Hematopoietic Stem Cell Transplantation

Abstract:
All blood cells arise from a type of cell called Hematopoietic stem cell. Stem cells have
received a great deal of publicity as lately, due both to recent achievements in their
isolation and cultivation and their potential widespread therapeutic uses. A simple
definition of stem cells is that they have the capacity both to self-renew and to generate
differentiated progeny. This means that they can generate undifferentiated daughter cells
are committed along a certain developmental pathway. In this presentation, we would like
to communicate about the different clinical uses of Hematopoietic stem cell
transplantation in various disease conditions like SCID, Sickle cell anemia and other
cancers.

Introduction:
Stem cells have two important characteristics that distinguish them from other
types of cells. First, stem cells are unspecialized cells that are capable of self-renewal.
Second, under certain physiologic or experimental conditions, stem cells can differentiate
into cells with special functions. Scientists primarily work with two kinds of stem cells:
embryonic stem cells and adult stem cells that each have different functions and
characteristics [4-6]. Embryonic stem cells are a type of Pluripotent stem cell derived from
the inner cell mass of the blastocyst. They are primitive and undifferentiated cells
that have the potential to become a wide variety of specialized cell types. In some adult
tissues, such as bone marrow, muscle, and brain, discrete populations of adult stem cells
generate replacements for cells that are normally lost or damaged by injury or
disease. Pluristem has decided to work with adult stem cells, focusing on the expansion
of Pluripotent Hematopoietic Stem Cells (HSCs). Bone marrow is the spongy tissue
found in the cavities of the body’s bones that contains special stem cells, called
hematopoietic stem cells (HSC). Each type of blood cell begins its life as a hematopoietic
stem cell. The stem cells divide and differentiate to form the various cells that are later
found in our blood and immune systems. These cells include: leukocytes, lymphocytes,
erythrocytes and Platelets that are responsible for blood clotting.
HSCs have a greater self-renewal and differentiation capacity than any other
adult tissue and hold the promise of being able to repair or replace damaged cells and
tissues. A cardinal property of hematopoietic stem cells is their ability to divide without
significant alteration of their proliferative potential or differentiation state. The first
demonstration that such stem cell self-renewal divisions can occur in vitro (albeit without
a net increase in their numbers) made use of retroviral marking to identify the clonal
progeny in multiple recipients of individual hematopoietic stem cells that had been
amplified in 4-week-old long-term cultures (LTC)[1]. Subsequent attempts to improve the
output of stem cells in these cultures by using various cell lines as feeders have allowed
input numbers to be maintained, but a net expansion has not been achieved[2-4]. Within the
hematopoietic system, Pluripotent HSCs are the only cells with extensive capacities to
expand, differentiate and self-renew. These HSCs are exclusively required for
hematopoietic reconstitution following transplantation and serve as a primary target for
gene therapy. In spite of the key role of HSCs in maintaining the hematopoietic system,
their extremely low frequency in the hematopoietic tissue, as well as the limited ability to
maintain or expand undifferentiated stem cells under ex vivo conditions, not only remains
a major drawback to essential clinical applications of these cells, but also reflects the
current unavailability of, and the need for, novel stem cell regulators.

Sources of hematopoietic stem cells:

The primary source of hematopoietic stem and progenitor cells for use in autologous and
allogeneic transplantation has been bone marrow. More recently, use of peripheral blood
as a source of these cells has increased. This product is referred to variously as peripheral
blood stem cells (PBSC), peripheral blood progenitor cells (PBPC), or stem cells.
Although each cell source used for hematopoietic transplantation contains stem cells,
when the term stem cell is used without a qualifier, it usually refers to PBSC. Table 1
lists the major sources of hematopoietic stem cells used in transplantation, with the
cellular characteristics of each. The use of PBSC has advantages and disadvantages, and
the relative balance between these differs, depending on the type of transplant being
performed and the disease state being treated. The majority of transplantable HSCs in
adults come from adult donor bone marrow or mobilized peripheral blood. A new and
very effective source of transplantable and lasting HSCs comes from umbilical cord
blood (CB). Today, there is a tremendous amount of focus on research, development and
business in the area of cord blood innovations. The collection of cord blood is simple and
non-invasive. CB is drawn from the umbilical cord after birth, before the placenta is
discharged. As opposed to working with embryonic stem cells, CB is not ethically or
controversially charged. It is also important to note that there is no difference in the
functionality of hematopoietic stem cells from bone marrow, mobilized peripheral blood
or umbilical cord blood. In the last few years, a new industry has evolved for the
collection and storage of cord blood. With the increased development and use of this
extraordinary source of HSC for BMT, the number of cord blood banks is rapidly
increasing.

Table 1. Cellular Characteristics of Various Stem Cell Sources

Bone Umbilical Cord

Stem Cell Source PBSC
Marrow Blood

Stem cell content Adequate Good Low

Progenitor cell content Adequate High Low

Verylow/
T cell content Low High functionally
immature

Risk of tumor cell

High Low Not applicable
contamination
Hematopoietic Stem Cell Transplantation[1-3] is a procedure based on a very simple
principle. First a patient is identified who has a potentially lethal disease (e.g. acute
myeloid leukemia or beta thalassaemia major). This disease should be such that it can be
eradicated by high dose chemoradiotherapy. Such treatment is highly toxic and will
invariably lead to permanent destruction of hematopoietic stem cell - i.e. the body's blood
forming cells. Thus the potentially curative therapy can only be used if new normal
hematopoietic stem cells can be infused and made to work in the patient's body. Such
normal blood stem cells are harvested from a donor and reinfused into the patient (after
being given the potentially curative chemo-radiotherapy)[5,6,8]. HSCT is a unique mode of
therapy in the field of oncology that
1. it is the most intense form of treatment followed by medical oncologists.
2. it exposes the entire human body to potentially life threatening consequences because
this is the only hope of cure.
3. it is the only transplantation procedure which does not require a surgeon.

