Bone Marrow and Stem Cell Transplant Program

Dr. Matthew Fero “Autologous bone marrow transplantation is the process of taking bone marrow stem cells out of a patient and then infusing them back in after the patient receives high dose therapy ... This allows us to use treatments that would otherwise harm the bone marrow.”

– Matthew Fero, MD, FACP
Bone Marrow Stem Cell Program Director

How an Autologous Transplant Works

“Because bone marrow is a liquid organ,” Dr. Fero says, “it can pass through an IV [intravenous] line.” Doctors rarely need to take stem cells directly out of the bone, he explains. They use drugs to coax bone marrow stem cells into the bloodstream. From there, the blood travels through an IV line into an apheresis machine that sorts the stem cells out and returns the rest of the blood. The experience is like donating blood at a blood bank.

Once stem cells are safely stored out of the bloodstream, doctors use high-dose chemotherapy to eradicate the remaining cancer. When chemotherapy is out of their system, the patients’ stem cells are reinfused. The process is similar to blood transfusion. Stem cells find their way back to bone marrow where they begin to grow and make new blood cells.

Bone marrow, the soft reddish material that fills the inside of our bones, produces millions of new blood cells each second. These millions of cells come from a tiny number of bone marrow stem cells. These stem cells are special because they can mature into all of the different types of cells in the blood. These are the cells doctors collect for a transplant.

Autologous bone marrow transplants are standard treatments for lymphoma and myeloma.

This treatment works very well against aggressive lymphomas. “In this case the goal is to cure the disease,” says Fero.
For multiple myeloma the goal of treatment is to extend people’s lives and give them a better quality of life.

How an Allogeneic Transplant Works

The difference between an allogeneic (allo) and an autologous (auto) transplant is that allo uses stem cells collected from a donor, who is often a close relative. This difference has two important implications. First, it eliminates the risk that the transplant cells will be contaminated with tumor cells. Secondly, and perhaps more importantly, even a closely matched donor will provide a new immune system capable of causing an immune reaction in the patient's tissues. This can cause serious inflammation so potent medications are needed to regulate the immune system. However, this immune reaction is also therapeutic and reduces the risk of disease relapse. Since much of the benefit from an allo transplant comes from this immune reaction, there is less of a need to rely on high doses of chemotherapy to do the job.

How CAR T Cell Therapy Works

A recent development in the field of transplant and cell therapy is the use of Chimeric-Antigen Receptor T cell (CAR T). The process of CAR T therapy is very similar to an auto transplant. The major distinction is that instead of collecting blood stem cells from the patient, T-lymphocytes are harvested. These lymphocytes are not simply frozen away for future use; instead they are sent to a laboratory that modifies their genes so that they are programmed to attack the tumor cells using a new "chimeric antigen receptor". This modification means that when the cells that are infused back into the patient they will induce a very potent immune reaction to the tumor. Like an allo transplant, CAR T is a potent immunotherapy. However, CAR T cells are directed very specifically to molecules on the surface of tumor cells so they cause less inflammation in normal tissues.

Learn More: Bone Marrow & Stem Cell Transplant Treatments

What is Transplantation and Cell Therapy?

What are bone marrow blood stem cells?

Every blood cell starts from a special kind of cell called a bone marrow stem cell. Your body makes all of the other blood cells from bone marrow stem cells.

The cells in our blood do several vital things:

White blood cells (WBC or leucocytes) fight infections
Lymphocytes are a special kind of WBC that provides immunity to prior infections
Red blood cells (RBC or erythrocytes) carry oxygen
Platelets help blood to clot and stop bleeding

The process of blood cell growth is called hematopoiesis.

Who might need a stem cell transplant?

Stem cell transplants are an option if they are likely to extend a person’s survival time or cure them of their cancer. These treatments are often an option for people who have received other treatments already.

Autologous stem cell transplant is a standard treatment option for people diagnosed with Multiple Myeloma and some types of Lymphoma. It may help people with other cancer types, too. Not everyone with these cancers will need a transplant.

An allogeneic transplant (using stem cells from a donor) is most often used for cancers of bone marrow cells, particularly acute leukemia (AML or ALL) or for related diseases: Myelodysplastic syndrome and myelofibrosis. While other treatments exist for these diagnoses, an allogeneic transplant is sometimes the only option that has the potential to cure the disease.

