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Link-Rachner CS, Göbel A, Jaschke NP, Rachner TD. Endocrine health in survivors of adult-onset cancer. Lancet Diabetes Endocrinol 2024; 12:350-364. [PMID: 38604215 DOI: 10.1016/s2213-8587(24)00088-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/13/2024]
Abstract
Long-term survivors of cancer (ie, the patient who is considered cured or for whom the disease is under long-term control and unlikely to recur) are at an increased risk of developing endocrine complications such as hypothalamic-pituitary dysfunctions, hypogonadisms, osteoporosis, or metabolic disorders, particularly when intensive tumour-directed therapies are applied. Symptom severity associated with these conditions ranges from mild and subclinical to highly detrimental, affecting individual health and quality of life. Although they are usually manageable, many of these endocrine pathologies remain underdiagnosed and untreated for years. To address this challenge, a higher degree of awareness, standardised screening tools, comprehensible treatment algorithms, and a close collaborative effort between endocrinologists and oncologists are essential to early identify patients who are at risk, and to implement appropriate treatment protocols. This Review highlights common symptoms and conditions related to endocrine disorders among survivors of adult-onset cancer, provides a summary of the currently available practice guidelines, and proposes a practical approach to diagnose affected patients among this group.
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Affiliation(s)
- Cornelia S Link-Rachner
- Division of Haematology and Oncology, Department of Medicine I, Technische Universität Dresden, Dresden, Germany
| | - Andy Göbel
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nikolai P Jaschke
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Tilman D Rachner
- Division of Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), partner site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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2
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Rachner TD, Link-Rachner CS, Bornhäuser M, Hofbauer LC. Skeletal health in patients following allogeneic hematopoietic cell transplantation. Bone 2022; 158:115684. [PMID: 33049368 DOI: 10.1016/j.bone.2020.115684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is a potentially curative approach for patients with certain hematological diseases, including several forms of lymphoma and leukemia. Besides several treatment-associated risks, transplanted patients are at an increased risk of developing osteoporosis. The underlying pathophysiology is complex and includes factors influenced directly by the disease as well as applied therapies like irradiation, chemotherapy and adjuvant immunosuppressive agents. In addition, patients are prone to secondary hypogonadism, and many patients will require long-term glucocorticoid therapy to mitigate graft-versus-host reactions. All these factors contribute to bone loss, but the individual risk profile may vary greatly. This review summarizes our knowledge on bone loss following allogenic HCT and provides screening and treatment recommendations.
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Affiliation(s)
- Tilman D Rachner
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Cornelia S Link-Rachner
- Division of Hematology and Oncology, Department of Medicine I, Technische Universität Dresden, Dresden, Germany
| | - Martin Bornhäuser
- German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany; Division of Hematology and Oncology, Department of Medicine I, Technische Universität Dresden, Dresden, Germany; National Center for Tumor Diseases (www.nct-dresden.de), Dresden, Germany
| | - Lorenz C Hofbauer
- Division of Endocrinology and Metabolic Bone Diseases, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; Center for Healthy Ageing, Department of Medicine III, Technische Universität Dresden, Dresden, Germany; German Cancer Consortium (DKTK), Dresden and German Cancer Research Center (DKFZ), Heidelberg, Germany
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3
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Gubrianska D, Machaczka M, Hassan M, Hägglund H, Ljungman P, Palmér M. Bone and hormonal status 10 years post-allogeneic bone marrow transplantation. Clin Transplant 2019; 33:e13742. [PMID: 31650625 DOI: 10.1111/ctr.13742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/15/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022]
Abstract
Bone loss and endocrine dysfunction are potential late complications of allogeneic stem cell transplant (allo-SCT); however, scant information concerning the long-term effects in SCT adult patients is available. In the present study, we evaluated bone status, expressed as bone mineral density (BMD), and endocrine functions including PTH, TSH, free T4, testosterone, SHBG, FSH, LH, and IGF-1, in 20 adult leukemia patients >10 years after allo-SCT. A low BMD (Z score <-2.0) was observed in two patients; two patients had osteoporotic fractures, and two had a unilateral avascular necrosis of the femoral head. Elevated PTH was observed in 30% of patients, and 25-hydroxy vitamin D (25(OH)D) was low (<50 nmol/L) in 45% of the patients. The majority of the patients had thyroid tests within the reference range, while elevated FSH values were present in 8 of 12 males. We conclude that adult leukemia patients have relatively well-preserved BMD >10 years post-allo-SCT. Prophylactic treatment of osteoporosis should be individualized, but control of BMD is necessary for long-term follow-up. Control of PTH and vitamin D levels before and after allo-SCT is recommended, and vitamin D supplementation should be considered if indicated. Estrogen replacement therapy is a routine treatment in females, whereas gonadal function in males requires further investigation.
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Affiliation(s)
- Danica Gubrianska
- Experimental Cancer Medicine (ECM), KFC, Novum, Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Maciej Machaczka
- Department of Clinical Science and Education, Stockholm South Hospital and Karolinska Institutet, Stockholm, Sweden.,Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Moustapha Hassan
- Experimental Cancer Medicine (ECM), KFC, Novum, Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Research Center, Novum, Karolinska University Hospital, Huddinge, Sweden
| | - Hans Hägglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Huddinge, Sweden.,Division of Hematology, Deptartment of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mats Palmér
- Department of Endocrinology, Karolinska University Hospital, Huddinge, Sweden
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Prevention and treatment of bone loss and fractures in patients undergoing a hematopoietic stem cell transplant: a systematic review and meta-analysis. Bone Marrow Transplant 2017; 52:663-670. [PMID: 28112742 DOI: 10.1038/bmt.2016.312] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/23/2016] [Accepted: 09/29/2016] [Indexed: 11/08/2022]
Abstract
The most effective method to prevent and treat bone loss following hematopoietic stem cell transplantation (HSCT) remains uncertain. We conducted a comprehensive search in four electronic databases until August 2015. We retrieved articles describing patients with bone loss or fractures who received HSCT. Controlled trials, with a follow-up period of at least 12 months, were included. Twelve studies (19 publications) met our inclusion criteria. A total of 643 participants underwent HSCT (85.7% allogeneic HSCT). There was a statistically significant lower mean bone mineral density (g/cm2) percentage change of the lumbar spine (mean difference (MD) 7.8, 95% confidence interval (CI) 5.6-10.0) and femoral neck (MD 6.7, 95% CI 5.6-7.9) in the bisphosphonate therapy group compared with the control group with no bisphosphonate therapy at 12 months. In a subgroup analysis, seven different comparison groups were evaluated. The rate of fractures or X-ray findings of subclinical vertebral fractures was similar between groups. Bisphosphonates are promising in the prevention and treatment of bone loss following HSCT. Additional research is required to determine whether they reduce long-term fracture risk.
