1. Hematopoietic Progenitor
Cell Transplantation:
Chronic Graft-Versus-Host
Disease
Kimberly Thormann Powers, MA RN CPNP
APHON/PBMTC’s Foundations of Pediatric Hematopoietic
Progenitor Cell Transplantation: A Core Curriculum, 2nd
Edition
© 2012 APHON © 2012 APHON 1

2. Objectives
• Define chronic graft versus host
disease (cGVHD).
• Identify risk factors for cGVHD.
• Discuss cGVHD diagnosis and evaluation.
• List the factors associated with poor prognosis in
cGVHD.
• Describe cGVHD management and treatment.
© 2012 APHON 2

3. cGVHD: Process
• Donor T lymphocytes (graft) attack the
immunologically incompetent recipient (host)
 Damage of host tissues
• Often resembles an autoimmune collagen
vascular disease
• Poorly understood
© 2012 APHON 3

4. cGVHD: Types
• Progressive cGVHD
 Extension of acute GVHD (aGVHD)
• De novo cGVHD
 Without preceding GVHD
• Quiescent cGVHD
 After resolution of aGVHD
© 2012 APHON 4

5. cGVHD: Target Organs
• Skin
• Oral
• Ocular
• Hepatic
• Pulmonary
• Gastrointestinal (GI)
• Gynecological
• Musculoskeletal
• Immunologic
© 2012 APHON 5

6. Spectrum of manifestations in cGVHD
© 2012 APHON 6

7. cGVHD Complications
© 2012 APHON 7

8. cGVHD: Risk Factors
• Hematopoietic progenitor cell • Recipient related
transplantation (HPCT) related  Older age
 aGVHD  Viral infection
 Number of post-HPCT
 Human leukocyte antigen (HLA)
transfusions
disparity
 Splenectomy
 Older donor age
 Prolonged steroid
 Peripheral blood stem cells treatment
(PBSCs) as hematopoietic
progenitor cell source
 Short-course cyclosporine
 Donor lymphocyte infusion
 Female-to-male bone marrow
transplantation (BMT)
 Unrelated HPCT
© 2012 APHON 8

9. cGVHD: Poor Prognostic Signs
• Persistent severe
thrombocytopenia
• Lichenoid changes on
skin histology
• Serum bilirubin >1.2 mg/dl
• Progressive onset from
acute to chronic
• Karnofsky performance <70%
© 2012 APHON 9

10. Who Is at Higher Risk of Developing
cGVHD?
• Case study
 1. A 12-year-old boy with AML s/p matched
unrelated donor (45-year-old woman) bone
marrow with nonmyeloablative HPCT who
has a viral infection after being treated for
aGVHD.
 2. A 4-year-old boy with MDS s/p matched
unrelated donor (30-year-old woman)
peripheral blood HPCT with myeloablative
conditioning who has never had aGVHD.
© 2012 APHON 10

11. cGVHD: Incidence
• 40% in patients receiving
HLA-identical sibling HPCT
• >50% in HLA-mismatched
related sibling HPCT
• 40% to 60% unrelated
HPCT, 70% in patients >50
years
• Greater incidence of cGVHD
with PBSCs
© 2012 APHON 11

12. Skin cGVHD
• Most commonly involved organ
• Inflammatory changes cause
 Sclerodermatous presentation
o Fibrotic thickening
o Leads to contractures and nerve compression
 Lichenoid changes
o Erythematous raised papular skin rash
o May present with only dryness,
hypo- or hyperpigmentation
© 2012 APHON 12

13. Skin cGVHD: Clinical Manifestations
• Itching • Pain
• Burning • Flakiness
• Ulcerations • Shiny appearance
• Erythema • Vertical ridging and
• Hyperpigmentation splitting of the nail beds
• • Alopecia
Hypopigmentation
• • Graying hair
Atrophy
• Loss of sweating
© 2012 APHON 13

14. cGVHD: Sclerodermatous Skin
Involvement
© 2012 APHON 14

15. © 2012 APHON 15

16. cGVHD: Lichenoid Skin Changes
© 2012 APHON 16

17. © 2012 APHON 17

18. Skin cGVHD: Diagnostic Biopsy
Healthy Skin cGVHD Skin
Biopsy Biopsy
© 2012 APHON 18

19. Skin cGVHD: Nursing Assessment
• Assess for
 Altered integrity
 Altered body image
 Nail integrity
 Monitor for infection
© 2012 APHON 19

