IBMT: FAQ - Autologous Stem Cell Transplant Process

Autologous Stem Cell Transplant Process

You are considered a potential candidate for an autologous stem-cell transplant. In this pamphlet we will try to explain the why and how of such a procedure.

Why A Stem Cell Transplant?

Most patients undergoing an autologous stem-cell transplant are suffering from a malignant disease that is sensitive to chemotherapy. It is believed that administering a much higher dose of chemotherapy will result in a better chance of your cancer remaining in remission. Hopefully, a long remission will ultimately lead to a cure for your disease.

To treat your cancer more intensively, higher doses of chemotherapy are needed. Radiation of a part of your body, or of your entire body (TBI = Total Body Irradiation), may also be part of the treatment. Both the high-dose chemotherapy and the radiation will suppress and damage your bone marrow. Inside the bone marrow reside the stem cells, which are the "mother" cells that can produce all the cells that you find in your blood: the red cells, platelets, and white cells. High-dose chemotherapy and/or radiation lead to damage of the stem cells, resulting in low levels of red cells, platelets, and white cells. Consequently, the patient is at risk for anemia, bleeding, and infection. A stem cell transplant is done to restore the stem cells, which in turn can produce sufficient white cells, platelets, and red cells to protect you from long-term complications.

Why An Autologous Stem Cell Transplant?

In your case, your physicians feel that the use of your own stem cells would be more beneficial than the use of stem cells from a donor. Many factors are considered when selecting an autologous or an allogeneic stem cell transplant. In general, an autologous stem cell transplant is safer and simpler than an allogeneic (donor) stem cell transplant. Autologous transplants rely completely on the efficiency of the chemotherapy and radiation ("preparative regimen") to kill the cancer cells. Since the donor and the recipient are the same (=you!), no immunological differences exist. The new stem cells will not attack the cancer, but they won't attack your body either!

For What Diseases Are Autologous Stem Cell Transplants Used?

The most common indications for autologous stem cell transplants are:

malignant lymphoma and Hodgkin's disease
multiple myeloma
leukemia (acute myelogenous, acute lymphocytic)
breast cancer
ovarian cancer
testicular cancer
neuroblastoma
certain sarcomas and brain tumors

How Is An Autologous Stem Cell Transplant Done?

The first step is to obtain sufficient stem cells for transplant. Currently, stem cells are mostly obtained from the blood stream ("peripheral blood stem cells"). In order to push stem cells from the bone marrow to the blood stream, a "mobilization treatment" is done.

You will either receive daily injections (like insulin shots) of a growth factor (e.g, Neupogen®) for four days, followed by daily stem cell collections, or you will receive moderately high-dose chemotherapy, followed by daily injections of a growth factor. In the latter case, collections will not start until 11-14 days after the chemotherapy. In the meantime, your white cells and platelets may be very low, and you are at risk for infection and bleeding. Collections will be done with an "apheresis machine", which is a blood separator (see Apheresis pamphlet). The same machine is used to obtain platelets or plasma at blood centers. You will be connected to the machine through a large-bore catheter, which will be inserted on the first day of collections. Each collection takes 3-5 hours. Side-effects are rare and mostly minor. To obtain sufficient stem cells, between 2 and 5 daily collections are necessary. Each collection will be checked for its stem cell content (CD34⁺ cells), and once the threshold goal is reached, the collection process is stopped.

Once sufficient stem cells have been collected, the patient is ready for the start of the actual transplant therapy. Depending on the disease, either 3 days of radiation (TBI) are given, followed by 1-4 days of chemotherapy, or only 2-6 days of chemotherapy are used. The radiation is given twice a day for a total of six doses. The chemotherapy may consist of only one drug, or of a combination of drugs. Your IBMT physician will discuss with you which drugs will be used, and give you a calendar precisely indicating which drugs will be given and when. Most chemotherapy drugs are given by intravenous infusion. Many additional drugs will be administered during the days of radiation and chemotherapy. Some are meant to prevent nausea from chemotherapy, some to prevent infections, others to prevent complications from the chemotherapy drugs. Many are given by mouth, some are given by vein. You will also receive lots of fluid by vein to remove the waste products as rapidly as possible.

Two days after the last chemotherapy, your stem cells will be re-infused. After collection, the stem cells were stored in bags in liquid nitrogen to keep them viable. Now they will be thawed at the bedside in a water bath, until they are liquid again. Then the stem cells will be slowly injected with a syringe into your central line. The process lasts 15-30 minutes. Possible side-effects include allergic reactions to DMSO, a chemical added to the stem cells to prevent damage during freezing. The possible allergic reactions are quite benign, and can often be prevented or treated with drugs such as Benadryl^®. All patients will smell the "garlic-like" smell of DMSO for a while.

After the re-infusion of stem cells, the wait is on for the growth of new blood cells. It takes about 8-10 days before the first white cells re-appear. In the meantime, the "old" blood cells will start dying off, and patients will be prone to infections and bleeding. You will probably need transfusions of platelets and red cells (see Blood Transfusion pamphlet). Once the white cells and platelets re-appear, they mostly return rapidly to the normal range. Transfusions are usually only needed in the first 2-3 weeks after transplant.

The mobilization phase usually takes place as an outpatient. The actual transplant phase can be done either as an outpatient or as an inpatient. Depending on the availability of a (non-medical) caregiver, your own preferences, and insurance issues, outpatient or inpatient treatment will be recommended.

What Happens After Transplant?

Following an autologous stem cell transplant, most patients are back to work and feeling like their "old self" again after 4-6 weeks. At times energy may still be low, appetite may vary, and emotionally patients may feel up and down. The IBMT nurses and physicians, the social worker, and the oncology chaplain are available for any help you may need.

If you have additional questions or concerns, we encourage you to discuss them with your IBMT physician, the clinic nurses, or the transplant coordinator.