Bone Marrow/Stem Cell Transplantation Process
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.
- Red Blood Cells - carry oxygen from the lungs to all the organs and pick up carbon dioxide which is carried to the lungs and expelled from the body when you exhale.
- White Blood Cells - are infection fighters. There are several types of white blood cells including granulocytes (also called neutrophils, polys, segs, bands, basophils, and eosinophils), monocytes and lymphocytes. They work to prevent infection, and they are necessary to fight infection if it develops.
- Platelets - help the blood to clot and prevent serious bleeding when you are injured, as well as perform normal repair work in your blood vessels.
Originally, it was thought that stem cells were only found in the bone marrow. However, as scientists became more skilled at identifying different types of cells circulating in the blood, it was discovered that stem cells are also found in the blood stream or peripheral blood.
What types of transplants are there?
Patients with certain diseases - such as lymphoma, leukemia, or multiple
myeloma - may be referred to a transplant center to undergo a bone marrow/stem
cell transplant. There are different types of transplant:
- Allogeneic - refers to a transplant of stem cells from a donor (someone other than yourself)
- Autologous - refers to a transplant in which you will receive your own stem cells back.
- MUD or matched unrelated transplant - this is a type of allogeneic transplant in which you receive stem cells from someone who is not related to you.
What is a stem cell transplant?
Prior to the transplant, you will receive very high-dose chemotherapy
to treat your cancer. The chemotherapy will destroy cancer cells, but
unfortunately the chemotherapy cannot tell the difference between cancer
and healthy cells. The chemotherapy 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 of infections, bleeding problems, and lower amounts of oxygen
in the blood (anemia) is present.
Your own stem cells or a donor's stem cells can be collected and stored before the high-dose chemotherapy is given. The stored stem cells can then be returned to you intravenously after the high-dose chemotherapy to replace the stem cells that were destroyed. This is a stem cell transplant. These stem cells may come from either the peripheral blood or bone marrow.
Sometimes the terms bone marrow transplant and peripheral stem cell transplant are interchanged. A peripheral blood stem cell transplant is done to replace the same type of cell (the stem cell) that is replaced in a bone marrow transplant. The main difference between the two terms is the method in which the stem cells are collected.
There are some reasons that the transplant physician will chose one collection method over the other that will be discussed with you.
How is stem cell transplantation done?
There are several steps to receiving a stem cell transplant. Our team
will work with you and your caregivers during each step of the process
to assure the best possible outcome. The steps are:
- Initial Evaluation
- Pre-Transplant Evaluation
- Central Venous Catheter (CVC) Placement
- Stem Cell Collection
- High-Dose Chemotherapy
- Stem Cell Transplant
- Post-Chemotherapy
- Engraftment
- Recovery
Initial Evaluation
Your primary oncologist may determine that transplant may benefit you, he
will discuss this with you. He may then also recommend that you be seen
by, evaluated by and receive more information from a transplant physician
and a transplant nurse coordinator. The transplant physician will review
your medical history, previous treatment, type of cancer and make a recommendation
whether or not you are a candidate. You may be already undergoing chemotherapy
to treat your cancer, and you may also need further treatment from your
primary oncologist prior to transplant. Once you and your doctors decide
you are ready to proceed with transplant, you will follow these next steps.
Pre-Transplant Evaluation
Your oncologist or transplant physician will perform tests to determine
if you are physically ready for transplant and if your disease is stable.
Restaging
These tests will evaluate the current stage of your cancer so that your
response to the initial chemotherapy can be assessed.
Depending on the type of cancer you have, these tests may include:
- X-rays
- CT scans
- MRIs, bone scans
- blood tests
- urine tests
- bone marrow biopsy and aspirate
Organ function testing
Other tests will be done to evaluate your general physical condition.
The high-dose chemotherapy places extra stress on your body.
These tests will include:
- MUGA scan (heart function)
- EKG
- Lung function tests (Pulmonary Function Tests, or PFT?s)
- X-rays
- blood tests
- urine tests
Once these tests have been performed, your physician or nurse will notify you if any abnormal results make transplant inadvisable or increase the risks associated with the transplant.
Your treatment options will be reviewed with you once again - especially what to expect from transplant therapy - and you will be given a consent form for the transplant treatment to read. You will be given an opportunity to ask any additional questions you may have.
If you then decide that you want to proceed with the transplant therapy, you will be asked to sign the consent form.
Our financial counselors will obtain insurance approval during this time.
Central Venous Catheter (CVC) Placement
During the transplant process, you will need a central venous catheter
(CVC). A CVC is a tube that is placed in a large vein in your upper chest
with the internal tip extending as far down as your heart. This catheter
will be used for chemotherapy, lab work, intravenous fluids etc. ... A
surgeon or a radiologist with local anesthetic and intravenous sedation
usually inserts the catheter.
Stem Cell Collection
Stem cells can be collected by two methods: pheresis or bone marrow harvest.
- Pheresis - stem cells in the blood stream can be
collected peripherally for later use by a process called pheresis. During
this process, blood is taken from a vein, processed by a machine that
removes stem cells, and then the remainder of the blood is returned
to the person.
The collection of stem cells takes approximately four to eight hours for each procedure. You may need to have several apheresis procedures over several days to collect enough stem cells
- Bone Marrow Harvest - stem cells can also be collected by a bone marrow harvest. This is done in the operating room. The patient or donor is asleep while the transplant doctors take bone marrow from the iliac crest, or hipbone. The procedure is over in 45 minutes and the patient or donor will go home later that day.
High-Dose Chemotherapy
High-dose chemotherapy and sometimes radiation is usually given after
collection of your or your donor?s stem cells. The purpose of this
therapy is to destroy cancer cells with higher doses of chemotherapy than
are used in standard chemotherapy treatments.
There are many chemotherapy drugs that can be given to you. Chemotherapy treatment plans vary with the type of cancer, its stage, and the treatment protocols being used for you. Your physician will discuss the best drugs and doses for your disease. You will be taught the way the drugs work and how they will be given.
After the therapy is complete, you will have several rest days for the chemotherapy to be cleared from your body. During this time, you will still be monitored closely by the nurses and physicians. Your catheter will still be hooked to an IV pump for anti-nausea medication and intravenous fluids.
Stem Cell Transplant
Several days after the high-dose chemotherapy is completed, your
own stem cells will be given back to you. This is called a stem cell reinfusion.
Your nurse will give you medication to decrease any side effects and you will be monitored closely throughout the procedure. It usually takes about 60-90 minutes.
- Because your white blood cells will be low, you will be susceptible to infections and will be medications to prevent or control infections.
- During this time when your white blood cells are low, it is very important for you to practice good hygiene habits. The most effective measure you can take is frequent washing of your hands, especially before and after using the bathroom and before you eat.
- Your platelets will also be low at this time, you need to avoid activities which could cause bleeding. This includes strenuous activities, shaving (except with an electric razor), blowing your nose and flossing your teeth.
- Other common complications are gastrointestinal including mouth sores, taste changes, nausea, vomiting, lack of appetite and diarrhea. You will be given various medications to treat these symptoms (i.e. anti-nausea drugs, anti-diarrhea drugs, etc.).
- Because of mouth sores, nausea, and/or vomiting, patients sometimes find it very difficult to eat. If this is the case, you will be supported with intravenous fluids and possibly nutrition either in the hospital or at home, until you can eat enough calories again on your own.
- If you are able to eat, you may need to follow a certain diet low in bacteria to prevent infections due to low white blood cell counts. Your transplant nurse will help you with nutritional recommendations during this time.
- Most patients experience profound fatigue during this time. Coping at this time can be a challenge. It is important to keep in mind that fatigue is common, and it is important to establish reasonable expectations for yourself.
Engraftment
Approximately 10 to 20 days following your transplant, signs that your
stem cells are growing (engrafting) and beginning to produce blood cells
are expected. 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 physician or nurse will let you know when you may stop taking antibiotics and relax some other restrictions that you had.
- You also will notice that other side effects you have been experiencing will begin to get better.
- If you have had an allogeneic transplant only (this does not apply to autologous transplant) this will be the time you will be monitored closely for Graft vs Host disease. This is a serious complication in which your donor cells (the graft) sees your cells (the host) as "foreign" and launches an attack, just as your immune system would normally attack an infection. You will be given medication to prevent this, and will be monitored very closely for any signs. There are several medications that can be given to treat this complication. This will be discussed in great detail if you were to undergo an allogeneic transplant.
Recovery
Progress during this phase of treatment may seem slow. Keep in mind that
the long-term recovery phase may take months to a year or longer. You
may feel frustrated because you want to get well rapidly but it takes
time to recover. Once you are stable, you will be transferred back to
your primary oncologist. For autologous transplant patients this is usually
one month after transplant. Allogeneic transplant patients have a longer
recovery period, and it make be several months before they are transferred.
Your primary oncologist or transplant physician will let you know when tests will be done to measure the effects of the chemotherapy and the results of the transplant. Some tests are done on the blood and others will be X-rays or scans. You will also have regularly scheduled check-ups by your primary oncologist as well as the transplant team to monitor your disease and check for any long-term side effects.
Patients tell us they coped by taking one day at a time, and setting simple, realistic goals for themselves. Community support groups such as Life with Cancer may help. Other recipients of stem cell transplants are also a good source of support. Ask your nurse or physician for names of recipients who are willing to talk with you.
Re-establishing your life after transplant varies from patient to patient. However, the great majority of patients report that the quality of their lives is now the same or better than before transplant.