Who can have a transplant? To be eligible for any form of bone marrow transplant a
patient's general health must be good enough to withstand very high dose treatment with
anti- cancer drugs and radiation. One of the major factors predicting the risks of
transplantation is the age of the patient. Younger patients tend to have a far better chance
of success than older patients and less risk of a transplant related death. Most transplant
centres will not carry out allogeneic transplants on patients over the age of about 55
years, in some centres the limit is set at 50 years. It is usually acceptable to perform
autologous transplants on older patients because the risk is not so great.
Indications for transplant: Acute leukaemia, Acute lymphoblastic leukaemia, Acute
myeloid leukaemia, Chronic lymphocytic leukaemia, Chronic myeloid leukaemia,
Hodgkin's disease, Non-Hodgkin's lymphoma, Multiple myeloma, myelodysplastic
syndromes and myelofibrosis.

The transplant procedure: Before a patient can receive a transplant their own marrow
and immune system must be destroyed with high doses of drugs with or without
total body irradiation (TBI). This is necessary even in patients with aplastic
anaemia in whom the marrow appears to have already failed. This preparation is
called conditioning treatment. There are several different conditioning regimens (a
regimen is a specific combination of drug and radiation treatment). For autologous
transplantation a regimen called BEAM is frequently used, this is a combination of
several drugs given over a period of five days. For myeloma melphalan is
frequently used, with or without TBI. Conditioning for allogeneic transplant is
either with busulphan and cyclophosphamide or cyclophosphamide with TBI.
Because the chemotherapy used is often at high dose and is given intravenously a
tube called a Hickman line is placed under the skin of the chest and into a vein.
This is often done in the operating theatre where an X-ray machine can be used to
ensure it is correctly inserted. Local painkillers and a sedative are given and it is not
painful.
Hematopoietic stem cells in circulation: Presence of circulating CD 34 +ve stem cells
in humans has been known since 1971. However their number is too small to be
of clinical use for transplantation (being less than 0.5% in adults). With the
advent of recombinant human hematopoietic growth factors, we now have a
method to mobilise them (make them come out of the marrow into circulation)
in sufficient number for clinical use. Initially HSCTs were performed only in the
autologous setting. Now many centres, including in India, are also performing
allogenetic HSCTs[8]. As an alternate to mobilised HSCs, AIIMS, New Delhi has
also used unprocessed whole blood transplantation for multiple myeloma. The
ideal mode of counting CD34+ve cells is by flowcytometry currently available
at most transplant centres in India. About 4 x 106 CD 34+ve cells/ kg body
weight of the recipient (minimum of 3 x 106 CD 34+ve cells/ kg) must be
collected so that there is a good chance of success.

Major risks after Hematopoietic stem cell transplantation: Patients who undergo
these transplantation may experience short-term side effects such as nausea, vomiting,
fatigue, loss of appetite, mouth sores, hair loss, and skin reactions. Additionally, patients
receiving stem cells may experience nausea and vomiting while receiving the transplant,
and chills and fever during the first 24 hours after the transplant. Potential long-term risks
include infertility (the inability to produce children); cataracts (clouding of the lens of the
eye, which causes loss of vision); secondary (new) cancers; and complications in the
liver, kidneys, lungs, and/or heart. With allogeneic transplantation, a complication known
as graft-versus-host disease (GVHD) sometimes develops. GVHD can generally be
treated with steroids or another immunosuppressive agent. Clinical trials are being
conducted to find ways to prevent GVHD from occurring.

Gene Therapy:
In gene addition the whole emphasis is on normal cells where a new gene is added to
confer a survival advantage. For example the hematopoietic cells can be made more
resistant to the therapeutic consequences of myelosuppression. Gene transfer is used for
several indications like repair of mutations. For instance replacing mutated p53 with the
normal functioning counterpart in lung cancer leads to a higher response rate
(mechanisms involved in this and other potential beneficial effects include increased
tumor sensitivity, host sensitivity and host response to therapy as well as gene marking).
Certain drugs need activation by enzymes before they become active. The classical
examples are gancyclovir, which requires phosphorylation with thymidine kinase. Cells
that are transfected with genes for the corresponding enzymes will specifically become
susceptible to the toxic effects of these drugs and can be targeted in vivo for selective
elimination. In the hematopoietic transplantation setting its immediate application would
be in the use of donor lymphocyte transfusions. Such DLT are commonly used for
cytogenetic or clinical relapse following allogeneic BMT for its graft v/s leukemia effect.
However it has the potential to cause life threatening GVHD and aplastic anemia. Such
donor lymphocytes can be transfected with the thymidine kinase gene. Currently clinical
trials using gene therapy and hematopoietic transplantation are ongoing for Gene marking
(no therapeutic benefit to patient),ADA SCID,X SCID,Chronic Granulomatous
Disease,Goucher's Disease, Fanconi's Anemia.

Conclusion:
Hematopoietic stem cell transplantation is by no means an ideal mode of therapy. It is
currently the only available curative mode of treatment for several oncological ailments.
However, in the future, Gene therapy and stem cell research is expected to change the
way we cure patients completely changing the application of HSCT. Ethical problems are
the main barriers to treat many diseases using Hematopoietic Stem Cell Transplantation.
Existing centres need to focus on the development of regimen/ strategies tailored to our
needs. For instance, cancers are diagnosed very early in our population. They are in the
most productive phase of their lives and are fit to tolerate dose intensive therapy. Hence
they should be subject to strategies that lead to a curative outcome.

References:

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