A new unit at St James's Hospital is helping to bring cutting-edge researchto leukaemia patients, writes Dr Muiris Houston.
When the Taoiseach, Bertie Ahern, opened the John Durkan Leukaemia Laboratories at St James's Hospital in Dublin at the start of the summer it marked the culmination of many people's dreams.
For Profs Shaun McCann and Mark Lawler it was the realisation of an idea to build a facility dedicated to molecular-medicine research on the hospital site. For the family of John Durkan, who died from leukaemia, it offered the opportunity to commemorate his life and advance the care of people with cancer of the blood. Durkan was a noted horse trainer who spotted the potential of Istabraq, the three-time Cheltenham champion hurdler. The Bone Marrow for Leukaemia Trust also made a significant contribution to the development.
As one of the first research laboratories to be situated in the grounds of a hospital, as part of Trinity College's Centre for Health Sciences, the Durkan leukaemia unit is a testament to the concept of "bench to bedside". In other words, it is part of a process that seeks to integrate the latest research with patients undergoing treatment.
As he shows off the 4,500 square metre facility that houses the Institute of Molecular Medicine and the Durkan laboratories, Prof Lawler, the laboratories' scientific director, says it has two main aims. "We hope to better understand haematological malignancies while at the same time contributing to new diagnostic tests and treatments."
One such test is used to assess a patient's response to a bone-marrow transplant, a treatment for leukaemia. DNA fingerprinting to assess the mix of circulating blood cells helps predict whether a patient may be at risk of relapse after a bone-marrow transplant. Under the direction of Prof McCann St James's Hospital is the national centre for such transplants.
In another laboratory researchers are working on the Children's Leukaemia Research Project. A collaboration with Our Lady's Hospital for Sick Children in Crumlin and the oncology and haematology consultants there, it is looking at the genetic profile of children with leukaemia in the Republic. It hopes to identify early molecular markers of disease response that will help decide when treatment is complete and identify who may require more intensive therapy.
Bone marrow is the factory in the body that produces blood cells. Leukaemia, a type of cancer affecting the bone marrow, was originally divided into acute and chronic forms of the disease. The advent of molecular-diagnostic techniques, such as those in everyday use at the Durkan laboratories, means more than 15 types of acute lymphoblastic leukaemia have been identified, based on different pathways within the diseased cell.
Some 80 per cent of children with acute leukaemia can expect to be cured with standard chemotherapy and radiotherapy. The remaining patients will be offered bone-marrow transplants.
The ideal donor is a sibling who shares the same genetic make-up as the patient. If this does not work out, Dr Emer Lawlor of the Irish Blood Transfusion Service has access to a world panel of eight million potential donors. "We have an 80-90 per cent chance of finding a donor who is a match," says Prof McCann.
Aidan Bermingham (42), a self-employed businessman involved in automotive engine management, remembers his transplant in 1994. After six months of night sweats and feeling run-down he was diagnosed with chronic myeloid leukaemia. Unable to secure a suitable donor from those in his family tree, the world marrow bank came up with two suitable matches, one in Dublin and the other in Norway.
"My transplant went ahead on February 24th, 1994, using the Irish donor, who remains anonymous to this day," he says. After a week of preparation Bermingham was given whole-body irradiation while the donor's bone-marrow cells were prepared for infusion into his blood.
"I was in isolation for a month. I never believed you could be so sick," he says of the time when he was unable to eat because of a constant threat of infection. He remembers the daily expectation while waiting for the first neutrophil - a white blood cell - to appear, confirming that the transplant had "taken". Then, once the precious first cell appeared on a blood test, he was able to eat. "A Marietta biscuit was the first food I held down."
A few steps from the Durkan laboratories, the Eugene Murray transplant unit is a high-tech place. Complete with 21 "positive pressure" single rooms and all modern techniques to prevent cross-infection, this is where transplant patients are looked after. Because of the long isolation period, Prof McCann says they hope to equip every ward with full sound and video-projection facilities, to enable patients to experience some of the sights and sounds of the outside world.
There has been huge progress since the first bone-marrow transplant was carried out, in somewhat more primitive surroundings, in 1984. Cancer molecular diagnostics, a flagship project for St James's Hospital, has been developed through the cancer strategy group at the hospital. Very much the cutting edge of modern cancer treatment, cancer molecular diagnostics is based on the knowledge that cancer involves changes in cells' genetic make-up. These can be detected using a variety of techniques that examine the genes of cancer cells.
From a practical point of view, this helps improve the accuracy of diagnosis and helps doctors decide both when and how to intervene. Looking forward, cancer molecular diagnostics helps to increase our understanding of the mechanism of cancer development and facilitate new approaches to treatment.
With St James's Hospital the largest provider of acute cancer care in the State, it is entirely appropriate that the molecular-medicine facility incorporating the Durkan laboratories is located here.
"It is a great national facility and morale-booster for the hospital," says Prof McCann. Prof Lawler agrees: "It is so important to link the research strategies of the hospital and the university."
Digging up the past
When the foundations of the Durkan laboratories were being dug the contractors came across evidence of an old building. Dúchas, the heritage service, helped to confirm that the ancient walls and chambers were of Dublin's Foundling Hospital, dating from 1704.
According to Davis Coakley, professor of geriatric medicine at St James's Hospital, who is writing a history of the hospital, a workhouse, or institution for the relief of the poor, was built first. Located at the James's Street entrance to the present hospital, the Foundling Hospital opened in 1727 as part of the workhouse. One of its aims was to prevent "the exposure, death and actual murder of illegitimate children".
To facilitate the anonymous abandonment of infants a turning wheel was erected on the outer wall of the hospital. The baby was laid in a basket and a bell rung; then the gate porter turned the wheel and received the child, prevented from seeing who had abandoned it.
It is estimated that 200,000 infants passed through the cradle over the next 130 years.
The Foundling Hospital walls were preserved during the construction of the new laboratories. Although they are not open to the public, consideration is being given to commemorating the original hospital.