Physician-scientist Marcel van den Brink and graduate student Melissa DoCampo are studying the side effects of bone marrow transplants.
The allogeneic stem cell or bone marrow transplant (BMT), which is used to treat certain types of blood cancer, may be one of the most rigorous cancer treatments.
The regimen that is given to patients before the transplant, known as conditioning, has many side effects, both short and long term. It involves heavy doses of chemotherapy, radiation, and antibody treatments, or some combination of the three. In addition, some patients have had months or even years of chemotherapy leading up to the transplant, resulting in further side effects.
Collateral Damage
“The purpose of conditioning is to attack the tumor cells in the patient’s bone marrow and destroy the cancer, but it also results in collateral damage to various tissues,” explains physician-scientist Marcel van den Brink, who is head of MSK’s Division of Hematologic Oncology and also has a lab in the Sloan Kettering Institute’s Immunology Program. Conditioning also destroys immune cells, including T cells, which makes the patient’s body more tolerant of the donated stem cells and less likely to attack them but also leaves the patient extremely vulnerable to infections with bacteria, viruses, fungi, and parasites.
“Because of their damaged immune systems, these patients must live like people with AIDS,” he adds. “They are susceptible to everything.”
Unfortunately, the regimen damages healthy tissues, including the kidneys, liver, lungs, and skin, and especially the gastrointestinal tract. Additional problems may also arise from the transplant. For example, immune cells from the donor may attack the patient’s healthy tissues as well, a condition known as graft-versus-host disease (GVHD).
Back to topStrategies for a Quicker Recovery
The transplant itself — in which blood stem cells or bone marrow cells from a matched donor are infused into the patient to replace cancerous cells — is actually the first part of the recovery process. MSK investigators are developing several strategies to both enable the immune system to recover more quickly after transplant and minimize organ and tissue damage from the transplant process.
“When the immune system reconstitutes itself after a transplant, the T cells are the last ones to come back,” Dr. van den Brink says. “T cells are made in an organ called the thymus, and in BMT patients the thymus is very beaten up. In addition, the thymus gets less functional as patients age, and most of our patients tend to be older.”
His lab is focused on developing ways to boost the thymus’s activity. One approach is treatment with a protein called interleukin-22 (IL-22), which is made naturally in the body by cells called innate lymphoid cells. Research done in mouse models has shown that elevated IL-22 levels can lead to an increase in the production of T cells — and potentially speed recovery of immune function.
Back to topAdvancing Clinical Trials
“IL-22 also appears to be helpful in recovering the lining of the gut after transplant,” Dr. van den Brink says. “The cells in the thymus that regulate T cell development and the cells of the gut lining are both types of epithelial cells [cells that line the cavities and surfaces of the body], and IL-22 seems to help them rebuild and regenerate.” MSK recently received approval from the US Food and Drug Administration to study IL-22 in BMT patients; a trial will open in the next few months. Another interleukin protein, called IL-7, already has shown promise as a potential therapy to boost T cell regeneration in one early-stage study.
In other mouse studies, Dr. van den Brink’s lab has found that endothelial cells, which line blood and lymphatic vessels, can play an important role in regeneration of the thymus, suggesting another possible avenue for new treatments.
Finally, a trial is under way to determine whether two drugs that are already approved for other uses — either alone or in combination — may help boost the production of T cells after transplant and also reduce the incidence of GVHD in the intestinal tract. One drug is leuprolide, which is used to shut off production of sex hormones in men with advanced prostate cancer. Earlier studies have indicated that men treated with this drug have an increase in T cells.
The other drug, palifermin, is used to treat mouth sores after BMT. Palifermin stimulates epithelial cells, so it may help boost production of T cells in the thymus as well as help the gastrointestinal tract to recover more quickly.
“Infections and graft-versus-host disease are serious complications,” Dr. van den Brink says. “Our quest with all of this research is to improve patient outcomes by helping them overcome the most serious side effects of treatment.”
Back to topComments
Anonymous
Jul 8, 2015 • 11:34 PM
Thanks so much for the great question. The patient’s blood type would eventually change to match the donor’s blood type if the blood types are in fact different. We have some good educational materials on allogeneic transplants, meaning transplants where a donor is involved. You can browse some of our resources here: https://www.mskcc.org/cancer-care/patient-education?category[]=2436. Or for very detailed information on allogeneic transplants at MSK, you can read our guide for patients: https://www.mskcc.org/cancer-care/patient-education/allogeneic-stem-cel….
