Page 1801 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 104 Indications and Outcomes of Allogeneic Hematopoietic Cell Transplantation for Hematologic Malignancies in Adults 1605

BOX 104.4 Recommended Practices for Allogeneic Transplant Recipients in Long-term Follow-up
a
6 mo 12 mo Annual Comments ( )
Liver:
Liver Function Tests √ √ a Annual check only if previously abnormal or new signs/symptoms
Serum Ferritin √ a
Respiratory:
Clinical Assessment √ √ √
Smoking/Tobacco Avoidance √ √ √
Formal Pulmonary Function Tests √ a Annual study/Imaging as needed in follow up of prior/new abnormalities
Chest X-Ray a a a
Bone Density Screening √ a Consider repeat testing in ones with recognized defects, ongoing risk
factors or for response assessment
Kidney:
Blood Pressure Screen √ √ √
Proteinuria Screen √ √ a As needed annually
BUN/Creatinine level √ √ √
Nervous System:
Clinical Assessment √ a Annually as needed
Endocrine:
Thyroid Function √ a Annually as needed
Gonadal Function in postpubertal women √ √
Cardiac/Vascular:
Cardiovascular Risk Factor Screen √ √
Immune System/Infection Risk:
Encapsulated organism Prophylaxis a a a If on immune suppression or with ongoing GVHD
Pneumocystis prophylaxis √ a a
CMV test √ √
Immunizations √ √
Endocarditis prophylaxis a a Follow AHA guidelines
Antifungal/Antiherpes viral prophylaxis a a a If on immune suppression or with GVHD; if not, no consensus
Second Cancer Risk:
Cancer Risk Assessment and Education √ √
Pap Smear √ √
Mammogram (women over 40 years) √ √
Breast/Skin/Testes self-examination √ √
Clinical Screen for second cancers √ √
Psychosocial:
Clinical psychosocial and QOL screen √ √ √
Sexual function screen √ √ √
Dental Assessment √ √ √
Ocular:
Clinical Evaluation √ √ √
Fundus Exam √ a As needed annually
Schirmer test a a If with ongoing GVHD or on immune suppression
AHA, American Heart Association; BUN, blood urea nitrogen; CMV, cytomegalovirus; GVHD, graft-versus-host disease; QOL, quality of life.

patients with Philadelphia chromosome (Ph)-positive ALL. For is also a consideration for patients who have BCR-ABL mutations
adults with Ph-negative ALL, the appropriate timing of HCT is more that predict for TKI nonresponse (e.g., T325I mutation). It is impor-
controversial despite the largest prospective study (Medical Research tant to establish a monitoring plan for early signs of progression and
Council/Eastern Cooperative Oncology Group [MRC/ECOG]) and for mutation screening since outcomes are significantly better if HCT
a metaanalysis suggesting a survival advantage for those assigned to is performed before transformation to advanced disease. Definitions
transplant in CR1. 25,26 Allogeneic transplantation is currently consid- of suboptimal response and failure with TKIs and guidelines for
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ered by NCCN expert consensus as the best curative therapy for adult monitoring have been developed. European Leukemia-Net guide-
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patients with high-risk features such Ph+ ALL or those with a poor lines recently addressed timing of allogeneic HCT in CML. Allo-
response to initial induction therapy and among adults with t(4;11) geneic HCT was recommended in all CML patients presenting in
ALL. Evidence-based policy statement from the ASBMT recom- blast phase, and for the accelerated phase patients who do not achieve
mended allogeneic HCT for standard-risk, young (<35 years) adults an optimal response. HCT transplantation was also recommended
in first CR and for ALL in second or higher remission. Related and for TKI-treated chronic phase patients subsequently progressing to
unrelated donor HCT were recommended as being similar in out- accelerated or blast phase, after achieving optimal disease control. For
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comes. For those without suitable matched adult donors, cord patients in chronic phase, recommendation was to reserve allogeneic
blood grafts should be considered. HCT for those who are resistant or intolerant to at least one second-
generation TKI, and in patients developing T315I mutation.
Chronic Myelogenous Leukemia
Chronic Lymphocytic Leukemia
In general, HCT is indicated for patients whose initial presentation
is in blast phase and should be considered for those with a suboptimal Current NCCN guidelines recommend allogeneic HCT in chronic
response or relapse while on tyrosine kinase inhibitors (TKIs). HCT lymphocytic leukemia (CLL) for those of younger age with high-risk