Bone Marrow Transplant -- Failed, Now What?

So first of all, peripheral blood stem cell transplants (PBSCT) are more commonly done now than bone marrow transplants (BMT).

Okay, so GVHD occurs when the immune cells in the donor graft attack the host (patient's body). This graft-versus-host activity actually means graft-versus-leukemia activity, and can actually kill any remaining cancer cells left over from chemo.

A graft failure is when the stem cells do not produce enough RBCs. This requires another transplant.

The primary treatment for leukemia is chemotherapy. There is a remission induction phase where high doses of certain drugs are given. This is often when CNS prophylaxis is done to prevent spread to the central nervous system. There is then--if the patient goes into remission--the consolidation phase where lower doses of drugs are given. At this point, patients with a high risk for relapse are offered the option of transplant (either allogenic if there is a good donor available or autogenic). Transplants allow higher doses of radiation and chemotherapy to be used, but it still isn't entirely clear how helpful they actually are.

When treatment fails (which happens in up to 1/5 of cases in ALL for example), higher doses may be tried; unfortunately, they are less likely to work. A transplant may be tried if the leukemia can be put into at least partial remission, but it isn't always an option. If the leukemia is refractory, there is the option to keep trying; however, the likelihood of additional chemo working is pretty low. It's usually at that point that doctors will suggest the patient take a look at palliative therapy and focus on staying positive.