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Philip McCarthy, MD
PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified) )| Communities: CLL (Chronic Lymphocytic Leukemia) , Myeloma , Non-Hodgkin Lymphoma , Hodgkin Lymphoma | Answers: 8 |
| Member Since: Sep. 2012 |
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Professional Statement
Professor of Oncology
Director, Blood and Marrow Transplant Program
Roswell Park Cancer Institute
Director, Blood and Marrow Transplant Program
Roswell Park Cancer Institute
Professional Info
Credential: MD
Primary specialty: Oncology - Hematology/Oncology
Medical school: Tufts University School of Medicine
Residency: Yale-New Haven Hospital
Internship: Yale-New Haven Hospital
Fellowship: Brigham and Women's Hospital/Harvard Medical School
Research interests:
Clinical trials in blood and marrow transplantation
Modulation of graft versus host disease and chemotherapy toxicity
Cancer immunotherapy and immune modulation after transplantation
Assessment of radiation exposure and environmental medicine
Evidence-based reviews in blood and marrow transplantation
Blood and marrow transplantation and maintenance therapy for multiple myeloma
Application of clinical guidelines to clinical practice
Clinical decision making in blood and marrow transplantation
Hospital affiliation: Roswell Park Cancer Institute
Practice address:
Elm and Carlton Streets
Buffalo, NY
14263
Practice phone number: (716) 845-4074
PhilipMcCarthyMD Activities
First, please remember that this is a very unusual problem. If the allogeneic hematopoietic stem cells do not take or engraft, (low WBC, red cell and platelet counts) the treating team will make sure that the cells have not engrafted usually by doing a bone marrow test to see if there are any donor cells in the bone marrow. There are two types of poor engraftment. One is primary graft failure where the donor cells do not engraft at all. The second type is secondary graft failure which occurs when the graft takes but then it goes away. Both of these types of graft failure are unusual (1 to 9%) depending on the type of transplant, the degree of matching between donor and recipient and if an infection such as a virus that has interfered with engraftment. If the infection can be treated, this can sometimes reverse the low blood counts. If not, then a second transplant is usually tried. The Transplant center will usually have some back-up plan in case of graft failure. This might include harvesting hematopoietic blood or marrow cells which are frozen as a backup. If the allogeneic HSCT uses hematopoietic cells from an unrelated adult donor, often the BMT center will have identified a back-up adult donor, cord blood or a half matched (haplo) donor. There are cases where the donor changes his/her mind before donation so there is a back-up so as not to delay the transplant too much. Failure to engraft from a sibling donor is unusual. If that is occurs, the transplant team may ask the sibling to donate again. It is rare for a patient not to have some form of long term engraftment.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
There are several timepoints where the clinical team will see how the patient is recovering after an allogeneic BMT or allogeneic hematopoietic stem cell transplant (HSCT). First, we make sure that patient has recovery of white blood cells, red blood cells and platelet count. The team may check the blood and/or do a bone marrow test to see if there are donor cells present. This is often done by day 30 after transplant and/or day 100. For an allogeneic HSCT, we do what is called chimerism testing. The chimera was a mythic animal made of more than one animal or organism (lion, serpent, goat etc.). This term has been adapted to determining how much of the donor cells have engrafted in the patient. Chimerism testing can be done by molecular testing to look for donor molecular markers that are different from the recipient. In some cases of gender-mismatched (male donor and female recipient, female donor and male recipient) transplants, the laboratory will look for the sex chromosomes, X and Y to determine engraftment. We are always looking for markers that allow the clinical team to determine differences between donor and recipient. For syngeneic allogeneic HSCT, there are no differences so we cannot tell with certainty what is donor and what is recipient in the blood and bone marrow.
Other ways to tell how the allogeneic HSCT worked are tests to make sure the cancer or underlying disease has not come back. This could be bone marrow and blood testing for all patients and radiographic imaging (CT Scans, PET Scans) for lymphoma patients. Most patients undergo staging after allogeneic HSCT over time to determine if the graft has taken and that the underlying cancer or disease has not come back or recurred.
