Pre-Transplant Work-Up

Before your admission, a pre-transplant work-up is required. Each work-up is unique and individualized. The specific tests that you will need before the transplant will depend upon your situation and health status. Certain tests must be completed before beginning the stem cell collection and/or transplant. These tests will provide important information about your medical condition and readiness to safely undergo the transplantation procedure(s). Even though you may have had these tests in the past, current results may need to be obtained.

The Transplant Coordinator or your transplant physician will discuss which tests you need. You may or may not require the following tests/procedures:

• Echocardiogram or MUGA scan and EKG
• Chest and sinus x-rays
• Pulmonary function test (PFT)
• Dental exam
• 24-hour urine collection
• Blood tests (including screening for infectious diseases)
• Imaging studies (PET, CT, MRI scans)
• Bone marrow aspirate and biopsy
• Psychosocial evaluation

Catheter Insertion

A catheter is a flexible hollow silicone tube similar to intravenous tubing. Fluids such as blood, medications, or nutritional liquids can flow easily through the catheter’s tubes, often called ports or lumens. The catheter allows blood to be drawn and medication to be given without repeated needed sticks or intravenous insertions, which may cause discomfort and increase the risk of infection. Catheters for transplantation are used as follows:

• Autologous Transplants:  A double lumen central venous tunneled catheter is inserted prior to the stem cell collection, and will also be utilized for the transplant.
• Allogeneic Transplants:  A triple lumen central venous tunneled catheter is inserted prior to admission for transplant.

The central venous tunneled catheter insertion is usually done as an outpatient procedure under x-ray guidance in the Interventional Radiology Department. Local anesthesia is used and the procedure generally takes 30-45 minutes, not including pre-operation preparation and post-operation recovery. A PICC line insertion can either be done in the Interventional Radiology Department, or at bedside upon admission.  You may feel some tenderness after your catheter is inserted, but it usually subsides within two to three days.

Pre-Transplant Collection or Harvesting

Depending on the type of transplant you will have, stem cells can be collected from one of the following individuals:

• You, the patient (autologous transplant)
• A related family member, unrelated donor, cord blood unit, or combination of a human donor and cord blood unit. (allogeneic transplant)
• An identical twin (syngeneic transplant)

Stem Cell Mobilization and Collection (Autologous Transplant Only)

Stem cell collection involves removing cells from the peripheral circulation. During this process the stem cells are removed from the patient’s (or donor’s) circulating blood and may be stored until they are transplanted intravenously (infused into a vein) during the actual transplant. The Stem cell collection is an outpatient procedure performed in our Apheresis Unit, located on the 3rd floor of the Starr Pavilion.

To prepare for peripheral blood stem cell collection (PBSC), the stem cells need to be “mobilized” or stimulated. There are two ways to achieve mobilization:

• Without chemotherapy:  Your doctor will prescribe blood cell “growth factor” injections beginning 4 days before your stem cell collection. You and/or a family member/friend will be taught how to subcutaneously inject the growth factor, Neupogen (Filgrastim). In some cases, it may be necessary to have a nurse administer the injections in our outpatient clinic each day.

• With chemotherapy: Depending upon the type of chemotherapy being used to mobilize your stem cells, this process can begin with chemotherapy given during a hospital stay, or with a single outpatient chemotherapy infusion. In both cases, you will begin Neupogen injections approximately 24 hours after the chemotherapy has ended.  Your blood counts will be monitored very closely after chemotherapy and collection will begin when your white blood count begins to rise (generally 7-10 days following chemotherapy).

The stem cell collection procedure is painless. You will sit (or lie) in a reclining chair while the apheresis nurse attaches your catheter to the apheresis machine (some patients who will only have their stem cells collected for a transplant in the future may not require a catheter if their veins are adequate for the collection). Blood will be withdrawn through one of the catheter’s lumens, stem cells will be removed, and the remainder of the blood will be returned to you through the second lumen. This procedure takes approximately 5 hours each day and may require repeat collection days. Occasionally, you may need red blood cell and/or platelet transfusions after the stem cell collection.  This generally occurs only in patients who begin with low blood counts because of prior chemotherapy.

In rare instances, a bone marrow harvest (BMH) may be required if an insufficient number of stem cells is collected. Bone marrow is the soft, spongy material found inside certain bones. It resembles blood and actually is the factory where stem cells develop. The bone marrow makes stem cells, red blood cells, white blood cells, and platelets. The harvest is an outpatient surgical procedure performed in an operating room. The procedure is performed under general anesthesia and generally takes an hour to complete.

Bone Marrow Registry Participation

The Bone Marrow and Hematopoietic Stem Cell Transplantation Program at NewYork-Presbyterian Hospital/Weill Cornell is a participating Transplant Center, Collection Center & Apheresis Center for the National Marrow Donor Program (NMDP) and its cooperative registries. As a participating member of the NMDP and its cooperative registries, the NYPH/WC transplantation program is able to search for suitable matched donors and/or cord blood units to facilitate stem cell transplantation for patients without related donors. Additionally, as a Collection and Apheresis Center, the program collects stem cell products (bone marrow and stem cells) for other NMDP centers and cooperative registries.  The Transplantation Program is an active participating member of the Center for International Blood and Marrow Transplant Research (CIBMTR) network and reports transplantation data to the CIBMTR.

Donor Identification and Search (Allogeneic Transplants Only)

In cases where your own stem cells cannot be used, a donor must be identified. A blood sample will be drawn from you to identify your HLA (human leukocyte antigen) type. A blood sample will also be drawn from a potential donor for the same purpose. Each full sibling (same mother and father) has a 25 percent chance of being a match for you. Other family members (cousins, nephews/nieces, etc.) are very unlikely to match you, and are generally not tested.

If a suitable donor match cannot be found within your immediate family, your Transplant Coordinator will search a worldwide database of potential donors. The National Marrow Donor Program will facilitate the process of identifying and locating a potentially suitable stem cell donor or cord blood unit(s). A matched donor will have their stem cells collected in the same manner as a patient would, using Neupogen injections to mobilize the stem cells.

Next: During Your Transplant