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Late Effects

Bone Marrow Transplant and GVHD

 

Long Term Health Risks:

 

The chronic health risks after BMT are for the most part due to radiation therapy (RT) and intensive chemotherapy given in the conditioning regime prior to transplant and also to cGvHD.

A study of the European Bone Marrow Transplant Registry showed that patients who survived more than 5 years after transplantation had an increased risk of death compared  to normal.

Causes of death were related to:

  • Relapse of the underlying cancer
  • Development of a second cancer
  • Chronic GVHD
  • Transfusion-acquired viral infection.

Certain patients were at high risk for severe late effects:

  • Males
  • Recipients of stem cells from female donors
  • Patients younger than 10 years at time of transplant
  • Patients with non-identical donors
  • Patients give radiation therapy (RT) in conditioning regime.

 

Frequency of different long-term health problems in BMT survivors:
Approx. % of survivors affected Chronic Health condition

 

50%
  • Immunodeficiency

  • Renal dysfunction
  • Cataracts
  • Chronic GVHD
20 - 50%
  • Endocrine dysfunction
  • Infertility
  • Delayed sexual development
  • Oral and dental problems
  • Psychosocial stress
Less than 20%
  • Secondary malignant neoplasms
  • Cognitive disorders
  • Avascular necrosis of the hips and other joints
  • Pulmonary dysfunction

 

The following table outlines major health problems in BMT survivors and their etiology:

Organ System

Problem

Etiology

Kidney
  • Renal dysfunction and failure
  • RT to kidney
  • Intensive chemotherapy
  • Hypertension
  • Hypertension
  • Renal damage
  • Cranial RT
Thyroid
  • Hypothyroidism
  • RT to thyroid
  • Benign thyroid nodules
  • Papillary thyroid cancer
  • RT to thyroid

Metabolic Syndrome

 

 

  • Truncal obesity
  • Hypertension
  • Hyperlipidemia
  • Increased risk of diabetes
  • Increased risk of vascular disease (CVE or MI)
  • Cranial RT
Gonadal dysfunction
  • Hypogonadism:
  • Reduced sex hormone levels
  • RT to gonads
  • RT to pituitary and hypothalamus
  • Infertility

 

  • RT to gonads
  • High dose alkylating chemotherapy
CNS
  • Short term memory problems and cognitive dysfunction
  • Cranial RT
  • IT and IV Methotrexate
  • Increased risk of cerebrovascular event (CVE)
  • Cranial RT
  • Meningiomas
  • Cranial RT
Psychological
  • Depression
  • Illness and entire therapy

Skin/Nail

 

  • skin disease
  • cGvHD

Increased risk of skin cancers:

  • Melanoma
  • Non-melanoma
  • RT to skin
  • Chemotherapy

Oropharynx

  • Dry mouth (xerostomia) and accelerated dental decay
  • Abnormal tooth development in young children

  • RT to salivary glands
  • cGvHD

Eyes and lacrimal glands

  • Cataracts
  • RT to lens of eye
  • Dry and gritty eyes (sicca symptoms)
  • cGvHD

Gastrointestinal

  • Esophageal web
  • Malabsorption
  • cGvHD

  • Anemia (Fe deficiency)
  • Serum B12 deficiency
  • Malabsorption from cGvHD
  • Increased risk of colon cancer
  • RT

Hepatic

  • Infective hepatits
  • Acquired Hepatitis B and C through contaminated blood products
  • Hepatitis/VOD
  • RT to liver
  • Intensive chemotherapy
  • cGvHD

Pulmonary

  • Interstitial lung disease
  • cGvHD
  • RT to lungs

Cardiac
  • Coronary artery disease
  • Metabolic syndrome
  • Hypertension
  • RT to heart

Bones

Muscles

Fascia

Joints

  • Short stature

 

  • RT at young age causes reduced growth of all structures within RT field
  • RT induced damage to pituitary and hypthalamus with reduced GH levels
  • Joint disease with contractures
  • cGvHD
  • Osteoporosis
  • Leukemia prior to BMT can infiltrate and damage bone
  • RT
  • Chemotherapy
  • Corticosteroids
  • Illness and inactivity
  • Malnutrition

Hematopoietic

  • Risk of secondary leukemia
  • RT
  • Alkylating agent chemotherapy

  • Abnormal blood count
  • Thrombocytopenia
  • cGvHD
  • Autoantibodies (ANA, anti-dsDNA, Coombs positive)

Immune System

  • Recurrent infections
  • cGvHD
Second Cancers
  • Development of a second malignant neoplasm
  • RT
  • cGvHD

 

 

 

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