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Course: Oncology Nursing

Topic: Stem Cell Transplantation in Cancer Treatment Part 1

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Module Goals

Learners will be able to:

Describe the hematological and immunological principles of hematopoietic stem cell transplantation (HSCT).
Define donor histocompatibility.
List the types of HSCT.
Recognise diseases treatable by HSCT.
Explain acute and chronic graft-versus-host disease.

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Hematopoietic Stem Cell Transplantation (HSCT)

ASCO,2021

Also known as Bone Marrow Transplant.
Involves the administration of healthy hematopoietic stem cells to patients with dysfunctional or depleted bone marrow.
The replacement cells can either be Autologous (own body)or Allogeneic (donor).

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Hematopoietic Stem Cell Transplantation (HSCT)

American Cancer Society, 2020

Depending on where the stem cells come from, the transplant may be called:

Bone marrow transplant
Peripheral blood cells transplant
Cord blood transplant

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Sources of Hematopoietic Stem Cells

The three options for HSCT include:

Bone marrow (BM)

The first source of stem cells
Harvested from the iliac crests of a donor under general anesthetic

Peripheral blood stem cells (PBSC)

Offers advantages over BM in collection procedure

No anaesthesia
Less invasive procedure
No hospitalisation

Edcan Cancer Australia, 2021

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Sources of Hematopoietic Stem Cells

Cord blood (CB)

Increasing use in the last decade
Advantages include:

No apparent risk to donors
No prolonged screening process
Immunologically immature T cells allow for cord blood to be transplanted in mismatched donors without the significant risk of GVHD

Edcan Cancer Australia, 2021

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Hematopoiesis

Hematopoiesis is a multistep process where human blood cells are produced, regulated and maintained
Organs involved in formation of blood include:

Bone marrow
Spleen, and
Liver

Hematopoiesis occurs in:

The flat bones: The sternum, ribs, skull, pelvis, shoulders, vertebrae, and innominates

Australian Government Cancer Australia 2021

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Donor Histocompatibility

The state in which a donor and recipient share antigens so that a graft is accepted and remains functional.
Also, refers to the study of factors that determine the acceptance or rejection of grafted tissues or organs.
Histocompatibility testing is the performance of assays to determine whether recipient and donor are histocompatible.

Hahn, 2021

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Donor Histocompatibility

Histocompatibility antigens are proteins on the surface of the cells in the body
Histocompatibility antigens in humans are called Human Leukocyte Antigens (HLA)
Their main function is to help the immune system defend against invaders such as bacteria, viruses, and parasites.
The immune system can also recognize other people’s cells as foreign antigens and will fight them, causing rejection of grafts

Hahn, 2021

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Donor Histocompatibility

Major Histocompatibility Complex (MHC)

The group of genes on the short arm of chromosome 6 (p6) that encodes HLAs which are considered being highly polymorphic leading to a large difference in the resultant expressed proteins on human cells.
They are divided into:

MHC I
MHC II

Khaddour et al., 2021

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Donor Histocompatibility

Human Leukocyte Antigens (HLA)

These are the proteins expressed on the cellular surface and play an important role in alloimmunity.

HLA can be divided into:

(HLA-A, B, and C) which are encoded by class I MHC and expressed on all cell types and present peptides derived from the cytoplasm and are recognized by CD8+ T cells.
(HLA- DP, DQ, and DR) which are encoded by MHC II and can be found on antigen-presenting cells (APCs) and this class is recognized by CD4+ T cells.

Khaddour et al., 2021

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Donor Histocompatibility

Matching:

HLA antigens can be recognized as foreign by another person's immune system.
Transplant professionals try to match as many of the HLA antigens as possible, between the donated organ and the recipient so, there is less of a chance that the recipient's body will reject the organ
Bone marrow transplants require an even higher level of HLA antigen matching, because not only are they susceptible to graft rejection, they can also lead to "graft versus host disease”.

Hahn, 2021

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Principles of Transplantation

Other factors considered after HLA typing are donor characteristics such as:

Gender
Weight
Number of pregnancies
Overall health
Age
Negative serology (for CMV-negative recipients)
ABO compatibility
Matched race

EdCan Cancer Australia, 2021

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Principles of Transplantation

Recipient considerations:

Physician considers the individual's disease, risk factors, and reported survival data to determine appropriate disease management.

Disease factors associated with improved outcomes include:

Transplantation in individuals with chemotherapy-induced remission.
Transplantation earlier in the course of the disease.

Individual factors that increase the risk associated with HSCT:

Advanced age, abnormal hepatic function, abnormal renal function,presence of an active infection.

EdCan Cancer Australia, 2021

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Case Study/Critical Thinking Question/What would the nurse do?

A patient is going to have a allogeneic bone marrow transplant after chemotherapy failure in an oncology unit. The oncologist will do a specific blood test to determine if the patient will have an increased chance of not rejecting a marrow transplant. What is the specific test?

Answer:

_______________________________

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Types of HSCT

Australian Government Cancer Australia, 2021

The three types of HSCT:

Allogeneic:

The HSCs are obtained from:

A human leukocyte antigen-matched sibling
An unrelated volunteer donor, or
Cryopreserved umbilical cord blood

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Types of HSCT

2. Autologous HSCT:

Are collected from the bone marrow or blood of an individual when the cancer is in remission or a state of minimal residual disease.
Advantage are: No risk for graft rejection, But risk for graft-versus-cancer” effect.

