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
Red Blood Cells - carry oxygen from the lungs to all the organs and pick up
carbon dioxide that is carried to the lungs and expelled from the body when
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
Most stem cells are found in the bone marrow but stem cells may also be found
circulating in the blood stream. Blood in the blood stream is called peripheral
blood. Until recently, patients who needed high-dose chemotherapy to treat their
disease often received bone marrow transplants. Bone marrow transplants are
very helpful in replacing the stem cells destroyed by chemotherapy, but we now
know that peripheral blood stem cells can also be used for a transplant.
Peripheral blood stem cells are often easier to collect and may produce a more
rapid recovery of white blood cells and platelets after a transplant than bone
What is a stem cell transplant?
Your oncologist has recommended that you receive very high-dose
chemotherapy to treat your cancer. The chemotherapy will destroy cancer cells,
but unfortunately the chemotherapy can’t 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 is present. Your
own stem cells can be collected before the high-dose chemotherapy is given and
returned to you intravenously after the high-dose chemotherapy to replace the
stem cells that were destroyed. These stem cells may come from either the
peripheral blood or bone marrow.
Originally, it was thought that stem cells were only found in the bone marrow.
However, as scientists become 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. There are certain times when greater numbers of stem cells are
found in the blood stream. These times are when the stem cells in the bone
marrow are very actively producing large numbers of new blood cells. This
happens when the stem cells in the bone marrow are stimulated by substances
called colony stimulating factors. These factors include G-CSF, also known as
Neupogen, and GM-CSF, also known as Leukine. This also happens when the
stem cells in the bone marrow are recovering after having been suppressed by
chemotherapy drugs. The greater the suppression, without actually destroying
the stem cells, the greater the number of stem cells that will be found in the blood
stream. Colony stimulating factors can also be given after fairly large doses of
chemotherapy to increase the number of stem cells in the blood stream. The
process of causing greater numbers of stem cells to be present in the blood
stream is known as mobilization. Stem cells in the blood stream can be collected
for later use by a process call apheresis or leukapheresis. During this process,
blood is taken from a vein, processed by a machine that removes mostly white
blood cells that include stem cells, and then the remainder of the blood is
returned to the person.
Is a stem cell transplant similar to a bone marrow transplant?
A peripheral blood stem cell transplant is done to replace the same type of cell
that is replaced in a bone marrow transplant. However, there are several
important differences between the two types of transplants that may make a
peripheral blood stem cell transplant more desirable. Both types of transplants
are done to allow higher doses of chemotherapy to be given to treat cancer. The
chemotherapy is the part of the process that treats the cancer. The same types
and doses of chemotherapy are used whether the transplant is peripheral blood
stem cells or bone marrow, so the effect on the cancer cells is the same with
either type of transplant.
Advantages of peripheral blood stem cell transplants include:
1. Stem cells from the peripheral blood are generally easier to collect
because they do not require general or epidural anesthesia. After a bone
marrow collection, a patient also will have some pain and tenderness in the hips
for several weeks.
2. After a peripheral blood stem cell transplant, the white blood cell and
platelet counts usually return to normal several days sooner than after a bone
marrow transplant. This reduces the risk of serious infections and bleeding
problems. Because the risk of these complications is less, peripheral blood stem
cell transplants can often be done outside of the hospital.
3. Sometimes cancer cells may be found in the bone marrow. They may be
present in sufficient numbers to be found in a laboratory examination, or
they may be present in such small numbers that they cannot be readily
detected. Some scientists believe that the chance of collecting cancer cells
along with the stem cells is less when the stem cells are taken from the
peripheral blood than when they are taken from the bone marrow.
However, this has not yet been proven.
4. Some scientists also believe that certain cells of the immune system that
may help to destroy any cancer cells that remain after the high-dose
chemotherapy are found in greater numbers in peripheral blood stem cells
than in bone marrow. If this is true, patients who receive peripheral blood
stem cell transplants should have their cancers spread or return less
frequently after a transplant than patients who receive a bone marrow
transplant. Again, this has not yet been proven.
How is a 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
The steps are:
1. Initial Evaluation
2. Induction Chemotherapy
3. Pre-Transplant Evaluation
4. Central Venous Catheter (CVC) Placement
6. Stem Cell Collection
7. High-Dose Chemotherapy
8. Stem Cell Transplant
After carefully reviewing all of the characteristics and aspects of your cancer,
your oncologist will determine if you might benefit from high-dose chemotherapy
with a peripheral blood stem cell transplant at this time. Because the high-dose
chemotherapy will cause side effects that could be life threatening, your
oncologist must carefully consider what the chances are that this treatment may
help you significantly. Your oncologist may review your case with a physician
specializing in stem cell transplant before deciding whether to recommend this
treatment at this time.
