Obstructive lung disease in children after allogeneic bone marrow transplantation docx

1994 84: 3212-3220




Rogers and KW Chan
KR Schultz, GJ Green, D Wensley, MA Sargent, JF Magee, JJ Spinelli, S Pritchard, JH Davis, PC

transplantation
Obstructive lung disease in children after allogeneic bone marrow
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Obstructive Lung Disease in Children After Allogeneic
Bone Marrow Transplantation
By
Kirk
R.
Schultz, Gordon J. Green, David Wensley, Michael
A.
Sargent, J.F. Magee, John

J.
Spinelli,
Sheila Pritchard, Jeffrey
H.
Davis, Paul C.J. Rogers, Ka Wah Chan, and Gordon
L.
Phillips
Obstructive lung disease (OLD) has been described as a sig-
nificant complication after allogeneic bone marrow trans-
plantation (BMT). The incidence of OLD
in
adults appears to
be low
(-3%).
but
there is lile data for children. We ana-
lyzed
89
consecutive pediatric allogeneic BMTs,
21.5
years
post-BMT, performed at British Columbia‘s Children’s Hospi-
tal from
1980
to
1992
for evidence of OLD. Diagnosis of OLD
was based on clinical findings (nonproductive cough. wheez-
ing, and dyspnea
with

no evidence of infection), pulmonary
function tests (RV,
<
80%
and FEF2S.7S.h
c
60%
predicted),
lung biopsy, and computed tomography scan. Sixty-seven
of the
89
children evaluated survived
290
days and were
classified as
at
risk for OLD. Thirteen of
67 (19.4%),
devel-
oped OLD,
3
of which were transient. The development of
OLD was strongly associated
with
the following high-risk
ONE
MARROW transplantation (BMT) has become an
established life-saving therapy for many children with
lethal diseases. These disorders include malignancies, BM
dysfunction, inherited metabolic diseases, and immune dis-

eases. Complications of BMT include opportunistic infec-
tions secondary to immune incompetence, toxicity caused
by the cytotoxic agents used to ablate the recipient’s marrow
before infusion of the donor marrow, and graft-versus-host
disease
(GVHD).
With improved supportive care, toxicity
and infections have become less important as significant side
effects.
Clinically significant obstructive lung disease
(OLD)
is
one additional complication after BMT. Only rare cases have
been examined histologically, and show a pattern character-
istic of bronchiolitis obliterans.’ The incidence of
OLD
in
adults appears to be relatively low at
-3%?3
Although there
are few data regarding
this
complication in children, the
reported mortality in adults who develop
OLD
secondary to
bronchiolitis obliterans after BMT is
65%:
Patients develop
an obstructive pattern on pulmonary function testing as a late

complication (>90 days post-BMT), which usually appears
B
From the Department of Pediatrics, the Divisions of Hematology/
Oncology/Bone Marrow Transplantation and Intensive Carefiespi-
rology, the Department of Radiology, and the Department of Pathol-
ogy, University
of
British Columbia and British Columbia’s Chil-
dren’s Hospital, and the Department of Medicine, University of
British Columbia, Vancouver General Hospital Bone Marrow Trans-
plantation Program, Vancouver, BC, Canada.
Submitted December
8,
1993; accepted June 29, 1994.
Address reprint requests to Kirk R. Schultz, MD, Department
of
Pediatrics, Division
of
Hematology/Oncology/Bone
Marrow Trans-
plantation, University
of
British Columbia, British Columbia’s Chil-
dren’s Hospital,
4480
Oak St, Vancouver, BC V6H 3V4 Canada.
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be hereby marked
“advehsement”
in accordance with

18
U.S.C. section 1734 solely to
indicate this fact.
0
1994 by The American Society of Hematology.
OOO6-4971/94/8409-0010$3.00/0
3212
groups: chronic graft-versus-host disease (GVHD)
(37.1%
OLD), increased donor age, acute GVHD, and either mis-
matched related or matched unrelated donor transplants.
No
correlation was found
with
methotrexate prophylaxis for
GVHD, total body irradiation, or cytomegalovirus reactivity
in
either donor or recipient and the development of OLD.
Further analysis
of
only children
with
chronic GVHD showed
that liver involvement by GVHD before the onset of OLD
(57.9%)
was the only other significant predictive factor. We
observed an overall increased prevalence of OLD
in
children
compared

with
that previously reported
in
adults. Further
studies are required
to
confirm whether age is a risk factor
for development
of
OLD after allogeneic BMT.
0
1994
by
The
American Society
of
Hematology.
within
1.5
years post-BMT.’ Chest roentgenograms are usu-
ally normal, or may show slightly hyperinflated lung fields.
Associations with
OLD
after BMT in adults include hypo-
gammaglobulinemia and decreased salivary IgA? metho-
trexate prophylaxis for
GVHD2
that may increase class
I1
major histocompatibility complex expression in the lungs:

and concurrent viral infections? Others have suggested
that esophageal disease with repeated aspiration may con-
tribute to small airway di~ease.4.~ The strongest association
is that of
OLD
with chronic
GVHD.
This leads to the hy-
pothesis that
OLD
secondary to clinical evidence of bron-
chiolitis obliterans represents pulmonary involvement from
GVHD?8.9
Because little has been previously published describing
the complication of
OLD
in children after allogeneic BMT,
we evaluated the occurrence
of
OLD
in the children receiv-
ing allogeneic BMTs at British Columbia’s Children’s
Hos-
pital from
1980
to 1992.
MATERIALS
AND
METHODS
Patient population.

