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Alvarado SM, Cohen OG, Lattanzio K, Haun P, Gelfand JM, Loren AW, Chung J, Baumrin E. Histopathologic Analysis of Chronic Cutaneous Graft-Versus-Host Disease. Am J Dermatopathol 2024:00000372-990000000-00419. [PMID: 39288748 DOI: 10.1097/dad.0000000000002841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
ABSTRACT Chronic graft-versus-host disease (cGVHD) is the leading cause of morbidity and nonrelapse mortality after allogeneic hematopoietic cell transplantation. Skin biopsy of cGVHD is recommended when clinical features are not diagnostic, yet the histopathologic features of skin cGVHD are not well described. The objective of this study is to describe the histopathologic features of skin cGVHD in epidermal, sclerotic, and combination cGVHD. Of 49 patients with skin cGVHD, 30 of 49 (61.2%) were male, and mean age was 55 years (SD 11.1). Clinically, 33 of 49 (67.3%) had epidermal cGVHD (E-cGVHD), 1 of 49 (2.1%) had sclerotic cGVHD (S-cGVHD), and 15 of 49 (30.6%) had combination disease. The 49 patients corresponded to 83 unique pathologic specimens with 67 of 83 (80.7%) taken from E-cGVHD, and 16 of 83 (19.3%) from S-cGVHD lesions. Nearly all biopsy specimens from E-cGVHD showed minimal features of active GVHD, including apoptosis in the epidermal basal layer (n = 63, 94.0%), vacuolar change (n = 62, 92.5%), and lymphocyte satellitosis (n = 57, 85.1%). The predominant histologic pattern of E-cGVHD was lichen planus/interface dermatitis (n = 31, 47.0%). S-cGVHD specimens also showed minimal features of active GVHD with apoptosis of the epidermal basal layer (n = 11, 68.8%) and vacuolar change (n = 8, 50.0%). In addition, S-cGVHD showed sclerosis of the papillary and reticular dermis and subcutaneous septae (n = 8, 50.0%; n = 11, 68.8%; n = 5, 31.2%, respectively). The predominant histologic pattern of S-cGVHD was lichen sclerosus/morphea-like pattern (n = 10, 62.5%). Although minimal pathologic features of active GVHD are common, the majority of cGVHD biopsies share features with the inflammatory skin diseases that they clinically resemble. Complete histologic reporting is recommended with implications for disease endotyping and personalized therapy.
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Affiliation(s)
| | - Olivia G Cohen
- Department of Dermatology, University of Virginia Medical Center, Charlottesville, VA
| | | | - Paul Haun
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA
| | - Joel M Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA
| | - Alison W Loren
- Blood and Marrow Transplant, Cell Therapy and Transplant Program, Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and
- Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jina Chung
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA
| | - Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia, PA
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Bangolo A, Dey S, Nagesh VK, Gumer K, Avetisyan L, Islam S, Sahotra M, Millett M, Alqinai B, Pender S, Dunraj Y, Syeda H, Tasneem B, Duran M, Deugd ND, Thakur P, Weissman S, Cho C. Role of Endoscopic Techniques in the Diagnosis of Complications of Allogeneic Hematopoietic Stem Cell Transplantation: A Review of the Literature. J Clin Med 2024; 13:4343. [PMID: 39124609 PMCID: PMC11313381 DOI: 10.3390/jcm13154343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Allogeneic stem cell transplantation (Allo-SCT) implies that a donor and a recipient are not genetically identical. Allo-SCT is used to cure a variety of conditions, including hematologic malignancies using the graft versus tumor effect, nonmalignant hematologic, immune deficiencies, and, more recently, genetic disorders and inborn errors of metabolism. Given the immunosuppressive and myeloablative nature of some of the conditioning chemotherapy regimens used during the Allo-SCT, patients are often at high risk of infection, including viral infections affecting the gastrointestinal tract, following the transplant. Furthermore, other complications such as hepatic sinusoidal obstruction syndrome (SOS) or graft-versus-host disease may occur post-transplant and may require endoscopy to assist in the diagnosis. This review will provide newer insights into the importance of endoscopic techniques in the diagnosis of post-Allo-SCT complications with a focus on safety and timing.
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Affiliation(s)
- Ayrton Bangolo
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Shraboni Dey
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Vignesh Krishnan Nagesh
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Kabir Gumer
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Lida Avetisyan
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Saima Islam
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Monika Sahotra
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Melissa Millett
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Budoor Alqinai
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Silvanna Pender
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Yazmika Dunraj
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Habiba Syeda
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Beegum Tasneem
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Mikel Duran
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Nicoleta De Deugd
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Prasad Thakur
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Simcha Weissman
- Department of Internal Medicine, HMH Palisades Medical Center, North Bergen, NJ 07047, USA; (A.B.)
| | - Christina Cho
- Division of Bone Marrow Transplant and Cellular Therapy, John Theurer Cancer Center, Hackensack, NJ 07601, USA
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Quiroga-Garza ME, Ruiz-Lozano RE, Rodriguez-Gutierrez LA, Khodor A, Ma S, Komai S, Mohamed-Noriega K, Perez VL. Lessons Learned From Ocular Graft versus Host Disease: An Ocular Surface Inflammatory Disease of Known Time of Onset. Eye Contact Lens 2024; 50:212-221. [PMID: 38518064 DOI: 10.1097/icl.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/24/2024]
Abstract
ABSTRACT The ocular surface inflammatory disorders (OSIDs) comprise a group of conditions characterized by persistent inflammation of the ocular surface and adnexal tissues. Systemic autoimmune diseases and hypersensitivity reactions cause them, and, if left untreated, can result in severe inflammatory dry eye, corneal damage, and vision loss. Ocular graft-versus-host disease (oGVHD) forms part of the ocular surface inflammatory disease umbrella. It is a condition occurring after allogeneic hematopoietic stem cell or bone marrow transplantation, usually in chronic graft-versus-host disease. oGVHD can virtually affect any ocular adnexal tissue, especially the meibomian glands, and cause persistent inflammation, tissue fibrosis, and subsequent chronic, severe dry eye disease. Among the OSIDs, oGVHD has the particularity that it has a "time zero," meaning we know when the disease started. As such, preclinical models have leveraged this to investigate the molecular mechanisms involved in the damage oGVHD causes to the ocular surface. In oGVHD, establishing a "time zero" allows for predicting the clinical course and establishing adequate treatment. This is also possible because the inflammatory infiltration occurs in ocular surface tissues, which are readily accessible. Using oGVHD, we might be able to understand the immune response mechanisms in other OSIDs better (i.e., Sjögren syndrome, Stevens-Johnson syndrome, among others). This review presents an up-to-date overview of the pathogenesis, clinical presentation, and treatment of oGVHD. In addition, we will discuss the value of the "time zero" concept in the study of oGVHD.
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Affiliation(s)
- Manuel E Quiroga-Garza
- Department of Ophthalmology (M.E.Q.-G., R.E.R.-L., S.M., S.K., V.L.P.), Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, NC; Bascom Palmer Eye Institute (M.E.Q.-G., R.E.R.-L., L.A.R.-G., A.K., S.M., S.K., V.L.P.), University of Miami, Miami, FL; and Department of Ophthalmology (K.M.-N.), University Hospital and Faculty of Medicine, Autonomous University of Nuevo León (UANL), Monterrey, Mexico
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Baumrin E, Shin DB, Mitra N, Pidala J, El Jurdi N, Lee SJ, Loren AW, Gelfand JM. Patient-Reported Outcomes and Mortality in Cutaneous Chronic Graft-vs-Host Disease. JAMA Dermatol 2024; 160:393-401. [PMID: 38416506 PMCID: PMC10902778 DOI: 10.1001/jamadermatol.2023.6277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/29/2023] [Indexed: 02/29/2024]
Abstract
Importance Chronic graft-vs-host disease (GVHD) is associated with impaired quality of life and symptom burden. The independent association of skin involvement with patient-reported outcomes (PROs) and their utility as a clinical prognostic marker remain unknown. Identification of patients with cutaneous chronic GVHD and impaired PROs could assist in initial risk stratification and treatment selection. Objective To compare the association of sclerotic and epidermal-type chronic GVHD with longitudinal PROs and to evaluate whether PROs can identify patients with cutaneous chronic GVHD at high risk for death. Design, Setting, and Participants This multicenter prospective cohort study involved patients from the Chronic GVHD Consortium of 9 US medical centers, enrolled between August 2007 and April 2012, and followed up until December 2020. Participants included adults 18 years and older with a diagnosis of chronic GVHD requiring systemic immunosuppression and with skin involvement during the study period. Main Outcomes and Measures Patient-reported symptom burden was assessed using the Lee Symptom Scale (LSS) skin subscale with higher scores indicating worse outcomes. Quality of life was measured using the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) instrument with lower scores indicating worse outcomes. Nonrelapse mortality, overall survival, and their association with PROs at diagnosis were also assessed. Results Among 436 patients with cutaneous chronic GVHD (median [IQR] age at transplant, 51 [41.5-56.6] years; 261 [59.9%] male), 229 patients had epidermal-type chronic GVHD (52.5%), followed by 131 with sclerotic chronic GVHD (30.0%), and 76 with combination disease (17.4%). After adjusting for confounders, patients with sclerotic chronic GVHD had mean FACT-BMT scores 6.1 points worse than those with epidermal disease (95% CI, 11.7-0.4; P = .04). Patients with combination disease had mean LSS skin subscale scores 9.0 points worse than those with epidermal disease (95% CI, 4.2-13.8; P < .001). Clinically meaningful differences were defined as at least 7 points lower for FACT-BMT and 11 points higher for LSS skin subscale. At diagnosis, clinically meaningful worsening in FACT-BMT score was associated with an adjusted odds of nonrelapse mortality increased by 9.1% (95% CI, 2.0%-16.7%; P = .01). Similarly, for clinically meaningful worsening in LSS skin subscale score, adjusted odds of nonrelapse mortality increased by 16.4% (95% CI, 5.4%-28.5%; P = .003). These associations held true after adjusting for clinical severity by the National Institutes of Health Skin Score. Conclusions and Relevance The results of this cohort study demonstrated that skin chronic GVHD was independently associated with long-term PRO impairment, with sclerotic and combination disease carrying the highest morbidity. The degree of impairment at skin chronic GVHD diagnosis was a prognostic marker for mortality. Therefore, PROs could be useful for risk stratification and treatment selection in clinical practice and clinical trials.
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Affiliation(s)
- Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Daniel B. Shin
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Joseph Pidala
- Blood and Marrow Transplantation and Cellular Immunotherapy, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Najla El Jurdi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis
| | - Stephanie J. Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Alison W. Loren
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Joel M. Gelfand
- Department of Dermatology, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
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Baumrin E, Loren AW, Falk SJ, Mays JW, Cowen EW. Chronic graft-versus-host disease. Part I: Epidemiology, pathogenesis, and clinical manifestations. J Am Acad Dermatol 2024; 90:1-16. [PMID: 36572065 PMCID: PMC10287844 DOI: 10.1016/j.jaad.2022.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/08/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Chronic graft-versus-host disease is a major complication of allogeneic hematopoietic cell transplantation and a leading cause of long-term morbidity, nonrelapse mortality, and impaired health-related quality of life. The skin is commonly affected and presents heterogeneously, making the role of dermatologists critical in both diagnosis and treatment. In addition, new clinical classification and grading schemes inform treatment algorithms, which now include 3 U.S. Food and Drug Administration-approved therapies, and evolving transplant techniques are changing disease epidemiology. Part I reviews the epidemiology, pathogenesis, clinical manifestations, and diagnosis of chronic graft-versus-host disease. Part II discusses disease grading and therapeutic management.
