Childhood cancer survivors are a growing population with special medical needs. It is projected that 66% of these survivors will have at least 1 adverse health effect and 33% will have a severe, chronic, or lethal health disorder. The Institute of Medicine (2003) has recognized the skeletal system to be at risk for long-term complications from treatment for childhood cancer. Bone marrow transplant is frequently used to treat childhood malignancies and is known to cause skeletal complications. Complex mechanisms contribute to skeletal outcomes after bone marrow transplant, all of which can affect optimal physical functioning. Nurses have taken an important role in providing clinical care and conducting research for this population. A thorough understanding of the mechanisms involved in skeletal complications can help the nurse provide state-of-the-art care and design studies to promote optimal results for bone marrow transplant survivors. This article reviews the literature on skeletal complications associated with allogeneic bone marrow transplant and identifies incidence, etiology, symptoms, monitoring, and treatment of specific complications.
Ades, L., Mary, J.Y., Robin, M., Ferry, C., Porcher, R., Esperou, H., et al. (2004). Long-term outcome after bone marrow transplantation for severe aplastic anemia. Blood, 103, 2490-2497.
2.
Adler, R.A. (2007). Cancer treatment-induced bone loss. Current Opinion in Endocrinology, Diabetes, and Obesity, 14, 442-445.
3.
Arikoski, P., Komulainen, J., Riikonen, P., Voutilainen, R., Knip, M., & Kroger, H. (1999). Alterations in bone turnover and impaired development of bone mineral density in newly diagnosed children with cancer: A 1-year prospective study. Journal of Clinical Endocrinology and Metabolism , 84, 3174-3181.
4.
Athanassiadou, F., Tragiannidis, A., Rousso, I., Katsos, G., Sidi, V., Koliouskas, D., et al. (2005). Evaluation of bone metabolism in children with acute lymphoblastic leukemia after induction chemotherapy treatment. Pediatric Hematology and Oncology, 22, 285-289.
5.
Bath, L.F., Crofton, P.M., Evans, A.E., Ranke, M.B., Elmlinger, M.W., Kelnar, C.J., et al. (2004). Bone turnover and growth during and after chemotherapy in children with solid tumors. Pediatric Research , 55, 224-230.
6.
Bhatia, S., Ramsay, N.K., Weisdorf, D., Griffiths, H., & Robison, L.L. (1998). Bone mineral density in patients undergoing bone marrow transplantation for myeloid malignancies. Bone Marrow Transplantation, 22, 87-90.
7.
Bordigoni, P., Turello, R., Clement, L., Lascombes, P., Leheup, B., Galloy, M.A., et al. (2002). Osteochondroma after pediatric hematopoietic stem cell transplantation: report of eight cases. Bone Marrow Transplantation, 29, 611-614.
8.
Boulad, F., Sands, S., & Sklar, C. (1998). Late complications after bone marrow transplantation in children and adolescents. Current Problems in Pediatrics , 28, 273-297.
9.
Brennan, B.M., Mughal, Z., Roberts, S.A., Ward, K., Shalet, S.M., Eden, T.O., et al. (2005). Bone mineral density in childhood survivors of acute lymphoblastic leukemia treated without cranial irradiation. Journal of Clinical Endocrinology and Metabolism, 90, 689-694.
10.
Brouwer, C.A., Gietema, J.A., Kamps, W.A., de Vries, E.G., & Postma, A. (2007). Changes in body composition after childhood cancer treatment: impact on future health status—A review. Critical Reviews in Oncology andHematology, 63, 32-46.
11.
Children's Oncology Group. (2006). Survivorship Guidelines. Curesearch. Retrieved November 12, 2007, from http://www.survivorshipguidelines.org/ .
12.
Crofton, P.M., Ahmed, S.F., Wade, J.C., Stephen, R., Elmlinger, M.W., Ranke, M.B., et al. (1998). Effects of intensive chemotherapy on bone and collagen turnover and the growth hormone axis in children with acute lymphoblastic leukemia. Journal of Clinical Endocrinology and Metabolism , 83, 3121-3129.
13.
Daniels, M.W., Wilson, D.M., Paguntalan, H.G., Hoffman, A.R., & Bachrach, L.K. (2003). Bone mineral density in pediatric transplant recipients. Transplantation, 76, 673-678.
14.
Enright, H., Haake, R., & Weisdorf, D. (1990). Avascular necrosis of bone: A common serious complication of allogeneic bone marrow transplantation. American Journal of Medicine, 89, 733-738.
15.
Fox, K.R., & Riddoch, C. (2000). Charting the physical activity patterns of contemporary children and adolescents. Proceedings of the Nutrition Society , 59, 497-504.
16.
