Autologous Stem Cell Transplant Process

An autologous stem cell transplant is a multi-step process:

Step One: Pre-transplant evaluation
Step Two: Central venous catheter placement
Step Three: Mobilization therapy
Step Four: Stem cell collection
Step Five: High-dose therapy
Step Six: Stem cell transplant
Step Seven: Awaiting engraftment
Step Eight: Recovery

Introduction


What is a stem cell transplant?
Your oncologist has recommended that you receive very high-dose therapy to treat your cancer. This will include high-dose chemotherapy and possibly total body irradiation (TBI). This will destroy cancer cells, but unfortunately the treatment cannot tell the difference between cancerous cells and healthy cells.

The high-dose therapy destroys many types of cells that divide and reproduce rapidly, including healthy cells that produce red blood cells, white blood cells, and platelets. Without these blood cells, the risk exists for infections, bleeding problems and lower amounts of oxygen in the blood.

Your own stem cells can be collected before the high-dose therapy is given and returned to you intravenously afterwards to replace the stem cells that were destroyed. These stem cells may come from either the peripheral blood or bone marrow.

What is a stem cell?
A stem cell is the cell from which all blood cells develop. Blood cells are essential to life. The different types of blood cells are red blood cells, white blood cells, and platelets.
 
White blood cells
White blood cells are the body's primary defense against infections. They are produced mainly in the bone marrow. White blood cells divide rapidly, have a relatively short life span and are very sensitive to therapy. While receiving high-dose chemotherapy, your white blood cell count will drop below normal.

  • Normal White Blood Cell Count:  3,000 to 10,000.

Red blood cells
Red blood cells carry oxygen to the body's cells and tissues. When your red cell count is low, you may be considered anemic. The bone marrow is responsible for producing red blood cells. They generally live approximately 120 days. Because of their long life span, they are less affected by the high-dose therapy. Other measurements of red blood cell function are the hemoglobin and hematocrit. The hemoglobin is often used to determine whether you will need a red blood cell transfusion.

  • Normal Red Blood Cell Count:  3.8 to 5.9 million
  • Normal Hemoglobin:  12 to 17 grams
  • Normal Hematocrit:  35 to 51

Platelets
Platelets are small cells with a relatively short life span. They are produced in the bone marrow and help form clots that stop bleeding when tissues are damaged. While receiving high-dose therapy, your platelet count will also drop below normal.

  • Normal Platelet Count:  140,000 to 420,000

What is the difference between bone marrow transplant and stem cell transplant?
A peripheral blood stem cell transplant is done to replace the same type of cell (stem cell) that is replaced in a bone marrow transplant. The difference is the method of stem cell collection.

To collect or "harvest" bone marrow stem cells for a bone marrow transplant, the patient is taken into the operating room and given general anesthesia. A needle can be inserted into the pelvic (hip) bones to draw out the bone marrow.  This is repeated until enough bone marrow is obtained for the transplant. The area from which the marrow is drawn may be sore for several days.

In contrast to a bone marrow harvest, stem cell collection is done without general anesthesia, involves little discomfort, can be performed in an outpatient setting, and offers a faster recovery.

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Step One: Pre-transplant evaluation

Before your stem cells are collected, your oncologist or transplant physician will order diagnostic tests to determine if you should proceed with the transplant. Depending on the type of cancer you have, these tests may include X-rays, CT scans, PET imaging, MRIs, bone scans, blood tests, urine tests, heart scan, EKG, and lung function tests. 

You will also undergo one or two marrow sampling tests to determine if the cancer involves your bone marrow and the extent of the involvement. Other tests will be done to evaluate your general physical condition. High-dose chemotherapy places extra stress on your body. Minor problems that may not be readily apparent can cause major complications after high-dose chemotherapy.

You will also be asked to have a dentist check your teeth if this has not been done recently.

Before mobilization, your history and evaluation will be reviewed by a transplant committee, and you will meet with a transplant coordinator and social worker. After this evaluation, your doctor will review treatment options with you. You will be given an opportunity to ask any additional questions you may have and if you decide to proceed with the transplant, you will be asked to sign a consent form.

