Blood and Marrow Transplantation Long Term Management

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Hematopoietic cell transplantation (HCT) provides curative therapy for a variety of diseases. Over the past several decades, significant advances have been made in the field of HCT, to the point where HCT has become an integral part of treatment modality for a variety of hematologic malignancies and some nonmalignant diseases. HCT remains an important treatment option for a wide variety of hematologic and nonhematologic disorders, despite recent advances in the field of immunologic therapies. Factors driving this growth include expanded disease indications, greater donor options (expanding unrelated donor registries and haploidentical HCT), and accommodation of older and less fit recipients. 
The development of less toxic pretransplant conditioning regimens, more effective prophylaxis of graft-versus-host disease (GVHD), improved infection control, and other advances in transplant technology have resulted in a rapidly growing number of transplant recipients surviving long-term free of the disease for which they were transplanted. The changes over decades in the transplant recipient population and in the practice of HCT will have almost inevitably altered the composition of the long-term survivor population over time. Apart from an increasingly older transplant recipient cohort, the pattern of transplant indications has shifted from the 1990s when chronic myeloid leukemia made up a significant proportion of allo-HCT indications. Changes in cell source, donor types, conditioning regimens, GVHD prophylaxis, and supportive care have all occurred, with ongoing reductions in both relapse and non-relapse mortality (NRM) have been demonstrated. 
These patients have increased risks for a variety of late complications, which can cause morbidity and mortality. Most long-term survivors return to the care of their local hematologists/oncologists or primary care physicians, who may not be familiar with specialized monitoring and management of long complications after HCT for this patient population. As HCT survivorship increases, the focus of care has shifted to the identification and treatment of long-term complications that may affect quality of life and long-term morbidity and mortality. 
Preventive care as well as early detection and treatments are important aspects to reducing morbidity and mortality in long-term survivors after allo-HCT. This second edition, 
, provides up-to-date information about diagnosis, screening, treatment, and long-term surveillance of long-term survivors after HCT.

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19 Chapter 26Table 26.1 Dyslipidemia ScreeningTable 26.2 Screening for HypertensionTable 26.3 Screening for diabetesTable 26.4 Screening for endocrinopathiesTable 26.5 Screening for metabolic syndrome /obesity

20 Chapter 27Table 27.1 GI side effects of common transplant conditioning medications [2,7...Table 27.2 Organ staging of acute graft versus host disease [33]Table 27.3 Freiburg criteria for macroscopic diagnosis of aGVHD [42]Table 27.4 Adapted Lerner histologic grading scale for aGVHD [50, 51]Table 27.5 Diagnostic cGVHD GI‐related organ symptoms, adapted [32]Table 27.6 NIH scoring of gastrointestinal chronic GVHD, adapted [32]

21 Chapter 28Table 28.1 Indicators of liver diseaseTable 28.2 Interpretation of HBV serologyTable 28.3 Late hepatic complications following hematopoietic stem cell transpl...

22 Chapter 29Table 29.1 Risk factors for AKI post HSCTTable 29.2 Risk factors for CKD post HSCTTable 29.3 Thrombotic microangiopathy post‐hematopoietic stem cell transplant...

23 Chapter 30Table 30.1 Screening Recommendations: Low Bone‐Mineral DensityTable 30.2 Bisphosphonate Prevention and Treatment Studies: Osteoporosis

24 Chapter 31Table 31.1 Cytotoxic and immunosuppressive agents associated with neurotoxici...Table 31.2 Cerebrovascular complications of hematopoietic stem cell transplan...Table 31.3 Immune‐mediated central and peripheral nervous system complication...Table 31.4 CNS secondary malignancies among HCT recipients in published studi...

25 Chapter 32Table 32.1 Neurocognitive Dysfunction in Special Populations

26 Chapter 33Table 33.1 Describe the most common tools assessing depression, anxiety, dist...

27 Chapter 34Table 34.1 ICD‐10 Criteria for Cancer‐Related FatigueTable 34.2 Risk factors and potential etiologies for fatigue in HSCT survivor...Table 34.3 Interventions for Fatigue Management in Cancer and HSCT SurvivorsTable 34.4 Fatigue Management Recommendations for Transplant Survivors

28 Chapter 35Table 35.1 Social Issues Associated with HCT

29 Chapter 36Table 36.1 PRO Instruments for Adult HSCT SurvivorsTable 36.2 PRO Instruments for Pediatric and AYA HSCT SurvivorsTable 36.3 Implementation Considerations for Patient‐Reported Outcome Measure...Table 36.4 Online Patient ResourcesTable 36.5 Interventions to address common issues that impair HRQL in cancer ...

30 Chapter 37Table 37.1 Comparative side effects of calcineurin inhibitors

31 Chapter 41Table 41.1 Selected examples of different CAM use in HCT literature in the la...

32 Chapter 45Table 45.1 Caregivers of long‐term survivors’ tasks and concerns

33 Appendix 1Appendix A. GVHD Prophylactic TherapyAppendix B. GVHD Treatment Therapy

List of Illustrations

1 Chapter 1 Figure 1.1 Timelines for post‐HCT late effects.

2 Chapter 3 Figure 3.1 Components of different long‐term follow‐up survivorship care. Figure 3.2 Protagonists of the multidisciplinary team of a long‐term follow‐... Figure 3.3 Role distribution of responsibilities between the LTFU clinic, th...