20. Skin cGVHD: Nursing Management
• Promote skin care
• Administer hydrating lotions, pain medications,
antibiotics, and topical medications
• Give immunosuppressant therapy and obtain
drug levels as indicated
• Use clear nail polish to strengthen nails and
prevent breakage
• Encourage frequent nail care
• Consult dermatology
• Educate on sun damage and use of sunscreen
• Promote range of motion (ROM) exercises
• Support the altered body image and give
multidisciplinary team support
© 2012 APHON 20

21. Oral Mucosa cGVHD
• Changes range from erythema to lichenoid
eruption to ulceration
• Xerostomia
• Associated infection is frequent
• Commonly misdiagnosed as oral candidiasis
© 2012 APHON 21

22. Oral Mucosa cGVHD
Oral cavity 1 Oral cavity 2
Oral cavity 3 Oral cavity 4
© 2012 APHON 22

23. Oral Mucosa: Nursing
Assessment
• Assess for
 Intake
 Altered taste
 Anorexia
 Increased sensitivity to
acidic or spicy foods
 Oral pain
 Oral infections
 Ability to open the mouth
© 2012 APHON 23

24. Oral Mucosa cGVHD: Nursing
Management
• Provide steroid rinses as
indicated
• Instruct patient and family on
dental hygiene
• Assist with mouth care
• Educate regarding dietary
recommendations
• Consult dental and nutrition
© 2012 APHON 24

25. Ocular cGVHD: Clinical Manifestations
• Incidence of ocular cGVHD in
those with cGVHD: 65% to 80%
• Presentation
 Initially, may have
excessive tearing
 Burning or gritty sensation
 Sicca syndrome
 Photophobia
 Corneal abrasions
 Pseudomembrane formation
may lead to blindness
© 2012 APHON
 Keratitis and scarring may occur 25

26. Ocular cGVHD
Lymphoplasmacytic infiltrates around ductal
structures of lacrimal glands
© 2012 APHON 26

27. Schirmer’s Test
© 2012 APHON 27

28. Ocular cGVHD: Nursing Assessment
• Assess
 Ability for eyes to tear
 Need for preservative-free
artificial tears
 Vision changes
 Pain or gritty sensation
© 2012 APHON 28

29. Ocular cGVHD: Nursing Management
• Assist and instruct family with
ophthalmic medication
• Give immunosuppressants
 Obtain indicated levels
• Prepare patient and family for
Schirmer’s test
• Educate the patient and family
• Discuss therapeutic treatment
 : drops/ lubrications
 Punctal plugs
 Sutures
 Protective lenses
© 2012 APHON 29

30. Hepatic cGVHD
• May have few
relatively mild
symptoms
until cGVHD
hepatic
disease
becomes
severe
 Jaundice
 Mild hepatomegaly
 Abnormal coagulation
 Elevated alkaline phosphatase
© 2012 APHON 30

31. Liver: Diagnostic Biopsy
Healthy Hepatic cGVHD Hepatic
Biopsy Biopsy
© 2012 APHON 31

32. Hepatic cGVHD: Nursing
Assessment
• Assess
 Jaundice
 Hepatic size
 Right upper quadrant pain
 Skin irritation associated with hyperbilirubinemia
© 2012 APHON 32

33. Hepatic cGVHD: Nursing Management
• Administer
immunosuppressants.
• Avoid hepatotoxic agents.
• Send necessary laboratory
tests.
• Prepare for diagnostic
testing.
• Provide skin care.
© 2012 APHON 33

34. Pulmonary cGVHD: Clinical
Manifestations
• 5% to 10% incidence
• Range of clinical manifestations and
presentations of pulmonary cGVHD
 Sinusitis
 Bronchiolitis Obliterans (BO)
syndrome
 Bronchiolitis Obliterans organizing
pneumonia (BOOP)
 Restrictive pulmonary disease
© 2012 APHON 34

35. cGVHD: Sinopulmonary
Complications
• Sinusitis
 Sicca syndrome
• Bronchiolitis Obliterans (BO)
 Fibrotic process
 Dyspnea, cough, and/or exercise intolerance
 Computed tomograpy (CT) scan:
patchy hyperaeration, bronchial dilation, increased
density
• Bronchiolitis Obliterans organizing pneumonia (BOOP)
 Shortness of breath (SOB), cough, and fever
 CT scan: peripheral patchy airspace consolidation,
nodular opacities
© 2012 APHON 35

