Bone marrow transplant

Answer 1

Definition

A bone marrow transplant delivers healthy bone marrow stem cells into the patient. It replaces bone marrow that is either not working properly or has been destroyed (ablated) by chemotherapy or radiation.

Alternative Names

Transplant - bone marrow; Stem cell transplant; Hematopoietic stem cell transplant; Reduced intensity, nonmyeloablative transplant; Mini transplant; Allogenic bone marrow transplant; Autologous bone marrow transplant; Umbilical cord blood transplant

Description

Bone marrow is the soft, fatty tissue inside your bones. Stem cells are immature cells in the bone marrow that give rise to all of your blood cells. Your blood is made of:

• Red blood cells (which carry oxygen to your tissues)
• White blood cells (which fight infection)
• Platelets (which help your blood clot)

In a bone marrow transplant, you will receive healthy stem cells after your own bone marrow has been destroyed.

There are three kinds of bone marrow transplants:

• Autologous bone marrow transplant. "Auto" means "self." Stem cells are taken from the patient before the patient gets chemotherapy or radiation treatment. When chemotherapy or radiation is done, the patient gets their stem cells back. This is called a "rescue" transplant. It allows the patient to receive high doses of chemotherapy and radiation.
• Allogeneic bone marrow transplant. "Allo" means "other." Stem cells come from another person, who is called a donor. Donor stem cells come from the donor's bone marrow or their blood. Most times, a donor must have the same genetic typing as the patient, so that their blood "matches" the patient's. Special blood tests will tell whether a possible donor is a good match for the patient. A patient's brothers and sisters have the highest chance of being a good match (25% chance for each full sibling), but sometimes parents and children of the patient and other relatives may be matches. Donors who are not related to the patient may be found through national bone marrow registries.
• Umbilical cord blood transplant. Stem cells are taken from an umbilical cord right after delivery of an infant. The stem cells are tested, typed, counted, and frozen until they are needed for a transplant. Umbilical cord blood requires less stringent matching because the stems cells are so immature.

Many patients get high doses of chemotherapy, radiation, or both, before the bone marrow transplant. This is called ablative (or myeloablative) treatment. It kills any cancer cells that might remain, and it makes room in the bone marrow for the new stem cells to grow.

Today, some patients are getting less chemotherapy and radiation before their transplant. This is called a reduced intensity (nonmyeloablative) or "mini" transplant.

After the patient gets chemotherapy and radiation, a doctor will do the stem cell transplant. The patient gets the stem cells through a tube called a central venous catheter. The process is similar to receiving a blood transfusion. The cells go right into the bloodstream and find their own way to the bone marrow. Usually, no surgery is required.

Donors may have minor surgery to collect their bone marrow and stem cells. For a bone marrow harvest, they will be unconscious and pain-free (under general anesthesia) while their bone marrow is removed from their hip bone. In many cases however, stem cells can be collected right from the blood. The donor will first receive injections for a few days.

When receiving stem cells, a patient may have these symptoms:

• Pain
• Chills
• Fever
• Hives
• Chest pain
• Drop in blood pressure
• Shortness of breath
• Nausea
• Flushing
• Headache
• Funny taste in the mouth

Why the Procedure Is Performed

Bone marrow or stem cell transplant may be recommended for:

• Certain cancers, such as leukemia, lymphoma, and multiple myeloma
• Illnesses where the bone marrow does not produce the right kind of or enough cells. Some of these are:
  • Sickle cell anemia
  • Aplastic anemia
  • Thalassemia
  • Congenital neutropenia
  • Severe immunodeficiency syndromes
• Rescue transplant to replace bone marrow, when treatment for cancer has destroyed a patient's bone marrow

Risks

All bone marrow transplants have risks. The risk is higher or lower depending on many factors. Some of these factors are:

• What disease you have
• What type of treatment (chemotherapy, radiation) you have before the bone marrow transplant
• How old you are
• How healthy you are when you have your transplant
• How good a match your donor is
• What type of bone marrow transplant patient you are having (autologous, allogeneic, or umbilical cord blood)

Complications you may have are:

• Infections: These may be very serious.
• Bleeding: This can happen in the lungs, the intestines, brain, and any other part of the body.
• Anemia
• Diarrhea, nausea, and vomiting
• Pain
• Severe mucositis (inflammation and soreness) in the mouth, throat, esophagus, and stomach
• Damage to the kidneys, liver, lungs, and heart
• Cataracts
• Early menopause
• Graft failure, which means that the new cells do not settle into the body and start producing stem cells
• Graft-versus-host disease: This is when your donor's cells attack your own body. In the first few months after the transplant, symptoms may be a skin rash, diarrhea, or abnormal liver tests. Later, symptoms may be dry eyes or mouth, tightness of the skin, scarring in the lungs, chronic diarrhea, and other problems.
• Children who get transplants may have delayed growth.

