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Hosokawa Y, Toubai T, Ohya K, Nagano Y, Ishizawa Y, Hosokawa M, Sato R, Watanabe S, Yamada A, Suzuki T, Aizawa K, Ito S, Onozato Y, Peltier D, Ishizawa K. Exocrine Pancreatic Insufficiency Possibly Related to Atypical Chronic Graft-versus-Host Disease. Case Rep Oncol 2023; 16:857-862. [PMID: 37900836 PMCID: PMC10601733 DOI: 10.1159/000533381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/29/2023] [Indexed: 10/31/2023] Open
Abstract
We report the case of a 66-year-old woman who presented with diarrhea and weight loss approximately 14 months after unrelated allogeneic bone marrow transplantation for acute myeloid leukemia. Her early post-transplant course was notable for mild acute skin graft-versus-host disease (GVHD) and biopsy-proven upper gastrointestinal (GI) acute GVHD, both of which resolved with treatment. She then developed weight loss and diarrhea treated with prednisolone for what was thought to be GI late acute GVHD. However, her diarrhea and weight loss persisted. Colonoscopy showed a grossly intact mucosa, and stool studies only confirmed steatorrhea. However, an atrophic pancreas was found on an abdominal computed tomography (CT) scan. Exocrine pancreatic enzymes, such as lipase and pancreatic amylase, were markedly decreased, yet pancreatic endocrine function remained intact. The patient's diarrhea and weight loss improved upon treatment with pancrelipase. Therefore, we suggest that her exocrine pancreatic insufficiency was likely partly caused by atypical chronic GVHD.
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Affiliation(s)
- Yuka Hosokawa
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tomomi Toubai
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Koichi Ohya
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yusuke Nagano
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yuki Ishizawa
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Masashi Hosokawa
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Ryo Sato
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Shotaro Watanabe
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Akane Yamada
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Takuma Suzuki
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Keiko Aizawa
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Satoshi Ito
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yusuke Onozato
- Department of Internal Medicine II, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Daniel Peltier
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Herman B. Wells Center for Pediatric Research, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenichi Ishizawa
- Division of Hematology and Cell Therapy, Department of Internal Medicine III, Yamagata University Faculty of Medicine, Yamagata, Japan
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Okada Y, Nakasone H, Nakamura Y, Kawamura M, Kawamura S, Takeshita J, Yoshino N, Misaki Y, Yoshimura K, Matsumi S, Gomyo A, Tanihara A, Tamaki M, Kusuda M, Kameda K, Kimura SI, Kako S, Oyama-Manabe N, Kanda Y. Pancreatic atrophy and recovery after allogeneic hematopoietic cell transplantation. J Gastroenterol 2022; 57:571-580. [PMID: 35657566 DOI: 10.1007/s00535-022-01881-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic atrophy after allogeneic hematopoietic cell transplantation (HCT) is one of the symptoms associated with chronic graft-versus-host disease (GVHD). Although pancreatic atrophy has been considered to cause exocrine insufficiency and weight loss, it is not yet clear what kinds of recipients can be expected to recover their body weight (BW) or pancreatic thickness. In addition, the effect of pancreatic atrophy on the prognosis has not been clarified. METHODS We retrospectively analyzed 170 recipients who received allogeneic bone marrow transplantation or peripheral blood stem cell transplantation, and evaluated them using the CT scan images obtained closest to 1, 2, 3, and 4 years after HCT. RESULTS Fifty-five recipients (32.4%) demonstrated pancreatic atrophy, and 11 (20%) of them recovered their pancreatic thickness. While recipients without pancreatic atrophy gradually recovered their BW (P < 0.001), those with atrophy did not (P = 0.12). Moderate and severe chronic GVHD tended to be slightly more common in the atrophy group (47.3% vs 38.3%), whereas the pancreatic thickness tended to recover in these recipients (30.8% vs 10.3%). HCT from a female donor to a male recipient showed superior pancreatic recovery compared to other donor and recipient sex combinations. Pancreatic atrophy treated as a significantly associated with inferior survival (HR 4.91, P < 0.001) and an increased risk of non-relapse mortality (HR 8.75, P < 0.001). CONCLUSIONS These results suggest that it is important to monitor pancreatic thickness after HCT. Further prospective investigations are warranted to clarify the significance of pancreatic atrophy on clinical outcomes.
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Affiliation(s)
- Yosuke Okada
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yuhei Nakamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masakatsu Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shunto Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Junko Takeshita
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Nozomu Yoshino
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yukiko Misaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shimpei Matsumi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Ayumi Gomyo
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Aki Tanihara
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masaharu Tamaki
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Machiko Kusuda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kazuaki Kameda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Noriko Oyama-Manabe
- Division of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan.