CAR T therapy uses T-lymphocytes from the patient that are reprogrammed to attack the tumor cells. It is currently available for patients with Acute Lymphoblastic Leukemia, multiple myeloma, and certain types of Lymphomas.

If a transplant or CAR T therapy cell transplant is a treatment option for you, our UNM Transplant team is here to support you. Stem cell and CAR T cell transplantation is complex. You may find the process physically and emotionally difficult. We will guide you and help you through your evaluation and treatment process.

If a transplant or CAR T therapy is a treatment
option for you, our UNM Transplant team is here to support you.
You can ask our team questions: call 505-925-0062.

Overview: Cell Collection & Transplants

Pre-transplant evaluation

A transplant physician will review your medical history and preferences with you to decide if a transplant will help you. If the transplant physician thinks a transplant will help you, and if you decide you would like to undergo treatment, we will perform several tests to make sure you are healthy enough to tolerate the procedure.

We will test how well your heart, lungs, liver and kidneys work and will test to see if you have any infections. We will also advise you about staying close to the UNM Cancer Center and about whether you can get regular support from caregivers while you are being treated in the outpatient clinic.

Cell collection (harvest)

Once you have been cleared to begin a stem cell transplant or CAR T therapy, we will begin the treatment by collecting white blood cells from your blood. If stem cells are needed, then you will be given shots to "mobilize" or coax stem cells out of the bone marrow and into the blood stream. To collect these cells:

We will give you drugs that make your bone marrow stem cells leave your bone marrow and flow into your blood
We will place a central venous catheter in you. A catheter is a tube that we will insert into one of your veins.
We will collect your bone marrow stem cells or lymphocytes through your catheter using an apheresis machine.

Processing and storing your cells

We will send your blood cells to a specialized processing lab.

At the lab, your bone marrow stem cells or lymphocytes are counted. For CAR T patients, the lymphocytes are then transduced with DNA that will cause them to display chimeric antigen receptors on their surface. The cells are then and carefully frozen. The freezing process allows them to be stored for many years.

During your infusion, bags of stem cells or CAR T cells are thawed in a warm water bath minutes before they are infused.

Stem cell transplantation

When your bone marrow stem cells are safely frozen and stored, you can receive chemotherapy to treat your cancer. Once you finish your chemotherapy, your bone marrow stem cells will be thawed and reinfused into you through an IV line. The infused stem cells will help your bone marrow to start making blood cells again.

Recovery period

Once your stem cells go back into your blood, they find their way back into your bone marrow. CAR T cells, on the other hand, may stay in the blood stream or hone in on lymph nodes. They then start to grow and make more cells. This process usually takes several weeks.

Often people need to stay in the hospital for the first two to three weeks after their transplant. If needed, you will stay at UNM Hospital after your transplant. Within a couple of days after your discharge from UNM Hospital, our team will follow up with you. We will continue to follow up with you often for some time.

Long term follow up

You may take several months to fully recover your strength and energy.
We will recommend a program for you to get vaccines to rebuild your immune system during your recovery.
A transplant physician will talk with you and your cancer doctor about maintaining your long term health.

Download and print Stem Cell Overview information: English • Spanish

Cells Collection

An apheresis machine is used to collect your stem cells.

Getting your blood stem cells lymphocytes

Stem cells are the blood-forming cells that reside in the bone marrow. Collecting the bone marrow stem cells is the first step of the transplant process. For an autologous transplant, you will donate your own stem cells (a stem cell collection), which will be given back to you after you have completed chemotherapy. For an allogeneic transplant, a volunteer donor (often a close relative) will provide the cells.

The most common way to collect the stem cells is to use medication that causes the stem cells to leave the bone marrow and circulate in your bloodstream. This process is called stem cell mobilization. From your bloodstream, we collect your stem cells through an IV.

The medication most commonly used for stem cell mobilization is called Filgrastim, or GCSF, for Granulocyte Colony Stimulating Factor. It is given as an injection under the skin once daily. By the fifth day of fligrastim treatment, most patients will have enough stem cells in their blood stream to begin the collection procedure. If the number of stem cells in your circulation is too low, we might give you an additional medication to help move your bone marrow stem cells into your bloodstream. One common medication for this is called Plerixafor.

