For an autologous transplantation, the patient receives their own stem cells that were collected and frozen prior to admission for high-dose chemotherapy or radiation.
A bone marrow transplant physician will begin the evaluation by reviewing your medical record and history, performing a physical exam, and discuss the procedure with you. This visit will be your initial consult and will also include a bone marrow transplant coordinator, who will help you through the process. If it is determined that you are a candidate for an autologous stem cell transplant, a treatment plan will be determined.
Before being admitted to the hospital, you will have several days of laboratory and other diagnostic tests to determine if you have normal function of the heart, lungs, kidney and liver and that you do not have an undiagnosed infection. Most of these tests will be done as an outpatient before you are admitted to the hospital. These tests may include:
- Blood tests
- Urine test and/or 24 hour urine collection
- Bone marrow aspiration and biopsy
- Chest X-ray
- Pulmonary function tests (PFTs)
- CAT Scans/PET Scan
- Dental Exam
Having vascular access enables the health team to administer chemotherapy, other drugs, blood products and even the stem cell transplant to you painlessly. Also, the catheter will be used to withdraw samples for blood tests required during the course of treatment, thereby minimizing the need to insert needles into your arms or hands. In general, the catheter is present throughout the hospital stay, and will be removed once you no longer need it and your counts have recovered.
Stem Cell Collection
Stem cells are found predominantly in the bone marrow but can be stimulated to travel out into the blood. When the stem cells are collected from the hip bone by performing many bone marrow aspirations, which are usually performed in the operating room, the transplant procedure is called a bone marrow transplant. When the stem cells are collected from the blood after stimulating the stem cells with a hormone called G-CSF, the transplant is called a peripheral blood stem cell transplant. Currently, most transplant procedures involve collecting stem cells from the peripheral blood. When bone marrow or blood stem cells are infused into the recipient, they are administered through an intravenous catheter or central venous catheter just like a blood transfusion. The stem cells are not administered directly back into the bone, but travel to the bones from the blood stream.
Bone Marrow Harvest
The collection of stem cells from the marrow is a surgical procedure in a hospital operating room, usually under general anesthesia. It involves little risk and minimal discomfort. While under anesthesia, a needle is inserted into the cavity of the rear hip bone called the iliac crest, where a large quantity of bone marrow is located. The bone marrow is a thick, red liquid which is extracted with a needle and syringe. One or two punctures on each hip and multiple bone punctures are usually required to extract the bone marrow. There are no surgical incisions or stitches involved -- only skin punctures where the needle was inserted.
Admission to the Hospital
You will be admitted to the hospital on the day your chemotherapy begins. Your admission date may be changed based on bed availability. The length of your admission will be between two to four weeks.
High Dose Chemotherapy
Chemotherapy begins soon after you are admitted to the hospital. Your doctor will discuss all of the drugs you will receive and their side effects. Your transplant coordinator and inpatient nurse will be available to answer questions. In addition, you will receive written information on these drugs in the consent form.
Precautions are taken to minimize side effects from these drugs.
Total Body Irradiation
Some patients receive total body irradiation (TBI) in addition to chemotherapy. This radiation therapy is intended to destroy remaining cancer cells and further suppress the immune system. TBI treatments are given in the radiotherapy department usually over a period of three to four days. The treatment itself is painless, but there may be uncomfortable side effects after treatment, such as mouth and throat sores, nausea, stomach and intestinal irritations, and skin redness. Antinausea medication is usually given before each treatment to reduce nausea.
The Transplant Procedure
The transplant or stem cells will be infused one to two days after the last chemotherapy or radiation dose. The day of transplantation is referred to as Day 0. The days before the transplant are counted as minus days and the days after the transplant are plus days.
The transplant procedure is similar to a simple blood transfusion and will be done in your hospital room. You may have a family member in the room with you if you wish. The actual procedure will take approximately 15-20 minutes, depending on the volume of stem cells. The blood stem cells will be infused through your central venous catheter just like a regular blood transfusion. Your nurse will check your blood pressure, temperature, breathing and pulse, and will watch for any side effects. Usually there are no side effects, but occasional patients may experience chills, flushing of the face, nausea and vomiting, headache, and changes in blood pressure and breathing. Your urine also may be tinged red for the first 24 hours after transplantation. However, if your urine remains red after this time or becomes red later, tell your nurse.
Waiting for Engraftment
The new bone marrow does not recover immediately after it has been transplanted. It takes approximately two weeks for your marrow to start producing white blood cells, red blood cells and platelets.
Engraftment is the term used to describe when your new marrow begins to function and produce cells. While awaiting engraftment, no mature cells leave the marrow and enter the blood stream. Your blood counts will show very low values and you will require careful monitoring by the health care team. The goal is to support you with red blood cell and platelet transfusions until you are producing cells again.
What to Bring
You are encouraged to identify and bring with you things from home that will help make your surroundings more comfortable while you are in the hospital. You may bring your own comfortable clothing to wear, such as sleepwear, shorts and T-shirts. Using your own clothing will make it feel less like a foreign environment. After it has been worn, clothing will be given to a family member to launder.
For health reasons, no fresh flowers or live plants are allowed. If you have questions about what is appropriate to bring into the hospital, your transplant coordinator can discuss it with you. Please do not bring toilet items such as: razors and nail clippers. They are not allowed. Electric razors are allowed. If you wear eye glasses, please bring them. Do not bring contact lenses as you will not be allowed to wear them.
You may bring your own computer, stereo, video games, crossword puzzles, books or anything else that may keep you comfortable while you are in the hospital.
A nurse will check your vital signs (temperature, pulse, respiration and blood pressure) at intervals around the clock. In the early morning, the nurse also will draw your blood from your catheter and will do your daily weight.
Medications and transfusions are given throughout the day and night. Consultants' visits and tests may be done on an on-call basis. Your doctors will visit you at least once a day. If you or your family has questions consult with your inpatient nurse who can contact your coordinator, physician or other member of the team to take care of your question quickly. Do not hesitate to talk with your inpatient nurse.
Nutrition in the Hospital
While you are receiving treatment, your resistance to infection is low and as a result some there are some foods you cannot eat. These include fresh fruits and vegetables. Because these foods have a high bacteria count, they are not safe to eat while your blood counts are low. Other food restrictions will be explained to you by the dietician, who will talk to you about food preferences and meals prepared in our kitchen.
You will need to get out of bed and move around as much as possible to keep your lungs and muscles in good shape. In addition, walking around your room and the hall as well as sitting in a chair a few times each day can be helpful. However, when you walk around the floor, you must wear a mask and keep your hands clean. Patients are not allowed to leave the unit unless it is for a medical test or procedure.
In the private rooms on the BMT unit, visiting hours are unrestricted and one family member or caretaker may stay with you at night. Care must be taken to avoid transmitting infections from the visitors to the patient. Children less than 12 years of age and individuals with active symptoms of an infection are not allowed. No more than three visitors are allowed at a time. Visitors are required to wash their hands upon entering the room.
Preparing to Leave the Hospital
When your neutrophil count is over 1000, your team will finalize your discharge plans. You will need to be sure that arrangements have been made for someone to stay with you after you are discharged and to be available for clinic visit transportation. You or a family member will learn how to care for your catheter.
To be discharged, you will need to be:
- Eating at least 50% of required calories a daily
- Drinking at least one quart of fluid daily
- Free of active problems
- Without a fever
- Off intravenous medications & taking pills
- Able to care for your catheter
Your transplant coordinator can assist with arrangements for home care. Your transplant coordinator or your doctor will go over your discharge and outpatient instructions and will review your medications with you.