A clinical guide to stem cell and bone marrow transplantation - part 1 pps

Page iiiA Clinical Guide to Stem Cell and Bone Marrow Transplantation Terry Wikle Shapiro RN-C, MSN, CFNP University of Arizona Adult and Pediatric Bone Marrow Transplantation Program, T

Page x

Page ii

The Jones and Bartlett Series in Oncology

Blood and Marrow Stem Cell Transplantation, Second Edition, Whedon/Wujcik

Cancer Chemotherapy: A Nursing Process Approach, Second Edition, Barton Burke et al.

Cancer Nursing: Principles and Practice, Fourth Edition, Groenwald et al.

Cancer Symptom Management, Groenwald et al.

Cancer Symptom Management Patient Self-Care Guides, Groenwald et al.

A Cancer Source Book for Nurses, Seventh Edition, American Cancer Society

Homecare Management of the Bone Marrow Transplant Patient, Second Edition, Lonergan et al.

Hospice and Palliative Care: Concepts and Practice, Sheehan/Forman

Oncology Nursing Drug Reference, Second Edition, Wilkes et al.

Memory Bank for Chemotherapy, Third Edition, Preston/Wilfinger

Page iii

A Clinical Guide to Stem Cell and Bone Marrow

Transplantation

Terry Wikle Shapiro RN-C, MSN, CFNP

University of Arizona Adult and Pediatric Bone Marrow

Transplantation Program, Tucson, AZ

Deborah Branney Davison RP-C, MSN, CRNP

Western Pennsylvania Cancer Institute, Pittsburgh, PA

Deborah M Rust RN, MSN, CRNP, OCN

University of Pittsburgh School of Nursing, Oncology Subspecialty,

Nurse Practitioner Program, Pittsburgh, PA

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Library of Congress Cataloging-in-Publication Data

Shapiro, Terry Wikle

A clinical guide to stem cell and bone marrow transplantation /

Terry Wikle Shapiro, Deborah Branney Davison, Deborah M Rust

p cm

Includes bibliographical references and index

ISBN 0-7637-0217-X (alk paper)

1 Bone marrow—Transplantation—Handbooks, manuals, etc

2 Hematopoietic stem cells—Transplantation—Handbooks, manuals, etc

I Davison, Deborah Branney II Rust, Deborah M III Title

[DNLM: 1 Stem Cells—transplantation—handbooks 2 Bone Marrow

Transplantation—handbooks 3 Tissue Transplantation—nursing—handbooks

QH 581.2 5529c 1997]

RD123.5.S535 1997

617.4'4—dc21

DNLM/DLC

for Library of Congress 97-9563

Printed in the United States of America

01 00 99 98 10 9 8 7 6 5 4 3 2

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Disclaimer

The nature of clinical bone marrow transplantation information is that it is constantly evolvingbecause of ongoing research and clinical experience and is often subject to interpretation Whilegreat care has been taken to ensure the accuracy of the information presented, the reader is advisedthat the authors, editors, reviewers, contributors, and publishers cannot be responsible for thecontinued currency of the information, for any errors or omissions in this handbook, or for anyconsequences arising therefrom Because of the dynamic nature of clinical bone marrow

transplantation, readers are advised that decisions regarding therapy must be based on the

independent judgment of the clinician, changing information about a drug (e.g., as reflected in theliterature and manufacturer's most current product information), and hanging medical practices

Contributors

Deborah Branney Davidson, MSN, RP-C, CRNP

Coordinator, Western Pennsylvania Cancer Institute

Cynthia Monheim, BA

Graduate Student, Department of Clinical Psychology, University of Arizona

Deborah M Rust, RN, MSN, CRNP, OCN

Program Manager, Oncology Nurse Practitioner Program, University of Pittsburgh School ofNursing

Nurse Practitioner, Adult Bone Marrow Transplant Program, University of Pittsburgh CancerInstitute

Daniel E Shapiro, PhD, Assistant Professor, Department of Psychiatry, College of Medicine,University of Arizona

Terry Wikle Shapiro, RN-C, MSN, CFNP

Pediatric and Adult Nurse Practitioner, Bone Marrow Transplant Program, University MedicalCenter, University of Arizona

Dedication

To Patricia Schaefer, RN, MD, who gave us the push

we needed to see this project become a reality We also cannot thank our families enough—our husbands Daniel, Dan, and Keith, and our children Alexandra, Derek, and Leah, who lent support and sanity in our times of need we love you!