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Affiliation(s)
- Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alison W Loren
- Blood and Marrow Transplant, Cell Therapy and Transplant Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sandy J Falk
- Adult Survivorship Program, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline W Mays
- Oral Immunobiology Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
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6
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Hong J, Fraebel J, Yang Y, Tkacyk E, Kitko C, Kim TK. Understanding and treatment of cutaneous graft-versus-host-disease. Bone Marrow Transplant 2023; 58:1298-1313. [PMID: 37730800 DOI: 10.1038/s41409-023-02109-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
The skin is the outermost mechanical barrier where dynamic immune reactions take place and is the most commonly affected site in both acute and chronic graft-versus-host disease (GVHD). If not properly treated, pain and pruritis resulting from cutaneous GVHD can increase the risk of secondary infection due to erosions, ulcerations, and damage of underlying tissues. Furthermore, resulting disfiguration can cause distress and significantly impact patients' quality of life. Thus, a deeper understanding of skin-specific findings of GVHD is needed. This review will highlight some promising results of recent pre-clinical studies on the pathophysiology of skin GVHD and summarize the diagnostic and staging/grading procedures according to the clinical manifestations of skin GVHD. In addition, we will summarize outcomes of various GVHD treatments, including skin-specific response rates.
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Affiliation(s)
- Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Johnathan Fraebel
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yenny Yang
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Tkacyk
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carrie Kitko
- Monroe Carell Jr Children's Hospital, Vanderbilt Division of Pediatric Hematology-Oncology, Nashville, TN, USA
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Veterans Affairs Tennessee Valley Health Care, Nashville, TN, USA.
- Vanderbilt-Ingram Cancer Center, Nashville, TN, USA.
- Vanderbilt Center for Immunobiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Baumrin E, Baker LX, Byrne M, Martin PJ, Flowers ME, Onstad L, El Jurdi N, Chen H, Beeghly-Fadiel A, Lee SJ, Tkaczyk ER. Prognostic Value of Cutaneous Disease Severity Estimates on Survival Outcomes in Patients With Chronic Graft-vs-Host Disease. JAMA Dermatol 2023; 159:393-402. [PMID: 36884224 PMCID: PMC9996455 DOI: 10.1001/jamadermatol.2022.6624] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/28/2022] [Indexed: 03/09/2023]
Abstract
Importance Prior studies have demonstrated an association between cutaneous chronic graft-vs-host disease (cGVHD) and mortality. Assessment of the prognostic value of different measures of disease severity would assist in risk stratification. Objective To compare the prognostic value of body surface area (BSA) and National Institutes of Health (NIH) Skin Score on survival outcomes stratified by erythema and sclerosis subtypes of cGVHD. Design, Setting, and Participants Multicenter prospective cohort study from the Chronic Graft-vs-Host Disease Consortium including 9 medical centers in the US, enrolled from 2007 through 2012 and followed until 2018. Participants were adults and children with a diagnosis of cGVHD requiring systemic immunosuppression and with skin involvement during the study period, who had longitudinal follow-up. Data analysis was performed from April 2019 to April 2022. Exposures Patients underwent continuous BSA estimation and categorical NIH Skin Score grading of cutaneous cGVHD at enrollment and every 3 to 6 months thereafter. Main Outcomes and Measures Nonrelapse mortality (NRM) and overall survival (OS), compared between BSA and NIH Skin Score longitudinal prognostic models, adjusted for age, race, conditioning intensity, patient sex, and donor sex. Results Of 469 patients with cGVHD, 267 (57%) (105 female [39%]; mean [SD] age, 51 [12] years) had cutaneous cGVHD at enrollment, and 89 (19%) developed skin involvement subsequently. Erythema-type disease had earlier onset and was more responsive to treatment compared with sclerosis-type disease. Most cases (77 of 112 [69%]) of sclerotic disease occurred without prior erythema. Erythema-type cGVHD at first follow-up visit was associated with NRM (hazard ratio, 1.33 per 10% BSA increase; 95% CI, 1.19-1.48; P < .001) and OS (hazard ratio, 1.28 per 10% BSA increase; 95% CI, 1.14-1.44; P < .001), while sclerosis-type cGVHD had no significant association with mortality. The model with erythema BSA collected at baseline and first follow-up visits retained 75% of the total prognostic information (from all covariates including BSA and NIH Skin Score) for NRM and 73% for OS, with no statistical difference between prognostic models (likelihood ratio test χ2, 5.9; P = .05). Conversely, NIH Skin Score collected at the same intervals lost significant prognostic information (likelihood ratio test χ2, 14.7; P < .001). The model incorporating NIH Skin Score instead of erythema BSA accounted for only 38% of the total information for NRM and 58% for OS. Conclusions and Relevance In this prospective cohort study, erythema-type cutaneous cGVHD was associated with increased risk of mortality. Erythema BSA collected at baseline and follow-up predicted survival more accurately than the NIH Skin Score in patients requiring immunosuppression. Accurate assessment of erythema BSA may assist in identifying patients with cutaneous cGVHD at high risk for mortality.
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Affiliation(s)
- Emily Baumrin
- Department of Dermatology, University of Pennsylvania, Philadelphia
| | - Laura X. Baker
- Department of Dermatology, University of California, San Francisco
| | - Michael Byrne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul J. Martin
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Mary E. Flowers
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Lynn Onstad
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Najla El Jurdi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Stephanie J. Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Eric R. Tkaczyk
- Department of Veterans Affairs, Nashville, Tennessee
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
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Parks K, Liu X, Reasat T, Khera Z, Baker LX, Chen H, Dawant BM, Saknite I, Tkaczyk ER. Non-Expert Markings of Active Chronic Graft-Versus-Host Disease Photographs: Optimal Metrics of Training Effects. J Digit Imaging 2023; 36:373-378. [PMID: 36344635 PMCID: PMC9984572 DOI: 10.1007/s10278-022-00730-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022] Open
Abstract
Lack of reliable measures of cutaneous chronic graft-versus-host disease (cGVHD) remains a significant challenge. Non-expert assistance in marking photographs of active disease could aid the development of automated segmentation algorithms, but validated metrics to evaluate training effects are lacking. We studied absolute and relative error of marked body surface area (BSA), redness, and the Dice index as potential metrics of non-expert improvement. Three non-experts underwent an extensive training program led by a board-certified dermatologist to mark cGVHD in photographs. At the end of the 4-month training, the dermatologist confirmed that each trainee had learned to accurately mark cGVHD. The trainees' inter- and intra-rater intraclass correlation coefficient estimates were "substantial" to "almost perfect" for both BSA and total redness. For fifteen 3D photos of patients with cGVHD, the trainees' median absolute (relative) BSA error compared to expert marking dropped from 20 cm2 (29%) pre-training to 14 cm2 (24%) post-training. Total redness error decreased from 122 a*·cm2 (26%) to 95 a*·cm2 (21%). By contrast, median Dice index did not reflect improvement (0.76 to 0.75). Both absolute and relative BSA and redness errors similarly and stably reflected improvements from this training program, which the Dice index failed to capture.
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Affiliation(s)
- Kelsey Parks
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiaoqi Liu
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Tahsin Reasat
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Zain Khera
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura X Baker
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benoit M Dawant
- Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Inga Saknite
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Riga, Latvia
| | - Eric R Tkaczyk
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
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9
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Shen Z, Ma J, Peng R, Hu B, Zhao Y, Liu S, Hong J. Biomarkers in Ocular Graft-Versus-Host Disease: Implications for the Involvement of B Cells. Transplant Cell Ther 2022; 28:749.e1-749.e7. [DOI: 10.1016/j.jtct.2022.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
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10
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Wongvibulsin S, Frech TM, Chren MM, Tkaczyk ER. Expanding Personalized, Data-Driven Dermatology: Leveraging Digital Health Technology and Machine Learning to Improve Patient Outcomes. JID INNOVATIONS 2022; 2:100105. [PMID: 35462957 PMCID: PMC9026581 DOI: 10.1016/j.xjidi.2022.100105] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/13/2021] [Accepted: 01/07/2022] [Indexed: 11/30/2022] Open
Abstract
The current revolution of digital health technology and machine learning offers enormous potential to improve patient care. Nevertheless, it is essential to recognize that dermatology requires an approach different from those of other specialties. For many dermatological conditions, there is a lack of standardized methodology for quantitatively tracking disease progression and treatment response (clinimetrics). Furthermore, dermatological diseases impact patients in complex ways, some of which can be measured only through patient reports (psychometrics). New tools using digital health technology (e.g., smartphone applications, wearable devices) can aid in capturing both clinimetric and psychometric variables over time. With these data, machine learning can inform efforts to improve health care by, for example, the identification of high-risk patient groups, optimization of treatment strategies, and prediction of disease outcomes. We use the term personalized, data-driven dermatology to refer to the use of comprehensive data to inform individual patient care and improve patient outcomes. In this paper, we provide a framework that includes data from multiple sources, leverages digital health technology, and uses machine learning. Although this framework is applicable broadly to dermatological conditions, we use the example of a serious inflammatory skin condition, chronic cutaneous graft-versus-host disease, to illustrate personalized, data-driven dermatology.
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Affiliation(s)
- Shannon Wongvibulsin
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tracy M. Frech
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- VA Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee, USA
| | - Mary-Margaret Chren
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric R. Tkaczyk
- VA Tennessee Valley Healthcare System, U.S. Department of Veterans Affairs, Nashville, Tennessee, USA
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, School of Engineering, Vanderbilt University, Nashville, Tennessee, USA
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11
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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12
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Levy RB, Mousa HM, Lightbourn CO, Shiuey EJ, Latoni D, Duffort S, Flynn R, Du J, Barreras H, Zaiken M, Paz K, Blazar BR, Perez VL. Analyses and Correlation of Pathologic and Ocular Cutaneous Changes in Murine Graft versus Host Disease. Int J Mol Sci 2021; 23:184. [PMID: 35008621 PMCID: PMC8745722 DOI: 10.3390/ijms23010184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/22/2022] Open
Abstract
Graft versus host disease (GVHD) is initiated by donor allo-reactive T cells activated against recipient antigens. Chronic GVHD (cGVHD) is characterized by immune responses that may resemble autoimmune features present in the scleroderma and Sjogren's syndrome. Unfortunately, ocular involvement occurs in approximately 60-90% of patients with cGVHD following allo-hematopoietic stem cell transplants (aHSCT). Ocular GVHD (oGVHD) may affect vision due to ocular adnexa damage leading to dry eye and keratopathy. Several other compartments including the skin are major targets of GVHD effector pathways. Using mouse aHSCT models, the objective was to characterize cGVHD associated alterations in the eye and skin to assess for correlations between these two organs. The examination of multiple models of MHC-matched and MHC-mismatched aHSCT identified a correlation between ocular and cutaneous involvement accompanying cGVHD. Studies detected a "positive" correlation, i.e., when cGVHD-induced ocular alterations were observed, cutaneous compartment alterations were also observed. When no or minimal ocular signs were detected, no or minimal skin changes were observed. In total, these findings suggest underlying cGVHD-inducing pathological immune mechanisms may be shared between the eye and skin. Based on the present observations, we posit that when skin involvement is present in aHSCT patients with cGVHD, the evaluation of the ocular surface by an ophthalmologist could potentially be of value.
