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Late Effects

Bone Marrow Transplant and cGvHD

 

Therapy

 

To maintain health, prevent progression and treat long-term health conditions arising as a result of bone marrow transplant is complex and requires a team (primary health care provider, hematologist and other medical subspecialists):

This table outlines health maintenance and therapy for the more common health problems after BMT:

Organ System

Health Maintenance

Therapy
Kidney TREAT ELEVATED BLOOD PRESSURE

Therapy of hypertension is very important. 

Untreated hypertension will result in:

  • Further deterioration in renal function
  • Increased risk of cerebrovascular events
  • Increased risk of coronary artery disease

Any renal dysfunction:

  • Patient should see a nephrologist in consultation
Thyroid Hypothyroidism should be treated with thyroid replacement therapy

Patient should be evaluated by an endocrinologist.

Thyroid replacement therapy:

  • Prevents TSH stimulation of thyroid tissue and potentially could reduce the risk of thyroid cancer

Ultrasound of thyroid every 3 years

 

A thyroid nodule that is

  • Increasing in size
  • Vascular
  • solid

Should have an ultrasound guided FNA biopsy

 

Many patients have multiple stable benign nodules on follow up.

Thyroid cancer is treated by referral to a surgeon with expertise in this area for:

  • Thyroidectomy and lymph node sampling
  • Assessment regarding further cancer therapy by head and neck oncology team
  • Post-op thyroid replacement therapy

Metabolic Syndrome

 

 

Life style changes should be recommended:

  • Regular exercise
  • Dietary assessment and intervention with help of nutritionist

Patient should be evaluated by an endocrinologist to:

  • check pituitary/hypothalamic function
Gonadal dysfunction

Hypogonadism with no sex hormone output:

  • Hormone replacement therapy
 Patient should be evaluated by an endocrinologist
Infertility Patient should be evaluated by a gynecologist/fertility specialist.
CNS

Document:

  • Short term memory problems
  • Learning difficulties in school
  • Employment problems

Referral to psychologist for:

  • detailed assessment and neuropsychological testing

Referral to:

  • Vocational & recreational rehab programs

 

May need assistance to apply for a disability pension.
MR scan of head every 3 years to exclude RT induced meningioma Meningiomas generally amenable to neurosurgical resection
Psychological

Document depression and act immediately on any suicidal ideation

 Referral to counseling and psychiatry

Skin and nails

 Document extent of skin and hair changes

Treat cGvHD

Oropharynx

Document problems:

  • Dry mouth (xerostomia)
  • Ulceration
  • Dental caries and gum disease

Refer to oral oncology program or dentist for:

  • Assessment
  • Cleaning
  • Education/Advice about maintenance of oral health

Eyes and lacrimal glands

Document visual and sicca symptoms

Refer promptly to an ophthalmologist for assessment and therapy for:

  • Cataracts
  • Keratoconjunctivitis sicca

Gastrointestinal

 Document symptoms such as dysphagia, anorexia and diarrhoea

Refer to a gastroenterologist for:

  • Detailed evaluation and possible endoscopy

Fe deficiency and B12

  • Replacement therapy
  • Nutritional intervention (e.g. elemental diet) or parenteral nutrition
Treat cGvHD

Hepatic

For hepatitis:

  • avoid other causes of liver inflammation such as alcohol
 Treat cGvHD

Chronic Hepatitis C or B

  • Vaccination against hepatitis A
 Refer to liver specialist for potential antiviral therapy

Pulmonary

Assess and document extent of pulmonary disease

 

Patient should not smoke

Treat cGvHD

 

Refer to a respirologist

Bones

Muscles

Fascia

Joints

 cGvHD with chronic joint changes

Treat cGvHD

 

Refer to rheumatologist

 

Osteoporosis:

  • Measure bone density
  • Check oral intake of Calcium and Vit D
  • Encourage exercise

 

Patient should be evaluated by an endocrinologist to:

  • assess extent of problem
  • advise re pamidronate

Hematopoietic

 Low/abnormal blood counts

Patient should be evaluated by a hematologist for:

  • Further investigation
  • Possible bone marrow biopsy
Secondary leukemia BM biopsy if symptomatic

Immune System

 Problems with recurrent infections

Vaccination Program

 

Patient should be evaluated by an immunologist

Thyroid cancer and meningiomas as a second malignancies are not uncommon, but both have a very slow natural history.  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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