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Step Two: Central venous catheter placement

A central venous catheter (CVC) is a flexible, hollow tube made of soft silicone. A surgeon or radiologist places the catheter through the skin and into a vein in the chest or neck. The tip of the catheter is threaded through the vein to a point just above the heart. There will be a catheter exit site on your chest, and several inches of the catheter will remain outside of the body.

The external portion of the catheter will have two or three ports, or lumens, that have special connectors on the ends that can be used to draw blood for lab tests and to administer chemotherapy, medications, IV fluids and blood products.

When not in use, a CVC must be flushed regularly with a heparin solution in order to keep the catheter open. Instructions on how to care for the catheter will be provided to patients and caregivers.

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Step Three: Mobilization therapy

Mobilization is the process used to increase the number of stem cells in the peripheral blood. Two common methods of mobilization are chemotherapy and growth factors, or growth factors alone.

Growth factors (such as Neupogen) are human proteins that the body normally produces to increase blood cell production. As the stem cells in the bone marrow begin producing more blood cells, increased numbers of stem cells are also produced and released into the blood stream. Growth factors are given daily for three to 14 or more days. You may receive it in the clinic or hospital. 

The most common side effect of growth factor is mild-to-moderate bone pain or fever, which can often be controlled with Tylenol (acetaminophen). You may also experience a fever when taking growth factors. Always inform your doctor if you have a fever.

If you receive chemotherapy as part of mobilization, you may receive it in the clinic where you received your other chemotherapy treatments or in the hospital. This chemotherapy may be the same as your other chemotherapy treatments or may be stronger. If it is stronger, you may experience different side effects and may have different instructions for taking care of yourself after the chemotherapy. Your doctor and nurse will explain the chemotherapy treatment and how you should care for yourself.

After you have received a certain number of doses of the growth factor or when your white blood cell count reaches a certain level, it will be time to start collecting stem cells from your blood. Your blood counts may be checked every day or two to determine when to start stem cell collection. Your doctor or nurse will let you know when it is time to start the collection. If you do not already have a CVC, one may be inserted now.

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Step Four: Stem cell collection

The collection of stem cells (apheresis) is a painless procedure that takes about four hours. During the procedure, you may relax in bed, watch television, listen to tapes or read. Your blood will be withdrawn through your CVC and circulated through a cell-separating machine. This machine separates and collects white blood cells, including the stem cells, along with a few red blood cells and platelets. The remaining blood cells are returned to you through your CVC. Only a small amount (about 1 unit) of your blood is in the separator machine at any one time. Your blood is returned to you at the same rate it is removed.

Sometimes patients have a little dizziness, numbness, tingling, chilling, or lightheadedness during the procedure. These symptoms are caused by a substance that  keeps the blood from clotting as the cells are collected. If you notice any of these symptoms during the collection procedure, tell your transplant or pheresis nurse immediately. These symptoms can be managed by temporarily slowing or stopping the procedure, giving you some calcium, or covering you with warm blankets. 

You may need to undergo several collection procedures before enough stem cells are collected to give back to you after your high-dose chemotherapy. These collections are usually performed daily. It is a good idea to eat a normal meal before collection and include calcium-rich foods (milk, yogurt, or cheese for example). These foods can help prevent some of the side effects of the procedure.

Lab tests are done each day on the cells to check how many have been collected. The cells are frozen and stored in separate bags under special conditions until they are needed for your transplant.

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Step Five: High-dose therapy

High-dose therapy will include high-dose chemotherapy and sometimes total body irradiation (TBI). The purpose of this therapy is to destroy cancer cells with higher doses of chemotherapy than are used in standard chemotherapy treatments. 

Chemotherapy treatment plans vary with the type of cancer, its stage, and the treatment protocols being used. These chemotherapy drugs may be given in the outpatient clinic or hospital. The treatment lasts several days. The daily treatment may take up to eight hours and requires the administration of large amounts of fluid. 