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Lindsay J, Kabir M, Gilroy N, Dyer G, Brice L, Moore J, Greenwood M, Hertzberg M, Gottlieb D, Larsen SR, Hogg M, Brown L, Huang G, Tan J, Ward C, Kerridge I. Epidemiology of complementary and alternative medicine therapy use in allogeneic hematopoietic stem cell transplant survivorship patients in Australia. Cancer Med 2016; 5:3606-3614. [PMID: 27790858 PMCID: PMC5224858 DOI: 10.1002/cam4.889] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/09/2022] Open
Abstract
In addition to prescribed conventional medicines, many allogeneic hematopoietic stem cell transplant (HSCT) survivors also use complementary and alternative medical therapies (CAM), however, the frequency and types of CAMs used by allogeneic HSCT survivors remain unclear. Study participants were adults who had undergone an allogeneic HSCT between 1st January 2000 and 31st December 2012. Participants completed a 402-item questionnaire regarding the use of CAM, medical complications, specialist referrals, medications and therapies, infections, vaccinations, cancer screening, lifestyle, and occupational issues and relationship status following stem cell transplantation. A total of 1475 allogeneic HSCT were performed in the study period. Of the 669 recipients known to be alive at study sampling, 583 were contactable and were sent study packs. Of 432 participants who returned the completed survey (66% of total eligible, 76% of those contacted), 239 (54.1%) HSCT survivors used at least one form of CAM. These included dietary modification (13.6%), vitamin therapy (30%), spiritual or mind-body therapy (17.2%), herbal supplements (13.5%), manipulative and body-based therapies (26%), Chinese medicine (3.5%), reiki (3%), and homeopathy (3%). These results definitively demonstrate that a large proportion of HSCT survivors are using one or more form of CAM therapy. Given the potential benefits demonstrated by small studies of specific CAM therapies in this patient group, as well as clearly documented therapies with no benefit or even toxicity, this result shows there is a large unmet need for additional studies to ascertain efficacy and safety of CAM therapies in this growing population.
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Affiliation(s)
- Julian Lindsay
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Masrura Kabir
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Nicole Gilroy
- Westmead Hospital, Sydney, New South Wales, Australia.,Cancer Institute NSW, Sydney, New South Wales, Australia
| | - Gemma Dyer
- Cancer Institute NSW, Sydney, New South Wales, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Brice
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - John Moore
- Department of Haematology, St Vincents Hospital, Sydney, New South Wales, Australia
| | - Matthew Greenwood
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Blood Research Centre, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Hertzberg
- Department of Haematology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | - Stephen R Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Megan Hogg
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Louisa Brown
- Department of Haematology, Calvary Mater Newcastle, Sydney, New South Wales, Australia
| | - Gillian Huang
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Jeff Tan
- Department of Haematology, St Vincents Hospital, Sydney, New South Wales, Australia
| | - Christopher Ward
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Blood Research Centre, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Ian Kerridge
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Blood Research Centre, Kolling Institute, University of Sydney, Sydney, New South Wales, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
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7
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Hamidieh AA, Hamidi Z, Behfar M, Pajouhi Z, Alimoghaddam K, Mohseni F, Ghavamzadeh A, Sobhani M, Larijani B, Mohajeri Tehrani MR. Relationship between endocrine changes and bone markers in pediatric thalassemic patients after hematopoietic stem cell transplantation. Minerva Pediatr (Torino) 2016; 73:414-419. [PMID: 27416038 DOI: 10.23736/s2724-5276.16.04553-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Beta thalassemia major and its treatment by hematopoietic stem cell transplantation can have deleterious effects on bone integrity and a main part of such effects is due to their deleterious effects on endocrine systems. So, we assessed the effects of endocrine changes during HSCT (Hematopoietic Stem Cell Transplantation) on growing bones of pediatric thalassemic patients. METHODS Bone-specific alkaline phosphatase and osteocalcin (bone formation markers), N-terminal telopeptide (NTX, bone resorption marker), calcium (Ca), phosphorus (P), alkaline phosphatase (Alk ph), parathyroid hormone (PTH), vitamin D (vit D), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), insulin-like growth factor 1 (IGF-1), testosterone (in males) or estradiol (in females), measured in 20 major thalassemic patients with mean age of 10.8±3.9 years. Parameters at the baseline (before HSCT), and 1 month and 3 months after HSCT. RESULTS After stem cell transplantation, changes of mean serum levels of NTX, osteocalcin, prolactin, LH, T4, IGF-1, testosterone (in males), Ca, Alk ph, PTH, and vit D were not significant, but bone specific Alk ph, P, T3, TSH, FSH and estradiol changed significantly (P=0.013, P=0.001, P=0.48, P=0.02, P=0.04 and P=0.001, respectively). After one month, there was a significant positive relationship between osteocalcine and T3 (p= 0.009). After 3 months, also, there was a significant positive relationship between osteocalcine and T3 and T4 as well as a negative one with IGF-1 (P<0.001, P<0.02 and P<0.03, respectively). CONCLUSIONS Endocrine disorders do not appear to have an overall positive or negative effect on bone metabolism (anabolism or catabolism) in HSCT pediatric thalassemic patients in short term (three months).