Other ways to tell how the allogeneic HSCT worked are tests to make sure the cancer or underlying disease has not come back. This could be bone marrow and blood testing for all patients and radiographic imaging (CT Scans, PET Scans) for lymphoma patients. Most patients undergo staging after allogeneic HSCT over time to determine if the graft has taken and that the underlying cancer or disease has not come back or recurred.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
Please see this question as well (http://talkabouthealth.com/would-you-describe-the-process-of-having-non-ablative-conditioning-prior-to-having-a-bone-marrow-transplant).
Older patients, those with co-morbidities or those who are not well, may benefit the most from a reduced intensity or non-ablative allogeneic hematopoietic stem cell transplant (HSCT). Co-morbidities could include lung, heart, kidney or liver disease as examples. We have found that older patients do not tolerate the intensity of a full intensity regimen (sometimes called myeloablative regimen) and they can have terrible complications and die from these complications. With reduced intensity allogeneic HSCT, we can offer this type of treatment to patients who are up to 70 years of age and older who have life-threatening diseases such as leukemia or high risk myelodysplastic syndrome. This type of transplant relies more on the Graft-versus-Tumor (GvT) or Graft-versus-Leukemia (GvL) effect to eradicate the cancer rather than an intensive regimen. The reduced intensity regimen as noted in this question (http://talkabouthealth.com/would-you-describe-the-process-of-having-non-ablative-conditioning-prior-to-having-a-bone-marrow-transplant) is designed to facilitate engraftment of the donor cells and prevent the recipient from rejecting the donor cells. So the donor cells “take” or engraft in the patient.
Older patients, those with co-morbidities or those who are not well, may benefit the most from a reduced intensity or non-ablative allogeneic hematopoietic stem cell transplant (HSCT). Co-morbidities could include lung, heart, kidney or liver disease as examples. We have found that older patients do not tolerate the intensity of a full intensity regimen (sometimes called myeloablative regimen) and they can have terrible complications and die from these complications. With reduced intensity allogeneic HSCT, we can offer this type of treatment to patients who are up to 70 years of age and older who have life-threatening diseases such as leukemia or high risk myelodysplastic syndrome. This type of transplant relies more on the Graft-versus-Tumor (GvT) or Graft-versus-Leukemia (GvL) effect to eradicate the cancer rather than an intensive regimen. The reduced intensity regimen as noted in this question (http://talkabouthealth.com/would-you-describe-the-process-of-having-non-ablative-conditioning-prior-to-having-a-bone-marrow-transplant) is designed to facilitate engraftment of the donor cells and prevent the recipient from rejecting the donor cells. So the donor cells “take” or engraft in the patient.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
Please also see this question (http://talkabouthealth.com/what-is-a-hematopoietic-stem-cell-and-how-do-they-help-treat-cancer).
There is a spectrum of conditioning regimens for allogeneic hematopoietic stem cell transplant (HSCT) These range from reduced to full intensity conditioning regimens. The conditioning regimen is designed to immunosuppress the recipient to facilitate donor cell engraftment and prevent the recipient from rejecting the graft. The conditioning regimen is also designed to help kill the underlying disease, usually a hematologic cancer such as leukemia or lymphoma. Conditioning regimens use chemotherapy but also may use radiation therapy. If the patient is thought to be able to withstand the toxicity of a myeloablative or full intensity regimen, that will be used. If there is concern that the patient may have too many toxic complications, a reduced intensity on non-ablative conditioning transplant might be offered. Briefly, the patient will receive chemotherapy with or without radiation. After a wash out period, the hematopoietic stem cells (blood, bone marrow or cord blood) are infused into the patient just like a blood transfusion. These cells then start growing to cause engraftment when the blood count recovery takes place. Then the patient is followed very carefully in the clinic for the development of Graft-versus-Host Disease (GvHD), infections or other complications after allogeneic HSCT.
