Delayed Complications and Long-Term Effects After Bone Marrow Transplantation

Cyclophosphamide Pharmacogenomic Variation in Cancer Treatment and Its Effect on Bioactivation and Pharmacokinetics

Cyclophosphamide (Cy) is a prodrug that is mainly bioactivated by cytochrome P450 (CYP) 2B6 enzyme. Several other enzymes are also involved in its bioactivation and affect its kinetics. Previous studies have shown the effect of the enzymes' genetic polymorphisms on Cy kinetics and its clinical outcome. These results were controversial primarily because of the involvement of several interacting enzymes in the Cy metabolic pathway, which can also be affected by several clinical factors as well as other drug interactions. In this review article, we present the effect of CYP2B6 polymorphisms on Cy kinetics since it is the main bioactivating enzyme, as well as discussing all previously reported enzymes and clinical factors that can alter Cy efficacy. Additionally, we present explanations for key Cy side effects related to the nature and site of its bioactivation. Finally, we discuss the role of busulphan in conditioning regimens in the Cy metabolic pathway as a clinical example of drug-drug interactions involving several enzymes. By the end of this article, our aim is to have provided a comprehensive summary of Cy pharmacogenomics and the effect on its kinetics. The utility of these findings in the development of new strategies for Cy personalized patient dose adjustment will aid in the future optimization of patient specific Cy dosages and ultimately in improving clinical outcomes. In conclusion, CYP2B6 and several other enzyme polymorphisms can alter Cy kinetics and consequently the clinical outcomes. However, the precise quantification of Cy kinetics in any individual patient is complex as it is clearly under multifactorial genetic control. Additionally, other clinical factors such as the patient's age, diagnosis, concomitant medications, and clinical status should also be considered.

Total body irradiation of bone marrow transplant using helical TomoTherapy with a focus on the quality of dose contribution at junction target volumes

PURPOSE

Total body irradiation (TBI) can be safely delivered on TomoTherapy (Accuray, Sunnyvale, CA, USA) in both pediatric and adult patients with proper imaging and planning despite the length constraint of 135 cm. To overcome this limitation, two CT (Computed Tomography) scans (CT1& CT2) are taken in patients above 135 cm in height. Adequate junction dose coverage is important in TBI. Presently, there is no clinical report with a focus on the quality of dose distribution at the CT junction in view of the guidelines on quality of coverage from the RTOG. Hence, our main objectives were to evaluate the dose distribution and quality of coverage at the junction in 16 patients who received TBI using TomoTherapy.

METHODS

PTV(upper) and PTV(lower) along with a junction were created on CT1 and CT2, respectively. Subsequently, the 10 cm junction in the thigh region was divided into five target volumes of 2 cm thickness with dose prescription ranging from 10 to 90% to deliver a total dose equal to 100% when fused.

RESULTS

The D₅₀ was equal to the prescribed dose in most of the cases ranging from 99.5 to 104% for PTV(upper), 100-103% for PTV(lower), and 99.5-108% for junctional PTVs (1PTV, 2PTV, 3PTV, 4PTV, and 5PTV). The average D₉₅ doses from PTV(upper) and PTV(lower) were 97 ± 1.4% and 96.7 ± 1.08%, respectively. The average D₉₅ doses for 1PTV, 2PTV, 3PTV, 4PTV, and 5PTV were 96.1 ± 1.88%, 91.6 ± 1.82%, 87.3 ± 1.5%, 91.6 ± 1.4%, and 96.2 ± 1.5% respectively. Q_RTOG values ranged between 0.85 and 1.05 and were in concordance with RTOG guidelines.

CONCLUSION

Since junction-based planning was required for most TBI patients, it is essential to evaluate the quality of dose coverage in the junction for better TBI plans.

Targets for protection and mitigation of radiation injury

Protection of normal tissues against toxic effects of ionizing radiation is a critical issue in clinical and environmental radiobiology. Investigations in recent decades have suggested potential targets that are involved in the protection against radiation-induced damages to normal tissues and can be proposed for mitigation of radiation injury. Emerging evidences have been shown to be in contrast to an old dogma in radiation biology; a major amount of reactive oxygen species (ROS) production and cell toxicity occur during some hours to years after exposure to ionizing radiation. This can be attributed to upregulation of inflammatory and fibrosis mediators, epigenetic changes and disruption of the normal metabolism of oxygen. In the current review, we explain the cellular and molecular changes following exposure of normal tissues to ionizing radiation. Furthermore, we review potential targets that can be proposed for protection and mitigation of radiation toxicity.

