Standardized Long-Term Follow-up after Allogeneic Stem Cell Transplantation: A Cross-Sectional 1-Year Evaluation in 260 Adults

Introduction

Allogeneic hematopoietic cell transplantation (HCT) is an effective therapeutic option for high-risk hematological malignancies; 80% of those who survive the first 2 years are expected to become long-term survivors.

The prevalence of chronic health conditions approaches 75% among HCT survivors and that for severe or life-threatening conditions exceeds 20%.

Patients and Methods

A standardized follow-up of HCT survivors is applied at our Center, according to Jacie Standards. Here we report the analysis of data collected between July 2014 and July 2015 in 260 adult patients (pts) who underwent an HCT between 1992 and 2014. Data on 7 items - selected to monitor relevant comorbidities - were prospectively collected in our Institutional database.

A written consent was given by pts allowing the use of medical records for research in accordance with the Declaration of Helsinki.

Results

Pts characteristics are reported in table 1, median time of follow-up 4.4y (r1–22), cumulative follow-up 1404y; 13 pts deceased during the time of observation (6 due to disease relapse, 2 to late major infection, 2 to second cancer, 1 to GvHD, 1 to myocardial infarction, 1 unknown).

- chronic Graft-versus-Host-Disease (c-GvHD): at a median follow-up of 43 months (r 16 months – 21 years) 84 (32%) pts are presenting c-GvHD features.  According to NIH 2014 consensus criteria 23 cases were classified as mild, 32 moderate, 29 severe. Median number of involved organs 2 (r1-5), 39 pts were experiencing skin lesions, 55 eyes, 28 mouth, 19 joint and fascia, 18 lungs. Topical therapy was the treatment of choice for mild cases, while moderate and severe were treated with systemic therapy. The partnership with the lung specialist and the ophthalmologist was crucial for the management of lung and eyes GvHD.

- Late infectious manifestation: 38 (15%) pts present late infection, 2 pts deceased due to major events. Of note pneumonia was reported in 12 pts, Varicella Zoster virus reactivation in 7, CMV late reactivation in 4 pts.

- Second cancer screening was performed according to international guidelines. The incidence of new cases is 10% (26 pts) and 11 pts are actually under work-up for suspicious lesions. Non-melanoma skin cancer was the most frequent diagnosis (13 cases); 3 pts were diagnosed with cervix cancer, 2 with lung cancer. The prevalence of second cancer in our population is 18% (47 cases). All pts were treated according to standard for general population, 45/47 are alive.

- Cardiovascular diseases were frequently observed in our setting: hypertension was documented in 36 pts, arterial diseases in 10 pts, cardiomyopathy in 28 pts. Overall 27% of pts were diagnosed with cardiovascular comorbidities.

- Metabolic syndrome (MS) is reported as a very common complication in long-term survivors: 65 (25%) pts were presenting features of MS (3/5 among hypertension, dyslipidemia, raised fasting glucose, and central obesity). A concomitant thyroid dysfunction – requiring hormonal replacement – was present in 27/65 pts.

- Secondary hemosiderosis was documented (with MRI and blood parameters) and treated in 39 pts (15%) – 8 pts received deferasirox while phlebotomy was used in 31.

- Osteoporosis and bone loss were evaluated measuring bone mineral density using dual-energy X-ray absorptiometry; osteopenia was detected in 81 pts and osteoporosis in 42 (47%). Pts were evaluated in conjunction with the endocrinologist and treated according to the fracture risk score.

According to donor source no difference were observed (Chi-square test - p ns) except for higher incidence of moderate/severe GvHD incidence in HLA identical sibling (p 0.0097) as compared to alternative donors.

Discussion

HCT survivors are at a defined relevant risk of developing long-term complications that have a direct impact on the morbidity and mortality. A multidisciplinary active screening within routine HCT long-term follow-up care is mandatory to enhance early diagnosis/treatment and overall outcome.

The next challenge will be to enhance the primary prevention to reduce the incidence of preventable comorbidities.

Table 1 – patients characteristics		N (range)
Pts		260
Age	At transplant	48y (10 - 76)
	At follow-up	54y (20 - 82)
Male / Female		169 / 91
Diagnosis	AML / ALL	106 / 33
	MDS	27
	HD / NHL	23 / 29
	MM	14
	CML	8
	CLL	5
	SAA / EPN	4 / 1
	Others	10
Status at transplant	CR / PD	169 / 91
Donor	Haploidentical	100
	HLA identical Sibling	76
	Match Unrelated Donor	82
	Cord Blood	2