In combination with high-dose chemotherapy, stem cell transplantation can offer durable remission for multiple myeloma patients, but the process of transplantation can be intimidating, sometimes involving a lengthy hospital stay. High-dose chemotherapy attacks multiple myeloma cells, and a stem cell transplant provides a new source of healthy plasma cells.
There are generally two types of transplants performed for multiple myeloma:
- Autologous stem cell transplants. Most patients with multiple myeloma who are eligible for transplant undergo autologous transplant. The word “autologous” is derived from the Greek root “auto-,” meaning “self.” The stem cells for an autologous transplant are taken from a patient’s own blood.
- Allogeneic stem cell transplants. While an allogeneic stem cell transplant has the potential in rare instances to be curative, it is generally not recommended for multiple myeloma patients because the risks are incredibly high. The word “allogeneic” is derived from the Greek roots “allo-,” meaning “other” and “-gen,” meaning “born.” Allogeneic transplants involve donor stem cells.
Additionally, a third option is available if a patient happens to have an identical twin. A syngeneic transplant, in which the identical twin serves as a donor, can be the optimal situation for individuals with multiple myeloma.
The potential benefits and risks of these types of transplants are significantly different. In rare instances, allogeneic and syngeneic transplants can be curative due to the graft-versus-tumor effect, in which the healthy donor cells help to destroy any remaining myeloma cells in the patient. However, while these cells can sometimes destroy multiple myeloma cells, there is a high risk for graft-versus-host disease (GVHD). This occurs when the donor immune cells see the patient’s tissues as foreign and attack them. Allogeneic transplants, though, are rarely recommended in multiple myeloma due to complications that lead to high treatment-related mortality. Furthermore, superior efficacy of allogeneic over autologous stem cell transplants has not been adequately demonstrated for patients with multiple myeloma. For most patients, the potential benefits of an allogeneic transplant don’t justify the high risks of the procedure.
Because the “donor” tissue for an autologous transplant is provided by patients themselves, there is no risk for GVHD. Autologous transplants are associated with longer survival than chemotherapy alone, but they are not without risks. For some patients, tandem transplants may be the appropriate course of treatment. This occurs when patients do not achieve a complete or near complete response following the first transplant. A second transplant has been shown to potentially benefit these patients. For more in-depth information about what to expect during an autologous transplant, read the timeline below.
General timeline of an autologous transplant
Part 1: Primary therapy
- Consists of: Generally, primary therapy includes a three-drug regimen called “VRd” or “KRd”: the proteasome inhibitor bortezomib (Velcade) or carfilzomib (Kyprolis), an immunomodulator such as lenalidomide (Revlimid), and a corticosteroid (dexamethasone).
- Timing: 3-4 months
- Location: Outpatient clinic
Part 2: Stem cell collection
- Consists of: Patients will have a “transplant catheter” inserted into a large vein. This tube is used to obtain stem cells and also to give chemotherapy. It will remain in place until after the transplant is completed. Patients will receive granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF) to stimulate the production of stem cells. Multiple rounds of collection may be needed to obtain sufficient numbers of cells for transplant. These cells are collected and frozen for use during the transplant.
- Timing: 1-2 weeks
- Location: Hospital or clinic (no overnight stay)
Part 3: Transplant treatment
- Consists of: High-dose chemotherapy, such as melphalan, is given to kill as many myeloma cells as possible.
- Timing: 5-10 days
- Location: Some transplant centers have patients stay in the hospital throughout this phase and the remainder of the transplant (≈3 weeks), whereas other clinics allow patients to visit daily during this phase.
Part 4: Stem cell transfusion
- Consists of: Your transplant team puts your thawed stem cells back into your blood.
- Timing: About 30 minutes per infusion; some patients may receive more than one infusion.
- Location: Hospital or clinic
Part 5: Recovery
- Consists of: Patients wait for their body to begin producing healthy stem cells. Until this occurs 2-4 weeks after transplant, patients have little to no immune defense system and are at high risk for infection and bleeding. Patients usually receive antibiotics to lower the likelihood of infection and will receive blood transfusions to prevent bleeding and treat anemia.
- Timing: About 2 weeks in a sterile unit, but full immune system recovery may take several weeks to months.
- Location: Hospital or clinic
Additional resources for information about stem cell transplants: