- Feature Story: Physician to Physician Collegial Consultation Services
- 2007 Pan Pacific Lymphoma Conference-June 11-15, 2007, Maui, Hawaii
- Bone Marrow Transplantation; A Success Story
- Biosketch: Dr. James Armitage
Physician to Physician Collegial Consultation Services
International Healthcare Services at UNMC is very pleased to introduce its latest Collegial Consultation services.
We provide the best solution for electronic consultation, pathology review and second opinion.
In today’s world there are many times we would like to consult with another colleague or expert when treating our patients. It may be something as simple as an opinion to back up your decisions about a particular treatment, or a complex pathological diagnosis, or gene rearrangement studies, or treatment protocol recommendations.
UNMC is internationally renowned for the diagnosis, treatment and research of lymphoma, cancer care, transplantation and other serious diseases. UNMC has treated patients from all over the world. Our patients come from across the globe for initial diagnosis, second opinions, treatment, and participation in clinical research trials, bone marrow / stem cell and solid organ transplants. UNMC is among the top three transplant centers in the USA.
UNMC employs over 1,500 staff physicians/faculty/researchers in all healthcare disciplines to assist in collegial consultations.
Our service provides you with an opportunity to share opinions, discuss cases and collaborate with world-renowned physician experts at a very reasonable cost. The system employs the latest state-of-the-art, easy to use, Web-based software (provided at no cost to partner institutions) to facilitate worldwide transmission of electronic medical information, images, interactive diagnoses and “real-time” consultations in all areas of medicine. This sophisticated, yet easy-to-use, secure communication technology, enables UNMC specialists to receive patient reports for evaluation and consultation, in a matter of seconds, from any location across the globe.
2007 Pan Pacific Lymphoma Conference – June 11-15 Maui, Hawaii
We would so enjoy seeing members of our Global Strategic Partnership Program attend the Pan Pacific Lymphoma Conference. This year it is being held June 11-15 at the Grand Wailea Hotel in Maui, Hawaii. Please review and download our brochure and contact us with any questions you may have.
Bone Marrow Transplantation; A Success Story
Editorial in Middle East Health Magazine, Dec. 2006 by James O. Armitage, MD/University of Nebraska Medical Center, Omaha, NE, USA
It is very popular today to speak of stem cell research and the use of stem cells to treat disease. However, many involved in the debate regarding research and clinical applications of stem cells might not appreciate that hematopoietic stem cells have been used therapeutically for half a decade. Attempts to use hematopoietic stem cells to replace marrow aplastic anemia or to support intensive therapy of cancer began even more than 50 years ago. However, it was not until more was understood about bone marrow functions and the nature of the hematopoietic stem cell before the procedure that we know today as hematopoietic stem cell transplantation became practical. In the 1960’s successful allogeneic (i.e. from one individual to another) hematopoietic stem cell transplantation was reported for the treatment of leukemia and for the treatment of inherited immune defects. Working at the University of Washington in Seattle Dr. Don Thomas (i.e. who won the Nobel Prize) and his colleagues worked out the techniques of hematopoietic stem cell transplantation to treat leukemia and aplastic anemia. By the mid 1970s they reported 100 patients with acute leukemia treated with this approach with some patients surviving free of disease and apparently cured.
The presumed benefit of allogeneic hematopoietic stem cell transplantation was originally thought to be a consequence of the very intensive therapy administered before the infusion of hematopoietic stem cells. It was known that unless a severely immunosuppressive treatment was applied, the patients own immune system would destroy the new hematopoietic stem cells. Thus, high dose therapy was administered before the transplant in an attempt to allow engraftment and to eradicate the malignancy i.e. usually leukemia. Proof that immunosuppression was also required came from attempts to do hematopoietic stem cell transplantation in aplastic anemia. It was originally felt that simply infusing hematopoietic stem cells should cure this disease since the marrow was “empty”. However, it became apparent that in the absence of destruction of the patient’s residual immune cells, the new hematopoietic stem cells would be destroyed. Thus, in patients with cancer, the very intensive therapy administered before infusion of the new hematopoietic stem cells was felt to be both curative of the cancer and engraftment.
In the late 1970’s and early 1980’s, it became apparent that the new hematopoietic stem cells and the new immune system that they produced in the patient might also have an anticancer effect. The main complication of allogeneic hematopoietic stem cell transplantation is the development of a condition known as graft versus host disease. In this illness, the new immune system produced by the infused, allogeneic hematopoietic stem cells can recognize the patient as “foreign” and carry out an immune attack on the patient’s organs. Injury in this condition is especially frequently seen in the skin, liver, and gastrointestinal tract, and can some times be fatal. In the late 1970s and early 1980s remission of relapsed leukemia was noted in patients who developed severe graft versus host disease. It was speculated that there might be a graft versus leukemia effect and that it could be therapeutically important. Careful studies of large numbers of patients demonstrated that patients who developed graft versus host, were less likely to have recurrent leukemia. In fact, it appeared that much of the curative effect of allogeneic hematopoietic stem cell transplantation might be from the anticancer effect of the new immune system.
