs
2 5 0 y ears i n hematolog y
Sickle Cell Disease and Thalassemia:
Disorders of Globin Production
B y E ll i ot T V i ch i nsk y , M D , Children’s Hospital and Research Center Oakland, Oakland, CA
1949 Linus Pauling discovers that sickle cell disease is caused by an abnormal
hemoglobin.
1957 Vernon Ingram discovers that a change in one amino acid in hemoglobin S
causes sickling.
1970s Sickle cell anemia becomes the first human disease to be explained at the
level of a single nucleotide mutation: Using recombinant DNA technology
techniques, scientists find that the nucleotide change in the DNA for sickle
hemoglobin results from an A to T substitution.
The civil rights movement calls attention to racial inequality in health care.
Charles Whitten establishes the Sickle Cell Disease Association of America
Linus Pauling. Photo courtesy of The Linus Pauling to improve research, education, and health care for sickle cell patients.
Papers, Special Collections, Oregon State University.
1972 The Sickle Cell Anemia Control Act allocates government funding for
complication of sickle cell disease, screening, research, and treatment. With these funds, the National Heart,
and developed new ways to identify Lung, and Blood Institute establishes the Cooperative Study of Sickle Cell
Disease.
genetic risk factors for other disease
complications. 1980 Robert P. Hebbel observes that sickle cells stick to the lining of blood
vessels and shows that this correlates with severity of illness.
Thalassemia 1983 The Prophylactic Penicillin Study (PROPS) finds that treatment of well
sickle cell patients with penicillin could prevent death related to serious
Thalassemia, or Mediterranean infections.
anemia, was first described in 1925 by
a Detroit physician who studied Italian
1995 The Multicenter Study of Hydroxyurea proves the usefulness of hydroxyurea
in preventing complications in patients with sickle cell disease.
children with severe anemia (low
levels of red blood cells), poor growth, 1996 The Multicenter Bone Marrow Transplant Study demonstrates a cure for
huge abdominal organs, and early children with sickle cell disease.
childhood death. In 1946, the cause
of thalassemia was found to be an 1998 The Stroke Prevention in Sickle Cell Disease clinical trials show that
transcranial Doppler ultrasonography, a method of analyzing blood flow in
abnormal hemoglobin structure. The
the brain, is an effective screening tool.
body reacts by destroying red blood
cells, causing anemia. To compensate 2000 A published study by Lennette J. Benjamin demonstrates that a day
for the loss, the body tries to make hospital for the treatment of pain improves quality of life and prevents
red blood cells more rapidly, causing hospitalizations.
other thalassemia complications, such
as bone abnormalities and spleen Hemolysis (a breakdown of red blood cells) results in free hemoglobin, which
decreases the availability of nitric oxide (an important signaling molecule),
enlargement. causing widespread pathologic consequences, including pulmonary
hypertension. Further studies determine that pulmonary hypertension is
In the 1960s, doctors treating common in sickle cell disease and a strong predictor of death.
thalassemia patients started to
transfuse them with fresh red blood 2001 Gene therapy successfully cures a sickle-cell mouse.
cells every month. This alleviated most
of the childhood symptoms and led
2005 Genetic methods are developed to predict complications of sickle cell
disease.
to a major improvement in survival.
It is still used as a treatment today. 2007 Techniques are developed in sickle-cell mice to convert normal cells into
However, since blood contains large stem cells to be used for gene therapy and transplant.
amounts of iron, which the body cannot
eliminate naturally, most patients died
4 5 0 y ears i n hematolog y
Milestones in Thalassemia
in their teenage years from damage 1948 The thalassemia mutation is found to protect against malaria.
caused by too much iron. Researchers
later found that excess iron could be 1964 Treatment with regular blood transfusions begins to improve patient
survival.
removed from the body by treatment
with a drug called desferoxamine. This 1975 Prenatal diagnosis for thalassemia becomes available.
drug prevented iron-induced heart
disease and helped patients live much 1977 Richard Propper discovers that the iron toxicity caused by frequent blood
longer. Recently, two oral drugs have transfusions can be eliminated with desferoxamine.
become available to remove iron. They
have dramatically improved the quality 1982 Azacytidine is found to increase fetal hemoglobin in thalassemia patients.
of life of patients with iron overload
from transfusions for thalassemia. Bone marrow transplantation is first used to cure thalassemia.
Furthermore, specialized imaging tests
can now find iron in the heart and 1998 Oral chelators (such as deferiprone) are shown to be clinically beneficial
allow patients to be treated before they for the treatment of iron toxicity.
develop iron-related heart failure.