A
retrospective analysis was performed
us-
ing the British Columbia’s Children’s Hospital BMT program data
base.
All
children receiving allogeneic
BMT
from 1980 to 1992
aged
0
to 17 were evaluated for the development
of
OLD. Patients
were excluded if there was an acute complication resulting in
SW-
viva1 less than
90
days or had not had sufficient time to develop
OLD with a transplant less than
1.5 years before analysis. These
exclusion criteria were based on previous findings in adult patients
which demonstrated that OLD is a late complication after
BMT
associated with chronic GVHD and usually develops within the first
1.5
years post-BMT?
Conditioning regimens, transplantation, and supportive care.
Conditioning regimens were selected based
on

the disease and donor
type (Table
1).
Two children with immunodeficiency syndromes
received no conditioning before transplantation. Patients were placed
in positive pressure rooms with strict aseptic procedures from days
-1
and until an absolute neutrophil count of
z
0.5
X
lo9
ceUs/L
for
2 consecutive days was reached. Broad-spectrum antibiotics were
initiated when patients developed fever and after 1986 all patients
received acyclovir
(1,500
mg/m*/day divided into three doses) if
either
the
donor or recipient were cytomegalovirus (CMV) seroposi-
Blood,
Vol
84,
No
9
(November
l),
1994:

pp
3212-3220
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LUNG
DISEASE
IN
CHILDREN
AFTER BMT
Table
1.
Comparison
of
the
Characteristics
of
Children
Unaffected and Affected
by
OLD
Cateaorv
Unaffected
OLD
($6)
1%)
No. of patients
Age (mean years
2
SD)
Sex
ratio M:F

Diagnosis
ALL
AM
L
AAFA
Other malignancies
Solid Tumors (NB, Rhabdo)
NHL
JCMUMDSICMUPCV
Nonmalignancies
Immunodeficiency (WAS, SCID)
Genetic
(MLD,
Thalassemia, Gaucher)
Cell dose (mean
2
SD)*
Preparative regimen
TB1
(dose
Gy)
12.6
+
Cy
2
Vcr
12.6
+
Ara-C
10

f
CP/MNM/D
10
+
VP/CP/M
6
+
VPIM
4
+
cy
7.5
(TLI)
+
Bu/Cy
CY
Bu/Cy
None
10
+
CyNP
54 (80.6)
7.3
2
4.9
1.41
13 (24.1)
11 (20.4)
12 (22.2)
9 (16.7)

4 (7.4)
2 (3.7)
3 (5.6)
12 (22.2)
4 (7.4)
a
(
14.8)
54
4.3
2
4.1
16
1
8
2
1
1
2
1
8
12
2
13 (19.4)
7.4
2
4.7
1.6:l
5 (38.9)
2 (15.4)

2 (15.4)
2 (15.4)
1
(7.7)
0
1 (7.7)
2 (15.4)
1 (7.7)
1 (7.7)
13
4.0
2
0.7
4
0
3
1
0
0
1
0
1
3
0
All
factors were not significant
by
the
x'
test for comparison of

sex ratio and diagnosis and the t-test for independent samples for
evaluation
of
age and cell dose.
Abbreviations: ALL, acute lymphoblastic leukemia;
AML,
acute
my-
eloblastic leukemia;
AA,
aplastic anemia;
FA,
Fanconi's anemia;
NB,
neuroblastoma; Rhabdo, rhabdomyosarcoma; NHL, non-Hodgkin's
lymphoma; JCML, juvenile chronic myelogenous leukemia; MDS,
my-
elodysplastic syndrome;
CML,
chronic myelogenous leukemia;
PCV,
polycythemia vera; WAS, Wiskott-Aldrich syndrome; SCID, severe
combined immunodeficiency; MLD, metachromatic leukodystrophy;
Cy, cyclophosphamide; Vcr, vincristine;
VP,
VP-16;
M, melphalan;
VM,
VM-26;
D, doxorubicin;

Bu,
busulfan;
TLI,
total lymphoid irradiation;
CP, cisplatin.
* Cell dose
is
expressed
in
mean number
of
cells
x
lO*/kg of the
recipient
f
SD.
tive. Prophylactic nystatin mouthwash was given as antifungal pro-
phylaxis. Intravenous (IV) Ig
0.5
g/kg was administered weekly
after transplantation and monthly after discharge until day
180
if no
GVHD was present. Patients with GVHD were treated weekly until
day 100 and then monthly until off immunosuppression. GVHD
prophylaxis consisted of cyclosporine A
3
mg/kg/d IV divided into
two doses and starting on day