36. Pulmonary Function Test
(PFT)
• Ideally obtained at Day 100 and at 3-month intervals with
any new significant air-flow obstruction
• Significant airflow obstruction
 Defined as a decrease in forced expiratory
volume in 1 second (FEV1) by > 10%
compared to pretransplant values and the
FEV1 is < 80%, with an FEV1/forced vital capacity ratio < 0.7
without response to bronchodilators
• Obtain full PFT when the FEV1 is < 80% of the predicted
normal value
• Significant air trapping: a residual volume > 120% or air
trapping noted on high-resolution CT scan
• Pulmonary consultation for significant obstructive
pulmonary changes
© 2012 APHON 36

37. Pulmonary cGVHD: Nursing
Assessment
• Assess
 Breath sounds
 Color
 Dyspnea
 Cough
 Oxygen saturation
 Activity intolerance and fatigue
 Inability to complete activities
of daily living (ADL)
 Infection
© 2012 APHON 37

38. Pulmonary cGVHD: Nursing
Management
• Encourage breathing exercises
• Perform pulmonary toilet
as necessary
• Prepare for follow-up scans and PFTs
• Administer immunosuppressants and
draw appropriate levels
© 2012 APHON 38

39. Case Study
• 13-year-old girl who underwent matched
related sibling donor peripheral blood
HPCT for AML. She has falling
chimerism, and the immune suppression
was manipulated. She developed cGVHD
of the skin. During the next few months
she noticed some SOB with activity and
was treated with steroids. Symptoms
resolved, and 3 months after all immune
suppression stopped, she again had an
increase in her SOB and new lichenoid
skin findings.
© 2012 APHON 39

40. Pre-HPCT PFT
FEV1 %
predicted
93%
PFT evaluation
for SOB
FEV1 %
predicted ↓
to 34%
© 2012 APHON 40

41. Case Study: Radiographic Findings
CXR: Opacities
seen in both lung
bases and bilateral
pleural effusions
greater on the left
than the right
High-resolution chest CT
© 2012 APHON 41

42. Gut cGVHD: Clinical Manifestations
• Diarrhea
• Anorexia
• Nausea and vomiting
• Abdominal pain and cramping
• Wasting syndrome
 Malabsorption
 Weight loss
 Poor performance status
 Progressive GI symptoms
(early satiety, dysphagia)
• Infection
© 2012 APHON 42

43. Gut: Diagnostic Biopsy
Normal Gut cGVHD Gut
Biopsy Biopsy
© 2012 APHON 43

44. Gut cGVHD: Nursing Assessment
• Assess
 Nausea and vomiting
 Diarrhea
 Pain
 Dysphagia
 Weight loss
 Bleeding
 Fluid status
 Caloric intake
© 2012 APHON 44

45. Gut cGVHD: Nursing
Management
• Test stools for blood
• Measure stool output
• Administer fluids
• Provide nutritional support
 Enteral
 Parenteral
• Administer medications
 Immunosuppressants
 Supportive care agents
• Prepare for diagnostic procedures
• Consult nutrition
• Educate regarding diet, immunosuppression, and
associated infection
© 2012 APHON 45

46. Gynecological cGVHD:
Clinical Manifestations
• Vaginal epithelial damage occurs due to cGVHD
 Inflammation
 Stricture formation
 Narrowing
• Vaginal sicca
• Vaginal atrophy
 Leads to painful sexual intercourse
• Symptoms may include
 Inflammation
 Dry vagina
 Obstruction of menstrual flow
because of strictures
© 2012 APHON 46

47. Gynecology: Nursing Assessment
and Management
• Assess (within the • Management
context of normal  Consult gynecologist
growth and  Encourage use of
development) lubricants
 Sexual dysfunction  Encourage discussion of
 Pain sexual issues
 Altered body image  Encourage
 Infection interdisciplinary team
management/specialty
referral
 Administer medications
© 2012 APHON 47

48. Musculoskeletal cGVHD:
Clinical Manifestations
• The severe damage done by sclerodermatous
skin cGVHD can cause significant
musculoskeletal involvement
 Stiffness
 Contractures
 Joint pain
 Limited ROM
 Muscle cramps
 Carpal spasm
 Swelling
 Arthralgias
© 2012 APHON 48

49. cGVHD: Contractures
© 2012 APHON 49

50. Physical Therapy Evaluation
Therapist objective findings:
2-minute walk test: 7 laps (patient not out of breath
after test, limited by shoes, wearing sandals with heel)
(1 lap = 50 feet)
Grip Strength
Trial Left Right
1 18 kg/40 lb 19 kg/42 lb
2 21 kg/45 lb 20 kg/45 lb
3 20 kg/43 lb 22 kg/52 lb
Dominant hand: right
Dynamometer position: 2
© 2012 APHON 50

