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Explaining Haematopoietic stem cell transplants

Explaining Haematopoietic stem cell transplants

Explaining Haematopoietic stem cell transplants

1. What are Haematopoietic stem cells?

Stem cells are very early specialised blood cells that live in your bone marrow. Your stem cells can develop into red blood cells (transporting oxygen around your body), white blood cells (that fight infection) and platelets (that help your blood to clot). They can also make a new immune system. We need our stem cells to survive.

2. What is Haematopoietic stem cell transplantation?

Haematopoietic stem cell transplantation (HSCT) can be used to treat blood cancers such as leukaemia, lymphoma and myeloma, and autoimmune disorders such as multiple sclerosis (MS). High doses of chemotherapy can kill cancer cells, but can often kill your bone marrow stem cells that we need to survive.

Your doctor can collect your blood stem cells from your bone marrow and freeze them outside of your body, meaning that you can receive much higher doses of treatment to kill your cancer cells. Following the treatment your stem cells are reinfused where they return to the bone marrow to grow into new red and white blood cells and platelets and a rebooted immune system.

This often means there is a higher chance of curing your disease, or achieving a more prolonged remission than with standard chemotherapy. In auto immune diseases the rebooted immune system may halt further damage to your organs or tissues (eg. Myelin)

Private HSCT.

Private Care at Guy’s offers autologous stem cell transplant treatment (AHSCT) for adult patients for the following diseases. Autologous means something that ‘comes from you’ rather than a donation from someone else.

  • Lymphoma
  • Myeloma
  • Autoimmune disorders including Multiple Sclerosis (MS)

This is a very intensive treatment, and requires a lot of preparation and may take a long recovery. At Private Care at Guy’s we have a specially trained team who have experience with treating cancer and caring for patients undergoing complex transplant treatments. As well as our consultants, who have over 150 years of experience between them, we have specialist nurses in symptom control, cancer and haematology, as well as supporting dietitians, physiotherapists and psychological support. Our individual patient bedrooms offer a spacious and reassuring environment to help you recover.

Our team of specialists

Dr Majid Kazmi

Dr Robert Marcus

Dr Paul Fields

Professor Steven Deveraux

Professor Steve Schey

Professor George Mikhaeel

AHSCT for cancer

If you have had a confirmed or suspected diagnosis of cancer, your case will be discussed at our haematology multi-disciplinary team meeting (MDT) of expert consultants including haematologists, clinical oncologists and radiologists, together with haematology specialist nurses, pharmacists, dieticians and symptom management specialists. The MDT will decide your initial line of treatment, which would usually involve a course of chemotherapy treatment. Throughout your treatment you will be continually assessed through blood tests and imaging. If it is felt AHSCT is necessary for you it will be discussed at the MDT. All recommendations from the MDT are in line with the British Society for Bone Marrow Transplantation Guidelines or international best practice. All MDT outcomes are recorded. You will be kept informed throughout the process and supported by a clinical nurse specialist
and your consultant.

AHSCT for MS

There is accumulating evidence of the benefit this treatment can have on selected patients.

People with MS who may be eligible to be offered AHSCT include:

  • People who continue to relapse in spite of treatment with at least 1 high efficacy disease modifying therapy (DMT).
  • People with active progressive MS for whom there is no available disease modifying treatment available but who have evidence of on-going inflammatory activity.
  • We may consider on a case by case basis patients who have not taken or are unwilling to take a high efficacy DMT for a private transplant (currently not funded through the NHS)

AHSCT will usually only be offered to people

  • Who have had other treatments that have not helped or is not available
  • Where the potential benefits of a transplant outweigh the risks
  • Who are in relatively good health, despite their underlying condition of MS.

If you have MS and would like to investigate AHSCT, you will need to book an appointment with a consultant neurologist for confirmationof diagnosis and appropriateness of referral. At London Bridge Hospital, Consultant Neurologists Dr Ben Turner and Dr Eli Silber work closely with Dr Majid Kazmi, our Consultant Haematologist leading the stem cell transplantation
programme. Both Dr Turner and Dr Silber have many years of experience in treating patients with MS.

Once you have been assessed by the neurologist your case will then be reviewed in the pan London MS-AHSCT Collaborative Group multi-disciplinary meeting. This panel comprises NHS and private hospital consultants with neurological and haematological clinical expertise to consider suitability for any patient requesting a stem cell transplant for MS.

If the pan London MS-AHSCT MDT approves your suitability, you will then be referred to Dr Majid Kazmi at Private Care at Guy’s. Dr Kazmi will then assess your physical fitness for the procedure and present your case to the haematology MDT at Private Care at Guy’s to review against our stem cell transplant criteria and progress the treatment.

When making a referral for AHSCT, your local neurology consultant or GP should provide the following information:

  • Documented diagnosis of MS by a neurologist with the date of the diagnosis
  • Record the ability to walk 20 meters without resting and needing, at most, bilateral assistance with two sticks or a rollator frame.
  • If you have relapsing MS, documentation to show that treatment with one of the high efficacy disease modifying drugs has been unsuccessful.
  • If no high efficacy DMT has been tried the reason for moving directly to AHSCT needs to be recorded.
  • MRI scans showing activity within the last 12 months compared to a comparative scan that was done in the previous 2 to 3 years. The radiology reports from both time frames should be included with the written referral.

