Connecticut & New England PRP Platelet-Rich Plasma …

What is PRP?

Maybe the acronym PRP is unfamiliar to you; its one of the newer sports injury treatments. We work with patients throughout New England and the Northeast and beyond by using PRP as one of our treatments. Our doctors are experts at using these treatments and can get you relief from your sports injury fast. Please read on to find out more about PRP available from Valley Sports Physicians & Orthopedic Medicine. You can also call us at (860) 430-9690 to learn more and schedule an appointment.

PRP, or platelet-rich plasma, is a revolutionary new treatment for chronic sports and musculoskeletal injuries that is taking the sports medicine and orthopedic community by storm. Professional and recreational athletes alike credit PRP treatment for enabling them to get back in the game, and patients with joint arthritis are experiencing less pain and greater function.

Dr. Tortland has been performing PRP treatments since December 2007, making him among the firstand most experiencedphysicians in the country offering this treatment.

Platelets are a specialized type of blood cell. Blood is made up of 93% red cells (RBCs), 6% platelets, 1% white blood cells (WBCs), and plasma. The goal of PRP is to maximize the number or concentration of platelets while minimizing the number of RBCs. Generally speaking, the higher the concentration of platelets, the better.

Unlike many other practices, at Valley Sports Physicians all of our PRP injections are given under direct ultrasound guidance to insure accurate placement of the platelet concentrate in the damaged area. In fact, Drs. Tortland is anationally-recognized expert in musculoskeletal ultrasound.

The entire treatment, from blood draw, to solution preparation, to injection, takes 30-40 minutes. Before injections are given the skin and underlying tissue is first anesthetized to minimize the discomfort.

Currently there are over half a dozen companies making & selling commercial PRP preparation systems, of course with each company claiming that their PRP is the best! PRP products can vary widely in terms of platelet concentrations, the presence or absence of red blood cells (RBCs), the presence/absence of white blood cells (WBCs), and the volume of PRP created.

Some PRP is not much better than whole blood or platelet poor plasma, with very low platelet concentrations. Much of the commercial PRP is rich in RBCs, which have been shown to kill as many as 15% of synovial cells inside a joint. Many PRP products contain high amounts of inflammatory WBCs, contributing to increased post-injection pain.

At Valley Sports Physicians we spent a year researching and pioneering a new method of creating a high quality PRP, containing an average of 1.5 million platelets per microliter (well above the commercial PRP average), essentially free of RBCs, and containing helpful pro-growth WBCs while eliminating the inflammatory WBCs. Our method was validated via independent clinical laboratory testing. So you can be assured that the PRP product you receive from us is the absolute highest quality, purity, and effectiveness currently available. When youre spending hundreds of dollars on a treatment, you want to be sure that youre getting the best possible product!

In most cases, after the initial treatment, a follow up visit is scheduled 6-8 weeks later to check on healing progress. Some patients respond very well to just one treatment. However, typically 2-3 treatments are necessary. Injections are given every 8-12 weeks on average. In rare cases, such as more severe hip arthritis, PRP injections may be given once every 4 weeks for 2-3 treatments.

PRP treatment works best for chronic ligament and tendon sprains/strains that have failed other conservative treatment, including:

In addition, PRP can be very helpful for many cases of osteoarthritis (the wear & tear kind). PRP can help stimulate a smoothing over of the roughened and arthritic cartilage, reducing the pain and disability of arthritis. This includes:

Most insurance plans, including Medicare, do NOT pay for PRP injections.

The level of discomfort of the treatment depends in part on the area being treated. For example, injections given into a joint often are minimally uncomfortable and in some cases painless. Injections given into tendons tend to be more uncomfortable. There is usually moderate pain for the next few days.

For the first week after the injections it is critical to avoid anti-inflammatory medications, including Advil, Motrin, ibuprofen, Aleve, Celebrex, and Mobic. These will interfere with the healing response. Tylenol is OK. Your doctor may prescribe pain medication also for post-injection discomfort.

On average, most patients start to see signs of improvement anywhere from 4-8 weeks after treatment. This can be less overall pain, an ability to do more activity before pain sets in, and/or faster recovery from pain.

Anytime a needle is placed anywhere in the body, even getting blood drawn, there is a risk of infection, bleeding, and nerve damage. However, these are very rare. Other complications, though rare, can occur depending on the area being treated, and will be discussed by your doctor before starting treatment. Because PRP uses your own blood, you cannot be allergic to it.

Studies suggest an improvement of 80-85%, though some arthritic joints, namely the hip, do not respond as well. Some patients experience complete relief of their pain. In the case of tendon and ligament injuries the results are generally permanent. In the case of joint arthritis, how long the treatment lasts depends partly on the severity of the condition. Mild arthritis may not need another round of treatments. More advanced arthritis, on the other hand, typically requires a repeat course of treatment, usually in 1-3 years.

The goal of PRP treatment is to reduce pain and to improve function. While there is some weak evidence that treatment occasionally does result in increased cartilage thickness, the important point to keep in mind is that the cartilage lining the joint surfaces has no pain fibers! For example, often we see patients with knee or hip arthritis where the joint that does NOT hurt has WORSE arthritis on x-ray! Pain from arthritis is very complex and involves far more than just how thick the cartilage is.

At Valley Sports Physicians the cost of PRP treatment is based on the level of complexity involved in treating a given area(s). Prices range from $700 to $1100 per treatment. If two joints or areas are treated at the same time, the cost is NOT double there is a slight increase.

The last 10 years has seen an explosion in research dedicated to investigating the potential benefits of PRP. One problem with PRP research, however, is that often investigators do not specify what the quality & character of the PRP used. See the discussion above, Not All PRP is the Same!

Below are some summaries from a few representative research studies:

Tennis Elbow:

Peerbooms et al in 2010 compared a single PRP injection to a cortisone injection for the treatment of chronic tennis elbow. 51 patients received the PRP injection while 49 received a cortisone injection. At one year follow up 73% of the PRP subjects were significantly better, compared to only 51% of the cortisone injection subjects. Of note was the observation that those receiving the cortisone injection felt better initially than the PRP group, whereas the PRP group progressively improved. Their conclusion: Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. (Peerbooms et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial. Am J Sports Med. 2010;38(2):255-262).

In a 2011 study by Hechtman & colleagues, 30 patients (31 elbows) with epicondylitis unresponsive to nonsurgical treatment (including steroid injection) for >6 months received a single PRP injection. Results: Patient satisfaction scores improved from 5.12.5 at 1 month to 9.11.9 (on a scale of 1-10) at 1-year follow-up. Only 1 patient reported no improvement after 6 months. Results suggest that a single platelet-rich plasma injection can improve pain and function scores, thus avoiding surgery. (Hechtman et al. Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics. 2011 Jan 1;34(2):92.

Rotator Cuff:

In 2012 Rha & associates compared PRP treatment to dry needling for the treatment of chronic rotator cuff tendinitis. 39 patients were randomized to receive either 2 PRP injections 4 weeks apart, or 2 dry needling treatments, also 4 weeks apart. All treatments were done under ultrasound guidance. Conclusions: Autologous platelet-rich plasma injections lead to a progressive reduction in the pain and disability when compared to dry needling. This benefit is certainly still present at six months after treatment. These findings suggest that treatment with platelet-rich plasma injections is safe and useful for rotator cuff disease. (Rha et al. Comparison of the therapeutic effects of ultrasound guided platelet-rich plasma injection and dry needling in rotator cuff disease: A randomized controlled trial. Clin Rehab. 2012;27(2):113-122.)

Chronic Plantar Fasciitis:

Monto in 2014 looked at the effectiveness of PRP for recalcitrant plantar fasciitis. Forty patients (23 females and 17 males) with unilateral chronic plantar fasciitis that did not respond to a minimum of 4 months of standardized traditional nonoperative treatment modalities were prospectively randomized and treated with either a single ultrasound guided injection of 3 cc PRP or 40 mg DepoMedrol cortisone. Patients were evaluated at 3, 6, 12, and 24 month after treatment. Those receiving the cortisone injection felt better initially than the PRP group, but their improved waned and their pain returned completely to baseline by 12 months. Those in the PRP group, on the other hand, continued to experience gradual improvement and were markedly better at 12 and 24 months. Conclusion: PRP was more effective and durable than cortisone injection for the treatment of chronic recalcitrant cases of plantar fasciitis. (Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot & Ankle International. 2014;35(40):313-318.)

Hamstring Injuries:

A 2014 study by Hamid et al looked at effectiveness of PRP injections for Grade 2 hamstring injuries. 28 patients with acute hamstring injuries were randomly assigned to receive either a PRP injection in combination with a rehab program, or a rehab program only. The primary outcome measure was time to return to play, while secondary measurements included pain severity and interference with activity from pain. Results: Patients in the PRP group had an average return to play time of 27 days, while the rehab-only group took 42 days. The PRP group also had significantly lower pain scores throughout the study. (Hamid et al. Platelet-rich plasma injections for the treatment of hamstring injuries: a randomized controlled trial. Am J Sports Med. 2014;42(10):2410-2418.)

Patellar Tendinitis:

Volpi et al treated the affected knees of 8 athletes (10 knees) with chronic patellar tendinosis that had failed to respond to conservative treatment and who were considering surgical intervention. Patients received a single ultrasound-guided PRP injection into the damage patellar tendon. At follow up in 120 days all subjects reported an average 91% improvement, and MRI showed interval healing. (Volpi et al. Treatment of chronic patellar tendinosis with buffered platelet-rich plasma: a preliminary study. Medsport. 2007;60:595-603.)

