1. CHAPTER 1 BLOOD AND MARROW TRANSPLANTATION Editors: Dr Alan Teh Kee Hean Prof Dr Chan Lee Lee Expert Panel: Dr Alan Teh Kee Hean (co-chairperson) Prof Dr Chan Lee Lee (co-chairperson) Prof Dr Gan Gin Gin Dr Hishamshah Mohd Ibrahim Prof Dr S. Fadilah Abdul Wahid Dr Ong Tee Chuan

2. Table 1.1.1: Stock and Flow of Blood and Marrow Transplantation, 1987-2008 Figure 1.1.1: Stock and Flow of Blood and Marrow Transplantation, 1987-2008 Year19871988198919901991199219931994199519961997 New transplant patients 8622512211925302833 Deaths 11661295171115 Lost to follow- up 00000000000 Alive at 31 st December 712282738576787100117135 Year 19981999200020012002200320042005200620072008 New transplant patients 496294108114128140148136149181 Deaths 1716314734565261425071 Lost to follow- up 00000000000 Alive at 31 st December 167213276337417489577664758857967 0 200 400 600 800 1,000 Number of patients (n) 87888990919293949596979899000102030405060708 Year New patientsAlive at 31st Dec

3. Table 1.1.2: New Transplant Rate per million population (pmp), 1987-2008 Figure 1.1.2: New Transplant Rate per million population (pmp), 1987-2008 Year19871988198919901991199219931994199519961997 New transplant patients8622512211925302833 New transplant rate, pmp10101111112 Year19981999200020012002200320042005200620072008 New transplant patients496294108114128140148136149181 New transplant rate, pmp23455556557 0 1 2 3 4 5 6 7 New Tranplant rate pmp 87888990919293949596979899000102030405060708 Year

4. Table 1.1.3: Distribution of Patients by Transplant Centre, 1987-2008 Year 1987198819891990199119921993 No.% % % % % % % KLA00000000000000 HKLP00000000000000 HUKM00000000000000 SJMCA00001500000000 UMA00000000000015 UMP81006 2195510012100211001895 GMC00000000000000 LWE00000000000000 SJMCP00000000000000 HUSM00000000000000 APSH00000000000000 HA00000000000000 HPP00000000000000 Others00000000000000 TOTAL81006 221005 121002110019100 Year1994199519961997199819992000 No.% % % % % % % KLA00000000006101516 KLP41610331036927163319311617 UKM000000000023910 SJA0000000000581920 UMA416723621927153011181314 UMP1768134311391546183719312223 GMC00000000000000 LWE00000000000000 SJP00001400000000 HUSM00000000000000 ASH00000000000000 HA00000000000000 HPP00000000000000 Others00000000000000 TOTAL25100301002810033100491006210094100

5. Table 1.1.3: Distribution of Patients by Transplant Centre, 1987-2008 KLAHospital Kuala Lumpur, (Adult) KLPHospital Kuala Lumpur, Institute Paediatrics (Paed) UKMHospital Universiti Kebangsaan Malaysia SJASime Darby Medical Centre, Subang Jaya (Adult) UMAUniversity of Malaya Medical Centre (Adult) UMPUniversity of Malaya Medical Centre (Paed) GMCGleneagles Medical Centre, Penang LWELam Wah Ee Hospital, Penang SJPSime Darby Medical Centre, Subang Jaya (Paed) HUSMHospital Universiti Sains Malaysia ASHAmpang Puteri Specialist Hospital HAHospital Ampang HPPHospital Pulau Pinang Year2001200220032004200520062007 No.% % % % % % % KLA20192825362842304530312300 KLP1817201819152216211426192617 UKM121198 914101711972114 SJA1716201823182115231622162114 UMA19181614108 714997128 UMP2220 182016 1113918131611 GMC00000021214321 LWE00000064112111 SJP001197641286453 HUSM00000000000000 ASH00000000001111 HA0000000000864430 HPP00000000000000 Others00000011000000 TOTAL108100114100128100140100148100136100149100 Year 2008Total No.% % KLA 0022315 KLP 291626517 UKM 24131288 SJA 251419713 UMA 17917311 UMP 16934723 GMC 11111 LWE 00101 SJP 42443 HUSM 6360 ASH 0020 HA 57311097 HPP 2120 Others 0010 TOTAL 1811001518100

