Immune mediated lung disease - Publicatie-online€¦ · Immune mediated lung disease after HCT in...

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une mediated lung disease after H

CT in children A

nne Birgitta Versluys

Anne Birgitta Versluys

Immune mediated lung disease after Hematopoietic Cell Transplantation in children

UITNODIGING voor het bijwonen van de openbare verdediging van

het proefschrift

Immune mediated lung disease after Hematopoietic Cell Transplantation

in children

op dinsdag 8 mei 2018 om 14:30 uur preciesin de Senaatzaal van

het AcademiegebouwDomplein 29 te Utrecht

Aansluitend receptie in Café Lebowski, Domplein 17 te Utrecht

Birgitta [email protected]

ParanimfenTjitske Vreugdenhil

Geza Kovacs

Immune mediated lung disease after hematopoietic cell

transplantation in children

Anne Birgitta Versluijs




All rights reserved. No part of this thesis may be reproduced or transmitted in any form by any means without permission in writing of the author. The copyright of the articles that have been published has been transferred to the respective journals.

Publication of this thesis was kindly supported by the University Medical Center Utrecht.

Copyright © 2018, Birgitta Versluijs, Utrecht, The Netherlands.

Author Birgitta VersluysCover design Birgitta Versluys Layout by Menno van den BerghPrinting Ridderprint BV | www.ridderprint.nlISBN 978-94-6299-916-9

All rights reserved. No part of this thesis may be reproduced or transmitted in any form by any means without permission in writing of the author. The copyright of the articles that have been published has been transferred to the respective journals.

Publication of this thesis was kindly supported by the University Medical Center Utrecht.

Copyright © 2018, Birgitta Versluijs, Utrecht, The Netherlands.

Author Birgitta VersluysCover design Birgitta Versluys Layout by Menno van den BerghPrinting Ridderprint BV | www.ridderprint.nlISBN 978-94-6299-916-9



Immuun gemedieerde longziekte na hematopoïetische stamceltransplantatie in kinderen

(met een samenvatting in het Nederlands)

Proefschrift

ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen

op dinsdag 8 mei 2018 des middags te 2.30 uur

door


geboren op 24 augustus 1967 te Amsterdam



Immuun gemedieerde longziekte na hematopoïetische stamceltransplantatie in kinderen

(met een samenvatting in het Nederlands)

Proefschrift

ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen

op dinsdag 8 mei 2018 des middags te 2.30 uur

door


geboren op 24 augustus 1967 te Amsterdam

Promotor:Prof.dr. C.K. van der Ent

Copromotoren:Dr. M.B. BieringsDr. J.J. Boelens

Promotor:Prof.dr. C.K. van der Ent

Copromotoren:Dr. M.B. BieringsDr. J.J. Boelens

TABLE OF CONTENTS

CHAPTER 1 Introduction 9

CHAPTER 2 Pulmonary complications of childhood cancer treatmentPaediatr Respir Rev. 2016; 17: 63-70

21

CHAPTER 3 Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndromesBiol Blood Marrow Transplant. 2010; 16: 782-791

41

CHAPTER 4 High-resolution CT can differentiate between alloimmune and non-alloimmune lung disease early after hematopoietic cell transplantationAJR Am J Roentgenol. 2014; 203: 656–661

63

CHAPTER 5 High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in childrenBiol Blood Marrow Transplant. 2015; 21: 1622-1626

79

TABLE OF CONTENTS

CHAPTER 1 Introduction 9

CHAPTER 2 Pulmonary complications of childhood cancer treatmentPaediatr Respir Rev. 2016; 17: 63-70

21

CHAPTER 3 Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndromesBiol Blood Marrow Transplant. 2010; 16: 782-791

41

CHAPTER 4 High-resolution CT can differentiate between alloimmune and non-alloimmune lung disease early after hematopoietic cell transplantationAJR Am J Roentgenol. 2014; 203: 656–661

63

CHAPTER 5 High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in childrenBiol Blood Marrow Transplant. 2015; 21: 1622-1626

79

CHAPTER 6 Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplant patientsSubmitted

95

CHAPTER 7 Infection with a respiratory virus before hematopoietic cell transplantation is associated with alloimmune-mediated lung syndromesJ Allergy Clin Immunol. 2017; 141: 697-703.e8

107

CHAPTER 8 Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantationSubmitted

133

CHAPTER 9 Discussion 157

CHAPTER 10 Nederlandse samenvattingCurriculum VitaeDankwoord

181190192

CHAPTER 6 Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplant patientsSubmitted

95

CHAPTER 7 Infection with a respiratory virus before hematopoietic cell transplantation is associated with alloimmune-mediated lung syndromesJ Allergy Clin Immunol. 2017; 141: 697-703.e8

107

CHAPTER 8 Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantationSubmitted

133

CHAPTER 9 Discussion 157

CHAPTER 10 Nederlandse samenvattingCurriculum VitaeDankwoord

181190192

1Introduction

1Introduction

10

1

Principles of HCT

General introduction

The bone marrow is the organ where blood cells are generated from hematopoietic stem cells. Allogeneic Hematopoietic Cell Transplantation (HCT) refers to the transfer of these hematopoietic stem cells from one individual to another, to obtain lifelong engraftment of the administered stem cells and thus guarantee the production of healthy donor de-rived blood cells. The cellular components of blood (erythrocytes, thrombocytes and leucocytes) are essential for oxygen supply, coagulation and immunity. HCT is a poten-tially life-saving procedure for selected patients with malignant diseases (leukemia, lymphoma) and non-malignant diseases (bone marrow failure syndromes, hemoglobinopa-thies, primary immune deficiencies, inborn errors of metabolism). In the Netherlands, a total of 350-400 allogeneic HCTs are performed annually, of which approximately 80-90 in children.1

Principles of hematopoietic cell transplantation

Donor selection is based primarily on Human Leucocyte Antigen (HLA) match. The HLA system is the most polymorphic genetic system in humans. The biological role of the HLA class I and class II molecules is to present processed peptide antigens on the outer part of body cells, leading to a highly specific signature. In HCT, HLA-A, -B, -C, -DR, -DQ and -DP are clinically important. The immune system differentiates “self-cells” from “non-self” via HLA. In HCT a donor-derived immune system will develop in a “non-self” environment, so HLA-matching is important to avoid immune mediated com-plications. In general, better HLA-matching leads to a decreased risk of graft rejection, as well as a lower incidence of Graft versus Host Disease (GvHD), an inflammatory disease caused by donor immune cells attacking normal recipient tissue. HLA inheritance fol-lows Mendelian rules, so a sibling has only 25% chance of being HLA identical. Expan-sion of the donor pool, in order to be able to offer HCT to more patients, was achieved by the establishment of international bone marrow donor registries and cord blood banks. Over time the use of unrelated donors has increased.

Donor source can be either Bone Marrow (BM), Peripheral Blood Stem Cells (PBSC) or Cord Blood (CB). Every option has its own advantages and disadvantages. BM harvesting requires general anaesthesia of the donor, but the product contains useful stromal cells besides the hematopoietic stem cells. PBSC are mobilized using granulocyte stimulating factors with potential side effects for the donors. Very high stem cell doses can be ob-tained, but there is an increased risk for chronic GvHD. It thus never became popular in pediatric HCT. Cord blood units are harvested direct post-partum, without any risk for the donor. A great advantage is the less stringent HLA matching criteria, the down side

10

1

Principles of HCT

General introduction

The bone marrow is the organ where blood cells are generated from hematopoietic stem cells. Allogeneic Hematopoietic Cell Transplantation (HCT) refers to the transfer of these hematopoietic stem cells from one individual to another, to obtain lifelong engraftment of the administered stem cells and thus guarantee the production of healthy donor de-rived blood cells. The cellular components of blood (erythrocytes, thrombocytes and leucocytes) are essential for oxygen supply, coagulation and immunity. HCT is a poten-tially life-saving procedure for selected patients with malignant diseases (leukemia, lymphoma) and non-malignant diseases (bone marrow failure syndromes, hemoglobinopa-thies, primary immune deficiencies, inborn errors of metabolism). In the Netherlands, a total of 350-400 allogeneic HCTs are performed annually, of which approximately 80-90 in children.1

Principles of hematopoietic cell transplantation

Donor selection is based primarily on Human Leucocyte Antigen (HLA) match. The HLA system is the most polymorphic genetic system in humans. The biological role of the HLA class I and class II molecules is to present processed peptide antigens on the outer part of body cells, leading to a highly specific signature. In HCT, HLA-A, -B, -C, -DR, -DQ and -DP are clinically important. The immune system differentiates “self-cells” from “non-self” via HLA. In HCT a donor-derived immune system will develop in a “non-self” environment, so HLA-matching is important to avoid immune mediated com-plications. In general, better HLA-matching leads to a decreased risk of graft rejection, as well as a lower incidence of Graft versus Host Disease (GvHD), an inflammatory disease caused by donor immune cells attacking normal recipient tissue. HLA inheritance fol-lows Mendelian rules, so a sibling has only 25% chance of being HLA identical. Expan-sion of the donor pool, in order to be able to offer HCT to more patients, was achieved by the establishment of international bone marrow donor registries and cord blood banks. Over time the use of unrelated donors has increased.

Donor source can be either Bone Marrow (BM), Peripheral Blood Stem Cells (PBSC) or Cord Blood (CB). Every option has its own advantages and disadvantages. BM harvesting requires general anaesthesia of the donor, but the product contains useful stromal cells besides the hematopoietic stem cells. PBSC are mobilized using granulocyte stimulating factors with potential side effects for the donors. Very high stem cell doses can be ob-tained, but there is an increased risk for chronic GvHD. It thus never became popular in pediatric HCT. Cord blood units are harvested direct post-partum, without any risk for the donor. A great advantage is the less stringent HLA matching criteria, the down side

11

Introduction

1is the limited amount of stem cells in the graft.

In order to replace blood production in the marrow by donor-derived hematopoiesis se-veral hurdles need to be overcome: elimination of the recipients’ hematopoietic stem cells and immune system are essential. This part of the treatment is called conditioning. Conditioning regimens are based on chemotherapy or Total Body Irradiation (TBI).

In myeloablative regimens, total ablation of the bone marrow cell compartment is the goal, giving the donor stem cells direct opportunity for engraftment. In non-myeloabla-tive regimens, also called reduced intensity conditioning (RIC), less intensive preparative treatment is used, not eliminating the whole hematopoietic system of the recipient, but relying more on slower donor cell influx after HCT.

Serotherapy (such as ATG, campath) is another important component of conditioning regimen, given to prevent graft rejection and GvHD in case of an unrelated donor. The main mechanism of action is in vivo depletion of (T) lymphocytes.

After the conditioning treatment, donor stem cells are infused. There will be a period of aplasia until donor engraftment takes place, usually leading to recovery from neutrope-nia in 2-4 weeks, and recovery of full immunity in the months to follow. In almost all pa-tients, immune suppressive (IS) therapy is given to prevent GvHD. Eventually tolerance will occur between donor immunity and host, diminishing the chance of GvHD, so IS can be tapered (Figure 1).

FIGURE 1. Schematic overview of hematopoietic cell transplantation (HCT).

Graft versus Host Disease (GvHD)

Direct toxicity conditioning

Infectious threat

11

Introduction

1is the limited amount of stem cells in the graft.

In order to replace blood production in the marrow by donor-derived hematopoiesis se-veral hurdles need to be overcome: elimination of the recipients’ hematopoietic stem cells and immune system are essential. This part of the treatment is called conditioning. Conditioning regimens are based on chemotherapy or Total Body Irradiation (TBI).

In myeloablative regimens, total ablation of the bone marrow cell compartment is the goal, giving the donor stem cells direct opportunity for engraftment. In non-myeloabla-tive regimens, also called reduced intensity conditioning (RIC), less intensive preparative treatment is used, not eliminating the whole hematopoietic system of the recipient, but relying more on slower donor cell influx after HCT.

Serotherapy (such as ATG, campath) is another important component of conditioning regimen, given to prevent graft rejection and GvHD in case of an unrelated donor. The main mechanism of action is in vivo depletion of (T) lymphocytes.

After the conditioning treatment, donor stem cells are infused. There will be a period of aplasia until donor engraftment takes place, usually leading to recovery from neutrope-nia in 2-4 weeks, and recovery of full immunity in the months to follow. In almost all pa-tients, immune suppressive (IS) therapy is given to prevent GvHD. Eventually tolerance will occur between donor immunity and host, diminishing the chance of GvHD, so IS can be tapered (Figure 1).

FIGURE 1. Schematic overview of hematopoietic cell transplantation (HCT).

Graft versus Host Disease (GvHD)

Direct toxicity conditioning

Infectious threat

12

1

Limitations of HCT

Successful HCT is considered disease free survival, with donor engraftment providing adequate immunity to prevent infections, in the absence of (severe) GvHD.

For malignant diseases, HCT is not only used to simply replace the leukemia-affected bone marrow, but it is currently regarded as the most common and effective form of im-munotherapy. The role of the graft-versus-leukemia (GVL) effect in allogeneic HCT has been well established in several conditions. Novel therapies using dendritic cell vaccina-tions, tumor-infiltrating lymphocytes, and chimeric antigen receptor (CAR)T cells are being evaluated as potential adjuvants to HCT, or even to replace HCT. The outcome and efficacy of HCT in malignancies is influenced by several factors, including (remission state of ) the underlying disorder, the degree of graft-versus-leukemia/tumor (GVL/T) effect, and the toxicities associated with the preparative chemotherapy regimens.2

In contrast, in non-malignant diseases there is no benefit from the graft-versus-disease effect. Here the engrafted donor cells compensate for the disease-causing deficiencies by producing certain lacking enzymes, normal hemoglobin or blood/immune cells. In many of these diseases less toxic therapies like gene therapy, especially avoiding the risk of GVHD, are expected to be used in the near future.3-7

Limitations of hematopoietic cell transplantation

Graft failure, disease recurrence, direct toxicity from conditioning, infectious problems (because of low immunity) and GvHD (because of increased donor immunity) remain important obstacles influencing morbidity and mortality and quality of life in HCT re-cipients.8 Risk factors for these complications include donor/host HLA-incompatibility, disease status, viral status, donor source, conditioning intensity, degree of immune reco-very and time from transplantation.

Virtually every organ can be adversely affected in some way after HCT, the most im-portant being the gastrointestinal, renal, cardiac, endocrine/fertility, metabolic and pul-monary systems.9,10 Appropriate supportive care during HCT is essential, but life-long monitoring of survivors of HCT is also needed. Many late effects may not manifest for years or even decades, and early detection might mitigate the long-term consequences of some late effects.11

12

1

Limitations of HCT

Successful HCT is considered disease free survival, with donor engraftment providing adequate immunity to prevent infections, in the absence of (severe) GvHD.

For malignant diseases, HCT is not only used to simply replace the leukemia-affected bone marrow, but it is currently regarded as the most common and effective form of im-munotherapy. The role of the graft-versus-leukemia (GVL) effect in allogeneic HCT has been well established in several conditions. Novel therapies using dendritic cell vaccina-tions, tumor-infiltrating lymphocytes, and chimeric antigen receptor (CAR)T cells are being evaluated as potential adjuvants to HCT, or even to replace HCT. The outcome and efficacy of HCT in malignancies is influenced by several factors, including (remission state of ) the underlying disorder, the degree of graft-versus-leukemia/tumor (GVL/T) effect, and the toxicities associated with the preparative chemotherapy regimens.2

In contrast, in non-malignant diseases there is no benefit from the graft-versus-disease effect. Here the engrafted donor cells compensate for the disease-causing deficiencies by producing certain lacking enzymes, normal hemoglobin or blood/immune cells. In many of these diseases less toxic therapies like gene therapy, especially avoiding the risk of GVHD, are expected to be used in the near future.3-7

Limitations of hematopoietic cell transplantation

Graft failure, disease recurrence, direct toxicity from conditioning, infectious problems (because of low immunity) and GvHD (because of increased donor immunity) remain important obstacles influencing morbidity and mortality and quality of life in HCT re-cipients.8 Risk factors for these complications include donor/host HLA-incompatibility, disease status, viral status, donor source, conditioning intensity, degree of immune reco-very and time from transplantation.

Virtually every organ can be adversely affected in some way after HCT, the most im-portant being the gastrointestinal, renal, cardiac, endocrine/fertility, metabolic and pul-monary systems.9,10 Appropriate supportive care during HCT is essential, but life-long monitoring of survivors of HCT is also needed. Many late effects may not manifest for years or even decades, and early detection might mitigate the long-term consequences of some late effects.11

13

Introduction

1Pulmonary complications of hematopoietic cell transplantation

Pulmonary complications, both infectious and non-infectious occur in 25-50% of HCT recipients and are associated with high rates of morbidity and mortality. Pulmonary com-plications thus are an important limitation for successfull HCT.

Infectious lung problems can be either viral (common respiratory viruses, CMV, Ade-novirus), bacterial or fungal. Other opportunistic infections, like Pneumocystis jiroveci also need to be considered. Infections can occur throughout the HCT course because of impaired immunity due to the procedure itself or by IS therapy (long) after HCT.

Because of improved diagnostic techniques and management of infectious pulmonary problems, non-infectious conditions have become relatively more important over time.12-14

Non-infectious complications after HCT can roughly be subdivided in early and late complications (Figure 2).

FIGURE 2. Schematic overview of allo-immune mediated lung syndromes (allo-LS) in relation to HCT. Abbreviations: DAH, diffuse alveolar hemorrhage; PERDS, peri-engraftment respira-tory distress syndrome; IPS, idiopathic pneumonia syndrome; COP, cryptogenic organizing pneumonia; BOS, bronchiolitis obliterans syndrome.

13

Introduction

1Pulmonary complications of hematopoietic cell transplantation

Pulmonary complications, both infectious and non-infectious occur in 25-50% of HCT recipients and are associated with high rates of morbidity and mortality. Pulmonary com-plications thus are an important limitation for successfull HCT.

Infectious lung problems can be either viral (common respiratory viruses, CMV, Ade-novirus), bacterial or fungal. Other opportunistic infections, like Pneumocystis jiroveci also need to be considered. Infections can occur throughout the HCT course because of impaired immunity due to the procedure itself or by IS therapy (long) after HCT.

Because of improved diagnostic techniques and management of infectious pulmonary problems, non-infectious conditions have become relatively more important over time.12-14

Non-infectious complications after HCT can roughly be subdivided in early and late complications (Figure 2).

FIGURE 2. Schematic overview of allo-immune mediated lung syndromes (allo-LS) in relation to HCT. Abbreviations: DAH, diffuse alveolar hemorrhage; PERDS, peri-engraftment respira-tory distress syndrome; IPS, idiopathic pneumonia syndrome; COP, cryptogenic organizing pneumonia; BOS, bronchiolitis obliterans syndrome.

14

1

Pulmonary complications of HCT

Idiopathic Pneumonia Syndrome (IPS), is regarded an early onset non-infectious lung complication occurring within the first 100 days after HCT. IPS usually has an acute onset of respiratory insufficiency and hypoxia. IPS has an overall incidence of 2-12% after HCT and a poor prognosis, with mortality rates of 50-80% within the first month of diagnosis.15 It is defined by evidence of alveolar disease in the absence of infection or cardiac disease/ fluid overload otherwise explaining pulmonary symptoms.16 Diagnostic criteria are shown in Table 1.

IPS by definition also includes Peri Engraftment Respiratory Distress Syndrome (PERDS) and Diffuse Alveolar Hemorrhage, clinical entities used in daily practice. PERDS occurs typically within 5 days of engraftment, and is the pulmonary manifestation of a diffuse systemic capillary leak disorder known as engraftment syndrome (ES). In its fulminant presentation, patients may have fever in the absence of infection, erythrodermatous rash > 25% of the body, diffuse pulmonary infiltrates causing dyspnea and hypoxia, and rapid weight gain caused by fluid retention. The prognosis of engraftment syndrome is gene-

TABLE 1. Definitions of Idiopathic Pneumonia Syndrome (American Thoracic Society 2010)16

I. Evidence of widespread alveolar injury:a. Multilobar infiltrates on routine chest radiographs or computed tomographyb. Symptoms and signs of pneumonia (cough, dyspnea, tachypnea, rales)c. Evidence of abnormal pulmonary physiology

1. Increased alveolar to arterial oxygen difference2. New or increased restrictive pulmonary function test abnormality

II. Absence of active lower respiratory tract infection based upon:a. Bronchoalveolar lavage negative for significant bacterial pathogens, including

acid-fast bacilli, Nocardia, and Legionella speciesb. Bronchoalveolar lavage negative for pathogenic nonbacterial microorganisms:

1. Routine culture for viruses and fungi2. Shell vial culture for CMV and respiratory RSV3. Cytology for CMV inclusions, fungi, and Pneumocystis jirovecii4. Direct fluorescence staining with antibodies against CMV, RSV, HSV, VZV,

influenzavirus, parainfluenzavirus, adenovirus, and other organismsc. Other organisms/tests to also consider:

1. Polymerase chain reaction for human metapneumovirus, rhinovirus, coronavirus and HHV6

2. Polymerase chain reaction for Chlamydia, Mycoplasma, and Aspergillus 3. Serum galactomannan ELISA for Aspergillus species

d. Transbronchial biopsy if condition of the patient permits

III. Absence of cardiac dysfunction, acute renal failure, or iatrogenic fluid overload asetiology for pulmonary dysfunction

14

1


Idiopathic Pneumonia Syndrome (IPS), is regarded an early onset non-infectious lung complication occurring within the first 100 days after HCT. IPS usually has an acute onset of respiratory insufficiency and hypoxia. IPS has an overall incidence of 2-12% after HCT and a poor prognosis, with mortality rates of 50-80% within the first month of diagnosis.15 It is defined by evidence of alveolar disease in the absence of infection or cardiac disease/ fluid overload otherwise explaining pulmonary symptoms.16 Diagnostic criteria are shown in Table 1.

IPS by definition also includes Peri Engraftment Respiratory Distress Syndrome (PERDS) and Diffuse Alveolar Hemorrhage, clinical entities used in daily practice. PERDS occurs typically within 5 days of engraftment, and is the pulmonary manifestation of a diffuse systemic capillary leak disorder known as engraftment syndrome (ES). In its fulminant presentation, patients may have fever in the absence of infection, erythrodermatous rash > 25% of the body, diffuse pulmonary infiltrates causing dyspnea and hypoxia, and rapid weight gain caused by fluid retention. The prognosis of engraftment syndrome is gene-

TABLE 1. Definitions of Idiopathic Pneumonia Syndrome (American Thoracic Society 2010)16

I. Evidence of widespread alveolar injury:a. Multilobar infiltrates on routine chest radiographs or computed tomographyb. Symptoms and signs of pneumonia (cough, dyspnea, tachypnea, rales)c. Evidence of abnormal pulmonary physiology

1. Increased alveolar to arterial oxygen difference2. New or increased restrictive pulmonary function test abnormality

II. Absence of active lower respiratory tract infection based upon:a. Bronchoalveolar lavage negative for significant bacterial pathogens, including

acid-fast bacilli, Nocardia, and Legionella speciesb. Bronchoalveolar lavage negative for pathogenic nonbacterial microorganisms:

1. Routine culture for viruses and fungi2. Shell vial culture for CMV and respiratory RSV3. Cytology for CMV inclusions, fungi, and Pneumocystis jirovecii4. Direct fluorescence staining with antibodies against CMV, RSV, HSV, VZV,

influenzavirus, parainfluenzavirus, adenovirus, and other organismsc. Other organisms/tests to also consider:

1. Polymerase chain reaction for human metapneumovirus, rhinovirus, coronavirus and HHV6

2. Polymerase chain reaction for Chlamydia, Mycoplasma, and Aspergillus 3. Serum galactomannan ELISA for Aspergillus species

d. Transbronchial biopsy if condition of the patient permits

III. Absence of cardiac dysfunction, acute renal failure, or iatrogenic fluid overload asetiology for pulmonary dysfunction

15

Introduction

1rally favorable. Mild cases are managed by supportive care only, severe cases generally respond well — with improvement within one day — to systemic corticosteroid treat-ment.12,13 Diffuse Alveolar Hemorrhage (DAH) is characterized by dyspnea, fever, multi-focal infiltrates on chest X-ray, and rapid progression to respiratory failure. Hemoptysis may occur. Typical findings on Chest High Resolution CT scan includes diffuse ground glass opacities and interlobular septal thickening, resulting in a “crazy-paving” appea-rance. It is distinguished from other types of IPS by broncho-alveolar lavage (BAL), be-cause of the finding of progressively bloodier lavage fluid return. Despite treatment with corticosteroids, reported mortality rate in DAH is 48-100%, the cause of death being a result of superimposed multi-organ failure rather than respiratory failure.12,13

The most important late onset non-infectious pulmonary complications following HCT is Bronchiolitis Obliterans Syndrome (BOS). It is defined as an obstructive lung disease, in the absence of infections and not responding to bronchodilators. BOS usually has an insidious onset, with cough, dyspnea and wheezing occurring months after HCT. Diagnostic criteria, mainly based on Pulmonary Function Tests (PFT) and radiologic abnormalities, are shown in Table 2.

TABLE 2. Diagnostic criteria for Bronchiolitis Obliterans Syndrome / lung GVHD. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chro-nic Graft-versus-Host Disease, 2015.17

1. FEV1/vital capacity < 0.70 or the fifth percentile of predicted.a. Vital capacity includes FVC or slow vital capacity, whichever is greater.b. The fifth percentile of predicted is the lower limit of the 90% confidence interval.c. For pediatric or elderly patients, use the lower limits of normal, defined according

to National Health and Nutrition Examination Survey III calculations

2. FEV1 < 75% of predicted with > 10% decline over less than 2 years. FEV1 should not correct to >75% of predicted with albuterol, and the absolute de-cline for the corrected values should still remain at >10% over 2 years.

3. Absence of infection in the respiratory tract, documented with investigations directedby clinical symptoms, such as chest radiographs, computed tomographic scans, or microbiologic cultures (sinus aspiration, URT viral screen, sputum culture, BAL).

4. One of the 2 supporting features of BOS:a. Evidence of air trapping by expiratory CT or small airway thickening or bronchiec-

tasis by high resolution chest CT, orb. Evidence of air trapping by PFTs: residual volume > 120% of predicted or residual

volume/total lung capacity elevated outside the 90% confidence interval.

FVC, forced vital capacity.; URT, upper respiratory tract; BAL, broncheoalveolar lavage. * If a patient already car-ries the diagnosis of chronic GVHD by virtue of organ involvement elsewhere, then only the first 3 criteria above are necessary to document chronic GVHD lung involvement.

15

Introduction

1rally favorable. Mild cases are managed by supportive care only, severe cases generally respond well — with improvement within one day — to systemic corticosteroid treat-ment.12,13 Diffuse Alveolar Hemorrhage (DAH) is characterized by dyspnea, fever, multi-focal infiltrates on chest X-ray, and rapid progression to respiratory failure. Hemoptysis may occur. Typical findings on Chest High Resolution CT scan includes diffuse ground glass opacities and interlobular septal thickening, resulting in a “crazy-paving” appea-rance. It is distinguished from other types of IPS by broncho-alveolar lavage (BAL), be-cause of the finding of progressively bloodier lavage fluid return. Despite treatment with corticosteroids, reported mortality rate in DAH is 48-100%, the cause of death being a result of superimposed multi-organ failure rather than respiratory failure.12,13

The most important late onset non-infectious pulmonary complications following HCT is Bronchiolitis Obliterans Syndrome (BOS). It is defined as an obstructive lung disease, in the absence of infections and not responding to bronchodilators. BOS usually has an insidious onset, with cough, dyspnea and wheezing occurring months after HCT. Diagnostic criteria, mainly based on Pulmonary Function Tests (PFT) and radiologic abnormalities, are shown in Table 2.

TABLE 2. Diagnostic criteria for Bronchiolitis Obliterans Syndrome / lung GVHD. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chro-nic Graft-versus-Host Disease, 2015.17

1. FEV1/vital capacity < 0.70 or the fifth percentile of predicted.a. Vital capacity includes FVC or slow vital capacity, whichever is greater.b. The fifth percentile of predicted is the lower limit of the 90% confidence interval.c. For pediatric or elderly patients, use the lower limits of normal, defined according

to National Health and Nutrition Examination Survey III calculations

2. FEV1 < 75% of predicted with > 10% decline over less than 2 years. FEV1 should not correct to >75% of predicted with albuterol, and the absolute de-cline for the corrected values should still remain at >10% over 2 years.

3. Absence of infection in the respiratory tract, documented with investigations directedby clinical symptoms, such as chest radiographs, computed tomographic scans, or microbiologic cultures (sinus aspiration, URT viral screen, sputum culture, BAL).

4. One of the 2 supporting features of BOS:a. Evidence of air trapping by expiratory CT or small airway thickening or bronchiec-

tasis by high resolution chest CT, orb. Evidence of air trapping by PFTs: residual volume > 120% of predicted or residual

volume/total lung capacity elevated outside the 90% confidence interval.

FVC, forced vital capacity.; URT, upper respiratory tract; BAL, broncheoalveolar lavage. * If a patient already car-ries the diagnosis of chronic GVHD by virtue of organ involvement elsewhere, then only the first 3 criteria above are necessary to document chronic GVHD lung involvement.

16

1


Reported incidence rate of BOS in literature varies widely from 0-48%, depending on de-finition and cohort of patients. Prognosis is poor, with improvement of lung function on aggressive therapy in only 8-20% and mortality rates of 50-80%. In many reports BOS following HCT is seen as a chronic progressive disease leading to irreversible air flow obstruction, with patients usually dying from pneumonia.12,18 Cryptogenic Organizing Pneumonia (COP; formerly called Bronchiolitis Obliterans Organizing Pneumonia, BOOP) is also considered a late non-infectious lung complication of HCT, with an incidence of 1-2%. COP usually develops earlier than BOS, has a more acute onset and is accompa-nied by fever. COP has a better prognosis with good response to corticosteroid therapy and mortality rate of around 19%.12,13

In all abovementioned disease-entities (allo)immunity and pro-inflammatory state play an important role. The clinical observation that there was an increase in the incidence of Allo-immune mediated Lung Syndromes (Allo-LS) in our pediatric HCT patients, with a very poor outcome raised our interest in this subject, and was the basis for this thesis.

16

1


Reported incidence rate of BOS in literature varies widely from 0-48%, depending on de-finition and cohort of patients. Prognosis is poor, with improvement of lung function on aggressive therapy in only 8-20% and mortality rates of 50-80%. In many reports BOS following HCT is seen as a chronic progressive disease leading to irreversible air flow obstruction, with patients usually dying from pneumonia.12,18 Cryptogenic Organizing Pneumonia (COP; formerly called Bronchiolitis Obliterans Organizing Pneumonia, BOOP) is also considered a late non-infectious lung complication of HCT, with an incidence of 1-2%. COP usually develops earlier than BOS, has a more acute onset and is accompa-nied by fever. COP has a better prognosis with good response to corticosteroid therapy and mortality rate of around 19%.12,13

In all abovementioned disease-entities (allo)immunity and pro-inflammatory state play an important role. The clinical observation that there was an increase in the incidence of Allo-immune mediated Lung Syndromes (Allo-LS) in our pediatric HCT patients, with a very poor outcome raised our interest in this subject, and was the basis for this thesis.

17

Introduction

1Aims and outline of this thesis

Allo-immune mediated Lung Syndromes (Allo-LS) are important contributors to Treat-ment Related morbidity and mortality after Hematopoietic Cell Transplantation.

The aim of this thesis is to:1. better understand predictors for Allo-LS 2. improve diagnostic tools to distinguish primarily infectious pathology from immune

mediated disease3. elucidate on determinants influencing therapy response 4. evaluate the impact of Allo-LS on long term outcome

More insight in underlying pathophysiology hopefully results in the identification of fu-ture targets for preventive and therapeutic strategies.

Chapter 2 gives a general overview of pulmonary complications in childhood cancer sur-vivors. Chapter 3 shows the relation between the presence of community acquired Respi-ratory Viruses (RV) and severe Allo-LS in pediatric HCT recipients. Chapter 4 discusses the importance of chest HRCT in diagnosing Allo-LS. Chapter 5 unveils the yield of pre-HCT pulmonary screening in children. Chapter 6 focusses on Respiratory Syncytial Virus (RSV) infection in pediatric HCT-recipients. Chapter 7 further explores the risk of early RV infection in the lungs as being cause for Allo-LS in children after HCT. Chap-ter 8 describes an Allo-LS cohort and gives prognostic factors for therapy response and overall outcome. In chapter 9 the results outlined in this thesis are discussed, with focus on implications of our findings for clinical care, and future perspectives for (clinical) research. Chapter 10 provides a summary in Dutch of this thesis.

17

Introduction

1Aims and outline of this thesis

Allo-immune mediated Lung Syndromes (Allo-LS) are important contributors to Treat-ment Related morbidity and mortality after Hematopoietic Cell Transplantation.

The aim of this thesis is to:1. better understand predictors for Allo-LS 2. improve diagnostic tools to distinguish primarily infectious pathology from immune

mediated disease3. elucidate on determinants influencing therapy response 4. evaluate the impact of Allo-LS on long term outcome

More insight in underlying pathophysiology hopefully results in the identification of fu-ture targets for preventive and therapeutic strategies.

Chapter 2 gives a general overview of pulmonary complications in childhood cancer sur-vivors. Chapter 3 shows the relation between the presence of community acquired Respi-ratory Viruses (RV) and severe Allo-LS in pediatric HCT recipients. Chapter 4 discusses the importance of chest HRCT in diagnosing Allo-LS. Chapter 5 unveils the yield of pre-HCT pulmonary screening in children. Chapter 6 focusses on Respiratory Syncytial Virus (RSV) infection in pediatric HCT-recipients. Chapter 7 further explores the risk of early RV infection in the lungs as being cause for Allo-LS in children after HCT. Chap-ter 8 describes an Allo-LS cohort and gives prognostic factors for therapy response and overall outcome. In chapter 9 the results outlined in this thesis are discussed, with focus on implications of our findings for clinical care, and future perspectives for (clinical) research. Chapter 10 provides a summary in Dutch of this thesis.

18

1

References

1. Matchis F. Europdonor Foundation An-nual Report 2015.

2. Mallhi K, Lum LG, Schultz KR, Yankele-vich M. Hematopoietic cell transplan-tation and cellular therapeutics in the treatment of childhood malignancies. Pediatric clinics of North America. 2015;62(1):257-73.

3. Chiesa R, Wynn RF, Veys P. Haemato-poietic stem cell transplantation in in-born errors of metabolism. Current opi-nion in hematology. 2016;23(6):530-5.

4. Peffault de Latour R, Peters C, Gibson B, Strahm B, Lankester A, de Heredia CD, et al. Recommendations on he-matopoietic stem cell transplantation for inherited bone marrow failure syn-dromes. Bone marrow transplantation. 2015;50(9):1168-72.

5. Robinson TM, Fuchs EJ. Allogeneic stem cell transplantation for sickle cell disease. Current opinion in hematology. 2016;23(6):524-9.

6. Makis A, Hatzimichael E, Papassotiriou I, Voskaridou E. 2017 Clinical trials up-date in new treatments of beta-thalas-semia. American journal of hematology. 2016;91(11):1135-45.

7. Booth C, Silva J, Veys P. Stem cell trans-plantation for the treatment of immu-nodeficiency in children: current status and hopes for the future. Expert review of clinical immunology. 2016;12(7):713-23.

8. Talano JM, Pulsipher MA, Symons HJ, Militano O, Shereck EB, Giller RH, et al. New frontiers in pediatric Allo-SCT. Bone marrow transplantation. 2014;49(9):1139-45.

9. Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, et al. National Cancer Institute-National Heart, Lung and Blood Institute/pedia-tric Blood and Marrow Transplant Con-

sortium First International Consensus Conference on late effects after pedia-tric hematopoietic cell transplantation: long-term organ damage and dysfunc-tion. Biol Blood Marrow Transplant. 2011;17(11):1573-84.

10. Munchel A, Chen A, Symons H. Emer-gent Complications in the Pediatric Hematopoietic Stem Cell Transplant Patient. Clinical pediatric emergency medicine. 2011;12(3):233-44.

11. Chow EJ, Anderson L, Baker KS, Bha-tia S, Guilcher GM, Huang JT, et al. Late Effects Surveillance Recommen-dations among Survivors of Childhood Hematopoietic Cell Transplantation: A Children’s Oncology Group Re-port. Biol Blood Marrow Transplant. 2016;22(5):782-95.

12. Soubani AO, Pandya CM. The spectrum of noninfectious pulmonary complicati-ons following hematopoietic stem cell transplantation. Hematology/oncology and stem cell therapy. 2010;3(3):143-57.

13. Ahya VN. Noninfectious Acute Lung In-jury Syndromes Early After Hematopoie-tic Stem Cell Transplantation. Clinics in chest medicine. 2017;38(4):595-606.

14. Radhakrishnan SV, Hildebrandt GC. A call to arms: a critical need for interven-tions to limit pulmonary toxicity in the stem cell transplantation patient popu-lation. Current hematologic malignancy reports. 2015;10(1):8-17.

15. Yanik GA, Grupp SA, Pulsipher MA, Levine JE, Schultz KR, Wall DA, et al. TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consor-tium and Children’s Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant. 2015;21(1):67-73.

References

18

1

References

1. Matchis F. Europdonor Foundation An-nual Report 2015.

2. Mallhi K, Lum LG, Schultz KR, Yankele-vich M. Hematopoietic cell transplan-tation and cellular therapeutics in the treatment of childhood malignancies. Pediatric clinics of North America. 2015;62(1):257-73.

3. Chiesa R, Wynn RF, Veys P. Haemato-poietic stem cell transplantation in in-born errors of metabolism. Current opi-nion in hematology. 2016;23(6):530-5.

4. Peffault de Latour R, Peters C, Gibson B, Strahm B, Lankester A, de Heredia CD, et al. Recommendations on he-matopoietic stem cell transplantation for inherited bone marrow failure syn-dromes. Bone marrow transplantation. 2015;50(9):1168-72.

5. Robinson TM, Fuchs EJ. Allogeneic stem cell transplantation for sickle cell disease. Current opinion in hematology. 2016;23(6):524-9.

6. Makis A, Hatzimichael E, Papassotiriou I, Voskaridou E. 2017 Clinical trials up-date in new treatments of beta-thalas-semia. American journal of hematology. 2016;91(11):1135-45.

7. Booth C, Silva J, Veys P. Stem cell trans-plantation for the treatment of immu-nodeficiency in children: current status and hopes for the future. Expert review of clinical immunology. 2016;12(7):713-23.

8. Talano JM, Pulsipher MA, Symons HJ, Militano O, Shereck EB, Giller RH, et al. New frontiers in pediatric Allo-SCT. Bone marrow transplantation. 2014;49(9):1139-45.

9. Nieder ML, McDonald GB, Kida A, Hingorani S, Armenian SH, Cooke KR, et al. National Cancer Institute-National Heart, Lung and Blood Institute/pedia-tric Blood and Marrow Transplant Con-

sortium First International Consensus Conference on late effects after pedia-tric hematopoietic cell transplantation: long-term organ damage and dysfunc-tion. Biol Blood Marrow Transplant. 2011;17(11):1573-84.

10. Munchel A, Chen A, Symons H. Emer-gent Complications in the Pediatric Hematopoietic Stem Cell Transplant Patient. Clinical pediatric emergency medicine. 2011;12(3):233-44.

11. Chow EJ, Anderson L, Baker KS, Bha-tia S, Guilcher GM, Huang JT, et al. Late Effects Surveillance Recommen-dations among Survivors of Childhood Hematopoietic Cell Transplantation: A Children’s Oncology Group Re-port. Biol Blood Marrow Transplant. 2016;22(5):782-95.





References

19

Introduction

116. Panoskaltsis-Mortari A, Griese M, Mad-

tes DK, Belperio JA, Haddad IY, Folz RJ, et al. An official American Thoracic So-ciety research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneu-monia syndrome. American journal of respiratory and critical care medicine. 2011;183(9):1262-79.

17. Jagasia MH, Greinix HT, Arora M, Wil-liams KM, Wolff D, Cowen EW, et al. Na-tional Institutes of Health Consensus Development Project on Criteria for Cli-nical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Sta-ging Working Group report. Biol Blood Marrow Transplant. 2015;21(3):389-401 e1.

18. Williams KM. How I treat bronchiolitis obliterans syndrome after hematopoie-tic stem cell transplantation. Blood. 2017;129(4):448-55.

19

Introduction

116. Panoskaltsis-Mortari A, Griese M, Mad-

tes DK, Belperio JA, Haddad IY, Folz RJ, et al. An official American Thoracic So-ciety research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneu-monia syndrome. American journal of respiratory and critical care medicine. 2011;183(9):1262-79.



2Pulmonary complications of childhood cancer treatment

2Pulmonary complications of childhood cancer treatment

Pulmonary complications of childhood cancer treatment

A.B.Versluys, D. Bresters

Paediatric Respiratory Reviews 2016; 17: 63–70

Abstract

Pulmonary complications of childhood cancer treatment are fre-quently seen. These can lead to adverse sequelae many years after treatment, with important impact on morbidity, quality of life and mortality in childhood cancer survivors. This review addresses the effects of chemotherapy, radiotherapy, surgery and alloimmunity (in haematopoietic cell transplantation) on the lung in children. It highlights the complexity of lung damage and lung disease in rela-tion to growth and development, infections and other external fac-tors. Screening high risk childhood cancer survivors for treatment related late effects, with therapy based screening protocols, using full medical assessment and pulmonary function tests is impor-tant. This will lead to recognition of pulmonary sequelae of cancer treatment, early detection of lung damage in survivors and better treatment and prevention.

Blood and Marrow Transplantation

Program, Depart-ment of Pediatrics University Medical

Center Utrecht (UMCU), Utrecht, The Netherlands

A.B. Versluys

Willem-Alexander Children’s Hospital,

Leiden Univer-sity Medical Center

(LUMC), Leiden, The Netherlands

D. Bresters


A.B.Versluys, D. Bresters

Paediatric Respiratory Reviews 2016; 17: 63–70

Abstract

Pulmonary complications of childhood cancer treatment are fre-quently seen. These can lead to adverse sequelae many years after treatment, with important impact on morbidity, quality of life and mortality in childhood cancer survivors. This review addresses the effects of chemotherapy, radiotherapy, surgery and alloimmunity (in haematopoietic cell transplantation) on the lung in children. It highlights the complexity of lung damage and lung disease in rela-tion to growth and development, infections and other external fac-tors. Screening high risk childhood cancer survivors for treatment related late effects, with therapy based screening protocols, using full medical assessment and pulmonary function tests is impor-tant. This will lead to recognition of pulmonary sequelae of cancer treatment, early detection of lung damage in survivors and better treatment and prevention.




A.B. Versluys

Willem-Alexander Children’s Hospital,

Leiden Univer-sity Medical Center

(LUMC), Leiden, The Netherlands

D. Bresters

23


Introduction

With advances in therapeutic strategies, the number of childhood cancer survivors con-tinues to increase. The 5 years survival rate for children with cancer approaches 75%, and an estimated 1 in 600 young adults in western countries is a survivor of childhood cancer. This increase in survival is not without consequences. Treatment related com-plications can result in adverse sequelae, which may not become evident for many years They represent a major cause of morbidity with a large impact on quality of life, and predispose to increased mortality during adulthood. Large cohort studies in childhood cancer survivors show a high burden of disease in 40-85% of survivors, depending on treatment, follow up time and age at time of assessment.1–3 Mortality among 5-year survi-vors of childhood cancer is 8-10 times higher when compared to the general population. Causes of death change over time; recurrence of primary disease is the leading cause in the first 15 years from diagnosis, but after that, most survivors die from secondary malig-nancies or cardiac or pulmonary disease.4,5

Pulmonary complications of cancer treatment can be divided into acute (during treat-ment), early (within months after treatment) and late effects. Lung surgery, lung ir-radiation, certain chemotherapeutic agents and immune mediated phenomena after Haematopoietic Cell Transplantation (HCT) are all associated with pulmonary damage. Interactions of these treatment related effects with other factors like infections, growth and other organ dysfunction may further influence long term pulmonary outcome of children treated for cancer.

Studies on this subject vary in design. Some use self-reported data on clinical symptoms in all survivors, others use data retrieved from screening programs for high-risk survi-vors with history taking and physical examination. Some studies use sibling controls, some compare treatment modalities within childhood cancer survivors, and others com-pare with data from the general population. Questionnaires and findings on medical as-sessment can be useful. Often pulmonary function tests are used as an objective test for lung damage, also detecting asymptomatic lung injury. Chronic health conditions can be classified using National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading from mild to life threatening/death (see Figure 1). Most studies present data from only one or few centres, definitions and classifications of PFT abnor-malities vary somewhat, and many studies are retrospective or cross-sectional. None-theless these studies help define the extent and patterns of pulmonary dysfunction in survivors of childhood cancer.

Here we review the pulmonary toxicity of cancer treatment in children and focus on the non-acute, non-infectious adverse effects on the lungs.

2

23


Introduction

With advances in therapeutic strategies, the number of childhood cancer survivors con-tinues to increase. The 5 years survival rate for children with cancer approaches 75%, and an estimated 1 in 600 young adults in western countries is a survivor of childhood cancer. This increase in survival is not without consequences. Treatment related com-plications can result in adverse sequelae, which may not become evident for many years They represent a major cause of morbidity with a large impact on quality of life, and predispose to increased mortality during adulthood. Large cohort studies in childhood cancer survivors show a high burden of disease in 40-85% of survivors, depending on treatment, follow up time and age at time of assessment.1–3 Mortality among 5-year survi-vors of childhood cancer is 8-10 times higher when compared to the general population. Causes of death change over time; recurrence of primary disease is the leading cause in the first 15 years from diagnosis, but after that, most survivors die from secondary malig-nancies or cardiac or pulmonary disease.4,5

Pulmonary complications of cancer treatment can be divided into acute (during treat-ment), early (within months after treatment) and late effects. Lung surgery, lung ir-radiation, certain chemotherapeutic agents and immune mediated phenomena after Haematopoietic Cell Transplantation (HCT) are all associated with pulmonary damage. Interactions of these treatment related effects with other factors like infections, growth and other organ dysfunction may further influence long term pulmonary outcome of children treated for cancer.

Studies on this subject vary in design. Some use self-reported data on clinical symptoms in all survivors, others use data retrieved from screening programs for high-risk survi-vors with history taking and physical examination. Some studies use sibling controls, some compare treatment modalities within childhood cancer survivors, and others com-pare with data from the general population. Questionnaires and findings on medical as-sessment can be useful. Often pulmonary function tests are used as an objective test for lung damage, also detecting asymptomatic lung injury. Chronic health conditions can be classified using National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) grading from mild to life threatening/death (see Figure 1). Most studies present data from only one or few centres, definitions and classifications of PFT abnor-malities vary somewhat, and many studies are retrospective or cross-sectional. None-theless these studies help define the extent and patterns of pulmonary dysfunction in survivors of childhood cancer.

Here we review the pulmonary toxicity of cancer treatment in children and focus on the non-acute, non-infectious adverse effects on the lungs.

2

24

Introduction

FIGURE 1. Summary of CTCAE 4.0 criteria for chronic respiratory health conditions. CTCAE, National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0

2

24

Introduction

FIGURE 1. Summary of CTCAE 4.0 criteria for chronic respiratory health conditions. CTCAE, National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0

2

25


Prevalence of pulmonary complications in childhood cancer survivors

In a questionnaire-based study, Mertens reported on pulmonary complications in a large cohort of 12,390 childhood cancer survivors.6 The prevalence of the pulmonary conditi-ons covered in the questionnaire was 0-25.8%. Compared with a control group (consis-ting of nearest age siblings) the survivors had a significantly increased relative risk for lung fibrosis, emphysema, recurrent pneumonia, chronic cough, need for supplemental oxygen, chest wall abnormalities and exercise induced shortness of breath. This was es-pecially true after chest irradiation. The association with pulmonary toxic chemotherapy was less evident (Figure 3).6

Several studies described the health outcomes of childhood cancer survivors as recorded after full medical assessment according to standardized screening protocols, using CT-CAE criteria for chronic health conditions.

Geenen looked at the severity and total burden of late effects in a cohort of 1362 survi-vors (median age 24.4 years, median follow up 17 years after diagnosis).3 At least one adverse event was found in the majority of survivors (74.5%). In 36.8% of patients these adverse events were severe, disabling or life threatening. Pulmonary adverse events ac-counted for 5% of all events. In this study no pulmonary function tests [PFTs] were done, and events were only recorded by history taking and physical examination.3 The same group further analysed the prevalence of pulmonary injury with PFTs in a subset of high-risk adult childhood cancer survivors treated with potentially pulmotoxic therapy.7 They found PFT abnormalities in 44% of survivors, most frequently in patients treated with radiotherapy, bleomycin or thoracic surgery, especially when these treatment modalities were combined.7 Others reported comparable findings, and showed a clear increase in PFT abnormalities with longer follow up and aging of survivors.2

Mortality from pulmonary causes in childhood cancer survivors has been studied in a few population based studies, in which mortality among 5 years survivors was compa-red to the age adjusted expected survival rates of the general population, expressed as the standardized mortality ratio (SMR). In the USA the childhood cancer survivor study (CCSS) showed an overall SMR of 10.8. The SMR for death from pulmonary causes (pneumonia, fibrosis or other) was 8.8 (95% CI 6.8-11.2, p<0.01). In survivors of acute myeloid leukaemia, astrocytoma, Hodgkin’s disease and neuroblastoma, pulmonary SMR was even higher. Specific treatment related risk factors for pulmonary death were not mentioned.4 In a study of childhood cancer survivors in the Nordic countries, overall SMR was 8.3, with large variations depending on follow up time and decade of diagno-sis. Pulmonary causes comprised 16.2% of non-cancer causes of death. This was not expressed as SMR.5

2

25


Prevalence of pulmonary complications in childhood cancer survivors

In a questionnaire-based study, Mertens reported on pulmonary complications in a large cohort of 12,390 childhood cancer survivors.6 The prevalence of the pulmonary conditi-ons covered in the questionnaire was 0-25.8%. Compared with a control group (consis-ting of nearest age siblings) the survivors had a significantly increased relative risk for lung fibrosis, emphysema, recurrent pneumonia, chronic cough, need for supplemental oxygen, chest wall abnormalities and exercise induced shortness of breath. This was es-pecially true after chest irradiation. The association with pulmonary toxic chemotherapy was less evident (Figure 3).6

Several studies described the health outcomes of childhood cancer survivors as recorded after full medical assessment according to standardized screening protocols, using CT-CAE criteria for chronic health conditions.

Geenen looked at the severity and total burden of late effects in a cohort of 1362 survi-vors (median age 24.4 years, median follow up 17 years after diagnosis).3 At least one adverse event was found in the majority of survivors (74.5%). In 36.8% of patients these adverse events were severe, disabling or life threatening. Pulmonary adverse events ac-counted for 5% of all events. In this study no pulmonary function tests [PFTs] were done, and events were only recorded by history taking and physical examination.3 The same group further analysed the prevalence of pulmonary injury with PFTs in a subset of high-risk adult childhood cancer survivors treated with potentially pulmotoxic therapy.7 They found PFT abnormalities in 44% of survivors, most frequently in patients treated with radiotherapy, bleomycin or thoracic surgery, especially when these treatment modalities were combined.7 Others reported comparable findings, and showed a clear increase in PFT abnormalities with longer follow up and aging of survivors.2

Mortality from pulmonary causes in childhood cancer survivors has been studied in a few population based studies, in which mortality among 5 years survivors was compa-red to the age adjusted expected survival rates of the general population, expressed as the standardized mortality ratio (SMR). In the USA the childhood cancer survivor study (CCSS) showed an overall SMR of 10.8. The SMR for death from pulmonary causes (pneumonia, fibrosis or other) was 8.8 (95% CI 6.8-11.2, p<0.01). In survivors of acute myeloid leukaemia, astrocytoma, Hodgkin’s disease and neuroblastoma, pulmonary SMR was even higher. Specific treatment related risk factors for pulmonary death were not mentioned.4 In a study of childhood cancer survivors in the Nordic countries, overall SMR was 8.3, with large variations depending on follow up time and decade of diagno-sis. Pulmonary causes comprised 16.2% of non-cancer causes of death. This was not expressed as SMR.5

2

26

Pulmonary complications of radiotherapy


Radiation exposure of the lungs occurs during chest radiation for mediastinal disease or lung metastasis, Total Body Irradiation (TBI) in HCT setting, or by scattering from abdominal irradiation or spinal cord irradiation.

Radiation induced lung injury takes place in 3 phases over weeks to months. The im-mediate effect of irradiation is oxidative damage to DNA, resulting in cell injury and apoptosis of pneumocytes. This stimulates the recruitment of inflammatory cells, cy-tokine production and loss of normal barrier function, leading to a local inflammatory response. During the repair process there is an influx of cells, mainly activated macro-phages with proinflammatory activity, contributing to tissue remodelling and the deve-lopment of fibrosis. During inflammation and repair, local oedema and vascular changes lead to hypoxia, again inducing cell injury and inflammation. This ongoing non-healing tissue response leads to chronic radiation injury (see Figure 2).8

FIGURE 2. Early responses to pulmonary radiation include an increase in Reactive Oxygen (ROS) and Nitrogen (RNS) Species, cytokine induction and an increase in hypoxia, edema and a drop in lung perfusion. A delayed response, consisting of a second wave of cytokine induction and hypoxia, along with macrophage infiltration in the lung occurs at 6-8 weeks. Late injury is often observed in the form of fibrosis at 24-32 weeks. (Reproduced with permis-sion from P. Graves8).

2

Cytokines

RT

IL-1α

TNFαTGF-β1

IL-6

Cytokines

Radiation effects

ROS/RNSDNA damage

Apoptosis

HypoxiaLung Density

Edema

Physiological effects


Perfusion


Perfusion

HypoxiaLung Density

Edema


FibrosisBreathingdifficulty

Lung injuryIncrease

Decrease

growth factorschemokines

VEGFIL-1α

TNFαTGF-β1

IL-6

Leukocytes

Infiltrating cells

1d 3d 6-8w 24 weeks

26



Radiation exposure of the lungs occurs during chest radiation for mediastinal disease or lung metastasis, Total Body Irradiation (TBI) in HCT setting, or by scattering from abdominal irradiation or spinal cord irradiation.

Radiation induced lung injury takes place in 3 phases over weeks to months. The im-mediate effect of irradiation is oxidative damage to DNA, resulting in cell injury and apoptosis of pneumocytes. This stimulates the recruitment of inflammatory cells, cy-tokine production and loss of normal barrier function, leading to a local inflammatory response. During the repair process there is an influx of cells, mainly activated macro-phages with proinflammatory activity, contributing to tissue remodelling and the deve-lopment of fibrosis. During inflammation and repair, local oedema and vascular changes lead to hypoxia, again inducing cell injury and inflammation. This ongoing non-healing tissue response leads to chronic radiation injury (see Figure 2).8

FIGURE 2. Early responses to pulmonary radiation include an increase in Reactive Oxygen (ROS) and Nitrogen (RNS) Species, cytokine induction and an increase in hypoxia, edema and a drop in lung perfusion. A delayed response, consisting of a second wave of cytokine induction and hypoxia, along with macrophage infiltration in the lung occurs at 6-8 weeks. Late injury is often observed in the form of fibrosis at 24-32 weeks. (Reproduced with permis-sion from P. Graves8).

2

Cytokines

RT

IL-1α

TNFαTGF-β1

IL-6

Cytokines

Radiation effects

ROS/RNSDNA damage

Apoptosis

HypoxiaLung Density

Edema



Perfusion


Perfusion

HypoxiaLung Density

Edema


FibrosisBreathingdifficulty

Lung injuryIncrease

Decrease

growth factorschemokines

VEGFIL-1α

TNFαTGF-β1

IL-6

Leukocytes

Infiltrating cells

1d 3d 6-8w 24 weeks

27


A thorough understanding of the complex pulmonary response to injury identifies po-tential targets for intervention, but no such therapy is currently being widely used in clinical practice. An important consideration is that the use of any protective agent in the context of cancer therapy might negatively influence the effect of radiation on the tumor.9

Clinically radiation injury may result in radiation pneumonitis, an early inflammatory process within 2-4 months after radiation, associated with mild to severe dyspnoea and a non-productive cough. Radiation fibrosis occurs months to years after radiation. Patients may be asymptomatic or present with a varying degree of dyspnoea. Chronic respiratory failure may develop leading to pulmonary hypertension and cor pulmonale.

Factors associated with radiation induced lung injury are dosimetric factors, co-admi-nistration of certain chemotherapeutic agents and patient factors like female gender and smoking habits.8

Within the CCSS cohort there was a cumulative incidence of lung fibrosis at 20 years follow up of 3.5%. Chest radiation therapy was significantly associated with lung fibrosis (RR 4.3; 95% CI 2.9-6.6, p < 0.01), supplemental oxygen use (RR=1.8; 95% CI 1.5-2.2, p< 0.01), recurrent pneumonia (RR 2.2; 95% CI 1, 4-3.5, p< 0.01), and chronic cough (RR = 2.0; 95% CI 1.6-2.4, p< 0.01). There was an association with pulmotoxic chemo-therapy as well (nitrosureas, bleomycin, busulphan and cyclophosphamide), but weaker and mostly in combination with irradiation. This study also showed that the incidence of lung fibrosis, chronic cough and shortness of breath continued to increase up to 25 years from time of diagnosis (Figure 3).6

A recent study looked at pulmonary outcomes in a cohort of 109 children at least 2 years after therapeutic irradiation of the lung. The cumulative incidence of any pulmonary condition was 70%, mostly pneumonia, chest wall deformity or interstitial lung disease. In multivariate analysis only mean lung irradiation dose (MLD) was associated with ad-verse long term pulmonary outcome (p=0.01), with the probability of having at least one pulmonary complication 5 years after radiation determined as follows: MLD 5 Gy: 53%, MLD 10 Gy: 64%, MLD 15 Gy: 75% and MLD 20 Gy: 84%. Thoracic surgery, age at expo-sure and bleomycin were not predictors in this model.10

In several other small studies the effect of whole lung irradiation for lung metastases or mantle/involved field/mediastinal radiation for Hodgkin lymphoma was studied.11–13 Radiation affected lung parenchyma resulted in reduced lung volume, impaired dyna-mic compliance and led to deformity of the chest wall in a dose dependent way. Despite abnormal PFTs in the majority of patients (40%-80%) only 5%-20% of patients were symptomatic. As irradiation damage seems to be dose dependent, one can suspect mild lung injury due to scattering after irradiation of other organs. This issue has not been widely studied so far.

2

27


A thorough understanding of the complex pulmonary response to injury identifies po-tential targets for intervention, but no such therapy is currently being widely used in clinical practice. An important consideration is that the use of any protective agent in the context of cancer therapy might negatively influence the effect of radiation on the tumor.9

Clinically radiation injury may result in radiation pneumonitis, an early inflammatory process within 2-4 months after radiation, associated with mild to severe dyspnoea and a non-productive cough. Radiation fibrosis occurs months to years after radiation. Patients may be asymptomatic or present with a varying degree of dyspnoea. Chronic respiratory failure may develop leading to pulmonary hypertension and cor pulmonale.

Factors associated with radiation induced lung injury are dosimetric factors, co-admi-nistration of certain chemotherapeutic agents and patient factors like female gender and smoking habits.8

Within the CCSS cohort there was a cumulative incidence of lung fibrosis at 20 years follow up of 3.5%. Chest radiation therapy was significantly associated with lung fibrosis (RR 4.3; 95% CI 2.9-6.6, p < 0.01), supplemental oxygen use (RR=1.8; 95% CI 1.5-2.2, p< 0.01), recurrent pneumonia (RR 2.2; 95% CI 1, 4-3.5, p< 0.01), and chronic cough (RR = 2.0; 95% CI 1.6-2.4, p< 0.01). There was an association with pulmotoxic chemo-therapy as well (nitrosureas, bleomycin, busulphan and cyclophosphamide), but weaker and mostly in combination with irradiation. This study also showed that the incidence of lung fibrosis, chronic cough and shortness of breath continued to increase up to 25 years from time of diagnosis (Figure 3).6

A recent study looked at pulmonary outcomes in a cohort of 109 children at least 2 years after therapeutic irradiation of the lung. The cumulative incidence of any pulmonary condition was 70%, mostly pneumonia, chest wall deformity or interstitial lung disease. In multivariate analysis only mean lung irradiation dose (MLD) was associated with ad-verse long term pulmonary outcome (p=0.01), with the probability of having at least one pulmonary complication 5 years after radiation determined as follows: MLD 5 Gy: 53%, MLD 10 Gy: 64%, MLD 15 Gy: 75% and MLD 20 Gy: 84%. Thoracic surgery, age at expo-sure and bleomycin were not predictors in this model.10

In several other small studies the effect of whole lung irradiation for lung metastases or mantle/involved field/mediastinal radiation for Hodgkin lymphoma was studied.11–13 Radiation affected lung parenchyma resulted in reduced lung volume, impaired dyna-mic compliance and led to deformity of the chest wall in a dose dependent way. Despite abnormal PFTs in the majority of patients (40%-80%) only 5%-20% of patients were symptomatic. As irradiation damage seems to be dose dependent, one can suspect mild lung injury due to scattering after irradiation of other organs. This issue has not been widely studied so far.

2

28


Data on age at irradiation as a risk factor for pulmonary complications is conflicting. Some studies reported small lung volume but normal gas transfer per unit of lung vo-lume in those exposed at a very young age, suggesting that underdevelopment of the tho-rax is more important than parenchymal lung damage.11,14 Others have suggested a more pronounced effect of irradiation in the developing lung.11,15 By contrast, some studies found older age at irradiation to be associated with reduced lung function, hypothesizing loss of repair capacity with increasing age.16

FIGURE 3. Cumulative incidence of medical conditions reported > 5 years after diagno-sis. CRX only: chest radiation therapy only. PTC only: pulmonary toxic chemotherapy only. (With permission Professor A. Mertens6)

2

28


Data on age at irradiation as a risk factor for pulmonary complications is conflicting. Some studies reported small lung volume but normal gas transfer per unit of lung vo-lume in those exposed at a very young age, suggesting that underdevelopment of the tho-rax is more important than parenchymal lung damage.11,14 Others have suggested a more pronounced effect of irradiation in the developing lung.11,15 By contrast, some studies found older age at irradiation to be associated with reduced lung function, hypothesizing loss of repair capacity with increasing age.16

FIGURE 3. Cumulative incidence of medical conditions reported > 5 years after diagno-sis. CRX only: chest radiation therapy only. PTC only: pulmonary toxic chemotherapy only. (With permission Professor A. Mertens6)

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Pulmonary complications of chemotherapy

There is a paucity of literature on late onset chemotherapy induced pulmonary disease, and most reports date from the 1980s and 1990s. The agents associated with lung toxi-city include bleomycin, alkylating agents (such as busulphan and cyclophosphamide), and nitrosureas (BCNU and CCNU).6,7,11,17,18

Bleomycin is an antibiotic agent with antitumor activity by inducing free radicals. It is mainly applied in children with germcell tumours or Hodgkin’s disease. Bleomycin is poorly metabolized in the lung because of low levels of the bleomycin detoxifying en-zyme bleomycin hydrolase. Accumulation of the drug leads to vascular and cell damage, inducing an inflammatory process with influx of macrophages and fibroblasts in lung parenchyma, ultimately leading to lung fibrosis.18–20 Pulmonary toxicity of bleomycin increases with impaired renal function at the time of administration, the cumulative dose and concomitant thoracic irradiation or administration of other chemotherapeutic agents.11,19–21

Bleomycin induced pneumonitis is a severe and sometimes fatal complication. It usually starts gradually during or early after treatment. Patients have non-productive cough and exertional dyspnoea, sometimes progressing to dyspnoea at rest and cyanosis. Cortico-steroids can be considered, but most important is that further bleomycin administration is withheld.20

Lung fibrosis has been reported in 10% of adults treated with bleomycin above a thres-hold dose of 400 units/m2.18,21,22 For these doses there are no data in children. In a study by De et al.23 at least one PFT abnormality was present in 52.2% of patients with a me-dian follow up of 3.9 years after bleomycin treatment (median cumulative dose of only 65 units/m2). Obstructive lung disease and hyperinflation were the most common PFT abnormalities, but only a minority of survivors were symptomatic.23

It has been suggested that oxygen therapy may exacerbate bleomycin induced lung toxi-city.11,19 In a large cohort study of bleomycin-exposed patients undergoing surgery, howe-ver, Aakre et al.24 showed that smoking habits, preoperative PFT and fluid management during the procedure were more important risk factors for postoperative acute respirato-ry distress syndrome than supplemental oxygen administration. Others have confirmed that the risk for late deterioration of lung function due to high oxygen. exposure (either during anaesthesia or scuba diving) in bleomycin exposed survivors is negligible as long as PFTs are normal and exposure occurred more than one year prior.21,25

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There is a paucity of literature on late onset chemotherapy induced pulmonary disease, and most reports date from the 1980s and 1990s. The agents associated with lung toxi-city include bleomycin, alkylating agents (such as busulphan and cyclophosphamide), and nitrosureas (BCNU and CCNU).6,7,11,17,18

Bleomycin is an antibiotic agent with antitumor activity by inducing free radicals. It is mainly applied in children with germcell tumours or Hodgkin’s disease. Bleomycin is poorly metabolized in the lung because of low levels of the bleomycin detoxifying en-zyme bleomycin hydrolase. Accumulation of the drug leads to vascular and cell damage, inducing an inflammatory process with influx of macrophages and fibroblasts in lung parenchyma, ultimately leading to lung fibrosis.18–20 Pulmonary toxicity of bleomycin increases with impaired renal function at the time of administration, the cumulative dose and concomitant thoracic irradiation or administration of other chemotherapeutic agents.11,19–21

Bleomycin induced pneumonitis is a severe and sometimes fatal complication. It usually starts gradually during or early after treatment. Patients have non-productive cough and exertional dyspnoea, sometimes progressing to dyspnoea at rest and cyanosis. Cortico-steroids can be considered, but most important is that further bleomycin administration is withheld.20

Lung fibrosis has been reported in 10% of adults treated with bleomycin above a thres-hold dose of 400 units/m2.18,21,22 For these doses there are no data in children. In a study by De et al.23 at least one PFT abnormality was present in 52.2% of patients with a me-dian follow up of 3.9 years after bleomycin treatment (median cumulative dose of only 65 units/m2). Obstructive lung disease and hyperinflation were the most common PFT abnormalities, but only a minority of survivors were symptomatic.23

It has been suggested that oxygen therapy may exacerbate bleomycin induced lung toxi-city.11,19 In a large cohort study of bleomycin-exposed patients undergoing surgery, howe-ver, Aakre et al.24 showed that smoking habits, preoperative PFT and fluid management during the procedure were more important risk factors for postoperative acute respirato-ry distress syndrome than supplemental oxygen administration. Others have confirmed that the risk for late deterioration of lung function due to high oxygen. exposure (either during anaesthesia or scuba diving) in bleomycin exposed survivors is negligible as long as PFTs are normal and exposure occurred more than one year prior.21,25

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Busulphan has long been recognized as a potentially pulmotoxic cytostatic drug.6,11,17,26,27 Busulphan is almost exclusively applied within the preparative regimen for either au-tologous or allogeneic HCT and is usually combined with other chemotherapy agents, most frequently cyclophosphamide, melfalan or fludarabine. This makes it difficult to assess the relative contribution of busulphan to pulmonary late effects after HCT. Also, in the allogeneic transplant setting immune-mediated lung disease (Idiopathic Pneu-monia Syndrome, Bronchiolitis Obliterans Syndrome) may contribute to pulmonary in-jury. Busulphan can cause both acute lung problems, i.e. interstitial pneumonia, and late pulmonary function abnormalities.6,11,17,26 It has been suggested that after busulphan obstructive lung involvement may be more common,27 but in the allogeneic transplant setting immune-mediated lung disease may confound the busulphan effect. Late pul-monary damage may develop insidiously and symptoms include non-productive cough, dyspnoea, or fever.6,11,28 It is unclear whether the risk of lung damage is dose dependent, although pulmonary toxicity has mostly been described after high cumulative transplan-tation doses.11,18,22

Cyclophosphamide is one of the most widely used cytotoxic drugs in the treatment of paediatric malignancy and is frequently used in the preparative regimen for HCT as well. Cyclophosphamide is associated with early-onset interstitial pneumonia and late-onset more insidious disease that may progress to pulmonary fibrosis.6,18,29,30 Pulmonary toxi-city of cyclophosphamide has almost exclusively been described in the setting of HCT conditioning, when other pulmotoxic therapy is also being used and immune mediated lung injury may play a role. This hampers the assessment of the pulmonary toxicity and late effects of cyclophosphamide by itself. Few cases have been described of pulmonary toxicity in patients who were not exposed to other pulmonary toxic modalities, such as radiotherapy.29,30 In a study by Mulder et al.7 in long-term childhood cancer survivors, high dose cyclophosphamide was not a significant risk factor for PFT abnormalities. There was no apparent relationship with dose or duration of cyclophosphamide use.11,28

Although nitrosureas have been shown to be toxic to pulmonary tissue and are conside-red an indication for long-term PFT screening in childhood cancer survivors, only limi-ted data is available to support this notion. Of the nitrosurea derivatives, BCNU (carm-ustine) is applied in high dose preparative regimens for autologous HCT such as in the treatment of lymphoma. CCNU (lomustine) is used in the treatment of malignant brain tumours in children.

BCNU has been found to cause pulmonary toxicity in a dose dependent way in 20-30% of the treated patients.11 Pulmonary toxicity of CCNU has only been described in isolated case reports.18,22,31 Early-onset toxicity of BCNU can present as interstitial pneumonia and fibrosis, but pulmonary fibrosis can also present as a late-onset complication.31,32 Higher cumulative dose and younger age have been described as risk factors for pulmonary toxi-

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Busulphan has long been recognized as a potentially pulmotoxic cytostatic drug.6,11,17,26,27 Busulphan is almost exclusively applied within the preparative regimen for either au-tologous or allogeneic HCT and is usually combined with other chemotherapy agents, most frequently cyclophosphamide, melfalan or fludarabine. This makes it difficult to assess the relative contribution of busulphan to pulmonary late effects after HCT. Also, in the allogeneic transplant setting immune-mediated lung disease (Idiopathic Pneu-monia Syndrome, Bronchiolitis Obliterans Syndrome) may contribute to pulmonary in-jury. Busulphan can cause both acute lung problems, i.e. interstitial pneumonia, and late pulmonary function abnormalities.6,11,17,26 It has been suggested that after busulphan obstructive lung involvement may be more common,27 but in the allogeneic transplant setting immune-mediated lung disease may confound the busulphan effect. Late pul-monary damage may develop insidiously and symptoms include non-productive cough, dyspnoea, or fever.6,11,28 It is unclear whether the risk of lung damage is dose dependent, although pulmonary toxicity has mostly been described after high cumulative transplan-tation doses.11,18,22

Cyclophosphamide is one of the most widely used cytotoxic drugs in the treatment of paediatric malignancy and is frequently used in the preparative regimen for HCT as well. Cyclophosphamide is associated with early-onset interstitial pneumonia and late-onset more insidious disease that may progress to pulmonary fibrosis.6,18,29,30 Pulmonary toxi-city of cyclophosphamide has almost exclusively been described in the setting of HCT conditioning, when other pulmotoxic therapy is also being used and immune mediated lung injury may play a role. This hampers the assessment of the pulmonary toxicity and late effects of cyclophosphamide by itself. Few cases have been described of pulmonary toxicity in patients who were not exposed to other pulmonary toxic modalities, such as radiotherapy.29,30 In a study by Mulder et al.7 in long-term childhood cancer survivors, high dose cyclophosphamide was not a significant risk factor for PFT abnormalities. There was no apparent relationship with dose or duration of cyclophosphamide use.11,28

Although nitrosureas have been shown to be toxic to pulmonary tissue and are conside-red an indication for long-term PFT screening in childhood cancer survivors, only limi-ted data is available to support this notion. Of the nitrosurea derivatives, BCNU (carm-ustine) is applied in high dose preparative regimens for autologous HCT such as in the treatment of lymphoma. CCNU (lomustine) is used in the treatment of malignant brain tumours in children.

BCNU has been found to cause pulmonary toxicity in a dose dependent way in 20-30% of the treated patients.11 Pulmonary toxicity of CCNU has only been described in isolated case reports.18,22,31 Early-onset toxicity of BCNU can present as interstitial pneumonia and fibrosis, but pulmonary fibrosis can also present as a late-onset complication.31,32 Higher cumulative dose and younger age have been described as risk factors for pulmonary toxi-

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31


city of BCNU.31,32 When BCNU is given in the HCT setting, often other potentially pul-motoxic modalities (radiotherapy and alkylating agents) have been applied, which might increase the risk for pulmonary toxicity. Mertens et al.6 showed treatment with BCNU and CCNU to be a risk factor for supplemental oxygen use at older age, which can be a sign of lung fibrosis.

Pulmonary complications of surgery

Although primary lung cancer is exceedingly rare in childhood, pulmonary metastases of other malignancies do occur, and surgical resection is a key component of treatment for such pulmonary metastases. Children appear to tolerate resection better than adults, possibly due to adaptive mechanisms such as hypertrophy or hyperinflation to compen-sate for the loss of lung tissue in the long term.11 A recent study on osteosarcoma survi-vors after metastatectomy showed abnormal PFTs in a higher number of cases (30-67%) depending on the specific tests considered and the number of thoracotomies. All of the-se survivors had received multiagent chemotherapy for osteosarcoma, but few received known pulmotoxic agents. The negative effect of chemotherapy in general on lung reco-very after surgery was suggested to cause the impaired lung function.33

Pulmonary complications of allogeneic hematopoietic cell transplantation

Children undergoing HCT are exposed to a number of injurious factors that can impair pulmonary function. Mainly non-infectious aetiologies are responsible for pulmonary complications months to years after HCT.34

Effects of high dose chemotherapy (Busulphan, Cyclophosphamide) and irradiation (To-tal Body or Thoraco-Abdominal Irradiation, TBI/TAI) have been described above. On top of this, other contributing factors include prolonged immune suppression (with incre-ased risk of bacterial and fungal infection or viral reactivation) and immune-mediated phenomena (Graft versus Host Disease, GvHD]. Lung injury following HCT can be cate-gorized as damage to lung parenchyma (alveolar and interstitial), airway epithelium andvascular endothelium.

Idiopathic pneumonia syndrome (IPS) is seen within weeks to months after HCT. It is a clinical syndrome of alveolar injury, with marked radiographic abnormalities, in the absence of an identifiable infectious cause. Interstitial pneumonia, Diffuse Alveolar Hae-morrhage and Engraftment Syndrome are considered subsets of IPS. Patients with IPS present with cough, hypoxia and progressive dyspnoea. The exact aetiology of IPS is currently being unravelled, but more and more evidence leads to the view that in IPS the

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31


city of BCNU.31,32 When BCNU is given in the HCT setting, often other potentially pul-motoxic modalities (radiotherapy and alkylating agents) have been applied, which might increase the risk for pulmonary toxicity. Mertens et al.6 showed treatment with BCNU and CCNU to be a risk factor for supplemental oxygen use at older age, which can be a sign of lung fibrosis.

Pulmonary complications of surgery

Although primary lung cancer is exceedingly rare in childhood, pulmonary metastases of other malignancies do occur, and surgical resection is a key component of treatment for such pulmonary metastases. Children appear to tolerate resection better than adults, possibly due to adaptive mechanisms such as hypertrophy or hyperinflation to compen-sate for the loss of lung tissue in the long term.11 A recent study on osteosarcoma survi-vors after metastatectomy showed abnormal PFTs in a higher number of cases (30-67%) depending on the specific tests considered and the number of thoracotomies. All of the-se survivors had received multiagent chemotherapy for osteosarcoma, but few received known pulmotoxic agents. The negative effect of chemotherapy in general on lung reco-very after surgery was suggested to cause the impaired lung function.33

Pulmonary complications of allogeneic hematopoietic cell transplantation

Children undergoing HCT are exposed to a number of injurious factors that can impair pulmonary function. Mainly non-infectious aetiologies are responsible for pulmonary complications months to years after HCT.34

Effects of high dose chemotherapy (Busulphan, Cyclophosphamide) and irradiation (To-tal Body or Thoraco-Abdominal Irradiation, TBI/TAI) have been described above. On top of this, other contributing factors include prolonged immune suppression (with incre-ased risk of bacterial and fungal infection or viral reactivation) and immune-mediated phenomena (Graft versus Host Disease, GvHD]. Lung injury following HCT can be cate-gorized as damage to lung parenchyma (alveolar and interstitial), airway epithelium andvascular endothelium.

Idiopathic pneumonia syndrome (IPS) is seen within weeks to months after HCT. It is a clinical syndrome of alveolar injury, with marked radiographic abnormalities, in the absence of an identifiable infectious cause. Interstitial pneumonia, Diffuse Alveolar Hae-morrhage and Engraftment Syndrome are considered subsets of IPS. Patients with IPS present with cough, hypoxia and progressive dyspnoea. The exact aetiology of IPS is currently being unravelled, but more and more evidence leads to the view that in IPS the

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lung becomes a target for cytotoxic and immunemediated attack.35 Cumulative incidence of IPS in children is estimated at 5-10%.36,37 Treatment of IPS generally includes suppor-tive care and systemic corticosteroids.35 Prognosis is poor with reported mortality rates of 50%-75%.36,37

Bronchiolitis Obliterans Syndrome (BOS) is typically seen months after HCT. It is de-fined as chronic obstructive lung disease with PFT abnormalities (Forced expiratory vo-lume in 1 sec (FEV1) < 75% of predicted and FEV1/forced vital capacity (FVC) ratio < 0.7) and signs of air trapping and ground glass on high–resolution computed tomography. Patients with BOS may be asymptomatic but typically present with cough, wheezing or dyspnoea on exertion. Incidence of BOS in paediatric HCT is 4-9%, mortality ranges between 11-67%.38,39 Both in IPS and in BOS, pre-HCT lung damage by conditioning regimen or infection attenuated by immune mediated processes lead to the actual lung disease, which can be regarded as pulmonary GVHD. Treatment consists of stepping up immunosuppression.39,40

Primary pulmonary vascular complications of HCT are rarely seen. Pulmonary Arterial Hypertension (PAH) has a relation with thrombotic microangiopathy, a severe compli-cation of HCT in which toxic endothelial injury causes microangiopathy leading to mi-crothrombi and end organ injury, mostly in the kidneys but sometimes also affecting lungs.41,42 PAH may also develop secondary to left sided heart disease, hypoxia and in-terstitial lung disease. The true incidence of PAH in children after HCT is unknown. Transthoracic echocardiography is recommended in any patient with unexplained hypo-xemic respiratory failure after HCT.41

Pulmonary Veno-Occlusive Disease (VOD) is a very rare event, occurring early after HCT, with a suggested association with hepatic VOD.

