Peripheral Stem Cell Transplant

Initially you will be given treatment to reduce the cancer to as low a level as possible with chemotherapy. This gives the high dose chemotherapy the best chance to work and reduces the risk that your stem cell harvest will be contaminated with cancer cells. The type of chemotherapy will depend on what cancer you have.

Then we will plan to collect your stem cells. Stem cells can be collected and stored if you do not need further treatment straight away.

Mobilising stem Cells

In order to collect stem cells from your blood, they must be ‘mobilised’ from the bone marrow into the blood stream.

There are different methods used to mobilise stem cells. You may be given a single dose of chemotherapy as a day patient followed by daily injections of growth factors. These injections are given under the skin of your stomach, we will arrange for a District Nurse to administer them if required.

Growth factor injections can cause some bone pain, especially in the lower back, femur and the sternum, but this is usually controlled with simple painkillers.

Your blood counts and the number of stem cells will be monitored on the day unit. When they are at the right level, your stem cells can be collected.

Collecting your stem cells 

You will be asked to attend the Haematology Day Unit at 8:30am on the day we plan to start testing your blood for stem cells. We will take routine blood samples and an additional sample to check how many stem cells your bone marrow has released. If the result is satisfactory our Doctor, Nurse Consultant or Advanced Nurse Practitioner will examine you, explain the procedure and ask for your written consent. We will then harvest your stem cells (this procedure is called ‘apheresis’) and you will remain in the Haematology Day Unit all day.

If your blood test indicates that the stem cell count is not high enough, we will not proceed with the harvest but you will continue your growth factor injections and be asked to return to the Day Unit at 8:30am the following day. There are several factors which can determine how long it takes for your body to make the optimum number of stem cells and it is not unusual for some patients’ harvest not to go ahead in that first day or two.

Sometimes the first attempt to mobilise stem cells may be unsuccessful and a second mobilisation may be arranged to commence at a later date.

Stem cell collections are performed using 2 intravenous needles, one in each arm. Blood is removed from one arm, which must be kept straight and still, processed through the apheresis machine and returned through your other arm via a cannula. This is a continuous cycle and there is only a small volume of your blood in the machine at any one time. Local anaesthetic cream will be used to make the procedure more comfortable for you. We recommend you wear comfortable clothes with short sleeves to allow us to access your arms easily. If you have small or fragile veins the placement of a central venous catheter or femoral line may be necessary. Your venous access will be assessed by the Transplant Specialist Nurse before your stem cell harvest and you will be informed of this.

The stem cell harvest procedure last approximately 4-5 hours. You will be attached to the cell separator machine until 3pm and stay in the Haematology Day Unit until approximately 4:30pm when we receive the provisional results informing us how many stem cells we have collected.

We have 2 apheresis machines therefore there may be another patient having a stem cell harvest at the same time. Privacy curtains are in place and an apheresis trained nurse will be in the room with you all day providing one to one care. You will be able to watch TV or listen to the radio and lunch will be provided.

If we do not collect sufficient stem cells for your transplant from the first harvest, your growth factor injections will continue (we can administer these) and you will be required to return to the Haematology Day Unit at 8:30am the following day. We will test your blood again and if the results are satisfactory, repeat the stem cell harvest. In most cases 2-3 harvests are required over a period of 2-3 days. All stem cells harvested will be stored and subsequent collections will be added until we have enough for your transplant(s).

Peripheral blood stem cell collection (harvest) is a safe procedure, but side effects can sometimes occur.

The anticoagulant used in apheresis can sometimes cause tingling or unusual sensations around the mouth, lips, fingers and toes and occasionally cramp in the hands and/or feet. It is very important to notify the nurse if these symptoms occur and we will give you a calcium supplement in tablet and intravenous form to relieve them. These symptoms are associated with a reduction in your blood calcium level due to the anticoagulant. The risks and potential side effects will be explained to you prior to us asking for your written consent before the procedure.

Many people feel tired following apheresis and you may need to rest in the evening after the procedure.

Once your stem cells have been harvested, they will be sent away for preservation and storage. You will then be admitted to the Haematology Ambulatory Care Unit and the Haematology Ward for your transplant 4 weeks later.

During this time the Transplant Specialist Nurse will arrange for insertion of an intravenous central line. This will be a ‘Peripherally Inserted Central Catheter’ (PICC) in your arm, or a ‘Hickman’ line in your chest.

You will also see your Consultant in clinic who will discuss your transplant in more detail and ask for your written consent to proceed. You will also be informed of your date for admission to the Haematology Ward (Ward E) Telephone 01253 953403.

It is recommended that you agree a password with your family before admission if they will be telephoning the ward to enquire about you. This allows the staff to discuss your care with them ensuring there is no breach of confidentiality.

Once admitted to the Haematology ward you will be allocated a bed and a single side room with en-suite shower when side-effects are unmanageable in a shared area. It is likely you will remain in hospital for 2-4 weeks depending on your condition and recovery following a stem cell transplant.

We want you to be comfortable during your time in hospital and welcome you to bring any home comforts with you e.g. Pillows, blankets, photographs of family or pets, pictures, books etc. There is a 40” free to use TV in each room. Please do not bring any valuables.

Before having your stem cells returned you will be given high dose chemotherapy. This is called conditioning. It is given as a drip via your PICC or Hickman line. It may be given on one day or over several days depending on your condition. The high dose chemotherapy kills cancer cells but also eliminates the blood producing stem cells that are in your bone marrow. You will have blood tests daily and this will be taken from your PICC or Hickman line.