6. Figure 1.1.3: Distribution of Patients by Centre, 1987-2008 0 10 20 30 40 50 60 70 80 90 100 Number of patients (n) 87888990919293949596979899000102030405060708 Year GMCLWESJPHUSM ASHHAHPPOthers

7. 0 10 20 30 40 50 60 70 80 90 100 Percentage of patients (%) 87888990919293949596979899000102030405060708 Year MaleFemale Table 1.2.1: Distribution of Patients by Gender, 1987-2008 Figure 1.2.1: Distribution of Patients by Gender, 1987-2008 Year19871988198919901991199219931994 Gender No. % % % % % % % % Male 7884671255360758136213681664 Female 1132331045240542838632936 TOTAL 81006 221005 12100211001910025100 Year19951996199719981999200020012002 GenderNo.% % % % % % % % Male 11371554185533673658545766616254 Female 19631346154516332642404342395246 TOTAL 301002810033100491006210094100108100114100 Year200320042005200620072008Total GenderNo.% % % % % % % Male 71558460714880599060995586557 Female 57455640775256415940824565343 TOTAL 1281001401001481001361001491001811001518100

8. Table 1.2.2: Distribution of Patients by Ethnic Group, 1987-2008 Year19871988198919901991199219931994 RaceNo.% % % % % % % % Malay2254671359240433419316936 Chinese563233836360758104810531248 Indian113000000184191500 Bumiputra Sabah 00001500002103164 Bumiputra Sarawak 00000000000021000 Others0000000000150000 TOTAL81006 221005 12100211001910025100 Year19951996199719981999200020012002 RaceNo.% % % % % % % % Malay72382992720413150333547443732 Chinese14471139206124492642485148446557 Indian310621004846788787 Bumiputra Sabah 1300130000331111 Bumiputra Sarawak 00311000000001111 Others51700391212333322 TOTAL301002810033100491006210094100108100114100 Year200320042005200620072008Total RaceNo.% % % % % % % Malay46365137533661455940774258038 Chinese65516345694750375940713969045 Indian659614101181812 71178 Bumiputra Sabah 4396537564148624 Bumiputra Sarawak 437553211153312 Others321121546421383 TOTAL1281001401001481001361001491001811001518100

9. Figure 1.2.2: Distribution of Patients by Ethnic Group, 1987-2008

10. Table 1.2.3: Distribution of Patients by Age Group, 1987-2008 Year19871988198919901991199219931994 Age groupNo.% % % % % % % % 0-945046717775100108315719471144 10-194502335230021762910531144 20-3900000000000000312 40-590000000000000000 ≥600000000000000000 TOTAL81006 221005 12100211001910025100 Mean978667911 SD43334457 Median97.586661011 Minimum22121111 Maximum1510139 141729 Year19951996199719981999200020012002 Age groupNo.% % % % % % % % 0-912401346195821432845272923213026 10-191343124382416331524272928262522 20-3941331151512241220192040373632 40-5913001300711202116152320 ≥600000000000111100 TOTAL301002810033100491006210094100108100114100 Mean131112131723 SD991210151716 Median11 61011182221.5 Minimum3115 months111 month1 Max4137453957616455 Year200320042005200620072008Total Age groupNo.% %.No.% % % % % 0-942332619292040293826251444830 10-1918144129322229212215422336824 20-3947375237503438283523633541928 40-5921161914362425184329472625917 ≥600021114311742242 TOTAL1281001401001481001361001491001811001518100 Mean22232624292822 SD15 16182017 Median22.52023.519282518 Minimum5 months111121 month Maximum52706669686670