51. Physical Therapy Clinician Evaluation
ROM is measured for all the joints by physical therapy, but the MD
/APN can do a basic evaluation: 1- poor mobility to 7= full mobility
Shoulder
2 3 6
Elbow
2 4 7
Wrist and Fingers Foot Dorsiflexion
1 4 6 2 3
© 2012 APHON 51

52. cGVHD: Fasciitis and Myositis
• Fasciitis
 Diagnostic sign of cGVHD
 Skin swelling: skin taut, bound down,
and irregularly thickened, with small
depressed areas (orange peel)
 Contractures, joint stiffness
 Pathology: lymphocytic infiltrates,
increase of collagen fibers
• Myositis
 Distinctive sign of cGVHD
 Moderate to severe proximal muscle
weakness, myalgia, fever,
contracture, and skin induration
 Elevated creatinine phosphokinase
and aldolase enzyme
 Pathology: degeneration, necrosis,
and regeneration of muscle fibers
© 2012 APHON 52

53. Musculoskeletal: Nursing
Assessment and Management
• Assess • Management
 Performance score  Prepare for diagnostic
 Ability to perform ADL tests
 Pain  Consult rehabilitation
 ROM services
 Monitor for signs and  Consult orthopedics
symptoms of
 Administer
physiologic
dysfunction medications
 Monitor for bone  Collaborate with
damage interdisciplinary team
 Nutritional status
© 2012 APHON 53

54. Physical Therapy: Evaluation Report
Summary: patient reports functionally ↑ endurance. Low
2-minute walk test d/t patient’s choice of footwear and
self-selected pace. Educated patient on gastroc stretch
and reviewed importance of hydration to prevent cramping.
GOAL TIME FRAME MET COMMENTS
Will report no Goal to be met 1 No New goal
cramps with session from
activity 7/9/2010
Will increase Goal to be met 1 No New goal
2-minute walk session from
to 8 7/9/2010
Follow-up: continue to see patient at each clinic visit, every 2 weeks
© 2012 APHON 54

55. Immune System: Clinical
Manifestations
• cGVHD is immunosuppressive,
and cGVHD treatment is further
immunosuppressive, resulting in
 Functional asplenia
 Variable immunoglobulin G (IgG) levels
 Opportunistic infections
 Cytopenia (thrombocytopenia)
© 2012 APHON 55

56. cGVHD: Infection Risk
• Assess • Management
 Signs and symptoms  Administer medications
of infection  Prepare for diagnostic
 Relative risk of tests
infection  Obtain laboratory work
 Home environment  Educate patient and
 School reentry family
o Immunosuppressive
treatment
 Administer appropriate
vaccines
© 2012 APHON 56

57. cGVHD: NIH Consensus
Scoring Criteria
• cGVHD is defined by the presence of at least one distinctive
manifestation with support by histologic, radiologic, or laboratory
evidence or diagnostic clinical sign of cGVHD without the features of
aGVHD overlap syndrome where there are features of aGVHD and
cGVHD present
• There is no time limit after stem cell transplant for the diagnosis of any
clinical features
• The differential diagnosis must be ruled out for each system affected
• Clinical score of 0 to 3 for involved sites/organs
© 2012 APHON 57

58. NIH Consensus: Scoring
Criteria
• Clinically based
• Organs/sites assessed/scored
 Skin
 Mouth
 Eyes
 GI tract
 Liver
 Lungs
 Joints and fascia
 Genitourinary tract
© 2012 APHON 58

59. NIH cGVHD organ-specific staging
From Filipovich, A. H., et al. (2005). National Institutes of Health consensus development project
on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working
group report. Biology of Blood and Marrow Transplantation, 11(12), 945-956. Reprinted with
permission of Elsevier.
© 2012 APHON 59

60. Classification of GVHD
Site or Organ Diagnostic Distinctive Other
Skin Poikiloderma Depigmentation Keratosis pilaris
Lichen planus Hyperpigmentation
Sclerotic Hypopigmentation
Morphea like Sweat impairment
Lichen sclerosus Ichthyosis
GI Esophageal web Exocrine pancreatic
Esophageal stricture insufficiency
Esophageal stenosis
Lung BO on biopsy BO by PFT and radiology
Muscles, joints, fascia Fasciitis Myositis Edema
Stiff joints Polymyositis Muscle cramps
Contractures Arthralgias/arthritis
Mouth Lichen type Xerostomia
Hyperkeratosis plaques Mucocele
Mouth opens less Ulcers
Pseudomembranes
From Filipovich, A. H. et al. (2005). National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I.
© 2012 APHON Diagnosis and staging working group report. Biology of Blood and Marrow Transplantation , 11(12), 948. Reprinted with permission of Elsevier. 60

