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© 2012 APHON 1
APHON/PBMTC’s Foundations of Pediatric Hematopoietic Progenitor Cell Transplantation: A Core Curriculum, 2nd Edition
© 2012 APHON
Hematopoietic Progenitor Hematopoietic Progenitor Cell Transplantation: Cell Transplantation: Chronic Graft-Versus-Host Chronic Graft-Versus-Host DiseaseDisease
Kimberly Thormann Powers, MA RN CPNPKimberly Thormann Powers, MA RN CPNP
© 2012 APHON 2
ObjectivesObjectives
• Define chronic graft versus host disease (cGVHD).
• Identify risk factors for cGVHD.• Discuss cGVHD diagnosis and evaluation. • List the factors associated with poor prognosis in
cGVHD.• Describe cGVHD management and treatment.
© 2012 APHON 3
cGVHD: ProcesscGVHD: Process
• Donor T lymphocytes (graft) attack the immunologically incompetent recipient (host)Damage of host tissues
• Often resembles an autoimmune collagen vascular disease
• Poorly understood
© 2012 APHON 4
cGVHD: TypescGVHD: Types
• Progressive cGVHDExtension of acute GVHD (aGVHD)
• De novo cGVHDWithout preceding GVHD
• Quiescent cGVHDAfter resolution of aGVHD
© 2012 APHON 5
cGVHD: Target OrganscGVHD: Target Organs
• Skin• Oral• Ocular• Hepatic
• Pulmonary• Gastrointestinal (GI)• Gynecological• Musculoskeletal• Immunologic
© 2012 APHON 6
Spectrum of manifestations in cGVHD
© 2012 APHON 7
cGVHD ComplicationscGVHD Complications
© 2012 APHON 8
cGVHD: Risk FactorscGVHD: Risk Factors
• Hematopoietic progenitor cell transplantation (HPCT) related aGVHD Human leukocyte antigen (HLA)
disparity Older donor age Peripheral blood stem cells
(PBSCs) as hematopoietic progenitor cell source
Short-course cyclosporine Donor lymphocyte infusion Female-to-male bone marrow
transplantation (BMT) Unrelated HPCT
• Recipient related Older age Viral infection Number of post-HPCT
transfusions Splenectomy Prolonged steroid
treatment
© 2012 APHON 9
cGVHD: Poor Prognostic SignscGVHD: Poor Prognostic Signs
• Persistent severe thrombocytopenia
• Lichenoid changes on skin histology
• Serum bilirubin >1.2 mg/dl• Progressive onset from
acute to chronic • Karnofsky performance <70%
© 2012 APHON 10
Who Is at Higher Risk of Developing Who Is at Higher Risk of Developing cGVHD?cGVHD?
• Case study1. A 12-year-old boy with AML s/p matched
unrelated donor (45-year-old woman) bone marrow with nonmyeloablative HPCT who has a viral infection after being treated for aGVHD.
2. A 4-year-old boy with MDS s/p matched unrelated donor (30-year-old woman) peripheral blood HPCT with myeloablative conditioning who has never had aGVHD.