AHSCT may be offered if you meet the following criteria:

  1. Age 18 – 65
  2. Disease duration of 15 years or less from diagnosis of MS
  3. A firm diagnosis of MS according to McDonald’s criteria
  4. For those people with primary progressive MS (PPMS) a lumbar puncture should demonstrate oligoclonal bands within the spinal fluid.
  5. If you have relapsing MS, documentation that high efficacy disease modifying drugs have not worked after 6 months of treatment. This should be evidenced by on-going relapses, increased MRI activity or progression of MS by increase in mobility score (EDSS)
  6. Mobility score (EDSS) should be between 0 – 6.5 (walking with bilateral assistance such as two sticks or a rollator frame)
  7. Active MS as defined by an MRI scan that shows 1 enhancing lesion after being off steroids for one month OR 2 or more new T2 lesions in MRI within the last 12 months compared to a comparative scan that was done less than 36 months previously and preferably within the last 24 months
  8. Approval from London MS-AHSCT Collaborative Group

What to expect during your stem cell transplant treatment:

Throughout your transplant, a Haematology Clinical Nurse Specialist will co-ordinate your care, arranging appointments and working together with you to ensure that your journey is as smooth as possible. They will also be available to answer questions that you and your family might have.

Mobilising your stem cells

Stem cells normally reside in low numbers in the bone marrow. We can increase the numbers of stem cells and encourage them to come out into the blood by a process called mobilisation. This often involves some chemotherapy followed by injections of growth factor (G-CSF) under the skin. Sometimes we just give the growth factor alone. The recommended approach for mobilisation in you will be discussed with you by your consultant.

Collecting your stem cells

You will be referred to our private HCA facility at University College Hospital to harvest your stem cells. You will be given the growth factor drug injection (G-CSF) under the skin for between 5-10 days to stimulate your body to produce more stem cell numbers and release them from the bone marrow into the peripheral blood. They can be collected through a process called Peripheral Blood Stem Cell Harvesting (PBSCH) or apheresis.

For the PBSCH, a cannula is inserted into both arms. Blood is removed from you, is circulated in a machine called an Apheresis machine, the stem cells are extracted and blood is then returned to you via the other arm. This is undertaken as a day-case procedure, and usually takes 1-2 days (although some patients may require additional days to enable enough stem cells to be collected for transplant).

Your stem cells will be processed at a specialist laboratory and frozen and stored in liquid nitrogen; they can be stored for up to 5 years. You will then complete any chemotherapy and cancer treatment you may have left. After harvesting, you will usually be given at least a 3-4 week period for your body to recover before being admitted for your transplant.

Transplant treatment

You will be admitted into our hospital Private Care at Guy’s, to a private en-suite room for the entire duration of your treatment, usually 3-4 weeks (depending on your diagnosis and clinical needs). You will have a central venous catheter inserted (this is used to reinfuse your cells), and then receive your high dose of chemotherapy and other supporting medications (this is known as the preparative or conditioning regime). The time this takes will depend on your diagnosis, though it can be anything from 1 day to seven days.

Your haematology nurse specialist and consultant will visit you daily throughout your treatment. Our nursing team have been educated and trained in caring for stem cell transplant patients. You will be seen by our specialist dieticians who will oversee your diet and nutrition, and physiotherapists to keep you moving.

Getting your stem cells back

Your stem cells will be thawed and re-infused by our specially trained nurses. The day you receive your stem cells back is known as ‘Day Zero’. This takes place in your private patient room and the time this takes will depend on how many bags of stem cells you are having re-infused. Generally this takes the course of an afternoon. The stem cells are reinfused like a
blood transfusion into your bloodstream.

Engraftment and recovery

After reinfusion, the stem cells find their way back to the bone marrow and start to divide and repopulate the bone marrow and the immune system. This period is the aplastic phase when you are most prone to infection and may be in isolation. The engraftment period occurs when the blood cells start to recover to a safe level. This occurs over a few days and usually the white blood cells (neutrophils) recover first

Patients will usually stay in hospital for approximately three weeks from Day Zero, though this can vary depending on recovery rates. You will be discharged when it is medically safe for you to be at home although the recovery phase post AHSCT will take many weeks.

Stem Cell Transplant: After the procedure

Once you have been discharged from hospital, you will continue to be closely monitored with regular blood tests and scans, initially at least weekly for the first month, then fortnightly for an additional month, then at increasing intervals as per your clinical condition. A clinical nurse specialist is on hand to provide support should you require it. You will be given advice on post-transplant care, including any signs and symptoms to be aware of, and contact details for the team.

Questions for your consultant:

You may want to learn more about the stem cell transplant treatment and below are some suggested questions to run through with your doctor prior to commencing treatment:

What type of stem cell transplant would be recommended for me?

What type of treatment will I need beforehand?

How long will I be in hospital?

How will this affect my life? Can I walk, work and exercise?

Are there any side effects?

What tests will I need and how often?

Is there anyone who can help me manage the cost of my treatment?

Support and Useful Information

https://www.myeloma.org.uk/videos/high-dose-therapy-and-autologous-stem-cell-transplantation/

http://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatment/bone-marrow-stem-cell-transplants/stem-cell-transplants

https://www.lymphomas.org.uk/about-lymphoma/treatment/stem-cell-transplants/autologous-stem-cell-transplant#stem-cell-collection

Published: July 12, 2017

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