[Management of endocrine dysfunctions after allogeneic hematopoietic stem cell transplantation: a report of the SFGM-TC on dyslipidemia and thyroid disorders]

Thyroid dysfunctions in adult patients after allogeneic hematopoietic stem cell transplantation

INTRODUCTION

Thyroid dysfunction (TD) is one of the major endocrinopathies shown after allogeneic hematopoietic stem cell transplantation over the long term. The incidence and the risk factors for TD have varied widely.

PATIENTS AND METHODS

Two hundred and fifty-nine patients with pre-transplant normal thyroid function tests who survived at least 1 year after allo-HSCT between 2006-2016 were included in the study.

RESULTS

Sixty-four patients (25%) developed TD at median of 34 months (range, 1-112 months). Hypothyroidism was detected in 32 patients (12%): 5 patients had primary hypothyroidism, and subclinical hypothyroidism occurred in 27 patients. 18 patients (7%) were diagnosed with hyperthyroidism: 2 patients (0.07%) were treated for primary hyperthyroidism, and 16 patients (6%) were followed for subclinical hyperthyroidism. Euthyroid sick syndrome occurred in 14 cases. None of the patients with thyroid dysfunction developed secondary thyroid malignancy. Receiving high-dose TBI (P = .001) was found to be significant risk for hypothyroidism; older age than median (P = .01) and pre-transplant active disease (P < .0001) were related to hyperthyroidism.

CONCLUSIONS

Thyroid dysfunction, mostly hypothyroidism, is a long-term complication after allo-HSCT in 25% of patients. Older age, pre-transplant active disease, and receiving TBI are among the risk factors. Sustained long-term monitoring of thyroid function test should be considered post allo-HSCT.

Managing Endocrine Disorders in Adults After Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) has become a potentially curative therapy for an increasing number of malignant and non-malignant conditions. As survival rates continue to improve, the focus of patient care has shifted from managing not only immediate but also long-term complications. Endocrine disorders are among the most prevalent late effects following HSCT. Detecting and treating such conditions offer new challenges, as well as opportunities to reduce preventable morbidity and mortality associated with HSCT. Our objective is to summarize recent literature and describe practical approaches to screening for and managing endocrine-related late effects. We focus on dyslipidemia, diabetes, thyroid disorders, osteoporosis, and hypogonadism. Mechanisms, monitoring, and management recommendations for each disorder are outlined. Growing data on these disorders in the post-transplant setting highlight the need for future study and evidence-based guidelines.

A review of late complications of allogeneic hematopoietic stem cell transplantations

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective and curative treatment of different malignant and non-malignant diseases. Early transplant-related mortality after allo-HSCT has decreased with reduced-intensity conditioning regimens and effective anti-infectious treatments, but late transplant-related mortality is still a problem. Physicians are now paying more attention to late complications that may worsen the quality of life of many transplant recipients. Chronic graft versus host disease (cGVHD) is one of the major causes of late transplant-related mortality after allo-HSCT. This review discusses recent advances that have been made in clinical evaluation and treatment of late transplant-related complications including cGVHD. The different sites of involvement are organs, especially the skin and eye, and the gastrointestinal, endocrinologic, metabolic, renal, cardiologic, pulmonary, connective tissue, and neurological systems. In addition, this review includes infections and secondary malignancies in post-transplant settings that worsen quality of life in long-term follow-ups.

[How we harmonize HSCT clinical practices among the SFGM-TC centers]

In hematopoietic transplantation, clinical patient care is localized and practices differ from one country to another and even from center to center. International guidelines are not always well adapted to the evolution of daily clinical practice, and they do not address all issues, especially practical ones. Therefore, in the absence of well-established guidelines, each center tends to make do by developing local procedures. In the attempt to harmonize localized clinical practices between different centers belonging to the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), our society set up in 2010 what would become an annual workshop series, bringing together practitioners from all member centers. Each workshop group is responsible for discussing a specific issue and then drafting, in the form of an article, a set of guidelines that address the issue practically. With the aim of covering all practical issues and providing widely-usable guidelines when international consensus is lacking, the SFGM-TC has succeeded in establishing national guidelines by those who use them. So as to be easily localized by all centers, the guidelines are written in French. In this article, we set out the process by which the workshops are conducted and how the final guidelines produced are approved each year.

[Post-hematopietic stem cell transplant complications]

Under the long-term monitoring of patients treated in childhood or adolescence for cancer, we present in this article the long-term monitoring and therefore possible effects of patients who underwent allergenic hematopoietic stem cell transplantation. This article is based on a collaborative effort organized by the French Society of Bone Marrow Transplantation and Cell Therapy (SFGM-TC), which took place during the 4th day of allograft harmonization practices. Patients affected are children and young adults (0-25 years). We defined the monitoring effects beyond 1 year post-transplant. Our recommendations are based on a literature review, in line with the Leucémie Enfant Adulte (LEA) study cohort of long-term monitoring of patients treated for hematological malignancies in childhood, grafted or not. It became important to determine the nature of problems, their risk factors, frequency and monitoring necessary to implement for their detection. We will not address the therapeutic management of sequelae.

Endocrinopathies after allogeneic and autologous transplantation of hematopoietic stem cells

Early and late endocrine disorders are among the most common complications in survivors after hematopoietic allogeneic- (allo-) and autologous- (auto-) stem cell transplant (HSCT). This review summarizes main endocrine disorders reported in literature and observed in our center as consequence of auto- and allo-HSCT and outlines current options for their management. Gonadal impairment has been found early in approximately two-thirds of auto- and allo-HSCT patients: 90–99% of women and 60–90% of men. Dysfunctions of the hypothalamus-pituitary-growth hormone/insulin growth factor-I axis, hypothalamus-pituitary-thyroid axis, and hypothalamus-pituitary-adrenal axis were documented as later complicances, occurring in about 10, 30, and 40–50% of transplanted patients, respectively. Moreover, overt or subclinical thyroid complications (including persistent low-T3 syndrome, chronic thyroiditis, subclinical hypo- or hyperthyroidism, and thyroid carcinoma), gonadal failure, and adrenal insufficiency may persist many years after HSCT. Our analysis further provides evidence that main recognized risk factors for endocrine complications after HSCT are the underlying disease, previous pretransplant therapies, the age at HSCT, gender, total body irradiation, posttransplant derangement of immune system, and in the allogeneic setting, the presence of graft-versus-host disease requiring prolonged steroid treatment. Early identification of endocrine complications can greatly improve the quality of life of long-term survivors after HSCT.