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Affiliation(s)
- Robert B. Levy
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Hazem M. Mousa
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - Casey O. Lightbourn
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Eric J. Shiuey
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - David Latoni
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - Stephanie Duffort
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Ryan Flynn
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Jing Du
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Henry Barreras
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Michael Zaiken
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Katelyn Paz
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Victor L. Perez
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
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13
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Shakshouk H, Tkaczyk ER, Cowen EW, El-Azhary RA, Hashmi SK, Kenderian SJ, Lehman JS. Methods to Assess Disease Activity and Severity in Cutaneous Chronic Graft-versus-Host Disease: A Critical Literature Review. Transplant Cell Ther 2021; 27:738-746. [PMID: 34107339 DOI: 10.1016/j.jtct.2021.05.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 12/26/2022]
Abstract
Chronic graft-versus-host disease (cGVHD), a potentially debilitating complication of hematopoietic cell transplantation, confers increased risk for mortality. Whereas treatment decisions rely on an accurate assessment of disease activity/severity, validated methods of assessing cutaneous cGVHD activity/severity appear to be limited. In this study, we aimed to identify and evaluate current data on the assessment of disease activity/severity in cutaneous cGVHD. Using modified PRISMA methods, we performed a critical literature review for relevant articles. Our literature search identified 1741 articles, of which 1635 were excluded as duplicates or failure to meet inclusion criteria. Of the included studies (n = 106), 39 (37%) addressed clinical and/or histopathologic parameters, 53 (50%) addressed serologic parameters, 8 (7.5%) addressed imaging parameters, and 6 (5.5%) addressed computer-based technologies. The only formally validated metric of disease activity/severity assessment in cutaneous cGVHD is the National Institutes of Health consensus scoring system, which is founded on clinical assessment alone. The lack of an objective marker for cGVHD necessitates further studies. An evaluation of the potential contributions of serologic, imaging, and/or computer-based technologies is warranted.
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Affiliation(s)
- Hadir Shakshouk
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota; Department of Dermatology, Andrology and Venerology, Alexandria University, Alexandria, Egypt
| | - Eric R Tkaczyk
- Dermatology and Research Services, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN; Department of Dermatology, Vanderbilt University Medical Center, Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Edward W Cowen
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Shahrukh K Hashmi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota; Department of Medicine, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | | | - Julia S Lehman
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota.
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14
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Schain F, Batyrbekova N, Liwing J, Baculea S, Webb T, Remberger M, Mattsson J. Real-world study of direct medical and indirect costs and time spent in healthcare in patients with chronic graft versus host disease. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:169-180. [PMID: 33275188 PMCID: PMC7822787 DOI: 10.1007/s10198-020-01249-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 11/17/2020] [Indexed: 06/12/2023]
Abstract
Chronic graft versus host disease (cGVHD) is a debilitating and costly complication following haemopoietic stem cell transplantation (HSCT). This study describes the economic burden associated with cGVHD. Direct costs associated with specialised healthcare utilisation (inpatient admissions and outpatient visits), as well as indirect costs associated with sickness absence-associated productivity loss were estimated in patients who underwent allogeneic HSCT in Sweden between 2006 and 2015, linking population-based health and economic registers. To capture the period of chronic GVHD, patients were included who survived > 182 days post-HSCT (start of follow-up), and cGVHD was classified based on patient treatment records to correct for any diagnosis underreporting. Patients were classified as 'non-cGVHD' if they received no immunosuppressive treatment, 'mild cGVHD' if they received only systemic corticosteroid treatment or immunosuppressive treatment, or 'moderate-severe cGVHD' if they received extracorporeal photopheresis (ECP) only, corticosteroid treatment and immunosuppressive treatment, or systemic corticosteroid treatment and ECP treatments. Patients with moderate-severe cGVHD spent more time in healthcare, had higher healthcare resource costs and higher sickness absence-related productivity loss compared to patients with non- or mild cGVHD. The cumulative total costs during the first 3 years of follow-up were EUR 14,887,599, EUR 20,544,056, and EUR 47,811,835 for non-, mild, and moderate-severe groups, respectively. The long-term costs incurred with cGVHD following HSCT continue to be very high and significantly impacted by cGVHD severity. This study adds real-world health resource and economic insight relevant for policy-makers and healthcare providers when considering the clinical challenge of balancing immunosuppression to reduce cGVHD.
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Affiliation(s)
- Frida Schain
- Janssen Global Services, Stockholm, Sweden.
- Department of Medicine, Division of Hematology, Karolinska Institutet, Solna, Sweden.
- Schain Research, Bromma, Sweden.
| | - Nurgul Batyrbekova
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Scandinavian Development Services, Stockholm, Sweden
| | - Johan Liwing
- Janssen Global Services, Stockholm, Sweden
- Department of Medicine, Division of Hematology, Karolinska Institutet, Huddinge, Sweden
| | | | | | - Mats Remberger
- KFUE, Uppsala University Hospital and Institution of Medical Science, Uppsala University, Uppsala, Sweden
| | - Jonas Mattsson
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
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15
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Gut Microbiota Influence in Hematological Malignancies: From Genesis to Cure. Int J Mol Sci 2021; 22:ijms22031026. [PMID: 33498529 PMCID: PMC7864170 DOI: 10.3390/ijms22031026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
Hematological malignancies, including multiple myeloma, lymphoma, and leukemia, are a heterogeneous group of neoplasms that affect the blood, bone marrow, and lymph nodes. They originate from uncontrolled growth of hematopoietic and lymphoid cells from different stages in their maturation/differentiation and account for 6.5% of all cancers around the world. During the last decade, it has been proven that the gut microbiota, more specifically the gastrointestinal commensal bacteria, is implicated in the genesis and progression of many diseases. The immune-modulating effects of the human microbiota extend well beyond the gut, mostly through the small molecules they produce. This review aims to summarize the current knowledge of the role of the microbiota in modulating the immune system, its role in hematological malignancies, and its influence on different therapies for these diseases, including autologous and allogeneic stem cell transplantation, chemotherapy, and chimeric antigen receptor T cells.
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16
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Overt gastrointestinal bleeding following haploidentical haematopoietic stem cell transplantation: incidence, outcomes and predictive models. Bone Marrow Transplant 2021; 56:1341-1351. [PMID: 33414512 DOI: 10.1038/s41409-020-01187-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/18/2020] [Accepted: 12/02/2020] [Indexed: 01/04/2023]
Abstract
Gastrointestinal bleeding (GIB) accounts for a significant proportion of life-threatening bleeding cases occurring after allogeneic haematopoietic stem cell transplantation (allo-HSCT). However, data on GIB after haploidentical HSCT (haplo-HSCT) are not available. A total of 3180 patients received haplo-HSCT at Peking University People's Hospital from January 2015 to November 2019, and GIB occurred in 188 of these patients (incidence of 5.9%). Platelet counts <30 × 109/L, viral hepatitis, acute kidney injury (AKI), gastrointestinal disease or bleeding before HSCT and sinusoidal obstruction syndrome (SOS) were determined to be significant risk factors for the occurrence of GIB after haplo-HSCT. Grade III-IV acute graft-versus-host disease (aGVHD), AKI, thrombotic microangiopathy (TMA), disseminated intravascular coagulation (DIC) and gastrointestinal disease or bleeding before HSCT were significantly related to mortality in patients with GIB after haplo-HSCT. The predictive models developed for the occurrence and mortality of GIB performed well in terms of discrimination, and they might assist clinicians with personalised strategies for GIB prevention and treatment in patients after haplo-HSCT.
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17
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Cho A, Paulitschke V, Just U, Knobler R. Cutaneous manifestations of acute and chronic graft-versus-host disease. GIORN ITAL DERMAT V 2020; 155:76-87. [PMID: 32100975 DOI: 10.23736/s0392-0488.19.06535-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Graft-versus-host disease (GvHD) is a commonly occurring immunological reaction and frequent complication following allogeneic hematopoietic stem cell transplantation. Its highly diverse manifestations including skin involvement as the most common appearance of GvHD, can dramatically influence patient's quality of life, in particular in the chronic stage, in addition to patient's decreased survival outcome. Hence, the role of the dermatologist has become very crucial in an interdisciplinary setting, particularly since appearances of GvHD in the skin can be multifaceted and challenging. Clinical manifestation of the acute GvHD (aGvHD) is limited to erythematous maculopapular rash and oral mucosal lesions while the chronic form manifests in a wider range in a localized area or disseminated including involvement of nail, scalp and genital area. This article aims to provide a comprehensive overview on the variable cutaneous presentations of acute and chronic GvHD for a proper and early diagnosis on the one hand, and to discuss updated therapeutic options for both acute and chronic GvHD on the other hand, to initiate an adequate treatment to obtain the most beneficial clinical outcome.
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Affiliation(s)
- Ara Cho
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Verena Paulitschke
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Ulrike Just
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria -
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18
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Csanádi M, Ágh T, Farkas-Ráduly S, Gros B, Tapprich C, Trudeau JJ, Lipton JH, Mattsson J. Patient-reported symptom burden of chronic graft versus host disease: a systematic literature review. Expert Rev Hematol 2020; 13:1119-1130. [PMID: 32865071 DOI: 10.1080/17474086.2020.1818065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Chronic graft-versus-host disease (GVHD) is a life-threating complication of allogeneic hematopoietic stem cell transplantation (HSCT) leading to high morbidity and quality of life issues. We conducted a systematic literature review on the patient reported symptom burden of chronic GVHD. AREAS COVERED English-language articles published between 2005 and November 2018 were searched using CENTRAL, EMBASE and MEDLINE. Studies that used the 2005 or 2015 National Institute of Health consensus criteria for the diagnosis and staging of chronic GVHD were included. EXPERT OPINION Patient reported symptom burden was widely assessed in the literature (n = 38). The Lee Chronic GVHD Symptom Scale was the most frequently used instrument (n = 28), followed by the NIH Patient-reported Symptom scores (n = 11). Association of symptom burden with clinical outcome assessment endpoints (e.g. mortality) and with quality of life measures was investigated by fairly low number of studies with limited generalizability. By systematically investigating the influencing factors of symptom burden this review helps to better understand patients' perceptions and may help improving the management and care of chronic GVHD. However, data on influencing factors was quite diverse, which indicates that specific questions identified as research gaps need to be incorporated in randomized clinical trials in a more systematic way.