A Retrospective Study of Ocular Side Effects in Children Undergoing Bone Marrow Transplantation

Bone marrow transplantation (BMT) is recognized as a successful treatment for malignant and non-malignant hematological diseases. Thanks to transplantation, the number of long-term survivors has risen and with the improved prognosis a problem of ocular side effects has arisen. We carried out a retrospective study to determine the incidence and etiopathogenesis of ocular complications in a series of young patients undergoing BMT. One hundred children (62 males and 38 females) with a mean age of 7.12 (+/- 3.3) years at the time of BMT (autologous in 66 cases, allogenic in 34) were followed for a mean of 4.2 years (range 2-9). The conditioning regimens preceding BMT induced cytoreductive chemotherapy alone (47 cases) or associated with total body irradiation (TBI) (53 cases) in three or six fractions for a total dose of 10-12 Gy. We examined every child before BMT and subsequently every six months. We did not include patients with ocular complications due to the primary disease. Thirty-three children showed several complications after BMT: 17 had subcapsular posterior cataract in both eyes and eight had tear hyposecretion; one had dramatic fungal panuveitis, four had hemorrhagic complications and five optic disk edema. TBI was significantly associated with the development of subcapsular posterior cataract.

Virtual bolus for total body irradiation treated with helical tomotherapy

Intensity‐modulated radiation therapy (IMRT) for total body irradiation (TBI) is practiced in several centers using the TomoTherapy System. In this context the planning target volume (PTV) is the entire body including the skin. A safety margin in the air surrounding the body should be added to take into account setup errors. But using inverse planning, over‐fluence peak could be generated in the skin region to insure dose homogeneity. This work proposes to study the performance of the use of a virtual bolus (VB). A VB is a material placed on the skin surface during planning, but absent for the real treatment. The optimal VB that compensates large setup errors without introducing a high‐dose increase or hot spots for small setup errors was determined. For two cylindrical phantoms, 20 VBs with different densities, thicknesses or designs were tested. Dose coverage of the PTV (V95%) in the presence of simulated setup errors was computed to assess the VB performance. A measure of the dose increase in the phantom center due to the absence of the VB during treatment was also achieved. Finally, the fluence peak at the phantom edge was measured in complete buildup conditions using a large phantom and a detector matrix. Using these VBs, simulated setup errors were compensated to a minimum value of 2.6 and 2.1 cm for small and large phantom, respectively (and only 1.2 and 1.7 cm with no VB). An optimal double‐layer VB was found with a density of 0.4 kg.m−3 and a total thickness of 8 mm; an inner layer of 5 mm was declared as the target for the treatment planning system and an additional layer of 3 mm was added to avoid the over‐fluence peak. Using this VB, setup errors were compensated up to 2.9 cm. The dose increase was measured to be only +1.5% at the phantom center and over‐fluence peak was strongly decreased.

PACS numbers: 87.53 Bn, 87.55 D‐, 87.55 de, 87.55 dk

Long-term outcome after allo-SCT: close follow-up on a large cohort treated with myeloablative regimens

We analyzed the late outcomes of 429 long-term survivors post allogeneic hematopoietic SCT (allo-HSCT) who received transplant in our center between 1981 and 2002, and were free of their primary disease for > or =2 years after allo-HSCT. Late recurrent primary malignancy was found in 58 (13.5%) patients and was the primary cause of late death. A total of 37 (8.6%) patients died of non-relapse causes at a median of 5.5 years (range, 2-15.6 years) post allo-HSCT. The major non-relapse causes of death were chronic GVHD (cGVHD), secondary malignancy and infection. The probabilities of OS and EFS were 85% (95% cumulative incidence (CI) (81-89%)) and 79% (95% CI (74-83%)) at 10 years, respectively. Long-term allo-HSCT survivors were evaluated for late complications (median follow-up, 8.6 years (range, 2.3-22.8 years)). cGVHD was diagnosed in 196 (53.1%) survivors. The endocrine and metabolic complications were hypogonadism in 134 (36.3%) patients, osteopenia/osteoporosis in 90 (24.4%), dyslipidemia in 33 (8.9%), hypothyroidism in 28 (7.6%) and diabetes in 28 (7.6%). Hypertension was diagnosed in 79 (21.4%), renal impairment in 70 (19.0%), depression in 40 (10.8%) and sexual dysfunction in 33 (8.9%) survivors. We conclude that in patients who receive allo-HSCT as treatment for hematological malignancy and who are free of their original disease 2 years post transplant, mortality is low and the probability of durable remission is high. Lifelong surveillance is recommended.