61. NIH Consensus: Scoring Criteria
• Scoring
 0: no manifestations or symptoms
 1: no significant impairment of function
 2: significant impairment of ADL and
www.asbmt.org no major disability
 3: significant impairment of ADL and
major disability
© 2012 APHON 61

62. cGVHD: NIH Global
Scoring
• Mild
 No significant impairment of function
 Only 1 or 2 organs (except lung)
 Maximum organ score of 1
• Moderate
 Significant impairment but no major disability
 3 or more organs with maximum score of 1
 One organ with maximum score of 2
 Lung score of 1
• Severe
 Major disability
 Score of 3 in any organ or site
 Lung score >2 62
© 2012 APHON

63. cGVHD: Primary
Treatment
• Systemic treatment
 Multiple organs sites affected >3
 Pulmonary involvement
 Onset of cGVHD while on steroid therapy
 Progressive onset
 Thrombocytopenia
• Initial treatment often employs corticosteroids
 Single agent
 Combination with calcineurin inhibitor
© 2012 APHON 63

64. cGVHD: Salvage Therapy
• Refractory cGVHD treatment
 Monoclonal antibodies
o Infliximab
o Etanercept
o Alemtuzumab
 Polyclonal antibodies
o Antithymocyte globulin
 Other agents and modalities
o Thalidomide
o Hydroxychloroquine
o Pentostatin
o Imatinib mesylate (GLEEVEC®)
o Ultraviolet (UV) radiation
 Extracorporeal photopheresis (ECP)
© 2012 APHON 64

65. Treatment Side Effects
Agent Class Side effect
Pentostatin Nucleoside analogue Nausea, vomiting,
infections, anemia
Etanercept TNF receptor Infections
Imatinib Tyrosine kinase inhibitor, Myelosuppression,
PDGF inhibitor weight gain, hepatitis
Montelukast Leukotriene inhibitor Nausea, headache
Infliximab Anti-TNF-a Hypersensitivity,
infections
ECP UV irradiation, 8-MOP Skin hypersensitivity,
nausea, bleeding
Sirolimus Macrocyclic lactone Myelosuppression,
hyperlipidemia, HUS,
TTP, renal impairment,
fluid accumulation
© 2012 APHON 65

66. Extracorporeal
photopheresis (ECP)
© 2012 APHON 66

67. What Is Extracorporeal
photopheresis?
The photoactivated white blood
cells are returned to the patient
Photoactivatio
n with UVA
light
Methoxsalen
White blood cells are
treated with methoxsalen
and exposed to UVA
Blood is light
The UVAR XTS Instrument separated by
draws blood from the patient centrifugation and
red blood cells are
returned
© 2012 APHON 67

68. Extracorporeal photopheresis:
Procedure
• Procedure
 150-300 ml of buffy coat (white cells)
is collected by apheresis
 Methoxypsoralen (photosensitizing
agent) is added to collection bag
 Cells are exposed to UV light
 Infused into the patient
 Well tolerated
o Hypo- or hypertension may occur
o Fluid shifts
• Research
 Ongoing to determine length,
regularity, and timing of ECP
© 2012 APHON 68

69. Before ECP After ECP
Before ECP After ECP
© 2012 APHON 69

70. cGVHD: Pediatric Poor
Prognostic Signs
• Recipient age
• aGVHD Grade II-IV
• Female donor to male recipient
• Diagnosis of malignancy
• TBI in conditioning
© 2012 APHON 70

71. cGVHD: The Team
Family/Caregivers
BMT Team
Physical Therapy
Nursing Staff Pharmacy
Medical
Consultants
Home Care Company
Child Life Psychology
Insurance
Nutrition
Referring
Team Social Work
© 2012 APHON 71

72. Quality of Life Issues Facing HPCT
Recipients
• Fatigue
• Depression
• Sleep disturbance
• Stress
• Nutrition: weight loss or gain
• Activity and exercise
• Friendships
• Growth and development
• School or work
© 2012 APHON 72

73. Fatigue
• Symptoms
 Tired, unable to do what peers
are doing
 General weakness
 Unable to concentrate
 Irritability
 Lasting months to years
• Management
 Create schedule with quiet time
 Encourage routine exercise
 Get 10 to 12 hours of sleep a night
 Consider stimulant medication
© 2012 APHON 73