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Preface

As the science and technology of clinical stem cell and bone marrow transplantation has grown, sohas the need for a comprehensive guide to caring for these complex patients As the number ofadvanced practice nurses, specialty nurses, physician's assistants, fellows, residents, and medicalstudents who care for such patients grows, so does the need for relevant and practical information

We decided to put our combined 30-plus years of stem cell and bone marrow transplant experience

to good use, and thus, this handbook was developed The concept of this handbook also arose as aresult of multiple pleas for a comprehensive "nuts and bolts" guide from colleagues intimatelyinvolved in the day-to-day management of patients undergoing stem cell and bone marrow

transplantation

In summary, we have attempted to provide the clinician with a pocket guide to assist in referencing clinical issues and problems common to stem cell and bone marrow transplantation Inour experience, no single clinical handbook currently provides the bone marrow transplantationclinician with comprehensive information relevant to stem cell and bone marrow transplantation.Although we doubt this will be "the only handbook you'll ever need," we do think it will save thebone marrow transplantation clinician time and frustration when looking up clinical informationspecific to bone marrow transplantation

quick-The user should keep in mind that the content included in this text is general information

extrapolated from the literature, and that program and institutional differences are bound to occur

In addition, stem cell and bone marrow transplantation technology changes at a rapid pace Clearly,discoveries will be made before this text is published that will alter the accuracy of the information

in this handbook Nevertheless, it is our hope that this handbook will assist clinicians who provideday-to-day management to these challenging patients, providing an easier way to obtain the criticalinformation they need to care for their patients

TERRY WIKLE SHAPIRO, RN-C, MSN, CFNP

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Contents

Introduction to Stem Cell and Bone Marrow Transplantation

Terry Wikle Shapiro

Antimicrobial prophylaxis 85

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Chapter 4

Bone Marrow, Peripheral Blood Stem Cell, and Umbilical Cord Blood

Procurement and Infusion

Deborah Branney Davison

113

Mobilization and collection of peripheral blood stem cells 118

Chapter 5

Management of Stem Cell/Bone Marrow Transplantation Complications

Terry Wikle Shapiro, Deborah M Rust, Deborah Branney Davison

Page i

A Clinical Guide to Stem Cell and Bone Marrow

Transplantation

Page 1

Introduction to Stem Cell and Bone Marrow Transplantation

The pluripotent stem cells from which all committed blood cells arise (Figure I.1) are located in thebone marrow space, the peripheral blood, and the blood in the umbilical cord of newborns All ofthese sites can be used as a source of bone marrow stem cells, whether for autologous or allogeneicmarrow transplantation

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B Allografting using a monozygotic twin as a donor is termed a syngeneic transplant.

C The most common and preferred situation is for marrow to be donated by a six out of

six-antigen, human leukocyte antigen (HLA)-matched, (HLA-identical) sibling

D Partially matched family members or matched unrelated donors from a volunteer panel may also

be used as donors

E UCB may be used as a source of allogeneic stem cells in the matched sibling donor as well as inthe unrelated donor

F Allograft sources of marrow/blood cells

1 Matched sibling donor

a) Marrowb) PBSCsc) UCB

2 Identical twin donor

a) Marrowb) PBSCsc) UCB

3 Partially-matched related donor

a) Marrow

b) PBSCsc) UCB

4 Matched unrelated donor

a) Marrowb) UCB

5 Partially-matched unrelated donor

a) Marrowb) UCB

G Allografts are indicated for some congenital abnormalities of bone marrow function or wherethere is disease involving the marrow not amenable to cure with standard treatment.

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1 Leukemias

a) Acute myelogenous leukemia (AML)

b) Acute lymphoblastic leukemia (ALL)

c) Chronic myelogenous leukemia (CML)

4 Bone marrow failure syndromes

a) Severe aplastic anemia (SAA)

b) Fanconi's anemia (FA)

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B Since a marrow or stem cell source for allografting cannot always be found or may be too risky,autologous bone marrow or PBSC transplantation is also used as a method for treating a number ofmalignant disorders

1 Leukemias

a) AMLb) ALLc) CML

2 Lymphoproliferative disorders

a) Hodgkin's diseaseb) Non-Hodgkin's lymphomac) Multiple myeloma

d) Chronic lymphocytic leukemia

3 Solid tumors

a) Neuroblastomab) Ewing's sarcomac) Breast cancerd) Testicular cancere) Melanomaf) Osteosarcomag) Cerebral tumorsh) Others

C Using autologous marrow or PBSCs is not feasible for patients who have a deficiency of theirfunctional bone marrow, as with aplastic anemia, inborn errors of metabolism, and

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E In older patients (> 50 years of age), autografting may also be considered more desirable because

of the high morbidity and mortality associated with allografting and GVHD

F Autografting is most frequently used in the setting of high-risk solid tumors in which the chancefor cure is relatively low with standard or conventional doses of chemotherapy In this case,

autografting is considered a marrow or stem cell "rescue."

G In some autografting situations, it is questioned whether a low (undetectable) level of tumorcells persisting in the infused cells may promote relapse However, routine purging, even in

diseases that involve the marrow, is unproved Research in this area continues

H PBSCs are used as an autografting source in cases of prior pelvic irradiation, marrow fibrosis,unacceptable anesthesia risk, or when early engraftment is desired 2

III When Should Marrow or Blood Cell Transplantation be Considered?

