Hematopoietic Cell Transplantation and Cellular Therapy Fellowship
Program Overview
The UNMC division of oncology and hematology offers a Hematopoietic Cell Transplantation and Cellular Therapy Fellowship for physicians who have finished an ACGME-accredited hematology fellowship and wish to pursue a career in blood and marrow transplantation and cellular therapy. This comprehensive, one-year program prepares physicians to carry out the transplant procedures with confidence and have a firm grasp of the science behind it.
Program History
The TCT program at UNMC was started by Dr. James O Armitage in 1982, making it one of the country's oldest and most well-established transplant programs. Historically hematopoietic stem cells were collected by a bone marrow harvest, and the so-called “Bone Marrow Transplantation” was performed after myeloablative doses of chemotherapy or radiation. In the 1980s, pioneers at UNMC like Dr. Anne Kessinger had advanced the field of Hematopoietic Stem Cell Transplantation (HSCT) further by paving the path to a “reliable,” “mobilized” Peripheral Blood Stem Cell Transplantation (PBSCT). This paradigm shift made the process of HSCT safer, reliable, and scalable. The field moved from “Bone Marrow Transplantation” to “Post-high dose chemotherapy mobilized PBSCT” to “G-CSF mobilized PBSCT” using accurate stem cell dose calculation by CD34 cell count enumeration and cryopreservation.
Around 150-200 TCT procedures are performed at UNMC annually, including various types of HSCT, including Autologous, Allogeneic, Syngeneic, and Haploidentical transplantations. In addition, with rapid advances in cellular therapies in the last decade, Chimeric Antigen Receptor T-Cell (CAR-T) [Immune Effector Cell therapy – IEC] program was established at UNMC in 2014 under the leadership of Drs. Julie Vose and James O Armitage.
Federation for the Accreditation of Cellular Therapy (FACT), a nonprofit corporation, was founded in 1996 by the American Society for Transplantation and Cellular Therapy (ASTCT) and the International Society for Cell and Gene Therapy (ISCT). This was done by UNMC-led efforts to form FACT and meet the need to maintain a certain level of professional standards across the field of TCT around the globe. The FACT was headquartered in UNMC until 2021, when the FACT established itself as an independent operational entity. It accomplishes its mission of promoting quality patient care and laboratory practice, improving treatment outcomes, and fostering the continued development of the field of cellular therapy and regenerative medicine through the development of standards, voluntary accreditation, and education. Dr. Phyllis I. Warkentin, one of the original board members who helped set the standards, is the current Chief Medical Officer of FACT and was the director of the UNMC Biologics Production Facility. UNMC received its first FACT accreditation in 2001.
Curriculum and Schedule of the Training Program
By the end of the TCT fellowship, trainees are expected to clearly understand various aspects of TCT and be able to manage patients independently.
During this time, trainees will gain experience in various types of high-dose chemotherapy conditioning or treatment regimens used in patients with various hematological malignancies. They also will learn about the anticipated toxicities from chemotherapy, radiation therapy, and IEC and how to manage them. They will be able to understand approaches to prevent, identify and manage Sinusoidal Occlusion Syndrome (VOD) of the liver, CMV, and other viral, fungal, and bacterial infections. They will be able to identify and treat other standard transplant-related complications, including acute and chronic graft-versus-host disease(GVHD), ABO-related hemolytic complications, cytopenia, hemorrhagic cystitis, diffuse alveolar hemorrhage, Transplant Associated-Thrombotic Micro Angiopathy (TA-TMA), engraftment syndrome, graft failure. They will be able to diagnose and manage complications following IEC, including Immune Effect Cell-Associated Neurotoxicity Syndrome (ICANS) and Cytokine Release Syndrome (CRS). They also will learn about pharmacokinetic drug monitoring of drugs like busulfan, calcineurin inhibitors, and various potential drug interactions.
Trainees can better understand the indication of HSCT and IEC. They will also learn about the pre-transplantation patient education process, comorbidity index measurements, identification, and selection of stem cell sources, including donor registries and search process. They will be able to diagnose and manage the late complications of HSCT and IEC, including GVHD, cytopenias, relapse management, surveillance for secondary malignancies, and post-transplant lymphoproliferative disorder (PTLD). They also will be able to learn about the process of Donor Lymphocyte Infusion (DLI) and the expected complications following it. They will understand the long-term follow-up guidelines and the immunization schedules after TCT. They will be able to learn the interpretation of pulmonary function tests (PFTs) during the evaluation of TCT and follow-up for lung chronic GVHD.
