Workshop on Gastrointestinal GvHD

Transcription

1 Falk Workshop Workshop on Gastrointestinal GvHD November 13 14, 2015 University Hospital Regensburg Regensburg, Abstracts

2 FALK FOUNDATION e.v. Leinenweberstr Freiburg 2015 Falk Foundation e.v. All rights reserved.

3 Abstracts of Invited Lectures Falk Workshop WORKSHOP ON GASTROINTESTINAL GVHD Regensburg () November 13 14, 2015 Scientific Organization: E. Holler, Regensburg () D. Wolff, Regensburg () M. Edinger, Regensburg () E. Huber, Regensburg () W. Herr, Regensburg () M. Evert, Regensburg () H.T. Greinix, Graz (Austria) J. Halter, Basel (Switzerland)

4 CONTENTS Session I page Pathophysiology Chair: E. Holler, Regensburg M.R.M. van den Brink, New York Pathophysiology of GI-GvHD in mice R. Zeiser, Freiburg 9 Pathophysiology of GvHD in patients Results from serial biopsies E. Holler, E. Huber, Regensburg 10 Biomarkers of GI-GvHD J.L.M. Ferrara, New York 11 Chair: A. Gessner, Regensburg E. Holler, Regensburg Pathophysiology of GI-GvHD Role of microbiome in mice and men M.R.M. van den Brink, New York 12 Early and late-onset acute GvHD of the GI tract What are the differences? D. Weber, Regensburg 13 Session II Diagnosis and histopathology Chair: H.T. Greinix, Graz H. Shulman, Seattle Endoscopy for GI-GvHD C. Bojarski, Berlin 17 Histopathology of GI-GvHD in men A. Kreft, Mainz 18 3

5 Contrast-enhanced ultrasound for differential diagnosis of suspected GvHD in patients after allogeneic transplantation E.-M. Jung, A.G. Schreyer, K. Landfried, E. Holler, Regensburg 19 Radiology (CT and MRI) in GI-GvHD H. Brodoefel, Regensburg 20 MRI in GI-GvHD S.A. Klein, Mannheim 21 Pediatric aspects of diagnosis and histopathology of GI-GvHD A. Lawitschka, Vienna 22 Session III Clinical care in GI-GvHD Chair: W. Bethge, Tübingen O. Ringdén, Stockholm Which clinical symptoms guide treatment? G.C. Hildebrandt, Lexington 25 Topical steroids in treatment of GI-GvHD D. Wolff, Regensburg Systemic treatment of GI-GvHD H.T. Greinix, Graz 28 Cellular therapy of GI-GvHD M. Edinger, Regensburg Session IV Supportive care Chair: A. Gerbitz, Erlangen J. Halter, Basel Food for thought in gastrointestinal GvHD B.S. van der Meij, College Station 35 Nutrition in GI-GvHD Pediatric aspects A. Vécsei, Vienna 36 4

6 Homecare for prevention and decidual stromal cells for therapy of GI-GvHD O. Ringdén, Stockholm 37 List of Chairpersons, Speakers and Scientific Organizers

7 Session I Pathophysiology 7

8 Pathophysiology of GI-GvHD in mice Robert Zeiser Department of Hematology and Oncology, Freiburg University Medical Center, Freiburg, Allogeneic hematopoietic cell transplantation (allo-hct) is an established treatment option for patients with hematological malignancies. Acute intestinal graft-versus-host disease (GvHD) is a major complication of allo-hct which leads to significant morbidity and mortality in patients treated with allo-hct. Insight into intestinal GvHD pathophysiology via the use of mouse models has already lead to novel clinical approaches such as CCR5 inhibition which reduced visceral GvHD. A major event connected to GvHD is the extensive cell death leading to the consecutive release of danger associated molecular patterns (DAMPs). The abundance of cell death may overrule physiological mechanisms that normally counteract immune activation. There is accumulating evidence that this is the case when patients receive chemo- /radiotherapy leading to release of adenosine-5 -triphosphate (ATP), uric acid and HMGB-1. Therefore, analyses on GvHD development have to consider the effects of chemo-/radiotherapy related tissue damage leading to the release of exogenous and endogenous danger signals. The question which cells sense the danger has been addressed by several investigators and there is evidence for a role of hematopoietic cells such as dendritic cells but also non-hematopoetic cells which express MHC class II at a low level. Signals activating the Nlrp3 inflammasome lead to caspase-1 activation and pro-il-1β cleavage. A role for IL-1β has been shown in clinical allo- HCT. In contrast to sterile inflammation such as reperfusion injury, intestinal GvHD is more complex since bacterial components that leak through damaged intestinal barriers and the skin can activate pattern recognition receptors (PRRs) which will directly contribute to intestinal GvHD pathogenesis as the changes of the intestinal microflora where shown to precede GvHD. The microbiota derived exogenous danger signals transmit immune activation via toll-like receptors and NOD-like receptors of the innate immune system. A better understanding of the individual impact of endogenous and exogenous danger signals activating innate immunity in intestinal GvHD may help to develop novel approaches against this life-threatening disease. 9