-
1.
Methotrexate prophylaxis when
given with cyclosporine A was administered as
15
mg/m'
IV
on day
1
and
10
mg/m' on days
3,
6,
and
11
after transplantation. Patients
who received methotrexate without cyclosporine as GVHD prophy-
laxis received the same schedule as described above and
10
mg/m2/
dose weekly until day
100
after BMT marrow transplantation.
3213
Criteria for diagnosis of
OW.
In adults, the diagnosis of ob-
structive lung disease has been based on pulmonary function testing,
histopathologic evidence of bronchiolitis obliterans, and clinical

symptoms. Many of the children who received BMTs were too young
(<S
years) to perform routine pulmonary function tests. The diagno-
sis of OLD in the present study was based on patients meeting
all three of the following criteria:
(1)
No
evidence of pulmonary
abnormalities before transplantation;
(2)
clinical features, including
cough, wheezing,
pneumothorax/mediastinum,
or
dyspnea;
(3)
at
least one of the following findings, in the absence of infection: (a)
Abnormal pulmonary function tests after transplant:
-
FEV,,
430%
predicted; and
-
FEFz5.,5s
<60%
predicted; (b) Lung biopsy with
evidence of subpleural and/or interstitial fibrosis and bronchiolar
abnormalities; (c) computed tomography (CT) findings consistent
with bronchiolitis obliterans."

Pulmonary function testing.
Pulmonary function testing was
routinely done
1
year after transplant, if the patient was capable,
and was done at other times based on clinical suspicion. Pulmonary
function testing was done following the American Thoracic Society
guidelines." Forced vital capacity (WC), forced expiratory volume
in one second (FEVI), and forced expiratory flow of
25%
to
75%
of vital capacity (FEF25.75s) and diffusion (DLCO) were performed
using Sensormedics Horizon pulmonary function system
5
or
Quinton Master lab and Body box system (Jeager, Wurzburg, Ger-
many). Mean values for patients were expressed as percent predicted
for normals of same age and height based on data from Knudson
(flow volume loops) and Polgar (diffusion).".l3
Histopathologic evaluation of
lung
biopsy samples.
Open lung
biopsy was performed in five cases.
All
cases were formalin fixed.
Paraffin-embedded sections were stained with hematoxylin-eosin,
Gram, Grocott, periodic acid-Schiff (PAS), Masson-trichrome, and
Verhoeff van Gieson stains. In addition, samples were cultured for

bacterial and viral involvement using standard methods.
High-resolution CTevaluation ofpatients.
High-resolution com-
puted tomography (CT) was performed using l-mm sections at
10-
mm intervals
through
the whole chest. The diagnosis of bronchiolitis
obliterans was made if focal or general hypoattenuation, segmental
or subsegmental bronchial dilatation, and/or expiratory air trapping
in areas of hypoattenuation was present. Initial CT diagnoses were
made in a nonblinded fashion. In a separate analysi~,'~
7
initial and
3
follow-up scans were randomized and compared with
5
scans from
normal controls. Three blinded observers correctly identified all
5
controls as normal whereas all scans from the children suspected
as having OLD were identified as compatible with bronchiolitis
obliterans." Of
30 observer diagnoses,
26
were identified as bronchi-
olitis obliterans and
4
were equivocal.
Evaluation of potential risk factors.

Children affected with OLD
and those unaffected were compared on the basis of age, sex, diagno-
sis, and nucleated cell dose of marrow infused. Risk factors for the
development of OLD, previously described in adults, were evaluated
in this study. They included acute and chronic GVHD, donor type,
donor age, methotrexate GVHD prophylaxis, total body irradiation
(TBI), and (CMV) status. The assessment and grading of GVHD
disease was
as
previously de~cribed.'~.'~
Statistical analysis.
Relationships between categorical factors
were assessed by the Pearson
x'
test and comparisons of continuous
factors with categorical outcomes were done using the Mann-Whit-
ney test. Pulmonary function results were evaluated using the t-test
for independent samples. The cumulative incidence of OLD was
calculated by the method of Kaplan and Meier. Significance of prog-
nostic factors for the development of OLD were assessed on a univar-
iate and multivariate basis by the score test from the Cox proportional
hazards model. The following covariates were assessed: donor sex
and age, BMT type, methotrexate prophylaxis, TBI, and acute and
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3214
l
0
500
1000
1500

