THE CARE OF THE PEDIATRIC PATIENT AFTER HEMATOPOIETIC STEM CELL TRANSPLANTIONBone marrow transplantation is a well-established treatment for acute and chronic leukemias, myelodysplasia, some solid tumors, aplastic anemia, hemoglobinopathies, and congenital immune deficiencies and cytopenias. More recently, transplants have been performed using peripheral blood or umbilical cord blood as the source of stem cells, so the term hematopoietic stem cell transplant (HSCT) will be used in this chapter. The complications that occur after a HSCT depend on multiple factors, including the pretransplant conditioning regimen, human leukocyte antigen (HLA) compatibility of the donor, stem cell source, graft manipulation (e.g., T-cell depletion, or tumor purging), as well as the child’s age, underlying disease, and prior therapy.The conditioning regimen uses high-dose chemotherapy with or without regional or total body irradiation (TBI) and is usually completed in 4-8 days. After the stem cell infusion there is an obligatory period of pancytopenia, which has been shortened, to some extent, by the use of peripheral blood stem cells (PBSCs) and hematopoietic growth factors.Discharge from the transplant center usually occurs when the patient achieves a stable absolute neutrophil count (ANC) 500-1000 neutrophils/pL, has resolved any acute infectious or transplant related complications, and is obtaining adequate nutritional support. At the time of discharge all HSCT patients remain profoundly immunodeficient, especially those who develop graft-versus-host disease (GVHD), and many still require platelet and red cell transfusions. Economic pressures and the increased use of mobilized PBSC have resulted in earlier discharge from the transplant unit. Consequently, general pediatricians and pediatric oncologists who may have limited transplant experience are assuming greater responsibility for the care of these children. Management of the HSCT patient requires an understanding of the complications that can arise at different times after transplant, recognition of these problems, and the early implementation of appropriate therapy.*82\168\2*

Now, what about the symptoms of extensive or metastatic cancer? First of all, there are the local symptoms which depend on which parts of the body are affected. Whichever organs are involved may eventually stop working altogether.

If cancer affects the bones it weakens them. The weak bones break more easily than normal bones. If the spine is affected there may be pressure on the spinal cord or nerves. Such pressure can lead to pins and needles, or loss of strength in the limbs, usually the legs or feet. Cancer in the bones is not always painful. Sometimes one or two spots are painful while others which look very similar on an X-ray are not.

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