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Author: Dr Leah Jones, Medical Registrar, Christchurch, New Zealand. Medical Editor: Dr Helen Gordon, Auckland, New Zealand. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. September 2020.


Autologous stem cell transplantation — codes and concepts
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What is autologous stem cell transplantation?

Autologous stem cell transplantation is a procedure in which the patient’s stem cells are collected and are later injected back into the patient following chemotherapy or radiation therapy.

Autologous stem cell transplantation is used predominantly in haematological malignancies (lymphoma and leukaemia). It is sometimes used in autoimmune diseases including systemic lupus erythematosus, systemic sclerosis, and dermatomyositis, which have cutaneous manifestations.

Autologous stem cell transplantation is also known as autologous haematopoietic cell transplant and an autologous bone marrow transplant.

Who uses autologous stem cell transplantation?

Autologous stem cell transplantation enables higher doses of chemotherapy to be used than would be otherwise tolerated due to the toxicity of treatment on the bone marrow.

Autologous stem cell transplantation is well established in the treatment of various haematological malignancies with growing experience and use in solid tumours and autoimmune conditions.

Haematological malignancies

  • Multiple myeloma and other plasma cell disorders — autologous stem cell transplantation is the standard of care in patients younger than 70 years. Myeloma was the indication for 46% of all autologous stem cell transplants in Europe in 2011.
  • Non-Hodgkin and Hodgkin lymphoma. Lymphoma accounted for 41% of all autologous stem cell transplants in Europe in 2011.
  • Acute myeloid leukaemia.
  • Acute lymphoblastic leukaemia.
  • Diffuse large B-cell lymphoma.

Solid malignancies

  • Neuroblastoma.
  • Germinal cell tumours.
  • Ewing sarcoma.

Non-malignant indications

There is experience and emerging clinical-trial evidence for the use of autologous stem cell transplantation in the treatment of autoimmune conditions. These include:

What are the contraindications to autologous stem cell transplantation?

Contraindications for autologous stem cell transplantation can include:

  • Systemic or uncontrolled infection
  • Poor functional capacity
  • End organ damage (cardiac, renal, hepatic, pulmonary)
  • Psychological factors affecting the ability to adhere to treatment and follow-up
  • Myelodysplasia on bone marrow examination.

Tell me more about autologous stem cell transplantation

Prior to the transplant, a detailed health workup is required, followed by pretransplant induction treatment which will vary depending on the condition being treated. Autologous stem cell transplantation then involves multiple steps.

  • Haematopoietic stem cells are harvested by apheresis after stimulation with granulocyte colony stimulating factor (G-CSF) — apheresis is the removal of peripheral blood from which progenitor cells are removed while the rest of the blood is reinfused; G-CSF is used in more than 95% of cases due to quicker engraftment.
  • Progenitor cells are less often extracted from bone marrow or umbilical cord blood.
  • Sometimes G-CSF is combined with a chemotherapy drug, such as cyclophosphamide, to enhance stem cell mobilisation and reduce the tumour burden.
  • Cells are cryopreserved, then infused approximately 24 hours after completion of high dose chemotherapy, often with further G-CSF to encourage engraftment.

Following the transplant, red blood cell and platelet transfusions may be required until the subsequent pancytopenia resolves. Consolidation and maintenance treatment may follow, depending on the underlying condition.

What are the benefits of autologous stem cell transplantation?

Autologous stem cell transplantation is well established for use in lymphoma and plasma cell disorders. Overall survival and progression-free survival is improved for plasma cell myeloma, non-Hodgkin lymphoma, and Hodgkin lymphoma when treated with autologous stem cell transplantation with chemotherapy compared to chemotherapy alone.

Autoimmune conditions with dermatological manifestations with the best evidence for autologous stem cell transplantation use are:

What are the disadvantages of autologous stem cell transplantation?

The main disadvantages of autologous stem cell transplantation include:

  • Significant morbidity
  • Variable mortality, which depends on the disease being treated, patient comorbidities, and the treatment centre
  • Although transplantation prolongs survival, it does not offer a cure for plasma cell disorders
  • Autologous stem cell transplantation is time-consuming and expensive.

What are the side effects and risks of autologous stem cell transplantation?

Side effects of autologous stem cell transplantation include:

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References

  • Niederhuber J, Armitage J, Doroshow J, Kastan M, Tepper J. Abeloff’s Clinical Oncology, 6th edn, Elsevier, 2019.
  • Ng SA, Sullivan KM. Application of stem cell transplantation in autoimmune diseases. Curr Opin Hematol. 2019;26(6):392-8. doi:10.1097/MOH.0000000000000531. PubMed
  • Kanate AS, Majhail NS, Savani BN, et al. Indications for hematopoietic cell transplantation and immune effector cell therapy: guidelines from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant. 2020;26(7):1247-56. doi:10.1016/j.bbmt.2020.03.002. PubMed
  • Gratwohl A, Baldomero H, Aljurf M, et al. Hematopoietic stem cell transplantation: a global perspective. JAMA. 2010;303(16):1617-24. doi:10.1001/jama.2010.491. PubMed
  • Passweg J, Baldomero H, Bregni M, et al. Haemopoietic SCT in Europe: data and trends in 2011. Bone Marrow Transplant 2013; 48(9):1161–7. doi: 10.1038/bmt.2013.51. PubMed Central
  • Holmberg L. Determining eligibility for autologous haemopoietic cell transplantation. UpToDate 2020 [cited 12 May 2020]. Available at: https://www.uptodate.com/contents/determining-eligibility-for-autologous-hematopoietic-cell-transplantation
  • Ali N, Adil SN, Shaikh MU. Autologous hematopoietic stem cell transplantation-10 years of data from a developing country. Stem Cells Transl Med. 2015;4(8):873-7. doi:10.5966/sctm.2015-0015. PubMed Central
  • Mahajan S, Tandon N, Kumar S. The evolution of stem-cell transplantation in multiple myeloma. Ther Adv Hematol. 2018;9(5):123-33. doi:10.1177/2040620718761776. PubMed
  • Berz D, McCormack EM, Winer ES, Colvin GA, Quesenberry PJ. Cryopreservation of hematopoietic stem cells. Am J Hematol. 2007;82(6):463-72. doi:10.1002/ajh.20707. PubMed Central
  • Rancea M, Monsef I, von Tresckow B, Engert A, Skoetz N. High-dose chemotherapy followed by autologous stem cell transplantation for patients with relapsed/refractory Hodgkin lymphoma. Cochrane Database Syst Rev. 2013;(6):CD009411. doi:10.1002/14651858.CD009411.pub2. PubMed
  • Kumar L, Ganessan P, Ghosh I, Panda D, Gogia A, Mandhania S. Autologous blood stem cell transplantation for Hodgkin and non-Hodgkin lymphoma: complications and outcome. Natl Med J India. 2010;23(6):330-5. PubMed
  • Koreth J, Cutler CS, Djulbegovic B, et al. High-dose therapy with single autologous transplantation versus chemotherapy for newly diagnosed multiple myeloma: a systematic review and meta-analysis of randomized controlled trials. Biol Blood Marrow Transplant. 2007;13(2):183-96. doi:10.1016/j.bbmt.2006.09.010. PubMed
  • Kapucu S, Karacan Y. Physiological problems in patients undergoing autologous and allogeneic hematopoietic stem cell transplantation. Asia Pac J Oncol Nurs. 2014;1(1):50-4. doi:10.4103/2347-5625.135821. PubMed

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