2OOO
2500
3000
3500
Days
after
BMT
Fig
1.
Cumulative incidence for the development of
OLD.
Onset
of
OLD
was
measured in
a
time-dependent manner using
a
Kaplan-
Meier curve and is represented to
3,200
days after BMT.
chronic
GVHD.
Chronic
GVHD
and liver involvement were
used
as

time-dependent covariates
in
the
Cox
model.
RESULTS
Prevalence of
OLD
in children after allogeneic
BMT
at
British Columbia's Children's Hospital.
Eighty-nine chil-
dren received an allogeneic BMT between the years 1980
and 1992 at British Columbia's Children's Hospital. All
transplants were performed greater than
1.5
years previous
to
evaluation by this study. Sixty-seven of the 89 children
receiving transplants (75%) survived greater than or equal
to 90 days and were classified as at
risk
of developing OLD
(Table 1). Thirteen of 67 (19.4%) developed OLD. The cu-
mulative incidence of OLD in children transplanted and sur-
viving greater than 90 days after transplant was 26% (95%
confidence interval [CI], 14% to
44%)
by the method of

Kaplan and Meier (Fig 1).
SCHULTZ
ET
AL
Characteristics
of
children with
OLD
compared with unaf-
fected
BMT
patients.
Comparison of the children with
OLD to those who were unaffected demonstrated no differ-
ence in age distribution (Table 1). Moreover, we saw
no
difference in the sex ratio, the pre-BMT diagnosis, the cell
dose of nucleated marrow cells infused at the time of BMT,
and the preparative regimens used between the two groups.
Specific characteristics of children with
OLD.
Diagnosis
of OLD was made at a median time of 7.5 (range 3.0 to 55.3)
months after BMT (Table 2). Three patients had resolution
of
OLD and currently have normal pulmonary function tests.
All patients presented with cough,
8
of 13 with dyspnea
(62%), and

4
of 13 (31%) with wheezing (Table 2). Eight
(62%) had a history of bronchitis, 5 (39%) with sinusitis,
and 3 (21%) with a pneumothorax or pneumomediastinum.
Pulmonary function tests
(PFTs)
were consistent with severe
obstructive disease in
10
patients who were old enough
(25
years old) to be tested at time of presentation of OLD. An
additional two patients were evaluated by PFT after diagno-
sis of OLD at a later age (Table 2). All patients, except for
one, had confirmation of the diagnosis of OLD by pulmonary
function testing at some time. High-resolution CT confirmed
the diagnosis of OLD secondary to bronchiolitis obliterans
in 7 of 13 patients." Specific features evaluated were the
following:
(1)
focal or general parenchymal hypoattenuation
(present in 7/7), (2) segmental or subsegmental bronchial
dilatation (present in
5/7),
and/or
(3)
expiratory air trapping
in areas of hypoattenuation (present in 3/3). A representative
high-resolution CT (Fig
2)

shows diffuse parenchymal hypo-
attentuation and bronchial dilatation.
Lung biopsies were performed on five patients and showed
subpleural and interstitial fibrosis and bronchiolar abnormal-
ities in all cases (Fig 3,
A
and B). All 5 biopsy specimens
had histologic findings of variable subpleural and interstitial
fibrosis, with
4
having additional interstitial collections
of
lymphocytes. All had bronchiolar abnormalities including
findings of lymphocytic infiltration of the epithelium
(4),
Table
2.
Diagnosis of OLD in Children
After
Marrow Transplantation
Onset
of
OLD Duration
of
OLD Resolution Clinical
Pulmonary
Fibrosis
UPN
(mo)
(mo)

of
OLD
Symptoms Function on Biopsy CT Findings
9 3.0 6 No
(died)
c.
P
Abnormal
ND ND
10 9.7
87
Yes
C.
D
Abnormal
ND ND
55 55.3
9 No
C
Abnormal
ND ND
25 5.4 80 No
C,
Cl,
D,
P
Abnormal Yes
BO
61
7.0

49 No
C,
Cl,
D,
W
ND
Yes
ND
62 3.6
21
Yes
C
Abnormal
Yes
ND
74 31.8
12 No
c,
Cl
Abnormal*
ND
BO
75
7.5
36 No
C,
Cl,
D,
W
Abnormal

Yes
BO
99 6.8
20 No
c,
Cl,
W
Abnormal
ND
BO
103 10.9
13 No
(died)
C.
W.
D
Abnormal
ND
BO
107 3.9
12
Yes
C
Abnormal
ND ND
108 12.0
8 No
C,
Cl,
D,

W
Abnormal*
ND
BO
114
5.5
9 No
(died)
C,
Cl,
D,
W,
P
Abnormal
Yes
BO
Abbreviations:
C,
cough;
P,
pneumothorax and/or pneumomediastinum;
D,
dyspnea;
Cl,
chest infection (clinical diagnosis of recurrent bronchi-
*
Pulmonary function testing was not performed at the time of diagnosis of
OLD
because of age, but was abnormal at a later time when the
tis);

W,
wheezing;
ND,
not done;
BO,
bronchiolitis obliterans.
child was older.
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LUNG DISEASE IN CHILDREN AFTER BMT 321
5
Fig
2.
High-resolution CT of the chest in
a
child with
OLD.
The
CT (patient no.
25)
shows diffuse parenchymal hypoattenuation and
bronchial dilatation. The wedge of higher attenuation anterior to the
lateral aspect
of
the right oblique fissure represents normal lung.
regenerative changes of the epithelium
(3),
subepithelial
lymphocytes
(l),
and luminal fibrosis

