Controversies in Haematopoietic Stem Cell Transplantation
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Progress in the understanding and practice of haematopoietic stem cell transplantation has come a long way since its inception. Despite this, there is ever-increasing controversy within most haematological malignancies about the role and timing of transplantation. Medical practice today is governed by ‘evidence-based medicine’ and guidelines. However, guidelines are generic, with little quality evidence base available in many scenarios to help clinicians make decisions about transplantation in patients who fall into those controversial categories. The morbidity and mortality associated with allogeneic transplantation remains significant. Autologous transplantation is a safer procedure but does not offer the same curative potential. Consequently, decisions about which patients should be transplanted, how and when, continue to cause controversy. I have identified four clinical scenarios within haematopoietic stem cell transplantation where guidelines are not clear about the specifics of practice but in which we have specific clinical experience at St Bartholomew’s. These are the outcomes of two melphalan conditioning doses in autologous stem cell transplantation in multiple myeloma, the outcomes of allogeneic stem cell transplantation in multiple myeloma, the outcomes of patients with refractory and relapsed acute myeloid leukaemia and myelodysplasia undergoing sequential transplantation and finally the outcomes of allogeneic stem cell transplantation in lymphoma. The aim of this thesis has been to collate and analyse patient data in each of these areas of debate, in order to make recommendations regarding future clinical practice. Following on from this, I have evaluated the role of haematopoietic stem cell transplantation today and its future directions.
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