Follow-Up Care


–

Day 100 evaluation

Additional evaluation

Aplastic anemia

Bone marrow biopsy/aspirate for path, flow, and FISH for MDS panel

EBV titers monthly posttransplant × 12 months

–

Chimerismsa

–

–

CBC with diff/chemistry panel

–

–

Reticulocyte count (uncorrected)

–

Acute lymphocytic leukemia (ALL)

Bone marrow biopsy/aspirate path, flow, and cytogenetics with FISH probes for prior abnormalities

–

–

Chimerismsa

–

–

CBC with diff/chemistry panel

–

–

Molecular markers (BCR/abl, TEL) only if previously abnormal

–

–

LP if CNS disease

–

Acute myeloid leukemia (AML)

Bone marrow biopsy/aspirate path, flow and cytogenetics with FISH probes for prior abnormalities

–

–

Chimerismsa

–

–

CBC with diff/chemistry panel

–

–

Molecular markers (FLT3, NPM) if previously abnormal

–

–

LP if history of CNS disease

–

Amyloidosis

Bone marrow biopsy/aspirate path, flow, and cytogenetics, and FISH for myeloma panel

Quantitative immunoglobulins monthly

–

Quantitative serum immunoglobulins

Serum-free light chains monthly

–

SPEP

CBC

–

Serum free light chains

Chem panel

–

CBC with diff/Chemistry panel

TTE every month for 1 year
 
Troponin, BNP, PT/PTT

–
 
TTE

–
 
PFTs if hx of pulmonary involvement

–

Chronic lymphocytic leukemia (CLL)

Bone marrow biopsy/aspirate path, flow, and cytogenetics with FISH for CLL probes only if previously abnormal

–

–

Chimerismsa

–

–

CT scan chest/abd/pelvis if previously abnormal

–

–

CBC with diff/chemistry panel with LDH

–

CML

Bone marrow biopsy/aspirate path, flow, and cytogenetics, with FISH for BCR/abl and any prior abnormalities

Peripheral blood for quant PCR for BCR/abl at 2, 4, 6, 9, and 12 months post transplant, then q3 months during year 2. If PCR negative × 3 measurements, continue annual evaluation

–

Chimerismsa

–

–

Peripheral blood for quant PCR for BCR/abl

–

–

CBC with diff/chemistry panel

–

–

LP if hx of CNS disease

–

Germ cell

CT abdomen/pelvis with contrast

MRI brain

–

CXR

CT abd/pelvis with contrast every 3 months for 1 year, then every 6 months for 1 year

–

MRI brain if positive pre-transplant

AFP, HCG monthly for 1 year, then every 3 months for 1 year

–

Tumor markers (HCG, AFP, LDH)

–

–

CBC with diff/chemistry panel

–

Hodgkin/non-Hodgkin lymphoma

Bone marrow biopsy/aspirate path, and flow with cytogenetics and FISH if previously abnormal (all allogeneic recipients; autologous recipients only if positive pre-transplant)

Aggressive disease (DLBCL, mantle cell, Burkitt, Hodgkin): Repeat laboratory tests and imaging at 3, 6, 12,18, and 24 months post-HSCT

–

Chimerismsa

Indolent disease: Repeat laboratory tests and imaging every 6 months for 2 years

–

CT/PET

–

–

CBC with diff/chemistry panel with serum LDH

–

–

LP if hx of CNS disease

–

Myelodysplastic syndrome

Bone marrow biopsy/aspirate path, flow, and cytogenetics with FISH probes for prior abnormalities

–

–

Chimerismsa

–

–

CBC with diff/chemistry panel

–

Multiple myeloma

Bone marrow biopsy/aspirate path, flow, and cytogenetics with FISH for myeloma panel

CBC, chemistries monthly

–

Chimerismsa

SPEP monthly

–

Quantitative serum immunoglobulins

Quantitative immunoglobulins monthly

–

SPEP

–

–

Serum-free light chains

Serum-free light chains monthly

–

24-h urine for creatinine and protein

–

–

CBC with diff/chemistry panel

–

–

Bone survey

–


FISH fluorescent in situ hybridization, MDS myelodysplastic syndrome, CBC complete blood count, EBV Epstein–Barr virus, LP lumbar puncture, CNS central nervous system, SPEP serum protein electrophoresis, BNP B-type natriuretic peptide, TTE transthoracic echocardiogram, PFTs pulmonary function tests, PCR polymerase chain reaction, DLBCL diffuse large B cell lymphoma

aallogeneic recipients only




 





 






2.