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Affiliation(s)
- Amir A Hamidieh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Hamidi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran
| | - Maryam Behfar
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Pajouhi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran
| | - Kamran Alimoghaddam
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Mohseni
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran
| | - Ardeshir Ghavamzadeh
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Sobhani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran
| | - Mohammad R Mohajeri Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehrn, Iran -
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Pirsl F, Curtis LM, Steinberg SM, Tella SH, Katić M, Dobbin M, Hsu J, Hakim FT, Mays JW, Im AP, Pulanić D, Mitchell SA, Baruffaldi J, Masuch L, Halverson DC, Gress RE, Barsony J, Pavletic SZ. Characterization and Risk Factor Analysis of Osteoporosis in a Large Cohort of Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 22:1517-1524. [PMID: 27118572 DOI: 10.1016/j.bbmt.2016.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/16/2016] [Indexed: 01/23/2023]
Abstract
The National Institutes of Health Chronic Graft-versus-Host Disease (cGVHD) Consensus Project Ancillary and Supportive Care Guidelines recommend annual assessment of bone mineral density (BMD) to monitor bone health. The study of osteoporosis in patients with cGVHD has been limited to small numbers of patients, and the guidelines are based on experience with other chronic diseases and expert opinion. We hypothesized that the prevalence of osteoporosis is high in a cohort of 258 patients with moderate to severe cGVHD because of prolonged exposure to risk factors for osteoporosis after allogeneic hematopoietic stem cell transplantation. We defined osteoporosis using BMD criteria (T-score ≤-2.5) at 3 anatomic sites-the femoral neck (FN), lumbar spine (LS), and total hip (TH)-and characterized risk factors through univariate and multivariate analyses. We found that low body weight (FN, P < .0001; LS, P = .0002; TH, P < .0001), malnutrition (FN, P = .0002; LS, P = .03; TH, P = .0076), higher platelet count (FN, P = .0065; TH, P = .0025), higher average National Institutes of Health organ score (FN, P = .038), higher prednisone dose (LS, P = .032), lower complement component 3 (LS, P = .0073), and physical inactivity (FN, P = .01) were associated with osteoporosis in at least 1 site. T-scores were significantly lower in the FN compared with the LS or TH (P < .0001 for both). The prevalence of osteoporosis and osteopenia was high (17% and 60%, respectively), supporting current recommendations for frequent monitoring of BMD. The association of higher platelet count in patients with cGVHD and osteoporosis has not been reported previously and represents a new area of interest in the study of osteoporosis after allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Filip Pirsl
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Sri Harsha Tella
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Mašenjka Katić
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Marnie Dobbin
- Clinical Nutrition Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jennifer Hsu
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Fran T Hakim
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jacqueline W Mays
- Oral and Pharyngeal Cancer Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Annie P Im
- Adult Hematopoietic Stem Cell Transplant Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dražen Pulanić
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia; Faculty of Medicine Osijek, J. J. Strossmayer University of Osijek, Osijek, Croatia
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Judy Baruffaldi
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Licia Masuch
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - David C Halverson
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Ronald E Gress
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Julianna Barsony
- Division of Endocrinology and Metabolism, Department of Medicine, Georgetown University Medical Center, Washington, DC
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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9
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Pandit A, Garg MK, Kotwal N, Brar KS, Gundgurthi A, Sharma AK, Sharma S. Changes in bone mineral density and bone turnover markers in patients undergoing hematopoietic stem cell transplant. Indian J Endocrinol Metab 2015; 19:393-398. [PMID: 25932397 PMCID: PMC4366780 DOI: 10.4103/2230-8210.152785] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Hematopoietic stem cell transplant (HSCT) is frequently complicated by endocrine abnormalities and loss of bone mass. This prospective study was conducted to evaluate the bone loss post-HSCT. MATERIALS AND METHODS A total of 50 patients was evaluated pretransplantation, and 25 had HSCT (17 males, 8 females; 19 allogenic, 6 autologous). Bone mineral density (BMD) and bone markers were measured at baseline, 3-6 months and 12 months. RESULTS The mean age and body mass index were 25.1 ± 16.3 years and 19.4 ± 4.5 kg/m(2), respectively. There were 15 adults (60%), and 10 adolescents (40%). There was a significant decline in BMD from the baseline at total femur (-8.7%; P < 0.0001), femoral neck (-5.0%; P = 0.003), femoral trochanter (-6.0%; P = 0.001), and Ward's triangle (-9.9%; P < 0.0001) at 6 months posttransplantation. From the 6 months to 12 months, there was a significant improvement in BMD at above sites except at Ward's triangle. The decline in BMD was nonsignificant at the whole body (-0.3%, P = 0.748) and the lumbar spine (-2.7%, P = 0.130) at 6 months posttransplant. Younger patients with allogenic graft and steroid use are more likely to have significant loss of BMD at hip posttransplant. Serum osteocalcin decreased, and N-telopeptide increased at 3-6 months, which return to baseline at 1-year posttransplant. CONCLUSIONS A significant bone loss is observed at 6 months in patients with post-HSCT. The bone loss occurs predominantly at cortical bone. There is recovery of bone mass at 12 months posttransplant except at Ward's triangle. Bone loss after HSCT is multifactorial.
