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Allogeneic stem cell transplantation with myeloablative conditioning

Preparation

The application for a transplantation is submitted to the Allogeneic Stem Cell Group of Norway. As a minimum, the application must include a short disease history including  information about the time of remission, treatment given, precise diagnosis and evidence for it. It is also necessary to provide cytogenetic and molecular genetic data. Information about complications from treatment, general health status, organ function, and whether the patient has a blood-related donor should also be included.

Examinations before transplantation

In addition to the different blood tests and bone marrow tests, there are a series of examinations which all patients must complete before a stem cell transpIantation:

  • Lung function tests
  • Dental examination
  • Sperm examination/examination from gynecological clinic
  • Eye examination 
  • X-ray examination of heart and lungs, possibly other organs 

Sperm banking/ovarian tissue

It is important to offer sperm banking to men, if it is possible, before starting chemotherapy for a serious illness. It is realistic to assume the patient will be sterile after the transplantation.

Banking ovarian tissue is technically possible, but at current, use of this tissue is experimental.

Information

The patient and their family should receive thorough information about treatment, complications, and circumstances which should be in order before the treatment.

The patient will also be offered to speak to another patient who has completed a stem cell transplantation.

Preparation for stem cell transplant

Before starting conditioning, there are measures which must be taken to prevent and treat complications of chemotherapy and GVHD

Intravenous access

All patients must have a central vein catheter. If it is necessary to perform plasma replacement due to ABO incompatibility, the patient will need a two-way dialysis catheter. 

Hemotherapy

All blood products given during the time frame from one month before the transplantation to at least 12 hours after must be radiated to prevent proliferation of possibly included T-lymphocytes in the immunosuppressed patient, causing GVHD. Irradiation is necessary despite always using leukocyte-filtered blood products.  

All patients should receive blood products which are filtered for leukocytes. This ensures that the products are functional with CMV-negative patients and are used on both anti CMV-positive and negative patients.

Antibiotic prophylaxis

Three weeks before the transplantation, an antibiotic prophylaxis with trimetoprim-sulfa is started. This prophylaxis is taken until 4 days before the transplantation but is resumed with a stable graft. This treatment continues for 6 months from the transplantation day in patients without chronic GVHD, given the granulocyte count stays over 0.5 x 109/l. Patients requiring steroid treatment and/or who have chronic GVHD should continue with a pneumocystic pervecii prophylaxis for 6 months.

Valacyclovir is administered the day before the transplantation until 28 days after, if the patient is positive for herpes simplex and/or varicella zoster virus serology. The dosage is reduced if serum creatinine >150 mmol/l.

The mouth and throat are inspected daily for candida. For positive clinical findings, a nystatin mixture is given or amphotericin chewable tablets.

GVHD prophylaxis

Cyclosporin and methotrexate are given routinely to prevent acute and chronic GVHD. Other regimens are also used.

Prevention of CNS recurrence

For acute lymphoblastic leukemia, 2 intrathecal methotrexate injections are administered as part of pre-treatment.

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