Graft-versus-host disease: Battle of the cells
Network - Spring 2014
Multidisciplinary care is the cornerstone of treatment at MD Anderson.
This team approach means that patients may see oncologists and general internists, as well as specialists in cardiology, pulmonary medicine, dermatology and more.
For patients whose bone marrow has been destroyed by cancer or its treatment, stem cell transplants are a growing option. The transplants are intended to replenish blood-producing stem cells and restore the patient’s health.
In 2011, nearly 18,000 stem cell transplants were performed in the United States, according to the U.S. Department of Health and Human Services.
In this area of treatment, dermatology — the science of diagnosing and caring for skin disorders — plays a crucial role in monitoring and safeguarding recipients’ health after transplant.
Lifesaving treatment: a delicate balance
Of the more than 1,000 transplant procedures performed at MD Anderson each year, roughly half are autologous (using the patient’s own cells) and half are allogeneic (using cells from a donor).
Donors may be related to the patient or not, but the closer the match to the patients’ cells, the better the transplant is likely to go.
But they don’t always go smoothly.
A common complication of allogeneic transplants is graft-versus-host disease (GVHD). Its effects range from mild to severe, and the disease may even cause death. When MD Anderson patients develop skin disorders after an allogeneic stem cell transplant, they can see dermatologist Sharon Hymes, M.D., who monitors and manages complications of cutaneous GVHD in the Stem Cell Transplantation and Cellular Clinic.
In the brave new world of stem cell transplantation, nothing is simple. Recipients may be on a variety of medications. They are likely to have comorbidities (other health conditions). And early symptoms of GVHD reactions are similar to post-treatment side effects.
Hymes first became intrigued with the disease during her medical training, and later as a resident at Johns Hopkins Hospital.
There are two forms of GVHD, acute and chronic. Acute GVHD disease begins two to six weeks after transplantation. It occurs when immune cells in the tissue (graft) identify tissues of the patient (host) as foreign or different, and selectively damage the skin, gut, liver or lungs.
Chronic GVHD develops later, and is not as well understood. It may occur after the acute form of the disease, or to those who haven’t had it yet.
Partnership helps patients recover
When Hymes joined the dermatology unit at MD Anderson in 2001, GVHD complications became her area of expertise. She sought out Richard Champlin, M.D., chair of Stem Cell Transplantation and Cellular Therapy, who was receptive to the idea of a joint venture oncology-dermatology clinic designed to treat the disease.
The partnership is based on the premise that recognizing the disease early is key. Then, prompt therapeutic intervention may prevent progression to higher-grade disease, improving outcomes for stem cell transplant patients.
"When we see a patient who has GVHD, especially acutely, we look at their skin to make sure there isn’t a rash," Hymes says. "If the patient does have a rash, we document how widespread it is, and exactly what it looks like."
"The reason a patient develops chronic GVHD is less understood," she says. "It may be a disorder of immune regulation. But even so, the skin can show a multitude of changes that aid in the diagnosis of the disease."
Patients with a milder form of GVHD may be treated with topical (applied to the skin) medications, Hymes says. The development of blisters, however, indicates more serious disease and often prompts physicians to use systemic (throughout the body) therapy.
Hymes says there are currently a multitude of clinical trials for both acute and chronic GVHD at MD Anderson. The trials are not only trying to determine the best treatment for the disease, but are also working to regulate the anti-tumor effect that can occur in the setting of GVHD.
"That’s the dilemma," Hymes says. "Patients with GVHD may also experience an anti-tumor effect that decreases their chance of relapse."
"By learning more, we may be able to harness these reactions of the immune system and induce and maintain remissions."