9 Pathophysiology of GvHD in patients Results from serial biopsies E. Holler 1, E. Huber 2 1 Department of Internal Medicine III, 2 Institute of Pathology, University Medical Center Regensburg, Regensburg. Gastrointestinal (GI)-GvHD is still the most deleterious manifestation of acute GvHD, and patients with steroid-refractory GI-GvHD have a treatment related mortality as high as 70 90%. In order to study pathophysiology of intestinal GvHD in pts, we analyzed serial gastrointestinal biopsies from more than 150 pts by using classical histology, immunohistology (mostly single antibody staining) and PCR. As expected, stage of GvHD strongly correlated with apoptosis and infiltrates of CD8 positive lymphocytes. In contrast to published reports, infiltration of FoxP3 positive lymphocytes increased with severity of GvHD and strongly correlated with an increase in IDO positive macrophages, indicating compensatory induction of induced regulatory T cells by activation of IDO. Interestingly, higher steroid dosage completely interferes with this reactive immune regulation, which might at least partially explain the difficulties to recover from severe steroid-resistant GI-GvHD. A further unexpected finding was the decrease in IL17 positive lymphocytes in GvHD, which were, however, mainly CD4 negative. Thus, IL17 positive cells may represent innate lymphoid cells which are depleted in GI GvHD. A new and prognostic hallmark of GI GvHD is the destruction of Paneth cells in severe GvHD, which correlates with a reduced expression of mrna for alpha-defensins and Reg3alpha. This may contribute to failure to reconstitute a diverse microbiome in early acute GvHD, as it is suggested by microbiome analysis. Overall, these data show a strongly dysregulated immune response in GI-GvHD, which is amplified by dysbiosis of the intestinal microbiota. 10

10 Biomarkers of GI-GvHD J.L.M. Ferrara Division of Hematology/Medical Oncology, Hess Center for Science and Medicine, New York, NY, USA Graft-versus-host disease (GvHD) is the major cause of non-relapse mortality (NRM) after allogeneic hematopoietic stem-cell transplantation (HCT). The severity of symptoms at the onset of GvHD does not accurately define response to treatment or risk of NRM, and thus most patients are initially treated alike with high dose systemic corticosteroids. We have recently identified 6 biomarkers of acute GvHD. We prospectively collected plasma from 492 HCT patients with acute GvHD and randomly divided them into training and validation sets. We used the concentrations of 3 most predictive validated biomarkers (TNFR1, ST2, and REG3α) to create an algorithm that computed the probability of NRM 6 months after GvHD onset for individual patients in the training set. We rank ordered the probabilities and identified thresholds that created 3 distinct NRM scores. We then tested the algorithm in the validation set, and again in a second validation of 300 additional HCT patients enrolled on multicenter clinical trials of primary therapy for acute GvHD. In all 3 datasets, the cumulative incidence of 12 month NRM significantly increased as the GvHD score increased (8%, 27%, and 46%, for scores 1, 2 and 3 respectively in the multicenter validation set, p < 0.001). Conversely, the response rates to primary GvHD treatment decreased as the GVHD score increased (86%, 67%, and 46%, for scores 1, 2 and 3 respectively in the multicenter validation set, p < 0.001). This new scoring system which we have validated in a multi-center setting may be useful in guiding therapy for patients at the onset of acute GvHD. Additional data in mouse models show that REG3α is a key regulator of GI-GvHD, and that restoration of REG3α after allogeneic BMT can prevent damage to the GI-tract. 11

11 Pathophysiology of GI-GvHD Role of microbiome in mice and men Marcel R.M. van den Brink, M.D., Ph.D. Division of Hematologic Oncology, Weill Cornell Medical College, New York, NY, USA We have found, both in mouse models as well as fecal samples from allogeneic BMT patients, a number of associations between changes in the intestinal flora and clinical outcomes, such as infections, GvHD and relapse. We found that recipients of an allo- BMT experience an overall loss of diversity in their intestinal flora, which is related to overall survival. Moreover, this loss of diversity can result in increases of particular bacterial species, including certain pathogens (such as Vancomycin-resistant Enterococcus and Proteobacteria), which results in an increased risk of bacteremia/sepsis. We also observed a loss of gram positive anaerobe bacteria, such as Clostridiales, and this was associated with an increased risk of graft-versus-host disease. In our recent studies, we have found that the use of antibiotics with greater anaerobe activity in the post-transplant period is related to an increased risk of lethal graft-versus-host. In addition, we have observed an inverse correlation between the abundance of oral flora in the feces and the risk of post-transplant malignant relapse. 12

12 Early and late-onset acute GvHD of the GI tract What are the differences? Daniela Weber Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Historically the presence of graft-versus-host disease (GvHD) beyond 100 days after allogeneic stem cell transplantation (ASCT) was generally defined as chronic GvHD, even if clinical symptoms were indistinguishable from acute GvHD. In 2005 the National Institutes of Health proposed consensus criteria for the classification of GvHD in relation to clinical symptoms rather than time post-transplant and defined the diagnosis of late acute GvHD. Between 2008 until 2015 a total of 410 patients underwent ASCT at our transplant center. In a retrospective analysis we investigated clinical outcome data, markers of microbiome diversity and histological aspects in relation to the occurrence of early versus late acute GI-GvHD. 30.2% of patients developed acute GI-GvHD, whereby 20% suffered from early acute GvHD and 10.2% of patients exhibited late acute GvHD manifestations according to consensus criteria. Within these groups, only 47% of patients with early acute GvHD, but 81% of patients with late acute GvHD suffered from severe stages of GI-GvHD indicating that late acute GvHD seems to be associated more often with severe stages than early acute manifestations. While patients with acute GI-GvHD in general displayed a significant higher (TRM) and worse overall survival (OS) compared to patients without GI-GvHD, we found no differences regarding long-term outcome between early and late acute GvHD. Focusing on microbiome disruptions, which seem to play an important role in the pathophysiology of acute GvHD, we detected changes of microbiome composition, which were more pronounced in patients with early acute GvHD compared to late manifestations. However, early microbiome disruption was also more frequently seen in patients with late acute GI-GvHD, suggesting long lasting defects in intestinal immunoregulation. Paneth cell damage as indicated by loss of Paneth cells in histological sections and elevated Reg3a serum levels were equally present in both, early and late acute GvHD. (Immuno-)histological features such as apoptotic cells, CD8 infiltration and changes in IL17 and FoxP3-positive cells were observed in early and late GvHD, but seemed to be more pronounced in late acute GvHD. In summary, late acute GI-GvHD is a serious complication sharing many features with early acute GvHD also in the absence of conditioning related damage. As indicated by associations with early microbiome changes, conditions facilitating late acute GvHD may start early after ASCT but additional factors such as a shift of alloreactive versus regulatory T cells in the period of tapering of immunosuppression may contribute. 13

