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CHAPTER 94: Hematopoietic Stem Cell Transplantation and Graft-Versus-Host Disease 881

KEY REFERENCES • Stem cell transplant recipients may require admission to the
• Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines intensive care unit for close monitoring for volume and electrolyte
for the management of pediatric and adult tumor lysis syndrome: issues, vasopressor or renal support, and mechanical ventilation.
an evidence-based review. J Clin Oncol. June 1, 2008;26(16): • The approach to the diagnosis and management of infectious
2767-2778. disorders in the stem cell transplant recipient is dependent on the
• Damek DM. Cerebral edema, altered mental status, seizures, acute underlying disease and prior therapy, timing of the infection rela-
stroke, leptomeningeal metastases, and paraneoplastic syndrome. tive to the transplant, the type of transplant, the patient’s immuno-
Hematol Oncol Clin North Am. June 2010;24(3):515-535. logic history and comorbidities.
• Ganzel C, Becker J, Mintz PD, Lazarus HM, Rowe JM. • Pulmonary complications develop in up to 60% of allogeneic
Hyperleukocytosis, leukostasis and leukapheresis: practice man- transplant recipients and are the immediate cause of death in
agement. Blood Rev. May 2012;26(3):117-122. approximately half of the cases.
• Klimo P Jr, Thompson CJ, Kestle JR, Schmidt MH. A meta- • Major noninfectious pulmonary complications in the early trans-
analysis of surgery versus conventional radiotherapy for the treat- plant period include idiopathic pneumonia syndrome, diffuse
ment of metastatic spinal epidural disease. Neuro Oncol. January alveolar hemorrhage, and periengraftment respiratory distress
2005;7(1):64-76. syndrome; bronchiolitis obliterans syndrome and bronchiolitis
• Lewis MA, Hendrickson AW, Moynihan TJ. Oncologic emergen- obliterans organizing pneumonia occur later.
cies: pathophysiology, presentation, diagnosis, and treatment. CA • Despite advances in supportive care in the intensive care unit, the
Cancer J Clin. August 19, 2011. mortality rate of allogeneic transplant recipients who develop respi-
• Navi BB, Reichman JS, Berlin D, et al. Intracerebral and subarach- ratory failure and multiple organ failure remains extremely high.
noid hemorrhage in patients with cancer. Neurology. February 9,
2010;74(6):494-501.
• Sanchez O, Trinquart L, Caille V, et al. Prognostic factors for INTRODUCTION
pulmonary embolism: the prep study, a prospective multicenter
cohort study. Am J Respir Crit Care Med. January 15, 2010;181(2): Hematopoietic stem cell transplantation (HSCT) has become an expand-
ing modality for the treatment of benign and malignant hematologic
168-173. diseases. While HSCT has been shown to be of benefit in only a few
• Stewart AF. Clinical practice. Hypercalcemia associated with nonhematologic malignant diseases such as relapsed testicular cancer
cancer. N Engl J Med. January 27, 2005;352(4):373-379. and neuroendocrine tumors, it has been studied in clinical trials in a
• Wagner PL, McAleer E, Stillwell E, et al. Pericardial effusions in variety of others such as renal cell and breast cancer, without major
the cancer population: prognostic factors after pericardial window efficacy. In the area of benign diseases, it can restore hematopoiesis
1
and the impact of paradoxical hemodynamic instability. J Thorac and/or immune function in congenital or acquired immune deficiency
Cardiovasc Surg. January 2011;141(1):34-38. or marrow failure states. The most common diseases for which HSCT is
• Yu JB, Wilson LD, Detterbeck FC. Superior vena cava syndrome— performed are acute leukemia, myelodysplastic syndrome, Hodgkin and
a proposed classification system and algorithm for management. non-Hodgkin lymphomas, multiple myeloma, and less common disor-
2
J Thorac Oncol. August 2008;3(8):811-814. ders such as aplastic anemia. Classical HSCT is a lifesaving procedure
which utilizes high doses of chemotherapy and/or radiotherapy. In the
case of malignant disease, it is a treatment modality which is used after
at least one and often many courses of standard chemotherapy. Greater
REFERENCES numbers of patients over a wide age range are undergoing transplanta-
tion as a part of their oncologic therapy, and more of these patients are
Complete references available online at www.mhprofessional.com/hall becoming survivors. 3
A stem cell transplant can be broken down into three components:
the graft, the conditioning, and, in some types of transplant, the immu-
nosuppression. There are two types of HSCT based on the source of
Hematopoietic Stem Cell the graft—“autologous”—when the stem cells are harvested from the
CHAPTER patient at the time of blood count recovery after chemotherapy, or after
94 Transplantation and Graft- receiving a white blood cell growth factor (granulocyte-colony stimu-
lating factor [G-CSF]) or stem cell mobilizer (plerixafor)—which mobi-
Versus-Host Disease lizes bone marrow stem cells into the peripheral blood from which they
can be collected by apheresis. The second type of stem cell transplant
Stephen M. Pastores is “allogeneic” which utilizes stem cells donated from a family member,
Michael A. Rosenzweig an unrelated donor, or umbilical cord blood (Fig. 94-1). When derived
Ann A. Jakubowski from a donor, the stem cells are matched to the patient using the anti-
genic determinants that mediate tissue graft rejection responses, primar-
ily the human leukocyte antigens (HLAs). These are encoded by genes
KEY POINTS of the major histocompatibility complex located on chromosome 6.
4
A fully HLA matched sibling is the preferred donor source because the
• The complications of hematopoietic stem cell transplantation risk of graft rejection and graft-versus-host disease (GVHD) is lowest
generally relate to the consequences of the cytoreductive therapy, with this source of cells. When a matched related sibling is not avail-
infections, and in the case of allogeneic transplants, immunosup- able, an unrelated fully matched donor is the preferred alternative.
5
pression and development of graft-versus-host disease. Unfortunately, due to a limited availability, sometimes only a partially
• Graft-versus-host disease remains one of the most important matched or “mismatched” donor can be identified. Additional stem
complications of allogeneic transplantation. cell sources used in the allogeneic setting include umbilical cord blood
and stem cells from a haploidentical family member. The stem cells

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