Hematopoietic Stem-Cell Transplantation in the Developing World: Experience from a Center in Western India

We describe our experience of first 50 consecutive hematopoietic stem-cell transplants (HSCT) done between 2007 and 2012 at the Apollo Hospital, Gandhinagar, 35 autologous HSCT and 15 allogeneic HSCT. Indications for autologous transplant were multiple myeloma, non-Hodgkin lymphoma, Hodgkin lymphoma, and acute myeloid leukemia, and indications for allogeneic transplants were thalassemia major, aplastic anaemia, chronic myeloid leukemia, and acute lymphoblastic and myeloid leukaemia. The median age of autologous and allogeneic patient's cohort was 50 years and 21 years, respectively. Median follow-up period for all patients was 39 months. Major early complications were infections, mucositis, acute graft versus host disease, and venoocclusive disease. All of our allogeneic and autologous transplant patients survived during the first month of transplant. Transplant related mortality (TRM) was 20% (N = 3) in our allogeneic and 3% (N = 1) in autologous patients. Causes of these deaths were disease relapse, sepsis, hemorrhagic complications, and GVHD. 46% of our autologous and 47% of our allogeneic patients are in complete remission phase after a median follow-up of 39 months. 34% of our autologous patients and 13% of our allogeneic patients had disease relapse. Overall survival rate in our autologous and allogeneic patients is 65.7% and 57.1%, respectively. Our results are comparable to many national and international published reports.


Introduction
Trends of hematopoietic stem-cell transplantation (HSCT) evolved with the first successful transplantation done by Dr. E. Donnall Thomas in late 1950s, for which he received the Nobel Prize in Physiology or Medicine in 1990. That transplant was done between the identical twins in a case of leukemia [1]. In 1968, in Minnesota, the first successful nontwin (allogeneic) transplant was performed. In this case, the donor was a sibling of the patient. By this time, it was known that a key to a successful transplant was a specific type of genetic matching (known as HLA) of the donor to the patient [1]. The first successful unrelated donor transplant was done in 1973, when a young kid in New York with acute leukemia received multiple bone marrow transplants from a matched donor from Denmark [1]. The application of hematopoietic stem-cell transplantation is not new in India. India's first successful allogeneic bone marrow transplantation was done at Tata Memorial Hospital on March 20, 1983, on a nine-year-old girl with acute myeloid leukemia [2]. Since then, many sophisticated hematopoietic stem-cell transplant centers (HSCT) have been established across the nation. Until September 2005, data from six transplant centres in India were collected and a total of 1540 transplants have been performed in a country of over one billion population [2]. In India, there are 11 centres currently reporting their data to CIBMTR (Center for International Blood and Marrow Transplant Research) [3]. However these numbers are not large, and centres which perform regular HSCT are low due to various reasons like lack of infrastructure and expertise and lack of knowledge of safety, efficacy, and cost of the procedure both in general population and in medical fraternity. Family genotype analysis in India reveals that 39.3% of the total numbers of patients have an HLA-matched sibling and that families with sibship size of more than or equal to 4 have a higher probability (68.8%) compared with those with sibship size of less than 4 (29.7%) [4]. Recently most of the transplant centres have started marrow unrelated donor (MUD) 2 Journal of Oncology

Trends in Transplants by
Type and Recipient Age. The median age of autologous BMT was 50 years and allogeneic BMT was 21 years. Majority of autologous transplants were done between the ages of 51 and 60 years and in patients with multiple myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma, which are more common in this age group. Major indications of allogeneic BMT in age group less than 20 years were thalassemia and aplastic anemia and for autologous BMT they were Hodgkin's lymphoma. Figures 1 and 2 show graphical presentation of age of distribution and major indications below age of 20.

Indications for Hematopoietic Stem-Cell Transplants.
Common indications for autologous BMT were multiple myeloma (57%), non-Hodgkin's lymphoma (23%). Allogeneic BMTs were done in patients with acute lymphoblastic lymphoma relapse, chronic myeloid leukemia with imatinib failure, aplastic anemia, thalassemia, and myelodysplastic syndrome. Two AML relapse cases undergone allogeneic BMT whereas three AML patients undergone autologous BMT after induction and consolidation chemotherapy.

Stem-Cell Collection.
Stem cells were collected from peripheral blood in 92% [ = 46] of patients while in 8% [ = 4] patients bone marrow was the source. Till the date of analysis, we have not done allogeneic HSCT with stem-cells from cord blood, haploidentical donor, or marrow unrelated donor (MUD). All of the autologous stem-cells were collected from peripheral blood. All of our Allogeneic transplant patients were 6/6 HLA antigens matched according to standard protocols [12] except one patient in which we did transplant with 4/6 matched HLA antigens from sibling. Stem-cells from peripheral blood were collected after mobilization therapy consisted of G-CSF stimulation in the dose of 10 mcg/kg/day for 4-5 days and from bone marrow collected by standard methods. Median stem-cell dose (CD34 cells/kg) transplanted for our allogeneic BMT is 5.15 ∧ 10 6 and 2.56 ∧ 10 6 for autologous transplant patients. Autologous HSC were cryopreserved in a preservative called DMSO and the cells were cooled very slowly in a controlled rate freezer to avoid cell loss by osmotic injury [13]. Cryopreservation is necessary especially in autologous transplants because HSC collections are usually done much in advance of its transplant. We preferred allogeneic HSC collection to be done very near to the transplant to avoid cell loss during freezing and thawing.