13 Session II Diagnosis and histopathology 15

14 Endoscopy for GI-GvHD C. Bojarski Medical Clinic I, Charité University Medicine, Campus Benjamin Franklin (CBF), Berlin, Confocal endomicroscopy (CEM) has significantly broadened the field of innovative diagnostic high resolution endoscopy by pre-selecting biopsy sites and thus improving the output of final histology in a variety of gastrointestinal diseases. We have introduced CEM as one important diagnostic tool in patients with acute intestinal GvHD (agvhd) after stem cell transplantation. Targeting the biopsy sites by CEM and predicting the final histology with a high sensitivity allow the haematologists immediately changing current immunosuppressive therapy strategies and adapt the medication regimens after CEM was performed. The gold standard diagnostic method, classical histology, has a continuous relevance for exactly defining the final histology and for excluding other causes e.g. CMV infection. Also in long-term survivors of allogeneic stem cell transplantation gastrointestinal symptoms occur frequently and chronic intestinal GvHD (cgvhd), overlap syndrome or late onset agvhd as well as numerous infectious and non-infectious causes are differential diagnoses and it is often difficult to establish a diagnose by histology. In our second study in patients with cgvhd we have identified 3 patients with an esophageal manifestation of cgvhd. This was in good accordance to the published data. CEM in these patients identified the inflammatory cells as well as signs of apoptosis of squamous epithelial cells. Capillary leakage which may result in mucosal edema is also detectable by CEM. In summary, the detection of acute intestinal GvHD by CEM is well established, in chronic intestinal GvHD it remains still difficult and will not significantly improve the routine diagnostic work-up in long-term-survivors of allogeneic stem cell transplantation with gastrointestinal symptoms. Reference: Bojarski C, Günther U, Rieger K, Heller F, Loddenkemper C, Grünbaum M, et al. In vivo diagnosis of acute intestinal graft-versus-host disease by confocal endomicroscopy. Endoscopy. 2009;41:

15 Histopathology of GI-GvHD in men Andreas Kreft Institute of Pathology, University Hospital Mainz, Mainz, Histopathology is an integral part of the diagnosis of gastro-intestinal graft-versushost disease (GvHD) and has two principal functions. One is to rule out infection or toxic drug effects, which may clinically imitate GvHD. This has to be carried out in close interaction with the clinic. The other is to diagnose and grade GvHD. However, this topic has been a matter of debate, since histological diagnosis and grading only weakly correlate with the clinical course. To address this topic some efforts have been made recently. The traditional histological features of acute GvHD crypt or gland cell apoptosis, crypt or gland destruction and mucosal denudation are confirmed by the recent NIH consensus on GvHD pathology. A consensus standard of the minimal diagnostic criteria for daily diagnosis was shown to improve interobserver agreement in both the histological diagnosis and grading of acute intestinal GvHD. There may be different grades of severity of GvHD in various sites of the gut simultaneously and there is still some uncertainty whether there is a site of predilection for GvHD in the intestine. This has an impact on the selection of the region to biopsy in early disease and to define a threshold for the histological diagnosis of GvHD. Morphological signs of chronic mucosal injury are crypt or gland loss and architectonic changes of the mucosa. They may result from GvHD but can also originate from toxic therapy. This makes it difficult to establish criteria for chronic GvHD in the gut. Nevertheless, the histological parameter which correlates best with diarrhea and GvHD of other organs is crypt loss. The signs of active disease were found to be less predictive in the days of effective immunosuppressive therapy. Thus, histological scores which emphasize the loss of crypts or glands, were superior to scores which only grade acute GvHD. 18

16 Contrast-enhanced ultrasound for differential diagnosis of suspected GvHD in patients after allogeneic transplantation E.-M. Jung 1, A.G. Schreyer 1, K. Landfried 2, E. Holler 2 1 Institute of Radiology, University Medical Center Regensburg, Regensburg, 2 Department of Haematology/Oncology, University Medical Center Regensburg, Regensburg, GvHD is a serious complication in patients after allo-sct, presenting with unspecific symptoms such as abdominal pain or cramps and diarrhea. Early diagnosis of GvHD, after differentiation from other causes leading to the same symptoms, such as viral or bacterial enteritis, is highly important because the time needed for diagnosing GvHD is directly correlated to a worsening of the outcome. We examined 23 patients presenting with the abdominal symptoms mentioned above, of whom 20 had received an allo-sct in their history and were thus potential candidates for enteric GvHD. The other 3 patients were included because they also presented with abdominal symptoms similar to those of GvHD, which could be ruled out due to their history. We wanted to evaluate CEUS in these patients as an additional subgroup to gain more data on the value of CEUS in early detection of enteral GvHD and in the differentiation of GvHD against other causes of abdominal discomfort. All patients underwent CEUS with particular attention to penetration of the intravenously applied microbubbles in the bowel lumen. In the patients having allo-sct in their history we strove to achieve histological confirmation of GvHD of the GI tract. The resulting examinations were documented digitally. Out of 17 patients with confirmed GvHD of the GI tract, 14 showed penetration of the intravenously applied microbubbles into the bowel lumen, leading to a sensitivity and specificity of 82% and 100% for transmural bubble penetration for GvHD of the GI tract, since the patients without GvHD of the GI tract showed no transmural bubble penetration. In patients with viral or bacterial infections of the GI tract, no transmural penetration of the microbubbles into the bowel lumen was observed. For microbubble penetration as a criterion for GvHD of the GI tract, this leads to a negative predictive value (NPV) of 67%, and a positive predicative value (PPV) of 100%. 19