3. Syngeneic HSCT:

The source of the graft in syngeneic transplantation is an identical twin.
Advantages are: No graft versus host disease (GVHD) ,No graft failure.

Australian Government Cancer Australia, 2021

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Case Study/Critical Thinking Question/What would the nurse do?

Mr. Max is a patient with a diagnosis of cancer and is planning to have a Syngeneic HSCT. What could be the advantages of this type of transplant? (Select all that apply)

Fewer complications
No Graft vs Host Diseases
No screening needed
No Graft failure

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Indications for an Allogeneic Transplant

Australian Government Cancer Australia, 2021

Aged over 16 years include:

Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Non-Hodgkin's lymphoma
Myelodysplasia

Aged 0-15 years include:

Acute lymphoblastic leukaemia
Acute myeloid leukaemia

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Indications for Autologous Transplant

Australian Government Cancer Australia, 2021

The most common indications:

Aged over 16 years include:

Multiple myeloma
Non-Hodgkin's lymphoma
Hodgkin lymphoma

Aged 0-15 years include:

Neuroblastoma
Medulloblastoma
Primitive neuro-ectodermal tumour

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Indications for HSCT

Khaddour, Hana, & Mewawalla, 2021

The other indication include:

Malignant Diseases:

Myelodysplastic Syndrome
Myelofibrosis,
Essential Thrombocytosis,
Polycythemia Vera
Solid Tumors

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Indication for HSCT

Non-malignant Diseases:

Aplastic Anemia
Severe Combined Immune Deficiency Syndrome (SCIDS)
Thalassemia
Sickle Cell Anemia
chronic granulomatous disease, leukocyte adhesion deficiency, Chediak-Higashi syndrome, Kostman syndrome, Fanconi anemia, Blackfan-Diamond anemia, and enzymatic disorders
Autoimmune diseases including systemic sclerosis, systemic lupus erythematosus

Khaddour, Hana, & Mewawalla, 2021

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Case Study/Critical Thinking Question/What would the nurse do?

What are the indications of HSCT in nonmalignant diseases? (Select all that apply)

Aplastic Anemia
Thalassemia
Sickle Cell Anemia
severe Combined Immune Deficiency Syndrome

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Graft-Versus-Host Disease (GVHD)

A complication after allogeneic bone marrow transplant.
Immune cells present in donor tissue (the graft) attack the host's own tissues.

Melissa, 2021

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Graft-Versus-Host Disease (GVHD)

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Graft-Versus-Host Disease (GVHD)

Two types:

Acute GVHD:

Typically occurs within 100 days of the transplant.

Chronic GVHD:

Usually begins after the first 100 days following a transplant
More likely to occur in patients who experienced the acute form of the disease.
But may occur in someone who never has had GVHD before.

Melissa, 2021

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Graft-Versus-Host Disease

Melissa, 2021

Acute GVHD: Usually involves a distinct set of clinical symptoms and signs:

Skin inflammation (itchy, red, and painful rash)
Hepatitis leading to jaundice
Enteritis can lead to:diarrhea, nausea, vomiting, cramping, abdominal pain, or blood in the stool
Acute GVHD diarrhea is characterised by, greenish, watery, having mucus and sloughed intestinal lining cell (lumps)

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Graft-Versus-Host Disease

Melissa, 2021

Chronic GVHD: Clinical symptoms and signs include:

Dry eyes or mouth
Vision changes
Mouth ulcers
Difficulty swallowing
Hair loss
Sensitivity to spicy or acidic foods
Pulmonary wheezing or shortness of breath
Muscle or joint pain and weakness
Fatigue
Weight loss

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What Would the Nurse Do?

Miss Lia has HSCT for the treatment of non -Hodgkin's Lymphoma. After 100 days of the HSCT she developed acute Graft-Versus-Host Disease (GVHD). What are the sign and symptoms a nurse can see in acute GVHD?

Answer:

_____________________________________________________

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References:

American Society of Clinical Oncology (2021). What is Bone Marrow Transplant. Cancer.net. Retrieved from:https://www.cancer.net/navigating-cancer-care/how-cancer-treated/bone-marrow stem-cell-transplantation/what-bone-marrow-transplant-stem-cell-transplant

American Cancer Society, 2020.Types of Stem Cell and Bone Marrow Transplants. Retrieved from:https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/stem-cell-transplant/types-of-transplants.htm

Australian Government Cancer Australia (2021)The role of HSCT in cancer control. Retrieved from: https://www.edcan.org.au/edcan-learning-resources/supporting-resources/stem-cell-transplantation/principl

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References:

Khaddour K, Hana CK, Mewawalla P. Hematopoietic Stem Cell Transplantation. [Updated 2020 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536951/

Hahn, A. B. (2021). Histocompatibility and Immunogenetics Terms. American Society for Histocompatibility and Immunogenetics. Retrieved from:https://www.ashi-hla.org/page/hi_terms es-of-transplantation/role-in-cancer-control

Melissa Conrad Stöppler, (1/15/2021). All About Graft Versus Host Disease (GVHD). Medicinenet. Retrieved from: https://www.medicinenet.com/graft_versus_host_disease_gvhd/article.htm

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