We are glad to present the second bone marrow transplant conducted at the SMC as the first was performed in September 1998.The first transplantation was conducted on a patient suffering from leukemia. Which required peripheral stem cell transplant. The latest was of different kind. Whereby autologuos bone marrow transplant

The first autologuos bone marrow transplant in Bahrain

A case report by
Dr. Abdullah Al-Ajami consultant hematologist & oncologist
& Dr Tariq Al-Mosawi resident
“Medical department at the SMC”

H.A. is a 38 year old Bahraini male presented in August 1993 with a left cervical lump which was eventually diagnosed to have Non-Hodgkin's Lymphoma (NHL) diffuse small cell, stage II a, from an excisional biopsy from a left cervical lymph node. So, the patient was started on CHOP chemotherapy for 6 cycles:
 
 

Vincristine 1.4    mg/m2 D1
Adriamycin  50    mg/m2 D1
Cyclophosphamide 750  mg/m2 D1
Prednisolone 60    mg/m2 D1

The patient remained doing well until July 1994, when he developed back pain and the X-ray revealed destruction of pedicle and body of D11, with partial compression of the cord, and underwent decompressive surgery at level T9 - L2 Followed by radiotherapy.

The patient then presented with lymph node enlargement in the left side of the neck in June 1995. Biopsy confirmed a relapse of the disease Intermediate grade Lymphoma IV with bone marrow involvement". The patient was subjective again to CHOP chemotherapy for 4 cycles & because of poor response the patient was given ESHAP chemotherapy for 3 cycles.

The reappearance of cervical lymph nodes in February 1996 led to the administration of mini-beam chemotherapy (BCNU. VP-I 6, Ara-C, Melphelan) for 2 cycles.

The patient was in remission for some time, being followed up in the clinic until March 1999, when the disease relapsed again. But with no bone marrow involvement where he was given 3 cycles of mini-beam and was prepared for hematopietic cell transplant.

PERIPHERAL STEM CELL TRANSPLANT
VS
AUTOLOGOUS BONE MARROW TRANSPLANT

Peripheral Stem Cell Transplantation (PSCT):

Benefits:
                The major goal (restoration of sustained hematopietic function) is the same for autologuos Bone Marrow Transplant (ABMT) & PSCT. PSCT must offer additional advantages over ABMT to provide clinical usefulness. As Peripheral blood provides an alternative source for hematopoictic graft for patients who are candidates for marrow ablative therapy and autologuos rescue but have a bone marrow abnormality e.g. (Hypocellularity and metastatic disease in the bone marrow). In addition A faster recovery of hematopoiesis following transplant (for some patients) than ABMT can be provided.

Collection:
                Sufficient peripheral cells for a transplant are collected with multiple leukapheres is procedures. The apheresis device is directed to collect either low-density mononuclear cells or lymphocytes. Usually between 7L & 10L with each procedure over a period of 3 to 4 hours , & the procedure can be repeated daily .

Mobilization:
                It is the process by which the number of assayable progenitors in the peripheral blood is increased. It offers two distinct advantages to the patient anticipating PTCA .An earlier hematopoitic recovery than ABMT or nonmobilized PSCT & the efficiency of the collection procedures is improved.   The mobilization is improved by the administration of myelosuppressive chemotherapy. Also by Administration of granulocyte-macrophage colony-stimulating tact or  (GM-CSF) to patients with malignancies who had no evidence of bone marrow metastases and who had received no chemotherapy prior to the study.

Processing:
                It is the method used to remove contaminated red cells,  granulocytes or platelets from the apheresis collections.

Cryopreservation:
                It is the technique used to maintain viability of peripheral stem cells while they are stored.

Infusion:
                The patient is often given intravenous hydration for 2 hours or more prior to PSCT to encourage optimal renal function.

The cells are transported from the storage freezer to the patient's bedside where the cells are thawed in a 370C water bath and immediately infused unfiltered through a central venous line.

If the total volume of the graft product is extraordinarily large, 50% of he cells are given of the first day and remaining 50% are given the second consecutive day; but typically all of the cells are infused over a 1- to 4- hour interval.

Autologuos bone marrow transplant:

* GA
* Bone marrow harvested (1070 ml)
                        Passed through 500-micron filter to remove bone debris.
                        Passed through 200-micron filter to remove fat droplets.
                        The marrow count was = 2.2 x 108 nucleated cells/Kg.
                        CD 34 count 10%.
* Bone marrow was stored at 400C for 58 hours.
* Myeloablative chemotherapy was given to the patient
 
 

VP-16 2700 mg / m2  IV / 20 hours
Malphan 3 mg /kg IV / 15 minutes

* Harvested bone marrow was infused to the patient on 26th January 2000 after 24 hours from the last chemotherapy.
* The following were given during the period of neutropenia:
 
 

Prophylactic antibiotic Cipro 500 mg BD P0
Antifungal Fluconazole 200 mg OD PO
Cytokine support G-CSF 5 micro g/Kg/day

* The patient was under supportive Packed RBC and platelet transfusion as needed.
* The period of neutropenia was complicated by an attack of neutropenic fever and mucositis  which were treated accordingly

The bone marrow was examined on day 30, which showed a trilineage engraftment, and no evidence of lymphoma & CT abdomen and chest revealed no evidence of recurrent lymphoma. The patient lastly visited the clinic on 26th March 2000, he  was  asymptomatic  and there was no lymphadenopathy & this is his CBC
 
 
Hb 10.9 gm/dl
Platelets 291 x 109/L
WBC 4.6 X 109/L
Neut 38 %

The patient resumed his daily activities normally and went back to his work.