At Kings today we contemplated our first double cord transplant. The patient, a 66 year old woman suffering from AML which had transformed from MDS, had teh bad risk features of absent chromosomes 5 and 7. Although she is in remission she has a less than 10% chance of living for a year. She has no sibling and there is no volunteer donor.
Cord blood transplants are mainly an option for children and small adults, like the Japanese. They have several advantages, the most important being that they are less immunoreactive so that you can allow for a mismatch at a single locus and have no greater risk of GVHD. But how to get round the volume problem?
The baby's umbilical cord and the placenta contain about 200 cc of blood, but it is rich in stem cells. If it is not frozen down it is thrown away. here is a donation that is easy to take and harms no-one. If you have a facility near you, you should offer your baby's cord for freezing. This alone would bean argument against home births.
The Minnesota protocol allows for two cords to be used. Only one will grow and repopulate the marrow, but the other supports and strengthens its growth. They don't have to be a match. It's better if they are a mismatch for the recipient and a mismatch for teh other cord, but in a different way.
So for our patient we have found a 5/6 match from Australia and a 4/6 match from Belgium. Just imagine the organization. A couple in Oz and a couple in Belgium, quite separately decide that they will allow their babies' cord bloods to be frozen down. Some months later those bloods will mingle to save the life of a woman in England they will never meet. Isn't technology wonderful!
Of course it is not completely safe. There is a 15% chance of treatment related mortality. This will be a reduced intensity conditioning (or mini-) transplant. Graft versus host disease of some degree is likely, but face with the likelihood of 85% chance of disease related mortality in the first year, it is a no-brainer.
The other highlight today was a case presentation called "Stroke, stroke, stroke."
A 63 year old woman had been having recurrent strokes since the age of 12. She always recovered after a day or so, but she had suffered progressive deterioration of her balance and control of fine movement. The obvious cause would be emboli coming off an abnormal heart valve, but no, the 'strokes' were preceded by the smell of bacon and eggs. This is hemiplegic migraine. And since her two younger brothers have it, it is familial hemiplegic migraine. The genetic abnormalities have been identified and involve calcium channels. The cerebellar ataxia is part of the syndrome. Treatment with acetazolamide prevents the attacks of migraine.
Learning new things is wonderful.