Autologous stem cell transplantation

Patient selection

Patients should good physical condition; age range for some procedures can be extended up to ~70. BM should be uninvolved or in CR at the time of harvest/mobilisation unless disease control rather than cure is the primary intent cf. myeloma.

Accepted indications

• Relapsed aggressive and very aggressive NHL.

• Relapsed Hodgkin's lymphoma.

• Adult AML (poor risk first CR without allogeneic option or second CR without allogeneic option).

• Adult ALL (poor risk first CR without allogeneic option or second CR without allogeneic option).

Possible indications

• Sclerosing mediastinal B-cell NHL in 1st CR.

300 • Patients with aggressive or very aggressive NHL with 2 of: stage III/IV, high LDH, ECOG performance status 3 or 4, bulk disease (mass >10cm).

• Indolent NHL (aged <60) relapsing after 2nd line therapy if still responsive to therapy.

• Relapsed germ cell tumours.

• Neuroblastoma.

• Soft tissue sarcoma.

• Autoimmune disease (multiple sclerosis, systemic sclerosis, rheumatoid arthritis, juvenile chronic arthritis, SLE).

Outline of autologous SCT procedure

• Haematopoietic stem cells harvested in CR are processed, frozen and stored in liquid N2.

• SCT may take place within days of harvest or several years later after treatment for recurrent disease.

• Different conditioning chosen for underlying indication e.g. cyclophosphamide plus busulphan for AML or BEAM (p612) for NHL or HL.

• After completion of conditioning (generally plus 24 hours to allow clearance of chemotherapeutic agents), the stem cell product is thawed rapidly and infused IV. Bags are thawed by transfer directly from liquid N2 into water at 37-43°C. Product is infused IV rapidly through indwelling central line.

• There is period of myelosuppression (7-25d) followed by WBC, platelet and RBC engraftment.

Early complications of the transplant procedure

• Overall transplant related mortality is 5-10%.

• Morbidity from conditioning regimens e.g. nausea from chemoradio-therapy and mucositis from the widespread mucosal damage to GIT:

oral ulceration, buccal desquamation, oesophagitis, gastritis, abdominal pain and diarrhoea may all be features.

• Spectrum of infective organisms seen is similar to allografts but severity and mortality are 5.

Late complications of autologous SCT

• Single commonest long-term complication is relapse of underlying disease.

• Other late complications similar to allografts, but less frequent and less severe.

Follow-up treatment and post-transplant surveillance

• Regular haematological follow-up is mandatory and psychological support from the transplant team, family and friends is important for readjustment to normal life.

• Prophylaxis against specific infections required including Pneumococcus, HZV and PCP. Most patients return to an active, working life without continuing medication.

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