2001 Specialized radiology imaging identifies iron toxicity in the heart.
As with sickle cell disease, drugs
Hepcidin, a hormone that controls iron absorption in the intestines, is first
that increase production of fetal discovered.
hemoglobin can partially correct the
anemia of thalassemia, but efforts to 2003 Deferasirox, a new iron chelator, becomes available.
improve the treatment of thalassemia
continue. 2007 Gene therapy is used for the first time in a patient with beta thalassemia,
a more severe form of the disorder.
Future Directions
Medications that increase fetal
hemoglobin in both sickle cell disease
and thalassemia have greatly improved
life for patients suffering from these
diseases; however, safer and more
effective drugs are still being sought. Blood smear; note
Stem cell transplantation can be used the pale color of
to treat both illnesses, but it has the red blood cells
(hypochromia)
many limitations. Further research to and the number
improve the safety of transplantation, of unusually small
especially when using stem cells from red blood cells
unrelated donors, is necessary before (microcytes), traits
it can be widely accepted as a safe and that are indicative of
thalassemia. Photo
effective treatment. Finally, the long- by Dr. Stanley Schrier,
term hope for successfully treating courtesy of the ASH
both of these diseases is to correct the Image Bank.
error in the globin gene itself. While it is
possible to do this type of gene therapy
in animals, there are several obstacles
that must be overcome before human
trials will be successful.
anemia, a shortage of red blood cells. Since red blood cells carry oxygen It wasn’t until the 1950s and ‘60s that
to the tissues and organs, anemia causes symptoms such as weakness, several American investigators again
took up the concept that a hormone
fatigue, and shortness of breath. Epo treats this condition by imitating the
regulated red cell production.
action of the hormone erythropoietin, stimulating the body to produce Refining the work of the French
scientists, the American investigators
more red blood cells. Patients who conclusively showed that a hormone
may benefit from Epo therapy include stimulated red cell production,
those with chronic kidney disease, that the kidneys were the primary
Erythropoietin: those who are anemic from AIDS or source of erythropoietin, and that
A Patient from a wide variety of hematologic
disorders (including multiple myeloma
low oxygen was the main driver of
erythropoietin production. Soon,
Perspective and myelodysplastic syndromes), and researchers found that patients with
some cancer patients who are anemic anemia responded by increasing their
B y N a n c y S pa e t h from receiving chemotherapy. In levels of erythropoietin to stimulate
Before dialysis, when I was 15, in 1963, selected patients, Epo may be used to increased red blood cell production.
I took first place skiing in a coed slalom reduce the need for blood transfusions Patients who required an increase
in surgery. in red blood cells in order to make
race. I beat the boys. Two years later, I
up for low oxygen levels
couldn’t walk from the lodge to the lift.
in the blood (such as
I started on dialysis in 1966. I don’t patients with lung disease
remember how many transfusions or patients living at
I had. It was many, at least one per high altitudes) also had
month. I had to be desperate before elevated erythropoietin
the doctor would order blood. levels.
I was part of the phase III clinical trial At the same time, other
in 1987. I was on home dialysis, raising technologies were being
two children, alone. My hematocrit developed that set the
(HCT) was 11-15 percent; I couldn’t stage for a remarkable
walk up the stairs. I had to crawl on Adapted from Eschbach et al, New England Journal of Medicine. 1987. breakthrough involving a
my hands and knees because I was combination of medical
so out of breath. Once I started on the A century ago, two French and molecular engineering. In the
drug, I could tell there was a change investigators reported that small early 1960s came the development of
amounts of plasma from anemic hemodialysis, a method of removing
within two weeks. Within 30 days, my
rabbits injected into normal animals waste products from the blood when
HCT was 40! My daughter said, “All
caused an increase in red blood the kidneys are unable to perform
of a sudden you were up and going.”
cell production (erythropoiesis) this function, to sustain the lives
Eventually, I could run up the stairs. within a few hours. They referred to of patients with end-stage kidney
I used to be asked, “What are you this activity as hemopoietine. Over disease. As a result of this treatment
doing?” I answered, “What can I time, as investigators became more advance, these patients were able
do? My body has me in prison.” Epo convinced that this red-blood-cell- to survive the underlying disease,
stimulating activity was caused by a but their damaged kidneys could
changed all of that. What a difference
no longer make erythropoietin,
it made in my life!
6 5 0 y ears i n hematolog y
Milestones in the Study and Development
of Erythropoietin
1940s C.L. Krumdieck and other investigators report evidence that a factor in
anemic or hypoxic (low oxygen) plasma could increase the release of
young red blood cells (reticulocytes).
8 5 0 y ears i n hematolog y
Milestones in Transfusion Medicine
1900 Karl Landsteiner develops the classification of blood into A, B, and C (later
changed to O) groups.
stem cell transplantation. Because HPCs are
easier to extract and the process is safer for 1902 Alfred Decastello and Adriano Sturli add AB to the blood classification system.
donors, HPC transplantation has replaced
bone marrow transplantation for many 1907 Ludvig Hektoen is the first to suggest that donors and patients should be
screened for compatibility (now known as cross-matching).
cancers and other diseases.
