Transplantation:

Patients with relapsed or progressive HD are often treated with high-dose chemotherapy followed by stem cell transplantation procedures. (Transplantation does not appear to offer an advantage compared to standard chemotherapy as initial treatment for patients with high-risk advanced HD.)

This treatment involves removal and replacement of stem cells, which are produced in the bone marrow. This allows the patient to receive high-dose chemotherapy without destroying these important cells. Stem cells are the early forms for all blood cells in the body (including red, white, and immune cells). Cancer treatments harm growing cells as well as cancer cells, and so the healthy stem cells must be replaced by transplanting them.

For Hodgkinâ ' s disease, the most common type of transplant is an autologous procedure, using the patientâ ' s own cells. An allogeneic transplant, using cells from a donor, is more risky for patients with Hodgkinâ ' s disease and is generally used only when an autologous transplant has failed. (This section provides information pertinent to autologous procedures. Detailed information on allogeneic transplants, including such complications as graft-versus-host-disease, can be found in In-Depth Report #84: Non-Hodgkinâ ' s Lymphoma.)

Transplantation Procedure

Stem cells must first be collected in one of the following ways:

• Directly from blood (peripheral blood stem cell transplantation)
• From bone marrow (bone marrow transplantation)

Stem cells are collected several weeks before the procedure. They are frozen and stored while the patient undergoes high-dose chemotherapy. Some patients receive high-dose whole body radiation therapy along with chemotherapy.

After the patient completes the pre-transplant therapy, the frozen cells are thawed and then infused into the patient. Within a few weeks, these cells start to generate new white blood cells and then new red blood cells.

Infection

The risk for infection is greatest during the first 6 weeks following the transplant. During this period, a patient usually remains in isolation and receives antibiotics and intravenous nutrition. It takes 6 - 12 months post-transplant for a patientâ ' s immune system to fully recover.

Many patients develop severe herpes zoster virus infections (shingles) or have a recurrence of herpes simplex virus infections (cold sores and genital herpes). Pneumonia, cytomegalovirus, aspergillus (a type of fungus), and Pneumocystis jirovecii (a fungus) are among the most important life-threatening infections.

It is very important that patients take precautions to avoid infections. Guidelines for infection prevention include:

• Discuss with your doctor what vaccinations you need and when you should get them.
• Avoid crowds, especially during cold and flu season.
• Be diligent about handwashing, and make sure that visitors wash their hands. Alcohol-based handrubs are best.
• Avoid eating raw fruits and vegetables -- food should be well cooked. Do not eat foods purchased at salad bars or buffets. In the first few months after the transplant, be sure to eat protein-rich foods to help restore muscle mass and repair cell damage caused by chemotherapy and radiation.
• Boil tap water before drinking it.
• Dental hygiene is very important, including daily brushing and flossing. Schedule regular visits with your dentist.
• Do not sleep with pets. Avoid contact with petsâ ' excrement.
• Avoid fresh flowers and plants as they may carry mold. Do not garden.
• Swimming may increase exposure to infection. If you swim, do not submerge your face in water. Do not use hot tubs.
• Report to your doctor any symptoms of fever, chills, cough, difficulty breathing, rash or changes in skin, and severe diarrhea or vomiting. Fever is one of the first signs of infection.
• Report to your ophthalmologist any signs of eye discharge or changes in vision. Patients who undergo radiation or who are on long-term steroid therapy have an increased risk for cataracts.

Other Side Effects and Complications

Common side effects of stem cell transplants include nausea, vomiting, fatigue, mouth sores, and loss of appetite.

The procedures themselves are fairly dangerous and carry a small risk for death. When it was first used, transplantation procedures had 10 - 25% morality rates. Now mortality rates are below 5%.

There is a small long-term risk for leukemia after transplantation in young people. Chemotherapy itself increases the risk of secondary cancers. Recent studies suggest that transplantation after chemotherapy does not add any additional risks. In addition, use of newer chemotherapeutic drugs may not pose as high a danger as older treatments.

Other serious potential complications include:

• Bleeding because of reduced platelets (highest risk within the first 4 weeks); blood transfusions may be required
• Infertility
• Organ complications to the liver, heart, kidney, or lungs
• Failure of the transplant
• Muscle problems including stiffness, cramps, and joint pain
• Frequent urination and bladder control problems
• Older patients should be screened for osteoporosis (bone thinning) and hypothyroidism (underactive thyroid)