Patient Profile: A 35-Year-Old Woman with Chronic GVHD

Video

Nelson J. Chao, MD, presents a patient profile of a 35-year-old woman diagnosed with chronic graft-vs-host disease, and provides his initial thoughts.

Case: A 35-Year-Old Woman with Chronic GVHD

  • A 35-year-old woman received busulfan and cyclophosphamide conditioning prior to a matched unrelated donor peripheral blood stem cell transplant for acute myeloid leukemia; tacrolimus and methotrexate were administered as graft-vs-host disease prophylaxis.
  • PMH of type 2 diabetes.
  • Post-transplant, experienced the following:
    • +1 month post-transplant, grade II acute skin GVHD, resolved with glucocorticoids
    • +6 months post-transplant, grade I vaginal dryness, treated with topical estrogen
    • +11 months post-transplant, grade I dry eyes/foreign body sensation, treated with lubricating eye drops
  • Now, + 12 months post-transplant, grade 2 muscle and joint paint that limits daily exercise routine, treated with prednisone
  • Supportive care and counseling provided
  • 1 mg/kg/day prednisone tapered to 0.25 mg/kg/day
  • During steroid taper, patient developed grade 2 mouth symptoms with ulceration and lichenoid features as well as maculopapular rash/erythema on lower torso (BSA 10%)

Transcript:

Nelson J. Chao, MD: Hello, my name is Nelson Chao. I’m a professor of medicine at Duke University. Today we’re going to discuss a [Targeted Oncology™] Case-Based Peer Perspective on a 35-year-old woman with chronic graft-vs-host disease [GVHD].

This is a 35-year-old woman who received busulfan and cyclophosphamide conditioning prior to a matched unrelated donor peripheral blood stem cell transplant for a diagnosis of acute myeloid leukemia. She then received tacrolimus methotrexate as part of graft-vs-host disease prophylaxis. Her past medical history was remarkable for type 2 diabetes.

The transplants did well. About 1 month after transplant, she developed grade 2 acute skin GVHD, which resolved with glucocorticoids. Six months after transplant, she developed grade 1 vaginal dryness, which was treated with topical estrogen. Eleven months after transplant, she developed grade 1 dry eyes with a foreign body sensation. That was treated primarily with lubricating eye drops. She returns 12 months after transplant with grade 2 muscle joint pain that limits daily exercise routine, and she has been started on prednisone. Supportive care and counseling are provided. She was started on 1 mg/kg of prednisone. Over the next several months, that was tapered down to 0.25 mg/kg/day. However, during this steroid taper, she developed grade 2 mouth symptoms with ulceration, lichenoid changes, and maculopapular erythema on her lower torso, which is about 10% of her body surface area.

This is a patient who had still very little acute GVHD but clearly seems to be progressing with chronic graft-vs-host disease. Chronic graft-vs-host disease is scored based on the NIH [National Institutes of Health] consensus criteria, which includes 9 organ systems. The score goes from 0 to 3. Each of these organ systems, including the skin, mouth, GI [gastrointestinal] tract, liver, lungs, joints, fascia, and the female genitalia, has this scoring system: 0 is no involvement, and 3 is severe involvement.

What one can do with this, and this has been helpful with in terms of setting this up, is it allows clinical trials to proceed where the language of chronic GVHD is uniform across different centers. Once we get these scores, we can put these together and score these patients between mild, moderate, and severe. Mild chronic GVHD is 1 or 2 organs with a score of 1 but a lung score of 0. That’s the low end. At the moderate level, you have 3 or more organs involved with no more than a score of 1, or at least 1 organ but not the lung, with a score of 2. Everything above that would be a score higher than that, which would place those patients in the severe category. This patient has a score 2 of the fascia, which puts the patient at the moderate category for chronic graft-vs-host disease.

Transcript edited for clarity.

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