1912 Roger Lee shows that O blood can be given to a person with any blood type
Researchers are also using umbilical cord (universal donor) and that a person with AB blood can receive blood from any
stem cells (UCSCs) as a source of HPCs. blood group (universal recipient).
UCSCs are collected and processed in a
method similar to whole blood and are a 1939 Karl Landsteiner, Alex Wiener, Philip Levine, and R.E. Stetson develop the
Rhesus (Rh) blood classification system.
rich resource for transplantation therapy
in pediatric and some adult patients. In 1943 J.F. Loutit and Patrick L. Mollison develop a solution of acid citrate dextrose,
the future, these cells may be grown and which allows greater volumes of blood to be transfused and makes longer-term
expanded for clinical use. Furthermore, storage possible.
researchers have isolated specialized
cell types other than HPCs that play an 1950 Audrey Smith successfully freezes red blood cells using glycerol
cryoprotectant.
important role in cellular therapy because
they can modify proliferation and immune 1950 Carl Walter and W.P. Murphy Jr. develop the plastic bag for blood collection.
responses during the engraftment of
transplanted cells. 1958 Jean Dausset discovers the first human leukocyte antigen (HLA) on the surface
of blood cells, which determines whether blood from one person might be
Today, the hematology community successfully transfused into another individual. Rose Payne and others identify
other HLAs, key discoveries for understanding tissue compatibility.
continues to advance its transfusion
systems, guided by the AABB, American 1960 Alan Solomon and John L. Fahey develop plasmapheresis, a procedure for
Red Cross, American Society of Hematology, separating whole blood into plasma and red blood cells.
U.S. Food and Drug Administration, and
other federal and professional organizations. 1964 A method of concentrating clotting factors from fresh frozen plasma is
Researchers are also establishing new discovered by Judith Pool, allowing patients with hemophilia to receive
transfusions outside of the hospital.
surveillance systems that record data and
transfusion outcomes to better understand 1968 Rh Immune Globulin, the first treatment that addresses the differences
and manage the risks associated with between negative and positive blood types, proves effective in preventing
transfusion. They are offering more hemolytic disease of the newborn. This condition, once a major cause of fetal
personalized treatment, limiting transfusions death, occurs when an incompatibility between the mother’s and the baby’s
based on careful assessment of need, and blood causes her antibodies to destroy the baby’s red blood cells.
ultimately improving patient care. 1969 Scott Murphy and Frank Gardner develop a method for storing platelets at
room temperature.
Transfusion medicine today is using lessons
learned from the past to dramatically 1971 The practice of testing donated
improve outcomes in the future. Areas blood for hepatitis B begins.
of study include technologies that will
more precisely identify blood components
1972 The use of apheresis, the process
of separating out only plasma or
to increase patient safety and simplify one specific type of blood cell
blood inventory; improved automation to from donated blood, and then
increase efficiency and decrease error; and returning the remaining blood
screening methods that will help reduce the cells back to the donor, begins.
risk of infection. In addition, novel cellular A young man undergoing apheresis.
Mid-1980s The practice of testing donated Photo courtesy of the Children’s National Medical
therapies continue to be developed and blood for HIV begins. Center.
tested to offer more effective treatment
options. These innovations will help 1999 The use of nucleic acid amplification testing for active viruses in donated blood
hematologists not only to reduce the risks begins.
associated with blood transfusions, but
also to provide new therapies for a wide 2005 The FDA approves the first West Nile virus blood test to screen blood donors.
range of diseases.
W h i t e B l o o d C e l l , th e pr o t e ct o r :
helps the body fight off diseases and infections
Curing Pediatric Acute
Lymphoblastic Leukemia
B y J oseph V . S i mone , M D , University of Florida Shads Cancer Center, Gainesville, FL
1948 Sidney Farber treats leukemia with aminopterin, which blocks folic acid
and becomes the first agent to cause remission in children with ALL.