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Affiliation(s)
- Aditi Pandit
- Commandant, Military Hospital, Shillong, Meghalaya,, India
| | - M. K. Garg
- Commandant, Military Hospital, Shillong, Meghalaya,, India
| | - N. Kotwal
- Department of Endocrinology, Army Hospital Research and Referral, New Delhi, India
| | - K. S. Brar
- Department of Endocrinology, Army Hospital Research and Referral, New Delhi, India
| | - Abhay Gundgurthi
- Department of Endocrinology, Army Hospital Research and Referral, New Delhi, India
| | - A. K. Sharma
- Department of Hematology, Army Hospital Research and Referral, New Delhi, India
| | - Sanjeevan Sharma
- Department of Hematology, Army Hospital Research and Referral, New Delhi, India
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10
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Campos DJ, Boguszewski CL, Funke VAM, Bonfim CMS, Kulak CAM, Pasquini R, Borba VZC. Bone mineral density, vitamin D, and nutritional status of children submitted to hematopoietic stem cell transplantation. Nutrition 2013; 30:654-9. [PMID: 24613437 DOI: 10.1016/j.nut.2013.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/15/2013] [Accepted: 10/28/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the effect of allogeneic hematopoietic stem cell transplantation (HSCT) on bone mineral density (BMD), serum vitamin D levels, and nutritional status of 50 patients between ages 4 and 20 y. METHODS We conducted pre-HSCT and 6-mo post-HSCT evaluations. We measured BMD at the lumbar spine (LS) and total body (TB) by dual energy x-ray absorptiometry (DXA); body composition by bioimpedance analysis, and dietary intakes of calcium and vitamin D using the 24-h recall and semiquantitative food frequency questionnaire methods. RESULTS We observed a significant reduction in BMD 6 mo post-HSCT. Nearly half (48%) of patients had reductions at the LS (average -9.6% ± 6.0%), and patients who developed graft-versus-host disease (GVHD) had the greatest reductions (-5.6% versus 1.2%, P < 0.01). We also found reductions in serum levels of 25-hydroxyvitamin D (25-OHD), from 25.6 ± 10.9 ng/dL to 20.4 ± 11.4 ng/dL (P < 0.05), and in body weight. Corticosteroid treatment duration, severity of chronic GVHD, serum 25-OHD levels, and family history of osteoporosis were all risk factors associated with variations in BMD at the LS. CONCLUSION HSCT in children and adolescents negatively effects their BMD, nutritional status, and vitamin D levels. We suggest that early routine assessment be done to permit prevention and treatment.
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Affiliation(s)
- Denise Johnsson Campos
- Bone Marrow Transplantation Unit, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil; Endocrine Division (SEMPR), Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil.
| | - César Luiz Boguszewski
- Endocrine Division (SEMPR), Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Carmem Maria Sales Bonfim
- Bone Marrow Transplantation Unit, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
| | - Carolina Aguiar Moreira Kulak
- Endocrine Division (SEMPR), Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
| | - Ricardo Pasquini
- Bone Marrow Transplantation Unit, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
| | - Victória Zeghbi Cochenski Borba
- Endocrine Division (SEMPR), Department of Internal Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, Brazil
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Bone mineral deficits in recipients of hematopoietic cell transplantation: the impact of young age at transplant. Bone Marrow Transplant 2013; 49:258-63. [PMID: 24121211 PMCID: PMC3946360 DOI: 10.1038/bmt.2013.156] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/22/2013] [Indexed: 11/21/2022]
Abstract
Low bone mineral density (BMD) has been reported in recipients of
pediatric hematopoietic cell transplantation (HCT), but it is unclear whether
age at HCT plays a role. The objective of this cross-sectional study was to
determine if patients treated with HCT before age 10 years have long-term BMD
deficits compared to patients transplanted at an older age and to sibling
controls. The study included 151 HCT recipients (87 males), age at study
24.7±8.6 years treated with HCT for hematologic malignancies at age
10.9±6.4 years, and 92 healthy sibling controls (49 males), age at study
22.3±8.0 years. Dual-energy x-ray absorptiometry was performed to
measure BMD Z-scores for total body (TBMD), lumbar spine (LBMD), and femoral
neck (FNBMD, for subjects ≥20 years at study visit). Patients <10
years at HCT had significantly lower TBMD and FNBMD Z-scores (by 0.5 and 0.8 SD,
respectively) compared to controls (P=0.003 and
P=0.0001, respectively) and patients >18 years
at HCT (P=0.04 and P=0.004,
respectively) at an average of 14 years after HCT. In conclusion, this study
identified young age at transplant as an important risk factor for bone deficits
in young adulthood, suggesting that efforts to reduce bone loss should focus on
this patient population.
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Hari P, DeFor TE, Vesole DH, Bredeson CN, Burns LJ. Intermittent Zoledronic Acid Prevents Bone Loss in Adults after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2013; 19:1361-7. [DOI: 10.1016/j.bbmt.2013.06.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 06/18/2013] [Indexed: 11/30/2022]
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13
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Dvorak CC, Gracia CR, Sanders JE, Cheng EY, Baker KS, Pulsipher MA, Petryk A. NCI, NHLBI/PBMTC first international conference on late effects after pediatric hematopoietic cell transplantation: endocrine challenges-thyroid dysfunction, growth impairment, bone health, & reproductive risks. Biol Blood Marrow Transplant 2011; 17:1725-38. [PMID: 22005649 DOI: 10.1016/j.bbmt.2011.10.006] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/10/2011] [Indexed: 12/12/2022]
Abstract
The endocrine system is highly susceptible to damage by high-dose chemotherapy and/or irradiation before hematopoietic cell transplantation (HCT) during childhood. The specific endocrine organs most affected by HCT include the thyroid gland, the pituitary, and the gonads. In addition, hormones that support development and stability of the skeletal system are also affected. Insufficiency of thyroid hormone is 1 of the most common late sequelae of HCT, and occurs more often in young children. Deficiency in the pituitary's production of growth hormone is a problem of unique concern to the pediatric population. The reproductive risks of HCT depend on the patient's gender and pubertal status at the time of HCT. Pubertal or gonadal failure frequently occurs, especially in females. Infertility risks for both genders remain high, whereas methods of fertility preservation are limited in all but postpubertal males. Bone health post-HCT can be compromised by low bone mineral density as well as avascular necrosis, but the data on both problems in the pediatric HCT population are limited. In this paper, the current state of knowledge, gaps in that knowledge, and recommendations for future research are addressed in detail for each of these systems.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Blood & Marrow Transplant, University of California San Francisco, San Francisco, California, USA
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Decreased bone mineral density in young adults treated with SCT in childhood: the role of 25-hydroxyvitamin D. Bone Marrow Transplant 2011; 47:657-62. [DOI: 10.1038/bmt.2011.147] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Bone mineral density in adult survivors of childhood acute leukemia: impact of hematopoietic stem cell transplantation and other treatment modalities. Blood 2011; 118:1481-9. [PMID: 21596857 DOI: 10.1182/blood-2011-01-332866] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Femoral and lumbar bone mineral densities (BMDs) were measured in 159 adults enrolled in the Leucémies de l'Enfant et de l'Adolescent program, a French prospective multicentric cohort of childhood leukemia survivors. BMDs were expressed as Z-scores, and multivariate linear regression analyses were used to construct association models with potential risk factors. Mean age at evaluation and follow-up was 23 and 14.7 years, respectively. In the whole cohort, mean femoral Z-score was -0.19 ± 0.08. Two factors were associated with lower femoral BMD transplantation (-0.49 ± 0.15 vs -0.04 ± 0.10 in the chemotherapy group; P = .006) and female sex (-0.34 ± 0.10 vs -0.03 ± 0.13; P = .03). Among patients who received a transplant, the only significant risk factor was hypogonadism (-0.88 ± 0.16 vs -0.10 ± 0.23; P = .04). A slight reduction in lumbar BMD (mean Z-score, -0.37 ± 0.08) was detected in the whole cohort without difference between the transplantation and chemotherapy groups. Among patients who received a transplant, younger age at transplantation was correlated with a low lumbar BMD (P = .03). We conclude that adults who had received only chemotherapy for childhood leukemia have a slight reduction in their lumbar BMD and a normal femoral BMD. Patients who received a transplant with gonadal deficiency have a reduced femoral BMD which might increase the fracture risk later in life.
