Bone marrow or stem cell transplants for AML

If you have acute myeloid leukaemia (AML) your doctors may suggest intensive treatment to try to cure it. Intensive treatment is high dose chemotherapy, and sometimes total body radiotherapy. This treatment kills off all your bone marrow cells. The bone marrow is the spongy substance inside your bones. It contains the stem cells that make all your blood cells. Your doctors need to replace the stem cells so you survive the treatment. You have the stem cells replaced by a drip (transfusion) of

• Someone else’s bone marrow or stem cells
• Your own bone marrow
• Your own stem cells - this is not common for AML

The choice between a donor transplant and having your own bone marrow or stem cells depends on a number of different factors, including

• The type of leukaemia you have
• Whether you have a close relative whose blood cells closely match yours

Stem cells are very early blood cells made by the bone marrow. The donor will have growth factor injections. This makes the body produce more stem cells, and they move from the bone marrow into the bloodstream. The doctor can then collect them with a machine called a cell separator. This process is called leucopheresis (pronounced loo-koh-for-ee-sis).

The donor has a drip put into each of their arms. The drips attach to the machine. Their blood passes out of one of the drips and goes through the machine. The machine filters their stem cells out and then passes the blood back into their body through the other drip. If you are going to have a transplant of your own stem cells, you will have them collected in this way.

Your doctors can then freeze the stem cells and store them until you are ready to have your transplant.

Stem cell transplants are similar to bone marrow transplants but your blood counts recover more quickly. So you are at risk of infection for a shorter period of time than with a bone marrow transplant. A lot of research has looked into using stem cells in the past few years. You can now have a transplant using a relative's stem cells and even stem cell transplants from a completely unrelated donor. Giving stem cells rather than bone marrow is more convenient for the donor. They don't need an anaesthetic to have stem cells collected and tend to recover more quickly.

Collecting bone marrow is also called a bone marrow harvest. It is a minor operation under general anaesthetic. The doctor uses a large syringe to suck out the marrow from your hip bones and sometimes your breast bone. This is not as bad as it sounds! Usually the donor will feel very bruised for a couple of days, and need to take painkillers, such as paracetamol.

With an auto transplant you have your own stem cells or bone marrow taken, stored and given back after your treatment. Your doctors will try to collect stem cells first. If they can't get enough, they may then try to collect your bone marrow. This is not a very common treatment for AML.

You have marrow or stem cells collected when there is no sign of leukaemia. (remission). The cells or marrow are frozen until you have had your high dose chemotherapy, and possibly radiotherapy. Then, after defrosting, you have them back as a drip through your central line. Due to the risk of infection, you have to stay in an isolation room until your marrow or stem cells have started to make new blood cells again.

Having someone else’s marrow or stem cells is called a donor transplant, or an allogeneic transplant. This is pronounced al-lo-jen-ay-ik.

The donor’s bone marrow cells must match your own as closely as possible. The most suitable donor is usually a close relative, such as a brother or sister. It is sometimes possible to find a match in an unrelated donor. Doctors call this a matched unrelated donor (MUD). To find out if there is a suitable donor for you, your doctor will contact The Anthony Nolan Bone Marrow Register and other UK based and international bone marrow registers. 

To make sure that your donor’s cells match, you and the donor will have blood tests. These are to see how many of the proteins on the surface of their blood cells match yours. This is called tissue typing or HLA matching. HLA stands for ‘human leucocyte antigen’.

Once you have a donor and are in remission, you have your high dose chemotherapy and radiotherapy. A week later the donor comes into hospital and their stem cells or marrow are collected. You then have the stem cells or bone marrow as a drip through your central line.

If you've had a transplant from a donor, there is a risk of GVHD. This happens because the transplanted stem cells or bone marrow contain cells from your donor's immune system. These cells can sometimes recognise your own tissues as being foreign and attack them. This can be an advantage as the immune cells may also attack cancer cells left after your treatment.

Acute GVHD starts within 100 days of the transplant and can cause

• Diarrhoea
• Weight loss
• Changes in the way your liver works
• Skin rashes

If you develop GVHD after your transplant, your doctor will prescribe drugs to damp down this immune reaction. These are called immunosuppressants.

Chronic GVHD starts more than 100 days after the transplant and you may have skin rashes, diarrhoea, sore joints and dry eyes. Your doctor is likely to suggest that you stay out of the sun because GVHD skin rashes can often get worse in the sun.

There is detailed information about graft versus host disease in the cancer section on coping physically with cancer of CancerHelp UK.

After your chemotherapy and radiotherapy, you have the bone marrow or stem cells through a drip, into a vein. The cells find their own way to the centre of your bones. They begin to make blood cells after a few days or weeks.

You usually have to stay in hospital while your blood cell counts are very low. This may be for a few weeks at least. You will be at risk of picking up infections and will need anti-viral and antibiotic treatments. Sometimes you may need anti-fungal treatments.

It is very unusual for anyone to get through this treatment without picking up infections. So don't worry too much when you get one. Make sure you tell your doctors if you think you have signs of an infection. It is important to start treatment as soon as possible. Infections may make you feel very ill and low.

Many people find it hard to eat after such intensive treatment. This may be because your digestive system is very upset and sore after all your chemotherapy and radiotherapy. Or it may be because you have a very sore mouth. Your dietician may give you meals in a drink.

If you have lost a lot of weight during treatment, your doctors may order liquid food (nutrition) that you have through your drip. This gives you all the calories you need while you recover. Your nurses will still encourage you to eat, so you can start getting back to normal. Once you are able to eat and drink again, you can slowly replace the liquid feeds with normal meals.

You can find out more about stem cell and bone marrow transplants in the about cancer treatment section of CancerHelp UK.