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Understanding Stem Cell Transplantation for Myelodysplasia: Insights from Dr. Catherine Flynn

This presentation by Dr. Catherine Flynn, a Consultant Haematologist at St. James's Hospital, delves into myelodysplasia (MDS) and the potential of stem cell transplantation as a treatment. It covers the increasing incidence of MDS and the current trends in transplant activity, discussing types of transplants, patient factors influencing decisions, and the significance of timing for transplant referrals. The presentation also addresses the impact of comorbidities and highlights crucial survival statistics for patients undergoing transplantation.

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Understanding Stem Cell Transplantation for Myelodysplasia: Insights from Dr. Catherine Flynn

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Presentation Transcript

  1. What about stem cell transplantation? Dr Catherine Flynn Consultant Haematologist St James’s Hospital 17/06/2011

  2. What is Myelodysplasia? • Stem cell disorder with a variable clinical course • Treatment strategy with the highest curative potential is an allogeneic stem cell transplant

  3. Incidence LRF;Leeds UK

  4. MDS transplant Activity Increase in the number of reduced intensity transplants Increase in the number of unrelated donor transplants Increase in patients >50 years

  5. Current transplant activity in MDS EBMT 2008: 1147 allografts for MDS ~ 10% of total 1998-2006 1333 MDS patients > 50yrs allografted

  6. Types of transplant • Autograft • Allogeneic • Syngeneic • Myeloablative/traditional • Mini-transplant/reduced intensity

  7. MA Allogeneic 2009:Disease Indication

  8. RIC Allogeneic Transplants 2009:Disease Indication

  9. 25 years of BMT in Ireland

  10. Decision to Transplant Patient Factors Disease Factors Patient Wishes + Support Stage Age and Performance MRD Co-Morbidities Previous Treatment Transfusions/Iron Status Indolent/Proliferative Infection Extramedullary Disease

  11. Curative Potential Mc Clune et al JCO

  12. Outcomes (Kroger MDS ESH meeting) • Survival without relapse 29-40% • Mortality without relapse 37-50% • Relapse 23-48%

  13. Early Consideration of Transplant • Potential candidates should have a donor search and be referred for discussion

  14. Timing Is important…… • Delaying SCT can result in maximising overall survival for low and intermediate risk MDS (Cutler et al) • Optimal Timing • Time of a new cytogenetic abnormality • Appearance of a clinically significant cytopenia • Increase in the percentage of bone marrow blasts

  15. . Net benefit or loss overall discounted life expectancy for the 4 IPSS risk groups are shown above and below the x-axis. Patients over 60 excluded, MA conditioning only Cutler C S et al. Blood 2004;104:579-585 ©2004 by American Society of Hematology

  16. Co-Morbidities • Lung problems • Liver problems • Joint/Bone problems • Psychiatric disorders • Previous other cancer • Stomach Ulcer • Brain/stroke illness

  17. Performance Score

  18. Biological Age • Chronological Age • Physical Function • Organ co-morbidities • Ability to withstand the harshness of chemo-radiotherapy • To process different medications and large volumes of fluid • To tolerate serious infections and harmful effects of GVHD

  19. Low Risk MDS High Risk MDS Disease Stage

  20. Chromosomes Count….. 46, XY [80%] 46, XY, del (5q)(q11q33), del (7q)(q11q36) [20%].

  21. International prognostic Scoring System

  22. WHO Prognostic Scoring System

  23. Number of transfusions and iron overload

  24. High Ferritin pre transplant is associated with a poor survival

  25. To make a treatment decision or a risk assessment in any patient…. • Patient factors • medical co-morbidity • Disease Factors • Cytogenetics, Transfusion/Iron, WHO subtype

  26. Impact not yet known…… • Timing of Transplant • Chemotherapy before HCT or not ?

  27. Miss A 24 year old girl referred in 2008 with anaemia Hb=9.7g/DL, normal WCC and platelet count Karyotype normal Bone marrow Refractory Cytopenia and multi-lineage dysplasia April 2011 Hb= 8.8g/DL ? Consider Transplant

  28. What to do?? • IPSS score = 0, WPSS =1 • Low risk MDS • No sibling donor • Defer transplant at present

  29. Mrs B • 56 year old lady seen in September 2010 • Hb 9.1, platelets 41, WCC 1.2 • Normal karyotype • Bone marrow refractory cytopenia and ring sideroblasts • Not requiring Transfusions • HLA matched sibling

  30. What to do? • IPSS= 0.5, WPSS =1 • Low risk MDS • Defer transplant at present

  31. Update January 2011 • Increasing transfusion requirment • Bone marrow and karyotype unchanged • March 2011 reduced intensity sibling transplant • Currently 80 days post transplant with skin and liver GVHD

  32. Mrs C • 46 year old woman • Presented June 2008 Hb 7, WCC 3, Plats = 53 • Bone marrow 7% blasts • Complex karyotype • No sibling donor

  33. What did we do? • IPSS Int-2 • Unrelated donor search started • 2 courses of chemotherapy • Unrelated transplant May 2009 • Some minor liver GVHD

  34. Unfortunately…. • Died May 2011 with pneumonia • Delayed immune recovery

  35. High TRM Low relapse Low TRM Higher relapse Myeloablative Vs Reduced Intensity

  36. Transplant Complications

  37. Immune Recovery Mackall et al BMT 2009

  38. Questions……

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