17 Radiology (CT and MRI) in GI-GvHD Harald Brodoefel Institute of Radiology, University Medical Center Regensburg, Regensburg, If all classic target organs are affected severely, diagnosis of GvHD can usually be made on clinical grounds alone. However, symptoms of isolated acute gastrointestinal GvHD are frequently non-specific, including abdominal cramping, diarrhea, fever, nausea and vomiting. In such scenario, a purely clinical diagnosis is challenging. Nowadays, it becomes even more difficult due to the temporal variability of lateonset acute GvHD, which is broadening the traditional list of differential diagnoses. Hence, in clinical practice, unspecific presentation of gastrointestinal GvHD is frequently prompting abdominal CT as a first line tool for diagnostic screening. Despite the increasing importance of CT for timely diagnosis of severe acute GvHD, reports on characteristic CT patterns are rare. The aim of this presentation is to present typical abdominal CT findings in patients with biopsy proven acute GvHD and compare the pattern to those of potential differential diagnoses. 20

18 MRI in GI-GvHD Stefan A. Klein Department of Medicine III, University Hospital Mannheim, Mannheim, Acute graft-versus-host disease (agvhd) of the GI-tract is a severe complication after allogeneic stem cell transplantation (SCT). Major differential diagnoses are infections, drug toxicity and residual effects of the conditioning. Since an early immunosuppressive treatment of agvhd is essential a rapid, reliable and non-invasive differentiation between agvhd and infections is necessary. Thus imaging can be a valuable addition in the diagnostic workup of intestinal complications after SCT. However, magnetic resonance imaging (MRI) has proven its superiority regarding soft tissue contrast and the possibility to detect even slight abnormalities in the evaluation of intestinal pathologies e.g. in inflammatory bowel disease. Consequently, MRI should be an optimal tool to assess agvhd of the GI-tract. Acute intestinal GvHD was assessed systematically by MRI in two studies. Budjan et al. (Eur Radiol, 2014) compared MRI findings of patients with histologically proven intestinal agvhd stage 2 4 with control group patients after allogeneic SCT with GI-tract symptoms due to other reasons. In this study a unique MRI pattern could be defined: Gut involvement presented as long-segment (> 20 cm) bowel wall thickening with profound submucosal edema of the affected bowel segments. The terminal ileum was always involved. Mucosal wall was significantly thickened in patients with intestinal agvhd in comparison with control group patients: (mean large bowel wall thickness: GvHD group 0.9 ± 0.1 cm, control group 0.4 ± 0.05 cm, p < ; mean small bowel wall thickness: GvHD group 0.8 ± 0.1 cm, control group 0.4 ± 0.05 cm, p < ). A mucosal diffusion restriction was seen in all patients of the GvHD group. The perfusion of the bowel spared the submucosa while demonstrating strong and patchy mucosal perfusion in the T1 sequence. Ascites was present in half of agvhd patients, whereas no patient showed enlarged lymph nodes. Derlin et al. (Eur Radiol, 2015) demonstrated in their larger series by magnetic resonance enterography the following frequencies of findings: Intestinal wall thickening (81.5% of GvHD patients), luminal stenosis (81.5%), mural contrast enhancement (70.4%), and ascites (59.3%). In conclusion, intestinal agvhd shows a characteristic MRI pattern. In patients with clinically suspected agvhd, MRI can strongly support the suspected diagnosis and allow the initiation of an immunosuppressive therapy days before a final histological diagnosis. Therefore MRI is suggested as a readily available non-invasive diagnostic tool in suspected intestinal agvhd. A MRI-guided earlier therapy of intestinal agvhd might help to improve the unsatisfactory outcome in severe intestinal agvhd. 21

19 Pediatric aspects of diagnosis and histopathology of GI-GvHD Anita Lawitschka SCT Outpatient Clinic, St. Anna Children s Hospital, Vienna, Austria The GI tract is a prominent target organ involved both in acute and chronic GvHD with a major impact on the burden of the disease and the long-term outcome. In general manifestations of pediatric GI-GvHD are similar to adult features. Due to the fact that there are considerable fewer published data in children diagnosis and differential diagnosis still relies on expert opinion. Here, we provide background information on specific pediatric issues regarding the clinical presentation, differential diagnoses and the possible co-incidence of infections. Furthermore we will focus on histopathological features in this context also. The possible strategies for early identification of high-risk patients with perception of co-morbidities and their implications on future clinical research activities will be discussed. 22