Another way to mobilize your bone marrow stem cells is to give you chemotherapy first and then GCSF injections. You may need to stay in the hospital for the chemotherapy. You can usually get the GCSF injections and stem cell collection at the UNM Cancer Center outpatient clinic. The transplant physician will determine the best mobilization regimen for you.

For patients undergoing CAR T cell therapy, it is the lymphocytes that are collected from the blood, not stem cells. Because your blood already has lymphocytes, you do not need to first receive shots to mobilize the stem cells.

Hematopoietic cells are collected by connecting an IV to an apheresis machine. The apheresis machine separates your white blood cells from the other cells in your blood, directs them into a blood collection bag, and then returns the remaining red blood cells back to your body. We will place a central venous catheter into a large vein in your body. This catheter can be used for both the collection and the transplant.

Your Transplant Nurse Navigator will give you a schedule that lists your procedures and appointments.

What to expect during your collection process

A nurse connects the stem cell harvest machine to your catheter. The central venous catheter is placed into a large vein in your body before the day of your stem cell harvest.

You will come to the UNM Cancer Center and we will draw blood samples to check whether there are enough cells in your blood.
The apheresis machine will circulate your blood through the machine, remove the stem cells from your blood, and store them in a transfusion bag. The rest of your blood will be returned to you. Your blood will be circulated through the machine several times in order to collect enough stem cells. We’ll use a small amount of blood thinning medication to prevent blood clots.
The collection process takes about three to four hours. An apheresis nurse will be with you during the entire process.
You should feel no pain during the apheresis process. You may, however, feel tingling or muscle cramps due to changes in your calcium levels. Your nurse can treat any tingling and cramps you feel with Calcium given through your IV line, so tell your nurse if you feel anything.
The apheresis machine will also remove a small amount of red blood cells or platelets during the process. These counts will be checked at the end of collection.I If your red blood cells or platelets are too low, we will give you a transfusion after the apheresis process.
Although the procedure is usually well tolerated, you should have a caregiver available to give you a ride home afterwards.

If we don’t collect enough cells from you, you may need to repeat the collection process the following day.

Once the stem cells are collected, they are processed and frozen in the laboratory and stored until it is time for your transplant.

Click to download and print Stem Cell Collection information: English • Spanish

Cells Infusion

Pre-Transplant chemotherapy

The chemotherapy that is given prior to a stem cell transplant is called the Conditioning or Preparative regimen. Its purpose is to eliminate the tumor cells in your body. In the case of an allogeneneic transplant it also lowers your immune systems potential to reject the cells from your donor. In patients receiving CAR T cells, the chemotherapy is called "lymphodepletion". Its main goal is to reduce the number of other lymphocytes in your body before infusing your CAR T cells.

Most chemotherapy treatments take between one and five days. Depending on your health and the chemotherapy you receive, you may have to stay in the hospital.

After the chemotherapy is gone from your system, we will bring your stem cells or CAR T cells from the laboratory, thaw them, and infuse them back into you.

What to expect during your cell infusion

An IV catheter used during a stem cell transplant.

The bone marrow stem cells are infused through an IV catheter.

Nurses will stay with you during the stem cell infusion to check your vital signs and to make sure that you are comfortable. The stem cell infusion may take several hours or it may be quicker. The length of your infusion depends on the total number of cells that need to be infused and whether you have any side effects.

In order to protect your stem cells during the freezing process, a chemical called DMSO (Dimethyl Sulfoxide) is added to the stem cells at the time of collection. After your stem cells are reinfused, your body will get rid of DMSO through your breathing and through your urine. This will make your breath smell like garlic or creamed corn for several hours or even days. You might also notice a funny taste in your mouth, but this taste is not harmful. Lemon drops or hard candy might help you.

Frozen stem cells are removed from a storage container.

During your transfusion, bags of stem cells are thawed in a warm water bath minutes before they are transfused.

You might feel fever, chills, rash, or shortness of breath during infusion of your stem cells. The infusion may also cause nausea, headaches or, rarely, more serious reactions. We will give you medication to help prevent these symptoms, and extra treatments if necessary.