Several groups have studied long-term lung function among HCT survivors in detail.38,43,44 Both obstructive lung disease and restrictive lung disease are observed. A triphasic mo-del has been suggested for chronic lung injury after HCT. First, alloantigen recognition takes place and initiates an influx of inflammatory cells, and then the persistence of this inflammatory signal makes lymphocytes migrate into the airway mucosa and contribute to epithelial injury. Subsequently, lung fibroblasts increase in number and lead to enhan-ced production of collagen.45

Restrictive lung disease has been described in 10-33%, either as an isolated finding or in combination with decreased diffusion capacity of carbon monoxide (DLCO).38,43 Ge-nerally speaking these findings are seen early after HCT and show some improvement 1-2 years after HCT and stabilize, but do not return to pre-HCT values. Risk factors for restrictive lung disease are certain cytotoxic agents and irradiation. Skin GvHD leading to scleroderma, chest wall deformities, short stature and respiratory and skeletal muscle

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lung becomes a target for cytotoxic and immunemediated attack.35 Cumulative incidence of IPS in children is estimated at 5-10%.36,37 Treatment of IPS generally includes suppor-tive care and systemic corticosteroids.35 Prognosis is poor with reported mortality rates of 50%-75%.36,37

Bronchiolitis Obliterans Syndrome (BOS) is typically seen months after HCT. It is de-fined as chronic obstructive lung disease with PFT abnormalities (Forced expiratory vo-lume in 1 sec (FEV1) < 75% of predicted and FEV1/forced vital capacity (FVC) ratio < 0.7) and signs of air trapping and ground glass on high–resolution computed tomography. Patients with BOS may be asymptomatic but typically present with cough, wheezing or dyspnoea on exertion. Incidence of BOS in paediatric HCT is 4-9%, mortality ranges between 11-67%.38,39 Both in IPS and in BOS, pre-HCT lung damage by conditioning regimen or infection attenuated by immune mediated processes lead to the actual lung disease, which can be regarded as pulmonary GVHD. Treatment consists of stepping up immunosuppression.39,40

Primary pulmonary vascular complications of HCT are rarely seen. Pulmonary Arterial Hypertension (PAH) has a relation with thrombotic microangiopathy, a severe compli-cation of HCT in which toxic endothelial injury causes microangiopathy leading to mi-crothrombi and end organ injury, mostly in the kidneys but sometimes also affecting lungs.41,42 PAH may also develop secondary to left sided heart disease, hypoxia and in-terstitial lung disease. The true incidence of PAH in children after HCT is unknown. Transthoracic echocardiography is recommended in any patient with unexplained hypo-xemic respiratory failure after HCT.41

Pulmonary Veno-Occlusive Disease (VOD) is a very rare event, occurring early after HCT, with a suggested association with hepatic VOD.

Several groups have studied long-term lung function among HCT survivors in detail.38,43,44 Both obstructive lung disease and restrictive lung disease are observed. A triphasic mo-del has been suggested for chronic lung injury after HCT. First, alloantigen recognition takes place and initiates an influx of inflammatory cells, and then the persistence of this inflammatory signal makes lymphocytes migrate into the airway mucosa and contribute to epithelial injury. Subsequently, lung fibroblasts increase in number and lead to enhan-ced production of collagen.45

Restrictive lung disease has been described in 10-33%, either as an isolated finding or in combination with decreased diffusion capacity of carbon monoxide (DLCO).38,43 Ge-nerally speaking these findings are seen early after HCT and show some improvement 1-2 years after HCT and stabilize, but do not return to pre-HCT values. Risk factors for restrictive lung disease are certain cytotoxic agents and irradiation. Skin GvHD leading to scleroderma, chest wall deformities, short stature and respiratory and skeletal muscle

2

Genetic predispositionAtopyInnate immunityPulmonary condition prior to cancer treatment

Chemotherapy Bleomycin Busulfan Cyclophosphamide Nitrosureas

Radiation Chest TBI Scattering

Surgery Alloimmunity IPS/BO

Other late effects of cancer treatment Chest wall deformity Growth retardation Cardiac dysfunction Obesity Muscle weakness

Occupational hazards

Pollution

Smoking

Infections

33


weakness may contribute to restrictive lung disease.38,43 Obstructive lung disease is seen in 8-19% of survivors of paediatric HCT.38,43 The most common form of obstructive lung disease after HCT is Bronchiolitis Obliterans. With longer follow up time PFTs show steady decline up to 10 years after treatment.44

Other factors influencing lung function in childhood cancer survivors

It is important to emphasize that apart from lung damage due to treatment, several other factors play an important role in pulmonary function abnormalities in survivors of child-hood cancer. Recurrent infections during treatment and long after, impaired growth, chest wall abnormalities, muscle weakness, obesity, cardiac function and lifestyle issues (smoking habits) are among those (see Figure 4).

FIGURE 4. Overview of pulmonary complications of childhood cancer treatment on long term follow up. TBI, Total Body Irradiation; IPS, Idiopathic Pneumonia Syndrome; BO, Bron-chiolitis Obliterans; SOB, shortness of breath.

Abnormal pulmonary function test

obstructive restrictive

Symptoms

cough exertional SOB dyspnea at rest supplemental oxygen

Morbidity

lung fibrosis bronchiolitis obliterans lung cancer?

Mortality

end stage lung disease pneumonia

Childhoodcancer

AgeingGrowing childLung developmentuntil age 8 yr

2

Genetic predispositionAtopyInnate immunityPulmonary condition prior to cancer treatment

Chemotherapy Bleomycin Busulfan Cyclophosphamide Nitrosureas

Radiation Chest TBI Scattering

Surgery Alloimmunity IPS/BO

Other late effects of cancer treatment Chest wall deformity Growth retardation Cardiac dysfunction Obesity Muscle weakness

Occupational hazards

Pollution

Smoking

Infections

33


weakness may contribute to restrictive lung disease.38,43 Obstructive lung disease is seen in 8-19% of survivors of paediatric HCT.38,43 The most common form of obstructive lung disease after HCT is Bronchiolitis Obliterans. With longer follow up time PFTs show steady decline up to 10 years after treatment.44

Other factors influencing lung function in childhood cancer survivors

It is important to emphasize that apart from lung damage due to treatment, several other factors play an important role in pulmonary function abnormalities in survivors of child-hood cancer. Recurrent infections during treatment and long after, impaired growth, chest wall abnormalities, muscle weakness, obesity, cardiac function and lifestyle issues (smoking habits) are among those (see Figure 4).

FIGURE 4. Overview of pulmonary complications of childhood cancer treatment on long term follow up. TBI, Total Body Irradiation; IPS, Idiopathic Pneumonia Syndrome; BO, Bron-chiolitis Obliterans; SOB, shortness of breath.

Abnormal pulmonary function test

obstructive restrictive

Symptoms

cough exertional SOB dyspnea at rest supplemental oxygen

Morbidity

lung fibrosis bronchiolitis obliterans lung cancer?

Mortality

end stage lung disease pneumonia

Childhoodcancer

AgeingGrowing childLung developmentuntil age 8 yr

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Lung transplantation in childhood cancer survivors

Lung cancer as a second malignancy after childhood cancer treatment

Childhood cancer survivors have a six fold increased relative risk for (second) malignan-cies compared to the general population.46 Lung cancer is rarely reported as a second malignancy after treatment for childhood cancer. Amongst over 14,000 survivors only 11 cases were observed (cumulative incidence after 30 years 0.1%). Compared to the expec-ted rate in the general population the standardized incidence ratio (SIR) is 3.4 (CI 1.9-6.1). The median time to lung cancer from diagnosis was 20.3 (14.0-25.6) years. As this is a rare event no risk factors have yet been identified, but the role of ionizing radiation as a carcinogen has been well reported in the literature. As this is a secondary malignancy that occurs late after treatment, one can assume that with longer follow up the incidence of lung cancer in childhood cancer survivors may increase.


Soubani reviewed the literature on lung transplantation (LT) following HCT. In total of 84 patients (median age at LT: 22 years (range 1-66), median time between HCT and LT: 52.3 months (range 6-240). Most patients were transplanted because of end stage Bronchiolitis Obliterans Syndrome (BOS). Survival rates of HCT survivors undergoing lung transplantation seem not to be different from general lung transplant recipients, with a 5 years survival of about 50%. Death from infection was more frequently seen in patients receiving lung transplantation after HCT. BOS in the transplanted lung occur-red in 32.5% of cases, this incidence is comparable with the incidence rate in other LT re-cipients. One of the main controversies about performing lung transplantation following HCT is the best timing of transplant in view of risk of relapse of underlying disease. In the reported series, relapse rate was relatively low (2.5%). This may be a result of proper timing of LT, or of the protective role of cGvHD against relapse by a graft versus leukae-mia effect.47 There are very little data on lung transplantation in children following treat-ment of malignancy without HCT.48 Current international guidelines for the selection of lung transplant candidates exclude patients with a history of malignancy within 2 years, with significant comorbidity in other organs and with chest abnormalities (International Society of Heart and Lung Transplantation 2006). All these items are relevant in child-hood cancer survivors with end stage lung disease.

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Lung cancer as a second malignancy after childhood cancer treatment

Childhood cancer survivors have a six fold increased relative risk for (second) malignan-cies compared to the general population.46 Lung cancer is rarely reported as a second malignancy after treatment for childhood cancer. Amongst over 14,000 survivors only 11 cases were observed (cumulative incidence after 30 years 0.1%). Compared to the expec-ted rate in the general population the standardized incidence ratio (SIR) is 3.4 (CI 1.9-6.1). The median time to lung cancer from diagnosis was 20.3 (14.0-25.6) years. As this is a rare event no risk factors have yet been identified, but the role of ionizing radiation as a carcinogen has been well reported in the literature. As this is a secondary malignancy that occurs late after treatment, one can assume that with longer follow up the incidence of lung cancer in childhood cancer survivors may increase.


Soubani reviewed the literature on lung transplantation (LT) following HCT. In total of 84 patients (median age at LT: 22 years (range 1-66), median time between HCT and LT: 52.3 months (range 6-240). Most patients were transplanted because of end stage Bronchiolitis Obliterans Syndrome (BOS). Survival rates of HCT survivors undergoing lung transplantation seem not to be different from general lung transplant recipients, with a 5 years survival of about 50%. Death from infection was more frequently seen in patients receiving lung transplantation after HCT. BOS in the transplanted lung occur-red in 32.5% of cases, this incidence is comparable with the incidence rate in other LT re-cipients. One of the main controversies about performing lung transplantation following HCT is the best timing of transplant in view of risk of relapse of underlying disease. In the reported series, relapse rate was relatively low (2.5%). This may be a result of proper timing of LT, or of the protective role of cGvHD against relapse by a graft versus leukae-mia effect.47 There are very little data on lung transplantation in children following treat-ment of malignancy without HCT.48 Current international guidelines for the selection of lung transplant candidates exclude patients with a history of malignancy within 2 years, with significant comorbidity in other organs and with chest abnormalities (International Society of Heart and Lung Transplantation 2006). All these items are relevant in child-hood cancer survivors with end stage lung disease.

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Recommendations for screening and treatment of pulmonary late effects

Long-term follow up, using exposure driven, risk based screening protocols is warran-ted in childhood cancer survivors. Besides thorough history taking and physical exami-nation, PFTs can help in screening for pre-symptomatic lung damage. Implications of subclinical findings are yet unknown, but could have important meaning when the po-pulation ages and pulmonary function shows its physiological decline.

The Dutch Children’s Oncology Group-late effects group (SKION LATER) currently recommends screening in all survivors exposed to chest irradiation (including TBI), busulphan, bleomycin, nitrosureas, and pulmonary or thoracic surgery, with lifelong re-gular full medical assessment, and PFTs at least 5 and 10 years after diagnosis. Whenever necessary, (paediatric) respiratory specialists are to be consulted. Yearly influenza im-munization is recommended in case of impaired lung function and strong nonsmoking advice is given (in all survivors). This screening will be of benefit for the individual sur-vivor, as early detection of pulmonary problems will guide future therapy. This will also provide further insight in risk factors for pulmonary late effects and add knowledge by exploring genetic susceptibility, identification of predictive biomarkers and monitoring for late effects of new agents.

Increasing awareness of adverse pulmonary outcomes in general practitioners and adult pulmonologists, will help identify patients with early symptoms of pulmonary disease.

Future directions for research

• The spectrum of pulmonary late effects with longer follow up and ageing of child-hood cancer survivors, with special emphasis on lung cancer, vasculopathy and other degenerative diseases.

• Estimation of the precise absorbed radiation dose/volume parameters for the lung and the heart using a novel dosimetry approach in CCS, and correlate this with pul-monary late effects.

• The total burden of self-reported persistent cough and other respiratory problems the relation with treatment and the impact on quality of life, daily activities and other organs. This is currently being studied in a nationwide cohort of long-term CCS versus healthy siblings.

• Pulmonary effects of new agents used in treatment of childhood cancer.

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35


Recommendations for screening and treatment of pulmonary late effects

Long-term follow up, using exposure driven, risk based screening protocols is warran-ted in childhood cancer survivors. Besides thorough history taking and physical exami-nation, PFTs can help in screening for pre-symptomatic lung damage. Implications of subclinical findings are yet unknown, but could have important meaning when the po-pulation ages and pulmonary function shows its physiological decline.

The Dutch Children’s Oncology Group-late effects group (SKION LATER) currently recommends screening in all survivors exposed to chest irradiation (including TBI), busulphan, bleomycin, nitrosureas, and pulmonary or thoracic surgery, with lifelong re-gular full medical assessment, and PFTs at least 5 and 10 years after diagnosis. Whenever necessary, (paediatric) respiratory specialists are to be consulted. Yearly influenza im-munization is recommended in case of impaired lung function and strong nonsmoking advice is given (in all survivors). This screening will be of benefit for the individual sur-vivor, as early detection of pulmonary problems will guide future therapy. This will also provide further insight in risk factors for pulmonary late effects and add knowledge by exploring genetic susceptibility, identification of predictive biomarkers and monitoring for late effects of new agents.

Increasing awareness of adverse pulmonary outcomes in general practitioners and adult pulmonologists, will help identify patients with early symptoms of pulmonary disease.

Future directions for research

• The spectrum of pulmonary late effects with longer follow up and ageing of child-hood cancer survivors, with special emphasis on lung cancer, vasculopathy and other degenerative diseases.

• Estimation of the precise absorbed radiation dose/volume parameters for the lung and the heart using a novel dosimetry approach in CCS, and correlate this with pul-monary late effects.

• The total burden of self-reported persistent cough and other respiratory problems the relation with treatment and the impact on quality of life, daily activities and other organs. This is currently being studied in a nationwide cohort of long-term CCS versus healthy siblings.

• Pulmonary effects of new agents used in treatment of childhood cancer.

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References

1. Landier W, Armenian S, Bhatia S. Late effects of childhood cancer and its treatment. Pediatr Clin North Am 2015;62:275–300.

2. Hudson MM, Ness KK, Gurney JG, et al. Clinical ascertainment of health out-comes among adults treated for child-hood cancer. JAMA 2013;309: 2371–81.

3. Geenen MM, Cardous-Ubbink MC, Kre-mer LC, et al. Medical assessment of adverse health outcomes in long-term survivors of childhood cancer. JAMA 2007;297:2705–15.

4. Armstrong GT, Liu Q, Yasui Y, et al. Late mortality among 5-year survivors of childhood cancer: a summary from the Childhood Cancer Survivor Study. J Clin Oncol 2009;27:2328–38.

5. Garwicz S, Anderson H, Olsen JH, et al. Late and very late mortality in 5-year survivors of childhood cancer: changing pattern over four decades–experience from the Nordic countries. Int J Cancer 2012;131:1659–66.

6. Mertens AC, Yasui Y, Liu Y, et al. Pulmo-nary complications in survivors of child-hood and adolescent cancer. A report from the Childhood Cancer Survivor Study. Cancer 2002;95:2431–41.

7. Mulder RL, Thonissen NM, van der Pal HJ, et al. Pulmonary function impair-ment measured by pulmonary function tests in long-term survivors of child-hood cancer. Thorax 2011;66:1065–71.

8. Graves PR, Siddiqui F, Anscher MS, Movsas B. Radiation pulmonary toxi-city: from mechanisms to manage-ment. Seminars in radiation oncology 2010;20:201–7.

9. Williams JP, Johnston CJ, Finkelstein JN. Treatment for radiation-induced pul-monary late effects: spoiled for choice or looking in the wrong direction? Curr Drug Targets 2010;11:1386–94.

10. Venkatramani R, Kamath S, Wong K, et al. Correlation of clinical and dosimetric factors with adverse pulmonary outco-mes in children after lung irradiation. Int J Radiat Oncol Biol Phys 2013;86:942–8.

11. Huang TT, Hudson MM, Stokes DC, Krasin MJ, Spunt SL, Ness KK. Pulmo-nary outcomes in survivors of child-hood cancer: a systematic review. Chest 2011;140:881–901.

12. Motosue MS, Zhu L, Srivastava K, et al. Pulmonary function after whole lung ir-radiation in pediatric patients with solid malignancies. Cancer 2012;118: 1450–6.

13. Green DM, Lange JM, Qu A, et al. Pul-monary disease after treatment for Wilms tumor: a report from the national wilms tumor long-term follow-up study.Pediatr Blood Cancer 2013;60:1721–6.

14. Attard-Montalto SP, Kingston JE, Eden OB, Plowman PN. Late follow-up of lung function after whole lung irradiati-on for Wilms’ tumour. Br J Radiol 1992; 65:1114–8.

15. Oguz A, Tayfun T, Citak EC, et al. Long-term pulmonary function in survivors of childhood Hodgkin disease and non-Hodgkin lymphoma. Pediatr Blood Can-cer 2007;49:699–703.

16. Venkatramani R, Kamath S, Wong K, et al. Pulmonary outcomes in patients with Hodgkin lymphoma treated with involved field radiation. Pediatr Blood Cancer 2014;61:1277–81.

17. Cooper Jr JA, White DA, Matthay RA. Drug-induced pulmonary disease. Part 1: Cytotoxic drugs. Am Rev Respir Dis 1986;133:321–40.

18. Abid SH, Malhotra V, Perry MC. Radiati-on-induced and chemotherapy-induced pulmonary injury. Curr Opin Oncol 2001;13:242–8.

19. Eigen H, Wyszomierski D. Bleomycin lung injury in children. Pathophysiology

References

2

36

References

1. Landier W, Armenian S, Bhatia S. Late effects of childhood cancer and its treatment. Pediatr Clin North Am 2015;62:275–300.

2. Hudson MM, Ness KK, Gurney JG, et al. Clinical ascertainment of health out-comes among adults treated for child-hood cancer. JAMA 2013;309: 2371–81.

3. Geenen MM, Cardous-Ubbink MC, Kre-mer LC, et al. Medical assessment of adverse health outcomes in long-term survivors of childhood cancer. JAMA 2007;297:2705–15.

4. Armstrong GT, Liu Q, Yasui Y, et al. Late mortality among 5-year survivors of childhood cancer: a summary from the Childhood Cancer Survivor Study. J Clin Oncol 2009;27:2328–38.

5. Garwicz S, Anderson H, Olsen JH, et al. Late and very late mortality in 5-year survivors of childhood cancer: changing pattern over four decades–experience from the Nordic countries. Int J Cancer 2012;131:1659–66.

6. Mertens AC, Yasui Y, Liu Y, et al. Pulmo-nary complications in survivors of child-hood and adolescent cancer. A report from the Childhood Cancer Survivor Study. Cancer 2002;95:2431–41.

7. Mulder RL, Thonissen NM, van der Pal HJ, et al. Pulmonary function impair-ment measured by pulmonary function tests in long-term survivors of child-hood cancer. Thorax 2011;66:1065–71.

8. Graves PR, Siddiqui F, Anscher MS, Movsas B. Radiation pulmonary toxi-city: from mechanisms to manage-ment. Seminars in radiation oncology 2010;20:201–7.

9. Williams JP, Johnston CJ, Finkelstein JN. Treatment for radiation-induced pul-monary late effects: spoiled for choice or looking in the wrong direction? Curr Drug Targets 2010;11:1386–94.

10. Venkatramani R, Kamath S, Wong K, et al. Correlation of clinical and dosimetric factors with adverse pulmonary outco-mes in children after lung irradiation. Int J Radiat Oncol Biol Phys 2013;86:942–8.

11. Huang TT, Hudson MM, Stokes DC, Krasin MJ, Spunt SL, Ness KK. Pulmo-nary outcomes in survivors of child-hood cancer: a systematic review. Chest 2011;140:881–901.

12. Motosue MS, Zhu L, Srivastava K, et al. Pulmonary function after whole lung ir-radiation in pediatric patients with solid malignancies. Cancer 2012;118: 1450–6.

13. Green DM, Lange JM, Qu A, et al. Pul-monary disease after treatment for Wilms tumor: a report from the national wilms tumor long-term follow-up study.Pediatr Blood Cancer 2013;60:1721–6.

14. Attard-Montalto SP, Kingston JE, Eden OB, Plowman PN. Late follow-up of lung function after whole lung irradiati-on for Wilms’ tumour. Br J Radiol 1992; 65:1114–8.

15. Oguz A, Tayfun T, Citak EC, et al. Long-term pulmonary function in survivors of childhood Hodgkin disease and non-Hodgkin lymphoma. Pediatr Blood Can-cer 2007;49:699–703.

16. Venkatramani R, Kamath S, Wong K, et al. Pulmonary outcomes in patients with Hodgkin lymphoma treated with involved field radiation. Pediatr Blood Cancer 2014;61:1277–81.

17. Cooper Jr JA, White DA, Matthay RA. Drug-induced pulmonary disease. Part 1: Cytotoxic drugs. Am Rev Respir Dis 1986;133:321–40.

18. Abid SH, Malhotra V, Perry MC. Radiati-on-induced and chemotherapy-induced pulmonary injury. Curr Opin Oncol 2001;13:242–8.

19. Eigen H, Wyszomierski D. Bleomycin lung injury in children. Pathophysiology

References

2

37


and guidelines for management. Am J Pediatr Hematol Oncol 1985;7:71–8.

20. Sleijfer S. Bleomycin-induced pneumo-nitis. Chest 2001;120:617–24.

21. Mathes DD. Bleomycin and hyperoxia exposure in the operating room. Anesth Analg 1995;81:624–9.

22. Liles A, Blatt J, Morris D, et al. Monito-ring pulmonary complications in long-term childhood cancer survivors: gui-delines for the primary care physician. Cleve Clin J Med 2008;75:531–9.

23. De A, Guryev I, LaRiviere A, et al. Pul-monary function abnormalities in childhood cancer survivors treated with bleomycin. Pediatr Blood Cancer 2014;61:1679–84.

24. Aakre BM, Efem RI, Wilson GA, Kor DJ, Eisenach JH. Postoperative acute res-piratory distress syndrome in patients with previous exposure to bleomycin. Mayo Clin Proc 2014;89:181–9.

25. de Wit R, Sleijfer S, Kaye SB, et al. Bleo-mycin and scuba diving: where is the harm? Lancet Oncol 2007;8:954–5.

26. Bruno B, Souillet G, Bertrand Y, Werck-Gallois MC, So Satta A, Bellon G. Effects of allogeneic bone marrow transplanta-tion on pulmonary function in 80 child-ren in a single paediatric centre. Bone Marrow Transplant 2004;34:143–7.

27. Marras TK, Chan CK, Lipton JH, Mes-sner HA, Szalai JP, Laupacis A. Long-term pulmonary function abnormalities and survival after allogeneic marrow transplantation. Bone Marrow Trans-plant 2004;33:509–17.

28. Limper AH. Chemotherapy-induced lung disease. Clin Chest Med 2004;25: 53–64.

29. Malik SW, Myers JL, DeRemee RA, Specks U. Lung toxicity associated with cyclophosphamide use. Two distinct patterns. Am J Resp Crit Care Med 1996; 154:1851–6.

30. Segura A, Yuste A, Cercos A, et al. Pulmonary fibrosis induced by cycl-ophosphamide. Ann Ppharmacother 2001;35:894–7.

31. Weiss RB, Poster DS, Penta JS. The ni-trosoureas and pulmonary toxicity. Can-cer Treat Rev 1981;8:111–25.

32. O’Driscoll BR, Kalra S, Gattamaneni HR, Woodcock AA. Late carmustine lung fibrosis. Age at treatment may influence severity and survival. Chest 1995; 107:1355–7.

33. Denbo JW, Zhu L, Srivastava D, et al. Long-term pulmonary function after metastasectomy for childhood osteo-sarcoma: a report from the St Jude lifetime cohort study. J Am Coll Surg 2014;219:265–71.

34. Gower WA, Collaco JM, Mogayzel Jr PJ. Pulmonary dysfunction in pediatric hematopoietic stem cell transplant pa-tients: non-infectious and long-term complications. Pediatr Blood Cancer 2007;49:225–33.

35. Panoskaltsis-Mortari A, Griese M, Mad-tes DK, et al. An official American Tho-racic Society research statement: nonin-fectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome. Am J Resp Crit Care Med 2011;183:1262–79.

36. Sano H, Kobayashi R, Iguchi A, et al. Risk factor analysis of idiopathic pneu-monia syndrome after allogeneic hema-topoietic SCT in children. Bone Marrow Transplant 2014;49:38–41.

37. Sakaguchi H, Takahashi Y, Watanabe N, et al. Incidence, clinical features, and risk factors of idiopathic pneumo-nia syndrome following hematopoietic stem cell transplantation in children. Pediatr Blood Cancer 2012;58:780–4.

38. Gower WA, Collaco JM, Mogayzel Jr PJ. Lung function and late pulmonary complications among survivors of he-matopoietic stem cell transplantation

2

37


and guidelines for management. Am J Pediatr Hematol Oncol 1985;7:71–8.

20. Sleijfer S. Bleomycin-induced pneumo-nitis. Chest 2001;120:617–24.

21. Mathes DD. Bleomycin and hyperoxia exposure in the operating room. Anesth Analg 1995;81:624–9.

22. Liles A, Blatt J, Morris D, et al. Monito-ring pulmonary complications in long-term childhood cancer survivors: gui-delines for the primary care physician. Cleve Clin J Med 2008;75:531–9.

23. De A, Guryev I, LaRiviere A, et al. Pul-monary function abnormalities in childhood cancer survivors treated with bleomycin. Pediatr Blood Cancer 2014;61:1679–84.

24. Aakre BM, Efem RI, Wilson GA, Kor DJ, Eisenach JH. Postoperative acute res-piratory distress syndrome in patients with previous exposure to bleomycin. Mayo Clin Proc 2014;89:181–9.

25. de Wit R, Sleijfer S, Kaye SB, et al. Bleo-mycin and scuba diving: where is the harm? Lancet Oncol 2007;8:954–5.

26. Bruno B, Souillet G, Bertrand Y, Werck-Gallois MC, So Satta A, Bellon G. Effects of allogeneic bone marrow transplanta-tion on pulmonary function in 80 child-ren in a single paediatric centre. Bone Marrow Transplant 2004;34:143–7.

27. Marras TK, Chan CK, Lipton JH, Mes-sner HA, Szalai JP, Laupacis A. Long-term pulmonary function abnormalities and survival after allogeneic marrow transplantation. Bone Marrow Trans-plant 2004;33:509–17.

28. Limper AH. Chemotherapy-induced lung disease. Clin Chest Med 2004;25: 53–64.

29. Malik SW, Myers JL, DeRemee RA, Specks U. Lung toxicity associated with cyclophosphamide use. Two distinct patterns. Am J Resp Crit Care Med 1996; 154:1851–6.

30. Segura A, Yuste A, Cercos A, et al. Pulmonary fibrosis induced by cycl-ophosphamide. Ann Ppharmacother 2001;35:894–7.

31. Weiss RB, Poster DS, Penta JS. The ni-trosoureas and pulmonary toxicity. Can-cer Treat Rev 1981;8:111–25.

32. O’Driscoll BR, Kalra S, Gattamaneni HR, Woodcock AA. Late carmustine lung fibrosis. Age at treatment may influence severity and survival. Chest 1995; 107:1355–7.

33. Denbo JW, Zhu L, Srivastava D, et al. Long-term pulmonary function after metastasectomy for childhood osteo-sarcoma: a report from the St Jude lifetime cohort study. J Am Coll Surg 2014;219:265–71.

34. Gower WA, Collaco JM, Mogayzel Jr PJ. Pulmonary dysfunction in pediatric hematopoietic stem cell transplant pa-tients: non-infectious and long-term complications. Pediatr Blood Cancer 2007;49:225–33.

35. Panoskaltsis-Mortari A, Griese M, Mad-tes DK, et al. An official American Tho-racic Society research statement: nonin-fectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome. Am J Resp Crit Care Med 2011;183:1262–79.

36. Sano H, Kobayashi R, Iguchi A, et al. Risk factor analysis of idiopathic pneu-monia syndrome after allogeneic hema-topoietic SCT in children. Bone Marrow Transplant 2014;49:38–41.

37. Sakaguchi H, Takahashi Y, Watanabe N, et al. Incidence, clinical features, and risk factors of idiopathic pneumo-nia syndrome following hematopoietic stem cell transplantation in children. Pediatr Blood Cancer 2012;58:780–4.

38. Gower WA, Collaco JM, Mogayzel Jr PJ. Lung function and late pulmonary complications among survivors of he-matopoietic stem cell transplantation

2

38

References

during childhood. Paediatr Respir Rev 2010;11:115–22.

39. Haddad IY. Stem cell transplantation and lung dysfunction. Curr Opin Pediatr 2013;25:350–6.

40. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Muller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant 2012;47:1020–9.

41. Jodele S, Hirsch R, Laskin B, Davies S, Witte D, Chima R. Pulmonary arterial hypertension in pediatric patients with hematopoietic stem cell transplant-associated thrombotic microangio-pathy. Biol Blood Marrow Transplant 2013;19:202–7.

42. Dandoy CE, Hirsch R, Chima R, Davies SM, Jodele S. Pulmonary hypertension after hematopoietic stem cell transplan-tation. Biol Blood Marrow Transplant 2013;19:1546–56.

43. Nieder ML, McDonald GB, Kida A, et al. National Cancer Institute-National Heart, Lung and Blood Institute/pedia-tric Blood and Marrow Transplant Con-sortium First International Consensus Conference on late effects after pedia-tric hematopoietic cell transplantation: long-term organ damage and dysfunc-tion. Biol Blood Marrow Transplant 2011;17:1573–84.

44. Inaba H, Yang J, Pan J, et al. Pulmonary dysfunction in survivors of childhood hematologic malignancies after allogen-eic hematopoietic stem cell transplanta-tion. Cancer 2010;116:2020–30.

45. Cooke KR YG. Lung injury following he-matopoietic cell transplantation. Tho-mas’Hematopoietic Cell transplanta-tion. 4th ed. 2009.

46. Friedman DL, Whitton J, Leisenring W, et al. Subsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study. J Natl Cancer Inst 2010;102:1083–95.

47. Soubani AO, Kingah P, Alshabani K, Muma G, Haq A. Lung transplantation following hematopoietic stem cell trans-plantation: report of two cases and sys-tematic review of literature. Clin Transpl 2014;28:776–82.

48. Pechet TV, de le Morena M, Mendeloff EN, Sweet SC, Shapiro SD, Huddleston CB. Lung transplantation in children following treatment for malignancy. J Heart Lung Transplant 2003;22:154–60.

2

38

References

during childhood. Paediatr Respir Rev 2010;11:115–22.

39. Haddad IY. Stem cell transplantation and lung dysfunction. Curr Opin Pediatr 2013;25:350–6.

40. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Muller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant 2012;47:1020–9.

41. Jodele S, Hirsch R, Laskin B, Davies S, Witte D, Chima R. Pulmonary arterial hypertension in pediatric patients with hematopoietic stem cell transplant-associated thrombotic microangio-pathy. Biol Blood Marrow Transplant 2013;19:202–7.

42. Dandoy CE, Hirsch R, Chima R, Davies SM, Jodele S. Pulmonary hypertension after hematopoietic stem cell transplan-tation. Biol Blood Marrow Transplant 2013;19:1546–56.

43. Nieder ML, McDonald GB, Kida A, et al. National Cancer Institute-National Heart, Lung and Blood Institute/pedia-tric Blood and Marrow Transplant Con-sortium First International Consensus Conference on late effects after pedia-tric hematopoietic cell transplantation: long-term organ damage and dysfunc-tion. Biol Blood Marrow Transplant 2011;17:1573–84.

44. Inaba H, Yang J, Pan J, et al. Pulmonary dysfunction in survivors of childhood hematologic malignancies after allogen-eic hematopoietic stem cell transplanta-tion. Cancer 2010;116:2020–30.

45. Cooke KR YG. Lung injury following he-matopoietic cell transplantation. Tho-mas’Hematopoietic Cell transplanta-tion. 4th ed. 2009.

46. Friedman DL, Whitton J, Leisenring W, et al. Subsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study. J Natl Cancer Inst 2010;102:1083–95.

47. Soubani AO, Kingah P, Alshabani K, Muma G, Haq A. Lung transplantation following hematopoietic stem cell trans-plantation: report of two cases and sys-tematic review of literature. Clin Transpl 2014;28:776–82.

48. Pechet TV, de le Morena M, Mendeloff EN, Sweet SC, Shapiro SD, Huddleston CB. Lung transplantation in children following treatment for malignancy. J Heart Lung Transplant 2003;22:154–60.

2

3Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndromes

3Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndromes

Strong association between respiratory viral infec-tion early after hematopoietic stem cell transplan-tation and the development of life-threatening acute and chronic alloimmune lung syndromes

A.B. Versluys, J.W.A. Rossen, B. van Ewijk, R. Schuurman, M.B. Bierings, J.J. Boelens

Biol Blood Marrow Transplant 2010; 16: 782-791

Abstract

Alloimmune lung syndromes (allo-LS), including idio-pathic pneumonia syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans organizing pneumonia, are severe complications after hemato-poietic stem cell transplantation (HSCT). In our co-hort of 110 pediatric patients, 30 had allo-LS (27.3%), 18 with ideopathic pneumonia syndrome and 12 with bronchiolitis obliterans syndrome. Multivariate analysis showed that respiratory viral infection early after HSCT is an important predictor for the development of allo-LS (P <.0001). This was true for all viruses tested. In multi-variate analysis, allo-LS was the only predictor for higher mortality (P = .04). Paradoxically, prolonged adminis-tration of immunosuppressive agents because of acute graft-versus-host disease had a protective effect on the development of allo-LS (P = .004). We hypothesize that early infection of the respiratory tract with a common cold virus makes the lungs a target for alloimmunity.

Blood and Marrow Transplan-tation Program, Department of Pediatrics, University Me-

dical Center Utrecht (UMCU), Utrecht, The Netherlands

A.B. Versluys M.B. Bierings

J.J. Boelens

Department of Virology, Eijk-man-Winkler Center, UMCU,

Utrecht, The Netherlands J.W.A. Rossen

R. Schuurman

Laboratory of Medical Micro-biology and Immunology,

St Elisabeth Hospital, Tilburg, The Netherlands

J.W. A. Rossen

Department of Paediatric Respiratory Medicine, UMCU,

Wilhelmina Children’s Hospital, Utrecht, The Netherlands

B. van Ewijk

Strong association between respiratory viral infec-tion early after hematopoietic stem cell transplan-tation and the development of life-threatening acute and chronic alloimmune lung syndromes

A.B. Versluys, J.W.A. Rossen, B. van Ewijk, R. Schuurman, M.B. Bierings, J.J. Boelens


Abstract

Alloimmune lung syndromes (allo-LS), including idio-pathic pneumonia syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans organizing pneumonia, are severe complications after hemato-poietic stem cell transplantation (HSCT). In our co-hort of 110 pediatric patients, 30 had allo-LS (27.3%), 18 with ideopathic pneumonia syndrome and 12 with bronchiolitis obliterans syndrome. Multivariate analysis showed that respiratory viral infection early after HSCT is an important predictor for the development of allo-LS (P <.0001). This was true for all viruses tested. In multi-variate analysis, allo-LS was the only predictor for higher mortality (P = .04). Paradoxically, prolonged adminis-tration of immunosuppressive agents because of acute graft-versus-host disease had a protective effect on the development of allo-LS (P = .004). We hypothesize that early infection of the respiratory tract with a common cold virus makes the lungs a target for alloimmunity.

Blood and Marrow Transplan-tation Program, Department of Pediatrics, University Me-

dical Center Utrecht (UMCU), Utrecht, The Netherlands


J.J. Boelens

Department of Virology, Eijk-man-Winkler Center, UMCU,

Utrecht, The Netherlands J.W.A. Rossen

R. Schuurman

Laboratory of Medical Micro-biology and Immunology,

St Elisabeth Hospital, Tilburg, The Netherlands

J.W. A. Rossen

Department of Paediatric Respiratory Medicine, UMCU,

Wilhelmina Children’s Hospital, Utrecht, The Netherlands

B. van Ewijk

43

Association between respiratory virus and alloimmune lung syndromes

Introduction

Pulmonary complications are common after allogeneic hematopoietic stem cell trans-plantation (HSCT). Between 30% and 60% of adult HSCT recipients reportedly expe-rience pulmonary complications, representing a major cause of mortality.1-4 In children undergoing HSCT, the incidence of pulmonary complications varies from 10% to 25%, and onset is a poor prognostic event carrying a significantly increased risk of mortality.5,6 At one time, most pulmonary complications were directly related to infection; today, however, noninfectious pulmonary complications, such as idiopathic pneumonia syn-drome (IPS) and bronchiolitis obliterans syndrome (BOS), are seen more frequently.2,5,6

Respiratory virus (RV) infections occur in 1%-56% of HSCT recipients. Most previous studies have examined the progression from upper respiratory tract infection (URTI) to lower respiratory tract infection (LRTI) and described the risk factors for this progressi-on.7-16 Some have reported an association of early RV infection with late, obstructive lung injury.17 An association between RV infection and alloimmunity in lung transplant reci-pients was recently reported.18 Lung transplant recipients develop more acute and chro-nic graft rejection after common RV infection early (<100 days) after transplantation.18

Isolated alloimmune lung disease (ie, BOS or IPS) after HSCT suggests a specific trig-ger making the lung a target organ for alloreactivity. This is in line with the 3-step pro-cess reflecting the current view of the development of alloreactivity: (1) tissue damage, resulting in (2) release of inflammatory cytokines, resulting in (3) activation and influx of T lymphocytes.19 We speculated that the presence of a common RV might trigger allo-immune lung syndrome (allo-LS) in HSCT. We prospectively studied the influence of these RVs on the development of allo-LS and overall survival (OS) in a cohort of pediatric HSCT recipients.

Patients and methods

Study desgin and population All patients who underwent allogeneic HSCT between January 2004 and May 2008 at the pediatric Hematology and Immunology Department of the Wilhelmina Children’s Hospital, University Medical Center Utrecht were included in this prospective study. Patients were enrolled in the HSCT protocol after providing written informed consent for the HSCT and the research protocol.

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43


Introduction

Pulmonary complications are common after allogeneic hematopoietic stem cell trans-plantation (HSCT). Between 30% and 60% of adult HSCT recipients reportedly expe-rience pulmonary complications, representing a major cause of mortality.1-4 In children undergoing HSCT, the incidence of pulmonary complications varies from 10% to 25%, and onset is a poor prognostic event carrying a significantly increased risk of mortality.5,6 At one time, most pulmonary complications were directly related to infection; today, however, noninfectious pulmonary complications, such as idiopathic pneumonia syn-drome (IPS) and bronchiolitis obliterans syndrome (BOS), are seen more frequently.2,5,6

Respiratory virus (RV) infections occur in 1%-56% of HSCT recipients. Most previous studies have examined the progression from upper respiratory tract infection (URTI) to lower respiratory tract infection (LRTI) and described the risk factors for this progressi-on.7-16 Some have reported an association of early RV infection with late, obstructive lung injury.17 An association between RV infection and alloimmunity in lung transplant reci-pients was recently reported.18 Lung transplant recipients develop more acute and chro-nic graft rejection after common RV infection early (<100 days) after transplantation.18

Isolated alloimmune lung disease (ie, BOS or IPS) after HSCT suggests a specific trig-ger making the lung a target organ for alloreactivity. This is in line with the 3-step pro-cess reflecting the current view of the development of alloreactivity: (1) tissue damage, resulting in (2) release of inflammatory cytokines, resulting in (3) activation and influx of T lymphocytes.19 We speculated that the presence of a common RV might trigger allo-immune lung syndrome (allo-LS) in HSCT. We prospectively studied the influence of these RVs on the development of allo-LS and overall survival (OS) in a cohort of pediatric HSCT recipients.


Study desgin and population All patients who underwent allogeneic HSCT between January 2004 and May 2008 at the pediatric Hematology and Immunology Department of the Wilhelmina Children’s Hospital, University Medical Center Utrecht were included in this prospective study. Patients were enrolled in the HSCT protocol after providing written informed consent for the HSCT and the research protocol.

3

44


Supportive care and graft-versus-host disease prophylaxisAll patients received antiemetic drugs. Prophylactic anticonvulsive therapy (clonazepam) was given to those patients receiving busulfan. Antibiotic prophylaxis involved daily ci-profloxacillin and fluconazole from the start of conditioning until the resolution of neu-tropenia (3 days of >500,000 neutrophils/mL). Additional prophylaxis against Strepto-coccus viridans in the mucositis phase was given with cefazoline. Starting 1 month after transplantation, cotrimoxazole 3 times a week was given as Pneumocystis carinii pneu-monia prophylaxis. Only in cases of positive serology for herpes simplex virus was prop-hylaxis (with acyclovir) administered. No prophylaxis for other viruses was given. IgG levels were checked every 2 weeks; intravenous immunoglobulin was given only to those patients with an IgG level <4 g/L.

Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (aiming for a trough level of 100-250 mg/L, based on national protocol guidelines), supplemented with methylprednisolone (MP; 1 mg/kg/day for 28 days) in patients receiving a cord blood (CB) transplant, or methotrexate (short course, 10 mg/m2 on days 1, 3, and 6) in patients receiving an unrelated bone marrow (BM) or peripheral blood stem cell (PBSC) transplant. In patients receiving an unrelated donor graft (CB, BM, or PBSC), antithymo-cyte globulin (ATG) serotherapy was administered until day –1, with ATG-fresenius for patients with acute lymphoblastic leukemia and thymoglobulin for all other indications.

Infection monitoring

Bacterial, fungalTo monitor bacterial colonization, nose/throat swabs and stools were cultured weekly and processed in accordance with standard microbiological procedures. Up to June 2006, we tested for galactomannan (Platelia Aspergillus enzyme immunoassay; Bio-Rad, Hercules, CA) in cases of suspected Aspergillus infection, based on such clinical symptoms as pro-longed fever during systemic broad antibiotic therapy and radiologic findings. After June 2006, we routinely monitored galactomannan twice weekly.

ViralPlasma was tested weekly for Epstein-Barr virus (EBV), cytomegalovirus (CMV), hu-man herpes 6 virus (HHV6), and adenovirus DNA positivity by real-time polymerase chain reaction (PCR) (see next section). In patients deemed positive (viral load >400 cp/mL), this test was done twice a week. Adenovirus (viral load >1000 cp/mL) was treated preemptively with cidofovir. CMV (viral load .1000 cp/mL) was treated preemptively with foscavir or ganciclovir. Depending on the viral load, the immunosuppressive regimen, and signs of posttransplantation lymphoproliferative disease, EBV was treated preempti-vely with anti-CD20 (rituximab).

3

44


Supportive care and graft-versus-host disease prophylaxisAll patients received antiemetic drugs. Prophylactic anticonvulsive therapy (clonazepam) was given to those patients receiving busulfan. Antibiotic prophylaxis involved daily ci-profloxacillin and fluconazole from the start of conditioning until the resolution of neu-tropenia (3 days of >500,000 neutrophils/mL). Additional prophylaxis against Strepto-coccus viridans in the mucositis phase was given with cefazoline. Starting 1 month after transplantation, cotrimoxazole 3 times a week was given as Pneumocystis carinii pneu-monia prophylaxis. Only in cases of positive serology for herpes simplex virus was prop-hylaxis (with acyclovir) administered. No prophylaxis for other viruses was given. IgG levels were checked every 2 weeks; intravenous immunoglobulin was given only to those patients with an IgG level <4 g/L.

Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine (aiming for a trough level of 100-250 mg/L, based on national protocol guidelines), supplemented with methylprednisolone (MP; 1 mg/kg/day for 28 days) in patients receiving a cord blood (CB) transplant, or methotrexate (short course, 10 mg/m2 on days 1, 3, and 6) in patients receiving an unrelated bone marrow (BM) or peripheral blood stem cell (PBSC) transplant. In patients receiving an unrelated donor graft (CB, BM, or PBSC), antithymo-cyte globulin (ATG) serotherapy was administered until day –1, with ATG-fresenius for patients with acute lymphoblastic leukemia and thymoglobulin for all other indications.

Infection monitoring

Bacterial, fungalTo monitor bacterial colonization, nose/throat swabs and stools were cultured weekly and processed in accordance with standard microbiological procedures. Up to June 2006, we tested for galactomannan (Platelia Aspergillus enzyme immunoassay; Bio-Rad, Hercules, CA) in cases of suspected Aspergillus infection, based on such clinical symptoms as pro-longed fever during systemic broad antibiotic therapy and radiologic findings. After June 2006, we routinely monitored galactomannan twice weekly.

ViralPlasma was tested weekly for Epstein-Barr virus (EBV), cytomegalovirus (CMV), hu-man herpes 6 virus (HHV6), and adenovirus DNA positivity by real-time polymerase chain reaction (PCR) (see next section). In patients deemed positive (viral load >400 cp/mL), this test was done twice a week. Adenovirus (viral load >1000 cp/mL) was treated preemptively with cidofovir. CMV (viral load .1000 cp/mL) was treated preemptively with foscavir or ganciclovir. Depending on the viral load, the immunosuppressive regimen, and signs of posttransplantation lymphoproliferative disease, EBV was treated preempti-vely with anti-CD20 (rituximab).

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Respiratory viralBefore August 2005, nasal pharyngeal aspirate (NPA) samples were obtained for PCR only in the presence of symptoms of aURTI or LRTI, and then only up to day +100 post-transplantation. From August 2005 onward, we performed surveillance studies onNPA-samples of all patients admitted to our HSCT unit. Reversetranscriptase (RT)-PCR was done for all common RVs (see later).We repeated the NPA weekly in patients negative for RV and twice weekly in patients positive for RV.

Real-time PCR for respiratory virusesNucleic acids were extracted using the total nucleic acid protocol with the MagNA Pure LC nucleic acid isolation system (Roche Diagnostics, Basel, Switzerland). For detection of RNA viruses, cDNA was synthesized using MultiScribe RT and random hexamers (Ap-plied Biosystems, Foster City, CA). Detection of viral and atypical pathogens was perfor-med in parallel, using real-time PCR assays specific for the following viruses: CMV; EBV; HHV-6; respiratory syncytial virus A and B; influenzavirus A and B; parainfluenzavirus 1-4; rhinoviruses; adenoviruses; human coronaviruses OC43, NL63, and 229E; human metapneumovirus; Mycoplasma pneumoniae; and Chlamydia pneumoniae.Real-time PCR procedures were performed as described previously.20 In brief, samples were assayed in duplicate in a 25-mL reaction mixture containing 10 mL of cDNA, 12.5 mL of TaqMan Universal PCR Master Mix (Applied Biosystems), 300-900 nmol/L of the forward and reverse primers, and 75-200 nmol/L of each probe. All samples had been spiked before extraction with an internal control virus (murine encephalomyocarditis vi-rus [RNA virus] and porcine herpesvirus [DNA virus]) to monitor for efficient extraction and amplification, essentially as described previously.21 The cycle of threshold (Ct) gives an impression of the quantity of the viral load (ie, a semiquantitative value).

Recording pulmonary complicationsAll patients were observed for signs of respiratory disease early and late after transplanta-tion. All clinical symptoms were recorded. In patients with URTI symptoms, NPA sam-ples were obtained and tested for RV infection by PCR (see earlier). In patients with signs of LRTI, chest X-rays were obtained. Other tests, performed as indicated, included bronchoalveolar lavage (BAL) for broad infectious screening with bacterial/fungal cul-tures, viral PCR, and galactomannan, as well as high-resolution computed tomography (HRCT) scans. In cases of suspected allo-LS, HRCT and BAL were always performed (see definitions of disease shortly).

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Respiratory viralBefore August 2005, nasal pharyngeal aspirate (NPA) samples were obtained for PCR only in the presence of symptoms of aURTI or LRTI, and then only up to day +100 post-transplantation. From August 2005 onward, we performed surveillance studies onNPA-samples of all patients admitted to our HSCT unit. Reversetranscriptase (RT)-PCR was done for all common RVs (see later).We repeated the NPA weekly in patients negative for RV and twice weekly in patients positive for RV.

Real-time PCR for respiratory virusesNucleic acids were extracted using the total nucleic acid protocol with the MagNA Pure LC nucleic acid isolation system (Roche Diagnostics, Basel, Switzerland). For detection of RNA viruses, cDNA was synthesized using MultiScribe RT and random hexamers (Ap-plied Biosystems, Foster City, CA). Detection of viral and atypical pathogens was perfor-med in parallel, using real-time PCR assays specific for the following viruses: CMV; EBV; HHV-6; respiratory syncytial virus A and B; influenzavirus A and B; parainfluenzavirus 1-4; rhinoviruses; adenoviruses; human coronaviruses OC43, NL63, and 229E; human metapneumovirus; Mycoplasma pneumoniae; and Chlamydia pneumoniae.Real-time PCR procedures were performed as described previously.20 In brief, samples were assayed in duplicate in a 25-mL reaction mixture containing 10 mL of cDNA, 12.5 mL of TaqMan Universal PCR Master Mix (Applied Biosystems), 300-900 nmol/L of the forward and reverse primers, and 75-200 nmol/L of each probe. All samples had been spiked before extraction with an internal control virus (murine encephalomyocarditis vi-rus [RNA virus] and porcine herpesvirus [DNA virus]) to monitor for efficient extraction and amplification, essentially as described previously.21 The cycle of threshold (Ct) gives an impression of the quantity of the viral load (ie, a semiquantitative value).

Recording pulmonary complicationsAll patients were observed for signs of respiratory disease early and late after transplanta-tion. All clinical symptoms were recorded. In patients with URTI symptoms, NPA sam-ples were obtained and tested for RV infection by PCR (see earlier). In patients with signs of LRTI, chest X-rays were obtained. Other tests, performed as indicated, included bronchoalveolar lavage (BAL) for broad infectious screening with bacterial/fungal cul-tures, viral PCR, and galactomannan, as well as high-resolution computed tomography (HRCT) scans. In cases of suspected allo-LS, HRCT and BAL were always performed (see definitions of disease shortly).

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Pulmonary function testsBecause performing pulmonary function tests (PFTs) is difficult in young children, in our cohort routine PFTs before transplantation were performed only in children aged ≥6 years. PFTs also were performed in all children with such respiratory symptoms as short-ness of breath, dry cough, and tachypnea after discharge. In patients with a diagnosis of allo-LS, PFTs were repeated at least monthly until the disorder resolved. Patients aged ≥6 years underwent spirometry testing and, when technically possible, body plethysmograp-hy and COdiffusion testing according to European Respiratory Society guidelines.22 Total lung capacity (TLC) and forced expiratory volume in 1 second (FEV1) were expressed as percentage of the predicted normal value, using published equations for children and adults,23 giving TLC % predicted and FEV1 % predicted. A TLC % predicted of <80% was designated a ‘‘restrictive’’ pattern; an FEV1 % predicted of <80% and FEV1/forced vital capacity (FVC) of <70%, an ‘‘obstructive’’ pattern; a TLC% predicted of <80% and FEV1/FVC of <70%, a ‘‘mixed’’ pattern; and CO diffusion of <80%, ‘‘impaired diffusion.’’

Definitions of disease URTI was defined as rhinorrhea and/or dry cough only. LRTI/pneumonia was defined as cough and/or fever and pulmonary infiltrates on chest x-ray, with elevated C-reactive protein and/or positive microbiological cultures from sputum, BAL fluid, or blood. IPS was defined as the presence of acute bilateral pulmonary infiltrates with cough, dyspnea, and hypoxemia in the absence of infection (excluding an RV) or heart failure. By this de-finition, IPS included such entities as diffuse alveolar bleeding and periengraftment syn-drome.2 BOS was defined as typical HRCT changes, such as bronchial wall thickening, air trapping, and mosaic parenchymal attenuation1, in the absence of signs of infection and, whenever pulmonary function testing could be done, abnormal pulmonary func-tion test results (ie, decrease in FEV1 of >20% or in FEV1/FVC of <70%). bronchiolitis obliterans organizing pneumonia (BOOP) was defined as restrictive PFT (if PFT were done) and consolidation on chest x-ray.1 Allo-LS was defined as IPS, BOS, and BOOP, subdivided into acute (IPS) and chronic (BOS/BOOP) forms.

Treatment of lung diseaseIn general, URTI was not treated; only in the 2 patients with influenza A was a neu-raminidase inhibitor administered. LRTI/pneumonia was treated with empiric antibiotic therapy (vancomycin and ceftazidime). Whenever a bacterial pathogen was found, the-rapy was adjusted according to antibiotic resistance. In patients with probable or proven Aspergillus spp, voriconazole was administered; if no response to voriconazole was noted (progressive clinical or radiologic findings), granulocyte transfusions were given. Allo-LS was treated with MP 10 mg/kg/day i.v. for 3 days and 2 mg/kg/day thereafter, tapering by 25% per week to 0.5 mg/kg/day. The MP pulses were repeated every 4 weeks

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Pulmonary function testsBecause performing pulmonary function tests (PFTs) is difficult in young children, in our cohort routine PFTs before transplantation were performed only in children aged ≥6 years. PFTs also were performed in all children with such respiratory symptoms as short-ness of breath, dry cough, and tachypnea after discharge. In patients with a diagnosis of allo-LS, PFTs were repeated at least monthly until the disorder resolved. Patients aged ≥6 years underwent spirometry testing and, when technically possible, body plethysmograp-hy and COdiffusion testing according to European Respiratory Society guidelines.22 Total lung capacity (TLC) and forced expiratory volume in 1 second (FEV1) were expressed as percentage of the predicted normal value, using published equations for children and adults,23 giving TLC % predicted and FEV1 % predicted. A TLC % predicted of <80% was designated a ‘‘restrictive’’ pattern; an FEV1 % predicted of <80% and FEV1/forced vital capacity (FVC) of <70%, an ‘‘obstructive’’ pattern; a TLC% predicted of <80% and FEV1/FVC of <70%, a ‘‘mixed’’ pattern; and CO diffusion of <80%, ‘‘impaired diffusion.’’

Definitions of disease URTI was defined as rhinorrhea and/or dry cough only. LRTI/pneumonia was defined as cough and/or fever and pulmonary infiltrates on chest x-ray, with elevated C-reactive protein and/or positive microbiological cultures from sputum, BAL fluid, or blood. IPS was defined as the presence of acute bilateral pulmonary infiltrates with cough, dyspnea, and hypoxemia in the absence of infection (excluding an RV) or heart failure. By this de-finition, IPS included such entities as diffuse alveolar bleeding and periengraftment syn-drome.2 BOS was defined as typical HRCT changes, such as bronchial wall thickening, air trapping, and mosaic parenchymal attenuation1, in the absence of signs of infection and, whenever pulmonary function testing could be done, abnormal pulmonary func-tion test results (ie, decrease in FEV1 of >20% or in FEV1/FVC of <70%). bronchiolitis obliterans organizing pneumonia (BOOP) was defined as restrictive PFT (if PFT were done) and consolidation on chest x-ray.1 Allo-LS was defined as IPS, BOS, and BOOP, subdivided into acute (IPS) and chronic (BOS/BOOP) forms.

Treatment of lung diseaseIn general, URTI was not treated; only in the 2 patients with influenza A was a neu-raminidase inhibitor administered. LRTI/pneumonia was treated with empiric antibiotic therapy (vancomycin and ceftazidime). Whenever a bacterial pathogen was found, the-rapy was adjusted according to antibiotic resistance. In patients with probable or proven Aspergillus spp, voriconazole was administered; if no response to voriconazole was noted (progressive clinical or radiologic findings), granulocyte transfusions were given. Allo-LS was treated with MP 10 mg/kg/day i.v. for 3 days and 2 mg/kg/day thereafter, tapering by 25% per week to 0.5 mg/kg/day. The MP pulses were repeated every 4 weeks

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until recovery, up to a maximum of 6 courses. Recovery was defined as normalization of PFTs and/or resolved symptoms, with no extra oxygen requirement. In between the subsequent courses of MP, prednisone 0.5 mg/kg/day was given. Other immunosup-pressive agents (usually cyclosporine) were continued. In addition, azythromycin was gi-ven, because of its suggested immunomodulatory effect.24 Along with immunosuppres-sive therapy, supportive care was provided, with extra oxygen and mechanical ventilation when necessary. IgG level was maintained above 4 g/L.

EndpointsThe primary endpoint of this study was the development of acute and chronic allo-LS. The secondary endpoint was OS.

Statistical analysisDifferences between the RV-positive and RV-negative groups were tested using Pearson’s X2 test. Results with a P value <.05 were considered statistically significant.

The duration of follow-up was the time to the endpoints, the development of an allo-LS and death, or the last assessment for survivors. To analyze risk factors for outcomes, we considered variables associated with the recipient (age at transplantation, sex, CMV se-rology, RV positivity, single/multiple viruses), the disease (malignant vs nonmalignant), the donor/transplantation technique (cell source, HLA disparity, donor relationship, conditioning regimen), HSCT complications (allo-LS, acute GVHD [aGVHD], CMV and adenovirus plasma DNA positivity, venoocclusive disease), and relapse. To examine the influence of the various viruses on the primary endpoint, rhinovirus was compared with the other viruses, and multiple viral infection was compared with single viral infection.

In the analyses, we tested for allo-LS as a group (IPS 1 BOS/BOOP) based on the hypo-thesis that early viral infection might be a trigger for both acute and chronic allo-LS. In addition, we tested both syndromes separately (ie, BOS/BOOP excluding IPS from the analyses, and IPS excluding BOS/BOOP).

Associations between variables (including recipient, disease, and HSCT technique) and the primary endpoint were evaluated using Cox proportional hazard models. Dichoto-mous outcomes (eg, allo-LS: yes/no) were used as dependent variables, and predictors were used as independent variables. Univariate predictors of outcome with a P-value <.10 were used for multivariate analysis. Results are expressed as hazard ratios (HRs) and corresponding 95% confidence interval (CIs). CIs not including 1 were considered statistically significant.

Analyses for the association between HSCT complications and the primary endpoint (allo-LS) as well as the secondary endpoint (OS) were done using logistic regression. Di-chotomous outcomes (eg, allo-LS or survival: yes/no) were used as dependent variables,

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until recovery, up to a maximum of 6 courses. Recovery was defined as normalization of PFTs and/or resolved symptoms, with no extra oxygen requirement. In between the subsequent courses of MP, prednisone 0.5 mg/kg/day was given. Other immunosup-pressive agents (usually cyclosporine) were continued. In addition, azythromycin was gi-ven, because of its suggested immunomodulatory effect.24 Along with immunosuppres-sive therapy, supportive care was provided, with extra oxygen and mechanical ventilation when necessary. IgG level was maintained above 4 g/L.

EndpointsThe primary endpoint of this study was the development of acute and chronic allo-LS. The secondary endpoint was OS.

Statistical analysisDifferences between the RV-positive and RV-negative groups were tested using Pearson’s X2 test. Results with a P value <.05 were considered statistically significant.

The duration of follow-up was the time to the endpoints, the development of an allo-LS and death, or the last assessment for survivors. To analyze risk factors for outcomes, we considered variables associated with the recipient (age at transplantation, sex, CMV se-rology, RV positivity, single/multiple viruses), the disease (malignant vs nonmalignant), the donor/transplantation technique (cell source, HLA disparity, donor relationship, conditioning regimen), HSCT complications (allo-LS, acute GVHD [aGVHD], CMV and adenovirus plasma DNA positivity, venoocclusive disease), and relapse. To examine the influence of the various viruses on the primary endpoint, rhinovirus was compared with the other viruses, and multiple viral infection was compared with single viral infection.

In the analyses, we tested for allo-LS as a group (IPS 1 BOS/BOOP) based on the hypo-thesis that early viral infection might be a trigger for both acute and chronic allo-LS. In addition, we tested both syndromes separately (ie, BOS/BOOP excluding IPS from the analyses, and IPS excluding BOS/BOOP).

Associations between variables (including recipient, disease, and HSCT technique) and the primary endpoint were evaluated using Cox proportional hazard models. Dichoto-mous outcomes (eg, allo-LS: yes/no) were used as dependent variables, and predictors were used as independent variables. Univariate predictors of outcome with a P-value <.10 were used for multivariate analysis. Results are expressed as hazard ratios (HRs) and corresponding 95% confidence interval (CIs). CIs not including 1 were considered statistically significant.

Analyses for the association between HSCT complications and the primary endpoint (allo-LS) as well as the secondary endpoint (OS) were done using logistic regression. Di-chotomous outcomes (eg, allo-LS or survival: yes/no) were used as dependent variables,

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Results

and predictors were used as independent variables. Univariate predictors of outcome with a P value <.10 were used for multivariate logistic regression analysis. Results are expressed as odds ratio (ORs) and corresponding 95% CIs. CIs not including 1 were con-sidered statistically significant.

Probabilities of allo-LS andOSwere calculated using the Kaplan-Meier estimate; the 2-si-ded log-rank test was used for comparisons. All statistical analyses were performed using SPSS 15.1 (SPSS Inc, Chicago, IL).

Results

Patient characteristicsA total of 110 patients were included in the study, 42 from January 2004 to August 2006 (before routine NPA testing), and 68 after from August 2006 to May 2008. Six patients who underwent transplantation during this period were excluded from the study be-cause they experienced autologous recovery (n = 2), early graft rejection (within 1 month after transplantation; n = 2), or early death (before engraftment; n = 2) and thus were considered not prone to alloreactive disease. The median age at transplantation was 5.0 years (range, 2 months to 21 years), and body weight ranged between 2 and 100 kg. Base-line characteristics of the RV-positive and RV-negative groups are shown in Table 1. No significant differences between the 2 groups were evident, although there were slightly more matched donor transplants in the RV-negative group and more CB donors in the RV-positive group.

RV infections and presenting symptomsIn this cohort of patients, 55 (50%) had an RV infection. The median day of onset was day 116 posttransplantatio (range, day 27 to day 1100). Symptoms were usually mild. The majority of patients with RV infection (n = 43) had URTI symptoms only. Eleven patients required extra oxygen, and 1 patient needed ventilator support (associated with a bacterial infection). Two patients, both with influenza A infection, were treated with a neuraminidase inhibitor; all other patients experienced spontaneous clinical recovery within 7-14 days. Although symptoms disappeared, virus was detected in NPAsamples for weeks to months afterward, with high viral loads (PCR Ct values of 17-24; see Patients and methods). Thirty-eight patients had a single RV, and 14 patients had multiple viruses. In 3 patients, no RV was detected, but the clinical picture was typical for RV infection. These patients had mild respiratory symptoms (rhinorrhea) with no other cause, and all recovered spontaneously. The distribution of the various viruses is shown in Table 2.

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Results

and predictors were used as independent variables. Univariate predictors of outcome with a P value <.10 were used for multivariate logistic regression analysis. Results are expressed as odds ratio (ORs) and corresponding 95% CIs. CIs not including 1 were con-sidered statistically significant.

Probabilities of allo-LS andOSwere calculated using the Kaplan-Meier estimate; the 2-si-ded log-rank test was used for comparisons. All statistical analyses were performed using SPSS 15.1 (SPSS Inc, Chicago, IL).

Results

Patient characteristicsA total of 110 patients were included in the study, 42 from January 2004 to August 2006 (before routine NPA testing), and 68 after from August 2006 to May 2008. Six patients who underwent transplantation during this period were excluded from the study be-cause they experienced autologous recovery (n = 2), early graft rejection (within 1 month after transplantation; n = 2), or early death (before engraftment; n = 2) and thus were considered not prone to alloreactive disease. The median age at transplantation was 5.0 years (range, 2 months to 21 years), and body weight ranged between 2 and 100 kg. Base-line characteristics of the RV-positive and RV-negative groups are shown in Table 1. No significant differences between the 2 groups were evident, although there were slightly more matched donor transplants in the RV-negative group and more CB donors in the RV-positive group.

RV infections and presenting symptomsIn this cohort of patients, 55 (50%) had an RV infection. The median day of onset was day 116 posttransplantatio (range, day 27 to day 1100). Symptoms were usually mild. The majority of patients with RV infection (n = 43) had URTI symptoms only. Eleven patients required extra oxygen, and 1 patient needed ventilator support (associated with a bacterial infection). Two patients, both with influenza A infection, were treated with a neuraminidase inhibitor; all other patients experienced spontaneous clinical recovery within 7-14 days. Although symptoms disappeared, virus was detected in NPAsamples for weeks to months afterward, with high viral loads (PCR Ct values of 17-24; see Patients and methods). Thirty-eight patients had a single RV, and 14 patients had multiple viruses. In 3 patients, no RV was detected, but the clinical picture was typical for RV infection. These patients had mild respiratory symptoms (rhinorrhea) with no other cause, and all recovered spontaneously. The distribution of the various viruses is shown in Table 2.

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TABLE 1. Patient characteristics

RV-positive RV-negative P

Age at HSCT, median (range) in years 6.0 (0.5-19) 2.6 (0.2-21) NS

Follow-up, median (range) in weeks 70 (4-230) 57 (4-192) NS

Sex, n (%) Male Female

29 (53)26 (47)

29 (53)26 (47) NS

Indication, n (%)* Malignant Nonmalignant

31 (56)24 (44)

25 (46)30 (54) NS

HLA disparity, n (%)† Matched Mismatched

39 (71)16 (29)

30 (54)25 (46) .076

Number of HSCT, n (%) First Second Third

52 (94)3 (6)0 (0)

50 (91)4 (6)1 (2) NS

Conditioning, n (%)‡ TBI-based Chemotherapy-based

21 (38)34 (67)

12 (22)43 (78) NS

Donor relationship, n (%) Family Unrelated

18 (33)37 (67)

15 (27)40 (73) NS

Graft source, n (%) BM/PBSC CB§

43 (78)12 (22)

34 (62)21 (38) .061

HSCT indicates hematopoietic stem cell transplantation; BM, bone marrow; PBSC, peripheral blood stem cell; CB, cord blood; TBI, total body irradiation; NS, not significant.*Malignant indications: Acute lymphoblastic leukemia, 34; myelodysplastic syndrome, 9; acute myelogenous leukemia, 8; juvenile myelomonocytic leukemia, 1; lymphoma, 4. Nonmalignant indications: inborn errors of metabolism, 23; immune deficiency, 13; hemophagocytic lymphohistiocytosis, 5; BM failure, 11; others, 2.†Matched donor was defined as either 10 of 10 for BM/PBSC grafts molecularly typed or 6 of 6 for CB grafts based on intermediate resolution (HLA-A and HLA-B on serology and HLA-DR on high resolution).‡Conditioning regimens: TBI-based (n = 33): Fractionated TBI (3x2x2 Gy) and etoposide 40 mg/kg, 29; thora-coabominal irradiation/cyclophosphamide 10 mg/kg)/fludarabine (90 mg/m2), 2; TBI (7 Gy)/etoposide (40 mg/kg), 1; TBI/thiotepa/etoposide, 1. Chemotherapy-based (n = 77): busulfan 480 mg/m2/cyclophosphamide 120 or 200 mg/kg, 46; busulfan 480 mg/m2/cyclophosphamide 120 mg/kg/melphalan 140 mg/m2, 17; busulfan 480 mg/m2/cyclophosphamide 120 mg/kg/etoposide 40 mg/kg, 3; busulfan 480 mg/m2/fludarabine 180 mg/m2, 3; busulfan 160 mg/m2/cyclophosphamide 40 mg/kg/fludarabine 90 mg/m2, 3; cyclophosphamide 120 mg/kg, 2; treosulfan 42 g/m2/etoposide 40 mg/kg/cyclophosphamide 120 mg/kg, 1; treosulfan 42 g/m2, 1; none, 1. Patients receiving an unrelated donor graft received serotherapy (thymoglobuline, 37; ATG-fresenius, 16; campath-1H, 3).§Median cell dose of CB: in nucleated cells, 7.8 (range, 2.7-20.0) x107 cells/kg; in CD34+ cells, 4.5 (range, 1.1-10.0) x105 cells/kg. All CB grafts were unrelated. One patient received a double CB graft.

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TABLE 1. Patient characteristics

RV-positive RV-negative P

Age at HSCT, median (range) in years 6.0 (0.5-19) 2.6 (0.2-21) NS

Follow-up, median (range) in weeks 70 (4-230) 57 (4-192) NS

Sex, n (%) Male Female

29 (53)26 (47)

29 (53)26 (47) NS

Indication, n (%)* Malignant Nonmalignant

31 (56)24 (44)

25 (46)30 (54) NS

HLA disparity, n (%)† Matched Mismatched

39 (71)16 (29)

30 (54)25 (46) .076

Number of HSCT, n (%) First Second Third

52 (94)3 (6)0 (0)

50 (91)4 (6)1 (2) NS

Conditioning, n (%)‡ TBI-based Chemotherapy-based

21 (38)34 (67)

12 (22)43 (78) NS

Donor relationship, n (%) Family Unrelated

18 (33)37 (67)

15 (27)40 (73) NS

Graft source, n (%) BM/PBSC CB§

43 (78)12 (22)

34 (62)21 (38) .061

HSCT indicates hematopoietic stem cell transplantation; BM, bone marrow; PBSC, peripheral blood stem cell; CB, cord blood; TBI, total body irradiation; NS, not significant.*Malignant indications: Acute lymphoblastic leukemia, 34; myelodysplastic syndrome, 9; acute myelogenous leukemia, 8; juvenile myelomonocytic leukemia, 1; lymphoma, 4. Nonmalignant indications: inborn errors of metabolism, 23; immune deficiency, 13; hemophagocytic lymphohistiocytosis, 5; BM failure, 11; others, 2.†Matched donor was defined as either 10 of 10 for BM/PBSC grafts molecularly typed or 6 of 6 for CB grafts based on intermediate resolution (HLA-A and HLA-B on serology and HLA-DR on high resolution).‡Conditioning regimens: TBI-based (n = 33): Fractionated TBI (3x2x2 Gy) and etoposide 40 mg/kg, 29; thora-coabominal irradiation/cyclophosphamide 10 mg/kg)/fludarabine (90 mg/m2), 2; TBI (7 Gy)/etoposide (40 mg/kg), 1; TBI/thiotepa/etoposide, 1. Chemotherapy-based (n = 77): busulfan 480 mg/m2/cyclophosphamide 120 or 200 mg/kg, 46; busulfan 480 mg/m2/cyclophosphamide 120 mg/kg/melphalan 140 mg/m2, 17; busulfan 480 mg/m2/cyclophosphamide 120 mg/kg/etoposide 40 mg/kg, 3; busulfan 480 mg/m2/fludarabine 180 mg/m2, 3; busulfan 160 mg/m2/cyclophosphamide 40 mg/kg/fludarabine 90 mg/m2, 3; cyclophosphamide 120 mg/kg, 2; treosulfan 42 g/m2/etoposide 40 mg/kg/cyclophosphamide 120 mg/kg, 1; treosulfan 42 g/m2, 1; none, 1. Patients receiving an unrelated donor graft received serotherapy (thymoglobuline, 37; ATG-fresenius, 16; campath-1H, 3).§Median cell dose of CB: in nucleated cells, 7.8 (range, 2.7-20.0) x107 cells/kg; in CD34+ cells, 4.5 (range, 1.1-10.0) x105 cells/kg. All CB grafts were unrelated. One patient received a double CB graft.

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Results

Primary endpoint: Allo-LSThirty patients were diagnosed with allo-LS (27.3%), 12 with BOS (10.9%) and 18 with IPS (16.4%). No patient developed BOOP. One patient presented with pulmonary hyper-tension with histologically proven vasculopathy, with lymphocyte infiltration that res-ponded to immunosuppressive agents. We considered this patient to have IPS. For the 30 patients with allo-LS, the median time of onset was 8 weeks (range, 2-26 weeks) after transplantation. IPS occurred earlier, with a median time of onset of 7 weeks (range, 2-12 weeks); BOS developed later, after a median of 16 weeks (range, 10-26 weeks).

In univariate analysis, RV positivity, CB stem cell graft, and a chemotherapy-based con-ditioning regimen were predictors for the development of allo-LS (Table 3). In multi-variate analysis, only RV positivity remained a predictor for the development of allo-LS (HR, 8.37; 95% CI, 1.78-39.43; P = .007). Analyzing the separate endpoints acute allo-LS (IPS) and chronic allo-LS (BOS) revealed that RV positivity was the sole predictor for the development of BOS (HR, 107; 95% CI, 0.9-13,347; P = .05). For IPS, RV positivity (HR, 11.4; 95% CI, 2.61-49.8; P 5 .001), CB stem cell graft (HR, 4.8; 95% CI, 1.79-12.7; P = .002), and nonmalignant indication for transplantation (HR, 3.3; 95% CI, 1.1-10.2; P = .034) were found to be predictors in univariate analysis. In multivariate analysis, only RV-positivity remained significant (HR, 8.65; 95% CI, 1.9-38.4; P = .005).

The median duration from RV positivity and the development of allo-LS was 7 weeks (range, 1.2-20 weeks) (Figure 1A). The timing of development of RV positivity seems to be important as well. Patients who were RV-positive early after transplantation (before

TABLE 2. Viruses detected by real-time RT-PCR

Virus N

Rhinovirus Parainfluenzavirus-3 Influenza-A virus Coronavirus Adenovirus Multiple viruses* ‘‘Negative’’†

284231

143

* Subdivided: adenovirus/rhinovirus, 4; parainfluenza-3/rhinovirus, 2; human metapneumovirus/rhinovirus, 2; rhinovirus/adenovirus/parain-fluenza-3, 2; respiratory syncytial virus/rhinovirus, 1; coronavirus/parain-fluenza-3, 1; coronavirus/adenovirus, 1; coronavirus/rhinovirus, 1.† Typical clinical symptoms of an URTI with no other explanation.

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Results

Primary endpoint: Allo-LSThirty patients were diagnosed with allo-LS (27.3%), 12 with BOS (10.9%) and 18 with IPS (16.4%). No patient developed BOOP. One patient presented with pulmonary hyper-tension with histologically proven vasculopathy, with lymphocyte infiltration that res-ponded to immunosuppressive agents. We considered this patient to have IPS. For the 30 patients with allo-LS, the median time of onset was 8 weeks (range, 2-26 weeks) after transplantation. IPS occurred earlier, with a median time of onset of 7 weeks (range, 2-12 weeks); BOS developed later, after a median of 16 weeks (range, 10-26 weeks).

In univariate analysis, RV positivity, CB stem cell graft, and a chemotherapy-based con-ditioning regimen were predictors for the development of allo-LS (Table 3). In multi-variate analysis, only RV positivity remained a predictor for the development of allo-LS (HR, 8.37; 95% CI, 1.78-39.43; P = .007). Analyzing the separate endpoints acute allo-LS (IPS) and chronic allo-LS (BOS) revealed that RV positivity was the sole predictor for the development of BOS (HR, 107; 95% CI, 0.9-13,347; P = .05). For IPS, RV positivity (HR, 11.4; 95% CI, 2.61-49.8; P 5 .001), CB stem cell graft (HR, 4.8; 95% CI, 1.79-12.7; P = .002), and nonmalignant indication for transplantation (HR, 3.3; 95% CI, 1.1-10.2; P = .034) were found to be predictors in univariate analysis. In multivariate analysis, only RV-positivity remained significant (HR, 8.65; 95% CI, 1.9-38.4; P = .005).

The median duration from RV positivity and the development of allo-LS was 7 weeks (range, 1.2-20 weeks) (Figure 1A). The timing of development of RV positivity seems to be important as well. Patients who were RV-positive early after transplantation (before

TABLE 2. Viruses detected by real-time RT-PCR

Virus N

Rhinovirus Parainfluenzavirus-3 Influenza-A virus Coronavirus Adenovirus Multiple viruses* ‘‘Negative’’†

284231

143

* Subdivided: adenovirus/rhinovirus, 4; parainfluenza-3/rhinovirus, 2; human metapneumovirus/rhinovirus, 2; rhinovirus/adenovirus/parain-fluenza-3, 2; respiratory syncytial virus/rhinovirus, 1; coronavirus/parain-fluenza-3, 1; coronavirus/adenovirus, 1; coronavirus/rhinovirus, 1.† Typical clinical symptoms of an URTI with no other explanation.

3

51


TABLE 3. Univariate analysis of predictors for alloimmune mediated lung syndromes.

Allo-LS

Total N % HR 95% CI P

Overall 110 30 27.3

Age 0.95 0.88-1.02 .18

Sex Male Female

5852

1515

25.928.8

11.03 0.5-2.12 .93

Indication for HSCT Malignant disorder Nonmalignant disorder

5654

1020

18.035.7

12.67 0.87-3.97 .11

HLA disparity Matched Mismatched

6941

17 13

24.631.7

11.14 2 0.55-2.36 .7

Conditioning TBI-based Chemotherapy-based

3377

4 26

12.134.0

13.05 1.06-8.75 .04

Donor Family Unrelated

3367

921

27.331.3

11.07 0.49-2.35 .80

Stem cell source BM/PBSC CB

6733

1713

25.439.4

12.13 1.03-4.41 .042

RV infection No Yes

5555

327

6.752.9

110.3 3.14-34.3 .00

Recipient CMV serology Serology-negative 76 19 25 1 Serology-postive

7634

1911

2532.4

11.41 0.59-4.78 .68

HSCT indicates hematopoietic stem cell transplantation; TBI, total body irradiation; BM, bone marrow; PBSC, peripheral blood stem cell; CB, cord blood; CMV, cytomegalovirus; Allo-LS, alloimmune mediated lung syndromes

3

51


TABLE 3. Univariate analysis of predictors for alloimmune mediated lung syndromes.

Allo-LS

Total N % HR 95% CI P

Overall 110 30 27.3

Age 0.95 0.88-1.02 .18

Sex Male Female

5852

1515

25.928.8

11.03 0.5-2.12 .93

Indication for HSCT Malignant disorder Nonmalignant disorder

5654

1020

18.035.7

12.67 0.87-3.97 .11

HLA disparity Matched Mismatched

6941

17 13

24.631.7

11.14 2 0.55-2.36 .7

Conditioning TBI-based Chemotherapy-based

3377

4 26

12.134.0

13.05 1.06-8.75 .04

Donor Family Unrelated

3367

921

27.331.3

11.07 0.49-2.35 .80

Stem cell source BM/PBSC CB

6733

1713

25.439.4

12.13 1.03-4.41 .042

RV infection No Yes

5555

327

6.752.9

110.3 3.14-34.3 .00

Recipient CMV serology Serology-negative 76 19 25 1 Serology-postive

7634

1911

2532.4

11.41 0.59-4.78 .68

HSCT indicates hematopoietic stem cell transplantation; TBI, total body irradiation; BM, bone marrow; PBSC, peripheral blood stem cell; CB, cord blood; CMV, cytomegalovirus; Allo-LS, alloimmune mediated lung syndromes

3

52

Results

the median of day 116) had a slightly greater likelihood of developing allo-LS than those who became RV-positive after day 116 (HR, 2.10; 95% CI, 0.89-5.00 P = .089).

Univariate analysis of the influence of HSCT associated complications on allo-LS sho-wed that adenovirus reactivation (OR, 3.86; 95% CI, 1.56-9.5; P = .004) was predictive of allo-LS. aGVHD grade II-IV in other organs appeared to be a negative predictor (OR, 0.22; 95% CI, 0.061-0.78; P 5 .02). In multivariate analysis, only aGVHD remained a strong predictor for preventing allo-LS (OR, 0.1; 95% CI, 0.02-0.47; P = .004).

The influence of aGVHD on the development of allo-LS for the whole group and for the RV-positive patients is shown in Figure 1B and C. In this study, aGVHD clearly develo-ped before the onset of allo-LS. The mean time to onset was 4 weeks for GVHD (range, 2-15 weeks) and 8 weeks for allo-LS (range, 2-26 weeks). In particular, in the RV-positive group, aGVHD grade II-IV in another organ was strongly protective against the develop-ment of allo-LS.

We found no influence of the different individual viral species, or of the presence of a single virus or multiple viruses, on the development of allo-LS (data not shown).

All patients who developed allo-LS were treated according to the protocol with MP pulse therapy, as discussed earlier. All patients demonstrated prompt initial improvement of clinical symptoms.