Allogeneic HSCT:



a.

Follow-up in clinic twice weekly after discharge through day + 50–60, then weekly through day + 100. Visits may occur more frequently for patients with complications.

 

b.

After day + 100, patients may be seen at least every 1–2 weeks for 6 months, then monthly. Visits may occur more frequently for patients with chronic graft-versus-host disease (cGVHD) or other post-HSCT complications.

 

c.

All allogeneic HSCT recipients should be checked thoroughly for signs and symptoms of GVHD at every follow-up visit.

 

d.

Restaging studies may be completed between days + 80 and + 100 with future restaging based upon the patient’s primary disease (see Table 15.1).

 

e.

Generally, around day + 100, the patient returns to their primary oncologist:



i.

At the time of transfer of care, complete documentation should be shared to assure continuity of care.

 

ii.

Depending on the distance to the patient’s home, visits are often shared with the local care provider. This approach is particularly helpful for patients with cGVHD.

 

iii.

If the patient is unable to travel to the transplant center, thorough communication with the local oncologist is essential.

 

 

 

3.

Cord blood HSCT:



a.

Follow-up in clinic twice weekly through day + 50–60, then weekly through day + 100.

 

b.

Visits may occur more often for patients with post-HSCT complications.

 

c.

After day + 100, patients may follow-up at least every 1–2 weeks for 6 months, then monthly.

 

d.

Visits should occur more frequently for patients with cGVHD or with other post-HSCT complications.

 

e.

All patients should be thoroughly assessed for signs and symptoms of GVHD at every follow-up visit.

 

f.

Restaging studies may be completed between days + 80 and + 100 with future restaging based upon the patient’s primary disease (see Table 15.1).

 

g.

Generally, around day + 100, the patient returns to their primary oncologist:



i.

At the time of transfer of care, complete documentation should be shared to assure continuity of care.

 

ii.

Depending on the distance to the patient’s home, visits are often shared with the local care provider. This approach is particularly helpful for patients with cGVHD.

 

iii.

If the patient is unable to travel to the transplant center, thorough communication with the local oncologist is essential.

 

 

 

4.

Laboratory and radiologic studies:



a.

Autologous HSCT:



i.

Complete blood count (CBC) with differential twice weekly until stable, then weekly through day + 30, then at each follow-up visit .

 

ii.

Complete chemistry profile that includes magnesium, lactate dehydrogenase (LDH), and renal and liver function tests twice weekly until stable, then weekly through day + 30; reassess at each follow-up visit.

 

iii.

Consider assessment of immunoglobulin G (IgG) levels in patients experiencing repeated infections.

 

iv.

Cytomegalovirus polymerase chain reaction (CMV PCR) in patients with CD34-selected HSCT procedures.

 

 

b.

Myeloablative allogeneic HSCT:



i.

CBC with differential twice weekly through day + 56, then weekly if clinically appropriate through day + 100. Frequency after day + 100 is dictated by the patient’s clinical status.

 

ii.

Complete chemistry profile that includes renal and liver function studies, LDH, electrolytes and magnesium twice weekly through day + 56, then weekly if clinically appropriate through day + 100. Frequency after day + 100 is dictated by the patient’s clinical status.

 

iii.

CMV by PCR weekly through day + 100 in seropositive recipients or if the donor is seropositive; monthly in seronegative recipients with seronegative donors (see Chap. 10 for additional CMV monitoring recommendations).

 

iv.

Consider surveillance blood cultures weekly while the patient is receiving prednisone ≥ 10 mg/day and has an indwelling catheter. Positive surveillance cultures in asymptomatic patients should be repeated before initiation of antibiotic therapy (see Chap. 17 for additional therapy guidelines).

 

v.

Galactomannan assays weekly through day + 100 for patients receiving fluconazole prophylaxis.

 

vi.

IgG levels every other week through day + 100. Intravenous immunoglobulin (IVIG) should be administered per institutional replacement guidelines. If GVHD is present, consider continued monitoring with IVIG replacement per institutional replacement guidelines.

 

vii.

Calcineurin inhibitor (CNI) troughs twice weekly and prn through day + 60. Levels may then be assessed weekly while targeting therapeutic trough levels. CNI levels may be discontinued on initiation of taper:

 





  • If the patient is enrolled on a clinical trial, trough goals may be determined by the protocol.


  • If the patient is not on clinical trial, trough goals are determined institutionally.