See also this question (http://talkabouthealth.com/in-what-situations-is-non-ablative-conditioning-recommended-before-a-bone-marrow-transplant-instead-of-typical-conditioning-therapy).
Some people use the term conditioning regimen for autologous HSCT. I prefer to use dose intensive therapy as we do not routinely use reduced intensity regimens for autologous HSCT and the patient is not “conditioned” to accept the hematopoietic stem cells as the patient’s body recognizes them as “self” or the patient’s own cells.
There is a spectrum of conditioning regimens for allogeneic hematopoietic stem cell transplant (HSCT) These range from reduced to full intensity conditioning regimens. The conditioning regimen is designed to immunosuppress the recipient to facilitate donor cell engraftment and prevent the recipient from rejecting the graft. The conditioning regimen is also designed to help kill the underlying disease, usually a hematologic cancer such as leukemia or lymphoma. Conditioning regimens use chemotherapy but also may use radiation therapy. If the patient is thought to be able to withstand the toxicity of a myeloablative or full intensity regimen, that will be used. If there is concern that the patient may have too many toxic complications, a reduced intensity on non-ablative conditioning transplant might be offered. Briefly, the patient will receive chemotherapy with or without radiation. After a wash out period, the hematopoietic stem cells (blood, bone marrow or cord blood) are infused into the patient just like a blood transfusion. These cells then start growing to cause engraftment when the blood count recovery takes place. Then the patient is followed very carefully in the clinic for the development of Graft-versus-Host Disease (GvHD), infections or other complications after allogeneic HSCT.
See also this question (http://talkabouthealth.com/in-what-situations-is-non-ablative-conditioning-recommended-before-a-bone-marrow-transplant-instead-of-typical-conditioning-therapy).
Some people use the term conditioning regimen for autologous HSCT. I prefer to use dose intensive therapy as we do not routinely use reduced intensity regimens for autologous HSCT and the patient is not “conditioned” to accept the hematopoietic stem cells as the patient’s body recognizes them as “self” or the patient’s own cells.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
A hematopoietic stem cell is one of a group of cells that can develop into mature cells usually arising from the bone marrow. These mature cells include white blood cells (WBC), red blood cells (RBC) and a portions of cells called platelets. WBC help fight off infections and are the major effector cells of the immune system. Certain WBC make antibodies that capture bacteria and other pathogens which are then eaten up by other WBC. Red cells carry oxygen throughout the body. Platelets which are fragments of a type of cell called the megakaryocyte, help clot the blood.
As mentioned in another question (http://talkabouthealth.com/i-am-confused-with-the-terminology-for-bone-marrow-transplants-is-an-alloegeneic-hematopoietic-cell-transplantation-the-same-thing-as-a-bone-marrow-transplant), there are different types of hematopoietic stem cell transplants (HSCT). Using the patient’s own hematopoietic cells is called an autologous HSCT. Sometimes these are called autologous peripheral blood stem cell transplants because we often obtain blood stem cells from the patient for the transplant. This is not really so much a transplant as a rescue. The patient is given a toxic dose of chemotherapy with or without radiation. This high dose therapy would wipe out the patient’s bone marrow and hopefully kill the patient’s cancer enough so that it goes away forever or enough so that it takes a long time for the cancer to return. The hematopoietic stem cells “rescue” the patient’s bone marrow and allow the treating doctors to give a large dose of therapy to treat the cancer.
If a patient has an identical twin who donates; then this is called a syngeneic HSCT. This type of transplant is similar to an autologous transplant. The patient and donor are identical so there is no Graft-versus-Host Disease (GvHD). GvHD is a complication of allogeneic HSCT. The donor cells attack the recipient normal tissues, primarily the skin, liver and GI tract. However GvHD is accompanied by a Graft-versus-Tumor or Graft-versus Leukemia or Lymphoma effect. So in addition to attacking normal tissue, the donor cells will attack the underlying cancer to help eradicate it. The cells that do this work are primarily donor T lymphocytes, a type of WBC. Thus, in allogeneic HSCT, the patient receives therapy to help kill the cancer and to allow the recipient to accept and not reject the donor cells. This dual effect may completely eliminate the cancer and allow the patient to be cured. The donor cells “take over” or engraft and provide the patient with a new hematopoietic system and a new immune system.