A Acute myelogenous leukemia (AML)1 3

1 The classification of AML can be divided into seven main categories based on

morphology and cytochemistry as proposed by the French American and British (FAB)group4 (Table I.1) Some of these subtypes, such as M5, are associated with poor outcomesafter chemotherapy alone Other subtypes, such as M3, are associated with more favorableoutcomes Overall, the FAB classification has not been found to be significantly useful as apredictive factor for outcome after chemotherapy alone

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Table I.1 Classification of AML

Disease class Morphology

M0 AML with minimal evidence of myeloid differentiation

M3 Acute hypergranular promyelocytic leukemia

M4 Acute myelomonocytic leukemia

M5 Acute monocytic/monoblastic leukemia

M7 Acute megakaClassification of AML

2 Allogeneic bone marrow transplantation (BMT) for AML

a) Patients with AML who have an HLA-identical donor have the best prognosiswhen transplanted in first remission (40% to 60% probability of long-term survival).b) It may be preferable for patients with AML to be transplanted in first relapserather than second remission, since the additional chemotherapy may increasetransplant-related complications The probability of long-term survival of the twogroups appears to be about the same, approximately 25% to 35%

c) Transplant results using family members who are one-antigen HLA-mismatchedwith the patient do not differ from those in patients with genotypically or

phenotypically HLA-identical donors

d) Results obtained using related donors who are more severely mismatched (two- orthree-antigen disparity) are inferior (< 20%) to using chemotherapy alone and areusually only considered after first or subsequent relapse(s) or in patients who do notachieve first remission (refractory AML)

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e) Matched unrelated donor transplants are considered for AML patients in firstremission who are considered very high risk for relapse, patients with refractorydisease, or as salvage therapy in second or later remission

3 Autologous BMT for AML

a) May be performed in first or second remission

b) Autologous BMT is most often considered for patients over age 50 in order toeliminate the morbidity and mortality associated with GVHD

c) Major drawbacks include the presence of minimal residual disease at the time ofmarrow harvest, and the absence of the "graft versus leukemia" effect associatedwith allogeneic BMT

d) To date, no statistically significant difference in disease-free survival has beendemonstrated for autologous marrow purged of tumor cells compared to unpurgedmarrow

e) The use of PBSCs may circumvent the problem of minimal residual marrowdisease, but this is still under investigation

B Acute lymphoblastic leukemia (ALL) 1, 3

1 In adults, ALL carries a much poorer prognosis than does childhood ALL, with onlyapproximately 20% of patients remaining disease-free after five years with chemotherapyalone Adult patients should probably undergo allogeneic BMT in first remission Patientswith newly diagnosed ALL can be subdivided into high and low-risk groups Assignment tothe high-risk group is based on the following criteria:

a) White blood cell (WBC) count greater than 30 x 109/L at diagnosisb) Phenotype of blast cells: B or null

c) Slow to achieve first complete remissiond) Age of patient

a) WBC count greater than 100 x 109/Lb) Infants

c) Males with high WBC count at presentationd) Some chromosomal translocations (t[9;22] and t[4;11)e) Cell phenotype (b-cell ALL)

f) Presence of extramedullary disease

g) Relapsed disease

3 Allogeneic BMT for ALL

a) Patients who belong to "high-risk" groups should receive an allogeneic BMT infirst remission if an HLA-identical or one-antigen mismatched related donor isavailable

b) Patients lacking an HLA-identical or one-antigen mismatched related donorshould be considered for a matched unrelated donor transplant (using marrow orUCB as source)

c) Patients with a two- or three-antigen mismatched donor may be considered forBMT in second or subsequent remission if they are less than 20 years old

d) "Low-risk" patients are generally considered for allogeneic BMT on achieving asecond remission, using a matched related donor, matched unrelated donor, orpartially matched donor if they are less than 20 years old

4 Autologous BMT for ALL

a) Preferred for patients who are more than 50 years old or who lack a matchedrelated or matched unrelated donor

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b) The bone marrow or PBSCs of such patients may be harvested and stored afterachieving a first remission Autologous BMT is then carried out in second orsubsequent remission

c) Relapse rates remain high using autologous versus allogeneic BMT for ALL (52%

vs 9%)

d) Use of purged marrow for ALL remains controversial and is still underinvestigation

C Chronic myelogenous leukemia (CML) 1, 3

1 CML is characterized by the presence of the Philadelphia (Ph1) chromosome;

chromosome 22 is shortened, secondary to a reciprocal translocation between chromosomes

9 and 22 CML usually follows a prolonged chronic phase (three to five years) that

eventually proceeds through an accelerated phase and a blastic transformation (blast crisis)

to acute leukemia, which may be myeloid or lymphoid type With CML, no conventionalchemotherapy is curative; hydroxyurea, busulfan, and interferon-a offer only temporarycontrol

2 Allogeneic BMT for CML

a) CML patients with an HLA-identical, one-antigen mismatched, or matchedunrelated donor should be transplanted in chronic phase

b) Patients transplanted in blast transformation have a very poor prognosis

c) Patients who achieve a second chronic phase following blast transformation, usingconventional chemotherapy, have a better prognosis than if transplanted in blasttransformation