Knee Arthritis:

Cerza & associates compared PRP injections to hyaluronic acid (HA) injections for the treatment of knee osteoarthritis in 2012. 120 patients were randomly divided into 2 groups. One group received 4 weekly injections of PRP, while the other group received 4 weekly injections of HA. Patients were evaluated at 4, 12 and 24 weeks after the 1st injection. Results: Treatment with PRP showed a statistically significant better clinical outcome than did treatment with HA. Of note was that patients with more severe arthritis (Grade III-IV) did not see improvement with HA, whereas severity of disease did not matter with respect to improvement with the PRP. (Cerza et al. Comparison between hyaluronic acid and platelet-rich plasma, intra-articular infiltration in the treatment of gonarthrosis. Am J Sports Med. 2012;40(12):2822-2827.)

Gobbi et al also looked at the effectiveness of PRP for knee osteoarthritis. 50 patients were treated with 2 PRP injections, 1 month apart. 25 patients had previously undergone surgery for cartilage lesions. Results: All patients showed significant improvement in all measured scores at 6 & 12 months and returned to previous activities. No difference in improvement was found among various subgroups (prior surgery vs. no surgery, severity of disease, age). (Gobbi et al. Platelet-rich plasma treatment in symptomatic patients with knee osteoarthritis: Preliminary results in a group of active patients. Sports Health. 2012;4(2):162-172.)

Hip Arthritis:

Sanchez & co. looked at PRP for hip osteoarthritis in 2012. 40 patients with severe hip were included. Each subject received an injection of PRP into the affected hip once a week x 3 weeks. Patients were evaluated at 7 weeks and 6 months. 60% of subjects reported a positive response (characterized by at least a 30% improvement in symptoms). 40% of those who had a favorable response were classified as excellent responders. Conclusions: This preliminary non-controlled randomized prospective study supported the safety, tolerability and efficacy of PRP injections for pain relief and improved function in a limited number of patients with OA of the hip. (Sanchez et al. Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology. 2012;51:141-150.)

Healing is a caloric-demanding task. The body expends energy trying to repair itself. It is important, therefore, to optimize your nutritional status, preferably before you undergo treatment. Ensuring adequate protein, eliminating (or at least significantly reducing) consumption of sugar and sugar-containing products, and adding healthy fats are essential components of a healing diet. Specifically, minimum protein intake consists of at least 0.5g protein per pound of body weight per day. For a 150 lb person thats 75 grams of protein daily, evenly divided among breakfast, lunch, dinner, and an evening snack. If you exercise your protein needs go up, to as much as 1.0g per pound of body weight daily.

As a general rule of thumb, 1 oz of chicken, beef, or pork contains 7 grams of protein, wheres fish has 5 grams per ounce. For a more complete discussion of protein requirements, see AuthorityNutrition.com.

Healthy fats include avocado, organic coconut oil, olive oil, organic peanut butter, organic butter, and organic raw (not pasteurized) milk. Contrary to popular belief, eating fat does NOT make you fat.

To get maximum benefit from the treatment, and to help prevent re-injury, a specially-designed rehabilitation and exercise program may incorporated into your treatment. This helps the newly developing connective tissue mature into healthy and strong tendon or ligament fibers. In addition, nutritional support, such as glucosamine, MSM, and increased protein intake can help the healing process.

PRP can be a very effective and relatively cost-efficient treatment alternative for persons suffering from painful musculoskeletal conditions. However, because it is still a relatively new treatment, there are many practitioners who are newcomers to the party. Therefore, it is important that patients choose a practitioner who:

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Stem Cell Clinics Questions to Ask – National Multiple …

Exciting progress is being made through innovative and carefully conducted research related to the potential of many types of stem cells for slowing MS disease activity and for repairing damage to the nervous system.

At present, there are no approved stem cell therapies for MS. There are different types of stem cells and the effects of receiving them depend on additional factors, including the specific procedures used to prepare and administer them, and biological conditions in the person to whom they are given. Stem cell therapy is still in the experimental stage, so its important for people to have the best available information to understand this exciting area of research and make decisions related to this complex issue.

In the U.S. and in other places around the world, for-profit stem cell clinics are appearing in increasing numbers. These clinics claim to have treated people with MS and people with many other disorders with stem cells. However, these clinics are unregulated and none have provided medical evidence that their treatments work or are safe. A recent study published in June 2016 confirmed that many different types of unproven stem cell treatments are being offered in these clinics. The study highlighted concerns for the safety of people who undergo these treatments, emphasized the need for better oversight and raised ethical issues and regulatory concerns related to marketing unproven treatments for a range of health conditions.

The papers findings support the need for stem cell therapy to be explored in the context of carefully conducted clinical trials that can determine what the optimal cells, delivery methods, safety and actual effectiveness of cell therapies might be for people with MS. For more details about this study:

Many experts in the MS community have expressed concern that:

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Stem Cell Clinics Questions to Ask - National Multiple ...

Embryonic stem cell research – alsa.org

Overview

Stem cells have the ability to divide for indefinite periods in culture and give rise to multiple specialized cell types. They can develop into blood, neurons, bone, muscle, skin and other cell types. They have emerged as a major tool for research into the causes of ALS, and in the search of new treatments.

Types of Stem Cells:

The field of stem cell research is progressing rapidly, and The ALS Association is spearheading work on several critical fronts. The research portfolio supports innovative projects using IPSCs for drug development and disease modeling. The Association is supporting an IPSC core at Cedars-Sinai Medical Center providing access to lines for researchers globally. Several of the big data initiatives are collecting skin cells or blood for IPSC generation, such as Genomic Translation for ALS Clinical Care (GTAC), Project MinE, NeuroLINCS and Answer ALS. The ALS Association also sponsors pre-clinical studies and pilot clinical trials using stem cell transplant approaches to develop the necessary tools for stem cell transplant studies and to improve methods for safety and efficiency. We also support studies that involve isolating IPSCs to develop biomarkers for clinical trials through ALS ACT. In addition, the retigabine clinical trial that we sponsor uses iPSCs derived from participants in parallel with clinical data to help test whether the drug has the desired effect.

Stem cells are being used in many laboratories today for research into the causes of and treatments for ALS. Most commonly, researchers use iPSCs to make a unique source of motor neurons from individual ALS patients to try to understand why and how motor neurons die in ALS. Two types of motor neurons are affected in ALS are upper coriticospinal motor neurons, that when damaged, cause muscle spasticity (uncontrolled movement), and lower motor neurons, that when damaged, cause muscle weakness. Both types can be made from iPSCs to cover the range of pathology and symptoms found in ALS. Astrocytes, a type of support cell, called glia, of the central nervous system (CNS), are also being generated from iPSCs. It is well established that glia play a role in disease process and contribute to motor neuron death.

Motor neurons created from iPSCs have many uses. The availability of large numbers of identical neurons, made possible by iPSCs, has dramatically expanded the ability to search for new treatments. For example, they can also be used to screen for drugs that can alter the disease process. Motor neurons derived from iPSCs can be genetically modified to produce colored fluorescent markers that allow clear visualization under a microscope. The health of individual motor neurons can be tracked over time to understand if a test compound has a positive or negative effect.

Because iPSCs can be made from skin samples or blood of any person, researchers have begun to make cell lines derived from dozens of individuals with ALS. One advantage of iPSCs are that they capture a persons exact genetic material and provide an unlimited supply of cells that can be studied in a dish, which is like persons own avatar. Comparing the motor neurons derived from these cells lines allows them to ask what is common, and what is unique, about each case of ALS, leading to further understanding of the disease process. They are also used to correlate patients clinical parameters, such as site of onset and severity with any changes in the same patients motor neurons.

Stem cells may also have a role to play in treating the disease. The most likely application may be to use stem cells or cells derived from them to deliver growth factors or protective molecules to motor neurons in the spinal cord. Clinical trials of such stem cell transplants are in the early stages, but appear to be safe. In addition, transplantation of healthy astrocytes have the potential to be beneficial in supporting motor neurons in the brain and spinal cord.

While the idea of replacing dying motor neurons with new ones derived from stem cells is appealing, using stem cells as a delivery tool to provide trophic factors to motor neurons is a more realistic and feasible approach. The significant challenge to replacing dying motor neurons is making the appropriate connections between muscles and surrounding neurons.

Isolation of IPSCs from people with ALS in clinical trials is extremely valuable for the identification of unique signatures in the presence or absence of a specific treatment approach and as a read out to test whether a drug or test compound has an impact on the health of motor neurons and/or astrocytes. A positive result gives researchers confidence to move forward to more advanced clinical trials. For example, The ALS Association is currently funding a clinical trial to test the effects of retigabine on motor neurons, which use the enrolled patients individual iPSCs lines derived from collected skin samples and testing whether there is a change in the excitability of motor neurons in people with ALS. (see above).

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Cloning/Embryonic Stem Cells – National Human Genome Research …

Cloning/Embryonic Stem Cells

The term cloning is used by scientists to describe many different processes that involve making duplicates of biological material. In most cases, isolated genes or cells are duplicated for scientific study, and no new animal results. The experiment that led to the cloning of Dolly the sheep in 1997 was different: It used a cloning technique called somatic cell nuclear transfer and resulted in an animal that was a genetic twin -- although delayed in time -- of an adult sheep. This technique can also be used to produce an embryo from which cells called embryonic stem (ES) cells could be extracted to use in research into potential therapies for a wide variety of diseases.

Thus, in the past five years, much of the scientific and ethical debate about somatic cell nuclear transfer has focused on its two potential applications: 1) for reproductive purposes, i.e., to produce a child, or 2) for producing a source of ES cells for research.

The technique of transferring a nucleus from a somatic cell into an egg that produced Dolly was an extension of experiments that had been ongoing for over 40 years. In the simplest terms, the technique used to produce Dolly the sheep - somatic cell nuclear transplantation cloning - involves removing the nucleus of an egg and replacing it with the diploid nucleus of a somatic cell. Unlike sexual reproduction, during which a new organism is formed when the genetic material of the egg and sperm fuse, in nuclear transplantation cloning there is a single genetic "parent." This technique also differs from previous cloning techniques because it does not involve an existing embryo. Dolly is different because she is not genetically unique; when born she was genetically identical to an existing six-year-old ewe. Although the birth of Dolly was lauded as a success, in fact, the procedure has not been perfected and it is not yet clear whether Dolly will remain healthy or whether she is already experiencing subtle problems that might lead to serious diseases. Thus, the prospect of applying this technique in humans is troubling for scientific and safety reasons in addition to a variety of ethical reasons related to our ideas about the natural ordering of family and successive generations.

