Corey S. Cutler, MD, MPH, FRCPC: How do we define chronic graft-versus-host disease [GvHD]? First and foremost, chronic graft-versus-host disease is a clinical syndrome and is defined based on a clinical diagnosis. The name implies that the disease occurred late after transplant. But in fact, the temporal relationship of GvHD to transplant actually does not matter. You can have chronic GvHD that occurs early. It more typically occurs late. But the clinical constellation of symptoms that this patient has defines this as chronic GvHD with lichenoid changes in the mouth, the skin, the nail bed, and the joint involvement. All of those factors together make this chronic graft-versus-host disease.
Chronic GvHD occurs between 20% and 50% of all transplant recipients, depending on a number of factors, such as donor, stem cell source, and the type of GvHD prevention regimen that was used. Again, you make the diagnosis based on clinical factors. There are no real imaging tests that are required. However, I do recommend that pulmonary function tests are done on all patients at the time of initial diagnosis of chronic GvHD, so that you can exclude subclinical lung involvement. That’s very important because lung involvement can be subclinical until it gets fairly severe. We don’t biopsy organs for the most part unless there’s a clinical conundrum. Usually the presentation of the skin rash, or the erythema, or ulcers in the mouth are generally diagnostic enough. But in certain circumstances, we do biopsies when there is a clinical differential diagnosis.
Transcript edited for clarity.
Case: A 49-Year-Old Man With Steroid-Refractory Chronic Graft Versus Host Disease