In order to help children with blood diseases return to campus safely and safely, in September, Gaobo Medical Group launched a series of science popularization live broadcast activities, bringing together authoritative experts in various fields of the industry to provide professional and reliable science knowledge! In order to increase the accessibility of patients, the wonderful content of the live broadcast is compiled into a text, and there are many forms of presentation such as playback, welcome everyone to pay more attention!
At the beginning of September, primary and secondary schools across the country have opened and returned to school, and children with blood diseases are no exception. However, after the treatment of children with blood diseases, regular follow-up is needed to monitor and control the condition, and how to return to school safely is a special concern for children and parents.
In order to help the children return to campus more smoothly and with peace of mind, Wu Tong, director of Beijing Boren Hospital of Gaobo Medical (Blood Disease) Beijing Research Center, and Dr. Li Zhizhi shared a special lecture on "What are the precautions for children with leukemia to return to campus".
<h1 class="pgc-h-arrow-right" data-track="7" what are > the main factors that affect the return of children to school after transplantation? </h1>
Dr. Li Zhizhi stressed that the primary factor for children to return to school is to carry out psychological construction - the mentality of sunshine and positive energy is very important, not only the child, but also the whole family must pass on to the child an optimistic, positive and upward mentality and emotions.
Secondly, Dr. Li Zhizhi pointed out that the ultimate goal of leukemia treatment is to return to normal study and life. Another major factor in the decision to return to school is that the child's immune function is basically or completely back to normal.
What are the main observation indicators of immune function recovery?
After treatment, 6 months, 9 months, one year and one and a half years, the hospital should be sent to the hospital for relevant tests of immune function recovery, including blood routine, lymphocyte subsets and specific proteins.
Blood routine: pay attention to the recovery of white blood cells, hemoglobin and platelets, especially whether the values of neutrophils and lymphocytes are in the normal range;
Lymphocyte subset: whether the proportion of CD19 B cells, T cells, and NK cells is normal;
Six specific proteins: immunoglobulins are detected, which can affect immunoglobulin levels if B cells are poorly developed, and high IgE values may indicate chronic graft-versus-host disease (cGVHD), but mild illness does not affect return to school.
Another concern: How long does it take for immune function to recover?
Dr. Li Zhizhi pointed out:
In general, the immune function of children with chemotherapy begins to recover 3-6 months after stopping chemotherapy drugs, and most children basically return to normal after stopping drugs for one year; immunotherapy is more special, and most children who have received rituximab recover immune function at 6 months after the last rituximab treatment; in children treated with CAR-T, the time of immune function recovery is related to the duration of CAR-T, and most of them begin to recover more than a year after CAR-T return After transplantation, it is possible for children to start recovering about 1 year after transplantation depending on the use of immunosuppressants.
There are also parents who are more concerned about the problem of vaccination
Dr. Li Zhizhi explains:
Many schools have requirements for vaccination, first of all, to clarify that vaccines can be divided into inactivated vaccines, live attenuated vaccines and so on. For children with good B cell function, try to start with inactivated vaccines and not get live attenuated vaccines first. For children whose B cell function and T cell function have been restored, they can first be vaccinated with inactivated vaccines, and if there is no obvious adverse reaction, they can then be vaccinated with live attenuated vaccines. For children who have just finished treatment, due to low immune function, vaccination should be suspended, especially live attenuated vaccines, so as not to cause serious side effects.
Whether your child can be vaccinated should also be carefully decided after consulting the attending physician for advice.
In addition, Dr. Li Zhizhi concluded: it is recommended that the child should be at least one year after transplantation, and then consider going to school after the immune function is basically restored; the basic principle of diet is still clean, fresh and hygienic, avoid buying finished products and semi-finished products from supermarkets, and must pay attention to the problem of intestinal infection during chemotherapy, avoid cold and spicy and various drinks; pay attention to wearing masks when going to school to avoid cross infection; physical education classes need to reduce strenuous exercise, choose suitable exercise according to their own situation, such as skin cGVHD patients to avoid daylight exposure; vaccination needs to think twice , relevant examinations should be improved and fully communicated with the competent doctor.
<h1 class="pgc-h-arrow-right" Data-track="34" How to follow up after transplantation >? </h1>
After school, you still need to follow the doctor's instructions
Follow-up to the hospital mainly includes the following items:
Blood routine, biochemical kit, viral testing, monitoring of plasma concentrations (eg, patients taking cyclosporine, tacrolimus, voriconazole, posaconazole).
