Graft vs. host skin disease

Graft vs. host skin disease

Chronic graft vs. host disease
A paradigm for the study of skin disease co-morbidity

by: Dermatotoxicity session
Society for Investigative Dermatology
Burden of Skin Disease Co-Morbidity Conference


Edward W. Cowen, MD, MHSc
Dermatology Branch, CCR
National Cancer Institute, NIH


Objectives


* Epidemiology of chronic graft-versus-host disease (cGVHD)
* Brief review of skin and other organ manifestations

* Barriers to effective management and a few (possible) solutions

Graft-versus-host disease (GVHD)

* Allogeneic hematopoietic stem cell transplantation (Allo-SCT)

* Autologous-SCT, solid organ, transfusion-related

* Host: Patient
o Hematopoietic ablation (chemotherapy/radiation)

* Graft: Donor stem cells
o Bone marrow
o Cord blood
o Peripheral blood (PBSCT)
+ Mobilization (Filgrastim;Neupogen®) - apheresis

* NIH Clinical Center
o 100+ allogeneic transplants/year

* 15,000 allogeneic transplants/year

* Indications
o Hematologic malignancies
o Primary immunodeficiencies
o Inherited enzymatic defects
o Solid tumors
o Autoimmune disease

Diseases treated by transplantation

Chronic GVHD
Incidence of chronic GVHD
Homeostasis
Hematopoeitic chimerism
All other tissues
All hematopoeitic cells
Hematopoeitic chimerism
Lymphocyte Infusion
Graft vs. leukemia/
Graft vs. tumor effect
Hematopoeitic cells
Other tissues
Homeostasis
Immunosuppressive therapy
Recurrent malignancy,
Opportunistic infection
Hematopoeitic cells
cGVHD: non-dermatologic manifestations
Erythema and ulcers
Viral or fungal infection
Abnormal motility
Secondary viral or fungal infection
Bronchiolitis obliterans
Dryness, strictures
Myasthenia gravis
cGVHD: a polymorphous skin disorder
Epidermal cGVHD
Dermal cGVHD
Subcutaneous cGVHD
cGVHD is a cutaneous mimic
Co-morbidity of cutaneous cGVHD
cGVHD: management
cGVHD salvage therapy
cGVHD: (barriers to) management
Barriers to effective management
Possible solutions
Barriers to effective management
Possible solutions
Chronic Cutaneous GVHD Skin Assessment
Erosion vs. Ulceration
Biology Blood Marrow Transplant 2005-6.

cGVHD
Hematology/Oncology
Dermatology
Dentistry/Oral Surgery
Rheumatology
Infectious Diseases
Ophthalmology
Pain/Palliative Care
Nutritional Support
Rehabilitation Medicine
NIH: multidisciplinary approach to cGVHD
Natural history of disease
Montelukast (Singulair®)
Extracorporal photopheresis
Imatinib for sclerotic cGVHD
DNA Microarray analysis
High-resolution MRI/US
Topical thalidomide
Cyclosporine implants
NIH National Consensus Guidelines for cGVHD Clinical Trials and Management
Barriers to effective management
Possible solutions
A final thought

Graft vs. host skin disease.ppt