20 Session III Clinical care in GI-GvHD 23

21 Which clinical symptoms guide treatment? Gerhard Carl Hildebrandt, M.D., FACP Division of Hematology & Blood and Marrow Transplantation, University of Kentucky, Lexington, KY, USA The gastrointestinal tract is a critical target organ of both acute and chronic graftversus-host disease (GvHD). Clinical signs and symptoms are often non-specific and can be attributed to a variety of other medical conditions, which are frequently seen in the allogeneic HCT recipient as well. Acute upper GI-GvHD often presents with nausea and anorexia, and histologic proof is needed to differentiate it from other conditions, such as drug and virus-related causes. Lower GI tract involvement in acute GvHD often is hard to distinguish from infectious enteritis. Preceding and concurrent infections, especially the growing incidence and prevalence of Clostridium difficile infections, can not only be misinterpreted as GvHD, but also can mask the onset and response of GI GvHD, therefore making GvHD management in these patients more difficult. In chronic GI-GvHD, symptoms range from those in acute GvHD, such as anorexia, nausea, vomiting, diarrhea, abdominal pain and weight loss, to symptoms related to pancreatic insufficiency and related to fibrotic changes, such as development of esophageal structures, stenosis and the so called esophageal web. Only the latter alone is diagnostic without biopsy for chronic GvHD, whereas the former require diagnostic or distinct signs from other sites to be called chronic GvHD. In addition, histology in those patients with non-diagnostic symptoms often is compatible with acute GvHD. GI involvement during either acute or chronic GvHD significantly affects overall non-relapse mortality and overall survival, and early identification and adequate treatment is critical. Therefore, patients with symptoms listed above should undergo a thorough work as soon as possible, including extensive infectious work up plus upper and lower GI tract endoscopy to obtain histologic proof of GvHD and/or identification/exclusion of other or concurrent underlying causes. The diagnostic role of standard imaging techniques, such as abdominal XR, CT, MRI and conventional ultrasound is rather limited, yet PET/CT and wireless video-capsule endoscopy may aid in diagnostic management and are currently under investigation. Treatment is usually initiated once the diagnosis of acute GI-GvHD is either confirmed or if clinical symptoms suggest the possibility of GvHD and other causes have been ruled out. Initial treatment of acute GI-GvHD usually consists of systemic methylprednisolone. Non-(little-) absorbable steroids, such as budesonide or beclomethasone diproprionate can be considered to augment topical steroid delivery and to potentially spare systemic steroid exposure. In chronic GI-GvHD, systemic immunosuppression with steroids plus/minus calcineurin inhibitor are commonly initiated and optimized when clinical symptoms develop or worsen. Mechanic dilation and enzyme replacement therapy are utilized for esophageal structures and pancreatic insufficiency, respectively. The role for non-absorbable steroids in chronic GI-GvHD is not well defined, and in both acute and chronic GI-GvHD, switching to second/third line immunosuppressive strategies often will be required. 25

22 Topical steroids in treatment of GI-GvHD D. Wolff Department of Internal Medicine III, University of Regensburg, Regensburg, Topical steroids represent a central treatment option in inflammatory bowel disease (IBD). Since IBD shares pathophysiologic similarities with gastrointestinal manifestations of acute and chronic graft-versus-host disease (GvHD) a number of trials have been performed evaluating its efficacy which unfortunately have not let to approval but resulted in a widespread off-label use in clinical routine as shown within a recently published survey. Beclomethasone has been evaluated within several clinical trials demonstrating an improved response rate and duration if applied in addition to systemic steroids in patients with gastrointestinal manifestations of acute GvHD. [1] Moreover, beclomethasone enabled a significantly faster taper of the systemic steroid dose within a randomized trial in patients with acute gastrointestinal GvHD and significantly reduced the risk for treatment failure at study day 50. This resulted in a significant reduction in the hazard of mortality in patients receiving additional beclomethasone, which was even more prominent in recipients of unrelated and HLA-mismatched stem cells where the mortality at transplantation day 200 was reduced by 91% in the beclomethasone group as compared to the placebo group. [2] In addition to its use in combination with systemic steroids, beclomethasone may be a therapeutic alternative as single agent treatment of mild isolated gastrointestinal acute and chronic GvHD. [3] While Beclomethasone is currently not available within Europe Budesonide has been studied within small single center cohorts for its use in combination with systemic steroids for treatment of acute gastrointestinal manifestations or as single agent in case of mild GI manifestations of chronic GvHD. [4, 5] Interestingly, a subsequent randomized trial evaluating Budesonide in prophylaxis of acute gastrointestinal GvHD failed to show any benefit. [6] References: 1. McDonald GB, Bouvier M, Hockenbery DM, Stern JM, Gooley T, Farrand A, et al. Oral beclomethasone dipropionate for treatment of intestinal graft-versushost disease: a randomized, controlled trial. Gastroenterology. 1998;115(1): Hockenbery DM, Cruickshank S, Rodell TC, Gooley T, Schuening F, Rowley S, et al. A randomized, placebo-controlled trial of oral beclomethasone dipropionate as a prednisone-sparing therapy for gastrointestinal graft-versus-host disease. Blood. 2007;109(10): Villanueva FN, Pérez-Simón JA, Silva FF, Caballero-Velázquez TT, Sánchez- Guijo FF, Cañizo CC, et al. Oral beclomethasone dipropionate for the treatment of gastrointestinal chronic graft-versus-host disease. Biol Blood Marrow Transplant. 2009;15(10): Andree H, Hilgendorf I, Leithaeuser M, Junghanss C, Holzhueter S, Loddenkemper C, et al. Enteral budesonide in treatment for mild and moderate gastrointestinal chronic GVHD. Bone Marrow Transplant. 2008;42(8):

23 5. Bertz H, Afting M, Kreisel W, Duffner U, Greinwald R, Finke J. Feasibility and response to budesonide as topical corticosteroid therapy for acute intestinal GVHD. Bone Marrow Transplant. 1999;24(11): Schmelz R, Bornhäuser M, Schetelig J, Kiani A, Platzbecker U, Schwanebeck U, et al. Randomised, double-blind, placebo-controlled trial of oral budesonide for prophylaxis of acute intestinal graft-versus-host disease after allogeneic stem cell transplantation (PROGAST). BMC Gastroenterol. 2014;14:

24 Systemic treatment of GI-GvHD Univ. Prof. Dr. Hildegard T. Greinix Division of Haematology, Medical University of Graz, Graz, Austria Despite all the recent scientific achievements, systemic first-line therapy of acute GI-GvHD has not changed and consists of corticosteroids at a dose of 2 mg/kg body weight (bw)/day as internationally accepted standard. Whereas in previous decades steroid doses had been increased to 5 to 10 mg/kg bw/day demonstrating no advantage regarding response of GI-GvHD but substantially increasing toxicity, recent studies investigated lower corticosteroid doses. The Seattle group reported that in patients with GI-GvHD grades IIa a dose of 0.5 mg/kg bw/day was effective whereas in patients with GI-GvHD grades IIb and more a dose of 1 mg/kg bw/day was associated with a significantly higher need for secondary immunosuppressive therapy. In view of the side effects corticosteroid taper should start as early as major improvements in GI manifestations have been observed. Patients not responding to first-line treatment defined as progression after 3 days, or unimproving GvHD after 1 week have a dismal prognosis with high non-relapse mortality (NRM) and poor overall survival. So far, no standardized salvage treatment for corticosteroid-refractory GI-GvHD is available. Use of extracorporeal photopheresis (ECP) led to complete and partial response of GI-GvHD in 40 to 83% of afflicted patients. Improved response rates have been achieved in patients with grade I and II GI-GvHD compared to ones with more severe GI manifestations. Responding patients had improved survival and decreased NRM rates. Other frequently applied immunosuppressive therapies consist of the anti-tnfα antibody etanercept, the anti-cd25 antibody basiliximab, mycophenolate mofetil, the mtor inhibitor sirolimus. Although some immunosuppressive treatments achieve responses in GI-GvHD, none has improved patients outcome due to serious side effects including severe viral and fungal infections, EBVlymphoproliferative disease and cytopenias. Thus, choice of second-line regimen should not only be guided by published efficacy but also by considerations of potential toxicities including infections, interactions with other agents and prior experience of the physician with an agent. Novel approaches consist of the use of ruxolitinib, a selective Janus kinase 1/2 inhibitor known to reduce the proliferation of effector T cells and to suppress proinflammatory cytokine production as well as the use of Tocilizumab, an anti-interleukin-6r antibody that inhibits naive T cell differentiation into Th17 cells. To improve outcome of patients with severe GI-GvHD better strategies are urgently needed including prevention and preemptive treatment based on biomarker results. 28

25 Cellular therapy of GI-GvHD M. Edinger Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Mesenchymal stroma/stem cells (MSC) are currently under investigation for the treatment of acute GvHD. MSC are multipotent progenitors isolated from bone marrow, fat, umbilical cord blood, placenta and even dental pulp. In vitro, they can be differentiated into various cell types such as adipocytes, chondrocytes, muscle cells and osteoblasts. Yet, the rationale for MSC therapy in GvHD is not primarily based on their differentiation potential, but on their immune modulatory effects. Their mode of action is not yet identified in detail, but they do suppress alloreactive T cells in vitro 1 3 and in vivo 4 and seem to foster tissue repair mainly by paracrine effects that dampen inflammation and support tissue regeneration 5. Ringden and colleagues initially reported on the successful treatment of 6 of 8 patients with steroid resistant agvhd using either MSC from HLA-identical family or unrelated donors or even from haploidentical donors 6. Based on these promising results, a multicenter trial was performed in which 30 of 55 pts (55%) showed a complete response to MSC therapy in steroid-resistant agvhd and 9 additional patients an improvement of GvHD symptoms 7. Importantly, patients achieving CR also showed a lower TRM and superior survival. As the efficacy of this treatment was independent of the HLA-disparity of the MSC donor, such cellular products could be generated pre-emptively from cells of healthy volunteers. In a company-sponsored randomized phase III trial, such thirdparty MSC did not seem to fulfill the expectations, as complete response rates in steroid-resistant GvHD did not differ significantly from the control group at day 28 post therapy. Yet, therapeutic efficacy in liver and gastrointestinal (GI)-GvHD was shown, while the insufficient response of skin GvHD was mainly responsible for the disappointing overall results 8. Since GI-GvHD is primarily responsible for the TRM of agvhd, MSC treatment might still prove to be beneficial even if complete responses are not regularly achieved. In children and young adults, however, MSC seem to be more effective as compared to elderly agvhd patients 9. Recent reports on the successful treatment of chronic GvHD are also encouraging and justify further studies on MSC-based GvHD therapy 10. The adoptive transfer of donor-type CD4 + CD25 + FOXP3 + regulatory T cells (Treg) is another potential strategy for the treatment of agvhd. In mouse models, these socalled natural Treg prevent agvhd 11,12 and even seem to ameliorate ongoing GvHD 13. Recent clinical trials revealed the safety of Treg transfusion 14 and also their efficacy for the prevention of agvhd in haploidentical SCT 15. For potential therapeutic applications, efficient in vitro expansion systems are required for the generation of pure Treg cell products not contaminated with potentially harmful effector T cells. Strategies developed in pre-clinical studies include the expansion of Tregenriched cell products in the presence of rapamycin that permits the preferential outgrowth of Treg 16, or the in vitro expansion of CD45RA + naïve Treg that maintain all phenotypic and functional Treg characteristics even upon long-term culture 17. Such cell products are currently tested in clinical trials and preliminary findings will be presented. Yet, the main caveat of such strategies is the impairment of Treg function and/or survival by most pharmacologic immunosuppressants administered in agvhd. 29