(I)
(Table
3).
Type 2
pneumocyte hyperplasia was
also
seen
in
the alveoli of
4
cases.
No
organisms could be identified
in
the histologic
sections examined and
in
the
4
cases submitted for bacterial
and viral culture, no growth of organism was detected.
Pulmonary function tests
in
some children were difficult
to obtain because many of the patients were too young (<S
years old)
to
have PFTs done either before
or
after BMT

(Table
4).
Of those tested, children appeared to have either
transient
or
permanent obstructive patterns. Three patients
developed transient severe obstructive changes (Table
4)
in
that at the onset of OLD the FEV,, the FEF2S.7SCk and the
DLCO were all significantly decreased compared with before
transplantation
(P
<
.OS).
Each completely resolved after
immunosuppressive therapy (Table
4).
The only patient to
show a response
to
bronchodilators during evaluation by
PFT was one patient with transient OLD.
In
the patients with
permanent changes, PFTs showed a significantly lower FEV,
at the time of diagnosis of OLD compared with pre-BMT
values
(P
=

.001)
(Table
4).
FEF2S.7sth was even more se-
verely affected (Table
4)
in
the OLD group at the time of
diagnosis compared with those pre-BMT
(P
=
<
.001).
The
DLCO was similarly affected. All three (FEV,, FEF?S.7s,k,
and DLCO) continued to be significantly lower at later evalu-
ations. Because the obstructive changes were severe, the
FVC was also decreased at the time of diagnosis of OLD
(Table
4).
Restriction of school and physical activities (Karnofsky
S
70%) at the time
of
diagnosis was apparent
in
7 of
IO
with permanent OLD and
I

of
3
with transient OLD (Fig
4).
After treatment with immunosuppressive therapy, Karnofsky
scoring of the children with permanent OLD showed an
overall improvement
in
the activity. The three children
in
the transient group
all
returned to normal pulmonary function
and improved activity performance. One of these three chil-
dren subsequently developed a drop
in
performance as her
underlying disease (metachromatic leukodystrophy) pro-
gressed, although the marrow graft is functional. Three pa-
tients with OLD died; two of pulmonary failure and one of
relapse.
Associntions
between
the
developntertt
of
OLD
and
poten-
tial

risk factor.7.
Donor type strongly correlated with the
development of OLD. Patients receiving mismatched related
donor
(40%)
or
matched unrelated donor
(44.4%)
transplants
developed OLD compared to 13.2% with matched related
donor transplants
(P
=
.OM).
Because increased donor age
is associated with matched unrelated donors compared to
matched sibling donors
in
children, we evaluated donor age
as
an independent variable and saw a significant increase
in
median donor age
in
the children
with
OLD compared to
unaffected children
(P
=

.036). Further evaluation of the
significance of donor age by donor type (HLA typing)
showed no significant influence of donor age. On the other
hand, the increased median age
(12
years)
in
the OLD group
of HLA-identical donors compared with the unaffected chil-
dren
(10
years) approached significance
(P
=
.0S7).
Evalua-
tion of other potential risk factors showed that there was no
clear association of methotrexate prophylaxis, TBI,
or
CMV
reactivity pre-BMT with the development of OLD after BMT
(Table 5). Eleven of 36
(30.6%)
patients with acute GVHD
had OLD compared to 2 of
31
(6.5%) without. This differ-
ence was statistically significant
(P
=

.009). Chronic GVHD
(Table 5) was also significantly associated with OLD with
37.1%
(
13/35) developing OLD compared to 0/32 of patients
without chronic GVHD
(P
<
.OOl).
Because all patients with OLD also had chronic GVHD,
further multivariate analysis could not be performed on the
entire population. Multivariate analysis was performed for
further risk factors
in
the population of patients with chronic
GVHD to evaluate for other contributing factors. Patients
with evidence of liver involvement as a part of chronic
GVHD had a strong association with OLD, with 57.9% of
chronic GVHD patients with liver involvement developing
OLD compared to 12.5%
in
the unaffected patients
(P
<
.001).
Evaluation of other potential risk factors
in
children
who developed chronic GVHD showed that there was no
significant risk associated with donor sex, donor type, donor

age. acute GVHD (=grade 2), methotrexate prophylaxis,
cyclosporine prophylaxis,
or
TB1 after adjustment for liver
involvement. Thus, chronic GVHD, particularly of the liver,
was the major risk factor associated with OLD
in
this popula-
tion.
Comparison
?f
children
with
perntottertt
versus
trnnsient
OLD.
Comparison of patients who developed permanent
rather than transient OLD showed no significant difference
in
patient age, onset of acute
or
chronic GVHD,
or
in
the
onset of OLD (Table
6).
Patients who developed OLD were
treated with many combinations of immunosuppressive ther-