Before the Procedure

Your health care provider will ask you about your health record and do a physical exam. You will also have many tests before your treatment begins.

Your doctor or nurse should discuss the emotional stress of having a bone marrow transplant. You may want to meet with a mental health counselor talk. Talking with your family and children to help them understand and prepare is important.

You will need to make plans for when you have the transplant. Items to consider are:

• Household chores
• Care of pets
• Payment of bills
• Bank or financial statements
• Schedules and care for your children
• Insurance coverage
• Arranging medical leave from work
• Advanced care directives

You may need to find housing for yourself or your family near the hospital.

Before the transplant, one or two catheters are inserted into larger blood vessels, usually in the neck, for you to receive treatments, fluids, and sometimes nutrition.

After the Procedure

Bone marrow transplant patients usually go to medical centers, or hospitals, that specialize in this treatment. Most times the patient will stay in a bone marrow transplant unit in the center to limit their chance of getting an infection.

Some patients who get autologous or non-myeloablative allogeneic transplants do not have to stay in the hospital or medical center. They can get the transplant as an outpatient.

Some patients may have part of their autologous or allogeneic transplant done as an outpatient.

Most patients will be in the hospital for 4 to 6 weeks. During this time, you will be isolated and watched closely because of the increased risk of infection.

While you are in the hospital, these things may happen:

• Close monitoring of your blood and vital signs
• You may have to take antibiotics, antifungal medications, and antivrial medications to prevent or treat infection.
• You may need many blood transfusions.
• You may have to stay in a room where special things are done to prevent infection.
• You may get calories and proteins through an intravenous (IV) line until you can eat on your own, and until your diarrhea, nausea, or mouth sores have cleared up.
• You may have to take medicine to prevent graft-versus-host disease.

Outlook (Prognosis)

How well you do after transplant greatly depends on these things:

• What type of bone marrow transplant you had
• How well your donor's cells match yours
• What type of cancer or illness you have
• Your age and overall health
• What type of chemotherapy or radiation therapy you had before your transplant
• What kind of complications happened after the transplant
• Your genetic make-up

Possible results of a bone marrow transplant are complete cure of the illness being treated, a partial cure, or death. Death may be caused by complications of the bone marrow transplant or because the transplant did not work to treat the illness.

If the transplant works, you can go back to most of your normal activities as soon as you feel well enough. Most times it takes up to 12 months to recover fully.

References

Bishop MR, Pavletic SZ. Hematopoietic stem cell transplantation. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG, eds. Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2008:chap 32.

Vose JM, Pavletic SZ. Hematopoietic stem cell transplantation. In: Goldman L, Ausiello D. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 184.

Answer 2

Definition

A bone marrow transplant is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells.

Bone marrow is the soft, fatty tissue inside your bones. Stem cells are immature cells in the bone marrow that give rise to all of your blood cells.

Alternative Names

Transplant - bone marrow; Stem cell transplant; Hematopoietic stem cell transplant; Reduced intensity, nonmyeloablative transplant; Mini transplant; Allogenic bone marrow transplant; Autologous bone marrow transplant; Umbilical cord blood transplant

Description

There are three kinds of bone marrow transplants:

• Autologous bone marrow transplant: "Auto" means "self." Stem cells are removed from you before you receive high-dose chemotherapy or radiation treatment. After these treatments are done, your stems cells are put back in your body. This is called a "rescue" transplant.
• Allogeneic bone marrow transplant: "Allo" means "other." Stem cells are removed from another person, called a donor. Most times, the donor must have the same genetic makeup as the patient, so that their blood is a "match" to yours. Special blood tests are done to determine if a donor is a good match for you. A brother or sister is most likely to be a good match. However, sometimes parents, children, and other relatives may be good matches. Donors who are not related to the patient may be found through national bone marrow registries.
• Umbilical cord blood transplant: Stem cells are removed from a newborn baby's umbilical cord immediately after being born. The stem cells are stored until they are needed for a transplant. Umbilical cord blood cells are so immature, there is less of a concern that they will not match.

Before the transplant, chemotherapy, radiation, or both may be given. This may be done in two ways:

• Ablative (myeloablative) treatment: High-dose chemotherapy, radiation, or both are given to kill any cancer cells. This allows new stem cells to grow in the bone marrow.
• Reduced intensity (nonmyeloablative) treatment, also called a mini transplant: Today, some patients are getting lower doses of chemotherapy and radiation before a bone marrow transplant.

A stem cell transplant is done after chemotherapy and radiation is complete. The stem cells are delivered into your bloodstream through a tube called a central venous catheter. The process is similar to getting a blood transfusion. The stem cells travel through the blood into the bone marrow. Usually, no surgery is required.