Several important concerns remain about the science and safety of nuclear transfer cloning using adult cells as the source of nuclei. To date, five mammalian species -- sheep, cattle, pigs, goats, and mice -- have been used extensively in reproductive cloning studies. Data from these experiments illustrate the problems involved. Typically, very few cloning attempts are successful. Many cloned animals die in utero, even at late stages or soon after birth, and those that survive frequently exhibit severe birth defects. In addition, female animals carrying cloned fetuses may face serious risks, including death from cloning-related complications.

An additional concern focuses on whether cellular aging will affect the ability of somatic cell nuclei to program normal development. As somatic cells divide they progressively age, and there is normally a defined number of cell divisions that can occur before senescence. Thus, the health effects for the resulting liveborn, having been created with an "aged" nucleus, are unknown. Recently it was reported that Dolly has arthritis, although it is not yet clear whether the five-and-a-half-year-old sheep is suffering from the condition as a result of the cloning process. And, scientists in Tokyo have shown that cloned mice die significantly earlier than those that are naturally conceived, raising an additional concern that the mutations that accumulate in somatic cells might affect nuclear transfer efficiency and lead to cancer and other diseases in offspring. Researchers working with clones of a Holstein cow say genetic programming errors may explain why so many cloned animals die, either as fetuses or newborns.

The announcement of Dolly sparked widespread speculation about a human child being created using somatic cell nuclear transfer. Much of the perceived fear that greeted this announcement centered on the misperception that a child or many children could be produced who would be identical to an already existing person. This fear is based on the idea of "genetic determinism" -- that genes alone determine all aspects of an individual -- and reflects the belief that a person's genes bear a simple relationship to the physical and psychological traits that compose that individual. Although genes play an essential role in the formation of physical and behavioral characteristics, each individual is, in fact, the result of a complex interaction between his or her genes and the environment within which he or she develops. Nonetheless, many of the concerns about cloning have focused on issues related to "playing God," interfering with the natural order of life, and somehow robbing a future individual of the right to a unique identity.

Several groups have concluded that reproductive cloning of human beings creates ethical and scientific risks that society should not tolerate. In 1997, the National Bioethics Advisory Commission recommended that it was morally unacceptable to attempt to create a child using somatic cell nuclear transfer cloning and suggested that a moratorium be imposed until safety of this technique could be assessed. The commission also cautioned against preempting the use of cloning technology for purposes unrelated to producing a liveborn child.

Similarly, in 2001 the National Academy of Sciences issued a report stating that the United States should ban human reproductive cloning aimed at creating a child because experience with reproductive cloning in animals suggests that the process would be dangerous for the woman, the fetus, and the newborn, and would likely fail. The report recommended that the proposed ban on human cloning should be reviewed within five years, but that it should be reconsidered "only if a new scientific review indicates that the procedures are likely to be safe and effective, and if a broad national dialogue on societal, religious and ethical issues suggests that reconsideration is warranted." The panel concluded that the scientific and medical considerations that justify a ban on human reproductive cloning at this time do not apply to nuclear transplantation to produce stem cells. Several other scientific and medical groups also have stated their opposition to the use of cloning for the purpose of producing a child.

The cloning debate was reopened with a new twist late in 1998, when two scientific reports were published regarding the successful isolation of human stem cells. Stem cells are unique and essential cells found in animals that are capable of continually reproducing themselves and renewing tissue throughout an individual organism's life. ES cells are the most versatile of all stem cells because they are less differentiated, or committed, to a particular function than adult stem cells. These cells have offered hope of new cures to debilitating and even fatal illness. Recent studies in mice and other animals have shown that ES cells can reduce symptoms of Parkinson's disease in mouse models, and work in other animal models and disease areas seems promising.

In the 1998 reports, ES cells were derived from in vitro embryos six to seven days old destined to be discarded by couples undergoing infertility treatments, and embryonic germ (EG) cells were obtained from cadaveric fetal tissue following elective abortion. A third report, appearing in the New York Times, claimed that a Massachusetts biotechnology company had fused a human cell with an enucleated cow egg, creating a hybrid clone that failed to progress beyond an early stage of development. This announcement served as a reminder that ES cells also could be derived from embryos created through somatic cell nuclear transfer, or cloning. In fact, several scientists believed that deriving ES cells in this manner is the most promising approach to developing treatments because the condition of in vitro fertilization (IVF) embryos stored over time is questionable and this type of cloning could overcome graft-host responses if resulting therapies were developed from the recipient's own DNA.

For those who believe that the embryo has the moral status of a person from the moment of conception, research or any other activity that would destroy it is wrong. For those who believe the human embryo deserves some measure of respect, but disagree that the respect due should equal that given to a fully formed human, it could be considered immoral not to use embryos that would otherwise be destroyed to develop potential cures for disease affecting millions of people. An additional concern related to public policy is whether federal funds should be used for research that some Americans find unethical.

Since 1996, Congress has prohibited researchers from using federal funds for human embryo research. In 1999, DHHS announced that it intended to fund research on human ES cells derived from embryos remaining after infertility treatments. This decision was based on an interpretation "that human embryonic stem cells are not a human embryo within the statutory definition" because "the cells do not have the capacity to develop into a human being even if transferred to the uterus, thus their destruction in the course of research would not constitute the destruction of an embryo." DHHS did not intend to fund research using stem cells derived from embryos created through cloning, although such efforts would be legal in the private sector.

In July 2001, the House of Representatives voted 265 to 162 to make any human cloning a criminal offense, including cloning to create an embryo for derivation of stem cells rather than to produce a child. In August 2002, President Bush, contending with a DHHS decision made during the Clinton administration, stated in a prime-time television address that federal support would be provided for research using a limited number of stem cell colonies already in existence (derived from leftover IVF embryos). Current bills before Congress would ban all forms of cloning outright, prohibit cloning for reproductive purposes, and impose a moratorium on cloning to derive stem cells for research, or prohibit cloning for reproductive purposes while allowing cloning for therapeutic purposes to go forward. As of late June, the Senate has taken no action. President Bush's Bioethics Council is expected to recommend the prohibition of reproductive cloning and a moratorium on therapeutic cloning later this summer.

Prepared by Kathi E. Hanna, M.S., Ph.D., Science and Health Policy Consultant

Last Reviewed: April 2006

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Cloning/Embryonic Stem Cells - National Human Genome Research ...

Pros and Cons of Stem Cell Research – thebalance.com

Debates over the ethics of embryonic stem cell research continue to divide scientists, politicians and religious groups. However, promising developments in other areas of stem cell research might lead to solutions that bypass these ethical issues. These new developments could help win stem cell research more support from those against embryonic stem cell research, since they don't require the destruction of blastocysts.

Latest Developments

The most recent research has shown that there are many options available other than working with embryonic stem cells. Stem cells can be obtained from cord blood or derived by manipulating differentiated cells (i.e. skin cells) to revert them to a pluripotent state. These are alternatives that may help broaden the acceptance of stem cell research.

Background

In November 1998 the first published research paper reported that stem cells could be taken from human embryos. Subsequent research led to the ability to maintain undifferentiated stem cell lines (pluripotent cells) and techniques for differentiating them into cells specific to various tissues and organs.

The debates over the ethics of stem cell research began almost immediately in 1999, despite reports that stem cells cannot grow into complete organisms.

In 2000 2001, governments worldwide were beginning to draft proposals and guidelines in an effort to control stem cell research and the handling of embryonic tissues, and reach universal policies to prevent brain-drains (emigration of top scientists) between countries.

The CIHR (Canadian Institute of Health Sciences) drafted a list of recommendations for stem cell research in 2001. The Clinton administration drafted guidelines for stem cell research in 2000, but Clinton left office prior to them being released. The Bush government has had to deal with the issue throughout his administration.

Australia, Germany, UK and other countries have also formulated policies.

Pros

The excitement about stem cell research is primarily due to the medical benefits in areas of regenerative medicine and therapeutic cloning. Stem cells provide huge potential for finding treatments and cures to a vast array of diseases including different cancers, diabetes, spinal cord injuries, Alzheimers, MS, Huntingtons, Parkinsons and more.

There is endless potential for scientists to learn about human growth and cell development from studying stem cells.

Use of adult-derived stem cells, from blood, cord blood, skin and other tissues, known as IPSCs, has been demonstrated to be effective for treating different diseases in animal models. Umbilical-cord-derived stem cells (obtained from the cord blood) have also been isolated and utilized for various experimental treatments. Another option is use of uniparental stem cells. Although these cells lines have some disadvantages or shortcomings compared to embryonic cell lines (they are shorter-lived), there is vast potential if enough money is invested in researching them further, and they are not technically considered individual living beings by pro-life advocates.

Cons

Use of embryonic stem cells for reasearch involves the destruction of blastocysts formed from laboratory-fertilized human eggs. For those who believe that life begins at conception, the blastocyst is a human life and to destroy it is unacceptable and immoral.

This seems to be the only controversial issue standing in the way of stem cell research in North America.

Where It Stands

In the summer of 2006 President Bush stood his ground on the issue of stem cell research and vetoed a bill passed by the Senate that would have expanded federal funding of embryonic stem cell research.

Currently, American federal funding can only go to research on stem cells from existing (already destroyed) embryos. Similarly, in Canada, as of 2002, scientists cannot create or clone embryos for research but must used existing embryos discarded by couples. The UK allows embryonic stem cell cloning.