11. Figure 1.2.3: Distribution of Patients by Age Group, 1987-2008

12. Table 1.2.4: Distribution of Patients by Primary Diagnosis, 1987-2008 Year 19871988198919901991199219931994 DiagnosisNo.% % % % % % % % Acute leukaemia563467836240184196328 Chronic leukaemia00001512018419211416 Hypoplastic anaemia2250041800433524421520 Erythrocytic disorders00001512018150000 Lymphoma0000000000000000 Solid tumors00000000003141514 Myelodysplasia0000000000001528 Haemoglobinopathy113233732120433419211520 Multiple myeloma0000000000000000 Others00001500180031600 TOTAL81006 221005 12100211001910025100 Year 19951996199719981999200020012002 DiagnosisNo.% % % % % % % % Acute leukaemia10331346113323472845373948444842 Chronic leukaemia5175186 714711131418171917 Hypoplastic anaemia827414515485811127644 Erythrocytic disorders0014000000000011 Lymphoma0000265106 192023212018 Solid tumors1300132458220033 Myelodysplasia0000001200114444 Haemoglobinopathy5175186 2446774487 Multiple myeloma0000000035111144 Others13002651046333333 TOTAL301002810033100491006210094100108100114100 Year 200320042005200620072008Total DiagnosisNo.% % % % % % % Acute leukaemia42334633553743325436623455837 Chronic leukaemia1814221613997755316711 Hypoplastic anaemia541295314101391791389 Erythrocytic disorders22000000001191 Lymphoma28223626342332243523432428319 Solid tumors220021545311342 Myelodysplasia326443431153362 Haemoglobinopathy1713961611 81391161449 Multiple myeloma5432851071611169674 Others656411786532011825 TOTAL1281001401001481001361001491001811001518100

13. Table 1.3.1: Distribution of Patients by Graft Number, 1987-2008 Year 19871988198919901991199219931994 Graft number No.% % % % % % % % 181006 1986480975199018952496 20000291203252101514 30000150000000000 TOTAL81006 221005 12100211001910025100 Year 19951996199719981999200020012002 Graft number No.% % % % % % % % 129972810031944796619891971039511399 21300131212335511 30000131200000000 TOTAL301002810033100491006210094100108100114100 Year 200320042005200620072008Total Graft number No.% % % % % % % 1125981359812598123971219815692139596 23232222222138484 300000011000040 TOTAL1281001381001271001261001231001691001447100 Note: Missing in graft number = 71 patients (5%)

14. Figure 1.3.1: Distribution of Patients by Graft Number, 1987-2008 0 20 40 60 80 100 Percentage of patients (%) 87888990919293949596979899000102030405060708 Year Graft number 1Graft number 2Graft number 3

15. Table 1.3.2: Distribution of Patients by Transplantation Type, 1987-2008 Year19871988198919901991199219931994 Type of transplant No.% % % % % % % % Allogeneic + Syngeneic 81006 2195510012100209518952496 Autologous0000150000151514 TOTAL81006 221005 12100211001910025100 Year19951996199719981999200020012002 Type of transplant No.% % % % % % % % Allogeneic + Syngeneic 29972693278232654471566075697566 Autologous132761817351829384033313934 TOTAL301002810033100491006210094100108100114100 Year200320042005200620072008Total Type of transplant No.% % % % % % % Allogeneic + Syngeneic 8365906491618764755011564101967 Autologous45355036573949367450663649933 TOTAL1281001401001481001361001491001811001518100

16. Figure 1.3.2: Distribution of Patients by Transplantation Type, 1987-2008 0 20 40 60 80 100 120 140 160 180 Number of patients (n) 87888990919293949596979899000102030405060708 Year Allogeneic+SyngeneicAutologous

17. 0 50 100 150 200 250 300 Number of patients (n) KLAKLPUKMSJAUMAUMPGMCLWESJPHUSMASHHAHPPOther Centre Allogeneic+Syngeneic Autologous Table 1.3.3: Type of Transplant by Centre, 1987-2008 Figure 1.3.3: Type of Transplant by Centre, 1987-2008 Type of transplantAllogeneic + SyngeneicAutologousTOTAL Centre No.% % % KLA112111112222315 KLP2362329626517 UKM69759121288 SJA7571222419713 UMA11912541117311 UMP3073040834723 GMC5061111 LWE9110101 SJP38461443 HUSM006160 ASH101020 HA47562121097 HPP002020 Other100010 TOTAL10191004991001518100

