Hello Everyone. We had our meeting with our transplant doctor this afternoon and now have a pretty detailed idea of what is being planned for Ann's second transplant. Not everything is set in stone yet, so a few of the details may change, hopefully not much though.
The plan is for Ann to have a second transplant, and this time they want to be much more aggressive than before, so Ann's next transplant will differ from her first in a couple of ways. First the source of stem cells will be a 9 out of 10 match (9/10) with a mismatch on the A antigen. Next they are planning a new preparatory chemo regime than the first one she had, and it will include additional chemo after the transplant. Finally the use of immune suppressants like cellcept and tacrolimus will be kept to a minimum this time around.
So what is this all going to accomplish? The 9/10 HLA-A mismatched marrow will be a fully formed adult immune system with a distinct memory. The mismatch should theoretically lead to more GvHD than she had in the first transplant. Unfortunately this can be a good and bad thing. More GvHD means (in theory) more anti-tumor effect, but it can also means that the transplant will be more dangerous. The new chemo regime is supposed to address this. Specifically the chemo (Cytoxan) that will be given a couple of days after the transplant is supposed to kill off some of the T-cells that could direct an immune response to Ann's organs and leave the ones in the bone marrow in place where they can still react to any lingering leukemia. Finally the reduction in initial immune suppressants means that the new immune system will "come out swinging". I'm sure that if if there is too much GvH then they will start to add immune suppressants to try to get things under control.
If this sounds rough and maybe dangerous, it is. To put things in perspective the relative danger of a run-away immune response is about a million times more dangerous than leukemia. GvH can be fatal in hours or days and leukemia in months. However, MDA really feels like they NEED to stomp on Ann's leukemia as hard as they can this time because it might be our last chance.
By the way, I did check and the 9/10 donor is the same one that turned up just a short time (days) before the last transplant a year ago. MDA did "activate" the donor then and they "demonstrated a willingness to donate", but because of the selection of the cords they where never called in for testing. So the donor will have to be contacted again and then go in for testing. I really, really hope with all of my heart that the donor is still willing and nothing turns up in the donor's work up that disqualifies them.
No problems with insurance yet. Ann is scheduled to start pre-transplant testing Thursday, so hopefully that is a sign that there will be none this time around. MDA wants to be able to do this transplant in roughly 6 weeks, and I'm not sure we can afford any delays this time.
Tomorrow we have our follow up with Dr. Thomas and she will have the gene studies back from Ann's BMB from last week. Hopefully we are still on track for remission and Ann's counts will have recovered sufficiently by Thursday for us to officially be there. Needless to say if Ann misses getting to remission it will jeopardize moving forward.
Thursday is going to be a very, very long day.