Table 9.
Musculoskeletal, Connective Tissue, Skeletal, and Dermatologic Complications
| Recommendation | Grade | Ref | Comments |
|---|---|---|---|
| • Routinely evaluate patients on glucocorticoid treatment for glucocorticoid-induced myopathies • Patients with/at risk for steroid myopathy should engage in physical activity and physical therapy |
2A | • Observe patient rising from a squatting position • Physiatry referral may be helpful. • Low resistance exercise to prevent/slow loss of muscle mass |
|
| • cGVHD-associated polymyositis, statin toxicity, or myasthenia gravis should be included in differential diagnosis of myalgia/weakness if persistent or progressive, | 2A | • CPK, aldolase, anti-acetylcholine antibodies are a reasonable next step. If negative, muscle MRI, EMG or muscle biopsy may be considered | |
| • Encourage patients with cGVHD to perform self-assessment of ROM and perform ROM evaluation at each clinic visit | 2A | • Ideally with medical photos for subsequent comparison | |
| • Standard risk patients: DEXA at 1-year post-HCT. If abnormal, repeat every 1-2 years, sooner if ongoing risks, or response assessment. • High risk patients pre-HCT, or post-HCT high-dose glucocorticoids: Obtain DEXA at 3 months post-HCT. |
2B | [211,398–400] | • <5 years old, lumbar spine BMD may be measured. DEXA hip measurements less reliable for age <13 • FRAX and vertebral fracture assessment (VFA) may help evaluation/management |
| • Optimize Ca and vitamin D intake through diet, supplementation. • Recommend regular, weight-bearing exercise. |
2A | • Vitamin D may be measured regularly in those at deficiency risk. | |
| • Consider bisphosphonates in high-risk patients, significant abnormalities on DEXA or FRAX assessments, or fragility fractures. | 2A | [211,401] | • Bisphosphonate choice made with consideration of the patient’s presentation, renal function, and respective adverse events. |
| • For patients with MM, supportive management with use of bisphosphonates for at least 2 years. | 2A | [211,402] | • Such as zoledronic acid and pamidronate |
| • Hormone replacement therapy should be discussed for patients with hypogonadism if age-appropriate, and not otherwise contraindicated (see Endocrine complications). | 2A | ||
| • Routine imaging screening for asymptomatic AVN not indicated. • Maintain a high index of suspicion for AVN in patients with prior AVN, radiation exposure or prolonged glucocorticoids. Those with joint symptoms should be evaluated promptly |
2A | [211] | • Symptomatic patients: non-contrast MRI is the most sensitive way to confirm and stage AVN; Once diagnosis of AVN prompt referral to orthopedic specialist recommended. |
| • Following HCT for Hurler Syndrome, neurologic screening for spinal canal narrowing and carpal tunnel syndrome should be considered | 2A | [403,404] | |
| • Inform patients about risk of dermatological complications, particularly related to cGVHD, medications, and radiation | 2B | • Advise to seek medical attention for non-healing skin lesions, skin tightening or other changes. | |
| • Undergo regular skin self-examination; refer to a dermatologist for further evaluation of suspicious lesions. • Frequency/extent of examination tailored to individual risk factors: prior or present GVHD, sun exposure and radiation history, voriconazole exposure, family history, and history of skin cancer |
2A | [57,80,232] | • Minimum of every 6-12 months for malignancy screening and general examination, including for cutaneous cGVHD based on NIH-criteria. • Regular skin exam involves exposure of all body areas and includes manual palpation to detect sclerosis |
| • Advise to avoid direct sun exposure without appropriate protection: proper clothing, hats, applying UVA/UVB sunscreen to exposed areas | 2A | • Particularly important for patients on immunosuppression, voriconazole, with a history of TBI or skin cGVHD |
Abbreviations: AVN: Avascular Necrosis, BMD: Bone Mineral Density, Ca: Calcium, CPK: Creatine Phosphokinase, DEXA: Dual Energy X-ray Absorptiometry, EMG: Electromyography, FRAX: Fracture Risk Assessment Tool, GVHD: Graft versus Host Disease, MRI: Magnetic Resonance Imaging, MM: Multiple Myeloma, ROM: range of motion, TBI: Total Body Irradiation, UVA: Ultraviolet A, UVB: Ultraviolet B