Clinical review meet 16th Nov 2023:

Challenges in setting up a new HSCT centre in a tier-2 city in India

Subbaiah Ramanathan*, Vinod Gunasekaran, Priyanka Raju, Prabhakaran Shankar, Anand Vikas, Thilagavathy, Anitha Jasmine, Senthilvel Murugan, Senthilkumar Kaliannan

Kauvery Hospitals, Trichy, Tamil Nadu, India

*Correspondence: drrms5@yahoo.in

Graphical Abstract

Graphical-Abstract

BMT as a cure in

  1. Bone marrow failure/stem cell disorders
  2. Haematological malignancies
  3. Primary immunodeficiency/HLH
  4. Autoimmune disorders (extremely rare).

Background

Most HSCT centres are established in tier-1 cities (population of 1 million and above). Establishing an HSCT centre in a tier-2 city (0.5 to less than 1 million population) remains a challenge for a new transplant physician, especially in a private-sector health centre.

Here, we share our experience in establishing a new and the first HSCT in Tiruchirappalli (a tier-2 city in Tamil Nadu, South India).

List of disorders taken for HSCT in our set-up

  • ALL, AML, MPAL
  • PMF
  • MDS
  • AA, FA
  • Myeloma
  • Lymphomas (HL, IV DLBCL, PTCL, PBL)
  • NB
  • Thalassemia
  • Osteopetrosis

The Numbers

  • Total BMT: 48
  • Autologous: 27
  • Allogeneic: 21
  • Haploidentical: 5
  • Expired: 11 (2 per-transplant, 9 on follow up till date)
  • Adult: 30
  • Paediatric: 10
  • 2020: 1
  • 2021: 9
  • 2022: 19
  • 2023: 19 till date
  • Myeloma: 20
  • AML: 9
  • ALL: 4
  • MPAL: 1
  • Hodgkin lymphoma: 3
  • Myelodysplastic syndrome: 1
  • Myelofibrosis: 1
  • Osteopetrosis: 1
  • Aplastic anemia: 1
  • Fanconi anemia: 2
  • Thalassemia: 1
  • Neuroblastoma: 1
  • Peripheral T-cell lymphoma: 1
  • Intravascular DLBCL: 1
  • Plasmablastic lymphoma: 1

Methods

  1. A two-bed HSCT unit with HEPA filter (high-efficiency particulate air filter) at the 6th floor of Kauvery Hospitals, Tiruchirappalli, TN, India in Aug 2020.
  2. Patients with myeloma were managed with standard regimens.
  1. First line regimen was VRD (Bortezomib, Lenalidomide, Dexamethasone), CyBorD (Cyclophosphamide, Bortezomib, Dexamethasone).
  2. Second-line regimens (VDT PACE or KPD) were used in the first-line regimen (minimum 4 cycles) and failed to show at least a partial response as per IMWG criteria.
  1. Patients with at least a PR and up to 65 years of good physical performance were counselled for an ASCT.
  2. Stem cell mobilization was done with G-CSF + Plerixafor.
  3. PBSC harvest was done using haemonetics MCS+ or Spectra optia apheresis systems through a Jugular venous HD catheter.
  4. The conditioning regimen used was Melphalan (200 mg/sq.m if normal renal function, 140 mg/sq.m if renal failure or age > 65 years).
  5. Supportive care (antibiotics, mucositis care, irradiated blood products) was given until engraftment and recovery of mucositis or defervescence.

Results

  1. Among 48 HSCTs done in the last 3.5 years, 20 (14 males, 6 females) myeloma patients have undergone ASCT
  2. Median age is 56.4 years (range 25-73 years), 8 above 60 years, and 1 above 70 years.
  3. Anaemia was present in 15/19 patients, bone lesions were present in 14/19, renal failure in 10/19 and 3/19 had hypercalcemia at diagnosis.
  4. Six had DM, 7 had SHT, 3 had peripheral neuropathy, and 1 had diastolic heart failure.
  5. VGPR was achieved in 8, CR in 8, and 3 had only a PR.
  6. Mean CD34 cell dose infused was 8 * 106/kg (ranged from 3.3 * 106/kg to 17.6 * 106/kg).
  7. The 19 patients engrafted neutrophils and platelets successfully (95%).
  8. Two patients grew microbes in blood culture (Pseudomonas aeruginosa and Acinetobacter baumanii).
  9. One patient expired on day 18 before engraftment in view of Acinetobacter sepsis.
  10. Two of the above 20 patients also underwent a tandem transplant, subsequently.

Conclusion

  1. Confidence of a haematologist can lead to establishing sophisticated HSCT services even at a tier 2 city/peripheral centre.
  2. Myeloma still remains the most common disorder where a haematologist starts HSCT services at a new centre.
  3. It brings hope for both the patient as well as the new HSCT team.
  4. Allogeneic 7K-10K USD, autologous 4K-6K USD in our tier 2 city.
  5. A training institute should also motivate and inspire residents to establish services at places where they are devoid of > joining an already established one.
  6. It’s challenging and unmasks the talent of a new developing team.
  7. A major proportion of the population need not travel to tier 1 cities for high-end care.
  8. Patient can be close to his hometown.
  9. It cuts down cost in travel and accommodation elsewhere.
  10. More emotional support with close relatives around.
  11. Expenses are likely to be less at peripheral cities than large cities.
  12. Post transplantation follow up becomes easy, esp, if complication ensues.
Ramanathan

Dr. Ramanathan Kannan Suppiah

Critical Care Specialist

Vinod-Gunasekaran

Dr. Vinod Gunasekaran

Paediatric Hematology, Oncology & Bone Marrow Transplantation

Thilagavathy

Dr. Thilagavathy

Microbiologist

Senthilvel

Dr. Senthilvel Murugan

HOD Radiology

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