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Abstract
UNLABELLED Over 4500 hematopoietic stem cell transplants (HSCT) are performed on patients in the United States each year. As HSCT patients shift their survivorship care from large transplant centers to community health care providers, many gynecologists are assuming their pre- and post-HSCT gynecologic care. This article reviews recommendations, current research, and expert opinions on the gynecologic care of HSCT patients. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completing this educational activity, the physician should be better able to implement strategies for the prevention and management of menstrual bleeding during hematopoietic stem cell transplants; educate female patients regarding Fertility Preservation options before hematopoietic stem cell transplantation; and apply posthematopoietic stem cell transplant reproductive care screening and treatment recommendations for bone health, sexual health, and secondary cancer development.
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17
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Efficacy of hormone therapy for osteoporosis in adolescent girls after hematopoietic stem cell transplantation: a longitudinal study. Fertil Steril 2011; 95:731-5. [DOI: 10.1016/j.fertnstert.2010.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 09/09/2010] [Accepted: 09/21/2010] [Indexed: 11/17/2022]
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Prospective assessment of bone turnover and clinical bone diseases after allogeneic hematopoietic stem-cell transplantation. Transplantation 2010; 89:1354-61. [PMID: 20216480 DOI: 10.1097/tp.0b013e3181d84c8e] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bone complications after hematopoietic stem-cell transplantation (HSCT) are relatively frequent. Evaluation of biomarkers of bone turnover and dual energy x-ray absorptiometry (DEXA) are not known in this context. METHODS We prospectively evaluated bone mineral density, biomarkers of bone turnover, and the cumulative incidence of bone complications after allogeneic HSCT. One hundred forty-six patients were included. Bone mineral density was measured by DEXA 2-month and 1-year post-HSCT. The markers of bone turnover were serum C-telopeptide (C-TP), 5 tartrate-resistant acid phosphatase (bone resorption), and osteocalcin (bone formation) determined pre-HSCT and 2 months and 1 year thereafter. Potential association between osteoporosis at 2 months, osteoporotic fracture or avascular necrosis and, individual patient's characteristics and biologic markers were tested. RESULTS C-TP was high before and 2 months after transplant. At 2 months, DEXA detected osteoporosis in more than half the patients tested. Male sex, median age less than or equal to 15 years, and abnormal C-TP before HSCT were risk factors significantly associated with osteoporosis. Three-year cumulative incidences of fractures and avascular necrosis were 8% and 11%, respectively. Children were at higher risk of fracture, whereas corticosteroid treatment duration was a significant risk factor for developing a clinical bone complication post-HSCT. Bone complications and osteoporosis are frequent after HSCT. Bone biologic markers and DEXA showed that subclinical bone abnormalities appeared early post-HSCT. CONCLUSION The risk factors, age, gender, and C-TP easily available at the time of transplantation were identified. Biphosphonates should probably be given to patients with those risk factors.
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Dumas A, Brigitte M, Moreau MF, Chrétien F, Baslé MF, Chappard D. Bone mass and microarchitecture of irradiated and bone marrow-transplanted mice: influences of the donor strain. Osteoporos Int 2009; 20:435-43. [PMID: 18548305 DOI: 10.1007/s00198-008-0658-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 04/24/2008] [Indexed: 10/22/2022]
Abstract
UNLABELLED Total body irradiation and bone marrow transplantation induced dramatic trabecular bone loss and cortical thickening in mice. Transplanted cells were engrafted in bone marrow, along trabeculae, and in periosteal and endosteal envelopes. None of the osteocytes were of donor origin. Bone microarchitecture of transplanted mice changed to tend toward the donor phenotype. INTRODUCTION Osteopenia and osteoporosis are complications of bone marrow transplants (BMT) attributed to related chemotherapy. However, the specific influence of total body irradiation (TBI) is unknown. METHODS We investigated the effects of TBI and BMT on bone mass and microarchitecture by micro-CT. Eighteen C57Bl/6 (B6) mice receiving lethal TBI had a BMT with marrow cells from green fluorescent protein--transgenic-C57Bl/6 (GFP) mice. Transplanted (T(GFP)B6), B6, and GFP mice were euthanized 1, 3, and 6 months after BMT or at a related age. RESULTS T(GFP)B6 presented a dramatic bone loss compared with B6 and did not restore their trabecular bone mass over time, despite a cortical thickening 6 months after BMT. Serum testosterone levels were not significantly reduced after BMT. During aging, GFP mice have less trabeculae, thicker cortices, but a narrower femoral shaft than B6 mice. From 3 months after BMT, cortical characteristics of T(GFP)B6 mice differed statistically from B6 mice and were identical to those of GFP mice. GFP(+) cells were located along trabecular surfaces and in periosteal and endosteal envelopes, but none of the osteocytes expressed GFP. CONCLUSION Our findings suggest that engrafted cells did not restore the irradiation-induced trabecular bone loss, but reconstituted a marrow microenvironment and bone remodeling similar to those of the donor. The effects of irradiation and graft on bone remodeling differed between cortical and trabecular bone.