apy and Ig preparations (Table 6). Patients with permanent
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3216
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Fig
3.
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LUNG
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Permanent Transient
a higher incidence of OLD than is representative of the adult
population. If we eliminate the unrelated donor transplants
from our population in this comparison (not included in the
Seattle study),
9
of
20
children
(5
17 years) with chronic
GVHD (45%) in our study developed OLD compared to 33
of
141
(23.4%) adults with chronic GVHD (>l7 years) in

the Seattle study. Assuming that these two populations are
equivalent except for age, we can see an increase of OLD
in children that approaches a significant difference
(P
=
.07).
In
addition, review of the Johns Hopkins group study
evaluating OLD after marrow transplantation shows that all
patients receiving allogeneic transplants affected with OLD
were under 30 years old (7/291), whereas none of
95
patients
older than 30 years were affected with OLD.4 Thus, young
age may be a significant risk factor for the development of
There are a number of reasons why children might be at
Time
of
evaluation
higher risk for the development of OLD. Firstly, children
Fig
4.
Karnofsky
rating of
with
OLD.
status
of
may be at an increased risk of primary viral infection because
each patient was made using the Karnofsky scale at the time of onset

they have not had the previous viral exposure equivalent
of OLD and with the most recent visit. Patients are divided into those
to that in adults. However. we observed
no
concomitant
Onset Most recent Onset Most recent OLD after allogeneic BMT.
who have resolution of OLD (transient) and those who have perma-
nent changes (permanent). The dotted line represents the level below
which patients are restricted in the abili to attend school and main-
tain normal physical activities (Karnofsky
s
70%).
The patient in the
transient group with a decrease in activity after onset of
OLD
cur-
rently has no pulmonary symptoms, but has poor performance be-
cause of progression of metachromatic leukodystrophy despite suc-
cessful marrow engraftment.
OLD did receive 3 or more immunosuppressive agents in
6
of
10
patients compared with
1
of 3 in the transient group.
However,
no
significant difference was demonstrable
in

the
therapy used to suggest that the children who were classified
with transient OLD were transient because
of
improved ther-
apy.
DISCUSSION
This study shows a relatively high prevalence of OLD in
the pediatric population receiving allogeneic BMTs at British
Columbia’s Children’s Hospital. We hypothesize that the
incidence of OLD observed
in
this study which is increased
compared with previously published studies in adults, may
be partially related to patient age. To evaluate this hypothesis
we compared our results with the adult study done in Seattle
that used OLD diagnostic criteria similar to ours.’ Because
of a strong association of OLD with chronic GVHD, a con-
servative comparison between adults and children can be
made looking at the prevalence of OLD in all patients who
have chronic GVHD. This comparison corrects for the higher
prevalence of chronic GVHD in adults, which may lead to
infections associated with the onset of OLD. Host presenta-
tion of self
or
viral antigens has been suggested previously”
as important in the induction of GVHD and there may be
tissue to tissue variation of self-antigen expression.” This
leads to the hypothesis that certain tissues in children, such
as the lung, may be more susceptible to involvement by

GVHD. It is possible that there is a difference
in
antigen
presentation of self antigen in the lungs of children compared
with adults by dendritic cells,’’ but this has not been investi-
gated. Gastro-esophageal reflux may be more prominent in
children, and has been associated with an increased incidence
of OLD in children.’ However, the most plausible explana-
tion relates to the size of a child’s airways compared with
that
of
an adult. Because the pediatric airway is already
smaller in size, once an inflammatory response secondary to
GVHD has ensued the resulting airway obstruction is much
more clinically significant in a child compared with that seen
in an adult. This may lead to a higher incidence of OLD.
Whatever the reason, further investigation is definitely war-
ranted to address these questions.
OLD has been previously associated with chronic GVHD.
We observed a very strong correlation between OLD and
chronic GVHD. One interesting observation was a very
strong association of liver enzyme elevation interpreted as
chronic liver GVHD with OLD in our population. It could
be argued that the alanine transferase (ALT) elevations are
secondary to pulmonary damage, but we would have ex-
pected an even greater elevation of the aspartate aminotrans-
ferase (AST). This leads us to conclude that we were observ-
ing ALT elevations secondary to liver involvement, not lung.
<
Fig

3.
Pathology
of
a lung biopsy specimens in children with OLD. (A) An open-lung biopsy (unique patient number [UP] 114) showing
spindled fibroblasts almost totally plugging airspace (hematoxylin-eosin, original magnification
x
400).
fBJ
An open-lung biopsy
(UPN
62)
showing a bronchiole lumen containing inflammatory debris, bronchiolar epithelium exhibiting reactive change, and a predominantly lympho-
cytic infiltrate extending into surrounding interstitium (hematoxylin and eosin, original magnification
x
100).
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3218
SCHUCTZ ET
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Table
3.
Summary of Histopathologic Findings From Five Open-Lung Biopsy Specimens
UPN Pleura Interstitium
25
Fibrosis Fibrosis
Lymphocytes
61
Fibrosis Fibrosis
Lymphocytes
62