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Affiliation(s)
| | - Tamas Ágh
- Syreon Research Institute , Budapest, Hungary
| | | | | | | | | | - Jeffrey H Lipton
- Princess Margaret Cancer Centre, University of Toronto , Toronto, Canada
| | - Jonas Mattsson
- Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Department of Medicine, Princess Margaret Cancer Centre, University of Toronto , Toronto, Canada.,Department of Oncology and Pathology, Karolinska Institutet , Stockholm, Sweden
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19
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Kilgour JM, Wali G, Gibbons E, Scherwath A, Barata Badiella A, Peniket A, Schoemans H, Matin RN. Systematic Review of Patient-Reported Outcome Measures in Graft-versus-Host Disease. Biol Blood Marrow Transplant 2020; 26:e113-e127. [DOI: 10.1016/j.bbmt.2020.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 11/12/2022]
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20
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Olivieri A, Mancini G, Olivieri J, Marinelli Busilacchi E, Cimminiello M, Pascale SP, Nuccorini R, Patriarca F, Corradini P, Bacigalupo A, Angelini S, Poloni A, Grillo G, Onida F, Martino M, Di Renzo N, Nagler A, Mordini N, Bruno B, Ciceri F, Bonifazi F. Nilotinib in steroid-refractory cGVHD: prospective parallel evaluation of response, according to NIH criteria and exploratory response criteria (GITMO criteria). Bone Marrow Transplant 2020; 55:2077-2086. [PMID: 32332918 DOI: 10.1038/s41409-020-0902-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/19/2020] [Accepted: 04/03/2020] [Indexed: 11/10/2022]
Abstract
We conducted a phase I-II study to evaluate Nilotinib (NIL) safety and pharmacokinetics in 22 SR-cGVHD patients; we also evaluated ORR by using in parallel NIH criteria and an exploratory approach, combining objective improvement (OI) without failure criteria (GITMO criteria). Results: 22 patients were enrolled. After dose escalation up to 600 mg/day, MTD was not reached. Main toxicities were asthenia, headache, nausea, pruritus, cramps, and mild anemia. Mean and median plasma concentrations of NIL (C-NIL) were 817 (SD ± 450) and 773 ng/ml. ORR at 6 months, according to 2005 and 2014 NIH and GITMO criteria were 27.8%, 22.2%, and 55.6% respectively; close correspondence has been observed for ORR, according to 2014 NIH criteria, both assessed in a conventional way and assisted by dedicated software (CROSY). At 48 months OS was 75% while FFS, according to NIH and GITMO criteria, was 30 and 25%. In conclusion the safety profile of NIL and long-term outcome makes NIL an attractive option in SR-cGVHD. Exploratory GITMO criteria could represent an alternative tool for easy response evaluation in patients with prevalent skin and lung involvement, but require validation in a larger population; CROSY software showed excellent reliability in capturing ORR according to the 2014 NIH criteria.
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Affiliation(s)
- A Olivieri
- Unit of Hematology, AUO Ospedali Riuniti di Ancona, Ancona, Italy. .,Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy.
| | - G Mancini
- Unit of Hematology, AUO Ospedali Riuniti di Ancona, Ancona, Italy
| | - J Olivieri
- Department of Hematology, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - E Marinelli Busilacchi
- Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - M Cimminiello
- Regional Department of Hematology, U.O.C. of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - S P Pascale
- Regional Department of Hematology, U.O.C. of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - R Nuccorini
- Regional Department of Hematology, U.O.C. of Hematology and Stem Cell Transplantation, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - F Patriarca
- Department of Hematology, Centro Trapianti e Terapie Cellulari, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - P Corradini
- Department of Oncology and Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - A Bacigalupo
- Department of Hematology, Fondazione Policlinico Universitario Gemelli IRCCS, Universita' Cattolica del Sacro Cuore, Roma, Italy
| | - S Angelini
- U.O.C of Hematology, Ospedale C.G. Mazzoni, Ascoli Piceno, Italy
| | - A Poloni
- Unit of Hematology, AUO Ospedali Riuniti di Ancona, Ancona, Italy.,Department of Clinical and Molecular Science, Università Politecnica delle Marche, Ancona, Italy
| | - G Grillo
- Division of Hematology and Oncology, ASST Grande Ospedale Metropolitano Niguarda Milan, Milan, Italy
| | - F Onida
- BMT Center, Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - M Martino
- Stem Cell Transplantation Unit (CTMO), Department of Hemato-Oncology and Radiotherapy, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - N Di Renzo
- Haematology and BMT Unit, Ospedale Vito Fazzi, Lecce, Italy
| | - A Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Tel Aviv University, Tel Aviv, Israel
| | - N Mordini
- BMT Center, Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - B Bruno
- S.S.D. Allogenic Stem Cell Transplantation, Department of Oncology, Presidio Molinette, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - F Ciceri
- IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy
| | - F Bonifazi
- Institute of Hematology, "Seragnoli" University Hospital S. Orsola-Malpighi, Bologna, Italy
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21
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Hu B, Qiu Y, Hong J. Tear cytokine levels in the diagnosis and severity assessment of ocular chronic graft-versus-host disease(GVHD). Ocul Surf 2020; 18:298-304. [DOI: 10.1016/j.jtos.2019.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/26/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022]
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22
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Martin PJ, Storer BE, Palmer J, Jagasia MH, Chen GL, Broady R, Arora M, Pidala JA, Hamilton BK, Lee SJ. Organ Changes Associated with Provider-Assessed Responses in Patients with Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2019; 25:1869-1874. [PMID: 31085305 PMCID: PMC6755054 DOI: 10.1016/j.bbmt.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/21/2022]
Abstract
Assessments of overall improvement and worsening of chronic graft-versus-host disease (GVHD) manifestations by the algorithm recommended by National Institutes of Health (NIH) response criteria do not align closely with those reported by providers, particularly when patients have mixed responses with improvement in some manifestations but worsening in others. To elucidate the changes that influence provider assessment of response, we used logistic regression to generate an overall change index based on specific manifestations of chronic GVHD measured at baseline and 6 months later. We hypothesized that this overall change index would correlate strongly with overall improvement as determined by providers. The analysis included 488 patients from 2 prospective observational studies who were randomly assigned in a 3:2 ratio to discovery and replication cohorts. Changes in bilirubin and scores of the lower gastrointestinal tract, mouth, joint/fascia, lung, and skin were correlated with provider-assessed improvement, suggesting that the main NIH response measures capture relevant information. Conversely, changes in the eye, esophagus, and upper gastrointestinal tract did not correlate with provider-assessed response, suggesting that these scales could be modified or dropped from the NIH response assessment. The area under the receiver operator characteristic curve in the replication cohort was 0.72, indicating that the scoring algorithm for overall change based on NIH response measures is not well calibrated with provider-assessed response.
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Affiliation(s)
- Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | - Madan H Jagasia
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - George L Chen
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Raewyn Broady
- Leukemia/Bone Marrow Transplant Program of British Columbia, BC Cancer Agency, Vancouver, British Columbia, Canada
| | - Mukta Arora
- Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Joseph A Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Betty K Hamilton
- Blood and Marrow Transplantation, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
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23
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Cardones AR, Sullivan KM, Green C, Chao NJ, Rowe-Nichols K, Bañez LL, Burton CS, Horwitz ME, Long GD, Rao CL, Sarantopoulos S, Sidhu-Malik N, Sung AD, Hall RP. Interrater Reliability of Clinical Grading Measures for Cutaneous Chronic Graft-vs-Host Disease. JAMA Dermatol 2019; 155:833-837. [PMID: 30994873 PMCID: PMC6583829 DOI: 10.1001/jamadermatol.2018.5459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Cutaneous chronic graft-vs-host disease (cGVHD) is common after allogeneic hematopoietic stem cell transplant and is often associated with poor patient outcomes. A reliable and practical method for assessing disease severity and response to therapy among these patients is urgently needed. Objective To evaluate the interrater agreement and reliability of skin-specific and range of motion (ROM) variables of the 2014 National Institutes of Health (NIH) response criteria for cGVHD and a skin sclerosis grading scale (SSG). Design, Setting, and Participants In this observational study performed at a single tertiary academic center, 6 academic blood and marrow transplant specialists and 4 medical dermatologists examined 8 patients with diagnosed cutaneous cGVHD on July 10, 2015. The patient cohort was enriched for patients with sclerotic features. Each patient was evaluated by using the skin-specific and ROM criteria of the 2014 NIH response criteria for cGVHD and an SSG ranging from 0 to 3. Each patient was also asked to complete quality-of-life scoring instruments. Interrater agreement and reliability were estimated by calculating the Krippendorff α and Cohen κ statistics. Data were analyzed from September 29, 2015, through November 22, 2018. Main Outcomes and Measures Estimation of interrater agreement by interclass coefficient (Krippendorff α and Cohen κ statistics) for the skin-specific and ROM components of the 2014 NIH Response Criteria for Chronic GVHD and for the SSG. Results The median age of the patients evaluated was 54 years (range, 46-58 years). Patients were predominantly male (6 [75%]). Six of the 8 patients had a predominantly sclerotic cutaneous phenotype. Interrater agreement among our experts was acceptable for NIH skin feature score (0.68; 95% CI, 0.30-0.86) and good for NIH ROM scoring (0.80; 95% CI, 0.68-0.86). Dermatologists had acceptable agreement for NIH skin GVHD score (0.69; 95% CI, 0.25-0.82) and skin feature score (0.78; 95% CI, 0.17-0.98), good agreement in ROM grading (0.85; 95% CI, 0.69-0.90), and near perfect agreement in identifying sclerosis (0.82; 95% CI, 0.27-0.97). Conclusions and Relevance Although dermatologists had acceptable agreement in NIH skin GVHD score and skin features score, near perfect agreement in identifying cutaneous sclerosis, better agreement in grading severity of cutaneous cGVHD, especially in the intermediate grades, appears to be needed.
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Affiliation(s)
- Adela R Cardones
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Department of Dermatology, Duke University, Durham, North Carolina.,Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Keith M Sullivan
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Cindy Green
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Nelson J Chao
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Krista Rowe-Nichols
- Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Lionel L Bañez
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Claude S Burton
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Mitchell E Horwitz
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Gwynn D Long
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Caroline L Rao
- Department of Dermatology, Duke University, Durham, North Carolina.,Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Stefanie Sarantopoulos
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | | | - Anthony D Sung
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina.,Division of Cellular Therapy, Department of Medicine, Duke University, Durham, North Carolina
| | - Russell P Hall
- Department of Dermatology, Duke University, Durham, North Carolina
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24
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Agh T, Csanadi M, Voko Z, Webb T, Jeyakumaran D, Trudeau J, Sengupta N, Schain F, Mattsson J. Humanistic burden of patients with chronic graft-versus-host disease - systematic literature review of health-related quality of life and functional status. Expert Rev Hematol 2019; 12:295-309. [PMID: 30925855 DOI: 10.1080/17474086.2019.1602036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Chronic graft-versus-host disease (GVHD) is a serious complication of allogeneic hematopoietic stem cell transplantation (HSCT). This study aims to provide a systematic overview of evidence on the health-related quality of life (HRQoL) and functional capacity of HSCT patients with National Institutes of Health (NIH)-defined chronic GVHD. Areas covered: English-language articles published between 2007 and 2017 were searched using PubMed. Studies that used the 2005 or 2015 NIH consensus criteria for the diagnosis and staging of chronic GVHD and had a cohort size of at least 100 patients were included. Expert opinion: Disease severity and organ involvement were the most important predictors of HRQoL and functionality in chronic GVHD patients. Further, identified predictors of HRQoL were nutrition status and functional capacity, while functional status was also associated with disease symptoms, nutrition status, age, and survival. Data regarding the effect of symptom bother on HRQoL were limited. Our findings confirm that the management of chronic GVHD should focus on improving not only clinical outcomes but also on HRQoL and functional capacity. Therefore, to evaluate new treatment options it is recommended to include patient relevant endpoints into prospective studies. This study also highlights the importance of nonpharmacological aspects in the management of chronic GVHD.