26 The same limitations apply to in vitro induced Treg cell populations, such as Tr1 cells, a cell population generated from naïve conventional T cells in the presence of IL References: 1. Aggarwal S, Pittenger MF. Human mesenchymal stem cells modulate allogeneic immune cell responses. Blood. 2005;105(4): Di Nicola M, Carlo-Stella C, Magni M, et al. Human bone marrow stromal cells suppress T-lymphocyte proliferation induced by cellular or nonspecific mitogenic stimuli. Blood. 2002;99(10): Le Blanc K, Tammik C, Rosendahl K, Zetterberg E, Ringden O. HLA expression and immunologic properties of differentiated and undifferentiated mesenchymal stem cells. Exp Hematol. 2003;31(10): Uccelli A, Moretta L, Pistoia V. Mesenchymal stem cells in health and disease. Nat Rev Immunol. 2008;8(9): Caimi PF, Reese J, Lee Z, Lazarus HM. Emerging therapeutic approaches for multipotent mesenchymal stromal cells. Curr Opin Hematol. 2010;17(6): Ringden O, Uzunel M, Rasmusson I, et al. Mesenchymal stem cells for treatment of therapy-resistant graft-versus-host disease. Transplantation. 2006;81(10): Le Blanc K, Rasmusson I, Sundberg B, et al. Treatment of severe acute graftversus-host disease with third party haploidentical mesenchymal stem cells. Lancet. 2004;363(9419): Martin PJ UJ, Soiffer RJ, Klingemann H, Waller EK, Daly AS, Herrmann RP, et al. Prochymal improves response rates in patients with steroid-refractory acute graft-versus-host disease involving the liver and gut: results of a randomized, placebo-controlled multicenter phase III trial in GVHD. Biol Blood Marrow Transplantat. 2010;16: Kurtzberg J, Prockop S, Teira P, et al. Allogeneic human mesenchymal stem cell therapy (remestemcel-l, Prochymal) as a rescue agent for severe refractory acute graft-versus-host disease in pediatric patients. Biol Blood Marrow Transplant. 2014;20(2): Weng JY, Du X, Geng SX, et al. Mesenchymal stem cell as salvage treatment for refractory chronic GVHD. Bone Marrow Transplant. 2010;45(12): Hoffmann P, Ermann J, Edinger M, Fathman CG, Strober S. Donor-type CD4(+)CD25(+) regulatory T cells suppress lethal acute graft-versus-host disease after allogeneic bone marrow transplantation. J Exp Med. 2002;196(3): Taylor PA, Lees CJ, Blazar BR. The infusion of ex vivo activated and expanded CD4(+)CD25(+) immune regulatory cells inhibits graft-versus-host disease lethality. Blood. 2002;99(10): Jones SC, Murphy GF, Korngold R. Post-hematopoietic cell transplantation control of graft-versus-host disease by donor CD4(+)25(+) T cells to allow an effective graft-versus-leukemia response. Biol Blood Marrow Transplant. 2003;9(4):

27 14. Brunstein CG, Miller JS, Cao Q, et al. Infusion of ex vivo expanded T regulatory cells in adults transplanted with umbilical cord blood: safety profile and detection kinetics. Blood. 2011;117(3): Di Ianni M, Falzetti F, Carotti A, et al. Tregs prevent GVHD and promote immune reconstitution in HLA-haploidentical transplantation. Blood. 2011; 117(14): Battaglia M, Stabilini A, Roncarolo MG. Rapamycin selectively expands CD4+CD25+FoxP3+ regulatory T cells. Blood. 2005;105(12): Hoffmann P, Eder R, Boeld TJ, et al. Only the CD45RA+ subpopulation of CD4+CD25high T cells gives rise to homogeneous regulatory T-cell lines upon in vitro expansion. Blood. 2006;108(13): Roncarolo MG, Battaglia M. Regulatory T-cell immunotherapy for tolerance to self antigens and alloantigens in humans. Nat Rev Immunol. 2007;7(8):

28 Session IV Supportive care 33

29 Food for thought in gastrointestinal GvHD Barbara S. van der Meij, Ph.D. Department of Health & Kinesiology, Texas A&M University, College Station, TX, USA Acute gastrointestinal graft-versus-host disease (GvHD) is characterized by diarrhea, abdominal pain, cramping, nausea and vomiting, and sometimes gastrointestinal bleeding and dysphagia. Even with immunosuppressive treatment and symptom management, symptoms can last for weeks to months, require intensive supportive care and negatively affect quality of life and nutritional status. Weight loss and muscle wasting are common in gastrointestinal GvHD and related to reduced dietary intake, malabsorption, pancreatic insufficiency and treatment related steroid-induced muscle wasting. Besides recommendations on calcium, vitamin D, bowel rest and a gastrointestinal diet, few evidence-based nutrition support guidelines for gastrointestinal GvHD are available, which makes it a challenge for clinicians to provide optimal nutrition support to these patients. This lecture will address the latest outcomes of nutritional assessment in patients with gastrointestinal GvHD, including the prevalence of malnutrition, protein losing enteropathy, vitamin and mineral deficiencies, and pancreatic dysfunction. Practicebased guidelines on energy and protein requirements and parenteral, enteral and oral nutrition in GvHD will be discussed, as well as innovative nutritional strategies, including n-3 polyunsaturated fatty acids as a potentially immunomodulating nutrient. In addition, data from a pilot study assessing fecal output, energy and macronutrient absorption and resting energy expenditure in patients with chronic gastrointestinal GvHD will be presented. This information helps to improve nutrition monitoring and nutrition support in patients with gastrointestinal GvHD and gives directions for future research. 35