This observation led to attempts at reducing the intensity of the pretransplant therapy to reduce some of the risks of the procedure. It is possible to use predominantly drugs that impair lymphocyte function with relatively minor toxic effects in the patient and avoid very high doses of other chemotherapeutic agents or total body radiotherapy. It became apparent that sufficient impairment of the patient’s lymphocytes could allow the new hematopoietic stem cell graft to grow and eventually destroy the residual host lymphocytes giving a complete graft. In some cancers that seem to be particularly sensitive to immunological attack, e.g. chronic myeloid leukemia and chronic lymphoid leukemia, the graft versus leukemia effect seems to be potentially curative and the reduced intensity treatment before the transplant appears to reduce transplant related mortality. In those patients in whom the cancer does recur, reinfusing more of the donor’s lymphocytes often will reestablish remission. This approach is sometimes termed reduced intensity allogeneic hematopoietic stem cell transplantation, or mini transplant is now undergoing intensive study in transplant centers throughout the world.
The idea that very high doses of anticancer therapy might be curative for some patients with cancer, and that the use of reinfusion of the patients own hematopoietic stem cells could avoid the dangers of graft versus host disease, led to clinical trials in what is called autologous hematopoietic stem cell transplantation. In this treatment, hematopoietic stem cells have to be removed from the patient and stored until after the intensive cancer therapy is administered. Since the patient’s own hematopoietic stem cells would be used to reestablish bone marrow function after the treatment, there would be no risk of graft versus host disease. However, early problems with this treatment approach included occasional difficulties in collecting hematopoietic stem cells that were free of contamination by cancer cells and finding a way to store the hematopoietic stem cells for extended periods of time and keep them alive. In allogeneic transplantation, the hematopoietic stem cells are taken from one individual and reinfused quickly into another. However, since it takes time to administer the very intensive therapy, hematopoietic stem cells in autologous transplantation have to be cryopreserved for days to weeks before they are used. Initial attempts at autologous hematopoietic stem cell transplantation involved repetitive bone marrow aspirations from the pelvis and sternum to collect sufficient cells. It was not unusual for 200 aspirates to be required. However, in the mid to late 1980s it became apparent that circulating hematopoietic stem cells could be collected using the process called aphersis where the blood is taken from the body, separated by centrifugation, and the desired cells collected with the rest of the blood reinfused into the patient.
Autologous hematopoietic stem cell transplantation tested the hypothesis that very intensive anticancer therapy could cure some patients when standard therapy failed. Early studies in lymphoma showed that this can, in fact, be the case. In patients whose recurrent or resistant lymphoma still can partially respond to standard doses or chemotherapy and achieve a minimal disease state, hematopoietic stem cell transplantation can often be curative. As is the situation with allogeneic hematopoietic stem cell transplantation, treatment doesn’t benefit patients with all cancers, but is especially effective in patients with lymphoma, certain leukemias, multiple myeloma, and occasional other cancers.
Today both allogeneic and autologous hematopoietic stem cell transplantation are widely utilized to treat patients with cancer. Many patients who would otherwise have died of their malignancy are now cured because of these procedures. Allogeneic hematopoietic stem cell transplantation is also utilized for patients with aplastic anemia, inherited immune deficiency states, and certain other inherited disorders of blood production. Both allogeneic and autologous hematopoietic stem cell transplantation are being studied in the treatment of patients with other life threatening immune diseases. It is likely that both treatments will continue to be an important part of our therapeutic armentarium for years to come.
Biosketch: Dr. James O. Armitage
James O. Armitage, M.D.
Professor, Internal Medicine
Section of Hematology & Oncology
UNMC Oncology/Hematology Section
987680 Nebraska Medical Center
Omaha, NE 681980-7680
Main practice location:
Peggy D. Cowdery Patient Care Center
Lied Transplant Center
987835 Nebraska Medical Center
Omaha, NE 68198-7835
The Nebraska Medical Center
Management and classification of lymphoma and leukemia
Bone marrow transplantation
University of Nebraska Medical Center, Omaha, NE, Intern, (1974)
University of Nebraska Medical Center, Omaha, NE, Resident, (1975)
University of Nebraska, Lincoln, NE, B.S., (1969)
University of Nebraska Medical Center, Omaha, NE, M.D., (1973)
University of Iowa Hospitals and Clinics, Iowa City, IA, Fellow, (1977)’
Academic Rank:Shapiro Professor of Medicine
Department: Internal Medicine
College: College of Medicine
Membership in Societies: ASCO; ASH, AFCR, ASCR, ASCR, ASBMT, Royal College of Physicians
Dr. James O. Armitage graduated from the University of Nebraska Medical Center in 1973 where he completed his internship and residency in internal medicine in 1975. In 1977 he completed a fellowship in hematology-oncology at the University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Armitage was in private practice from 1977-79, and in 1979 he returned to the University of Iowa as an Assistant Professor of Medicine, where he developed and was director of the Bone Marrow Transplantation Program. In 1982 he returned to Nebraska as Associate Professor of Medicine and was promoted in 1987 to Professor of Medicine. He has served as Vice Chairman of the Department of Medicine (1982-90), Chief of the Section of Oncology/Hematology (1986-89), Chairman of the Department of Internal Medicine (1990-99), Dean, College of Medicine (2000-03), and presently holds the position of the Joe Shapiro Professor of Medicine. He is a member of several professional organizations as well as serving on the editorial boards of several peer-reviewed journals. He serves on several national and international committees and served as President of ASCO (1996-97) and President of ASBMT (2000-01). He has authored or co-authored 400 articles, 86 book chapters, more than 450 abstracts, and is the editor/co-editor of 21 books. He is married to Nancy Armitage and the father of four children and grandfather of two grandchildren.