Secondary endpoints OS was 72% (80/110) after a median follow up of 66 weeks (range, 4-230 weeks). Cau-se of death was relapse in 9 patients (8.2%) and nonrelapse mortality in 21 patients (19.1%). Fourteen of the 30 patients with allo-LS died (47%), all from transplantation-related causes: 3 from refractory aGVHD, 2 from invasive fungal infection, 1 from adeno-virus disease, 2 from sudden cardiac death of unknown cause, and 6 from ongoing lung disease. Univariate analysis identified adenovirus reactivation (OR, 0.28; 95% CI, 0.08-0.96; P = .043) and the development of allo-LS (OR, 0.25; 95% CI, 0.10-0.61; P = .003) as predictors for lower survival. Relapse had no significant influence on OS (HR, 1.89; 95% CI, 0.246-14.59; P = .54). In multivariate analysis, only allo-LS remained a predictorin this cohort (OR, 0.29; 95% CI, 0.09-0.94; P = .04). The impact of allo-LS on OS is depicted in Figure 1D.

3

52

Results

the median of day 116) had a slightly greater likelihood of developing allo-LS than those who became RV-positive after day 116 (HR, 2.10; 95% CI, 0.89-5.00 P = .089).

Univariate analysis of the influence of HSCT associated complications on allo-LS sho-wed that adenovirus reactivation (OR, 3.86; 95% CI, 1.56-9.5; P = .004) was predictive of allo-LS. aGVHD grade II-IV in other organs appeared to be a negative predictor (OR, 0.22; 95% CI, 0.061-0.78; P 5 .02). In multivariate analysis, only aGVHD remained a strong predictor for preventing allo-LS (OR, 0.1; 95% CI, 0.02-0.47; P = .004).

The influence of aGVHD on the development of allo-LS for the whole group and for the RV-positive patients is shown in Figure 1B and C. In this study, aGVHD clearly develo-ped before the onset of allo-LS. The mean time to onset was 4 weeks for GVHD (range, 2-15 weeks) and 8 weeks for allo-LS (range, 2-26 weeks). In particular, in the RV-positive group, aGVHD grade II-IV in another organ was strongly protective against the develop-ment of allo-LS.

We found no influence of the different individual viral species, or of the presence of a single virus or multiple viruses, on the development of allo-LS (data not shown).

All patients who developed allo-LS were treated according to the protocol with MP pulse therapy, as discussed earlier. All patients demonstrated prompt initial improvement of clinical symptoms.

Secondary endpoints OS was 72% (80/110) after a median follow up of 66 weeks (range, 4-230 weeks). Cau-se of death was relapse in 9 patients (8.2%) and nonrelapse mortality in 21 patients (19.1%). Fourteen of the 30 patients with allo-LS died (47%), all from transplantation-related causes: 3 from refractory aGVHD, 2 from invasive fungal infection, 1 from adeno-virus disease, 2 from sudden cardiac death of unknown cause, and 6 from ongoing lung disease. Univariate analysis identified adenovirus reactivation (OR, 0.28; 95% CI, 0.08-0.96; P = .043) and the development of allo-LS (OR, 0.25; 95% CI, 0.10-0.61; P = .003) as predictors for lower survival. Relapse had no significant influence on OS (HR, 1.89; 95% CI, 0.246-14.59; P = .54). In multivariate analysis, only allo-LS remained a predictorin this cohort (OR, 0.29; 95% CI, 0.09-0.94; P = .04). The impact of allo-LS on OS is depicted in Figure 1D.

3

53


FIGURE 1. RV= Respiratory Virus, allo-LS = alloimmune lungsyndrome, aGVHD = acute graft versus host disease, IPS = Idiopathic Pulmonary Syndrome, BO = Bronchiolitis Obliterans (Syndrome).

3

Occurence of allo-LS according to respiratory virus positivity in NPA

Occurence of allo-LS according to aGvHD (> grade 1)

Time to allo-LS (weeks) Time to allo-LS (weeks)

Cum

allo

-LS

Cum

allo

-LS

Cum

allo

-LS

Cum

surv

ival

Time to allo-LS (weeks) Follow-up post-SCT (weeks)

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

Log rank = 0.000

RV positivityNegativePositiveNegative-censoredPositive-censored

aGvHDNoYes,00-censored1,00-censored

Occurence of allo-LS in RV-positive patients according to aGvHD (>1)

Overall survival according to Allo-LS


NoYesno-censoredyes-censored

Allo-LS (IPS + BO)

Log rank = 0.049

Log rank = 0.008Log rank = 0.000

0,00 20,00 40,00 60,00 80,00 100,00 0,00 20,00 40,00 60,00 80,00 100,00

0,00 20,00 40,00 60,00 80,00 100,00 0 50 100 150 200 250

A B

C D

53


FIGURE 1. RV= Respiratory Virus, allo-LS = alloimmune lungsyndrome, aGVHD = acute graft versus host disease, IPS = Idiopathic Pulmonary Syndrome, BO = Bronchiolitis Obliterans (Syndrome).

3

Occurence of allo-LS according to respiratory virus positivity in NPA

Occurence of allo-LS according to aGvHD (> grade 1)

Time to allo-LS (weeks) Time to allo-LS (weeks)

Cum

allo

-LS

Cum

allo

-LS

Cum

allo

-LS

Cum

surv

ival

Time to allo-LS (weeks) Follow-up post-SCT (weeks)

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

Log rank = 0.000

RV positivityNegativePositiveNegative-censoredPositive-censored


Occurence of allo-LS in RV-positive patients according to aGvHD (>1)

Overall survival according to Allo-LS


NoYesno-censoredyes-censored

Allo-LS (IPS + BO)

Log rank = 0.049

Log rank = 0.008Log rank = 0.000

0,00 20,00 40,00 60,00 80,00 100,00 0,00 20,00 40,00 60,00 80,00 100,00

0,00 20,00 40,00 60,00 80,00 100,00 0 50 100 150 200 250

A B

C D

54

Discussion

Discussion

Our cohort of 110 patients had a high incidence (50%) of early RV infection, occurring at a median of 16 days after HSCT. Rhinovirus infection was the most common RV detec-ted. The RV infections usually had a mild clinical course, and most patients experienced spontaneous recovery within 2 weeks. RV infection occurring during the first 100 days after HSCT appeared to be the sole predictor for the development of acute and chronic allo-LS, which was found in 27.3% of the patients. All patients had recovered from their initial URTI symptoms before a new episode of respiratory symptoms occurred, leading to the diagnosis of allo-LS. The presence of a single RV or multiple RVs, or the presence of rhinovirus and other (non-rhinovirus) RVs, was not associated with the development of allo-LS. Paradoxically, aGVHD had a protective effect against the development of allo-LS, likely resulting from the prolonged immunosuppressive therapy in the patients with aGVHD. All of the patients with allo-LS initially exhibited good clinical response to MP pulse therapy. The development of allo-LS was associated with high mortality, however.

A possible weakness of our study is that we changed our policy on testing for RV during the study period. In the early phase of the study, we tested NPA samples for RV only in those patients exhibiting symptoms. Later in the study period, once the significance of RV was recognized, weekly surveillance assays were done in all patients. These surveil-lance assays identified 7 RV-positive patients without symptoms at the time of sampling; however, all of these patients developed URTI symptoms within 14 days after positive sampling, and so these RVs would ultimately have been detected regardless of the testing policy. Thus, we believe that we did not miss any RV-positive patients in the presurveil-lance period, and that the change in testing policy had no major impact on our results (data not shown), the only difference being that the median time to RV positivity would have been shorter had we monitored the whole group routinely.

Three patients with symptoms and a clinical course typical of viral URTI were considered RV-positive despite negative RV-PCR results. In these patients, symptoms might have resulted from a virus not detectable by our PCR panel. It would be interesting to test these for more recently identified viruses, such Boca and Wu/KI. Because of the obvious symptoms and the fact that other study groups have included similar patients in their analyses, we decided to do so as well.10 Had we considered these patients RV-negative in our analysis, the results would have been the same (only 1 of the 3 patients developed allo-LS). We realize that we may well have missed some mild URTI symptoms in the period between discharge and day 1100 and so do not have full data on RV positivity after discharge from the hospital. No patient who was RV-PCR–negative on discharge developed allo-LS, however. Acquisition of RV very early after HSCT appears to be im-portant for the development of allo-LS; the patients who were RV-positive within 16 days of HSCT tended to be more susceptible to allo-LS.

3

54

Discussion

Discussion

Our cohort of 110 patients had a high incidence (50%) of early RV infection, occurring at a median of 16 days after HSCT. Rhinovirus infection was the most common RV detec-ted. The RV infections usually had a mild clinical course, and most patients experienced spontaneous recovery within 2 weeks. RV infection occurring during the first 100 days after HSCT appeared to be the sole predictor for the development of acute and chronic allo-LS, which was found in 27.3% of the patients. All patients had recovered from their initial URTI symptoms before a new episode of respiratory symptoms occurred, leading to the diagnosis of allo-LS. The presence of a single RV or multiple RVs, or the presence of rhinovirus and other (non-rhinovirus) RVs, was not associated with the development of allo-LS. Paradoxically, aGVHD had a protective effect against the development of allo-LS, likely resulting from the prolonged immunosuppressive therapy in the patients with aGVHD. All of the patients with allo-LS initially exhibited good clinical response to MP pulse therapy. The development of allo-LS was associated with high mortality, however.

A possible weakness of our study is that we changed our policy on testing for RV during the study period. In the early phase of the study, we tested NPA samples for RV only in those patients exhibiting symptoms. Later in the study period, once the significance of RV was recognized, weekly surveillance assays were done in all patients. These surveil-lance assays identified 7 RV-positive patients without symptoms at the time of sampling; however, all of these patients developed URTI symptoms within 14 days after positive sampling, and so these RVs would ultimately have been detected regardless of the testing policy. Thus, we believe that we did not miss any RV-positive patients in the presurveil-lance period, and that the change in testing policy had no major impact on our results (data not shown), the only difference being that the median time to RV positivity would have been shorter had we monitored the whole group routinely.

Three patients with symptoms and a clinical course typical of viral URTI were considered RV-positive despite negative RV-PCR results. In these patients, symptoms might have resulted from a virus not detectable by our PCR panel. It would be interesting to test these for more recently identified viruses, such Boca and Wu/KI. Because of the obvious symptoms and the fact that other study groups have included similar patients in their analyses, we decided to do so as well.10 Had we considered these patients RV-negative in our analysis, the results would have been the same (only 1 of the 3 patients developed allo-LS). We realize that we may well have missed some mild URTI symptoms in the period between discharge and day 1100 and so do not have full data on RV positivity after discharge from the hospital. No patient who was RV-PCR–negative on discharge developed allo-LS, however. Acquisition of RV very early after HSCT appears to be im-portant for the development of allo-LS; the patients who were RV-positive within 16 days of HSCT tended to be more susceptible to allo-LS.

3

55


A remark about the definition of IPS is warranted. In the consensus definition of IPS (established by a 1997 National Institutes of Health workshop), all infectious agents, including RVs, should be excluded. In our patients, we observed prolonged shedding of RV for months, and thus we could not formally diagnose IPS. In all patients, the initial URTI symptoms disappeared spontaneously within 1-2 weeks, however. Subsequently, after a period of at least 14 days without significant respiratory problems, symptoms of hypoxia and/or airway obstruction recurred. We believe that this represents not a direct progression of viral infection, but rather a combination of several factors in which allo-reactivity (triggered by tissue damage because of persistent viral infection) plays a pivotal role. Therefore, we chose to define IPS as discussed earlier, not taking into account the presence of an RV identified by PCR as was done in this study. Moreover, the formal definition of IPS was promulgated in an era when molecular diagnosis of RV was not yet available.

We hypothesize that RVs may contribute to the pathogenesis of any allo-LS as follows. The RV damages the respiratory epithelium, causing an inflammatory response at the time of immune recovery. Normally IPS and BOS/BOOP are viewed as distinct clinical entities, and so we first studied them separately. Because we noted the same strong as-sociations among RV positivity, GVHD, and OS in the 2 groups, we combined both IPS and BOS/BOOP in subsequent analyses.

We also combined BM and PBSC sources in our analysis. It would be interesting to evaluate patients receiving PBSCs as a separate group, because of their apparent higher risk of chronic GVHD (cGVHD). The small number of patients our cohort who received PBSCs (n = 7) precludes meaningful analysis, however.

Numerous studies have explored the incidence and outcome of both nosocomial and community-acquired RV infections after HSCT.7-16 Reported incidence varies from 1% to 56%. This wide range of incidence can be explained by differences among studies in the definition of RV infection, the period of monitoring for RV infection (eg, inpatients/outpatients, seasonal influence), and sensitivity of the analysis methods used. In our co-hort, the high incidence of RV URTI (50%) might be attributed to our close monitoring for respiratory symptoms and performance of RT-PCR surveillance assays. In addition, nosocomial RV infections were frequently observed, and genotyping studies suggested that these had spread throughout the ward during the study period, also contributing to the relatively high incidence (data not shown).

Literature data on the morbidity associated with RV infection after HSCT are conflicting. Some groups found no progression of viral URTI to LRTI in patients after HSCT,10,15 whereas others reported progression in up to 58% of patients.7,8,11,13,16 In our cohort, we found no direct progression to LRTI. Almost all patients had mild URTI symptoms and recovered spontaneously. The median day of onset of RV infection was only 16 days in

3

55


A remark about the definition of IPS is warranted. In the consensus definition of IPS (established by a 1997 National Institutes of Health workshop), all infectious agents, including RVs, should be excluded. In our patients, we observed prolonged shedding of RV for months, and thus we could not formally diagnose IPS. In all patients, the initial URTI symptoms disappeared spontaneously within 1-2 weeks, however. Subsequently, after a period of at least 14 days without significant respiratory problems, symptoms of hypoxia and/or airway obstruction recurred. We believe that this represents not a direct progression of viral infection, but rather a combination of several factors in which allo-reactivity (triggered by tissue damage because of persistent viral infection) plays a pivotal role. Therefore, we chose to define IPS as discussed earlier, not taking into account the presence of an RV identified by PCR as was done in this study. Moreover, the formal definition of IPS was promulgated in an era when molecular diagnosis of RV was not yet available.

We hypothesize that RVs may contribute to the pathogenesis of any allo-LS as follows. The RV damages the respiratory epithelium, causing an inflammatory response at the time of immune recovery. Normally IPS and BOS/BOOP are viewed as distinct clinical entities, and so we first studied them separately. Because we noted the same strong as-sociations among RV positivity, GVHD, and OS in the 2 groups, we combined both IPS and BOS/BOOP in subsequent analyses.

We also combined BM and PBSC sources in our analysis. It would be interesting to evaluate patients receiving PBSCs as a separate group, because of their apparent higher risk of chronic GVHD (cGVHD). The small number of patients our cohort who received PBSCs (n = 7) precludes meaningful analysis, however.

Numerous studies have explored the incidence and outcome of both nosocomial and community-acquired RV infections after HSCT.7-16 Reported incidence varies from 1% to 56%. This wide range of incidence can be explained by differences among studies in the definition of RV infection, the period of monitoring for RV infection (eg, inpatients/outpatients, seasonal influence), and sensitivity of the analysis methods used. In our co-hort, the high incidence of RV URTI (50%) might be attributed to our close monitoring for respiratory symptoms and performance of RT-PCR surveillance assays. In addition, nosocomial RV infections were frequently observed, and genotyping studies suggested that these had spread throughout the ward during the study period, also contributing to the relatively high incidence (data not shown).

Literature data on the morbidity associated with RV infection after HSCT are conflicting. Some groups found no progression of viral URTI to LRTI in patients after HSCT,10,15 whereas others reported progression in up to 58% of patients.7,8,11,13,16 In our cohort, we found no direct progression to LRTI. Almost all patients had mild URTI symptoms and recovered spontaneously. The median day of onset of RV infection was only 16 days in

3

56

Discussion

our cohort, compared with at least 60 days in previous studies. Progression to LRTI might be expected in patients with RV infection early after transplantation, because of poor immune status, but this was not seen. In our opinion, it is more likely that the mo-ment of immune recovery defines the onset of symptoms. What we define as IPS in this study (ie, symptoms after a period of quiescent RV infection) might have been reported in other stud-ies as progressive viral pneumonia, with symptoms occurring at the onset of RV infection later after HSCT, when some immune recovery has already occurred.

The reported incidence of IPS after HSCT ranges from 2% to 15% of patients,2,4,25,26 and that of BOS ranges from 0% to 26%.1,4,27,28 Most reported data are from adult studies. The combined incidence of allo-LS in our cohort of 27.3% is comparable to that reported in the literature. Our incidence of IPS is relatively high, most likely because our cohort included a high number of early RV-positive patients.

We found a strong association between RV infection and the development of allo-LS. To the best of our knowledge, this is the first report of such a strong association between RV infection and life-threatening allo-LS.Earlier, Erard et al.17 described a relationship be-tween RV infection during the first 100 days after HSCT and a decline in airflow leading to increased overall mortality. The decline in airflow was detected immediately after in-fection and did not return to baseline values, suggesting sustained airway inflammation leading to permanent loss of lung function. Pulmonary disease was much more severe in our cohort compared with the cohort of Erard et al.17 This discrepancy can be explained by the early moment of RV infection, when immune recovery has not yet occurred and the persistent RV likely causes more tissue damage, ultimately resulting in a stronger inflammatory response. The absence of immunity at the time of primary RV infection also might explain the absence of an immediate decline in clinical lung function. Pulmo-nary function deteriorated only after at least 2 weeks after RV infection, when the first signs of immune recovery were evident. It would be interesting to routinely perform PFTs earlier after HSCT, but for reasons of hygiene and patient comfort, we decided not to do this in the present study.

Most previous studies have found an association between the presence of GVHD and the development of allo-LS.1,2,25,29 In those studies, aGVHD was associated with IPS, but other risk factors, including conditioning regimen and infection, might have been in-volved as well. cGVHD is considered an important risk factor for BOS in adults. Allore-active T cells, in the context of aGVHD or cGVHD, play an important role in BOS.29 BOS is also seen in the absence of cGVHD in 7%-18% of patients, however.27 This percentage may be different in children, who are less susceptible to cGVHD.30 Our finding that aGVHD grade II-IV in other organs has a protective effect on the development of allo-LS does not necessarily contradict these results. Like aGVHD, allo-LS is a manifestation of alloimmunity. We speculate that the apparent protective effect of aGVHD reflects the

3

56

Discussion

our cohort, compared with at least 60 days in previous studies. Progression to LRTI might be expected in patients with RV infection early after transplantation, because of poor immune status, but this was not seen. In our opinion, it is more likely that the mo-ment of immune recovery defines the onset of symptoms. What we define as IPS in this study (ie, symptoms after a period of quiescent RV infection) might have been reported in other stud-ies as progressive viral pneumonia, with symptoms occurring at the onset of RV infection later after HSCT, when some immune recovery has already occurred.

The reported incidence of IPS after HSCT ranges from 2% to 15% of patients,2,4,25,26 and that of BOS ranges from 0% to 26%.1,4,27,28 Most reported data are from adult studies. The combined incidence of allo-LS in our cohort of 27.3% is comparable to that reported in the literature. Our incidence of IPS is relatively high, most likely because our cohort included a high number of early RV-positive patients.

We found a strong association between RV infection and the development of allo-LS. To the best of our knowledge, this is the first report of such a strong association between RV infection and life-threatening allo-LS.Earlier, Erard et al.17 described a relationship be-tween RV infection during the first 100 days after HSCT and a decline in airflow leading to increased overall mortality. The decline in airflow was detected immediately after in-fection and did not return to baseline values, suggesting sustained airway inflammation leading to permanent loss of lung function. Pulmonary disease was much more severe in our cohort compared with the cohort of Erard et al.17 This discrepancy can be explained by the early moment of RV infection, when immune recovery has not yet occurred and the persistent RV likely causes more tissue damage, ultimately resulting in a stronger inflammatory response. The absence of immunity at the time of primary RV infection also might explain the absence of an immediate decline in clinical lung function. Pulmo-nary function deteriorated only after at least 2 weeks after RV infection, when the first signs of immune recovery were evident. It would be interesting to routinely perform PFTs earlier after HSCT, but for reasons of hygiene and patient comfort, we decided not to do this in the present study.

Most previous studies have found an association between the presence of GVHD and the development of allo-LS.1,2,25,29 In those studies, aGVHD was associated with IPS, but other risk factors, including conditioning regimen and infection, might have been in-volved as well. cGVHD is considered an important risk factor for BOS in adults. Allore-active T cells, in the context of aGVHD or cGVHD, play an important role in BOS.29 BOS is also seen in the absence of cGVHD in 7%-18% of patients, however.27 This percentage may be different in children, who are less susceptible to cGVHD.30 Our finding that aGVHD grade II-IV in other organs has a protective effect on the development of allo-LS does not necessarily contradict these results. Like aGVHD, allo-LS is a manifestation of alloimmunity. We speculate that the apparent protective effect of aGVHD reflects the

3

57


influence on alloreactive T cells of immunosuppressive agents used to treat aGVHD grade II-IV. None of our patients had lung involvement at the onset of aGVHD. This may be because the lungs are less susceptible to acute alloreactivity than the classic tar-get organs of gut, liver, and skin. This is also reflected by the fact that the median time to allo-LS was longer (8 weeks) than the median time to aGVHD (4 weeks). All patients who developed allo-LS did so during tapering of immunosuppressive therapy or after this therapy had been stopped. All of the patients with aGVHD where on prolonged im-munosuppressive therapy (including steroids) and thus likely had less chance to develop alloimmunity in the lungs. In other words, the RV-positive patients who did not develop allo-LS had significantly greater immune suppression than the RV-positive patients who did develop allo-LS (data not shown). This effect of immunosuppressive therapy on the development of allo-LS is in line with previous findings.31 Regarding cGVHD, in contrast to other studies, in our cohort, only 1 of 12 patients (11%) with BOS had signs of cGVHD in other organs. Our finding of no association between cGVHD and BOS/BOOP might be because of the generally low incidence of cGVHD in the pediatric HSCT population. This, together with the fact that viral infections are more frequent in childhood, might make the respiratory epithelium a preferential target for chronic allo-reactivity, at least in this pediatric cohort. No protective effect of cGVHD on the development of allo-LS was noted, most likely because cGVHD (mainly the limited form) was not treated with systemic immunosuppressive agents (eg, steroids).

A similar association between RV infection and allo-LS has been reported after lung transplantation. A recent prospective cohort study in 100 lung transplant recipients clearly showed had significantly more acute or chronic rejection episodes in patients with an RV infection occurring within 100 days post-transplantation.18 BOS occurring af-ter lung transplantation is considered a manifestation of allograft rejection32,33 because of an alloimmune process. Some animal models of lung transplantation have demonstra-ted an association between the presence of RV and the development of BOS exclusively in the allogeneic transplantation setting.34 These results are in line with the association between RV infection and allo-LS seen in our HSCT population, and strongly support the hypothesis that airway damage from an RV infection alone does not lead to severe pro-blems, but triggers alloimmunity. Because of this strong association, the current practice in lung transplantation is to increase immunosuppression by adding steroids in the pre-sence of an RV infection posttransplantation, to avoid rejection (personal communica-tion Lung transplantation programme UMC Groningen and UMC Utrecht, 2007). This practice has led to a decreased graft rejection rate.

Increasing immunosuppression solely because of the presence of a RV may sound pa-radoxical, possibly predisposing the patient to other potentially life-threatening compli-cations, but it is supported by our observation that patients with RV infection early after HSCT were less vulnerable to allo-LS when receiving immunosuppression for aGVHD.

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influence on alloreactive T cells of immunosuppressive agents used to treat aGVHD grade II-IV. None of our patients had lung involvement at the onset of aGVHD. This may be because the lungs are less susceptible to acute alloreactivity than the classic tar-get organs of gut, liver, and skin. This is also reflected by the fact that the median time to allo-LS was longer (8 weeks) than the median time to aGVHD (4 weeks). All patients who developed allo-LS did so during tapering of immunosuppressive therapy or after this therapy had been stopped. All of the patients with aGVHD where on prolonged im-munosuppressive therapy (including steroids) and thus likely had less chance to develop alloimmunity in the lungs. In other words, the RV-positive patients who did not develop allo-LS had significantly greater immune suppression than the RV-positive patients who did develop allo-LS (data not shown). This effect of immunosuppressive therapy on the development of allo-LS is in line with previous findings.31 Regarding cGVHD, in contrast to other studies, in our cohort, only 1 of 12 patients (11%) with BOS had signs of cGVHD in other organs. Our finding of no association between cGVHD and BOS/BOOP might be because of the generally low incidence of cGVHD in the pediatric HSCT population. This, together with the fact that viral infections are more frequent in childhood, might make the respiratory epithelium a preferential target for chronic allo-reactivity, at least in this pediatric cohort. No protective effect of cGVHD on the development of allo-LS was noted, most likely because cGVHD (mainly the limited form) was not treated with systemic immunosuppressive agents (eg, steroids).

A similar association between RV infection and allo-LS has been reported after lung transplantation. A recent prospective cohort study in 100 lung transplant recipients clearly showed had significantly more acute or chronic rejection episodes in patients with an RV infection occurring within 100 days post-transplantation.18 BOS occurring af-ter lung transplantation is considered a manifestation of allograft rejection32,33 because of an alloimmune process. Some animal models of lung transplantation have demonstra-ted an association between the presence of RV and the development of BOS exclusively in the allogeneic transplantation setting.34 These results are in line with the association between RV infection and allo-LS seen in our HSCT population, and strongly support the hypothesis that airway damage from an RV infection alone does not lead to severe pro-blems, but triggers alloimmunity. Because of this strong association, the current practice in lung transplantation is to increase immunosuppression by adding steroids in the pre-sence of an RV infection posttransplantation, to avoid rejection (personal communica-tion Lung transplantation programme UMC Groningen and UMC Utrecht, 2007). This practice has led to a decreased graft rejection rate.

Increasing immunosuppression solely because of the presence of a RV may sound pa-radoxical, possibly predisposing the patient to other potentially life-threatening compli-cations, but it is supported by our observation that patients with RV infection early after HSCT were less vulnerable to allo-LS when receiving immunosuppression for aGVHD.

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Discussion

At present, we cannot predict which RV-positive patients are actually at risk for develo-ping allo-LS. Early recognition of the disease by the detection of biomarkers associated with lung damage and the development of allo-LS, or the identification of certain risk groups by studying the genetic polymorphisms of innate immunity in these patients, might be of additional value to fine-tune the initiation or adjustment of immunosuppres-sive therapy in the HSCT setting.

In conclusion, we have shown a clear relation between early RV infection and the deve-lopment of allo-LS in pediatric HSCT recipients. Tissue damage because of the persis-tence of RV in the lung might be a trigger for the development of allo-LS. aGVHD, but more likely greater immunosuppression because of the aGVHD, appears to protect for allo-LS. These findings suggest that prevention of RV infections early after HSCT is of utmost importance. In addition, prolonged immune suppression in transplant recipients with an RV infection might prevent development of allo-LS, in analogy with current prac-tice in lung transplantation.

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Discussion

At present, we cannot predict which RV-positive patients are actually at risk for develo-ping allo-LS. Early recognition of the disease by the detection of biomarkers associated with lung damage and the development of allo-LS, or the identification of certain risk groups by studying the genetic polymorphisms of innate immunity in these patients, might be of additional value to fine-tune the initiation or adjustment of immunosuppres-sive therapy in the HSCT setting.

In conclusion, we have shown a clear relation between early RV infection and the deve-lopment of allo-LS in pediatric HSCT recipients. Tissue damage because of the persis-tence of RV in the lung might be a trigger for the development of allo-LS. aGVHD, but more likely greater immunosuppression because of the aGVHD, appears to protect for allo-LS. These findings suggest that prevention of RV infections early after HSCT is of utmost importance. In addition, prolonged immune suppression in transplant recipients with an RV infection might prevent development of allo-LS, in analogy with current prac-tice in lung transplantation.

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1. Afessa B, Peters SG. Chronic lung disease after hematopoietic stem cell transplantation. Clin Chest Med. 2005; 26:571-586.

2. Peters SG, Afessa B. Acute lung injury after hematopoietic stem cell transplan-tation. Clin Chest Med. 2005;26:561-569.

3. Sharma S, Nadrous HF, Peters SG, et al. Pulmonary complica-tions in adult blood and marrow transplant recipients: autopsy findings. Chest. 2005;128:1385-1392.

4. Soubani AO, Miller KB, Hassoun PM. Pulmonary complica-tions of bone mar-row transplantation. Chest. 1996;109: 1066-1077.

5. Eikenberry M, Bartakova H, Defor T, et al. Natural history of pulmonary com-plications in children after bone marrow trans-plantation. Biol Blood Marrow Transplant. 2005;11:56-64.

6. Griese M, Rampf U, Hofmann D, et al. Pulmonary complica-tions after bone marrow transplantation in children: twenty-four years of experience in a sin-gle pediatric center. Pediatr Pulmonol. 2000;30:393-401.

7. Nichols WG, Corey L, Gooley T, et al. Parainfluenza virus in-fections after he-matopoietic stem cell transplantation: risk fac-tors, response to antiviral the-rapy, and effect on transplant outcome. Blood. 2001;98:573-578.

8. Martino R, Porras RP, Rabella N, et al. Prospective study of the incidence, cli-nical features, and outcome of symp-tomatic upper and lower respiratory tract infections by respiratory viruses in adult recipients of hematopoietic stem cell transplants for hema-tologic malig-nancies. Biol Blood Marrow Transplant. 2005;11:781- 796.

9. Ljungman P, Ward KN, Crooks BN, et al.

Respiratory virus in-fections after stem cell transplantation: a prospective study from the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant. 2001;28:479-484.

10. van Kraaij MG, van Elden LJ, van Loon AM, et al. Frequent de-tection of respi-ratory viruses in adult recipients of stem cell transplants with the use of real-time polymerase chain reaction, compa-red with viral culture. Clin Infect Dis. 2005;40:662-669.

11. Whimbey E, Champlin RE, Couch RB, et al. Community respi-ratory virus in-fections among hospitalized adult bone marrow transplant recipients. Clin In-fect Dis. 1996;22:778-782.

12. Ghosh S, Champlin R, Couch R, et al. Rhinovirus infections in myelo-suppressed adult blood and marrow transplant recipients. Clin Infect Dis. 1999;29:528-532.

13. Chemaly RF, Ghosh S, Bodey GP, et al. Respiratory viral infec-tions in adults with hematologic malignancies and human stem cell transplantation reci-pients: a retrospective study at a major cancer center. Medicine (Baltimore). 2006;85:278-287.

14. Veys P, Owens C. Respiratory infecti-ons following haemo-poietic stem cell transplantation in children. Br Med Bull. 2002;61:151-174.

15. Bredius RG, Templeton KE, Scheltinga SA, et al. Prospective study of respirato-ry viral infections in pediatric hemopoie-tic stem cell transplantation patients. Pediatr Infect Dis J. 2004;23:518-522.

16. Lujan-Zilbermann J, Benaim E, Tong X, et al. Respiratory virus infections in pediatric hematopoietic stem cell trans-plantation. Clin Infect Dis. 2001;33:962-968.

References

3

59


1. Afessa B, Peters SG. Chronic lung disease after hematopoietic stem cell transplantation. Clin Chest Med. 2005; 26:571-586.

2. Peters SG, Afessa B. Acute lung injury after hematopoietic stem cell transplan-tation. Clin Chest Med. 2005;26:561-569.

3. Sharma S, Nadrous HF, Peters SG, et al. Pulmonary complica-tions in adult blood and marrow transplant recipients: autopsy findings. Chest. 2005;128:1385-1392.

4. Soubani AO, Miller KB, Hassoun PM. Pulmonary complica-tions of bone mar-row transplantation. Chest. 1996;109: 1066-1077.

5. Eikenberry M, Bartakova H, Defor T, et al. Natural history of pulmonary com-plications in children after bone marrow trans-plantation. Biol Blood Marrow Transplant. 2005;11:56-64.

6. Griese M, Rampf U, Hofmann D, et al. Pulmonary complica-tions after bone marrow transplantation in children: twenty-four years of experience in a sin-gle pediatric center. Pediatr Pulmonol. 2000;30:393-401.

7. Nichols WG, Corey L, Gooley T, et al. Parainfluenza virus in-fections after he-matopoietic stem cell transplantation: risk fac-tors, response to antiviral the-rapy, and effect on transplant outcome. Blood. 2001;98:573-578.

8. Martino R, Porras RP, Rabella N, et al. Prospective study of the incidence, cli-nical features, and outcome of symp-tomatic upper and lower respiratory tract infections by respiratory viruses in adult recipients of hematopoietic stem cell transplants for hema-tologic malig-nancies. Biol Blood Marrow Transplant. 2005;11:781- 796.

9. Ljungman P, Ward KN, Crooks BN, et al.

Respiratory virus in-fections after stem cell transplantation: a prospective study from the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant. 2001;28:479-484.

10. van Kraaij MG, van Elden LJ, van Loon AM, et al. Frequent de-tection of respi-ratory viruses in adult recipients of stem cell transplants with the use of real-time polymerase chain reaction, compa-red with viral culture. Clin Infect Dis. 2005;40:662-669.

11. Whimbey E, Champlin RE, Couch RB, et al. Community respi-ratory virus in-fections among hospitalized adult bone marrow transplant recipients. Clin In-fect Dis. 1996;22:778-782.

12. Ghosh S, Champlin R, Couch R, et al. Rhinovirus infections in myelo-suppressed adult blood and marrow transplant recipients. Clin Infect Dis. 1999;29:528-532.

13. Chemaly RF, Ghosh S, Bodey GP, et al. Respiratory viral infec-tions in adults with hematologic malignancies and human stem cell transplantation reci-pients: a retrospective study at a major cancer center. Medicine (Baltimore). 2006;85:278-287.

14. Veys P, Owens C. Respiratory infecti-ons following haemo-poietic stem cell transplantation in children. Br Med Bull. 2002;61:151-174.

15. Bredius RG, Templeton KE, Scheltinga SA, et al. Prospective study of respirato-ry viral infections in pediatric hemopoie-tic stem cell transplantation patients. Pediatr Infect Dis J. 2004;23:518-522.

16. Lujan-Zilbermann J, Benaim E, Tong X, et al. Respiratory virus infections in pediatric hematopoietic stem cell trans-plantation. Clin Infect Dis. 2001;33:962-968.

References

3

60

References

17. Erard V, Chien JW, Kim HW, et al. Airflow decline after myeloablative allogeneic hematopoietic cell transplantation: the role of community respiratory viruses. J Infect Dis. 2006;193: 1619-1625.

18. Kumar D, Erdman D, Keshavjee S, et al. Clinical impact of com-munity-acquired respiratory viruses on bronchiolitis obli-terans after lung transplant. Am J Trans-plant. 2005;5:2031-2036.

19. Reddy P. Pathophysiology of acute graft-versus-host disease. Hematol Oncol. 2003;21:149-161.

20. van de Pol AC, Wolfs TF, Jansen NJ, et al. Diagnostic value of real-time poly-merase chain reaction to detect viruses in young children admitted to the pae-diatric intensive care unit with lower respiratory tract infection. Crit Care. 2006;10:R61.

21. van Doornum GJ, Guldemeester J, Os-terhaus AD, et al. Diag-nosing herpesvi-rus infections by real-time amplification and rapid culture. J Clin Microbiol. 2003;41:576-580.

22. Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS Work-shop on Lung Volume Measure-ments. Official Statement of The Euro-pean Respiratory Society. Eur Respir J. 1995;8:492-506.

23. Zapletal A, Samanek M, Paul T. Lung function in children and adolescents: methods and reference values. Prog Respir Res. 1987; 22:83-112.

24. Rubin BK, Henke MO. Immunomodula-tory activity and effec-tiveness of macro-lides in chronic airway disease. Chest. 2004; 125:70S-78S.

25. Cooke KR, Yanik G. Acute lung injury af-ter allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease? Bone Marrow Transplant. 2004;34:753-765.

26. Keates-Baleeiro J, Moore P, Koyama T, et al. Incidence and outcome of idiopa-thic pneumonia syndrome in pediatric stem cell transplant recipients. Bone Marrow Transplant. 2006;38:285-289.

27. Soubani AO, Uberti JP. Bronchiolitis obliterans following haematopoietic stem cell transplantation. Eur Respir J. 2007;29: 1007-1019.

28. Afessa B, Litzow MR, Tefferi A. Bron-chiolitis obliterans and other late onset noninfectious pulmonary complicati-ons in he-matopoietic stem cell trans-plantation. Bone Marrow Transplant. 2001;28:425-434.

29. Freudenberger TD, Madtes DK, Curtis JR, et al. Association between acute and chronic graft-versus-host disease and bronchiolitis obliterans organizing pneumonia in recipients of hemato-poietic stem cell transplants. Blood. 2003;102:3822-3828.

30. Ditschkowski M, Elmaagacli AH, Tren-schel R, et al. T-cell de-pletion pre-vents from bronchiolitis obliterans and bronchiolitis obliterans with orga-nizing pneumonia after allogeneic he-matopoietic stem cell transplantation with related donors. Haematologica. 2007;92:558-561.

31. Patriarca F, Skert C, Sperotto A, et al. Incidence, outcome, and risk factors of late-onset noninfectious pulmonary complications after unrelated donor stem cell transplantation. Bone Marrow Transplant. 2004;33:751-758.

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60

References

17. Erard V, Chien JW, Kim HW, et al. Airflow decline after myeloablative allogeneic hematopoietic cell transplantation: the role of community respiratory viruses. J Infect Dis. 2006;193: 1619-1625.

18. Kumar D, Erdman D, Keshavjee S, et al. Clinical impact of com-munity-acquired respiratory viruses on bronchiolitis obli-terans after lung transplant. Am J Trans-plant. 2005;5:2031-2036.

19. Reddy P. Pathophysiology of acute graft-versus-host disease. Hematol Oncol. 2003;21:149-161.

20. van de Pol AC, Wolfs TF, Jansen NJ, et al. Diagnostic value of real-time poly-merase chain reaction to detect viruses in young children admitted to the pae-diatric intensive care unit with lower respiratory tract infection. Crit Care. 2006;10:R61.

21. van Doornum GJ, Guldemeester J, Os-terhaus AD, et al. Diag-nosing herpesvi-rus infections by real-time amplification and rapid culture. J Clin Microbiol. 2003;41:576-580.

22. Stocks J, Quanjer PH. Reference values for residual volume, functional residual capacity and total lung capacity. ATS Work-shop on Lung Volume Measure-ments. Official Statement of The Euro-pean Respiratory Society. Eur Respir J. 1995;8:492-506.

23. Zapletal A, Samanek M, Paul T. Lung function in children and adolescents: methods and reference values. Prog Respir Res. 1987; 22:83-112.

24. Rubin BK, Henke MO. Immunomodula-tory activity and effec-tiveness of macro-lides in chronic airway disease. Chest. 2004; 125:70S-78S.

25. Cooke KR, Yanik G. Acute lung injury af-ter allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease? Bone Marrow Transplant. 2004;34:753-765.

26. Keates-Baleeiro J, Moore P, Koyama T, et al. Incidence and outcome of idiopa-thic pneumonia syndrome in pediatric stem cell transplant recipients. Bone Marrow Transplant. 2006;38:285-289.

27. Soubani AO, Uberti JP. Bronchiolitis obliterans following haematopoietic stem cell transplantation. Eur Respir J. 2007;29: 1007-1019.

28. Afessa B, Litzow MR, Tefferi A. Bron-chiolitis obliterans and other late onset noninfectious pulmonary complicati-ons in he-matopoietic stem cell trans-plantation. Bone Marrow Transplant. 2001;28:425-434.

29. Freudenberger TD, Madtes DK, Curtis JR, et al. Association between acute and chronic graft-versus-host disease and bronchiolitis obliterans organizing pneumonia in recipients of hemato-poietic stem cell transplants. Blood. 2003;102:3822-3828.

30. Ditschkowski M, Elmaagacli AH, Tren-schel R, et al. T-cell de-pletion pre-vents from bronchiolitis obliterans and bronchiolitis obliterans with orga-nizing pneumonia after allogeneic he-matopoietic stem cell transplantation with related donors. Haematologica. 2007;92:558-561.

31. Patriarca F, Skert C, Sperotto A, et al. Incidence, outcome, and risk factors of late-onset noninfectious pulmonary complications after unrelated donor stem cell transplantation. Bone Marrow Transplant. 2004;33:751-758.

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61


32. Sharples LD, McNeil K, Stewart S, et al. Risk factors for bronchiolitis obli-terans: a systematic review of recent publica-tions. J Heart Lung Transplant. 2002;21:271-281.

33. Vilchez RA, Dauber J, Kusne S. Infec-tious etiology of bronchio-litis obli-terans. The respiratory viruses connec-tion: myth or reality? Am J Transplant. 2003;3:245-249.

34. Winter JB, Gouw AS, Groen M, et al. Respiratory viral infec-tions aggravate airway damage caused by chronic rejec-tion in rat lung allografts. Transplanta-tion. 1994;57:418-422.

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61


32. Sharples LD, McNeil K, Stewart S, et al. Risk factors for bronchiolitis obli-terans: a systematic review of recent publica-tions. J Heart Lung Transplant. 2002;21:271-281.

33. Vilchez RA, Dauber J, Kusne S. Infec-tious etiology of bronchio-litis obli-terans. The respiratory viruses connec-tion: myth or reality? Am J Transplant. 2003;3:245-249.

34. Winter JB, Gouw AS, Groen M, et al. Respiratory viral infec-tions aggravate airway damage caused by chronic rejec-tion in rat lung allografts. Transplanta-tion. 1994;57:418-422.

3

4High-resolution CT can differentiate between allo-immune and non-alloimmune lung disease early after hematopoietic cell transplantation

4High-resolution CT can differentiate between allo-immune and non-alloimmune lung disease early after hematopoietic cell transplantation

High-resolution CT can differentiate betweenalloimmune and non-alloimmune lung disease early after hematopoietic cell transplantation

A.B. Versluys, M.B. Bierings, F.J. Beek, J.J. Boelens, C.K. van der Ent, P.A. de Jong

American Journal of Roentgenology (AJR) 2014; 203: 656–661

Abstract

Objective The purpose of this study was to develop a sim-ple semiquantitative high-resolution CT (HRCT) scoring system to differentiate alloimmune-mediated lung syndro-mes (allo-LS) from other lung diseases early after hemato-poietic cell transplantation. Allo-LS should be differentiated from other abnormalities, such as infections and toxicity, because they are life-threatening and require prompt and specific treatment.

Materials and methods In 52 pediatric hematopoietic cell transplant recipientswith early symptoms of pulmonary disease, a clinical diagnosis was made by an expert physi-cian. HRCT studies were scored by two independent radio-logists for various airway and parenchyma abnormalities. HRCT scores were compared with the final clinical diagno-ses.

Results Patients with allo-LS had significantly higher HR-CT severity scores for ground-glass pattern and airtrapping compared with patients with non-alloimmune disease. A combined score was constructed (the “allo-score”) that appeared to have good predictive capacity for clinical allo-LS (AUC = 0.82). HRCT scoring was reproducible for all items except airway wall thickening and septal thickening.

Conclusion A simple HRCT severity score can be helpful to differentiate allo-LS from other pulmonary complications early after hematopoietic cell transplantation.

Blood and Marrow Transplantation Program, Department of Pediatrics, University Medical Center Utrecht (UMCU), Utrecht,

The Netherlands A.B. Versluys

M.B. Bierings J.J. Boelens

Department of Pediatric Radiology, UMCU, Wilhel-mina Children's Hospital, Utrecht, The Netherlands

F.J. Beek P.A. de Jong

Department of Paediatric Pulmonology, UMCU, Wilhelmina Children’s Hospital, Utrecht, The

Netherlands C.K. van der Ent

High-resolution CT can differentiate betweenalloimmune and non-alloimmune lung disease early after hematopoietic cell transplantation

A.B. Versluys, M.B. Bierings, F.J. Beek, J.J. Boelens, C.K. van der Ent, P.A. de Jong

American Journal of Roentgenology (AJR) 2014; 203: 656–661

Abstract

Objective The purpose of this study was to develop a sim-ple semiquantitative high-resolution CT (HRCT) scoring system to differentiate alloimmune-mediated lung syndro-mes (allo-LS) from other lung diseases early after hemato-poietic cell transplantation. Allo-LS should be differentiated from other abnormalities, such as infections and toxicity, because they are life-threatening and require prompt and specific treatment.

Materials and methods In 52 pediatric hematopoietic cell transplant recipientswith early symptoms of pulmonary disease, a clinical diagnosis was made by an expert physi-cian. HRCT studies were scored by two independent radio-logists for various airway and parenchyma abnormalities. HRCT scores were compared with the final clinical diagno-ses.

Results Patients with allo-LS had significantly higher HR-CT severity scores for ground-glass pattern and airtrapping compared with patients with non-alloimmune disease. A combined score was constructed (the “allo-score”) that appeared to have good predictive capacity for clinical allo-LS (AUC = 0.82). HRCT scoring was reproducible for all items except airway wall thickening and septal thickening.

Conclusion A simple HRCT severity score can be helpful to differentiate allo-LS from other pulmonary complications early after hematopoietic cell transplantation.




Department of Pediatric Radiology, UMCU, Wilhel-mina Children's Hospital, Utrecht, The Netherlands

F.J. Beek P.A. de Jong



65

HRCT after hematopoietic cell transplantation

Introduction

Hematopoietic cell transplantation is a potentially curative therapy for many patients with a variety of malignant and nonmalignant disorders.1 Unfortunately, hematopoietic cell transplantation can be complicated by life-threatening infectious and noninfectious pulmonary complications.2 Infectious complications are caused by viruses, fungi, and bacteria. Noninfectious complications include toxicity of treatment (for instance, fluid overload, capillary leakage, and late fibrosis due to chemotherapy) and alloimmune me-diated lung syndromes. The management of these complications is critically dependent on the most probable diagnosis; which is based on patient characteristics; clinical pre-sentation; time of onset after hematopoietic cell trans-plantation; and additional tests including laboratory tests, cultures, and imaging workup. Early after hematopoietic cell transplantation, clinical symptoms largely overlap, and differentiating alloimmune lung syndromes (allo-LS) from non-alloimmune lung syndromes (nonallo-LS) is therefore difficult. This distinction is crucial because the treatment of these complications is op-posite: either increasing or decreasing immunosuppressive therapy. Therefore, sensi-tive early diagnosis strategies will definitely impact the treatment response of these life-threatening pulmonary complications and subsequent survival after hematopoietic cell transplantation.

High-resolution CT (HRCT) findings for various pulmonary complications after hema-topoietic cell transplantation have been described,3–16 and much overlap is present in the prevalence of individual findings. Whether HRCT can differentiate between allo-LS and nonallo-LS is not well known. It remains challenging to provide useful additional diag-nostic information from HRCT in hematopoietic cell transplantation recipients who pre-sent with respiratory symptoms. We hypothesize that it is not the presence of a specific HRCT finding but rather the combination and severity of HRCT abnormalities described in a semi-quantitative alloimmune score (allo-score) that might be helpful in making a diagnosis of allo-LS. The aims of this study were to develop an HRCT score to predict allo-LS in patients with respiratory complications after hematopoietic cell transplanta-tion and to assess its interobserver reliability.

Materials and methods

Study population This was a retrospective study of all chest HRCT in pediatric hematopoietic cell trans-plant recipients between January 2004 and September 2012. The studies were perfor-med because of significant respiratory symptoms after hematopoietic cell transplanta-tion. This study focuses on patients with respiratory symptoms early (< 100 days) after

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Introduction

Hematopoietic cell transplantation is a potentially curative therapy for many patients with a variety of malignant and nonmalignant disorders.1 Unfortunately, hematopoietic cell transplantation can be complicated by life-threatening infectious and noninfectious pulmonary complications.2 Infectious complications are caused by viruses, fungi, and bacteria. Noninfectious complications include toxicity of treatment (for instance, fluid overload, capillary leakage, and late fibrosis due to chemotherapy) and alloimmune me-diated lung syndromes. The management of these complications is critically dependent on the most probable diagnosis; which is based on patient characteristics; clinical pre-sentation; time of onset after hematopoietic cell trans-plantation; and additional tests including laboratory tests, cultures, and imaging workup. Early after hematopoietic cell transplantation, clinical symptoms largely overlap, and differentiating alloimmune lung syndromes (allo-LS) from non-alloimmune lung syndromes (nonallo-LS) is therefore difficult. This distinction is crucial because the treatment of these complications is op-posite: either increasing or decreasing immunosuppressive therapy. Therefore, sensi-tive early diagnosis strategies will definitely impact the treatment response of these life-threatening pulmonary complications and subsequent survival after hematopoietic cell transplantation.

High-resolution CT (HRCT) findings for various pulmonary complications after hema-topoietic cell transplantation have been described,3–16 and much overlap is present in the prevalence of individual findings. Whether HRCT can differentiate between allo-LS and nonallo-LS is not well known. It remains challenging to provide useful additional diag-nostic information from HRCT in hematopoietic cell transplantation recipients who pre-sent with respiratory symptoms. We hypothesize that it is not the presence of a specific HRCT finding but rather the combination and severity of HRCT abnormalities described in a semi-quantitative alloimmune score (allo-score) that might be helpful in making a diagnosis of allo-LS. The aims of this study were to develop an HRCT score to predict allo-LS in patients with respiratory complications after hematopoietic cell transplanta-tion and to assess its interobserver reliability.


Study population This was a retrospective study of all chest HRCT in pediatric hematopoietic cell trans-plant recipients between January 2004 and September 2012. The studies were perfor-med because of significant respiratory symptoms after hematopoietic cell transplanta-tion. This study focuses on patients with respiratory symptoms early (< 100 days) after

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hematopoietic cell transplantation because, especially in this period, it is important to make a distinction between allo-LS and nonallo-LS.16 At the start of the hematopoietic cell transplantation procedure, all parents and patients more than 12 years old signed informed consent for data collection and analysis in accordance with national and insti-tutional ethical board protocols. Characteristics of the patients included in the study are shown in Table 1.

High-resolution CTHRCT examinations were performed using a single-detector row scanner (Tomoscan EVT, Philips Healthcare). In infants and young children, the anesthesiologist controlled the airway during the scanning procedure. Depending on the preference of the anes-thesiologist, the child was either intubated or a laryngeal mask was used. Studies were performed at 25-cm H2O pressure (inspiration) and 0-cm H2O pressure (expiration). In older children (from approximately 5 years old and older), studies were performed using a breath-hold technique at suspended inspiration and at expiration. Inspiration images were obtained using fixed 90 kVp and 18–60 mAs (depending on body weight). For ex-piration images, we used 90 kVp and 11 mAs. We made 1-mm slices every centimeter in inspiration and at five levels in expiration. FOV was adapted to patient size.

High-resolution CT scoringFor the purposes of this study, a scoring system for hematopoietic cell transplant re-cipients was developed on the basis of common HRCT findings in this patient group (Table 2). Relevant morphologic abnormalities (bronchiectasis, bronchial wall thicke-ning, tree-in-bud, nodules, consolidation, ground-glass pattern, and septa thickening) and expiratory airtrapping were scored for each lobe of the lung, including the lingula, on a scale ranging from 0 (no abnormality) to 3 (severe). Abnormalities were defined accor-ding to the Fleischner Society criteria.17 Scores for each abnormality and the composite scores were expressed on a 0–100 scale as a percentage of the maximum score.

After the first statistical analyses, we defined an allo-score on the basis of the individual items that showed to be significantly different between alloimmune and non-alloimmu-ne lung disease.

All HRCT scans were scored by two independent observers (9 and 14 years of experience in HRCT interpretation) who were blinded to patient characteristics. One observer repea-ted the scoring after more than 1 month.

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hematopoietic cell transplantation because, especially in this period, it is important to make a distinction between allo-LS and nonallo-LS.16 At the start of the hematopoietic cell transplantation procedure, all parents and patients more than 12 years old signed informed consent for data collection and analysis in accordance with national and insti-tutional ethical board protocols. Characteristics of the patients included in the study are shown in Table 1.

High-resolution CTHRCT examinations were performed using a single-detector row scanner (Tomoscan EVT, Philips Healthcare). In infants and young children, the anesthesiologist controlled the airway during the scanning procedure. Depending on the preference of the anes-thesiologist, the child was either intubated or a laryngeal mask was used. Studies were performed at 25-cm H2O pressure (inspiration) and 0-cm H2O pressure (expiration). In older children (from approximately 5 years old and older), studies were performed using a breath-hold technique at suspended inspiration and at expiration. Inspiration images were obtained using fixed 90 kVp and 18–60 mAs (depending on body weight). For ex-piration images, we used 90 kVp and 11 mAs. We made 1-mm slices every centimeter in inspiration and at five levels in expiration. FOV was adapted to patient size.

High-resolution CT scoringFor the purposes of this study, a scoring system for hematopoietic cell transplant re-cipients was developed on the basis of common HRCT findings in this patient group (Table 2). Relevant morphologic abnormalities (bronchiectasis, bronchial wall thicke-ning, tree-in-bud, nodules, consolidation, ground-glass pattern, and septa thickening) and expiratory airtrapping were scored for each lobe of the lung, including the lingula, on a scale ranging from 0 (no abnormality) to 3 (severe). Abnormalities were defined accor-ding to the Fleischner Society criteria.17 Scores for each abnormality and the composite scores were expressed on a 0–100 scale as a percentage of the maximum score.

After the first statistical analyses, we defined an allo-score on the basis of the individual items that showed to be significantly different between alloimmune and non-alloimmu-ne lung disease.

All HRCT scans were scored by two independent observers (9 and 14 years of experience in HRCT interpretation) who were blinded to patient characteristics. One observer repea-ted the scoring after more than 1 month.

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Establishment of the final diagnosis For each patient, an experienced pediatric hematologist who was unaware of the HRCT scores (10 years of experience in clinical hematopoietic cell transplantation) decided on the most probable final diagnosis. For this purpose, the physician had access to all avai-lable data including initial symptoms, physical examination findings, laboratory tests (including microbial tests from bronchoalveolar lavage), and imaging tests as well as response to therapy and follow-up examinations after the disease episode. In case of uncertainty, a second pediatric oncologist-immunologist (10 years of experience in cli-nical hematopoietic cell transplantation) was consulted and a consensus diagnosis was obtained. All patients were given a diagnosis: either nonallo-LS (consisting of infection and toxicity) or allo-LS (including idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome).

Both idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome were clini-cally defined according to international criteria as acute respiratory symptoms, hypoxe-mia, abnormal radiographic findings, and restrictive physiology in the absence of infec-tion or heart failure.18 We only further analyzed the HRCT score in scans obtained early after hematopoietic cell transplantation because in this phase it is both difficult and of utmost importance to discriminate between allo-LS and nonallo-LS.

Statistical analysisReproducibility of HRCT scoring between and within observers was assessed visually in scatter-plots with a line of identity and by using an intra-class correlation coefficient. An intraclass correlation coefficient between 0.6 and 0.8 represents moderate agreement and a value above 0.8 represents good agreement.

To determine whether the severity of HRCT ab-normalities was different between allo-LS and nonallo-LS, a Mann-Whitney U test was done. The variables that showed statistical significance were then analyzed using logistic regression to identify their effect on the likelihood the patient had allo-LS. The regression coefficients were then transformed to integers according to their relative contributions to the risk, leading to a simplified weig-hed score. The different allo-scores and their value as a diagnostic test for allo-LS were analyzed using the ROC curve method. Accuracy of a test was measured by the AUC: an area greater than 0.8 was regarded as a good test.

Finally we estimated sensitivity, specificity, positive predictive value, negative predictive value, and absolute percentage of correctly diagnosed patients for different cutoff values for the allo-score. We used Graphpad and SPSS 20.0 soft-ware for data analysis. Data are given as median unless indicated otherwise, and the significance level was set at p < 0.05.

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Establishment of the final diagnosis For each patient, an experienced pediatric hematologist who was unaware of the HRCT scores (10 years of experience in clinical hematopoietic cell transplantation) decided on the most probable final diagnosis. For this purpose, the physician had access to all avai-lable data including initial symptoms, physical examination findings, laboratory tests (including microbial tests from bronchoalveolar lavage), and imaging tests as well as response to therapy and follow-up examinations after the disease episode. In case of uncertainty, a second pediatric oncologist-immunologist (10 years of experience in cli-nical hematopoietic cell transplantation) was consulted and a consensus diagnosis was obtained. All patients were given a diagnosis: either nonallo-LS (consisting of infection and toxicity) or allo-LS (including idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome).

Both idiopathic pneumonia syndrome and bronchiolitis obliterans syndrome were clini-cally defined according to international criteria as acute respiratory symptoms, hypoxe-mia, abnormal radiographic findings, and restrictive physiology in the absence of infec-tion or heart failure.18 We only further analyzed the HRCT score in scans obtained early after hematopoietic cell transplantation because in this phase it is both difficult and of utmost importance to discriminate between allo-LS and nonallo-LS.

Statistical analysisReproducibility of HRCT scoring between and within observers was assessed visually in scatter-plots with a line of identity and by using an intra-class correlation coefficient. An intraclass correlation coefficient between 0.6 and 0.8 represents moderate agreement and a value above 0.8 represents good agreement.

To determine whether the severity of HRCT ab-normalities was different between allo-LS and nonallo-LS, a Mann-Whitney U test was done. The variables that showed statistical significance were then analyzed using logistic regression to identify their effect on the likelihood the patient had allo-LS. The regression coefficients were then transformed to integers according to their relative contributions to the risk, leading to a simplified weig-hed score. The different allo-scores and their value as a diagnostic test for allo-LS were analyzed using the ROC curve method. Accuracy of a test was measured by the AUC: an area greater than 0.8 was regarded as a good test.

Finally we estimated sensitivity, specificity, positive predictive value, negative predictive value, and absolute percentage of correctly diagnosed patients for different cutoff values for the allo-score. We used Graphpad and SPSS 20.0 soft-ware for data analysis. Data are given as median unless indicated otherwise, and the significance level was set at p < 0.05.

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TABLE 1. Characteristics of 52 patients in study population.

Characteristic No.

Median age at transplantation (range) in years 4.4 (0.2-17.5)

Male 29 (56)

HCT indication Malignant Nonmalignant

21 (40)31 (60)

Donor type Matched related Matched unrelated Mismatched unrelated

10 (19)20 (38)22 (42)

Stem cell source Bone marrow Cord blood

22 (42)30 (58)

Conditioning regimen Chemotherapy-based Total body irridiation-based

47 (90)5 (10)

Note—Except where indicated otherwise, data in parentheses are percentages.

a Malignant diseases included acute lymphoblastic leukemia (n = 9); acute myeloid leu-kemia, chronic myeloid leukemia, or myelodysplastic syndrome (n = 9); and lymphoma (n = 3). Nonmalignant disorders included bone marrow failure (n = 7), inherited immune deficiency (n = 13), and inborn errors of metabolism (n = 11).

b Matched donor was defined as 10/10 for bone marrow/peripheral blood stem cell mole-cularly typed or 6/6 for cord blood on basis of intermediate resolution (human leukocyte antigen [HLA]-A and HLA-B on serology) and high-resolution (HLA-DR).

c Standard chemotherapy-based conditioning consisted of busulfan (IV, targeted on AUC of 85–95 mg × h × L) in combination with cyclophosphamide (120 mg/kg) or fludarabine (160 mg/m2 in 4 days). Total body irradiation was given as six fractions of 2 Gy in three consecutive days followed by etoposide (60 mg/kg).

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Results

TABLE 1. Characteristics of 52 patients in study population.

Characteristic No.

Median age at transplantation (range) in years 4.4 (0.2-17.5)

Male 29 (56)

HCT indication Malignant Nonmalignant

21 (40)31 (60)

Donor type Matched related Matched unrelated Mismatched unrelated

10 (19)20 (38)22 (42)


22 (42)30 (58)

Conditioning regimen Chemotherapy-based Total body irridiation-based

47 (90)5 (10)

Note—Except where indicated otherwise, data in parentheses are percentages.

a Malignant diseases included acute lymphoblastic leukemia (n = 9); acute myeloid leu-kemia, chronic myeloid leukemia, or myelodysplastic syndrome (n = 9); and lymphoma (n = 3). Nonmalignant disorders included bone marrow failure (n = 7), inherited immune deficiency (n = 13), and inborn errors of metabolism (n = 11).

b Matched donor was defined as 10/10 for bone marrow/peripheral blood stem cell mole-cularly typed or 6/6 for cord blood on basis of intermediate resolution (human leukocyte antigen [HLA]-A and HLA-B on serology) and high-resolution (HLA-DR).

c Standard chemotherapy-based conditioning consisted of busulfan (IV, targeted on AUC of 85–95 mg × h × L) in combination with cyclophosphamide (120 mg/kg) or fludarabine (160 mg/m2 in 4 days). Total body irradiation was given as six fractions of 2 Gy in three consecutive days followed by etoposide (60 mg/kg).

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Results

PatientsDuring the study period, 124 chest HRCT examinations were performed in 72 child-ren after hematopoietic cell transplantation. The mean interval between hematopoietic cell transplantation and chest HRCT was 84 days. For our study, we only used the first HRCT study because disease episodes may be interrelated. In 52 children, HRCT was performed because of early respiratory symptoms within 100 days after hematopoietic cell transplantation: 18 children had allo-LS and 34 had nonallo-LS. The 18 patients with allo-LS all had symptoms during recovery of immunity, none had significant signs of infection (fever or raised C-reactive protein [CRP]), and all had initial improvement on immunosuppressive therapy. Most nonallo-LS patients had an infection, suggested by fever, raised CRP, or positive microbial tests.

TABLE 2. Chest high-resolution CT scoring system for pulmonary complications in hematopoietic cell transplant patients.

Per lobe Score 0 Score 1 Score 2 Score 3

Bronchiectasis Absent <33 33-67 >67

Airway wall thickening Absent <33 33-67 >67

Tree-in-bud pattern Absent Limited Marked Extensive

Nodules Absent Limited Marked Extensive

Consolidation Absent <33 33-67 >67

Ground-glass pattern Absent <33 33-67 >67

Septa thickening Absent Mild Moderate Severe

Airtrapping Absent <33 33-67 >67

Note—Numeric data are percentages of lobar volume involved. The score was applied to each lobe, including the lingula, leading to a range of 0–18. The composite score is the sum of the eight item scores, ranging from 0 to 144. Scores were then expressed on a 0–100 scale as percentage of maximum score to make interpretation easier.

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Results

PatientsDuring the study period, 124 chest HRCT examinations were performed in 72 child-ren after hematopoietic cell transplantation. The mean interval between hematopoietic cell transplantation and chest HRCT was 84 days. For our study, we only used the first HRCT study because disease episodes may be interrelated. In 52 children, HRCT was performed because of early respiratory symptoms within 100 days after hematopoietic cell transplantation: 18 children had allo-LS and 34 had nonallo-LS. The 18 patients with allo-LS all had symptoms during recovery of immunity, none had significant signs of infection (fever or raised C-reactive protein [CRP]), and all had initial improvement on immunosuppressive therapy. Most nonallo-LS patients had an infection, suggested by fever, raised CRP, or positive microbial tests.

TABLE 2. Chest high-resolution CT scoring system for pulmonary complications in hematopoietic cell transplant patients.

Per lobe Score 0 Score 1 Score 2 Score 3

Bronchiectasis Absent <33 33-67 >67

Airway wall thickening Absent <33 33-67 >67

Tree-in-bud pattern Absent Limited Marked Extensive

Nodules Absent Limited Marked Extensive

Consolidation Absent <33 33-67 >67

Ground-glass pattern Absent <33 33-67 >67

Septa thickening Absent Mild Moderate Severe

Airtrapping Absent <33 33-67 >67

Note—Numeric data are percentages of lobar volume involved. The score was applied to each lobe, including the lingula, leading to a range of 0–18. The composite score is the sum of the eight item scores, ranging from 0 to 144. Scores were then expressed on a 0–100 scale as percentage of maximum score to make interpretation easier.

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Results

Interobserverd agreement for high-resolution CT scoringThe between-observer agreement was moderate to good for all items except septa thick-ening and airway wall thickening. The within-observer agreement was moderate to good for all items. The composite score had good agreement both between and within obser-vers. Further details are presented in Table 3.

TABLE 3. Within-observer and between-observer agreement of HRCT score.

Finding Within-observer agreement Between-observer agreement

Bronchiectasis 0.81 0.70

Airway wall thickening 0.78 0.59

Tree-in-bud pattern 0.78 0.66

Nodules 0.78 0.71

Consolidation 0.79 0.86

Ground-glass pattern 0.90 0.71

Septa thickening 0.80 0.53

Airtrapping 0.77 0.75

Composite score 0.92 0.80

Note—Data are intraclass correlation coefficients: < 0.6, no agreement; 0.6–0.8, moderate agreement; > 0.8, good agreement.

Prevalence of high-resolution CT abnormalities for the various pulmonary complications early after hematopoietic cell transplantationThe prevalence of individual HRCT abnormalities overlapped substantially between allo-LS and nonallo-LS groups (Table 4). Consolidations and ground-glass pattern were seen in more than half of the patients; tree-in-bud pattern was relatively rare. Only for ground-glass pattern, there was a significantly higher prevalence in the allo-LS group compared with the nonallo-LS group.

Severity score of high-resolution CT abnormalities for pulmonary complications early after hematopoietic cell transplantationIn allo-LS, the HRCT scores for ground-glass pattern and airtrapping were significantly higher than in nonallo-LS (Table 5). This was also true for the total of all abnormali-ties (composite-score). For the early pulmonary complications, we made an allo-score by combining the two individual parameters that had shown to be significantly different in

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Results

Interobserverd agreement for high-resolution CT scoringThe between-observer agreement was moderate to good for all items except septa thick-ening and airway wall thickening. The within-observer agreement was moderate to good for all items. The composite score had good agreement both between and within obser-vers. Further details are presented in Table 3.

TABLE 3. Within-observer and between-observer agreement of HRCT score.

Finding Within-observer agreement Between-observer agreement

Bronchiectasis 0.81 0.70

Airway wall thickening 0.78 0.59

Tree-in-bud pattern 0.78 0.66

Nodules 0.78 0.71

Consolidation 0.79 0.86

Ground-glass pattern 0.90 0.71

Septa thickening 0.80 0.53

Airtrapping 0.77 0.75

Composite score 0.92 0.80

Note—Data are intraclass correlation coefficients: < 0.6, no agreement; 0.6–0.8, moderate agreement; > 0.8, good agreement.

Prevalence of high-resolution CT abnormalities for the various pulmonary complications early after hematopoietic cell transplantationThe prevalence of individual HRCT abnormalities overlapped substantially between allo-LS and nonallo-LS groups (Table 4). Consolidations and ground-glass pattern were seen in more than half of the patients; tree-in-bud pattern was relatively rare. Only for ground-glass pattern, there was a significantly higher prevalence in the allo-LS group compared with the nonallo-LS group.

Severity score of high-resolution CT abnormalities for pulmonary complications early after hematopoietic cell transplantationIn allo-LS, the HRCT scores for ground-glass pattern and airtrapping were significantly higher than in nonallo-LS (Table 5). This was also true for the total of all abnormali-ties (composite-score). For the early pulmonary complications, we made an allo-score by combining the two individual parameters that had shown to be significantly different in

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TABLE 4. Prevalence of imaging findings in patients with respiratory symptoms early after hematopoietic cell transplantation.

Finding Total (N = 52)

Allo-LS (N = 18)

Nonallo-LS(N=34)

DifferenceP a

Bronchiectasis 13 (25) 7 (39) 6 (17) NS

Airway wall thickening 14 (27) 6 (33) 8 (24) NS

Tree-in-bud pattern 6 (12) 3 (17) 3 (9) NS

Nodules 20 (38) 9 (50) 11 (32) NS

Consolidation 37 (71) 13 (72) 24 (70) NS

Ground-glass pattern 34 (67) 15 (83) 19 (56) 0.04

Septa thickening 13 (25) 5 (28) 8 (24) NS

Airtrapping 25 (48) 11 (61) 14 (41) NS

Note—Data are number of patients with percentage in parentheses. Allo-LS = alloimmu-ne-mediated lung syndromes, Nonallo-LS = non-alloimmune-mediated lung syndromes, NS = not significant. a Fisher exact test.

TABLE 5. High-resolution CT scores for alloimmune- (Allo-LS) and non-alloimmune mediated lung syndromes (Nonallo-LS) early after hematopoietic cell transplantation

Finding Allo-LS Nonallo-LS P a

Bronchiectasis 0 (0-12.5) 0 (0-0) 0.063

Airway wall thickening 0 (0-15.2) 0 (0-1.4) 0.382

Tree-in-bud pattern 0 (0-0) 0 (0-0) 0.499

Nodules 2.7 (0-16.7) 0 (0-6.9) 0.210

Consolidation 11.1 (0-33.3) 5.6 (0-16.7) 0.399

Ground-glass pattern 25 (9.7-51.4) 5.6 (0-16.7) 0.017

Septa thickening 0 (0-9.7) 0 (0-1.4) 0.704

Airtrapping 13.9 (0-45.8) 0 (0-11.1) 0.039

Composite score (total of 8) 12.1 (9.7-18.9) 6.6 (1.4-10.4) 0.000

"Allo-score" (ground-glass pattern + airtrapping)

29.2 (19.4-33.3) 6.9 (0-16.7) 0.000

Note—Data are medians with 25–75% quartiles in parentheses. Statistically significant p values are in bold. a Mann-Whitney U test.

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TABLE 4. Prevalence of imaging findings in patients with respiratory symptoms early after hematopoietic cell transplantation.

Finding Total (N = 52)

Allo-LS (N = 18)

Nonallo-LS(N=34)

DifferenceP a

Bronchiectasis 13 (25) 7 (39) 6 (17) NS

Airway wall thickening 14 (27) 6 (33) 8 (24) NS

Tree-in-bud pattern 6 (12) 3 (17) 3 (9) NS

Nodules 20 (38) 9 (50) 11 (32) NS

Consolidation 37 (71) 13 (72) 24 (70) NS

Ground-glass pattern 34 (67) 15 (83) 19 (56) 0.04

Septa thickening 13 (25) 5 (28) 8 (24) NS

Airtrapping 25 (48) 11 (61) 14 (41) NS

Note—Data are number of patients with percentage in parentheses. Allo-LS = alloimmu-ne-mediated lung syndromes, Nonallo-LS = non-alloimmune-mediated lung syndromes, NS = not significant. a Fisher exact test.

TABLE 5. High-resolution CT scores for alloimmune- (Allo-LS) and non-alloimmune mediated lung syndromes (Nonallo-LS) early after hematopoietic cell transplantation

Finding Allo-LS Nonallo-LS P a

Bronchiectasis 0 (0-12.5) 0 (0-0) 0.063

Airway wall thickening 0 (0-15.2) 0 (0-1.4) 0.382

Tree-in-bud pattern 0 (0-0) 0 (0-0) 0.499

Nodules 2.7 (0-16.7) 0 (0-6.9) 0.210

Consolidation 11.1 (0-33.3) 5.6 (0-16.7) 0.399

Ground-glass pattern 25 (9.7-51.4) 5.6 (0-16.7) 0.017

Septa thickening 0 (0-9.7) 0 (0-1.4) 0.704

Airtrapping 13.9 (0-45.8) 0 (0-11.1) 0.039

Composite score (total of 8) 12.1 (9.7-18.9) 6.6 (1.4-10.4) 0.000

"Allo-score" (ground-glass pattern + airtrapping)

29.2 (19.4-33.3) 6.9 (0-16.7) 0.000

Note—Data are medians with 25–75% quartiles in parentheses. Statistically significant p values are in bold. a Mann-Whitney U test.

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Results

allo-LS and nonallo-LS patients. This score was also significantly different between the groups of diseases (Figure 1). A logistic regression analysis was performed to ascertain the effects of the individual severity scores of ground-glass pattern and airtrapping on the likelihood that the patients had allo-LS. Increasing scores in ground-glass pattern and airtrapping were associated with increased likelihood of allo-LS, with odds ratios of 1.04 and 1.06 per score point. The regression coefficients were transformed to weight factors according to their relative contribution to the risk estimation to reach a final weighed allo-score: ground-glass pat-tern + 1.5 airtrapping (Table 6).The capacity of the weighed and non-weighed allo-scores to predict allo-LS was calcula-ted using an ROC curve model. There was no significant difference between the weighed score and the non-weighed score, both with an AUC of 0.82, which is considered good for a diagnostic test. Therefore, we further studied the simple nonweighed score consis-ting of the sum of ground-glass pattern and air trapping scores only. Test characteristics for the different cutoff values of this allo-score are shown in Table 7.

FIGURE 1. Box and whisker chart shows median, interquartile range, and range for “alloscore” (ground-glass pattern + airtrap-ping) in alloimmune-mediated lung syndromes (allo-LS) and non-alloimmune lung syndromes (nonallo-LS) early after hema-topoietic cell transplantation. Median allo-score for nonallo-LS patients was 6.9 (25–75%, 0–16.7). Median allo-score for allo-LS patients was 29.2 (25–75%, 19.4–33.3). Circle indicates outlier.

Med

ian

Allo

-Sco

re

60

50

40

30

20

10

00

Nonallo-LS1

Allo-LS

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Results

allo-LS and nonallo-LS patients. This score was also significantly different between the groups of diseases (Figure 1). A logistic regression analysis was performed to ascertain the effects of the individual severity scores of ground-glass pattern and airtrapping on the likelihood that the patients had allo-LS. Increasing scores in ground-glass pattern and airtrapping were associated with increased likelihood of allo-LS, with odds ratios of 1.04 and 1.06 per score point. The regression coefficients were transformed to weight factors according to their relative contribution to the risk estimation to reach a final weighed allo-score: ground-glass pat-tern + 1.5 airtrapping (Table 6).The capacity of the weighed and non-weighed allo-scores to predict allo-LS was calcula-ted using an ROC curve model. There was no significant difference between the weighed score and the non-weighed score, both with an AUC of 0.82, which is considered good for a diagnostic test. Therefore, we further studied the simple nonweighed score consis-ting of the sum of ground-glass pattern and air trapping scores only. Test characteristics for the different cutoff values of this allo-score are shown in Table 7.

FIGURE 1. Box and whisker chart shows median, interquartile range, and range for “alloscore” (ground-glass pattern + airtrap-ping) in alloimmune-mediated lung syndromes (allo-LS) and non-alloimmune lung syndromes (nonallo-LS) early after hema-topoietic cell transplantation. Median allo-score for nonallo-LS patients was 6.9 (25–75%, 0–16.7). Median allo-score for allo-LS patients was 29.2 (25–75%, 19.4–33.3). Circle indicates outlier.

Med

ian

Allo

-Sco

re

60

50

40

30

20

10

00

Nonallo-LS1

Allo-LS

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TABLE 6. Logistic regression.

Diagnostic variable Odds ratioa Regression coefficientb P Weight factorc

Ground-glass patternAirtrapping

1.04 (1.01-1.07)1.06 (1.02-1.10)

0.0360.053

0.010.005

1 (0.036/0.036)1.5 (0.053/0.036)

a Numbers in parentheses indicate 95% CIs. b Natural logarithm of odds ratio. c The weight factor was calculated by dividing the applicable regression coefficient by the regression coefficient for ground-glass pattern.

TABLE 7. Test characteristics of the “allo-score” (ground-glass pattern + airtrapping) depending on different cutoff values.

Cutoff Sensitivity Specificity PPV NPV Correct (%)

> 5 1 0.38 0.46 1 60

> 10 0.89 0.56 0.52 0.90 67

> 15 0.89 0.65 0.57 0.92 73

> 20 0.67 0.79 0.63 0.82 75

> 25 0.67 0.91 0.80 0.84 83

> 30 0.50 0.88 0.69 0.77 75

> 35 0.17 0.94 0.60 0.68 67

> 40 0.17 0.97 0.75 0.69 69

> 45 0.11 0.97 0.67 0.67 67

> 50 0.06 0.97 0.50 0.66 65

> 55 0 1 NA 0.65 65

Note—Sensitivity is the probability that the test result is positive in a patient with alloim-mune-mediated lung syndromes (allo-LS). Specificity is the probability that the test result is negative in a patient without allo-LS.

Positive predictive value (PPV) is the probability that the patient has allo-LS given a positive test result.

Negative predictive value (NPV) is the probability that the patient does not have allo-LS given a negative test result. Correct (%) indicates the percentage of patients with the cor-rect diagnosis. NA indicates not applicable.

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TABLE 6. Logistic regression.

Diagnostic variable Odds ratioa Regression coefficientb P Weight factorc

Ground-glass patternAirtrapping

1.04 (1.01-1.07)1.06 (1.02-1.10)

0.0360.053

0.010.005

1 (0.036/0.036)1.5 (0.053/0.036)

a Numbers in parentheses indicate 95% CIs. b Natural logarithm of odds ratio. c The weight factor was calculated by dividing the applicable regression coefficient by the regression coefficient for ground-glass pattern.

TABLE 7. Test characteristics of the “allo-score” (ground-glass pattern + airtrapping) depending on different cutoff values.

Cutoff Sensitivity Specificity PPV NPV Correct (%)

> 5 1 0.38 0.46 1 60

> 10 0.89 0.56 0.52 0.90 67

> 15 0.89 0.65 0.57 0.92 73

> 20 0.67 0.79 0.63 0.82 75

> 25 0.67 0.91 0.80 0.84 83

> 30 0.50 0.88 0.69 0.77 75

> 35 0.17 0.94 0.60 0.68 67

> 40 0.17 0.97 0.75 0.69 69

> 45 0.11 0.97 0.67 0.67 67

> 50 0.06 0.97 0.50 0.66 65

> 55 0 1 NA 0.65 65

Note—Sensitivity is the probability that the test result is positive in a patient with alloim-mune-mediated lung syndromes (allo-LS). Specificity is the probability that the test result is negative in a patient without allo-LS.

Positive predictive value (PPV) is the probability that the patient has allo-LS given a positive test result.

Negative predictive value (NPV) is the probability that the patient does not have allo-LS given a negative test result. Correct (%) indicates the percentage of patients with the cor-rect diagnosis. NA indicates not applicable.

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Discussion

Discussion

In this study, we describe the development of an HRCT score for patients with respira-tory complications after hematopoietic cell transplantation. There is a large overlap in the presence of individual HRCT abnormalities in allo-LS and nonallo-LS, such as in-fection or toxicity. The HRCT severity score can differentiate between these two groups of diseases, especially in the early phase after transplantation.

FIGURE 2. Examples of chest high-resolution CT (HRCT). A and B, Chest HRCT images in 7-year-old girl early after hematopoietic cell transplantation with respiratory symptoms. Com-posite HRCT score was 10 and “allo-score” (ground-glass pattern + airtrapping) was 0. Final diagnosis was toxicity. C and D, Chest HRCT images in 2-year-old boy early after hemato-poietic cell transplantation with respiratory symptoms. Composite HRCT score was 10 and allo-score was 31. Final diagnosis was idiopathic pneumonia syndrome.

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Discussion

Discussion

In this study, we describe the development of an HRCT score for patients with respira-tory complications after hematopoietic cell transplantation. There is a large overlap in the presence of individual HRCT abnormalities in allo-LS and nonallo-LS, such as in-fection or toxicity. The HRCT severity score can differentiate between these two groups of diseases, especially in the early phase after transplantation.

FIGURE 2. Examples of chest high-resolution CT (HRCT). A and B, Chest HRCT images in 7-year-old girl early after hematopoietic cell transplantation with respiratory symptoms. Com-posite HRCT score was 10 and “allo-score” (ground-glass pattern + airtrapping) was 0. Final diagnosis was toxicity. C and D, Chest HRCT images in 2-year-old boy early after hemato-poietic cell transplantation with respiratory symptoms. Composite HRCT score was 10 and allo-score was 31. Final diagnosis was idiopathic pneumonia syndrome.

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The allo-score, the sum of the HRCT severity score of ground-glass pattern and airtrap-ping, is an easily applicable test with good test characteristics, depending on the cutoff value. To determine the cutoff value for the allo-score, one has to decide whether it is more important to correctly treat early allo-LS with increased immune suppression (ai-ming at high sensitivity and high negative predictive value) or to avoid giving immune suppressive therapy to those who do not need it (aiming at high specificity and high positive predictive value). In our opinion, the optimum should be somewhere between 15 and 25 (Figure 2).