  • An example of a common trough goal is 200–250 ng/dL for cyclosporine and 5–10 ng/dL for tacrolimus. Of note, these blood levels are trough goals (blood drawn approximately 12 h after the last dose).



viii.

Immune reconstitution panels for humoral and cellular immunity may be evaluated at days + 28, + 56, + 100, and + 180, then at 1 year, and annually through 5 years or until reconstitution complete.

 

 

c.

Nonmyeloablative transplant (outpatient setting):



i.

For patients enrolled on a clinical trial, laboratory studies should be drawn per study protocol. For patients not receiving care on a clinical trial, consider:

 





  • CBC with differential daily until nadir is reached and ANC returns to > 500/mm3. If the patient’s absolute neutrophil count (ANC) does not fall below 500/mm3, daily CBCs continue until there is a clear increase of ANC × 2 consecutive days. After daily CBCs are no longer required, monitor CBCs three times weekly until day + 28.


  • Chemistry profile that includes renal and liver function studies, LDH , electrolytes, and magnesium three times weekly until day + 28, then weekly through day + 100.


  • CMV by PCR weekly through day + 100 in seropositive recipients or if the donor is seropositive; monthly in seronegative recipients with seronegative donors (see Chap. 10 for additional CMV monitoring recommendations).


  • If the patient has GVHD and requires steroid therapy, surveillance blood cultures can be considered weekly as long as the patient is receiving prednisone ≥ 10 mg/day and has an indwelling catheter. Consider repeating cultures prior to initiation of antibiotic therapy in asymptomatic patients (see Chap. 17 for additional therapy guidelines).


  • Galactomannan assays weekly through day + 100 for patients receiving fluconazole prophylaxis.


  • IgG levels every other week through day + 100. IVIG should be administered per institutional replacement guidelines . If GVHD is present, consider continued monitoring with IVIG replacement per institutional replacement guidelines.


  • CNI trough levels twice weekly until day + 56, then discontinued if patient begins a drug taper. Therapeutic CNI trough levels are typically determined by protocol:


  • A common standard cyclosporine trough goal is 300–400 ng/dL through day + 28 and then 250–350 ng/dL from day + 28–56.


  • 5–10 ng/dL for tacrolimus.


  • Of note, these blood levels are trough goals (blood drawn approx 12 h after the last dose).



ii.

Peripheral chimerisms may be drawn on days + 28, + 56, + 84, + 180, at 12 months, 18 and 24 months, then annually for 5 years.

 

iii.

Immune reconstitution panels for humoral and cellular immunity may be evaluated at days + 28, + 56, + 100, and + 180, then at 1 year, and annually through 5 years or until reconstitution complete.

 

iv.

Bone marrow aspirate/biopsy can be done on varying schedules:

 





  • One example includes procedures on days + 56 and + 84, then at 6 months, 12 months, 18 months, 2 years, and then annually through year 5.



5.

Other follow-up studies are determined by disease state (see Table 15.1).

 

 

d.

Cord blood transplants:



i.

For patients enrolled on a clinical trial, laboratory studies should be drawn per study protocol . For patients not receiving care on a clinical trial, consider:

 





  • CBC with differential daily until ANC returns to > 500/mm3. After daily CBCs are no longer required, check CBC twice weekly until day + 28, then weekly through day + 100


  • Chemistry profile that includes renal and liver function studies, LDH, electrolytes, and magnesium three times weekly until day + 28, then weekly through day + 100.


  • Viral testing should include CMV by PCR and Epstein–Barr virus (EBV) by PCR weekly and human herpes virus 6 (HHV6) every 2 weeks until day + 100 (see Chap. 10 for additional viral monitoring recommendations).


  • If the patient has GVHD and requires steroid therapy, surveillance blood cultures can be considered weekly as long as the patient is receiving prednisone ≥ 10 mg/day and has an indwelling catheter. Consider repeating cultures prior to initiation of antibiotic therapy on asymptomatic patients.


  • Galactomannan assays weekly through day + 100 for patients receiving fluconazole prophylaxis.


  • IgG levels every other week through day + 100. IVIG should be administered per institutional replacement guidelines. If GVHD is present, consider continued monitoring with IVIG replacement per institutional replacement guidelines .


  • CNI trough levels twice weekly until day + 56, then weekly until the patient begins a drug taper :

 



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Jun 23, 2017 | Posted by in HEMATOLOGY | Comments Off on Follow-Up Care

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