Use of stem cell lines from alternative non-embryonic sources has received more attention in recent years and has already been demonstrated as a successful option for treatment of certain diseases. For example, adult stem cells can be used to replace blood-cell-forming cells killed during chemotherapy in bone marrow transplant patients. Biotech companies such as Revivicor and ACT are researching techniques for cellular reprogramming of adult cells, use of amnionic fluid, or stem cell extraction techniques that do not damage the embryo, that also provide alternatives for obtaining viable stem cell lines.

Out of necessity, the research on these alternatives is catching up with embryonic stem cell research and, with sufficient funding, other solutions might be found that are acceptable to everyone.

On March 9, 2009, President Obama overturned Bush's ruling, allowing US Federal funding to go to embryonic stem cell research. However, the stipulation applies that normal NIH policies on data sharing must be followed. Despite the progress being made in other areas of stem cell research, using pluripotent cells from other sources, many American scientists were putting pressure on the government to allow their participation and compete with the Europeans. However, many people are still strongly opposed.

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Pros and Cons of Stem Cell Research - thebalance.com

Embryonic Stem Cells and the Germ Cell Lineage | InTechOpen

2.1. Primordial germ cell specification and candidate genes controlling germline establishment

The establishment of early germ cells and their successful maturation are complex processes, and require frequent changes in physiology, location and transcriptional profile of involved cells. Germline establishment in mammals occurs via inductive signaling, in contrast to lower organisms such as flies and worms where the germ cell identity is transmitted via the inheritance of germ plasm (McLaren, 1999, 2000; Saitou et al., 2002). In rodents and humans, the first glimpses of primordial germ cell (PGC) formation are observed in the embryo after implantation and gastrulation, when the epiblast, endoderm, mesoderm and ectoderm are first established (Matsui & Okamura, 2005). At this time, in response to molecular cues including Bone Morphogenetic Proteins (BMP4 and BMP8a) from the yolk sac, a population of pluripotent stem cells is segregated from the ICM and set physically apart from the extra-embryonic ectoderm or yolk sac of the embryo (Figure 1) (Lawson et al., 1999; Ying 2000, 2001). While BMPs provide the inductive signal to epiblast stem cells to supply PGCs, it is not clear what signals control the size of the PGC founder population or what molecules signal the termination of PGC specification. BMPs are crucial to specification of PGCs due to their activation of the ALK2 receptor and Smad-1/5 signaling pathways, as evidenced in mice (Hayashi et al., 2002). In the human embryo, the effects of BMPs on germline specification are unclear because there is very limited access to early embryonic samples. From work in our laboratory, it appears that similar BMP protein pathways are activated in the human embryo during gastrulation that direct PGC specification (Clark & Reijo Pera, 2006, Kee et al, 2006).

Additional mechanisms that may assist germline specification are the activation of pathways that either promote PGC survival and/or inhibit molecules that promote somatic differentiation of PGCs (Ewen & Koopman, 2010). As such, mouse and human PGCs retain expression of several biomarkers of pluripotency, including Oct4, Nanog and Sox2 which underlies their close resemblance to other pluripotent stem cells (Clark & Reijo Pera, 2006; Medrano et al., 2010; Nicholas et al., 2009). Interestingly, the transcription factor Sox2 is expressed on both mouse and human embryonic stem cells but unlike in the mouse, human Sox2 expression is diminished when PGCs migrate to the fetal gonad (Perrett et al., 2008). Coincident with the timing of germline specification in the mouse (E7.5), PGCs near the extraembryonic ectoderm begin to express germ-cell specific markers such as Blimp-1 (Prdm1 in human), Stella (Dppa3 in human), E-Cadherin, and Dazl and harbor alkaline phosphatase activity. Blimp-1/Prdm-1 is a transcriptional repressor whose activity is restricted to the germ lineage and appears to be critical for maintaining a PGC fate. There is strong evidence to suggest that in the mouse, Blimp-1 actively represses the somatic fate of PGCs by inhibiting expression of key somatic regulators during development (Ohinata et al., 2005; Hayashi et al., 2007). It is unclear whether Prdm-1 carries out a similar function in human germline formation. Once cell-cell communication has been established, the Fragilis (IFITIM-1 in human) and Stella/ Dppa3 genes promote further development of PGCs and may do so in a similar fashion as Blimp-1 in mice (Saitou et al., 2002).

Migration of germ cells to the gonad begins at E8.5 in the mouse and during weeks 4 to 6 of human gestation (first trimester). At this stage, PGCs accumulating at the base of the allantois exit the extraembryonic ectoderm and begin migration to the developing gonads, also known as the genital ridge. During migration, PGCs also proliferate by undergoing mitosis and express a new set of biomarkers, including the CXCR4 receptor in mice and the proto-oncogene c-KIT and its ligand, KIT in both mice and humans (Molyneaux & Wylie, 2004; Gomperts et al., 1994). The DAZ gene homologue, DAZL is also expressed on migrating PGCs. In the mouse, migratory PGCs display pseudopodia that may assist in movement through the hindgut and it is plausible that human germ cells behave similarly since they are also observed in the hindgut during migration. Various somatic tissues interact with PGCs during the migratory path to the gonad. It is likely therefore, that these tissues express molecules and factors that guide or cue the PGCs and help maintain their survival. In the mouse, several candidate molecules have been identified, including receptors such as -1 Integrin and extracellular matrix components such as Collagen I (Chuva de Sousa Lopes et al., 2005; De Felici et al., 2005). Although migration of PGCs is less well understood in human development, germ cells have been histologically observed during the late first trimester, when they undergo migration to the hindgut (Fujimoto et al., 1977; Gaskell et al., 2004; Goto et al., 2004). Male and female PGCs have been isolated from

Developmental Cycle of Mammalian Germ Cells. Life cycle of the mouse and human embryo following fertilization, progressing through gastrulation and producing the germline. The germline develops in the gonads and transmits genetic information to the next generation, thus completing the cycle. Fertilization of oocytes by sperm promotes the formation of a 1-cell zygote that undergoes cell division and cleavage to form a blastocyst. The outer layer of blastocyst gives rise to the trophectoderm while the inner cell mass (ICM) contains embryonic stem cells (ESCs). During gastrulation (E7.5 in mouse; Day 15+ in human), the blastocyst cavitates and develops the three germ layers and the epiblast. The primordial germ cells (PGCs) are specified and localize near the extra-embryonic ectoderm, at the base of the allantois. Once PGCs are specified, they migrate to the fetal gonads and undergo sex-specific developmental to male and female gonocytes. Subsequently, male gonocytes undergo spermatogenesis while female gonocytes enter meiotic prophase I and begin oogenesis. Adapted from Schuh-Huerta et al., 2011.

10-week old fetuses and were observed to express Alkaline Phosphatase (AP), a marker of PGCs (Goto et al., 2004). The morphology of human PGCs also resemble the rounded shape of mouse PGCs. Female-specific germ cells have also been visualized at the ultrastructural level during gonadal development in human fetuses (Motta et al., 1997). Finally, recent studies by Kerr et al. with human fetal gonads (testis and ovary) provide a detailed analysis of pluripotency and germ cell-specific markers. The germ cells of the fetal testis are Oct4 +/Nanog +/ c-Kit+ from week 7 to 15 after which these cells become localized to the testis periphery. Meanwhile, the presumptive gonocytes in the week 15 testis show strong expression of Pumilio2 (PUM2), VASA and DAZL and express low to no pluripotency markers (Oct4, Nanog, c-Kit, Tra1-60, Tra1-81) (Kerr et al., 2007). In the human fetal ovary, as in the testis, the expression of pluripotency markers peaks by week 8 and then declines after week 9, as oocytes enter meiosis (Kerr et al., 2008). Interestingly, the cell surface markers SSEA-1 and SSEA-4 are co-expressed on the female germ cells from week 5 onwards although only SSEA-1 is restricted to the germ cell lineage.

Upon arrival at the genital ridge, germ cells express another germ-cell specific marker, VASA, a cytoplasmic protein that is implicated in translational regulation. The gene encoding VASA expression, DDX4 (Mvh in mouse) is highly conserved among species and is expressed exclusively in both male and female pre-meiotic germ cells (Gustafson & Wessel, 2010). This finding underlines the importance of the VASA protein in germline function and makes it an attractive candidate for further study. Along with VASA, other factors produced are germ cell nuclear antigen-1 (GCNA-1) and E-cadherin. The sex-specific character of the developing gonad is controlled by the chromosomal constitution of gonadal somatic cells. In particular, the SRY gene expressed on the Y chromosome in mammals is thought to be an essential regulator of various downstream targets including the Sox9 gene that controls male gonadal development (McLaren, 1995, 2003). Once within the gonad, germ cells associate with Sertoli cells to form testis cords and this interaction induces the expression of VASA in post-migratory PGCs. VASA expression is induced in both male and female PGCs and persists until these cells enter meiosis and after which its levels diminish (Castrillon et al., 2000; Toyooka et al., 2000).

During germline development, an extensive remodeling of the epigenetic landscape occurs. This takes place during embryogenesis and during PGC migration to the gonad (Nicholas et al, 2009). The first wave of epigenetic remodeling occurs during implantation of the blastocyst and involves the erasure of all DNA methylation at CpG islands except those at imprinted gene loci. This transition is observed in all cells of the embryo, including the primitive germline. In female PGCs, there is another level of epigenetic change in the form of random X inactivation wherein one copy of the X chromosome pair is silenced. The second wave of epigenetic remodeling occurs when PGCs migrate to the primitive gonads and their paternal or maternal imprinted loci undergo a gradual process of erasure (Hajkova et al., 2002; Yamazaki et al., 2003). This phase occurs only in germ cells and may help to prime them for sex-specific DNA remethylation, when their developmental programs are established (Durcova-Hills et al., 2006). In the mouse, the re-establishment of imprints takes place prior to birth in the male prospermatogonia (E15) and only after birth in oocytes (Lucifero et al., 2002). In addition to DNA methylation changes, male and female germ cells also undergo post-translational histone modifications and RNA-mediated silencing (Reviewed in Tasler, 2009 & Nicolas et al., 2009).

