Stem Cell Transplant-An Overview for The COVID-19 Era
by C.D. Buckner M.D. Medically updated by C.H.Weaver M.D. 12/2020
A stem cell transplant (SCT) is the best treatment available for many kinds of cancer. The SCT procedure was considered such a major development of biomedical science that the individuals responsible were awarded the Nobel Prize in Medicine in 1989. Continued refinements has made SCT safer, widely available, and part of the overall management strategy for several kinds of cancer.
Stem cells are early blood-forming cells that grow and mature in the bone marrow, but can circulate in the blood. Blood Stem Cell Transplants are used to either treat a disease with a dysfunctional stem cell like leukemia, or to restore bone marrow blood cell production when the very high doses of chemotherapy or radiation used to treat the cancer kill the stem cells and they need to be replaced like in Hodgkin Disease.
Stem cell transplants work to treat cancer by utilizing very high doses of chemotherapy or take advantage of the donor immunologic cells to treat the cancer. Higher doses of chemotherapy drugs and radiation therapy may kill more cancer cells than lower doses. When higher doses of therapy kill more cancer than lower doses, doctors say there is a “dose response effect.” The delivery of higher doses of therapy is referred to as “dose intensive or high-dose therapy”. Unfortunately, the higher doses of therapy used to destroy cancer cells also cause damage to normal cells. The body’s normal cells that are most sensitive to destruction by high-dose therapy are the blood-producing stem cells in the bone marrow and these can be effectively replaced with a stem cell transplant. When donor cells are used from someone other than the patient the transplanted immune system also treats the cancer.
Stem cell transplants are classified based on which individual donates the stem cells and from where the stem cells are collected. Stem cells may be collected from the bone marrow, peripheral blood or umbilical cord. Therefore, the terms bone marrow transplantation, peripheral blood stem cell transplantation, and umbilical cord transplantation are utilized. There are important advantages and disadvantages to utilizing stem cells collected from these different sources. The second part of stem cell transplant classification is determined by who donates the stem cells. Stem cells may come from the patient (autologous), an identical twin (syngeneic), or someone other than the patient (allogeneic). Allogeneic stem cells are further classified by whether the individual donating the stem cells is related or unrelated to the patient and the degree of genetic similarity. Donors may either be HLA identical, mismatched or haplo-identical or “half” matched to the patient.
Is it safe to undergo a stem cell transplant during COVID-19 pandemic?
The answer appears to be yes assuming appropriate precautions have been put in place. The Dana Farber Cancer Institute has reported no differences in infection or survival rates between patients getting an autologous stem cell transplant during the COVID-19 pandemic compared to similar patients treated before the pandemic.
Special Precautions During the Pandemic Are Necessary
Transplant centers recommend patients quarantine at home for the 14 days prior transplant in order to reduce the risk of infection. Other standard precautions during COVID-19 include:
- Frequent hand Wash washing
- Avoid people who are ill, especially those with a cough, fever, or other cold and flu symptoms.
- Wear a mask when outside your home.
- Avoid gatherings, even small gatherings of people.
- Call your doctor if you have a fever, cough, or cold.
- Notify your care team about these symptoms before visiting the clinic for an appointment.
- Use telehealth visits when possible to reduce the number of visits and resulting exposures for patients no longer on active treatment.
Consideration for stem cell donors
For allogenic transplants the health of both the donor and the recipient needs to be considered. Donors reporting symptoms of illness that could be consistent with COVID-19 should be tested and deferred until recovery if positive. Donors who are asymptomatic but reporting sick contact should be deferred for donation to reassess for symptoms.
What if I experience symptoms and/or test positive for COVID-19? Will I still be able to have a transplant?
If an individual develops symptoms or tests positive for COVID-19 transplant centers recommend delaying the transplant until symptoms resolve and there are two negative COVID-19 tests.
What if my caregiver is exposed to coronavirus?
If a caregiver is exposed to coronavirus centers recommend identifying another person who could be your caregiver if your primary caregiver becomes ill.
If I need to stay at a hotel during/after my transplant. Is it safe to do so?
It is ok to stay at a hotel if needed during/after your transplant however extra precautions are recommend.
- Make arrangements with the hotel to restrict housekeeping from entering your room. This will limit your potential for exposure by limiting the number of people in your room. You can request that cleaned bed linens and towels be left outside your door each day.
- Bring cleaning supplies (wipes, hand sanitizer, etc.) with you to disinfect your room daily.
What extra precautions should my caregivers and I take after my transplant?
Because your immune system will be recovering after stem cell transplant, it is very important that you limit your potential exposure to COVID-19. It is recommended that you stay home as much as possible. If you leave the home, wear a mask and gloves and follow the appropriate social distancing guidelines. In addition, do not have visitors to your home, as they increase your risk for exposure. It is also important that you follow the other standard post-transplant precautions for what you eat and drink, taking medications, and staying safe at home.
Are visitors permitted to be with me during my transplant?
In an effort to protect the health and safety of patients and staff, no visitors are currently permitted with adult patients at most transplant centers and outpatient clinics. When possible, you to use your smartphone or other mobile device to stay in touch with your loved ones during your appointment.
- Collection & Processing of Stem Cells
- Selecting a Transplant Center
- Cancers Treated with ASCT
- Complication and Side Effects of ASCT
- Donor Selection
- Collection & Processing of Stem Cells
- Selecting a Transplant Center
- Cancers Treated with alloSCT
- Complication and Side Effects of alloSCT
Stem Cell Transplant-Key Terms to Know
An allogeneic stem cell transplant is a procedure in which a person receives blood-forming stem cells (cells from which all blood cells develop) from a genetically similar but not identical donor. This may also be called an allogeneic stem cell transplant.