© 2012 APHON 11
cGVHD: Incidence cGVHD: Incidence
• 40% in patients receiving HLA-identical sibling HPCT
• >50% in HLA-mismatched related sibling HPCT
• 40% to 60% unrelated HPCT, 70% in patients >50 years
• Greater incidence of cGVHD with PBSCs
© 2012 APHON 12
Skin cGVHDSkin cGVHD
• Most commonly involved organ• Inflammatory changes cause
Sclerodermatous presentationoFibrotic thickeningoLeads to contractures and nerve compression
Lichenoid changes oErythematous raised papular skin rashoMay present with only dryness,
hypo- or hyperpigmentation
© 2012 APHON 13
Skin cGVHD: Clinical ManifestationsSkin cGVHD: Clinical Manifestations
• Itching• Burning• Ulcerations• Erythema• Hyperpigmentation• Hypopigmentation• Atrophy• Loss of sweating
• Pain• Flakiness• Shiny appearance• Vertical ridging and
splitting of the nail beds• Alopecia• Graying hair
© 2012 APHON 14
cGVHD: Sclerodermatous Skin cGVHD: Sclerodermatous Skin InvolvementInvolvement
© 2012 APHON 15
© 2012 APHON 16
cGVHD: Lichenoid Skin ChangescGVHD: Lichenoid Skin Changes
© 2012 APHON 17
© 2012 APHON 18
Healthy Skin Biopsy
cGVHD Skin Biopsy
Skin cGVHD: Diagnostic BiopsySkin cGVHD: Diagnostic Biopsy
© 2012 APHON 19
Skin cGVHD: Nursing AssessmentSkin cGVHD: Nursing Assessment
• Assess forAltered integrityAltered body imageNail integrityMonitor for infection
© 2012 APHON 20
Skin cGVHD: Nursing ManagementSkin cGVHD: Nursing Management
• Promote skin care• Administer hydrating lotions, pain medications,
antibiotics, and topical medications• Give immunosuppressant therapy and obtain
drug levels as indicated• Use clear nail polish to strengthen nails and
prevent breakage• Encourage frequent nail care• Consult dermatology• Educate on sun damage and use of sunscreen • Promote range of motion (ROM) exercises• Support the altered body image and give
multidisciplinary team support
© 2012 APHON 21
Oral Mucosa cGVHDOral Mucosa cGVHD
• Changes range from erythema to lichenoid eruption to ulceration
• Xerostomia • Associated infection is frequent• Commonly misdiagnosed as oral candidiasis
© 2012 APHON 22
Oral Mucosa cGVHDOral Mucosa cGVHD
Oral cavity 1 Oral cavity 2
Oral cavity 3 Oral cavity 4
© 2012 APHON 23
Oral Mucosa: Nursing Oral Mucosa: Nursing AssessmentAssessment• Assess for
IntakeAltered tasteAnorexiaIncreased sensitivity to
acidic or spicy foodsOral painOral infections Ability to open the mouth
© 2012 APHON 24
Oral Mucosa cGVHD: Nursing Oral Mucosa cGVHD: Nursing ManagementManagement
• Provide steroid rinses as indicated
• Instruct patient and family on dental hygiene
• Assist with mouth care• Educate regarding dietary
recommendations• Consult dental and nutrition
© 2012 APHON 25
Ocular cGVHD: Clinical ManifestationsOcular cGVHD: Clinical Manifestations
• Incidence of ocular cGVHD in those with cGVHD: 65% to 80%
• PresentationInitially, may have
excessive tearingBurning or gritty sensationSicca syndromePhotophobiaCorneal abrasionsPseudomembrane formation
may lead to blindnessKeratitis and scarring may occur
© 2012 APHON 26
Ocular cGVHD Ocular cGVHD
Lymphoplasmacytic infiltrates around ductal structures of lacrimal glands
© 2012 APHON 27
Schirmer’s TestSchirmer’s Test
© 2012 APHON 28
Ocular cGVHD: Nursing AssessmentOcular cGVHD: Nursing Assessment
• AssessAbility for eyes to tearNeed for preservative-free
artificial tearsVision changesPain or gritty sensation
© 2012 APHON 29
Ocular cGVHD: Nursing ManagementOcular cGVHD: Nursing Management
• Assist and instruct family with ophthalmic medication
• Give immunosuppressants Obtain indicated levels
• Prepare patient and family for Schirmer’s test
• Educate the patient and family• Discuss therapeutic treatment
: drops/ lubricationsPunctal plugsSuturesProtective lenses
© 2012 APHON 30
• May have few relatively mild symptoms until cGVHD hepatic disease becomes severe Jaundice Mild hepatomegaly Abnormal coagulation Elevated alkaline phosphatase Elevated transaminases Elevated bilirubin• Rule out infectious etiology
Hepatic cGVHDHepatic cGVHD
© 2012 APHON 31
Liver: Diagnostic BiopsyLiver: Diagnostic Biopsy
Healthy Hepatic Biopsy
cGVHD Hepatic Biopsy
© 2012 APHON 32
Hepatic cGVHD: Nursing Hepatic cGVHD: Nursing AssessmentAssessment• Assess
JaundiceHepatic sizeRight upper quadrant painSkin irritation associated with hyperbilirubinemia
© 2012 APHON 33
Hepatic cGVHD: Nursing ManagementHepatic cGVHD: Nursing Management
• Administer immunosuppressants.