The successful passage of germ cells through meiosis is a unique and highly rigorous process. However, between male and female embryos, the timing of meiosis is different. Male germ cells are restricted from entering meiosis while female germ cells enter meiosis within the embryo. Although the mechanisms for these contrasting behaviors are unclear, it appears that the gonadal cells provide the signal for (or against) meiotic entry (Brennan & Capel, 2004; Ewen & Koopman, 2010). One signal could be retinoic acid (RA) produced in the fetal ovary, which in turn induces Stra8, a key regulator of meiotic entry. In female germ cells destined to become oocytes, mitotic divisions cease and meiotic prophase begins with the correct stimuli (Borum, 1961); eventually oocytes arrest during Meiosis I prior to fetal birth and will only resume meiosis upon receiving hormonal signals during adulthood (Peters, 1970). Meanwhile, male germ cells transition from primordial status to the gonocyte stage, stop proliferating and remain quiescent in the fetal seminiferous tubules until after birth. The post-natal gonocytes then commit to a spermatogonial stem cell (SSC) fate and amplify through self-renewal or enter meiosis to initiate spermatogenesis. In both male and female germ cells, the synaptonemal complex proteins (SCPs) SCP-1, SCP-2 and SCP-3 are critical components of the meiotic machinery during chromosomal segregation (Chuma et al., 2001; Parra et al., 2004; Yuan et al., 2000). The completion of meiosis signals that germ cells have matured into haploid male and female gametes. At this stage, oocytes exclusively express GDF9 and spermatocytes express TEKT1. However, one feature that distinguishes human and mouse germline differentiation is the synchronization of meiotic entry, as in human fetal gonads, one can observe both pre-meiotic and meiotic germ cells in close proximity (Anderson, 2007).

Significant efforts have been made to culture mouse and human PGCs and gonocyes in vitro. In the case of mouse germ cells, the addition of endogenous factors known to affect germ cell development such as BMPs, RA, LIF and Forskolin have produced mixed results in maintaining PGCs in culture. For example, adding LIF enhanced PGC survival but the observations with the use of other factors not as clear. PGCs may also behave erratically in culture (showing low survival rates and non sex-specific behavior) because of the lack of a normal somatic environment (Childs et al., 2008). Studies of PGCs by Shamblott et al., Turnpenny et al. and Tu et al. with fetal human gonocytes resulted in a mixture of cellular phenotypes. Some gonocytes appeared rounded while others took on an elongated or spindly appearance. In addition, they appeared to have different proliferation rates (Shamblott et al., 1998; Turnpenny et al., 2003; Tu et al., 2007). Currently, it is not at all clear that these cells resemble their germ cell counterparts in vivo, but improvements in culture conditions and the cellular microenvironment will certainly help in this regard.

As delineated earlier, mammalian germ cells populate the testis and ovary during development in a incredibly dynamic manner. During early prenatal mice and human embryo development, PGCs migrate to the primitive gonad (gonadal ridge) and associate with Sertoli cells to form primitive testicular cords (Brennan et al., 2004). Within the testicular cords, the primitive germline stem cells (now termed gonocytes) remain in the testis as the gonad differentiates. Eventually, Sertoli cells, peritubular myoid cells and gonocytes form more compact structures known as the seminiferous tubules. When the gonocytes migrate to the periphery of the tubules, they transform into prospermatogonia and then into spermatogonia (Gondos & Hobel, 1971). In the fetal testis, prospermatogonia enter mitotic arrest, a feature observed at E12.5 to E14.5 in the mouse. At the molecular level, during entry into meiosis, both male and female human gonocytes express DAZL proteins and Vasa transcripts and downregulate OCT3/4 expression (Anderson et al., 2007). Interestingly, it is the early migrating germ cells that share similar properties with embryonic stem cells and testicular germ cell tumors (Ezeh et al., 2005). From what is known, the development of gonocytes in the fetal ovary follows a similar path in that OCT3/4 expression is reduced while VASA, Germ Cell Nuclear Antigen (GCNA) and DAZL are expressed (McLaren, 2003). In contrast to the male gonocytes, the female gonocytes receive sex-specific signals from the fetal gonad to enter meiotic prophase. After initiating meiosis, the female gonocytes will develop into primordial follicles and subsequently into primary follicles at puberty. A key difference between mouse and human systems is the timing of primary follicle formation: the mouse achieves this stage at birth while in the human ovary, this occurs at puberty (Bukovsky et al., 2005). There is some speculation whether this difference in follicle development is due to autocrine signals produced from the oocyte itself or from the ovarian environment (Hutt & Albertini, 2007). A plausible hypothesis is that the immediate environment of early germ cells determines whether they are commit to spermatogenesis or oogenesis. The most obvious source of signals are the mesonephros, primitive Sertoli cells in the testis, and primitive Granulosa cells in the ovary.

Timeline of Germline Specification and Germ Cell Marker Expression. A temporal representation of the stages of human and mouse germline differentiation in vivo. At each cellular stage, important molecular and somatic signals controlling that stage are indicated above the diagram. Specific germ cell molecular markers are indicated on left with arrows depicting the duration of development during which they expression has been observed. Genes that are italicized are present in both mouse and human germ cells. At the bottom, an approximate timing of each stage during mouse or human germline development is indicated. Adapted from Schuh-Huerta & Reijo Pera, 2011.

The seminiferous tubule serves as the sperm production center, where approximately 123 x 106 spermatozoa are produced from germ cells daily, or about 1000 sperm/second (Amann et al., 1980; de Rooij, 2009). Developing germ cells are arranged along the basement membrane in a highly ordered sequence and extend into the lumen of the tubule. At the most basal portion of the tubules lies the spermatogonial stem cell (SSC) population, closely associated with the adjacent Sertoli cells. Morphologic analysis of the various germ cells reveals at least 13 recognizable germ cell types in the human testis (Heller & Clermont, 1963, 1964). Each cell type is thought to represent a different step in spermatogenesis. From the least to the most differentiated, they have been named dark type A spermatogonia (Ad); pale type A spermatogonia (Ap); type B spermatogonia (B); preleptotene (R), leptotene (L), zygotene (z) and pachytene primary spermatocytes (p); secondary spermatocytes (II); and Sa, Sb, Sc, Sd1, and Sd2 spermatids (Figure 3). The early, type A spermatogonia are the most interesting germ cell type from a stem cell point of view (de Rooij, 2009). In fact, time-course studies using GFP-based reporters with early type A, type Ad and type Ap spermatogonia in the mouse revealed that the early type A cell has the ability to divide, self-renew, and give rise to the Ad and Ap sun-populations (Nakagawa T. et al., 2007). These observations provide evidence for the existence of SSCs in the testis and their clonal behavior is protypical of other adult stem cells.

It is currently thought that pale type A (Ap) spermatogonia in the basal, stem cell niche of the seminiferous tubule divide at 16-day intervals and differentiate to type B spermatogonia, which then become spermatocytes (Clermont, 1972). The ability of SSCs within the testis stem cell niche to undergo stem cell renewal is governed by several known factors. The growth factor-receptor kit ligand/c-kit receptor system and the niche factor glial cell line-derived neurotrophic factor (GDNF) are important in this process (Oatley & Brinster, 2008). In fact, spermatogenesis in the rat is dependent on c-Kit receptor activity, whereas spermatogonial stem cell renewal may be c-kit independent (Dym, 1994). GDNF appears to provide a significant stimulus to self-renewal of SSCs through receptors for GDNF on SSCs such as c-Ret and GFR-1(Meng et al., 2000). Despite this, our knowledge of other receptor-ligand systems that control human SSC renewal is limited at this point. During spermatogenesis, the cytoplasm between spermatogonial daughter cells remains conjoined after mitosis, forming cytoplasmic bridges between adjacent cells (Ewing et al., 1980). Cytoplasmic bridges are thought to be important for synchronized cellular proliferation, differentiation, and possibly regulation of gene expression. Thus, SSCs and early spermatogonia in the adult testis are critical for germ cell renewal and differentiation into sperm and raise important questions about the source of proliferative and differentiation signals for spermatogenesis. The majority of stages in mouse spermatogenesis delineated above are translatable to the human germ cell development pathway except for differences in the timing of each stage during development.

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Embryonic Stem Cells and the Germ Cell Lineage | InTechOpen

Non-Small Cell Lung Cancer Treatment (PDQ)Health …

General Information About Non-Small Cell Lung Cancer (NSCLC)

NSCLC is any type of epithelial lung cancer other than small cell lung cancer (SCLC). The most common types of NSCLC are squamous cell carcinoma, large cell carcinoma, and adenocarcinoma, but there are several other types that occur less frequently, and all types can occur in unusual histologic variants. Although NSCLCs are associated with cigarette smoke, adenocarcinomas may be found in patients who have never smoked. As a class, NSCLCs are relatively insensitive to chemotherapy and radiation therapy compared with SCLC. Patients with resectable disease may be cured by surgery or surgery followed by chemotherapy. Local control can be achieved with radiation therapy in a large number of patients with unresectable disease, but cure is seen only in a small number of patients. Patients with locally advanced unresectable disease may achieve long-term survival with radiation therapy combined with chemotherapy. Patients with advanced metastatic disease may achieve improved survival and palliation of symptoms with chemotherapy, targeted agents, and other supportive measures.

Estimated new cases and deaths from lung cancer (NSCLC and SCLC combined) in the United States in 2016:[1]

Lung cancer is the leading cause of cancer-related mortality in the United States.[1] The 5-year relative survival rate from 1995 to 2001 for patients with lung cancer was 15.7%. The 5-year relative survival rate varies markedly depending on the stage at diagnosis, from 49% to 16% to 2% for patients with local, regional, and distant-stage disease, respectively.[2]

NSCLC arises from the epithelial cells of the lung of the central bronchi to terminal alveoli. The histological type of NSCLC correlates with site of origin, reflecting the variation in respiratory tract epithelium of the bronchi to alveoli. Squamous cell carcinoma usually starts near a central bronchus. Adenocarcinoma and bronchioloalveolar carcinoma usually originate in peripheral lung tissue.

