Damage to bone marrow

Radiation to the bone marrow can affect blood cell production long after treatment ends. The amount of damage depends on the radiation dose and the amount of bone marrow in the radiation field.

Chemotherapy can also cause long-term effects in bone marrow function. Although the blood counts of most survivors return to normal within weeks after therapy ends, a few survivors treated with chemotherapy have problems with low blood counts for years after treatment.

Children who have undergone a stem cell transplant have lowered immune system function for months after treatment. The bone marrow of these children has been destroyed by chemotherapy and/or radiation to allow the healthy marrow or stem cells to grow. Re-establishing the immune function takes time. All stem cell transplant recipients have profound impairment of the immune system for up to a year. Transplant teams give families specific instructions about ways to prevent infections during that time.

Graft-versus-host disease

Graft-versus-host disease (GVHD) occurs when the bone marrow or stem cells provided by the donor (graft) attack the tissues and organs of the child receiving the transplant (host). It is a frequent complication of stem cell transplants when stem cells come from a donor (allogeneic). It does not occur in transplants when stem cells come from the patient’s own body (autologous) or when stem cells come from the patient’s identical twin (syngeneic). There are two types: acute GVHD and chronic GVHD.

Acute GVHD occurs within the first 100 days and chronic GVHD occurs or persists after day 100. Patients can develop one type, both types, or neither one. Approximately 30-50% of survivors who have a related human leukocyte antigens (HLA)-matched transplant develop some degree of GVHD. The incidence and severity of GVHD are increased for children or teens who receive unrelated or mismatched marrow, but are decreased if cells that cause GVHD are reduced prior to infusion. The majority of GVHD cases are mild, although some can be life-threatening.

Chronic GVHD delays the return of normal immune function. Even when survivors with chronic GVHD have normal numbers of T and B cells, they may still be at risk for infection. Up to one-third of survivors with chronic GVHD develop serious, life-threatening infections.

Signs and symptoms of graft-versus-host disease

GVHD primarily affects the following parts of the body:

• Skin (itchy rash, discoloration or tightening of the skin, hair loss)

• Eyes (dryness, light sensitivity)

• Mouth and esophagus (dryness, tooth decay, difficulty swallowing)

• Intestines (diarrhea, cramping, weight loss)

• Liver (jaundice)

• Lungs (shortness of breath, wheezing, coughing)

• Joints (decreased mobility)

• Delayed immune response

Signs and symptoms of infection in those with delayed immune response

Children or teens who underwent autologous stem cell transplants (stem cells from their own body) do not develop GVHD, but they can have a delayed immune response. The signs and symptoms of infection are fevers, sore throat, and shortness of breath, often accompanied by fatigue. However, fatigue by itself is not a symptom of infection.

Chicken pox and/or shingles can pose a threat to life if they are contracted when a child or teen is immunosuppressed.

Screening and detection

Survivors of stem cell transplantations receive a multitude of tests that evaluate immune system function. Your institution will have its own list of tests and schedules, but it should include tests for both immune function and GVHD.

Medical management (after transplant)

Stem cell transplant survivors with GVHD may be treated with corticosteroids (known as steroids and which are used to treat inflammation) and other medications. All stem cell transplant survivors get prophylactic antibiotics (antibiotics given to prevent future possible infection) for at least 6 to 12 months, and those with chronic GVHD continue to take antibiotics until all GVHD therapy has ended. If the survivor has low levels of immunoglobulin G (IgG) (a type of antibody that helps prevent infection), she may get monthly IV IgG until her serum levels are normal for 2 months.

Prior immunizations are no longer effective after stem cell transplantation. Each treating institution has its own schedule for re-immunizing children and teens. Generally, survivors with no GVHD are given inactivated polio, influenza, and DPT (diphtheria-pertussis-tetanus) immunization after the first year. The MMR (measles-mumps-rubella) vaccine is usually given after the second year (survivors with GVHD do not receive the MMR). Find out when you (or your child) should get each immunization and talk with a healthcare provider about ways to avoid exposure to diseases until you are fully immunized. You also need to know how the treating institution manages chicken pox and shingles after a transplant.

Medical management (after treatment for any cancer)