Jem
Oct 31, 2015 • 5:25 PM
Marianne
Jan 13, 2016 • 9:30 PM
Memorial Sloan Kettering
Jan 14, 2016 • 5:20 PM
In reply to My partner had a bone marrow… by Marianne
Marianne, we sent your question to Ann Jakubowski, one of our transplant doctors, and she responded, “Recovery of the immune system is variable dependent upon many factors including the patient (such as age, previous therapy, etc), the donor, and the medications the patient is on. If the patient has graft vs. host disease and is on medication for it, the recovery may be slower. Often by 7 years if the patient is off medications from the transplant and has been revaccinated, the doctor has felt that the immune system has recovered. You should check with the bone marrow transplant doctor to confirm. It’s also a good thing to have the veterinarian check the dog for possible infections as well. DVMs usually know what to look for in the animal when there is concern that the owner may be immunocompromised.” Thank you for your comment.
Dan Peshkin
May 4, 2016 • 6:26 PM
In your experience, how long does it take, post- allogeneic transplant for an individual's hemoglobin level to reach levels where the individual would not be considered to be anemic? Is there anything, aside from receiving transfusions or medications that an individual may do to help the body generate more hemoglobin?
Memorial Sloan Kettering
May 5, 2016 • 11:04 AM
In reply to In your experience, how long… by Dan Peshkin
Dan, thank you for reaching out. We consulted with Dr. van den Brink, who responds:
All patients will experience anemia in the course of their transplant and the majority of patients will require occasionally a blood transfusion in the first weeks after transplant. We decide regarding the need for transfusion based upon the hemoglobin level and the patient’s condition. Upon discharge most patients will still be anemic but not require any transfusions anymore. It can take a few months before the hemoglobin has reached levels which would be considered normal. The most important thing that patients can do for their recovery, including anemia, is adherence to a good diet and moderate exercise. In rare cases your doctor can administer specific vitamins or growth factors (such as erythropoietin).
Mickey
May 4, 2016 • 11:10 PM
Mickey, thank you for your question. We consulted with Dr. van den Brink, who responds:
Her T cell reconstitution will be delayed and will occur mostly through the expansion of T cells that were part of the allograft that she received. There is more and more evidence that T cells can also be generated in other tissues than the thymus, although this is less effective. Therefore, she might have some de novo T cell generation for example in the mucosa of the intestines and in lymph nodes.
Sherr
Jul 25, 2016 • 6:53 PM
Sherr, thank you for reaching out. We sent your question to Ann Jakubowski, one of our transplant doctors, and she responds:
Obviously people have to go back to living with their children (or grandchildren). It is harder to determine when children are becoming ill with viruses because they often aren’t aware of symptoms or can’t tell you about them ahead of time. The best you can do is inform the children of the patient’s (in this case your husband) susceptibility to infections, ask them to let the responsible adult know if they develop any symptoms and for the adult to let the patient know if anyone has any symptoms. If someone in the house is suspected of developing even a cold, the patient should try to spend a little time as possible away from them. All adults should be educated about good maintenance of a clean environment and using lots of hand sanitizer and hand washing. Paper towels are better than shared cloth towels for hand washing with water. Everyone should help in keeping the environment as clean as possible, sharing the responsibility for cleaning bathrooms. If the patient can have a separate bathroom that is best, but not always possible. Disinfectant cleaners for cleaning – Lysol spray is good for spraying doorknobs, etc. quickly. Carefully washing, preferably with a dishwasher, of shared utensils, cups, etc. or using disposables. If someone is sick in the house and the patient still has to be exposed to the same environment – consider wearing a mask at home (usually we don’t tell them they need it if everyone is healthy at home) until coughing, sneezing, etc. is done. And if the patient starts to feel ill, notify his MD as soon as possible. These recommendations are for general upper respiratory infections. If anyone has something more complicated, then need to discuss with the patient’s MD.
Diane
Aug 27, 2016 • 6:50 PM
Hi Diane, during the first few months after transplant your sister in law will need to see her healthcare team frequently, so this will partly depend on how easy it is for her to travel into the city. We recommend that she discuss this with her doctors and nurses before her transplant so that she can make plans for her follow-up care. Thank you for your comment.
Sylvia Read
Sep 14, 2016 • 8:21 AM
Hi Sylvia, we’re sorry to hear that your grandson is going through this. You didn’t say whether he is having an autologous or allogeneic transplants, but we have guides for caregivers of both types. You can find them here: https://www.mskcc.org/cancer-care/patient-education/autologous-stem-cel… and here: https://www.mskcc.org/cancer-care/patient-education/allogeneic-stem-cel…
You may also be interesting in joining Connections, our online support group for cancer patients and their caregivers. You can learn more at https://www.mskcc.org/experience/patient-support/counseling/groups/conn…. Thank you for your comment.