Lymphocyte subsets and immunoglobulin monitoring are important indicators for detecting the recovery of immune function.
Regularly review bone wear and waist wear. Bone puncture: 1-2 years after transplantation, review every three months, more than two years after transplantation, every six months; the interval between lumbar punctures is longer than bone puncture, which can be carried out once a year or once a year according to the situation, mainly to assess the disease state and whether to achieve complete remission.
In addition, chest CT, lung function, heart examination, blood hormone level examination, etc. are also required according to the situation. Dr. Li Zhizhi stressed that chest CT examination can detect lung lesions such as lung GVHD in children as soon as possible, and timely intervention and symptomatic treatment can avoid deterioration of the condition.
After transplantation, the monitoring of small residual lesions (MRD) and maintenance therapy are also required, and MRD detection methods include flow cytometry, fusion gene quantification, and second-generation sequencing (NGS).
Flow cytometry is the most common method for detecting MRD, and it is capable of detecting levels of 10-4 levels. The more sensitive NGS and fusion gene quantification methods can detect levels of 10-6 levels.
However, the quantitative detection of fusion genes is not suitable for all children, the method is limited to a small number of patients with fusion genes, according to the recommendations of the European Leukemia Network (ELN), the expression of WT1 should not be used as a marker for MRD; the expression of FLT-ITD, FLT-TKD, NRAS, KRAS, DNMT3A, ASXL1, IDH1, IDH2, MLL-PTD and EV1 can not be used as a marker for MRD alone; NPM1, RUNX1, TP53, IKFZ1 gene mutations and IgG/TCR gene rearrangements can be used as markers for MRD; cloning hematopoietic-related gene mutations can also be seen in normal elderly people and are therefore not suitable as markers for MRD.
<h1 class="pgc-h-arrow-right" data-track="50" what should be paid attention to after transplantation > different types of diseases? </h1>
Blood system disease transplantation is mainly divided into benign diseases and malignant diseases.
1. Benign diseases:
Aplastic anemia should pay attention to the concentration of cyclosporine or tacrolimus to maintain within the effective range within 9 months, early drug reduction too quickly may lead to poor blood picture growth, late remediation effect is not good;
Pay attention to GVHD and plasma EBV DNA quantification after transplantation of hemophagocytic syndrome, and if the viral copy number is quantitatively monitored according to whole blood EBV DNA, it will lead to overtreatment.
2. Malignant diseases:
After transplantation of relapsed refractory acute B-lymphoblastic leukemia after BRID transplantation after CAR-T, pay attention to the primary disease, GVHD manifestations, and the recovery of B-cell immune function;
Attention to the occurrence of infection after transplantation of relapsed refractory T hematologic malignancies after BRID transplantation after CAR-T.
<h1 class="pgc-h-arrow-right" data-track="63" > live Q&A session</h1>
Q1. Do children need to wear masks all the time during school? Can I eat in the school cafeteria?
Director Wu Tong: First of all, during the current COVID-19 epidemic, children should still wear masks in public. In the autumn and winter seasons when respiratory tract infections are frequent, it is recommended to wear a mask to reduce the chance of respiratory infections.
In addition, school canteen meals need to pay attention to eating fresh and clean food after full heating; avoid eating cold vegetables, pickles, do not drink drinks, and drink disinfectant and sterilized water.
Q2. After the child returns to school, what do I need to pay attention to in sports?
Director Wu Tong: After the child returns to school, the physical activity should gradually increase, such as starting from gymnastics, walking, physical strength needs to be gradually restored after transplantation, and strenuous sports such as sprinting and vaulting should be avoided in the early stage.
In addition, pay attention to osteoporosis, heart function and other issues, and some post-transplant children, such as the presence of pulmonary GVHD, may occur shortness of breath after activity, due to organ limitations to reduce oxygen consumption, this part of the patient can not exercise strenuously. Exercise is helpful for the child's recovery and mood, and children should be encouraged to do some activities within their ability, such as gymnastics, walking, etc.
Q3. Will leukemia treatment affect the menstrual and reproductive function of female children?
