Multiple myeloma is a cancer originating from plasma cells, a type of white blood cell in the bone marrow responsible for producing antibodies. When these cells become cancerous, they multiply uncontrollably and release a single type of antibody known as a paraprotein. For many individuals diagnosed with this condition, an Autologous Stem Cell Transplant (ASCT) is an intensive treatment used to extend remission. The procedure uses the patient’s own stem cells to help their body recover after receiving high-dose chemotherapy.
Determining Candidacy for ASCT
A patient’s suitability for an autologous stem cell transplant is evaluated based on several factors to ensure the potential benefits outweigh the risks. A primary consideration is the patient’s overall health, often referred to as performance status. The focus is more on a person’s physiological fitness than their chronological age, with some centers treating patients up to 77 years old. The medical team will also conduct a thorough review of comorbid conditions to gauge overall resilience.
Proper functioning of major organs is another fundamental requirement. The high-dose chemotherapy used during the transplant can be demanding on the heart, lungs, kidneys, and liver. Physicians perform detailed tests to ensure these organs are healthy enough to withstand the treatment. Any significant impairment, such as severe heart disease or renal failure, might make a patient ineligible.
The status of the multiple myeloma itself plays a large part in determining eligibility. Patients undergo an initial round of “induction therapy,” and a positive response, meaning a significant reduction in cancer cells, is required before moving forward with ASCT. The procedure is most effective for patients with responsive disease rather than for those whose cancer is resistant to treatment. Any active, uncontrolled infections must also be fully resolved before the transplant can begin.
The ASCT Procedure Explained
The autologous stem cell transplant process is a multi-stage journey that unfolds over several weeks. The first step is stem cell mobilization and collection. Patients receive injections of a growth factor medication that stimulates the bone marrow to produce a large number of stem cells and release them into the peripheral blood.
Once the stem cells have moved into the bloodstream, they are collected through a procedure called apheresis. This process involves drawing blood through a central venous catheter and passing it through a machine that separates the stem cells. The remaining blood is then returned to the patient’s body. This collection may need to be repeated over a few days to gather enough cells, which are then frozen and stored.
After the stem cells are stored, the patient is admitted to the hospital for the conditioning regimen. This high-dose chemotherapy is aimed at destroying the remaining myeloma cells. The most common agent used is melphalan, administered intravenously. While effective at killing cancer, this treatment also destroys the healthy blood-forming cells in the bone marrow, making the subsequent stem cell infusion necessary for recovery.
The day of the stem cell infusion is referred to as “Day Zero.” The previously collected stem cells are thawed and infused back into the patient’s bloodstream through their central catheter, similar to a blood transfusion. Because these are the patient’s own cells, there is no risk of the immune complications that can occur with donor cells. Following the infusion, the patient enters a period known as engraftment, which lasts two to three weeks. The infused stem cells travel to the bone marrow, where they begin to produce new, healthy blood cells.
The Recovery Phase and Potential Complications
The period immediately following the stem cell infusion, often spanning the first 100 days, is a time of focused recovery. The primary challenge is neutropenia, a condition of extremely low white blood cells that fight infection. Patients are closely monitored for any signs of infection, and supportive care includes preventative antibiotics, antiviral medications, and blood or platelet transfusions to manage anemia and bleeding risks.
The high-dose chemotherapy leads to several predictable side effects. One of the most common is mucositis, which causes painful sores in the mouth and digestive tract. Nausea, vomiting, and diarrhea are also frequent and are managed with medications. Profound fatigue is nearly universal and can persist for some time after the procedure.
Upon discharge from the hospital, the recovery journey continues at home with the support of a caregiver. Patients are given specific dietary restrictions to avoid foodborne illnesses while their immune system is still recovering. There will also be limitations on physical activities and exposure to crowds to minimize infection risk. Frequent follow-up appointments are necessary to monitor blood counts and overall health.
Post-Transplant Care and Remission Management
After the initial 100-day recovery, care shifts to long-term strategies aimed at maintaining remission. A common strategy is maintenance therapy, which involves taking a less intensive, long-term medication to control any residual myeloma cells. Lenalidomide is a frequently used oral medication for this purpose and is often started once a patient’s blood counts have adequately recovered.
Long-term follow-up involves a schedule of regular appointments for ongoing monitoring. These visits include blood tests to measure paraprotein levels and other markers of the disease. Periodically, a bone marrow biopsy may be performed to assess the health of the bone marrow and check for myeloma cells.
More sensitive tests are also used to detect very low levels of disease. Minimal Residual Disease (MRD) testing is a sophisticated technique that can identify even a single myeloma cell among a million healthy cells. Achieving an MRD-negative status, where no cancer cells are detected by these methods, is associated with better long-term outcomes.