It will be of interest to patients that the New England Journal of Medicine published an article this week that compared unrelated donor mobilized peripheral blood to bone marrow as a hematopoietic stem cell source for allogeneic HSCT. There was no major difference in outcome in terms of survival. There was more graft failure with bone marrow and there was more chronic GvHD in the blood stem cell arm. The editorial writer favored bone marrow as an unrelated donor hematopoietic stem cell source. This is something that the patient should discuss with the BMT physician. Sometimes an unrelated donor cannot donate bone marrow or peripheral blood. Depending on the number of suitable donors, age and other factors, bone marrow or blood may be the best stem cell source for an unrelated donor allogeneic HSCT.
As mentioned in another question (http://talkabouthealth.com/i-am-confused-with-the-terminology-for-bone-marrow-transplants-is-an-alloegeneic-hematopoietic-cell-transplantation-the-same-thing-as-a-bone-marrow-transplant), there are different types of hematopoietic stem cell transplants (HSCT). Using the patient’s own hematopoietic cells is called an autologous HSCT. Sometimes these are called autologous peripheral blood stem cell transplants because we often obtain blood stem cells from the patient for the transplant. This is not really so much a transplant as a rescue. The patient is given a toxic dose of chemotherapy with or without radiation. This high dose therapy would wipe out the patient’s bone marrow and hopefully kill the patient’s cancer enough so that it goes away forever or enough so that it takes a long time for the cancer to return. The hematopoietic stem cells “rescue” the patient’s bone marrow and allow the treating doctors to give a large dose of therapy to treat the cancer.
If a patient has an identical twin who donates; then this is called a syngeneic HSCT. This type of transplant is similar to an autologous transplant. The patient and donor are identical so there is no Graft-versus-Host Disease (GvHD). GvHD is a complication of allogeneic HSCT. The donor cells attack the recipient normal tissues, primarily the skin, liver and GI tract. However GvHD is accompanied by a Graft-versus-Tumor or Graft-versus Leukemia or Lymphoma effect. So in addition to attacking normal tissue, the donor cells will attack the underlying cancer to help eradicate it. The cells that do this work are primarily donor T lymphocytes, a type of WBC. Thus, in allogeneic HSCT, the patient receives therapy to help kill the cancer and to allow the recipient to accept and not reject the donor cells. This dual effect may completely eliminate the cancer and allow the patient to be cured. The donor cells “take over” or engraft and provide the patient with a new hematopoietic system and a new immune system.
It will be of interest to patients that the New England Journal of Medicine published an article this week that compared unrelated donor mobilized peripheral blood to bone marrow as a hematopoietic stem cell source for allogeneic HSCT. There was no major difference in outcome in terms of survival. There was more graft failure with bone marrow and there was more chronic GvHD in the blood stem cell arm. The editorial writer favored bone marrow as an unrelated donor hematopoietic stem cell source. This is something that the patient should discuss with the BMT physician. Sometimes an unrelated donor cannot donate bone marrow or peripheral blood. Depending on the number of suitable donors, age and other factors, bone marrow or blood may be the best stem cell source for an unrelated donor allogeneic HSCT.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
When allogeneic transplant for hematologic disorders was first done, bone marrow was the stem cell source. The first consistently initially successful bone marrow transplants (BMT) were syngeneic which stands for identical twin. There is no Graft-versus-Host Disease (GvHD) because the donor and recipient are identical. But there is also no Graft-versus-Tumor (GvT) or Graft-versus-Leukemia (GvL) effect. So, later on in the 1980s investigators found that peripheral blood could be used for allogeneic hematopoietic stem cell transplant (alloHSCT) especially when the normal donor was given granulocyte colony-stimulating factor (GCSF) to mobilized stem cells into the blood stream for collection on a leukopheresis machine. A leukopheresis machine is the same machine used for platelet donations but the settings are different to allow for the stem cells to be collected. Cord blood collected from the placenta after a baby is born is also a source of hematopoietic stem cells. Cord blood is collected and stored in cord blood banks and made available for alloHSCT. So, alloHSCT means that hematopoietic stem cells from bone marrow, mobilized peripheral blood or cord blood can be used as a hematopoietic stem cell source. There are pros and cons to the use of each hematopoietic stem cell source. These are issues that will be discussed with the patient by the transplant team. We sometime use the term BMT as standing for Blood or Marrow Transplant so as to cover all three stem cell sources for allogeneic BMT.