Some of the drugs used to prevent nausea and vomiting may make you drowsy or forgetful. Your caregiver is welcome to remain with you as long as he/she desires. If you are in the outpatient clinic  your caregiver should plan to spend time with the nurses to receive final instructions. Your caregiver will need to drive you home after your chemotherapy treatment.

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Step Six: Stem cell transplant

Your transplant day is the day your stem cells are given back to you. This will occur 24-72 hours after the high-dose chemotherapy is completed. Several staff members will help you during this time, including nurses and laboratory technicians. Your caregiver may also be with you.

You may notice some chilling, nausea, fever, cough, flushing, headache, abdominal cramps or diarrhea. Your nurse will give you medication to decrease these effects.

Although a stem cell transplant sounds dramatic, the actual procedure is simple. The stored frozen cells will be thawed in warm sterile saline and infused through your CVC. During the cell infusion, you may notice a garlic-like odor and taste. Sucking on hard, candy may decrease this taste if you find it unpleasant. 

The cause of this odor is the preservative DMSO (Dimethyl sulfoxide), which is used during the freezing process to prevent ice crystals from damaging the cells. The odor, which may be detected in your breath, urine, stool, saliva, and perspiration, will be noticeable to those around you for one to two days after the infusion and will then disappear.

Additionally, your urine turns a reddish-burgundy color following the infusion. This is due to the painless passing of red blood cells that may have been contained in the stem cell infusion. Your urine will return to its normal color in one to two days.

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Step Seven: Awaiting engraftment

The high-dose therapy can cause a variety of side effects as it destroys normal cells in addition to cancer cells. Some of these side effects may be apparent during the chemotherapy or immediately afterward. Other side effects may not occur until days, weeks, or even months later. 

Your body will begin to repair the damage from the high-dose therapy as soon as it occurs, but the repair efforts will be more effective once your blood counts have recovered. You and your caregiver will be taught how to treat and relieve these side effects.

You will need careful monitoring until you recover from most of the side effects of the high-dose therapy and your stem cells begin to grow. You will have lab work done and will be seen by a doctor daily.

The most common side effect of the high-dose therapy is low blood cell counts. You will be supported with red blood cell transfusions and platelet transfusions until your body  makes enough of these cells on its own. You also may receive injections of a growth factor to stimulate the growth of your stem cells.

Because your white blood cells will be low, you will be at risk for infections and will be given antibiotics to prevent or control these. While your white blood cell count is low, it is very important for you and your caregiver to practice good hygiene habits.

One to three weeks after your transplant, we expect to see signs that your stem cells are growing (engrafting) and beginning to produce blood cells. As this starts to occur, you may notice aching in your bones, especially your pelvis, lower back and thighs. As your blood counts begin to rise, your white blood cells will start to fight and prevent infections. If you have had fevers while your white blood count was low, they may get better now. 

Your doctor or nurse will let you know when you can stop taking antibiotics and relax some other restrictions. Remember, it is a good idea to wash your hands often regardless of your white blood count. Transfusions will no longer be needed, and other side effects you may have experienced will resolve.

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Step Eight: Recovery

Progress during this phase of treatment may seem slow. Keep in mind that the long-term recovery phase may take a year or more. You may feel frustrated because you want to get well rapidly and put this experience behind you. Everyone feels some fatigue and many patients feel depressed during this period. 

Community support groups and other transplant recipients are good sources of support. You may ask your nurse or doctor for names of transplant recipients who are willing to talk with you about their transplant experience.

Despite feeling fatigued, it is important to stay as active as possible. You will need to identify which activities are most important for you. (In other words, pace yourself). Low impact exercise such as walking may help you regain your energy level.  Please remember that all patients will have some fatigue. This may persist for several months after transplant. 

Your doctor or nurse will let you know when tests (blood tests, X-rays, scans) will be done to measure the effects of the high-dose therapy and the results of the transplant. The transplant team will monitor you closely after your treatment.