Trainees will be able to gain knowledge of blood and marrow stem cell collection and procession. They will be able to learn about the cryopreservation procedure, CD34 selection and other graft manipulation procedures, HLA typing, Donor-Specific-Antibody (DSA) testing, Complement-dependent Cytotoxicity (CDC) crossmatching, Flow Crossmatching to evaluate for donor compatibility and other allogeneic antibody related complications. They will gain an understanding of chimerism analysis. They will be able to observe and participate in a Bone Marrow Harvest. They also will have an opportunity to learn and perform other procedures, including bone marrow biopsy, skin punch biopsy, and lumbar puncture. Trainees will interact with Transfusion Medicine and be able to understand RBC antibody testing, CD34+ cell evaluation following PBSC collection, and apheresis techniques.
Accreditation and standards: During this time, trainees will be able to spend time with quality and data managing teams to understand the necessary standards for data documentation, reporting, and assessing outcomes of a particular transplant program to continue maintaining accreditations to maintain standards to improve patient safety. In addition, trainees will be able to understand the importance of intuitional standard operating protocols (SOP) and the process of inspection by agencies like Center for International Blood and Marrow Transplant Research (CIBMTR), FACT and the US FDA. They also will be able to understand practicing cost-effective health care and resource allocation.
Infectious complications are prevalent during prolonged immunosuppressive state in which patients undergoing HSCT/IEC are expected to be in. Trainees will be able to work along the side of the transplant infectious diseases team and will be able to diagnose and manage various complications, including neutropenic fever, CMV prophylaxis & treatment, invasive fungal infections and other opportunistic infections. They will develop an understanding on the importance of immune reconstitution post-TCT.
Trainees will be able to work closely with the palliative care team and learn about managing terminally ill patients. In addition, they will be able to participate in multidisciplinary meetings and learn more about supportive care, including nausea/vomiting, cancer-associated pain, and psychological challenges in complex situations surrounding HSCT/IEC.
UNMC offers a robust supporting environment to nurture research to advance the field of medicine. Understanding the role of the Institutional Review Board, Scientific Review Committee and ethical conduct in clinical trials is essential. During this time, trainees will be able to understand the process of grant writing and are expected to work with an assigned mentor to submit training proposals, grants and develop an investigator-initiated study. They also will be able to interact with the clinical trials office to learn the screening process, consenting, data gathering, adverse event reporting, and professional communications necessary for patients enrolled in a clinical trial. We have developed a mini-trial course and developed strategy to support transitioning to physician scientists. Several training, pilot and scholar grant opportunities are available through the Fred and Pamela Buffett Cancer Center, College of Medicine and the Great Plains IDeA Clinical and Translational Research Network.
Program Benefits
- As a division we are committed to providing the best treatment available today as well as discovering and evaluating new therapies for the future. This important work saves lives and forever changes the face of cancer and blood-related diseases.
- The state-of-the-art Fred & Pamela Buffett Cancer Center is an NCI designated cancer center with an eight-story clinical tower including an 108-bed inpatient unit, a 24/7 infusion center, and a large multi-disciplinary clinic.
- Both inpatient and outpatient teams perform cellular therapy procedures at UNMC. In addition, both these locations are staffed by nurses around the clock.
- The Biologics Production Facility provides manufacturing, processing, cryopreservation, and storage of cells, tissues, and cellular and tissue-derived productions for human administration, such as vaccines and hematopoietic stem cells. It is compliant with the Good Manufacturing Practices (GMP) regulations.
- Transfusion Medicine and Apheresis division supports patients needing outpatient or inpatient services. The outpatient suite is fully equipped with state-of-the-art machines and dedicated pathologists with expertise. In addition to peripheral stem cell collection by apheresis, they offer various services, including RBC exchange, Plasma exchange and Extracorporeal Photopheresis(ECP).
- 200-250 transplant and CAR-T procedures are performed at UNMC annually.
- Opportunities for collaboration for investigator initiated clinical research, and translational research.
- UNMC's clinical partner, Nebraska Medicine, works with the multi-disciplinary teams to provide state of the are clinical care and research.
Application Process
If you are interested in learning more about this opportunity, please contact Dr. Vijaya Bhatt or apply online.