1
Supplementary table 1. Pulmonary function tests before allo-HCT and at BOS-
2
diagnosis. Individual pulmonary function tests are displayed before allo-HCT and at the time
3
of diagnosis of BOS. *Pulmonary function tests performed shortly after allo-HCT
4
transplantation is shown for this patient. FEV1, forced expiratory volume in 1 s.; FVC, forced
5
volume capacity; RV, residual volume; TLC total lung capacity; DLCOc SB, diffusion
6
capacity of the lung for carbon monoxide corrected to haemoglobin (single-breath); Allo-
7
HCT, allogeneic hematopoietic transplantation; BOS, bronchiolitis obliterans syndrome; n.d.,
8
not done.
9
10
Supplementary table 2. Univariate analysis of clinical factors for developing BOS after
11
reduced-intensity conditioning. Hazard ratios and confidence intervals for clinical factors
12
were estimated by Cox proportional hazards regression model. Last follow-up and death were
13
used as censored observation. 1GvHD prophylaxis with in vivo T-cell depletion includes
14
patients who received CyA/ATG or CyA/alemtuzumab before allo-HCT. 2Controlled disease
15
included complete remission (CR), partial remission (PR), stable disease (SD) and chronic
16
phase of CML (CP). 3Patients with acute GvHD grad II-IV were included. 4cGvHD besides
17
BOS was analysed as a time-dependent covariate. Patients with both limited and extensive
18
cGvHD were included. Allo-HCT, allogeneic hematopoietic cell transplantation; GvHD,
19
graft-versus-host disease; CMV, cytomegalovirus; ATG, anti T-cell globulin; BOS,
20
bronchiolitis obliterans syndrome; HR, hazard ratio.
21
22
Supplementary table 3. Extension and severity of GvHD in patients with BOS. Organs
23
affected and clinical grade of GvHD are shown for patients with BOS.
24
aGvHD, which lasted beyond 100th day of allo-HCT. 2BOS developed in this patient after
25
early cyclosporine withdrawal due to disease progression. 3Patient received interferon alpha
26
due to mixed chimerism before BOS. 4Patient received DLIs due to relapse before BOS. BOS,
27
bronchiolitis obliterans syndrome; DLI, donor lymphocyte infusion.
1
Patient developed
28
29
Supplementary table 4. Univariate analysis of risk factors for developing cGvHD besides
30
BOS after reduced-intensity conditioning. Hazard ratios and confidence intervals were
31
estimated by Cox proportional hazards regression model. 1Patients who did not receive
32
CyA/ATG or CyA/alemtuzumab before allo-HCT were included in this group.
33
disease included complete remission (CR), partial remission (PR), stable disease (SD) and
34
chronic phase of CML (CP). 3Patients with acute GvHD grad II-IV were included. Allo-HCT,
35
allogeneic hematopoietic cell transplantation; GvHD, graft-versus-host disease; cGvHD,
1
2
Controlled
1
chronic graft-versus-host disease; CMV, cytomegalovirus; ATG, anti-T cell globulin; BOS,
2
bronchiolitis obliterans syndrome; HR, hazard ratio.
3
4
Supplementary table 5. Multivariate analysis of risk factors for cGvHD besides BOS
5
after reduced-intensity conditioning. Hazard ratios and confidence intervals were estimated
6
by Cox proportional hazards regression model. Clinical characteristics with a p-value <0.1 in
7
univariate analysis were included in multivariate analysis.
8
CyA/ATG or CyA/alemtuzumab before allo-HCT as GvHD prophylaxis were included in this
9
group.
2
1
Patients who did not receive
Patients with acute GvHD grad II-IV were included. Allo-HCT, allogeneic
10
hematopoietic cell transplantation; GvHD, graft-versus-host disease; cGvHD, chronic graft-
11
versus-host disease; ATG, anti T-cell globulin; CyA, cyclosporine A; BOS, bronchiolitis
12
obliterans syndrome; HR, hazard ratio.
