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Late Effects

Bone Marrow Transplant and GVHD

 

Assessment

 

Multiple systems are at risk for late effects after bone marrow transplant. Survivors should be carefully monitored for late effects.

Screening and prevention guidelines for BMT survivors have been developed by a consensus panel consisting of members of the Center for International Blood and Marrow Transplant Research (CIBMTR), European Group for Blood and Marrow Transplantation (EBMT), and American Society for Bone Marrow Transplantation.

A thorough history and physical examination (including height, weight and blood pressure) should be performed on at least an annual basis.  The following table gives an overview of the most important long term health risks to assess and monitor in long-term follow up after BMT:

 

Organ System

History: Ask about

Investigation
Kidney
  • General malaise?
  • May be perfectly well and asymptomatic

MEASURE BLOOD PRESSURE

Hypertension is common in this group of patients as a late effect

Renal function tests:

  • Serum creatinine, electrolytes and BUN
Thyroid
  • Tired?
  • Lacking energy?

Check thyroid function tests:

  • exclude hypothyroidism
  • Any new swelling in neck?
  • Unlikely to be symptomatic

Examine thyroid every year

 

Ultrasound scan of thyroid every 3 years

  • To exclude new nodules and thyroid cancer

Metabolic Syndrome

 

 
  • Any weight gain recently?
  • Tiredness or malaise?
  • Ask about life-style (diet and exercise)
 Measure BMI and BP
Gonadal dysfunction

Hypogonadism:

Examples of relevant questions:

  • Onset of puberty?
  • Regular menstrual cycle?
  • Pregnancy history?
  • Normal sexual function?
 Measure gonadal and pituitary hormone levels

Infertility:

 

 Referral to fertility specialist
CNS
  • Short term memory problems?
  • School and or employment history
  • New neurological symptoms?

Neurological examination of higher mental status

 

May need referral to psychologist for:

  • detailed assessment and neuropsychological testing
  • Headaches, but usually patients are asymptomatic
 MR of brain every 3 years to exclude RT induced meningioma
Psychological
  • Depressed
  • Crying often
  • Suicidal ideation
 May need referral to counseling and psychiatry

Skin and nails
  • Dry itchy skin?
  • Hair loss?

Examination of skin for:

cGvHD:

  • Lichen planus-like features
  • Sclerotic Skin
  • Morphea-like features
  • Lichen sclerosis-like features
  • Depigmentation

 

Skin cancers:

  • Pigmented lesions
  • Basal cell and squamous cell carcinomas

Oropharynx
  • Dry mouth? (xerostomia)
  • Painful ulcerations?
  • Problems with dental caries and gum disease?

Examination of mouth, teeth and oral cavity for:

  • Dental caries
  • Oral ulcers
  • Panorex of mandible

Eyes and lacrimal glands
  • Reduced vision?
  • Dry and gritty eyes (sicca symptoms)?
  • Painful eyes?
  • Photophobia?

Examination for:

  • Cataracts
  • Keratoconjunctivitis sicca

Gastrointestinal
  • Anorexia?
  • Nausea?
  • Dysphagia?
  • Vomiting?
  • Weight loss?
  • Diarrhea?
  • Bloating and cramps?

Examination for:

  • Anemia
  • Abdominal tenderness and distention
  • Rectal examination to exclude masses

Blood work:

  • CBC (Fe deficiency)
  • Serum B12
  • Early screening for colorectal cancer

Hepatic
  • Nausea?

Examination of liver

 

Blood work:

  • Liver function tests, serum transaminases, serum albumin
  • Check Hepatitis B and C status

Pulmonary
  • Short of breath on exertion or at rest?
  • Cough?
  • Does the patient smoke?

Examination of chest:

  • Signs of interstitial lung disease

CXR

Chest CT

Pulmonary function tests

Bones

Muscles

Fascia

Joints
  • Any previous assessments for osteoporosis?
  • Any previous fractures?
  • Joint stiffness?
  • Limited joint mobility?
  • Joint swelling?
  • Joint pain?
  • Muscle pain?

Examination of joints:

  • looking for joint swelling and contractures

Assessment of bone density

  • Osteoporosis is a significant risk

Hematopoietic
  • Tendency to bruise easily?

Examination of skin:

  • Purpura and bruises

 

Measure:

  • CBC
  • Autoantibodies (ANA, anti-dsDNA, Coombs positive)
  • History of new bone pain, bleeding tendency and lethargy?
 Bone marrow biopsy to exclude treatment related leukemia

Immune System
  • Recurrent infections?
 

Thyroid cancer and RT induced meningiomas as second malignancies are not uncommon, but have very slow natural histories.  Other malignant second neoplasms are unlikely to have such indolent courses, or to be picked up by screening. Patients should know to seek immediate advice should they develop new symptoms such as pain, swelling or headache.

 

 

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