3 Chapter 4 Figure 4.1 Fred Hutch/SCCA Transplant Clinical Model Timeline that Includes ...

4 Chapter 6 Figure 6.1 Dynamics of etiology of late effects in allogeneic HCT survivors....

5 Chapter 8 Figure 8.1 HCT late effects relate to exposures, genetics, age gender and li...

6 Chapter 11Figure 11.1 (a) Cumulative incidence of cardiovascular events after BMT by n...Figure 11.2 ROC curves of three different models. Clinical model includes fe...Figure 11.3 Cumulative incidence of therapy‐related myeloid neoplasia by age...Figure 11.4 Differential gene expression in patients with therapy‐related my...Figure 11.5 Cumulative incidence of therapy‐related myeloid neoplasia (TMN) ...Figure 11.6 Area under receiver operating characteristic curves (AUCs) for p...

7 Chapter 16Figure 16.1 Progression of histologic changes from lichen to SS‐like feature...Figure 16.2 Skin biopsy of cGVHD showing several basal apoptotic keratinocyt...Figure 16.3 Skin biopsy of cGVHD showing several apoptotic cells along an ec...Figure 16.4 Skin biopsy of cGVHD showing a band‐like lymphocytic infiltrate ...Figure 16.5 Skin biopsy showing hyperplastic and hyperkeratotic changes in t...Figure 16.6 cGVHD: skin biopsy showing the signs of active apoptosis lymphoc...Figure 16.7 Lichenoid cGVHD with extensive lichenoid subepidermal infiltrate...Figure 16.8 Sclerotic cGVHD with diffuse fibrosis located in the reticular d...Figure 16.9 Sclerotic cGVHD with lichen sclerosus‐like pattern: the superfic...Figure 16.10 Cutaneous cGVHD characterized by face poikiloderma with hypo/hy...Figure 16.11 Cutaneous cGVHD. Epidermal GVHD characterized by inflammatory p...Figure 16.12 Cutaneous cGVHD characterized by erosive lesions and fissures o...Figure 16.13 Cutaneous cGVHD characterized by a) thickening of the mucosa of...Figure 16.14 Cutaneous cGVHD characterized by desquamative and brownish patc...Figure 16.15 Cutaneous cGVHD characterized by a) eczematous features with di...Figure 16.16 Cutaneous cGVHD characterized by eczematous like changes with d...Figure 16.17 Cutaneous cGVHD characterized by an eczema‐like eruption with p...Figure 16.18 Cutaneous cGVHD characterized by diffuse purpuric macule of the...Figure 16.19 Cutaneous cGVHD characterized by psoriasiform changes with scal...Figure 16.20 Cutaneous cGVHD characterized by erythema, desquamation, and pl...Figure 16.21 Cutaneous cGVHD characterized by a hypopigmented macula of the ...Figure 16.22 Cutaneous cGVHD characterized by a) brownish patches of the arm...Figure 16.23 Cutaneous cGVHD characterized by diffuse hypo and hyperpigmenta...Figure 16.24 Cutaneous cGVHD characterized by keratosis pilaris‐like eruptio...Figure 16.25 Cutaneous cGVHD characterized by diffuse ichthyosiform xerosis ...Figure 16.26 Cutaneous cGVHD characterized by diffuse ichthyosiform xerosis ...Figure 16.27 (a) Cutaneous cGVHD characterized by fingernails dystrophy and ...Figure 16.28 Cutaneous cGVHD characterized by diffuse hyperpigmentation of t...Figure 16.29 (a) Cutaneous cGVHD characterized by diffuse dermal and subcuta...Figure 16.30 Cutaneous cGVHD characterized by band‐like deep dermal sclerosi...Figure 16.31 Cutaneous cGVHD characterized by diffuse dermal fibrosis and th...Figure 16.32 A case of overlap skin GVHD rapidly arose 12 months after allog...Figure 16.33 A case of GVHD overlap in which a morbilliform rash typically o...Figure 16.34 The high‐frequency US study of the skin has proved useful in id...

8 Chapter 17Figure 17.1 Characteristics of lens structures and different types of catara...

9 Chapter 18Figure 18.1 Oral cGVHD.Figure 18.2 SCC of the oral mucosa in a patient with long‐lasting cGVHD invo...

10 Chapter 20Figure 20.1 Reproductive Health considerations throughout HSCT. apost‐pubert...

11 Chapter 21Figure 21.1 Reproductive Health considerations throughout HSCT.Figure 21.2 Form for assessment of genital cGVHD.Figure 21.3 Female external genitalia anatomy.

12 Chapter 22Figure 22.1 Predicting age of ovarian failure after radiation.Figure 22.2 Risk of azoospermia according to score. TBI counted for 2 points...Figure 22.3 Fertility preservation measures and counseling in HSCT. The grap...

13 Chapter 24Figure 24.1 Spectrum of pulmonary complications following HSCT.Figure 24.2 High‐resolution chest CT image of a patient with bronchiolitis o...Figure 24.3 Chest CT scan image in a patient with pulmonary fibrosis and air...Figure 24.4 Algorithm of the initial diagnostic approach to HSCT patient pre...

14 Chapter 25Figure 25.1 Cumulative incidence of congestive heart failure after HSCT for ...Figure 25.2 Possible multifactorial mechanisms for accelerated development o...

15 Chapter 27Figure 27.1 Image from upper endoscopy of a 27‐year‐old man with aplastic an...Figure 27.2 Image from flexible sigmoidoscopy of a 36‐year‐old man with acut...Figure 27.3 Image from flexible sigmoidoscopy of a 30‐year‐old woman with no...Figure 27.4 Image from flexible sigmoidoscopy of a 42‐year‐old woman with B‐...

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