Treatment of a severe extensive cutaneous chronic GVHD after allo-HSCT using glycerolyzed skin allografts and cultured epidermis from the same donor

A 34-year-old woman was diagnosed with myelodysplastic syndrome–secondary AML in December 2007. A DNR plus cytarabine-based chemotherapy regimen lead to CR. Relapse occurred in February 2008 and a salvage treatment resulted in a second CR. Allogeneic BMT was performed from her HLA-identical sister in May 2008, after a myeloablative conditioning regimen (CY 120 mg/kg + 12 Gy TBI) and cyclosporin A plus MTX as GVHD prophylaxis. The patient remained in CR and full donor chimerism throughout the time. Grade 2 cutaneous acute GVHD occurred during the first 100 days and resolved after steroid treatment. In September 2008, extensive skin chronic GVHD developed. Despite four different treatment lines (rituximab, imatinib, extra-corporeal photopheresis and MTX), extensive cutaneous GVHD worsened and multiple ulcerations appeared, particularly in the back, groin and the flanks (15% of total body surface area) with multi-resistant Pseudomonas aeruginosa superinfection in September 2009 (Figure 1a). Because of infectious risk and intense chronic pain requiring daily morphinomimetics, a surgical tangential excision of the necrotic areas was performed followed by a biweekly program of wound cleansing using local colimycine applications under general anesthesia. Instead of performing a classical skin autograft, at high-risk of GVHD reactivation, allogeneic skin transplantation from the same BM donor represented an attractive option, as the donor's immune system was responsible for the pathogenesis of chronic GVHD.

Figure 1

(a) Representative picture of necrotic lesions at day 510 after allogeneic HSCT. (b) Skin status after skin mesh allograft. (c) Skin status after allograft of cultured skin cells. (d) Skin status at day 269 after skin allograft.

The first stage of skin reconstruction was to transplant 1.5 meshed allogeneic glycerolyzed skin to ensure a proper dermal bed for the following transplantation of cultured keratinocytes (Figure 1b).

After obtaining informed consent from the sister, a 5 cm2 full-thickness skin biopsy was harvested. Keratinocytes were isolated and then cultured, as previously described,1 for 3 weeks. Passage 2 and 3 keratinocytes were grafted after dispase treatment and clipping on Vaseline gauzes as support for transfer onto the patient's back2 (Figure 1c). Biweekly dressings under general anesthesia were performed, alternating antiseptic dressings and graft of cultured epidermis.

This procedure allowed the healing of 90% of the wounds within 3 weeks and the pain disappeared. Hospital discharge was possible by mid-December 2009. Chimerism analysis obtained from two successive skin punch biopsies from two different sites at day 50 after skin allograft demonstrated the presence of both donor and recipient's DNA, confirming efficient donor skin engraftment. The mixed chimerism observed was probably related to the presence of recipient dermal cells in the biopsies (Figure 2).

Figure 2

(a) Short tandem repeats (STR) informative peaks from the recipient (blood). (b) STR informative peaks from the donor (blood). (c) STR informative peaks observed in first skin biopsy performed at day 50 after skin allograft showing 69% of mixed chimerism. (d) STR informative peaks observed in second skin biopsy performed at day 50 after skin allograft showing 47% of mixed chimerism. Chimerism was determined by STR based on fluorescent analysis of repetitive sequences. Peak areas gave us the percentage of recipient cells for each sample. Mixed chimerism was defined by the presence of at least 5% of recipient cells.

Allogeneic BMT offers the best hope of long-term survival in AML patients.3 Extensive cutaneous chronic GVHD might result in life-threatening consequences with chronic pain, deep–large infected wounds and denutrition. Skin allografts from cadaveric donors may provide a temporary coverage, allowing autologous definitive engraftment, a strategy commonly used for burns, but it contains living cells and would represent, in our case, a third-party genotype, complicating the immune problem. We initially used glycerolyzed-killed allografts4 for a rapid and painless clinical improvement and for providing a new dermal layer necessary for the adequate engraftment of the cultured epidermis. Usually, allogeneic keratinocyte cultures lead to transient wound coverage and are rejected later,5 but in this case, a stable mixed chimerism was observed. This surgical approach circumvented the bacterial infection and dramatically improved patient's chronic pain and quality of life, characterized by wound healing and reduction of ulcerations (Figure 1d).

To our knowledge, this is the first described case of successful allogeneic skin transplantation from the same donor in a BM allo-transplanted patient suffering from severe, refractory extensive skin chronic GVHD, obtained from donor's skin after in vitro expansion. Further similar cases are necessary to evaluate the feasibility and tolerability of this multidisciplinary approach of severe extensive cutaneous chronic GVHD.


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Correspondence to M Michallet.

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Crocchiolo, R., Nicolini, F., Sobh, M. et al. Treatment of a severe extensive cutaneous chronic GVHD after allo-HSCT using glycerolyzed skin allografts and cultured epidermis from the same donor. Bone Marrow Transplant 46, 1153–1155 (2011).

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