Armitage JO, Weisenburger DD, Hutchins M, Moravec DF, Dowling M, Sorensen S, Mailliard J, Okerbloom J, Johnson PS, Howe D, Bascom GK, Casey J, Linder J, Purtilo DJ: Chemotherapy for Diffuse Large Cell Lymphomas–Rapidly Responding Patients Have More Durable Remissions. Journal of Clinical Oncology 4:160-164, 1986.
Kessinger A, Armitage JO, Landmark JD, Weisenburger DD: Reconstitution of Human Hematopoietic Function with Autologous Cryopreserved Circulating Stem Cells. Experimental Hematology 14:192-196, 1986
Philip T, Armitage JO, Spitzer G, Chauvin F, Jagannath S, Cahn JY, Colombat P, Goldstone AH, Groin NC, Flesh M. Laporte JP, Maraninchi D, Pico JL, Bosly A, Anderson C, Schots R, Biron P, Cabanillas F, Dicke K: High Dose Therapy and Autologous Bone Marrow Transplantation in 100 Adults with Intermediate or High Grade Non-Hodgkin’s Lymphoma. N Engl J Med 316:1493-1498, 1987
Kessinger A, Smith DM, Strandjord SE, Landmark JD, Dooley DC, Law P. Coccia PF, Warkentin PI, Weisenburger DD, Armitage JO: Allogeneic Transplantation of Blood-Derived, T-cell Depleted Hematopoietic Stem Cells after Myeloablative Treatment in Patients with Acute Lymphblastic Leukemia. Bone Marrow Transplantation 4:643-646, 1989.
Armitage JO, Weisenburger DD: New Approach to Classifying Non-Hodgkin’s Lymphomas: Clinical Features of the Major Histological Subtypes. Non-Hodgkin’s Lymphoma Classification Project. J Clin Oncol.16:2780-95, 1998.
Hasenclever D, Diehl V, Armitage JO, Assouline D, Bjorkholm M, Brusamolino E, Canellos Gp, Carde P, Crowther D, Cunningham D, Eghbali H, Ferme C, Fisher RI, Glick JH, Glimelius B, Gobbi PG, holte H, Horning SJ, Lister TA, Longo DL, Mandelli F, Polliack A, Proctor SJ, Specht L, Sweetenham JW, Vaughan Hudson G for the International Prognostic Factors Project on Advanced Hodgkin’s Disease: A Prognostic score for advanced Hodgkin’s disease. NEJM 339:1506-14, 1998
Allzadeh AA, Elson MB, David RE, MaC, Lossos IS, Rosenwald A, Boldrick JC, Sabet H, Tran T, Yu X, Powel JI, Yang L, Martl GE, Moore T, Hudson J, Lu L, Lewis DB, Tibshirani R, Sherlock G, Chan WC, Greiner TC, Weisenburger DD, Armitage JO, Warnke R, Levy R, Wilson W, Grover MR, Byrd JC, Boststein D, Brown PO, Staudt LM: Distinct Types of Diffuse Large B-cell Lymphoma Identified by Gene Expression Profiling. Nature 403:503-511, 2000.
Weisenburger DD, Anderson JR, Diebold J, Gascoyne RD, MacLennan KA, Muller-Hermelink HK, Nathwani BN, Ullrich F, Armitage JO for the Non-Hodgkin’s Lymphoma Classification Project. Systemic Anaplastic Large Cell Lymphoma. Results from the Non-Hodgkin’s Lymphoma Classification Project. American J Hemat 67:172-178, 2001.
Weekes CD, Vose JM, Lynch JC, Weisenburger DD, Bierman PJ, Greiner T, Bociek G, Enke C, Bast M, Chan WC, Armitage JO for the Nebraska Lymphoma Study Group. Hodgkin’s Disease in the Elderly: Improved Treatment Outcome With a Doxorubicin-Containing Regimen. J Clin Oncol 20:1087-1093, 2002.
Vose JM, Sharp G, Chan WC, Nichols C, Loh K, Inwards D, Rifkin R, Bierman PJ, Lynch JC, Weisenburger DD, Kessinger A, Armitage JO: Autologous Transplantation for Aggressive Non-Hodgkin’s Lymphoma: Results of Randomized Trial Evaluating Graft Source and Minimal Residual Disease. J Clin Oncol 20:2344-2352, 2002
Armitage JO. Staging Aggressive Non-Hodgkin’s Lymphoma: A Work in Progress. New England J Medicine 2005.