Molly's Relapse Bone Marrow Transplant Chemo Treatment Schedule (updated periodically as we go along)

Molly's Bone Marrow Transplant Conditioning Regimen (Protocol AALL0932)
(Intermediate-Risk Non-T cell Isolated-Marrow ALL Early-Relapse (18+ months after first diagnosis, within 6 months of end of therapy))

After visiting with the oncologists and the transplant specialists, we have an idea of what we're in for. There is no certainty that things will go one way or the other, and we have a few paths that we could end up taking, but we're wishing, hoping, praying, and working for the best.

The possible protocol below does not include prophylactic medications or medications to help with side-effects.

If all goes splendidly, and Molly has a good remission (<0.1% blasts in marrow) at 28 days of Block 1, this is what we expect will happen:

• Block 1: Remission Induction. The goal of induction therapy is to bring the disease into remission. Remission is when the patient's blood counts return to normal and bone marrow samples show no sign of disease. 28 days long. Because of higher doses, neutrophils, platelets, and blood counts are expected to stay very low during the first few weeks. Hospitalization is required until counts are staying up, about 3-5 weeks.
  
  • 2x/day chemo steroids on days 1-5 and 15-19 by mouth (dexamethasone) (Side effects: increased appetite, insomnia, irritability, water retention in face and other possible areas of body, weakness, increased stomach acid)
  • 2x/block chemo drug on days 1-2 through port implant over 30 minutes (mitoxantrone) (Side effects: bladder pain, mouth sores, dizziness, weakness, stomach pain, low blood counts) 
  • 1x/week chemo drug on days 1, 8, 15, & 22 through the port implant (vincristine) (Side effects: hair loss)
  • 1x/block chemo drug on days 3 & 17 through the port implant over 2 hours (peg-aspargase) (Side effects: nausea, weakness, poor appetite, stomach pain)
  • 2x/block prophylactic central nervous system (CNS) chemo drug on days 1 & 8 via lumbar puncture (methotrexate) (Side effects: low blood counts, nausea, mouth sores, poor appetite)

• Block 2: Consolidation. The goal of consolidation therapy is to reduce the number of disease cells left in the body. The drugs and doses used during consolidation therapy depend on the patient's risk factors. 28 days long. There are a couple of chemo administrations that require up to a week's hospitalization at a time (days 8-11, 15-20 probably).
  
  • 2x/day chemo steroids on days 1-5 by mouth (dexamethasone) (Side effects: increased appetite, insomnia, irritability, water retention in face and other possible areas of body, weakness, increased stomach acid)
  • 1x/block chemo drug on day 1 through the port implant (vincristine) (Side effects: hair loss)
  • 1x/block chemo drug on day 9 or 10 through the port implant over 2 hours (peg-aspargase) (Side effects: nausea, weakness, poor appetite, stomach pain)
  • 1x/block prophylactic central nervous system (CNS) chemo drug on day 8 via lumbar puncture (methotrexate) (Side effects: low blood counts, nausea, mouth sores, poor appetite)
  • 1x/block chemo drug on day 8 through the port implant over 36 hours (methotrexate) (Side effects: low blood counts, nausea, mouth sores, poor appetite)
  • 1x/day chemo drug on days 15-19 through the port implant over 30 minutes (cyclophosphamide) (Side effects: cough, fever, elevated heartbeat, painful urination, weakness) 
  • 1x/day chemo drug on days 15-19 through the port implant over 2 hours (etoposide) (Side Effects: chills, cough, fever, mouth sores, low blood counts)

• Total Body Irradiation (TBI). TBI can reach cancer cells in scar tissue, the brain and spine where chemotherapy may not reach as well. However, the dose of radiation must be low enough so the body's healthy cells can recover. For this reason, TBI alone cannot be used to destroy large numbers of cancer cells.
  
  • TBI treatment is given in the week immediately before transplant, and will be done at the Huntsman Caner Institute. Each treatment session will last 30-60 minutes, and it is unknown at this time how many treatments will be given.

• Bone Marrow Transplant (BMT). The chemotherapy and TBI destroys the bone marrow, and a donor's bone marrow is transplanted into the host to become a new immune system that can recognize and destroy the cancer cells.
  
  • Transplant day is called "day 0" and every day after that will be +1, +2, +3, etc. Around day +3, mouth sores (mucousitis) occurs, and IV nutrition or tube feeding will need to happen. The mouth sores are expected to clear up around day +15.
  • Engraftment usually happens by day +30. This is when the new stem cells start to grow and make new blood cells. An ANC of 500 or more for 3 days in a row is an indicator of engraftment. Because of a high risk of infection, hospitalization is common for about 5 weeks post transplant, or until lab counts recover. 
  • In the first 3 months, the risk of fatal infections is still very high so the patient must adhere to strict medicinal regimens, avoid leaving home, and keep up with hygiene.  
  • Immune suppressants are given for about 9 months afterwards, and it is strongly recommended that those who receive a BMT not attend school or go on vacations for 1 year post transplant.