• Avoid hepatotoxic agents.• Send necessary laboratory
tests.• Prepare for diagnostic
testing.• Provide skin care.
© 2012 APHON 34
Pulmonary cGVHD: Clinical Pulmonary cGVHD: Clinical ManifestationsManifestations
• 5% to 10% incidence• Range of clinical manifestations and
presentations of pulmonary cGVHDSinusitis Bronchiolitis Obliterans (BO)
syndromeBronchiolitis Obliterans organizing
pneumonia (BOOP)Restrictive pulmonary disease
© 2012 APHON 35
cGVHD: Sinopulmonary cGVHD: Sinopulmonary ComplicationsComplications• Sinusitis
Sicca syndrome• Bronchiolitis Obliterans (BO)
Fibrotic processDyspnea, cough, and/or exercise intoleranceComputed tomograpy (CT) scan:
patchy hyperaeration, bronchial dilation, increased density
• Bronchiolitis Obliterans organizing pneumonia (BOOP)Shortness of breath (SOB), cough, and feverCT scan: peripheral patchy airspace consolidation,
nodular opacities
© 2012 APHON 36
Pulmonary Function Test Pulmonary Function Test (PFT)(PFT)• Ideally obtained at Day 100 and at 3-month intervals with
any new significant air-flow obstruction• Significant airflow obstruction
Defined as a decrease in forced expiratory volume in 1 second (FEV1) by > 10% compared to pretransplant values and the FEV1 is < 80%, with an FEV1/forced vital capacity ratio < 0.7 without response to bronchodilators
• Obtain full PFT when the FEV1 is < 80% of the predicted normal value
• Significant air trapping: a residual volume > 120% or air trapping noted on high-resolution CT scan
• Pulmonary consultation for significant obstructive pulmonary changes
© 2012 APHON 37
Pulmonary cGVHD: Nursing Pulmonary cGVHD: Nursing AssessmentAssessment
• Assess Breath soundsColorDyspneaCoughOxygen saturationActivity intolerance and fatigueInability to complete activities
of daily living (ADL)Infection
© 2012 APHON 38
Pulmonary cGVHD: Nursing Pulmonary cGVHD: Nursing ManagementManagement
• Encourage breathing exercises• Perform pulmonary toilet
as necessary• Prepare for follow-up scans and PFTs• Administer immunosuppressants and
draw appropriate levels
© 2012 APHON 39
Case StudyCase Study
• 13-year-old girl who underwent matched related sibling donor peripheral blood HPCT for AML. She has falling chimerism, and the immune suppression was manipulated. She developed cGVHD of the skin. During the next few months she noticed some SOB with activity and was treated with steroids. Symptoms resolved, and 3 months after all immune suppression stopped, she again had an increase in her SOB and new lichenoid skin findings.