Fibrosis Fibrosis
75
Fibrosis
114
Fibrosis
Fibrosis
Lymphocytes
Fibrosis
Lymphocytes
Bronchioles
Epithelial lymphocytes
Epithelial lymphocytes
Epithelial regeneration
Epithelial lymphocytes
Epithelial regeneration
Subepithelial lymphocytes
Epithelial lymphocytes
Epithelial regeneration
Epithelial
loss
Luminal fibrosis
Alveoli
Type
2
pneurnocyte hyperplasia
Macrophages
Macrophages
Type
2
pneurnocyte hyperplasia

Macrophages, PMN
Type
2
pneumocyte hyperplasia
Type
2
pneurnocyte hyperplasia
Macrophages
Moreover, we observed that liver enzyme elevations were
present either at the time of diagnosis of OLD or preceded
the diagnosis in
11 of
13
patients. These abnormalities cor-
rected in most patients after increased immunosuppression
was initiated for treatment of chronic GVHD. Whether this
association of liver GVHD with OLD is unique for children
is uncertain, but the association is strong enough in our
population that we believe that it may he a marker for the
development of OLD.
We
observed
no
other associations with other factors
pre-
viously identified in adults. Previously, methotrexate GVHD
prophylaxis has been identified as a risk factor for develop-
ment
of
OLD in adults.' We observed no similar association.

The number
of
children not receiving methotrexate were few
in
number decreasing the statistical power of our analysis,
possibly excluding our ability to identify this as a risk factor.
Mechanisms involved in the development of airspace
fi-
brosis leading to OLD in humans are poorly understood.
One group evaluated the cell populations isolated by bron-
choalveolar lavage after development
of
bronchiolitis ohlit-
Table
4.
Pulmonary Function Tests
of
Patients Affected
With
OLD
FEV,
FEF25-,5%
FVC
DLCO
UPN Pre-BMT Onset Current Pre-BMT Onset Current Pre-BMT Onset Current Pre-BMT Onset Current Bronchodilators
Response
to
Permanent
9
25

55
61
74
75
99
103
108
114
Mean
95%
cl
Transient
10
62
107
Mean
95%
Cl
Unaffected
87
ND
ND
ND
ND
ND
111
131
ND
96
106

(87, 124)
74
49 40
85 78
ND ND
ND
49
38 37
42 57
29 36
ND
27
41 43
51
46
(36, 67) (35, 57)
-
76
58
ND
24
14
ND
49 52
ND ND ND
ND ND
91
ND
18 9
123 17 17

118
10
13
ND ND
23
112 8 9
107 26 29
(86, 128) (11, 41) (9, 49)
-
90 81
ND
53
67
ND
96 87
ND ND ND
ND ND
43
ND
75 77
102
60
82
129 72 52
ND ND
26
90
63
74
103 71 64

(85, 121) (61,
81)
(49, 79)
-
87 65
90 68
50 107
102
65
86
88 46 95 76
31 105
92
53 90
133 79 126 130 54 130 130
86
103
(74, 132) (44, 82) (81, 125) (54, 128) (30, 59) (98. 130) (85. 131) (49, 87) (83, 103)
103 63 103 91 45 114 108 68 93
ND
ND
ND
ND
ND
ND
95
98
ND
92
95

(92,98)
ND
96
ND
96
ND
-
ND
91
77 82
ND ND
ND ND
ND
73
81 102
69 41
ND ND
19 51
62 73
(34, 90) (54, 90)
ND
112
54 93
54 61
54 89
(60,
118)
No
No
No

ND
No
No
No
No
ND
No
No
No
Yes
controls
Mean
99
-
93 95
-
112 97
-
90 89
-
92
95%CcI
(91, 107)
-
186,
100)
(79,
111)
-
(96, 130) (89, 105)

-
(83, 97) (93, 951
-
(84,
100)
FEV,, FEFZ5.759/., FVC, and
DLCO
are expressed as percent
of
that expected for age and height. The values are shown as baseline evaluations
before BMT (pre-BMT), at the time
of
diagnosis of OLD (onset), and as the most recent value (current). Unaffected patients are shown
as
the
most recent values (current).
UPN
9
died soon after diagnosis of
OLD
and therefore no current PFTs are available.
Abbreviation:
ND,
not done, because of young age
(<5
years).
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LUNG DISEASE
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3219
Table
5.
Potential Risk Factors for the Development of OLD
Category
Unaffected
With
OLD
No. No.
Patients
Patients
(%l
PValue"
Donor type
HLA identical
1
Ag mismatch
Matched unrelated
Evaluation for donor age,
median years (range)
HLA identical
1
Ag mismatch
Matched unrelated
All donors
Methotrexate prophylaxis
Yes
No
TB1
Yes

No
CMV DonorIRecipient
+I+
+/-
-l+
GVHD
-I-
Acute GVHD (zgrade
2)
Yes
No
Chronic GVHD
Yes
No
Liver involvement in patients
with chronic GVHD
Yes
No
46 7 (13.2)
3 2 (40.0)
5 4 (44.4)
10
(1, 27) 12 (6, 23)
23 (5, 35)
4 (2, 6)
42 (31, 47) 39 (34, 43)
11
(1,
47)
16