18. Table 1.3.4: Source of Stem Cells, 1987-2008 Year19871988198919901991199219931994 Transplant sourceNo.% % % % % % % % Marrow 81006 221005 12100211001910025100 PBSC / Marrow + PBSC 0000000000000000 Cord blood / Marrow + cord 0000000000000000 TOTAL 81006 221005 12100211001910025100 Year19951996199719981999200020012002 Transplant sourceNo.% % % % % % % % Marrow 3010028100247325513760313330283127 PBSC / Marrow + PBSC 000072123472337576174697969 Cord blood / Marrow + cord 0000261223664444 TOTAL 301002810033100491006210094100108100114100 Year200320042005200620072008Total Transplant sourceNo.% % % % % % % Marrow 443430212517 132315201151334 PBSC / Marrow + PBSC 7962101721167810980119801528493962 Cord blood / Marrow + cord 5496751077595664 TOTAL 1281001401001481001361001491001811001518100

19. Figure 1.3.4: Source of Stem Cells, 1987-2008

20. Table 1.3.5: Distribution of Patients by HLA Match, 1987-2008 Year19871988198919901991 HLA MatchNo.% % % % % Identical81006 211005 12100 1 AG0000000000 2 AG0000000000 ≥3 AG Disparate0000000000 TOTAL81006 211005 12100 Year19921993199419951996 HLA MatchNo.% % % % % Identical201001810023962910026100 1 AG0000140000 2 AG0000000000 ≥3 AG Disparate0000000000 TOTAL2010018100241002910026100 Year19971998199920002001 HLA MatchNo.% % % % % Identical25933197409152936992 1 AG2700370045 2 AG0013124711 ≥3 AG Disparate0000000011 TOTAL2710032100441005610075100 Year20022003200420052006 HLA MatchNo.% % % % % Identical70937894839286958193 1 AG3434334445 2 AG2322441122 ≥3 AG Disparate0000000000 TOTAL7510083100901009110087100 Year20072008Total HLA MatchNo.% % % Identical68911028995394 1 AG4576384 2 AG2365263 ≥3 AG Disparate110020 TOTAL751001151001019100

21. Table 1.3.6: Distribution of Patients by Allogeneic Donor Relationship, 1987-2008 Year19871988198919901991 Allogeneic Donor RelationshipNo.% % % % % Sibling81006 211005 1192 Unrelated0000000000  Marrow 0000000000  PBSC / Marrow + PBSC 0000000000  Cord blood / Marrow + cord 0000000000 Others0000000018 TOTAL81006 211005 12100 Year19921993199419951996 Allogeneic Donor RelationshipNo.% % % % % Sibling201001810022922910026100 Unrelated0000000000  Marrow 0000000000  PBSC / Marrow + PBSC 0000000000  Cord blood / Marrow + cord 0000000000 Others0000280000 TOTAL2010018100241002910026100 Year19971998199920002001 Allogeneic Donor RelationshipNo.% % % % % Sibling2696321004410055987296 Unrelated1400001234  Marrow 0000000000  PBSC / Marrow + PBSC 0000000000  Cord blood / Marrow + cord 110000001 3 Others0000000000 TOTAL2710032100441005610075100 Year20022003200420052006 Allogeneic Donor RelationshipNo.% % % % % Sibling71958096819083917687 Unrelated4534910891113  Marrow 0000111225218  PBSC / Marrow + PBSC 000022211319  Cord blood / Marrow + cord 41003 667563873 Others0000000000 TOTAL7510083100901009110087100 Year20072008Total Allogeneic Donor RelationshipNo.% % % Sibling65871028995394 Unrelated1013 11636  Marrow 110006  PBSC / Marrow + PBSC 2205381117  Cord blood / Marrow + cord 7708624673 Others000030 TOTAL751001151001019100

22. Table 1.4.1: Distribution of Patients by Cause of Death, 1987-2008 Year19871988198919901991 Cause of deathNo.% % % % % Sepsis11000000001 GVHD00000011700 Underlying disease0000610058300 Haemorrhage001100000000 VOD0000000000 Organ Failure0000000000 Interstitial pneumonitis0000000000 Secondary malignancy0000000000 Others0000000000 Unknown0000000000 TOTAL11001 6 6 1 Year19921993199419951996 Cause of deathNo.% % % % % Sepsis150222120424655 GVHD00000042400 Underlying disease00667360318327 Haemorrhage001110021219 VOD0000001619 Organ Failure1500012021200 Interstitial pneumonitis0000000000 Secondary malignancy0000001600 Others0000000000 Unknown0000000000 TOTAL21009 5 1710011100

