Authors’ Reply

Abstract

The number of lung transplants (LTx) performed to treat bronchiolitis obliterans in patients with end-stage lung disease caused by chronic graft-versus-host disease (cGvHD) is small, limiting comparison of outcome between centers. Holm et al. (1) report 13 patients with LTx for bronchiolitis obliterans after allogeneic stem cell transplantation (SCT) with a much lower mortality rate (15%) compared with our patients (57%). However, Koenecke et al. published 12 patients in a multicenter study with a case fatality rate of 33% (2). When we focus on the patient characteristics, there is a remarkable difference in the extensiveness of cGvHD. Nearly half of the patients reported by Holm et al. (1) did not have any other organ involvement with cGvHD. This is an interestingly high incidence rate of solitary cGvHD of the lung. All of our patients presented with at least two other organs involved with cGvHD (3). Therefore, the intensity and number of immunosuppressants in our patient series are much higher (median of four treatment lines). One could speculate that this results in a higher rate of infectious complications and secondary malignancies, which limits the prognosis after LTx. Another unresolved question is the ideal time point of LTx after allogeneic SCT. Our patients were considered for LTx if, despite multiple lines of immunosuppressants for at least 6 months, patients were immobilized and oxygen dependent with severe respiratory distress. Depending on the onset and progression of cGvHD, patients received the first available matching lung. The guidelines of the International Society of Heart and Lung Transplantation that recommend an interval of 5 years between LTx and previous malignancy are not applicable for SCT after hematologic malignancies. The time and the interval of listing is dependent on the clinical presentation of the patient and the worsening of lung function tests. In summary, the differing survival rates clearly derive from a center-dependent patient selection for LTx. The outcome of LTx patients after allogeneic SCT is at least similar to patients whose underlying disease is other than cGvHD. Due to the limitation of systemic immunosuppressants for disease stabilization, LTx is still a good treatment option that should be offered to selected patients with cGvHD of the lung. Ursula M. Vogl 1 Kazuhiro Nagayama2,3 Werner Rabitsch1 1 Department of Internal Medicine I Bone Marrow Transplantation Medical University Vienna Vienna, Austria 2 Department of Thoracic Surgery Vienna, Austria 3 Department of Thoracic Surgery The University of Tokyo Graduate School of Medicine Tokyo, Japan