Frost, H.M., & Schonau, E. (2000). The “muscle-bone unit” in children and adolescents: A 2000 overview. Journal of Pediatric Endocrinology and Metabolism, 13, 571-590.
17.
Goldbloom, E.B., Cummings, E.A., & Yhap, M. (2005). Osteoporosis at presentation of childhood ALL: Management with pamidronate. Pediatric Hematology and Oncology , 22, 543-550.
18.
Gordon, B.G., Warkentin, P.I., Strandjord, S.E., Abromowitch, M., Bayever, E., Harper, J.L., et al. (1997). Allogeneic bone marrow transplantation for children with acute leukemia: Long-term follow-up of patients prepared with high-dose cytosine arabinoside and fractionated total body irradiation . Bone Marrow Transplantation, 20, 5-10.
19.
Groot-Loonen, J.J., van Setten, P., Otten, B.J., van't Hof, M.A., Lippens, R.J., & Stoelinga, G.B. (1996). Shortened and diminished pubertal growth in girls treated for acute lymphoblastic leukaemia. Acta Paediatrica, 85, 1091-1095.
20.
Gunnes, M., Lehmann, E.H., Mellstrom, D., & Johnell, O. (1996). The relationship between anthropometric measurements and fractures in women. Bone, 19, 407-413.
21.
Halton, J.M., Atkinson, S.A., Fraher, L., Webber, C.E., Cockshott, W.P., Tam, C., et al. (1995). Mineral homeostasis and bone mass at diagnosis in children with acute lymphoblastic leukemia. Journal of Pediatrics, 126, 557-564.
22.
Hansen, M.A., Overgaard, K., Riis, B.J., & Christiansen, C. (1991). Role of peak bone mass and bone loss in postmenopausal osteoporosis: 12 year study. BMJ, 303, 961-964.
23.
Harper, G.D., Dicks-Mireaux, C., & Leiper, A.D. (1998). Total body irradiation-induced osteochondromata . Journal of Pediatric Orthopedics, 18, 356-358.
24.
Henderson, R.C., Madsen, C.D., Davis, C., & Gold, S.H. (1996). Bone density in survivors of childhood malignancies . Pediatric Hematology and Oncology, 18, 367-371.
25.
Institute of Medicine. (2003). Childhood cancer survivorship: Improving care and quality. The Washington, DC: National Academy Press.
26.
Jarfelt, M., Fors, H., Lannering, B., & Bjarnason, R. (2006). Bone mineral density and bone turnover in young adult survivors of childhood acute lymphoblastic leukaemia. European Journal of Endocrinology, 154, 303-309.
27.
Kaste, S.C. (2004). Bone-mineral density deficits from childhood cancer and its therapy: A review of at-risk patient cohorts and available imaging methods. Pediatric Radiology, 34, 373-378.
28.
Kaste, S.C., Rai, S.N., Fleming, K., McCammon, E.A., Tylavsky, F.A., Danish, R.K., et al. (2006). Changes in bone mineral density in survivors of childhood acute lymphoblastic leukemia. Pediatric Blood and Cancer, 46, 77-87.
29.
Kaste, S.C., Shidler, T.J., Tong, X., Srivastava, D.K., Rochester, R., Hudson, M.M., et al. (2004). Bone mineral density and osteonecrosis in survivors of childhood allogeneic bone marrow transplantation. Bone Marrow Transplantation, 33, 435-441.
30.
Kaste, S.C., Tong, X., Hendrick, J.M., Karimova, E.J., Srivastava, D.K., Tylavsky, F.A., et al. (2006). QCT versus DXA in 320 survivors of childhood cancer: Association of BMD with fracture history. Pediatric Blood and Cancer, 47, 936-943.
31.
Kelly, J., Damron, T., Grant, W., Anker, C., Holdridge, S., Shaw, S., et al. (2005). Cross-sectional study of bone mineral density in adult survivors of solid pediatric cancers. Pediatric Hematology and Oncology, 27, 248-253.
32.
Kerschan-Schindl, K., Mitterbauer, M., Fureder, W., Kudlacek, S., Grampp, S., Bieglmayer, C., et al. (2004). Bone metabolism in patients more than five years after bone marrow transplantation. Bone Marrow Transplantation , 34, 491-496.
33.
Kroger, H., Vainio, P., Nieminen, J., & Kotaniemi, A. (1995). Comparison of different models for interpreting bone mineral density measurements using DXA and MRI technology. Bone, 17, 157-159.
34.
Ladas, E.J., Sacks, N., Meacham, L., Henry, D., Enriquez, L., Lowry, G., et al. (2005). A multidisciplinary review of nutrition considerations in the pediatric oncology population: A perspective from children's oncology group. Nutrition in Clinical Practice, 20, 377-393.
