Cord of life

http://www.haaretz.com/hasen/spages/1063056.html

Suffering from acute leukemia, E. was gravely ill. All attempts to find a suitable donor to replace her bone marrow that had been destroyed by intensive chemotherapy treatments were to no avail. After a half year search, the doctors at the Tel Aviv medical center where she was being treated said that there was nothing more to do. They explained to her husband that in her condition there were no more treatments they could give her.

But the family was not prepared to give up. In feverish searches on the Internet they chased every possible lead, even an experimental treatment. E.'s son came upon a doctor in Texas who was an expert on umbilical cord blood transplants. The specialist explained that the treatment is usually given only up to the age of 45 and expressed doubt as to the possibility that the woman of 68, who most probably also suffered from other conditions common to her age, would survive the transplant.

Only after the son insisted, and showed the specialist all the medical data on his mother, who until the disease was diagnosed had been completely healthy, did he agree to try.
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He wondered, though, why it was necessary to drag the patient all the way to Texas when there was a department in Israel, at Sheba Medical Center in Tel Hashomer, which could provide the same treatment.

The family hastened to apply to Sheba where Dr. Avichai Shimoni, the director of the bone marrow transplant unit, more or less repeated the reservations of the specialist in Texas.

This is a transplant that is more usual among children. In Israel, several dozen children and about 20 adults have undergone the procedure, 12 of them at Sheba.

"Dr. Shimoni said to us, 'Look, we don't have experience with people of her age,'" said the son. "'We need to go with the method of trial and error. Are you prepared to take the risk?' We told him, 'We have no choice, the alternative is clear.'"

Shimoni agreed, and thus E. became the oldest person in Israel and one of the few in the world of her age to have had an umbilical cord blood transplant.

The transplant procedure went well for E. Stem cells from umbilical blood that was donated by a blood bank in Holland were introduced into her body. Her body accepted the transplant and after the procedure it looked as though the disease was in remission and E. gradually returned to her ordinary life.

However, half a year later the disease attacked again. Because of her depressed physical condition, and the recurrence of the disease after a short time, there was no possibility of another transplant. E. passed away two and a half years after her illness was first diagnosed.

Nonetheless, for her husband, the extra time granted his wife and all those who were close to her following the treatment was an achievement.

"She returned to her everyday functioning, we went to parties, we took a trip abroad and we even did a 15 kilometer climb in the mountains," he said.

The case of E. has succeeded in establishing an approach that is becoming more and more common among the experts, whereby less importance should be attributed to the patient's age.

"Nowadays the perception is that age as such is not the center but rather the patient's physical condition and whether he suffers from other conditions," says Shimoni. "If he is in good shape, then his age does not constitute a reason not to treat him by means of a transplant."

The pluses of immaturity

For patients suffering from malignancies of the blood (various types of leukemia) and the lymph nodes, treatment via transplanted umbilical cord blood and bone marrow has virtually the same effect. The aggressive chemotherapy that these patients undergo destroys the cancerous cells but also harms the healthy bone marrow. The transplant makes it possible to administer the chemotherapy in large doses and to replace the bone marrow that has been destroyed. The bone marrow itself is extremely crucial in fighting the disease. It is made up of stem cells, which are the building blocks of the tissues, the organs and the blood system and they also make up the immune system. A transplant enables the body to produce a new immune system that will fight the disease.

However, anything foreign that is transplanted into the body, including a bone marrow transplant, has to match the patient's body - otherwise it will be rejected.

For the transplant to be accepted, a donor is needed who is a perfect tissue type match for the patient. For the most part, the best match would be from a patient's sibling. If there is none, an unrelated donor can sometimes be the best match.

In E.'s case, no matching bone marrow donor was found in the blood banks in Israel and abroad, and thus the family came to the possibility of a placental blood transplant.

Placental blood contains the stem cells that are also found in bone marrow, but because of the cells' relative immaturity, a perfect match is not needed for to transplant the blood from the passed placenta after a birth.

The disadvantage in the placental blood cell transplant option is in the small quantity of stem cells in the placenta, which do not suffice for transplants in adults.

In order to solve this problem in recent years, the practice has been to transplant stem cells from two placentas.

This is the treatment that was given to E. Doctors have found that the transfusion of two such units has a more powerful effect on the disease.

"Usually only the blood from one placenta is accepted by the body but the other unit helps it become absorbed and also helps it act against the disease," explained Shimoni.

As compared to bone marrow transplants, the absorption stage for placental blood is longer and takes several weeks because of the relatively small quantity of stem cells in the placental blood.

During the period following the transplant and until it is absorbed, the patient's body is vulnerable to various infections. However, the main complication of the transplant is still the transplant's fight against the host body.

Shimoni explained the affect of the patient's age on the success of the treatment.

"Age is a less important parameter when it comes to enduring the transplant, but it is a parameter with respect to the disease," he said. "In some patients, the malignancy returns even after a transplant of any sort. Since this is a very violent disease, even chemotherapy in a high dosage and a transplant don't always eliminate it. This is what happened to E. Though the transplant was absorbed, the aggressive disease, which is common among older patients, returned."

Nevertheless, Shimoni can testify to quite a number of cases in which the combined treatment of chemotherapy and a transplant achieved a complete cure, without a recurrence of the disease.

Still, Shimoni says in most cases bone marrow transplants are better than umbilical cord blood, unless a match can't be found.

"A bone marrow transplant with a perfect match is always preferable," said Shimoni. "In a case when the bone marrow comes from an unrelated donor and there is not a perfect match with the patient, we will often prefer umbilical cord blood."