Transplant Conditioning Protocols.
All patients were given myeloablative conditioning chemotherapy without the use of total body irradiation (TBI). We have not used nonmyeloablative or reduced intensity regimens. Chemotherapy was given through central lines in all patients. BEAM regimen was used for Hodgkin and non-Hodgkin lymphomas. BuCy regimen was used for acute leukaemias. Melphalan was used for myelomas according to standard protocols [14]. Table 2 describes our major conditioning regimens. Tables 4 and 5.

VOD Prophylaxis.
This included tablets of Ursodeoxycholic acid 300 mg thrice daily to all allogeneic patients. Table 3 shows GVHD prophylaxis in our allogeneic HSCT patients.

Posttransplant Complications: Early Complications within
100 Days after Transplant. The most common early posttransplant complications were mucositis, infections, venoocclusive disease (VOD), graft versus host disease (GVHD), and hemorrhagic cystitis. We have taken references from CTCAE (Common Terminology Criteria for Adverse Events) to grade our posttransplant complications [15]. Table 6 shows major early posttransplant complications in our autologous and allogeneic patients.

Oral Mucositis.
Oral mucositis was one of the most common complications of both allogeneic and autologous BMT. Four (27%) (two grade 2 and two grade 3) of our allogeneic transplant patients and five (15%) (one grade 1, two grade 2, and two grade 3) of our autologous transplant patients had mucositis [16]. Grade 2 mucositis patients were managed with dietary modification, analgesics, and oral care and patients with grade 3 required some kind of intervention like parental nutrition and/or feeding tube insertion. We use ice sucking during melphalan and fludarabine conditioning chemotherapy to prevent/reduce mucositis. Chemotherapy and HSCT were the probable causes of the mucositis [17].

Acute Graft versus Host Disease (Acute GVHD).
Four incidences of GVHD were noted in allogeneic BMT. Two patients have skin GVHD, one was grade 1 and the other was grade 2. Two were hepatic acute GVHD grade 2/3 with elevated SGPT, bilirubin, and LDH.

Periengraftment Syndrome.
Five incidences (10%) (one allogeneic and four autologous) were noted. Common symptoms were weight gain, low grade fever, and electrolyte imbalances, which were treated with short courses of steroids.

Gastrointestinal Complications.
These were twelve incidences of grade 2 and grade 3 diarrhoea. There were three incidences of oral and/or anal bleeding.

Renal Complications.
Three incidences of acute renal failure (2 autologous and 1 allogeneic) were noted with rise in blood urea nitrogen and creatinine. One incidence of allergic acute kidney injury was noted.

Pulmonary Complications.
Two incidences of restrictive lung disease were noted with reduced DLCO and were probably related to previous chemotherapy exposure.
3.1.9. Neurological Toxicity. This was one incidence of peripheral motor and sensory neuropathy.

Infections.
Three incidences of bacterial infections were noted. One incidence was bilateral fungal lung infection and was treated with oral voriconazole. One incidence of Herpes zoster was noted. (Table 7). By definition, WBC engraftment is absolute neutrophil count >500 for three consecutive days and the platelet engraftment is the platelet count >20,000 for three consecutive days without any external transfusion support [18]. The median engraftment for our autologous BMT was 15 days with range of 10-35 days. The median engraftment days for our allogeneic BMT are 14 days with range of 9-34 days. One allogeneic BMT patient had delayed engraftment because of graft rejection. (Table 7). Average duration of hospital stay after autologous BMT is 18 days with a range of 10-80 days. Average duration of hospital stay after allogeneic BMT is 20 days with a range of 14-70 days. (Tables 7  and 8 Figure 3 shows the alive and dead patients in various indications of transplants being performed. Figure 4 shows number of patients alive at particular posttransplant follow-up period. All of our transplant patients survived during the first month after transplant. Transplant related mortality was four (3 allogeneic and 1 autologous). Major downfall in this graph comes between

