Magnetic resonance imaging in sclerotic-type chronic graft-vs-host disease

Abstract

Background: Sclerotic-type chronic graft-vs-host disease (cGVHD) of the skin is an uncommon but potentially debilitating sequela of allogeneic hematopoietic stem cell transplantation. There is no standardized assessment measure for this form of cGVHD. Because a full-thickness incisional biopsy specimen to the level of the fascia may be needed to make a definitive histologic diagnosis of cGVHD-related fasciitis, a noninvasive technique for the assessment and monitoring of sclerotic-type cGVHD, particularly cGVHD-related fasciitis, would be of potential value.

Observations: Sixty-two consecutive patients with cGVHD following allogeneic hematopoietic stem cell transplantation were evaluated for sclerotic skin disease. Forty-four patients (71%) had cutaneous cGVHD, and 28 patients (45%) had evidence of sclerotic involvement based on physical examination findings. Fifteen patients agreed to undergo research magnetic resonance imaging to evaluate quantifiable changes in the dermis, subcutaneous tissue, and muscle. Among 15 patients, magnetic resonance imaging identified abnormalities in the skin in 7 (47%), subcutaneous fibrous septa in 13 (87%), deep fascia in 12 (80%), epimysium in 9 (60%), and muscle in 3 (20%).

Conclusions: Magnetic resonance imaging should be considered in the evaluation of patients with cGVHD suspected of having subcutaneous or fascial involvement. Additional studies are needed to validate this noninvasive modality for serial monitoring of disease activity and response to therapy. Trial Registration clinicaltrials.gov Identifier: NCT00331968.

Figure 1.

Fasciitis with overlying skin involvement in a 56-year-old man 37 months after allogeneic hematopoietic stem cell transplantation for multiple myeloma (patient 5 in Table 1 and Table 2). A, Erythema and induration on the anterolateral aspect of the right thigh. B, Axial T1-weighted spin-echo image demonstrates thickening of the skin, with intervening fat dropout (arrowheads) overlying a region of narrowing and sclerosis of the subcutis. There is also thickening of the adjacent superficial fascia (arrow). C, Axial 3-dimensional gradient recalled echo image after administration of contrast medium demonstrates mild enhancement of the skin and subcutis in the region of sclerosis, with more prominent and extensive enhancement along the deep fascia (arrows). Magnetic resonance imaging total score of 8 (score of 2 each for skin, septa, deep fascia, and epimysium).

Figure 2.

Fasciitis without overlying superficial skin sclerosis in a 45-year-old man 26 months after allogeneic hematopoietic stem cell transplantation for T-cell lymphoblastic leukemia (patient 10 in Table 1 and Table 2). A, A subtle rippled appearance is present on the right medial thigh. A firm nodular texture was detected on deep palpation. B, Axial 3-dimensional gradient recalled echo (out-of-phase echo time) image demonstrates mild thickening of the subcutaneous septa (arrows) and minimal thickening of the deep fascia (arrowheads). C, Axial short tau inversion recovery image demonstrates widespread linear increased signal along the deep fascia (arrowheads) and along the epimysium of various muscles (arrows). Magnetic resonance imaging total score of 7 (score of 1 for skin and 2 each for septa, deep fascia, and epimysium).