High-dose chemotherapy and stem cell transplant for Hodgkin disease
Standard doses of chemotherapy (chemo) drugs can damage cells that divide fast, such as those in the bone marrow (where new blood cells are made). 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) lets doctors use very high doses of chemo. After the chemo, the patient gets blood-forming stem cells to restore their bone marrow.
Types of transplants
There are 2 kinds of transplants. They use different sources of blood-forming stem cells.
Autologous stem cell transplant: This is the more common type of transplant for Hodgkin disease. It uses 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 the patient is given very high doses of chemo (with or without radiation therapy) to kill the cancer. 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, an allogeneic transplant may be done.
Allogeneic stem cell transplant: In this type of transplant, the stem cells come from someone else. The donor’s tissue type (also known as the HLA type) should match the patient’s tissue type closely to help prevent the risk of 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. This attack is 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 SCT unit of the hospital or get treatment as an outpatient. If they are going to be treated in the hospital, they usually are admitted the day before the high-dose chemo is to begin. They 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 make new blood cells in the following weeks.
People who get a donor’s stem cells are given drugs to keep this new immune system from attacking the body.
Patients having SCT have to be kept away from germs as much as possible until their white blood cell count returns to a safe level. They are kept in a special room in the hospital until part of the white blood cell count (known as the ANC) reaches a certain number. 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 person might be helped by this treatment, it should 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.
A stem cell transplant often requires a long hospital stay and can be very expensive. 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 many 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. They can include:
- Low blood cell counts (with fatigue and increased risks of infection and bleeding)
- Nausea and vomiting
- Loss of appetite
- Mouth sores
- Hair loss
Long-term or late side effects: Some side effects can last for a long time, or may not happen until years after the transplant. These can include:
- Graft-versus-host disease, which occurs only in a donor (allogeneic) transplant (see below)
- Loss of fertility
- Damage to the thyroid gland
- 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 might need to have part of the bone and joint replaced)
- Getting another cancer (such as leukemia) several years later
Graft-versus-host disease can be a major problem with a donor stem cell transplant. It happens when the new immune system from the donor 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, the new immune system may kill any remaining lymphoma cells. Mild graft-versus-host disease can be a good thing.
To learn more about stem cell transplants, see our document Stem Cell Transplant (Peripheral Blood, Bone Marrow, and Cord Blood Transplants).
Last Medical Review: 08/19/2014
Last Revised: 01/13/2015