Chronic Graft-versus-Host Disease in the Oral Cavity of Patients Following Allogeneic Hematopoietic Stem Cell Transplant and Including Healthy Controls

Background:

• Chronic graft-versus-host disease (cGVHD) is a multi-organ severe alloimmune and - autoimmune disorder that occurs after allogeneic hematopoietic stem cell transplantation (HSCT). It is characterized by immune dysregulation, immunodeficiency, impaired organ function, and decreased survival.
• Manifestations of cGVHD in the oral cavity are observed in 45-85% of cGVHD patients and include 3 components: limitation of mouth opening, oral mucosal changes (lichenoid lesions, ulceration) and salivary gland changes.
• There is an urgent need for new tools to diagnose and treat oral cGVHD. To develop targeted therapies and non-invasive methods for serial screening, an improved understanding of the clinical course and underlying mechanisms of oral cGVHD are required.

Objectives:

• Advance understanding of cGVHD pathophysiology and generate hypotheses for future cGVHD studies by tracking the longitudinal development of cGVHD in the oral cavity and transplant-related changes in the oral microenvironment.
• Leverage knowledge about the impact of transplant on the oral cavity to develop better protocols for supportive dental care, to refine clinical definitions and classifications of oral cGVHD, and to test and improve criteria and tools for clinical trials.
• Include healthy volunteer cohorts both as a direct control group for HSCT patients, and to characterize measures of interest that were not previously defined in the normal oral cavity.

Eligibility:

• Patients who are scheduled to undergo allogeneic HSCT at the National Institutes of Health (NIH) or who have already undergone allogeneic HSCT at the NIH or elsewhere.
• Healthy individuals who have not undergone transplant and are willing to undergo oral exam and sample collection will be included in a control group.
• All study subjects, including patients and healthy individuals, must be able to provide written informed consent and be willing to return to the NIH Dental Clinic for scheduled evaluations.

Design:

• This is a single site, observational study with four cohorts. There are 2 transplant cohorts: the New Transplant Cohort ("Cohort NT"; approximate n=300) consists of patients who are scheduled to undergo allogeneic HSCT (under another protocol at the NIH) and the Prior Transplant Cohort ("Cohort PT"; approximate n=100) consists of patients who have already undergone allogeneic HSCT. These Cohorts will have up to 7 regularly scheduled visits across 3 years, along with a variable number of acute-episode visits. Subjects enrolled as NT or PT, who require a subsequent transplant are eligible to be either enrolled or re-enrolled into the PT cohort to be followed for the 7 visits in 3 years. Additionally, subjects will have the opportunity to participate in optional annual follow-up visits in years 4-10 post transplant.
• The other 2 Cohorts include healthy volunteers: the Healthy-controls Longitudinal (HL) Cohort ("Cohort HL"; approximate n=20) includes subjects who will participate in up to 4 study visits across 1 year, and the Healthy-controls Short-term (HS) Cohort ("Cohort HS"; approximate n=80) will participate in a single baseline visit.
• Each visit will include collection of biologic samples, patient-reported data and clinical assessments.
• Initial statistical analysis will begin with unsupervised clustering methods and simple logistic regression to identify biomarkers important in oral cGVHD. Based upon the results of these initial analyses, more complex multivariate statistical models will be developed to both classify and predict onset of oral cGVHD. Given the hypothesisgenerating nature of this study, additional prospective statistical analysis plans will be developed in consultation with a statistician as the study progresses to address specific scientific questions.

• INCLUSION CRITERIA:
• Subjects in Cohort NT and Cohort PT must satisfy all of the following criteria in order to participate in the study:

• Scheduled to undergo allogeneic HSCT at the NIH (Cohort NT) or have already undergone allogeneic HSCT at the NIH or another institution (Cohort PT) and are within 3 years of most recent bone marrow transplant
• Willing to participate in protocol evaluations including saliva collection, oral swab collection, and completion of patient-reported outcome (PRO) forms
• Willing to return to the NIH Dental Clinic for scheduled evaluations
• Be at least 18 years of age at screening
• Be able to understand and provide written informed consent
• Subjects in Cohort HL and Cohort HS must satisfy all of the following criteria in order to participate in the study:

• Willing to undergo oral exam and participate in Visit 1 protocol evaluations including saliva collection, oral swab collection and oral biopsies.
• Be at least 18 years of age at screening
• Be able to understand and provide written informed consent
• Potentially be age- and/or sex-matched with a transplant patient
• Subjects in Cohort HL must additionally be willing and able to return to the NIH Dental Clinic for scheduled visits across 1 year and participate in evaluations including saliva collection, oral swab collection, and completion of PRO forms

Exclusion criteria

• Subjects in any Cohort will be excluded if they are pregnant, as pregnancy can have a confounding effect on the oral microbiome
• Subjects in Cohort NT may not participate in the study if, in the opinion of the NIH transplant team, participation in the protocol would not be safe or in the subject s best interest
• Subjects in Cohort PT. There are no additional exclusion criteria for subjects in this cohort.
• Subjects in Cohorts HL and Cohort HS may not participate in the study if they meet either of the following criteria:

• Have any acute oral mucosal or dental infection requiring multiple dental appointments or specialist referral for treatment; uncontrolled chronic disease; active systemic illness; are currently undergoing orthodontic treatment; history of frequent opportunistic infection; autoimmune disease; immunosuppressive medications; or prior organ, bone marrow, or peripheral blood stem cell transplant
• Are taking medications or are on other ongoing therapies that have a known or suspected major impact on the oral microbiome
• Subjects in Cohort HL additionally may not participate if they are planning to become pregnant within the next year or refuse to have oral biopsies.