If your oncologist does determine that this treatment may benefit you, s/he will
discuss this with you. S/he may also recommend that you be seen by, evaluated
by, and receive more information from a specialized transplant physician and a
transplant nurse coordinator.
If it is determined that you are an active transplant candidate and you wish to
continue to pursue transplant as a treatment option, you will receive financial
information about transplant. A transplant financial coordinator will obtain
information about your insurance coverage and will start to determine if your
insurance company will be willing to pay for the cost of the peripheral blood stem
cell collection, high-dose chemotherapy, and transplant. Even if you are still
deciding whether you want to have high-dose chemotherapy and a stem cell
transplant, it is a good idea to determine what insurance coverage you have for
the procedure. Approval for payment of transplant expenses by your insurance
company does not mean that you have to have the transplant. Knowing the
financial arrangements for the costs of transplant can help you in the decision
making process. Do not be discouraged if your insurance company initially
declines to cover the cost of your therapy. Often they only need more specific
information to understand why you are an appropriate candidate for this
treatment and how important it is to your well-being. We will work with your
insurance company to provide them with information and will keep you informed
of the progress we are making. Financial arrangements related to your treatment
will be determined prior to starting collection of stem cells.
Almost every patient who receives high-dose chemotherapy with a peripheral
blood stem cell transplant receives several cycles of regular dose chemotherapy
first. This is to see if the cancer cells respond to chemotherapy drugs and to
reduce the number of cancer cells to a minimum. If the cancer cells are not
affected by regular doses of chemotherapy, the chance that the high-dose
chemotherapy will affect them is usually very small. In many cases, the risks
associated with the high-dose chemotherapy are not worth taking if regular doses
of chemotherapy have been ineffective. If the regular doses of chemotherapy
destroy a large number of the tumor cells, this increases the chance that the
high-dose chemotherapy will be able to get rid of most of the remaining cancer
cells. The cancer may then be cured or kept away for a longer time.
These courses of regular dose chemotherapy are called induction chemotherapy.
They are usually given every two to four weeks. They may last for one or several
days. Your oncologist will carefully monitor your reaction to these treatments and
how they affect your cancer. These responses will help in developing the best
treatment plan for you.
Once you have completed your induction chemotherapy your oncologist or
transplant physician will perform tests to determine if you should proceed with the
transplant phase of the treatment. These tests will evaluate the current stage of
your cancer so that your response to the induction 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, and urine tests. You will also
undergo one or two bone marrow sampling tests to determine if the cancer
involves your bone marrow and the extent of the involvement. In many cases,
tumor cells in the bone marrow make it impractical to use your own stem cells for
a transplant. This is not always the case, however. If tumor cells are present in
your bone marrow, your doctor or nurse coordinator will explain what this means
for you. Other tests will be done to evaluate your general physical condition.
The high-dose chemotherapy places extra stress on your body. Minor problems
that may not be readily apparent can be aggravated and cause major
complications after high-dose chemotherapy. These tests will include a heart
scan and EKG, lung function tests, x-rays, blood tests, and urine tests. You may
be asked to have a dentist check your teeth, if this has not been done recently.
Some of these tests are done to determine how well certain vital organs function
and others are done to check for hidden infections.
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. This consent form will include giving permission that
information from your treatment records may be reported in medical literature
and to insurance companies and possibly be reviewed by agencies such as the
FDA. This reporting will be done anonymously and your privacy will be
respected if your chart is reviewed.
Central Venous Catheter (CVC) Placement
During your mobilization, pheresis, and transplant treatment, you will need a
central venous catheter (CVC) for several reasons. 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. The external portion of the tube will probably have 2 or 3
tails, referred to as ports or lumens. The catheter is usually inserted by a
surgeon or a radiologist with local anesthetic. It is used to administer
chemotherapy, other medications, IV fluids, blood products, and IV feedings.
Your peripheral blood stem cell transplant will be given through your CVC. In
some cases, blood for lab tests can be taken from the CVC. A special type of
CVC, called a pheresis catheter, is also used to remove and return blood during
the collection of peripheral blood stem cells. If you already have a CVC when
you are ready to start mobilization, your transplant physician will decide if it can
continue to be used, if it needs to be replaced, or if it can be kept but an
additional CVC inserted. It is almost always necessary to have a special
pheresis catheter inserted to be used to collect the stem cells. Whatever your
CVC needs, your transplant physician and coordinator will explain them to you.