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Affiliation(s)
- A Dumas
- INSERM, U922, "Remodelage osseux et biomatériaux", LHEA-Faculté de Médecine, 49045 Angers Cedex, France
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20
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Baek KH, Kang MI. Chapter 5 Biomarkers of bone and mineral metabolism following bone marrow transplantation. Adv Clin Chem 2009; 49:99-120. [DOI: 10.1016/s0065-2423(09)49005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Osteoporosis is prevalent in transplant recipients and is related to pre- and post-transplantation factors. Low bone density and fractures may antedate transplantation, related to traditional risk factors for osteoporosis, effects of chronic illness, and end-stage organ failure and its therapy, on the skeleton. Bone loss after transplantation is related to adverse effects of immunosuppressive drugs (glucocorticoids and calcineurin inhibitors) on bone remodeling. Newer immunosuppressive medications may permit lower doses of glucocorticoids and may be associated with decreased bone loss and fractures. Bisphosphonates are currently the most effective agents for the prevention and treatment of post-transplantation osteoporosis.
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Affiliation(s)
- Emily Stein
- Division of Endocrinology, Department of Medicine, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, PH8-864, New York, NY 10032, USA
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Tauchmanovà L, Colao A, Lombardi G, Rotoli B, Selleri C. Bone loss and its management in long-term survivors from allogeneic stem cell transplantation. J Clin Endocrinol Metab 2007; 92:4536-45. [PMID: 17911175 DOI: 10.1210/jc.2006-2870] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Recently, great efforts have been made to understand the pathogenesis of bone loss after allogeneic stem cell transplant (allo-SCT) and possible treatments. EVIDENCE ACQUISITION A literature search of the MEDLINE database was performed to find articles in English using the search terms "allogeneic stem cell transplant" or "bone marrow transplant," in combination with "bone loss," "osteoporosis treatment," "osteoblast," "cytokines," or "osteoprotegerin." Reference lists from the articles retrieved were also evaluated for relevant information. EVIDENCE SYNTHESIS Bone mineral density at the lumbar spine, but not at the femur, can improve or even recover several years after SCT. Multiple risk factors for posttransplant bone loss have been recently identified: abnormalities in the immune system function and their treatments, reduced production of growth factors, osteoclast activation by increased cytokine release, and decreased number and function of osteoblast precursors within the stromal stem cell compartment. Pamidronate was partially successful in preventing posttransplant bone loss, whereas both oral and parenteral bisphosphonates had beneficial effects on documented osteoporosis in long-term survivors. CONCLUSIONS There is clear evidence that transplant-related bone loss is a multifactorial, early, and possibly long-lasting disorder. All patients who have already received allo-SCT should be evaluated as to their bone status and treated with appropriate supportive measures and specific treatments as soon as abnormalities are detected. Although preventive antiresorptive treatments are only partially effective, they should be started in all patients before or at the time of allo-SCT, regardless of their bone mineral density values, and continued at least for the first year after transplant.
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Affiliation(s)
- Libuse Tauchmanovà
- Department of Molecular and Clinical Endocrinology, Federico II University of Naples, via S. Pansini 5, 80131 Naples, Italy.
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High prevalence of early-onset osteopenia/osteoporosis after allogeneic stem cell transplantation and improvement after bisphosphonate therapy. Bone Marrow Transplant 2007; 41:393-8. [PMID: 17994116 DOI: 10.1038/sj.bmt.1705918] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Osteopenia/osteoporosis (O/O) has been associated with allogeneic stem cell transplantation (alloSCT). We retrospectively reviewed 102 patients undergoing a first alloSCT from 2000 to 2005 at our center to evaluate the prevalence of O/O < or =6 and >6 months post-alloSCT. Fifty-six patients did not have a dual energy X-ray absorptiometry (DXA) scan following alloSCT. Approximately half (n=13/27) of those with a first DXA scan < or =6 months post-alloSCT had O/O and a similar rate (n=9/19) was seen in those with a first DXA scan >6 months. There were no significant differences in patient characteristics between the normal and O/O groups. The dual femur (DF) appeared to be more vulnerable to alloSCT-induced bone mineral density (BMD) loss than the lumbar spine (LS), regardless of screening time. O/O patients were treated with bisphosphonates and 41% had a repeat DXA scan post-treatment. No patient developed jaw osteonecrosis and significant BMD improvement was seen at the LS (mean BMD, 1.03+/-0.13 vs 1.08+/-0.12, P=0.004) but not the DF (mean BMD, 0.84+/-0.06 vs 0.85+/-0.08, P=0.29), indicating BMD loss at the DF is more resistant than the LS to antiresorptive therapy. Our results demonstrate that O/O is an early and late complication post-alloSCT and bisphosphonate treatment reverses BMD loss at the LS.
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Taskinen M, Saarinen-Pihkala UM, Hovi L, Vettenranta K, Mäkitie O. Bone health in children and adolescents after allogeneic stem cell transplantation. Cancer 2007; 110:442-51. [PMID: 17549692 DOI: 10.1002/cncr.22796] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This cross-sectional study evaluated the overall bone health and the prevalence of vertebral complications after stem cell transplantation (SCT) in prepubertal children and adolescents. METHODS A total of 44 children and adolescents (median age, 10 years) were evaluated at a median of 3.8 years after SCT for areal bone mineral density (aBMD) with dual-energy X-ray absoptiometry and for vertebral fractures with instant vertebral assessment. Pretransplant and posttransplant medications and nutritional parameters were recorded, and plasma levels of vitamin D, calcium, phosphate, and parathormone were measured. RESULTS Of the 44 patients, 16 (36%) had a BMD Z-score of <-1.0. The patients with low BMD did not differ from the others with regard to their clinical or biochemical characteristics. Prepubertal patients had better BMD Z-scores at all sites compared with pubertal or postpubertal subjects. This was evident especially at the hip, in which the median aBMD Z-score in prepubertal patients (-0.2; range, -0.5 to +1.7) was found to be significantly higher than in pubertal (-1.1; range, -1.5 to +0.4) and postpubertal (-1.1; range, -2.6 to +0.5) patients (P = .03). Five patients (11%) had a history of peripheral fractures. Nine patients (20%) had vertebral compression fractures, which were asymptomatic in 7 patients. CONCLUSIONS Approximately one-third of patients who had undergone allogeneic SCT in childhood were found to have a reduced BMD before reaching adulthood. This was due in part to inadequate BMD gain during the pubertal years. The high prevalence of asymptomatic vertebral compression fractures calls for the systematic assessment of spinal health during the posttransplantation follow-up.