Crystal
Sep 16, 2016 • 12:55 PM
hi my name is crystal. i had a allo bmt in july 2016. after being discharged i was admitted 3 times after my bmt for kidney and liver functions that were abnormal then twice for cmv infection and a drop in my wbc and platelets. my question is how long is it going to take for my body to recover as i am 63 days post transplant. i am depressed because i get discharged for 1 week and readmitted for 3 weeks and i have a 4 year old son. please help me as i feel like its never going to get better and my life and families life will never go back to normal, thank you.
Memorial Sloan Kettering
Sep 16, 2016 • 2:03 PM
In reply to hi my name is crystal. i had… by crystal
Dear Crystal, the time it takes to recover after a transplant varies. Most people find that it takes about three months, while others may need more or less time. Please speak with your doctor about any specific concerns you may have. In the meantime, you may be interested in reading through our patient education materials on this topic, which includes information about recovering from a BMT and resuming your everyday activities: https://www.mskcc.org/cancer-care/patient-education/returning-home-afte….
We wish you all our best as you continue to heal and recover. Thank you for reaching out to us.
Mahendra K
Oct 12, 2016 • 12:06 PM
My younger child(baby boy) of 8 months age suffering from SCID(T-, NK- B+).
He was getting the recurrent respiratory infection since his 4 months age. As per the diagnosis last month doctor suggested BMT is needed to restore his immune system.
We started the HLA profile matching tests with the sibling(his elder sister of 5 years age). the HLA AB luminux test shows matching and submitted for the HLA DQ luminux, yet to get the results.
We would go with the sibling donor if 100% matches.
Here are my questions/quires/doubts.
1. Since the donor is 5 years baby girl, is there any impact on her health in feature due to donate the bone marrow to his brother?
2. How long the baby needs to be in the hospital after the bone marrow is done?
3. Do the frequent visit to the hospital is needed after the BMT is done?
4. Give me some inputs on how to take care of the baby from the infections after the BMT is done.
Appreciate your support...!
Memorial Sloan Kettering
Oct 13, 2016 • 11:31 AM
In reply to My younger child(baby boy)… by mahendra k
Veronica Edmond
Oct 13, 2016 • 3:00 PM
Memorial Sloan Kettering
Oct 14, 2016 • 9:10 AM
In reply to I'm 21 looking to get a bmt… by Veronica edmond
Dear Veronica, every patient’s experience is unique and many factors affect an individual’s recovery. We recommend that you discuss your specific questions and concerns with your doctor.
You may also be interested in learning more about what to expect after a bone marrow transplant (depending on which kind you are having) by visiting the following patient education materials on our website:
Autologous: https://www.mskcc.org/cancer-care/patient-education/autologous-stem-cel…
Allogeneic: https://www.mskcc.org/cancer-care/patient-education/returning-home-afte…
Thank you for reaching out to us.
Mart
Dec 12, 2016 • 12:52 PM
Dear Mart, the time it takes to recover after a transplant varies. Most people find that it takes about 3 months, while others may need more or less time. Fatigue and weakness are not unusual but each week, patients typically start to regain more of their strength and feel progressively better. For most people, the first 2 to 3 months to 1 year after transplant remain a time of recovery.
This patient education pamphlet offers more information about recovering after an allogeneic stem cell transplant: https://www.mskcc.org/cancer-care/patient-education/returning-home-afte….
We hope this is helpful and wish your wife our best as she continues to recover. Thank you for reaching out to us.
Anil
Jan 28, 2017 • 5:37 PM
Dear Anil, this is something that your brother should discuss with his doctors. To learn about fertility preservation in cancer patients, you can go to https://www.mskcc.org/cancer-care/treatments/symptom-management/sexual-…. Thank you for your comment.
Edna
Feb 8, 2017 • 2:20 PM
Dear Edna, we do recommend that someone have a caregiver who is available at all times during the first part of their recovery. Generally this is about three months. Sometimes patients will designate two or three caregivers, so that one person doesn’t have to do everything, but we recommend limiting it to no more than two or three. If you’d like to learn more, you may wish to refer to our patient education guides for autologous transplant: https://www.mskcc.org/cancer-care/patient-education/autologous-stem-cel… and allogeneic transplant: https://www.mskcc.org/cancer-care/patient-education/allogeneic-stem-cel…. Thank you for your comment.