The yin and yang of integrative clinical care, education, and research

Communication between mainstream clinician scientists and complementary therapists is often problematic, in part because of different perspectives, assumptions, and values. However, a simple conceptual model can help conventional scientists and less conventional practitioners find common ground and appreciate their unique approaches toward achieving the same goals. The model described in this article has grown out of my experience in integrating complementary therapies and approaches into clinical care, education, and research. It uses the familiar yin-yang symbol from Chinese medicine to build bridges between mainstream Western clinician-scientists and complementary therapists from other traditions. Over the past seven years, I have developed and used this model in caring for patients, teaching medical students and residents, and conducting research in conjunction with complementary clinicians. This paper describes the yin-yang model as a way to integrate and enhance the understanding of different cultures of healthcare.

Spontaneous conceptions and live birth after heterotopic ovarian transplantation: is there a germline stem cell connection?

Ovarian cryopreservation and transplantation is an emerging technology to preserve fertility in women and children undergoing cancer treatment. Recent reports of live births after orthotopic transplantation raised hopes for the future success of this procedure. However, doubts remained whether the reported pregnancies were as a result of resumed function in the remaining ovary. We recently performed an autologous heterotopic ovarian transplantation in a 32-year-old Hodgkin lymphoma survivor who was menopausal for 2.5 years as a result of a preconditioning chemotherapy given before a hematopoietic stem cell transplant. Subsequent to the transplantation, the patient conceived twice within 3 months and delivered a healthy female child at 40 weeks of gestation. The occurrence of spontaneous pregnancies after heterotopic ovarian transplantation highlights the need for caution when interpreting the source of pregnancies in recipients with intact ovaries. On the other hand, the temporal relationship between the ovarian transplant and the spontaneous resumption of ovarian function and pregnancies in previously menopausal women is intriguing, especially in the light of recent reports of germ cell renewal and migration from the bone marrow to the ovary in rodents.

Return of fertility after autologous stem cell transplantation

OBJECTIVE

To study cases where bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT)-induced menopause was entirely reversed.

DESIGN

Retrospective analysis.

SETTING

An inpatient BMT unit and an ambulatory fertility center in a university hospital.

PATIENT(S)

Two patients with Hodgkin's disease and two with advanced breast carcinoma requiring stem cell transplantation.

INTERVENTION(S)

Estrogen treatment, monitoring of follicle-stimulating hormone (FSH) and estradiol (E(2)) levels, and, ultimately, monitoring of pregnancy.

MAIN OUTCOME MEASURE(S)

Pregnancy.

RESULT(S)

All four patients established pregnancies, but two of them elected to terminate due to the use of tamoxifen early in pregnancy.

CONCLUSION(S)

Menopausal changes resulting from BMT may spontaneously reverse, with reestablishment of normal hormonal function and viable pregnancies.

Stem cell transplantation: supportive care and long-term complications

With increasing hematopoietic stem cell transplant (HSCT) activity and improvement in outcomes, there are many thousands of HSCT survivors currently being followed by non-transplant clinicians for their healthcare. Several types of late sequelae from HSCT have been noted, and awareness of these complications is important in minimizing late morbidity and mortality. Late effects can include toxicities from the treatment regimen, infections from immunodeficiency, endocrine disturbances, growth impairment, psychosocial adjustment disorders, second malignancies, and chronic graft-versus-host disease (GVHD). A variety of risk factors for these complications have been noted. The clinician should be alert to the potential for these health issues. Preventive and treatment strategies can minimize morbidity from these problems and optimize outcomes.

Longitudinal study of adaptation to the stress of bone marrow transplantation

PURPOSE

This prospective longitudinal study of adaptation to bone marrow transplantation (BMT) addressed three questions: (1) When during BMT do individuals experience the greatest distress? (2) What factors are associated with this distress? (3) Are there variables that could be potential clinical indicators of persons in greatest need of preventive intervention?