Studies addressing the question of diagnostic accuracy of HRCT findings in patients with respiratory problems after hematopoietic cell transplantation are scarce. Most stu-dies look at HRCT signs in patients with a proven specific lung disease and not at the added value of HRCT findings in patients presenting with symptoms. However, the latter strategy is required for diagnostic studies.19

Our study has several limitations. Although for most HRCT score items the interobser-ver agreement was only moderate, we considered the intraclass coefficient of greater than 0.7 for airtrapping and ground-glass pattern acceptable. In the future, it will be possible to perform computerized calculation of the HRCT score and thus overcome the important issue of reproducibility. Because HRCT results were incorporated in establi-shing the final diagnosis (although the scores were not available), the opportunity for in-corporation bias exists. Nevertheless, given the large difference in HRCT scores between allo-LS and nonallo-LS patients, we believe that bias does not substantially affect our results. The sample size of our study is fairly small, and we propose that our findings be reproduced in an independent cohort. Despite these limitations, we think our findings add to the growing evidence that HRCT is important for diagnosis (and prognosis) in these patients, especially in the early phase after transplantation.

In conclusion, our study confirms that the types of HRCT abnormalities considerably overlap between allo-LS and nonallo-LS, but the severity score of certain abnormalities (bronchiectasis, ground-glass pattern, and airtrapping) can differentiate between these complications, especially when applied as the allo-score (ground-glass pattern plus air-trapping). Our findings require confirmation, preferably in an independent prospective cohort, and further testing in more complex diagnostic studies. Early and proper diagno-sis of life-threatening pulmonary complications after hematopoietic cell transplantation is of utmost importance to impact the safety of hematopoietic cell transplantation.

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75


The allo-score, the sum of the HRCT severity score of ground-glass pattern and airtrap-ping, is an easily applicable test with good test characteristics, depending on the cutoff value. To determine the cutoff value for the allo-score, one has to decide whether it is more important to correctly treat early allo-LS with increased immune suppression (ai-ming at high sensitivity and high negative predictive value) or to avoid giving immune suppressive therapy to those who do not need it (aiming at high specificity and high positive predictive value). In our opinion, the optimum should be somewhere between 15 and 25 (Figure 2).

Studies addressing the question of diagnostic accuracy of HRCT findings in patients with respiratory problems after hematopoietic cell transplantation are scarce. Most stu-dies look at HRCT signs in patients with a proven specific lung disease and not at the added value of HRCT findings in patients presenting with symptoms. However, the latter strategy is required for diagnostic studies.19

Our study has several limitations. Although for most HRCT score items the interobser-ver agreement was only moderate, we considered the intraclass coefficient of greater than 0.7 for airtrapping and ground-glass pattern acceptable. In the future, it will be possible to perform computerized calculation of the HRCT score and thus overcome the important issue of reproducibility. Because HRCT results were incorporated in establi-shing the final diagnosis (although the scores were not available), the opportunity for in-corporation bias exists. Nevertheless, given the large difference in HRCT scores between allo-LS and nonallo-LS patients, we believe that bias does not substantially affect our results. The sample size of our study is fairly small, and we propose that our findings be reproduced in an independent cohort. Despite these limitations, we think our findings add to the growing evidence that HRCT is important for diagnosis (and prognosis) in these patients, especially in the early phase after transplantation.

In conclusion, our study confirms that the types of HRCT abnormalities considerably overlap between allo-LS and nonallo-LS, but the severity score of certain abnormalities (bronchiectasis, ground-glass pattern, and airtrapping) can differentiate between these complications, especially when applied as the allo-score (ground-glass pattern plus air-trapping). Our findings require confirmation, preferably in an independent prospective cohort, and further testing in more complex diagnostic studies. Early and proper diagno-sis of life-threatening pulmonary complications after hematopoietic cell transplantation is of utmost importance to impact the safety of hematopoietic cell transplantation.

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1. Copelan EA. Hematopoietic stem-cell transplan-tation. N Engl J Med 2006; 354:1813–1826

2. Afessa B, Peters SG. Major complicati-ons follow-ing hematopoietic stem cell transplantation. Se-min Respir Crit Care Med 2006; 27:297–309

3. Franquet T, Muller NL, Gimenez A, Mar-tinez S, Madrid M, Domingo P. Infec-tious pulmonary nod-ules in immuno-compromised patients: usefulness of computed tomography in predicting their etiol-ogy. J Comput Assist Tomogr 2003; 27:461–468

4. Franquet T, Muller NL, Lee KS, Oikono-mou A, Flint JD. Pulmonary candidiasis after hematopoi-etic stem cell trans-plantation: thin-section CT findings. Ra-diology 2005; 236:332–337

5. Gunn ML, Godwin JD, Kanne JP, Flo-wers ME, Chien JW. High-resolution CT findings of bron-chiolitis obliterans syndrome after hematopoietic stem cell transplantation. J Thorac Imaging 2008; 23:244–250

6. Todd NW, Peters WP, Ost AH, Roggli VL, Pi-antadosi CA. Pulmonary drug toxicity in patients with primary breast cancer treated with high-dose combi-nation chemotherapy and autologous bone marrow transplantation. Am Rev Respir Dis 1993; 147:1264–1270

7. Escuissato DL, Gasparetto EL, Marchi-ori E, et al. Pulmonary infections after bone marrow trans-plantation: high-resolution CT findings in 111 pa-tients. AJR 2005; 185:608–615

8. Marchiori E, Escuissato DL, Gasparetto TD, Con-sidera DP, Franquet T. “Crazy-paving” patterns on high-resolution CT scans in patients with pulmo-nary com-plications after hematopoietic stem cell transplantation. Korean J Radiol 2009; 10:21–24

9. Caillot D, Couaillier JF, Bernard A, et al. Increas-ing volume and changing cha-racteristics of inva-sive pulmonary as-pergillosis on sequential tho-racic com-puted tomography scans in patients with neutropenia. J Clin Oncol 2001; 19:253–259

10. Nomura F, Shimokata K, Sakai S, Yamauchi T, Kodera Y, Saito H. Cytome-galovirus pneumonitis occurring after allogeneic bone marrow trans-plantati-on: a study of 106 recipients. Jpn J Med 1990; 29:595–602

11. Merlini L, Borzani IM, Anooshiravani M, Rochat I, Ozsahin AH, Hanquinet S. Correlation of lung abnormalities on high-resolution CT with clinical graft-versus-host disease after allogeneic ver-sus autologous bone marrow transplan-tation in chil-dren. Pediatr Radiol 2008; 38:1201–1209

12. Kanne JP, Godwin JD, Franquet T, Escui-ssato DL, Muller NL. Viral pneumonia after hemato-poietic stem cell trans-plantation: high-resolution CT findings. J Thorac Imaging 2007; 22:292–299

13. Shah RM, Miller J. Pulmonary compli-cations of transplantation: radiographic considerations. Clin Chest Med 2005; 26:545–560

14. Marras TK, Chan CK. Obliterative bron-chiolitis complicating bone marrow transplantation. Semin Respir Crit Care Med 2003; 24:531–542

15. Choi YH, Leung AN. Radiologic fin-dings: pul-monary infections after bone marrow transplanta-tion. J Thorac Ima-ging 1999; 14:201–206

16. Worthy SA, Flint JD, Muller NL. Pulmo-nary complications after bone marrow transplantation: high-resolution CT and pathologic findings. Ra-dioGraphics 1997; 17:1359–1371

References

References

4

76

1. Copelan EA. Hematopoietic stem-cell transplan-tation. N Engl J Med 2006; 354:1813–1826

2. Afessa B, Peters SG. Major complicati-ons follow-ing hematopoietic stem cell transplantation. Se-min Respir Crit Care Med 2006; 27:297–309

3. Franquet T, Muller NL, Gimenez A, Mar-tinez S, Madrid M, Domingo P. Infec-tious pulmonary nod-ules in immuno-compromised patients: usefulness of computed tomography in predicting their etiol-ogy. J Comput Assist Tomogr 2003; 27:461–468

4. Franquet T, Muller NL, Lee KS, Oikono-mou A, Flint JD. Pulmonary candidiasis after hematopoi-etic stem cell trans-plantation: thin-section CT findings. Ra-diology 2005; 236:332–337

5. Gunn ML, Godwin JD, Kanne JP, Flo-wers ME, Chien JW. High-resolution CT findings of bron-chiolitis obliterans syndrome after hematopoietic stem cell transplantation. J Thorac Imaging 2008; 23:244–250

6. Todd NW, Peters WP, Ost AH, Roggli VL, Pi-antadosi CA. Pulmonary drug toxicity in patients with primary breast cancer treated with high-dose combi-nation chemotherapy and autologous bone marrow transplantation. Am Rev Respir Dis 1993; 147:1264–1270

7. Escuissato DL, Gasparetto EL, Marchi-ori E, et al. Pulmonary infections after bone marrow trans-plantation: high-resolution CT findings in 111 pa-tients. AJR 2005; 185:608–615

8. Marchiori E, Escuissato DL, Gasparetto TD, Con-sidera DP, Franquet T. “Crazy-paving” patterns on high-resolution CT scans in patients with pulmo-nary com-plications after hematopoietic stem cell transplantation. Korean J Radiol 2009; 10:21–24

9. Caillot D, Couaillier JF, Bernard A, et al. Increas-ing volume and changing cha-racteristics of inva-sive pulmonary as-pergillosis on sequential tho-racic com-puted tomography scans in patients with neutropenia. J Clin Oncol 2001; 19:253–259

10. Nomura F, Shimokata K, Sakai S, Yamauchi T, Kodera Y, Saito H. Cytome-galovirus pneumonitis occurring after allogeneic bone marrow trans-plantati-on: a study of 106 recipients. Jpn J Med 1990; 29:595–602

11. Merlini L, Borzani IM, Anooshiravani M, Rochat I, Ozsahin AH, Hanquinet S. Correlation of lung abnormalities on high-resolution CT with clinical graft-versus-host disease after allogeneic ver-sus autologous bone marrow transplan-tation in chil-dren. Pediatr Radiol 2008; 38:1201–1209

12. Kanne JP, Godwin JD, Franquet T, Escui-ssato DL, Muller NL. Viral pneumonia after hemato-poietic stem cell trans-plantation: high-resolution CT findings. J Thorac Imaging 2007; 22:292–299

13. Shah RM, Miller J. Pulmonary compli-cations of transplantation: radiographic considerations. Clin Chest Med 2005; 26:545–560

14. Marras TK, Chan CK. Obliterative bron-chiolitis complicating bone marrow transplantation. Semin Respir Crit Care Med 2003; 24:531–542

15. Choi YH, Leung AN. Radiologic fin-dings: pul-monary infections after bone marrow transplanta-tion. J Thorac Ima-ging 1999; 14:201–206

16. Worthy SA, Flint JD, Muller NL. Pulmo-nary complications after bone marrow transplantation: high-resolution CT and pathologic findings. Ra-dioGraphics 1997; 17:1359–1371

References

References

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17. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner So-ciety: glossary of terms for thoracic imaging. Ra-diology 2008; 246:697–722

18. Afessa B, Peters SG. Noninfectious pneumonitis after blood and marrow transplant. Curr Opin Oncol 2008; 20:227–233

19. Bossuyt PM, Reitsma JB, Bruns DE, et al. To-wards complete and accurate reporting of studies of diagnostic ac-curacy: the STARD initiative. BMJ 2003; 326:41–44

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17. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner So-ciety: glossary of terms for thoracic imaging. Ra-diology 2008; 246:697–722

18. Afessa B, Peters SG. Noninfectious pneumonitis after blood and marrow transplant. Curr Opin Oncol 2008; 20:227–233

19. Bossuyt PM, Reitsma JB, Bruns DE, et al. To-wards complete and accurate reporting of studies of diagnostic ac-curacy: the STARD initiative. BMJ 2003; 326:41–44

4

5High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children

5High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children

High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children

A.B. Versluys, C.K. van der Ent, J.J. Boelens, T.F.W. Wolfs, P.A. de Jong, M.B. Bierings


AbstractPulmonary complications are an important cause for treatment-related morbidity and mortality in hematopoie-tic cell transplantation (HCT) in children. The aim of this study was to investigate the yield of our pre-HCT pulmo-nary screening program. We also describe our management guidelines based on these findings and correlate them with symptomatic lung injury after HCT. Since 2008, all patients undergo a dedicated pulmonary screening consisting of pulmonary function test (PFT), chest high-resolution com-puted tomography (HRCT), and bronchial alveolar lavage (BAL) before HCT. We systematically evaluated the yield during the first 5 years of our screening program. We inclu-ded 142 consecutive children. In 74% of patients, abnorma-lities were found. In 66% of patients, 1 or more PFT results were <80% of normal. Chest HRCT showed abnormali-ties in 55%; 19% of these abnormalities were considered “clinically significant.” BAL was abnormal in 43% of pa-tients; respiratory viruses (PCR) were found in 35 patients, fungi (antigen or culture) in 21, and bacteria (culture) in 22. All 3 screening tests contributed separately to clinically relevant information regarding pulmonary status in these pre-HCT children. In 46 patients (33%), screening results had diagnostic and/or therapeutic implications. We found an association between pre-SCT HRCT findings and lung injury after transplantation. Pre-HCT screening with the combination of 3 modalities, reflecting different domains of respiratory status (function, structure, and microbial colo-nization), reveals important abnormalities in a substantial number of patients. Whether this improves patient outco-me requires further investigation.






Department of Paediatric Infectious Diseases, UMCU,

Wilhelmina Children's Hospital, Utrecht, The

Netherlands T.F.W. Wolfs

Department of Radiology, UMCU, Wilhelmina Child-

ren's Hospital, Utrecht, The Netherlands P.A. de Jong

High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children

A.B. Versluys, C.K. van der Ent, J.J. Boelens, T.F.W. Wolfs, P.A. de Jong, M.B. Bierings


AbstractPulmonary complications are an important cause for treatment-related morbidity and mortality in hematopoie-tic cell transplantation (HCT) in children. The aim of this study was to investigate the yield of our pre-HCT pulmo-nary screening program. We also describe our management guidelines based on these findings and correlate them with symptomatic lung injury after HCT. Since 2008, all patients undergo a dedicated pulmonary screening consisting of pulmonary function test (PFT), chest high-resolution com-puted tomography (HRCT), and bronchial alveolar lavage (BAL) before HCT. We systematically evaluated the yield during the first 5 years of our screening program. We inclu-ded 142 consecutive children. In 74% of patients, abnorma-lities were found. In 66% of patients, 1 or more PFT results were <80% of normal. Chest HRCT showed abnormali-ties in 55%; 19% of these abnormalities were considered “clinically significant.” BAL was abnormal in 43% of pa-tients; respiratory viruses (PCR) were found in 35 patients, fungi (antigen or culture) in 21, and bacteria (culture) in 22. All 3 screening tests contributed separately to clinically relevant information regarding pulmonary status in these pre-HCT children. In 46 patients (33%), screening results had diagnostic and/or therapeutic implications. We found an association between pre-SCT HRCT findings and lung injury after transplantation. Pre-HCT screening with the combination of 3 modalities, reflecting different domains of respiratory status (function, structure, and microbial colo-nization), reveals important abnormalities in a substantial number of patients. Whether this improves patient outco-me requires further investigation.








Netherlands T.F.W. Wolfs

Department of Radiology, UMCU, Wilhelmina Child-

ren's Hospital, Utrecht, The Netherlands P.A. de Jong

81

Pulmonary screening before hematopoietic cell transplantation in children

Introduction

Hematopoietic cell transplantation (HCT) is a curative treatment for various diseases. Pulmonary complications, both infectious and noninfectious, are frequently seen in pa-tients undergoing HCT. In children, the incidence of pulmonary complications varies from 25% to 74% and is associated with a significantly increased risk for mortality.1-3 Be-cause of the risk of life-threatening complications of the procedure, patients are routinely screened for HCT eligibility. Lung screening can potentially impact selection of HCT patients as well as affect preemptive treatment and prognosis.

Invasive fungal infections (IFI) are an important cause of morbidity and mortality during HCT. Diagnostic imaging, culturing pathogens, and antigen detection can be helpful toidentify patients at high risk for IFI, which may guide therapy.4

Also, respiratory viruses (RV) may have impact on the overall survival of HCT, either directly as a cause of pneumonitis in the severe immune-compromised patient or indi-rectly by triggering allo-immunity in the setting of allogeneic transplantation.5

In 2008, we implemented extensive pre-HCT lung screening, which includes pulmona-ry function test (PFT), chest high-resolution computed tomography (HRCT), and bron-chial alveolar lavage (BAL) in all patients. Here, we evaluate the yield of such an extensive pulmonary screening program and describe our treatment guidelines according to these findings as well as the outcome of patients.


Study population All consecutive pediatric patients undergoing a first allogeneic HCT in our center between January 2008 and August 2013 were included. Patients were enrolled in the HCT research protocol after providing written informed consent for data collection and analysis, according to national ethical regulations (Ethical Commission Number 05/143 and 11/063K). Patient characteristics (age, gender, underlying disease), clinical symptoms, results of pulmonary screening tests, and occurrence of symptomatic lung disease after HCT was registered.

Pulmonary screening Standard pre-HCT pulmonary screening is performed in the week before transplantation and consists of a PFT, HRCT scan, and BAL. PFT includes spirometry, whole body plethysmography, and measurement of carbon monoxide diffusion capacity. Measurements are performed in children aged 5 years and

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Introduction

Hematopoietic cell transplantation (HCT) is a curative treatment for various diseases. Pulmonary complications, both infectious and noninfectious, are frequently seen in pa-tients undergoing HCT. In children, the incidence of pulmonary complications varies from 25% to 74% and is associated with a significantly increased risk for mortality.1-3 Be-cause of the risk of life-threatening complications of the procedure, patients are routinely screened for HCT eligibility. Lung screening can potentially impact selection of HCT patients as well as affect preemptive treatment and prognosis.

Invasive fungal infections (IFI) are an important cause of morbidity and mortality during HCT. Diagnostic imaging, culturing pathogens, and antigen detection can be helpful toidentify patients at high risk for IFI, which may guide therapy.4

Also, respiratory viruses (RV) may have impact on the overall survival of HCT, either directly as a cause of pneumonitis in the severe immune-compromised patient or indi-rectly by triggering allo-immunity in the setting of allogeneic transplantation.5

In 2008, we implemented extensive pre-HCT lung screening, which includes pulmona-ry function test (PFT), chest high-resolution computed tomography (HRCT), and bron-chial alveolar lavage (BAL) in all patients. Here, we evaluate the yield of such an extensive pulmonary screening program and describe our treatment guidelines according to these findings as well as the outcome of patients.


Study population All consecutive pediatric patients undergoing a first allogeneic HCT in our center between January 2008 and August 2013 were included. Patients were enrolled in the HCT research protocol after providing written informed consent for data collection and analysis, according to national ethical regulations (Ethical Commission Number 05/143 and 11/063K). Patient characteristics (age, gender, underlying disease), clinical symptoms, results of pulmonary screening tests, and occurrence of symptomatic lung disease after HCT was registered.

Pulmonary screening Standard pre-HCT pulmonary screening is performed in the week before transplantation and consists of a PFT, HRCT scan, and BAL. PFT includes spirometry, whole body plethysmography, and measurement of carbon monoxide diffusion capacity. Measurements are performed in children aged 5 years and

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82


older, according to American Thoracic Society/European Respiratory Society criteria, using calibrated pneumotachometer systems (Jaeger, Hochberg, Germany). Values are expressed as percentage of predicted values for age, race, sex, and height-matched con-trols (The Utrecht data set, Koopman6).

Forced expiratory volume in 1 second, forced vital capacity, total lung capacity, and lung diffusion capacity for CO, corrected for hemoglobin and alveolar volume < 80% of pre-dicted values are considered to be abnormal. Residual volume of >25% of total lung capacity is considered to be abnormal and suggestive for trapped air. HRCT scans are acquired using a 16-detector row scanner (Philips Medical Systems, Best, Netherlands). For infants and young children, scans are obtained at 25-cm H2O pressure (inspiration) and 0-cm H2O pressure (expiration). For older children, who were able to cooperate with breath hold instruction, scans were obtained at full inspiration and at end of exhalation. Inspiration images are obtained using fixed 90 kVp and 18 to 60 mAs (depending on bodyweight). For expiration images, we used 90 kVp and 11 mAs. Acquisition was volu-metric thin-slice for both inspiratory and expiratory computed tomography.

All HRCT scans were assessed by a pediatric radiologist. Fleischner Society terms for thoracic imaging were used.7 All abnormalities, as stated in the radiology report, were registered. Those abnormalities with clinical implications, such as antimicrobial treat-ment, guided lung biopsy or diuretics, were defined as clinically significant.

BAL was performed under general anesthesia. BAL fluid was cultured and processed in accordance with standard microbiological procedures. Galactomannan (GM) tests are performed using BioRad Platelia Aspergillus EIA. Any positive culture or GM levels > .5 was considered to be abnormal.

Nucleic acids are extracted using the total nucleic acid protocol with the MagNA pure LC nucleic acid isolation system (Roche Diagnostics, Basel, Switzerland). For detection of RNA-viruses cDNA is synthesized by using MultiScribe reverse transcriptase and ran-dom hexamers (Applied Bio-systems, Foster City, CA). Detection of viral and atypical pa-thogens was performed in parallel, using real-time PCR assays specific for the following viruses: bocavirus, human herpesvirus 6, respiratory syncytial virus, influenzavirus A and B, parainfluenzavirus 1 to 4, rhinoviruses, adenoviruses, human coronavirus OC43, NL63 and 229E, human metapneumovirus, and Mycoplasma pneumoniae. Real-time PCR procedures were performed as described previously.8 Any positive PCR is considered to be abnormal.

The total costs for the pulmonary screening were approximately 900 euro. Chest HRCT costs 300 euro, RV panel PCR 495, bacterial cultures 11 euro, GM 12 euro, PFT (com-plete) cost 48 euro.

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older, according to American Thoracic Society/European Respiratory Society criteria, using calibrated pneumotachometer systems (Jaeger, Hochberg, Germany). Values are expressed as percentage of predicted values for age, race, sex, and height-matched con-trols (The Utrecht data set, Koopman6).

Forced expiratory volume in 1 second, forced vital capacity, total lung capacity, and lung diffusion capacity for CO, corrected for hemoglobin and alveolar volume < 80% of pre-dicted values are considered to be abnormal. Residual volume of >25% of total lung capacity is considered to be abnormal and suggestive for trapped air. HRCT scans are acquired using a 16-detector row scanner (Philips Medical Systems, Best, Netherlands). For infants and young children, scans are obtained at 25-cm H2O pressure (inspiration) and 0-cm H2O pressure (expiration). For older children, who were able to cooperate with breath hold instruction, scans were obtained at full inspiration and at end of exhalation. Inspiration images are obtained using fixed 90 kVp and 18 to 60 mAs (depending on bodyweight). For expiration images, we used 90 kVp and 11 mAs. Acquisition was volu-metric thin-slice for both inspiratory and expiratory computed tomography.

All HRCT scans were assessed by a pediatric radiologist. Fleischner Society terms for thoracic imaging were used.7 All abnormalities, as stated in the radiology report, were registered. Those abnormalities with clinical implications, such as antimicrobial treat-ment, guided lung biopsy or diuretics, were defined as clinically significant.

BAL was performed under general anesthesia. BAL fluid was cultured and processed in accordance with standard microbiological procedures. Galactomannan (GM) tests are performed using BioRad Platelia Aspergillus EIA. Any positive culture or GM levels > .5 was considered to be abnormal.

Nucleic acids are extracted using the total nucleic acid protocol with the MagNA pure LC nucleic acid isolation system (Roche Diagnostics, Basel, Switzerland). For detection of RNA-viruses cDNA is synthesized by using MultiScribe reverse transcriptase and ran-dom hexamers (Applied Bio-systems, Foster City, CA). Detection of viral and atypical pa-thogens was performed in parallel, using real-time PCR assays specific for the following viruses: bocavirus, human herpesvirus 6, respiratory syncytial virus, influenzavirus A and B, parainfluenzavirus 1 to 4, rhinoviruses, adenoviruses, human coronavirus OC43, NL63 and 229E, human metapneumovirus, and Mycoplasma pneumoniae. Real-time PCR procedures were performed as described previously.8 Any positive PCR is considered to be abnormal.

The total costs for the pulmonary screening were approximately 900 euro. Chest HRCT costs 300 euro, RV panel PCR 495, bacterial cultures 11 euro, GM 12 euro, PFT (com-plete) cost 48 euro.

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Standard antimicrobial prophylaxisAntibiotic prophylaxis involved daily ciprofloxacin and fluconazole, from the start of con-ditioning until the resolution of neutropenia. Additional prophylaxis against Streptococ-cus viridans was given with cefazoline in the mucositis phase. Empiric antibiotic treat-ment for febrile neutropenia included vancomycin and ceftazidime. Pneumocystis jeroveci pneumonia prophylaxis was started from 1 month after transplantation as cotrimoxazole 3 times a week. In case of positive serology for herpes simplex virus in all patients, and in case of positive serology for varicella zoster virus in cord blood transplantation reci-pients, prophylaxis with aciclovir was given. No other antiviral prophylaxis was given. In patients at high risk for IFI, according to our protocol, based on pretreatment, duration of neutropenia, and history of fungal infection, Aspergillus prophylaxis was given with daily voriconazole or twice weekly amphotericin B.

Practical guidelines according to findings on pulmonary screeningPatients with severely impaired PFT (<50% of normal) were considered to have an unac-ceptable high risk for treatment-related mortality and were excluded for HCT.

Patients with RV from BAL were considered to have a high risk for alloimmune-media-ted lung syndromes. In elective HCT procedures, HCT was postponed until the RV was cleared. In other cases when the underlying disease did not allow treatment delay tape-ring of immune suppression after HCT was adjusted to prevent allo-immune mediated lung syndromes. In cases with probable fungal disease (positive cultures or GM from BAL), antifungal treatment was considered. Patients with positive bacterial cultures from BAL were not treated, unless pulmonary symptoms developed. Bacterial culture results guide the choice of empirical antibiotic treatment for neutropenic fever after HCT.

In patients with nodular lesions on HRCT, lung biopsy was considered to identify the possible infectious cause and antimicrobial resistance pattern.

In patients with possible or proven IFI based on BAL findings, biopsy results, or HRCT findings, antifungal treatment was started and granulocyte transfusions or haploidenti-cal stem cell support (combined with cord blood grafts) were considered.

Statistical analysisCalculation of mean values and standard deviation was done for PFTs. Comparing the results with predicted values for age, race, sex, and height-matched controls was done using t-test (test value 100%). Comparison of the means between the different disease groups was done using ANOVA. The chi-square test was used for comparison of pro-portions between 2 or more groups. Differences with a P value of < .05 were considered statistically significant. Associations between pre-HCT pulmonary screening findings and clinically manifested lung injury after HCT were analyzed using Cox proportional

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Standard antimicrobial prophylaxisAntibiotic prophylaxis involved daily ciprofloxacin and fluconazole, from the start of con-ditioning until the resolution of neutropenia. Additional prophylaxis against Streptococ-cus viridans was given with cefazoline in the mucositis phase. Empiric antibiotic treat-ment for febrile neutropenia included vancomycin and ceftazidime. Pneumocystis jeroveci pneumonia prophylaxis was started from 1 month after transplantation as cotrimoxazole 3 times a week. In case of positive serology for herpes simplex virus in all patients, and in case of positive serology for varicella zoster virus in cord blood transplantation reci-pients, prophylaxis with aciclovir was given. No other antiviral prophylaxis was given. In patients at high risk for IFI, according to our protocol, based on pretreatment, duration of neutropenia, and history of fungal infection, Aspergillus prophylaxis was given with daily voriconazole or twice weekly amphotericin B.

Practical guidelines according to findings on pulmonary screeningPatients with severely impaired PFT (<50% of normal) were considered to have an unac-ceptable high risk for treatment-related mortality and were excluded for HCT.

Patients with RV from BAL were considered to have a high risk for alloimmune-media-ted lung syndromes. In elective HCT procedures, HCT was postponed until the RV was cleared. In other cases when the underlying disease did not allow treatment delay tape-ring of immune suppression after HCT was adjusted to prevent allo-immune mediated lung syndromes. In cases with probable fungal disease (positive cultures or GM from BAL), antifungal treatment was considered. Patients with positive bacterial cultures from BAL were not treated, unless pulmonary symptoms developed. Bacterial culture results guide the choice of empirical antibiotic treatment for neutropenic fever after HCT.

In patients with nodular lesions on HRCT, lung biopsy was considered to identify the possible infectious cause and antimicrobial resistance pattern.

In patients with possible or proven IFI based on BAL findings, biopsy results, or HRCT findings, antifungal treatment was started and granulocyte transfusions or haploidenti-cal stem cell support (combined with cord blood grafts) were considered.

Statistical analysisCalculation of mean values and standard deviation was done for PFTs. Comparing the results with predicted values for age, race, sex, and height-matched controls was done using t-test (test value 100%). Comparison of the means between the different disease groups was done using ANOVA. The chi-square test was used for comparison of pro-portions between 2 or more groups. Differences with a P value of < .05 were considered statistically significant. Associations between pre-HCT pulmonary screening findings and clinically manifested lung injury after HCT were analyzed using Cox proportional

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Results

hazard models. Dichotomous outcomes were used as dependent variables. Univariate predictors with a P value of < .05 were used for multivariate analysis. All statistics were done using SPSS 21.

Results

Patient cohortWe included 142 consecutive children receiving a first allogeneic HCT. Apart from mild upper respiratory tract symptoms in some, all patients were asymptomatic for lung disease at the time of pre-HCT screening. Patient characteristics are shown in Table 1.

In 3 patients, no pre-SCT lung screening was performed at all; 2 of them were under 4 months of age. In 122 patients (86%), all planned screening modalities could be perfor-med. In 19 children, only some of the tests were done either for logistic reasons (n=9) or because screening BAL was the only reason for general anesthesia, which was then

TABLE 1. Patient characteristics.

Characteristic Value

Median age (range) in years 7.0 (0.2-19.4)

Gender, n Female Male

5488

Underlying disease, n Immune deficiency† Leukemia/lymphoma Bone marrow failure, bone marrow disease without chemotherapy‡ Inborn error of metabolism§

276030

25

* Immune deficiencies include combined immune deficiency, severe combined immune deficiency, hemophagocytic lympho histiocytosis, autoimmune lymphoproliferative syn-drome, and chronic granulomatous disease. Leukemia includes acute lymphoblastic leu-kemia and acute myeloid leukemia.† Bone marrow failure includes Fanconi anemia, congenital agranulocytosis and thallase-mia.‡ Bone marrow diseases not pretreated with chemotherapy include myelodysplastic syn-drome and juvenile myelomonocytotic leukemia.§ Inborn errors of metabolism includes predominantly Hurler syndrome.

5

84

Results

hazard models. Dichotomous outcomes were used as dependent variables. Univariate predictors with a P value of < .05 were used for multivariate analysis. All statistics were done using SPSS 21.

Results

Patient cohortWe included 142 consecutive children receiving a first allogeneic HCT. Apart from mild upper respiratory tract symptoms in some, all patients were asymptomatic for lung disease at the time of pre-HCT screening. Patient characteristics are shown in Table 1.

In 3 patients, no pre-SCT lung screening was performed at all; 2 of them were under 4 months of age. In 122 patients (86%), all planned screening modalities could be perfor-med. In 19 children, only some of the tests were done either for logistic reasons (n=9) or because screening BAL was the only reason for general anesthesia, which was then

TABLE 1. Patient characteristics.

Characteristic Value

Median age (range) in years 7.0 (0.2-19.4)

Gender, n Female Male

5488

Underlying disease, n Immune deficiency† Leukemia/lymphoma Bone marrow failure, bone marrow disease without chemotherapy‡ Inborn error of metabolism§

276030

25

* Immune deficiencies include combined immune deficiency, severe combined immune deficiency, hemophagocytic lympho histiocytosis, autoimmune lymphoproliferative syn-drome, and chronic granulomatous disease. Leukemia includes acute lymphoblastic leu-kemia and acute myeloid leukemia.† Bone marrow failure includes Fanconi anemia, congenital agranulocytosis and thallase-mia.‡ Bone marrow diseases not pretreated with chemotherapy include myelodysplastic syn-drome and juvenile myelomonocytotic leukemia.§ Inborn errors of metabolism includes predominantly Hurler syndrome.

5

85


considered a disproportional invasive procedure (n=7). In 2 children above the age of 5, PFT was not feasible because of developmental delay. In 1 patient, HRCT was omitted because of the risk of irradiation damage related to underlying disease (Fanconi anemia).

PFTPFT were performed in 83 patients. This was 94% of all patients in whom we were able to perform these tests, according to age and developmental level. Results are shown in Table 2. We found PFT patterns of restrictive and obstructive lung disease as well as dif-fusion abnormalities with forced expiratory volume in 1 second, mean 82.7% (SD 11.5); forced vital capacity, mean 87.8% (SD 14.1); total lung capacity, 86% (SD 10.2); and lung diffusion capacity for CO, corrected for hemoglobin and alveolar volume, 81.9% (SD 18.5). Compared with the reference population with values of 100% (SD 12), all diffe-rences were statistically significant; with P values of < .0001. There was no difference in abnormalities in PFT between the different disease categories, see Table 2.

HRCTChest HRCT was performed in 137 (96%) patients. In 74 patients (55%), abnormalities were seen; in 63 of 74 patients (85%) these findings were “new” findings. In the group of patients without pretreatment with chemotherapy or immune deficiency, the incidence of HRCT abnormalities before HCT was significantly lower than in the other patients (Figure 1). In 18 patients (13%), clinically significant abnormalities were found. Four (3%) had lesions suspect for fungus. Fourteen patients (10%) showed other abnormalities, including bronchiectasis, pleural effusion, consolidations, and aspecific nodules > 1 cm. These were new findings in 8 of 14 patients (57%). Most clinically significant abnormal-ities were found in the subgroup of patients with immune deficiencies, but this did not reach statistical significance (Figure 1).

BALBAL was performed in 127 (90%) patients. Unfortunately, for logistic reasons, it was not always possible to do all microbial tests. Overall, in 47% of tested patients, 1 or more of the microbial tests were positive. Positive PCR for RV was found in 35 (31%) of tested pa-tients. Rhinovirus was the most frequently detected virus (Table 3). In 21 (17%) patients, we found microbial evidence of fungal colonization either with positive cultures or GM. In only 2 patients, a positive GM corresponded with a positive culture for Aspergillus; in 1 patient with a positive Aspergillus culture, GM from BAL was negative. The positive findings for the whole cohort are shown in Table 3. In patients under 5 years of age, the incidences of BAL abnormalities in general, RV positivity, and bacteria positivity were significant higher than in older patients (P values of .001, .01, and .0003 respectively).

5

85


considered a disproportional invasive procedure (n=7). In 2 children above the age of 5, PFT was not feasible because of developmental delay. In 1 patient, HRCT was omitted because of the risk of irradiation damage related to underlying disease (Fanconi anemia).

PFTPFT were performed in 83 patients. This was 94% of all patients in whom we were able to perform these tests, according to age and developmental level. Results are shown in Table 2. We found PFT patterns of restrictive and obstructive lung disease as well as dif-fusion abnormalities with forced expiratory volume in 1 second, mean 82.7% (SD 11.5); forced vital capacity, mean 87.8% (SD 14.1); total lung capacity, 86% (SD 10.2); and lung diffusion capacity for CO, corrected for hemoglobin and alveolar volume, 81.9% (SD 18.5). Compared with the reference population with values of 100% (SD 12), all diffe-rences were statistically significant; with P values of < .0001. There was no difference in abnormalities in PFT between the different disease categories, see Table 2.

HRCTChest HRCT was performed in 137 (96%) patients. In 74 patients (55%), abnormalities were seen; in 63 of 74 patients (85%) these findings were “new” findings. In the group of patients without pretreatment with chemotherapy or immune deficiency, the incidence of HRCT abnormalities before HCT was significantly lower than in the other patients (Figure 1). In 18 patients (13%), clinically significant abnormalities were found. Four (3%) had lesions suspect for fungus. Fourteen patients (10%) showed other abnormalities, including bronchiectasis, pleural effusion, consolidations, and aspecific nodules > 1 cm. These were new findings in 8 of 14 patients (57%). Most clinically significant abnormal-ities were found in the subgroup of patients with immune deficiencies, but this did not reach statistical significance (Figure 1).

BALBAL was performed in 127 (90%) patients. Unfortunately, for logistic reasons, it was not always possible to do all microbial tests. Overall, in 47% of tested patients, 1 or more of the microbial tests were positive. Positive PCR for RV was found in 35 (31%) of tested pa-tients. Rhinovirus was the most frequently detected virus (Table 3). In 21 (17%) patients, we found microbial evidence of fungal colonization either with positive cultures or GM. In only 2 patients, a positive GM corresponded with a positive culture for Aspergillus; in 1 patient with a positive Aspergillus culture, GM from BAL was negative. The positive findings for the whole cohort are shown in Table 3. In patients under 5 years of age, the incidences of BAL abnormalities in general, RV positivity, and bacteria positivity were significant higher than in older patients (P values of .001, .01, and .0003 respectively).

5

86

Results

TABL

E 2.

Pul

mon

ary

func

tion

test

bef

ore

hem

atop

oiet

ic ce

ll tr

ansp

lant

atio

n.

Tota

l N=8

3M

ean

diffe

renc

e fro

m

refe

renc

e po

pula

tion

(1-s

ided

t-te

st)

Imm

une

defic

ienc

y N

=13

Mal

igna

nt d

iseas

e pr

etre

ated

with

ch

emot

hera

pyN

=41

Bone

mar

row

di

seas

e, in

born

erro

rs

of m

etab

olism

no

pret

reat

men

t N

=29

Diffe

renc

es

betw

een

dise

ase

grou

ps (A

NO

VA)

FEV1

(% p

red)

82.7

(11

.5)

-17.

3 (9

5% C

I: -2

0.5-

14.1

)P

<.00

0183

.5 (

12.9

)81

.3 (

10.1

)84

.3 (

12.6

) N

S

FVC

(% p

red)

87

.8 (

14.1

)-1

2.2

(95%

CI:

-16.

2-8.

2)P

<.00

0191

.5 (

14.6

)86

.3 (

12.7

)88

.1 (

15.7

)N

S

TLC

(% p

red)

86.9

(10

.2)

-14.

5 (9

5% C

I: -1

7.9-

11.1

)P

<.00

0192

.2 (

8.3)

83

.8 (

10.8

)84

.5 (

7.6)

NS

RV/T

LC25

.2 (

5.7)

25.4

(5.

8)

23.6

(4.

9)

27.5

(6.

0)N

S

TLCO

(% p

red)

81.9

(18

.5)

-18

(95%

CI:

-25.

8-10

.4)

P <.

0001

85.7

(21

.6)

81.0

(19

.8)

81.2

(13

.2)

Abno

rmal

PFT

*8

(62)

28 (

68)

19 (

65)

* A

bnor

mal

PFT

def

ined

as

<80%

pre

d or

RV

/TLC

> 2

5, d

ata

are

num

bers

(pe

rcen

tage

). F

EV1

indi

cate

s fo

rced

exp

irato

ry v

olum

e in

1

seco

nd; %

pre

d, p

erce

ntag

e of

pre

dict

ed v

alue

; 95%

CI,

95%

con

fiden

ce in

terv

al; N

S, n

ot s

igni

fican

t; FV

C, f

orce

d vi

tal c

apac

ity; T

LC, t

otal

lu

ng c

apac

ity; R

V, r

esid

ual v

olum

e; T

LCO

, lun

g di

ffusi

on c

apac

ity fo

r C

O.

Mea

n va

lues

and

SD

in

all

patie

nts,

com

pare

d w

ith r

efer

ence

pop

ulat

ion,

mea

n va

lues

and

SD

per

dis

ease

gro

up,

and

com

paris

on

betw

een

dise

ase

grou

ps.

5

86

Results

TABL

E 2.

Pul

mon

ary

func

tion

test

bef

ore

hem

atop

oiet

ic ce

ll tr

ansp

lant

atio

n.

Tota

l N=8

3M

ean

diffe

renc

e fro

m

refe

renc

e po

pula

tion

(1-s

ided

t-te

st)

Imm

une

defic

ienc

y N

=13

Mal

igna

nt d

iseas

e pr

etre

ated

with

ch

emot

hera

pyN

=41

Bone

mar

row

di

seas

e, in

born

erro

rs

of m

etab

olism

no

pret

reat

men

t N

=29

Diffe

renc

es

betw

een

dise

ase

grou

ps (A

NO

VA)

FEV1

(% p

red)

82.7

(11

.5)

-17.

3 (9

5% C

I: -2

0.5-

14.1

)P

<.00

0183

.5 (

12.9

)81

.3 (

10.1

)84

.3 (

12.6

) N

S

FVC

(% p

red)

87

.8 (

14.1

)-1

2.2

(95%

CI:

-16.

2-8.

2)P

<.00

0191

.5 (

14.6

)86

.3 (

12.7

)88

.1 (

15.7

)N

S

TLC

(% p

red)

86.9

(10

.2)

-14.

5 (9

5% C

I: -1

7.9-

11.1

)P

<.00

0192

.2 (

8.3)

83

.8 (

10.8

)84

.5 (

7.6)

NS

RV/T

LC25

.2 (

5.7)

25.4

(5.

8)

23.6

(4.

9)

27.5

(6.

0)N

S

TLCO

(% p

red)

81.9

(18

.5)

-18

(95%

CI:

-25.

8-10

.4)

P <.

0001

85.7

(21

.6)

81.0

(19

.8)

81.2

(13

.2)

Abno

rmal

PFT

*8

(62)

28 (

68)

19 (

65)

* A

bnor

mal

PFT

def

ined

as

<80%

pre

d or

RV

/TLC

> 2

5, d

ata

are

num

bers

(pe

rcen

tage

). F

EV1

indi

cate

s fo

rced

exp

irato

ry v

olum

e in

1

seco

nd; %

pre

d, p

erce

ntag

e of

pre

dict

ed v

alue

; 95%

CI,

95%

con

fiden

ce in

terv

al; N

S, n

ot s

igni

fican

t; FV

C, f

orce

d vi

tal c

apac

ity; T

LC, t

otal

lu

ng c

apac

ity; R

V, r

esid

ual v

olum

e; T

LCO

, lun

g di

ffusi

on c

apac

ity fo

r C

O.

Mea

n va

lues

and

SD

in

all

patie

nts,

com

pare

d w

ith r

efer

ence

pop

ulat

ion,

mea

n va

lues

and

SD

per

dis

ease

gro

up,

and

com

paris

on

betw

een

dise

ase

grou

ps.

5

87


FIGURE 1. Prevalence of HRCT abnormalities before HCT, per disease group. 1. Immune deficiencies, n=27 2. Malignancies with chemotherapy, n=56 3. Other (inborn errors of metabolism, bone marrow failure, malignancies without chemotherapy), n=54

Relationship between different testsFigure 2 shows the yield of all screening tests. Abnormalities were found in tests of 74% of patients. We found abnormalities in radiological tests among patients with normal and abnormal PFTs, as well as positive microbial test results in patients with normal PFTs and normal HRCT.

Impact on outcomeIn 46 patients, the screening outcome had implications, such as guided BAL/lung bio-psy (n=8), change in antifungal treatment/prophylaxis (n=12), granulocyte transfusions (n=2), addition of haploidentical stem cells (n=3), postponement of HCT (n=11), or gui-ded tapering of immune suppressive agents (n=35). These interventions overlapped in some patients.In 4 patients, the pre-HCT HRCT showed new or progressive signs of infiltrative fungal infection. Antifungal therapy was intensified in 3 based on resistance pattern of the cul-tured pathogen. In 2 patients, we postponed HCT. In 3 cord blood transplant recipients, we added haploidentical CD34+ cells from a family donor for early myeloid support,

5

80%

70%

60%

50%

40%

30%

20%

10%

0%1 2 3

** p>0.05any abnormalityclinically significant abnormality

NS

87


FIGURE 1. Prevalence of HRCT abnormalities before HCT, per disease group. 1. Immune deficiencies, n=27 2. Malignancies with chemotherapy, n=56 3. Other (inborn errors of metabolism, bone marrow failure, malignancies without chemotherapy), n=54

Relationship between different testsFigure 2 shows the yield of all screening tests. Abnormalities were found in tests of 74% of patients. We found abnormalities in radiological tests among patients with normal and abnormal PFTs, as well as positive microbial test results in patients with normal PFTs and normal HRCT.

Impact on outcomeIn 46 patients, the screening outcome had implications, such as guided BAL/lung bio-psy (n=8), change in antifungal treatment/prophylaxis (n=12), granulocyte transfusions (n=2), addition of haploidentical stem cells (n=3), postponement of HCT (n=11), or gui-ded tapering of immune suppressive agents (n=35). These interventions overlapped in some patients.In 4 patients, the pre-HCT HRCT showed new or progressive signs of infiltrative fungal infection. Antifungal therapy was intensified in 3 based on resistance pattern of the cul-tured pathogen. In 2 patients, we postponed HCT. In 3 cord blood transplant recipients, we added haploidentical CD34+ cells from a family donor for early myeloid support,

5

80%

70%

60%

50%

40%

30%

20%

10%

0%1 2 3

** p>0.05any abnormalityclinically significant abnormality

NS

88

Results

TABLE 3. Results from screening tests in BAL before HCT.

Test Viral PCRN=113

Bacterial cultureN=123

Fungal cultureN=123

GM*N=119

No positive (%)

35 (31)

22 (17)

8 (7)†21 (18)

17 (14)

Rhinovirus, 18RSV, 3Influenzavirus, 2Coronavirus, 2Adenovirus, 2Bocavirus, 1Metapneumovirus, 1Parainfluenzavirus, 1Mixed viruses, 5

H. influenzae, 7Streptococci, 3Mycoplasma Pn, 1Pseudomonas, 1Stenotrophomonas, 1Klebsiella, 1Mixed, 7

Candida spp, 2Aspergillus spp, 3Penicillium spp, 3

* Galactomannan (GM) in bronchoalveolar lavage (BAL), > .5 = positive.

† There was overlap between fungal culture results and galactomannan findings in BAL (2 of 3 Aspergillus-positive patients were also galactomannan positive, 1 patient with Candida and 1 with Penicillium also had positive GM) so 21 patients were considered positive for fungus.

and in 2 patients we gave granulocyte transfusions during the period of neutropenia. One patient had graft rejection and showed fatal progression of Aspergillus infection in prolonged neutropenia. The 3 others did not show progression of infection, and therapy could be stopped safely after engraftment.No patient with RV or bacteria isolated showed progression of pulmonary infection during HCT. None of the patients with isolated positive findings for fungus from BAL, of whom the majority received intensification of fungal prophylaxis/treatment, developed pulmonary fungal disease.Cox regression analysis did not show a relation between pre-HCT screening findings in BAL or PFT and symptomatic lung injury after HCT. A clinically significant abnormality on chest HRCT before HCT, however, was a predictor for the development of immune-mediated lung injury after HCT (hazard ratio, 3.49; 95% confidence interval, 1.07 to 11.35; P = .037).

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Results

TABLE 3. Results from screening tests in BAL before HCT.

Test Viral PCRN=113

Bacterial cultureN=123

Fungal cultureN=123

GM*N=119

No positive (%)

35 (31)

22 (17)

8 (7)†21 (18)

17 (14)

Rhinovirus, 18RSV, 3Influenzavirus, 2Coronavirus, 2Adenovirus, 2Bocavirus, 1Metapneumovirus, 1Parainfluenzavirus, 1Mixed viruses, 5

H. influenzae, 7Streptococci, 3Mycoplasma Pn, 1Pseudomonas, 1Stenotrophomonas, 1Klebsiella, 1Mixed, 7

Candida spp, 2Aspergillus spp, 3Penicillium spp, 3

* Galactomannan (GM) in bronchoalveolar lavage (BAL), > .5 = positive.

† There was overlap between fungal culture results and galactomannan findings in BAL (2 of 3 Aspergillus-positive patients were also galactomannan positive, 1 patient with Candida and 1 with Penicillium also had positive GM) so 21 patients were considered positive for fungus.

and in 2 patients we gave granulocyte transfusions during the period of neutropenia. One patient had graft rejection and showed fatal progression of Aspergillus infection in prolonged neutropenia. The 3 others did not show progression of infection, and therapy could be stopped safely after engraftment.No patient with RV or bacteria isolated showed progression of pulmonary infection during HCT. None of the patients with isolated positive findings for fungus from BAL, of whom the majority received intensification of fungal prophylaxis/treatment, developed pulmonary fungal disease.Cox regression analysis did not show a relation between pre-HCT screening findings in BAL or PFT and symptomatic lung injury after HCT. A clinically significant abnormality on chest HRCT before HCT, however, was a predictor for the development of immune-mediated lung injury after HCT (hazard ratio, 3.49; 95% confidence interval, 1.07 to 11.35; P = .037).

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FIGURE 2. Overview results pre-HCT screening tests. PFT, pulmonary function test; defined as abnormal if <80% of normal or RV/TLC >25 HRCT, high-resolution CT scan; abnormal in case of "clinical significant" abnormalities BAL, bronchoalveolar lavage RV: respiratory virus, PCR positivity; bact, bacteria * not all patients < 5 years had PFT done (N=8) ** not all patients had HRCT performed (N=5) *** not all patients with HRCT underwent BAL (N=15)

HRCTabnormal

N=7 (14%)**

HRCT normalN=43

HRCT abnormal

N=8

HRCTnormalN=45

HRCT abnormal

N=3

HRCT normalN=24

BALabnormalN=2(33%)***

Fungi 1RV 1


Fungi 7Bact 16RV 17


Fungi 2Bact 7

BAL abnormal N=10(24%)***

Fungi 4Bact 2RV 5

BAL abnormalN=1(33%)***

Fungi 1


Fungi 3Bact 2RV 5

Children>5 yearsN=88

PFTnormalN=27

PFT abnormal

N=53(66%)*

Children <5 years

N=54

5

89


FIGURE 2. Overview results pre-HCT screening tests. PFT, pulmonary function test; defined as abnormal if <80% of normal or RV/TLC >25 HRCT, high-resolution CT scan; abnormal in case of "clinical significant" abnormalities BAL, bronchoalveolar lavage RV: respiratory virus, PCR positivity; bact, bacteria * not all patients < 5 years had PFT done (N=8) ** not all patients had HRCT performed (N=5) *** not all patients with HRCT underwent BAL (N=15)

HRCTabnormal

N=7 (14%)**

HRCT normalN=43

HRCT abnormal

N=8

HRCTnormalN=45

HRCT abnormal

N=3

HRCT normalN=24


Fungi 1RV 1


Fungi 7Bact 16RV 17


Fungi 2Bact 7

BAL abnormal N=10(24%)***

Fungi 4Bact 2RV 5


Fungi 1


Fungi 3Bact 2RV 5

Children>5 yearsN=88

PFTnormalN=27

PFT abnormal

N=53(66%)*

Children <5 years

N=54

5

90

Discussion

Discussion

Our study in 142 pediatric patients shows that pulmonary screening before HCT with PFT, HRCT, and BAL is feasible. We could perform all the tests in the majority of pa-tients (86%). Abnormalities were found in 72% of patients. In 32% of patients, these abnormalities led to supportive/preemptive treatment according to guidelines. Only in patients with clinically significant chest HRCT, abnormalities a higher incidence of lung-injury was noted after HCT. Although not negligible, the costs seem justified in relation to the findings.

It is well known that pulmonary function declines early after HCT,9,10 and some studies have shown a continuous decline without reaching a plateau during prolonged follow-up.9 Several studies have demonstrated that impaired PFT before transplantation in-creases the risk for post-transplantation lung complications and mortality.1,9,11-14 Possible explanations for these observations are that patients can have such marginal lung reserve capacity, endangering a period of critical illness and/or further lung toxic events. Also, in patients with pre-existing lung injury, this organ may be at increased risk for allo-immune phenomena, such as graft-versus-host disease.

We evaluated the yield of HRCT scanning. Omitting HRCT from our screening in this cohort would have missed 7 (5%) children with abnormalities, including 2 of the 4 with infiltrative lesions suspect for fungus. On the other hand, HRCT leads to radiation ex-posure and may require general anesthesia in children and, therefore, deserves critical appraisal. The relevance of abnormal findings on HRCT are a matter of debate. In the radiological reports in this study, abnormalities were described in 55% of patients. Be-cause the severity of the reported abnormalities varied considerably, we chose to take into account those HRCT findings which had “significant clinical meaning” at time of transplantation, such as consolidations requiring antibiotic or antifungal therapy, bron-chiectasis as a risk factor for infections warranting change in prophylaxis, or pleural ef-fusions requiring diuretics. In most patients, a plain chest x-ray was available but showed abnormalities in only 50%, and, of note, did not show any abnormalities in the 4 patients with signs of invasive fungal infection on HRCT (data not shown).

The yield of BAL procedures was high in our study. Omitting BAL would have missed 19 (14%) patients with fungal colonization and 35 (25%) with RV. All these patients had normal HRCT scans and no significant pulmonary symptoms.

5

90

Discussion

Discussion

Our study in 142 pediatric patients shows that pulmonary screening before HCT with PFT, HRCT, and BAL is feasible. We could perform all the tests in the majority of pa-tients (86%). Abnormalities were found in 72% of patients. In 32% of patients, these abnormalities led to supportive/preemptive treatment according to guidelines. Only in patients with clinically significant chest HRCT, abnormalities a higher incidence of lung-injury was noted after HCT. Although not negligible, the costs seem justified in relation to the findings.

It is well known that pulmonary function declines early after HCT,9,10 and some studies have shown a continuous decline without reaching a plateau during prolonged follow-up.9 Several studies have demonstrated that impaired PFT before transplantation in-creases the risk for post-transplantation lung complications and mortality.1,9,11-14 Possible explanations for these observations are that patients can have such marginal lung reserve capacity, endangering a period of critical illness and/or further lung toxic events. Also, in patients with pre-existing lung injury, this organ may be at increased risk for allo-immune phenomena, such as graft-versus-host disease.

We evaluated the yield of HRCT scanning. Omitting HRCT from our screening in this cohort would have missed 7 (5%) children with abnormalities, including 2 of the 4 with infiltrative lesions suspect for fungus. On the other hand, HRCT leads to radiation ex-posure and may require general anesthesia in children and, therefore, deserves critical appraisal. The relevance of abnormal findings on HRCT are a matter of debate. In the radiological reports in this study, abnormalities were described in 55% of patients. Be-cause the severity of the reported abnormalities varied considerably, we chose to take into account those HRCT findings which had “significant clinical meaning” at time of transplantation, such as consolidations requiring antibiotic or antifungal therapy, bron-chiectasis as a risk factor for infections warranting change in prophylaxis, or pleural ef-fusions requiring diuretics. In most patients, a plain chest x-ray was available but showed abnormalities in only 50%, and, of note, did not show any abnormalities in the 4 patients with signs of invasive fungal infection on HRCT (data not shown).

The yield of BAL procedures was high in our study. Omitting BAL would have missed 19 (14%) patients with fungal colonization and 35 (25%) with RV. All these patients had normal HRCT scans and no significant pulmonary symptoms.

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91


Figure 2 illustrates that all tests contribute separately to information regarding pulmona-ry status in pre-HCT children. This argues that all these screening modalities, reflecting different domains of respiratory status (function, structure, and microbial colonization), should be done in all pediatric pre-HCT patients, if a sensitive pre-HCT screening for pulmonary pathology is desired. The impact of the finding and the invasiveness of the test should guide clinicians in decision-making on whether or not to perform all tests.

As far as we know, this is the first report on such comprehensive pulmonary screening with PFT, HRCT, and BAL in a large cohort of children before HCT. We have shown considerable decrease in pulmonary function, a significant amount of clinical important HRCT findings, and high prevalence of infectious agents. This is most likely because of underlying disease, pretreatment with chemotherapy, and the age distribution of our patients.

In this cohort of patients, there is a significant association between clinically significant HRCT findings before HCT and lung injury after HCT. The findings in BAL and PFT were not related with outcome. This might be due to small numbers.

We might also conclude that with current treatment strategies for this group of pulmo-nary compromised patients, we manage to have comparable outcome.

We conclude that this screening protocol is feasible and provides important information for risk classification with therapeutic consequences. We would advocate all 3 screening methods, as they all contribute separately. Prospective studies are needed to further iden-tify the importance of baseline abnormalities in the risk for pulmonary complications and treatment-related mortality and whether outcome is improved by using intensive screening.

5

91


Figure 2 illustrates that all tests contribute separately to information regarding pulmona-ry status in pre-HCT children. This argues that all these screening modalities, reflecting different domains of respiratory status (function, structure, and microbial colonization), should be done in all pediatric pre-HCT patients, if a sensitive pre-HCT screening for pulmonary pathology is desired. The impact of the finding and the invasiveness of the test should guide clinicians in decision-making on whether or not to perform all tests.

As far as we know, this is the first report on such comprehensive pulmonary screening with PFT, HRCT, and BAL in a large cohort of children before HCT. We have shown considerable decrease in pulmonary function, a significant amount of clinical important HRCT findings, and high prevalence of infectious agents. This is most likely because of underlying disease, pretreatment with chemotherapy, and the age distribution of our patients.

In this cohort of patients, there is a significant association between clinically significant HRCT findings before HCT and lung injury after HCT. The findings in BAL and PFT were not related with outcome. This might be due to small numbers.

We might also conclude that with current treatment strategies for this group of pulmo-nary compromised patients, we manage to have comparable outcome.

We conclude that this screening protocol is feasible and provides important information for risk classification with therapeutic consequences. We would advocate all 3 screening methods, as they all contribute separately. Prospective studies are needed to further iden-tify the importance of baseline abnormalities in the risk for pulmonary complications and treatment-related mortality and whether outcome is improved by using intensive screening.

5

92

1. Kaya Z, Weinier DJ, Yilmaz D, et al. Lung function, pulmonary com-pli-cations and mortality after allogeneic blood and marrow trans-plantation in children. Biol Blood Marrow Transplant. 2009;15:817-826.

2. Gower WA, Collaco MC, Mogayzel PJ. Lung function and late pulmonary complications among survivors of he-matopoietic stem cell trans-plantation during childhood. Paediatr Respir Rev. 2010;11:115-122.

3. Eikenberry M, Bartakova H, Defor T, et al. Natural history of pulmonary com-plications in children after bone mar-row transplantation. Biol Blood Marrow Transplant. 2005;11:56-64.

4. Ruhnke M, Bohme A, Buchheidt D, et al. Diagnosis of invasive fungal infections in hematology and oncology- guidelines from the Infectious Disease Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO). Ann Oncol. 2012;23:823-833.

5. Versluys AB, Rossen JW, van Ewijk B, et al. Strong association between res-piratory viral infection early after he-matopoietic stem cell trans-plantation and the development of life-threatening acute and chronic alloimmune lung syn-dromes. Biol Blood Marrow Transplant. 2010;16:782-791.

6. Koopman M, Zanen P, Kruitwagen C, et al. Reference values for pae-diatric pulmonary function testing: the Utrecht dataset. Respir Med. 2011;105:15-23.

7. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: glos-sary of terms for thoracic imaging. Radiology. 2008;246:697-722.

8. van de Pol AC, Wolfs TF, Jansen NJ, et al. Diagnostic value of real-time poly-merase chain reaction to detect viruses

in young children admitted to the pae-diatric intensive care unit with lower respiratory tract infection. Crit Care. 2006;10:R61.

9. Inaba H, Yang J, Pan J, et al. Pulmonary dysfunction in survivors of childhood hematological malignancies after allo-geneic hematopoietic stem cell trans-plantation. Cancer. 2010;116:2020-2030.

10. Uhlving HH, Bang CL, Christensen IJ, et al. Lung function after alloge-neic he-matopoietic stem cell transplantation in children: a longitudinal study in a popu-lation based cohort. Biol Blood Marrow Transplant. 2013; 19:1348-1354.

11. Chien JW, Madtes DK, Clark JG. Pulmo-nary function testing prior to hemato-poietic stem cell transplantation. Bone Marrow Transplant. 2005;35:429-435.

12. Ramirez-Sarmiento A, Orozco-Levi M, Walter E, et al. Influence of pretrans-plantation restrictive lung disease on allogeneic hematopoietic cell transplan-tation outcomes. Biol Blood Marrow Transplant. 2010;16:199-206.

13. Walter EC, Orozco-Levi M, Ramirez-Sarmiento A, et al. Lung function and long-term complications after hemato-poietic cell transplant. Biol Blood Mar-row Transplant. 2010;16:53-61.

14. Ginsberg JP, Aplenc R, McDonough J, et al. Pretransplant lung function is predic-tive of survival following pediatric bone marrow trans-plantation. Pediatr Blood Cancer. 2010;54:454-460.

References

References

5

92

1. Kaya Z, Weinier DJ, Yilmaz D, et al. Lung function, pulmonary com-pli-cations and mortality after allogeneic blood and marrow trans-plantation in children. Biol Blood Marrow Transplant. 2009;15:817-826.

2. Gower WA, Collaco MC, Mogayzel PJ. Lung function and late pulmonary complications among survivors of he-matopoietic stem cell trans-plantation during childhood. Paediatr Respir Rev. 2010;11:115-122.

3. Eikenberry M, Bartakova H, Defor T, et al. Natural history of pulmonary com-plications in children after bone mar-row transplantation. Biol Blood Marrow Transplant. 2005;11:56-64.

4. Ruhnke M, Bohme A, Buchheidt D, et al. Diagnosis of invasive fungal infections in hematology and oncology- guidelines from the Infectious Disease Working Party in Haematology and Oncology of the German Society for Haematology and Oncology (AGIHO). Ann Oncol. 2012;23:823-833.

5. Versluys AB, Rossen JW, van Ewijk B, et al. Strong association between res-piratory viral infection early after he-matopoietic stem cell trans-plantation and the development of life-threatening acute and chronic alloimmune lung syn-dromes. Biol Blood Marrow Transplant. 2010;16:782-791.

6. Koopman M, Zanen P, Kruitwagen C, et al. Reference values for pae-diatric pulmonary function testing: the Utrecht dataset. Respir Med. 2011;105:15-23.

7. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: glos-sary of terms for thoracic imaging. Radiology. 2008;246:697-722.

8. van de Pol AC, Wolfs TF, Jansen NJ, et al. Diagnostic value of real-time poly-merase chain reaction to detect viruses

in young children admitted to the pae-diatric intensive care unit with lower respiratory tract infection. Crit Care. 2006;10:R61.

9. Inaba H, Yang J, Pan J, et al. Pulmonary dysfunction in survivors of childhood hematological malignancies after allo-geneic hematopoietic stem cell trans-plantation. Cancer. 2010;116:2020-2030.

10. Uhlving HH, Bang CL, Christensen IJ, et al. Lung function after alloge-neic he-matopoietic stem cell transplantation in children: a longitudinal study in a popu-lation based cohort. Biol Blood Marrow Transplant. 2013; 19:1348-1354.

11. Chien JW, Madtes DK, Clark JG. Pulmo-nary function testing prior to hemato-poietic stem cell transplantation. Bone Marrow Transplant. 2005;35:429-435.

12. Ramirez-Sarmiento A, Orozco-Levi M, Walter E, et al. Influence of pretrans-plantation restrictive lung disease on allogeneic hematopoietic cell transplan-tation outcomes. Biol Blood Marrow Transplant. 2010;16:199-206.

13. Walter EC, Orozco-Levi M, Ramirez-Sarmiento A, et al. Lung function and long-term complications after hemato-poietic cell transplant. Biol Blood Mar-row Transplant. 2010;16:53-61.

14. Ginsberg JP, Aplenc R, McDonough J, et al. Pretransplant lung function is predic-tive of survival following pediatric bone marrow trans-plantation. Pediatr Blood Cancer. 2010;54:454-460.

References

References

5

6Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplantation

6Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplantation

Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplantation

A.B. Versluys, T.E. Faber, J.J. Boelens, L.J. Bont

Manuscript submitted

Abstract

Little is known about untreated respiratory syncytial virus (RSV) infection in pediatric hematopoietic cell transplan-tation (HCT). In 310 HCT-recipients, 8 children (3%) had RSV-infection, none received antiviral treatment, and none progressed to severe RSV-disease. These results support restrictive use of costly antivirals to prevent or treat RSV in pediatric HCT-recipients.



J.J. Boelens

Department of Pediatrics, Medical Center Leeuwar-

den, Leeuwarden, The Netherlands

T.E. Faber

U-DANCE Laboratory of Translational Immunology,

University Medical Center Utrecht, The Netherlands

J.J. Boelens



Netherlands L.J. Bont

Favorable outcome of untreated RSV infection in pediatric hematopoietic cell transplantation

A.B. Versluys, T.E. Faber, J.J. Boelens, L.J. Bont


Abstract

Little is known about untreated respiratory syncytial virus (RSV) infection in pediatric hematopoietic cell transplan-tation (HCT). In 310 HCT-recipients, 8 children (3%) had RSV-infection, none received antiviral treatment, and none progressed to severe RSV-disease. These results support restrictive use of costly antivirals to prevent or treat RSV in pediatric HCT-recipients.



J.J. Boelens

Department of Pediatrics, Medical Center Leeuwar-

den, Leeuwarden, The Netherlands

T.E. Faber

U-DANCE Laboratory of Translational Immunology,

University Medical Center Utrecht, The Netherlands

J.J. Boelens



Netherlands L.J. Bont

97

Good outcome of untreated RSV in pediatric HCT

Introduction

Children with immunodeficiency are at increased risk for complicated respiratory syncy-tial virus (RSV) disease. Hematopoietic cell transplant (HCT) recipients are considered particularly vulnerable for progression to lower respiratory tract infection (LRTI) and RSV-related mortality.1 In adult HCT-patients with RSV, antiviral therapy with ribavirin is suggested to lead to better outcome.2 Several important groups, including the European Conference on Infection in Leukemia (ECIL-4) recommend treatment with ribavirin and intravenous immunoglobulin (IVIG) in HCT-recipients.3,4 Not much is known about the natural course of RSV in pediatric HCT-patients. Because of a lack of well-designed trials on the efficacy of antiviral therapy, treatment of RSV in this context remains controver-sial. Here, we describe be the incidence and outcome of untreated RSV-infection in a cohort of pediatric HCT-recipients.

Methods

All consecutive patients, undergoing first HCT between 2004 and 2015 at Wilhelmina Children’s Hospital, UMCUtrecht, The Netherlands, were included. According to local screening policy,5 all patients were routinely tested for respiratory viruses, including RSV, by polymerase chain reaction (PCR) in nasal pharyngeal aspirate (NPA) and/or bron-choalveolar lavage (BAL) prior to HCT.5 Tests were repeated in patients that developed (new) respiratory symptoms after HCT. In case of PCR positivity, elective HCT procedu-res were postponed for two weeks, aiming for clearance of the virus. When underlying disease did not allow treatment delay, immune suppression was continued for a longer period after HCT, because earlier studies have shown that respiratory virus infection is a predictor for allo-immune mediated lung disease. Prolonged immunosuppressive therapy was suggested to prevent this life-threatening event.6 Immunoprophylaxis by palivizumab or antiviral treatment with ribavirin was never used.

Patients were classified either (1) asymptomatic, (2) upper respiratory infection (URTI) with signs of rhinitis, otitis media or pharyngitis, or (3) LRTI when tachypnea, dyspnea, wheezing, cough or hypoxia was present . Development of RSV-infection within the first three days of hospitalization was considered community acquired. RSV-patients were scored using the Immunodeficiency Scoring Index for RSV-infection (ISI-RSV) in HCT-recipients.7 This score combines neutrophil count, lymphocyte count, age, myelo-ablative regimen, GVHD, corticosteroids and recent engraftment or pre-engraftment. It predicts the risk of progression to LRTI and RSV-related mortality. A score of 0-2 is considered low risk, 3-6 moderate risk and 7-12 high risk.7

6

97


Introduction

Children with immunodeficiency are at increased risk for complicated respiratory syncy-tial virus (RSV) disease. Hematopoietic cell transplant (HCT) recipients are considered particularly vulnerable for progression to lower respiratory tract infection (LRTI) and RSV-related mortality.1 In adult HCT-patients with RSV, antiviral therapy with ribavirin is suggested to lead to better outcome.2 Several important groups, including the European Conference on Infection in Leukemia (ECIL-4) recommend treatment with ribavirin and intravenous immunoglobulin (IVIG) in HCT-recipients.3,4 Not much is known about the natural course of RSV in pediatric HCT-patients. Because of a lack of well-designed trials on the efficacy of antiviral therapy, treatment of RSV in this context remains controver-sial. Here, we describe be the incidence and outcome of untreated RSV-infection in a cohort of pediatric HCT-recipients.

Methods

All consecutive patients, undergoing first HCT between 2004 and 2015 at Wilhelmina Children’s Hospital, UMCUtrecht, The Netherlands, were included. According to local screening policy,5 all patients were routinely tested for respiratory viruses, including RSV, by polymerase chain reaction (PCR) in nasal pharyngeal aspirate (NPA) and/or bron-choalveolar lavage (BAL) prior to HCT.5 Tests were repeated in patients that developed (new) respiratory symptoms after HCT. In case of PCR positivity, elective HCT procedu-res were postponed for two weeks, aiming for clearance of the virus. When underlying disease did not allow treatment delay, immune suppression was continued for a longer period after HCT, because earlier studies have shown that respiratory virus infection is a predictor for allo-immune mediated lung disease. Prolonged immunosuppressive therapy was suggested to prevent this life-threatening event.6 Immunoprophylaxis by palivizumab or antiviral treatment with ribavirin was never used.

Patients were classified either (1) asymptomatic, (2) upper respiratory infection (URTI) with signs of rhinitis, otitis media or pharyngitis, or (3) LRTI when tachypnea, dyspnea, wheezing, cough or hypoxia was present . Development of RSV-infection within the first three days of hospitalization was considered community acquired. RSV-patients were scored using the Immunodeficiency Scoring Index for RSV-infection (ISI-RSV) in HCT-recipients.7 This score combines neutrophil count, lymphocyte count, age, myelo-ablative regimen, GVHD, corticosteroids and recent engraftment or pre-engraftment. It predicts the risk of progression to LRTI and RSV-related mortality. A score of 0-2 is considered low risk, 3-6 moderate risk and 7-12 high risk.7

6

98

Results

TABL

E 1.

Cha

ract

eris

tics

of R

SV-p

osit

ive

pati

ents

.

Patie

nt ch

arac

teris

tics

12

34

56

78

Age

at H

CT

(yea

rs)

1.3

105.

211

.22.

67.

72.

60.

2

Dia

gnos

is*

MPS

IA

LL

ALL

A

LLM

PS II

IX-

CG

D

ALL

HLH

Type

of d

onor

**5/

6 uC

B5/

6 uC

B10

/10

MU

D6/

6 uC

B6/

6 uC

B6/

6 uC

B10

/10

MU

D6/

6 uC

B

Con

ditio

ning

re

gim

en**

*

Bu/

Flu/

ATG

TBI/

VP1

6/AT

GTB

I/V

P16/

ATG

TBI/

VP1

6/AT

GB

u/C

y/AT

GTr

eo/F

lu/

Cam

path

Bu/

Cy/

VP1

6/AT

GB

u/Fl

u/AT

G

GV

HD

pro

phyl

axis

****

CsA

, Pr

edC

sA, P

red

CsA

, MTX

CsA

, Pre

dC

sA, P

red

CsA

, Pre

dC

sA, M

TXC

sA, P

red

RSV

pos

itivi

tyB

AL+

/N

PA-

BA

L+/

NPA

+B

AL-

/NPA

+B

AL+

/N

PA+

NPA

+B

AL+

/NPA

+B

AL+

/NPA

+N

PA +

Tim

e af

ter

HC

T (d

ays)

-9-1

4 -1

4 -1

1 -2

1-1

7-1

4 +

52

ISI-R

SV§

99

810

810

81

Low

est R

SV C

T-va

lue

2720

4217

4015

1722

Initi

al R

SV s

ympt

oms

AS

AS

UR

TIU

RTI

UR

TIU

RTI

UR

TILR

TI

Prog

ress

ion

sym

ptom

s N

ON

ON

ON

ON

OYE

SD

ay +

2,

dysp

nea,

su

pple

men

-ta

l oxy

gen

YES

Day

+23

, ta

chyp

nea,

su

pple

men

-ta

l oxy

gen

YES

Day

+55

, ta

chyp

nea,

su

pple

men

-ta

l oxy

gen

Tabl

e co

ntin

ues

on n

ext p

age

6

98

Results

TABL

E 1.

Cha

ract

eris

tics

of R

SV-p

osit

ive

pati

ents

.

Patie

nt ch

arac

teris

tics

12

34

56

78

Age

at H

CT

(yea

rs)

1.3

105.

211

.22.

67.

72.

60.

2

Dia

gnos

is*

MPS

IA

LL

ALL

A

LLM

PS II

IX-

CG

D

ALL

HLH

Type

of d

onor

**5/

6 uC

B5/

6 uC

B10

/10

MU

D6/

6 uC

B6/

6 uC

B6/

6 uC

B10

/10

MU

D6/

6 uC

B

Con

ditio

ning

re

gim

en**

*

Bu/

Flu/

ATG

TBI/

VP1

6/AT

GTB

I/V

P16/

ATG

TBI/

VP1

6/AT

GB

u/C

y/AT

GTr

eo/F

lu/

Cam

path

Bu/

Cy/

VP1

6/AT

GB

u/Fl

u/AT

G

GV

HD

pro

phyl

axis

****

CsA

, Pr

edC

sA, P

red

CsA

, MTX

CsA

, Pre

dC

sA, P

red

CsA

, Pre

dC

sA, M

TXC

sA, P

red

RSV

pos

itivi

tyB

AL+

/N

PA-

BA

L+/

NPA

+B

AL-

/NPA

+B

AL+

/N

PA+

NPA

+B

AL+

/NPA

+B

AL+

/NPA

+N

PA +

Tim

e af

ter

HC

T (d

ays)

-9-1

4 -1

4 -1

1 -2

1-1

7-1

4 +

52

ISI-R

SV§

99

810

810

81

Low

est R

SV C

T-va

lue

2720

4217

4015

1722

Initi

al R

SV s

ympt

oms

AS

AS

UR

TIU

RTI

UR

TIU

RTI

UR

TILR

TI

Prog

ress

ion

sym

ptom

s N

ON

ON

ON

ON

OYE

SD

ay +

2,

dysp

nea,

su

pple

men

-ta

l oxy

gen

YES

Day

+23

, ta

chyp

nea,

su

pple

men

-ta

l oxy

gen

YES

Day

+55

, ta

chyp

nea,

su

pple

men

-ta

l oxy

gen

Tabl

e co

ntin

ues

on n

ext p

age

6

99


TABL

E 1.

Cha

ract

eris

tics

of R

SV-p

osit

ive

pati

ents

— co

ntin

ued.

Patie

nt ch

arac

teris

tics

12

34

56

78

Trea

tmen

tN

ON

ON

ON

ON

ON

ON

OA

ntib

iotic

s

RSV

-att

ribut

able

de

ath

N/A

N/A

N/A

NO

N/A

NO

NO

N/A

Out

com

eA

live

and

wel

lA

live

and

wel

lA

live

and

wel

lD

ied

+27

mon

ths:

cG

VH

D,

aspe

rgil-

losi

s,

orga

n fa

ilure

Aliv

e,

prog

res-

sive

un-

derly

ing

dise

ase

Die

d +5

3 da

ys:

aspe

rgil-

losi

s,

imm

une-

med

iate

d lu

ng

dise

ase

Die

d +7

m

onth

s:R

elap

sed

dise

ase

Aliv

e an

d w

ell

* Dia

gnos

is: A

LL =

acu

te ly

mph

obla

stic

leuk

emia

, MPS

1 =

Muc

oPol

ySac

harr

idos

e ty

pe I

= H

urle

rs d

isea

se, M

PS II

I = M

ucoP

olyS

acha

r-rid

ose

type

III =

San

Fili

ppo’

s di

seas

e, X

-CG

D =

X-li

nked

chr

onic

gra

nulo

mat

ous

dise

ase,

HLH

= H

ered

itary

Hem

ofag

ocyt

ic L

ymph

ohis

-tio

cyto

sis.

**

Typ

e of

don

or: 1

0/10

MU

D =

fully

mat

ched

unr

elat

ed d

onor

, uC

B =

unr

elat

ed C

ord

Blo

od, 5

/6 a

nd 6

/6 in

dica

tes

HLA

mat

ch.

*** C

ondi

tioni

ng re

gim

en: B

u =

Bus

ulfa

n, C

y =

Cyc

lofo

sfam

ide,

VP1

6 =

Etop

osid

e, A

TG =

ant

i thy

moc

yte

glob

ulin

, TB

I = to

tal b

ody

irrad

i-at

ion,

Tre

o =

Treo

sulfa

n, F

lu =

Flu

dara

bine

. **

** G

VH

D p

rofy

laxi

s: C

sA =

Cic

losp

orin

e A

, MTX

= M

etho

trex

ate,

Pre

d =

Pred

niso

ne.

§ ISI

-RSV

= im

mun

odef

icie

ncy

scor

ing

inde

x fo

r RSV

infe

ctio

n, in

a p

edia

tric

coh

ort m

ax 1

0, lo

w ri

sk 0

-2, m

oder

ate

risk

3-6,

hig

h ris

k 7-

10

6

99


TABL

E 1.

Cha

ract

eris

tics

of R

SV-p

osit

ive

pati

ents

— co

ntin

ued.

Patie

nt ch

arac

teris

tics

12

34

56

78

Trea

tmen

tN

ON

ON

ON

ON

ON

ON

OA

ntib

iotic

s

RSV

-att

ribut

able

de

ath

N/A

N/A

N/A

NO

N/A

NO

NO

N/A

Out

com

eA

live

and

wel

lA

live

and

wel

lA

live

and

wel

lD

ied

+27

mon

ths:

cG

VH

D,

aspe

rgil-

losi

s,

orga

n fa

ilure

Aliv

e,

prog

res-

sive

un-

derly

ing

dise

ase

Die

d +5

3 da

ys:

aspe

rgil-

losi

s,

imm

une-

med

iate

d lu

ng

dise

ase

Die

d +7

m

onth

s:R

elap

sed

dise

ase

Aliv

e an

d w

ell

* Dia

gnos

is: A

LL =

acu

te ly

mph

obla

stic

leuk

emia

, MPS

1 =

Muc

oPol

ySac

harr

idos

e ty

pe I

= H

urle

rs d

isea

se, M

PS II

I = M

ucoP

olyS

acha

r-rid

ose

type

III =

San

Fili

ppo’

s di

seas

e, X

-CG

D =

X-li

nked

chr

onic

gra

nulo

mat

ous

dise

ase,

HLH

= H

ered

itary

Hem

ofag

ocyt

ic L

ymph

ohis

-tio

cyto

sis.

**

Typ

e of

don

or: 1

0/10

MU

D =

fully

mat

ched

unr

elat

ed d

onor

, uC

B =

unr

elat

ed C

ord

Blo

od, 5

/6 a

nd 6

/6 in

dica

tes

HLA

mat

ch.

*** C

ondi

tioni

ng re

gim

en: B

u =

Bus

ulfa

n, C

y =

Cyc

lofo

sfam

ide,

VP1

6 =

Etop

osid

e, A

TG =

ant

i thy

moc

yte

glob

ulin

, TB

I = to

tal b

ody

irrad

i-at

ion,

Tre

o =

Treo

sulfa

n, F

lu =

Flu

dara

bine

. **

** G

VH

D p

rofy

laxi

s: C

sA =

Cic

losp

orin

e A

, MTX

= M

etho

trex

ate,

Pre

d =

Pred

niso

ne.

§ ISI

-RSV

= im

mun

odef

icie

ncy

scor

ing

inde

x fo

r RSV

infe

ctio

n, in

a p

edia

tric

coh

ort m

ax 1

0, lo

w ri

sk 0

-2, m

oder

ate

risk

3-6,

hig

h ris

k 7-

10

6

100

Results

Results

During the study period, 310 children with a median age of 7.3 (0.1-22.7) years, received an allogenic HCT. The indication for transplantation was malignant disease in 53%. Non-malignant indications included bone marrow failure syndromes, inborn errors of meta-bolism and primary immune deficiencies. All patients received myelo-ablative conditio-ning; in 76% an unrelated donor was used.