© 2012 APHON 40
Pre-HPCT PFT
PFT evaluation for SOB
FEV1 % predicted 93%
FEV1 % predicted ↓ to 34%
© 2012 APHON 41
Case Study: Radiographic FindingsCase Study: Radiographic Findings
High-resolution chest CT
CXR: Opacities seen in both lung bases and bilateral pleural effusions greater on the left than the right
© 2012 APHON 42
Gut cGVHD: Clinical ManifestationsGut cGVHD: Clinical Manifestations
• Diarrhea• Anorexia• Nausea and vomiting• Abdominal pain and cramping• Wasting syndrome
MalabsorptionWeight lossPoor performance statusProgressive GI symptoms
(early satiety, dysphagia)• Infection
© 2012 APHON 43
Normal Gut Biopsy
cGVHD Gut Biopsy
Gut: Diagnostic BiopsyGut: Diagnostic Biopsy
© 2012 APHON 44
Gut cGVHD: Nursing AssessmentGut cGVHD: Nursing Assessment
• AssessNausea and vomitingDiarrheaPainDysphagiaWeight lossBleedingFluid statusCaloric intake
© 2012 APHON 45
Gut cGVHD: Nursing Gut cGVHD: Nursing ManagementManagement• Test stools for blood• Measure stool output• Administer fluids• Provide nutritional support
EnteralParenteral
• Administer medications ImmunosuppressantsSupportive care agents
• Prepare for diagnostic procedures• Consult nutrition• Educate regarding diet, immunosuppression, and
associated infection
© 2012 APHON 46
Gynecological cGVHD: Gynecological cGVHD: Clinical Manifestations Clinical Manifestations • Vaginal epithelial damage occurs due to cGVHD
InflammationStricture formationNarrowing
• Vaginal sicca• Vaginal atrophy
Leads to painful sexual intercourse• Symptoms may include
InflammationDry vaginaObstruction of menstrual flow
because of strictures
© 2012 APHON 47
Gynecology: Nursing Assessment Gynecology: Nursing Assessment and Managementand Management
• Assess (within the context of normal growth and development)Sexual dysfunctionPainAltered body image Infection
• ManagementConsult gynecologistEncourage use of
lubricantsEncourage discussion of
sexual issuesEncourage
interdisciplinary team management/specialty referral
Administer medications
© 2012 APHON 48
Musculoskeletal cGVHD: Musculoskeletal cGVHD: Clinical Manifestations Clinical Manifestations • The severe damage done by sclerodermatous
skin cGVHD can cause significant musculoskeletal involvement StiffnessContracturesJoint painLimited ROMMuscle crampsCarpal spasmSwellingArthralgias
© 2012 APHON 49
cGVHD: Contractures cGVHD: Contractures
© 2012 APHON 50
Physical Therapy EvaluationPhysical Therapy Evaluation
Therapist objective findings:2-minute walk test: 7 laps (patient not out of breath after test, limited by shoes, wearing sandals with heel)(1 lap = 50 feet)
Grip Strength
Trial Left Right
1 18 kg/40 lb 19 kg/42 lb
2 21 kg/45 lb 20 kg/45 lb
3 20 kg/43 lb 22 kg/52 lb
Dominant hand: rightDynamometer position: 2
© 2012 APHON 51
Physical Therapy Clinician EvaluationPhysical Therapy Clinician Evaluation
ROM is measured for all the joints by physical therapy, but the MD /APN can do a basic evaluation: 1- poor mobility to 7= full mobility
Shoulder2 3 6
Elbow2 4 7
Wrist and Fingers6
Foot Dorsiflexion
2 341
© 2012 APHON 52
cGVHD: Fasciitis and MyositiscGVHD: Fasciitis and Myositis
• Fasciitis Diagnostic sign of cGVHD Skin swelling: skin taut, bound down,
and irregularly thickened, with small depressed areas (orange peel)
Contractures, joint stiffness Pathology: lymphocytic infiltrates,
increase of collagen fibers
• Myositis Distinctive sign of cGVHD Moderate to severe proximal muscle
weakness, myalgia, fever, contracture, and skin induration
Elevated creatinine phosphokinase and aldolase enzyme
Pathology: degeneration, necrosis, and regeneration of muscle fibers
© 2012 APHON 53
Musculoskeletal: Nursing Musculoskeletal: Nursing Assessment and ManagementAssessment and Management
• AssessPerformance scoreAbility to perform ADLPainROMMonitor for signs and
symptoms of physiologic dysfunction
Monitor for bone damage
Nutritional status
• ManagementPrepare for diagnostic
testsConsult rehabilitation
services Consult orthopedicsAdminister
medicationsCollaborate with
interdisciplinary team
© 2012 APHON 54
Physical Therapy: Evaluation Report Physical Therapy: Evaluation Report
Summary: patient reports functionally ↑ endurance. Low 2-minute walk test d/t patient’s choice of footwear and self-selected pace. Educated patient on gastroc stretch and reviewed importance of hydration to prevent cramping.