You will see your Consultant in clinic after your stem cells have been harvested and before you are admitted for transplant. Details of your conditioning chemotherapy and side effects will be explained to you then.

Procedure: Stem Cell Transplant / Return 

Twenty-four hours after you finish your conditioning chemotherapy you will be given your stem cells back.

About an hour before your stem cell return, the nurse will give you anti-sickness, anti-histamine and steroid injections into your PICC or Hickman Line.

These will reduce the occurrence of side effects. A drip will be attached to your line. Your stem cells are brought up to the ward and defrosted one bag at a time. They are infused via a pump. The time this procedure takes depends on how many bags of stem cells are being returned. If there are a lot of bags, you may receive your stem cells back on two consecutive days.

Side effects 

The preservative in the stem cells can sometimes affect you. It may cause a temporary discomfort in the chest or a feeling of breathlessness. Other side effects that you may notice during the return are a dry cough, flushing of your skin or nausea.

The injections you received beforehand should reduce the chance of these occurring. Tell your doctor or nurse straight away if you notice any of these symptoms.

Two nurses will be present throughout the procedure and you will be closely monitored.

Recovery from peripheral blood stem cell return.

Once you have had your stem cells returned, it will take time for the stem cells to settle into the bone marrow and start to produce new blood cells. You will remain on the ward for approximately 2-3 weeks.

During this time, you will experience the side effects of the high dose chemotherapy.

Mucositis 

The chemotherapy will damage the lining of your mouth and gut. This is called mucositis. You can develop a very sore mouth and throat, abdominal pain, nausea, vomiting and diarrhoea. It is important to follow your mouth care instructions and to tell your nurse or doctor if you have any of these problems. They can give you medication to help. Ice-pops can be soothing and if you bring some into hospital they can be labelled and stored in the ward freezer.

Infection.

The white blood cells that fight infection fall to very low levels after the chemotherapy and you may develop an infection. The nurses will monitor your temperature and other observations regularly for signs of infection. You will be given antibiotics into your PICC/ Hickman line when infections occur. Seven days after you have had your stem cells returned, you will start daily injections of growth factors again. These will encourage the stem cells to produce white cells more rapidly.

Anaemia.

Your bone marrow will not be making red blood cells as normal and you may need blood transfusions to treat anaemia.

Bleeding

The platelets that make your blood clot will also be very low and you will be more at risk of bleeding and bruising. Do tell the doctor or nurse if you notice any bleeding at all. You will need platelet transfusions until your blood count recovers.

Eating and drinking.

You may have problems eating and drinking because of mucositis. It is important to try and drink as much as you can. If it is too difficult, you may be given extra fluids through a drip. Try eating small meals and snacks. The nurses can also give you high protein drinks and ask the dietitian to see you. Your mucositis will settle down as your blood count improves. You may lose weight while you are in hospital, so it is a good idea to try and put some extra weight on before you come in for your treatment if you are underweight.

Hair loss

If your hair has grown back after previous treatment, you will lose it again due to your conditioning chemotherapy. It will start to grow back again a few weeks after treatment is completed.

While your blood counts are low, you will feel tired and unwell with a poor appetite. All these symptoms will begin to improve as your blood count starts to recover. This takes two to three weeks. When your white blood cells have reached a safe level, you will be allowed to go home. Having high dose chemotherapy and stem cell return, can be an anxious time for you. If you have any worries, concerns or questions, please talk to your doctor or nurse.

Although you are well enough to leave hospital, it will take a few months to recover fully from your transplant. During this time, you will need to attend the Day Unit / Ambulatory Care Unit regularly and to follow precautions to prevent infections.

Day Unit / Ambulatory Unit Check Ups 

You will have regular check ups and blood tests to make sure your blood counts are getting back to normal. It is not unusual to need some blood or platelet transfusions for a while after your discharge from hospital. When your blood levels are safe, your PICC or Hickman line will be removed.

You need to continue with some of the tablets that you were taking in hospital. The doctor will tell you when you can stop taking them.

When your blood counts are normal, you will be invited to attend the Macmillan Windmill Clinic to see your consultant. If you normally attend another hospital, you will be referred back to this hospital once the transplant consultant has discharged you.

Avoiding Infection

Because it takes time for your immune system to get back to normal, you will still be at risk of infection. It is not unusual to have to be readmitted to hospital for antibiotic treatment. In order to reduce the risk of infections, it is important to follow advice on mouth care and maintain good personal hygiene. If you have any signs of infection, you must contact the ward straight away. These may include:

• Feeling unwell or unusually sleepy

• A temperature over 37.5°C for more than 2 hours or severe shivering (rigors)

• Signs of infection such as pain, redness swelling or discharge particularly around your PICC or Hickman line

• Shortness of breath or difficulty breathing

• Diarrhoea

• Skin rashes

Avoid contact with anyone who has an infection especially chickenpox, shingles or measles.

Bleeding

The cells that help your blood to clot (platelets) may also remain low for some time. You should look out for signs of bleeding:

• Bruising

• Bleeding from gums or nosebleeds

• Red / purple spots or rashes particularly on legs

• Any other bleeding.

Contact the department if you notice any of these symptoms.

Once your blood count is back to normal, discuss with your doctor when you can return to work. If possible, it would be better to go back part time at first. It could take longer to get back to work if you have a stressful or physically demanding job.

Once your blood counts improve and you need to visit hospital less often, you may want to take a holiday. You should discuss this with the doctor, particularly if you are thinking of going abroad.

If you have any worries, concerns or questions, do contact the staff at the hospital. They are always happy to help you.

You will be given additional information regarding going home after a stem cell transplant before you are discharged from the ward.