RSV-infection was detected in 8 patients (3%) with a median age of 5.2 years (0.2–11 years), Table 1. All infections were community-acquired. Seven patients (88%) contracted RSV before start of conditioning (day -21 to -9 pre-HCT). According to ISI-RSV, 7 patients had a high risk for progression to serious RSV-disease. Only one patient had signs of LRTI at diagnosis. In three patients we saw RSV shedding for 2-7 months.

Most patients presented with URTI and did not progress to LRTI. Patient 6, developed dyspnea and hypoxia 3 weeks after HCT, 5 weeks after positive PCR for RSV. Although repeated BAL still showed RSV (CT value 15, compared to 27 pre-HCT), invasive fungal infection was more likely to be the cause of symptoms, based on positive BAL galacto-mannan and findings on chest-HRCT. After initial recovery with antifungal treatment and neutrophil engraftment, the patient died 3 weeks later from respiratory deterioration from a combination of allo-immune lung disease and fungal infection. Patient 7, with initial signs of rhinitis 2 weeks prior to HCT, progressed to LRTI with tachypnea more than 5 weeks later. BAL was still positive for RSV (CT value 18, versus 23 pre-HCT) and negative for other pathogens. At that time, there were early signs of neutrophil engraft-ment. The patient was not hypoxemic and recovered spontaneously within several days. Clinically this was likely to be a mild engraftment syndrome. The patient with RSV ac-quisition post-HCT (patient 8), was also the only child with signs of LRTI at presentation, with tachypnea, cough, hypoxia and fever. She had a normal neutrophil count and only mild lymphopenia. With extra oxygen, stress dose steroids and antibiotics, there was an uneventful recovery within 5 days.

Overall, none of the patients received antiviral treatment, none of the patients had severe RSV-related disease and there were no RSV-attributable deaths.

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Results

Results

During the study period, 310 children with a median age of 7.3 (0.1-22.7) years, received an allogenic HCT. The indication for transplantation was malignant disease in 53%. Non-malignant indications included bone marrow failure syndromes, inborn errors of meta-bolism and primary immune deficiencies. All patients received myelo-ablative conditio-ning; in 76% an unrelated donor was used.

RSV-infection was detected in 8 patients (3%) with a median age of 5.2 years (0.2–11 years), Table 1. All infections were community-acquired. Seven patients (88%) contracted RSV before start of conditioning (day -21 to -9 pre-HCT). According to ISI-RSV, 7 patients had a high risk for progression to serious RSV-disease. Only one patient had signs of LRTI at diagnosis. In three patients we saw RSV shedding for 2-7 months.

Most patients presented with URTI and did not progress to LRTI. Patient 6, developed dyspnea and hypoxia 3 weeks after HCT, 5 weeks after positive PCR for RSV. Although repeated BAL still showed RSV (CT value 15, compared to 27 pre-HCT), invasive fungal infection was more likely to be the cause of symptoms, based on positive BAL galacto-mannan and findings on chest-HRCT. After initial recovery with antifungal treatment and neutrophil engraftment, the patient died 3 weeks later from respiratory deterioration from a combination of allo-immune lung disease and fungal infection. Patient 7, with initial signs of rhinitis 2 weeks prior to HCT, progressed to LRTI with tachypnea more than 5 weeks later. BAL was still positive for RSV (CT value 18, versus 23 pre-HCT) and negative for other pathogens. At that time, there were early signs of neutrophil engraft-ment. The patient was not hypoxemic and recovered spontaneously within several days. Clinically this was likely to be a mild engraftment syndrome. The patient with RSV ac-quisition post-HCT (patient 8), was also the only child with signs of LRTI at presentation, with tachypnea, cough, hypoxia and fever. She had a normal neutrophil count and only mild lymphopenia. With extra oxygen, stress dose steroids and antibiotics, there was an uneventful recovery within 5 days.

Overall, none of the patients received antiviral treatment, none of the patients had severe RSV-related disease and there were no RSV-attributable deaths.

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Discussion

In this single center study, all HCT-recipients were routinely screened for RSV, while the absence of immunoprophylaxis or antiviral treatment allowed us to study the natural course of disease. The incidence of RSV was low (3%). Although most children acquired RSV pre-HCT, and received subsequent full myeloablative conditioning, none of them developed severe RSV-disease, despite not being treated.

To our knowledge this is the first report on untreated RSV-infection early during HCT in children. Reported incidence of RSV in HCT-recipients varies between 1-17%,8,9 de-pending largely on season, patients’ age and detection methods. Progression to LRTI occurs in 18-55%,8,10 with risk factors for progression related to age, donor source, use of steroids, immune status and concomitant infections.1,7,10,11 Our results are in line with these numbers, although LRTI was clinically less severe in our patients.

RSV-related mortality of 10-45% has been reported.8,10-14 Here, our results compare favor-able. Moreover, it is important to realize that in almost all pediatric studies, RSV-positive patients were treated with the antiviral drug ribavirin,13 with anti-RSV monoclonal an-tibodies (palivizumab) or with non-specific intravenous immunoglobulins,15 or with a combination.12

Teusink et al. saw no change in the incidence of RSV-infection, nor in the course of disease in RSV-infected HCT-recipients after cost-saving restriction of the use of prophy-lactic palivizumab in their center, which made them change their preventive strategy.16 One other study determined natural course of disease in untreated RSV-infection. In an outpatient care unit, 31 adult HCT-patients showed similar favourable course of RSV-infection detected at a median of 7 weeks after HCT, which was explained by some resto-ration of immunity.17 These two studies underline our conclusions that prophylaxis nor treatment is routinely indicated for RSV in HCT.

In healthy infants, there is supporting evidence for an important role of immune medi-ated pathology in RSV-disease. Upregulation of pro-inflammatory cytokines and chemo-kines and recruitment of neutrophils, results in a cascade of inflammation that can inhe-rently exert pathogenic as well as protective effects.18 There is incomplete understanding of the immune response to RSV in an immune compromised host, and data suggest that morbidity and mortality are not correlated to the degree of immune suppression.15 The absence of immunity may in fact aid to prevent neutrophil exerted epithelial damage upon RSV-infection. Likewise, we have shown that infection with respiratory viruses early during HCT does not directly progress to LRTI, but that symptoms only occur when there is some immune-recovery, with an important increased risk for allo-immune mediated lung syndromes.7,19

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Discussion

In this single center study, all HCT-recipients were routinely screened for RSV, while the absence of immunoprophylaxis or antiviral treatment allowed us to study the natural course of disease. The incidence of RSV was low (3%). Although most children acquired RSV pre-HCT, and received subsequent full myeloablative conditioning, none of them developed severe RSV-disease, despite not being treated.

To our knowledge this is the first report on untreated RSV-infection early during HCT in children. Reported incidence of RSV in HCT-recipients varies between 1-17%,8,9 de-pending largely on season, patients’ age and detection methods. Progression to LRTI occurs in 18-55%,8,10 with risk factors for progression related to age, donor source, use of steroids, immune status and concomitant infections.1,7,10,11 Our results are in line with these numbers, although LRTI was clinically less severe in our patients.

RSV-related mortality of 10-45% has been reported.8,10-14 Here, our results compare favor-able. Moreover, it is important to realize that in almost all pediatric studies, RSV-positive patients were treated with the antiviral drug ribavirin,13 with anti-RSV monoclonal an-tibodies (palivizumab) or with non-specific intravenous immunoglobulins,15 or with a combination.12

Teusink et al. saw no change in the incidence of RSV-infection, nor in the course of disease in RSV-infected HCT-recipients after cost-saving restriction of the use of prophy-lactic palivizumab in their center, which made them change their preventive strategy.16 One other study determined natural course of disease in untreated RSV-infection. In an outpatient care unit, 31 adult HCT-patients showed similar favourable course of RSV-infection detected at a median of 7 weeks after HCT, which was explained by some resto-ration of immunity.17 These two studies underline our conclusions that prophylaxis nor treatment is routinely indicated for RSV in HCT.

In healthy infants, there is supporting evidence for an important role of immune medi-ated pathology in RSV-disease. Upregulation of pro-inflammatory cytokines and chemo-kines and recruitment of neutrophils, results in a cascade of inflammation that can inhe-rently exert pathogenic as well as protective effects.18 There is incomplete understanding of the immune response to RSV in an immune compromised host, and data suggest that morbidity and mortality are not correlated to the degree of immune suppression.15 The absence of immunity may in fact aid to prevent neutrophil exerted epithelial damage upon RSV-infection. Likewise, we have shown that infection with respiratory viruses early during HCT does not directly progress to LRTI, but that symptoms only occur when there is some immune-recovery, with an important increased risk for allo-immune mediated lung syndromes.7,19

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Discussion

The strength of our study is that we performed routine pre-transplant screening for res-piratory viruses in all patients, including those with assumed high risk factors for severe RSV disease such as cord-blood transplant, young age, severe lymphopenia and neu-tropenia.7 This study is limited by the small number of patients. We cannot exclude there is a subgroup of patients with increased risk of severe RSV-infection.

In short, there was no case of severe RSV infection in 310 high-risk HCT recipients wit-hout specific treatment. The excellent outcome supports a restrictive policy in the use of preventive or antiviral treatment.

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Discussion

The strength of our study is that we performed routine pre-transplant screening for res-piratory viruses in all patients, including those with assumed high risk factors for severe RSV disease such as cord-blood transplant, young age, severe lymphopenia and neu-tropenia.7 This study is limited by the small number of patients. We cannot exclude there is a subgroup of patients with increased risk of severe RSV-infection.

In short, there was no case of severe RSV infection in 310 high-risk HCT recipients wit-hout specific treatment. The excellent outcome supports a restrictive policy in the use of preventive or antiviral treatment.

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1. Chemaly RF, Shah DP, Boeckh MJ. Ma-nagement of respiratory viral infections in hematopoietic cell transplant reci-pients and patients with hematologic malignancies. Clin Infect Dis 2014; 59 Suppl 5: S344-51.

2. Shah DP, Ghantoji SS, Shah JN, et al. Impact of aerosolized ribavirin on mor-tality in 280 allogeneic haematopoie-tic stem cell transplant recipients with respiratory syncytial virus infections. J Antimicrob Chemother 2013; 68(8): 1872-80.

3. Waghmare A, Englund JA, Boeckh M. How I treat respiratory viral infections in the setting of intensive chemotherapy or hematopoietic cell transplantation. Blood 2016; 127(22): 2682-92.

4. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on Infec-tions in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluen-za virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013; 56(2): 258-66.

5. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High Diagnostic Yield of Dedicated Pulmona-ry Screening before Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant 2015; 21(9): 1622-6.

6. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the deve-lopment of life-threatening acute and chronic alloimmune lung syndromes. Biol Blood Marrow Transplant 2010; 16(6): 782-91.

7. Shah DP, Ghantoji SS, Ariza-Heredia EJ, et al. Immunodeficiency scoring index

to predict poor outcomes in hemato-poietic cell transplant recipients with RSV infections. Blood 2014; 123(21): 3263-8.

8. Shah DP, Ghantoji SS, Mulanovich VE, Ariza-Heredia EJ, Chemaly RF. Manage-ment of respiratory viral infections in hematopoietic cell transplant recipients. Am J Blood Res 2012; 2(4): 203-18.

9. Robinson JL, Grenier D, MacLusky I, Al-len UD. Respiratory syncytial virus infec-tions in pediatric transplant recipients: A Canadian Paediatric Surveillance Pro-gram study. Pediatr Transplant 2015; 19(6): 659-62.

10. Kim YJ, Guthrie KA, Waghmare A, et al. Respiratory syncytial virus in hemato-poietic cell transplant recipients: factors determining progression to lower res-piratory tract disease. J Infect Dis 2014; 209(8): 1195-204.

11. Renaud C, Xie H, Seo S, et al. Mortality rates of human metapneumovirus and respiratory syncytial virus lower respi-ratory tract infections in hematopoie-tic cell transplantation recipients. Biol Blood Marrow Transplant 2013; 19(8): 1220-6.

12. Chávez-Bueno S, Mejías A, Merryman RA, Ahmad N, Jafri HS, Ramilo O. Intra-venous palivizumab and ribavirin com-bination for respiratory syncytial virus disease in high-risk pediatric patients. Pediatr Infect Dis J 2007; 26(12): 1089-93.

13. Molinos-Quintana A, Pérez-de Soto C, Gómez-Rosa M, Pérez-Simón JA, Pérez-Hurtado JM. Intravenous ribavirin for respiratory syncytial viral infections in pediatric hematopoietic SCT recipients. Bone Marrow Transplant 2013; 48(2): 265-8.

14. Waghmare A, Campbell AP, Xie H, et al. Respiratory syncytial virus lower respira-

References

6

103


1. Chemaly RF, Shah DP, Boeckh MJ. Ma-nagement of respiratory viral infections in hematopoietic cell transplant reci-pients and patients with hematologic malignancies. Clin Infect Dis 2014; 59 Suppl 5: S344-51.

2. Shah DP, Ghantoji SS, Shah JN, et al. Impact of aerosolized ribavirin on mor-tality in 280 allogeneic haematopoie-tic stem cell transplant recipients with respiratory syncytial virus infections. J Antimicrob Chemother 2013; 68(8): 1872-80.

3. Waghmare A, Englund JA, Boeckh M. How I treat respiratory viral infections in the setting of intensive chemotherapy or hematopoietic cell transplantation. Blood 2016; 127(22): 2682-92.

4. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on Infec-tions in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluen-za virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013; 56(2): 258-66.

5. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High Diagnostic Yield of Dedicated Pulmona-ry Screening before Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant 2015; 21(9): 1622-6.

6. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoietic stem cell transplantation and the deve-lopment of life-threatening acute and chronic alloimmune lung syndromes. Biol Blood Marrow Transplant 2010; 16(6): 782-91.

7. Shah DP, Ghantoji SS, Ariza-Heredia EJ, et al. Immunodeficiency scoring index

to predict poor outcomes in hemato-poietic cell transplant recipients with RSV infections. Blood 2014; 123(21): 3263-8.

8. Shah DP, Ghantoji SS, Mulanovich VE, Ariza-Heredia EJ, Chemaly RF. Manage-ment of respiratory viral infections in hematopoietic cell transplant recipients. Am J Blood Res 2012; 2(4): 203-18.

9. Robinson JL, Grenier D, MacLusky I, Al-len UD. Respiratory syncytial virus infec-tions in pediatric transplant recipients: A Canadian Paediatric Surveillance Pro-gram study. Pediatr Transplant 2015; 19(6): 659-62.

10. Kim YJ, Guthrie KA, Waghmare A, et al. Respiratory syncytial virus in hemato-poietic cell transplant recipients: factors determining progression to lower res-piratory tract disease. J Infect Dis 2014; 209(8): 1195-204.

11. Renaud C, Xie H, Seo S, et al. Mortality rates of human metapneumovirus and respiratory syncytial virus lower respi-ratory tract infections in hematopoie-tic cell transplantation recipients. Biol Blood Marrow Transplant 2013; 19(8): 1220-6.

12. Chávez-Bueno S, Mejías A, Merryman RA, Ahmad N, Jafri HS, Ramilo O. Intra-venous palivizumab and ribavirin com-bination for respiratory syncytial virus disease in high-risk pediatric patients. Pediatr Infect Dis J 2007; 26(12): 1089-93.

13. Molinos-Quintana A, Pérez-de Soto C, Gómez-Rosa M, Pérez-Simón JA, Pérez-Hurtado JM. Intravenous ribavirin for respiratory syncytial viral infections in pediatric hematopoietic SCT recipients. Bone Marrow Transplant 2013; 48(2): 265-8.

14. Waghmare A, Campbell AP, Xie H, et al. Respiratory syncytial virus lower respira-

References

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104

tory disease in hematopoietic cell trans-plant recipients: viral RNA detection in blood, antiviral treatment, and clinical outcomes. Clin Infect Dis 2013; 57(12): 1731-41.

15. El-Bietar J, Nelson A, Wallace G, et al. RSV infection without ribavirin treat-ment in pediatric hematopoietic stem cell transplantation. Bone Marrow Transplant 2016; 51(10): 1382-4.

16. Teusink-Cross A, Davies SM, Danziger-Isakov L, El-Bietar J, Grimley MS. Res-trictive Palivizumab Use Does Not Lead to Increased Morbidity and Mortality in Pediatric Hematopoietic Stem Cell Transplantation Patients. Biol Blood Marrow Transplant 2016; 22(10): 1904-6.

17. Mendes ET, Ramos J, Peixoto D, et al. An outbreak of respiratory syncytial vi-rus infection in hematopoietic stem cell transplantation outpatients: good outcome without specific antiviral tre-atment. Transpl Infect Dis 2013; 15(1): 42-8.

18. Russell CD, Unger SA, Walton M, Schwarze J. The Human Immune Res-ponse to Respiratory Syncytial Virus In-fection. Clin Microbiol Rev 2017; 30(2): 481-502.

19. Versluys B, Bierings M, Murk JL, et al. Infection with a respiratory virus before hematopoietic cell transplantation is associated with alloimmune-mediated lung syndromes. J Allergy Clin Immunol 2017.

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tory disease in hematopoietic cell trans-plant recipients: viral RNA detection in blood, antiviral treatment, and clinical outcomes. Clin Infect Dis 2013; 57(12): 1731-41.

15. El-Bietar J, Nelson A, Wallace G, et al. RSV infection without ribavirin treat-ment in pediatric hematopoietic stem cell transplantation. Bone Marrow Transplant 2016; 51(10): 1382-4.

16. Teusink-Cross A, Davies SM, Danziger-Isakov L, El-Bietar J, Grimley MS. Res-trictive Palivizumab Use Does Not Lead to Increased Morbidity and Mortality in Pediatric Hematopoietic Stem Cell Transplantation Patients. Biol Blood Marrow Transplant 2016; 22(10): 1904-6.

17. Mendes ET, Ramos J, Peixoto D, et al. An outbreak of respiratory syncytial vi-rus infection in hematopoietic stem cell transplantation outpatients: good outcome without specific antiviral tre-atment. Transpl Infect Dis 2013; 15(1): 42-8.

18. Russell CD, Unger SA, Walton M, Schwarze J. The Human Immune Res-ponse to Respiratory Syncytial Virus In-fection. Clin Microbiol Rev 2017; 30(2): 481-502.

19. Versluys B, Bierings M, Murk JL, et al. Infection with a respiratory virus before hematopoietic cell transplantation is associated with alloimmune-mediated lung syndromes. J Allergy Clin Immunol 2017.

6

7Infection with a respiratory virus before hematopoietic cell transplantation is associatedwith alloimmune-mediated lung syndromes

7Infection with a respiratory virus before hematopoietic cell transplantation is associatedwith alloimmune-mediated lung syndromes

Pre HCT BAL Respiratory virus PCR-negative

Respiratory virus PCR-positive

aGVHD(treatment for)

Increased risk

Decreased risk

Alloimmune Lung Syndromes withTRM OS

Time after HCT

HCT = Hematopoietic Cell Transplantation TRM = Treatment Related MortalityOS= Overall Survival aGVHD = acute Graft versus Host Disease

Infection with a respiratory virus beforehematopoietic cell transplantation is associatedwith alloimmune-mediated lung syndromes

A.B. Versluys, M.B. Bierings, J.L. Murk, T.F.W. Wolfs, C.A. Lindemans, C.K. van der Ent, J.J. Boelens

J Allergy Clin Immunol 2017; 141: 697-703.e8




Increased risk

Decreased risk


Time after HCT


Infection with a respiratory virus beforehematopoietic cell transplantation is associatedwith alloimmune-mediated lung syndromes

A.B. Versluys, M.B. Bierings, J.L. Murk, T.F.W. Wolfs, C.A. Lindemans, C.K. van der Ent, J.J. Boelens

J Allergy Clin Immunol 2017; 141: 697-703.e8

109

Respiratory virus infection pre-HCT and alloimmune-mediated lung syndromes

7

Abstract

Background Alloimmune-mediated lung syndromes (allo-LSs) are life-threatening complications after hematopoietic cell transplantation (HCT). Respiratory virus (RV) has been suggested to play a role in the pathogenesis.

Objective We studied the relation between RV DNA/RNA detection in the upper/lower airways before HCT and the oc-currence of allo-LSs.

Methods We retrospectively analyzed all HCT recipients between 2004 and 2014, in whom real-time PCR for RV was performed in nasopharyngeal aspirates (NPAs) and bron-choalveolar lavage (BAL) fluid before HCT. The main out-come of interest was the presence of an allo-LS, which was defined as idiopathic pneumonia syndrome or bronchiolitis obliterans syndrome. Other outcomes were overall survival and treatment-related mortality. We used Cox proportional hazard models, logistic regression models, and Fine-Gray competing risk regression for analyses.

Results One hundred seventy-nine children (median age, 6.8 years) were included.RVs were found in 61% (41% in BAL fluid/NPAs and 20% in NPAs only). Rhinovirus was the most frequently detected RV (42%). Allo-LSs occurred in 13%. RV positivity in BAL fluid was a predictor for allo-LSs (hazard ratio, 3.8; 95%CI, 1.4-10.7; P = .01), whereas RV positivity in NPAs only was not. No other predictors were found. Grade II to IV acute graft-versus-host disease related to steroid treatment shows a trend toward a protective effect (odds ra-tio, 0.16; 95% CI, 0.0-1.3;P = .08). Allo-LSs significantly incre-ased treatment-related mortality (52% ± 10% in allo-LSs and 20% ± 4% in non–allo-LSs, P = .007).

Conclusions These results show that pre-HCT BAL fluid RVpositivity was a predictor for allo-LSs. Screening for RVs befo-re HCT might identify patients at risk for allo-LSs. This couldhave implications for prevention and treatment and might subsequently influence the outcomes of HCT.



M.B. Bierings C.A. Lindemans

J.J. Boelens

Department of Virology and Microbiology, UMCU, Utrecht, The Netherlands

J.L. Murk

Department of Paedia-tric Infectious Diseases,

UMCU, Utrecht, The Netherlands T.F.W. Wolfs

Department of Paediatric Pulmonology, UMCU,

Utrecht, The Netherlands C.K. van der Ent

U-DANCE Laboratory of Translational Immuno-

logy, UMCU, Utrecht, The Netherlands

J.J. Boelens

109


7

Abstract

Background Alloimmune-mediated lung syndromes (allo-LSs) are life-threatening complications after hematopoietic cell transplantation (HCT). Respiratory virus (RV) has been suggested to play a role in the pathogenesis.

Objective We studied the relation between RV DNA/RNA detection in the upper/lower airways before HCT and the oc-currence of allo-LSs.

Methods We retrospectively analyzed all HCT recipients between 2004 and 2014, in whom real-time PCR for RV was performed in nasopharyngeal aspirates (NPAs) and bron-choalveolar lavage (BAL) fluid before HCT. The main out-come of interest was the presence of an allo-LS, which was defined as idiopathic pneumonia syndrome or bronchiolitis obliterans syndrome. Other outcomes were overall survival and treatment-related mortality. We used Cox proportional hazard models, logistic regression models, and Fine-Gray competing risk regression for analyses.

Results One hundred seventy-nine children (median age, 6.8 years) were included.RVs were found in 61% (41% in BAL fluid/NPAs and 20% in NPAs only). Rhinovirus was the most frequently detected RV (42%). Allo-LSs occurred in 13%. RV positivity in BAL fluid was a predictor for allo-LSs (hazard ratio, 3.8; 95%CI, 1.4-10.7; P = .01), whereas RV positivity in NPAs only was not. No other predictors were found. Grade II to IV acute graft-versus-host disease related to steroid treatment shows a trend toward a protective effect (odds ra-tio, 0.16; 95% CI, 0.0-1.3;P = .08). Allo-LSs significantly incre-ased treatment-related mortality (52% ± 10% in allo-LSs and 20% ± 4% in non–allo-LSs, P = .007).

Conclusions These results show that pre-HCT BAL fluid RVpositivity was a predictor for allo-LSs. Screening for RVs befo-re HCT might identify patients at risk for allo-LSs. This couldhave implications for prevention and treatment and might subsequently influence the outcomes of HCT.



M.B. Bierings C.A. Lindemans

J.J. Boelens

Department of Virology and Microbiology, UMCU, Utrecht, The Netherlands

J.L. Murk

Department of Paedia-tric Infectious Diseases,

UMCU, Utrecht, The Netherlands T.F.W. Wolfs

Department of Paediatric Pulmonology, UMCU,

Utrecht, The Netherlands C.K. van der Ent

U-DANCE Laboratory of Translational Immuno-

logy, UMCU, Utrecht, The Netherlands

J.J. Boelens

110

Introduction

Introduction

Allogeneic hematopoietic cell transplantation (HCT) is a curative treatment for several malignant and nonmalignant childhood diseases. Its success is limited by toxic events. Pulmonary complications contribute to posttransplantation morbidity and mortality. Noninfectious causes, such as alloimmune-mediated lung syndromes (allo-LSs), are res-ponsible for a significant proportion of posttransplantation lung injury in pediatric HCT recipients.1

There is growing interest in the role of the microbiome in patients with graft-versus-host disease (GVHD). Pretransplanta-tion conditioning regimens disrupt the intestinal bar-rier, and the gut flora shows major changes during HCT, causing dysregulation of intes-tinal immune homeostasis, which can eventually lead to acute graft-versus-host disease (aGVHD).2,3 Little is known about the respiratory microbiome and its relation to health and disease.4

Studies in patients undergoing lung transplantation or allogeneic HCT suggest that the presence of common cold viruses early after transplantation is associated with either graft rejection (in lung transplantation) or development of alloimmune lung disease (in HCT).5,6 On this basis, we hypothesize that early presence of viruses in the respiratory tract can cause tissue damage, resulting in activation of the alloimmune system. Howe-ver, distinguishing allo-LSs from progressive viral infection remains a point of contro-versy.

To assess the effect of common cold viruses on the development of allo-LSs, we perfor-med a retrospective analysis to relate the presence of viral DNA/RNA in either nasopha-ryngeal aspirates (NPAs), bronchoalveolar lavage (BAL) fluid, or both to various outcome parameters, such as allo-LSs and survival.

Methods

Study design and patientsWe included all consecutive pediatric patients receiving their first allogeneic HCT from January 2004 to October 2013 who underwent routine BAL and nasal aspiration accor-ding to our previously described pre-HCT screening protocol, which consisted of chest high-resolution computed tomography (HRCT), pulmonary function tests (PFTs; in children >5 years of age), nasal aspiration for viral tests, and BAL for viral, bacterial, and fungal diagnostics.7 Clinical data were collected prospectively, starting before conditio-ning, and registered in the clinical database. Minimum follow-up for surviving patients was 6 months. Patients were included and data were collected after written informed

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110

Introduction

Introduction

Allogeneic hematopoietic cell transplantation (HCT) is a curative treatment for several malignant and nonmalignant childhood diseases. Its success is limited by toxic events. Pulmonary complications contribute to posttransplantation morbidity and mortality. Noninfectious causes, such as alloimmune-mediated lung syndromes (allo-LSs), are res-ponsible for a significant proportion of posttransplantation lung injury in pediatric HCT recipients.1

There is growing interest in the role of the microbiome in patients with graft-versus-host disease (GVHD). Pretransplanta-tion conditioning regimens disrupt the intestinal bar-rier, and the gut flora shows major changes during HCT, causing dysregulation of intes-tinal immune homeostasis, which can eventually lead to acute graft-versus-host disease (aGVHD).2,3 Little is known about the respiratory microbiome and its relation to health and disease.4

Studies in patients undergoing lung transplantation or allogeneic HCT suggest that the presence of common cold viruses early after transplantation is associated with either graft rejection (in lung transplantation) or development of alloimmune lung disease (in HCT).5,6 On this basis, we hypothesize that early presence of viruses in the respiratory tract can cause tissue damage, resulting in activation of the alloimmune system. Howe-ver, distinguishing allo-LSs from progressive viral infection remains a point of contro-versy.

To assess the effect of common cold viruses on the development of allo-LSs, we perfor-med a retrospective analysis to relate the presence of viral DNA/RNA in either nasopha-ryngeal aspirates (NPAs), bronchoalveolar lavage (BAL) fluid, or both to various outcome parameters, such as allo-LSs and survival.

Methods

Study design and patientsWe included all consecutive pediatric patients receiving their first allogeneic HCT from January 2004 to October 2013 who underwent routine BAL and nasal aspiration accor-ding to our previously described pre-HCT screening protocol, which consisted of chest high-resolution computed tomography (HRCT), pulmonary function tests (PFTs; in children >5 years of age), nasal aspiration for viral tests, and BAL for viral, bacterial, and fungal diagnostics.7 Clinical data were collected prospectively, starting before conditio-ning, and registered in the clinical database. Minimum follow-up for surviving patients was 6 months. Patients were included and data were collected after written informed

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consent was obtained in accordance with the Declaration of Helsinki. Institutional ethics committee approval for sample and data collection was obtained through trial numbers 05/143 and 11/063-k.

ProceduresBAL was performed after achievement of general anesthesia (only if patients had a pro-cedure requiring anesthesia planned [ie, central line placement or HRCT in younger children]) by instilling 10 mL of normal saline aliquots through an endotracheal catheter wedged in the distal bronchi. From 2007, all patients underwent BAL (except for pa-tients who did not have general anesthesia); before 2007, all patients underwent nasal aspiration, but not all had a paired BAL sample taken. Nasal aspiration was done with a disposable catheter connected to a mucous trap. Dry nasopharyngeal suction was perfor-med, followed by instillation and immediate suction of 2 to 3 mL of sterile normal saline through the catheter.

Real-time PCR for RVs was performed, as described previously.8 For detection of RNA viruses, cDNA was synthesized with MultiScribe Reverse Transcriptase and random hexamers (Applied Biosystems, Foster City, Calif ). Detection of viral pathogens was performed in parallel by using real-time PCR assays specific for the following viru-ses: bocavirus; human herpesvirus 6; respiratory syncytial virus; influenzavirus A and B; parainfluenzavirus 1 to 4; rhinoviruses; adenoviruses; human coronaviruses OC43, NL63, and 229E; human metapneumovirus, and Mycoplasma pneumoniae. Semiquanti-tative viral load was expressed in cycle threshold (Ct) values.

In case of a positive RV result, we postponed the HCT procedure with 2 weeks in elective HCT (non–primary immunodeficiency benign disorders) and/or we prolonged immu-nosuppressive therapy after HCT as allo-LS prophylaxis. This fits our hypothesis that RV positivity is a predictor for allo-LSs and that steroid treatment for aGVHD has a protec-tive effect on the occurrence of allo-LSs.6 Apart from the pre-HCT screening, no routine moni-toring for RV was performed. Only in the case of onset/progression of respiratory symptoms was nasal aspiration, BAL, or both repeated.

Conditioning regimens were performed according to international protocols. In patients with nonmalignant disease, thus consisted of targeted busulfan (area under the curve, 90 mg h/L in 4 days) and fludarabine (160 mg/m2 in 4 days). In patients with malignant disease, either fractioned total-body irradiation–based conditioning (3 x 2 x 2 Gy; etopo-side, 60 mg/kg) or targeted busulfan (area under the curve, 90 mg h/L) plus fludarabine (160 mg/m2) or fludarabine plus clofarabine (40 and 120 mg/m2) was given, depending on the patient’s age, myeloid or lymphoid origin of disease, central nervous system invol-vement, and high-risk disease characteristics. In patients receiving an unrelated donor transplant, serotherapy was performed with antithymocyte globulin (thymoglobulin). In

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consent was obtained in accordance with the Declaration of Helsinki. Institutional ethics committee approval for sample and data collection was obtained through trial numbers 05/143 and 11/063-k.

ProceduresBAL was performed after achievement of general anesthesia (only if patients had a pro-cedure requiring anesthesia planned [ie, central line placement or HRCT in younger children]) by instilling 10 mL of normal saline aliquots through an endotracheal catheter wedged in the distal bronchi. From 2007, all patients underwent BAL (except for pa-tients who did not have general anesthesia); before 2007, all patients underwent nasal aspiration, but not all had a paired BAL sample taken. Nasal aspiration was done with a disposable catheter connected to a mucous trap. Dry nasopharyngeal suction was perfor-med, followed by instillation and immediate suction of 2 to 3 mL of sterile normal saline through the catheter.

Real-time PCR for RVs was performed, as described previously.8 For detection of RNA viruses, cDNA was synthesized with MultiScribe Reverse Transcriptase and random hexamers (Applied Biosystems, Foster City, Calif ). Detection of viral pathogens was performed in parallel by using real-time PCR assays specific for the following viru-ses: bocavirus; human herpesvirus 6; respiratory syncytial virus; influenzavirus A and B; parainfluenzavirus 1 to 4; rhinoviruses; adenoviruses; human coronaviruses OC43, NL63, and 229E; human metapneumovirus, and Mycoplasma pneumoniae. Semiquanti-tative viral load was expressed in cycle threshold (Ct) values.

In case of a positive RV result, we postponed the HCT procedure with 2 weeks in elective HCT (non–primary immunodeficiency benign disorders) and/or we prolonged immu-nosuppressive therapy after HCT as allo-LS prophylaxis. This fits our hypothesis that RV positivity is a predictor for allo-LSs and that steroid treatment for aGVHD has a protec-tive effect on the occurrence of allo-LSs.6 Apart from the pre-HCT screening, no routine moni-toring for RV was performed. Only in the case of onset/progression of respiratory symptoms was nasal aspiration, BAL, or both repeated.

Conditioning regimens were performed according to international protocols. In patients with nonmalignant disease, thus consisted of targeted busulfan (area under the curve, 90 mg h/L in 4 days) and fludarabine (160 mg/m2 in 4 days). In patients with malignant disease, either fractioned total-body irradiation–based conditioning (3 x 2 x 2 Gy; etopo-side, 60 mg/kg) or targeted busulfan (area under the curve, 90 mg h/L) plus fludarabine (160 mg/m2) or fludarabine plus clofarabine (40 and 120 mg/m2) was given, depending on the patient’s age, myeloid or lymphoid origin of disease, central nervous system invol-vement, and high-risk disease characteristics. In patients receiving an unrelated donor transplant, serotherapy was performed with antithymocyte globulin (thymoglobulin). In

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Methods

patients with very high-risk malignancies (relapsed myeloid leukemia and early relapsed lymphoid leukemia) receiving a cord blood (CB) donor, we omitted antithymocyte globu-lin from December 2012 onward.

Stool samples and nose/throat swabs were cultured weekly to monitor for bacterial co-lonization. Plasma was tested weekly for the presence of EBV, cytomegalovirus, human herpesvirus 6, and adenovirus DNA by using real-time PCR. Weekly galactomannan tes-ting (Platelia Aspergillus enzyme immunoassay; Bio-Rad Laboratories, Hercules, Calif ) was performed to screen for Aspergillus species infection.

Antimicrobial prophylaxis involved daily ciprofloxacin and fluconazole during neutrope-nia, with additional prophylaxis against Streptococcus viridans with cefazolin in the mu-cositis phase. Pneumocystis jirovecii pneumonia prophylaxis was administered as co-trim-oxazole 3 times a week. In case of positive serologic results for herpes simplex virus (in all patients) and varicella zoster virus (in CB recipients), prophylaxis with acyclovir was given. No other antiviral prophylaxis was given. In high-risk patients for invasive fun-gal infection, Aspergillus species prophylaxis was done with daily voriconazole or twice-weekly amphotericin B.

GVHD prophylaxis consisted of cyclosporine (through a level of 150-250 mg/L) in all patients. In CB recipients we added prednisolone (1 mg/kg/d for 28 days); in patients receiving an unrelated volunteer donor transplant, methotrexate (short course, 10 mg/m2 on days 1, 3, and 6) was added to cyclosporine. From 2013, we also administered a short course of methotrexate to patients receiving bone marrow from an HLA-matched sibling.

Treatment of allo-LSs consisted of 10 mg/kg/d intravenous methylprednisolone for 3 days and 2 mg/kg/d thereafter, tapering by 25% per week to 0.5 mg/kg/d. Methylprednisolone pulses were repeated monthly until recovery up to a maximum of 6 pulses. Recovery was defined as normalization of PFTs, resolved symptoms, or both. In between subsequent pulses, 0.5 mg/kg/d prednisone was administered. Other immunosuppressive agents (usually cyclosporine) were continued. In addition, azithromycin was given because of its suggested immunomodulatory effect. Along with immunosuppressive therapy, sup-portive care was provided with extra oxygen and mechanical ventilation, when necessary.

OutcomesThe main outcome of interest was the occurrence of allo-LSs, which were defined as idiopathic pneumonia syndrome (IPS) or bronchiolitis obliterans syndrome (BOS). IPS is defined by the American Thoracic Society as evidence of widespread lung injury by clinical symptoms and radiologic abnormalities in the absence of active lower respiratory tract infection and other factors explaining pulmonary dysfunction (cardiac dysfunction, fluid overload, or renal failure).9 BOS is defined according to the National Institutes of Health Consensus Criteria on Chronic GVHD 2014 as an FEV1/vital capacity ratio of less

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Methods

patients with very high-risk malignancies (relapsed myeloid leukemia and early relapsed lymphoid leukemia) receiving a cord blood (CB) donor, we omitted antithymocyte globu-lin from December 2012 onward.

Stool samples and nose/throat swabs were cultured weekly to monitor for bacterial co-lonization. Plasma was tested weekly for the presence of EBV, cytomegalovirus, human herpesvirus 6, and adenovirus DNA by using real-time PCR. Weekly galactomannan tes-ting (Platelia Aspergillus enzyme immunoassay; Bio-Rad Laboratories, Hercules, Calif ) was performed to screen for Aspergillus species infection.

Antimicrobial prophylaxis involved daily ciprofloxacin and fluconazole during neutrope-nia, with additional prophylaxis against Streptococcus viridans with cefazolin in the mu-cositis phase. Pneumocystis jirovecii pneumonia prophylaxis was administered as co-trim-oxazole 3 times a week. In case of positive serologic results for herpes simplex virus (in all patients) and varicella zoster virus (in CB recipients), prophylaxis with acyclovir was given. No other antiviral prophylaxis was given. In high-risk patients for invasive fun-gal infection, Aspergillus species prophylaxis was done with daily voriconazole or twice-weekly amphotericin B.

GVHD prophylaxis consisted of cyclosporine (through a level of 150-250 mg/L) in all patients. In CB recipients we added prednisolone (1 mg/kg/d for 28 days); in patients receiving an unrelated volunteer donor transplant, methotrexate (short course, 10 mg/m2 on days 1, 3, and 6) was added to cyclosporine. From 2013, we also administered a short course of methotrexate to patients receiving bone marrow from an HLA-matched sibling.

Treatment of allo-LSs consisted of 10 mg/kg/d intravenous methylprednisolone for 3 days and 2 mg/kg/d thereafter, tapering by 25% per week to 0.5 mg/kg/d. Methylprednisolone pulses were repeated monthly until recovery up to a maximum of 6 pulses. Recovery was defined as normalization of PFTs, resolved symptoms, or both. In between subsequent pulses, 0.5 mg/kg/d prednisone was administered. Other immunosuppressive agents (usually cyclosporine) were continued. In addition, azithromycin was given because of its suggested immunomodulatory effect. Along with immunosuppressive therapy, sup-portive care was provided with extra oxygen and mechanical ventilation, when necessary.

OutcomesThe main outcome of interest was the occurrence of allo-LSs, which were defined as idiopathic pneumonia syndrome (IPS) or bronchiolitis obliterans syndrome (BOS). IPS is defined by the American Thoracic Society as evidence of widespread lung injury by clinical symptoms and radiologic abnormalities in the absence of active lower respiratory tract infection and other factors explaining pulmonary dysfunction (cardiac dysfunction, fluid overload, or renal failure).9 BOS is defined according to the National Institutes of Health Consensus Criteria on Chronic GVHD 2014 as an FEV1/vital capacity ratio of less

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than 0.7, FEV1 of less than 75%, and evidence of air-trapping (on PFTs or HRCT scans) in the absence of respiratory tract infection.10 We adjusted these definitions by not exclu-ding patients only for a longer existing positive PCR result for RVs when they fulfilled all other criteria for allo-LSs, as described previously.6

Additionally, we investigated the association between allo-LSs and overall survival, tre-atment-related mortality (TRM), and aGVHD and chronic GVHD in other organs —classification according to the Glucksberg criteria.11

Statistical analysisThe duration of follow-up was the time to development of allo-LSs or death or the last assessment for survivors. We assessed the association between outcome and patient-re-lated variables (age at transplantation, sex, RV status, RV viral load expressed as Ct value, and cytomegalovirus status), disease (malignancy, bone marrow failure syndromes, and inborn errors of metabolism and primary immune deficiency), conditioning regimen (chemotherapy or total-body irradiation based), and donor factors (stem cell source and HLA disparity). Because of sample size, the median Ct value (as semiquantitative viral load) was taken to dichotomize the group in high or low RV viral load.

Variables associated with a P value of less than .1 by using univariate analysis were selec-ted for multivariate analysis. Probabilities of event-free and overall survival were calcula-ted by using the Kaplan-Meier estimate; we used the 2-sided log-rank test for univariate comparisons. Time-dependent outcomes were analyzed by using Cox proportional ha-zard models. For the end points of allo-LSs, overall survival, and TRM, we used Fine-Gray competing risk regressions. For dichotomous variables, univariate and multivariate logistic regression analyses were done. All statistical analyses were performed with either SPSS 22 (SPSS, Chicago, Ill) or R, version 3.0.1, software.

Results

Patients' characteristicsA total of 273 patients underwent transplantation during the study period. One hundred seventy-nine patients had paired NPA and BAL samples before HCT available for analy-sis; they were evaluated in the study. The other 94 patients did not have NPAs and BAL fluid taken. The median age at transplantation was 6.8 years (range, 0.6-22.7 years); half of the patients underwent transplantation for a malignant disease, and CB (54%) was the main source of stem cells, followed by bone marrow (44%). Baseline characteristics are shown in Table I. Median follow-up of surviving patients was 4.3 years (range, 0.7-9.7 years).

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than 0.7, FEV1 of less than 75%, and evidence of air-trapping (on PFTs or HRCT scans) in the absence of respiratory tract infection.10 We adjusted these definitions by not exclu-ding patients only for a longer existing positive PCR result for RVs when they fulfilled all other criteria for allo-LSs, as described previously.6

Additionally, we investigated the association between allo-LSs and overall survival, tre-atment-related mortality (TRM), and aGVHD and chronic GVHD in other organs —classification according to the Glucksberg criteria.11

Statistical analysisThe duration of follow-up was the time to development of allo-LSs or death or the last assessment for survivors. We assessed the association between outcome and patient-re-lated variables (age at transplantation, sex, RV status, RV viral load expressed as Ct value, and cytomegalovirus status), disease (malignancy, bone marrow failure syndromes, and inborn errors of metabolism and primary immune deficiency), conditioning regimen (chemotherapy or total-body irradiation based), and donor factors (stem cell source and HLA disparity). Because of sample size, the median Ct value (as semiquantitative viral load) was taken to dichotomize the group in high or low RV viral load.

Variables associated with a P value of less than .1 by using univariate analysis were selec-ted for multivariate analysis. Probabilities of event-free and overall survival were calcula-ted by using the Kaplan-Meier estimate; we used the 2-sided log-rank test for univariate comparisons. Time-dependent outcomes were analyzed by using Cox proportional ha-zard models. For the end points of allo-LSs, overall survival, and TRM, we used Fine-Gray competing risk regressions. For dichotomous variables, univariate and multivariate logistic regression analyses were done. All statistical analyses were performed with either SPSS 22 (SPSS, Chicago, Ill) or R, version 3.0.1, software.

Results

Patients' characteristicsA total of 273 patients underwent transplantation during the study period. One hundred seventy-nine patients had paired NPA and BAL samples before HCT available for analy-sis; they were evaluated in the study. The other 94 patients did not have NPAs and BAL fluid taken. The median age at transplantation was 6.8 years (range, 0.6-22.7 years); half of the patients underwent transplantation for a malignant disease, and CB (54%) was the main source of stem cells, followed by bone marrow (44%). Baseline characteristics are shown in Table I. Median follow-up of surviving patients was 4.3 years (range, 0.7-9.7 years).

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Results

Overall, RVs were detected in 110 (61%) of the patients. In BAL fluid RVs were detected in 74 (41%) samples; 36 (20%) children had RVs detected in NPAs only. Only 5 (6%) patients with positive BAL fluid RV results had negative NPA RV results. Rhinovirus was the most frequently detected RV (43%), followed by multiple RVs (38%), with a similar distribution in BAL fluid and NPAs, as shown in Table 2. No patients with negative RV results had signs of upper respiratory tract infection (URTI) during hospitalization.

TABLE 1. Demographics and baseline characteristics. N=179

Age at HCT (median in years (range)) 6.8 (0.6-22.7)

Male sex, n (%) 106 (59)

HCT indication, n(%)* Malignancy Bone marrow failure syndrome Inborn error of metabolism Primary immune deficiency

90 (50)16 (9)34 (19)39 (22)

Conditioning, n (%) TBI-based Chemotherapy-based

27 (15)152 (85)

Donor, n (%) MSD MUD uCB

47 (26)35 (20)97 (54)

HLA matching, n (%) Matched Mismatch

120 (67)59 (33)

CMV serology recipient, n (%) Positive Negative Unknown

103 (58)70 (39)6 (3)

BAL — PCR respiratory virus positive, n (%) 74 (41)

NPA — PCR respiratory virus positive, n (%) 105 (59)

Abbreviations: TBI, total-body irradiation; MSD, matched sibling donor; MUD, matched unrelated donor; uCB, unrelated cord blood; CMV, cytomegalovirus. *HCT indications: Malignancy, acute lymphoblastic leukemia, acute myeloblastic leukemia, myelodysplastic syndrome, juvenile myelomonoblastic leukemia, and lymphoma; bone marrow failure syn-dromes, Fanconi anemia, congenital agranulocytosis, and severe aplastic anemia; inborn errors of metabolism, Hurlers syndrome, hemoglobinopathies, and other; primary im-mune deficiencies, severe combined immune deficiency and combined immunodeficiency.

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Results

Overall, RVs were detected in 110 (61%) of the patients. In BAL fluid RVs were detected in 74 (41%) samples; 36 (20%) children had RVs detected in NPAs only. Only 5 (6%) patients with positive BAL fluid RV results had negative NPA RV results. Rhinovirus was the most frequently detected RV (43%), followed by multiple RVs (38%), with a similar distribution in BAL fluid and NPAs, as shown in Table 2. No patients with negative RV results had signs of upper respiratory tract infection (URTI) during hospitalization.

TABLE 1. Demographics and baseline characteristics. N=179

Age at HCT (median in years (range)) 6.8 (0.6-22.7)

Male sex, n (%) 106 (59)

HCT indication, n(%)* Malignancy Bone marrow failure syndrome Inborn error of metabolism Primary immune deficiency

90 (50)16 (9)34 (19)39 (22)

Conditioning, n (%) TBI-based Chemotherapy-based

27 (15)152 (85)

Donor, n (%) MSD MUD uCB

47 (26)35 (20)97 (54)

HLA matching, n (%) Matched Mismatch

120 (67)59 (33)

CMV serology recipient, n (%) Positive Negative Unknown

103 (58)70 (39)6 (3)

BAL — PCR respiratory virus positive, n (%) 74 (41)

NPA — PCR respiratory virus positive, n (%) 105 (59)

Abbreviations: TBI, total-body irradiation; MSD, matched sibling donor; MUD, matched unrelated donor; uCB, unrelated cord blood; CMV, cytomegalovirus. *HCT indications: Malignancy, acute lymphoblastic leukemia, acute myeloblastic leukemia, myelodysplastic syndrome, juvenile myelomonoblastic leukemia, and lymphoma; bone marrow failure syn-dromes, Fanconi anemia, congenital agranulocytosis, and severe aplastic anemia; inborn errors of metabolism, Hurlers syndrome, hemoglobinopathies, and other; primary im-mune deficiencies, severe combined immune deficiency and combined immunodeficiency.

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Most patients had no or very mild signs of a URTI and no signs of lower respiratory tract infection at the time of sampling. The median PCR Ct value for RV in BAL fluid was 32 (range, 17-43), which is comparable with the Ct values found in NPAs (29; range, 14-43).

Outcomes of interestDuring conditioning and early after HCT, the URTI symptoms did not progress to significant lower respiratory tract infection symptoms. On the contrary, most patients recovered spontaneously. Twenty-four (13%) patients were given a diagnosis of an allo-LS after a median of 159 days (range, 7-201 days). Fifteen patients had IPS, and 9 patients had BOS.

In multivariate analysis detection of RV in BAL fluid was the only predictor associated with allo-LSs (hazard ratio [HR], 3.8; 95% CI, 1.4-10.7; P = .01), as shown in Table 3 (see Table S1 for univariate analysis).

When subdividing into groups with BOS and those with IPS, similar results were found. RV detection in BAL fluid was a predictor for BOS (HR, 5.1; 95% CI, 1.1-24.7; P = .04; see Tables S2 and S3 and Figure S1). For patients with IPS, a positive BAL fluid RV result (HR, 3.6; 95% CI, 1.0-13.8; P = .06) was a borderline significant predictor, as was having an inborn error of metabolism as the indication for transplantation (HR, 3.6; 95% CI, 1.0-12.8; P = .05; see Tables S4 and S5 and Figure S2).

TABLE 2. Distribution of respiratory viruses in pre-HCT samples.

NPA onlyN=36

BAL fluid onlyN=74

Rhinovirus 14 (39%) 38 (51%)

Multiple viruses 10 (28%) 20 (27%)*

Parainfluenzavirus 4 (10%) 4 (6%)

Adenovirus 3 (8%) 2 (3%)

Coronavirus 2 (6%) 6 (9%)

Respiratory syncytial virus 1 (3%) 1 (1%)

Bocavirus 2 (6%) 1 (1%)

Influenzavirus — 1 (1%)

Human metapneumovirus — 1 (1%)

* Multiple: 2 to 4 different respiratory viruses, 14 with rhinovirus.

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Most patients had no or very mild signs of a URTI and no signs of lower respiratory tract infection at the time of sampling. The median PCR Ct value for RV in BAL fluid was 32 (range, 17-43), which is comparable with the Ct values found in NPAs (29; range, 14-43).

Outcomes of interestDuring conditioning and early after HCT, the URTI symptoms did not progress to significant lower respiratory tract infection symptoms. On the contrary, most patients recovered spontaneously. Twenty-four (13%) patients were given a diagnosis of an allo-LS after a median of 159 days (range, 7-201 days). Fifteen patients had IPS, and 9 patients had BOS.

In multivariate analysis detection of RV in BAL fluid was the only predictor associated with allo-LSs (hazard ratio [HR], 3.8; 95% CI, 1.4-10.7; P = .01), as shown in Table 3 (see Table S1 for univariate analysis).

When subdividing into groups with BOS and those with IPS, similar results were found. RV detection in BAL fluid was a predictor for BOS (HR, 5.1; 95% CI, 1.1-24.7; P = .04; see Tables S2 and S3 and Figure S1). For patients with IPS, a positive BAL fluid RV result (HR, 3.6; 95% CI, 1.0-13.8; P = .06) was a borderline significant predictor, as was having an inborn error of metabolism as the indication for transplantation (HR, 3.6; 95% CI, 1.0-12.8; P = .05; see Tables S4 and S5 and Figure S2).

TABLE 2. Distribution of respiratory viruses in pre-HCT samples.

NPA onlyN=36

BAL fluid onlyN=74

Rhinovirus 14 (39%) 38 (51%)

Multiple viruses 10 (28%) 20 (27%)*

Parainfluenzavirus 4 (10%) 4 (6%)

Adenovirus 3 (8%) 2 (3%)

Coronavirus 2 (6%) 6 (9%)

Respiratory syncytial virus 1 (3%) 1 (1%)

Bocavirus 2 (6%) 1 (1%)

Influenzavirus — 1 (1%)

Human metapneumovirus — 1 (1%)

* Multiple: 2 to 4 different respiratory viruses, 14 with rhinovirus.

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Results

The probability of having an allo-LS at 1 year was 26% for patients with positive BAL fluid RV results compared with 6% for those with negative RV results (P = .005; Figure 1, A). The presence of RVs in NPAs only was not associated with allo-LSs. There was no diffe-rence found for rhinovirus and nonrhinovirus in the probability of allo-LS development (Figure 1, B). There also was no influence of viral load (defined as high and low based on Ct values) on the occurrence of allo-LSs (see Figure S3).

In patients with RV in BAL fluid (n = 74), we determined the association between occur-rence of grade II to IV aGVHD treated with systemic steroids (occurring after a median of 141 days [range, 6-128 days]) and the development of allo-LSs. aGVHD appears to protect against development of allo-LSs, although results were not statistically significant (odds ratio, 0.16; 95% CI, 0.0-1.3; P = .08; Figure 2).

All 24 patients with allo-LSs were treated with immunosuppressive therapy according to the treatment guidelines described in the Methods section. Ten (42%) patients are alive with stabilized lung function, 1 patient died of relapsed disease, and 13 died of TRM (infection or progressive lung disease). Allo-LSs contributed significantly to a higher es-timated TRM at 5 years (52% ± 10% in patients with allo-LSs and 20% ± 4% in patients without allo-LSs; P = .007; Fig 3, A), leading to a trend for lower estimated overall survival at 5 years (48% ± 10% in patients with allo-LSs 66% ± 4% in patients without allo-LSs; P = .07; Figure 3, B).

TABLE 3. Multivariate analyses for predictors for Allo-LSs (BOS plus IPS)

UnivariateP value

Multivariate

HR (95% CI) P value

Sex Male Female .04 *

11.4 (1.0-2.2) .08

HCT indication Malignancy Bone marrow failure syndrome Inborn error of metabolism Primary immune deficiency

.98.04 *.07 *

10.0 (0-0)

1.9 (0.7-5.2)2.0 (0.7-5.3)

.98.21.19

BAL RV negative RV positive .001

13.8 (1.4-10.7) .01 *

Allo-LSs, alloimmune-mediated lung syndromes; BOS, bronchiolitis obliterans syndrome; IPS, idiopathic pneumonia syndrome. * Statistically significant.

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Results

The probability of having an allo-LS at 1 year was 26% for patients with positive BAL fluid RV results compared with 6% for those with negative RV results (P = .005; Figure 1, A). The presence of RVs in NPAs only was not associated with allo-LSs. There was no diffe-rence found for rhinovirus and nonrhinovirus in the probability of allo-LS development (Figure 1, B). There also was no influence of viral load (defined as high and low based on Ct values) on the occurrence of allo-LSs (see Figure S3).

In patients with RV in BAL fluid (n = 74), we determined the association between occur-rence of grade II to IV aGVHD treated with systemic steroids (occurring after a median of 141 days [range, 6-128 days]) and the development of allo-LSs. aGVHD appears to protect against development of allo-LSs, although results were not statistically significant (odds ratio, 0.16; 95% CI, 0.0-1.3; P = .08; Figure 2).

All 24 patients with allo-LSs were treated with immunosuppressive therapy according to the treatment guidelines described in the Methods section. Ten (42%) patients are alive with stabilized lung function, 1 patient died of relapsed disease, and 13 died of TRM (infection or progressive lung disease). Allo-LSs contributed significantly to a higher es-timated TRM at 5 years (52% ± 10% in patients with allo-LSs and 20% ± 4% in patients without allo-LSs; P = .007; Fig 3, A), leading to a trend for lower estimated overall survival at 5 years (48% ± 10% in patients with allo-LSs 66% ± 4% in patients without allo-LSs; P = .07; Figure 3, B).

TABLE 3. Multivariate analyses for predictors for Allo-LSs (BOS plus IPS)

UnivariateP value

Multivariate

HR (95% CI) P value

Sex Male Female .04 *

11.4 (1.0-2.2) .08


.98.04 *.07 *

10.0 (0-0)

1.9 (0.7-5.2)2.0 (0.7-5.3)

.98.21.19


13.8 (1.4-10.7) .01 *

Allo-LSs, alloimmune-mediated lung syndromes; BOS, bronchiolitis obliterans syndrome; IPS, idiopathic pneumonia syndrome. * Statistically significant.

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A B

Days after HCT Days after HCT

FIGURE 1. A: Cumulative incidence of allo-LSs for patients with negative RV results, positive BAL fluid RV results, and positive NPA-only RV results. B: Cumulative incidence of allo-LSs for patients with negative RV results and both those with and those without rhinovirus (from BAL fluid only, without taking NPA results into account).

Discussion

To our knowledge, this is the largest study analyzing the association between detection of RV DNA/RNA before pediatric HCT and the development of allo-LSs. We noted a very high incidence of RV in pre-HCT samples (61%), predominantly rhinovirus. Despite im-munosuppressive treatment of the conditioning and GVHD prophylaxis, no progression to viral pneumonitis occurred. After a median of 8.5 weeks, often coinciding with T-cell immune recovery, 13% of all included patients had respiratory symptoms fitting the diag-nostic criteria for allo-LSs. With the limitations of a retrospective cohort study taken into account, our data suggest that detection of RV in BAL fluid (and not from NPAs) before HCT is a strong predictor for the development of allo-LSs in children after HCT. No dif-ference in effect was found between the various viral species detected, nor did we see a relation with the PCR Ct value (as a semiquantitative measure for viral load) of the virus at detection. Grade II to IV aGVHD in another organ occurring earlier in time (median onset after 6 weeks) appears to have a protective effect on the occurrence of allo-LSs,

BAL RV POS 26% (±5)

RV POS 6% (±3)

NPA-only RVPOS 3% (±3)

non rhinovirus POS 28% (±8)

rhinovirus POS 24% (±7)

no RV 5% (±2)

p=0.005

NS

7

1,0

0,8

0,6

0,4

0,2

0,0

0 100 200 300 400 500 0 100 200 300 400 500

117


A B


FIGURE 1. A: Cumulative incidence of allo-LSs for patients with negative RV results, positive BAL fluid RV results, and positive NPA-only RV results. B: Cumulative incidence of allo-LSs for patients with negative RV results and both those with and those without rhinovirus (from BAL fluid only, without taking NPA results into account).

Discussion

To our knowledge, this is the largest study analyzing the association between detection of RV DNA/RNA before pediatric HCT and the development of allo-LSs. We noted a very high incidence of RV in pre-HCT samples (61%), predominantly rhinovirus. Despite im-munosuppressive treatment of the conditioning and GVHD prophylaxis, no progression to viral pneumonitis occurred. After a median of 8.5 weeks, often coinciding with T-cell immune recovery, 13% of all included patients had respiratory symptoms fitting the diag-nostic criteria for allo-LSs. With the limitations of a retrospective cohort study taken into account, our data suggest that detection of RV in BAL fluid (and not from NPAs) before HCT is a strong predictor for the development of allo-LSs in children after HCT. No dif-ference in effect was found between the various viral species detected, nor did we see a relation with the PCR Ct value (as a semiquantitative measure for viral load) of the virus at detection. Grade II to IV aGVHD in another organ occurring earlier in time (median onset after 6 weeks) appears to have a protective effect on the occurrence of allo-LSs,

BAL RV POS 26% (±5)

RV POS 6% (±3)

NPA-only RVPOS 3% (±3)

non rhinovirus POS 28% (±8)

rhinovirus POS 24% (±7)

no RV 5% (±2)

p=0.005

NS

7

1,0

0,8

0,6

0,4

0,2

0,0

0 100 200 300 400 500 0 100 200 300 400 500

118

Discussion

FIGURE 2. Cumulative incidence of allo-LSs in patients with po-sitive BAL fluid RV results according to the presence of grade II to IV aGVHD in another organ.

possibly because of earlier initiation of increased immunosuppression. Allo-LSs were treated with high-dose steroids but remained a life-threatening complication; patients with allo-LSs had significantly higher TRM associated with a trend toward lower overall survival. This high TRM warrants novel or additional treatment in prospective trials; etanercept is one of the agents suggested by others, although conflicting data exist.12,13 Identification of high-risk patients, preventive strategies, and awareness and early detec-tion of allo-LSs could lead to improved survival chances.

A limitation of our sampling method might be the possible contamination of the bron-choscope on its route through the upper airway, influencing the RV DNA/RNA positivity of the BAL samples. However, in all patients BAL was done through a tracheal tube some time after intubation, reducing the risk of direct contamination. Moreover, we have not found any differ-ence in Ct values between NPAs and BAL fluid, and therefore conta-mination seems unlikely (because one would expect a much higher Ct value and lower viral load when contaminated). If some positive BAL samples were contaminated, the suggested association between BAL fluid RVand allo-LSs would be even stronger. An im-portant note is that during the study period, as it became clear there was an association between RV positivity in NPAs and allo-LSs,6 we started taking preventive measures in

Days after HCT

No aGvHD 31% (±6)

aGvHD 7% (±7)

p=0.09

7

0 50 100 150 200 250

1,0

0,8

0,6

0,4

0,2

0,0

118

Discussion

FIGURE 2. Cumulative incidence of allo-LSs in patients with po-sitive BAL fluid RV results according to the presence of grade II to IV aGVHD in another organ.

possibly because of earlier initiation of increased immunosuppression. Allo-LSs were treated with high-dose steroids but remained a life-threatening complication; patients with allo-LSs had significantly higher TRM associated with a trend toward lower overall survival. This high TRM warrants novel or additional treatment in prospective trials; etanercept is one of the agents suggested by others, although conflicting data exist.12,13 Identification of high-risk patients, preventive strategies, and awareness and early detec-tion of allo-LSs could lead to improved survival chances.

A limitation of our sampling method might be the possible contamination of the bron-choscope on its route through the upper airway, influencing the RV DNA/RNA positivity of the BAL samples. However, in all patients BAL was done through a tracheal tube some time after intubation, reducing the risk of direct contamination. Moreover, we have not found any differ-ence in Ct values between NPAs and BAL fluid, and therefore conta-mination seems unlikely (because one would expect a much higher Ct value and lower viral load when contaminated). If some positive BAL samples were contaminated, the suggested association between BAL fluid RVand allo-LSs would be even stronger. An im-portant note is that during the study period, as it became clear there was an association between RV positivity in NPAs and allo-LSs,6 we started taking preventive measures in

Days after HCT

No aGvHD 31% (±6)

aGvHD 7% (±7)

p=0.09

7

0 50 100 150 200 250

1,0

0,8

0,6

0,4

0,2

0,0

119


A B


FIGURE 3. A: Probability of TRM for patients with and without allo-LSs. B: Probability of over-all survival (OS) for patients with and without allo-LSs

the patients with positive NPA RV results by postponing HCT, prolongation of immuno-suppressive therapy, or both. This might have influenced the study outcomes and could have led to the observed decrease in the incidence of allo-LSs over time.

A point of discussion could be the fact that the diagnostic criteria for allo-LSs historically insist on the exclusion of infectious causes. Our data suggest that the presence of an RV in the lower airways is rather a warning sign for the development of allo-LSs. The fact that we have pre-HCT, presymptomatic BAL samples gives new insight in this discus-sion. We show that an RV could be present for weeks (to months) before pulmonary symptoms occur. This is despite the fact that the patients are severely immunocompro-mised. In an era of more precise detection tools (eg, PCR), it is not surprising that certain disease (exclusion) criteria are subject to changes. Therefore we have allowed RV PCR positivity in the definition of allo-LSs.

The high incidence of RVs in pediatric HCT recipients is in line with other recent stu-dies.14-16 The effect of RVs in an HCT population is conflicting. Some groups describe progression to viral pneumonia,17,18 some describe spontaneous recovery,15,19 and others describe an association with poor outcome.6,14,20 Furthermore, there are emerging re-ports on rhinovirus being more than just a common cold virus.6,14,16,20

p=0.007

p=0.07Allo-LS 52% (±10)

No Allo-LS 20% (±4)


Allo-LS 48% (±10)

7

0 500 1000 1500 2000 0 1000 2000 3000 4000

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

119


A B


FIGURE 3. A: Probability of TRM for patients with and without allo-LSs. B: Probability of over-all survival (OS) for patients with and without allo-LSs

the patients with positive NPA RV results by postponing HCT, prolongation of immuno-suppressive therapy, or both. This might have influenced the study outcomes and could have led to the observed decrease in the incidence of allo-LSs over time.

A point of discussion could be the fact that the diagnostic criteria for allo-LSs historically insist on the exclusion of infectious causes. Our data suggest that the presence of an RV in the lower airways is rather a warning sign for the development of allo-LSs. The fact that we have pre-HCT, presymptomatic BAL samples gives new insight in this discus-sion. We show that an RV could be present for weeks (to months) before pulmonary symptoms occur. This is despite the fact that the patients are severely immunocompro-mised. In an era of more precise detection tools (eg, PCR), it is not surprising that certain disease (exclusion) criteria are subject to changes. Therefore we have allowed RV PCR positivity in the definition of allo-LSs.

The high incidence of RVs in pediatric HCT recipients is in line with other recent stu-dies.14-16 The effect of RVs in an HCT population is conflicting. Some groups describe progression to viral pneumonia,17,18 some describe spontaneous recovery,15,19 and others describe an association with poor outcome.6,14,20 Furthermore, there are emerging re-ports on rhinovirus being more than just a common cold virus.6,14,16,20

p=0.007

p=0.07Allo-LS 52% (±10)



Allo-LS 48% (±10)

7

0 500 1000 1500 2000 0 1000 2000 3000 4000

1,0

0,8

0,6

0,4

0,2

0,0

1,0

0,8

0,6

0,4

0,2

0,0

120

Discussion

The respiratory microbiome, which consists of viruses, bacteria, and fungi, closely in-teracts with local and systemic immunity. Viral immunomodulation is complex and multidimen-sional.21-23 There is growing interest in understanding how disturbances can lead to lung disease, especially in the field of chronic inflammatory diseases, such as asthma and chronic obstructive pulmonary disease (COPD).21 Our data suggest that similar processes can occur because of common cold RV persistence in the lungs in immune-deficient patients while reconstituting a donor-derived novel immune system. This concept fits the current understanding of alloimmunity after HCT, where host antigen-presenting cells are activated by danger signals expressed on damaged tissues, pathogens, or both, leading to alloactivation and cytokine release and inducing a cycle of inflammation and tissue damage.24-26 Therefore further studies on the influence of the microbiome/viriome on the development of alloreactive immune phenomena after HCT are of great interest. In line with this, in patients with an inborn error of metabolism, which was found to be a borderline predictor for IPS, storage of glycosaminoglycans in the lungs can lead to low-grade inflammation and activation of antigen-presenting cells as well.

The effects of viral infection and inflammation have been studied in other allograft set-tings. In lung transplant recipients several groups have found an association between RVs and the development of acute and chronic allograft rejection and BOS, the main limitation to long-term survival.5,27-29 Also, in patients receiving other solid-organ trans-plants, there is evidence of infection playing a role in allograft dysfunction both through immunologic factors and nonimmunologic components.30

In a recent study on RVs and IPS after HCT, Seo et al31 described that when using cur-rently available diagnostic methods, in retrospect, they found occult pathogens in the majority of BAL fluid samples taken at diagnosis from patients with IPS. The presence of a pathogen was associated with mortality, even for pathogens with uncertain pulmo-nary pathogenicity, such as rhinovirus. They reconsidered the diagnosis, suggesting viral pneumonitis instead of IPS, and pointed out the possible harmful effect of high-dose steroids in case of detectable pathogens. This is in contrast with the interpretation of our findings. An important difference with our study is that Seo et al have no information on the RV status of the patients before they experience IPS.

We have shown that in our pediatric population allo-LSs develop at a median of 8 weeks after first detection of RV (during T-cell reconstitution). Therefore we believe that it is not the RV itself that causes the respiratory deterioration but the inflammatory response (similar to immune reconstitution inflammatory syndrome in patients with HIV/AIDS). Timing of symptoms, protection by immunosuppressive therapy (in case of GVHD), and initial response to an increase in immunosuppression support our hypothesis of a primary immune-mediated process. On the basis of these results, we would recom-

7

120

Discussion

The respiratory microbiome, which consists of viruses, bacteria, and fungi, closely in-teracts with local and systemic immunity. Viral immunomodulation is complex and multidimen-sional.21-23 There is growing interest in understanding how disturbances can lead to lung disease, especially in the field of chronic inflammatory diseases, such as asthma and chronic obstructive pulmonary disease (COPD).21 Our data suggest that similar processes can occur because of common cold RV persistence in the lungs in immune-deficient patients while reconstituting a donor-derived novel immune system. This concept fits the current understanding of alloimmunity after HCT, where host antigen-presenting cells are activated by danger signals expressed on damaged tissues, pathogens, or both, leading to alloactivation and cytokine release and inducing a cycle of inflammation and tissue damage.24-26 Therefore further studies on the influence of the microbiome/viriome on the development of alloreactive immune phenomena after HCT are of great interest. In line with this, in patients with an inborn error of metabolism, which was found to be a borderline predictor for IPS, storage of glycosaminoglycans in the lungs can lead to low-grade inflammation and activation of antigen-presenting cells as well.

The effects of viral infection and inflammation have been studied in other allograft set-tings. In lung transplant recipients several groups have found an association between RVs and the development of acute and chronic allograft rejection and BOS, the main limitation to long-term survival.5,27-29 Also, in patients receiving other solid-organ trans-plants, there is evidence of infection playing a role in allograft dysfunction both through immunologic factors and nonimmunologic components.30

In a recent study on RVs and IPS after HCT, Seo et al31 described that when using cur-rently available diagnostic methods, in retrospect, they found occult pathogens in the majority of BAL fluid samples taken at diagnosis from patients with IPS. The presence of a pathogen was associated with mortality, even for pathogens with uncertain pulmo-nary pathogenicity, such as rhinovirus. They reconsidered the diagnosis, suggesting viral pneumonitis instead of IPS, and pointed out the possible harmful effect of high-dose steroids in case of detectable pathogens. This is in contrast with the interpretation of our findings. An important difference with our study is that Seo et al have no information on the RV status of the patients before they experience IPS.

We have shown that in our pediatric population allo-LSs develop at a median of 8 weeks after first detection of RV (during T-cell reconstitution). Therefore we believe that it is not the RV itself that causes the respiratory deterioration but the inflammatory response (similar to immune reconstitution inflammatory syndrome in patients with HIV/AIDS). Timing of symptoms, protection by immunosuppressive therapy (in case of GVHD), and initial response to an increase in immunosuppression support our hypothesis of a primary immune-mediated process. On the basis of these results, we would recom-

7

121


mend thorough screening of all pre-HCT patients with chest HRCT and BAL in search of fungal infection but also for RVas a predictor for allo-LSs. In case of RV positivity, we would advise slower tapering of immune suppression after HCT and close monitoring for respiratory symptoms during follow-up with prompt diagnostics and treatment when an allo-LS is suspected.

In conclusion, our findings show that the presence of RV DNA/RNA in BAL fluid before HCT is a strong predictor for the occurrence of allo-LSs weeks to months after HCT. Further studies are needed to unravel the mechanisms underlying alloimmune pheno-mena in different target organs after HCT and to determine a role for the respiratory microbiome. Recognizing BAL fluid RV positivity before HCT as a predictor for allo-LSs might have clinical implications for prevention (by adapting immune suppressive prophylaxis) and (pre-emptive) therapy. Early recognition might also lead to improved survival chances.

Clinical implicationsIn children positive RV results in BAL fluid before HCT predisposes to allo-LSs. Screening is important because prevention and treatment of allo-LSs is based on either prolonged or increased immune suppression.

7

121


mend thorough screening of all pre-HCT patients with chest HRCT and BAL in search of fungal infection but also for RVas a predictor for allo-LSs. In case of RV positivity, we would advise slower tapering of immune suppression after HCT and close monitoring for respiratory symptoms during follow-up with prompt diagnostics and treatment when an allo-LS is suspected.

In conclusion, our findings show that the presence of RV DNA/RNA in BAL fluid before HCT is a strong predictor for the occurrence of allo-LSs weeks to months after HCT. Further studies are needed to unravel the mechanisms underlying alloimmune pheno-mena in different target organs after HCT and to determine a role for the respiratory microbiome. Recognizing BAL fluid RV positivity before HCT as a predictor for allo-LSs might have clinical implications for prevention (by adapting immune suppressive prophylaxis) and (pre-emptive) therapy. Early recognition might also lead to improved survival chances.

Clinical implicationsIn children positive RV results in BAL fluid before HCT predisposes to allo-LSs. Screening is important because prevention and treatment of allo-LSs is based on either prolonged or increased immune suppression.

7

122

References

References

1. Cooke KR. Acute lung injury after allo-geneic stem cell transplantation: from the clinic, to the bench and back again. Pediatr Transplant 2005;9:24-36.

2. Shono Y, Docampo MD, Peled JU, Pero-belli SM, Jenq RR. Intestinal microbio-ta-related effects on graft-versus-host disease. Int J Hematol 2015;101:428-37.

3. van Montfrans J, Schulz L, Versluys B, de Wildt A, Wolfs T, Bierings M, et al. Viral PCR positivity in stool before al-logeneic hematopoietic cell transplan-tation is strongly associated with acute intestinal graft-versus-host disease. Biol Blood Marrow Transplant 2015;21:772-4.

4. Huang YJ, Charlson ES, Collman RG, Colombini-Hatch S, Martinez FD, Seni-or RM. The role of the lung microbiome in health and disease. A National Heart, Lung, and Blood Institute workshop re-port. Am J Respir Crit Care Med 2013; 187:1382-7.

5. Kumar D, Erdman D, Keshavjee S, Peret T, Tellier R, Hadjiliadis D, et al. Clinical impact of community-acquired respira-tory viruses on bronchiolitis obliterans after lung transplant. Am J Transplant 2005;5:2031-6.

6. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant 2010;16:782-91.

7. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children. Biol Blood Marrow Transplant 2015;21:1622-6.

8. van de Pol AC, Wolfs TF, Jansen NJ, van Loon AM, Rossen JW. Diagnostic value of real-time polymerase chain reaction to detect viruses in young children ad-mitted to the paediatric intensive care unit with lower respiratory tract infec-tion. Crit Care 2006;10:R61.

9. Panoskaltsis-Mortari A, Griese M, Mad-tes DK, Belperio JA, Haddad IY, Folz RJ, et al. An official American Thoracic So-ciety research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneu-monia syndrome. Am J Respir Crit Care Med 2011;183:1262-79.

10. Jagasia MH, Greinix HT, Arora M, Wil-liams KM, Wolff D, Cowen EW, et al. National Institutes of Health consensus development project on criteria for cli-nical trials in chronic graft-versus-host disease: I. The 2014 Diagnosis and Sta-ging Working Group report. Biol Blood Marrow Transplant 2015;21:389-401.e1.

11. Glucksberg H, Storb R, Fefer A, Buckner CD, Neiman PE, Clift RA, et al. Clini-cal manifestations of graft-versus-host disease in human recipients of marrow from HL-A-matched sibling donors. Transplantation 1974;18:295-304.

12. Yanik GA, Grupp SA, Pulsipher MA, Levine JE, Schultz KR, Wall DA, et al. TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consor-tium and Children’s Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant 2015;21:67-73.

13. Yanik GA, Horowitz MM, Weisdorf DJ, Logan BR, Ho VT, Soiffer RJ, et al. Randomized, double-blind, placebo-controlled trial of soluble tumor necro-sis factor receptor: enbrel (etanercept) for the treatment of idiopathic pneu-

7

122

References

References

1. Cooke KR. Acute lung injury after allo-geneic stem cell transplantation: from the clinic, to the bench and back again. Pediatr Transplant 2005;9:24-36.

2. Shono Y, Docampo MD, Peled JU, Pero-belli SM, Jenq RR. Intestinal microbio-ta-related effects on graft-versus-host disease. Int J Hematol 2015;101:428-37.

3. van Montfrans J, Schulz L, Versluys B, de Wildt A, Wolfs T, Bierings M, et al. Viral PCR positivity in stool before al-logeneic hematopoietic cell transplan-tation is strongly associated with acute intestinal graft-versus-host disease. Biol Blood Marrow Transplant 2015;21:772-4.

4. Huang YJ, Charlson ES, Collman RG, Colombini-Hatch S, Martinez FD, Seni-or RM. The role of the lung microbiome in health and disease. A National Heart, Lung, and Blood Institute workshop re-port. Am J Respir Crit Care Med 2013; 187:1382-7.

5. Kumar D, Erdman D, Keshavjee S, Peret T, Tellier R, Hadjiliadis D, et al. Clinical impact of community-acquired respira-tory viruses on bronchiolitis obliterans after lung transplant. Am J Transplant 2005;5:2031-6.

6. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant 2010;16:782-91.

7. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High diagnostic yield of dedicated pulmonary screening before hematopoietic cell transplantation in children. Biol Blood Marrow Transplant 2015;21:1622-6.

8. van de Pol AC, Wolfs TF, Jansen NJ, van Loon AM, Rossen JW. Diagnostic value of real-time polymerase chain reaction to detect viruses in young children ad-mitted to the paediatric intensive care unit with lower respiratory tract infec-tion. Crit Care 2006;10:R61.

9. Panoskaltsis-Mortari A, Griese M, Mad-tes DK, Belperio JA, Haddad IY, Folz RJ, et al. An official American Thoracic So-ciety research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneu-monia syndrome. Am J Respir Crit Care Med 2011;183:1262-79.

10. Jagasia MH, Greinix HT, Arora M, Wil-liams KM, Wolff D, Cowen EW, et al. National Institutes of Health consensus development project on criteria for cli-nical trials in chronic graft-versus-host disease: I. The 2014 Diagnosis and Sta-ging Working Group report. Biol Blood Marrow Transplant 2015;21:389-401.e1.

11. Glucksberg H, Storb R, Fefer A, Buckner CD, Neiman PE, Clift RA, et al. Clini-cal manifestations of graft-versus-host disease in human recipients of marrow from HL-A-matched sibling donors. Transplantation 1974;18:295-304.

12. Yanik GA, Grupp SA, Pulsipher MA, Levine JE, Schultz KR, Wall DA, et al. TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consor-tium and Children’s Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant 2015;21:67-73.

13. Yanik GA, Horowitz MM, Weisdorf DJ, Logan BR, Ho VT, Soiffer RJ, et al. Randomized, double-blind, placebo-controlled trial of soluble tumor necro-sis factor receptor: enbrel (etanercept) for the treatment of idiopathic pneu-

7

123


monia syndrome after allogeneic stem cell transplantation: blood and marrow transplant clinical trials network pro-tocol. Biol Blood Marrow Transplant 2014;20:858-64.

14. Campbell AP, Guthrie KA, Englund JA, Farney RM, Minerich EL, Kuypers J, et al. Clinical outcomes associated with respiratory virus detection before allo-geneic hematopoietic stem cell trans-plant. Clin Infect Dis 2015;61:192-202.

15. Srinivasan A, Flynn P, Gu Z, Hartford C, Lovins R, Sunkara A, et al. Detection of respiratory viruses in asymptomatic children undergoing allogeneic hema-topoietic cell transplantation. Pediatr Blood Cancer 2013;60:149-51.

16. Gerna G, Piralla A, Rovida F, Rognoni V, Marchi A, Locatelli F, et al. Correlation of rhinovirus load in the respiratory tract and clinical symptoms in hospitalized immunocompetent and immunocom-promised patients. J Med Virol 2009;81: 1498-507.

17. Hutspardol S, Essa M, Richardson S, Schechter T, Ali M, Krueger J, et al. Significant transplantation-related mor-tality from respiratory virus infections within the first one hundred days in children after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2015;21:1802-7.

18. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on In-fections in Leukaemia (ECIL-4): gui-delines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013;56:258-66.

19. Bredius RG, Templeton KE, Scheltinga SA, Claas EC, Kroes AC, Vossen JM. Prospective study of respiratory viral in-fections in pediatric hemopoietic stem cell transplantation patients. Pediatr In-fect Dis J 2004;23:518-22.

20. Seo S, Martin E, Xie H, Kuypers J, Campbell AP, Choi SW, et al. Human rhinovirus RNA detection in the lower respiratory tract of hematopoietic cell transplant recipients: association with mortality. Biol Blood Marrow Transplant 2013;19(suppl):S167-77.