23. Table 1.4.1: Distribution of Patients by Cause of Death, 1987-2008 Year 19971998199920002001 Cause of death No.% % % % % Sepsis 533166382649 GVHD 00212162649 Underlying disease 960116574422713370 Haemorrhage 00160031024 VOD 0000001324 Organ Failure 1700160000 Interstitial pneumonitis 0016001324 Secondary malignancy 0000000000 Others 0000160000 Unknown 0016000000 TOTAL 1510017100161003110047100 Year 20022003200420052006 Cause of death No.% % % % % Sepsis 618152711211321819 GVHD 395991771125 Underlying disease 21623155275230492867 Haemorrhage 0000242312 VOD 0000000037 Organ Failure 3924001200 Interstitial pneumonitis 0012002300 Secondary malignancy 0000000000 Others 0000003500 Unknown 1324363500 TOTAL 3410056100521006110042100 Year 20072008Total Cause of death No.% % % Sepsis 612142010719 GVHD 12710489 Underlying disease 2754365130856 Haemorrhage 1234204 VOD 0034112 Organ Failure 0000122 Interstitial pneumonitis 001181 Secondary malignancy 000010 Others 112257204 Unknown 4823163 TOTAL 5010071100551100

24. Figure 1.4.1: Patient Survival by Year of Transplant, 1987-2008 Figure 1.4.2: Patient Survival by Gender, 1987-2008

25. Figure 1.4.3: Patient Survival by Age Group, 1987- 2008 Figure 1.4.4: Patient Survival by Type of Transplant, 1987-2008 0.00 0.25 0.50 0.75 1.00 Cumulative survival 01234567891011121314151617181920 Duration in years 0-9 years10-19 years 20-39 years≥40 years

26. Figure 1.5.1: Disease-free Survival for Acute Myeloid Leukaemia, 1987-2008 (Allogeneic vs. Autologous)

27. Figure 1.5.2: Disease-free Survival for Acute Lymphoblastic Leukaemia, 1987-2008 (Allogeneic)

28. Figure 1.5.3: Disease-free Survival for Thalassaemia, 1987-2008 (Allogeneic)

29. Figure 1.5.4: Disease-free Survival for Non-Hodgkin’s Lymphoma, 1987-2008 (Allogeneic vs. Autologous)

30. Figure 1.5.5: Disease-free Survival for Hodgkin’s Disease, 1987-2008 (Autologous)

31. Figure 1.5.6: Disease-free Survival for Chronic Myeloid Leukaemia, 1987-2008 (Allogeneic)

32. Figure 1.5.7: Disease-free Survival for Aplastic Anaemia, 1987-2008 (Allogeneic)

33. Figure 1.5.8: Disease-free Survival by Age Group for Acute Myeloid Leukaemia, 1987-2008 Pediatric is defined as age  18 years and adult age >18 years.

34. Figure 1.5.9: Disease-free Survival by Age Group for Acute Lymphoblastic Leukaemia, 1987-2008 Pediatric is defined as age  18 years and adult age >18 years.

35. Figure 1.5.10: Disease-free Survival by Age Group for Thalassaemia, 1987-2008

36. Figure 1.5.11: Disease-free Survival by Age Group for Non-Hodgkin’s Lymphoma, 1987-2008 Pediatric is defined as age  18 years and adult age >18 years.

37. Figure 1.5.12: Disease-free Survival by Age Group for Hodgkin’s Disease, 1987-2008 Pediatric is defined as age  18 years and adult age >18 years.

38. Figure 1.5.13: Disease-free Survival by Age Group for Chronic Myeloid Leukaemia, 1987-2008

39. Figure 1.5.14: Disease-free Survival by Age Group for Aplastic Anaemia, 1987-2008 Pediatric is defined as age  18 years and adult age >18 years.