12 5 0 y ears i n hematolog y
Targeted Therapy for Chronic
Myeloid Leukemia
B y B r i an D ruker , M D , Oregon Health and Science University Cancer Institute, Portland, OR
14 5 0 y ears i n hematolog y
Milestones in Targeted Therapies for
Chronic Myeloid Leukemia
radiation therapy and chemotherapy in the form of second cancers, heart The late 1970s and 80s presented
and blood vessel disease, and sterility shaped subsequent research efforts new challenges in the recognition
of adverse effects associated with
to maintain or improve cure rates with fewer complications, an important MOPP and radiation therapy, some of
goal in a disease that primarily affects individuals in their 20s and 30s. which were not apparent for decades
after treatment. This time period also
Today, as more than 80 percent of patients are cured after primary
featured another major advance in an
treatment, a major emphasis is now placed on survivorship. alternative four-drug chemotherapy
regimen (doxorubicin, bleomycin,
Sir Thomas Hodgkin is credited vinblastine, and dacarbazine),
with the initial description of the known as “ABVD,” that proved to
clinical disorder that bears his name. be more effective than MOPP in
In 1832, he reported on a group of treating advanced disease and had
patients with enlargement of lymph fewer side effects. In the 1990s,
nodes and spleen that differed even more effective and less toxic
from the major known maladies treatments for early-stage lymphoma
of the day. Some 60 years later, were devised by reducing the dose
pathologists in Germany and the and area of the body treated with
U.S. independently described the radiation therapy in combination
diagnostic microscopic characteristics with brief chemotherapy such as
of Hodgkin lymphoma. At about the ABVD. The German Hodgkin Study
same time, two physicians applied Group introduced an intensive
X-rays, then newly discovered by seven-drug chemotherapy program,
William Roentgen, to enlarged lymph “BEACOPP,” to address the fact
nodes in Hodgkin patients, reporting that approximately 30 percent of
remarkable tumor reductions. These advanced Hodgkin lymphoma was
In the 1960s, Vincent DeVita Jr. observations, together with increased not cured with ABVD. Although
(pictured) and colleagues studied the understanding of the patterns of associated with more severe early
MOPP combination chemotherapy
regimen for advanced-stage Hodgkin spread, led to advancements in the toxicity and sterility, a higher
lymphoma. application of radiation therapy to cure rate and improved survival
larger fields in the 1930s through the were achieved with BEACOPP in
1950s. The introduction of the linear a randomized clinical trial. Other
accelerator (a radiation machine advances in the 90s included the
used to treat cancer) in the treatment routine application of immunologic
of Hodgkin lymphoma at Stanford markers (specific proteins on the
University resulted in cures of early- cell surface that define subsets of
lymphocytes) that improved the
16 5 0 y ears i n hematolog y
Milestones in the Study and the Cure
of Hodgkin Lymphoma
1832 Sir Thomas Hodgkin publishes “On Some Morbid Appearances of the Absorbent
Glands and Spleen,” about a series of six patients with clinical findings that were
different from tuberculosis, syphilis, and inflammation.
1865 Samuel Wilks reports on similar cases with lymph node and splenic enlargement
and names the disorder “Hodgkin’s disease.” This invariably fatal illness is treated
with herbs, surgery, and arsenic.
precision of pathologic diagnosis and
single-cell analyses revealing that the
1900s German pathologist Carl Sternberg (1898) and American pathologist Dorothy
Reed (1902) independently provide detailed accounts of the giant “Reed-
cell of origin of Hodgkin lymphoma, Sternberg” cells, which are the microscopic hallmarks of Hodgkin lymphoma.
a mystery for more than 100 years,
was a B cell akin to the cell that
1902-03 W. Pusey and N. Senn note remarkable regressions of Hodgkin lymphoma upon
exposure to X-rays.
causes the majority of non-Hodgkin
lymphomas. 1931 Rene Gilbert administers large fields of radiation therapy to patients with Hodgkin
lymphoma.
The most recent advance in Hodgkin 1943 Temporary reduction in the size of lymph nodes is reported in six Hodgkin patients
lymphoma management has come treated with nitrogen mustard by Rene Gilbert and colleagues.
in the form of diagnostic imaging. 1950 Vera Peters reports excellent survival rates in Hodgkin patients treated with
FDG-PET scans are more specific radiotherapy to adjacent lymph nodes not known to contain disease.
for tumor identification than CT
scans and can be used to assess
1962 Henry Kaplan introduces the linear accelerator in the treatment of Hodgkin
lymphoma at Stanford University. Cures are reported after wide-field radiotherapy
the success of treatment at an early treatment of localized Hodgkin lymphoma.
time point. Application of FDG-PET
in clinical studies allows physicians
1964 Vincent DeVita Jr. and colleagues are the first to demonstrate the cure of
advanced-stage Hodgkin lymphoma in approximately 50 percent of patients with
to limit more toxic treatments to combination chemotherapy using the MOPP (mustard, vincristine, procarbazine,
the subset of patients who are prednisone) regimen.
likely to benefit while sparing the 1966 Robert J. Lukes and James J. Butler describe the natural history of Hodgkin
majority from adverse effects. Due lymphoma related to histopathologic classification. Saul Rosenberg and
to the success of conventional Henry Kaplan describe the orderly progression of Hodgkin lymphoma and
Rosenberg reports on the staging of this disease.
treatments, newer
biologic agents must be 1975 Gianni Bonadonna reports on a chemotherapy combination, ABVD
cautiously introduced (doxorubicin, bleomycin, vinblastine, dacarbazine), which is
effective after failure of MOPP. ABVD later becomes the standard Henry Kaplan and
in Hodgkin lymphoma chemotherapy regimen for Hodgkin lymphoma, curing more than Saul Rosenberg
therapy. However, high two-thirds of patients with advanced or bulky disease.
response rates have
been reported with the
1980s Adverse effects of MOPP, including secondary leukemia and sterility, are reported.
