Disorders of immune system in hematology Stomatologic complications of treatment in hematology. Semminar for students E.Faber

Transcription

1 Disorders of immune system in hematology Stomatologic complications of treatment in hematology Semminar for students E.Faber

2 Topics Disorders of immune system in hematology Principles of treatment in hematology and hematopoietic stem cell transplantation Selected aspects of supportive treatment in oncohematology Role of stomatologist in the care for hematologic patients

3 Disorders of immune system in hematology Inherited: CVID, cyclic neutropenia, IgA defficiency, DiGeorge syndrome, Wiskott-Aldrich syndrome, Aquired: malignant leukemias, lymphomas, myeloma, MDS nonmalignant marrow failure, agranulocytosis: idiopathic, drug-related, infectious, systemic collagen diseases,

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5 Principles of treatment in hematology Targeted/biologic treatment: selected conditions Immune/chemotherapy: curative, palliative; induction, consolidation, maintenance; high-dose chemotherapy Hematopoietic stem cell transplantation: marrow regeneration, substitution of malfunctioning stem cell, most efficient immunotherapy of malignancies that are not chemosensitive

6 HSCT vs organ transplantation Donor is a living person (registries) No surgery but conditioning Immune system is transplanted as well graft versus tumour effect Ideally there is no need of life-long immune supression therapy Immune defficiency after HSCT may be prolonged Autologous transplantation

7 Sources of stem cells Cord blood, foetal liver Bone marrow Blood after mobilization (healthy donors) or chemotherapy and stimulation (patients) Autologous freezing (dimethylsulfoxid) remission of disease

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10 Complications after transplantation Autologous (TRM < 5%) the most important problem is relapse of malignancy (purging?) Allogeneic (TRM 20 30%) GVHD, infections, relapse

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13 Components of supportive care Analgesics Anti-vomiting treatment Anti-infection measures Nutrition and venous access Dental care Resuscitation Transfusion therapy and treatment of haemorrhagic diathesis Psychologic support Prevention of long-term consequences

14 Patients at risk After chemotherapy / auto / allogeneic stem cell transplantation due to haematological malignancy High risk: acute leukaemias, allobmt Lower risk: malignant lymphoma, autobmt, solid tumours New: combined and high-dose chemotherapy, cytostatics with higher immunosupressive action, manipulation with graft

15 Risk factors Neutropenia depth 1,0 0,5 0,1x10 9 /l duration <7 14 days and more Lymphopenia deficiency of T4 subset Monocytopenia Hypogammaglobulinemia Disruption of barriers / venous cannulation Afunction of spleen Latent and focal infections

16 Risk factors Katabolism Diabetes mellitus GVHD Immunosupression Admission to the hospital / iatrogenic interventions (antibiotics) Age

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18 Microorganisms G-positive causing 60 70% of infections Staphylococcus aureus, epidermidis Streptococcus pneumoniae, pyogenes, viridující (mitis, oralis, salivarius,..) Enterococcus foecalis, faecium Corynebacterium Stomatococcus mucilag., Bacilus cereus, Rhodococcus equi, Lactobacillus sp.

19 Microorganisms G-negative causing % of infections E. coli, Pseudomonas aeruginosa, Klebsiella sp., Enterobacter sp., Proteus sp., Haemophilus influenzae, Salmonella sp., Acinetobacter sp., Stenotrophomonas maltophilia, Legionella sp., Alcaligenes xylosoxidans, Burkholderia cepacia

20 Microorganisms FUNGI Candida, Aspergilus, Mucor, Zygomycetes VIRUSES CMV, VZV, HSV, Influenza, Adenovirus, RSV PARASITES Pneumocystis carinii, Toxoplasma gondii MYKOBACTERIA

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23 Prophylaxis Hygienic and epidemiologic measures including proper planning of ward construction, isolation of patients, manipulation with infectious material, information of patients, etc. Antibiotic prophylaxis Special prophylaxis at the risk of actual infections (bacteria, viruses, fungi, protozoa) Vaccination

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25 Empiric ATB treatment Various regimens (single ATB, combinations) (parenteral and oral) a significant efficacy was achieved Increasing incidence of microbial resistance MRS, VRE, viridans streptococci, polyresistent G-negative bacteria

26 Empiric treatment Patients at low risk Oral therapy: quinolons / peniciline antibiotics / antimycotics Patients at high risk Parenteral therapy: cephalosporines / piperciline-tazobactame / aminoglycosides / carbapenemes DO NOT use vancomycine within front-line empiric therapy

27 Long-term complications Organ toxicity, GVHD Growth disturbances Deficiencies of inner glands Sexual problems, infertility Psychologic problems Ability to work Secondary malignancies QUALITY OF LIFE

28 Stomatologic intervention in haematologic patient Are you under supervision of haematologist? Bleeding / immune deficiency Haemophilia, aspirin, warfarine!!! Local haemostasis, suture Antibiotic prevention: short-term bactericid penicilin-type antibiotics (until complete healing)

29 Stomatologic care Importance of dentice and oral care for the risk of complication Prevention: eradication of infectious foci, education of proper oral care Occurence of mucositis and its scope generally correlate with other complications and overall survival

30 Stomatologic care New methods (e.g. keratinocyte stimulating growth factor (palifermin) have controversial role Granulocyte numbers in saliva correlates with the course of stomatitis and engraftment

31 Cytostatics with high mucosal toxicity 5-azacytidine 5-fluorouracile Antracyclins BCNU, CCNU Bleomycine Busulphan Cytosin-arabinoside Etoposide Hydroxyurea Methotrexate Prokarbasine Vinblastine

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35 Stomatologic care DIAGNOSIS OF HEMATOLOGIC DISORDER AT DENTIST ELIMINATION OF FOCAL INFECTION ORAL CARE EDUCATION AND PROPHYLAXIS OF COMPLICATIONS