Case 1: Staging of Acute Graft-vs-Host Disease

Corey Cutler, MD, MPH, FRCPC: Thanks for presenting that case. This is really, as you said, a classic case of acute graft-vs-host disease [GVHD], but it does bring up a number of questions that we can ask regarding this case of acute graft-vs-host disease. Some of the things we can talk about, and that we are going to review, are understanding how we stage or grade this patient’s graft-vs-host disease and your approach to whether this patient required a biopsy or histologic diagnosis. What are the alternative treatment approaches that you could have considered for this patient and the understanding that if this patient was treated with steroids, what would the prediction be for the likelihood for him to have responded? With that, I’m going to pass it back to you to take us through some of these questions.

Usama Gergis, MD, MBA: Indeed, Corey. At day 22, he had probably just been grafted. He has a skin rash and diarrhea. Is this acute graft-vs-host disease? It probably is, but what if it is not? What could that be? A chemotherapy effect? Engraftment syndrome? Drug effect? The majority of our patients get neutropenic fever when they start on antibiotics, and this is probably during the end of the antibiotics, so it could be many things. Should we biopsy this man? Can we do a skin biopsy? Should he go for a colonoscopy?

I think he should. I just moved to my new job at Sidney Kimmel Cancer Center in Philadelphia, Pennsylvania from New York, where we did T-cell depletion, and the diarrhea could indeed be something else. It could indeed be CMV [cytomegalovirus] infection. You don’t want to, as this case showed, commit this man to a huge burden of steroids for a long time while he has something like CMV colitis or, even worse, adenovirus colitis.

Corey Cutler, MD, MPH, FRCPC: I agree with you entirely, and I suspect Dan does as well. But let me ask Dan a question. If you chose to do a biopsy, would you wait for the results of that biopsy before starting steroids in this scenario?

Daniel Couriel, MD, MS: That is a great point. No, I would not. I would get the biopsy. I know there are differences in opinion there, but I would not delay therapy for the result of the biopsy.

Corey Cutler, MD, MPH, FRCPC: I agree. I suspect, Usama, that you do as well. Why don’t you tell us, though, how you stage and grade this. You alluded to body surface area, but why don’t you formally run us through how this patient’s GVHD is graded.

Usama Gergis, MD, MBA: Sure, Corey. I must also add that the majority of these cases come on a Friday afternoon, right before Memorial Day weekend. Waiting can make things worse, while you are waiting for that biopsy or colonoscopy on a Tuesday. I think we all have a consensus that while a biopsy is a good thing, we should not wait. We should treat before the genie is out of the bottle.

There are many staging and grading classifications for acute graft-vs-host disease. In my current institution, as well as at my prior institution, we use the oldest, Glucksberg grading, which dates to 1974. It has been adopted many times in more recent staging and grading, most notably the MAGIC Consortium, the Mount Sinai Acute Graft-vs-Host Disease International Consortium. Again, it is an adaptation of a more than 40-year-old staging and grading system.

In a nutshell, as you said, Corey, the 3 main organs, the only organs, that get affected by acute graft-vs-host disease, classic graft-vs-host disease, are the skin, the gastrointestinal [GI] tract, and the liver. Per organ, it is considered a stage, so we stage the organ. Together, we get a score or a grade.

Like the man here, he has 60% of his body surfaces involved; that is skin stage III. He had 4 bowel movements; that is a GI stage I. Together, that makes a grade II acute graft-vs-host disease.

Transcript edited for clarity.