Late effects of radiotherapy are observed in the form of secondary cancers
anti-B-cell antibody Gianni Bonadonna (particularly lung and breast) and cardiovascular disease.
rituximab in a subtype
Remissions are achieved with high-dose chemotherapy and autologous transplan-
of Hodgkin lymphoma with B- tation in Hodgkin lymphoma recurrent after chemotherapy and radiation therapy.
cell characteristics, and there is This approach becomes the standard second-line therapy for advanced disease.
active research with new agents
that target the microenvironment
1994 Ralf Küppers plucks individual Reed-Sternberg cells from Hodgkin tissues and
establishes that they represent malignant B cells by gene rearrangement analyses.
(non-malignant cells and tissues
surrounding sites of lymphoma that 1990s Randomized trials in North America and Europe combine limited field, lower-dose
radiotherapy with a brief course of less toxic chemotherapy (e.g. ABVD), resulting
modify the activity of the tumor in cure rates of 90 percent or greater in limited-stage disease. Brief chemotherapy
cells) as well as Hodgkin cells. (Stanford V) and radiotherapy are introduced for advanced disease.
The German Hodgkin Study Group reports superior survival with an intensive
Today, children, adolescents, and chemotherapy regimen, escalated BEACOPP (bleomycin, etoposide, doxorubicin,
young and older adults worldwide cyclophosphamide, vincristine, procarbazine, prednisone), in advanced Hodgkin
routinely survive Hodgkin lymphoma lymphoma.
with modern treatment. Current 2000s Positron-emission-tomography scans early in the treatment course predict
efforts seek to maintain optimal the outcome of treatment with ABVD, suggesting that therapy could be more
health for these survivors, to define personalized, reserving radiotherapy and prolonged or more intensive treatments
for a subset of patients.
the least complicated cures for newly
diagnosed patients, and, ultimately, First successful treatments of lymphocyte-predominant Hodgkin lymphoma with a
to better understand risks for and monoclonal antibody, rituximab, are reported by investigators in Germany and at
Stanford University.
prevention of this disease.
18 5 0 y ears i n hematolog y
Historical Milestones in the Study and Development of Erythropoietin
Milestones in the Development of
Rituximab
n 1868, two investigators from Prussia and Italy were the first to
I report that bone marrow generates blood cells in mammals. This
observation was the starting point of intense efforts to replace malfunctioning Hematopoietic cells can be obtained
marrow through the transplantation of blood-forming (hematopoietic) cells from suitably matched related or
unrelated volunteer donors (allogeneic
in humans. However, it took an entire century to develop reliable techniques HCT) or from the patient’s own
to identify suitable donors, design potent antibiotics, and establish essential tissues (autologous HCT). Sources
of hematopoietic cells include the
supportive care methods to successfully perform clinical hematopoietic cell bone marrow, blood, or umbilical
transplantation (HCT) procedures. This important accomplishment would cord blood. International unrelated
volunteer donor banks containing
not have been possible without decades of intense pre-clinical research in
information on approximately 12
animals, especially to understand issues related to graft rejection and the million volunteers are interconnected
prevention of graft-versus-host disease (GVHD), a serious reaction caused by worldwide computer systems.
Approximately 3,500 HCT procedures
by the donor’s immune cells attacking the recipient’s vital organs. The from unrelated donors are now
research team at the Fred Hutchinson Cancer Research Center in Seattle, performed annually, and almost 40
percent of such transplants involve
under the leadership of Dr. E. Donnall Thomas (Nobel Laureate in Medicine
a donor who is from a different
and Physiology, 1990), deserves the credit for the major contributions to our country from the recipient. In parallel,
knowledge in the field of HCT – although countless investigators around the umbilical cord blood banks are rapidly
growing in size and usage. To date,
globe have also made many essential research observations. some 10,000 HCT procedures with
umbilical cord blood grafts have been
In 1968, three patients in the United performed.