In many cases donor stem cells can be collected directly from the person's blood. Surgery is not needed. The donor will first receive injections for a few days.

Minor surgery may be needed to collect bone marrow and stem cells from a donor. This is called a bone marrow harvest. The surgery is done under general anesthesia, which means the donor will be asleep and pain-free during the procedure. The bone marrow is removed from the hip bones.

Why the Procedure Is Performed

A bone marrow transplant replaces bone marrow that is either not working properly or has been destroyed (ablated) by chemotherapy or radiation.

Your doctor may recommend a bone marrow transplant if you have:

• Certain cancers, such as leukemia, lymphoma, and multiple myeloma
• A disease that affects the production of bone marrow cells, such as:
  • Sickle cell anemia
  • Aplastic anemia
  • Thalassemia
  • Congenital neutropenia
  • Severe immunodeficiency syndromes
• Had chemotherapy that destroyed your bone marrow

Risks

A bone marrow transplant may cause the following symptoms:

• Pain
• Chills
• Fever
• Hives
• Chest pain
• Drop in blood pressure
• Shortness of breath
• Nausea
• Flushing
• Headache
• Funny taste in the mouth

Possible complications of a bone marrow transplant depend on many things, including:

• The disease you are being treated for
• If you had chemotherapy or radiation before the bone marrow transplant
• Your age
• Your overall health
• How good of a match your donor was
• The type of bone marrow transplant you received (autologous, allogeneic, or umbilical cord blood)

Complications can include:

• Infections, which can be very serious
• Bleeding in the lungs, the intestines, brain, and other areas of the body
• Anemia
• Stomach problems, including diarrhea, nausea, and vomiting
• Pain
• Inflammation and sorenes in the mouth, throat, esophagus, and stomach, called mucositis
• Damage to the kidneys, liver, lungs, and heart
• Cataracts
• Early menopause
• Graft failure, which means that the new cells do not settle into the body and start producing stem cells
• Graft-versus-host disease , a condition in which the donor cells attack your own body
• Delayed growth in children who receive a bone marrow transplant

Before the Procedure

Your health care provider will ask you about your medical history and do a physical exam. You will have many tests before your treatment begins.

Before your transplant, you will have one or two tubes, called catheters, inserted into a blood vessel in your neck. This tube allows you to receive treatments, fluids, and sometimes, nutrition.

Your doctor or nurse should discuss the emotional stress of having a bone marrow transplant. You may want to meet with a mental health counselor. It is important to talk to your family and children to help them understand what to expect.

You will need to make plans to help you prepare for the procedure and handle tasks after your transplant. Things to consider include:

• Advanced care directives
• Arranging medical leave from work
• Bank or financial statements
• Care of pets
• Household chores
• Insurance coverage
• Payment of bills
• Schedules and care for your children

You may need to find housing for yourself or your family near the hospital.

After the Procedure

A bone marrow transplant is usually done in a hospital or medical center that specializes in such treatment. Most of the time, you will stay in a special bone marrow transplant unit in the center to limit your chance of getting an infection.

All or part of an autologous or allogeneic transplant can be done on an outpatient basis. This means you do not have to stay in the hospital or medical center.

How long you stay in the hospital depends on how much chemotherapy or radiation you received, the type of transplant, and your medical center's procedures. While you are in the hospital, you will be isolated because of the increased risk of infection. The health care team will closely monitor your blood count and vital signs.

While you are in the hospital you may:

• Receive medications to prevent or treat infections, including antibiotics, antifungals, and antiviral drugs.
• Need many blood transfusions
• Be fed through a vein (IV) until you can eat by mouth and stomach side effects and mouth sores have gone away
• Be given medication to prevent graft-versus-host disease

Outlook (Prognosis)

How well you do after transplant greatly depends on:

• The type of bone marrow transplant
• How well the donor's cells matched yours
• What type of cancer or illness you have
• Your age and overall health
• The type of chemotherapy or radiation therapy you had before your transplant
• Any complications
• Your genes

A bone marrow transplant may completely or partially cure your illness. If the transplant is a success, you can go back to most of your normal activities as soon as you feel well enough. Most times it takes up to 1 year to recover fully.

Complications or failure of the bone marrow transplant can lead to death.

References

Bishop MR, Pavletic SZ. Hematopoietic stem cell transplantation. In: Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG, eds. Clinical Oncology. 4th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2008:chap 32.

Vose JM, Pavletic SZ. Hematopoietic stem cell transplantation. In: Goldman L, Ausiello D. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 184.

Reviewed By

Review Date: 03/17/2011

Yi-Bin Chen, MD, Leukemia/Bone Marrow Transplant Program, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.