GOAL TIME FRAME MET COMMENTS
Will report no cramps with activity
Goal to be met 1 session from 7/9/2010
No New goal
Will increase 2-minute walk to 8
Goal to be met 1 session from 7/9/2010
No New goal
Follow-up: continue to see patient at each clinic visit, every 2 weeks
© 2012 APHON 55
Immune System: Clinical Immune System: Clinical ManifestationsManifestations• cGVHD is immunosuppressive,
and cGVHD treatment is further immunosuppressive, resulting inFunctional asplenia Variable immunoglobulin G (IgG) levelsOpportunistic infectionsCytopenia (thrombocytopenia)
© 2012 APHON 56
cGVHD: Infection RiskcGVHD: Infection Risk
• AssessSigns and symptoms
of infectionRelative risk of
infectionHome environmentSchool reentry
• ManagementAdminister medicationsPrepare for diagnostic
testsObtain laboratory workEducate patient and
familyo Immunosuppressive
treatmentAdminister appropriate
vaccines
© 2012 APHON 57
cGVHD: NIH Consensus cGVHD: NIH Consensus Scoring CriteriaScoring Criteria
• cGVHD is defined by the presence of at least one distinctive
manifestation with support by histologic, radiologic, or laboratory
evidence or diagnostic clinical sign of cGVHD without the features of
aGVHD overlap syndrome where there are features of aGVHD and
cGVHD present
• There is no time limit after stem cell transplant for the diagnosis of any
clinical features
• The differential diagnosis must be ruled out for each system affected
• Clinical score of 0 to 3 for involved sites/organs
© 2012 APHON 58
NIH Consensus: Scoring NIH Consensus: Scoring CriteriaCriteria• Clinically based• Organs/sites assessed/scored
SkinMouthEyesGI tractLiverLungsJoints and fasciaGenitourinary tract
© 2012 APHON 59
NIH cGVHD organ-specific staging From Filipovich, A. H., et al. (2005). National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biology of Blood and Marrow Transplantation, 11(12), 945-956. Reprinted with permission of Elsevier.
© 2012 APHON 60
Classification of GVHDClassification of GVHD
Site or Organ Diagnostic Distinctive Other
Skin PoikilodermaLichen planus
ScleroticMorphea like
Lichen sclerosus
Depigmentation Keratosis pilarisHyperpigmentationHypopigmentationSweat impairment
Ichthyosis
GI Esophageal webEsophageal strictureEsophageal stenosis
Exocrine pancreatic insufficiency
Lung BO on biopsy BO by PFT and radiology
Muscles, joints, fascia FasciitisStiff joints
Contractures
MyositisPolymyositis
EdemaMuscle cramps
Arthralgias/arthritis
Mouth Lichen typeHyperkeratosis plaques
Mouth opens less
XerostomiaMucocele
UlcersPseudomembranes
From Filipovich, A. H. et al. (2005). National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biology of Blood and Marrow Transplantation , 11(12), 948. Reprinted with permission of Elsevier.