Immediately after a CVC is inserted, the area around the CVC may feel sore and
uncomfortable for a few days. Your physician can give you medication to ease
this soreness until it resolves. It is very important to keep the area around your
CVC clean to prevent infections. The nurses caring for your will teach you and
your Caregiver how to do this. Your nurses will give you some hints on how to
bathe to protect your CVC from germs that can be in bathwater. You should
avoid lifting heavy objects or activities that could cause pulling or tugging at the
CVC. Even with the best of care, a CVC sometimes becomes infected and may
have to be removed and possibly replaced. If this happens, your physician and
transplant coordinator will explain things to you. Do not blame yourself or your
Caregiver for the infection.
Your CVC will also need to have medication injected into it regularly to keep it
free of blood that can clot and plug it. This is called “flushing”. You and your
Caregivers will be taught how to flush your CVC, what to flush it with, and when
to flush it. You will be taught how to clean and care for the area around your
CVC and how to recognize signs or symptoms that might indicate the beginning
of problems. A nurse will assist you and your Caregivers in caring for your CVC
until you are comfortable doing it alone. Detailed instructions for the care of your
CVC are found later in this guide.
New advances in technology now allow physicians to increase the number of
stem cells in the peripheral blood. This is the process called mobilization. Two
common methods of mobilization are colony stimulating factors (CSFs) and
CSFs are human proteins that are normally produced by the body 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. CSFs are given by an injection or an intravenous
infusion daily for a period ranging from three to fourteen or more days. Your
nurse may teach you or your Caregiver how to inject this medication, or you may
receive it in the clinic. The most common side effect of CSFs is mild-to-moderate
bone pain or fever, which can often be controlled with Tylenol. Special
instructions on how to give injections of CSFs are included later in this manual.
If you receive chemotherapy as part of mobilization, you will receive it in the
infusion clinic where you received your other chemotherapy treatments. 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 physician and nurse will explain the chemotherapy treatment and how you
should care for yourself.
At some point after the mobilization treatment is begun, your white blood cell
count will begin to rise. After you have received a certain number of doses of the
CSF or when your white blood cell count reaches a certain level, it will be time to
start collecting stem cells from your peripheral blood. Your blood counts may be
checked every day or every other day to determine when it is time 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 pheresis catheter, one may need to be
Stem Cell Collection / Apheresis
Apheresis is a painless procedure. The collection of stem cells takes
approximately three to four hours for each procedure. During the procedure you
may relax in a chair or bed, watch television, listen to tapes, or read. Your blood
will be withdrawn through your pheresis catheter 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. There is only a
small amount (several cups) of your blood 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 is used
to keep your blood from clotting as the cells are collected. If you notice any of
these symptoms during the pheresis procedure tell your nurse or pheresis
technician immediately. These symptoms can be managed by temporarily
slowing or stopping the procedure, giving you some calcium, or covering you with
warm blankets. Holding a piece of sugar-free hard candy in your mouth may
help to decrease unpleasant tastes that some patients have noticed.
You may need to have several apheresis procedures to collect enough stem cells
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 pheresis
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. After the
cells are collected, they are frozen and stored in separate bags under special
conditions until they are needed for your transplant. An example of your
apheresis schedule is found later in this manual. Once enough stem cells have
been collected, if you had a special catheter inserted just for pheresis, it can be
Occasionally peripheral blood stem cells are collected and stored for use
sometime in the future if they are needed. They can be stored safely for many
years. Most of the time, however, stem cells are collected with the intention of
giving high-dose chemotherapy and a stem cell transplant very soon after the
High-dose chemotherapy and sometimes irradiation is usually given within 60
days after collection of your 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.
These chemotherapy drugs are usually given in the infusion clinic where you
have received your other chemotherapy treatments. The treatment most often
lasts several days. The treatment each day may last ten or twelve hours and
requires the administration of large amounts of fluid. Do not be surprised if you
are asked to remain at the clinic most of the day during your chemotherapy. You
will be given a small room with a bed where you may rest. Your nurses will
monitor you closely. Some of the drugs you are given to prevent nausea and
vomiting may make you drowsy or forgetful. Your Caregiver is welcome to
remain with you for as much time as s/he desires. While you are in the clinic
receiving your chemotherapy, your Caregiver should plan on spending some time
with the nurses providing your care to receive final instructions regarding the care
you will need when you leave the clinic. Your Caregiver will need to drive you
home every day after your chemotherapy treatment.