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Affiliation(s)
- Tamas Agh
- a Syreon Research Institute , Budapest , Hungary
| | | | - Zoltan Voko
- a Syreon Research Institute , Budapest , Hungary
| | - Thomas Webb
- b Janssen Research & Development , High Wycombe , UK
| | | | | | | | | | - Jonas Mattsson
- e Department of Oncology and Pathology , Karolinska Institutet , Stockholm , Sweden.,f Division of Medical Oncology and Hematology, Department of Medicine , Princess Margaret Cancer Centre, University of Toronto , Toronto , Canada
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25
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Pusic I, Pavletic SZ. Challenges in Conducting Studies in Chronic Graft- versus-Host Disease. Clin Hematol Int 2019; 1:36-44. [PMID: 34595409 PMCID: PMC8432377 DOI: 10.2991/chi.d.190314.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/03/2022] Open
Abstract
The lack of standardized criteria for measuring therapeutic response has been a major obstacle to the development of therapeutic trials in chronic graft-versus-host disease (cGvHD). Nevertheless, recent advances have been made in understanding of the biology and pathophysiology of cGvHD, as well as establishing more precise criteria for the diagnosis and classification of disease manifestations. The momentum has shifted, and currently there is a long list of new potential treatment targets being identified for cGvHD. Consequently, new drugs are being implemented for its prophylaxis and treatment. It is crucial to continue that trend and develop better systems to test new drugs in clinical practice that would eventually translate toward seeking regulatory review and approval. We provide a historical perspective and current challenges in conducting cGvHD clinical trials.
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Affiliation(s)
- Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Steven Z Pavletic
- National Institutes of Health, National Cancer Institute, Center for Cancer Research, Bethesda, Maryland
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26
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Dermatologic Conditions of the Early Post-Transplant Period in Hematopoietic Stem Cell Transplant Recipients. Am J Clin Dermatol 2019; 20:55-73. [PMID: 30298481 DOI: 10.1007/s40257-018-0391-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hematopoietic stem cell transplants (HSCTs) are used to treat a variety of conditions, including hematologic malignancies, bone marrow failure syndromes, and immunodeficiencies. Over 60,000 HSCTs are performed annually worldwide, and the numbers continue to increase. Indeed, as new conditioning regimens develop, more and more individuals, including those of older age, will be eligible for transplants. Nevertheless, although HSCTs are clearly a life-saving and necessary treatment for thousands of patients per year, there is still substantial morbidity and mortality associated with the procedure. Of note, skin eruptions in the post-HSCT period are frequent and often significantly reduce quality of life in recipients. Moreover, these cutaneous findings sometimes herald an underlying systemic condition, presenting possible opportunities for timelier intervention. Dermatologists therefore play a vital role in distinguishing life-threatening conditions from benign issues and prompting recognition of critical complications earlier in their course. This article aims to review the major dermatologic conditions occurring in the early post-HSCT period.
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27
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Gandelman JS, Zic J, Dewan AK, Lee SJ, Flowers M, Cutler C, Pidala J, Chen H, Jagasia MH, Tkaczyk ER. The Anatomic Distribution of Skin Involvement in Patients with Incident Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2018; 25:279-286. [PMID: 30219700 DOI: 10.1016/j.bbmt.2018.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/06/2018] [Indexed: 01/15/2023]
Abstract
Little is known about the anatomic distribution of cutaneous chronic graft-versus-host disease (cGVHD). Using data from the cGVHD Consortium Improving Outcomes Assessment Study, we describe the frequency and extent of erythema and superficial and deep sclerosis in 8 anatomic sites in patients with incident disease (ie, new cGVHD diagnosis within 3 months of study entry) receiving systemic therapy. Of 339 patients with incident disease, 182 (54%) had skin involvement. When an extremity was involved, the same type of disease was present contralaterally in 92% of cases, revealing a high level of symmetry. As anticipated, erythema was the most common incident feature; however, sclerotic skin involvement at the time of cGVHD diagnosis was more common than has been suggested by previous studies. Erythema occurred in 155 (85%) and sclerosis in 53 (29%) of the patients with skin involvement (46% and 16%, respectively, of the entire cohort of 339 incident cGVHD cases). Erythema was least common on the lower extremities (n = 71; 39% of patients with skin involvement). Moveable sclerosis was rare on the head, neck, and scalp (n = 4; 2%). Deep sclerosis did not occur in this region, and instead was most likely to occur on the upper extremities (n = 14; 8%) and lower extremities (n = 14; 8%). More than one-half of patients with erythema (n = 107; 58.7%) had diffuse involvement (4 or more of 8 sites involved), compared with less than one-third of those with sclerosis (n = 16; 30.2%).
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Affiliation(s)
- Jocelyn S Gandelman
- Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee
| | - John Zic
- Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna K Dewan
- Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Corey Cutler
- Stem Cell/Bone Marrow Transplantation Program, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madan H Jagasia
- Vanderbilt University School of Medicine, Nashville, Tennessee; Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric R Tkaczyk
- Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.
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28
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Morello E, Malagola M, Bernardi S, Pristipino C, Russo D. The role of allogeneic hematopoietic stem cell transplantation in the four P medicine era. Blood Res 2018; 53:3-6. [PMID: 29662853 PMCID: PMC5898991 DOI: 10.5045/br.2018.53.1.3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/28/2018] [Accepted: 03/09/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Enrico Morello
- Clinical and Experimental Sciences Department, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili, Brescia, Italy
| | - Michele Malagola
- Clinical and Experimental Sciences Department, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili, Brescia, Italy
| | - Simona Bernardi
- Clinical and Experimental Sciences Department, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili, Brescia, Italy
| | | | - Domenico Russo
- Clinical and Experimental Sciences Department, University of Brescia, Bone Marrow Transplant Unit, ASST Spedali Civili, Brescia, Italy
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29
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Chen GL, Carpenter PA, Broady R, Gregory TK, Johnston LJ, Storer BE, Beumer JH, Qiu J, Cerda K, Le R, Otani JM, Liu H, Ross MA, Arai S, Flowers MED, McCarthy PL, Miklos DB. Anti-Platelet-Derived Growth Factor Receptor Alpha Chain Antibodies Predict for Response to Nilotinib in Steroid-Refractory or -Dependent Chronic Graft-Versus-Host Disease. Biol Blood Marrow Transplant 2018; 24:373-380. [PMID: 29051021 PMCID: PMC10917076 DOI: 10.1016/j.bbmt.2017.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/10/2017] [Indexed: 01/09/2023]
Abstract
Imatinib has clinical activity in chronic graft-versus-host disease (cGVHD), a significant complication of allogeneic hematopoietic cell transplant. Nilotinib is a tyrosine kinase inhibitor that targets the same receptors as imatinib but with different affinities. We tested the hypothesis that nilotinib is safe and has clinical activity in cGVHD. Thirty-three participants were enrolled in a phase I/II dose escalation and dose extension clinical trial of nilotinib for the treatment of steroid-refractory or- dependent cGVHD (ClinicalTrials.gov, NCT01155817). We assessed safety, clinical response, and pretreatment anti-platelet-derived growth factor receptor alpha chain (anti-PDGFRA) antibody levels. The 200-mg dose was identified as the maximum tolerated dose and used for the phase II dose extension study. At 6 months the incidence of failure-free survival (FFS), cGVHD progression, and nilotinib intolerance resulting in its discontinuation was 50%, 23%, and 23%, respectively. cGVHD responses in skin, joints, and mouth were observed at 3 and 6 months based on improvement in respective National Institutes of Health organ severity scores. Pretreatment anti-PDGFRA antibody levels ≥ .150 optical density as measured by ELISA correlated with longer FFS time (P < .0005) and trended with time until cGVHD progression (P < .06) but not drug intolerance. Nilotinib may be effective for corticosteroid-resistant or -refractory cGVHD in some patients, but its use is limited by intolerable side effects. Selection of patients with high pretreatment anti-PDGFRA antibody levels might improve the risk-to-benefit ratio of nilotinib and better justify its side effects.
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Affiliation(s)
- George L Chen
- Medicine/BMT Program and Pathology, Roswell Park Cancer Institute, Buffalo, New York
| | - Paul A Carpenter
- Department of Pediatrics, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Raewyn Broady
- Department of Medicine, Leukemia BMT Program of British Columbia, Vancouver, British Columbia, Canada
| | - Tara K Gregory
- Department of Hematology/Oncology, Colorado Blood Cancer Institute, Denver, Colorado
| | - Laura J Johnston
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jan H Beumer
- School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jingxin Qiu
- Medicine/BMT Program and Pathology, Roswell Park Cancer Institute, Buffalo, New York
| | - Kiara Cerda
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California
| | - Ryan Le
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California
| | - Joanne M Otani
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California
| | - Hong Liu
- Buffalo Medical Group, Buffalo, New York
| | - Maureen A Ross
- Medicine/BMT Program and Pathology, Roswell Park Cancer Institute, Buffalo, New York
| | - Sally Arai
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California
| | - Mary E D Flowers
- Department of Pediatrics, University of Washington, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Philip L McCarthy
- Medicine/BMT Program and Pathology, Roswell Park Cancer Institute, Buffalo, New York
| | - David B Miklos
- Department of Medicine, Medicine/BMT Division, Stanford University School of Medicine, Stanford, California.
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30
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Chen CT, Liu CY, Yu YB, Liu CJ, Hsiao LT, Gau JP, Chiou TJ, Liu JH, Liu YC. Characteristics and risk of chronic graft-versus-host disease of liver in allogeneic hematopoietic stem cell transplant recipients. PLoS One 2017; 12:e0185210. [PMID: 28934311 PMCID: PMC5608321 DOI: 10.1371/journal.pone.0185210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/10/2017] [Indexed: 12/21/2022] Open
Abstract
Chronic graft-versus-host-disease (cGvHD) is a serious complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Among various organ-specific cGvHD, the cGvHD of liver is less well-characterized. In this study, we applied the National Institutes of Health 2014 scoring criteria of cGvHD to analyze a retrospective cohort of 362 allo-HSCT recipients focusing on cGvHD of liver. The overall incidence of liver cGvHD with a score of 3 by 1.5 years post-transplant was 5.8% (21/362). Poor outcome, in terms of overall survival (OS), were observed in patients with scores of 3 liver cGvHD, comparing to those with scores less than 3 (hazard ratio [HR] 2.037, 95% confidence interval [CI] 1.123-3.696, P = 0.019). In multivariate analysis, male gender (HR 4.004, P = 0.042) and chronic hepatitis C virus (HCV) infection status (HR 19.087, P < 0.001) were statistically significant risk factors for scores of 3 liver cGvHD. Our results indicate that liver cGvHD with scores of 3 has a grave prognosis following allo-HSCT, and that HCV carrier status and male are risk factors. Early recognition of this devastating complication might help in prompt immunosuppressive therapy and reducing late poor outcome.