© 2012 APHON 61
NIH Consensus: Scoring CriteriaNIH Consensus: Scoring Criteria
• Scoring0: no manifestations or symptoms1: no significant impairment of function2: significant impairment of ADL and
no major disability3: significant impairment of ADL and
major disability
www.asbmt.org
© 2012 APHON 62
cGVHD: NIH Global cGVHD: NIH Global ScoringScoring• Mild
No significant impairment of functionOnly 1 or 2 organs (except lung)Maximum organ score of 1
• ModerateSignificant impairment but no major disability3 or more organs with maximum score of 1One organ with maximum score of 2Lung score of 1
• SevereMajor disabilityScore of 3 in any organ or siteLung score >2
© 2012 APHON 63
cGVHD: Primary cGVHD: Primary TreatmentTreatment• Systemic treatment
Multiple organs sites affected >3Pulmonary involvementOnset of cGVHD while on steroid therapyProgressive onset Thrombocytopenia
• Initial treatment often employs corticosteroidsSingle agentCombination with calcineurin inhibitor
© 2012 APHON 64
cGVHD: Salvage TherapycGVHD: Salvage Therapy
• Refractory cGVHD treatmentMonoclonal antibodies
o InfliximaboEtanerceptoAlemtuzumab
Polyclonal antibodiesoAntithymocyte globulin
Other agents and modalitiesoThalidomideoHydroxychloroquineoPentostatino Imatinib mesylate (GLEEVEC®)oUltraviolet (UV) radiation
Extracorporeal photopheresis (ECP)
© 2012 APHON 65
Treatment Side EffectsTreatment Side Effects
Agent Class Side effect
Pentostatin Nucleoside analogue Nausea, vomiting, infections, anemia
Etanercept TNF receptor Infections
Imatinib Tyrosine kinase inhibitor, PDGF inhibitor
Myelosuppression, weight gain, hepatitis
Montelukast Leukotriene inhibitor Nausea, headache
Infliximab Anti-TNF-a Hypersensitivity, infections
ECP UV irradiation, 8-MOP Skin hypersensitivity, nausea, bleeding
Sirolimus Macrocyclic lactone Myelosuppression, hyperlipidemia, HUS, TTP, renal impairment, fluid accumulation
© 2012 APHON 66
Extracorporeal Extracorporeal photopheresis (ECP)photopheresis (ECP)
© 2012 APHON 67
What Is Extracorporeal What Is Extracorporeal photopheresis?photopheresis?
The photoactivated white blood cells are returned to the patient
Photoactivation with UVA light
Methoxsalen
White blood cells are treated with methoxsalen and exposed to UVA lightBlood is
separated by centrifugation and red blood cells are returned
The UVAR XTS Instrument draws blood from the patient
© 2012 APHON 68
Extracorporeal photopheresis: Extracorporeal photopheresis: Procedure Procedure
• Procedure 150-300 ml of buffy coat (white cells)
is collected by apheresis Methoxypsoralen (photosensitizing
agent) is added to collection bag Cells are exposed to UV light Infused into the patient Well tolerated
o Hypo- or hypertension may occur
o Fluid shifts
• Research Ongoing to determine length,
regularity, and timing of ECP
© 2012 APHON 69
Before ECP
Before ECP
After ECP
After ECP
© 2012 APHON 70
cGVHD: Pediatric Poor cGVHD: Pediatric Poor Prognostic Signs Prognostic Signs • Recipient age• aGVHD Grade II-IV• Female donor to male recipient• Diagnosis of malignancy• TBI in conditioning
© 2012 APHON 71
cGVHD: The TeamcGVHD: The Team
Family/CaregiversBMT Team
Pharmacy
Medical Consultants
Psychology
Nutrition
Social WorkReferring
Team
Insurance
Child Life
Home Care Company
Nursing Staff
Physical Therapy
© 2012 APHON 72
Quality of Life Issues Facing HPCT Quality of Life Issues Facing HPCT RecipientsRecipients
• Fatigue
• Depression
• Sleep disturbance
• Stress
• Nutrition: weight loss or gain
• Activity and exercise
• Friendships
• Growth and development
• School or work
© 2012 APHON 73
FatigueFatigue
• Symptoms Tired, unable to do what peers
are doing General weakness Unable to concentrate Irritability Lasting months to years
