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Goals of This Talk:

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Title: Survivorship Issues Author: Michael A. Lew, M.D. Last modified by: CW Student Created Date: 10/17/2000 2:28:09 AM Document presentation format – PowerPoint PPT presentation

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Title: Goals of This Talk:


1
Goals of This Talk
  • Review potential benefits of protons
  • Clinical protocols using protons
  • Review- What have we learned to date?

2
Reasons for BMT in Leukemia
  • Poor prognosis chromosomal abnormalities
  • Prior myelodysplasia
  • Secondary AML
  • Prolonged Induction
  • Relapsing/Refractory Disease

3
Late Effects
  • Cataracts
  • Growth development
  • Fertility sexual function
  • Pneumonitis
  • Veno-occlusive disease
  • Renal damage
  • Psychosocial development
  • Secondary malignancies

4
Late Effects - Cataracts
  • Posterior subcapsular cataract
  • Almost all patients w/ single fraction
  • 18 with fractionated
  • Surgery almost always well tolerated
  • Steroids increase risk

5
Late Effects - Growth Development
  • Endocrine dysfunction
  • growth hormone esp.. poor in those receiving
    prior craniospinal XRT
  • subclinical hypothyroidism in 70
  • subnormal sex steroid concentrations
  • Growth plate damage
  • Seen in chemo only regimens also

6
Late Effects - Fertility Sexual Function
  • gt 95 of males w/ permanent azoospermia
  • no change w/ fractionation
  • Most female patients stop menstruating, but some
    can recover ( 20)
  • Some pregnancies documented

7
Late Effects - Pneumonitis
  • Clinical Symptoms
  • dyspnea
  • fever
  • non-productive cough
  • hypoxia
  • Within 90 days of transplant
  • High mortality

Classical ground glass appearance
8
Late Effects - Pneumonitis
  • Pathology
  • edema and fibrin exudation
  • endothelial hypertrophy
  • thickened alveolar septa

Late Pneumonitis w/ pulmonary fibrosis
9
Late Effects - Pneumonitis
  • TBI
  • Total dose
  • Dose rate
  • Fractionation
  • Infectious
  • CMV
  • Pneumocystis
  • Fungal
  • Disease
  • Malignancy
  • Remission status
  • Original Stage
  • Patient Factors
  • Age
  • Increased wt
  • Male gender
  • CML
  • GVHD
  • Lung XRT
  • Mean Lung Dose
  • V20
  • Previous thoracic irradiation
  • Other Chemo
  • Bleomycin
  • Cytoxan
  • Ara C
  • Busulfan

10
Late Effects - Veno-occlusive Disease
  • Clinical Symptoms
  • sudden weight gain
  • jaundice
  • hepatomegaly
  • ascites
  • high bilirubin
  • Incidence
  • 10 - 20 of patients, 50 mortality

Pathology - obliteration of small vessels More
frequent w/ Busulfan
11
Late Effects - Renal
  • Increase Cr, BUN,
  • Decrease GFR
  • Anemia, HTN, peripheral edema, inc. LDH
  • Increased risk
  • Ara C Amphotericin B
  • GVHD Busulfan
  • TBI dose
  • Cyclosporine

12
Late Effects - 2nd Malignancies
  • Influenced by genetics, chemotherapy (
    alkylating agents)
  • Witherspoon et al (Seattle) reported RR6.69 in
    2246 patients
  • Many B-cell lymphomas, sarcomas
  • Patients with genetic immunodeficiency at higher
    risk (i.e.. Wiskott Aldrich)
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