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Pereira AZ, Vigorito AC, Almeida ADM, Candolo ADA, Silva ACL, Brandão-Anjos AEDP, Sá BLD, Souza CLSD, Castro Junior CGD, Oliveira JSRD, Barban JB, Mancilha EMB, Todaro J, Lopes LP, Macedo MCMDA, Rodrigues M, Ribeiro PC, Silva RLD, Roberto TS, Rodrigues TDCR, Colturato VAR, Paton EJDA, Barros GMN, Almeida RDS, Moreira MCR, Flowers ME. Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Graft- versus -host disease. EINSTEIN-SAO PAULO 2020; 18:eAE4799. [PMID: 32215466 PMCID: PMC7069734 DOI: 10.31744/einstein_journal/2020ae4799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/27/2019] [Indexed: 02/02/2023] Open
Abstract
The Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplantation: Graft- versus -host disease was approved by Sociedade Brasileira de Transplante de Medula Óssea , with the participation of 26 Brazilian hematopoietic stem cell transplantation centers. It describes the main nutritional protocols in cases of Graft- versus -host disease, the main complication of hematopoietic stem cell transplantation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Juliana Todaro
- Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
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Moenen FCJI, Bakers FCH, Bos GMJ. Pancreatic atrophy after allogeneic peripheral blood stem cell transplantation. Br J Haematol 2015; 172:155. [PMID: 26303722 DOI: 10.1111/bjh.13643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Floor C J I Moenen
- Department of Haematology, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Frans C H Bakers
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Gerard M J Bos
- Department of Haematology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Nakasone H, Sahaf B, Miklos DB. Therapeutic benefits targeting B-cells in chronic graft-versus-host disease. Int J Hematol 2015; 101:438-51. [PMID: 25812839 DOI: 10.1007/s12185-015-1782-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 12/21/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) can be a curative strategy for hematological diseases, and the indications for allo-HCT have broadened widely due to recent progress in supportive strategies. However, patients must overcome various complications and chronic graft-versus-host disease (cGVHD) remains the most common allo-HCT cause of long-term morbidity and mortality. cGVHD is difficult to biologically assess due to the heterogeneity of cGVHD symptoms, and the pathogenesis of cGVHD has yet to be established. Recent experimental model progress has suggested that B-cells play a critical role in cGVHD development. Consistent with these experimental results, some clinical studies investigating B-cell depletion and modulation of B-cell signaling pathways have decreased cGVHD incidence and provided some therapeutic benefit. However, randomized control studies are necessary to confirm the efficacy of B-cell targeting drugs for cGVHD. Here, we review the pathophysiology of cGVHD, especially focusing on the role of B-cell immunity, and discuss the efficacy of both B-cell depletion and modulation of B-cell signaling pathways in human cGVHD prevention, initial treatment, and salvage treatment.
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Affiliation(s)
- Hideki Nakasone
- Division of Blood and Marrow Transplantation, Stanford University School of Medicine, 269 West Campus Dr., CCSR #2205, Stanford, CA, 94305, USA
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Abstract
PURPOSE To determine if patients with chronic graft-versus-host disease (cGVHD) following allogeneic hematopoietic stem cell transplantation (HSCT) develop greater loss of pancreatic tissue than patients without cGVHD. MATERIALS AND METHODS This is an IRB-approved, HIPAA-compliant retrospective study of patients receiving allogeneic HSCT at our institution from 01/2006 to 01/2010 with abdominal CT performed within 3 months prior to HSCT and CT performed at least 3 months after HSCT. Measurement of glandular tissue thickness of the head, body, and tail of the pancreas was performed independently by two radiologists blinded to clinical data. Statistical analysis was performed using the Student t-test, and interobserver agreement was evaluated with linear-weighted kappa. RESULTS 117 patients underwent HSCT during study period, with 36 patients meeting inclusion criteria. 22 subjects (61%) had clinical features of cGVHD, and 14 patients (39%) did not have evidence of cGVHD. Following HSCT, there was a significant decrease in mean total thickness (10.9%, p = 0.002) of the pancreas in the group of patients with cGVHD. The change from pretreatment to the nadir in pancreatic thickness was significantly greater in patient with cGVHD (13.9 ± 12.1 mm), but not in non-cGVHD patients (5.4 ± 4.7 mm) (p = 0.02), with head of the pancreas atrophy accounting for the difference (decrease of 4.8 ± 4.6 mm in cGVHD patients vs. 1.6 ± 2.1 mm in non-cGVHD patients (p = 0.02)). CONCLUSION Patients with cGVHD develop significantly greater loss of pancreatic glandular tissue than patients without cGVHD following HSCT, with atrophy of pancreatic head being a major contributor.