States and the Netherlands suffering
from severe combined The choices of which type of HCT
immunodeficiency (allogeneic or autologous) and the
syndromes, in which source of the graft (bone marrow,
the ability of the blood, or cord blood) depend mainly
body’s immune system on the patient’s underlying disease
to fight infections and whether it is in remission. Before
is compromised, transplant, the patient is treated with
were successfully high-dose chemotherapy, with or
transplanted and cured without radiation therapy, to eradicate
by HCT. Since then, the cancerous cells (prior to both
the number of HCT autologous and allogeneic HCT), and
procedures has risen to to suppress the patient’s immune
50,000-60,000 per year, system to prevent it from attacking the
and the cumulative donor hematopoietic cells (prior to
number of patients allogeneic HCT). More recently, it has
treated worldwide been established that less intensive
has now reached pre-transplant treatment also allows
Number of autologous (self graft) and
800,000. The majority of HCT recipients successful transplantation, but with
allogeneic (donor graft) HCT procedures
performed yearly since 1970. Graph courtesy are patients with leukemia, lymphoma, less severe side effects. Such “reduced
of Dr. Mary M. Horowitz and the Statistical Program myeloma, myelodysplasia, bone marrow intensity” transplants prevent later
of the Center for International Blood and Marrow failure conditions, severe red blood cell relapses by maintaining the body’s
Transplantation Research. disorders such as sickle cell disease or ability to launch an immune attack by
thalassemia, and certain solid tumors. the new marrow against the cancer.
20 5 0 y ears i n hematolog y
Milestones in Hematopoietic Cell
Transplantation (HCT)
1949-56 The humoral and cellular hypotheses of marrow reconstitution are debated.
1956- Advances in marrow grafting through animal studies in murine and canine
This “graft-versus-malignancy effect” present models.
is a critical element for cure through
allogeneic HCT. Reduced-intensity 1968-69 The first successful allogeneic HCT procedures are performed in patients
with severe combined immunodeficiency diseases.
regimens have also made it possible
to extend HCT to older patients (up 1975 The first large series of allogeneic HCT for leukemia is performed.
to 75 years) and younger patients
with health problems that make them 1977, 1980 Successful HCT procedures from unrelated marrow donors.
ineligible for high-intensity regimens.
1978 The first series of successful autologous HCT for lymphoma is performed.
Significant post-transplant problems
can result from toxic effects related 1987, 1989 Isolation of the murine and human
to the preparatory treatments, hematopoietic stem cells is achieved.
GVHD, infections, and relapse of
the underlying disease. Continued 1990 The Nobel Prize in Medicine/Physiology
research is leading to further is awarded to E. Donnall Thomas for the
development of HCT as a curative therapy for
improvements and better survival life-threatening hematologic disorders.
results. The long-term outcome of HCT
procedures depends on whether or 2008 More than 800,000 patients have been
not the patient is in remission. While transplanted worldwide during the past four
50-80 percent of leukemia patients decades.
can be cured by allogeneic HCT if E. Donnall Thomas
performed during first remission, the Photo by R. J. McDougall.
expectation for success is markedly
reduced for those whose HCT is
carried out in more advanced stages of
their disease. Likewise,
the long-term results Long-term survival after
of autologous HCT are HCT for Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia HCT of 79 patients
with Philadelphia
strongly influenced by
chromosome-positive
the amount of cancer in acute lymphoblastic
the patient’s body at the leukemia. The outcome of
time of transplantation, 49 patients transplanted
with relapse being while in their first complete
remission (1CR, solid line)
the leading cause for
is compared to that of 30
treatment failure. patients who underwent
Survival Probability
HCT post-first-complete-
Social studies conducted remission, after relapse
over an extended of their leukemia (>1CR,
dashed line). The graph
period of time indicate
illustrates that remission
that the quality of life status at the time of HCT
in the years after a is an important prognostic
patient receives HCT factor for outcome, with
usually ranges from approximately half of
patients cured if they
good to excellent,
undergo transplantation
and, ultimately, the while in 1CR. Graph courtesy
majority of patients are Time (Year) from Date of Transplant
of Dr. Ginna G. Laport. Blood.
successfully reintegrated 2008; 112: 903-9.
into their personal and
professional lives.
chapter 2 : wh i te blood cells 21
chapter 3:
platelets and blood clotting
P l at e l e t, th e c o n tr o l l e r :
clots blood and controls bleeding
Antiplatelet Therapy
B y A ndrew I . S chafer , M D , Weill Cornell Medical College, New York, NY
1960s Harvey Weiss, Sir John Vane, Philip Majerus, Gerald Roth, and others
elucidate the antiplatelet actions of aspirin.
Based on fundamental hematology
research that defined the mechanisms 1970s Alan T. Nurden, Jacques P. Caen, David R. Phillips, and others describe
of platelet aggregation, an American the molecular basis of platelet aggregation.
hematologist developed the next
clinically effective antiplatelet agent, 1994 Barry Coller’s monoclonal antibody to platelet
a monoclonal antibody against the GP IIb/IIIa is approved for use in coronary
angioplasty.
platelet membrane protein that initiates
aggregation (the glycoprotein (GP)
1998 ADP receptor antagonists are shown to be
IIb/IIIa complex). This drug (abciximab) effective antiplatelet agents in preventing
was approved by the FDA in 1994 to coronary stent thrombosis.
reduce the thrombotic complications of
coronary angioplasty. Other GP IIb/IIIa Barry Coller
receptor antagonists soon followed, and
this class of drugs is now in wide use to
also treat acute coronary syndromes.
