Gastrointestinal pathology of autologous graft-versus-host disease following hematopoietic stem cell transplantation: a clinicopathological study of 17 cases

Graft- versus -host disease is the major complication after allogeneic hematopoietic stem cell transplantation and is attributable to donor T-cell recognition of recipient alloantigens. In patients undergoing autologous hematopoietic stem cell transplantation in which there is no genetic disparity to induce an alloresponse, a syndrome similar to allogeneic graft- versus -host disease has been described. Designated as autologous graft- versus -host disease, it typically involves the skin and has reportedly caused little morbidity in this patient population. Recent data, however, suggest that autologous graft- versus -host disease can cause significant disease in the gastrointestinal tract, but its pathological spectrum of abnormalities and disease incidence are not well established. We report the development of autologous graft- versus -host disease following hematopoietic stem cell transplantation in 17 patients (15 with multiple myeloma) based on 388 autologous stem cell transplants carried out at our institution over a 6-year period. This represents a total incidence rate of 4% and among those transplanted for multiple myeloma, 6%. In all, 16 of the 17 patients had colonic biopsies performed for the diagnostic evaluation of persistent diarrhea. Biopsies in all 16 patients showed pathological evidence for graft- versus -host disease and were graded using standard grading criteria established for allogeneic graft- versus -host disease. Grades ranged from mild (grade 1/4) to severe (grade 4/4). Changes secondary to medication or infection were excluded. Responses to steroid and immunosuppressive therapy were variable but improved with continuing institutional experience. Outcomes ranged from a prompt, complete resolution of symptoms to death. Patients treated with autologous hematopoietic stem cell transplantation, particularly those with multiple myeloma, may develop a potentially life-threatening syndrome pathologically identical to allogeneic graft- versus -host disease. This diagnosis must be considered when interpreting biopsies from patients with gastrointestinal symptoms following autologous hematopoietic stem cell transplantation.