35.
Lee, W.Y., Kang, M.I., Baek, K.H., Oh, E.S., Oh, K.W., Lee, K.W., et al. (2002). The skeletal site-differential changes in bone mineral density following bone marrow transplantation: 3-year prospective study. Journal of Korean Medical Science, 17, 749-754.
36.
Leung, W., Ahn, H., Rose, S.R., Phipps, S., Smith, T., Gan, K., et al. (2007). A prospective cohort study of late sequelae of pediatric allogeneic hematopoietic stem cell transplantation. Medicine (Baltimore), 86, 215-224.
37.
Loebstein, R., Atanackovic, G., Bishai, R., Wolpin, J., Khattak, S., Hashemi, G., et al. (1999). Risk factors for long-term outcome of ifosfamide-induced nephrotoxicity in children. Journal of Clinical Pharmacology , 39, 454-461.
38.
Marcovici, P.A., Berdon, W.E., & Liebling, M.S. (2007). Osteochondromas and growth retardation secondary to externally or internally administered radiation in childhood. Pediatric Radiology, 37, 301-304.
39.
Marinovic, D., Dorgeret, S., Lescoeur, B., Alberti, C., Noel, M., Czernichow, P., et al. (2005). Improvement in bone mineral density and body composition in survivors of childhood acute lymphoblastic leukemia: A 1-year prospective study. Pediatrics, 116, e102-e108.
40.
Mei, Z., Grummer-Strawn, L.M., Pietrobelli, A., Goulding, A., Goran, M.I., & Dietz, W.H. (2002). Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. American Journal of Clinical Nutrition, 75, 978-985.
41.
Moell, C., Marky, I., Hovi, L., Kristinsson, J., Rix, M., Moe, P.J., et al. (1994). Cerebral irradiation causes blunted pubertal growth in girls treated for acute leukemia. Medical and Pediatric Oncology, 22, 375-379.
42.
Paulino, A.C., & Fowler, B.Z. (2005). Secondary neoplasms after radiotherapy for a childhood solid tumor. Pediatric Hematology and Oncology, 22, 89-101.
43.
Poustchi-Amin, M., Leonidas, J.C., & Elkowitz, S.S. (1996). Simultaneous occurrence of osteosarcoma and osteochondroma following treatment of neuroblastoma with chemotherapy, radiotherapy, and bone marrow transplantation. Pediatric Radiology, 26, 155-157.
44.
Sixou, L., Lassoued, S., Attal, M., Dromer, C., Leguennec, P., Ludot, I., et al. (1995). Symptomatic osteonecrosis in recipients of nonautologous bone marrow transplants. Revue du Rhumatisme (English ed), 62, 359-363.
45.
Socie, G., Cahn, J.Y., Carmelo, J., Vernant, J.P., Jouet, J.P., Ifrah, N., et al. (1997). Avascular necrosis of bone after allogeneic bone marrow transplantation: Analysis of risk factors for 4388 patients by the Societe Francaise de Greffe de Moelle (SFGM). Brirish Journal of Haematology, 97, 865-870.
46.
Steinberg, M.E., Hayken, G.D., & Steinberg, D.R. (1995). A quantitative system for staging avascular necrosis. Journal of Bone and Joint Surgery, British volume, 77, 34-41.
47.
Stern, J.M., Chesnut, C.H., III, Bruemmer, B., Sullivan, K.M., Lenssen, P.S., Aker, S.N., et al. (1996). Bone density loss during treatment of chronic GVHD. Bone Marrow Transplantation , 17, 395-400.
48.
Taitz, J., Cohn, R.J., White, L., Russell, S.J., & Vowels, M.R. (2004). Osteochondroma after total body irradiation: an age-related complication. Pediatric Blood and Cancer, 42, 225-229.
49.
Tauchmanova, L., De, R.G., Serio, B., Fazioli, F., Mainolfi, C., Lombardi, G., et al. (2003). Avascular necrosis in long-term survivors after allogeneic or autologous stem cell transplantation: A single center experience and a review. Cancer, 97, 2453-2461.
50.
Tsuchiya, H., Morikawa, S., & Tomita, K. (1990). Osteosarcoma arising from a multiple exostoses lesion: Case report. Japanese Journal of Clinical Oncology , 20, 296-298.
51.
van Leeuwen, B.L., Kamps, W.A., Jansen, H.W., & Hoekstra, H.J. (2000). The effect of chemotherapy on the growing skeleton. Cancer Treatment Reviews, 26, 363-376.
52.
World Health Organization. (2003). Prevention and Management of Osteoporosis (Rep. No. 921). Geneva: WHO.