24 5 0 y ears i n hematolog y
Hemophilia: From Plasma to
Recombinant Factors
B y J eanne M . L usher , M D , Children’s Hospital of Michigan, Detroit, MI
26 5 0 y ears i n hematolog y
Milestones in Hemophilia
1950s The use of fresh frozen plasma, which often required hospitalization, is the
mainstay of treatment for hemophilia.
innovative treatment products for 1970s The availability of lyophilized (dried) factor VIII or factor IX concentrates
“bypassing” the inhibitor, such as allows home infusion therapy to become a common treatment practice.
recombinant activated factor VII
(r factor VIIa), which was first 1973 The Hemophilia Act of 1973 allows federally funded comprehensive
hemophilia treatment centers to be established.
licensed for use in hemophilia in
1997. Newer second-generation 1982 Using gene sequencing techniques, researchers clone factor IX.
products to treat inhibitors are
actively being developed, and while 1984 Using gene sequencing techniques, researchers clone factor VIII.
much progress has been made in
treating inhibitors, this complication Luc Montagnier and Robert Gallo discover the virus that causes AIDS.
remains the greatest problem in the
management of hemophilia today. 1980s The hepatitis viruses and HIV threaten the worldwide blood supply. To
combat this, manufacturers of plasma-derived clotting factor concentrates
attempt to kill the viruses with dry heat, solvent-detergent treatment, and
Now that we have safer clotting factor pasteurization. Screening methods for these viruses, such as the ELISA
replacement products, preventive test, are also developed.
(prophylactic) treatment has gained
acceptance as a means to preserve 1990s After only a few years years of successful clinical trials, recombinant
normal joint and musculoskeletal human factor products become licensed and are available to hemophilia
patients.
function in boys and young men
with hemophilia. First described by 2000s Recent advances include a better understanding of the cause, detection,
Swedish physicians 40 years ago, then and elimination of inhibitor antibodies found in many hemophilia patients.
recommended by the (U.S.) National
Hemophilia Foundation’s Medical and
Scientific Advisory Council in 1994,
and recently documented as effective
in a multicenter controlled trial,
increasing numbers of young boys
with severe hemophilia A or B are
being started on prophylaxis with
r factor VIII or r factor IX. Because
of these developments, the future
for those with hemophilia looks
much brighter than it was only a few
decades ago.
ormally, blood flows through our arteries and veins smoothly and
N efficiently, but if a clot, or thrombus, blocks the smooth flow of
blood, the result – called thrombosis – can be serious and even cause Anticoagulant Drugs
death. Diseases arising from clots in blood vessels include heart attack
The anticoagulants heparin and
and stroke, among others. These disorders collectively are the most dicumarol were discovered by
common cause of death and disability in the developed world. We now chance, long before we understood
how they worked. Heparin was first
have an array of drugs that can be used to prevent and treat thrombosis
discovered in 1916 by a medical
– and there are more on the way – but this was not always the case. student at The Johns Hopkins
University who was investigating a
clotting product from extracts of dog
Classes of liver and heart. In 1939, dicumarol
Antithrombotic Drugs (the precursor to warfarin) was
extracted by a biochemist at the
The most important components of University of Wisconsin from moldy
a thrombus are fibrin and platelets. clover brought to him by a farmer
Fibrin is a protein that forms a whose prize bull had bled to death
mesh that traps red blood cells, after eating the clover.
while platelets, a type of blood cell,
form clumps that add to the mass Both of these anticoagulants
of the thrombus. Both fibrin and have been used effectively to
Aggregated Platelets and Fibrin: Arterial platelets stabilize the thrombus and prevent clots since 1940. These
thrombi are composed of aggregated prevent it from falling apart. Fibrin drugs produce a highly variable
(clumped) platelets supported by fibrin is the more important component
strands (black). anticoagulant effect in patients,
of clots that form in veins, and requiring their effect to be measured
platelets are the more important by special blood tests and their dose
component of clots that form in adjusted according to the results.
arteries where they can cause heart Heparin acts immediately and is
attacks and strokes by blocking given intravenously (through the
the flow of blood in the heart and veins). Warfarin is swallowed in
brain, respectively, although fibrin tablet form, but its anticoagulant
plays an important role in arterial effect is delayed for days. Therefore,
thrombosis as well. until recently, patients requiring
anticoagulants who were admitted to
There are two classes of a hospital were started on a heparin
antithrombotic drugs: infusion and were then discharged
anticoagulants and antiplatelet from the hospital after five to seven
drugs. Anticoagulants slow days on warfarin.