You will need to stay within a convenient distance to the office/hospital during
and for several weeks after the high-dose chemotherapy until your physician has
decided that you have recovered sufficiently. Your physician and nurse will let
you know exactly how near you must be to the hospital and if your home is close
enough. You also must be able to contact emergency services easily from your
home and have reliable transportation daily to the clinic and anytime an
emergency should arise. If your home and its location does not meet any of
these requirements, alternate housing during your therapy is available. Often the
cost of this housing is covered by your insurance. Your transplant nurse
coordinator will discuss your housing needs with you.
Stem Cell Transplant
Several days after the high-dose chemotherapy is completed, your own stem
cells will be given back to you. There will be several medical and nursing staff
members helping during this time, including nurses and laboratory technicians.
Your Caregiver may also be with you. There are few side effects to this
procedure. It is very much like a blood transfusion. 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 water, and infused through your
CVC. During the cell infusion, you may notice a garlic-like odor and taste.
Sucking on hard, sugar-free 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. A slight 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, you may notice your urine turn 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.
The high-dose chemotherapy 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. Most of the side effects
will be seen within two weeks of the start of the chemotherapy. Your body will
begin to repair the damage from the chemotherapy 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 ways to treat and relieve these side effects.
Additional information and teaching materials may be given to you as the
You will need careful monitoring until you recover from most of the side effects of
the chemotherapy and your stem cells begin to grow. You will have lab work
done and be checked by a physician or nurse daily.
The most common side effect of the chemotherapy is low blood cell counts. You
will be supported with red blood cell transfusions and platelet transfusions until
your body is making enough of these cells on its own. You also may receive
injections of a CSF to stimulate the growth of your stem cells. Because your
white blood cells will be low, you will be susceptible to infections and will be given
antibiotics to prevent or control these. During this time when your white blood
cells are low, it is very important for you and your Caregiver 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.
You should stay inside at home except for going to clinic appointments. Visitors
should be limited to a few people who are healthy. You should avoid contact with
animals and animal waste products. You should avoid being around a child or
anyone else who has received the oral polio vaccine recently. You should not do
any cooking, especially if it involves handling raw meat. When your platelets are
low, you need to avoid activities that could cause bleeding. This includes
strenuous activities, using sharp knives or tools, shaving, blowing your nose, and
brushing or 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 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 find this waiting time to be stressful. Because of all the
procedures, treatments, and side effects, they feel defenseless, vulnerable, and
out of control. In addition to all this, 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.
One to three weeks following your transplant, signs that your stem cells are
growing (engrafting) and beginning to produce blood cells are expected. As this
occurs, you may notice aching in your bones, especially your pelvis, lower back,
and thighs. As the blood counts begin to rise, the white blood cells will start to
fight and prevent infections. If you had fevers while the white blood count was
low, it may get better now. Your physician or nurse will tell you when you may
stop the antibiotics and relax some other restrictions that you had. It is a good
idea to always be careful about washing your hands no matter what the white
blood count. You also will no longer need platelet transfusions and will notice
that you do not bruise or bleed as easily. You will not feel as tired and will soon
no longer need red blood cell transfusions. You also will notice that other side
effects you have been experiencing will begin to get better.
Progress during this phase of treatment may seem slow. Keep in mind that the
long-term recovery phase may take a year or longer. You may feel frustrated
because you want to get well rapidly and put this experience behind you. Many
feel depressed at some point during this period. It just takes time to recover.
Patients tell us they coped by taking one day at a time, and setting simple,
realistic goals for themselves. Community support groups such as the American
Cancer Society and Cansurvive may help. Other recipients of stem cell
transplants are also a good source of support. Ask you nurse or physician for
names of recipients who are willing to talk with you.
It is common to continue to feel some fatigue in later months of your recovery.
Despite feeling fatigued, it is important to stay as active as possible. You will
need to identify the most important activities for you (in other words, pace
yourself). Low impact exercise such as walking may help you regain your energy
Your physician or nurse 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 be checked on
closely by the transplant team and your other physicians for many months after
your treatment. You will have regularly scheduled check-ups to monitor your
disease and check for any long-term side effects.
Re-establishing your life after transplant varies from difficult and rough to easy
going and smooth. However, the great majority or patients report that the quality
of their lives is now the same or better than before transplant. Despite the
intensity of the transplant experience, most patients are able to make
adjustments in their life and maintain an optimistic outlook for the future.