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Affiliation(s)
- Chien-Ting Chen
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chun-Yu Liu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Medical Oncology, Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jing-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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31
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Effect of Rituximab on Pulmonary Function in Bronchiolitis Obliterans Syndrome due to Graft-Versus-Host-Disease. Lung 2017; 195:781-788. [DOI: 10.1007/s00408-017-0051-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/06/2017] [Indexed: 12/30/2022]
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32
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Ventola CL. Cancer Immunotherapy, Part 2: Efficacy, Safety, and Other Clinical Considerations. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:452-463. [PMID: 28674473 PMCID: PMC5481296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article, the second in a series of three, provides an overview of the efficacy and safety of cancer immunotherapies ranging from monoclonal antibodies to vaccines, including additional clinical considerations regarding immune checkpoint blockers.
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33
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Xu J, Watts TE, Tobler G, Paydak H. Graft-versus-host disease: A rare complication of device implantation. HeartRhythm Case Rep 2017; 2:446-447. [PMID: 28491730 PMCID: PMC5419965 DOI: 10.1016/j.hrcr.2016.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jack Xu
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
- Address reprint requests and correspondence: Dr Jack Xu, 4301 W. Markham St., Slot #634, Little Rock, AR 72205.4301 W. Markham St., Slot # 634Little RockAR72205
| | - Thomas E. Watts
- Dept. of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Gareth Tobler
- Division of Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hakan Paydak
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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34
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Lazaryan A, Arora M. Evolving concepts in prognostic scoring of chronic GvHD. Bone Marrow Transplant 2017; 52:1361-1366. [PMID: 28346419 DOI: 10.1038/bmt.2017.50] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 01/03/2017] [Accepted: 02/16/2017] [Indexed: 01/27/2023]
Abstract
Chronic GvHD (cGvHD) remains one of the most complex and challenging complications after allogeneic hematopoietic cell transplantation. Emerging knowledge about the clinical manifestations and associated organ involvement of cGvHD has led to the establishment of prognostic parameters for post-transplant survival among affected allograft recipients. Studies employing the pre-National Institutes of Health (NIH) consensus data on cGvHD incidence and its risks have led to development of the CIBMTR's cGvHD risk stratification, which serves as the most refined and validated prognostic tool for estimating survival of patients with cGvHD. However, cGvHD global severity scoring has recently evolved as a powerful prognostic tool for patient survival in the post-NIH consensus era. Current use of the substantially redefined NIH criteria of cGvHD diagnosis and measurements of its severity makes it challenging to interpret prognostic scoring systems generated in the pre-NIH era. Some of the pre-NIH prognostic parameters, however, appear to retain their significance in predicting survival independently from the NIH global severity score. Thus, future analyses of prospective cohorts of patients with cGvHD defined by NIH consensus criteria will be critical in reconciling and integrating various prognostic scoring systems of cGvHD.
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Affiliation(s)
- A Lazaryan
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - M Arora
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota Medical Center, Minneapolis, MN, USA
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35
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Cooke KR, Luznik L, Sarantopoulos S, Hakim FT, Jagasia M, Fowler DH, van den Brink MRM, Hansen JA, Parkman R, Miklos DB, Martin PJ, Paczesny S, Vogelsang G, Pavletic S, Ritz J, Schultz KR, Blazar BR. The Biology of Chronic Graft-versus-Host Disease: A Task Force Report from the National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2017; 23:211-234. [PMID: 27713092 PMCID: PMC6020045 DOI: 10.1016/j.bbmt.2016.09.023] [Citation(s) in RCA: 274] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/30/2016] [Indexed: 12/12/2022]
Abstract
Chronic graft-versus-host disease (GVHD) is the leading cause of late, nonrelapse mortality and disability in allogeneic hematopoietic cell transplantation recipients and a major obstacle to improving outcomes. The biology of chronic GVHD remains enigmatic, but understanding the underpinnings of the immunologic mechanisms responsible for the initiation and progression of disease is fundamental to developing effective prevention and treatment strategies. The goals of this task force review are as follows: This document is intended as a review of our understanding of chronic GVHD biology and therapies resulting from preclinical studies, and as a platform for developing innovative clinical strategies to prevent and treat chronic GVHD.
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Affiliation(s)
- Kenneth R Cooke
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins Hospital, Baltimore, Maryland.
| | - Leo Luznik
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins Hospital, Baltimore, Maryland
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Department of Immunology and Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Frances T Hakim
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Madan Jagasia
- Division of Hematology-Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel H Fowler
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Marcel R M van den Brink
- Departments of Immunology and Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John A Hansen
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Department of Medicine, University of Washington, Seattle, Washington
| | - Robertson Parkman
- Division of Pediatric Stem Cell Transplantation and Regenerative Medicine, Stanford University, Palo Alto, California
| | - David B Miklos
- Division of Blood and Marrow Transplantation, Stanford University, Palo Alto, California
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Department of Medicine, University of Washington, Seattle, Washington
| | - Sophie Paczesny
- Departments of Pediatrics and Immunology, Wells Center for Pediatric Research, Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana
| | - Georgia Vogelsang
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins Hospital, Baltimore, Maryland
| | - Steven Pavletic
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Jerome Ritz
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Kirk R Schultz
- Michael Cuccione Childhood Cancer Research Program, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Bruce R Blazar
- Masonic Cancer Center and Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, Minnesota.
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Juric MK, Shevtsov M, Mozes P, Ogonek J, Crossland RE, Dickinson AM, Greinix HT, Holler E, Weissinger EM, Multhoff G. B-Cell-Based and Soluble Biomarkers in Body Liquids for Predicting Acute/Chronic Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2017; 7:660. [PMID: 28138325 PMCID: PMC5238459 DOI: 10.3389/fimmu.2016.00660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/16/2016] [Indexed: 02/02/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the main curative therapy for hematological malignancy such as leukemias, lymphomas, or multiple myelomas and some other hematological disorders. In this therapy, cure of hematological diseases relies on graft-versus-malignancy effects by allogenic immune cells. However, severe posttransplant treatment-associated complications such as acute graft-versus-host disease (aGvHD) and chronic graft-versus-host disease (cGvHD) limit this approach. Most research into GvHD has concentrated on the aGvHD, while the more complex and multifaceted chronic form has been largely poorly investigated. cGvHD is a multi-organ autoimmune disorder and is the major cause of non-relapse morbidity and mortality following allo-HSCT, occurring in about 50% of patients, or 13,000–15,000 patients per year worldwide. Therefore, there is a high medical need for an early prediction of these therapy-associated toxicities. Biomarkers have gained importance over the last decade in diagnosis, in prognosis, and in prediction of pending diseases or side effects. Biomarkers can be cells, factors isolated from target tissues, or soluble factors that can be detected in body fluids. In this review, we aim to summarize some of the recent developments of biomarkers in the field of allo-HSCT. We will focus on cell-based biomarkers (B-cell subsets) for cGvHD and soluble factors including microRNA (miRNA), which are excreted into serum/plasma and urine. We also discuss the potential role of cytosolic and extracellular 70 kDa heat shock proteins (HSP70) as potential biomarkers for aGvHD and their role in preclinical models. Proteomic biomarkers in the blood have been used as predictors of treatment responses in patients with aGvHD for many years. More recently, miRNAs have been found to serve as a biomarker to diagnose aGvHD in the plasma. Another development relates to urine-based biomarkers that are usually detected by capillary electrophoresis and mass spectrometry. These biomarkers have the potential to predict the development of severe aGvHD (grades III–IV), overall mortality, and the pending development of cGvHD in patients posttransplant.
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Affiliation(s)
- Mateja Kralj Juric
- Department of Internal Medicine I, BMT, Medical University of Vienna , Vienna , Austria
| | - Maxim Shevtsov
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München , Munich , Germany
| | - Petra Mozes
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München , Munich , Germany
| | - Justyna Ogonek
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Transplantation Biology, Hannover Medical School , Hannover , Germany
| | - Rachel E Crossland
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Anne M Dickinson
- Hematological Sciences, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | | | - Ernst Holler
- Department of Internal Medicine III, University Hospital of Regensburg , Regensburg , Germany
| | - Eva M Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Transplantation Biology, Hannover Medical School , Hannover , Germany
| | - Gabriele Multhoff
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München , Munich , Germany
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Lee SJ. Classification systems for chronic graft-versus-host disease. Blood 2017; 129:30-37. [PMID: 27821503 PMCID: PMC5216262 DOI: 10.1182/blood-2016-07-686642] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/15/2016] [Indexed: 12/11/2022] Open
Abstract
Chronic graft versus host disease (GVHD) is a major cause of morbidity and mortality after allogeneic hematopoietic cell transplantation. Clinically, chronic GVHD is a pleiotropic, multiorgan syndrome involving tissue inflammation and fibrosis that often results in permanent organ dysfunction. Chronic GVHD is fundamentally caused by replacement of the host's immune system with donor cells, although the heterogeneity of clinical manifestations suggests that patient, donor, and transplant factors modulate the phenotype. The diagnosis of chronic GVHD and determination of treatment response largely rely on clinical examination and patient interview. The 2005 and 2014 National Institutes of Health Consensus Development Projects on Criteria for Clinical Trials in Chronic GVHD standardized the terminology around chronic GVHD classification systems to ensure that a common language and procedures are being used in clinical research. This review provides a summary of these recommendations and illustrates how they are being used in clinical research and the potential for their use in clinical care.
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Barba P, Hilden P, Devlin SM, Maloy M, Dierov D, Nieves J, Garrett MD, Sogani J, Cho C, Barker JN, Kernan NA, Castro-Malaspina H, Jakubowski AA, Koehne G, Papadopoulos EB, Prockop S, Sauter C, Tamari R, van den Brink MRM, Avecilla ST, Meagher R, O'Reilly RJ, Goldberg JD, Young JW, Giralt S, Perales MA, Ponce DM. Ex Vivo CD34 +-Selected T Cell-Depleted Peripheral Blood Stem Cell Grafts for Allogeneic Hematopoietic Stem Cell Transplantation in Acute Leukemia and Myelodysplastic Syndrome Is Associated with Low Incidence of Acute and Chronic Graft-versus-Host Disease and High Treatment Response. Biol Blood Marrow Transplant 2016; 23:452-458. [PMID: 28017734 DOI: 10.1016/j.bbmt.2016.12.633] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/20/2016] [Indexed: 11/29/2022]
Abstract
Ex vivo CD34+-selected T cell depletion (TCD) has been developed as a strategy to reduce the incidence of graft-versus-host disease (GVHD) after allogeneic (allo) hematopoietic stem cell transplantation (HSCT). Clinical characteristics, treatment responses, and outcomes of patients developing acute (aGVHD) and chronic GVHD (cGVHD) after TCD allo-HSCT have not been well established. We evaluated 241 consecutive patients (median age, 57 years) with acute leukemia (n = 191, 79%) or myelodysplastic syndrome (MDS) (n = 50, 21%) undergoing CD34+-selected TCD allo-HSCT without post-HCST immunosuppression in a single institution. Cumulative incidences of grades II-IV and III-IV aGVHD at 180 days were 16% (95% confidence interval [CI], 12 to 21) and 5% (95% CI, 3 to 9), respectively. The skin was the most frequent organ involved, followed by the gastrointestinal tract. Patients were treated with topical corticosteroids, poorly absorbed corticosteroids (budesonide), and/or systemic corticosteroids. The overall day 28 treatment response was high at 82%. The cumulative incidence of any cGVHD at 3 years was 5% (95% CI, 3 to 9), with a median time of onset of 256 days (range, 95 to 1645). The 3-year transplant-related mortality, relapse, overall survival, and disease-free survival were 24% (95% CI, 18 to 30), 22% (95% CI, 17 to 27), 57% (95% CI, 50 to 64), and 54% (95% CI, 47 to 61), respectively. The 1-year and 3-year probabilities of cGVHD-free/relapse-free survival were 65% (95% CI, 59 to 71) and 52% (95% CI, 45 to 59), respectively. Our findings support the use of ex vivo CD34+-selected TCD allograft as a calcineurin inhibitor-free intervention for the prevention of GVHD in patients with acute leukemia and MDS.