Anatomy of the respiratory system.

Smoking-related lung carcinogenesis is a multistep process. Squamous cell carcinoma and adenocarcinoma have defined premalignant precursor lesions. Before becoming invasive, lung epithelium may undergo morphological changes that include the following:

Dysplasia and carcinoma in situ are considered the principal premalignant lesions because they are more likely to progress to invasive cancer and less likely to spontaneously regress.

In addition, after resection of a lung cancer, there is a 1% to 2% risk per patient per year that a second lung cancer will occur.[3]

NSCLC is a heterogeneous aggregate of histologies. The most common histologies include the following:

These histologies are often classified together because approaches to diagnosis, staging, prognosis, and treatment are similar.

Increasing age is the most important risk factor for most cancers. Other risk factors for lung cancer include:

The single most important risk factor for the development of lung cancer is smoking. For smokers, the risk for lung cancer is on average tenfold higher than in lifetime nonsmokers (defined as a person who has smoked <100 cigarettes in his or her lifetime). The risk increases with the quantity of cigarettes, duration of smoking, and starting age.

Smoking cessation results in a decrease in precancerous lesions and a reduction in the risk of developing lung cancer. Former smokers continue to have an elevated risk for lung cancer for years after quitting. Asbestos exposure may exert a synergistic effect of cigarette smoking on the lung cancer risk.[19]

A significant number of patients cured of their smoking-related lung cancer may develop a second malignancy. In the Lung Cancer Study Group trial of 907 patients with stage T1, N0 resected tumors, the rate was 1.8% per year for nonpulmonary second cancers and 1.6% per year for new lung cancers.[20] Other studies have reported even higher risks of second tumors in long-term survivors, including rates of 10% for second lung cancers and 20% for all second cancers.[21]

Because of the persistent risk of developing second lung cancers in former smokers, various chemoprevention strategies have been evaluated in randomized control trials. None of the phase III trials with the agents beta carotene, retinol, 13-cis-retinoic acid, [alpha]-tocopherol, N-acetylcysteine, or acetylsalicylic acid has demonstrated beneficial, reproducible results.[18,22-25][Level of evidence: 1iiA] Chemoprevention of second primary cancers of the upper aerodigestive tract is undergoing clinical evaluation in patients with early-stage lung cancer.

Refer to the PDQ summaries on Lung Cancer Prevention and Smoking in Cancer Care for more information.

In patients considered at high risk for developing lung cancer, the only screening modality for early detection that has been shown to alter mortality is low-dose helical computed tomography (CT) scanning.[26] Studies of lung cancer screening with chest radiography and sputum cytology have failed to demonstrate that screening lowers lung cancer mortality rates.

(Refer to the Screening by low-dose helical computed tomography subsection in the PDQ summary on Lung Cancer Screening for more information.)

Lung cancer may present with symptoms or be found incidentally on chest imaging. Symptoms and signs may result from the location of the primary local invasion or compression of adjacent thoracic structures, distant metastases, or paraneoplastic phenomena. The most common symptoms at presentation are worsening cough or chest pain. Other presenting symptoms include the following:

Symptoms may result from local invasion or compression of adjacent thoracic structures such as compression involving the esophagus causing dysphagia, compression involving the laryngeal nerves causing hoarseness, or compression involving the superior vena cava causing facial edema and distension of the superficial veins of the head and neck. Symptoms from distant metastases may also be present and include neurological defect or personality change from brain metastases or pain from bone metastases. Infrequently, patients may present with symptoms and signs of paraneoplastic diseases such as hypertrophic osteoarthropathy with digital clubbing or hypercalcemia from parathyroid hormone-related protein. Physical examination may identify enlarged supraclavicular lymphadenopathy, pleural effusion or lobar collapse, unresolved pneumonia, or signs of associated disease such as chronic obstructive pulmonary disease or pulmonary fibrosis.

Investigations of patients with suspected NSCLC focus on confirming the diagnosis and determining the extent of the disease. Treatment options for patients are determined by histology, stage, and general health and comorbidities of the patient.

The procedures used to determine the presence of cancer include the following:

Before a patient begins lung cancer treatment, an experienced lung cancer pathologist must review the pathologic material. This is critical because SCLC, which responds well to chemotherapy and is generally not treated surgically, can be confused on microscopic examination with NSCLC.[27] Immunohistochemistry and electron microscopy are invaluable techniques for diagnosis and subclassification, but most lung tumors can be classified by light microscopic criteria.

(Refer to the Staging Evaluation section of this summary for more information on tests and procedures used for staging.)

The identification of mutations in lung cancer has led to the development of molecularly targeted therapy to improve the survival of subsets of patients with metastatic disease.[28] In particular, subsets of adenocarcinoma now can be defined by specific mutations in genes encoding components of the epidermal growth factor receptor (EGFR) and downstream mitogen-activated protein kinases (MAPK) and phosphatidylinositol 3-kinases (PI3K) signaling pathways. These mutations may define mechanisms of drug sensitivity and primary or acquired resistance to kinase inhibitors.

Other genetic abnormalities of potential relevance to treatment decisions include translocations involving the anaplastic lymphoma kinase (ALK)-tyrosine kinase receptor, which are sensitive to ALK inhibitors, and amplification of MET (mesenchymal epithelial transition factor), which encodes the hepatocyte growth factor receptor. MET amplification has been associated with secondary resistance to EGFR tyrosine kinase inhibitors.

Multiple studies have attempted to identify the prognostic importance of a variety of clinicopathologic factors.[21,29-32] Factors that have correlated with adverse prognosis include the following:

For patients with inoperable disease, prognosis is adversely affected by poor performance status and weight loss of more than 10%. These patients have been excluded from clinical trials evaluating aggressive multimodality interventions.

In multiple retrospective analyses of clinical trial data, advanced age alone has not been shown to influence response or survival with therapy.[47]

Refer to the separate treatment sections for each stage of NSCLC in this summary for more information about prognosis.

Because treatment is not satisfactory for almost all patients with NSCLC, eligible patients should be considered for clinical trials. Information about ongoing clinical trials is available from the NCI website.

Other PDQ summaries containing information related to lung cancer include the following:

Malignant non-small cell epithelial tumors of the lung are classified by the World Health Organization (WHO)/International Association for the Study of Lung Cancer (IASLC). There are three main subtypes of non-small cell lung cancer (NSCLC), including the following:

There are numerous additional subtypes of decreasing frequency.[1]

Most squamous cell carcinomas of the lung are located centrally, in the larger bronchi of the lung. Squamous cell carcinomas are linked more strongly with smoking than other forms of NSCLC. The incidence of squamous cell carcinoma of the lung has been decreasing in recent years.

Adenocarcinoma is now the most common histologic subtype in many countries, and subclassification of adenocarcinoma is important. One of the biggest problems with lung adenocarcinomas is the frequent histologic heterogeneity. In fact, mixtures of adenocarcinoma histologic subtypes are more common than tumors consisting purely of a single pattern of acinar, papillary, bronchioloalveolar, and solid adenocarcinoma with mucin formation.

Criteria for the diagnosis of bronchioloalveolar carcinoma have varied widely in the past. The current WHO/IASLC definition is much more restrictive than that previously used by many pathologists because it is limited to only noninvasive tumors.

If stromal, vascular, or pleural invasion are identified in an adenocarcinoma that has an extensive bronchioloalveolar carcinoma component, the classification would be an adenocarcinoma of mixed subtype with predominant bronchioloalveolar pattern and a focal acinar, solid, or papillary pattern, depending on which pattern is seen in the invasive component. However, the future of bronchioloalveolar carcinoma as a distinct clinical entity is unclear; a multidisciplinary expert panel representing the IASLC, the American Thoracic Society, and the European Respiratory Society proposed a major revision of the classification of adenocarcinomas in 2011 that entails a reclassification of what was called bronchioloalveolar carcinoma into newly defined histologic subgroups.

The following variants of adenocarcinoma are recognized in the WHO/IASLC classification:

In addition to the general category of large cell carcinoma, several uncommon variants are recognized in the WHO/IASLC classification, including the following:

Basaloid carcinoma is also recognized as a variant of squamous cell carcinoma, and rarely, adenocarcinomas may have a basaloid pattern; however, in tumors without either of these features, they are regarded as a variant of large cell carcinoma.

LCNEC is recognized as a histologically high-grade non-small cell carcinoma. It has a very poor prognosis similar to that of small cell lung cancer (SCLC). Atypical carcinoid is recognized as an intermediate-grade neuroendocrine tumor with a prognosis that falls between typical carcinoid and high-grade SCLC and LCNEC.

Neuroendocrine differentiation can be demonstrated by immunohistochemistry or electron microscopy in 10% to 20% of common NSCLCs that do not have any neuroendocrine morphology. These tumors are not formally recognized within the WHO/IASLC classification scheme because the clinical and therapeutic significance of neuroendocrine differentiation in NSCLC is not firmly established. These tumors are referred to collectively as NSCLC with neuroendocrine differentiation.

This is a group of rare tumors. Spindle cell carcinomas and giant cell carcinomas comprise only 0.4% of all lung malignancies, and carcinosarcomas comprise only 0.1% of all lung malignancies. In addition, this group of tumors reflects a continuum in histologic heterogeneity as well as epithelial and mesenchymal differentiation. On the basis of clinical and molecular data, biphasic pulmonary blastoma is regarded as part of the spectrum of carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements.