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Affiliation(s)
- Mervi Taskinen
- Division of Hematology-Oncology and Stem Cell Transplantation, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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Taskinen M, Kananen K, Välimäki M, Löyttyniemi E, Hovi L, Saarinen-Pihkala U, Lipsanen-Nyman M. Risk factors for reduced areal bone mineral density in young adults with stem cell transplantation in childhood. Pediatr Transplant 2006; 10:90-7. [PMID: 16499594 DOI: 10.1111/j.1399-3046.2005.00405.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Slightly, but significantly, reduced bone mineral density (BMD) has been detected as a late effect after stem cell transplantation (SCT) performed in childhood. The aim of the study was to evaluate the risk factors of reduced BMD after SCT in childhood. We evaluated areal BMD of 16 young adults (six males, 10 females), aged 21 yr (range 15-34) by dual-energy X-ray absorptiometry at the lumbar spine, at the femoral neck, in the total hip, and in the total body. Bone turnover rate was evaluated by markers of bone formation and resorption. Six of the 16 patients had reduced BMD with a Z-score of < or = -1 at least at one measurement site. Factors associated with reduced BMD were prepubertal status at transplant (p = 0.03), delayed pubertal growth (p = 0.03), pubertal onset gonadal hormone insufficiency (p = 0.02), and female sex (p = 0.02). Surprisingly, height in SDs and lumbar spine BMD correlated negatively (p = 0.008) in those with reduced bone mass, indicating that low areal density could not be due the small size of the vertebrae. Bone turnover markers were similar for those with normal and reduced BMD. In conclusion, 38% of the SCT long-term survivors had reduced areal BMD. Prepubertal status at transplant with pubertal onset gonadal hormone insufficiency and female sex predisposed to reduced bone mass after SCT performed in childhood.
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Affiliation(s)
- Mervi Taskinen
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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Kananen K, Volin L, Laitinen K, Ruutu T, Välimäki MJ. Serum osteoprotegerin and receptor activator of nuclear factor-kappaB ligand (RANKL) concentrations in allogeneic stem cell transplant-recipients: a role in bone loss? Osteoporos Int 2006; 17:724-30. [PMID: 16437190 DOI: 10.1007/s00198-005-0040-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 11/09/2005] [Indexed: 01/06/2023]
Abstract
PURPOSE Osteoporosis is a long-term complication of allogeneic stem cell transplantation (SCT). Receptor activator of nuclear factor-kappaB ligand (RANKL) increases osteoclast activity, while osteoprotegerin (OPG) neutralizes RANKL. A deficiency of OPG or an excess of RANKL may contribute to post-SCT bone loss. METHODS Serum OPG and soluble RANKL (sRANKL) concentrations were determined in 30 patients who received calcium, vitamin D and sex steroids--with or without pamidronate--prior to SCT and 1, 3, 6, and 12 months post-SCT and compared to those in healthy controls. RESULTS Despite all treatments patients lost bone at the hip. At baseline, serum OPG was similar in patients and controls; in the two patient groups it increased by 26-27% at 6 months post-SCT (p=0.002-0.028) and over the control level (p=0.002). Serum sRANKL concentrations were also similar in patients and controls at baseline. In those patients receiving pamidronate sRANKL concentrations decreased by 42% (p=0.0007) at 3 months post-SCT. The findings on the effect of SCT on OPG and sRANKL serum levels were ascertained in 28 additional patients who did not receive pamidronate, at a median of 122 days after SCT. In this latter group, OPG but not sRANKL concentrations were clearly elevated (p<0.001) in comparison to healthy controls. In conclusion, the present study fails to support the view that an excess of sRANKL or a deficiency of OPG would have a substantial impact on bone loss in SCT-recipients. CONCLUSION Serum sRANKL concentrations may be modulated by bisphosphonates.
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Affiliation(s)
- K Kananen
- Division of Endocrinology, Department of Medicine, Helsinki University Central Hospital, 00290, Helsinki, Finland
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Tauchmanovà L, Selleri C, De Rosa G, Esposito M, Di Somma C, Orio F, Palomba S, Lombardi G, Rotoli B, Colao A. Endocrine disorders during the first year after autologous stem-cell transplant. Am J Med 2005; 118:664-70. [PMID: 15922699 DOI: 10.1016/j.amjmed.2005.02.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2004] [Accepted: 11/15/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Frequent endocrine disorders have been reported after allogeneic stem-cell transplant, but data on adult survivors of autologous transplants are still scarce. METHODS In this prospective study we investigated early (at 3 months) and late (at 12 months) endocrine dysfunctions in 95 consecutive autologous stem-cell transplant recipients (47 men and 48 women) aged 16 to 55 years. The functions of the hypothalamic-pituitary-gonadal/thyroid/adrenal/somatotroph axis were evaluated. RESULTS Three months after the transplant, insulin-like growth factor-1 values were below the normal range in 53 patients (56%); 37 of 40 women (93%) of reproductive age experienced precocious ovarian failure; 39 of 46 men (85%) showed high follicular stimulating hormone, and 17 men (37%) showed low testosterone levels. Adrenal insufficiency occurred in 28 patients (30%) during the peritransplant period after corticosteroid withdrawal. Transient subclinical hyperthyroidism was found in 15 patients (16%). Transient "low T(3)" syndrome was revealed in 29 patients (31%). Twelve months after the transplant, insulin-like growth factor-1 values were still low in 36 patients (38%). Menstrual cycles resumed in four women; follicular stimulating hormone, luteinizing hormone, and estradiol levels improved in 10 patients. Testosterone was low in only two men (4%). Seminal analysis revealed azoospermia in 32 (91%) of 35 men examined. Subclinical hypothyroidism was found in 11 patients (12%); eight of them had previously received radiotherapy for the upper half of the body. CONCLUSION This study documents frequent endocrine disorders during the first year after autologous stem-cell transplant. Despite a tendency to improve, in more than half of the cases, the complications persisted for more than 1 year. Therefore, to diagnose and correct early and late endocrine dysfunctions, endocrine screening is required during the first year in all patients undergoing autografting.