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Affiliation(s)
- Pere Barba
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematology Department, Hospital Universitario Vall d'Herbon-Universidad Autonoma de Barcelona, Spain
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Djamilia Dierov
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jimmy Nieves
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew D Garrett
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Julie Sogani
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christina Cho
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Juliet N Barker
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Nancy A Kernan
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Guenther Koehne
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Esperanza B Papadopoulos
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Susan Prockop
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Craig Sauter
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Roni Tamari
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Scott T Avecilla
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Meagher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J O'Reilly
- Bone Marrow Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jenna D Goldberg
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - James W Young
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Doris M Ponce
- Adult Bone Marrow Transplant Service, Division of Hematology/Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
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Chronic graft-versus-host disease: biological insights from preclinical and clinical studies. Blood 2016; 129:13-21. [PMID: 27821504 DOI: 10.1182/blood-2016-06-686618] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/06/2016] [Indexed: 12/15/2022] Open
Abstract
With the increasing use of mismatched, unrelated, and granulocyte colony-stimulating factor-mobilized peripheral blood stem cell donor grafts and successful treatment of older recipients, chronic graft-versus-host disease (cGVHD) has emerged as the major cause of nonrelapse mortality and morbidity. cGVHD is characterized by lichenoid changes and fibrosis that affects a multitude of tissues, compromising organ function. Beyond steroids, effective treatment options are limited. Thus, new strategies to both prevent and treat disease are urgently required. Over the last 5 years, our understanding of cGVHD pathogenesis and basic biology, born out of a combination of mouse models and correlative clinical studies, has radically improved. We now understand that cGVHD is initiated by naive T cells, differentiating predominantly within highly inflammatory T-helper 17/T-cytotoxic 17 and T-follicular helper paradigms with consequent thymic damage and impaired donor antigen presentation in the periphery. This leads to aberrant T- and B-cell activation and differentiation, which cooperate to generate antibody-secreting cells that cause the deposition of antibodies to polymorphic recipient antigens (ie, alloantibody) or nonpolymorphic antigens common to both recipient and donor (ie, autoantibody). It is now clear that alloantibody can, in concert with colony-stimulating factor 1 (CSF-1)-dependent donor macrophages, induce a transforming growth factor β-high environment locally within target tissue that results in scleroderma and bronchiolitis obliterans, diagnostic features of cGVHD. These findings have yielded a raft of potential new therapeutics, centered on naive T-cell depletion, interleukin-17/21 inhibition, kinase inhibition, regulatory T-cell restoration, and CSF-1 inhibition. This new understanding of cGVHD finally gives hope that effective therapies are imminent for this devastating transplant complication.
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Aki SZ, Inamoto Y, Carpenter PA, Storer BE, Sandmaier BM, Lee SJ, Martin PJ, Flowers MED. Confounding factors affecting the National Institutes of Health (NIH) chronic Graft-Versus-Host Disease Organ-Specific Score and global severity. Bone Marrow Transplant 2016; 51:1350-1353. [PMID: 27214071 PMCID: PMC5052092 DOI: 10.1038/bmt.2016.131] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/16/2016] [Accepted: 03/19/2016] [Indexed: 01/23/2023]
Abstract
The 2005 NIH chronic GVHD (cGVHD) organ severity is based on the assessment of current status regardless of whether abnormalities are due to GVHD. The score assignment does not require knowledge of past manifestations, attribution or whether cGVHD is still active. The aim of this study is to describe confounding factors affecting organ scores in patients with cGVHD. The study included 189 consecutive cGVHD patients evaluated at our center in 2013. Providers completed the NIH 0-3 organ-specific scoring evaluation with two questions added for each organ to identify abnormalities that were (i) not attributed to cGVHD or (ii) attributed to cGVHD plus other causes. Abnormalities attributed to causes other than GVHD were recorded. Eighty (14%) abnormalities were not attributed to cGVHD in at least one organ, and 41 (7%) abnormalities were attributed to cGVHD plus other causes in at least one organ. A total of 436 (78%) abnormalities were attributed only to cGVHD. Abnormalities not attributed to cGVHD were observed most frequently in the lung, gastrointestinal tract and skin. Most common abnormalities included pre-transplant condition, sequelae from GVHD, deconditioning, infections and medications. Our results support the 2014 NIH consensus recommendation to consider attribution when scoring organ abnormalities.
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Affiliation(s)
- S Z Aki
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- Gazi University Faculty of Medicine Department of Hematology, Ankara, Turkey
| | - Y Inamoto
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - P A Carpenter
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - B E Storer
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - B M Sandmaier
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - S J Lee
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - P J Martin
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
| | - M E D Flowers
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
- University of Washington, Division of Medical Oncology, Seattle, WA, USA
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Weissinger EM, Human C, Metzger J, Hambach L, Wolf D, Greinix HT, Dickinson AM, Mullen W, Jonigk D, Kuzmina Z, Kreipe H, Schweier P, Böhm O, Türüchanow I, Ihlenburg-Schwarz D, Raad J, Durban A, Schiemann M, Könecke C, Diedrich H, Holler E, Beutel G, Krauter J, Ganser A, Stadler M. The proteome pattern cGvHD_MS14 allows early and accurate prediction of chronic GvHD after allogeneic stem cell transplantation. Leukemia 2016; 31:654-662. [PMID: 27677743 DOI: 10.1038/leu.2016.259] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 08/24/2016] [Accepted: 08/30/2016] [Indexed: 12/14/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) may be curative, but is associated with significant morbidity and mortality. Chronic graft-versus-host disease (cGvHD), characterized by inflammation and fibrosis of multiple target organs, considerably contributes to the morbidity and mortality even years after allo-HSCT. Diagnosis of cGvHD is based on clinical features and histology of biopsies. Here, we report the generation of a urinary cGvHD-specific proteome-pattern (cGvHD_MS14) established by capillary electrophoresis-mass spectrometry to predict onset and severity of cGvHD as an unbiased laboratory test. cGvHD_MS14 was evaluated on samples from 412 patients collected prospectively in four transplant centers. Sensitivity and specificity was 84 and 76% by cGvHD_MS14 classification. Sensitivity further increased to 93% by combination of cGvHD_MS14 with relevant clinical variables to a logistic regression model. cGvHD was predicted up to 55 days prior to clinical diagnosis. Acute GvHD is not recognized by cGvHD_MS14. cGvHD_MS14 consists of 14 differentially excreted peptides, six of those have been sequenced to date and are fragments from thymosin β-4, eukaryotic translation initiation factor 4γ2, fibrinogen β-chain or collagens. In conclusion, the cGvHD_MS14-pattern allows early, highly sensitive and specific prediction of cGvHD as an independent diagnostic criterion of clinical diagnosis potentially allowing early therapeutic intervention.
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Affiliation(s)
- E M Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - C Human
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - J Metzger
- Mosaiques-Diagnostics, Hannover, Germany
| | - L Hambach
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - D Wolf
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | - H T Greinix
- 1st Department of Internal Medicine, Medical University of Vienna, Vienna, Austria and Division of Hematology, Medical University of Graz, Graz, Austria
| | - A M Dickinson
- Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - W Mullen
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - D Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Z Kuzmina
- 1st Department of Internal Medicine, Medical University of Vienna, Vienna, Austria and Division of Hematology, Medical University of Graz, Graz, Austria
| | - H Kreipe
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - P Schweier
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - O Böhm
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - I Türüchanow
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - D Ihlenburg-Schwarz
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - J Raad
- Mosaiques-Diagnostics, Hannover, Germany
| | - A Durban
- Mosaiques-Diagnostics, Hannover, Germany
| | | | - C Könecke
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - H Diedrich
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - E Holler
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | - G Beutel
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - J Krauter
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany.,Department of Hematology and Oncology, Klinikum Braunschweig, Braunschweig, Germany
| | - A Ganser
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
| | - M Stadler
- Department of Hematology, Hemostasis, Oncology and Stem cell transplantation, Hannover Medical School, Hannover, Germany
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Predicting chronic GVHD outcomes: are we there yet? Blood 2016; 127:14-5. [PMID: 26744439 DOI: 10.1182/blood-2015-11-681072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this issue of Blood, Palmer et al provide encouragement that important chronic graft-versus-host disease (GVHD) patient outcomes (such as overall survival [OS] and failure-free survival [FFS]) are predicted by clinician-assessed response, patient-reported outcomes, and 2014 National Institutes of Health (NIH)-response criteria.
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43
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Vasconcellos de Souza C, Vigorito AC, Miranda ECM, Garcia C, Rensi Colturato VA, Mauad MA, Rodrigues Moreira MC, da Silva Bouzas LF, Lermontov S, Hamerschlak N, Rodrigues M, Carlos de Almeida Barros J, Chiattone R, Lee SJ, Flowers MED. Translation, Cross-Cultural Adaptation, and Validation of the Lee Chronic Graft-versus-Host Disease Symptom Scale in a Brazilian Population. Biol Blood Marrow Transplant 2016; 22:1313-1318. [PMID: 27058616 DOI: 10.1016/j.bbmt.2016.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/09/2016] [Indexed: 12/11/2022]
Abstract
The Lee Chronic Graft-versus-Host Disease (GVHD) Symptom Scale is a patient-reported instrument developed and validated in English to measure the symptoms and functional impact of cGVHD. This tool has not yet been validated in a Latin American population, however. The Brazil-Seattle Chronic GVHD Consortium conducted a multicenter study at 5 Brazilian institutions to validate the Lee cGVHD Symptom Scale in adults with cGVHD. Study objectives included the translation and validation of the instrument in Brazilian Portuguese and evaluation of the correlation with other quality of life (QoL) tools, including the Medical Outcomes Study Short Form 36 (SF-36) and Functional Assessment of Chronic Illness Therapy with Bone Marrow Transplant subscale (FACT-BMT). Translation and validation were done according to the American Association of Orthopedic Surgeons Outcome Committee guidelines. Spearman's correlation coefficient was used to measure construct validity. Reliability was assessed using Cronbach's α and intraclass correlation coefficients. Between April 2011 and August 2012, 47 patients with cGVHD based on the 2005 National Institutes of Health criteria (29 males [62%], 18 females [38%]; median age, 48 years; range, 23 to 69 years) were enrolled in this study. The reliability of the Lee cGVHD Symptom Scale was adequate (Cronbach's α = 0.62 to 0.83). The correlations between similar domains of the Lee cGVHD Symptom Scale, SF-36, and FACT-BMT were moderate to high. Our data indicate that the Brazilian Portuguese version of the Lee cGVHD Symptom Scale is valid and reliable and can be used in clinical trials of cGVHD in Brazil.