13
14
Supplementary table 6. Carbon monoxide diffusion changes after reduced intensity
15
conditioning protocol with fludarabine, carmustine and melphalan. Changes in diffusion
16
capacity of the lungs were analysed by cumulative incidence rates. Event was defined as the
17
first time to achieve hemoglobin-corrected diffusion capacity of carbon monoxide (DLCOc
18
SB) below 60% (A) and below 80 % (B) of predicted value after allo-HCT. Statistical
19
analysis by competing risk regression by Fine and Gray was used.
20
21
Supplementary table 7. Immunosuppression before and after diagnosis of BOS and
22
clinical response regarding FEV1. Patients with BOS were classified based on
23
immunosuppressive treatment at the time of diagnosis and changes in immunosuppression
24
after diagnosis. Response was assessed regarding a decline or an increase in FEV1 in the
25
following pulmonary function test. The number of patients above the total number of patients
26
in each group is shown. BOS, bronchiolitis obstructive syndrome; CyA, cyclosporine A;
27
MMF, Mycophenolate mofetil; FEV1, forced expiratory volume in 1 s.
28
29
30
31
32
33
34
2
1
Supplementary table 1. Pulmonary function tests before allo-HCT and at diagnosis of
2
BOS.
Case #
FEV1
(% of predicted)
AlloHCT
BOS
FEV1/FVC
Ratio (%)
AlloHCT
BOS
RV
(% of predicted)
AlloHCT
BOS
TLC
(% of predicted)
AlloHCT
BOS
RV/TLC
Ratio (%)
AlloHCT
BOS
DLCOc SB
(% of predicted)
AlloHCT
BOS
NIH
lung
score
3
98
69
74
60
102
130
108
107
30
38
n.d.
49
2
5
104
33
84
66
98
160
93
71
28
60
n.d.
n.d.
3
8*
85
73
71
64
139
124
106
99
38
37
n.d.
81
1
9
77
57
90
60
107
168
79
110
44
50
n.d.
76
2
13
110
41
79
51
86
154
100
92
26
50
n.d.
61
2
15
90
30
82
47
74
264
87
121
27
70
93
78
3
38
83
68
81
69
106
129
84
86
38
45
82
75
1
39
68
61
82
67
121
140
82
90
30
47
65
50
2
43
81
71
73
66
151
151
100
140
41
42
64
59
2
49
85
41
73
51
152
160
111
68
42
48
68
66
2
56
101
33
82
57
52
162
80
93
24
64
69
58
3
63
76
35
82
61
113
189
84
96
42
61
73
44
3
65
93
50
79
64
94
129
73
107
41
43
77
53
2
77
72
59
88
68
107
121
82
84
43
46
n.d.
n.d.
2
87
80
74
70
68
224
135
122
90
49
41
69
67
1
89
94
48
76
59
155
230
107
111
60
62
88
50
2
118
83
47
81
61
127
186
99
113
49
64
75
66
2
127
84
52
78
69
128
151
102
96
45
56
80
56
2
130
72
59
76
60
109
136
85
90
38
45
64
59
2
149
80
46
77
58
155
187
99
95
43
54
71
43
3
164
70
65
74
67
129
121
95
85
51
46
n.d.
n.d.
1
184
90
55
78
62
124
196
91
104
42
58
79
73
2
237
70
64
82
69
108
126
85
81
44
54
73
n.d.
1
243
74
60
71
67
97
158
78
112
35
50
68
n.d.
1
Median
83
56
79
63
111
153
92
96
42
50
73
59
Min.
68
30
70
47
52
121
73
68
24
37
64
43
Max.