(2, 43)
51 12 (19.0)
3
1
(25.0)
32 10 (23.8)
22 3 (12.0)
16 3
(
15.8)
5 5 (50.0)
5
0
(0)
24 4
(
14.3)
25
11
(30.6)
29 2 (6.5)
22 13 (37.1)
32
0
(0)
8
11
(57.9)
14 2 (12.5)
.033

,057
.l4
.88
,036
.82
.2
1
.55t
,009
<.001
<.001
Abbreviations:
f,
recipients or donors who had serology that was
positive for the presence
of
CMV reactive IgG;
-,
recipients or donors
who had serology that was negative for the presence of CMV reactive
IgG.
*
Statistical analysis was performed using the score test from the
Cox proportional hazards model.
t
Analysis
of
all groups with reactivity with CMV in either donor
and/or recipient
(+l+,

+I-,
-l+)
compared to those with both donor
and recipient CMV nonreactive
(-1-1.
erans in both BMT and non-BMT patients." They noted that
most BMT patients had a lymphocyte predominance in the
lavage samples compared with a preponderance of neutro-
phils seen in the non-BMT patients. This suggests a different
pathologic process of airspace fibrosis associated with
GVHD in BMT patients. Bronchial associated lymphocytic
tissue (BALT) and epithelium can express class I1 major
histocompatibility complex antigens and may be the target
for T-cell-mediated injury leading to fibrosis. Histology
shows mural fibrosis with mononuclear inflammatory cells
with some areas completely obliterated. There appears to be
a moderate interstitial infiltration of lymphocytes and plasma
cells adjacent to the involved bronchioles and normal paren-
chyma in other areas. In addition, dendritic cells have been
important in bronchiolitis obliterans in patients receiving
heart-lung transplants."
Why
it develops in some patients
with chronic GVHD and not in others is poorly understood.
Diagnosis
of
OLD in children is particularly difficult.
Many children are too young to perform pulmonary function
tests in a manner acceptable for an accurate evaluation. Lung
biopsy is invasive and we have noted excessive morbidity

in children receiving biopsies. Less invasive measures are
required. High-resolution CT has proven to be highly sensi-
tive in this seriesI4 and has allowed
us
to diagnose some
children not evaluable by other means. Noninvasive diagnos-
tic methods such as this need to be pursued in a more aggres-
sive manner to diagnose OLD in children early and accu-
rately.
Various therapies were used in treatment of the children
with OLD. Because chronic GVHD is strongly associated
with OLD, immunosuppressive therapy was used in all pa-
tients resulting in an improvement in performance in
10
of
13
patients. Patients with more severe disease (permanent)
received more intensive immune suppression with no obvi-
ous
advantage
of
one immunosuppressive agent or approach
over another. Most probably this represents the difference
in severity of
OLD
rather than in any efficacy of a particular
therapeutic approach. Thus, any immunosuppressive therapy
Table
6.
Comparison of Children With Permanent

Versus Transient OLD
Category
Permanent
Transient
P
Value
No.
of patients
Age (yrs)
Onset of acute GVHD
(days after BMT)
Onset of chronic GVHD
(days after BMT)
Onset of
OLD
(days after BMT)
Treatment of OLD
Aza
Budesonide
CsNPred
Predl
CsNPredIAzaflhal
CsNPredTThalI
Budesonide
CsNPredI
Budesonide
CsNPredlThalI
AzaIPredl
cyclophosphamide
Pentaglobulin

Cyclophosphamide
10
4.8*(0.5, 17.0)
13(5, 57)
90(90, 108)
217(90, 1,659)
2
1
1
1
0
3
8.5(5.7, 13.7) .69
13.5(12, 15) .91
108(90,
11
1)
.22
117(108, 291) .29
0
1
Abbreviations: Pred, Prednisone; Aza, Azathioprine; CsA, cyclo-
sporine; Thal, Thalidomide; Budesonide, aerosolized steroid; Pentag-
lobulin; IV Ig with increased IgA content.
*
Median (range).
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3220
SCHULTZ
ET

AL
appears to result in some therapeutic improvement, although
significant morbidity
may
still
be
present.
This study suggests that there
appears
to be
a
high preva-
lence of
OLD
in children compared
to
adults and is strongly
associated with chronic
GVHD,
particularly of the liver.
Prospective studies evaluating the
onset
of
OLD
and
possible
causative factors
are
necessary to improve understanding
of

this significant complication and possibly allow for early
intervention.
ACKNOWLEDGMENT
We thank Drs Ronald Anderson, John Wu, Christopher Fryer, and
Yigal Kaikov for the excellent clinical care provided to these pa-
tients. Additional thanks to the nursing staff of 3B, the clinical
pharmacists and the dietitians at British Columbia's Children's Hos-
pital for outstanding supportive care. Lastly, we thank Nita Takeuchi
for clinical coordination and Dr Michael Seear and Julia A. Schultz
for critical review of this manuscript.
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