Director Wu Tong: During the myelosuppressive phase of chemotherapy, such as when platelet values are low, clinicians may intervene in the child's menstrual cycle to reduce the risk of major bleeding. When the blood picture returns to normal, the medication is stopped and no intervention is made. Treatment of benign diseases, such as aplastic anemia using a non-myeloablative pretreatment regimen, does not affect menstruation, and most patients can recover menstruation on their own after immunosuppressants are discontinued.
However, if the treatment of malignant blood disease, such as the use of pulp clearing pretreatment regimen, will affect the level of sex hormones, menstruation is difficult to recover on its own. I will recommend this part of the patients to go to the obstetrics and gynecology department, detect hormone levels, B ultrasound, etc., by the guidance of professional doctors to form an artificial menstrual cycle, hormone levels close to the same age, hair, skin, bone, muscle, physical strength including sleep, appetite will have a significant improvement.
Q4. Do I need to eat health supplements that increase my resistance during maintenance treatment?
Director Wu Tong: First of all, we must emphasize a balanced diet, eat a good meal, and various nutrients can naturally be supplemented. Meat, fruits, vegetables, staple foods should be eaten. Some children have partial food or insufficient food intake, relying on health supplements or nutritional supplements, we do not advocate. The ingredients of health care products are not particularly clear, and after eating, they will disrupt the child's normal eating habits.
First of all, eat three meals well, this is the most important. In particular, some health care products may have hormones or iron supplements, and children with blood diseases may be infused with red blood cells multiple times during treatment, and then iron supplementation, iron overload may occur but it is not good.
Q5. Can children with light or slow row go to school?
Director Wu Tong: The existence of mild rejection or slow excretion is not a factor that restricts the return of children to school, most children can return to normal or close to normal levels 1-2 years after transplantation, immunosuppressants have been stopped or only need to take maintenance amounts, such as hormone dosage of less than three tablets or tacrolimus dosage of less than 0.1 mg, in this case, children can consider returning to school.
Q6. Do I need to drink Chinese medicine to condition my body after transplantation?
Dr. Li Zhizhi: Since the specific composition of Chinese medicine is not clear and some Chinese medicines are immunomodulators, which deviate from the purpose of children taking immunosuppressants after transplantation, it is usually not recommended to take Chinese medicine preparations for children who are generally in good condition and stable condition. In addition, it is not recommended that patients eat cordyceps supplements casually.
Q7. Can I eat seafood during the maintenance stage of chemotherapy?
Dr. Li Zhizhi: I personally do not recommend eating seafood, seafood is more likely to cause allergies, in addition, if the cleaning process is not clean, it is easy to cause intestinal infections, diarrhea and other problems.
Finally, Director Wu Tong made the following summary:
It is recommended that the child return to school 1-2 years after transplantation, without active infection, no obvious rejection response, immune function, normal or near-normal blood picture.
In terms of diet, pay attention to eating clean and fresh food after full heating.
Pay attention to wearing a mask to prevent respiratory infections; if there is a flu situation in the class in winter, it is recommended to rest at home for a short time to avoid the high incidence of influenza.
It is recommended to consider vaccination with inactivated vaccine after one year of transplantation when immune function returns to normal; two years after transplantation, stop immunosuppressants, and consider vaccinating live attenuated vaccine after immune function is completely normal; specifically consult a managing doctor.
Follow-up after transplantation is very important, for patients with hematologic malignancies, more than 5 years without recurrence can become cured; in the first three months after transplantation, an assessment of the primary disease is done every month; during the period of three months to two years after transplantation, it is recommended to do an assessment of the primary disease every three months, and for patients who are particularly high-risk and prone to recurrence, shorten the follow-up interval according to the situation; in addition to the assessment of the primary disease, the evaluation of immune function is also required.
In addition, pay attention to the quality of life of the child such as oral teeth, eyes, cardiopulmonary function, and endocrine level health.
"I have been doing blood disease transplants for more than 30 years, and many of my former patients have now graduated from college, worked, married and had children, so we not only have to treat diseases, but also return to normal life, which is the purpose of our doctors." I hope every child cheers up, and I look forward to everyone's good news. Director Wu Tong finally said.
Expert introduction: Wu Tong
Director Wu Tong
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Director of the Department of Hematopoietic Stem Cell Transplantation, Beijing Boren Hospital, Beijing Research Center of Gaobo Medicine (Blood Diseases), and Medical Director.