Discussion
Apollo Hospital, Gandhinagar, is one of the major bone marrow transplant centres of India. The center is a registered transplant center of CIBMTR (Center for International Blood and Marrow Transplant Registry), USA. This hematopoietic stem-cell transplant data will be the first published data from Western India. The bone marrow/stem-cell transplant center at Apollo Hospital, Gandhinagar, is a new set-up compared to some other set-ups in India and across the world. The first successful autologous transplant was performed on July 5, 2007, in a six-year-old child with Hodgkin lymphoma and the first allogeneic transplant was performed on June 6, 2008, on a thirty-eight-year-old male with AML relapse. Within 5 years span, a total of 50 patients were treated with stem-cell transplants at Apollo Hospital, Gandhinagar. Majority of our HSC collections were done from peripheral blood after G-CSF mobilization. We have not done cord blood transplants, haploidentical donor transplants, or marrow unrelated donor (MUD) transplants yet. We have followed all patients for at least 22 months with median follow-up of 39 months, which is comparable to many national and international studies. Although number of transplants performed is not big enough and data is for shorter duration, still the data is comparable with some national and international published data.
Mean duration of engraftment in our patients was 17 days for autologous BMT and 16 days for allogeneic BMT which is comparable to other standard international data [18]. Only one allogeneic BMT patient had delayed engraftment due to graft failure. Major risk factors of graft failure are disparity between recipient and donor within the major histocompatibility complex (MHC) [19]. We have only used myeloablative conditioning regimen in our transplant patients. One western study shows that the graft failure in myeloablative conditioning regimens is 1/34 compared to 6/24 in nonmyeloablative regimen with = 0.02 [20]. Table 9 shows comparison of various parameters between Apollo Hospital, Gandhinagar, National Cancer Research Institute, Kolkata, Christian Medical College, Vellore, and western studies. Survival in patients of Apollo Hospital is parallel to most of the Indian published reports and many of the western countries.
Health Resources and Services Administration (HRSA), US Department of Health and Human Services, USA, publish their survival analysis data every year at 100 days, 1 year, and 3 years after transplant period [21]. Comparison of survival statistics are analogous to HRSA data from the United States of America but as the numbers of transplants in some of the categories are not sufficient, comparison can be misleading. There are some areas in our efforts, where our Apollo CBCC stem-cell transplant unit is behind some western studies.
For example, infection rates are comparable to other Indian centres but much higher than western studies, which report bacterial infection rate of 5%, viral infection rate of 7%, and fungal infection rate of 12% [8]. The possible risk factors of infections in our patients are aggressive myeloablative conditioning regimens at our center leading to prolonged neutropenia during preengraftment period and possible environmental factors in India [22]. Early posttransplant infection rates are higher in our allogeneic BMT patients probably because we use aggressive myeloablative conditioning regimens which produce very severe and prolonged neutropenia during preengraftment period. One western study demonstrates that, before neutrophil engraftment, the nonmyeloablative cohort had a 53% lower rate of bacterial infections, whereas after engraftment the density of bacterial infections was similar in myeloablative and nonmyeloablative groups. It also shows that, in the first month, both invasive fungal infections and viral infections were twofold less frequent in nonmyeloablative patients [23]. Incidence of viral infections is low (2 CMV and 1 HSV) as compared to two other published data of Indian centres. We do pretransplant evaluation for HIV, hepatitides B and C, and Cytomegalovirus (CMV). We also monitor CMV viral load in posttransplant period in all of our allogeneic HSCT patients. Other viruses 8 Journal of Oncology  [11] like Epstein Barr virus and Herpes simplex virus are not monitored regularly. Major complications during the transplant were GVHD, infections, mucositis, venoocclusive disease, disease related complications, and chemotherapy induced complications and complications related to other comorbidities. One of our myeloma patients required second transplant after the first one because of disease relapse.
Mortality rates are comparable to other Indian and western studies. Major causes of mortality in our patients were infections and disease relapse/progression. Transplant related mortality was found in 8% of our patients. By definition, transplant related mortality (TRM) means deaths occurring during the first 100 days after transplant due to complications of the transplant [24]. Majority of deaths occurred in the first year of posttransplant period. Common causes of non-TRM mortality in the first year after transplant period in our patients were disease relapse (45%), haemorrhagic complications (10%), GVHD (10%), and sepsis (10%).
Overall survival of our autologous and allogeneic HSCT transplant patients was 65.7% and 57.1%, respectively. 46% of our autologous and 47% of our allogeneic patients are in complete remission phase after a median follow-up of 39 months which is comparable to many national and international transplant centres as shown in Table 9. By definition, complete remission means disappearance of all signs of cancer in response to treatment and does not always mean that the cancer has been cured. It is also called complete response [25].
In a developing country like India, there are very few centres, which perform regular HSCT due to various reasons like lack of infrastructure and expertise and lack of knowledge of safety, efficacy, and cost of the procedure both in general population and in medical fraternity. This study will help in sharing its outcomes with other hematology/oncology practitioners and will encourage other centres to start performing stem-cell transplantations or refer eligible patients for this important treatment option available.

Conclusion
With these encouraging results at our center, we can conclude that our data is comparable to national and international hematopoietic stem-cell transplantation centres in terms of complications, outcomes of treatment, and cost effectiveness. These results provide evidence that the stem-cell transplant, which is a recommended treatment option in various diseases, is possible in a nonuniversity hospital of developing country with excellent safety profile. We will continue to provide our services in the future and try to take them to the next level in terms of application of haplotransplantation, marrow unrelated donor transplantations, and cord blood as the stem-cell source. We will also try to make transplantation possible to some rare indications, nonaffording patients, reduce the complications, and improve the outcomes of the HSCT at our center.