Recovery after Stem Cell Transplants

Once stem cells are infused, they will circulate in your bloodstream for a period of time and and, then eventually find their way back to your bone marrow to begin making blood cells again.

New blood cells will start forming in your bloodstream about 10-12 days after the stem cells infusion. This new blood cell growth is called “engraftment”.

The appearance of newly produced cells in the bloodstream is called engraftment.

Until your reinfused bone marrow produces enough new mature blood cells, you will have low blood counts including low white blood cells, low red blood cells, and low platelets. You might need to stay in the hospital if we think you may need a transfusion or if we need to watch you closely for infections. Our medical team will monitor you closely for any complications.

Recovery after CAR T cell infusions

CAR T cells will circulate through your blood stream for several days after their infusion. They will then home in on tumor cells and become "activated". The CAR T cells will grow and product chemical factors that enlist your immune system to fight the cancer. These factors might also make you feel sick, like you have a bad flu, with fever, low blood pressure or shortness of breath. These symptoms are called CRS (cytokine release syndrome). You will be monitored closely if you develop CRS and may need special treatments in the hospital. A second immune reaction can affect your brain and nervous system. These neurological symptoms can range from mild confusion to a severe coma. Fortunately, this too is highly treatable with anti-inflammatory corticosteroid medications.

For all patients:

We will check your blood counts daily.
We will give you antibiotics to help prevent infections. The antibiotics that you receive will depend on your blood counts, how long it has been since your transplant, and whether any infections develop.
If your red blood cells or platelets are low, we will give you transfusions.

One of the most important things you can do during your treatment is to walk every day. Getting out of bed and taking walks regularly — even while you are in the hospital — will help you to maintain your strength and stamina. Good strength and stamina speeds your long-term recovery.

Download and print Stem Cell Transplant information: English • Spanish

What to Expect after your Cell Therapy

Recovery and long term follow up

Dr. Fero speaks with a patient during a visit.

Once you have sufficiently recovered from your transplant, you can return to the care of your primary oncologists. This recovery time is typically 30 days after autologous transplant or CAR T therapies, or 100 days after an allogeneic transplant.

You and your transplant physician will review plans for your future care. We will also give you a summary of your treatment and contact information for your transplant team, in case you have questions later.

With your permission, we will continue follow up with you periodically for the rest of your life. This follow-up will include advice on reducing your risks and improving your quality of life with vaccinations and other activities.

It might take six to 12 months to fully recover your strength and stamina. Your immune system will take time to recover. During the first year after your transplant, you will be in a higher risk for infections.

You will be advised to take some medications to prevent infections up to a year after transplant.

After six to 12 months you may start to receive vaccinations and then boosters, similar to the types of vaccines normally given to children.

Allogeneic transplant recipients, in particular, will have long term plans on how to gradually taper off of their immune suppressive therapies, and how to treat any GVHD (graft versus host disease). The management of GVHD is very specialized, and we are here to help you and your regular oncologist whenever necessary.

Your transplant team will be available for you for any transplant related questions or concerns. Please don’t hesitate to reach out to us.

Available Resources

For more information, check the following resources.

Patient Assistance

BMT Infonet matches those wishing to offer support with those who need it.

NBMT Link (nbmtlink.org) provides phone support. Call 800.546.5268 to arrange for a call from a trained peer counselor.

CancerCare (cancercare.org)provides online, telephone, or face-to-face counseling by professional oncology social workers for cancer patients and their families.

Finance

Patient Advocacy Foundation: https://www.patientadvocate.org/connect-with-services/financial-aid-funds/

RxAssist maintains a list of brand name drug programs. Visit https://www.rxhope.com/Patient/BrandNameList.aspx

Partnership for Prescription Assistance (medicineassistancetool.org)

Patient Access Network offers programs for underinsured patients to assist with out-of-pocket costs

The Healthwell Foundation (healthwellfoundation.org) provides assistance with insurance co-pays and premiums for patients with a variety of specific diagnoses.

The Leukemia and Lymphoma Society (lls.org) provides co-pay assistance to underinsured patients with specific diagnoses.

Needymeds.com maintains a variety of resources, including co-pay assistance, discount cards, money-saving tips and other resources to assist patients in obtaining low- or no-cost medications.