Autologous Stem Cell Transplant or Bone Marrow Transplant

What does autologous mean?

Autologous means from the same person.

What are bone marrow and stem cells?

Bone marrow is a spongy material found inside our large bones, like the femur (thigh), hip, and ribs. Bone marrow is made up of cells called hematopoietic stem cells. There are also stem cells found in your bloodstream called peripheral blood stem cells. These stem cells are different than those used for research - those are embryonic stem cells.

Hematopoietic stem cells are "baby" cells that become white blood cells, red blood cells, or platelets. They can be called blood-forming stem cells. They grow and are stored in the bone marrow until they are needed. Each type of cell has a job:

• White blood cells (leukocytes): Cells that help fight infection.
• Red blood cells (erythrocytes): Carry oxygen from the lungs to the rest of the body and return carbon dioxide to the lungs as waste.
• Platelets (thrombocytes): Help the body form blood clots to control bleeding.

What is an autologous transplant?

An autologous transplant (called “auto transplant” for short) is a treatment for some cancers that transplants your own healthy cells back into your body. In the past, the stem cells were taken directly from your bone marrow during a procedure that placed needles into your hip bones. That is why transplants are sometimes called bone marrow transplants.

Transplants are used to treat many different cancers, such as leukemias, myelodysplastic syndrome, multiple myeloma, Hodgkin's disease, non-Hodgkin’s lymphoma, testicular cancer and neuroblastoma, among others.

What steps will you take before your transplant?

Your cells will be collected by using a medication called granulocyte colony-stimulating factor, or GCSF. This medicine stimulates (revs up) your stem cells to be released from the bone marrow and into the bloodstream. Using a blood test, they can tell how many cells are in your bloodstream. Once the number is high enough, you will go to the area of the hospital where pheresis is done to have the cells taken out. This procedure is called "apheresis.” With apheresis, there is no longer a need to remove stem cells from bone marrow. This is how apheresis works:

• Your cells are taken out using a catheter in the chest wall, or with 2 large intravenous (IV) catheters, one placed in each arm.
• Blood is taken out, run through the pheresis machine to remove the stem cells, and the rest of your blood is returned to you.
• The cells are frozen in the same dimethyl sulfoxide (DMSO) preservative that is used for bone marrow. Preserving the cells on ice, called “cryopreservation,” is needed because the cells must be removed (“harvested”) months before your transplant.
• During the collection, you may have tingling or numbness around your lips. This is caused by a loss of calcium and often gets better by eating some calcium tablets.

In the days before your transplant, you will get high doses of chemotherapy and in some cases radiation. Chemotherapy is a group of medications that work by killing cells that quickly divide in the body. Cancer cells tend to divide quickly, but so do many healthy cells (like cells in the gastrointestinal tract, hair follicles, and blood cells).

Chemotherapy can also damage your healthy cells, leading to side effects. "Dose limiting toxicity" is when your side effects are so serious that your provider lowers your dose of chemotherapy. Low blood counts (low white blood cells, red blood cells, and platelets) are a side effect that can limit your dose of chemotherapy.  

With an autologous transplant, providers give you high doses of chemotherapy to wipe out your bone marrow, but then later "rescue" the bone marrow using your own stem cells (which were collected earlier, before chemotherapy).

How is the transplant done?

After the preparation is done, you will then rest for 1 or 2 days to let your body process and clear out the chemotherapy, so the new cells are not damaged. The day of the transplant is sometimes called “Day 0”.

• On the day of the "transplant,” you are given some medications (called pre-medications) to prevent any reactions to the DMSO preservative.
• You will also get intravenous (IV) fluids.
• Your blood pressure and heart rate are closely watched. Once you have received the pre-medications, the frozen stem cells are thawed. They are given back to you like a blood transfusion. They are given through your intravenous line.

The stem cells go to the bone marrow space and start making new cells to replace all those that were killed ("ablated") by the chemo. Even though they are making cells, your body’s immune system is not working how it should be.

What happens after the transplant?

Right after the transplant, while you are waiting for cells to be made, is called the "nadir". It is often the hardest part. The blood cell counts are very low, putting you at risk for infections, bleeding, and severe fatigue. You do not have any white blood cells to fight infections, so you may have fevers and need antibiotics. All visitors and healthcare staff must wash their hands before entering your room. Anyone who is sick or lives with someone who is sick should stay home.

Low platelet counts can lead to bleeding, and platelet transfusions are common during this time. A low red blood cell count (called anemia) can also be hard. You may look pale, feel very tired, and need red blood cell transfusions. Many patients say the worst side effect is extreme fatigue. Just getting out of bed is a chore. When able, short walks in the halls or light exercise in your room can increase your energy.

You must also deal with the side effects of the chemotherapy you had. These are diarrhea, nausea and/or vomiting, hair loss, fever, chills, decreased appetite, and mouth sores (called mucositis). Every patient is different, and it is hard to tell who will have more side effects. The chemotherapy medications used before the transplant can vary, and some medications are more likely to cause certain side effects than others.

You may be in the hospital or at a nearby clinic during this time where your health can be closely monitored. During this time, you may want and need the support of your family. You may also not be feeling well and just want to rest. Be honest with your loved ones about how they can be helpful. You may also want to have one person that you update each day be the contact person for other loved ones.

What is engraftment?

Engraftment is the point when the stem cells start doing their job and blood cell counts start to come up. It can take about 7 to 12 days after Day 0 for the stem cells to make new cells, and for those new cells to work the way they should.

• The first number your care team will look for is the neutrophil count, which is the type of white blood cell that is most important in fighting infection. The care team will watch your neutrophil count and when it reaches a certain level, you can stop antibiotics and, in many cases, go home. The time until engraftment varies but is often between 7-12 days.
• The red blood cell and platelet counts can take a few weeks to get back to a normal range, but you can often go home once you are not regularly needing blood or platelet transfusions.

You will start to feel better as your numbers come up. Your providers will tell you what you need to do to stay as healthy as possible when you go home.

How will I feel once I am home?

This depends on what has happened over the past few weeks. It can take people weeks, months, or even a year to feel like their "old self" again. Some patients report having no appetite, or food tasting like metal, for months after the transplant. This can be a hard time, as family and friends may assume that the person is "better" since they are home, and the transplant is over. They may expect you to go back to normal life. If you need it, ask for help. Let others know what you need and how they can be most helpful.

If you have any questions about an autologous transplant, make sure to talk to your provider.  

Resources for More Information

Blood Forming Stem Cell Transplants from the NCI.

What is a Stem Cell Transplant from ASCO.