PATIENTS AND METHODS

One hundred one participants undergoing either an autologous or allogeneic BMT completed questionnaires before hospitalization, before bone marrow infusion, 7 days and 14 days after transplantation, and then 1 month, 3 months, and 12 months after hospitalization. Adaptation was indicated by the degree of emotional distress. Independent variables were personal control, social support from specific sources, cognitive response, self-perception, and coping strategies, controlling for symptomatology.

RESULTS

The greatest emotional distress occurred after admission to the hospital and before the bone marrow infusion. Anxiety and depression decreased 1 week after the transplant, although symptomatology increased during this time. The periods of least emotional distress were 3 months and 1 year after transplantation. Factors that accounted for the greatest variance in emotional distress/adaptation were the degree of emotional distress at baseline, personal control, cognitive response, and symptomatology.

CONCLUSION

According to this longitudinal study, which includes pretransplant data, data from in-hospital transplantation, and posttransplant data, (1) psychosocial vulnerability of these BMT recipients was greatest during hospitalization before the transplant, (2) perceived personal control may be a potential indicator of vulnerability to secondary psychosocial morbidity, and (3) the demonstrated significance of psychosocial well-being before BMT indicates the importance of obtaining prospective data for both research and clinical purposes.

Update on psychosocial research on leukaemia for social work practitioners

This article describes an Australian initiative that has undertaken the challenge of establishing a permanent psychosocial research program on leukaemia and associated haematological disorders to inform service provision and policy development for patients and their families. The description of this initiative is set in the context of a summary of the present research that exists in this area. This research indicates that this is a group of patients with a high rate of morbidity who, along with their family and carers, are vulnerable to physical, social, emotional and spiritual distress. The discussion concludes with a description of research projects that are presently being undertaken to extend our understanding of the psychosocial issues associated with these diagnostic groups.

Femoral head osteonecrosis after bone marrow transplantation

Thirty-five patients with bilateral osteonecrosis of the femoral head after bone marrow transplantation were reviewed retrospectively. The median age at the time of transplantation was 26 years. The first symptoms occurred within 2 years of transplantation. At presentation, 18 of the patients reported pain in both hips, 17 had symmetric radiographic lesions, and 39 of the hips had collapsed. Medical treatment was indicated initially. At the final examination before surgery (median, 3.5 years), 31 patients had bilateral hip pain, 22 patients had symmetric radiographic lesions, and 56 of the hips had collapsed. Fifty-seven of the hips required surgery, including one open drainage, four core decompressions, six cup arthroplasties, and 46 primary total hip replacements. Six hips (four core decompressions; two cups) later underwent total hip replacement revision, and a deep infection developed in one. By considering the requirement of a total hip replacement as a failure of conservative treatment, the rate of survival of the femoral head was 30% 5 years after the transplant. There was no significant difference between the Ficat grades, except for Grade 0, which showed a higher survival rate. The study of the specific features of the osteonecrosis may lead to the recommendation of primary total hip arthroplasty after failure of the medical treatment.

Long-Term Outcome After Marrow Transplantation for Severe Aplastic Anemia

We reviewed the records and reevaluated 212 patients with aplastic anemia transplanted at the Fred Hutchinson Cancer Research Center (FHCRC) between 1970 and 1993 who survived ≥2 years and who have been followed for up to 26 years. Parameters analyzed included hematopoietic function, chronic graft-versus-host disease (GVHD), skin disease, cataracts, lung disease, skeletal problems, posttransplant malignancy, depression, pregnancy/fatherhood, and the return to work or school, as well as patient self-assessment of physical and psychosocial health, social interactions, memory and concentration, and overall severity of symptoms. Survival probabilities at 20 years were 89% for patients without (n = 125) and 69% for patients with chronic GVHD (n = 86) (the status was uncertain in 1 surviving patient). All patients had normal hematopoietic parameters. Skin problems occurred in 14%, cataracts in 12%, lung disease in 24%, and bone and joint problems in 18% of patients. Eleven patients (12%) developed a solid tumor malignancy and 19% of patients experienced depression. Chronic GVHD was the dominant risk factor for late complications. Seventeen patients died at 2.5 to 20.4 years posttransplant; 13 of these had chronic GVHD and related complications. At 2 years, 83% of patients had returned to school or work; the proportion increased to 90% by 20 years. At least half of the patients preserved or regained the ability to become pregnant or father children. Patients rated their quality of life as excellent and symptoms as minimal or mild. In conclusion, marrow transplantation in patients with aplastic anemia established long-term normal hematopoiesis. No new hematologic disorders occurred. The major cause of morbidity and mortality was chronic GVHD. However, the majority of patients who survived beyond 2 years returned to a fully functional life.