30 Nutrition in GI-GvHD Pediatric aspects A. Vécsei SCT Oupatient Clinic, St. Anna Children s Hospital, Vienna, Austria Gastrointestinal (GI)-GvHD can lead to severe intestinal dysfunction owing to inflammatory damage throughout the entire digestive tract. Related to this dysfunction preexisting nutritional deficiencies become aggravated either caused by suboptimal caloric intake due to the associated loss of appetite, dysphagia and nausea, and/or by malabsorption, and/or increased losses caused by diarrhea. Furthermore, energy requirements increase since inflammation and tissue reparative processes in the gastrointestinal tract, which is the organ with the largest surface area of the whole body, are taking their toll. These increased energy requirements are met by protein degradation since infants and children lack endogenous stores and have greater baseline requirements compared to adults. Thus, loss of lean body mass ensues, associated with increased morbidity and mortality. Coping with these nutritional issues is difficult. Providing adequate calories using oral nutritional supplements is often hampered because the children might not be able to take enough food orally. In that case artificial nutrition comes into play, either administered enterally or parenterally. Enteral is preferred to parenteral nutrition as it is more physiologic, considerably less expensive, has fewer complications, might beneficially modulate the gut microbiota, helps to prevent mucosal atrophy, and maintains gut barrier function, which decrease intestinal bacterial translocation. Low-flow or trophic enteral nutrition may also be useful in combination with parenteral nutrition to maintain gut function and reduce the likelihood of cholestasis. Moreover, there are two special nutritional treatment modalities used in our transplant unit: 1. Exclusive enteral nutrition: In pediatric Crohn s disease exclusive enteral nutrition is useful not only as a means of providing macro- and micronutrients but also in reducing disease activity, thus being applied as an effective substitute for systemic corticosteroid treatment. Since pediatric Crohn s disease and GI-GvHD have many features in common including various treatment options, several years ago we started exclusive enteral feeding in GI-GvHD using the same enteral formulas as employed in pediatric Crohn s disease. 2. Moro s carrot soup: Adherence of microorganisms to the intestinal mucosa and activation of the innate immune system might be important steps in setting off GI-GvHD. Adherence is mediated by carbohydrate structures on the epithelial cell surface. Adherence can be blocked by carbohydrate receptor analogues. Moro s carrot soup contains acidic oligosaccharides, which are able to block adherence of various enteropathogenic microorganisms to HEp-2 cells and human intestinal mucosa in vitro. Over the last decade we have been applying Moro s carrot soup as a substitute for the standard decontamination with antibiotics in order to reduce the likelihood of the dysbiosis associated with antibiotic decontamination. I would like to gratefully acknowledge the persons whom I work with (in alphabetical order): K. Hammer, W. Holter, A. Innerhofer, H. Kogler, A. Lawitschka, S. Matthes- Leodolter, H. Pichler. 36

31 Homecare for prevention and decidual stromal cells for therapy of GI-GvHD Olle Ringdén Division of Therapeutic Immunology, Karolinska University Hospital Huddinge, Stockholm, Sweden Patients who undergo hematopoietic stem cell transplantation (HSCT) are as a rule treated in isolation rooms in the hospital. For 16 years, we let patients living within two hours driving distance from our hospital to be treated at home during the neutropenic phase after HSCT. Conditioning is given in the hospital. An experienced nurse visits the patients once or twice daily until engraftment. Our first matched-pair analysis showed several advantages in the homecare patients versus hospital isolation, such as fewer days with total parenteral nutrition (p < 0.01), less acute graftversus-host disease (GvHD) grades II IV (p = 0.01), lower TRM (p = 0.04), and lower costs (p = 0.05). Acute GvHD grades II IV occurred in 17% in the homecare patients vs. 44% in the controls. The probability of chronic GvHD and relapse was similar in the two groups and the graft-versus-leukemia effect was not affected. In a recent matched-pair analysis, factors associated with decreased acute GvHD were homecare (p = 0.02) and many days at home (p = 0.004). We introduced mesenchymal stromal cells (MSCs) to treat therapy-resistant severe acute GvHD with resolution in some, although not all, patients. The positive effects of MSCs were confirmed from many centers, although a randomized study did not show any difference in response between the MSC and the placebo group. The placenta protects the fetus from the mother s immune system and we switched to decidual stromal cells (DSCs) to treat acute GvHD. Indoleamine deoxygenase, prostaglandin E2, PD-L1 and IFN-γ participate in immunosuppression by DSCs. DSCs differ from bone marrow (BM)-derived MSCs in several ways. DSCs do not differentiate well to bone and cartilage, need direct contact to be immunosuppressive and are half the size of MSCs. With our most recent protocol using DSCs for steroid-refractory acute GvHD, 1-year survival is 70% (n = 17) and no patient has died from GvHD. This is significantly better than retrospective controls treated with other types of immunosuppressive therapies (n = 32), being 3% (p < 0.001), or patients treated with BM- MSCs (n = 22), 23% (p < 0.01). In the 2 latter cohorts of patients, 81% and 45% died from acute GvHD, respectively. DSCs were also used to successfully treat acute respiratory distress syndrome in an HSCT patient and to reverse paresis in the arms of one patient and in the legs of another patient. To conclude, homecare decrease acute GvHD. DSC is a novel effective therapy for acute GvHD. 37

32 List of Chairpersons, Speakers and Scientific Organizers Prof. Dr. Wolfgang Bethge Medizinische Universitätsklinik II Hämatologie/Onkologie Allogene Stammzelltransplantation Otfried-Müller Str Tübingen PD Dr. Christian Bojarski CC 13: Medizinische Klinik I Zentrale Endoskopie Charité Universitätsmedizin Berlin Campus Benjamin Franklin (CBF) Hindenburgdamm Berlin Prof. Dr. Harald Brodoefel Institut für Röntgendiagnostik Universitätsklinikum Regensburg Franz-Josef-Strauß-Allee Regensburg Prof. Dr. Matthias Edinger Klinik für Innere Medizin III Universitätsklinikum Regensburg Franz-Josef-Strauß-Allee Regensburg Prof. Dr. Matthias Evert Institut für Pathologie Universitätsklinikum Regensburg Franz-Josef-Strauß-Allee Regensburg James L.M. Ferrara, M.D. Professor of Pediatrics Hematologic Malignancies Translational Research Center The Tisch Cancer Institute Division of Hematology/Medical Oncology Hess Center for Science and Medicine 1470 Madison Avenue, 6th Floor New York, NY USA Prof. Dr. Armin Gerbitz Medizinische Klinik V Universitätsklinikum Erlangen Ulmenweg Erlangen Prof. Dr. Dr. Andre Gessner Institut für Medizinische Mikrobiologie und Hygiene Franz-Josef-Strauß-Allee Regensburg Prof. Dr. Hildegard T. Greinix Klinische Abteilung für Hämatologie Universitätsklinik für Innere Medizin Universitätsklinikum Graz Auenbruggerplatz Graz Austria PD Dr. Jörg Halter Klinik für Hämatologie Universitätsspital Basel Petersgraben Basel Switzerland 38