1Department of Medicine I, Bone Marrow Transplantation Unit, University Hospital of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
2Department of Dermatology, University Hospital of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria
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With reference to the paper by Child et al1 entitled 'Extracorporeal photopheresis (ECP) in the treatment of chronic graft-versus-host disease (GVHD)', published in your journal we would like to comment on the critical issue of evaluation of chronic graft-versus-host disease, which in our opinion, appears inappropriate in the above cited paper.
Currently accepted standards of evaluating the clinical manifestations of GVHD are based on those described initially by Shulman et al2 and Sullivan et al.3 Child et al have used a new, unvalidated skin scoring system which we find highly questionable. In the 'Methods' section the authors describe dermatological features of acute (erythema) and chronic cutaneous lichenoid GVHD and introduce gradings which are not listed in the 'Results' section. Moreover, we find it debatable whether erythematous and lichenoid eruptions should be combined with sclerodermatous lesions assessed by a modified Rodnan score, which is otherwise used in the evaluation of patients with progressive systemic sclerosis, to form one skin score. Even mucosal involvement is listed as part of that skin scoring system. We find it difficult to understand a skin score that appears to lump all variants of cutaneous and mucosal GVHD into one score with unvalidated criteria. Therefore, the results described by Child et al cannot be compared with the ones recently published by our group in Blood.4 There, 12 out of 15 patients with steroid-resistant, extensive chronic GVHD achieved a complete response to ECP and another three a partial response of the cutaneous manifestations. In addition, all patients with oral involvement showed a complete response.
With regards to the authors' observations on the effect of ECP on liver GVHD we would like to make the following comments: In Table 3 ALT and  GT are listed for documentation of liver involvement even though these two parameters are not routinely used to assess GVHD of the liver. When alkaline phosphatase and serum bilirubin levels are used to evaluate liver GVHD, as is commonly practiced, only two patients (patients 1 and 4) and not 5 as described in the manuscript had liver involvement due to GVHD at onset of ECP therapy. As briefly mentioned in the 'Discussion' other pathogenetic mechanisms (eg toxic, metabolic) could have been involved in their patient popu- lation. Clearly, this small number of patients does not justify a comparison with our larger group of patients with liver involvement, where 70% had a documented complete response to ECP.
In summary, we would like to state that the results as presented and discussed by Child et al are not comparable to those in our recent publication. Clearly, common standard criteria of disease assessment have to be applied for the evaluation of therapeutic efficacy of both standard immunosuppression, ECP and other new modalities.
At present, a randomized multi-center trial is ongoing. We assume that the criteria used therein will allow comparison of results obtained by multiple centers. Since our results with ECP achieved in patients with extensive steroid-resistant chronic GVHD are very promising we hope that well-designed studies will support our findings in the use of this immunomodulatory therapy in a larger cohort of patients under comparable conditions. This seems to be especially important, since at present no new efficient alternative immunosuppressive therapies with such a low side-effect profile are available for patients with chronic GVHD.
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