• Management Create schedule with quiet time Encourage routine exercise Get 10 to 12 hours of sleep a night Consider stimulant medication
© 2012 APHON 74
NutritionNutrition
• Symptoms cGVHD increases your calorie needs Encourage well-balanced meals Give healthy snacks throughout the day Increase the protein in the child’s diet Increase fluids to keep well hydrated
• Management Follow up with HPCT team Check dietary restrictions d/t medications May need supplements if diet is not
well balanced May need help creating a diet plan with the nutritionist Follow up with diabetic educator if diabetes from long-term
steroid use
© 2012 APHON 75
DepressionDepression
• Symptoms Sleeping moreLack of energyBody image alteredNoncomplianceEasily agitatedWithdrawnLack of interest in activities
• ManagementPlanned activitiesSchedule breaksTalk to specialistMedications
© 2012 APHON 76
Transitions Transitions
• Transition to schoolSharing information with schoolPreparing student for the transitionPlanning curriculum, educational supportEstablishing connections
• After schoolVocational planning in high schoolGuidance counselor assistance for planning
postsecondary educationSeek colleges and technical schools with learning
support programs
© 2012 APHON 77
Health Maintenance GuidelinesHealth Maintenance Guidelines
• Physical examination with labs• Eye examination• Dental examination • Pulmonary evaluation• Gynecological examination
(if of age)• Physical therapy evaluation with ROM testing• Endocrine evaluation
© 2012 APHON 78
cGVHD: ConclusioncGVHD: Conclusion
• Major cause of morbidity and mortality• Nurse’s role is vital
AssessmentMedicationsTreatmentsEducationProvide comprehensive multidisciplinary
continuity of careoChallenge
© 2012 APHON 79
ResourcesResources
• American Society for Blood and Marrow Transplantation www.asbmt.org
• BMT InfoNet www.bmtinfonet.org
• Candlelighters Childhood Cancer Foundation www.candlelighters.org
• Children and Adults with Attention-Deficit/ Hyperactivity Disorder (CHADD) www.chadd.org
• Children’s Oncology Group www.childrensoncologygroup.org
• CureSearch www.curesearch.org
• Chronic GVHD Learning www.asbmt.org/policystat/policy.htm
• Lance Armstrong Foundation www.laf.org
© 2012 APHON 80
cGVHD: ResourcescGVHD: Resources
• Learning Disabilities Association of America www.ldanatl.org
• Leukemia & Lymphoma Society www.lls.org
• Leukemia Research Foundation www.leukemia-research.org
• National Cancer Institute www.cancer.gov/cancertopics/eatinghint
• National Marrow Donor Program www.nmdp.org
• National Sleep Foundation www.centers.sleepfoundation.org/insomnia/children
• Pediatric Oncology Resource Center www.acor.org/ped-onc/
© 2012 APHON 81
cGVHD: ResourcescGVHD: Resources
• Pediatric Blood and Marrow Transplant Consortium www.pbmtc.org
• Schwab Learning www.schwablearning.org
• Supplementary information and updates www.marrow.org
• Books Educating the Child with Cancer, A Guide for Parents and
Teachers, edited by Nancy Keene. 2003, Candlelighters Foundation
Childhood Cancer Survivors, A Practical Guide to Your Future, Keene, Hobbie, Ruccione. 2000, O’Reilly and Associates
© 2012 APHON 82
QuestionsQuestions
1. What is the most frequently involved organ for cGVHD?
A. Gut
B. Lungs
C. Skin
D. Eyes
E. Liver
© 2012 APHON 83
QuestionsQuestions
2. What treatments would you think of using for cGVHD of the skin?
A. ECP
B. Pentostatin
C. GLEEVEC®
D. Hydroxychloroquine
E. Thalidomide
© 2012 APHON 84
QuestionsQuestions
3. A child with some cGVHD of the skin that is resolving and a lung score of 1 would be rated per the cGVHD global scoring as?
A. Mild
B. Moderate
C. Severe
© 2012 APHON 85
QuestionsQuestions
4. A child with a diagnostic clinical sign of cGVHD with no signs of aGVHD would be rated per the cGVHD global scoring as?