Just to be clear, if you use the patient’s own cells, this is an autologous hematopoietic stem cell transplant. The majority of these use mobilized peripheral blood. These are not so much transplants as a rescue from the toxic effects of the therapy on the bone marrow which hopefully will eradicate or greatly reduce the cancer cells.
Just to be clear, if you use the patient’s own cells, this is an autologous hematopoietic stem cell transplant. The majority of these use mobilized peripheral blood. These are not so much transplants as a rescue from the toxic effects of the therapy on the bone marrow which hopefully will eradicate or greatly reduce the cancer cells.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
The patient is seen by a transplant center that will initiate the search for a donor. First, the team looks at the patient’s brothers and sisters and then if no suitable donor, will look in the National Marrow Donor Program registry for a suitable donor. Confirmatory testing is done to make sure the donor is a good enough match and then timing of the transplant is considered as to when the patient needs to have the transplant. In some cases if an unrelated adult donor cannot be found, half matched transplants from a family member can be done. These are called haplotype transplants or haplotransplants. Also a cord blood transplant can be considered for certain patients. The process can take several weeks so an early referral is important to get the process going.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
First, I wanted to mention that IgG Waldenstrom disease is very rare. It is almost always IgM. I am not sure what you mean by doubled up with CML. If you have CML and Waldenstrom disease, that would be also unusual. There are other treatments for Waldenstrom beyond R CVP so be sure to discuss with your treating team.
An unrelated donor or even a related donor allogeneic blood or marrow transplant (BMT) is large undertaking. There are a variety of issues related to finding a donor. The donor should be well matched and preferably younger for better outcomes. The hospital stay can be around a month depending on the conditioning regimen used and the recipient needs to be near the transplant center for around 100 days total after BMT (including the hospital stay). One of the complications of allogeneic BMT is Graft-versus-Host Disease. This can be life threatening for several months after the BMT. It is often accompanied by a Graft-versus-Tumor or GvT effect. This is why allogeneic BMT is used for diseases that cannot be easily treated long term by chemotherapy. We usually tell our patients not to expect to return to work for at least 9 to 12 months after BMT especially if the job involves a lot of exertion.
An unrelated donor or even a related donor allogeneic blood or marrow transplant (BMT) is large undertaking. There are a variety of issues related to finding a donor. The donor should be well matched and preferably younger for better outcomes. The hospital stay can be around a month depending on the conditioning regimen used and the recipient needs to be near the transplant center for around 100 days total after BMT (including the hospital stay). One of the complications of allogeneic BMT is Graft-versus-Host Disease. This can be life threatening for several months after the BMT. It is often accompanied by a Graft-versus-Tumor or GvT effect. This is why allogeneic BMT is used for diseases that cannot be easily treated long term by chemotherapy. We usually tell our patients not to expect to return to work for at least 9 to 12 months after BMT especially if the job involves a lot of exertion.
New answer by PhilipMcCarthyMD (Physician - Oncology - Hematology/Oncology (Verified))
1
Answer |
7 months ago
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