21. Cadwell K. The virome in host health and disease. Immunity 2015;42:805-13.

22. Tracy M, Cogen J, Hoffman LR. The pe-diatric microbiome and the lung. Curr Opin Pediatr 2015;27:348-55.

23. Lynch SV. Viruses and microbiome al-terations. Ann Am Thorac Soc 2014; 11(suppl 1):S57-60.

24. Holtan SG, Pasquini M, Weisdorf DJ. Acute graft-versus-host disease: a bench-to-bedside update. Blood 2014; 124: 363-73.

25. Brennan TV, Rendell VR, Yang Y. Innate immune activation by tissue injury and cell death in the setting of hematopoie-tic stem cell transplantation. Front Im-munol 2015;6:101.

26. Reddy P, Ferrara JL. Immunobiology of acute graft-versus-host disease. Blood Rev 2003;17:187-94.

27. Kumar D, Husain S, Chen MH, Mous-sa G, Himsworth D, Manuel O, et al. A prospective molecular surveillance study evaluating the clinical impact of community-acquired respiratory viruses in lung transplant recipients. Transplan-tation 2010;89:1028-33.

28. Fisher CE, Preiksaitis CM, Lease ED, Edelman J, Kirby KA, Leisenring WM, et al. Symptomatic respiratory virus infec-tion and chronic lung allograft dysfunc-tion. Clin Infect Dis 2016;62:313-9.

29. Vu DL, Bridevaux PO, Aubert JD, Soc-cal PM, Kaiser L. Respiratory viruses in lung transplant recipients: a critical review and pooled analysis of clinical studies. Am J Transplant 2011;11:1071-8.

7

123


monia syndrome after allogeneic stem cell transplantation: blood and marrow transplant clinical trials network pro-tocol. Biol Blood Marrow Transplant 2014;20:858-64.

14. Campbell AP, Guthrie KA, Englund JA, Farney RM, Minerich EL, Kuypers J, et al. Clinical outcomes associated with respiratory virus detection before allo-geneic hematopoietic stem cell trans-plant. Clin Infect Dis 2015;61:192-202.

15. Srinivasan A, Flynn P, Gu Z, Hartford C, Lovins R, Sunkara A, et al. Detection of respiratory viruses in asymptomatic children undergoing allogeneic hema-topoietic cell transplantation. Pediatr Blood Cancer 2013;60:149-51.

16. Gerna G, Piralla A, Rovida F, Rognoni V, Marchi A, Locatelli F, et al. Correlation of rhinovirus load in the respiratory tract and clinical symptoms in hospitalized immunocompetent and immunocom-promised patients. J Med Virol 2009;81: 1498-507.

17. Hutspardol S, Essa M, Richardson S, Schechter T, Ali M, Krueger J, et al. Significant transplantation-related mor-tality from respiratory virus infections within the first one hundred days in children after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2015;21:1802-7.

18. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on In-fections in Leukaemia (ECIL-4): gui-delines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus. Clin Infect Dis 2013;56:258-66.

19. Bredius RG, Templeton KE, Scheltinga SA, Claas EC, Kroes AC, Vossen JM. Prospective study of respiratory viral in-fections in pediatric hemopoietic stem cell transplantation patients. Pediatr In-fect Dis J 2004;23:518-22.

20. Seo S, Martin E, Xie H, Kuypers J, Campbell AP, Choi SW, et al. Human rhinovirus RNA detection in the lower respiratory tract of hematopoietic cell transplant recipients: association with mortality. Biol Blood Marrow Transplant 2013;19(suppl):S167-77.

21. Cadwell K. The virome in host health and disease. Immunity 2015;42:805-13.

22. Tracy M, Cogen J, Hoffman LR. The pe-diatric microbiome and the lung. Curr Opin Pediatr 2015;27:348-55.

23. Lynch SV. Viruses and microbiome al-terations. Ann Am Thorac Soc 2014; 11(suppl 1):S57-60.

24. Holtan SG, Pasquini M, Weisdorf DJ. Acute graft-versus-host disease: a bench-to-bedside update. Blood 2014; 124: 363-73.

25. Brennan TV, Rendell VR, Yang Y. Innate immune activation by tissue injury and cell death in the setting of hematopoie-tic stem cell transplantation. Front Im-munol 2015;6:101.

26. Reddy P, Ferrara JL. Immunobiology of acute graft-versus-host disease. Blood Rev 2003;17:187-94.

27. Kumar D, Husain S, Chen MH, Mous-sa G, Himsworth D, Manuel O, et al. A prospective molecular surveillance study evaluating the clinical impact of community-acquired respiratory viruses in lung transplant recipients. Transplan-tation 2010;89:1028-33.

28. Fisher CE, Preiksaitis CM, Lease ED, Edelman J, Kirby KA, Leisenring WM, et al. Symptomatic respiratory virus infec-tion and chronic lung allograft dysfunc-tion. Clin Infect Dis 2016;62:313-9.

29. Vu DL, Bridevaux PO, Aubert JD, Soc-cal PM, Kaiser L. Respiratory viruses in lung transplant recipients: a critical review and pooled analysis of clinical studies. Am J Transplant 2011;11:1071-8.

7

124

References

30. Martin-Gandul C, Mueller NJ, Pascual M, Manuel O. The impact of infec-tion on chronic allograft dysfunction and allograft survival after solid or-gan transplantation. Am J Transplant 2015;15:3024-40.

31. Seo S, Renaud C, Kuypers JM, Chiu CY, Huang ML, Samayoa E, et al. Idiopa-thic pneumonia syndrome after hema-topoietic cell transplantation: evidence of occult infectious etiologies. Blood 2015;125:3789-97.

7

124

References

30. Martin-Gandul C, Mueller NJ, Pascual M, Manuel O. The impact of infec-tion on chronic allograft dysfunction and allograft survival after solid or-gan transplantation. Am J Transplant 2015;15:3024-40.

31. Seo S, Renaud C, Kuypers JM, Chiu CY, Huang ML, Samayoa E, et al. Idiopa-thic pneumonia syndrome after hema-topoietic cell transplantation: evidence of occult infectious etiologies. Blood 2015;125:3789-97.

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Supplemental data

Figure S1. A: Cumulative incidence of BOS according to sex. B: Cumulative incidence of BOS according to positive BAL fluid RV results.

Figure S2. A: Cumulative incidence of IPS according to positive BAL fluid RV results. B: Cumulative incidence of IPS according to diagnosis.

Inborn error of metabolism 23% (±8)

PID 10% (±5)

Malignancy 5% (±2)Bone marrow failure 0% (±0)

7

A


p=0.06

Female 12% (±5)

Male 4% (±2)

B

RV positive 2% (±2)

RV negative 12% (±4)

A B


p=0.002

p=0.02RV positive 17% (±5)


125


Supplemental data

Figure S1. A: Cumulative incidence of BOS according to sex. B: Cumulative incidence of BOS according to positive BAL fluid RV results.

Figure S2. A: Cumulative incidence of IPS according to positive BAL fluid RV results. B: Cumulative incidence of IPS according to diagnosis.

Inborn error of metabolism 23% (±8)

PID 10% (±5)

Malignancy 5% (±2)Bone marrow failure 0% (±0)

7

A


p=0.06

Female 12% (±5)

Male 4% (±2)

B

RV positive 2% (±2)


A B


p=0.002

p=0.02RV positive 17% (±5)


126

Supplemental data

Figure S3. Cumulative incidence of allo-LSs according to RV viral load in BAL fluid (defined as greater or lower than the median Ct value [32] for RV).

7

Days after HCT

Low viral load 27% (±8)

High viral load 21% (±2)

126

Supplemental data

Figure S3. Cumulative incidence of allo-LSs according to RV viral load in BAL fluid (defined as greater or lower than the median Ct value [32] for RV).

7

Days after HCT

Low viral load 27% (±8)

High viral load 21% (±2)

127


TABLE S1. Predictor analyses for outcome of interest allo-LSs (BOS plus IPS)Univariate analyses (N = 24)

HR (95% CI) P value

Age at HCT 1.0 (0.9-1.0) .28

Sex Male Female

11.5 (1.0-2.3) .04 *


10.0 (0-0)

2.8 (1.1-7.6)2.5 (0.9-6.6)

.98.04 *.07 *

Conditioning Chemotherapy-based TBI-based

10.04 (0.0-4.0) .17

Donor MSD MUD uCB

11 (0.3-3.1)

0.8 (0.3-2.2).99.73

HLA matching MSD 10/10 MUD 9/10 MUD 6/6 uCB 4-5/6 uCB

13.4 (0.7-15.9)0.9 (0.3-2.6)1.4 (0.5-3.5)

.11.82.52

CMV serology recipient Negative Positive

11.7 (0.6-4.3) .30

NPA RV negative RV positive

10.4 (0.0-3.9) .45

BAL RV negative RV positive

15.5 (2.0-14.7) .001 *

Abbreviations: CMV, Cytomegalovirus; MSD, matched sibling donor; MUD, matched unre-lated donor; TBI, total-body irradiation; uCB, unrelated cord blood. * Statistically significant

7

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TABLE S1. Predictor analyses for outcome of interest allo-LSs (BOS plus IPS)Univariate analyses (N = 24)

HR (95% CI) P value

Age at HCT 1.0 (0.9-1.0) .28

Sex Male Female

11.5 (1.0-2.3) .04 *


10.0 (0-0)

2.8 (1.1-7.6)2.5 (0.9-6.6)

.98.04 *.07 *


10.04 (0.0-4.0) .17

Donor MSD MUD uCB

11 (0.3-3.1)

0.8 (0.3-2.2).99.73


13.4 (0.7-15.9)0.9 (0.3-2.6)1.4 (0.5-3.5)

.11.82.52


11.7 (0.6-4.3) .30


10.4 (0.0-3.9) .45


15.5 (2.0-14.7) .001 *


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Supplemental data

TABLE S2. Predictor analyses for BOS. Univariate analyses (N = 9)

HR (95% CI) P value

Age at HCT 1.0 (0.9-1.1) .74

Sex Male Female

11.9 (0.9-3.8) .08 *


10.0 (0-0)

0.8 (0.1-7.1)2.5 (0.6-9.8)

.99.83.20


10.0 (0.0-62.2) .38

Donor MSD MUD uCB

10.7 (0.1-3.8)0.4 (0.1-1.7)

.67

.21


13.5 (0.4-30.4)0.3 (0.0-2.9)0.7 (0.1-3.4)

.25

.32

.62


14.3 (0.5-35.4) .18


15.7 (0.7-44.5) .10


15.3 (1.1-25.7) .04 *


7

128

Supplemental data

TABLE S2. Predictor analyses for BOS. Univariate analyses (N = 9)

HR (95% CI) P value

Age at HCT 1.0 (0.9-1.1) .74

Sex Male Female

11.9 (0.9-3.8) .08 *


10.0 (0-0)

0.8 (0.1-7.1)2.5 (0.6-9.8)

.99.83.20


10.0 (0.0-62.2) .38

Donor MSD MUD uCB

10.7 (0.1-3.8)0.4 (0.1-1.7)

.67

.21


13.5 (0.4-30.4)0.3 (0.0-2.9)0.7 (0.1-3.4)

.25

.32

.62


14.3 (0.5-35.4) .18


15.7 (0.7-44.5) .10


15.3 (1.1-25.7) .04 *


7

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TABLE S3. Predictor analyses for BOS. Multivariate analyses

UnivariateP value

Multivariate

HR (95% CI) P value

Sex Male Female .08

13.4 (0.8-13.5) .09


15.1 (1.1-24.7) .04 *

* Statistically significant

7

129


TABLE S3. Predictor analyses for BOS. Multivariate analyses

UnivariateP value

Multivariate

HR (95% CI) P value

Sex Male Female .08

13.4 (0.8-13.5) .09


15.1 (1.1-24.7) .04 *


7

130

Supplemental data

TABLE S4. Predictor analyses for IPS. Univariate analyses (N = 15)

HR (95% CI) P value

Age at HCT 0.9 (0.8-1.0) .12

Sex Male Female

11.4 (0.8-2.3) .21


10.0 (0-0)

4.8 (1.4-16.5)2.6 (0.7-10.6)

.98.01 *.17


10.04 (0.0-12.7) .27

Donor MSD MUD uCB

11.3 (0.3-6.6)1.4 (0.4-5.0)

.72.64


14.3 (0.5-38.5)1.5 (0.4-6.0)2.2 (0.6-7.6)

.19

.57.24


11.2 (0.4-3.7) .75


12.9 (0.8-10.2) .10


16.2 (1.7-21.8) .005 *


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130

Supplemental data

TABLE S4. Predictor analyses for IPS. Univariate analyses (N = 15)

HR (95% CI) P value

Age at HCT 0.9 (0.8-1.0) .12

Sex Male Female

11.4 (0.8-2.3) .21


10.0 (0-0)

4.8 (1.4-16.5)2.6 (0.7-10.6)

.98.01 *.17


10.04 (0.0-12.7) .27

Donor MSD MUD uCB

11.3 (0.3-6.6)1.4 (0.4-5.0)

.72.64


14.3 (0.5-38.5)1.5 (0.4-6.0)2.2 (0.6-7.6)

.19

.57.24


11.2 (0.4-3.7) .75


12.9 (0.8-10.2) .10


16.2 (1.7-21.8) .005 *


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TABLE S5. Predictor analyses for IPS. Multivariate analyses

UnivariateP value

Multivariate

HR (95% CI) P value


.98

.01

.17

10.0 (0.0-0.0)3.6 (1.0-12.8)2.9 (0.7-11.5)

.98.05 *.14


13.6 (1.0-13.8) .06


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131


TABLE S5. Predictor analyses for IPS. Multivariate analyses

UnivariateP value

Multivariate

HR (95% CI) P value


.98

.01

.17

10.0 (0.0-0.0)3.6 (1.0-12.8)2.9 (0.7-11.5)

.98.05 *.14


13.6 (1.0-13.8) .06


7

8Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantation

8Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantation

Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantation

A.B. Versluys, M.B. Bierings, J.J. Boelens, C.K. van der Ent


Abstract

Allo-immune Lung Syndromes (Allo-LS), including Idiopathic Pneumonia Syndrome (IPS) and Bronchiolitis Obliterans Syndro-me (BOS), have a high impact on non-relapse mortality (NRM) af-ter Hematopoietic Cell Transplantation (HCT). We studied therapy response in children with Allo-LS, looking for prognostic factors for long term outcome.

We analyzed the association between Allo-LS free survival and pa-tient characteristics, HCT characteristics, Allo-LS characteristics and initial response to Methyl Prednisolone pulse (MP-pulse) the-rapy in all patients developing Allo-LS after HCT in our center from 2004- 2016.

Fifty-three patients were included, median age of 6.9 (0.3-18.8) years; 30 with IPS and 23 with BOS, mean duration of follow up 9.0 (0.9-13.2) years. Overall Allo-LS free survival was 43%. In the group of 24 patients (45%) with initial therapy failure, the survival rate was only 4%. In multivariate analysis mechanical ventilation at time of diagnosis of Allo-LS (HR 3.61, 95% CI 1.49-8.76, p=0.005) and systemic treatment for GvHD prior to the occurrence of Allo-LS (HR 7.46, 95% CI 2.15-25.86, p=0.002) appeared risk factors for poor outcome, whereas positive PCR for Respiratory Virus (RV) from Broncho Alveolar Lavage or Nasal Pharyngeal Aspirate was associated with better outcome (HR 0.32, 95% CI 0.13-0.76, p=0.01). Good responders to initial MP pulse therapy had norma-lization of pulmonary function and an overall survival of 73%.

In conclusion, therapy failure in Allo-LS occurs in 45% and has very poor prognosis. Early recognition of these refractory patients is important, and improvement of salvage therapies are needed for better survival after Allo-LS.





J.J. Boelens

U-DANCE Labora-tory of Translatio-

nal Immunology UMCU, Utrecht,

The Netherlands J.J. Boelens

Department of Pediatric Pulmo-

nology, UMCU, Utrecht, The Netherlands

C.K. van der Ent

Predictors for long-term outcome in children with alloimmune lung syndromes after hematopoietic cell transplantation

A.B. Versluys, M.B. Bierings, J.J. Boelens, C.K. van der Ent


Abstract

Allo-immune Lung Syndromes (Allo-LS), including Idiopathic Pneumonia Syndrome (IPS) and Bronchiolitis Obliterans Syndro-me (BOS), have a high impact on non-relapse mortality (NRM) af-ter Hematopoietic Cell Transplantation (HCT). We studied therapy response in children with Allo-LS, looking for prognostic factors for long term outcome.

We analyzed the association between Allo-LS free survival and pa-tient characteristics, HCT characteristics, Allo-LS characteristics and initial response to Methyl Prednisolone pulse (MP-pulse) the-rapy in all patients developing Allo-LS after HCT in our center from 2004- 2016.

Fifty-three patients were included, median age of 6.9 (0.3-18.8) years; 30 with IPS and 23 with BOS, mean duration of follow up 9.0 (0.9-13.2) years. Overall Allo-LS free survival was 43%. In the group of 24 patients (45%) with initial therapy failure, the survival rate was only 4%. In multivariate analysis mechanical ventilation at time of diagnosis of Allo-LS (HR 3.61, 95% CI 1.49-8.76, p=0.005) and systemic treatment for GvHD prior to the occurrence of Allo-LS (HR 7.46, 95% CI 2.15-25.86, p=0.002) appeared risk factors for poor outcome, whereas positive PCR for Respiratory Virus (RV) from Broncho Alveolar Lavage or Nasal Pharyngeal Aspirate was associated with better outcome (HR 0.32, 95% CI 0.13-0.76, p=0.01). Good responders to initial MP pulse therapy had norma-lization of pulmonary function and an overall survival of 73%.

In conclusion, therapy failure in Allo-LS occurs in 45% and has very poor prognosis. Early recognition of these refractory patients is important, and improvement of salvage therapies are needed for better survival after Allo-LS.





J.J. Boelens

U-DANCE Labora-tory of Translatio-

nal Immunology UMCU, Utrecht,

The Netherlands J.J. Boelens

Department of Pediatric Pulmo-

nology, UMCU, Utrecht, The Netherlands

C.K. van der Ent

135

Outcome predictors in Allo-LS in children

Introduction

Non-infectious pulmonary complications after allogeneic hematopoietic cell transplanta-tion (HCT) causes significant morbidity and mortality.1-5 Idiopathic pneumonia syndro-me (IPS), an early non-infectious lung disease including the spectrum of engraftment syndrome (ES) and diffuse alveolar hemorrhage (DAH), has an incidence of 2-12% and a poor prognosis, with mortality rates up to 50-80% within the first month of diagnosis.2,6 Bronchiolitis Obliterans Syndrome (BOS) is a late onset non-infectious pulmonary com-plications following HCT. Reported incidence rate varies widely from 0-48%, depending on definition and cohort of patients. Prognosis of BOS is poor, with improvement of lung function with aggressive therapy in only 8-20% of patients5 and mortality rates of 50-80%.7 In these non-infectious pulmonary complications of allogeneic HCT, immunity plays a crucial role, for which we introduced the term Allo-immune Lung Syndromes (Allo-LS).8 We aimed to study predictors for response to Allo-LS treatment and long-term outcome in Allo-LS.


Study design and patientsWe did a retrospective cohort analysis on all consecutive patients who received an allo-geneic HCT in our Center between January 2004 – December 2016. Clinical data were collected prospectively after written informed consent was acquired. Ethical committee approval of the University Medical Centre Utrecht was given (Trial numbers 05/143 and 11/063K). All patients who developed Allo-LS were included in this analysis: no restricti-ons applied. The majority of patients (81%) was described in earlier predictors analyses for developing Allo-LS.4,8

HCT procedures Patients underwent a myeloablative conditioning: for non-malignant diseases (inborn errors of metabolism, primary immune deficiencies) the conditioning regimen consisted of targeted busulfan (AUC 90 mg*h/l in 4 days) and fludarabin (160 mg/m2 in 4 days), in malignant disease either fractioned total body irradiation (TBI) based conditioning was given (3 x 2 x 2 Gy TBI, etoposide 60 mg/kg), or targeted busulfan (AUC 90 mg*h/l in 4 days) and fludarabin (160 mg/m2), or targeted busulfan (AUC 90 mg*h/l in 4 days), fludarabin (40 mg/m2 in 4 days) and clofarabin (120 mg/m2 in 4 days) depending on patients age, myeloid or lymphoid origin of disease, central nervous system involvement and high risk disease characteristics. Bone marrow failure syndromes (including Fanco-ni anemia) and heavily pre-treated children with pre-existing organ failure received redu-

8

135


Introduction

Non-infectious pulmonary complications after allogeneic hematopoietic cell transplanta-tion (HCT) causes significant morbidity and mortality.1-5 Idiopathic pneumonia syndro-me (IPS), an early non-infectious lung disease including the spectrum of engraftment syndrome (ES) and diffuse alveolar hemorrhage (DAH), has an incidence of 2-12% and a poor prognosis, with mortality rates up to 50-80% within the first month of diagnosis.2,6 Bronchiolitis Obliterans Syndrome (BOS) is a late onset non-infectious pulmonary com-plications following HCT. Reported incidence rate varies widely from 0-48%, depending on definition and cohort of patients. Prognosis of BOS is poor, with improvement of lung function with aggressive therapy in only 8-20% of patients5 and mortality rates of 50-80%.7 In these non-infectious pulmonary complications of allogeneic HCT, immunity plays a crucial role, for which we introduced the term Allo-immune Lung Syndromes (Allo-LS).8 We aimed to study predictors for response to Allo-LS treatment and long-term outcome in Allo-LS.


Study design and patientsWe did a retrospective cohort analysis on all consecutive patients who received an allo-geneic HCT in our Center between January 2004 – December 2016. Clinical data were collected prospectively after written informed consent was acquired. Ethical committee approval of the University Medical Centre Utrecht was given (Trial numbers 05/143 and 11/063K). All patients who developed Allo-LS were included in this analysis: no restricti-ons applied. The majority of patients (81%) was described in earlier predictors analyses for developing Allo-LS.4,8

HCT procedures Patients underwent a myeloablative conditioning: for non-malignant diseases (inborn errors of metabolism, primary immune deficiencies) the conditioning regimen consisted of targeted busulfan (AUC 90 mg*h/l in 4 days) and fludarabin (160 mg/m2 in 4 days), in malignant disease either fractioned total body irradiation (TBI) based conditioning was given (3 x 2 x 2 Gy TBI, etoposide 60 mg/kg), or targeted busulfan (AUC 90 mg*h/l in 4 days) and fludarabin (160 mg/m2), or targeted busulfan (AUC 90 mg*h/l in 4 days), fludarabin (40 mg/m2 in 4 days) and clofarabin (120 mg/m2 in 4 days) depending on patients age, myeloid or lymphoid origin of disease, central nervous system involvement and high risk disease characteristics. Bone marrow failure syndromes (including Fanco-ni anemia) and heavily pre-treated children with pre-existing organ failure received redu-

8

136


ced intensity conditioning, omitting or reducing the dose of busulfan (AUC 60 mg*h/l in 3 days). In patients receiving an unrelated donor transplant serotherapy was given with antithymocyte globuline (ATG; thymoglobuline). During the time of this study the dosing schedule of ATG has changed. Until June 2009 ATG was administered until day -1, from June 2009 onwards it was given earlier, from day -9 until day - 6. In patients with very high risk malignancies (relapsed myeloid leukemia, early relapsed lymphoid leuke-mia) receiving a cord blood (CB) donor we omitted ATG from December 2012 onwards. Standard GvHD prophylaxis consisted of cyclosporine (aiming for a through level of 150-250 μg/l). In CB transplant prednisolone (1 mg/kg/day for 28 days, taper in 2 weeks) was added. Patients receiving an unrelated bone marrow (BM) transplant methotrexate (short course, 10 mg/m2 on day 1,3,6) was given. From 2013 we also gave short course methotrexate to the older patients (>12 yr) receiving bone marrow from an HLA matched sibling.

Antimicrobial screening and prophylaxisAntimicrobial prophylaxis consisted of daily ciprofloxacin and fluconazole, from the start of conditioning until the resolution of neutropenia. Additional prophylaxis against Strep-tococcus viridans was given with cefazoline in the mucositis phase. Pneumocystis jirovecii pneumonia prohylaxis was started from 1 month after transplantation as cotrimoxazole 3 times a week. In case of positive serology for herpes simplex virus in all patients, and in case of positive serology for varicella zoster virus in cord blood transplant recipients, prophylaxis with aciclovir was given until immune-recovery (CD4+ > 200/uL). Patients regarded high risk for invasive fungal infection (IFI) received Aspergillus prophylaxis with either daily voriconazol or twice weekly amfothericine B. Stools and nose/throat swabs were cultured weekly, for bacterial colonization and results guided empiric anti-biotic treatment in case of neutropenic fever. Plasma was tested weekly for Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpes-6 virus (HHV-6) and adenovirus (AdV) DNA positivity by real time PCR. Weekly galactomannan (Platelia Aspergillus en-zyme immunoassay; Bio-Rad, Hercules, CA) testing was performed to screen for Asper-gillus infection.

From 2008, all patients were screened according to our pre-HCT pulmonary screening protocol as described before:9 this includes microbial testing (bacterial cultures, PCR for Respiratory Virus (RV) panel, fungal cultures and Aspergillus antigen testing) in Bron-cho Alveolar Lavage (BAL) and NasoPharyngealAspirate (NPA), High Resolution Com-puted Tomography (HRCT) of the lungs and Pulmonary Function Tests (PFT) in child-ren over 5 years of age. Based on screening results, patients at high risk for developing Allo-LS (i.e. RV positive before HCT) received prolonged GvHD prophylaxis, as we have shown a protective effect of immunosuppressive therapy on the incidence of Allo-LS in RV positive patients.4,8

8

136


ced intensity conditioning, omitting or reducing the dose of busulfan (AUC 60 mg*h/l in 3 days). In patients receiving an unrelated donor transplant serotherapy was given with antithymocyte globuline (ATG; thymoglobuline). During the time of this study the dosing schedule of ATG has changed. Until June 2009 ATG was administered until day -1, from June 2009 onwards it was given earlier, from day -9 until day - 6. In patients with very high risk malignancies (relapsed myeloid leukemia, early relapsed lymphoid leuke-mia) receiving a cord blood (CB) donor we omitted ATG from December 2012 onwards. Standard GvHD prophylaxis consisted of cyclosporine (aiming for a through level of 150-250 μg/l). In CB transplant prednisolone (1 mg/kg/day for 28 days, taper in 2 weeks) was added. Patients receiving an unrelated bone marrow (BM) transplant methotrexate (short course, 10 mg/m2 on day 1,3,6) was given. From 2013 we also gave short course methotrexate to the older patients (>12 yr) receiving bone marrow from an HLA matched sibling.

Antimicrobial screening and prophylaxisAntimicrobial prophylaxis consisted of daily ciprofloxacin and fluconazole, from the start of conditioning until the resolution of neutropenia. Additional prophylaxis against Strep-tococcus viridans was given with cefazoline in the mucositis phase. Pneumocystis jirovecii pneumonia prohylaxis was started from 1 month after transplantation as cotrimoxazole 3 times a week. In case of positive serology for herpes simplex virus in all patients, and in case of positive serology for varicella zoster virus in cord blood transplant recipients, prophylaxis with aciclovir was given until immune-recovery (CD4+ > 200/uL). Patients regarded high risk for invasive fungal infection (IFI) received Aspergillus prophylaxis with either daily voriconazol or twice weekly amfothericine B. Stools and nose/throat swabs were cultured weekly, for bacterial colonization and results guided empiric anti-biotic treatment in case of neutropenic fever. Plasma was tested weekly for Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpes-6 virus (HHV-6) and adenovirus (AdV) DNA positivity by real time PCR. Weekly galactomannan (Platelia Aspergillus en-zyme immunoassay; Bio-Rad, Hercules, CA) testing was performed to screen for Asper-gillus infection.

From 2008, all patients were screened according to our pre-HCT pulmonary screening protocol as described before:9 this includes microbial testing (bacterial cultures, PCR for Respiratory Virus (RV) panel, fungal cultures and Aspergillus antigen testing) in Bron-cho Alveolar Lavage (BAL) and NasoPharyngealAspirate (NPA), High Resolution Com-puted Tomography (HRCT) of the lungs and Pulmonary Function Tests (PFT) in child-ren over 5 years of age. Based on screening results, patients at high risk for developing Allo-LS (i.e. RV positive before HCT) received prolonged GvHD prophylaxis, as we have shown a protective effect of immunosuppressive therapy on the incidence of Allo-LS in RV positive patients.4,8

8

137


Allo-immune Lung Syndromes (Allo-LS)Allo-LS were defined as (1) Idiopathic Pneumonia Syndrome (IPS) according to the American Thoracic Society definition: the evidence of widespread lung injury by clini-cal symptoms and radiological abnormalities, in the absence of active lower respiratory infection and other factors explaining pulmonary dysfunction (like cardiac dysfunction, fluid overload or renal failure);10 (2) Bronchiolitis Obliterans Syndrome (BOS) according to the National Institutes of Health Consensus Criteria on Chronic Graft-versus-Host Disease 2014 as Forced Expiratory Volume in 1 second (FEV1)/Forced Vital Capacity (FVC) < 0.7, FEV1 < 75%, evidence of air trapping (on PFT or HRCT) in the absence of respiratory tract infection.11 These definitions were adjusted by allowing PCR positivity for Respiratory Viruses (RV) in patients diagnosed with allo-LS, as we previously found that these viruses in BAL (or NPA) were already present in patients before HCT and were found to be an individual predictor for allo-LS.4,8

When allo-LS was suspected (e.g. new onset of respiratory signs or unforeseen worse-ning of respiratory condition, with a normal temperature and laboratory parameters un-suspicious for infections) patients underwent the following work up: PFT (if feasible, depending on age or respiratory state), chest HRCT, and NPA or BAL. PFT included at least spirometry (FEV1 and FVC), and in some cases body-box measurements (Residual Volume, Total Lung Capacity) and CO-diffusion tests were done. Chest HRCTs were routinely reviewed by the radiologist, looking for signs of infiltrations, air trapping, pleu-ral effusion, pneumothorax etc. A second radiologist examined all the scans to calculate the HRCT composite- and allo-score as described by our group before.12 BAL and NPA were tested for bacteria (by GRAM stain and culture), fungi (by culture and aspergillus antigen testing) and Respiratory Viruses (by PCR).

First line treatment for allo-LS consisted of methylprednisolone (MP) 10 mg/kg/day iv for 3 days and 2 mg/kg/day thereafter, tapering by 25% per week to 0.5 mg/kg/day. MP pulses where repeated monthly until recovery, up to a maximum of 6 pulses. Recovery was defined as normalization of PFT and/or resolved symptoms. In between subsequent MP pulses prednisone 0.5 mg/kg/day was given. For poor responders to MP-pulse the-rapy our protocol prescribes second line therapy of 3-weekly cycles of fludarabine 30 mg/m2/dose.

Other immunosuppressive agents (e.g. cyclosporin) were continued. In addition, azithro-mycin was given because of its suggested immune modulatory effect.13 In BOS patients, imatinib was added for its known antifibrotic effects.14 Supportive care was provided with extra oxygen and mechanical ventilation when necessary. Furthermore, because of in-creased immune suppressive treatment antifungal prophylaxis (voriconazol) was added.

8

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Allo-immune Lung Syndromes (Allo-LS)Allo-LS were defined as (1) Idiopathic Pneumonia Syndrome (IPS) according to the American Thoracic Society definition: the evidence of widespread lung injury by clini-cal symptoms and radiological abnormalities, in the absence of active lower respiratory infection and other factors explaining pulmonary dysfunction (like cardiac dysfunction, fluid overload or renal failure);10 (2) Bronchiolitis Obliterans Syndrome (BOS) according to the National Institutes of Health Consensus Criteria on Chronic Graft-versus-Host Disease 2014 as Forced Expiratory Volume in 1 second (FEV1)/Forced Vital Capacity (FVC) < 0.7, FEV1 < 75%, evidence of air trapping (on PFT or HRCT) in the absence of respiratory tract infection.11 These definitions were adjusted by allowing PCR positivity for Respiratory Viruses (RV) in patients diagnosed with allo-LS, as we previously found that these viruses in BAL (or NPA) were already present in patients before HCT and were found to be an individual predictor for allo-LS.4,8

When allo-LS was suspected (e.g. new onset of respiratory signs or unforeseen worse-ning of respiratory condition, with a normal temperature and laboratory parameters un-suspicious for infections) patients underwent the following work up: PFT (if feasible, depending on age or respiratory state), chest HRCT, and NPA or BAL. PFT included at least spirometry (FEV1 and FVC), and in some cases body-box measurements (Residual Volume, Total Lung Capacity) and CO-diffusion tests were done. Chest HRCTs were routinely reviewed by the radiologist, looking for signs of infiltrations, air trapping, pleu-ral effusion, pneumothorax etc. A second radiologist examined all the scans to calculate the HRCT composite- and allo-score as described by our group before.12 BAL and NPA were tested for bacteria (by GRAM stain and culture), fungi (by culture and aspergillus antigen testing) and Respiratory Viruses (by PCR).

First line treatment for allo-LS consisted of methylprednisolone (MP) 10 mg/kg/day iv for 3 days and 2 mg/kg/day thereafter, tapering by 25% per week to 0.5 mg/kg/day. MP pulses where repeated monthly until recovery, up to a maximum of 6 pulses. Recovery was defined as normalization of PFT and/or resolved symptoms. In between subsequent MP pulses prednisone 0.5 mg/kg/day was given. For poor responders to MP-pulse the-rapy our protocol prescribes second line therapy of 3-weekly cycles of fludarabine 30 mg/m2/dose.

Other immunosuppressive agents (e.g. cyclosporin) were continued. In addition, azithro-mycin was given because of its suggested immune modulatory effect.13 In BOS patients, imatinib was added for its known antifibrotic effects.14 Supportive care was provided with extra oxygen and mechanical ventilation when necessary. Furthermore, because of in-creased immune suppressive treatment antifungal prophylaxis (voriconazol) was added.

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Pulmonary follow-upWe perform routinely PFT at day 100, and at 5 and 10 years after HCT according to our national Dutch Childhood Oncology Group late effect screening protocol. During follow up of patients with Allo-LS, PFT is repeated more often.

Outcomes The main outcome of interest was “Allo-LS free survival” defined as time from Allo-LS to last follow up whereby death or “refractory or progressive” Allo-LS were regarded as events. Other outcomes of interest: Non Relapse Mortality (NRM) defined as death from another cause than relapse of disease. Therapy response defined as 1) Poor response/therapy failure: refractory disease leading to a switch in first line therapy and/or progres-sive lung disease leading to death or chronic severe pulmonary disease, including patient requiring lung transplantation or chronic ventilatory support. 2) Good response: impro-vement of respiratory situation (e.g. improvement of PFT, reducing oxygen dependency) leading to recovery of lung disease (while receiving the MP-pulse therapy).

Exploratory outcomes of interest were: Effect of baseline PFT and early response (after 1st MP pulse) on main outcome of interest was analysed. In addition, we were interested in the evolution of Pulmonary Function tests (PFT) in Allo-LS free survivors.

Statistical analysisDifferences in patient characteristics between Allo-LS and non Allo-LS patients were tested using Pearson’s chi-square. Results with a p value < 0.05 were considered statis-tically significant. The duration of follow up was the time to death, or to stable chronic Allo-LS or the last assessment for survivors. Patients were censored at the date of last contact. Factors considered to influence outcome included patient variables (gender, RV status pre HCT, age at HCT, primary disease), transplantation variables (year of trans-plant, conditioning regimen (chemotherapy or TBI based), donor factors (stem cell sour-ce, HLA disparity, (un)related)) and factors at diagnosis of Allo-LS (time between HCT and Allo-LS, time between symptoms Allo-LS and start therapy, RV status at time-point Allo-LS, HRCT scores, extra oxygen requirement, Intensive Care Unit (ICU) admission because of mechanical ventilation, systemic GVHD treatment prior to Allo-LS, viral re-activation prior to HCT). Allo-LS was analyzed as a total group, IPS and BOS were also analyzed separately. Only in BOS patients (because data were lacking in majority of IPS patients), we analyzed the effect of baseline PFT (FEV1%, FEV1/FVC, RV/TLC at diagno-sis of Allo-LS), and early after initiation of treatment (FEV1% after first MP-pulse, change in FEV1% after first MP-pulse) on the outcomes. For the outcomes of interest, we used Cox proportional hazard models; univariable predictors of outcome with a p-value ≤ 0.10 in the total group were used for multivariable analysis.

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Pulmonary follow-upWe perform routinely PFT at day 100, and at 5 and 10 years after HCT according to our national Dutch Childhood Oncology Group late effect screening protocol. During follow up of patients with Allo-LS, PFT is repeated more often.

Outcomes The main outcome of interest was “Allo-LS free survival” defined as time from Allo-LS to last follow up whereby death or “refractory or progressive” Allo-LS were regarded as events. Other outcomes of interest: Non Relapse Mortality (NRM) defined as death from another cause than relapse of disease. Therapy response defined as 1) Poor response/therapy failure: refractory disease leading to a switch in first line therapy and/or progres-sive lung disease leading to death or chronic severe pulmonary disease, including patient requiring lung transplantation or chronic ventilatory support. 2) Good response: impro-vement of respiratory situation (e.g. improvement of PFT, reducing oxygen dependency) leading to recovery of lung disease (while receiving the MP-pulse therapy).

Exploratory outcomes of interest were: Effect of baseline PFT and early response (after 1st MP pulse) on main outcome of interest was analysed. In addition, we were interested in the evolution of Pulmonary Function tests (PFT) in Allo-LS free survivors.

Statistical analysisDifferences in patient characteristics between Allo-LS and non Allo-LS patients were tested using Pearson’s chi-square. Results with a p value < 0.05 were considered statis-tically significant. The duration of follow up was the time to death, or to stable chronic Allo-LS or the last assessment for survivors. Patients were censored at the date of last contact. Factors considered to influence outcome included patient variables (gender, RV status pre HCT, age at HCT, primary disease), transplantation variables (year of trans-plant, conditioning regimen (chemotherapy or TBI based), donor factors (stem cell sour-ce, HLA disparity, (un)related)) and factors at diagnosis of Allo-LS (time between HCT and Allo-LS, time between symptoms Allo-LS and start therapy, RV status at time-point Allo-LS, HRCT scores, extra oxygen requirement, Intensive Care Unit (ICU) admission because of mechanical ventilation, systemic GVHD treatment prior to Allo-LS, viral re-activation prior to HCT). Allo-LS was analyzed as a total group, IPS and BOS were also analyzed separately. Only in BOS patients (because data were lacking in majority of IPS patients), we analyzed the effect of baseline PFT (FEV1%, FEV1/FVC, RV/TLC at diagno-sis of Allo-LS), and early after initiation of treatment (FEV1% after first MP-pulse, change in FEV1% after first MP-pulse) on the outcomes. For the outcomes of interest, we used Cox proportional hazard models; univariable predictors of outcome with a p-value ≤ 0.10 in the total group were used for multivariable analysis.

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Results are expressed as hazard ratio (HR) and corresponding 95% confidence interval (CI). Variables associated with a p-value of < 0.05 were considered statistically signifi-cant. Variables showing significance in the total Allo-LS group were also analyzed in the IPS and BOS subgroups. Probabilities of Allo-LS free survival were calculated by using the Kaplan Meier estimate, we used the 2-sided log-rank test for univariate comparison. For the endpoints of non-relapse mortality and treatment failure, we used cumulative-incidence estimates and p-values were calculated using Gray’s. We did the statistical ana-lyses using SPSS version 21 and R version 3.2.4, using the packages survival and cmprsk.

Results

361 patients underwent allogeneic HCT during study period, of whom 53 developed an allo-LS (14.7 %). Patient characteristics are shown in Table 1. In the group of Allo-LS patients busulfan-based conditioning regimen was used more often (p=0.02), and there were statistically more children with inborn errors of metabolism and less with bone marrow failure syndromes (p=0.04). Thirty patients were diagnosed with IPS (57 %) after a median time of 58 (range 16-140) days following HCT, and 23 (43%) patients developed BOS after a median time of 109 (16-331) days following HCT. Presenting symptoms were moderate to severe, with 43(81%) patients needing supplemental oxygen, and 22(42%) patients requiring mechanical ventilatory support. In 43/53 patients we have data on RV status at time of respiratory deterioration. In 23/43 patients one or more Respiratory Vi-ruses (RV) were detected (mostly rhinovirus), in the majority (65%) this RV was already found on pre-HCT screening. Chest HRCT scan was done in 44 patients and abnormal in all. The median HRCT composite score was 22.5 (range 8-50), the median HRCT allo-score was 11 (range 0-19). We have evaluable PFT at diagnosis in 20 patients (27 patients too young, 6 patients too dyspneic to perform PFT), 17 with BOS and 3 with IPS. Median FEV1% was 44% (SD 14.5), median FVC% was 55% (SD 15.1), median FEV1/FVC was 0.86 (SD 0.18), median RV/TLC was 51% (SD 13.9), median TLCO was 55 % (SD 10.1) of predicted values.

First line treatment was started after a median time of 3 days (range 0-22) after first symptoms in patients with IPS, and after a median time of 10 days (range 3-82) after first symptoms in patients with BOS. Of the 53 patients 46 received first line therapy ac-cording to protocol (MP-pulse therapy). Five of the earliest patients received prednisone 2 mg/kg/day instead of MP-pulse because of clinicians’ decision, one started with mo-noclonal antibody therapy because of concomitant severe GvHD (overall grade 3) in gut and skin and one received upfront fludarabine because of strong objections to (the side effects of ) steroid therapy.

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Results are expressed as hazard ratio (HR) and corresponding 95% confidence interval (CI). Variables associated with a p-value of < 0.05 were considered statistically signifi-cant. Variables showing significance in the total Allo-LS group were also analyzed in the IPS and BOS subgroups. Probabilities of Allo-LS free survival were calculated by using the Kaplan Meier estimate, we used the 2-sided log-rank test for univariate comparison. For the endpoints of non-relapse mortality and treatment failure, we used cumulative-incidence estimates and p-values were calculated using Gray’s. We did the statistical ana-lyses using SPSS version 21 and R version 3.2.4, using the packages survival and cmprsk.

Results

361 patients underwent allogeneic HCT during study period, of whom 53 developed an allo-LS (14.7 %). Patient characteristics are shown in Table 1. In the group of Allo-LS patients busulfan-based conditioning regimen was used more often (p=0.02), and there were statistically more children with inborn errors of metabolism and less with bone marrow failure syndromes (p=0.04). Thirty patients were diagnosed with IPS (57 %) after a median time of 58 (range 16-140) days following HCT, and 23 (43%) patients developed BOS after a median time of 109 (16-331) days following HCT. Presenting symptoms were moderate to severe, with 43(81%) patients needing supplemental oxygen, and 22(42%) patients requiring mechanical ventilatory support. In 43/53 patients we have data on RV status at time of respiratory deterioration. In 23/43 patients one or more Respiratory Vi-ruses (RV) were detected (mostly rhinovirus), in the majority (65%) this RV was already found on pre-HCT screening. Chest HRCT scan was done in 44 patients and abnormal in all. The median HRCT composite score was 22.5 (range 8-50), the median HRCT allo-score was 11 (range 0-19). We have evaluable PFT at diagnosis in 20 patients (27 patients too young, 6 patients too dyspneic to perform PFT), 17 with BOS and 3 with IPS. Median FEV1% was 44% (SD 14.5), median FVC% was 55% (SD 15.1), median FEV1/FVC was 0.86 (SD 0.18), median RV/TLC was 51% (SD 13.9), median TLCO was 55 % (SD 10.1) of predicted values.

First line treatment was started after a median time of 3 days (range 0-22) after first symptoms in patients with IPS, and after a median time of 10 days (range 3-82) after first symptoms in patients with BOS. Of the 53 patients 46 received first line therapy ac-cording to protocol (MP-pulse therapy). Five of the earliest patients received prednisone 2 mg/kg/day instead of MP-pulse because of clinicians’ decision, one started with mo-noclonal antibody therapy because of concomitant severe GvHD (overall grade 3) in gut and skin and one received upfront fludarabine because of strong objections to (the side effects of ) steroid therapy.

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Results

TABLE 1. Patient characteristics Allo-LS and Total Cohort

Allo-LS N=53

Total Cohort N=361

Pearsons chi-square

Age, median [yr] (range) 6.88 (0.3-18.8) 7.4 (0.2-22.7) NS

Gender Male Female

26 (49%)27 (51%)

216 (59%)145 (41%)

NS

Primary disease Malignant Bone marrow failure syndrome Inborn error of metabolism Primary Immune deficiency

22 (42%)4 (7%)16 (30%)11 (21%)

188 (52%)44 (12%)62 (17%)67 (18%)

*0.04

Donor Related Unrelated

13 (25%)40 (75%)

89 (25%)272 (75%)

NS

Stem cell source Bone marrow Cord Blood PBSC

23 (43%)29 (55%) 1 (2%)

151 (42%)199 (55%)11 (3%)

NS

Conditioning regimen Myeloablative Busulfan based RIC, no/lower dose Busulfan Myeloablative TBI based

46 (87%) 4 (7%) 3 (6%)

245 (68%)74 (20%)42 (11%)

*0.02

Serotherapy Yes No

35 (66%)18 (34%)

251 (70%)110 (30%)

NS

HLA matching Matched Bone marrow (10/10) Mismatched Bone marrow Matched Cord blood (6/6) Mismatched Cord blood (5/6) Mismatched Cord blood (4/6)

20 (38%)4 (7%)7 (13%)17 (32%)5 (9%)

142 (39%)25 (7%)71(20%)92 (25%)31(9%)

NS

Allo-LS, Alloimmune mediated lung syndrome; PBSC, Peripheral Blood Stem Cells; TBI, total body irradiation; RIC, reduced intensity conditioning; HLA, Human Leukocyte Anti-gen.

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Results

TABLE 1. Patient characteristics Allo-LS and Total Cohort

Allo-LS N=53

Total Cohort N=361

Pearsons chi-square

Age, median [yr] (range) 6.88 (0.3-18.8) 7.4 (0.2-22.7) NS

Gender Male Female

26 (49%)27 (51%)

216 (59%)145 (41%)

NS


22 (42%)4 (7%)16 (30%)11 (21%)

188 (52%)44 (12%)62 (17%)67 (18%)

*0.04

Donor Related Unrelated

13 (25%)40 (75%)

89 (25%)272 (75%)

NS

Stem cell source Bone marrow Cord Blood PBSC

23 (43%)29 (55%) 1 (2%)

151 (42%)199 (55%)11 (3%)

NS

Conditioning regimen Myeloablative Busulfan based RIC, no/lower dose Busulfan Myeloablative TBI based

46 (87%) 4 (7%) 3 (6%)

245 (68%)74 (20%)42 (11%)

*0.02

Serotherapy Yes No

35 (66%)18 (34%)

251 (70%)110 (30%)

NS

HLA matching Matched Bone marrow (10/10) Mismatched Bone marrow Matched Cord blood (6/6) Mismatched Cord blood (5/6) Mismatched Cord blood (4/6)

20 (38%)4 (7%)7 (13%)17 (32%)5 (9%)

142 (39%)25 (7%)71(20%)92 (25%)31(9%)

NS

Allo-LS, Alloimmune mediated lung syndrome; PBSC, Peripheral Blood Stem Cells; TBI, total body irradiation; RIC, reduced intensity conditioning; HLA, Human Leukocyte Anti-gen.

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Twenty-four patients (45%) were noted as poor responders to first line therapy, after a median of 19 days (range 3-260), see Figure 1. In 13 (54%) of these patients, second line therapy was given, without success: 9 received fludarabine 30 mg/m2 every 3 weeks, but in earlier years, especially when there were signs of GVHD in other organs, daclizu-mab, infliximab, basiliximab, etanercept or Mesenchymal Stroma Cells were given. Of the ‘poor responders’ to MP pulse therapy 1 is alive after lung transplantation (5.3 years post HCT), and 2 are alive with end-stage lung disease requiring either intermittent chronic ventilator support or oxygen therapy. Only 1 child is alive without Allo-LS (good response on second line treatment). Twenty children died of progressive lung disease, with secondary fungal infection (2), viral reactivation (3: EBV, Adenovirus) or severe gut GvHD (2) contributing to death in seven cases. In the group of 30 ‘good responders’ 8 (26%) children died. There were no pulmonary deaths, 2 children died from infection (1 from systemic candida, 1 from invasive fungal infection). During prolonged MP-pulse therapy most children had important side effects like weight gain, osteoporosis, steroid induced diabetes mellitus and hypertension.

FIGURE 1. Flow chart on response to therapy in 53 Allo-LS patients. Allo-LS, Alloimmune mediated lung syndrome

53 patients with Allo-LS

24 poor response to therapy 29 good response to therapy

2 died, infection3 died, GVHD/multiorgan failure3 died, primary disease21 alive and well

13 salvage therapy 11 died, progressive Allo-LS 1 end-stage lung disease 1 alive without lung disease

11 no salvage therapy 9 died, progressive Allo-LS 1 lung transplantation 1 end stage lung disease

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Twenty-four patients (45%) were noted as poor responders to first line therapy, after a median of 19 days (range 3-260), see Figure 1. In 13 (54%) of these patients, second line therapy was given, without success: 9 received fludarabine 30 mg/m2 every 3 weeks, but in earlier years, especially when there were signs of GVHD in other organs, daclizu-mab, infliximab, basiliximab, etanercept or Mesenchymal Stroma Cells were given. Of the ‘poor responders’ to MP pulse therapy 1 is alive after lung transplantation (5.3 years post HCT), and 2 are alive with end-stage lung disease requiring either intermittent chronic ventilator support or oxygen therapy. Only 1 child is alive without Allo-LS (good response on second line treatment). Twenty children died of progressive lung disease, with secondary fungal infection (2), viral reactivation (3: EBV, Adenovirus) or severe gut GvHD (2) contributing to death in seven cases. In the group of 30 ‘good responders’ 8 (26%) children died. There were no pulmonary deaths, 2 children died from infection (1 from systemic candida, 1 from invasive fungal infection). During prolonged MP-pulse therapy most children had important side effects like weight gain, osteoporosis, steroid induced diabetes mellitus and hypertension.

FIGURE 1. Flow chart on response to therapy in 53 Allo-LS patients. Allo-LS, Alloimmune mediated lung syndrome

53 patients with Allo-LS

24 poor response to therapy 29 good response to therapy

2 died, infection3 died, GVHD/multiorgan failure3 died, primary disease21 alive and well

13 salvage therapy 11 died, progressive Allo-LS 1 end-stage lung disease 1 alive without lung disease

11 no salvage therapy 9 died, progressive Allo-LS 1 lung transplantation 1 end stage lung disease

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Results

The results of the univariate predictor analyses for Allo-LS free survival in the total Allo-LS group as well as in the BOS and IPS subgroups is shown in the supplemental data (see Table S1, S2, S3). Multivariate predictor analyses for Allo-LS Free survival noted worse outcome in patients who needed ICU admission for ventilator support (HR 3.61, 95% CI 1.49-8.76, p=0.005), and in those receiving systemic GvHD therapy prior to Allo-LS (HR 7.46, 95% CI 2.15-25.86, p=0.002). Patients with a positive PCR for RV at time of diagnosis of Allo-LS did better (HR 0.32, 95% CI 0.13-0.76, p=0.01). In the IPS subgroup only ICU admission and GvHD prior to Allo-LS were found to be significantly associated with bad outcome, in the BOS patients no predictors for outcome were found. (Table 2) In the total Allo-LS group we then analyzed these variables as predictors for Therapy Failure and NRM. (see Table S4, S5) Previous GVHD treatment (HR 2.63, 95% CI 0.98-7.05, p=0.06) and ICU admission (HR 2.15, 95% CI 0.96-4.82, p=0.06) showed a trend to Therapy Failure. The presence of RV (HR 0.25, 95% CI 0.10-0.65, p=0.004) and ICU admission (HR 3.38, 95% CI 1.34-8.54, p=0.01) were associated with NRM.

TABLE 2. Multivariate predictor analyses for Allo-LS Free survival.

Hazard ratio (95% CI) p-value

Allo-LS group (IPS + BOS)

RV from NPA or BAL at diagnosis Allo-LS 0.32 (0.13-0.76) 0.01*

Intensive care for mechanical ventilation 3.61 (1.49-8.76) 0.005*

Systemic GvHD treatment prior to Allo-LS 7.46 (2.15-25.86) 0.002*

Subgroup BOS

RV from NPA or BAL at diagnosis Allo-LS 0.84 (0.16-4.50) 0.84

Intensive care for mechanical ventilation 0.68 (0.11-4.30) 0.68

Systemic GvHD treatment prior to Allo-LS 13.45 (0.65-277) 0.09

Subgroup IPS




Allo-LS = Alloimmune mediated lung syndrome, IPS= Idiopathic Pneumonia Syndrome, RV = Respiratory Virus, NPA = Nasal Pharyngeal Aspirate, BAL = Broncho Alveolar Lavage, BOS = Bronchiolitis Obliterans Syndrome, GvHD = Graft versus Host Disease.

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Results

The results of the univariate predictor analyses for Allo-LS free survival in the total Allo-LS group as well as in the BOS and IPS subgroups is shown in the supplemental data (see Table S1, S2, S3). Multivariate predictor analyses for Allo-LS Free survival noted worse outcome in patients who needed ICU admission for ventilator support (HR 3.61, 95% CI 1.49-8.76, p=0.005), and in those receiving systemic GvHD therapy prior to Allo-LS (HR 7.46, 95% CI 2.15-25.86, p=0.002). Patients with a positive PCR for RV at time of diagnosis of Allo-LS did better (HR 0.32, 95% CI 0.13-0.76, p=0.01). In the IPS subgroup only ICU admission and GvHD prior to Allo-LS were found to be significantly associated with bad outcome, in the BOS patients no predictors for outcome were found. (Table 2) In the total Allo-LS group we then analyzed these variables as predictors for Therapy Failure and NRM. (see Table S4, S5) Previous GVHD treatment (HR 2.63, 95% CI 0.98-7.05, p=0.06) and ICU admission (HR 2.15, 95% CI 0.96-4.82, p=0.06) showed a trend to Therapy Failure. The presence of RV (HR 0.25, 95% CI 0.10-0.65, p=0.004) and ICU admission (HR 3.38, 95% CI 1.34-8.54, p=0.01) were associated with NRM.

TABLE 2. Multivariate predictor analyses for Allo-LS Free survival.

Hazard ratio (95% CI) p-value

Allo-LS group (IPS + BOS)

RV from NPA or BAL at diagnosis Allo-LS 0.32 (0.13-0.76) 0.01*



Subgroup BOS


Intensive care for mechanical ventilation 0.68 (0.11-4.30) 0.68

Systemic GvHD treatment prior to Allo-LS 13.45 (0.65-277) 0.09

Subgroup IPS




Allo-LS = Alloimmune mediated lung syndrome, IPS= Idiopathic Pneumonia Syndrome, RV = Respiratory Virus, NPA = Nasal Pharyngeal Aspirate, BAL = Broncho Alveolar Lavage, BOS = Bronchiolitis Obliterans Syndrome, GvHD = Graft versus Host Disease.

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In Figure 2 the adjusted Allo-LS free survival according to therapy response is shown (75% vs 4%, p < 0.001) as well as the curves according to GvHD treatment (48% vs 0%, p < 0.001), ICU admission (57% vs 23%, p = 0.003) and RV presence (65% vs 20%, p = 0.004). Figure 3 shows the cumulative incidence of NRM according to therapy response (83% vs 17%, p < 0.001).

FIGURE 2. Allo-LS free survival according to (a) therapy response, (b) GVHD treatment prior to Allo-LS, (c) ICU admission for mechanical ventilation, (d) presence of RV at time of Allo-LS. Allo-LS, Alloimmune mediated lung syndrome

74.9% (60% − 93%)

4.17% (0.61% − 28%)p<0.001**

0.00

0.25

0.50

0.75

1.00

0 300 600 900Time after Allo−LS onset

Allo−L

S fre

e su

rviva

l

a aResponded to therapy Therapy failed

29 25 22 20

24 3 1 1−−

Number at risk

48.2% (36% − 65%)

p<0.001**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo GvHD treatment GvHD treatment

47 27 23 21

6 1 0 0−−

Number at risk

57.3% (42% − 78%)

22.7% (11% − 49%)

p=0.003**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo ICU admission ICU admission

31 21 17 15

22 7 6 6−−

Number at risk

20% (8.3% − 48%)

64.9% (48% − 88%)

p=0.004**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo RV present RV present

20 5 3 3

23 16 15 15−−

Number at risk

48.2% (36-65%)

8

A B

C D

74.9% (60-93%)

4.17% (0.6-28%)

p<0.001**p<0.001**

57.3% (42-78%)

22.7% (11-79%)

p=0.003** p=0.004**

64.9% (48-88%)

20% (8.3-48%)

31 21 17 15

22 7 6 6

29 25 22 20

24 3 1 1

47 27 23 21

6 1 0 0

20 5 3 3

22 16 16 16

— Responded to therapy — Therapy failed

Allo

-LS

free

sur

viva

l

1,0

0,75

0

Time after Allo-LS onset (days)0 300

Number at risk600 900

0,50

0,25

— No ICU admission — IC admission

Allo

-LS

free

sur

viva

l

1,0

0,75

0

0,50

0,25



1,0

0,75

0

0,50

0,25

1,0

0,75

0

0,50

0,25

— No GvHD treatment — GvHD treatment





— No RV present — RV present

143


In Figure 2 the adjusted Allo-LS free survival according to therapy response is shown (75% vs 4%, p < 0.001) as well as the curves according to GvHD treatment (48% vs 0%, p < 0.001), ICU admission (57% vs 23%, p = 0.003) and RV presence (65% vs 20%, p = 0.004). Figure 3 shows the cumulative incidence of NRM according to therapy response (83% vs 17%, p < 0.001).

FIGURE 2. Allo-LS free survival according to (a) therapy response, (b) GVHD treatment prior to Allo-LS, (c) ICU admission for mechanical ventilation, (d) presence of RV at time of Allo-LS. Allo-LS, Alloimmune mediated lung syndrome

74.9% (60% − 93%)

4.17% (0.61% − 28%)p<0.001**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l


29 25 22 20

24 3 1 1−−

Number at risk

48.2% (36% − 65%)

p<0.001**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo GvHD treatment GvHD treatment

47 27 23 21

6 1 0 0−−

Number at risk

57.3% (42% − 78%)

22.7% (11% − 49%)

p=0.003**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo ICU admission ICU admission

31 21 17 15

22 7 6 6−−

Number at risk

20% (8.3% − 48%)

64.9% (48% − 88%)

p=0.004**

0.00

0.25

0.50

0.75

1.00


Allo−L

S fre

e su

rviva

l

a aNo RV present RV present

20 5 3 3

23 16 15 15−−

Number at risk

48.2% (36-65%)

8

A B

C D

74.9% (60-93%)

4.17% (0.6-28%)

p<0.001**p<0.001**

57.3% (42-78%)

22.7% (11-79%)

p=0.003** p=0.004**

64.9% (48-88%)

20% (8.3-48%)

31 21 17 15

22 7 6 6

29 25 22 20

24 3 1 1

47 27 23 21

6 1 0 0

20 5 3 3

22 16 16 16


Allo

-LS

free

sur

viva

l

1,0

0,75

0



0,50

0,25

— No ICU admission — IC admission

Allo

-LS

free

sur

viva

l

1,0

0,75

0

0,50

0,25



1,0

0,75

0

0,50

0,25

1,0

0,75

0

0,50

0,25

— No GvHD treatment — GvHD treatment





— No RV present — RV present

144

Results

FIGURE 3. Cumulative incidence of Non Relapse Mortality (NRM) according to therapy response. Allo-LS, Alloimmune mediated lung syndrome

17 % ± 14 %

83 % ± 16 %

p<0.001**

0.00

0.25

0.50

0.75

1.00


NR

M In

cide

nce


29 25 22 20

24 6 4 3−−

Number at risk

Therapy failure according to ICU admission (55% vs 37%, p=0.015) and GvHD (100% vs 37%, p=0.002), as well as NRM according to RV presence (26% vs 72% p=0.02) and ICU admission (68% vs 33%, p=0.003) are shown in Figure S1 a,b and Figure S2 a,b.

In the additional exploratory analyses in BOS patients we related baseline PFT with Allo-LS free survival. FEV1/FVC (HR0.94, 95% CI 0.90-0.99, p=0.02) was the only predictor found, higher values predicting good outcome.

We also related early response (values of PFT after a median of 8 (5-53) days following first MP pulse) to Allo-LS free survival. Higher absolute FEV1% (HR 0.94 (0.89-0.98), p=0.01) and increase of FEV1% (HR 0.84, 95% CI 0.73-0.96, p= 0.01) on repeated PFT, were an indicator for better outcome. (see Table S4)

8

29 25 22

24 6 34

20

17% ± 14%

83% ± 16%

p<0.001**


Time after Allo-LS onset (days)

0 300

Number at risk

600 900

NR

M in

cide

nce

1,0

0,75

0

0,50

0,25

144

Results

FIGURE 3. Cumulative incidence of Non Relapse Mortality (NRM) according to therapy response. Allo-LS, Alloimmune mediated lung syndrome

17 % ± 14 %

83 % ± 16 %

p<0.001**

0.00

0.25

0.50

0.75

1.00


NR

M In

cide

nce


29 25 22 20

24 6 4 3−−

Number at risk

Therapy failure according to ICU admission (55% vs 37%, p=0.015) and GvHD (100% vs 37%, p=0.002), as well as NRM according to RV presence (26% vs 72% p=0.02) and ICU admission (68% vs 33%, p=0.003) are shown in Figure S1 a,b and Figure S2 a,b.

In the additional exploratory analyses in BOS patients we related baseline PFT with Allo-LS free survival. FEV1/FVC (HR0.94, 95% CI 0.90-0.99, p=0.02) was the only predictor found, higher values predicting good outcome.

We also related early response (values of PFT after a median of 8 (5-53) days following first MP pulse) to Allo-LS free survival. Higher absolute FEV1% (HR 0.94 (0.89-0.98), p=0.01) and increase of FEV1% (HR 0.84, 95% CI 0.73-0.96, p= 0.01) on repeated PFT, were an indicator for better outcome. (see Table S4)

8

29 25 22

24 6 34

20

17% ± 14%

83% ± 16%

p<0.001**


Time after Allo-LS onset (days)

0 300

Number at risk

600 900

NR

M in

cide

nce

1,0

0,75

0

0,50

0,25

145


Of 21/22 children who are alive without Allo-LS the PFT at last follow up, at a median of 7.0 (range 0.7-9.4) years after Allo-LS, show a median FEV1% of 79 (SD 21.6), median FVC% was 76 (SD 17.9), median FEV1/FVC was 0.94 (SD 0.10), median RV/TLC was 28 (SD 10.6), median TLCO was 80 (SD 15.5) % of normal. All patients were without pul-monary symptoms. In 13 patients, we had serial data on PFT over time, showing a trend to worsening of lung function after 2 years (see Figure S3).

Discussion

To our knowledge this is one of the very few reports on prognostic factors for outcome in children with Allo-LS. In 53 HCT recipients developing Allo-LS, the largest pediatric cohort published thus far, we studied predictors for response to first line treatment with MP-pulse therapy. 45% of patients were ‘poor responders’ resulting in very poor Allo-LS free survival (4%). Predictors for poor outcome were previous systemic treatment for GvHD and mechanical ventilation at time of diagnosis. PCR positivity for RV at diagnosis of Allo-LS was an indicator for favorable outcome. Failure to therapy was noted already very early after start of therapy. In BOS patients, inadequate increase of FEV1% after the first MP pulse predisposed for poor long term outcome. Responders to therapy were found to have good survival chances with improvement of clinical symptoms and almost normalization of pulmonary function.

Limitation of this cohort analyses are the relatively small numbers of patients, and the long study period in which a few important changes in policy regarding pulmonary complications took place (e.g. standard MP-pulse from 2005, screening for pulmonary disease from 2008). Over time we have become more aware of the risks and symptoms of Allo-LS, possibly leading to earlier diagnosis. In those patients who were RV positive prior to HCT, immune suppressive therapy was tapered slower, this may have resulted in the observed decrease in incidence of Allo-LS after 2008 from 25% to 10% (data not shown). However, we found no significant difference in Therapy Response and Allo-LS free survival between patients transplanted before or after 2008.

There are very few studies aiming to identify factors correlating with therapy response and mortality prediction in Allo-LS. In one study on IPS, patients requiring less oxygen, and not needing mechanical ventilation had higher response rates, and there was a trend to better response in those starting treatment within 3 days of supplemental oxygen sup-port.6 This is in line with our results. The importance of FEV1% in the characterization of severity of BOS is long established. Williams et al. showed a relation between FEV1% < 35% and mortality in adults with BOS after HCT.15 In our cohort we could not confirm a relation between FEV1% at time of Allo-LS and mortality, but we did not have such low FEV1% values at Allo-LS diagnosis.

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Of 21/22 children who are alive without Allo-LS the PFT at last follow up, at a median of 7.0 (range 0.7-9.4) years after Allo-LS, show a median FEV1% of 79 (SD 21.6), median FVC% was 76 (SD 17.9), median FEV1/FVC was 0.94 (SD 0.10), median RV/TLC was 28 (SD 10.6), median TLCO was 80 (SD 15.5) % of normal. All patients were without pul-monary symptoms. In 13 patients, we had serial data on PFT over time, showing a trend to worsening of lung function after 2 years (see Figure S3).

Discussion

To our knowledge this is one of the very few reports on prognostic factors for outcome in children with Allo-LS. In 53 HCT recipients developing Allo-LS, the largest pediatric cohort published thus far, we studied predictors for response to first line treatment with MP-pulse therapy. 45% of patients were ‘poor responders’ resulting in very poor Allo-LS free survival (4%). Predictors for poor outcome were previous systemic treatment for GvHD and mechanical ventilation at time of diagnosis. PCR positivity for RV at diagnosis of Allo-LS was an indicator for favorable outcome. Failure to therapy was noted already very early after start of therapy. In BOS patients, inadequate increase of FEV1% after the first MP pulse predisposed for poor long term outcome. Responders to therapy were found to have good survival chances with improvement of clinical symptoms and almost normalization of pulmonary function.

Limitation of this cohort analyses are the relatively small numbers of patients, and the long study period in which a few important changes in policy regarding pulmonary complications took place (e.g. standard MP-pulse from 2005, screening for pulmonary disease from 2008). Over time we have become more aware of the risks and symptoms of Allo-LS, possibly leading to earlier diagnosis. In those patients who were RV positive prior to HCT, immune suppressive therapy was tapered slower, this may have resulted in the observed decrease in incidence of Allo-LS after 2008 from 25% to 10% (data not shown). However, we found no significant difference in Therapy Response and Allo-LS free survival between patients transplanted before or after 2008.

There are very few studies aiming to identify factors correlating with therapy response and mortality prediction in Allo-LS. In one study on IPS, patients requiring less oxygen, and not needing mechanical ventilation had higher response rates, and there was a trend to better response in those starting treatment within 3 days of supplemental oxygen sup-port.6 This is in line with our results. The importance of FEV1% in the characterization of severity of BOS is long established. Williams et al. showed a relation between FEV1% < 35% and mortality in adults with BOS after HCT.15 In our cohort we could not confirm a relation between FEV1% at time of Allo-LS and mortality, but we did not have such low FEV1% values at Allo-LS diagnosis.

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Discussion

The high rates of failure to therapy and overall mortality are comparable to those re-ported by other groups.5-7,16 For the treatment of IPS in children only a few studies were done. In the only multicenter trial, etanercept, a TNF receptor inhibitor, was added to systemic corticosteroids.6 Complete response rate of 71%, with 1-year survival in 63 % of patients, compares superior to other reports.17-19 Most literature on the treatment of BOS after HCT in children is on corticosteroid therapy, with reported response rates of 33-80%.16,20-22 In some studies azithromycin and/or pravachol were added to cortico-steroids.20,21 The response rate in our cohort is comparable with others, but pulmonary outcome in survivors seems much better. In most studies stabilization of PFT occurs, in our cohort the majority of survivors had normalization of PFT within 1-2 years.

Extended systemic steroid courses are associated with high mortality from infectious complications. Ongoing clinical trials on effective and less toxic treatment of cGVHD and Allo-LS include studies on Fluticasone-Azithromycin-Montelukast (FAM), Ciclos-porin inhalation, Pirfenidone, neutrophil elastase inhibitors, Bortezomib, Everolimus, Extra Corporal Photopheresis, anti-TNF and JAK1/2 inhibitors (clinicaltrials.gov).

Given the suggestion that —after initial normalization — PFT decreases over time, fol-low up of this cohort of survivors is important, as we know that pulmonary late effects of chemotherapy and HCT continue to occur over time, and most studies only start chec-king PFT 5 years after treatment.23

In conclusion, Allo-LS is a severe complication of HCT associated with poor survival, especially for patients who develop Allo-LS after a period of GvHD requiring systemic treatment, those who need mechanical ventilation at diagnosis of Allo-LS, and BOS pa-tients with inadequate increase of FEV1% after the first MP-pulse. Early recognition of therapy failure is crucial and novel treatment strategies are warranted in these high risk patients to improve survival.

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Discussion

The high rates of failure to therapy and overall mortality are comparable to those re-ported by other groups.5-7,16 For the treatment of IPS in children only a few studies were done. In the only multicenter trial, etanercept, a TNF receptor inhibitor, was added to systemic corticosteroids.6 Complete response rate of 71%, with 1-year survival in 63 % of patients, compares superior to other reports.17-19 Most literature on the treatment of BOS after HCT in children is on corticosteroid therapy, with reported response rates of 33-80%.16,20-22 In some studies azithromycin and/or pravachol were added to cortico-steroids.20,21 The response rate in our cohort is comparable with others, but pulmonary outcome in survivors seems much better. In most studies stabilization of PFT occurs, in our cohort the majority of survivors had normalization of PFT within 1-2 years.

Extended systemic steroid courses are associated with high mortality from infectious complications. Ongoing clinical trials on effective and less toxic treatment of cGVHD and Allo-LS include studies on Fluticasone-Azithromycin-Montelukast (FAM), Ciclos-porin inhalation, Pirfenidone, neutrophil elastase inhibitors, Bortezomib, Everolimus, Extra Corporal Photopheresis, anti-TNF and JAK1/2 inhibitors (clinicaltrials.gov).

Given the suggestion that —after initial normalization — PFT decreases over time, fol-low up of this cohort of survivors is important, as we know that pulmonary late effects of chemotherapy and HCT continue to occur over time, and most studies only start chec-king PFT 5 years after treatment.23

In conclusion, Allo-LS is a severe complication of HCT associated with poor survival, especially for patients who develop Allo-LS after a period of GvHD requiring systemic treatment, those who need mechanical ventilation at diagnosis of Allo-LS, and BOS pa-tients with inadequate increase of FEV1% after the first MP-pulse. Early recognition of therapy failure is crucial and novel treatment strategies are warranted in these high risk patients to improve survival.

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3. Vande Vusse LK, Madtes DK. Early On-set Noninfectious Pulmonary Syndro-mes after Hematopoietic Cell Trans-plantation. Clinics in chest medicine. 2017;38(2):233-48.

4. Versluys B, Bierings M, Murk JL, Wolfs T, Lindemans C, Vd Ent K, et al. Infec-tion with a respiratory virus before he-matopoietic cell transplantation is asso-ciated with alloimmune-mediated lung syndromes. The Journal of allergy and clinical immunology. 2017.




8. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-

tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant. 2010;16(6):782-91.

9. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High Diagnostic Yield of Dedicated Pulmona-ry Screening before Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant. 2015;21(9):1622-6.

10. Panoskaltsis-Mortari A, Griese M, Mad-tes DK, Belperio JA, Haddad IY, Folz RJ, et al. An official American Thoracic So-ciety research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneu-monia syndrome. American journal of respiratory and critical care medicine. 2011;183(9):1262-79.


12. Versluys AB, Bierings MB, Beek FJ, Boe-lens JJ, van der Ent CK, de Jong PA. High-resolution CT can differentiate between alloimmune and nonalloimmune lung disease early after hematopoietic cell transplantation. AJR American journal of roentgenology. 2014;203(3):656-61.

13. Parnham MJ, Erakovic Haber V, Giama-rellos-Bourboulis EJ, Perletti G, Verleden GM, Vos R. Azithromycin: mechanisms of action and their relevance for clinical applications. Pharmacology & thera-peutics. 2014;143(2):225-45.

14. Watanabe S, Kasahara K, Waseda Y, Takato H, Nishikawa S, Yoneda T, et

References

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3. Vande Vusse LK, Madtes DK. Early On-set Noninfectious Pulmonary Syndro-mes after Hematopoietic Cell Trans-plantation. Clinics in chest medicine. 2017;38(2):233-48.





8. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-

tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant. 2010;16(6):782-91.

9. Versluys AB, van der Ent K, Boelens JJ, Wolfs T, de Jong P, Bierings MB. High Diagnostic Yield of Dedicated Pulmona-ry Screening before Hematopoietic Cell Transplantation in Children. Biol Blood Marrow Transplant. 2015;21(9):1622-6.



12. Versluys AB, Bierings MB, Beek FJ, Boe-lens JJ, van der Ent CK, de Jong PA. High-resolution CT can differentiate between alloimmune and nonalloimmune lung disease early after hematopoietic cell transplantation. AJR American journal of roentgenology. 2014;203(3):656-61.

13. Parnham MJ, Erakovic Haber V, Giama-rellos-Bourboulis EJ, Perletti G, Verleden GM, Vos R. Azithromycin: mechanisms of action and their relevance for clinical applications. Pharmacology & thera-peutics. 2014;143(2):225-45.

14. Watanabe S, Kasahara K, Waseda Y, Takato H, Nishikawa S, Yoneda T, et

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al. Imatinib ameliorates bronchiolitis obliterans via inhibition of fibrocyte mi-gration and differentiation. The Journal of heart and lung transplantation : the official publication of the Internatio-nal Society for Heart Transplantation. 2017;36(2):138-47.

15. Williams KM, Hnatiuk O, Mitchell SA, Baird K, Gadalla SM, Steinberg SM, et al. NHANES III equations enhance ear-ly detection and mortality prediction of bronchiolitis obliterans syndrome after hematopoietic SCT. Bone marrow trans-plantation. 2014;49(4):561-6.

16. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Muller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment op-tions. Bone marrow transplantation. 2012;47(8):1020-9.

17. Keates-Baleeiro J, Moore P, Koyama T, Manes B, Calder C, Frangoul H. Inci-dence and outcome of idiopathic pneu-monia syndrome in pediatric stem cell transplant recipients. Bone marrow transplantation. 2006;38(4):285-9.

18. Sano H, Kobayashi R, Iguchi A, Suzuki D, Kishimoto K, Yasuda K, et al. Risk factor analysis of idiopathic pneumonia syndrome after allogeneic hematopoie-tic SCT in children. Bone marrow trans-plantation. 2014;49(1):38-41.

19. Sakaguchi H, Takahashi Y, Watanabe N, Doisaki S, Muramatsu H, Hama A, et al. Incidence, clinical features, and risk fac-tors of idiopathic pneumonia syndrome following hematopoietic stem cell trans-plantation in children. Pediatric blood & cancer. 2012;58(5):780-4.

20. Duncan CN, Buonanno MR, Barry EV, Myers K, Peritz D, Lehmann L. Bron-chiolitis obliterans following pediatric allogeneic hematopoietic stem cell transplantation. Bone marrow trans-plantation. 2008;41(11):971-5.

21. Duncan CN, Barry EV, Lehmann LE. Tolerability of pravastatin in pediatric hematopoietic stem cell transplant pa-tients with bronchiolitis obliterans. J Pe-diatr Hematol Oncol. 2010;32(3):185-8.

22. Ratjen F, Rjabko O, Kremens B. High-dose corticosteroid therapy for bron-chiolitis obliterans after bone marrow transplantation in children. Bone mar-row transplantation. 2005;36(2):135-8.

23. Mertens AC, Yasui Y, Liu Y, Stovall M, Hutchinson R, Ginsberg J, et al. Pulmo-nary complications in survivors of child-hood and adolescent cancer. A report from the Childhood Cancer Survivor Study. Cancer. 2002;95(11):2431-41.

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al. Imatinib ameliorates bronchiolitis obliterans via inhibition of fibrocyte mi-gration and differentiation. The Journal of heart and lung transplantation : the official publication of the Internatio-nal Society for Heart Transplantation. 2017;36(2):138-47.

15. Williams KM, Hnatiuk O, Mitchell SA, Baird K, Gadalla SM, Steinberg SM, et al. NHANES III equations enhance ear-ly detection and mortality prediction of bronchiolitis obliterans syndrome after hematopoietic SCT. Bone marrow trans-plantation. 2014;49(4):561-6.

16. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Muller KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment op-tions. Bone marrow transplantation. 2012;47(8):1020-9.

17. Keates-Baleeiro J, Moore P, Koyama T, Manes B, Calder C, Frangoul H. Inci-dence and outcome of idiopathic pneu-monia syndrome in pediatric stem cell transplant recipients. Bone marrow transplantation. 2006;38(4):285-9.

18. Sano H, Kobayashi R, Iguchi A, Suzuki D, Kishimoto K, Yasuda K, et al. Risk factor analysis of idiopathic pneumonia syndrome after allogeneic hematopoie-tic SCT in children. Bone marrow trans-plantation. 2014;49(1):38-41.


20. Duncan CN, Buonanno MR, Barry EV, Myers K, Peritz D, Lehmann L. Bron-chiolitis obliterans following pediatric allogeneic hematopoietic stem cell transplantation. Bone marrow trans-plantation. 2008;41(11):971-5.


22. Ratjen F, Rjabko O, Kremens B. High-dose corticosteroid therapy for bron-chiolitis obliterans after bone marrow transplantation in children. Bone mar-row transplantation. 2005;36(2):135-8.

23. Mertens AC, Yasui Y, Liu Y, Stovall M, Hutchinson R, Ginsberg J, et al. Pulmo-nary complications in survivors of child-hood and adolescent cancer. A report from the Childhood Cancer Survivor Study. Cancer. 2002;95(11):2431-41.

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Supplemental data

TABLE S1. Univariate predictor analyses for Allo-LS free survival, BOS + IPS (N=53)

Variable HR (95% CI), P value

Age at Allo-LS 1.01 (0.96-1.07), p=0.69

Female 1.06 (0.52-2.14), p=0.88


10.87 (0.34-2.23), p=0.771.01 (0.21-4.90), p=0.991.09 (0.41-2.91), p=0.86

Stem cell source Bone marrow Cord blood Peripheral blood stem cells

10.25 (0.3-2.00), p=0.19

0.32 (0.41-2.48), p=0.27

Unrelated donor 1.61 (0.66-3.94), p=0.29

Conditioning regimen Myeloablative Busulfan based Myeloablative total body irridiation (TBI) based Reduced intensity conditioning (RIC), no/lower dose Busulfan

10.44 (0.13-1.47), p=0.180.55 (0.09-3.33), p=0.51

Human Leukocyte Antigen (HLA) mismatched* 1.98 (0.96-4.1), p=0.07

Hematopoietic cell transplantation (HCT) before 2008 0.75 (0.36-1.54), p=0.43

Respiratory viruses from broncho-alveolar lavage pre-HCT (n=36) 0.82 (0.32-2.08), p=0.67

Respiratory viruses from nasopharyngeal aspirate pre-HCT (n=48) 0.72 (0.33-1.56), p=0.40

Viral reactivation prior to Allo-LS 1.53 (0.75-3.10), p=0.24

Time from HCT to Allo-LS 0.99 (0.99-1.00), p=0.15

Time from symptoms to treatment Allo-LS 1.00 (0.99-1.02), p=0.71

Graft versus Host Disease treatment prior to Allo-LS 4.4 (1.76-11.12), p=0.002

Oxygen therapy 2.3 (0.8-6.59), p=0.12

Intensive care for mechanical ventilation 2.8 (1.38-5.74), p=0.005

Idiopathic Pneumonia Syndrome (IPS)Bronchiolitis Obliterans Syndrome (BOS)

10.57 (0.27-1.17), p=0.13

High resolution CT composite score (n=43) 1.03 (0.99-1.07), p=0.20

High resolution CT allo score (n=43) 1.03 (0.94-1.13), p=0.55

RV from NPA or BAL at diagnosis Allo-LS (n=43) 0.31 (0.14-0.72), p=0.006

* All 10/10 bone marrow/peripheral blood stem cell products and 6/6 cord blood units were considered matched. Allo-LS, Alloimmune mediated lung syndrome.