He is a member of the Academic Committee of the Asia-Pacific Bone Marrow Transplantation Society, a member of the Standing Committee of the Hematology and Tumor Professional Committee of the Chinese Anti-Cancer Association, the deputy leader of the Hematopoietic Stem Cell Transplantation and Cell Therapy Group, and the vice chairman of the Targeted Professional Committee of the Association of Women Physicians.
Graduated from the Department of Medicine, Beijing Medical University (now Peking University Health Science Center). From 1986 to 2006, he served as a resident, attending physician and deputy chief physician in the Institute of Hematology of Peking University People's Hospital, engaged in the diagnosis and treatment of blood diseases, and his main field of work since 1987 was hematopoietic stem cell transplantation. From 2006 to 2012, he served as the director of the Hematopoietic Stem Cell Transplant Department in Beijing Daopei Hospital. From 2012 to 2015, he served as the deputy director of Lu Daopei Hematology and Oncology Center and the director of the Hematopoietic Stem Cell Transplantation Department of Hebei Yanda Hospital. From 2015 to April 2017, he served as the vice president of Hebei Yanda Ludaopei Hospital and the director of the hematopoietic stem cell transplantation department.
Since May 2017, he has been the director of the Hematopoietic Stem Cell Transplant Department and the vice president of medical treatment of Beijing Boren Hospital. In 1994, he studied virology at the Institute of Virology, Chinese Academy of Medical Sciences. From 1996 to 2000, he was a postdoctoral fellow at the Institute of Cardiopulmonary And Blood at NIH (National Institutes of Health), mainly focusing on hematopoietic stem cell gene therapy.
He has been engaged in hematopoietic stem cell transplantation for more than 30 years and is an internationally renowned hematopoietic stem cell transplant expert. There are thousands of transplants with unique successful experiences in the choice of transplantation methods, the treatment of severe graft-versus-host disease (GVHD) and infection, the transplantation of refractory/relapsed leukemia and the prevention and treatment of recurrence after transplantation, the immunotherapy after transplantation (for leukemia, viruses, fungi), the transplantation of senile leukemia, cart bridging transplantation, etc. He has published more than 90 papers and spoken dozens of times at international conferences.
He is a member of the Hematology Branch of the Chinese Medical Association, a member of the American Society of Hematology, a member of the International Society of Haematology, a member of the Asia-Pacific Bone Marrow Transplantation Society (APBMT) and a member of the Academic Committee, a member of the Standing Committee of the Hematology and Tumor Professional Committee of the Chinese Anti-Cancer Association and the deputy leader of the Hematopoietic Stem Cell Transplantation and Cell Therapy Group, a vice chairman of the Targeted Professional Committee of the Association of Women Physicians, a member of the Standing Committee of the Blood Professional Committee of the Association of Women Physicians, and a member of the Integrated Hematology Professional Committee of the Integrative Medicine Branch of the Chinese Medical Doctor Association. He is a member of the editorial boards of the Chinese Journal of Hematology, Hematology/Oncology and Stem Cell Therapy, and Blood Chinese Edition.
He has won the Outstanding Teacher Award, the Second Prize of English Teaching, the Second Prize of Chinese Medical Science and Technology Progress Award, the First Prize of Beijing Science and Technology Progress Award, the Second Prize of Science and Technology Progress Of the General Logistics Department of the People's Liberation Army, the APBMT Top Ten Paper Award and the Outstanding Speech Award.
Expert introduction: Li Zhizhi
Dr. Lee
Gao Bo Medical (Blood Disease) Beijing Research Center Beijing Boren Hospital Hematology Department II (Transplant Technology) Ward 3, Deputy Chief Physician, Doctor of Medicine
He is a member of the Clinical Application Committee of Pharmaceutical Biotechnology of China Association of Pharmaceutical Biotechnology, and a member of the Hematology and Tumor Professional Committee of China Anti-Cancer Association.
Published several SCI articles in journals such as Bone Marrow Transplant, Leukemia & lymphoma, Journal of Pediatric Hematology/Oncology, etc
Several times in the United States Blood Annual Meeting ASH, European Blood Annual Conference EHA, European Bone Marrow Transplant Annual Conference EBMT, Asia-Pacific Bone Marrow Transplant Annual Conference APBMT and other international hematology conferences and poster exchanges.
He has extensive experience in the treatment of hematopoietic stem cell transplantation (HSCT) in the treatment of leukemia, MDS, lymphoma, aplastic anemia, hemophagocytic syndrome and other diseases and transplant comorbidities.