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Affiliation(s)
| | | | | | - Celso Garcia
- Bone Marrow Transplant Unit, University of Campinas, Campinas, Brazil
| | | | | | | | | | - Simone Lermontov
- Bone Marrow Transplant Unit, National Institute of Cancer/Bone Marrow Transplant Center, Rio de Janeiro, Brazil
| | - Nelson Hamerschlak
- Bone Marrow Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Morgani Rodrigues
- Bone Marrow Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ricardo Chiattone
- Bone Marrow Transplant Unit, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Medical Oncology, University of Washington, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Medical Oncology, University of Washington, Seattle, Washington.
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Ballester-Sánchez R, Navarro-Mira M, Sanz-Caballer J, Botella-Estrada R. Aproximación a la enfermedad injerto contra huésped cutánea. ACTAS DERMO-SIFILIOGRAFICAS 2016; 107:183-93. [DOI: 10.1016/j.ad.2015.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/29/2015] [Accepted: 10/04/2015] [Indexed: 12/22/2022] Open
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Ballester-Sánchez R, Navarro-Mira M, Sanz-Caballer J, Botella-Estrada R. Review of Cutaneous Graft-vs-Host Disease. ACTAS DERMO-SIFILIOGRAFICAS 2016. [DOI: 10.1016/j.adengl.2016.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Late Onset and Protracted Course of Steroid Refractory Chronic Graft-versus-Host Disease. Case Rep Hematol 2015; 2015:692175. [PMID: 26613052 PMCID: PMC4646988 DOI: 10.1155/2015/692175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/25/2015] [Indexed: 11/25/2022] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is one of the most important causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (aHSCT). Occurring in 30% to 70% of patients, cGVHD has a median time to onset of 4 to 6 months and most cases present within 2 years after aHSCT. Here, we present a patient transplanted at the age of 55 who developed refractory cutaneous cGVHD more than 5.5 years after aHSCT.
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Predictors of survival, nonrelapse mortality, and failure-free survival in patients treated for chronic graft-versus-host disease. Blood 2015; 127:160-6. [PMID: 26527676 DOI: 10.1182/blood-2015-08-662874] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/02/2015] [Indexed: 12/24/2022] Open
Abstract
Chronic graft-versus-host disease (GVHD) is a pleotropic syndrome that lacks validated methods of measuring response in clinical trials, although several end points have been proposed. To investigate the prognostic significance of these proposed end points, such as the 2005 National Institutes of Health (NIH) response measures, 2014 NIH response measures, clinician-reported response, and patient-reported response, we tested their ability to predict subsequent overall survival (OS), nonrelapse mortality (NRM), and failure-free survival (FFS). Patients (n = 575) were enrolled on a prospective chronic GVHD observational trial. At 6 months, clinician-reported response (P = .004) and 2014 NIH-calculated response (P = .001) correlated with subsequent FFS, and clinician-reported response predicted OS (P = .007). Multivariate models were used to identify changes in organ involvement, laboratory values, and patient-reported outcomes that were associated with long-term outcomes. At 6 months, a change in the 2005 NIH 0 to 3 clinician-reported skin score and 0 to 10 patient-reported itching score predicted subsequent FFS. Change in the Lee skin symptom score and Functional Assessment of Cancer Therapy-Bone Marrow Transplant score predicted subsequent OS. Change in the Lee skin symptom score predicted subsequent NRM. This study provides evidence that clinician-reported response and patient-reported outcomes are predictive of long-term survival. The trial was registered at www.clinicaltrials.gov as #NCT00637689.
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Arai S, Pidala J, Pusic I, Chai X, Jaglowski S, Khera N, Palmer J, Chen GL, Jagasia MH, Mayer SA, Wood WA, Green M, Hyun TS, Inamoto Y, Storer BE, Miklos DB, Shulman HM, Martin PJ, Sarantopoulos S, Lee SJ, Flowers MED. A Randomized Phase II Crossover Study of Imatinib or Rituximab for Cutaneous Sclerosis after Hematopoietic Cell Transplantation. Clin Cancer Res 2015; 22:319-27. [PMID: 26378033 DOI: 10.1158/1078-0432.ccr-15-1443] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/21/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE Cutaneous sclerosis occurs in 20% of patients with chronic graft-versus-host disease (GVHD) and can compromise mobility and quality of life. EXPERIMENTAL DESIGN We conducted a prospective, multicenter, randomized, two-arm phase II crossover trial of imatinib (200 mg daily) or rituximab (375 mg/m(2) i.v. weekly × 4 doses, repeatable after 3 months) for treatment of cutaneous sclerosis diagnosed within 18 months (NCT01309997). The primary endpoint was significant clinical response (SCR) at 6 months, defined as quantitative improvement in skin sclerosis or joint range of motion. Treatment success was defined as SCR at 6 months without crossover, recurrent malignancy or death. Secondary endpoints included changes of B-cell profiles in blood (BAFF levels and cellular subsets), patient-reported outcomes, and histopathology between responders and nonresponders with each therapy. RESULTS SCR was observed in 9 of 35 [26%; 95% confidence interval (CI); 13%-43%] participants randomized to imatinib and 10 of 37 (27%; 95% CI, 14%-44%) randomized to rituximab. Six (17%; 95% CI, 7%-34%) patients in the imatinib arm and 5 (14%; 95% CI, 5%-29%) in the rituximab arm had treatment success. Higher percentages of activated B cells (CD27(+)) were seen at enrollment in rituximab-treated patients who had treatment success (P = 0.01), but not in imatinib-treated patients. CONCLUSIONS These results support the need for more effective therapies for cutaneous sclerosis and suggest that activated B cells define a subgroup of patients with cutaneous sclerosis who are more likely to respond to rituximab.
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Affiliation(s)
- Sally Arai
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Iskra Pusic
- Division of Oncology, Section of Bone Marrow Transplantation, Washington University School of Medicine, St. Louis, Missouri
| | - Xiaoyu Chai
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Samantha Jaglowski
- Division of Hematology, Internal Medicine, Ohio State University, Columbus, Ohio
| | - Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - George L Chen
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Madan H Jagasia
- Department of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - William A Wood
- Department of Hematology/Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Michael Green
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Teresa S Hyun
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yoshihiro Inamoto
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David B Miklos
- Department of Medicine/Division of Blood and Marrow Transplant, Stanford University School of Medicine, Stanford, California
| | - Howard M Shulman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
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Martin PJ, Lee SJ, Przepiorka D, Horowitz MM, Koreth J, Vogelsang GB, Walker I, Carpenter PA, Griffith LM, Akpek G, Mohty M, Wolff D, Pavletic SZ, Cutler CS. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: VI. The 2014 Clinical Trial Design Working Group Report. Biol Blood Marrow Transplant 2015; 21:1343-59. [PMID: 25985921 PMCID: PMC4506719 DOI: 10.1016/j.bbmt.2015.05.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
Treatment of chronic graft-versus-host disease is intended to produce a sustainable benefit by reducing symptom burden, controlling objective manifestations of disease activity, preventing damage and impairment, and improving overall survival without causing disproportionate harms related to the treatment itself. Successful management can control the disease until systemic treatment is no longer needed. The complexity of the disease, the extended duration of follow-up needed to observe disease resolution and withdrawal of immunosuppressive treatment, and the lack of fully developed shorter term endpoints impede progress in the field. Identification and characterization of primary endpoints demonstrating clinical benefit without requiring years of follow-up is urgently needed, with the understanding that clinical benefit encompasses not only the self-evident benefit of the primary endpoint but also any other associated benefits. This report discusses regulatory considerations, eligibility criteria, the value of controlled trial designs, the merits of proposed primary endpoints, and key considerations elaborated from experience and progress during the past decade. The report concludes by mapping an overall approach that could support and lead to maximally informative clinical trials, especially those that seek to demonstrate clinical benefit along a pathway to regulatory review and approval.
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Affiliation(s)
- Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- Center for Drug Evaluation Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Mary M Horowitz
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Koreth
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Georgia B Vogelsang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Linda M Griffith
- Division of Allergy, Immunology and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Gorgun Akpek
- Stem Cell Transplant Program, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Mohamad Mohty
- Clinical Hematology and Cellular Therapy Department, Hôpital Saint-Antoine, University Pierre & Marie Curie, INSERM U938, Paris, France
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Steven Z Pavletic
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Corey S Cutler
- Division of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Lee SJ, Wolff D, Kitko C, Koreth J, Inamoto Y, Jagasia M, Pidala J, Olivieri A, Martin PJ, Przepiorka D, Pusic I, Dignan F, Mitchell SA, Lawitschka A, Jacobsohn D, Hall AM, Flowers MED, Schultz KR, Vogelsang G, Pavletic S. Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: IV. The 2014 Response Criteria Working Group report. Biol Blood Marrow Transplant 2015; 21:984-99. [PMID: 25796139 PMCID: PMC4744804 DOI: 10.1016/j.bbmt.2015.02.025] [Citation(s) in RCA: 274] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 02/26/2015] [Indexed: 12/17/2022]
Abstract
In 2005, the National Institutes of Health (NIH) Chronic Graft-versus-Host Disease (GVHD) Consensus Response Criteria Working Group recommended several measures to document serial evaluations of chronic GVHD organ involvement. Provisional definitions of complete response, partial response, and progression were proposed for each organ and for overall outcome. Based on publications over the last 9 years, the 2014 Working Group has updated its recommendations for measures and interpretation of organ and overall responses. Major changes include elimination of several clinical parameters from the determination of response, updates to or addition of new organ scales to assess response, and the recognition that progression excludes minimal, clinically insignificant worsening that does not usually warrant a change in therapy. The response definitions have been revised to reflect these changes and are expected to enhance reliability and practical utility of these measures in clinical trials. Clarification is provided about response assessment after the addition of topical or organ-targeted treatment. Ancillary measures are strongly encouraged in clinical trials. Areas suggested for additional research include criteria to identify irreversible organ damage and validation of the modified response criteria, including in the pediatric population.
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Affiliation(s)
- Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Wolff
- Department of Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Carrie Kitko
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - John Koreth
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Madan Jagasia
- Division of Hematology-Oncology, Vanderbilt University, Nashville, Tennessee
| | - Joseph Pidala
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Attilio Olivieri
- Department of Clinical and Molecular Sciences, University of Ancona, Ancona, Italy
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Donna Przepiorka
- US Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland
| | - Iskra Pusic
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Fiona Dignan
- Department of Clinical Haematology, University of Manchester, Manchester, United Kingdom
| | - Sandra A Mitchell
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland
| | - Anita Lawitschka
- Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - David Jacobsohn
- Division of Blood and Marrow Transplantation, Children's National Health System, Washington, District of Columbia
| | - Anne M Hall
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kirk R Schultz
- BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | | | - Steven Pavletic
- Outcomes Research Branch, National Cancer Institute, Bethesda, Maryland.
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