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Supplemental data

TABLE S1. Univariate predictor analyses for Allo-LS free survival, BOS + IPS (N=53)


Age at Allo-LS 1.01 (0.96-1.07), p=0.69

Female 1.06 (0.52-2.14), p=0.88


10.87 (0.34-2.23), p=0.771.01 (0.21-4.90), p=0.991.09 (0.41-2.91), p=0.86


10.25 (0.3-2.00), p=0.19

0.32 (0.41-2.48), p=0.27


Conditioning regimen Myeloablative Busulfan based Myeloablative total body irridiation (TBI) based Reduced intensity conditioning (RIC), no/lower dose Busulfan

10.44 (0.13-1.47), p=0.180.55 (0.09-3.33), p=0.51








Graft versus Host Disease treatment prior to Allo-LS 4.4 (1.76-11.12), p=0.002

Oxygen therapy 2.3 (0.8-6.59), p=0.12


Idiopathic Pneumonia Syndrome (IPS)Bronchiolitis Obliterans Syndrome (BOS)

10.57 (0.27-1.17), p=0.13



RV from NPA or BAL at diagnosis Allo-LS (n=43) 0.31 (0.14-0.72), p=0.006


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Supplemental data

TABLE S2. Univariate predictor analyses for Allo-LS free survival, BOS (N=23)


Age at Allo-LS 1.01 (0.91-1.12), p=0.92

Female 5.65 (1.22-26.1), p=0.03


11.17 (0.24-5.65), p=0.85

NA2.76 (0.46-16.62), p=0.27


1NANA


Conditioning regimen Myeloablative Busulfan based Myeloablative total body irridiation (TBI) based Non-myeloablative/reduced intensity conditioning (RIC)

11.0(0.04-228), p=1.0

1.0 (0.0-555), p=1.0


Hematopoietic cell transplantation (HCT) before 2008 0.9 (0.28-2.84) p=0.85

Respiratory viruses from broncho-alveolar lavage pre-HCT (n=16) 1.01 (0.25-4.10) p=0.99

Respiratory viruses from nasopharyngeal aspirate pre-HCT (n=19) 0.87 (0.23-3.29) p=0.84

Viral reactivation prior to Allo-LS 0.59 (0.17-1.96) p=0.39

Time from HCT to Allo-LS 0.99 (0.99-1.01) p=0.38

Time from symptoms to treatment Allo-LS 1.00 (0.98-1.02) p= 0.93

Graft versus Host Disease prior to Allo-LS 5.01 (1.00-25.10) p=0.05

Oxygen therapy 2.44 (0.65-9.11) p=0.18

Intensive care for mechanical ventilation 0.65 (0.14-2.99) p=0.58

High resolution CT composite score (n=22) 1.01 (0.95-1.06) p=0.86

High resolution CT allo score (n=22) 1.07 (0.93-1.25) p=0.35

Respiratory viruses from NPA or BAL at diagnosis Allo-LS (n=15) 0.94 (0.23-3.81) p=0.94


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Supplemental data

TABLE S2. Univariate predictor analyses for Allo-LS free survival, BOS (N=23)


Age at Allo-LS 1.01 (0.91-1.12), p=0.92

Female 5.65 (1.22-26.1), p=0.03


11.17 (0.24-5.65), p=0.85

NA2.76 (0.46-16.62), p=0.27


1NANA



11.0(0.04-228), p=1.0

1.0 (0.0-555), p=1.0


Hematopoietic cell transplantation (HCT) before 2008 0.9 (0.28-2.84) p=0.85

Respiratory viruses from broncho-alveolar lavage pre-HCT (n=16) 1.01 (0.25-4.10) p=0.99

Respiratory viruses from nasopharyngeal aspirate pre-HCT (n=19) 0.87 (0.23-3.29) p=0.84

Viral reactivation prior to Allo-LS 0.59 (0.17-1.96) p=0.39

Time from HCT to Allo-LS 0.99 (0.99-1.01) p=0.38

Time from symptoms to treatment Allo-LS 1.00 (0.98-1.02) p= 0.93

Graft versus Host Disease prior to Allo-LS 5.01 (1.00-25.10) p=0.05

Oxygen therapy 2.44 (0.65-9.11) p=0.18

Intensive care for mechanical ventilation 0.65 (0.14-2.99) p=0.58

High resolution CT composite score (n=22) 1.01 (0.95-1.06) p=0.86

High resolution CT allo score (n=22) 1.07 (0.93-1.25) p=0.35

Respiratory viruses from NPA or BAL at diagnosis Allo-LS (n=15) 0.94 (0.23-3.81) p=0.94


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TABLE S3. Univariate predictor analyses for Allo-LS free survival, IPS (N=30)


Age at Allo-LS 1.05 (0.98-1.13), p=0.19

Female 0.5 (0.2-1.31), p=0.16Primary disease Malignant Bone marrow failure syndrome Inborn error of metabolism Primary Immune deficiency

11.02 (0.29-3.52), p=0.981.30 (0.25-6.86), p=0.760.71 (0.22-2.29), p=0.57


11.08 (0.42-2.76), p=0.87



10.61 (0.14-2.67), p=0.510.32 (0.03-3.59), p=0.35








Graft versus Host Disease prior to Allo-LS 4.46 (1.43-13.90), p=0.01

Oxygen therapy 1.78 (0.23-13.40), p=0.58




Respiratory viruses from NPA or BAL at diagnosis Allo-LS (n=28) 0.17 (0.05-0.53), p=0.002


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TABLE S3. Univariate predictor analyses for Allo-LS free survival, IPS (N=30)


Age at Allo-LS 1.05 (0.98-1.13), p=0.19

Female 0.5 (0.2-1.31), p=0.16Primary disease Malignant Bone marrow failure syndrome Inborn error of metabolism Primary Immune deficiency

11.02 (0.29-3.52), p=0.981.30 (0.25-6.86), p=0.760.71 (0.22-2.29), p=0.57


11.08 (0.42-2.76), p=0.87



10.61 (0.14-2.67), p=0.510.32 (0.03-3.59), p=0.35








Graft versus Host Disease prior to Allo-LS 4.46 (1.43-13.90), p=0.01

Oxygen therapy 1.78 (0.23-13.40), p=0.58




Respiratory viruses from NPA or BAL at diagnosis Allo-LS (n=28) 0.17 (0.05-0.53), p=0.002


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Supplemental data

TABLE S4. Univariate/multivariate predictor analyses for Therapy Failure in Allo-LS

Univariate analyses Hazard ratio (95% CI), P value

RV from NPA or BAL at diagnosis Allo-LS 0.48 (0.19-1.18), p=0.11

Intensive care for mechanical ventilation 2.14 (0.96-4.79), p=0.06*

Systemic GvHD treatment prior to Allo-LS 2.60 (0.97-6.99, p=0.06*

Multivariate analyses Hazard ratio (95% CI), P value

Systemic GvHD treatment prior to Allo-LS 2.63 (0.98-7.05), p=0.06


Allo-LS = Alloimmune mediated lung syndrome, IPS= Idiopathic Pneumonia Syndrome, BOS = Bronchiolitis Obliterans Syndrome, GvHD = Graft versus Host Disease, RV = Res-piratory Virus. * variables with p<0.1 in univariate analyses where included in multivariate analyses.

TABLE S5. Univariate/multivariate predictor analyses for non relapse mortality in Allo-LS


RV from NPA or BAL at diagnosis Allo-LS 0.25 (0.10-0.64), p=0.004*







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Supplemental data

TABLE S4. Univariate/multivariate predictor analyses for Therapy Failure in Allo-LS




Systemic GvHD treatment prior to Allo-LS 2.60 (0.97-6.99, p=0.06*





TABLE S5. Univariate/multivariate predictor analyses for non relapse mortality in Allo-LS


RV from NPA or BAL at diagnosis Allo-LS 0.25 (0.10-0.64), p=0.004*







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TABLE S6. PFT in BOS patients, univariate analyses for association with Allo-LS free survival

Hazard ratio (95% CI), P value

PFT at diagnosis BOS (n=17)

FEV1% 0.96 (0.91-1.02), p=0.19

FVC% 1.02 (0.97-1.07), p=0.55

FEV1/FVC 0.94 (0.90-0.990, p=0.02

RV/TLC 1.01 (0.94-1.09), p=0.83

PFT after first MP pulse (n=17)

FEV1% after MP1 0.94 (0.89-0.98), p=0.01

FEV1% after MP1 below the median of 55% 8.03 (0.96-67.3), p=0.06

Increase in FEV1% after MP1 0.84 (0.73-0.96), p=0.01

Increase in FEV1% below the median of 10% after MP1 9.75 (1.14-83.6), p=0.04

PFT = Pulmonary Function Test, BOS = Bronchiolitis Obliterans Syndrome, Allo-LS = Alloimmune Lung Syndrome, FEV1% = Forced Expiratory Volume in 1 second as a percentage of normal values, FVC% = Forced Vital Capacity as a percentage of normal values, RV = Residual Volume, TLC = Total Lung Capacity, MP1= First Me-thyl Prednisolone pulse

8

153


TABLE S6. PFT in BOS patients, univariate analyses for association with Allo-LS free survival

Hazard ratio (95% CI), P value

PFT at diagnosis BOS (n=17)

FEV1% 0.96 (0.91-1.02), p=0.19

FVC% 1.02 (0.97-1.07), p=0.55

FEV1/FVC 0.94 (0.90-0.990, p=0.02

RV/TLC 1.01 (0.94-1.09), p=0.83

PFT after first MP pulse (n=17)

FEV1% after MP1 0.94 (0.89-0.98), p=0.01

FEV1% after MP1 below the median of 55% 8.03 (0.96-67.3), p=0.06

Increase in FEV1% after MP1 0.84 (0.73-0.96), p=0.01

Increase in FEV1% below the median of 10% after MP1 9.75 (1.14-83.6), p=0.04

PFT = Pulmonary Function Test, BOS = Bronchiolitis Obliterans Syndrome, Allo-LS = Alloimmune Lung Syndrome, FEV1% = Forced Expiratory Volume in 1 second as a percentage of normal values, FVC% = Forced Vital Capacity as a percentage of normal values, RV = Residual Volume, TLC = Total Lung Capacity, MP1= First Me-thyl Prednisolone pulse

8

154

Supplemental data

FIGURE S1. Cumulative incidences of therapy failure according to ICU admission for mechanical ventilation (a) and GVHD treatment prior to Allo-LS (b).

FIGURE S2. Cumulative inncidence of non relapse mortality (NRM) according to presence of respiratory viruses (a) and ICU admission for mechanical ventilation (b).

— No ICU admission — ICU admission — No GvHD treatment — GvHD treatment

— No RV present — RV present — No ICU admission — ICU admission

8

A B

A B

55% (28-72%)

37% (17-52%)

p=0.015*

22

31 21 18

8 6

Ther

apy

failu

re (

%)

100

75

50

25

0

100

75

50

25

0

Time after Allo-LS onset (days)0 200 400

Number at risk

100% (N/A)

37% (21-49%)

p=0.002**

47

6 1 0

28 24Time after Allo-LS onset (days)

0 200Number at risk

400

NR

M in

cide

nce

(%)

100

75

50

25

0

20

23 17 16


0 300Number at risk

600

15

4

900

p=0.002**

75% ± 20%

26% ± 18%

100

75

50

25

0p=0.003**

33% ± 17%

68% ± 20%

31

22 8 7


0 300Number at risk

600

7

16

900

154

Supplemental data

FIGURE S1. Cumulative incidences of therapy failure according to ICU admission for mechanical ventilation (a) and GVHD treatment prior to Allo-LS (b).

FIGURE S2. Cumulative inncidence of non relapse mortality (NRM) according to presence of respiratory viruses (a) and ICU admission for mechanical ventilation (b).

— No ICU admission — ICU admission — No GvHD treatment — GvHD treatment

— No RV present — RV present — No ICU admission — ICU admission

8

A B

A B

55% (28-72%)

37% (17-52%)

p=0.015*

22

31 21 18

8 6

Ther

apy

failu

re (

%)

100

75

50

25

0

100

75

50

25

0

Time after Allo-LS onset (days)0 200 400

Number at risk

100% (N/A)

37% (21-49%)

p=0.002**

47

6 1 0


0 200Number at risk

400

NR

M in

cide

nce

(%)

100

75

50

25

0

20

23 17 16


0 300Number at risk

600

15

4

900

p=0.002**

75% ± 20%

26% ± 18%

100

75

50

25

0p=0.003**

33% ± 17%

68% ± 20%

31

22 8 7


0 300Number at risk

600

7

16

900

155


FIGURE S3. Serial, median values of FEV1%, FVC%, FEV1/FVC and RV/TLC in 13 Allo-LS free survivors, at different time points after Allo-LS.

8

day 7-100 day 100 -1 yr 1-2 year 2-6 year >6 year

100

90

80

70

60

50

40

30

20

10

0

FEV1%

FVC%

FEV1/FVC

RV/TLC

155


FIGURE S3. Serial, median values of FEV1%, FVC%, FEV1/FVC and RV/TLC in 13 Allo-LS free survivors, at different time points after Allo-LS.

8

day 7-100 day 100 -1 yr 1-2 year 2-6 year >6 year

100

90

80

70

60

50

40

30

20

10

0

FEV1%

FVC%

FEV1/FVC

RV/TLC

9Discussion

9Discussion

158

Predictors for allo-LS

The primary aim of this thesis was to investigate predictors, diagnostic tools and deter-minants for outcome in Allo-immune mediated Lung Syndromes (Allo-LS) after pedia-tric Hematopoietic Cell Transplantation (HCT). In this Chapter the main findings are discussed in the context of current literature, with their implications for patient care and future research.

What are predictors for allo-LS?

Studies evaluating predictors for Allo-LS in adults are scarce, and they present con-flicting results. For IPS aGVHD, TBI conditioning, busulfan conditioning, age, malig-nant disease and unrelated donor are all identified as risk factors.1,2 For BOS cGVHD, aGVHD grade II-IV, PBSC grafts, HLA disparity, high donor age, male gender, cigarette smoking history, hypogammaglobinemia, pre-existing lung disease and Respiratory Vi-rus (RV) infections are thought to be predictors.3,4

A systematic search of the literature on predictors for non-infectious pulmonary compli-cations after allogeneic HCT in children revealed 17 studies, including our own studies as described in Chapter 3 and Chapter 7.5,6 All studies with more than 5 children were selected. All studies analyze the role of general patient characteristics, HCT characteris-tics, aGVHD and cGVHD on pulmonary endpoints. Some studies have special focus on biomarkers, innate immunity, drug reactions and the presence of Respiratory Viruses pre-HCT. Table 1 shows an overview of the data.

Limitations of the studies are their retrospective nature and small numbers of patients. When comparing the results of the studies one also has to consider the varying end-points (decline in Pulmonary Function Tests or clinical diagnosis like IPS and BOS) and the different statistical methods used for analyses.

The most consistent overall result is the strong association of aGVHD and cGVHD with Allo-LS,7-13 although some groups did not find this relation.14,15

Our group was the first to specifically study RV early during HCT5,6 and we found a strong association with the occurrence of Allo-LS (HR 8.37, 95% CI 1.78-39.43, p=0.007). In most other studies, RV was an exclusion criterion for Allo-LS, so nothing is noted on incidence or impact of viral infections. Although Duncan et al.13 do mention a high incidence of early viral infections in patients developing BOS, it was no significant pre-dictor however. This point will be further elucidated in the next section on Respiratory Viruses (“Why study Respiratory Viruses after lung transplantation and HCT?” and “RV and Allo-LS”).

9

158


The primary aim of this thesis was to investigate predictors, diagnostic tools and deter-minants for outcome in Allo-immune mediated Lung Syndromes (Allo-LS) after pedia-tric Hematopoietic Cell Transplantation (HCT). In this Chapter the main findings are discussed in the context of current literature, with their implications for patient care and future research.

What are predictors for allo-LS?

Studies evaluating predictors for Allo-LS in adults are scarce, and they present con-flicting results. For IPS aGVHD, TBI conditioning, busulfan conditioning, age, malig-nant disease and unrelated donor are all identified as risk factors.1,2 For BOS cGVHD, aGVHD grade II-IV, PBSC grafts, HLA disparity, high donor age, male gender, cigarette smoking history, hypogammaglobinemia, pre-existing lung disease and Respiratory Vi-rus (RV) infections are thought to be predictors.3,4

A systematic search of the literature on predictors for non-infectious pulmonary compli-cations after allogeneic HCT in children revealed 17 studies, including our own studies as described in Chapter 3 and Chapter 7.5,6 All studies with more than 5 children were selected. All studies analyze the role of general patient characteristics, HCT characteris-tics, aGVHD and cGVHD on pulmonary endpoints. Some studies have special focus on biomarkers, innate immunity, drug reactions and the presence of Respiratory Viruses pre-HCT. Table 1 shows an overview of the data.

Limitations of the studies are their retrospective nature and small numbers of patients. When comparing the results of the studies one also has to consider the varying end-points (decline in Pulmonary Function Tests or clinical diagnosis like IPS and BOS) and the different statistical methods used for analyses.

The most consistent overall result is the strong association of aGVHD and cGVHD with Allo-LS,7-13 although some groups did not find this relation.14,15

Our group was the first to specifically study RV early during HCT5,6 and we found a strong association with the occurrence of Allo-LS (HR 8.37, 95% CI 1.78-39.43, p=0.007). In most other studies, RV was an exclusion criterion for Allo-LS, so nothing is noted on incidence or impact of viral infections. Although Duncan et al.13 do mention a high incidence of early viral infections in patients developing BOS, it was no significant pre-dictor however. This point will be further elucidated in the next section on Respiratory Viruses (“Why study Respiratory Viruses after lung transplantation and HCT?” and “RV and Allo-LS”).

9

159

Discussion

TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Abu

gide

iri (

14)

2016

N=1

29, 1

2 (1

-21)

yr

Allo

-HC

T w

ith T

BI

IPS

: 23.

3%

TBI (

cGy/

min

) O

R 4

.94

(1.8

3-13

.35)

, p=0

.002

Dun

can

(13)

2008

N=2

16, 9

.8 y

rB

OS:

8.3

%

aGV

HD

, p=0

.001

cGV

HD

, p<

0.00

1

Dru

g re

actio

n, p

< 0.

001

Uni

varia

te t-

test

Early

vira

l inf

ectio

n:

p=0.

15

Gas

sas

(16)

2015

N=3

9, 8

.3 (

1-17

.2)

yrB

OS:

15.

4%

Seru

m K

L-6

pre

HC

T p<

0.05

Seru

m K

L-6

+ 1

mon

th p

<0.0

4

Seru

m K

L-6

+ 3

mon

ths

p<0.

12

Uni

varia

te t-

test

Gas

sas

(17)

2016

N=3

9, 8

.3 (

1-17

.2)

yrB

OS:

15.

4%

Neu

trop

hil c

ount

+ 3

mon

ths

p=0.

03

Neu

trop

hil c

ount

+ 6

mon

ths

p=0.

03

Uni

varia

te t-

test

Mad

anat

(12

)

2014

N=5

1, 1

1.2

(6.2

-19)

yr

Allo

-HC

T w

ith T

BI

IEM

exc

lude

d

Pulm

onar

y dy

sfun

ctio

n (c

linic

al o

r ↓

PFT

): 5

9%

Abn

orm

al b

asel

ine

PFT

HR

4.8

2, (

1.02

-22.

84)

p= 0

.05

aGV

HD

HR

4.3

1,(1

.47-

12.6

3), p

= 0.

008

cGV

HD

HR

10.

2 (1

.47-

12.6

3), p

=0.0

02

Uni

varia

te

Nag

asaw

a (1

1)

2017

N=6

7, 6

.5 (

0.6-

22.7

) yr

only

mal

igna

ncie

s

BO

S: 1

3.4%

cGV

HD

, HR

11.

3,(1

.77-

72.7

0,p=

0.01

)

RIC

: no

BO

S

Smal

l num

bers

Nis

hio

(10)

2009

N=9

7, 6

.6 (

0.4-

18)

yrB

OS/

IPS:

10.

3%

HR

-mal

igna

ncy

(no

CR

) H

R 5

.42(

1.36

-21.

7), p

=0.0

17

exte

nsiv

e cG

VH

D H

R 1

1.7

(2.4

0-57

.1),

p=0

.002

Tabl

e co

ntin

ues

on n

ext p

age

9

159

Discussion

TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Abu

gide

iri (

14)

2016

N=1

29, 1

2 (1

-21)

yr

Allo

-HC

T w

ith T

BI

IPS

: 23.

3%

TBI (

cGy/

min

) O

R 4

.94

(1.8

3-13

.35)

, p=0

.002

Dun

can

(13)

2008

N=2

16, 9

.8 y

rB

OS:

8.3

%

aGV

HD

, p=0

.001

cGV

HD

, p<

0.00

1

Dru

g re

actio

n, p

< 0.

001

Uni

varia

te t-

test

Early

vira

l inf

ectio

n:

p=0.

15

Gas

sas

(16)

2015

N=3

9, 8

.3 (

1-17

.2)

yrB

OS:

15.

4%

Seru

m K

L-6

pre

HC

T p<

0.05

Seru

m K

L-6

+ 1

mon

th p

<0.0

4

Seru

m K

L-6

+ 3

mon

ths

p<0.

12

Uni

varia

te t-

test

Gas

sas

(17)

2016

N=3

9, 8

.3 (

1-17

.2)

yrB

OS:

15.

4%

Neu

trop

hil c

ount

+ 3

mon

ths

p=0.

03

Neu

trop

hil c

ount

+ 6

mon

ths

p=0.

03

Uni

varia

te t-

test

Mad

anat

(12

)

2014

N=5

1, 1

1.2

(6.2

-19)

yr

Allo

-HC

T w

ith T

BI

IEM

exc

lude

d

Pulm

onar

y dy

sfun

ctio

n (c

linic

al o

r ↓

PFT

): 5

9%

Abn

orm

al b

asel

ine

PFT

HR

4.8

2, (

1.02

-22.

84)

p= 0

.05

aGV

HD

HR

4.3

1,(1

.47-

12.6

3), p

= 0.

008

cGV

HD

HR

10.

2 (1

.47-

12.6

3), p

=0.0

02

Uni

varia

te

Nag

asaw

a (1

1)

2017

N=6

7, 6

.5 (

0.6-

22.7

) yr

only

mal

igna

ncie

s

BO

S: 1

3.4%

cGV

HD

, HR

11.

3,(1

.77-

72.7

0,p=

0.01

)

RIC

: no

BO

S

Smal

l num

bers

Nis

hio

(10)

2009

N=9

7, 6

.6 (

0.4-

18)

yrB

OS/

IPS:

10.

3%

HR

-mal

igna

ncy

(no

CR

) H

R 5

.42(

1.36

-21.

7), p

=0.0

17

exte

nsiv

e cG

VH

D H

R 1

1.7

(2.4

0-57

.1),

p=0

.002

Tabl

e co

ntin

ues

on n

ext p

age

9

160


TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT —

cont

inue

d

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Park

(9)

2011

N=1

27,

7.7

(0.5

-18.

3) y

r

BO

S/IP

S: 8

.7%

cGV

HD

, p=0

.002

exte

nsiv

e cG

VH

D, p

=0.0

01

Prai

s(18

)

2014

N=1

4, 1

4.4

(5.6

-19.

2) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

TBI →

FV

C(p

=0.0

03),

FEV

1(p=

0.00

2), F

EF-2

5-75

% (

p=0.

02)

Chi

-squ

are

Smal

l num

bers

Qui

gg(1

9)

2012

N=4

1, 1

2.5

(5-1

9) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

HR

-Mal

igna

ncy

(no

CR

): F

EV1,

FV

C, T

LC

GV

HD

: RV

(p=

0.01

4)

Bus

ulfa

n/C

yclo

fosf

amid

e co

nditi

onin

g: C

Odi

ffusi

on (

p=0.

02)

Logi

stic

reg

ress

ion

Saka

gush

i(15

)

2012

N=1

89, 7

(0.

3-22

.7)

yrIP

S: 9

.5%

HR

-Mal

igna

ncy

(≥ C

R3)

HR

2.5

(1.0

-6.7

), p

= 0.

05

Bus

ulfa

n co

nditi

onin

g H

R 3

.5 (

1.3-

9.9)

, p=0

.01

Sano

(8)

2014

N=2

10, 7

(0-

21)

yrIP

S: 6

.7%

Prio

r H

CT

HR

5.1

3 (1

.5-1

7.4)

, p=0

.009

aGV

HD

HR

4.7

9( 1

.29-

17.8

), p

=0.0

2

Srin

ivas

an(2

0)

2014

N=4

10,1

3.6

(6.2

-20.

9) y

r

PFT

pre-

HC

T

Pulm

onar

y co

mpl

icat

ions

(in

fect

ious

35%

+ B

OS/

IPS:

7%

)

No

risk

fact

ors

for

non-

infe

ctio

us c

ompl

icat

ions

Logi

stic

reg

ress

ion

Tabl

e co

ntin

ues

on n

ext p

age

9

160


TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT —

cont

inue

d

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Park

(9)

2011

N=1

27,

7.7

(0.5

-18.

3) y

r

BO

S/IP

S: 8

.7%

cGV

HD

, p=0

.002

exte

nsiv

e cG

VH

D, p

=0.0

01

Prai

s(18

)

2014

N=1

4, 1

4.4

(5.6

-19.

2) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

TBI →

FV

C(p

=0.0

03),

FEV

1(p=

0.00

2), F

EF-2

5-75

% (

p=0.

02)

Chi

-squ

are

Smal

l num

bers

Qui

gg(1

9)

2012

N=4

1, 1

2.5

(5-1

9) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

HR

-Mal

igna

ncy

(no

CR

): F

EV1,

FV

C, T

LC

GV

HD

: RV

(p=

0.01

4)

Bus

ulfa

n/C

yclo

fosf

amid

e co

nditi

onin

g: C

Odi

ffusi

on (

p=0.

02)

Logi

stic

reg

ress

ion

Saka

gush

i(15

)

2012

N=1

89, 7

(0.

3-22

.7)

yrIP

S: 9

.5%

HR

-Mal

igna

ncy

(≥ C

R3)

HR

2.5

(1.0

-6.7

), p

= 0.

05

Bus

ulfa

n co

nditi

onin

g H

R 3

.5 (

1.3-

9.9)

, p=0

.01

Sano

(8)

2014

N=2

10, 7

(0-

21)

yrIP

S: 6

.7%

Prio

r H

CT

HR

5.1

3 (1

.5-1

7.4)

, p=0

.009

aGV

HD

HR

4.7

9( 1

.29-

17.8

), p

=0.0

2

Srin

ivas

an(2

0)

2014

N=4

10,1

3.6

(6.2

-20.

9) y

r

PFT

pre-

HC

T

Pulm

onar

y co

mpl

icat

ions

(in

fect

ious

35%

+ B

OS/

IPS:

7%

)

No

risk

fact

ors

for

non-

infe

ctio

us c

ompl

icat

ions

Logi

stic

reg

ress

ion

Tabl

e co

ntin

ues

on n

ext p

age

9

161

Discussion

TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT —

cont

inue

d

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Uhl

ving

(21

)

2013

N=1

30, 1

0.4

(6-1

6) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

aGV

HD

→ F

EV1,

FEV

1/FV

C, C

O-d

iffus

ion

Mal

igna

ncy

→ F

EV1,

FV

C, T

LC, C

O-d

iffus

ion

cGV

HD

→ F

EV1,

FV

C

Bus

ulfa

n →

FEV

1, F

EV1/

FVC

, CO

-diff

usio

n

CM

V(n

eg d

onor

/pos

rec

ipie

nt)

→ F

EV1,

FV

C

No

data

on

Res

idua

l

Volu

me

Vers

luys

(5)

2010

N=1

10, 5

(0.

2-21

) yr

BO

S/IP

S A

llo-L

S: 2

7.3%

RV

+ pr

e-H

CT

HR

8.3

7 (1

.78-

39.4

3), p

=0.0

07

aGV

HD

OR

0.1

(0.0

2-0.

47),

p=0.

004

GV

HD

trea

tmen

t:

prot

ectiv

e

Vers

luys

(6)

2017

N=1

79, 6

.8 (

0.6-

22.7

)

BA

L an

d N

PA p

re-H

CT

BO

S/IP

S A

llo-L

S: 1

3%

BA

L R

Vpos

itivi

ty H

R 3

.8 (

1.4-

10.7

), p

=0.0

1

NPA

RVp

ositi

vity

NS

Keat

es (

7)

2006

N=9

3, 7

.8 (

0.6-

20.5

) yr

IPS:

11.

8%

aGV

HD

p=0

.09

Abb

revi

atio

ns: A

llo-L

S =

Allo

imm

une

med

iate

d lu

ng s

yndr

ome,

HC

T= H

emat

opoi

etic

Cel

l Tra

nspl

anta

tion,

IPS

= Id

iopa

thic

Pne

umon

ia S

yndr

ome,

TB

I

= To

tal B

ody

Irra

diat

ion,

aG

VH

D =

acu

te G

raft

Ver

sus

Hos

t Dis

ease

, cG

VH

D =

chr

onic

Gra

ft V

ersu

s H

ost d

isea

se, K

L-6=

Kre

bs v

on d

er L

unge

n-6,

PFT

= Pu

lmon

ary

Func

tion

Test

, CR

3 =

third

com

plet

e re

mis

sion

, CM

V =

Cyt

oMeg

aloV

irus,

RV

= R

espi

rato

ry V

irus,

BA

L =

Bro

ncho

Alv

eola

r La

vage

, NPA

=

Nas

al P

hary

ngea

l Asp

irate

9

161

Discussion

TABL

E 1.

Ove

rvie

w o

f pub

licat

ions

on

pred

icto

rs fo

r Allo

-LS

in ch

ildre

n af

ter H

CT —

cont

inue

d

Auth

orSt

udy

popu

latio

n Pr

imar

y en

dpoi

nt, i

dent

ified

Pre

dict

or

Rem

arks

Uhl

ving

(21

)

2013

N=1

30, 1

0.4

(6-1

6) y

r

PFT

pre-

and

pos

t-HC

T

Dec

line

in P

FT

aGV

HD

→ F

EV1,

FEV

1/FV

C, C

O-d

iffus

ion

Mal

igna

ncy

→ F

EV1,

FV

C, T

LC, C

O-d

iffus

ion

cGV

HD

→ F

EV1,

FV

C

Bus

ulfa

n →

FEV

1, F

EV1/

FVC

, CO

-diff

usio

n

CM

V(n

eg d

onor

/pos

rec

ipie

nt)

→ F

EV1,

FV

C

No

data

on

Res

idua

l

Volu

me

Vers

luys

(5)

2010

N=1

10, 5

(0.

2-21

) yr

BO

S/IP

S A

llo-L

S: 2

7.3%

RV

+ pr

e-H

CT

HR

8.3

7 (1

.78-

39.4

3), p

=0.0

07

aGV

HD

OR

0.1

(0.0

2-0.

47),

p=0.

004

GV

HD

trea

tmen

t:

prot

ectiv

e

Vers

luys

(6)

2017

N=1

79, 6

.8 (

0.6-

22.7

)

BA

L an

d N

PA p

re-H

CT

BO

S/IP

S A

llo-L

S: 1

3%

BA

L R

Vpos

itivi

ty H

R 3

.8 (

1.4-

10.7

), p

=0.0

1

NPA

RVp

ositi

vity

NS

Keat

es (

7)

2006

N=9

3, 7

.8 (

0.6-

20.5

) yr

IPS:

11.

8%

aGV

HD

p=0

.09

Abb

revi

atio

ns: A

llo-L

S =

Allo

imm

une

med

iate

d lu

ng s

yndr

ome,

HC

T= H

emat

opoi

etic

Cel

l Tra

nspl

anta

tion,

IPS

= Id

iopa

thic

Pne

umon

ia S

yndr

ome,

TB

I

= To

tal B

ody

Irra

diat

ion,

aG

VH

D =

acu

te G

raft

Ver

sus

Hos

t Dis

ease

, cG

VH

D =

chr

onic

Gra

ft V

ersu

s H

ost d

isea

se, K

L-6=

Kre

bs v

on d

er L

unge

n-6,

PFT

= Pu

lmon

ary

Func

tion

Test

, CR

3 =

third

com

plet

e re

mis

sion

, CM

V =

Cyt

oMeg

aloV

irus,

RV

= R

espi

rato

ry V

irus,

BA

L =

Bro

ncho

Alv

eola

r La

vage

, NPA

=

Nas

al P

hary

ngea

l Asp

irate

9

162


With regard to the role of GVHD in Allo-LS, our results are in strong contrast with the other publications. We found that treatment of aGVHD (II-IV) was protective for Allo-LS (OR 0.1, 95%CI 0.02-0.47, p=0.004). In our cohort of patients, with a high prevalence of RV and a high incidence of Allo-LS related to RV, prior aGVHD requiring systemic steroid therapy prevented the development of Allo-LS. This could be explained as fol-lows. Tissue damage by RV makes the lung a target for allo-immunity. However in case of prior GVHD in another organ, as gut and skin seem to be preferential target organs for GVHD, increased immunosuppression will have a preventive effect, hampering the immune damage in the lung.

Why study respiratory viruses after lung transplantation and HCT?We started studying the role of RV in immune mediated lung disease after HCT, inspired by publications on RV after lung transplantation.

There is an obvious analogy between immune mediated lung problems after HCT (graft versus host) and graft rejection after lung transplantation (host versus graft). HLA dis-parity between donor and recipient, with the lung as the target organ for inflammation, is comparable to a certain extent. However in lung transplant immune tolerance will not occur, because the recipients’ immune system does not have mechanisms to induce immunity for the allograft. So, in contrast with HCT, prolonged immunosuppression is always needed, and graft survival is relatively short with allo-immunity and graft rejec-tion occurring very often.22,23 Despite this difference, much can be learnt from pathophy-siology and treatment of acute and chronic rejection in lung transplantation.

Kumar et al. showed that community acquired RV infection in the first 100 days after lung transplantation predisposed for immune mediated graft rejection(24). As described in Chapter 3 and Chapter 7 we found that the presence of a respiratory virus (RV) prior to HCT is an important risk factor for developing Allo-LS. And when we analyzed the data from paired NPA and Broncho Alveolar Lavage (BAL) samples, this association seemed particularly true for RV from pre-HCT BAL. Our hypothesis is that RV gives epithelial da-mage and triggers the allogeneic immune response leading to severe lung disease. In our opinion lung disease does not occur primarily from progressive viral infection during the period of low immunity, but from allo-immune mediated damage weeks after HCT. This hypothesis should largely influence the therapeutic decision of delaying transplant, treating RV and most important increasing or decreasing immune suppression after transplant.

Respiratory viruses and progressive infectionThere are many reports on RV prior to, or early after, HCT. Most studies discuss the risk of progressive pneumonia, for various types of RV. Only few groups looked at long term outcome. Results are conflicting, reported risk of progression is 5-75%.25-27 In general

9

162


With regard to the role of GVHD in Allo-LS, our results are in strong contrast with the other publications. We found that treatment of aGVHD (II-IV) was protective for Allo-LS (OR 0.1, 95%CI 0.02-0.47, p=0.004). In our cohort of patients, with a high prevalence of RV and a high incidence of Allo-LS related to RV, prior aGVHD requiring systemic steroid therapy prevented the development of Allo-LS. This could be explained as fol-lows. Tissue damage by RV makes the lung a target for allo-immunity. However in case of prior GVHD in another organ, as gut and skin seem to be preferential target organs for GVHD, increased immunosuppression will have a preventive effect, hampering the immune damage in the lung.

Why study respiratory viruses after lung transplantation and HCT?We started studying the role of RV in immune mediated lung disease after HCT, inspired by publications on RV after lung transplantation.

There is an obvious analogy between immune mediated lung problems after HCT (graft versus host) and graft rejection after lung transplantation (host versus graft). HLA dis-parity between donor and recipient, with the lung as the target organ for inflammation, is comparable to a certain extent. However in lung transplant immune tolerance will not occur, because the recipients’ immune system does not have mechanisms to induce immunity for the allograft. So, in contrast with HCT, prolonged immunosuppression is always needed, and graft survival is relatively short with allo-immunity and graft rejec-tion occurring very often.22,23 Despite this difference, much can be learnt from pathophy-siology and treatment of acute and chronic rejection in lung transplantation.

Kumar et al. showed that community acquired RV infection in the first 100 days after lung transplantation predisposed for immune mediated graft rejection(24). As described in Chapter 3 and Chapter 7 we found that the presence of a respiratory virus (RV) prior to HCT is an important risk factor for developing Allo-LS. And when we analyzed the data from paired NPA and Broncho Alveolar Lavage (BAL) samples, this association seemed particularly true for RV from pre-HCT BAL. Our hypothesis is that RV gives epithelial da-mage and triggers the allogeneic immune response leading to severe lung disease. In our opinion lung disease does not occur primarily from progressive viral infection during the period of low immunity, but from allo-immune mediated damage weeks after HCT. This hypothesis should largely influence the therapeutic decision of delaying transplant, treating RV and most important increasing or decreasing immune suppression after transplant.

Respiratory viruses and progressive infectionThere are many reports on RV prior to, or early after, HCT. Most studies discuss the risk of progressive pneumonia, for various types of RV. Only few groups looked at long term outcome. Results are conflicting, reported risk of progression is 5-75%.25-27 In general

9

163

Discussion

RSV and influenza virus are thought to be more virulent than other RV like rhinovirus.26 Recent reports however, also show an important role for rhinovirus in lung disease after HCT.28

In a large prospective study, including adults and children undergoing allogeneic HCT, clinical outcomes associated with RV detected prior to HCT were analyzed.29 Multiplex PCR-testing for RV was done on nasal washes or nasopharyngeal swabs. In 25 % of pa-tients they found a RV, 22% of them being asymptomatic. RV positive patients were sig-nificantly younger and had higher risk underlying disease with lower lymphocyte count. Overall mortality at day 100 was significantly higher in RV-patients than in non-RV pa-tients, patients with rhinovirus performing worse compared to the other RV (like RSV, influenza). In 28% of the deceased patients the cause of death was directly related to the pre-HCT RV.

This study largely supports our findings (as described in Chapter 3 and 7), with high prevalence of RV in patients prior to HCT, also in asymptomatic patients, especially in children, when using modern high sensitive virus detection methods. They also showed persistence of the RV after HCT in 40%, and direct progression to LRTI only in 4% of patients. Rhinovirus was at least as pathologic as the other RV.

Comments could be made about the stated relation between RV and death. It is impor-tant to realize that it is hard to distinguish death from RV pneumonia from Allo-LS. Given the time of death (median day + 32), and the description of clinical symptoms oc-curring weeks after first detection of RV with hypoxia, alveolar damage and pulmonary infiltrates, this might well all be allo-immune mediated lung disease. It would also be very interesting to see the data on follow up after day + 100, with regard to the develop-ment of BOS.

In Chapter 6 we discuss the risks of Respiratory Syncytial Virus (RSV) during HCT. In ge-neral the literature estimates the risk of progression from RSV-URTI to -LRTI at around 50%, with RSV-related mortality rates varying between 10-55%.25,27,30 These figures are found in the context of RSV treatment with antivirals. In adults, effect of treatment with ribavirin on progression to LRTI and RSV-related mortality is suggested, but in children this is unclear. In our small case series of untreated RSV-positive HCT recipients, we saw progression to mild LRTI in 38% and no RSV related deaths. Symptoms of LRTI occur-red rather late after the detection of RSV, coinciding with neutrophil engraftment and early T-cell reconstitution. Our observation suggests a role for immunity in the sympto-matology of RSV disease after HCT.

This is consistent with an ongoing discussion in the field of RSV bronchiolitis. What drives disease? Is it high viral load, is it an excessive immune response, or both?31 In our cohort of patients there were no RSV related deaths. We do not think that the risk of

9

163

Discussion

RSV and influenza virus are thought to be more virulent than other RV like rhinovirus.26 Recent reports however, also show an important role for rhinovirus in lung disease after HCT.28

In a large prospective study, including adults and children undergoing allogeneic HCT, clinical outcomes associated with RV detected prior to HCT were analyzed.29 Multiplex PCR-testing for RV was done on nasal washes or nasopharyngeal swabs. In 25 % of pa-tients they found a RV, 22% of them being asymptomatic. RV positive patients were sig-nificantly younger and had higher risk underlying disease with lower lymphocyte count. Overall mortality at day 100 was significantly higher in RV-patients than in non-RV pa-tients, patients with rhinovirus performing worse compared to the other RV (like RSV, influenza). In 28% of the deceased patients the cause of death was directly related to the pre-HCT RV.

This study largely supports our findings (as described in Chapter 3 and 7), with high prevalence of RV in patients prior to HCT, also in asymptomatic patients, especially in children, when using modern high sensitive virus detection methods. They also showed persistence of the RV after HCT in 40%, and direct progression to LRTI only in 4% of patients. Rhinovirus was at least as pathologic as the other RV.

Comments could be made about the stated relation between RV and death. It is impor-tant to realize that it is hard to distinguish death from RV pneumonia from Allo-LS. Given the time of death (median day + 32), and the description of clinical symptoms oc-curring weeks after first detection of RV with hypoxia, alveolar damage and pulmonary infiltrates, this might well all be allo-immune mediated lung disease. It would also be very interesting to see the data on follow up after day + 100, with regard to the develop-ment of BOS.

In Chapter 6 we discuss the risks of Respiratory Syncytial Virus (RSV) during HCT. In ge-neral the literature estimates the risk of progression from RSV-URTI to -LRTI at around 50%, with RSV-related mortality rates varying between 10-55%.25,27,30 These figures are found in the context of RSV treatment with antivirals. In adults, effect of treatment with ribavirin on progression to LRTI and RSV-related mortality is suggested, but in children this is unclear. In our small case series of untreated RSV-positive HCT recipients, we saw progression to mild LRTI in 38% and no RSV related deaths. Symptoms of LRTI occur-red rather late after the detection of RSV, coinciding with neutrophil engraftment and early T-cell reconstitution. Our observation suggests a role for immunity in the sympto-matology of RSV disease after HCT.

This is consistent with an ongoing discussion in the field of RSV bronchiolitis. What drives disease? Is it high viral load, is it an excessive immune response, or both?31 In our cohort of patients there were no RSV related deaths. We do not think that the risk of

9

164


direct progression of RSV-disease in HCT is a ground for delay of transplant or antiviral treatment. Somewhat counterintuitive we believe it is an indication for prolonged immu-nosuppression to prevent immune mediated lung disease later on. Donor immunity is thought to be the main culprit in lung complications shortly after transplant.

Respiratory viruses and the respiratory microbiome. More and more is known about the role of microbiota in human health. So far research has largely focused on the gut microbiota, also in the context of GvHD. But the micro-bial ecosystem at other body sites, including the respiratory tract is under growing at-tention. Host and environmental factors influencing the respiratory microbiota include genetics, microbial exposure (birth mode, feeding type, day care), vaccination, infections and antibiotics.32 Viral infection interacts with the microbiome by disrupting the airway epithelial barrier facilitating bacterial adhesion, liberating host derived nutrients and de-creasing muco-ciliary clearance. In addition RV can modulate innate and adaptive im-mune responses promoting bacterial colonization.32 The role of a disturbed respiratory microbiome/virome in lung disease is postulated for asthma and chronic obstructive pulmonary disease (COPD).33

Respiratory viruses and Allo-LSThe definition criteria for Allo-LS34,35 describe the clinical, radiologic and functional as-pects of lung pathology, with exclusion of other evident causes of this phenotype, like heart failure and infection, including RV infection. One can argue if this holds true for RV detected by PCR. The detection modes have become much more sensitive over time, so the impact of positive findings on the disease criteria should be reevaluated. In our cohort of HCT recipients we show a high RV prevalence, with RV persisting for weeks after HCT because of low immunity, with the onset of respiratory symptoms only after a median of 8.5 weeks after HCT. So, at the time of Allo-LS diagnosis, RV is still present in the majority of patients, but should not be regarded as the direct cause of the lung disease, and therefore must not be seen as an exclusion criterium for IPS nor BOS.

An interesting paper in this matter was recently published by Seo et al.36 In 69 patients with IPS, they went back to BAL samples at time of diagnosis, and applied more sensitive diagnostics for microbial pathogens. In 56% of patients an occult pathogen was found, 36% being a RV. All patients were treated with steroids because of IPS. Overall mortality was higher in the group of patients with an occult pathogen, than in the group without. The authors conclude that these patients had had to be excluded as IPS patients, that they had infectious pneumonia and that steroid treatment had adversely influenced their outcome.

9

164


direct progression of RSV-disease in HCT is a ground for delay of transplant or antiviral treatment. Somewhat counterintuitive we believe it is an indication for prolonged immu-nosuppression to prevent immune mediated lung disease later on. Donor immunity is thought to be the main culprit in lung complications shortly after transplant.

Respiratory viruses and the respiratory microbiome. More and more is known about the role of microbiota in human health. So far research has largely focused on the gut microbiota, also in the context of GvHD. But the micro-bial ecosystem at other body sites, including the respiratory tract is under growing at-tention. Host and environmental factors influencing the respiratory microbiota include genetics, microbial exposure (birth mode, feeding type, day care), vaccination, infections and antibiotics.32 Viral infection interacts with the microbiome by disrupting the airway epithelial barrier facilitating bacterial adhesion, liberating host derived nutrients and de-creasing muco-ciliary clearance. In addition RV can modulate innate and adaptive im-mune responses promoting bacterial colonization.32 The role of a disturbed respiratory microbiome/virome in lung disease is postulated for asthma and chronic obstructive pulmonary disease (COPD).33

Respiratory viruses and Allo-LSThe definition criteria for Allo-LS34,35 describe the clinical, radiologic and functional as-pects of lung pathology, with exclusion of other evident causes of this phenotype, like heart failure and infection, including RV infection. One can argue if this holds true for RV detected by PCR. The detection modes have become much more sensitive over time, so the impact of positive findings on the disease criteria should be reevaluated. In our cohort of HCT recipients we show a high RV prevalence, with RV persisting for weeks after HCT because of low immunity, with the onset of respiratory symptoms only after a median of 8.5 weeks after HCT. So, at the time of Allo-LS diagnosis, RV is still present in the majority of patients, but should not be regarded as the direct cause of the lung disease, and therefore must not be seen as an exclusion criterium for IPS nor BOS.

An interesting paper in this matter was recently published by Seo et al.36 In 69 patients with IPS, they went back to BAL samples at time of diagnosis, and applied more sensitive diagnostics for microbial pathogens. In 56% of patients an occult pathogen was found, 36% being a RV. All patients were treated with steroids because of IPS. Overall mortality was higher in the group of patients with an occult pathogen, than in the group without. The authors conclude that these patients had had to be excluded as IPS patients, that they had infectious pneumonia and that steroid treatment had adversely influenced their outcome.

9

165

Discussion

This conclusion seems to contradict our idea of the role of RV in IPS. However, as we are not informed about RV status pre-HCT, and the analysis on outcome was not done for RV and other pathogens separately, we are not convinced that these patients were actually having an infectious pneumonia. It could still mean that persisting RV after HCT, as a risk factor for IPS, triggered immune-mediated lung disease, and that steroids are bene-ficial in the treatment of these patient at the moment of clinical deterioration.

Which diagnostic tools contribute to prediction, diagnosis and follow-up of Allo-LS?

In the different phases of HC, various diagnostic tools for lung disease are used. We tho-roughly studied the yield of our pre-HCT pulmonary screening program, as described in Chapter 5. There is a high prevalence of RV in pediatric HCT recipients. In the pre-HCT samples we found RV PCR-positivity in 30-60 % of patients, as described in Chapter 3, 5 and 7. As RV from BAL is such an important predictor for Allo-LS, we implemented pre-HCT BAL screening in all HCT patients, to identify patients at high risk for Allo-LS. We stopped doing parallel routine NPA for RV, as we have shown that PCR-positivity in NPA-only did not increase the risk for Allo-LS (Chapter 7). Only in children who do not need an anesthetic procedure, and therefore cannot have a BAL done, NPA for RV is still performed. In case of BAL RV PCR-positivity, immunosuppression is now given for a longer period after HCT, to prevent Allo-LS. In our center, only Influenza Virus positive patients receive antiviral treatment, all other RV, including RSV, are left untreated. We do not postpone HCT in the presence of RV, as we have seen that RV persists for months in our mostly immunocompromised patient population. So we have not been able to study the impact of recently cleared RV infection (spontaneous or by treatment) on the risk of Allo-LS.

The other components of our pre-HCT pulmonary screening program, including BAL for non-viral pathogens, chest HRCT and PFT are not primarily done in the context of Allo-LS. Clinical significant HRCT abnormalities were associated with Allo-LS (Chapter 5), but we have not adjusted our HCT procedures on that finding, so far. It would be inte-resting to study the impact of chest-HRCT again, now we have a larger cohort of patients who have been screened in the same way, and we can apply the HRCT score, as descri-bed in Chapter 4. The other pre-HCT findings were not related to the development of Allo-LS. These tests are very important though, as they provide information about direct infectious threats (requiring antimicrobial treatment) and baseline pulmonary function, which in our center is an exclusion criterion for the HCT procedure if it is below 50% of normal. Overall, screening outcome had clinical implications for 33% of patients, and each screening modality contributes separately.

9

165

Discussion

This conclusion seems to contradict our idea of the role of RV in IPS. However, as we are not informed about RV status pre-HCT, and the analysis on outcome was not done for RV and other pathogens separately, we are not convinced that these patients were actually having an infectious pneumonia. It could still mean that persisting RV after HCT, as a risk factor for IPS, triggered immune-mediated lung disease, and that steroids are bene-ficial in the treatment of these patient at the moment of clinical deterioration.

Which diagnostic tools contribute to prediction, diagnosis and follow-up of Allo-LS?

In the different phases of HC, various diagnostic tools for lung disease are used. We tho-roughly studied the yield of our pre-HCT pulmonary screening program, as described in Chapter 5. There is a high prevalence of RV in pediatric HCT recipients. In the pre-HCT samples we found RV PCR-positivity in 30-60 % of patients, as described in Chapter 3, 5 and 7. As RV from BAL is such an important predictor for Allo-LS, we implemented pre-HCT BAL screening in all HCT patients, to identify patients at high risk for Allo-LS. We stopped doing parallel routine NPA for RV, as we have shown that PCR-positivity in NPA-only did not increase the risk for Allo-LS (Chapter 7). Only in children who do not need an anesthetic procedure, and therefore cannot have a BAL done, NPA for RV is still performed. In case of BAL RV PCR-positivity, immunosuppression is now given for a longer period after HCT, to prevent Allo-LS. In our center, only Influenza Virus positive patients receive antiviral treatment, all other RV, including RSV, are left untreated. We do not postpone HCT in the presence of RV, as we have seen that RV persists for months in our mostly immunocompromised patient population. So we have not been able to study the impact of recently cleared RV infection (spontaneous or by treatment) on the risk of Allo-LS.

The other components of our pre-HCT pulmonary screening program, including BAL for non-viral pathogens, chest HRCT and PFT are not primarily done in the context of Allo-LS. Clinical significant HRCT abnormalities were associated with Allo-LS (Chapter 5), but we have not adjusted our HCT procedures on that finding, so far. It would be inte-resting to study the impact of chest-HRCT again, now we have a larger cohort of patients who have been screened in the same way, and we can apply the HRCT score, as descri-bed in Chapter 4. The other pre-HCT findings were not related to the development of Allo-LS. These tests are very important though, as they provide information about direct infectious threats (requiring antimicrobial treatment) and baseline pulmonary function, which in our center is an exclusion criterion for the HCT procedure if it is below 50% of normal. Overall, screening outcome had clinical implications for 33% of patients, and each screening modality contributes separately.

9

166

Outcome determinants for allo-LS

When respiratory symptoms occur after HCT, procedures like BAL, NPA, chest X-ray, chest HRCT and PFT each have important diagnostic value. They can be used to distin-guish respiratory infection from Allo-LS, the most crucial consideration in that situation, with major therapeutic implications. BAL and NPA results showing the persistence or presence of RV, will reinforce the working diagnosis of Allo-LS, especially if there are signs of immune recovery. BAL can also confirm an alternative diagnosis like bacterial or fungal infection.

Depending on the time point of the occurrence of respiratory symptoms a chest X-ray or chest HRCT is performed. Certain HRCT findings (infiltrates, airway thickening, air-trapping) are essential in the diagnostic criteria for Allo-LS (especially BOS). It is also used to exclude other causes of respiratory symptoms after HCT, like fungal infection, bacterial pneumonia, pneumothorax or fluid overload, but there a X-ray could also suf-fice. From our study on the use of the HRCT “allo-score” in diagnosing Allo-LS (Chapter 4), we know that ground glass and air trapping are the abnormalities most useful in dis-tinguishing Allo-LS from other lung disorders. For radiologist and HCT clinicians this knowledge has been found very helpful in interpreting HRCT scans. In the total Allo-LS cohort the HRCT “allo-score” was not related to therapy response or long term outcome. The median “allo-score” in the total cohort was lower than we found in the validating cohort ( 11 (25%-75%: 7-1 4) versus 29 (25–75%: 19–33) possibly reflecting increased awa-reness of Allo-LS over time, and thus earlier diagnostics in the course of symptoms. PFT can be used to discriminate between restrictive lung disease and broncho-obstructive abnormalities, which can support the suspicion of Allo-LS and guide further manage-ment.

In the follow-up of Allo-LS during treatment, PFT is an important tool. Early response to therapy can be objectified by oxygen dependency and clinical symptoms, but change in PFT results, especially in FEV1% and FEV1%/FVC has shown to have prognostic im-plications (Chapter 8). Switch to second line therapy and duration of therapy in BOS is largely based on PFT. For children with IPS the role of PFT is less clear. For the young children other methods of evaluating Pulmonary Function should be developed. We cur-rently advise to perform PFT 7-14 days after start of treatment Allo-LS and repeat it before every Methyl Prednisolone pulse. In long term follow up of Allo-LS patients, PFT should be implemented earlier and more frequent than routinely done in other HCT-survivors.

What are determinants for favorable outcome after Allo-LS?

Prognosis of Allo-LS is poor. In adults mortality rates for IPS approach 60-80%, whereas BOS is considered an irreversible disease with dismal prognosis and only 10% of pa-tients surviving 5 years.2 In children prognosis seems slightly better. The difference in

9

166


When respiratory symptoms occur after HCT, procedures like BAL, NPA, chest X-ray, chest HRCT and PFT each have important diagnostic value. They can be used to distin-guish respiratory infection from Allo-LS, the most crucial consideration in that situation, with major therapeutic implications. BAL and NPA results showing the persistence or presence of RV, will reinforce the working diagnosis of Allo-LS, especially if there are signs of immune recovery. BAL can also confirm an alternative diagnosis like bacterial or fungal infection.

Depending on the time point of the occurrence of respiratory symptoms a chest X-ray or chest HRCT is performed. Certain HRCT findings (infiltrates, airway thickening, air-trapping) are essential in the diagnostic criteria for Allo-LS (especially BOS). It is also used to exclude other causes of respiratory symptoms after HCT, like fungal infection, bacterial pneumonia, pneumothorax or fluid overload, but there a X-ray could also suf-fice. From our study on the use of the HRCT “allo-score” in diagnosing Allo-LS (Chapter 4), we know that ground glass and air trapping are the abnormalities most useful in dis-tinguishing Allo-LS from other lung disorders. For radiologist and HCT clinicians this knowledge has been found very helpful in interpreting HRCT scans. In the total Allo-LS cohort the HRCT “allo-score” was not related to therapy response or long term outcome. The median “allo-score” in the total cohort was lower than we found in the validating cohort ( 11 (25%-75%: 7-1 4) versus 29 (25–75%: 19–33) possibly reflecting increased awa-reness of Allo-LS over time, and thus earlier diagnostics in the course of symptoms. PFT can be used to discriminate between restrictive lung disease and broncho-obstructive abnormalities, which can support the suspicion of Allo-LS and guide further manage-ment.

In the follow-up of Allo-LS during treatment, PFT is an important tool. Early response to therapy can be objectified by oxygen dependency and clinical symptoms, but change in PFT results, especially in FEV1% and FEV1%/FVC has shown to have prognostic im-plications (Chapter 8). Switch to second line therapy and duration of therapy in BOS is largely based on PFT. For children with IPS the role of PFT is less clear. For the young children other methods of evaluating Pulmonary Function should be developed. We cur-rently advise to perform PFT 7-14 days after start of treatment Allo-LS and repeat it before every Methyl Prednisolone pulse. In long term follow up of Allo-LS patients, PFT should be implemented earlier and more frequent than routinely done in other HCT-survivors.

What are determinants for favorable outcome after Allo-LS?

Prognosis of Allo-LS is poor. In adults mortality rates for IPS approach 60-80%, whereas BOS is considered an irreversible disease with dismal prognosis and only 10% of pa-tients surviving 5 years.2 In children prognosis seems slightly better. The difference in

9

167

Discussion

outcome of children and adults could be explained by factors like pulmonary situation pre-HCT (COPD, smoking), co-morbidities, different risk factors for developing Allo-LS influencing response to therapy (RV, less GVHD) etcetera.

There are few publications on treatment and outcome of IPS and BOS in children after HCT. In general the methodology of these studies is insufficient. Most studies are single center, retrospective analyses with small numbers of patients. Response is not always defined uniformly, and intervention is not blinded. With these remarks in mind, Table 2 gives an overview of the literature and can lead to some conclusions.

IPS therapy is always corticosteroid based. In the various reports either an increased dose of steroids, or the addition of TNF-alpha blockade with etanercept or infliximab are evaluated. In most IPS studies Initial Response (defined as recovery of respiratory symptoms and/or cessation of supplemental oxygen requirement at day 28), Overall Sur-vival and Non Relapsed Mortality (here defined as death, not due to relapsed disease, excluding progressive lung disease) are stated.

With regard to initial response our cohort (as described in Chapter 8) performed worse, with only 53% patients responding, versus 71-81% reported by others. This is partly due to the definition of response. We considered the need of salvage therapy as a sign of initial therapy failure, without restrictions to the day of this event. In most of the other papers response was defined as recovery at day 28 after first or second line therapy. When applying these criteria in our cohort of IPS patients Initial Response rate would be 60%, still slightly lower than what was seen in the other groups. Responders to therapy tend to do so within 8-17 days.7,8,37

Overall survival rates varied between 21% and 50%. Cause of death is not always men-tioned, but IPS contributed to death in 18-50%, and non-relapse mortality (NRM) other than lung disease was high (13-46%), mostly due to infection or GvHD in another organ. Here our results are in line with others.

Treatment of BOS in children after HCT is also based on corticosteroids. Different doses, given systemically and by inhalation, in combination with other immune suppressive agents, sometimes with the addition of immune modulating agents like azithromycin or pravastatin are studied.13,37-40 In contrast with IPS studies, overall survival in BOS is better (57%-78%), with less children dying from progressive lung disease (11%-30%) or NRM (0-11%). The BOS patients in our cohort did relatively poor with respect to overall survival, but remarkably there was normalization of lung function in the majority of survivors. This is in contrast with most studies, especially in adults. This could be due to early diagnosis and the fact that respiratory virus played a role in the development of BOS in a large proportion of patients, influencing reversibility of the immunological phenomena in these cases. Or it might be the anti-fibrotic effect of imatinib, which we gave to all our BOS patients.

9

167

Discussion

outcome of children and adults could be explained by factors like pulmonary situation pre-HCT (COPD, smoking), co-morbidities, different risk factors for developing Allo-LS influencing response to therapy (RV, less GVHD) etcetera.

There are few publications on treatment and outcome of IPS and BOS in children after HCT. In general the methodology of these studies is insufficient. Most studies are single center, retrospective analyses with small numbers of patients. Response is not always defined uniformly, and intervention is not blinded. With these remarks in mind, Table 2 gives an overview of the literature and can lead to some conclusions.

IPS therapy is always corticosteroid based. In the various reports either an increased dose of steroids, or the addition of TNF-alpha blockade with etanercept or infliximab are evaluated. In most IPS studies Initial Response (defined as recovery of respiratory symptoms and/or cessation of supplemental oxygen requirement at day 28), Overall Sur-vival and Non Relapsed Mortality (here defined as death, not due to relapsed disease, excluding progressive lung disease) are stated.

With regard to initial response our cohort (as described in Chapter 8) performed worse, with only 53% patients responding, versus 71-81% reported by others. This is partly due to the definition of response. We considered the need of salvage therapy as a sign of initial therapy failure, without restrictions to the day of this event. In most of the other papers response was defined as recovery at day 28 after first or second line therapy. When applying these criteria in our cohort of IPS patients Initial Response rate would be 60%, still slightly lower than what was seen in the other groups. Responders to therapy tend to do so within 8-17 days.7,8,37

Overall survival rates varied between 21% and 50%. Cause of death is not always men-tioned, but IPS contributed to death in 18-50%, and non-relapse mortality (NRM) other than lung disease was high (13-46%), mostly due to infection or GvHD in another organ. Here our results are in line with others.

Treatment of BOS in children after HCT is also based on corticosteroids. Different doses, given systemically and by inhalation, in combination with other immune suppressive agents, sometimes with the addition of immune modulating agents like azithromycin or pravastatin are studied.13,37-40 In contrast with IPS studies, overall survival in BOS is better (57%-78%), with less children dying from progressive lung disease (11%-30%) or NRM (0-11%). The BOS patients in our cohort did relatively poor with respect to overall survival, but remarkably there was normalization of lung function in the majority of survivors. This is in contrast with most studies, especially in adults. This could be due to early diagnosis and the fact that respiratory virus played a role in the development of BOS in a large proportion of patients, influencing reversibility of the immunological phenomena in these cases. Or it might be the anti-fibrotic effect of imatinib, which we gave to all our BOS patients.

9

168


TABL

E 2.

Ove

rvie

w o

f pub

licat

ions

on

trea

tmen

t out

com

e fo

r IPS

and

BO

S in

child

ren

afte

r HCT

.

Auth

ors

Patie

nts,

age

(yrs

)Tr

eatm

ent

Out

com

eRe

mar

ks

Keat

es (

7)

2006

N=1

1.

Med

ian

age

7.8

(0.6

-20.

5)

IPS

Cor

ticos

tero

ids

2-4

mg/

kg/d

ay.

MP

puls

e 10

/kg/

dose

, eta

nerc

ept,

infli

xim

ab in

poo

r re

spon

ders

Initi

al r

espo

nse

81%

Ove

rall

surv

ival

: 27%

Dea

th fr

om IP

S: 1

8%, N

RM

46%

Uni

form

upf

ront

trea

t-

men

t

No

follo

w u

p on

PFT

Saka

gush

i (15

)

2012

N=2

0. M

edia

n ag

e 6.

6

(0.9

-15.

2)

IPS

MP

1-2

mg/

kg/d

ay (

19)

Bas

ilixi

mab

(1)

Infli

xim

ab (

2)

Initi

al r

espo

nse:

80%

Ove

rall

surv

ival

45%

Dea

th fr

om IP

S: 3

6%, N

RM

15%

No

follo

w u

p on

PFT

Sano

(8)

2014

N=1

4. M

edia

n ag

e 9.

6 (0

-

16)

IPS

Cor

ticos

tero

ids

(dos

e?)

No

data

on

initi

al r

espo

nse

Ove

rall

surv

ival

: 21%

Dea

th fr

om IP

S: 5

0%, N

RM

: 29%

Trea

tmen

t unc

lear

No

follo

w u

p on

PFT

Yani

k (4

1)

2015

N=2

8. M

edia

n ag

e 14

(1-

17)

IPS

Pred

niso

ne 2

mg/

kg/d

ay, p

lus

etan

erce

pt 0

.4 m

g/kg

, 2x/

wk,

8

dose

s

Initi

al r

espo

nse:

71%

Ove

rall

surv

ival

: 50%

No

data

on

caus

e of

dea

th

Mul

ticen

ter

Uni

form

trea

tmen

t

No

follo

w u

p on

PFT

Nis

hio

(10)

2009

N=1

0. M

edia

n ag

e 12

.2

(1.6

-15.

2)

IPS

(2)/

BO

S (8

)

Cor

ticos

tero

ids

1-2

mg/

kg/d

ay,

Plus

inha

led

ster

oids

, CsA

Dea

th fr

om IP

S/B

OS:

40%

, NR

M:0

%

Ove

rall

surv

ival

: 40%

N

on r

espo

nse

20%

Pa

rtia

l res

pons

e 20

%

No

unifo

rm tr

eatm

ent

No

follo

w u

p on

PFT

Park

(9)

2010

N=1

1. M

edia

n ag

e 6.

6 (0

.8-

12.8

)

IPS

(5)/

BO

S (6

)

Cor

ticos

tero

ids

(dos

e?),

plu

s

CsA

, Azi

thro

myc

in

Dea

th fr

om IP

S/B

OS:

36%

, NR

M: 1

8%

Ove

rall

surv

ival

: 46%

Pa

rtia

l res

pons

e 37

%

C

ompl

ete

resp

onse

9%

Unc

lear

trea

tmen

t

No

follo

w u

p on

PFT

Allo

-LS

= A

lloim

mun

e m

edia

ted

lung

syn

drom

e, IP

S =

Idio

path

ic P

neum

onia

Syn

drom

e, M

P= M

ethy

lpre

dnis

olon

e, N

RM

= N

on R

elap

se M

orta

lity

(fro

m a

noth

er c

ause

than

IPS

or B

OS)

, G

vHD

= G

raft

ver

sus

Hos

t Dis

ease

, PFT

= P

ulm

onar

y Fu

nctio

n Te

sts

BO

S= B

ronc

hiol

itis

Obl

itera

ns S

yndr

ome,

CsA

= C

iclo

spor

in A

, MM

F =

Myc

ophe

nola

te M

ofet

il Ta

ble

cont

inue

s on

nex

t pag

e

9

168


TABL

E 2.

Ove

rvie

w o

f pub

licat

ions

on

trea

tmen

t out

com

e fo

r IPS

and

BO

S in

child

ren

afte

r HCT

.

Auth

ors

Patie

nts,

age

(yrs

)Tr

eatm

ent

Out

com

eRe

mar

ks

Keat

es (

7)

2006

N=1

1.

Med

ian

age

7.8

(0.6

-20.

5)

IPS

Cor

ticos

tero

ids

2-4

mg/

kg/d

ay.

MP

puls

e 10

/kg/

dose

, eta

nerc

ept,

infli

xim

ab in

poo

r re

spon

ders

Initi

al r

espo

nse

81%

Ove

rall

surv

ival

: 27%

Dea

th fr

om IP

S: 1

8%, N

RM

46%

Uni

form

upf

ront

trea

t-

men

t

No

follo

w u

p on

PFT

Saka

gush

i (15

)

2012

N=2

0. M

edia

n ag

e 6.

6

(0.9

-15.

2)

IPS

MP

1-2

mg/

kg/d

ay (

19)

Bas

ilixi

mab

(1)

Infli

xim

ab (

2)

Initi

al r

espo

nse:

80%

Ove

rall

surv

ival

45%

Dea

th fr

om IP

S: 3

6%, N

RM

15%

No

follo

w u

p on

PFT

Sano

(8)

2014

N=1

4. M

edia

n ag

e 9.

6 (0

-

16)

IPS

Cor

ticos

tero

ids

(dos

e?)

No

data

on

initi

al r

espo

nse

Ove

rall

surv

ival

: 21%

Dea

th fr

om IP

S: 5

0%, N

RM

: 29%

Trea

tmen

t unc

lear

No

follo

w u

p on

PFT

Yani

k (4

1)

2015

N=2

8. M

edia

n ag

e 14

(1-

17)

IPS

Pred

niso

ne 2

mg/

kg/d

ay, p

lus

etan

erce

pt 0

.4 m

g/kg

, 2x/

wk,

8

dose

s

Initi

al r

espo

nse:

71%

Ove

rall

surv

ival

: 50%

No

data

on

caus

e of

dea

th

Mul

ticen

ter

Uni

form

trea

tmen

t

No

follo

w u

p on

PFT

Nis

hio

(10)

2009

N=1

0. M

edia

n ag

e 12

.2

(1.6

-15.

2)

IPS

(2)/

BO

S (8

)

Cor

ticos

tero

ids

1-2

mg/

kg/d

ay,

Plus

inha

led

ster

oids

, CsA

Dea

th fr

om IP

S/B

OS:

40%

, NR

M:0

%

Ove

rall

surv

ival

: 40%

N

on r

espo

nse

20%

Pa

rtia

l res

pons

e 20

%

No

unifo

rm tr

eatm

ent

No

follo

w u

p on

PFT

Park

(9)

2010

N=1

1. M

edia

n ag

e 6.

6 (0

.8-

12.8

)

IPS

(5)/

BO

S (6

)

Cor

ticos

tero

ids

(dos

e?),

plu

s

CsA

, Azi

thro

myc

in

Dea

th fr

om IP

S/B

OS:

36%

, NR

M: 1

8%

Ove

rall

surv

ival

: 46%

Pa

rtia

l res

pons

e 37

%

C

ompl

ete

resp

onse

9%

Unc

lear

trea

tmen

t

No

follo

w u

p on

PFT

Allo

-LS

= A

lloim

mun

e m

edia

ted

lung

syn

drom

e, IP

S =

Idio

path

ic P

neum

onia

Syn

drom

e, M

P= M

ethy

lpre

dnis

olon

e, N

RM

= N

on R

elap

se M

orta

lity

(fro

m a

noth

er c

ause

than

IPS

or B

OS)

, G

vHD

= G

raft

ver

sus

Hos

t Dis

ease

, PFT

= P

ulm

onar

y Fu

nctio

n Te

sts

BO

S= B

ronc

hiol

itis

Obl

itera

ns S

yndr

ome,

CsA

= C

iclo

spor

in A

, MM

F =

Myc

ophe

nola

te M

ofet

il Ta

ble

cont

inue

s on

nex

t pag

e

9

169

Discussion

TABL

E 2.

Ove

rvie

w o

f pub

licat

ions

on

trea

tmen

t out

com

e fo

r IPS

and

BO

S in

child

ren

afte

r HCT

— co

ntin

ued

Vers

luys

(37

)

2018

w

N=5

3. M

edia

n ag

e

6.9

(0.3

-18.

8)

IPS

(30)

BO

S (2

3)

MP

puls

e 10

mg/

kg/d

ay,

3 da

ys, e

very

4 w

ks, p

lus

Imat

inib

and

azi

thro

myc

in

in B

OS

Initi

al r

espo

nse:

55%

(IP

S 53

%, B

OS

57%

)

Dea

th fr

om A

llo-L

S: 3

8% (

IPS

43%

, BO

S 30

%),

NR

M: 9

%

Ove

rall

surv

ival

: 47%

(IP

S 40

%, B

OS

57%

C

hron

ic A

llo-L

S: 6

% (

IPS

3%, B

OS

9%

C

ompl

ete

resp

onse

: 42%

, nor

mal

izat

ion

of P

FT

Uni

form

trea

tmen

t

Rat

jen

(38)

2005

N=9

Mea

n ag

e 8.

8

(±5.

6)

BO

S

MP

puls

e 10

mg/

kg/

day,

3 da

ys, e

very

4 w

ks,

plus

Inha

led

ster

oids

(bud

eson

ide)

Dea

th fr

om B

OS:

22%

, NR

M 0

%

Ove

rall

surv

ival

: 78%

St

able

lung

dis

ease

: 78%

N

O n

orm

aliz

atio

n of

PFT

Uni

form

trea

tmen

t

Dun

can

(13)

2008

N=1

8

Med

ian

age

10.7

BO

S

Cor

ticos

tero

ids

(dos

e?)

,

plus

CsA

, MM

F, r

apam

ycin

,

azith

rom

ycin

, pra

vast

atin

Dea

th fr

om B

OS:

28%

, NR

M: 1

1%

Ove

rall

surv

ival

: 61%

Pr

ogre

ssiv

e lu

ng d

isea

se: 1

7

St

able

lung

dis

ease

: 11%

/ P

artia

l res

pons

e: 3

3%

R

esol

ved

BO

S: 0

%

Trea

tmen

t unc

lear

No

unifo

rm tr

eatm

ent

Dun

can

(39)

2010

N=5

(+5

off

stud

y)

Med

ian

age

13

(8-1

5)

BO

S

Prav

asta

tin (

stat

in),

plu

s

Cor

ticos

tero

ids

(dos

e?)

Dea

th fr

om B

OS:

20%

, NR

M: 1

0%

Ove

rall

surv

ival

: 70%

Pa

rtia

l res

pons

e/St

able

dis

ease

: 70%

Unc

lear

, uni

form

trea

t-

men

t. St

udy

clos

ure:

slow

acc

rual

.

No

follo

w u

p on

PFT

Uhl

ving

(40

)

2012

N=9

Med

ian

age

10.5

(4-1

3)

BO

S

MP

puls

e 15

mg/

kg/d

ay, 2

-3

days

, eve

ry 4

-6 w

ks

Dea

th fr

om B

OS:

11%

, NR

M:1

1%

Ove

rall

surv

ival

: 66%

Pa

rtia

l/co

mpl

ete

resp

onse

: 66%

al

mos

t nor

mal

izat

ion

of P

FT

Uni

form

trea

tmen

t

Nag

asaw

a (1

1)

2017

N=9

. Med

ian

age

11.6

(0.6

-18.

6)

BO

S

(Inh

aled

) st

eroi

ds (

dose

?),

plus

leuk

otrie

ne r

ecep

tor

anta

goni

st a

nd M

MF

Dea

th fr

om B

OS:

44%

, NR

M 1

1%

Ove

rall

surv

ival

: 66%

Trea

tmen

t unc

lear

No

follo

w u

p on

PFT

9

169

Discussion

TABL

E 2.

Ove

rvie

w o

f pub

licat

ions

on

trea

tmen

t out

com

e fo

r IPS

and

BO

S in

child

ren

afte

r HCT

— co

ntin

ued

Vers

luys

(37

)

2018

w

N=5

3. M

edia

n ag

e

6.9

(0.3

-18.

8)

IPS

(30)

BO

S (2

3)

MP

puls

e 10

mg/

kg/d

ay,

3 da

ys, e

very

4 w

ks, p

lus

Imat

inib

and

azi

thro

myc

in

in B

OS

Initi

al r

espo

nse:

55%

(IP

S 53

%, B

OS

57%

)

Dea

th fr

om A

llo-L

S: 3

8% (

IPS

43%

, BO

S 30

%),

NR

M: 9

%

Ove

rall

surv

ival

: 47%

(IP

S 40

%, B

OS

57%

C

hron

ic A

llo-L

S: 6

% (

IPS

3%, B

OS

9%

C

ompl

ete

resp

onse

: 42%

, nor

mal

izat

ion

of P

FT

Uni

form

trea

tmen

t

Rat

jen

(38)

2005

N=9

Mea

n ag

e 8.

8

(±5.

6)

BO

S

MP

puls

e 10

mg/

kg/

day,

3 da

ys, e

very

4 w

ks,

plus

Inha

led

ster

oids

(bud

eson

ide)

Dea

th fr

om B

OS:

22%

, NR

M 0

%

Ove

rall

surv

ival

: 78%

St

able

lung

dis

ease

: 78%

N

O n

orm

aliz

atio

n of

PFT

Uni

form

trea

tmen

t

Dun

can

(13)

2008

N=1

8

Med

ian

age

10.7

BO

S

Cor

ticos

tero

ids

(dos

e?)

,

plus

CsA

, MM

F, r

apam

ycin

,

azith

rom

ycin

, pra

vast

atin

Dea

th fr

om B

OS:

28%

, NR

M: 1

1%

Ove

rall

surv

ival

: 61%

Pr

ogre

ssiv

e lu

ng d

isea

se: 1

7

St

able

lung

dis

ease

: 11%

/ P

artia

l res

pons

e: 3

3%

R

esol

ved

BO

S: 0

%

Trea

tmen

t unc

lear

No

unifo

rm tr

eatm

ent

Dun

can

(39)

2010

N=5

(+5

off

stud

y)

Med

ian

age

13

(8-1

5)

BO

S

Prav

asta

tin (

stat

in),

plu

s

Cor

ticos

tero

ids

(dos

e?)

Dea

th fr

om B

OS:

20%

, NR

M: 1

0%

Ove

rall

surv

ival

: 70%

Pa

rtia

l res

pons

e/St

able

dis

ease

: 70%

Unc

lear

, uni

form

trea

t-

men

t. St

udy

clos

ure:

slow

acc

rual

.

No

follo

w u

p on

PFT

Uhl

ving

(40

)

2012

N=9

Med

ian

age

10.5

(4-1

3)

BO

S

MP

puls

e 15

mg/

kg/d

ay, 2

-3

days

, eve

ry 4

-6 w

ks

Dea

th fr

om B

OS:

11%

, NR

M:1

1%

Ove

rall

surv

ival

: 66%

Pa

rtia

l/co

mpl

ete

resp

onse

: 66%

al

mos

t nor

mal

izat

ion

of P

FT

Uni

form

trea

tmen

t

Nag

asaw

a (1

1)

2017

N=9

. Med

ian

age

11.6

(0.6

-18.

6)

BO

S

(Inh

aled

) st

eroi

ds (

dose

?),

plus

leuk

otrie

ne r

ecep

tor

anta

goni

st a

nd M

MF

Dea

th fr

om B

OS:

44%

, NR

M 1

1%

Ove

rall

surv

ival

: 66%

Trea

tmen

t unc

lear

No

follo

w u

p on

PFT

9

170


Risk factors for outcome were not studied profoundly. Supplemental oxygen require-ment and mechanical ventilation were found to be bad prognostic factors bij several authors.8,41 These factors probably reflects more severe lung disease, with its logical im-pact on outcome. Our data confirm these findings and also showed that GvHD requiring systemic treatment and the presence of a respiratory virus (RV) at diagnosis of Allo-LS influence outcome. Allo-LS occurrence in a patient who already receives steroids for GvHD in another organ, apparently is more difficult to treat with mainly an increase of steroid dose. And if RV still plays a role in Allo-LS at time of diagnosis the chances for good long-term outcome are better.

We would still recommend initial treatment with MP pulse in all patients developing Allo-LS. However, as treatment failure occurs frequent and so early after the initiation of therapy, second line therapy should be optimized and started early in the course of the disease. For IPS this could be the addition of TNF-alpha blockade. For BOS an advice on second line therapy is less obvious.

What are the next steps in therapy development?Lack of efficacy and fear for side effects further drive research to develop new therapy strategies for allo-LS. The rationale of most ongoing clinical trials is based on pathophy-siology mechanisms. (See Figure 1 and Figure 2) And here again the parallel between Allo-LS after HCT and lung allograft rejection can be drawn, with IPS mimicking acute cellular or antibody mediated rejection and BOS regarded as the clinical correlate of chronic lung allograft dysfunction.22,42

In IPS initial tissue damage secondary to conditioning regimen, infection or transfusi-ons leads to release of inflammatory cytokines (especially TNF-alpha and IL-6) and incre-ased MHC class I and II expression on antigen presenting cells (APC) and target tissue. Lipopolysaccharides (LPS), translocating from the intestines in case of gut damage by conditioning or GvHD, also seem to play a role in activating the innate HCT-donor im-munity (neutrophils and macrophages). All this contributes to T-cell activation, directing T-cell injury in the target cells. From experimental allo-HCT models we have learnt the importance of T helper-2 response, with low IFN-gamma and high IL-6, inducing Th17 cells accumulation and IL-17 production causing lung injury.2,43,44

In IPS the only drug that has been studied in a clinical trial was Etanercept. Yanik et al have performed a double-blinded randomized trial in adults, adding Etanercept to corti-costeroid therapy.45 The study showed no benefit of etanercept on early response (62.5% vs 66.6% )or overall survival (23.7% vs 16.7%) in IPS, partly because the control arm initially performed much better than historical experience.

