Book Review

Bone Marrow Transplantation in Practice

N Engl J Med 1993; 329:1284October 21, 1993

Article

Bone Marrow Transplantation in Practice
Edited by Jennifer Treleaven and John Barrett. 399 pp., illustrated. New York, Churchill Livingstone, 1992. $150. ISBN: 0-443-04413-9

More than 500 teams around the world are carrying out bone marrow transplantation (BMT) on a daily basis. This book will undoubtedly find its place on the shelves of attending physicians, fellows, and residents directly involved in BMT. It will also serve those who are indirectly involved -- for example, physicians in supporting medical departments and referring physicians. The book's 34 chapters, written by experts in the field, are divided into two parts: the first covers indications for and results of BMT in the treatment of malignant and nonmalignant disorders, and the second discusses practical aspects of BMT.

The beneficial role of allogeneic BMT in second or subsequent remissions of acute myelocytic leukemia and acute lymphocytic leukemia seems clear. In the case of acute myelocytic leukemia in first remission, the question arises whether certain prognostic factors can be used to determine who should receive a transplant and who should not. The authors might have given more consideration to that issue. The chapter on chronic myelocytic leukemia provides clear recommendations for management, including indications for performing allografts (with an HLA-identical sibling donor or with a matched unrelated donor) and autografts. The authors make interesting observations about the graft-versus-leukemia effect, which seems to be particularly evident in chronic myelocytic leukemia. The chapters on myelodysplastic syndromes, myeloproliferative diseases, multiple myeloma, Hodgkin's disease, and the non-Hodgkin's lymphomas provide excellent overviews of transplantation results and include the new technique of peripheral-blood stem-cell reinfusion. Most of these data were derived from single-arm, phase 2 studies. It is imperative to establish the role of high-dose treatment followed by BMT by prospective, randomized phase 3 trials. Unfortunately, only a few such trials are under way. The application of BMT to solid tumors in children and adults is even less clear; the main question is to identify the patients who will benefit from BMT.

The book includes comprehensive chapters on BMT in the treatment of immunodeficiency syndromes, aplastic anemia, hemoglobinopathies, and inborn errors of metabolism. Gene therapy (introducing normal genes into defective pluripotent hematopoietic stem cells), however, is only briefly discussed. This new technique appears to be one of the most promising applications of BMT, not only to treat nonmalignant hematopoietic disorders but also to allow high-dose treatment without BMT (introduction of the multiple-drug-resistance gene) or to manipulate the graft-versus-host reaction (thymidine kinase suicide genes). A separate chapter on gene therapy would therefore have been a valuable addition to this excellent book.

The chapters on HLA typing, the pros and cons of T-cell depletion in allogeneic BMT, and the biology and clinical manifestations of graft-versus-host disease provide the newcomer to the field with a solid background after a few hours of reading. Preparative measures (use of indwelling catheters, bone marrow harvesting and handling, high-dose conditioning treatment, and prophylaxis for infections) and management after transplantation (treatment of graft-versus-host disease and of bacterial, fungal, and viral infections; transfusion strategies; nutrition; and -- not to be forgotten -- psychological support of the patient and family) are discussed step by step. A final chapter discusses international registries, which play an important part in data collection. Intergroup, prospective, randomized trials, however, remain essential to establish the role of BMT in various phases of different diseases. This book emphasizes “matching registries,” which collect HLA types from unrelated voluntary bone marrow donors. It is interesting to note how fast these “bone marrow banks” grow. The authors state that about “400,000 volunteer donors are now available”; since publication of the book, this number has grown to more than 1,400,000.

This book is recommended to those entering the field of BMT. The editors state that their aim was to “reflect as much as possible generally accepted approaches.” This goal has been achieved.

Anton Hagenbeek, M.D., Ph.D.
Dr. Daniel den Hoed Cancer Center, Rotterdam, the Netherlands