Long Term Follow-Up Post Allogeneic HSCT
Skeletal System

Updated: October 2010

Osteopenia/Osteoporosis

Osteopenia is a systemic condition characterized by reduced bone mass and increased susceptibility to bone fracture. Osteoporosis is associated with a more significant reduction in bone mass and a greater tendency to bone fracture. The risk of developing either can be related to dose and duration of steroid, cyclosporine/FK 506 use, TBI, inactivity and in women who are hypoestrogenic. As per WHO criteria nearly 50% of all patients have reduced bone density with 10% having osteoporosis 12-18 months post transplant. Nontraumatic stress fractures occur in 10% of patients.

Recommendations:

• Yearly dual photon densimetry in the presence of abnormalities or if the patient is on steroid therapy is recommended.
• Therapy with Calcium, Vitamin D, HRT in women, exercise, and judicious use of corticosteroids can be useful.
• Bisphosphonate therapy (Fosamax 70mg weekly) in osteoporosis can lead to improvement in bone density in the lumbar spine but the benefit to the femoral neck and hence fracture reduction is less clear. Please also assess thyroid hormone function in patients with reduced bone density.

Avascular Necrosis of Bone

The risk of developing avascular necrosis is between 4-10% at median time of 18 months post-transplant. The risk factors include corticosteroid therapy, fractionated TBI>12GY. Patients receiving transplants for ALL and SAA appear to be at a greater risk than those with other disease sub-types. Pain is often the presenting feature with 80% of AVNs occurring at the hip joint and 10% at the knees. AVN of the wrist and ankle bones can also occur. X-ray changes usually occur late. MRI of the relevant joint is the investigation of choice. Joint replacement is warranted in the majority (80%) of patients. Long term follow up of the prostheses is needed in younger patients.

The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use.