9

170


Risk factors for outcome were not studied profoundly. Supplemental oxygen require-ment and mechanical ventilation were found to be bad prognostic factors bij several authors.8,41 These factors probably reflects more severe lung disease, with its logical im-pact on outcome. Our data confirm these findings and also showed that GvHD requiring systemic treatment and the presence of a respiratory virus (RV) at diagnosis of Allo-LS influence outcome. Allo-LS occurrence in a patient who already receives steroids for GvHD in another organ, apparently is more difficult to treat with mainly an increase of steroid dose. And if RV still plays a role in Allo-LS at time of diagnosis the chances for good long-term outcome are better.

We would still recommend initial treatment with MP pulse in all patients developing Allo-LS. However, as treatment failure occurs frequent and so early after the initiation of therapy, second line therapy should be optimized and started early in the course of the disease. For IPS this could be the addition of TNF-alpha blockade. For BOS an advice on second line therapy is less obvious.

What are the next steps in therapy development?Lack of efficacy and fear for side effects further drive research to develop new therapy strategies for allo-LS. The rationale of most ongoing clinical trials is based on pathophy-siology mechanisms. (See Figure 1 and Figure 2) And here again the parallel between Allo-LS after HCT and lung allograft rejection can be drawn, with IPS mimicking acute cellular or antibody mediated rejection and BOS regarded as the clinical correlate of chronic lung allograft dysfunction.22,42

In IPS initial tissue damage secondary to conditioning regimen, infection or transfusi-ons leads to release of inflammatory cytokines (especially TNF-alpha and IL-6) and incre-ased MHC class I and II expression on antigen presenting cells (APC) and target tissue. Lipopolysaccharides (LPS), translocating from the intestines in case of gut damage by conditioning or GvHD, also seem to play a role in activating the innate HCT-donor im-munity (neutrophils and macrophages). All this contributes to T-cell activation, directing T-cell injury in the target cells. From experimental allo-HCT models we have learnt the importance of T helper-2 response, with low IFN-gamma and high IL-6, inducing Th17 cells accumulation and IL-17 production causing lung injury.2,43,44

In IPS the only drug that has been studied in a clinical trial was Etanercept. Yanik et al have performed a double-blinded randomized trial in adults, adding Etanercept to corti-costeroid therapy.45 The study showed no benefit of etanercept on early response (62.5% vs 66.6% )or overall survival (23.7% vs 16.7%) in IPS, partly because the control arm initially performed much better than historical experience.

9

171

Discussion

FIGURE 1. Proposed pathophysiologic mechanism involved in Allo-LS.

FIGURE 2. Currently used or studied treatment options for Allo-LS, in relation to proposed pathophysiologic mechanism.

conditioning regimeninfection

iron overloadtransfusions

endothelial injury epithelial injuryoxidative stress

Innate immunityneutrophils

macrophages

Donor T cellsTH-2, TH,17

Tregs

Gut GvHD

Fibroblasts

B cells

Collagen

LPS

TNF-alphaIL-17

IL-8

IL-6MHC

expression

PDGF-R

TGF-betaAntibodies

AzithromicinEtanercept

sdio

retS

Montelukast

Rituximab

Calcineurin inhibitorsSirolimus

PCE

Pirfenidone Bortezomib

9





macrophages


Tregs

Gut GvHD

Fibroblasts

B cells

Collagen

LPS

TNF-alphaIL-17

IL-8

IL-6MHC

expression

PDGF-RTGF-beta

Antibodies

171

Discussion

FIGURE 1. Proposed pathophysiologic mechanism involved in Allo-LS.

FIGURE 2. Currently used or studied treatment options for Allo-LS, in relation to proposed pathophysiologic mechanism.





macrophages


Tregs

Gut GvHD

Fibroblasts

B cells

Collagen

LPS

TNF-alphaIL-17

IL-8

IL-6MHC

expression

PDGF-R

TGF-betaAntibodies

AzithromicinEtanercept

sdio

retS

Montelukast

Rituximab

Calcineurin inhibitorsSirolimus

PCE

Pirfenidone Bortezomib

9





macrophages


Tregs

Gut GvHD

Fibroblasts

B cells

Collagen

LPS

TNF-alphaIL-17

IL-8

IL-6MHC

expression

PDGF-RTGF-beta

Antibodies

172


Less is known about the exact pathophysiology of BOS, but it is hypothesized that the first step in BOS is bronchiolar epithelium injury by conditioning, gastroesophageal re-flux or infection. BOS is regarded as a form of cGVHD, a complex immune dysregulation where failure of central tolerance leads to immune reactivity resembling autoimmune disease (T helper-2 cells, decreased regulatory T cells). B cells also play a key role in cGVHD, with autoantibodies contributing to tissue damage. These inflammatory pro-cesses result in fibrosis with eventually disruption of normal tissue architecture of for instance respiratory epithelium. The fibrotic mechanism is complex, with two mediators of special interest; transforming growth factor (TGF-beta) and platelet-derived growth factor receptor (PDGF-R). Stimulatory PDGF-R antibodies are found elevated in patients with cGVHD.3,4

In BOS after HCT more clinical trials exist, partly based on results seen in BOS af-ter lung transplantation.46 The only recently published trial is on inhaled Fluticasone, Azithromycin and Montelukast (FAM) therapy as treatment for new onset BOS after HCT.47 Mechanisms of action of these agents are decrease in local lung inflammation, reduction of local IL-8 and neutrophilia, and impairment of leukotriene activity respec-tively. Leukotrienes constitute a class of inflammatory mediators with the ability to me-diate bronchoconstriction and stimulate the secretion of mucus into the airways and the extravasation of fluids and proteins into the airway tissues, all contributing to obstruc-tion. Endpoint of the FAM study was failure to therapy, defined as decline in PFT > 10%. Only 6 % of patients experienced failure to therapy, most showed stabilization of BOS progression for at least 3 months. These results compare favorable to other studies in adults with BOS. There were no side effects of FAM therapy, and steroids could be tape-red, with at least 50% in the majority of patients by 6 months.

Other trials have studied Azithromycin and Inhalation steroids in combination with bronchodilators, both groups have not published their results though. The ongoing studies are on the role of Pirfenidone (antifibrotic, anti-inflammatory), Mesenchymal Stroma Cell infusions (anti-inflammatory), ciclosporin A inhalation, bortezomib (anti-TGF-beta) and an oral neutrophil elastase inhibitor.

Extra Corporeal Photopheresis (ECP), an immunomodulatory treatment with a complex mechanism (apoptosis of lymphocytes after irradiation, also leading to increase in Tregs), is already successfully used in chronic allograft rejection after lung transplantation46 and now also studied in BOS after HCT.

When regarded a lung manifestation of cGVHD, BOS is also included in many studies on cGVHD in a broader context. Of interest are the ongoing trials on Rituximab, JAK-inhibition, ECP and cellular therapies like Mesenchymal Stromal Cells.

9

172


Less is known about the exact pathophysiology of BOS, but it is hypothesized that the first step in BOS is bronchiolar epithelium injury by conditioning, gastroesophageal re-flux or infection. BOS is regarded as a form of cGVHD, a complex immune dysregulation where failure of central tolerance leads to immune reactivity resembling autoimmune disease (T helper-2 cells, decreased regulatory T cells). B cells also play a key role in cGVHD, with autoantibodies contributing to tissue damage. These inflammatory pro-cesses result in fibrosis with eventually disruption of normal tissue architecture of for instance respiratory epithelium. The fibrotic mechanism is complex, with two mediators of special interest; transforming growth factor (TGF-beta) and platelet-derived growth factor receptor (PDGF-R). Stimulatory PDGF-R antibodies are found elevated in patients with cGVHD.3,4

In BOS after HCT more clinical trials exist, partly based on results seen in BOS af-ter lung transplantation.46 The only recently published trial is on inhaled Fluticasone, Azithromycin and Montelukast (FAM) therapy as treatment for new onset BOS after HCT.47 Mechanisms of action of these agents are decrease in local lung inflammation, reduction of local IL-8 and neutrophilia, and impairment of leukotriene activity respec-tively. Leukotrienes constitute a class of inflammatory mediators with the ability to me-diate bronchoconstriction and stimulate the secretion of mucus into the airways and the extravasation of fluids and proteins into the airway tissues, all contributing to obstruc-tion. Endpoint of the FAM study was failure to therapy, defined as decline in PFT > 10%. Only 6 % of patients experienced failure to therapy, most showed stabilization of BOS progression for at least 3 months. These results compare favorable to other studies in adults with BOS. There were no side effects of FAM therapy, and steroids could be tape-red, with at least 50% in the majority of patients by 6 months.

Other trials have studied Azithromycin and Inhalation steroids in combination with bronchodilators, both groups have not published their results though. The ongoing studies are on the role of Pirfenidone (antifibrotic, anti-inflammatory), Mesenchymal Stroma Cell infusions (anti-inflammatory), ciclosporin A inhalation, bortezomib (anti-TGF-beta) and an oral neutrophil elastase inhibitor.

Extra Corporeal Photopheresis (ECP), an immunomodulatory treatment with a complex mechanism (apoptosis of lymphocytes after irradiation, also leading to increase in Tregs), is already successfully used in chronic allograft rejection after lung transplantation46 and now also studied in BOS after HCT.

When regarded a lung manifestation of cGVHD, BOS is also included in many studies on cGVHD in a broader context. Of interest are the ongoing trials on Rituximab, JAK-inhibition, ECP and cellular therapies like Mesenchymal Stromal Cells.

9

173

Discussion

What is the long term pulmonary outcome of children after Allo-LS?

Owing to an increased number of patients undergoing HCT and better survival rates, the population of HCT-recipients surviving into adulthood is growing. More and more is learnt about long term side effects of childhood cancer treatment, including HCT. Direct pulmonary toxicity of chemotherapy and radiation, combined with low grade infections and GVHD have impact on lung function years after treatment. Other treatment related morbidity (like cardiovascular side effects, impaired growth of thorax) and exogenous factors (smoking) also play a role. In Chapter 2 these themes are reviewed.

International collaboration is needed to establish a common vision and integrated stra-tegy on guidelines for surveillance of pulmonary dysfunctions in childhood cancer survi-vors to optimize quality of care and improve quality of life in survivors (The International Late Effects of Childhood Cancer Guideline Harmonization Group, IGHG, www.ighg.org). Follow-up of HCT survivors in our center, consists of regular visits to a specialized late effect outpatient clinic, standardized history taking and physical examination, and PFT 5 and 10 years after HCT in all who received TBI or busulfan.

From our study in Allo-LS patients, as described in Chapter 8, we have learnt that in survivors of Allo-LS PFT restores to lower levels of normal within 1-2 years. With longer follow up PFT seems to decline again, but solid data are lacking. Therefore we recom-mend closer monitoring with more frequent PFT screening in patients after Allo-LS. It is conceivable that lungs that have been target for Allo-LS, are prone for further damage and fibrotic processes on top of prior injury. Early detection of decrease in pulmonary function will enable timely intervention with immunosuppression, bronchodilators, vac-cination, antibiotic prophylaxis or physiotherapy.

What are future perspectives for research?

To further elucidate the pathophysiologic processes underlying IPS and BOS, research is needed. There should be focus on the role of tissue damage and the immunological pathways involved. This will be done in bronchial epithelial cultures or in human airway organoids made from stem cells derived from BAL material. In these models the effect of Respiratory Virus or other “damaging” triggers can be studied by measuring cytokines, antigen expression, gene profiling etcetera. This will be done in the presence or absence of neutrophils and T cells. This can be done while blocking certain pathways. We could study allogeneic and autologous settings. And ideally both luminal and basolateral ef-fects could be observed. From there we could study preventive strategies to decrease tis-sue damage and test new drugs to control immune response and minimize the fibrotic process in the lungs.

9

173

Discussion

What is the long term pulmonary outcome of children after Allo-LS?

Owing to an increased number of patients undergoing HCT and better survival rates, the population of HCT-recipients surviving into adulthood is growing. More and more is learnt about long term side effects of childhood cancer treatment, including HCT. Direct pulmonary toxicity of chemotherapy and radiation, combined with low grade infections and GVHD have impact on lung function years after treatment. Other treatment related morbidity (like cardiovascular side effects, impaired growth of thorax) and exogenous factors (smoking) also play a role. In Chapter 2 these themes are reviewed.

International collaboration is needed to establish a common vision and integrated stra-tegy on guidelines for surveillance of pulmonary dysfunctions in childhood cancer survi-vors to optimize quality of care and improve quality of life in survivors (The International Late Effects of Childhood Cancer Guideline Harmonization Group, IGHG, www.ighg.org). Follow-up of HCT survivors in our center, consists of regular visits to a specialized late effect outpatient clinic, standardized history taking and physical examination, and PFT 5 and 10 years after HCT in all who received TBI or busulfan.

From our study in Allo-LS patients, as described in Chapter 8, we have learnt that in survivors of Allo-LS PFT restores to lower levels of normal within 1-2 years. With longer follow up PFT seems to decline again, but solid data are lacking. Therefore we recom-mend closer monitoring with more frequent PFT screening in patients after Allo-LS. It is conceivable that lungs that have been target for Allo-LS, are prone for further damage and fibrotic processes on top of prior injury. Early detection of decrease in pulmonary function will enable timely intervention with immunosuppression, bronchodilators, vac-cination, antibiotic prophylaxis or physiotherapy.

What are future perspectives for research?

To further elucidate the pathophysiologic processes underlying IPS and BOS, research is needed. There should be focus on the role of tissue damage and the immunological pathways involved. This will be done in bronchial epithelial cultures or in human airway organoids made from stem cells derived from BAL material. In these models the effect of Respiratory Virus or other “damaging” triggers can be studied by measuring cytokines, antigen expression, gene profiling etcetera. This will be done in the presence or absence of neutrophils and T cells. This can be done while blocking certain pathways. We could study allogeneic and autologous settings. And ideally both luminal and basolateral ef-fects could be observed. From there we could study preventive strategies to decrease tis-sue damage and test new drugs to control immune response and minimize the fibrotic process in the lungs.

9

174

Concluding remarks and future perspectives

Currently a prospective study in both adults and children is done to identify new biomar-kers in BOS after HCT, which may lead to earlier identification of disease before FEV1% is reduced or clinical symptoms occur. Serial blood samples are taken every 3 months, and will be tested for neutrophil-, T cell-, fibrotic- and epithelium- biomarkers. Serial PFT are done as well. Endpoint of study is the development of BOS or the end of follow up at 3 years post HCT. Remarkably the incidence of BOS had decreased since we started the study, so we need more time for patient accrual to draw any conclusions. Currently 57 children are included, and only 2 of them have developed BOS.

Concluding remarks and further perspectives

Allo-LS after HCT is a life threatening complication. Respiratory Viruses play an impor-tant role by inducing tissue damage and triggering allo-immune mediated responses leading to severe lung disease.

Identification of patients at risk for Allo-LS, general preventive strategies (isolation stra-tegies), prolonged immune suppressive therapy in high risk patients, awareness of signs and symptoms of Allo-LS and routine PFT after HCT have all contributed to a decrease in incidence of Allo-LS and early diagnosis even in the mildly affected or asymptomatic patient.

Outcome of Allo-LS is still unsatisfactory, and further improvement of second line tre-atment strategies is needed for prompt adjustment of therapy in patients failing initial MP-pulse therapy. This should ideally be done in a randomized setting, in collaboration with other centers to get enough patients. Supportive care with attention for pulmonary rehabilitation and nutritional status is also very important.

Translational research, with input from pulmonary-, infectiology- and transplant- research groups will hopefully lead to further understanding of this intriguing disease, and help in the development of new strategies to improve outcome and quality of life of our patients.

9

174

Concluding remarks and future perspectives

Currently a prospective study in both adults and children is done to identify new biomar-kers in BOS after HCT, which may lead to earlier identification of disease before FEV1% is reduced or clinical symptoms occur. Serial blood samples are taken every 3 months, and will be tested for neutrophil-, T cell-, fibrotic- and epithelium- biomarkers. Serial PFT are done as well. Endpoint of study is the development of BOS or the end of follow up at 3 years post HCT. Remarkably the incidence of BOS had decreased since we started the study, so we need more time for patient accrual to draw any conclusions. Currently 57 children are included, and only 2 of them have developed BOS.

Concluding remarks and further perspectives

Allo-LS after HCT is a life threatening complication. Respiratory Viruses play an impor-tant role by inducing tissue damage and triggering allo-immune mediated responses leading to severe lung disease.

Identification of patients at risk for Allo-LS, general preventive strategies (isolation stra-tegies), prolonged immune suppressive therapy in high risk patients, awareness of signs and symptoms of Allo-LS and routine PFT after HCT have all contributed to a decrease in incidence of Allo-LS and early diagnosis even in the mildly affected or asymptomatic patient.

Outcome of Allo-LS is still unsatisfactory, and further improvement of second line tre-atment strategies is needed for prompt adjustment of therapy in patients failing initial MP-pulse therapy. This should ideally be done in a randomized setting, in collaboration with other centers to get enough patients. Supportive care with attention for pulmonary rehabilitation and nutritional status is also very important.

Translational research, with input from pulmonary-, infectiology- and transplant- research groups will hopefully lead to further understanding of this intriguing disease, and help in the development of new strategies to improve outcome and quality of life of our patients.

9

175

Discussion

References

1. Vande Vusse LK, Madtes DK. Early Onset Noninfectious Pulmonary Syndromes after Hematopoietic Cell Transplanta-tion. Clin Chest Med. 2017;38(2):233-48.


3. Gronningsaeter IS, Tsykunova G, Lil-leeng K, Ahmed AB, Bruserud O, Reik-vam H. Bronchiolitis obliterans syndro-me in adults after allogeneic stem cell transplantation-pathophysiology, diag-nostics and treatment. Expert review of clinical immunology. 2017;13(6):553-69.

4. Bergeron A. Late-Onset Noninfectious Pulmonary Complications After Allogen-eic Hematopoietic Stem Cell Transplan-tation. Clin Chest Med. 2017;38(2):249-62.

5. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant. 2010;16(6):782-91.


7. Keates-Baleeiro J, Moore P, Koyama T, Manes B, Calder C, Frangoul H. Inci-dence and outcome of idiopathic pneu-monia syndrome in pediatric stem cell transplant recipients. Bone Marrow Transplant. 2006;38(4):285-9.

8. Sano H, Kobayashi R, Iguchi A, Suzuki D, Kishimoto K, Yasuda K, et al. Risk factor analysis of idiopathic pneumonia syndrome after allogeneic hematopoie-tic SCT in children. Bone Marrow Trans-plant. 2014;49(1):38-41.

9. Park M, Koh KN, Kim BE, Im HJ, Seo JJ. Clinical features of late onset non-in-fectious pulmonary complications follo-wing pediatric allogeneic hematopoietic stem cell transplantation. Clinical trans-plantation. 2011;25(2):E168-76.

10. Nishio N, Yagasaki H, Takahashi Y, Mu-ramatsu H, Hama A, Tanaka M, et al. Late-onset non-infectious pulmonary complications following allogeneic he-matopoietic stem cell transplantation in children. Bone Marrow Transplant. 2009;44(5):303-8.

11. Nagasawa M, Mitsuiki N, Aoki Y, Ono T, Isoda T, Imai K, et al. Effect of redu-ced-intensity conditioning and the risk of late-onset non-infectious pulmonary complications in pediatric patients. European journal of haematology. 2017;99(6):525-31.

12. Madanat-Harjuoja LM, Valjento S, Vet-tenranta K, Kajosaari M, Dyba T, Taski-nen M. Pulmonary function following allogeneic stem cell transplantation in childhood: a retrospective cohort study of 51 patients. Pediatric transplantation. 2014;18(6):617-24.

13. Duncan CN, Buonanno MR, Barry EV, Myers K, Peritz D, Lehmann L. Bron-chiolitis obliterans following pediatric allogeneic hematopoietic stem cell transplantation. Bone Marrow Trans-plant. 2008;41(11):971-5.

14. Abugideiri M, Nanda RH, Butker C, Zhang C, Kim S, Chiang KY, et al. Fac-tors Influencing Pulmonary Toxicity in Children Undergoing Allogeneic He-matopoietic Stem Cell Transplantation

9

175

Discussion

References

1. Vande Vusse LK, Madtes DK. Early Onset Noninfectious Pulmonary Syndromes after Hematopoietic Cell Transplanta-tion. Clin Chest Med. 2017;38(2):233-48.


3. Gronningsaeter IS, Tsykunova G, Lil-leeng K, Ahmed AB, Bruserud O, Reik-vam H. Bronchiolitis obliterans syndro-me in adults after allogeneic stem cell transplantation-pathophysiology, diag-nostics and treatment. Expert review of clinical immunology. 2017;13(6):553-69.

4. Bergeron A. Late-Onset Noninfectious Pulmonary Complications After Allogen-eic Hematopoietic Stem Cell Transplan-tation. Clin Chest Med. 2017;38(2):249-62.

5. Versluys AB, Rossen JW, van Ewijk B, Schuurman R, Bierings MB, Boelens JJ. Strong association between respiratory viral infection early after hematopoie-tic stem cell transplantation and the development of life-threatening acute and chronic alloimmune lung syndro-mes. Biol Blood Marrow Transplant. 2010;16(6):782-91.


7. Keates-Baleeiro J, Moore P, Koyama T, Manes B, Calder C, Frangoul H. Inci-dence and outcome of idiopathic pneu-monia syndrome in pediatric stem cell transplant recipients. Bone Marrow Transplant. 2006;38(4):285-9.

8. Sano H, Kobayashi R, Iguchi A, Suzuki D, Kishimoto K, Yasuda K, et al. Risk factor analysis of idiopathic pneumonia syndrome after allogeneic hematopoie-tic SCT in children. Bone Marrow Trans-plant. 2014;49(1):38-41.

9. Park M, Koh KN, Kim BE, Im HJ, Seo JJ. Clinical features of late onset non-in-fectious pulmonary complications follo-wing pediatric allogeneic hematopoietic stem cell transplantation. Clinical trans-plantation. 2011;25(2):E168-76.

10. Nishio N, Yagasaki H, Takahashi Y, Mu-ramatsu H, Hama A, Tanaka M, et al. Late-onset non-infectious pulmonary complications following allogeneic he-matopoietic stem cell transplantation in children. Bone Marrow Transplant. 2009;44(5):303-8.

11. Nagasawa M, Mitsuiki N, Aoki Y, Ono T, Isoda T, Imai K, et al. Effect of redu-ced-intensity conditioning and the risk of late-onset non-infectious pulmonary complications in pediatric patients. European journal of haematology. 2017;99(6):525-31.

12. Madanat-Harjuoja LM, Valjento S, Vet-tenranta K, Kajosaari M, Dyba T, Taski-nen M. Pulmonary function following allogeneic stem cell transplantation in childhood: a retrospective cohort study of 51 patients. Pediatric transplantation. 2014;18(6):617-24.

13. Duncan CN, Buonanno MR, Barry EV, Myers K, Peritz D, Lehmann L. Bron-chiolitis obliterans following pediatric allogeneic hematopoietic stem cell transplantation. Bone Marrow Trans-plant. 2008;41(11):971-5.

14. Abugideiri M, Nanda RH, Butker C, Zhang C, Kim S, Chiang KY, et al. Fac-tors Influencing Pulmonary Toxicity in Children Undergoing Allogeneic He-matopoietic Stem Cell Transplantation

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16. Gassas A, Schechter T, Krueger J, Craig-Barnes H, Sung L, Ali M, et al. Serum Krebs Von Den Lungen-6 as a Biomar-ker for Early Detection of Bronchiolitis Obliterans Syndrome in Children Un-dergoing Allogeneic Stem Cell Trans-plantation. Biol Blood Marrow Trans-plant. 2015;21(8):1524-8.

17. Gassas A, Krueger J, Zaidman I, Schech-ter T, Craig-Barnes H, Ali M, et al. Infec-tions and neutrophils in the pathogene-sis of bronchiolitis obliterans syndrome in children after allogeneic stem cell transplantation. Pediatric transplanta-tion. 2016;20(2):303-6.

18. Prais D, Sinik MM, Stein J, Mei-Zahav M, Mussaffi H, Steuer G, et al. Effec-tiveness of long-term routine pulmo-nary function surveillance following pediatric hematopoietic stem cell transplantation. Pediatric pulmonology. 2014;49(11):1124-32.

19. Quigg TC, Kim YJ, Goebel WS, Haut PR. Lung function before and after pe-diatric allogeneic hematopoietic stem cell transplantation: a predictive role for DLCOa/VA. J Pediatr Hematol Oncol. 2012;34(4):304-9.

20. Srinivasan A, Srinivasan S, Sunthankar S, Sunkara A, Kang G, Stokes DC, et al. Pre-hematopoietic stem cell transplant lung function and pulmonary complica-tions in children. Annals of the Ameri-can Thoracic Society. 2014;11(10):1576-85.

21. Uhlving HH, Bang CL, Christensen IJ, Buchvald F, Nielsen KG, Heilmann CJ, et al. Lung function after allogeneic he-matopoietic stem cell transplantation in children: a longitudinal study in a popu-lation-based cohort. Biol Blood Marrow Transplant. 2013;19(9):1348-54.

22. Hachem RR. Acute Rejection and Antibody-Mediated Rejection in Lung Transplantation. Clin Chest Med. 2017;38(4):667-75.

23. Verleden SE, Sacreas A, Vos R, Vanaude-naerde BM, Verleden GM. Advances in Understanding Bronchiolitis Obliterans After Lung Transplantation. Chest. 2016;150(1):219-25.

24. Kumar D, Husain S, Chen MH, Mous-sa G, Himsworth D, Manuel O, et al. A prospective molecular surveillance study evaluating the clinical impact of community-acquired respiratory viruses in lung transplant recipients. Transplan-tation. 2010;89(8):1028-33.

25. Chemaly RF, Shah DP, Boeckh MJ. Ma-nagement of respiratory viral infections in hematopoietic cell transplant reci-pients and patients with hematologic malignancies. Clin Infect Dis. 2014;59 Suppl 5:S344-51.

26. Green ML. Viral Pneumonia in Patients with Hematopoietic Cell Transplantati-on and Hematologic Malignancies. Clin Chest Med. 2017;38(2):295-305.

27. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on Infec-tions in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainflu-enza virus, metapneumovirus, rhino-virus, and coronavirus. Clin Infect Dis. 2013;56(2):258-66.

28. Seo S, Waghmare A, Scott EM, Xie H, Kuypers JM, Hackman RC, et al. Human rhinovirus detection in the lower respiratory tract of hematopoie-

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176

in the Setting of Total Body Irradiation-Based Myeloablative Conditioning. In-ternational journal of radiation oncolo-gy, biology, physics. 2016;94(2):349-59.


16. Gassas A, Schechter T, Krueger J, Craig-Barnes H, Sung L, Ali M, et al. Serum Krebs Von Den Lungen-6 as a Biomar-ker for Early Detection of Bronchiolitis Obliterans Syndrome in Children Un-dergoing Allogeneic Stem Cell Trans-plantation. Biol Blood Marrow Trans-plant. 2015;21(8):1524-8.

17. Gassas A, Krueger J, Zaidman I, Schech-ter T, Craig-Barnes H, Ali M, et al. Infec-tions and neutrophils in the pathogene-sis of bronchiolitis obliterans syndrome in children after allogeneic stem cell transplantation. Pediatric transplanta-tion. 2016;20(2):303-6.

18. Prais D, Sinik MM, Stein J, Mei-Zahav M, Mussaffi H, Steuer G, et al. Effec-tiveness of long-term routine pulmo-nary function surveillance following pediatric hematopoietic stem cell transplantation. Pediatric pulmonology. 2014;49(11):1124-32.

19. Quigg TC, Kim YJ, Goebel WS, Haut PR. Lung function before and after pe-diatric allogeneic hematopoietic stem cell transplantation: a predictive role for DLCOa/VA. J Pediatr Hematol Oncol. 2012;34(4):304-9.

20. Srinivasan A, Srinivasan S, Sunthankar S, Sunkara A, Kang G, Stokes DC, et al. Pre-hematopoietic stem cell transplant lung function and pulmonary complica-tions in children. Annals of the Ameri-can Thoracic Society. 2014;11(10):1576-85.

21. Uhlving HH, Bang CL, Christensen IJ, Buchvald F, Nielsen KG, Heilmann CJ, et al. Lung function after allogeneic he-matopoietic stem cell transplantation in children: a longitudinal study in a popu-lation-based cohort. Biol Blood Marrow Transplant. 2013;19(9):1348-54.

22. Hachem RR. Acute Rejection and Antibody-Mediated Rejection in Lung Transplantation. Clin Chest Med. 2017;38(4):667-75.

23. Verleden SE, Sacreas A, Vos R, Vanaude-naerde BM, Verleden GM. Advances in Understanding Bronchiolitis Obliterans After Lung Transplantation. Chest. 2016;150(1):219-25.

24. Kumar D, Husain S, Chen MH, Mous-sa G, Himsworth D, Manuel O, et al. A prospective molecular surveillance study evaluating the clinical impact of community-acquired respiratory viruses in lung transplant recipients. Transplan-tation. 2010;89(8):1028-33.

25. Chemaly RF, Shah DP, Boeckh MJ. Ma-nagement of respiratory viral infections in hematopoietic cell transplant reci-pients and patients with hematologic malignancies. Clin Infect Dis. 2014;59 Suppl 5:S344-51.

26. Green ML. Viral Pneumonia in Patients with Hematopoietic Cell Transplantati-on and Hematologic Malignancies. Clin Chest Med. 2017;38(2):295-305.

27. Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P. Fourth European Conference on Infec-tions in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainflu-enza virus, metapneumovirus, rhino-virus, and coronavirus. Clin Infect Dis. 2013;56(2):258-66.

28. Seo S, Waghmare A, Scott EM, Xie H, Kuypers JM, Hackman RC, et al. Human rhinovirus detection in the lower respiratory tract of hematopoie-

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177

Discussion

tic cell transplant recipients: associ-ation with mortality. Haematologica. 2017;102(6):1120-30.

29. Campbell AP, Guthrie KA, Englund JA, Farney RM, Minerich EL, Kuypers J, et al. Clinical outcomes associated with res-piratory virus detection before allogen-eic hematopoietic stem cell transplant. Clin Infect Dis. 2015;61(2):192-202.

30. Shah DP, Ghantoji SS, Shah JN, El Ta-oum KK, Jiang Y, Popat U, et al. Impact of aerosolized ribavirin on mortality in 280 allogeneic haematopoietic stem cell transplant recipients with respira-tory syncytial virus infections. J Antimi-crob Chemother. 2013;68(8):1872-80.

31. Openshaw PJM, Chiu C, Culley FJ, Jo-hansson C. Protective and Harmful Im-munity to RSV Infection. Annual review of immunology. 2017;35:501-32.

32. Man WH, de Steenhuijsen Piters WA, Bogaert D. The microbiota of the res-piratory tract: gatekeeper to respiratory health. Nature reviews Microbiology. 2017;15(5):259-70.

33. Zou S, Caler L, Colombini-Hatch S, Glynn S, Srinivas P. Research on the hu-man virome: where are we and what is next. Microbiome. 2016;4(1):32.


35. Jagasia MH, Greinix HT, Arora M, Wil-liams KM, Wolff D, Cowen EW, et al. Na-tional Institutes of Health Consensus Development Project on Criteria for Cli-nical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Sta-ging Working Group report. Biol Blood Marrow Transplant. 2015;21:389-401 e1.

36. Seo S, Renaud C, Kuypers JM, Chiu CY, Huang ML, Samayoa E, et al. Idiopa-thic pneumonia syndrome after hema-topoietic cell transplantation: evidence of occult infectious etiologies. Blood. 2015;125(24):3789-97.

37. Versluys A. Predictors for outcome in children with Alloimmune Lung Syndro-mes after HCT. submitted. 2018.

38. Ratjen F, Rjabko O, Kremens B. High-dose corticosteroid therapy for bron-chiolitis obliterans after bone marrow transplantation in children. Bone Mar-row Transplant. 2005;36(2):135-8.


40. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Mul-ler KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant. 2012;47(8):1020-9.

41. Yanik GA, Grupp SA, Pulsipher MA, Levine JE, Schultz KR, Wall DA, et al. TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consor-tium and Children's Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant. 2015;21(1):67-73.

42. Verleden GM, Vos R, Vanaudenaerde B, Dupont L, Yserbyt J, Van Raemdonck D, et al. Current views on chronic rejection after lung transplantation. Transplant international : official journal of the Eu-ropean Society for Organ Transplanta-tion. 2015;28(10):1131-9.

9

177

Discussion

tic cell transplant recipients: associ-ation with mortality. Haematologica. 2017;102(6):1120-30.

29. Campbell AP, Guthrie KA, Englund JA, Farney RM, Minerich EL, Kuypers J, et al. Clinical outcomes associated with res-piratory virus detection before allogen-eic hematopoietic stem cell transplant. Clin Infect Dis. 2015;61(2):192-202.

30. Shah DP, Ghantoji SS, Shah JN, El Ta-oum KK, Jiang Y, Popat U, et al. Impact of aerosolized ribavirin on mortality in 280 allogeneic haematopoietic stem cell transplant recipients with respira-tory syncytial virus infections. J Antimi-crob Chemother. 2013;68(8):1872-80.

31. Openshaw PJM, Chiu C, Culley FJ, Jo-hansson C. Protective and Harmful Im-munity to RSV Infection. Annual review of immunology. 2017;35:501-32.

32. Man WH, de Steenhuijsen Piters WA, Bogaert D. The microbiota of the res-piratory tract: gatekeeper to respiratory health. Nature reviews Microbiology. 2017;15(5):259-70.

33. Zou S, Caler L, Colombini-Hatch S, Glynn S, Srinivas P. Research on the hu-man virome: where are we and what is next. Microbiome. 2016;4(1):32.


35. Jagasia MH, Greinix HT, Arora M, Wil-liams KM, Wolff D, Cowen EW, et al. Na-tional Institutes of Health Consensus Development Project on Criteria for Cli-nical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Diagnosis and Sta-ging Working Group report. Biol Blood Marrow Transplant. 2015;21:389-401 e1.

36. Seo S, Renaud C, Kuypers JM, Chiu CY, Huang ML, Samayoa E, et al. Idiopa-thic pneumonia syndrome after hema-topoietic cell transplantation: evidence of occult infectious etiologies. Blood. 2015;125(24):3789-97.

37. Versluys A. Predictors for outcome in children with Alloimmune Lung Syndro-mes after HCT. submitted. 2018.

38. Ratjen F, Rjabko O, Kremens B. High-dose corticosteroid therapy for bron-chiolitis obliterans after bone marrow transplantation in children. Bone Mar-row Transplant. 2005;36(2):135-8.


40. Uhlving HH, Buchvald F, Heilmann CJ, Nielsen KG, Gormsen M, Mul-ler KG. Bronchiolitis obliterans after allo-SCT: clinical criteria and treatment options. Bone Marrow Transplant. 2012;47(8):1020-9.

41. Yanik GA, Grupp SA, Pulsipher MA, Levine JE, Schultz KR, Wall DA, et al. TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consor-tium and Children's Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant. 2015;21(1):67-73.

42. Verleden GM, Vos R, Vanaudenaerde B, Dupont L, Yserbyt J, Van Raemdonck D, et al. Current views on chronic rejection after lung transplantation. Transplant international : official journal of the Eu-ropean Society for Organ Transplanta-tion. 2015;28(10):1131-9.

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43. Varelias A, Gartlan KH, Kreijveld E, Ol-ver SD, Lor M, Kuns RD, et al. Lung parenchyma-derived IL-6 promotes IL-17A-dependent acute lung injury af-ter allogeneic stem cell transplantation. Blood. 2015;125(15):2435-44.

44. Ahya VN. Noninfectious Acute Lung Injury Syndromes Early After Hemato-poietic Stem Cell Transplantation. Clin Chest Med. 2017;38(4):595-606.

45. Yanik GA, Horowitz MM, Weisdorf DJ, Logan BR, Ho VT, Soiffer RJ, et al. Randomized, double-blind, placebo-controlled trial of soluble tumor necro-sis factor receptor: enbrel (etanercept) for the treatment of idiopathic pneu-monia syndrome after allogeneic stem cell transplantation: blood and marrow transplant clinical trials network pro-tocol. Biol Blood Marrow Transplant. 2014;20(6):858-64.

46. Benden C, Haughton M, Leonard S, Huber LC. Therapy options for chronic lung allograft dysfunction-bronchiolitis obliterans syndrome following first-line immunosuppressive strategies: A syste-matic review. The Journal of heart and lung transplantation. 2017;36(9):921-33.

47. Williams KM, Cheng GS, Pusic I, Jagasia M, Burns L, Ho VT, et al. Fluticasone, Azithromycin, and Montelukast Treat-ment for New-Onset Bronchiolitis Obli-terans Syndrome after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant. 2016;22(4):710-6.

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43. Varelias A, Gartlan KH, Kreijveld E, Ol-ver SD, Lor M, Kuns RD, et al. Lung parenchyma-derived IL-6 promotes IL-17A-dependent acute lung injury af-ter allogeneic stem cell transplantation. Blood. 2015;125(15):2435-44.

44. Ahya VN. Noninfectious Acute Lung Injury Syndromes Early After Hemato-poietic Stem Cell Transplantation. Clin Chest Med. 2017;38(4):595-606.

45. Yanik GA, Horowitz MM, Weisdorf DJ, Logan BR, Ho VT, Soiffer RJ, et al. Randomized, double-blind, placebo-controlled trial of soluble tumor necro-sis factor receptor: enbrel (etanercept) for the treatment of idiopathic pneu-monia syndrome after allogeneic stem cell transplantation: blood and marrow transplant clinical trials network pro-tocol. Biol Blood Marrow Transplant. 2014;20(6):858-64.

46. Benden C, Haughton M, Leonard S, Huber LC. Therapy options for chronic lung allograft dysfunction-bronchiolitis obliterans syndrome following first-line immunosuppressive strategies: A syste-matic review. The Journal of heart and lung transplantation. 2017;36(9):921-33.

47. Williams KM, Cheng GS, Pusic I, Jagasia M, Burns L, Ho VT, et al. Fluticasone, Azithromycin, and Montelukast Treat-ment for New-Onset Bronchiolitis Obli-terans Syndrome after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant. 2016;22(4):710-6.

9

10Nederlandse samenvattingCurriculum VitaeDankwoord

10Nederlandse samenvattingCurriculum VitaeDankwoord

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Nederlandse samenvatting

Achtergrond en introductie

Allogene stamceltransplantatie (SCT) is een potentieel curatieve behandeling voor ern-stige ziekten als leukemie, immuun deficiënties, stofwisselingsziekten en beenmerg fa-len. Bij een allogene SCT worden hematopoietische stamcellen van een gezonde donor toegediend aan een patiënt. Deze stamcellen groeien uit tot beenmerg, en hieruit ont-staat een nieuw afweersysteem.

Over het algemeen wordt er een donor gekozen die qua weefseltypering het best overeen-komt met de ontvanger, de patiënt. Hiervoor wordt het zogenaamde Human Leucocyte Antigen (HLA) systeem gebruikt. Een donor is soms een familielid, maar vaak is de do-nor niet verwant en wordt via internationale databases gevonden. De stamcellen van de donor kunnen afkomstig zijn van beenmerg, bloed of navelstrengbloed.

Voorafgaand aan de transplantatie wordt de ontvanger behandeld met een combinatie van chemotherapie, radiotherapie en/of afweerdempende medicatie om ervoor te zorgen dat er ruimte ontstaat in het beenmerg om de stamcellen te laten innestelen, en om de afweer te onderdrukken opdat het transplantaat niet wordt afgestoten. Deze voorbehan-deling noemen we conditionering. Als gevolg van de conditionering zullen er bijwerkin-gen ontstaan in diverse organen, met klachten die in de acute fase, maar soms ook pas vele jaren later, tot uiting komen. In de eerste periode na de transplantatie is de afweer heel laag en is de patiënt vatbaar voor ernstige infecties. Als het transplantaat aanslaat zal de afweer na enkele weken weer langzaam herstellen.

Na de transplantatie worden medicijnen gegeven die de (donor)afweer onderdrukken om transplantatieziekte te voorkomen. Transplantatieziekte is het fenomeen van een uit-gebreide ontstekingsreactie veroorzaakt door afweercellen van de donor, die de gezonde cellen van de ontvanger herkennen als lichaamsvreemd en “aanvallen”. Transplantatie-ziekte (Graft versus Host Disease; GvHD) treedt meestal op in de huid, de darmen, de lever of de longen. GvHD wordt behandeld met extra afweer-dempende medicatie.

Uiteindelijk zal er een situatie van tolerantie ontstaan tussen de nieuwe gezonde afweer-cellen van de donor en de rest van het lichaam van de ontvanger. Dan kunnen de afweer-dempende medicijnen worden afgebouwd en uiteindelijk gestaakt (Figuur 1).

Zoals uit bovenstaande duidelijk wordt is een SCT een zeer intensieve behandeling met grote kans op levensbedreigende complicaties. Er wordt vaak onderscheid gemaakt tus-sen infectieuze en niet-infectieuze problemen. Niet-infectieuze problemen worden weer onderverdeeld in toxiciteit van de behandeling en immuun gemedieerde problemen (GvHD). In dit proefschrift gaat het voornamelijk over immuun gemedieerde longziek-ten na allogene stamceltransplantatie.

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Achtergrond en introductie

Allogene stamceltransplantatie (SCT) is een potentieel curatieve behandeling voor ern-stige ziekten als leukemie, immuun deficiënties, stofwisselingsziekten en beenmerg fa-len. Bij een allogene SCT worden hematopoietische stamcellen van een gezonde donor toegediend aan een patiënt. Deze stamcellen groeien uit tot beenmerg, en hieruit ont-staat een nieuw afweersysteem.

Over het algemeen wordt er een donor gekozen die qua weefseltypering het best overeen-komt met de ontvanger, de patiënt. Hiervoor wordt het zogenaamde Human Leucocyte Antigen (HLA) systeem gebruikt. Een donor is soms een familielid, maar vaak is de do-nor niet verwant en wordt via internationale databases gevonden. De stamcellen van de donor kunnen afkomstig zijn van beenmerg, bloed of navelstrengbloed.

Voorafgaand aan de transplantatie wordt de ontvanger behandeld met een combinatie van chemotherapie, radiotherapie en/of afweerdempende medicatie om ervoor te zorgen dat er ruimte ontstaat in het beenmerg om de stamcellen te laten innestelen, en om de afweer te onderdrukken opdat het transplantaat niet wordt afgestoten. Deze voorbehan-deling noemen we conditionering. Als gevolg van de conditionering zullen er bijwerkin-gen ontstaan in diverse organen, met klachten die in de acute fase, maar soms ook pas vele jaren later, tot uiting komen. In de eerste periode na de transplantatie is de afweer heel laag en is de patiënt vatbaar voor ernstige infecties. Als het transplantaat aanslaat zal de afweer na enkele weken weer langzaam herstellen.

Na de transplantatie worden medicijnen gegeven die de (donor)afweer onderdrukken om transplantatieziekte te voorkomen. Transplantatieziekte is het fenomeen van een uit-gebreide ontstekingsreactie veroorzaakt door afweercellen van de donor, die de gezonde cellen van de ontvanger herkennen als lichaamsvreemd en “aanvallen”. Transplantatie-ziekte (Graft versus Host Disease; GvHD) treedt meestal op in de huid, de darmen, de lever of de longen. GvHD wordt behandeld met extra afweer-dempende medicatie.

Uiteindelijk zal er een situatie van tolerantie ontstaan tussen de nieuwe gezonde afweer-cellen van de donor en de rest van het lichaam van de ontvanger. Dan kunnen de afweer-dempende medicijnen worden afgebouwd en uiteindelijk gestaakt (Figuur 1).

Zoals uit bovenstaande duidelijk wordt is een SCT een zeer intensieve behandeling met grote kans op levensbedreigende complicaties. Er wordt vaak onderscheid gemaakt tus-sen infectieuze en niet-infectieuze problemen. Niet-infectieuze problemen worden weer onderverdeeld in toxiciteit van de behandeling en immuun gemedieerde problemen (GvHD). In dit proefschrift gaat het voornamelijk over immuun gemedieerde longziek-ten na allogene stamceltransplantatie.

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Immuun gemedieerde longziekte na SCT

Longcomplicaties na SCT komen bij 25-75% van de patiënten voor. In ongeveer de helft van de gevallen gaat het om infecties door virussen, bacteriën of schimmels. In de loop van de jaren zien we relatief steeds vaker niet-infectieuze longproblemen. Er zijn ver-schillende vormen van niet-infectieuze immuun gemedieerde longziekten zoals Idiopa-thisch Pneumonie Syndroom (IPS) en Bronchiolitis Obliterans Syndroom (BOS).

IPS treedt vaak vroeg op na SCT en wordt gekarakteriseerd door het vrij acuut ontstaan van klachten van benauwdheid, zuurstofbehoefte en afwijkingen op de X-thorax. BOS treedt meestal later op, kent een sluimerend begin met inspanningsintolerantie, hoesten en benauwdheid, en heeft typische afwijkingen bij longfunctietesten en HRCT-scan van de longen. Bij deze ziektebeelden speelt de donorafweer (allo-immuniteit) een cruciale rol, vandaar dat we ze onder de verzamelnaam allo-immuun longbeeld vatten (Allo-long-beeld). Allo-longbeelden zijn ernstig en kennen een hoge mortaliteit, volgens gepubli-ceerde studies overlijdt 20-80 % van de patiënten met BOS of IPS.

In Hoofdstuk 2 wordt een overzicht gegeven van alle longcomplicaties die kunnen op-treden bij de behandeling van kinderkanker, inclusief SCT. Met de verbetering van kin-deroncologische behandelstrategieën is de overlevingskans van kinderen met kanker de laatste decennia gestegen tot ongeveer 75%. Hoe meer overlevers we gedurende langere tijd volgen, des te meer we leren over de (lange termijn) effecten van de behandeling op

FIGUUR 1. Schematisch overzicht traject van stamceltransplantatie (SCT).

Conditionering:chemotherapie ± bestraling

SCT

Immuun herstel-7 0 +28 +100

Immuun-suppressieve therapie

IPS

BOS

Graft versus Host Ziekte (GvHD)

Directe toxiciteit conditionering

Infectieuze dreiging

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10


Longcomplicaties na SCT komen bij 25-75% van de patiënten voor. In ongeveer de helft van de gevallen gaat het om infecties door virussen, bacteriën of schimmels. In de loop van de jaren zien we relatief steeds vaker niet-infectieuze longproblemen. Er zijn ver-schillende vormen van niet-infectieuze immuun gemedieerde longziekten zoals Idiopa-thisch Pneumonie Syndroom (IPS) en Bronchiolitis Obliterans Syndroom (BOS).

IPS treedt vaak vroeg op na SCT en wordt gekarakteriseerd door het vrij acuut ontstaan van klachten van benauwdheid, zuurstofbehoefte en afwijkingen op de X-thorax. BOS treedt meestal later op, kent een sluimerend begin met inspanningsintolerantie, hoesten en benauwdheid, en heeft typische afwijkingen bij longfunctietesten en HRCT-scan van de longen. Bij deze ziektebeelden speelt de donorafweer (allo-immuniteit) een cruciale rol, vandaar dat we ze onder de verzamelnaam allo-immuun longbeeld vatten (Allo-long-beeld). Allo-longbeelden zijn ernstig en kennen een hoge mortaliteit, volgens gepubli-ceerde studies overlijdt 20-80 % van de patiënten met BOS of IPS.

In Hoofdstuk 2 wordt een overzicht gegeven van alle longcomplicaties die kunnen op-treden bij de behandeling van kinderkanker, inclusief SCT. Met de verbetering van kin-deroncologische behandelstrategieën is de overlevingskans van kinderen met kanker de laatste decennia gestegen tot ongeveer 75%. Hoe meer overlevers we gedurende langere tijd volgen, des te meer we leren over de (lange termijn) effecten van de behandeling op

FIGUUR 1. Schematisch overzicht traject van stamceltransplantatie (SCT).

Conditionering:chemotherapie ± bestraling

SCT

Immuun herstel-7 0 +28 +100

Immuun-suppressieve therapie

IPS

BOS

Graft versus Host Ziekte (GvHD)

Directe toxiciteit conditionering

Infectieuze dreiging

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verschillende organen. De incidentie van longproblemen is vrij hoog (tot wel 45%), maar exacte getallen zijn moeilijk te geven. Dit hangt immers af van de manier van onderzoe-ken. Gaat het om zelf gerapporteerde klachten, om afwijkende longfunctietesten, om ge-objectiveerde klachten of om sterfte als gevolg van een longprobleem? Bij het bestuderen van de literatuur blijkt er vooral schade op te treden na behandeling met bestraling op de longen/borstkas, bepaalde chemotherapie (Bleomycine, Busulfan, Cyclophosphamide, Nitrosurea), chirurgie van de longen en na allogene SCT. Naast de directe schade van deze behandelingen tegen de achtergrond van een groeiend kind met een zich nog ont-wikkelende long, zijn er andere factoren die een rol spelen. In de loop van de tijd zijn er ook bijkomende invloeden van infecties in periodes van verminderde afweer, genetische factoren met betrekking tot gevoeligheid van de longen, en externe factoren zoals lucht-vervuiling en roken.

We weten dat ongeveer 40% van de overlevers van kinderkanker ernstige late effecten ervaart, soms nog jaren na de behandeling (ongeveer 5% longproblemen), met grote invloed op de kwaliteit van leven. Daarom is het belangrijk dat de zorg voor overlevers van kinderkanker op een gestructureerde wijze plaatsvindt, met screening van verschil-lende orgaansystemen op basis van het doorlopen behandelprotocol. Op die manier is het mogelijk om, voordat er symptomen zijn, preventieve maatregelen te nemen en de overlever de juiste zorg te bieden.

In Hoofdstuk 3 gaat het over de associatie tussen virale luchtweginfecties in een vroeg stadium van de SCT en het ontwikkelen van een allo-longbeeld. In een cohort van 110 kinderen die een SCT ondergingen, ontwikkelden er 30 een allo-longbeeld, waarvan er 14 overleden. We onderzochten verschillende risicofactoren met betrekking tot de ont-wikkeling van allo-longbeeld en vonden dat het hebben van een respiratoir virus (geme-ten met PCR-techniek op een neus/keel spoelsel) een belangrijke voorspeller was voor het ontwikkelen van allo-longbeeld, en dat immuun-suppressieve therapie voor GvHD in een ander orgaan juist een beschermend effect had tegen de ontwikkeling van allo-longziekte.

Ook bleek in dit cohort het allo-longbeeld de enige significante voorspeller voor mor-taliteit te zijn. Dit past in de hypothese dat weefselschade door een respiratoir virus de longen tot een targetorgaan voor GvHD maken, dat dit een ernstig fenomeen is, en dat het deels voorkomen kan worden door immuun-suppressieve therapie. Deze resultaten onderstrepen het belang van preventie tegen respiratoire virussen tijdens het SCT-traject en het mogelijke effect van het langer geven van immuun suppressie aan patiënten met een hoog risico op het krijgen van allo-longbeeld op basis van positiviteit voor respiratoir virus.

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verschillende organen. De incidentie van longproblemen is vrij hoog (tot wel 45%), maar exacte getallen zijn moeilijk te geven. Dit hangt immers af van de manier van onderzoe-ken. Gaat het om zelf gerapporteerde klachten, om afwijkende longfunctietesten, om ge-objectiveerde klachten of om sterfte als gevolg van een longprobleem? Bij het bestuderen van de literatuur blijkt er vooral schade op te treden na behandeling met bestraling op de longen/borstkas, bepaalde chemotherapie (Bleomycine, Busulfan, Cyclophosphamide, Nitrosurea), chirurgie van de longen en na allogene SCT. Naast de directe schade van deze behandelingen tegen de achtergrond van een groeiend kind met een zich nog ont-wikkelende long, zijn er andere factoren die een rol spelen. In de loop van de tijd zijn er ook bijkomende invloeden van infecties in periodes van verminderde afweer, genetische factoren met betrekking tot gevoeligheid van de longen, en externe factoren zoals lucht-vervuiling en roken.

We weten dat ongeveer 40% van de overlevers van kinderkanker ernstige late effecten ervaart, soms nog jaren na de behandeling (ongeveer 5% longproblemen), met grote invloed op de kwaliteit van leven. Daarom is het belangrijk dat de zorg voor overlevers van kinderkanker op een gestructureerde wijze plaatsvindt, met screening van verschil-lende orgaansystemen op basis van het doorlopen behandelprotocol. Op die manier is het mogelijk om, voordat er symptomen zijn, preventieve maatregelen te nemen en de overlever de juiste zorg te bieden.

In Hoofdstuk 3 gaat het over de associatie tussen virale luchtweginfecties in een vroeg stadium van de SCT en het ontwikkelen van een allo-longbeeld. In een cohort van 110 kinderen die een SCT ondergingen, ontwikkelden er 30 een allo-longbeeld, waarvan er 14 overleden. We onderzochten verschillende risicofactoren met betrekking tot de ont-wikkeling van allo-longbeeld en vonden dat het hebben van een respiratoir virus (geme-ten met PCR-techniek op een neus/keel spoelsel) een belangrijke voorspeller was voor het ontwikkelen van allo-longbeeld, en dat immuun-suppressieve therapie voor GvHD in een ander orgaan juist een beschermend effect had tegen de ontwikkeling van allo-longziekte.

Ook bleek in dit cohort het allo-longbeeld de enige significante voorspeller voor mor-taliteit te zijn. Dit past in de hypothese dat weefselschade door een respiratoir virus de longen tot een targetorgaan voor GvHD maken, dat dit een ernstig fenomeen is, en dat het deels voorkomen kan worden door immuun-suppressieve therapie. Deze resultaten onderstrepen het belang van preventie tegen respiratoire virussen tijdens het SCT-traject en het mogelijke effect van het langer geven van immuun suppressie aan patiënten met een hoog risico op het krijgen van allo-longbeeld op basis van positiviteit voor respiratoir virus.

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Sinds 2008 wordt bij al onze SCT-patiënten voorafgaand aan de behandeling een pul-monale screening gedaan met longfunctietesten, beeldvorming met een HRCT-scan en een longspoeling (Broncho Alveolaire Lavage = BAL) voor infectieuze diagnostiek van virussen, bacteriën en schimmels. In Hoofdstuk 4 worden de bevindingen van de eerste 5 jaar van deze screening beschreven. Bij 86% van de 142 patiënten die in die periode werden getransplanteerd kon het volledige programma worden gedaan. Geen van de pa-tiënten had symptomen ten tijde van de screening. Bij de meerderheid van de patiënten werden echter wel afwijkingen gevonden. De longfunctie was afwijkend in 66% van de gevallen, de BAL was positief in 47%, en de HRCT-longen liet afwijkingen zien in 55% van de gevallen. Patiënten zonder voorbehandeling met chemotherapie (zoals patiënten met een stofwisselingsziekte of beenmergfalen) hadden significant minder afwijkingen op de HRCT dan de rest van het cohort. Afwijkingen in longfunctie en BAL kwamen evenveel voor bij de verschillende categorieën patiënten.

Bij 46 patiënten had de uitkomst van de screening direct klinische implicaties in die zin dat is overgegaan tot het verrichten van een longbiopsie, een switch in antibiotica of de beslissing tot verlengde duur van immuun-suppressieve therapie.

We vonden een relatie tussen klinisch significante afwijkingen op de HRCT en het ont-wikkelen van allo-longbeeld. Voor andere afwijkingen was dit niet het geval. Screening op longproblemen levert dus vaak iets op met directe klinische implicaties, en soms heeft de uitkomst een voorspellende waarde als het gaat om het ontwikkelen van long-problemen in de toekomst.

In Hoofdstuk 5 gaat het over de waarde van een HRCT-scan van de longen voor het dif-ferentiëren tussen immuun-gemedieerde en niet-immuun-gemedieerde longziekte na SCT. Hiertoe werd eerst een scoringssysteem ontwikkeld gebaseerd op veelvoorkomen-de HRCT-afwijkingen bij SCT-patiënten. Hierbij krijgen 8 verschillende items een score van 0-18, en is er een totaalscore die varieert van 0-144 (hoe hoger de score hoe meer af-wijkingen). Twee ervaren kinderradiologen pasten de score toe op 124 long HRCT-scans, en een van hen herhaalde dit 1 maand later nog eens. De overeenkomst tussen de twee beoordelaars (inter-observer), en de overeenkomst tussen de scores van dezelfde beoor-delaar met een maand tussenpose (intra-observer) was redelijk tot goed.

Vervolgens werden, retrospectief, de HRCT-scans van 52 kinderen met respiratoire symptomen in de eerste 100 dagen na SCT met dit scoringssysteem bekeken. De ra-diologen waren geblindeerd voor de naam van de patiënt en de klinische vraagstelling. Bij diezelfde 52 kinderen is door een ervaren stamceltransplantatiearts de diagnose allo-longbeeld of non-allolongbeeld gesteld. Dit is gedaan op basis van klinische gegevens, laboratoriumuitslagen en het beloop in de tijd.

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Sinds 2008 wordt bij al onze SCT-patiënten voorafgaand aan de behandeling een pul-monale screening gedaan met longfunctietesten, beeldvorming met een HRCT-scan en een longspoeling (Broncho Alveolaire Lavage = BAL) voor infectieuze diagnostiek van virussen, bacteriën en schimmels. In Hoofdstuk 4 worden de bevindingen van de eerste 5 jaar van deze screening beschreven. Bij 86% van de 142 patiënten die in die periode werden getransplanteerd kon het volledige programma worden gedaan. Geen van de pa-tiënten had symptomen ten tijde van de screening. Bij de meerderheid van de patiënten werden echter wel afwijkingen gevonden. De longfunctie was afwijkend in 66% van de gevallen, de BAL was positief in 47%, en de HRCT-longen liet afwijkingen zien in 55% van de gevallen. Patiënten zonder voorbehandeling met chemotherapie (zoals patiënten met een stofwisselingsziekte of beenmergfalen) hadden significant minder afwijkingen op de HRCT dan de rest van het cohort. Afwijkingen in longfunctie en BAL kwamen evenveel voor bij de verschillende categorieën patiënten.

Bij 46 patiënten had de uitkomst van de screening direct klinische implicaties in die zin dat is overgegaan tot het verrichten van een longbiopsie, een switch in antibiotica of de beslissing tot verlengde duur van immuun-suppressieve therapie.

We vonden een relatie tussen klinisch significante afwijkingen op de HRCT en het ont-wikkelen van allo-longbeeld. Voor andere afwijkingen was dit niet het geval. Screening op longproblemen levert dus vaak iets op met directe klinische implicaties, en soms heeft de uitkomst een voorspellende waarde als het gaat om het ontwikkelen van long-problemen in de toekomst.

In Hoofdstuk 5 gaat het over de waarde van een HRCT-scan van de longen voor het dif-ferentiëren tussen immuun-gemedieerde en niet-immuun-gemedieerde longziekte na SCT. Hiertoe werd eerst een scoringssysteem ontwikkeld gebaseerd op veelvoorkomen-de HRCT-afwijkingen bij SCT-patiënten. Hierbij krijgen 8 verschillende items een score van 0-18, en is er een totaalscore die varieert van 0-144 (hoe hoger de score hoe meer af-wijkingen). Twee ervaren kinderradiologen pasten de score toe op 124 long HRCT-scans, en een van hen herhaalde dit 1 maand later nog eens. De overeenkomst tussen de twee beoordelaars (inter-observer), en de overeenkomst tussen de scores van dezelfde beoor-delaar met een maand tussenpose (intra-observer) was redelijk tot goed.

Vervolgens werden, retrospectief, de HRCT-scans van 52 kinderen met respiratoire symptomen in de eerste 100 dagen na SCT met dit scoringssysteem bekeken. De ra-diologen waren geblindeerd voor de naam van de patiënt en de klinische vraagstelling. Bij diezelfde 52 kinderen is door een ervaren stamceltransplantatiearts de diagnose allo-longbeeld of non-allolongbeeld gesteld. Dit is gedaan op basis van klinische gegevens, laboratoriumuitslagen en het beloop in de tijd.

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De vergelijking van de HRCT-scores van allo-longbeeld versus non-allo-longbeeld liet bij kinderen met allo-longbeeld een significant hogere score zien ten aanzien van matglasaf-wijkingen, airtrapping en de totaalscore. Op basis hiervan definieerden we de “allo-score” bestaand uit de som van de score voor matglasafwijking en airtrapping. Deze score heeft goede eigenschappen als diagnostische test waarbij de afkapwaarde tussen 20-25 ligt. In de toekomst kunnen we deze score gebruiken in de patiëntenzorg.

Van oudsher bestaat er bij virusinfecties rondom SCT de angst dat er progressie van de infectie optreedt vanwege de slechte afweer van de patiënten. Daarom wordt er in de meeste SCT-centra in het geval van Respiratoir Syncytieel Virus (RSV; een type virus dat bij jonge kinderen veel voorkomt) besloten tot behandeling met antivirale therapie. Deze therapie is duur, heeft bijwerkingen en de effectiviteit is niet goed onderzocht. In eerdere studies naar respiratoire virussen na SCT, zagen wij geen verergering van de virale infecties in de eerste periode na de transplantatie. Hoofdstuk 6 geeft een overzicht van het beloop van onbehandelde RSV-infectie bij kinderen tijdens of kort na SCT. Wij concluderen dat er bij geen van de 8 patiënten directe progressie van de RSV-infectie is opgetreden, en dat de symptomen mild zijn. Dit ondersteunt een terughoudend beleid ten aanzien van antivirale behandeling van RSV in kinderen rondom SCT.

Hoofdstuk 7 gaat door op de hypothese geformuleerd in Hoofdstuk 3. In dit grotere co-hort SCT-patiënten zien we dat het aantonen van een luchtwegvirus in de longen een voorspeller is voor het ontwikkelen van allo-longbeeld, maar dat deze relatie niet geldt voor virussen die alleen in de neus/keelholte worden gedetecteerd. Van de 179 in het onderzoek opgenomen kinderen was 41% positief voor een virus in de BAL. In totaal ontwikkelden 24 kinderen een allo-longbeeld (13%), de kans hierop was 26% bij virus-positieve BAL, versus 6 % in de virus-negatieve groep. Ook hier zagen we een trend naar een beschermend effect van de behandeling van GvHD tegen de ontwikkeling van allo-longbeeld in de virus-positieve groep (Figuur 2).

Hoofdstuk 8 beschrijft een cohort van 53 kinderen met allo-longbeeld na SCT, 30 hadden IPS en 23 BOS. Zij werden behandeld met methyl-prednisolon pulse therapie. Slechts 43% herstelde van de longziekte en overleefde. We onderzochten voorspellers voor uit-komsten op de langere termijn. Kinderen met beademingsbehoefte op het moment van diagnose allo-longbeeld, en kinderen waarbij het allo-longbeeld ontstond tijdens of na systemische behandeling met steroïden voor GvHD in een ander orgaan, hadden een slechtere prognose. Als er een respiratoir virus werd aangetoond in de luchtwegen was de kans op overleving zonder chronische longziekte juist beter. Bij slechte respons op initiële therapie, wat vaak al binnen 2 weken duidelijk werd, was de overlevingskans slechts 4%. Bij de overlevers herstelde de longfunctie tot ongeveer 70% van normaal, en zij waren grotendeels zonder luchtwegklachten. Er is dus nog veel te verbeteren aan de behandeling van allo-longbeeld. Het is meestal al snel duidelijk welke patiënten inten-sievere therapie nodig hebben.

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De vergelijking van de HRCT-scores van allo-longbeeld versus non-allo-longbeeld liet bij kinderen met allo-longbeeld een significant hogere score zien ten aanzien van matglasaf-wijkingen, airtrapping en de totaalscore. Op basis hiervan definieerden we de “allo-score” bestaand uit de som van de score voor matglasafwijking en airtrapping. Deze score heeft goede eigenschappen als diagnostische test waarbij de afkapwaarde tussen 20-25 ligt. In de toekomst kunnen we deze score gebruiken in de patiëntenzorg.

Van oudsher bestaat er bij virusinfecties rondom SCT de angst dat er progressie van de infectie optreedt vanwege de slechte afweer van de patiënten. Daarom wordt er in de meeste SCT-centra in het geval van Respiratoir Syncytieel Virus (RSV; een type virus dat bij jonge kinderen veel voorkomt) besloten tot behandeling met antivirale therapie. Deze therapie is duur, heeft bijwerkingen en de effectiviteit is niet goed onderzocht. In eerdere studies naar respiratoire virussen na SCT, zagen wij geen verergering van de virale infecties in de eerste periode na de transplantatie. Hoofdstuk 6 geeft een overzicht van het beloop van onbehandelde RSV-infectie bij kinderen tijdens of kort na SCT. Wij concluderen dat er bij geen van de 8 patiënten directe progressie van de RSV-infectie is opgetreden, en dat de symptomen mild zijn. Dit ondersteunt een terughoudend beleid ten aanzien van antivirale behandeling van RSV in kinderen rondom SCT.

Hoofdstuk 7 gaat door op de hypothese geformuleerd in Hoofdstuk 3. In dit grotere co-hort SCT-patiënten zien we dat het aantonen van een luchtwegvirus in de longen een voorspeller is voor het ontwikkelen van allo-longbeeld, maar dat deze relatie niet geldt voor virussen die alleen in de neus/keelholte worden gedetecteerd. Van de 179 in het onderzoek opgenomen kinderen was 41% positief voor een virus in de BAL. In totaal ontwikkelden 24 kinderen een allo-longbeeld (13%), de kans hierop was 26% bij virus-positieve BAL, versus 6 % in de virus-negatieve groep. Ook hier zagen we een trend naar een beschermend effect van de behandeling van GvHD tegen de ontwikkeling van allo-longbeeld in de virus-positieve groep (Figuur 2).

Hoofdstuk 8 beschrijft een cohort van 53 kinderen met allo-longbeeld na SCT, 30 hadden IPS en 23 BOS. Zij werden behandeld met methyl-prednisolon pulse therapie. Slechts 43% herstelde van de longziekte en overleefde. We onderzochten voorspellers voor uit-komsten op de langere termijn. Kinderen met beademingsbehoefte op het moment van diagnose allo-longbeeld, en kinderen waarbij het allo-longbeeld ontstond tijdens of na systemische behandeling met steroïden voor GvHD in een ander orgaan, hadden een slechtere prognose. Als er een respiratoir virus werd aangetoond in de luchtwegen was de kans op overleving zonder chronische longziekte juist beter. Bij slechte respons op initiële therapie, wat vaak al binnen 2 weken duidelijk werd, was de overlevingskans slechts 4%. Bij de overlevers herstelde de longfunctie tot ongeveer 70% van normaal, en zij waren grotendeels zonder luchtwegklachten. Er is dus nog veel te verbeteren aan de behandeling van allo-longbeeld. Het is meestal al snel duidelijk welke patiënten inten-sievere therapie nodig hebben.

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Increased risk

Decreased risk


Time after HCT


FIGUUR 2. Grafische samenvatting van de bevindingen in Hoofdstuk 7.

In Hoofdstuk 9 worden de bevindingen uit de afzonderlijke delen van dit proefschrift in de context van recente literatuur geplaatst.

Wat zijn voorpellers voor het ontwikkelen van allo-longbeeld? De belangrijke rol van respiratoire virussen die in dit proefschrift wordt beschreven, is in ander studies nooit aangetoond. Voornamelijk omdat er nooit naar is gekeken, maar ook omdat in de officiële definitie van allo-longbeeld iedere infectieuze verwekker als een exclusiecriterium geldt. De vraag is of —in de tijd van steeds gevoeligere testmethodes— het aangetoonde respiratoire virus ook echt de ziekteverwekker is. Onze hypothese is dat de virussen niet direct de ernstige longziekte veroorzaken, maar slechts milde schade aan het longweefsel aanrichten. In een latere fase zijn het dan vooral de donor afweercel-len die daar de ernstige ontstekingsreactie veroorzaken. Hiervoor pleit het feit dat wij de virussen al aantonen zonder dat er symptomen zijn, dat de klachten pas ontstaan

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Increased risk

Decreased risk


Time after HCT


FIGUUR 2. Grafische samenvatting van de bevindingen in Hoofdstuk 7.

In Hoofdstuk 9 worden de bevindingen uit de afzonderlijke delen van dit proefschrift in de context van recente literatuur geplaatst.

Wat zijn voorpellers voor het ontwikkelen van allo-longbeeld? De belangrijke rol van respiratoire virussen die in dit proefschrift wordt beschreven, is in ander studies nooit aangetoond. Voornamelijk omdat er nooit naar is gekeken, maar ook omdat in de officiële definitie van allo-longbeeld iedere infectieuze verwekker als een exclusiecriterium geldt. De vraag is of —in de tijd van steeds gevoeligere testmethodes— het aangetoonde respiratoire virus ook echt de ziekteverwekker is. Onze hypothese is dat de virussen niet direct de ernstige longziekte veroorzaken, maar slechts milde schade aan het longweefsel aanrichten. In een latere fase zijn het dan vooral de donor afweercel-len die daar de ernstige ontstekingsreactie veroorzaken. Hiervoor pleit het feit dat wij de virussen al aantonen zonder dat er symptomen zijn, dat de klachten pas ontstaan

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weken na de transplantatie als de afweer al weer wat herstelt, en dat er bij alle patiënten tenminste enige respons is op immuun-suppressieve therapie. Een aantal studies naar voorspellers voor BOS of IPS tonen een relatie met GvHD. In ons cohort zien we juist een beschermend effect van (de behandeling van) GvHD.

Wat is de betekenis van respiratoire virussen tijdens SCT? Van ervaringen bij longtransplantatiepatiënten weten we dat respiratoire virussen kort na transplantatie de kans op afstoting van de long vergroten. Dit is vergelijkbaar met het ontstaan van allo-longbeeld na SCT. Opvallend is dat wij geen kinderen zagen met progressieve virale luchtweginfectie in de periode van de laagste weerstand, net na de SCT. Studies over dit onderwerp bieden tegenstrijdige resultaten. In sommige studies wordt onze bevinding van een in principe mild beloop van de virusinfectie bevestigd. In andere studies wordt juist een relatie beschreven met slechte prognose, waarbij vaak niet duidelijk is of dit dan directe progressie is, of verslechtering in een latere fase, en in dat geval dus mogelijk beter passend bij een vorm van immuun gemedieerde longziekte.

Welk aanvullend onderzoek draagt bij aan de diagnose allo-longbeeld? Voorafgaand aan de SCT is het belangrijk om virale diagnostiek in BAL te verrichten om daarmee het risico op allo-longbeeld vast te stellen en preventieve maatregelen te kun-nen nemen. Ten tijde van symptomen is de combinatie van longfunctie, HRCT-scan van de longen en infectie diagnostiek van groot belang. Bij de beoordeling van de respons op therapie is de longfunctie een belangrijk meetinstrument.

Wat bepaalt de prognose van allo-longbeeld? Bestudering van de literatuur over allo-longbeeld bij kinderen onderstreept de ernst van de aandoening, met een hoge mortaliteit van 50-80% voor IPS, en 20-50% voor BOS. In de meeste studies wordt behandeld met systemische steroïden, maar er is dus zeker plaats voor het verbeteren van deze behandeling. Op basis van de pathofysiologische fenomenen die een rol spelen bij allo-longbeeld, worden op dit moment meerdere thera-pieën bestudeerd bij patiënten (vooral volwassenen). Hierbij worden zowel de effectivi-teit als het bijwerkingen-profiel in ogenschouw genomen.

De langetermijn uitkomsten van allo-longbeeld zijn niet vaak bestudeerd. Wij zien bij onze overlevers een herstel van de longfunctie tot ongeveer 70% van normaal. Dat is veel beter dan de resultaten die doorgaans worden beschreven bij BOS bij volwassenen. Over de langetermijn ontwikkeling van de longfunctie na IPS is heel weinig bekend.

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weken na de transplantatie als de afweer al weer wat herstelt, en dat er bij alle patiënten tenminste enige respons is op immuun-suppressieve therapie. Een aantal studies naar voorspellers voor BOS of IPS tonen een relatie met GvHD. In ons cohort zien we juist een beschermend effect van (de behandeling van) GvHD.

Wat is de betekenis van respiratoire virussen tijdens SCT? Van ervaringen bij longtransplantatiepatiënten weten we dat respiratoire virussen kort na transplantatie de kans op afstoting van de long vergroten. Dit is vergelijkbaar met het ontstaan van allo-longbeeld na SCT. Opvallend is dat wij geen kinderen zagen met progressieve virale luchtweginfectie in de periode van de laagste weerstand, net na de SCT. Studies over dit onderwerp bieden tegenstrijdige resultaten. In sommige studies wordt onze bevinding van een in principe mild beloop van de virusinfectie bevestigd. In andere studies wordt juist een relatie beschreven met slechte prognose, waarbij vaak niet duidelijk is of dit dan directe progressie is, of verslechtering in een latere fase, en in dat geval dus mogelijk beter passend bij een vorm van immuun gemedieerde longziekte.

Welk aanvullend onderzoek draagt bij aan de diagnose allo-longbeeld? Voorafgaand aan de SCT is het belangrijk om virale diagnostiek in BAL te verrichten om daarmee het risico op allo-longbeeld vast te stellen en preventieve maatregelen te kun-nen nemen. Ten tijde van symptomen is de combinatie van longfunctie, HRCT-scan van de longen en infectie diagnostiek van groot belang. Bij de beoordeling van de respons op therapie is de longfunctie een belangrijk meetinstrument.

Wat bepaalt de prognose van allo-longbeeld? Bestudering van de literatuur over allo-longbeeld bij kinderen onderstreept de ernst van de aandoening, met een hoge mortaliteit van 50-80% voor IPS, en 20-50% voor BOS. In de meeste studies wordt behandeld met systemische steroïden, maar er is dus zeker plaats voor het verbeteren van deze behandeling. Op basis van de pathofysiologische fenomenen die een rol spelen bij allo-longbeeld, worden op dit moment meerdere thera-pieën bestudeerd bij patiënten (vooral volwassenen). Hierbij worden zowel de effectivi-teit als het bijwerkingen-profiel in ogenschouw genomen.

De langetermijn uitkomsten van allo-longbeeld zijn niet vaak bestudeerd. Wij zien bij onze overlevers een herstel van de longfunctie tot ongeveer 70% van normaal. Dat is veel beter dan de resultaten die doorgaans worden beschreven bij BOS bij volwassenen. Over de langetermijn ontwikkeling van de longfunctie na IPS is heel weinig bekend.

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Wat zijn de toekomstplannen voor onderzoek? Verdere opheldering van het pathofysiologische proces van het ontstaan van immuun gemedieerde longbeelden is belangrijk. Welke afweercellen spelen een rol, kunnen we biomarkers identificeren die helpen bij vroeg-detectie van de aandoening en hoe kun-nen we betere therapieën ontwikkelen? Onderzoeksgroepen van verschillende discipli-nes werken nauw samen om deze vragen te beantwoorden. Dit zal hopelijk leiden tot beter inzicht in het ziekteproces en daardoor betere kansen op gezonde overleving voor onze patiënten.

189


10

Wat zijn de toekomstplannen voor onderzoek? Verdere opheldering van het pathofysiologische proces van het ontstaan van immuun gemedieerde longbeelden is belangrijk. Welke afweercellen spelen een rol, kunnen we biomarkers identificeren die helpen bij vroeg-detectie van de aandoening en hoe kun-nen we betere therapieën ontwikkelen? Onderzoeksgroepen van verschillende discipli-nes werken nauw samen om deze vragen te beantwoorden. Dit zal hopelijk leiden tot beter inzicht in het ziekteproces en daardoor betere kansen op gezonde overleving voor onze patiënten.

Curriculum Vitae Curriculum Vitae

Birgitta Versluys was born in Amsterdam on August 24th 1967. After finishing secon-dary education at Goois Lyceum in Bussum, she started her study medicine at the Vrije Universiteit Amsterdam in 1985. In 1993 she obtained her medical degree, after which she worked as a resident in pediatrics in several hospitals in England, Wales and the Netherlands. From 1996-2001 she did her pediatric training at the Wilhelmina Child-ren’s Hospital in Utrecht, followed by a fellowship pediatric hematology-oncology at the VU University Medical Center in Amsterdam. Since 2003 she works as a consultant in pediatric hematology-oncology and hematopoietic cell transplantation at the Wilhel-mina Children’s Hospital | University Medical Center Utrecht. In 2018 she will continue working in this field at the Prinsess Máxima Center for Pediatric Oncology in Utrecht.

Birgitta Versluys was born in Amsterdam on August 24th 1967. After finishing secon-dary education at Goois Lyceum in Bussum, she started her study medicine at the Vrije Universiteit Amsterdam in 1985. In 1993 she obtained her medical degree, after which she worked as a resident in pediatrics in several hospitals in England, Wales and the Netherlands. From 1996-2001 she did her pediatric training at the Wilhelmina Child-ren’s Hospital in Utrecht, followed by a fellowship pediatric hematology-oncology at the VU University Medical Center in Amsterdam. Since 2003 she works as a consultant in pediatric hematology-oncology and hematopoietic cell transplantation at the Wilhel-mina Children’s Hospital | University Medical Center Utrecht. In 2018 she will continue working in this field at the Prinsess Máxima Center for Pediatric Oncology in Utrecht.

DankwoordDankwoord DankwoordDankwoord

Kors van der Ent. Dank voor je rust en overzicht tijdens dit proces. Ik voelde me gesteund.Jaap Jan Boelens. Dank voor je prikkelende en onuitputtelijke energie. Dat houdt mij scherp. Marc Bierings. Dank voor je vertrouwen, je analytisch vermogen en je humor. Dat stimu-leert me. Collega’s van het Wilhelmina Kinderziekenhuis. Dank voor de inspirerende werkomgeving met ruimte voor discussie, emotie en plezier. Menno van den Bergh. Dank voor het verfraaien van dit boekje.Mijn vrienden. Dank voor alle afleiding.Tjitske Vreugdenhil en Geza Kovacs. Fijn dat jullie ook nu weer naast me staan.Zier Versluys en Henriette Vriesendorp. Dank voor de stevige basis van (zelf )vertrouwen, nieuwsgierigheid en relativeringsvermogen.Jan de Visser. De liefde, daar gaat het tenslotte allemaal om.

Dank. Dus.

Birgitta

Kors van der Ent. Dank voor je rust en overzicht tijdens dit proces. Ik voelde me gesteund.Jaap Jan Boelens. Dank voor je prikkelende en onuitputtelijke energie. Dat houdt mij scherp. Marc Bierings. Dank voor je vertrouwen, je analytisch vermogen en je humor. Dat stimu-leert me. Collega’s van het Wilhelmina Kinderziekenhuis. Dank voor de inspirerende werkomgeving met ruimte voor discussie, emotie en plezier. Menno van den Bergh. Dank voor het verfraaien van dit boekje.Mijn vrienden. Dank voor alle afleiding.Tjitske Vreugdenhil en Geza Kovacs. Fijn dat jullie ook nu weer naast me staan.Zier Versluys en Henriette Vriesendorp. Dank voor de stevige basis van (zelf )vertrouwen, nieuwsgierigheid en relativeringsvermogen.Jan de Visser. De liefde, daar gaat het tenslotte allemaal om.

Dank. Dus.

Birgitta

Imm

une mediated lung disease after H

CT in children A

nne Birgitta Versluys

Anne Birgitta Versluys

Immune mediated lung disease after Hematopoietic Cell Transplantation in children

UITNODIGING voor het bijwonen van de openbare verdediging van

het proefschrift

Immune mediated lung disease after Hematopoietic Cell Transplantation

in children

op dinsdag 8 mei 2018 om 14:30 uur preciesin de Senaatzaal van

het AcademiegebouwDomplein 29 te Utrecht

Aansluitend receptie in Café Lebowski, Domplein 17 te Utrecht

Birgitta [email protected]

ParanimfenTjitske Vreugdenhil

Geza Kovacs

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