What are the main side effects of an ASCT? How are those side effects managed? (hair loss- mucositis, GI. hematological)

What are the main side effects of an autologous stem cell transplant?

What are the acute toxicities of transplant?

So just a refresher. So, when we do a transplant, what the real treatment, it's the chemo, it's the melphalan. So the melphalan is what we call the conditioning agent. But really the melphalan is the drug that's killing the cancer cells. But unfortunately, it has the side effect of killing all the good cells, too. And so that's why we have to do the stem cell transplant, the infusion of stem cells to allow you to recover, to allow someone to recover from the chemo. So it's almost like a stem cell rescue. And that's what they used to call it many years ago.

So the side effects you get from a transplant are really from the melphalan. The most common side effects really are occur in the first few weeks after a transplant, typically weeks one, two and three after infusion of the stem cells. So the most common side effects, I think the big one that I think we sometimes don't talk about enough is fatigue. Fatigue is a really big issue with the transplant. It's just hard to get up, hard to get up and do things, hard to have that get up and go energy that typically gets better after 2 to 3 weeks, but sometimes it can stay for a little bit longer. Sometimes people have fatigue that lasts longer than a month, maybe even longer than two months.

And the key with the fatigue is just trying to do as much as you can, trying to stay active, trying to walk, trying to get up, because unfortunately, when you don't do things, it sort of becomes a perpetuating cycle where you and if you're in bed all day, then you're going to keep staying in bed all day. So you have to kind of there's an element of sort of trying to get up. But certainly if you need rest, you need rest. So fatigue is a big one.

The other big one that I typically counsel patients on are the gastrointestinal side effects. So the nausea, sometimes severe vomiting, intractable vomiting, sometimes and diarrhea. And why is this happening? So the three organs that typically are most affected by the melphalan when we get high doses of it are one the bone marrow. So that's why people become immunosuppressed. Two, the gut. So the gut cells are really sensitive to the melphalan, and so it causes those cells to die. And that's what my people get sick. This is where sometimes you might hear your doctor use as mucositis. Mucositis can happen not just in the mouth, but also can happen further down. And that's, that irritation is what causes the nausea, vomiting, how we deal with that sometimes if it's, you might get several medications to help suppress the nausea. Sometimes we might have to admit patients to the hospital if they can't eat at our center. We do commonly admit people if they can't eat and we often might give nutrition and through an IV to help support someone because we it's not good when you're not feeling well and you've just had high doses of chemo. It's not good to not eat for several days. So we have to make sure we give people nutrition and we have to make sure we get their nausea under control because it feels it doesn't feel good.

It is a very self-limited thing, though. Typically, the recovery of the nausea and the mucositis symptoms and the diarrhea happens around the time the stem cells start to what we call graft. And the engraftment just means that's when the new immune system has taken hold and started producing the immune cells that help heal the damage in the gut. And so when that happens, people start feeling better. Sometimes it can last a little bit longer than that, particularly the diarrhea. But for the most part, the symptoms get better after like 3 to 4 weeks. The mouth sores. That's another manifestation of mucositis. And if you've ever had a canker sores, it's similar, but it's much worse. We have found that using ice chips, having folks stuck on ice chips during the melphalan, helps reduce how much you get in your mouth because we're limiting blood flow to those areas so they don't get as much melphalan but certainly you can still get mucositis even if we use the ice chips and the management for that. I mean, that that becomes a pain issue. And so we have to use pain medications sometimes we have to use pain pumps to help get folks get through that. But that also gets better around the time that the other GI symptoms do.

Hair loss is really common. The cells that make our hair are really sensitive to that chemo. And so when patients receive that chemo, it causes hair to fall out. So it's pretty normal to have hair loss. Sometimes people just decide to shave their heads before undergoing the transplant or when the hair starts to fall out because it can be very distressing for obvious reasons. But just remember, it's a temporary side effect. Your hair will come back and it takes a while, but people's hair does come back. That's expected.

The other common toxicity that people can get is this related to when we give the chemo or wiping out the normal immune system. And so that really what we're wiping out all of the normal defender's against bacteria, viruses, etc. And so there's a risk of infections. So infections are very common reason for people to be admitted after getting chemotherapy of the melphalan for the transplant. And the most common way that would manifest would be what we call a neutropenic fever, which is where you get a fever while you have no neutrophils and neutrophils. So those spider white cells that help get rid of bacteria. And so when people get a neutropenic fever, we usually give them antibiotics just to prevent things from getting worse. Because without an immune system, if you can have just a simple bacterial infection that can become a big problem, people can become very sick very quickly. So we have to get on top of that quickly.

The other thing that folks might need is blood or platelet transfusions. If the red blood cells are too low or if the platelets are too low because having low platelets can predisposed to bleeding. But these, like the GI toxicities, do get better within 2 to 3 weeks once patients engraft. So those are kind of the short term toxicities. The long term toxicities really are sort of less about how you feel, but more about what the melphalan can do to your body and sort of the second the side effects of that. So one of them that we commonly counsel patients on is secondary malignancies. So for people who get a melphalan, transplant and get lenalidomide for maintenance, there is a probably 6 to 8% risk of a secondary malignancy down the road. Now, most of those are solid tumors. Many of those are skin cancers. There's a risk of getting what we call a secondary myeloid neoplasm. The risk of that is lower than 6 to 8%. But those are those are important for patients to be counseled about. There's also a risk of of earlier cataract formation and and endocrine abnormalities as well, that we have to monitor people for long term.

Melphalan is not toxic to the heart. There are other ways of giving transplant that combined drugs like for lymphoma, we sometimes give a chemo regimen called beam and that has a drug in it that can affect the heart. But typically cardiac abnormalities are not among the things that we are more concerned about after a transplant, it doesn't mean there's not probably some risk of cardiovascular disease after stem cell transplant, but it's not something that I typically call out.

So the main side effects of transplant are hair loss, which typically happens about two weeks after the melphalan is administered. The main other toxicity of melphalan is that damages the intestine. So diarrhea, nausea, decreased appetite, those are the main complications. There's also mucositis, which is inflammation of the mouth. Now that is typically managed by eating ice chips while the melphalan is being infused. That makes the mouth very cold. It decreases the delivery of muscle into the oral tissues and protects the mouth from developing sores. But there's no way of doing that for the rest of the intestine. So people do have those side effects, or most of the time it's very mild. They just patients don't want to eat very much. So their appetite drops considerably, but they can be supported with I.V. fluids. The diarrhea can be managed with anti motility agents like Imodium or LA Modo. Sometimes we have to give some stronger drugs, but most people can manage with that where they're going maybe once to twice a day, and the IV fluids helps them get through the rest of the procedure. And the side effects.