74. Nutrition
• Symptoms
 cGVHD increases your calorie needs
 Encourage well-balanced meals
 Give healthy snacks throughout the day
 Increase the protein in the child’s diet
 Increase fluids to keep well hydrated
• Management
 Follow up with HPCT team
 Check dietary restrictions d/t medications
 May need supplements if diet is not
well balanced
 May need help creating a diet plan with the nutritionist
 Follow up with diabetic educator if diabetes from long-term
steroid use
© 2012 APHON 74

75. Depression
• Symptoms
 Sleeping more
 Lack of energy
 Body image altered
 Noncompliance
 Easily agitated
 Withdrawn
 Lack of interest in activities
• Management
 Planned activities
 Schedule breaks
 Talk to specialist
 Medications
© 2012 APHON 75

76. Transitions
• Transition to school
 Sharing information with school
 Preparing student for the transition
 Planning curriculum, educational support
 Establishing connections
• After school
 Vocational planning in high school
 Guidance counselor assistance for planning
postsecondary education
 Seek colleges and technical schools with learning
support programs
© 2012 APHON 76

77. Health Maintenance Guidelines
• Physical examination with labs
• Eye examination
• Dental examination
• Pulmonary evaluation
• Gynecological examination
(if of age)
• Physical therapy evaluation with ROM testing
• Endocrine evaluation
© 2012 APHON 77

78. cGVHD: Conclusion
• Major cause of morbidity and mortality
• Nurse’s role is vital
 Assessment
 Medications
 Treatments
 Education
 Provide comprehensive multidisciplinary
continuity of care
o Challenge
© 2012 APHON 78

79. Resources
• American Society for Blood and Marrow Transplantation
 www.asbmt.org
• BMT InfoNet
 www.bmtinfonet.org
• Candlelighters Childhood Cancer Foundation
 www.candlelighters.org
• Children and Adults with Attention-Deficit/ Hyperactivity Disorder
(CHADD)
 www.chadd.org
• Children’s Oncology Group
 www.childrensoncologygroup.org
• CureSearch
 www.curesearch.org
• Chronic GVHD Learning
 www.asbmt.org/policystat/policy.htm
• Lance Armstrong Foundation
 www.laf.org
© 2012 APHON 79

80. cGVHD: Resources
• Learning Disabilities Association of America
 www.ldanatl.org
• Leukemia & Lymphoma Society
 www.lls.org
• Leukemia Research Foundation
 www.leukemia-research.org
• National Cancer Institute
 www.cancer.gov/cancertopics/eatinghint
• National Marrow Donor Program
 www.nmdp.org
• National Sleep Foundation
 www.centers.sleepfoundation.org/insomnia/children
• Pediatric Oncology Resource Center
 www.acor.org/ped-onc/
© 2012 APHON 80

81. cGVHD: Resources
• Pediatric Blood and Marrow Transplant Consortium
 www.pbmtc.org
• Schwab Learning
 www.schwablearning.org
• Supplementary information and updates
 www.marrow.org
• Books
 Educating the Child with Cancer, A Guide for Parents and
Teachers, edited by Nancy Keene. 2003, Candlelighters
Foundation
 Childhood Cancer Survivors, A Practical Guide to Your Future,
Keene, Hobbie, Ruccione. 2000, O’Reilly and Associates
© 2012 APHON 81

82. Questions
1. What is the most frequently
involved organ for cGVHD?
A. Gut
B. Lungs
C. Skin
D. Eyes
E. Liver
© 2012 APHON 82

83. Questions
2. What treatments would you
think of using for cGVHD of
the skin?
A. ECP
B. Pentostatin
C. GLEEVEC®
D. Hydroxychloroquine
E. Thalidomide
© 2012 APHON 83

84. Questions
3. A child with some cGVHD of the
skin that is resolving and a lung
score of 1 would be rated per the
cGVHD global scoring as?
A. Mild
B. Moderate
C. Severe
© 2012 APHON 84

85. Questions
4. A child with a diagnostic clinical
sign of cGVHD with no signs of
aGVHD would be rated per the
cGVHD global scoring as?
A. Mild
B. Moderate
C. Severe
© 2012 APHON 85

86. Questions
5. What type of cGVHD comes
after a resolution of aGVHD?
A. De novo
B. Progressive
C. Quiescent
© 2012 APHON 86

87. References
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