Long-Term Outcome After Marrow Transplantation for Severe Aplastic Anemia

We reviewed the records and reevaluated 212 patients with aplastic anemia transplanted at the Fred Hutchinson Cancer Research Center (FHCRC) between 1970 and 1993 who survived ≥2 years and who have been followed for up to 26 years. Parameters analyzed included hematopoietic function, chronic graft-versus-host disease (GVHD), skin disease, cataracts, lung disease, skeletal problems, posttransplant malignancy, depression, pregnancy/fatherhood, and the return to work or school, as well as patient self-assessment of physical and psychosocial health, social interactions, memory and concentration, and overall severity of symptoms. Survival probabilities at 20 years were 89% for patients without (n = 125) and 69% for patients with chronic GVHD (n = 86) (the status was uncertain in 1 surviving patient). All patients had normal hematopoietic parameters. Skin problems occurred in 14%, cataracts in 12%, lung disease in 24%, and bone and joint problems in 18% of patients. Eleven patients (12%) developed a solid tumor malignancy and 19% of patients experienced depression. Chronic GVHD was the dominant risk factor for late complications. Seventeen patients died at 2.5 to 20.4 years posttransplant; 13 of these had chronic GVHD and related complications. At 2 years, 83% of patients had returned to school or work; the proportion increased to 90% by 20 years. At least half of the patients preserved or regained the ability to become pregnant or father children. Patients rated their quality of life as excellent and symptoms as minimal or mild. In conclusion, marrow transplantation in patients with aplastic anemia established long-term normal hematopoiesis. No new hematologic disorders occurred. The major cause of morbidity and mortality was chronic GVHD. However, the majority of patients who survived beyond 2 years returned to a fully functional life.

melphalan, single-fraction total-body irradiation and allogeneic bone marrow transplantation for acute leukemia: review of transplant-related mortality

Causes of treatment-related death were studied amongst 138 patients with acute myeloid (n = 90) or lymphoblastic (n = 48) leukemia allografted from HLA-identical siblings in first (n = 107) or second (n = 31) remission after a conditioning regimen comprising 110 mg/m2 melphalan and 1050 cGy single-fraction total-body irradiation (TBI) prescribed as maximum lung dose. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (n = 78) or cyclosporine-methotrexate (n = 60). Eighty-one patients died of causes other than relapse 16-2917 days (median 77) after transplantation. The actuarial probability of non-relapse mortality was 62% at 5 years. The major primary causes of death were pneumonitis (n = 38, 47%), GVHD (n = 18, 22%), and sepsis (n = 11, 14%). Pneumonitis contributed to 42 of the deaths (52%), and its etiology was infective (n = 27), idiopathic (n = 14), or a combination of the two (n = 1). On multivariate analysis, GVHD prophylaxis with cyclosporine alone was associated with a higher overall toxic death rate. The use of cyclosporine alone and a low infused cell dose (<2.5 x 10(8) total nucleated cells/kg or <0.6 x 10(8) mononuclear cells/kg) were associated with a higher risk of death from pneumonitis. We conclude that the use of cyclosporine alone as GVHD prophylaxis is associated with increased transplant-related toxicity, and the addition of methotrexate and infusion of a higher number of cells decrease the incidence of fatal pneumonitis.

[Transplantation of hematopoietic stem cells. I: Definitions, principle indications, complications]

