- How is Hodgkin disease treated?
- Chemotherapy for Hodgkin disease
- Radiation therapy for Hodgkin disease
- High-dose chemotherapy and stem cell transplant for Hodgkin disease
- Treating Hodgkin disease in children
- Hodgkin disease in pregnancy
- Clinical trials for Hodgkin disease
- Complementary and alternative therapies for Hodgkin disease
High-dose chemotherapy and stem cell transplant for Hodgkin disease
Standard doses of chemotherapy drugs can cause serious side effects to cells that divide fast, such as those in the bone marrow. Although even higher doses of these drugs might work better to treat Hodgkin disease, they are not given because the severe damage to bone marrow cells would cause lethal shortages of blood cells, and other vital organs would likely be damaged, too.
But sometimes Hodgkin disease does not respond well to standard treatment, or the disease comes back after treatment. In these cases, a stem cell transplant (SCT) allows doctors to use very high doses of chemo. After chemo treatment the patient gets a transplant of blood-forming stem cells to restore the bone marrow.
Types of transplants
There are 2 kinds of transplants. They differ with regard to the source of the blood-forming stem cells.
Autologous stem cell transplant: This is the more common type of transplant for Hodgkin disease. It uses blood-forming stem cells from the patient’s own blood or, less often, from the bone marrow. The stem cells are removed, frozen, and stored in the weeks before treatment. Then very high doses of chemo (with or without radiation therapy) are given in order to kill the cancer. These high doses destroy bone marrow, too. When this happens, the body is no longer able to make new blood cells. So, after the treatment, the stored stem cells are thawed and put back into the patient’s bloodstream through a vein. Over time the stem cells return to the bone, replacing the marrow and making new blood cells.
If this type of transplant fails, another type of transplant may be done in which a matched donor supplies the stem cells. When the stem cells come from someone else it is called an allogenic stem cell transplant.
Allogenic stem cell transplant: The donor’s tissue type should match the patient’s tissue type as closely as possible to help prevent the risk of major problems with the transplant. Usually this donor is a brother or sister if they have the same tissue type as the patient. If there are no siblings with a good match, the cells may come from a matched, unrelated donor. Sometimes umbilical cord blood stem cells are used. These cells come from blood drained from the umbilical cord and placenta after a baby is born and the umbilical cord is cut.
Some patients (especially those who are older) may not be able to have a regular transplant using high doses of chemo because of the likely side effects. But some may be able to have what is called a “mini-transplant” (a non-myeloablative transplant; also called reduced-intensity transplant). For this type of transplant, lower doses of chemo and radiation are used so they do not destroy all the stem cells in the bone marrow. The patient is then given the donor stem cells. These cells enter the body and form a new immune system, which sees the cancer cells as foreign and attacks them (called a graft-versus-lymphoma effect). Doctors aren’t yet sure how well these types of transplants work for patients with Hodgkin disease, but studies are now being done to find out.
The transplant process
Patients may be in the stem cell transplant unit of the hospital or get treatment as an outpatient. If they are going to be treated in the hospital, the person usually goes into the hospital the day before the high-dose chemo is to begin. He or she will usually stay in the hospital until the stem cells have started to make new blood cells again, which often takes several weeks.
The patient is given very high doses of chemo to kill the cancer cells. The patient might also get total body radiation to kill any cancer cells that the chemo may not have killed. After treatment, the stored stem cells are given to the patient like a blood transfusion. The stem cells settle into the patient’s bone marrow over the next several days and start to grow and make new blood cells.
People who get a donor’s stem cells are given drugs to keep the new immune system from attacking the body. Usually within a couple of weeks after the stem cells are given, they start making new white blood cells. Then they begin making platelets, and finally, red blood cells.
Patients having SCT have to be kept away from germs as much as possible until their white blood cell count is at a safe level. They are kept in the hospital until part of the white cell count (known as the ANC) reaches a certain number, usually around 1,000. After they go home, they will be seen as an outpatient regularly for about 6 months.
Some things to keep in mind
A stem cell transplant is a complex treatment that can cause life-threatening side effects. If the doctors think that a patient might be helped by this treatment, it is important that it be done at a hospital where the staff has experience with the procedure. Some transplant programs may not have experience in certain transplants, especially those from unrelated donors.
Stem cell transplant is very expensive. It can cost well over $100,000 and often involves a long hospital stay. Because some insurance companies see it as an experimental treatment, they might not pay for it. Even if the transplant is covered by your insurance, your co-pays or other costs could easily amount to tens of thousands of dollars. It is important to find out what your insurance will cover and what you might have to pay before deciding to have a transplant.
Side effects of stem cell transplant
Side effects from stem cell transplant can be divided into short- and long-term effects.
Short-term or early side effects: These are about the same as those caused by any other type of high-dose chemo, which can be severe. One of the most common and serious short-term effects is the greater risk of infection. Other side effects include low red blood cell counts, nausea, vomiting, diarrhea, loss of appetite, mouth sores, and hair loss.
Long-term side effects: Some side effects can last for a long time, or may not happen until years after the transplant. These long-term side effects can include:
- Graft-versus-host disease, which occurs only in a donor (allogeneic) transplant (see below)
- Menstrual changes , early menopause, and not being able to get pregnant (women)
- Loss of fertility in male patients
- Damage to the thyroid gland that causes problems with changing food into energy
- Cataracts (damage to the eye that can affect vision)
- Damage to the lungs, causing shortness of breath
- Bone damage (if damage is severe, the patient may need to have part of the bone and joint replaced)
- Getting leukemia or another cancer several years later
Graft-versus-host disease can be a major problem with a donor stem cell transplant. It happens when the immune system of the patient is replaced by that of the donor. The donor’s immune system then starts to attack the patient’s other tissues and organs.
Symptoms can include severe skin rashes with itching, mouth sores, nausea and severe diarrhea. The liver and lungs may also be damaged. The patient may also become tired and have aching muscles. If bad enough, the disease can be fatal. Drugs that weaken the immune system may be given to try to control it, although they can have their own side effects. On the plus side, this disease may also cause any remaining lymphoma cells to be killed by the donor immune system. Mild graft-versus-host disease can be a good thing.
To learn more about stem cell transplants, see the American Cancer Society document, Stem Cell Transplant (Peripheral Blood, Bone Marrow, and Cord Blood Transplants).
Last Medical Review: 02/05/2013
Last Revised: 02/07/2014