Day 24, Thursday, February 21st, 2013

One of the ancillary effects of the extra time it is taking the SCCA to develop a specific treatment plan for me is that we are having a lot of downtime, and it's really not cost-effective to keep doing tourist things, no, it is not. We didn't really do anything interesting today. Oh, sure, there was a massive patch to Starcraft II, but that's not really news. I got coffee, we walked to Whole Foods, Mom's now at over a hundred versions of Unchained Melody, but nothing interesting.

Yesterday, I talked about why it is taking so long to get to my transplants, but I didn't say anything about why that is important. Today, I shall address that.

When someone gets an autogeneous hematopoeic stem-cell transplant, they are being given their own stem cells, harvested from the bloodstream. That person will have (primarily) three or four weeks of side effects and a compromised immune system, but most of that will actually be from the high-dose chemotherapy and radiation. Aside from infection, there's relatively little risk to the patient. Relatively.

When given an allogeneic transplant, risk abounds in the form of GVHD, or graft-versus host disease. This is when, as previously recounted, the transplanted stem cells, and more specifically the immune cells produced by those stem cells, recognize the host (the patient) as a foreign body and attack it. This can be mitigated with immune suppressive drugs, and is actually why the autogenous stem cell transplant is slated in addition to the allogeneic - it'll quiet my immune system down and drastically reduce the risk of GVHD. This is also why finding a donor who is a good genetic match is so important, and why improved genetic typing techniques (and knowledge of what should be typed) in the future will help in choosing a donor that produce as little GVHD as possible.

The quirk is that you actually want some GVHD, in the form of GVTE, or graft-versus tumour effect; or, in my case, GVLE, graft-versus lymphoma effect. You take advantage of it to rid the body of any cancerous material that has survived previous treatment regimens. In fact, this is why re-staging prior to transplant is so important: you need to know where the existing cancer stands, and knock it down far enough so that the stem cell transplant can get ahead of it, from a cell-line reproduction standpoint. Then it is a matter of balancing GVHD suppressing drugs to minimize risk to the patient, while still maximizing GVLE. You want to use as little GVLE as possible; the absolute minimum that it will take to do the work, but you definitely want it to happen.

This is where my aggressive, transformed T-cell lymphoma being in complete remission is massively advantageous. We can get away with a 'mini' allogeneic transplant, a mixed chimerism transplant, so named because my immune cells will coexist with the donor cells for a time, before being supplanted. It's gentler, and further reduces the risk of GVHD in a significant way, which is extra important because I don't have a 10/10 donor (mine is a 9/10, which is, from the standpoint of GVLE, slightly better than a 10/10, yet from a GVHD position, slightly worse). All the doctors at the SCCA have to worry about now is my mycosis fungoides, the indolent T-cell lymphoma in my skin (which spawned the aggressive form - it is derived from my existing cancer), which is, again, why we're waiting so long. The form that my existing cancer takes dictates certain aspects of the treatment process.

Patient: "Doc, I can't stop singing 'The Green, Green Grass of Home.'"

Doctor: "That sounds like Tom Jones Syndrome."

Patient: "Is it common?"

Doctor: "Well, It's Not Unusual."