The transplantation of hematopoietic and lymphopoetic stem and progenitor cells has become a standard procedure for the treatment of many malignant diseases. Autologous stem cells are derived from the patient himself, allogeneic cells from an HLA-identical or HLA-compatible family or unrelated donor. Hematopoietic stem cells can be obtained from bone marrow, blood and fetal cord blood. After 3 to 5 days treatment, the granulocyte-colony stimulating factor (G-CSF) mobilizes stem- and progenitor cells from the marrow into the blood. This method is now standard in autologous transplantation and is increasingly preferred in allogeneic transplantation. The time to hematopoietic recovery is shorter with blood stem cells than with bone marrow cells. With myeloablative high dose therapy followed by stem cell transplantation, long term disease free survival is possible in many cases and great proportions of patients can be cured (see part II). Improvements of supportive care have reduced toxicity of treatment substantially, however severe complications still occur at oropharynx, gastrointestinal tract, liver, lung, skin, kidney, urinary tract and nervous system. After allogeneic transplantation immunocompetent donor cells can react with the recipients tissue. In HLA-identical donor and recipients differences in the minor histocompatibility antigens account for this graft-versus-host-reaction (GvH), which is mainly mediated by transplanted T-cells. The GvH-reaction can affect skin, liver, gut and other organs and cause clinically relevant GvH-disease (GvHD). The GvHD is more severe in HLA-mismatched or unrelated transplantations. Immunodeficiency and organ dysfunction due to GvHD may predispose infections and impair the outcome of transplantation. Unrelated cord blood stem cells may have a minor risk of inducing acute GvHD, as stem and T-cells are immature. After allogeneic stem cell transplantation, the relapse rate of leukemia or lymphoma is significantly reduced by immunoreactive cells:graft-versus-tumor (GvT) or graft-versus-leukemia effect (GvL).

Renal dysfunction following autologous bone marrow transplantation in adult patients with acute leukemia

The serum creatinine level was used to determine the incidence of renal dysfunction in 70 adults with acute leukemia who were alive and well one year following autologous bone marrow transplantation (ABMT). Creatinine measurements at the time of ABMT, one year post-ABMT and at the last follow-up (12-128 months, median 35) were recorded, and a level of >120 micromol/l arbitrarily defined as clinically significant renal impairment. The incidence of renal impairment was 2.9% (n = 2) at 1 year, and 4.3% (n = 3) at the last follow-up in continuous remission. Significant renal impairment occurred after relapse in 8 of 12 patients, but was seen in only 3 of 58 patients who remained in remission (p < 0.001, Fisher's exact test), suggesting subclinical renal damage which became obvious with further nephrotoxic therapy. We conclude that clinically significant renal dysfunction is an uncommon long-term complication of ABMT, and should not be a concern in recommending this therapy to eligible patients.

Quality of life in adult cancer patients treated with bone marrow transplantation--a review of the literature

There is now an increasing interest in measuring quality of life (QOL) in cancer patients. Information on psychosocial issues and the patients' QOL give a more comprehensive evaluation of the treatment outcome than survival and relapse free intervals alone. Bone marrow transplantation (BMT) has become a standard, curative treatment in haematological diseases such as leukaemia and lymphomas. However, serious physical and psychological side effects are experienced by some patients. A review of the literature on QOL in adult BMT patients shows that the development in post-BMT research on psychosocial factors is slowly progressing. Most studies are retrospective with small sample sizes, and only five of 48 studies fulfilled our preset quality criteria. Identification of factors that are predictive for poor post-BMT outcome might provide a basis for targeted support programmes. This underlines the necessity of undertaking prospective studies using reliable and well-validated methods for measuring QOL in this patient group.

Graft-versus-host disease and the development of late complications

Graft-versus-host disease (GVHD) in both its acute and chronic forms is a severe complication after allogeneic marrow transplantation. GVHD is associated with structural and functional defects in many organs and tissues. Severe immunoincompetence may result in frequent, often severe and at times fatal infections caused by various organisms. Prolonged antibiotic prophylaxis, and possibly immunoglobulin administration are beneficial. Ocular complications, airway and pulmonary damage, and oral or dental problems may cause severe morbidity. Despite aggressive management, a proportion of patients will succumb to these complications. Severe skin disease and joint contractures are currently seen less frequently, mostly due to early treatment of the disease. Psychosocial rehabilitation of patients with chronic GVHD is a demanding and protracted challenge and should be approached by a multidisciplinary team.

Effect of nephrotoxic drugs on the development of radiation nephropathy after bone marrow transplantation

PURPOSE

Chronic renal failure is a significant cause of late morbidity in bone marrow transplant patients whose conditioning regimen includes total body irradiation (TBI). Radiation is a major cause of this syndrome (bone marrow transplant nephropathy), but it may not be the only cause. These studies use a rat syngeneic bone marrow transplant model to determine whether nephrotoxic agents used in conjunction with bone marrow transplantation (BMT) could be enhancing or accelerating the development of radiation nephropathy.