A. Mild
B. Moderate
C. Severe
© 2012 APHON 86
QuestionsQuestions
5. What type of cGVHD comes after a resolution of aGVHD?
A. De novo
B. Progressive
C. Quiescent
© 2012 APHON 87
ReferencesReferences
• Akhtari, M., Langston, A. A., Waller, E. K., & Gal, A. A. (2009). Eosinophilic pulmonary syndrome as a manifestation of GVHD following hematopoietic stem cell transplantation in three patients. Bone Marrow Transplant, 43(2), 155-158.
• Andree, H., Hilgendorf, I., Leithaeuser, M., Junghanss, C., Holzhueter, S., Loddenkemper, C., et al. (2008). Enteral budesonide in treatment for mild and moderate gastrointestinal chronic GVHD. Bone Marrow Transplant, 42(8), 541-546.
• Arora, M., Nagaraj, S., Witte, J., DeFor, T. E., MacMillan, M., Burns, L. J., et al. (2009). New classification of chronic GVHD: added clarity from the consensus diagnoses. Bone Marrow Transplant, 43(2), 149-153.
• Barkholt, L. (2009). Importance of CsA drug monitoring in SCT recipients to minimize GVHD and maximize graft vs. leukemia. Pediatr Transplant, 13(4), 400-403.
• Benson, D. M., Jr., Smith, M. K., Krugh, D., & Devine, S. M. (2008). Successful therapy of chronic graft-versus-host disease manifesting as pure red cell aplasia with single-agent rituximab. Bone Marrow Transplant, 41(6), 595-596.
• Berger, M., Pessolano, R., Albiani, R., Asaftei, S., Barat, V., Carraro, F., et al. (2007). Extracorporeal photopheresis for steroid resistant graft versus host disease in pediatric patients: a pilot single institution report. J Pediatr Hematol Oncol, 29(10), 678-687.
© 2012 APHON 88
ReferencesReferences
• Chiang, C. C., Lin, J. M., Chen, W. L., & Tsai, Y. Y. (2007). Allogeneic serum eye drops for the treatment of severe dry eye in patients with chronic graft-versus-host disease. Cornea, 26(7), 861-863.
• Couriel, D., Carpenter, P. A., Cutler, C., Bolanos-Meade, J., Treister, N. S., Gea-Banacloche, J., et al. (2006). Ancillary therapy and supportive care of chronic graft-versus-host disease: National Institutes of Health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report. Biol Blood Marrow Transplant, 12(4), 375-396.
• Daguindau, E., Lioure, B., Buzyn, A., Robin, M., Faucher, C., Kuentz, M., et al. (2009). Evidence for anti-tumour effect of allogeneic haematopoietic SCT in cases without sustained donor engraftment. Bone Marrow Transplant.
• Drew, D. Z., Donohue, T., Ramos, C., Cook, L., Goodwin, R., Patronas, N., et al. (2009). Chronic GVHD manifesting as parotitis after allogeneic hematopoietic SCT. Bone Marrow Transplant.
• Filipovich, A. H., Weisdorf, D., Pavletic, S., Socie, G., Wingard, J. R., Lee, S. J., et al. (2005). National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant, 11(12), 945-956.
• Fry, T. J. (2009). Is a little GVHD a good thing? Blood, 113(25), 6274-6275.
© 2012 APHON 89
ReferencesReferences
• Furlong, T., Martin, P., Flowers, M. E., Carnevale-Schianca, F., Yatscoff, R., Chauncey, T., et al. (2009). Therapy with mycophenolate mofetil for refractory acute and chronic GVHD. Bone Marrow Transplant, 44(11), 739-748.
• Garland, P., Dazzi, F., & Marin, D. (2009). Dasatinib may not suppress the GVL effect of donor lymphocyte infusions for CML. Bone Marrow Transplant.
• Gassas, A., Sung, L., Saunders, E. F., & Doyle, J. (2007). Graft-versus-leukemia effect in hematopoietic stem cell transplantation for pediatric acute lymphoblastic leukemia: significantly lower relapse rate in unrelated transplantations. Bone Marrow Transplant, 40(10), 951-955.
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