By Juraj Koska

Thomas was feeling better every day since coming home from the hospital on Christmas Eve. He hiked several peaks in the North Valley without any problem and his appetite was also improving. Twice a week he was coming back to the clinic for labs. The tests showed steady increases in blood counts with some numbers being very close to the pre-relapse time. Thus, we were cautiously optimistic about the effect of CAR T-cells, hoping that the leukemia was gone, and the lights would finally turn green for the bone marrow transplant. The team of doctors had very similar expectations and scheduled an extensive battery of typical pre-transplant examinations even before confirmation by a bone marrow biopsy. Thomas had an appointment at Mayo Clinic to see a radiation specialist and take all the necessary measures for the radiation treatment that is part of pre-transplantation bone marrow conditioning. He had CT scans of his sinuses and lungs, an echocardiography of his heart, EKG, detailed test of lung function, an examination of kidney function using radioactive dye, and a hearing test. Finally, on January 11^th he had a bone marrow biopsy and spinal tap. We were told that the results wouldn’t be available until early the next week.

Further prolonging the wait, MLK day fell on that Monday and the next scheduled appointment was not until Wednesday. Even on Wednesday morning, the results were still not available. Since they are done by the University of Washington lab, we wondered if there was some extended bereavement period still going on following the CFP Nationals. In the early afternoon, we received a call from the doctor that the biopsy was negative, and we had to come back the next day to sign the transplant paperwork. That was the best news since August. The next day, we met the team and were told the detailed plan. Coincidentally on the same day, at some other place in the US or the world (we were not told), the stem cells for Thomas’ new bone marrow were collected from the donor. Prior to receiving them, Thomas’ bone marrow has to be “conditioned”, i.e., completely and irreversibly wiped out. This will require several types of treatments, including an antibody (from a rabbit) to deplete his own T-Lymphocytes (both natural and CAR T-cells) for 3 days, very strong chemotherapy with cyclophosphamide to destroy other bone marrow cells for 2 days, and a final “sweep” with radiation for 3 days. For the last one, he will be transported to Mayo Clinic twice a day. There will be severe side effects, similar or even stronger than he already had previously, including nausea, fever or general weakness, yet we know that there is a light at the end of the tunnel.

The conditioning starts on January 24^th and will be completed on January 31^st. Thomas will get 1 day “rest” on February 1^st and receive his new blood stem cells on February 2^nd. There will be other medications he will take to help these new cells to survive in his body, to find home within his bones and to start producing blood elements. This may take several weeks and there will be more side effects. Thank God the CAR T-cells were effective and during the last 4 weeks he was able to regain the physical strength to better cope with many of them. We have never doubted his mental determination and during the last five months he’s shown an immense trust in God’s will.