down clotting, thereby reducing
fibrin formation and preventing In the 1970s, three different groups
clots from forming and growing. of researchers in Stockholm,
Antiplatelet agents prevent London, and Hamilton, Ontario,
platelets from clumping and also began work on low-molecular-weight
prevent clots from forming and heparin (LMWH). LMWH is produced
growing. by chemically splitting heparin
into one-third of its original size. It
has fewer side effects than heparin
and produces a more predictable
28 5 0 y ears i n hematolog y
Milestones in the Development of
Anticoagulant Drugs
Heparin
1916 Heparin is discovered in dog liver by a team from The Johns Hopkins
University in Baltimore, MD.
1930s Scientists purify heparin and produce enough pure material for clinical use.
anticoagulant response. By the mid
1932 A U.S. clinical scientist shows that heparin requires a plasma factor (now
1980s, LMWH preparations were known as antithrombin or AT) for its anticoagulant action.
being tested in clinical trials, and
they have now replaced heparin for 1970s The mechanism of the interaction between heparin and AT is explained by
most indications. Because LMWH is scientists from Harvard University and from the University of Uppsala.
injected subcutaneously (under the
skin) in a fixed dose without the need
Warfarin
for anticoagulant monitoring, patients
can now be treated at home instead of 1920s Cattle in the northern U.S. and Canada are dying
at the hospital. from a bleeding disease caused by a substance in
moldy sweet clover.
LMWH
Fondaparinux
Fondaparinux 1979 Scientists determine the structure of the high-affinity binding site on
heparin and soon after demonstrate that this high-affinity site is a
pentasaccharide (five-sugar unit) with a unique structure.
Heparin Derivatives: The three heparin-like
molecules are heparin (the largest), low- 1980s The pentasaccharide is synthesized, and, over the ensuing two decades,
molecular-weight heparin, and the synthetic the synthetic compound is developed into a drug for clinical use.
compound fondaparinux. Fondaparinux is a
modified form of the active pentasaccharide.
The activity of all three species is derived from
2000s Multicenter clinical trials show that fondaparinux is an effective
antithrombotic drug.
the pentasaccharide (blue) component.
30 5 0 y ears i n hematolog y
Milestones in the Development of
Antiplatelet Drugs
Aspirin
1899 Aspirin is introduced for pain and fever control by a German scientist and
is patented in 1900.
1978 The first randomized trial showing the beneficial effects of aspirin is
reported by a Canadian group who show that aspirin reduces the risk
of stroke in patients with minor strokes. Soon after, several clinical trials
demonstrate that aspirin is effective in treating heart attacks and stroke.
ADP-Receptor Antagonists
1980s The irreversible platelet ADP antagonist ticlopidine is developed and later
shown to be effective in stroke patients in 1989.
GPIIb/IIIa-Receptor Antagonists
1970s/1980s The glycoprotein IIb/IIIa (GPIIb/IIIa) receptor is found to mediate platelet
aggregation by binding to soluble adhesive proteins.
those activities. In the interest of full disclosure, ASH has asked David G. Maloney, MD, PhD: consultancy with ZymoGenetics,
Gloucester Pharmaceuticals, Biogen IDEC, Genentech, Eisai,
each of the authors of this brochure to identify any relationships
Wyeth, Millennium, and Roche.
that could influence – or could be perceived as influencing – the
Richard Miller, MD: stock ownership in Biogen IDEC.
content of his or her article. These disclosures are listed below.
Hematopoietic Cell Transplantation: From a Curative
Concept to Cure
Karl G. Blume, MD: indicated no conflicts of interest.
Editors
Kenneth Kaushansky, MD: membership on the scientific advisory
boards for Roche Palo Alto and Ligand.
Chapter 3: Platelets and Blood Clotting
Nancy Berliner, MD: patents and royalties from UpToDate.
Antiplatelet Therapy
Andrew I. Schafer, MD: indicated no conflicts of interest.
Chapter 1: Red Blood Cells
Hemophilia: From Plasma to Recombinant Factors
Sickle Cell Disease and Thalassemia: Disorders of Globin
Jeanne M. Lusher, MD: indicated no conflicts of interest.
Production
Elliott Vichinsky, MD: indicated no conflicts of interest.
Antithrombotic Therapy
Jack Hirsh, MD: indicated no conflicts of interest.
The Story of Erythropoietin
John W. Adamson, MD: indicated no conflicts of interest.
32 5 0 y ears i n hematolog y
The American Society of Hematology recently launched Blood: The Vital
Connection, a public awareness campaign to educate the public about
blood diseases and related disorders. We invite you to visit the campaign
Web site at www.bloodthevitalconnection.org to find information and
resources for patients, doctors, students, and others, such as: