Stem cell transplant

What is a stem cell transplant?

Bone marrow is the factory that makes blood cells. In this factory, blood-forming stem cells turn into red cells, white cells and platelets. Sometimes, to treat a disease, very strong medicines must be given, or together with radiation, and these destroy the bone marrow as well as the disease. A stem cell transplant means that after that intense treatment, new stem cells are put into the body so that blood cells are made again.

A transplant is used mostly for blood cancers, such as leukaemia, lymphoma and myeloma, and for some other bone marrow diseases. Sources say the transplant itself usually does not act directly on the cancer, but in a donor transplant the donor’s white cells can target remaining cancer cells.

Types of transplant

By the source of the cells:

• Autologous. The cells are taken from the patient. A small risk is that some cancer cells come back along with the cells.
• Donor (allogeneic). The cells come from another person. It may be a relative or an unrelated person who is a close enough match. The best match is usually a sister or brother.
• From an identical twin (syngeneic). The cells are taken from the patient’s identical twin.

The cells are collected from three sources: peripheral blood (more common), bone marrow and cord blood.

Donor matching is measured with a test called HLA. The more the markers are alike, the more likely the cells are to be accepted.

Who may a transplant suit?

The decision about a transplant rests only with the doctor and depends on the type and subgroup of the disease, the stage and response to earlier treatment, age, general health and other illnesses, and the availability of a suitable donor. Each patient is assessed separately. This page does not replace an assessment at a transplant centre.

The stages of a transplant

• 1. Assessment. Tests and checks of general health and, for a donor transplant, finding a matched donor.
• 2. Collecting the cells. In an autologous transplant, injections are given for a few days beforehand to raise the number of stem cells in the blood. Then a machine takes the blood, separates the cells and returns the rest. If bone marrow is used, it is taken from the hip bone under anaesthetic.
• 3. Preparation (conditioning). High-dose chemotherapy, sometimes with radiotherapy. Depending on the plan, from one to ten days or more. The aim is to destroy the diseased cells and, in a donor transplant, to suppress the immune system so the donor’s cells are accepted.
• 4. Infusing the cells. The cells enter the blood through a thin tube placed in a vein of the chest or arm, like a blood transfusion. It is not painful and needs no anaesthetic.
• 5. Time in hospital and recovery. Because immunity is weak, the patient is usually kept in a separate room, and visitors and the treatment team use masks, gloves and gowns. Blood counts are checked regularly and rise as new cells are made.

The whole process until the end of recovery takes several months. The blood count may return to normal sooner than immunity. Rebuilding immunity takes a few months after an autologous transplant and one to two years after a donor transplant. If no problems come up, about 100 days after receiving donor cells you may be able to return to your own city. Until then, even after discharge, you may need to stay near the transplant centre and attend regularly. After that too, follow-up with a doctor experienced in transplants is needed.

Risks and complications

A transplant is a heavy treatment and carries a risk of serious complications. The treatment team explains them to you beforehand. In general:

• Infection. After a transplant the chance of infection is higher, and fever is an emergency sign.
• Bleeding and anaemia because the cell counts are low
• Side effects of the preparation: nausea, vomiting, loss of appetite, mouth sores, hair loss (which usually comes back), tiredness
• GVHD (graft-versus-host disease). Only in a donor transplant. The donor’s white cells attack the patient’s tissues, such as the skin, gut, liver, mouth and eyes. It can occur straight away or months later. It is controlled with immune-suppressing medicines and can also be prevented, but it is sometimes serious and long-lasting.
• Clots. Their signs (pain and swelling in one leg or arm, shortness of breath) must be reported at once.
• Fertility. Radiation and some chemotherapy medicines can cause infertility. If you want to have children, ask before starting. Sometimes eggs or sperm can be stored.
• Late complications: over the long term there may be problems in organs, cataracts, weakness of bone and muscle, or a second cancer. Regular follow-up is for this reason.
• Anxiety and depression are common too, and can be treated

What should you do?

• Talk with the doctor about the chance of a transplant, the timing and a suitable centre. If you are referred to another centre, take your records complete.
• Ask the transplant team for the list of complications, the around-the-clock contact number and the plan after discharge
• Before starting, ask about fertility, dental care and vaccines
• Let your companions and family know. This path is hard for the family too (the page “For people supporting a patient”)
• If you are not sure, get a second opinion

When should you get urgent help?

• A fever of 38 degrees or higher, or a sign of infection (sore throat, cough, pain when passing urine): this is an emergency. Call the transplant team at once.
• Swelling, pain and warmth in one leg or arm: it may be a clot. Call the transplant team right now.
• Sudden shortness of breath, new or severe chest pain (sharp or pressing), coughing up blood: call 115 (the emergency number inside Iran).
• Bleeding that does not stop: call 115.
• Signs of GVHD (itchy, red skin, diarrhoea, mouth sores, yellow skin, dry and painful eyes): call the transplant team right now.

Details are on the page “When should I call for urgent help?” Whether a transplant suits you, and which type, is decided only by your treatment team.