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MGH to begin replacing hands

New approach to transplants; will be Hub’s 2d program

Pat Greenhouse/Globe Staff

James Barrows met with Dr. Curtis L. Cetrulo at Mass. General for a pretransplant workup. With him was his son, Jarel, 3.

Massachusetts General Hospital is launching Boston’s second hand transplant program, hoping eventually to pioneer a new way of replacing patients’ limbs without subjecting them to a lifetime of dangerous antirejection drugs — an advance that could turn a rare operation into a routine one.

The idea is to transplant a donor’s bone marrow along with the hand to trick the recipient’s immune system into accepting the donated hand as its own. The hospital has had early success with this experimental approach with certain kidney transplant patients.

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If it works with hands, these transplants could become more attractive to thousands of amputees — many of them veterans of recent conflicts — because they wouldn’t have to take medications that suppress the body’s defenses against infection.

Initially, Mass. General will do conventional hand transplants using antirejection drugs, while doctors prepare to test the new approach.

“We are starting a revolution in reconstructive surgery,’’ said Dr. Curtis Cetrulo, a plastic surgeon and senior investigator at the Transplantation Biology Research Center. “It’s a very exciting time.’’

Brigham and Women’s Hospital, which like Mass. General is part of the Partners HealthCare network, has done two double-hand transplants since June, one of which was successful. Leaders of the two hospitals said that offering the procedure at both facilities will not add extra costs to the health care system. They said they are not building new operating rooms or hiring new surgeons, but using existing resources.

“This is not an example of costs out of control in health care. We’re not making a major capital investment,’’ said Dr. Peter Slavin, Mass. General chief executive.

‘We are starting a revolution in reconstructive surgery.’

Dr. Curtis Cetrulo Transplantation Biology Research Center
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Dr. Michael Zinner, Brigham surgery chief, said the two hospitals, which run a joint plastic-surgery training program, are consulting each other on best approaches for hand transplant surgery and rehabilitation. “We see this program as collaborative, not competitive,’’ he said.

About 70 patients worldwide have received hand transplants, including at least 16 in seven US hospitals, while many more are developing programs. All have been done the conventional way, with patients having to take antirejection drugs so that their immune systems don’t attack the transplanted tissue.

Mass. General doctors plan to minimize the levels of drugs for their initial patients by using sensitive immune monitoring techniques developed at the hospital.

Slavin has approved the use of hospital funds for hand transplants on up to five patients. The surgery and hospital stay will probably cost between $100,000 and $200,000 and is not covered by insurance.

Mass. General doctors, nurses, and social workers are evaluating patients, including James Barrows, 49, of Woburn, whose shirt sleeve got caught in a meat grinder at work, pulling in his right hand.

“When I lost my hand I really felt I lost myself as a man,’’ he said. “To take my wife out for steak dinner, my wife would have to cut up my food for me.’’

The drugs Barrows will take can have debilitating side effects, such as warts, cataracts, and increased risks of heart disease, diabetes, kidney failure, and serious infections.

Transplant patients who receive new hearts, livers, lungs, and kidneys also face these risks, but they are especially problematic for patients considering hand transplants. They don’t need the surgery to save their lives. And they can use a prosthesis to pick up objects, although, Cetrulo said, prosthesis don’t allow a person to feel the things they touch.

Also, many amputees are young adults “with a whole life ahead of them,’’ and therefore would spend decades on the powerful drugs, said Dr. David Sachs, who pioneered the unorthodox bone marrow transplant approach in kidney transplant patients.

“The more we can minimize the risk, the more likely (hand transplants) will be a worthwhile operation do to,’’ said Sachs, who is director of the Transplantation Biology Research Center.

The marrow produces immune cells that identify whether tissue is the patient’s own, so in theory, transplanting the donor’s marrow should result in the recipient’s immune system identifying the transplanted hand as its own.

Sachs said 7 of 10 kidney transplant patients who have undergone a simultaneous bone marrow transplant at Mass. General have developed tolerance for the new organ and do not require antirejection drugs.

This approach can be difficult for patients to tolerate, however, and it will be more difficult to make work in hand transplant patients.

Five days before transplant surgery, patients begin to undergo low-dose chemotherapy to kill off some of their marrow cells and make room for injection of the donor’s bone marrow. The patients also receive a drug and radiation to the thymus to eliminate a type of immune system cell, known as a T cell, that typically attacks any tissue perceived as foreign.

On the day of the procedure, surgeons attach the new kidney while injecting the donor’s bone marrow into a blood vessel in the patient’s arm.

Kidney transplant patients who have undergone it have received an organ from a living donor, meaning doctors are able to schedule the surgery and begin preparations in advance. Hands will come from deceased donors and the timing will be unpredictable.

In his lab, Sachs is studying whether it’s possible to store the donor’s bone marrow and inject it after the transplant — an approach doctors hope will be ready to test in patients in one to two years.

Cetrulo said it is unclear how many amputees could benefit from a hand transplant. There are as many as 450,000 upper extremity amputees in the United States, he said, and thousands of the 44,000 veterans wounded in Iraq and Afghanistan are amputees.

Sachs and Cetrulo have met with members of Congress and the Department of Defense numerous times. Mass. General and the Brigham have also applied for a $2 million grant from the Defense Department to pay for hand transplant patients at Mass. General to undergo bone marrow transplantation to induce tolerance for the donated hand.

“The military is really very enthusiastic about this,’’ Cetrulo said.

Barrows, the former meat cutter, said he is not daunted by the antirejection drugs.

At the time of his injury in March 2005, Barrows had stayed late at the Mayflower Poultry Co. in Cambridge to fill a special order. As he was feeding a chicken into the meat cutter, the machinery pulled in his sleeve and then his right hand up to the wrist.

Firefighters cut off the front of the machine and rushed Barrows to Mass. General with the rest of the meat cutter attached to his hand. The pressure from the metal parts had stopped the bleeding.

After emergency surgery and a monthlong hospital stay, Barrows said he barely left home for two years because he “couldn’t deal with the way people looked at me.’’ He opted against a prosthesis because he didn’t want to draw further attention to his disfigured arm.

Barrows, who was right-handed, tries to write with his left hand, though at times his writing looks like that of a preschooler, he said. He needs help showering and shaving. He has gone back to work, as a delivery truck driver.

Barrows has two sons, ages 3 and 1. “My number one goal after this is done,’’ he said, “is I want to pick my children up with two hands.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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