Introduction
High dose therapy with peripheral blood stem cell rescue is
often recommended treatment for multiple myeloma or relapse
of lymphoma. Although these diseases may have responded to
conventional chemotherapy, it is often possible to achieve a better
response (and in some cases of relapsed lymphoma a cure) by
treating with much higher doses of chemotherapy. However, such
treatment will also destroy the normal blood forming cells in the bone
marrow and cannot be given without bone marrow stem cells to
‘rescue’ the marrow.
All your blood cells are made in the bone marrow, which is a spongy
tissue inside the bones. They begin as stem cells. After receiving
stem cell mobilisation treatment, more stem cells are produced than
your body needs. This is when they can release into the peripheral
blood and collection (harvesting) can commence. They can then
be given back to you when you have completed the high dose
‘conditioning’ chemotherapy.
You will be given your own stem cells back. This is called an
‘Autologous Transplant’.
The Procedure
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.
Venous Access
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 Procedure
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).
Risks and Side Effects
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.
Preparation for Admission and Stem Cell Transplant
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.
Page 6 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.
Conditioning Chemotherapy
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.
Discharge Advice Following Stem Cell Transplant
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.
Going Back to Work
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.
Holidays
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.
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Author Haematology Department
Approved by Chairpersons Action
Date of Publication 25/11/2025
Reference No PL/041 (v4)
Review Date 01/11/2028