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Schmitz-Winnenthal FH, Schmidt T, Lehmann M, Beckhove P, Kieser M, Ho AD, Dreger P, Büchler MW. Stem cell Transplantation for Eradication of Minimal PAncreatic Cancer persisting after surgical Excision (STEM PACE Trial, ISRCTN47877138): study protocol for a phase II study. BMC Cancer 2014; 14:168. [PMID: 24612467 PMCID: PMC4008264 DOI: 10.1186/1471-2407-14-168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 03/03/2014] [Indexed: 01/09/2023] Open
Abstract
Background Pancreatic cancer is the third most common cancer related cause of death. Even in the 15% of patients who are eligible for surgical resection the outlook is dismal with less than 10% of patients surviving after 5 years. Allogeneic hematopoietic (allo-HSCT) stem cell transplantation is an established treatment capable of to providing cure in a variety of hematopoietic malignancies. Best results are achieved when the underlying neoplasm has been turned into a stage of minimal disease by chemotherapy. Allo-HSCT in advanced solid tumors including pancreatic cancer have been of limited success, however studies of allo-HSCT in solid tumors in minimal disease situations have never been performed. The aim of this trial is to provide evidence for the clinical value of allo-HSCT in pancreatic cancer put into a minimal disease status by effective surgical resection and standard adjuvant chemotherapy. Methods/Design The STEM PACE trial is a single center, phase II study to evaluate adjuvant allogeneic hematopoietic stem cell transplantation in pancreatic cancer after surgical resection. The study will evaluate as primary endpoint 2 year progression free survival and will generate first time state-of-the-art scientific clinical evidence if allo-HSCT is feasible and if it can provide long term disease control in patients with effectively resected pancreatic cancer. Screened eligible patients after surgical resection and standard adjuvant chemotherapy with HLA matched related stem cell donor can participate. Patients without a matched donor will be used as a historical control. Study patients will undergo standard conditioning for allo-HSCT followed by transplantation of allogeneic unmanipulated peripheral blood stem cells. The follow up of the patients will continue for 2 years. Secondary endpoints will be evaluated on 7 postintervention visits. Discussion The principal question addressed in this trial is whether allo-HSCT can change the unfavourable natural course of this disease. The underlying hypothesis is that allo-HSCT has the capacity to provide long-term disease control to an extent otherwise not possible in pancreatic cancer, thereby substantially improving survival of affected patients. Trial registration This trial has been registered: ISRCTN47877138
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Affiliation(s)
| | | | | | | | | | | | | | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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van der Meij BS, de Graaf P, Wierdsma NJ, Langius JAE, Janssen JJWM, van Leeuwen PAM, Visser OJ. Nutritional support in patients with GVHD of the digestive tract: state of the art. Bone Marrow Transplant 2012; 48:474-82. [PMID: 22773121 DOI: 10.1038/bmt.2012.124] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
An important complication of allo-SCT is GVHD, which commonly affects the skin, liver and digestive tract. Clinical symptoms of GVHD of the digestive tract (GVHD-DT) include excessive diarrhoea, abdominal pain and cramps, nausea and vomiting, gastrointestinal bleeding, dysphagia, and weight loss. Treatment is complicated and regarding nutritional support, only a few guidelines are available. Our aim was to critically appraise the literature on nutritional assessment, nutritional status and nutritional support for patients with GVHD-DT. Evidence shows that GVHD-DT is often associated with malnutrition, protein losing enteropathy, magnesium derangements, and deficiencies of zinc, vitamin B12 and vitamin D. Limited evidence exists on derangements of magnesium, resting energy expenditure, bone mineral density and pancreatic function, and some beneficial effects of n-3 polyunsaturated fatty acids and pancreatic enzyme replacement therapy. Expert opinions recommend adequate amounts of energy, at least 1.5 g protein/kg body weight, supplied by total parenteral nutrition in cases of severe diarrhoea. When diarrhoea is <500 mL a day, a stepwise oral upgrade diet can be followed. No studies exist on probiotics, prebiotics, dietary fibre and immunonutrition in GVHD-DT patients. Future research should focus on absorption capacity, vitamin and mineral status, and nutritional support strategies.
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Affiliation(s)
- B S van der Meij
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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