Organ System Involvement and Mortality In Acute Graft-Versus-Host Disease

Acute graft-versus-host disease (aGVHD) is a significant source of morbidity and mortality following allogeneic hematopoietic stem cell transplantation (HSCT). aGVHD targets the skin, gastrointestinal (GI) tract, and liver resulting in three key clinical features: skin rash, serum bilirubin elevation, and diarrhea. The primary objective was to identify the incidence of GI tract and liver involvement in patients with cutaneous aGVHD, and to compare mortality between skin-limited and extra-cutaneous disease.

A retrospective medical record review was performed to collect data from patients who underwent allogeneic HSCT at a large, urban, NCI Comprehensive Cancer Center over a 24 month period (2010-2011). All patients diagnosed with cutaneous aGVHD by the primary transplant team or the dermatology consult service were analyzed. Data collected included timing of skin eruption relative to transplant, aGVHD symptoms, method of diagnosis of aGVHD of the GI tract and/or liver, and patient one-year post-transplant mortality.

137 patients received an allogeneic HSCT during 2010-2011. 45% (62/137) of these patients were diagnosed with cutaneous aGVHD. The mean onset of rash was day + 47 (range + 6 to +153). aGVHD was limited to the skin in 42% (26/62) of patients, and 58% (36/62) had cutaneous + GI tract and/or liver aGVHD. Of patients with aGVHD, 26% (16/62) had cutaneous + GI tract involvement, 6% (4/62) had cutaneous + liver involvement, and 26% (16/62) had cutaneous + GI tract + liver involvement.

Of the 62 aGVHD patients, 39 received a myeloablative transplant (63%) and 23 received a non-myeloablative transplant (37%). The incidence of skin-limited aGVHD in patients receiving myeloablative HSCT was 33% (13/39), as compared to an incidence of 57% (13/23) in patients receiving non-myeloablative HSCT. Extra-cutaneous disease occurred in 67% (26/39) of patients receiving myeloablative HSCT compared to 43% (10/23) of patients receiving non-myeloablative HSCT.

All-cause, one-year post-transplant mortality in patients with cutaneous aGVHD was 52% (32/62). Mortality was highest in the subgroup of patients with cutaneous + liver involvement (75%), followed by cutaneous + GI tract + liver involvement (56%), cutaneous involvement only (39%), and cutaneous + GI tract involvement (31%). There was no statistically significant difference in mortality between those with aGVHD limited to the skin as compared to those with skin + GI tract and/or liver disease (39% vs 44%; p=0.64).

In this study, cutaneous aGVHD presented more frequently with concurrent skin and extra-cutaneous disease compared to those who had skin-limited disease, and 26% (16/62) had involvement of all three organs. There was little difference in mortality between patients with aGVHD limited to the skin compared to patients with skin + GI tract and/or liver aGVHD.

Mehta:Celgene: Speakers Bureau; Millennium: Speakers Bureau. Cotliar:Therakos: Honoraria; BMS Oncology: Honoraria.