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Affiliation(s)
- Libuse Tauchmanovà
- Department of Molecular and Clinical Endocrinology and Oncology, "Federico II" University of Naples, Italy
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Kerschan-Schindl K, Mitterbauer M, Füreder W, Kudlacek S, Grampp S, Bieglmayer C, Fialka-Moser V, Pietschmann P, Kalhs P. Bone metabolism in patients more than five years after bone marrow transplantation. Bone Marrow Transplant 2004; 34:491-6. [PMID: 15286695 DOI: 10.1038/sj.bmt.1704618] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We investigated the bone metabolism of 22 patients (median age 38 years) over 6 years after allogeneic bone marrow transplantation (BMT). Biplanar roentgenograms of the thoracic and lumbar spine were used to diagnose vertebral deformities caused by fractures. The actual bone mineral density (BMD) of the lumbar spine and the femoral neck were measured. Laboratory tests included calcium, phosphate, parathyroid hormone, a marker of bone resorption (beta-crosslaps, CTX), markers of bone formation (osteocalcin, bone-specific alkaline phosphatase), osteoprotegerin (OPG)--antagonist of the osteoclast differentiation factor RANKL, and sex hormone status. One patient had a vertebral fracture. Seven patients (28%) had osteopenia in the lumbar spine while 12 patients (48%) had osteopenia in the femoral neck. Bone resorption was increased in nine patients (43%) and bone formation was increased in four patients (20%). BMT recipients had significantly increased serum levels of OPG (P=0.029). Three women (75%) and four men (25%) were hypogonadal. The data showed that BMD is reduced and bone metabolism is still disturbed more than 6 years after BMT. The RANKL/osteoprotegerin system appears to play an important role in the pathophysiology of late post transplantation osteoporosis.
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Affiliation(s)
- K Kerschan-Schindl
- Department of Physical Medicine and Rehabilitation, University of Vienna, Vienna, Austria
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29
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Abstract
Recipients of stem cell transplantation are at risk for osteopenia and osteoporosis. Longitudinal studies performed in adults have shown that significant bone demineralization occurs following myeloablative therapy and subsequent immune suppression. Among children and adolescents, cross-sectional analyses indicate that younger patients are also at risk for long-term bone toxicity. Strategies to detect and manage this disorder in pediatric SCT recipients are presented.
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Affiliation(s)
- Leonard A Mattano
- Division of Pediatric Hematology/Oncology, Michigan State University/Kalamazoo Center for Medical Studies, Kalamazoo, MI 49007, USA.
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31
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Schulte CMS, Beelen DW. Bone loss following hematopoietic stem cell transplantation: a long-term follow-up. Blood 2004; 103:3635-43. [PMID: 14630805 DOI: 10.1182/blood-2003-09-3081] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
Transplantation-associated bone loss is a well-known phenomenon, however, effects of hematopoietic stem cell transplantation are insufficiently characterized. We conducted a prospective, unicentric, long-term follow-up in 280 patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Bone mineral density (BMD) was measured before transplantation and then yearly for at least 4 years. Patients received vitamin D plus calcium until steroid withdrawal. Mean baseline BMD was normal. We demonstrated significant bone loss with nadir BMD at month 6 for the spine and at month 24 for total body and femoral neck. Average annual bone loss was 0.6% for spine, 0.4% for total body, 2.3% for femoral neck, and 3.5% for Ward triangle. While spine and total body BMD returned to baseline, bone loss at femoral neck sites was attenuated, but BMD did not return to baseline until month 48 (P < .0001 for femoral neck and Ward triangle). Univariate factor analysis of 15 potential risk factors for rapid bone loss revealed a positive correlation of bone loss with steroid and cyclosporine A use, baseline BMD, and loss of muscle mass (overwhelming power of steroid use in multifactor analysis). Such rapid BMD changes probably increase fracture risk consecutive to irreversible microarchitectural changes even if osteodensitometry shows long-term recovery.
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Affiliation(s)
- Claudia M S Schulte
- Department of Bone Marrow Transplantation, University Hospital of Essen, Essen, Germany.
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32
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Daniels MW, Wilson DM, Paguntalan HG, Hoffman AR, Bachrach LK. Bone mineral density in pediatric transplant recipients. Transplantation 2003; 76:673-8. [PMID: 12973107 DOI: 10.1097/01.tp.0000076627.70050.53] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reduced bone mass and fragility fractures are known complications after transplantation in adults. Far less is known about the skeletal effects of transplantation in children and adolescents. METHODS This cross-sectional study examined the skeletal status of children (ages 9-18 years) who were at least 1 year post-cardiac (n=13), post-renal (n=8), or post-bone marrow (BMT; n=15) transplantation. Bone mass at total hip, femoral neck, spine (L2-4), and whole body (WB) was determined by dual energy x-ray absorptiometry and compared with age, sex, and ethnic-specific reference data. Standard deviations (z-scores) were calculated for both areal bone mineral density (BMD) and estimated volumetric bone density (bone mineral apparent density [BMAD]). RESULTS Cardiac transplant patients had significantly lower BMD z-scores compared with the reference population at all skeletal sites. BMT recipients had significantly reduced BMD z-scores at total hip, spine, and WB. Kidney transplant patients had a significantly reduced WB BMD z-score only. Spine BMAD z-scores remained significantly reduced in cardiac and BMT subjects. Three of 36 patients had radiographic evidence of spinal fracture after transplantation. No correlation between steroid dosage and any measure of bone mass was observed. CONCLUSIONS Cardiac and BMT recipients had reduced BMD at multiple skeletal sites, and renal transplant recipients had reduced WB BMD for age. Deficits in spine bone density persisted after correcting for small bone size using BMAD. Low bone density and the occurrence of vertebral fractures indicate that cardiac, renal, and bone marrow transplantation in children is associated with reduced bone health.
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Affiliation(s)
- Mark W Daniels
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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