METHODS AND MATERIALS

Rats received 11-17 Gy TBI in six fractions over 3 days followed by syngeneic bone marrow transplant. In conjunction with the bone marrow transplants, animals received either no drugs, cyclosporine, amphotericin, gentamicin, or busulfan. Drugs were given in schedules analogous to their use in clinical bone marrow transplantation. Drug doses were chosen so that the drug regimen alone caused detectable acute nephrotoxicity. Animals were followed for 6 months with periodic renal function tests.

RESULTS

Gentamicin had no apparent interactions with TBI. Amphotericin increased the incidence of engraftment failure, but did not enhance radiation nephropathy. Cyclosporin with TBI caused late morbidity that appeared to be due to neurological problems, but did not enhance radiation nephropathy. Busulfan resulted in a significant enhancement of radiation nephropathy.

CONCLUSION

Of the nephrotoxins used in conjunction with bone marrow transplantation only radiation and busulfan were found to be risk factors for bone marrow transplant nephropathy.

Avascular necrosis of bone after allogeneic bone marrow transplantation: clinical findings, incidence and risk factors

In the present study we describe the incidence, clinical course, and management of avascular necrosis of bone following allogeneic bone marrow transplantation, and identify risk factors related to its development. All patients developing avascular necrosis of bone after allogeneic bone marrow transplantation between January 1974 and September 1992 were included in the analysis and were studied using the Hôpital Saint Louis Bone Marrow Transplant Database and hospital records. 27/727 allogeneic transplant recipients developed avascular necrosis leading to an 8.1% incidence at 5 years, by product limit estimate, ranging from 5% to 11.2%. Symptoms developed 119-1747 d (median 398 d) after transplantation. In these 27 patients a total of 52 joints were affected (mean 1.92 per patient, range 1-7). The hip joint was most often affected (69% of patients). All patients had joint pain that led to diagnosis by means of standard radiographs with or without the help of technetium-99 scans and/or magnetic resonance imaging. All but three patients received steroid therapy for acute graft-versus-host disease. Among 10 factors tested, three were shown to be significantly linked to an increased risk for developing avascular necrosis by multivariate analysis: male gender (relative risk (RR) 4.72, P = 0.002), age older than 16 (RR = 3.87, P = 0.004), and acute graft-versus-host disease requiring steroid therapy (RR = 6.30, P = 0.0002). 10 patients (37%) required joint replacement within 19 months (range 2-42) following diagnosis of avascular necrosis. In conclusion, avascular necrosis of bone is a frequent late complication of allogeneic bone marrow transplantation causing significant morbidity and requiring replacement surgery in one-third of affected patients. In this 18-year single-centre survey, older age, male gender and steroid therapy given for acute graft-versus-host disease were shown to independently increase the risk of avascular necrosis of bone.

Quality of life in adult bone marrow transplant patients: beyond the first year

Currently, there are more than 2,000 marrow transplant patients surviving between 5 and 20 years. Thus, increased attention is focusing on information about the nature of posttransplant survival and quality of life (QOL). Assessment of the survivor's QOL and rehabilitation needs should consider the domains of physical well-being and symptoms as well as psychological, social, and spiritual well-being. An analysis of the QOL reported in 780 adult survivors from 15 separate studies provides a perspective on the adult BMT survivor beyond the 1-year milestone.

Psychiatric and psychosocial aspects of bone marrow transplantation

Bone marrow transplantation (BMT) is being increasingly used to treat children and adults with a variety of life-threatening diseases. Although BMT is a life-saving intervention in many instances, it is a high-technology procedure--both aggressive and life-threatening--associated with an array of physical and psychological stressors. Therefore, psychiatric and psychosocial research and intervention can greatly contribute to the understanding and management of BMT recipients, donors, and their families. Seven major areas of psychiatric and psychosocial concern in BMT are identified and the literature relevant to each area is reviewed.

Allogeneic marrow transplantation for myelodysplastic syndrome complicating autologous bone marrow transplantation

A patient with refractory relapsed Hodgkin's disease underwent an autologous bone marrow transplant in July 1987 and achieved remission of Hodgkin's disease. He had complete hematological recovery but developed pancytopenia 3 years post bone marrow transplantation with morphological evidence of myelodysplasia. High-dose cyclophosphamide, 200 mg/kg, chemotherapy followed by an allogeneic bone marrow transplant from a HLA-matched sibling was performed in April 1991 with complete hematological recovery. Allogeneic bone marrow transplantation was thus used successfully to treat a potential complication of autologous bone marrow transplantation.