Zack
Oct 30, 2017 • 3:06 PM
Tracy L
Feb 25, 2018 • 2:01 PM
Hello. I am so happy to come across this page. I am an AML survivor. I also had to have an Allogenic bone marrow transplant. I am in my two year of recovery. My question or concern is I have been working out better for the last eight months. Here recently after working out a day or two later my whole body goes into severe pain! I do have nerve and muscle cramps because I have Chronic GVHD. This pain is certainly a different pain. Any advice or recommendations would be wonderful. I will be seeing my doctor this month but thought I would ask you as well. I've learned you can never have too much info with these situations. Thank you again for having this page.
Memorial Sloan Kettering
Feb 25, 2018 • 9:26 PM
In reply to Hello. I am so happy to come… by Tracy L
Calvin
Mar 5, 2018 • 12:52 PM
Tom
Jun 6, 2018 • 7:12 PM
My brother (age 69) had a bone marrow transplant on March 1st for Chronic Myelomonocytic Leukemia.The donner was 100% match. While he does not have cancer now, he is just not getting stronger. The blood levels are not where they should be according to the doctors (Mayo Clinic in Scottsdale) I feel at this point they just don't know what else to do and are suggesting he be at a nursing facility. That does not sound good. I guess I'm asking if recovery can be this slow is is there a chance he will never get better?
Tom, we are sorry to learn about your brother’s condition. Unfortunately we cannot comment on a specific person’s case or condition as it can be affected by a large number of factors. We suggest he consult further with his care team. He also might contact Be the Match, which can offer information and counseling regarding recovery:
https://bethematch.org/patients-and-families/support-for-you-and-your-f…
If he would like to come to MSK for a consultation, he can call
800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information.
Alecia Sattar
Jun 14, 2018 • 2:20 PM
Hello, my son did a BMT for sickle cell on 1/31/2018. He received the marrow from an unrelated donor and his hemoglobin level is 7.8 today. A few weeks ago it was as high as 10. The doctor is suggesting to do a blood transfusion next week but I am wondering why his hemoglobin would drop to such a low level if he has 99% donor cells. The doctor explained that since the BMT was in January, my son is probably losing all the cells he received from the donor and now making new ones. Can you give me an idea why you think the hemoglobin has dropped to 7.8?
Memorial Sloan Kettering
Jun 15, 2018 • 9:24 AM
In reply to Hello, my son did a BMT for… by Alecia Sattar
Dear Alecia, we’re sorry to hear about all that your son has been through. Because every case is unique, we recommend that you discuss this with his medical team. They are the ones who are most familiar with his treatments and his health history. Thank you for your comment, and best wishes to both of you.
Sara Smith
Dec 17, 2018 • 2:07 PM
Memorial Sloan Kettering
Dec 18, 2018 • 6:48 AM
In reply to Immunesuppressants are used… by sara smith
David Lett
Feb 2, 2019 • 3:23 PM
Memorial Sloan Kettering
Feb 4, 2019 • 9:11 AM
In reply to Had aml in 02. But with my t… by David Lett
Lorri
May 18, 2019 • 7:31 PM
I am post 120 days of having my SCT. My numbers are still very low platelets were just 10- hemoglobin 7.8 ABC 0.7 and AND 0.5. I am 100% donor engraftted. DR. Lowered my anti rejection pills in a week I won't be taking any. He is hoping this raises my counts. If not he is going to give me a boost and give me stem cells from my donor which he thinks will work. I had lots of strong chemo 2 cycles to put me in remission than I relapsed. Was on Vidazza shots went into remission had strong chemo and radiation before SCT. Have you seen any cases were this has happened?
Karen
Jul 20, 2019 • 5:58 PM
I have a dear friend recovering from a bmt. She is 3 weeks out, but she is not eating and refusing meds and won't get up and walk. They do not want to do a feeding tube because it is too soon after the procedure. Does anyone who has been through this have any suggestions as to what foods made you hungry, what foods kept you from feeling nauseated, etc.? She has come so far and we don't want to see her give up.
Thank you.
Dear Karen, we’re sorry to hear about what your friend is going through. This is a very common problem after BMT. Your friend might want to ask her doctors for a referral to a nutritionist who works with cancer patients. You may also find some recipes that appeal to her on our website. Many patients find the smoothies go down easily. You can find the recipes here. Thank you for your comment and best wishes to you and your friend.
How does the bone marrow transplant affect the patients blood type? Is the new bone marrow the same type or from an O donor? What discrepancies can be expected from the bone marrow transplant?