Means tissue taken from a patient and returned to the same patient. A transplant that uses stem cells taken previously from the patient (rather than stem cells from a donor is called an autologous stem cell transplant).
Bone marrow harvesting
A surgical procedure in which doctors insert long needles through the skin to withdraw bone marrow from the crests of the pelvic bones. Donors receive general or spinal anesthesia for the procedure.
This is also called a central venous catheter. It is a small, flexible tube inserted into a large vein near the heart to administer medications and draw blood. It is also used to give the stem cells that you receive during your transplant.
The process of preparing the patient to receive donated stem cells collected front the blood or bone marrow. Often done through the use of chemotherapy, radiation therapy or both, conditioning is intended to do one of three things:
- Eliminate cancer cells
- Disable the immune system in people with an autoimmune disease
- Destroy the bone marrow in people with other marrow-related diseases
High-dose conditioning leaves patients without an immune system or the ability to form new blood cells. Alternatively, some patients may receive (RIC) reduced-intensity conditioning which is designed to weaken, but not destroy, their bone marrow and immune system so their body can more readily accept the donor’s stem cells.
Cord blood transplant The injection of umbilical cord blood to restore a patient’s blood production system that has been suppressed by chemotherapy and/or radiation therapy used in treating severe blood disorders such as aplastic anemia or cancer. Cord blood contains high concentrations of stem cells needed to produce new blood cells.
When your doctor or nurse talks about monitoring your counts, they are talking about your “blood counts” or the numbers of blood cells, including white blood cells, red blood cells, and platelets that are measured in your blood. Your transplant team monitors your absolute neutrophil count (or ANC) while watching for signs of engraftment and your platelets closely.
A process in which a stem cell transplant becomes successfully integrated into the body. For example, bone marrow begins to manufacture new white blood cells, red blood cells, and platelets in the patient’s marrow cavities after bone marrow transplantation. Signs of engraftment usually appear about 10 to 28 days after the transplant. The first sign is a rising white blood count.
Graft-versus-host disease (GVHD)
GVHD is a common side effect in people who receive cells from a donor (allogeneic transplant). It occurs when the transplanted cells recognize the recipient’s tissues as foreign and attack the tissues. This can cause a variety of problems, including skin rashes, liver problems, and diarrhea. There are two types of GVHD: acute GVHD, which often happens in the first three months after a transplant, and chronic GVHD, which can develop any time between three months and three years after the transplant. Both acute and chronic GVHD can be mild to serious. Medications and other treatments that suppress the immune system are used to prevent and treat GVHD until the donor cells stop attacking.
A transplant using stem cells from a donor whose HLA type is a half-match for the recipient. This may be an option for people who need a transplant but have not been able to find a more closely matched donor in typically occurs from a family member.
Hematopoietic cell transplant (HCT)
HCT is the general term for all transplants of stem cells, regardless of the source of the stem cells. Stem cells used in transplants may be collected from bone marrow; from blood circulating around the body, called peripheral blood; or from blood collected from an umbilical cord donated by a mother right after her baby’s birth.
HLA stands for human leukocyte antigen. Human leukocyte antigens are protein molecules that are inherited. HLA typing is the process of testing blood or other tissue samples from a patient who needs a transplant and from any potential donor to see how closely they match. The more HLA molecules two people share, the better the match. When two people share the same HLA molecules, their immune systems will not see each other as foreign and are less likely to attack each other.
See reduced-intensity transplant.
Minimally mismatched donor
In an optimal HLA match, the patient and donor share all eight or 10 HLA (human leukocyte antigen) markers (genes or proteins) tested. This is ideal for bone marrow or stem cell transplantation because it minimizes risks of rejection or graft-versus-host disease. New techniques allow effective transplantation using stem cells from a donor who matches the patient in only seven of eight or nine of 10 HLA markers—a minimally mismatched donor. Using these donors allows many more people to benefit from a potentially life-saving transplant.
Mucositis means inflammation of mucous membranes that line the digestive tract. It may occur as a side effect of chemotherapy or radiation, which can break down the rapidly dividing cells in these membranes. This can lead to ulcers and infection. Mucositis can occur anywhere along the digestive tract from the mouth to the anus. It can be mild to severe.
See reduced-intensity transplant.
A type of hematopoietic stem cell transplant where the patient receives reduced-dose conditioning that is designed to weaken, but not destroy, their bone marrow and immune system so their body will accept the donor’s stem cells.
Sinusoidal obstruction syndrome (SOS)
SOS, also called veno-occlusive disease (VOD), is a complication of transplants. In SOS, your liver cannot remove waste products from your body as well as it should. This is most likely to occur during the first month after a transplant.
Stem cell mobilization and collection
Stem cell mobilization means receiving medicine that causes stem cells to leave the tissues they normally occupy and to circulate in the bloodstream. Typically it takes a few days after receiving the medicine for the stem cells to mobilize. Then the stem cells are collected using a machine similar to those used for blood donation at blood banks. A catheter (tube) is placed in a donor’s large vein so blood can flow out of the body and into the machine, which separates the stem cells from the blood and returns the blood through another catheter. Collection typically takes a few hours, and donors leave the same day.
Veno occlusive Disease of the Liver-see sinusoidal obstruction syndrome (SOS)
Total body irradiation (TBI)
TBI is a radiation treatment to the entire body. It is used to destroy cancer cells and bone marrow cells in preparation for a bone marrow or peripheral stem cell transplantation.