Outpatient Stem Cell Mobilisation and Collection Procedure: GCSF +/- Plerixafor

What are stem cells?

A transplant involves your receiving large doses of chemotherapy. Chemotherapy destroys cancer cells. However, as a side effect they also destroy normal blood cells and a person’s ability to produce new blood cells. Stem cells are the seeds from which blood cells (red cells, white cells and platelets) grow. Only very small numbers of stem cells are usually found in the blood. However, it may be possible to push the stem cells from the bone marrow into the blood. To do this we use a growth factor called GCSF (granulocyte colony stimulating factor, usually lenograstim or filgrastim). By taking your stem cells from you and returning them to you after chemotherapy/radiotherapy, we can overcome some of the side effects of chemotherapy, as these stem cells will seed and grow to produce new blood cells.

Do I need any tests prior to the stem cell collection?

Yes. You may need to have blood tests and a bone marrow test to ensure your body has recovered from previous treatment. Before stem cells can be collected and stored, all patients’ blood is tested for certain infections including hepatitis B, hepatitis C, HIV and in some cases HTLV 1 & 2 and CMV. You will need to consent to this testing on the stem cell collection consent form. Please let your consultant or nurse know before the blood sample is taken if you have any concerns.

What does this treatment involve?

This treatment involves two different steps. These will be discussed in turn.

Part 1 – administration of GCSF +/- plerixafor

You will be provided with injections of a growth factor called GCSF (lenograstim or filgrastim). This helps the bone marrow to push out stem cells into the blood, where they can be collected. These injections will need to be given by small needles under the skin every day, usually starting four days before the stem cell collection and continuing until the stem cell collection has been completed. If stem cell collection is planned just at the time that your blood counts are recovering after chemotherapy, you may need to start your GCSF injections earlier, and your transplant doctor will discuss this with you at your appointment beforehand. If you need help administering the injections, please tell the transplant team so they can arrange this. You will require a blood test the day before the stem cell collection to help us determine when there may be stem cells in your blood for us to collect. Arrangements will be made for you by the BMT coordinator to attend the transplant unit to have the blood test.

Potential side effects of GCSF include:

• Tiredness
• Headaches
• Bony pains (commonly experienced as the number of stem cells increase)
• Enlargement and rupture of the spleen (this is extremely rare.

You must call us straight away if you develop sudden pain in the abdomen or shoulder tip) Sometimes when we measure the level of stem cells in the blood before or during the planned stem cell collection we find that it is low, making successful stem collection unlikely. If this is the case, or you have previously had an unsuccessful attempt to collect stem cells, we often use another medicine to help mobilise the stem cells from the bone marrow into the blood where they can be collected. This is called plerixafor, and is given as an injection under the skin the evening before stem cell collection is planned.

Potential side effects of plerixafor include

• Nausea
• Diarrhoea
• Lightheadedness
• Allergic reactions, at the injection site or more generally

You should contact the transplant unit or your local hospital if you experience any problems during your time at home.

Part 2 - stem cell harvesting

Once the white blood cell count has reached a sufficiently high level, you will need to attend the Apheresis Unit at Addenbrooke’s for the stem cell collection. This will be confirmed at very short notice (12-24 hours) by telephone. Before the cells are collected a blood sample may be taken from you to determine the number of stems there are in your blood. There may be a waiting time of two hours for the results.

2a - How do you collect stem cells?

The timing of the stem cell collection is dependent upon your full blood count. For this reason we will arrange for you to have a blood count taken from you each day when you attend your local hospital. When your blood count is satisfactory, we will contact you and ask you to attend the Apheresis Unit. When you arrive we may take a further blood sample from you to try and identify how many stem cells you have in your blood. If you have adequate numbers in your blood we will proceed with the stem cell collection.

We collect stem cells in our apheresis unit, by connecting your veins to a cell separator (‘apheresis machine’) either by temporary insertion of cannula needles or via your central line. This machine spins the blood and separates it into different parts. The machine can detect the cells that we wish to collect and put them into a bag. The rest will be returned to you. If you wish you can see a cell separator machine when you attend for your outpatient appointment.

To prevent your blood from clotting in the cell separator an anticoagulant is added to it. This may cause temporary tingling or pins and needles in your fingertips or around your mouth. If this happens, let the nursing staff know.

2b - How long will stem cell collection take?

The stem cell collection itself takes about five and a half hours. We then calculate the numbers of cells we have collected. We aim to collect all we need in one harvest, but it is common to need to return for more than one stem cell collection on successive days. If we do not have enough cells, we may give you another injection of G-CSF and/or plerixafor, and collect more cells from you the following day. This could be done for three days in total if necessary.

Is it possible to collect stem cells from everybody after this treatment?

No, not everyone releases sufficient stem cells to enable a successful harvest. However we are successful in the majority of people. In the event that we are unable to collect stem cells from you we will discuss the alternatives.

Do I need to stay in hospital when the stem cells are collected?

No, you do not need to be admitted into hospital for the stem cell collection. This is an outpatient procedure. However for those living some distance from Cambridge, overnight hostel accommodation may be available if prior notice is given.

Am I allowed to eat before the stem cell collection?

Yes, we would encourage you to eat a good meal before the collection.

Can I bring a friend/relative with me when the stem cells are harvested?

Yes, but just one other person, as the space in the day unit is limited.

How long are the blood stem cells kept?

Once your stem cells have been collected they will be frozen until they are required. Most of the time we will be planning to use all the cells collected as part of the transplant, however there may be cells which are stored. The harvest can be stored for several years at very low temperatures but we cannot keep cells indefinitely.

With your permission your doctor will decide to dispose of the cells in the following circumstances:

• If you die.
• If your disease progresses and/or it is clear that a bone marrow transplant using your own cells is not in your best interests.
• If your disease appears to be in remission and there is no necessity for a bone marrow transplant.
• If we still have cells stored at six years and no likelihood of needing to use them.

If I do not need the cells could they be used for research?

Yes. However, to allow the haematology team to do this you will need to give us your permission on the harvest consent form. This form will be kept in your medical notes. The cells would only be used for research if they were to be otherwise destroyed.

Where the stored cells will not be used for treatment they may be used for research purposes rather than be discarded if your consent has been obtained in accordance with the requirements of the Human Tissue Act 2004.

Tissue from the living may be stored for use and/or used without consent, provided that:

• the research is ethically approved
• The tissue is anonymised such that the researcher is not in possession of information identifying the person from whose body the material has come and is not likely to come into possession of that information.

NOTE: You will be asked to sign the harvest consent form before this process can go ahead.

This information booklet has been designed to give you an overview of GCSF-primed peripheral blood stem cell collection. If you any questions please do not hesitate to contact: the BMT nursing team on 01223 217224 or the apheresis unit on 01223 256272

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high-tech equipment and/or specialist one to one care is required.