The identification of mutations in lung cancer has led to the development of molecularly targeted therapy to improve the survival of subsets of patients with metastatic disease.[2] In particular, subsets of adenocarcinoma now can be defined by specific mutations in genes encoding components of the epidermal growth factor receptor (EGFR) and downstream mitogen-activated protein kinases (MAPK) and phosphatidylinositol 3-kinases (PI3K) signaling pathways. These mutations may define mechanisms of drug sensitivity and primary or acquired resistance to kinase inhibitors. Other mutations of potential relevance to treatment decisions include:

These mutations are mutually exclusive, except for those involving PI3KCA and BRAF mutations, EGFR mutations, or ALK translocations.[3,4]

EGFR and ALK mutations predominate in adenocarcinomas that develop in nonsmokers, and KRAS and BRAF mutations are more common in smokers or former smokers. EGFR mutations strongly predict the improved response rate and progression-free survival of EGFR inhibitors. In a set of 2,142 lung adenocarcinoma specimens from patients treated at Memorial Sloan Kettering Cancer Center, EGFR exon 19 deletions and L858R were found in 15% of tumors from former smokers (181 of 1,218; 95% confidence interval [CI], 1317), 6% from current smokers (20 of 344; 95% CI, 49), and 52% from never-smokers (302 of 580; 95% CI, 4856; P < .001 for ever- vs. never-smokers).[5]

Fusions of ALK with EML4 genes form translocation products that occur in ranges from 3% to 7% in unselected NSCLC and are responsive to pharmacological inhibition of ALK by agents such as crizotinib. Sensitizing fusions of ALK with other genes have also been reported. Other mutations that occur in less than 5% of NSCLC tumors include:

BRAF mutations are mutually exclusive of EGFR and KRAS mutations. Somatic mutations in MAP2K1 (also known as MEK) have been identified in 1% of NSCLC. MET oncogene encodes hepatocyte growth factor receptor. Amplification of this gene has been associated with secondary resistance to EGFR tyrosine kinase inhibitors.

In non-small cell lung cancer (NSCLC), the determination of stage is important in terms of therapeutic and prognostic implications. Careful initial diagnostic evaluation to define the location and to determine the extent of primary and metastatic tumor involvement is critical for the appropriate care of patients.

In general, symptoms, physical signs, laboratory findings, or perceived risk of distant metastasis lead to an evaluation for distant metastatic disease. Additional tests such as bone scans and computed tomography (CT)/magnetic resonance imaging (MRI) of the brain may be performed if initial assessments suggest metastases or if patients with stage III disease are under consideration for aggressive local and combined modality treatments.

Stage has a critical role in the selection of therapy. The stage of disease is based on a combination of clinical factors and pathological factors.[1] The distinction between clinical stage and pathological stage should be considered when evaluating reports of survival outcome.

Procedures used to determine staging include the following:

Procedures used to obtain tissue samples include bronchoscopy, mediastinoscopy, or anterior mediastinotomy. Pathological staging of NSCLC requires the following:

Prognostic and treatment decisions are based on some of the following factors:

At diagnosis, patients with NSCLC can be divided into the following three groups that reflect both the extent of the disease and the treatment approach:

Surgical staging of the mediastinum is considered standard if accurate evaluation of the nodal status is needed to determine therapy.

Accurate staging of the mediastinal lymph nodes provides important prognostic information.

Evidence (nodal status):

CT scanning is primarily used for determining the size of the tumor. The CT scan should extend inferiorly to include the liver and adrenal glands. MRI scans of the thorax and upper abdomen do not appear to yield advantages over CT scans.[4]

Evidence (CT scan):

The wider availability and use of FDG-PET scanning for staging has modified the approach to staging mediastinal lymph nodes and distant metastases.

Randomized trials evaluating the utility of FDG-PET scanning in potentially resectable NSCLC report conflicting results in terms of the relative reduction in the number of noncurative thoracotomies.

Although the current evidence is conflicting, FDG-PET scanning may improve results of early-stage lung cancer by identifying patients who have evidence of metastatic disease that is beyond the scope of surgical resection and that is not evident by standard preoperative staging procedures.

Evidence (FDG-PET scan):

Decision analyses demonstrate that FDG-PET scanning may reduce the overall costs of medical care by identifying patients with falsely negative CT scans in the mediastinum or otherwise undetected sites of metastases.[9-11] Studies concluded that the money saved by forgoing mediastinoscopy in FDG-PET-positive mediastinal lesions was not justified because of the unacceptably high number of false-positive results.[9-11] A randomized study found that the addition of FDG-PET scanning to conventional staging was associated with significantly fewer thoracotomies.[12] A second randomized trial evaluating the impact of FDG-PET scanning on clinical management found that FDG-PET scanning provided additional information regarding appropriate stage but did not lead to significantly fewer thoracotomies.[13]

The combination of CT imaging and FDG-PET scanning has greater sensitivity and specificity than CT imaging alone.[14]

Evidence (CT/FDG-PET scan):

For patients with clinically operable NSCLC, the recommendation is for a biopsy of mediastinal lymph nodes that were found to be larger than 1 cm in shortest transverse axis on chest CT scan or were found to be positive on FDG-PET scan. Negative FDG-PET scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. Mediastinoscopy is necessary for the detection of cancer in mediastinal lymph nodes when the results of the CT scan and FDG-PET scan do not corroborate each other.

Patients at risk for brain metastases may be staged with CT or MRI scans. One study randomly assigned 332 patients with potentially operable NSCLC and no neurological symptoms to brain CT or MRI imaging to detect occult brain metastasis before lung surgery. MRI showed a trend towards a higher preoperative detection rate than CT scan (P = .069), with an overall detection rate of approximately 7% from pretreatment to 12 months after surgery.[17] Patients with stage I or stage II disease had a detection rate of 4% (i.e., eight detections out of 200 patients); however, individuals with stage III disease had a detection rate of 11.4% (i.e., 15 detections out of 132 patients). The mean maximal diameter of the brain metastases was significantly smaller in the MRI group. Whether the improved detection rate of MRI translates into improved outcome remains unknown. Not all patients are able to tolerate MRI, and for these patients contrast-enhanced CT scan is a reasonable substitute.

Numerous nonrandomized, prospective, and retrospective studies have demonstrated that FDG-PET scanning seems to offer diagnostic advantages over conventional imaging in staging distant metastatic disease; however, standard FDG-PET scans have limitations. FDG-PET scans may not extend below the pelvis and may not detect bone metastases in the long bones of the lower extremities. Because the metabolic tracer used in FDG-PET scanning accumulates in the brain and urinary tract, FDG-PET scanning is not reliable for detection of metastases in these sites.[17]

The Revised International System for Staging Lung Cancer, based on information from a clinical database of more than 5,000 patients, was adopted in 2010 by the American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer.[18,19] These revisions provide greater prognostic specificity for patient groups; however, the correlation between stage and prognosis predates the widespread availability of PET imaging.

Summary of Changes

This staging system is now recommended for the classification of both NSCLC and small cell lung carcinomas and for carcinoid tumors of the lung.[19]

The T (primary tumor) classifications have been redefined as follows:[19]

No changes have been made to the N (regional lymph nodes) classification. However, a new international lymph node map defining the anatomical boundaries for lymph node stations has been developed.

The M (distant metastasis) classifications have been redefined as follows:

The AJCC has designated staging by TNM classification to define NSCLC.[19]

In non-small cell lung cancer (NSCLC), results of standard treatment are poor except for the most localized cancers. All newly diagnosed patients with NSCLC are potential candidates for studies evaluating new forms of treatment.

Surgery is the most potentially curative therapeutic option for this disease. Postoperative chemotherapy may provide an additional benefit to patients with resected NSCLC. Radiation therapy combined with chemotherapy can produce a cure in a small number of patients and can provide palliation in most patients. Prophylactic cranial irradiation (PCI) may reduce the incidence of brain metastases, but there is no evidence of a survival benefit and the effect of PCI on quality of life is not known.[1,2] In patients with advanced-stage disease, chemotherapy or epidermal growth factor receptor (EGFR) kinase inhibitors offer modest improvements in median survival, though overall survival is poor.[3,4]

Chemotherapy has produced short-term improvement in disease-related symptoms in patients with advanced NSCLC. Several clinical trials have attempted to assess the impact of chemotherapy on tumor-related symptoms and quality of life. In total, these studies suggest that tumor-related symptoms may be controlled by chemotherapy without adversely affecting overall quality of life;[5,6] however, the impact of chemotherapy on quality of life requires more study. In general, medically fit elderly patients with good performance status obtain the same benefits from treatment as younger patients.

The identification of mutations in lung cancer has led to the development of molecularly targeted therapy to improve the survival of subsets of patients with metastatic disease.[7] In particular, genetic abnormalities in EGFR, MAPK, and PI3K signaling pathways in subsets of NSCLC may define mechanisms of drug sensitivity and primary or acquired resistance to kinase inhibitors. EGFR mutations strongly predict the improved response rate and progression-free survival of inhibitors of EGFR. Fusions of ALK with EML4 and other genes form translocation products that occur in ranges from 3% to 7% in unselected NSCLC and are responsive to pharmacological inhibition of ALK by agents such as crizotinib. MET oncogene encodes hepatocyte growth factor receptor. Amplification of this gene has been associated with secondary resistance to EGFR tyrosine kinase inhibitors.

The standard treatment options for each stage of NSCLC are presented in Table 11.

In addition to the standard treatment options presented in Table 11, treatment options under clinical evaluation include the following:

Several small series have reported that reduction in fluorodeoxyglucose-positron emission tomography (FDG-PET) after chemotherapy, radiation therapy, or chemoradiation therapy correlates with pathological complete response and favorable prognosis.[8-15] Studies have used different timing of assessments, FDG-PET parameters, and cutpoints to define FDG-PET response. Reduction in maximum standardized uptake value (SUV) of higher than 80% predicted for complete pathological response with a sensitivity of 90%, specificity of 100%, and accuracy of 96%.[16] Median survival after resection was greater for patients with tumor SUV values of lower than 4 (56 months vs. 19 months).[15] Patients with complete metabolic response following radiation therapy were reported to have median survivals of 31 months versus 11 months.[17]

FDG-PET may be more sensitive and specific than computed tomography (CT) scan in assessing response to induction therapy. Optimal timing of imaging remains to be defined; however, one study suggests that greater sensitivity and specificity of FDG-PET is achieved if repeat imaging is delayed until 30 days after radiation therapy.[16]

There is no clear role for routine posttreatment PET-CT scans.[18][Level of evidence: 3iiA]

Evidence (surveillance imaging after radiation therapy with or without chemotherapy):

Check the list of NCI-supported cancer clinical trials that are now accepting patients with non-small cell lung cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

In occult lung cancer, a diagnostic evaluation often includes chest x-ray and selective bronchoscopy with close follow-up (e.g., computed tomography scan), when needed, to define the site and nature of the primary tumor; tumors discovered in this fashion are generally early stage and curable by surgery.

After discovery of the primary tumor, treatment involves establishing the stage of the tumor. Therapy is identical to that recommended for other non-small cell lung cancer (NSCLC) patients with similar stage disease.

Standard treatment options for occult NSCLC include the following:

Check the list of NCI-supported cancer clinical trials that are now accepting patients with occult non-small cell lung cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

Stage 0 non-small cell lung cancer (NSCLC) frequently progresses to invasive cancer.[1-3] Patients may be offered surveillance bronchoscopies and, if lesions are detected, potentially curative therapies.

Standard treatment options for stage 0 NSCLC include the following:

Segmentectomy or wedge resection are used to preserve maximum normal pulmonary tissue since patients with stage 0 NSCLC are at a high risk for second lung cancers. Because these tumors are by definition noninvasive and incapable of metastasizing, they should be curable with surgical resection; however, such lesions, when identified, are often centrally located and may require a lobectomy.

Patients with central lesions may be candidates for curative endobronchial therapy. Endobronchial therapies that preserve lung function include photodynamic therapy, electrocautery, cryotherapy, and Nd-YAG laser therapy.[3-6]

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Non-Small Cell Lung Cancer Treatment (PDQ)Health ...

Types of Treatment: Stem Cell Transplant – National Cancer …

Stem cell transplants are procedures that restore blood-forming stem cells in people who have had theirs destroyed by the very high doses of chemotherapy or radiation therapy that are used to treat certain cancers.

Blood-forming stem cells are important because they grow into different types of blood cells. The main types of blood cells are:

You need all three types of blood cells to be healthy.

In a stem cell transplant, you receive healthy blood-forming stem cells through a needle in your vein. Once they enter your bloodstream, the stem cells travel to the bone marrow, where they take the place of the cells that were destroyed by treatment. The blood-forming stem cells that are used in transplants can come from the bone marrow, bloodstream, or umbilical cord. Transplants can be:

To reduce possible side effects and improve the chances that an allogeneic transplant will work, the donors blood-forming stem cells must match yours in certain ways. To learn more about how blood-forming stem cells are matched, see Blood-Forming Stem Cell Transplants.

Stem cell transplants do not usually work against cancer directly. Instead, they help you recover your ability to produce stem cells after treatment with very high doses of radiation therapy, chemotherapy, or both.

However, in multiple myeloma and some types of leukemia, the stem cell transplant may work against cancer directly. This happens because of an effect called graft-versus-tumor that can occur after allogeneic transplants. Graft-versus-tumor occurs when white blood cells from your donor (the graft) attack any cancer cells that remain in your body (the tumor) after high-dose treatments. This effect improves the success of the treatments.

Stem cell transplants are most often used to help people with leukemia and lymphoma. They may also be used for neuroblastoma and multiple myeloma.

Stem cell transplants for other types of cancer are being studied in clinical trials, which are research studies involving people. To find a study that may be an option for you, see Find a Clinical Trial.

The high doses of cancer treatment that you have before a stem cell transplant can cause problems such as bleeding and an increased risk of infection. Talk with your doctor or nurse about other side effects that you might have and how serious they might be. For more information about side effects and how to manage them, see the section on side effects.

If you have an allogeneic transplant, you might develop a serious problem called graft-versus-host disease. Graft-versus-host disease can occur when white blood cells from your donor (the graft) recognize cells in your body (the host) as foreign and attack them. This problem can cause damage to your skin, liver, intestines, and many other organs. It can occur a few weeks after the transplant or much later. Graft-versus-host disease can be treated with steroids or other drugs that suppress your immune system.

The closer your donors blood-forming stem cells match yours, the less likely you are to have graft-versus-host disease. Your doctor may also try to prevent it by giving you drugs to suppress your immune system.

Stem cells transplants are complicated procedures that are very expensive. Most insurance plans cover some of the costs of transplants for certain types of cancer. Talk with your health plan about which services it will pay for. Talking with the business office where you go for treatment may help you understand all the costs involved.

To learn about groups that may be able to provide financial help, go to the National Cancer Institute database, Organizations that Offer Support Services and search "financial assistance." Or call toll-free 1-800-4-CANCER (1-800-422-6237) for information about groups that may be able to help.

When you need an allogeneic stem cell transplant, you will need to go to a hospital that has a specialized transplant center. The National Marrow Donor Program maintains a list of transplant centers in the United States that can help you find a transplant center.

Unless you live near a transplant center, you may need to travel from home for your treatment. You might need to stay in the hospital during your transplant, you may be able to have it as an outpatient, or you may need to be in the hospital only part of the time. When you are not in the hospital, you will need to stay in a hotel or apartment nearby. Many transplant centers can assist with finding nearby housing.

A stem cell transplant can take a few months to complete. The process begins with treatment of high doses of chemotherapy, radiation therapy, or a combination of the two. This treatment goes on for a week or two. Once you have finished, you will have a few days to rest.

Next, you will receive the blood-forming stem cells. The stem cells will be given to you through an IV catheter. This process is like receiving a blood transfusion. It takes 1 to 5 hours to receive all the stem cells.

After receiving the stem cells, you begin the recovery phase. During this time, you wait for the blood cells you received to start making new blood cells.

Even after your blood counts return to normal, it takes much longer for your immune system to fully recoverseveral months for autologous transplants and 1 to 2 years for allogeneic or syngeneic transplants.

Stem cell transplants affect people in different ways. How you feel depends on:

Since people respond to stem cell transplants in different ways, your doctor or nurses cannot know for sure how the procedure will make you feel.

Doctors will follow the progress of the new blood cells by checking your blood counts often. As the newly transplanted stem cells produce blood cells, your blood counts will go up.

The high-dose treatments that you have before a stem cell transplant can cause side effects that make it hard to eat, such as mouth sores and nausea. Tell your doctor or nurse if you have trouble eating while you are receiving treatment. You might also find it helpful to speak with a dietitian. For more information about coping with eating problems see the booklet Eating Hints or the section on side effects.

Whether or not you can work during a stem cell transplant may depend on the type of job you have. The process of a stem cell transplant, with the high-dose treatments, the transplant, and recovery, can take weeks or months. You will be in and out of the hospital during this time. Even when you are not in the hospital, sometimes you will need to stay near it, rather than staying in your own home. So, if your job allows, you may want to arrange to work remotely part-time.

Many employers are required by law to change your work schedule to meet your needs during cancer treatment. Talk with your employer about ways to adjust your work during treatment. You can learn more about these laws by talking with a social worker.

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Types of Treatment: Stem Cell Transplant - National Cancer ...

CIRM Alpha Stem Cell Clinic – UCSD Stem Cell Program

Mission

The mission of the UC San Diego CIRM Alpha Stem Cell Clinic is to accelerate the design of innovative stem cell research to advance the testing and delivery of safe and effective stem cell-based therapies in regenerative medicine.

For more information, please visit the CIRM Alpha Stem Cell Clinic page on the UC San Diego Health website.

We are one of three alpha clinics in a network designated by theCalifornia Institute for Regenerative Medicine (CIRM), the states stem cell agency. The UC San Diego CIRM Alpha Stem Cell Clinic is the cell therapy arm ofSanford Stem Cell Clinical Center at UC San Diego Health.We specialize in early phase, first-in-human trials.

The Alpha Stem Cell Clinics are intended to create the long-term, networked infrastructure needed to launch and conduct numerous, extensive clinical trials of stem cell-based drugs and therapies in humans, including those developed by independent California-based investigators and companies. These trials are requisite before any new drug or treatment can be approved for clinical use.

The clinics will emphasize public education to raise awareness and understanding of stem cell science. This will combat stem cell tourism and the marketing of unproven, unregulated and potentially dangerous therapies. The clinics will also help establish sustainable business models for future, approved stem cell treatments.

See how we're improving the consent process by deploying enhanced electronic consent tablets.

An Overview of the UC San Diego CIRM Alpha Stem Cell Clinic

alphastemcellclinic@ucsd.edu

1-844-317-STEM (7836)

Excerpt from:
CIRM Alpha Stem Cell Clinic - UCSD Stem Cell Program

Treatment Abroad | Canadian Stem Cell Foundation

The scientific discoveries and innovations surrounding the potential of stem cell science have led to great enthusiasm about the benefits it could bring people.

The dark side of that enthusiasm is the hype, exaggerated publicity and inaccurate claims in the interest of financial gain.

People may develop unrealistic expectations of the benefits available from stem cell research and the speed with which they will be achieved.

Unfortunately, there will always be individuals and companies eager to take advantage of the necessary lag between research and clinical applications to offer the promise of so-called cures and therapies.

Many of these treatments are not based on sound scientific evidence, for example, this 2008 Stem Cell Network-funded study of the online marketing of 19 stem cell clinics found that the clinics claims of safe, effective and routine therapies were not substantiated by published evidence.

Patients considering these therapies are encouraged to review the information available at Closer look at stem cells, a website created by the International Society of Stem Cell Research. Other statements on experimental therapies have been published by the German Stem Cell Network North Rhine Westphaliaand the National Stem Cell Foundation of Australia.

Prof. Timothy Caulfield addresses the problem of websitesmarketing unproven stem cell therapies. Find out more here.

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Treatment Abroad | Canadian Stem Cell Foundation