110
74
90
69
224
264
122
140
60
70
93
81
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
3
1
2
Supplementary table 2. Univariate analysis of risk factors for BOS
BOS
Clinical characteristics
HR
95% CI
p-value
Patients <55 years at allo-HCT
4.35
1.89, 9.97
0.0005
GvHD prophylaxis without invivo T-cell depletion1
3.13
1.37, 7.14
0.01
Lung disease after allo-HCT
Lymphoid malignancies
5.76
2.06
1.35, 24.5
1.10, 3.86
0.02
0.02
Donor related
CMV donor status positivity
Donor sex (male)
Patient sex (male)
Disease remission status before
allo-HCT (uncontrolled vs.
controlled)2
2.31
2.09
2.06
1.73
2.19
1.01, 5.31
0.89, 4.88
0.90, 4.73
0.77, 3.87
0.74, 6.5
0.05
0.09
0.09
0.18
0.16
Disease remission status before
allo-HCT (untreated vs.
controlled)2
0.64
0.14, 2.87
0.56
Patients with prior lung disease
before allo-HCT
0.64
0.27, 1.50
0.30
Current or previous smokers
1.25
0.49, 3.15
0.64
CMV patient status positivity
0.83
0.36, 1.91
0.67
CMV reactivation
0.52
0.22, 1.22
0.16
HLA (A, B, DQB1, DRB1)
difference
HLA C difference
0.97
0.23, 4.12
0.97
0.67
0.20, 2.27
0.52
Acute GvHD3
cGvHD besides BOS4
0.99
2.00
0.42, 2.34
0.78, 5.00
0.99
0.14
3
4
5
6
7
8
9
10
11
12
13
14
15
4
1
Supplementary table 3. Extension and severity of GvHD in patients with BOS
aGvHD
Case #
Organs
3
-
cGvHD
clinical
grade
-
Organs
Skin, gut, liver, wasting, eye,
DLI-induced GvHD
clinical
grade
Organs
clinical
grade
3
-
-
musculoskeletal
51
Skin, liver, eye,
3
-
-
-
-
wasting
82
Skin, gut
2
Skin, gut, eye, sicca-syndrome
2
-
-
9
-
-
Skin, liver, scleroderma, eye,
2
-
-
gut
13
Skin
1
-
-
-
-
15
-
-
Gut, liver,
3
-
-
immunothrombopenia
38
-
-
Skin
2
-
-
39
Skin, gut
2
Skin, liver, eye
3
-
-
43
Skin
2
Skin, gut, wasting, alopecia,
3
-
-
2
-
-
scleroderma, sicca-syndrome,
eye, dyspigmentation
49
Skin, gut
4
Liver, gut, musculoskeletal,
scleroderma, eye
56
Skin
2
Gut, liver, sicca-syndrome
2
-
-
63
Skin
1
Skin, gut, liver
3
-
-
65
Skin
1
Skin, gut, liver
2
-
-
77
Skin, liver
2
Skin, eye, liver,
3
-
-
3
-
-
musculoskeletal
87
-
-
Gut, eye, liver,
musculoskeletal, wasting,
scleroderma
89
-
-
Skin
3
-
-
118
-
-
-
-
Skin, wasting, gut
2
127
-
-
Skin, gut, wasting
3
-
-
130
Skin
1
Skin, gut, eye, sicca-syndrome
3
-
-
149
-
-
-
-
Skin, liver, gut
3
1643
-
-
-
-
-
-
184
Skin, gut
1
Skin, liver, gut
3
-
-
237
-
-
Gut
1
Skin, gut
1
2434
Skin, liver
3
Liver
1
-
-
2
3
4
5
5
1
2
Supplementary table 4. Univariate analysis of risk factors for cGvHD besides BOS.
cGvHD besides BOS
Clinical characteristics
HR
95% CI
p-value
Patients <55 years at allo-HCT
1.14
0.78, 1.65
0.51
GvHD prophylaxis without invivo T-cell depletion1
Lung disease after allo-HCT
2.28
1.57, 3.31
<0.0001
1.44
0.99, 2.09
0.05
Lymphoid malignancies
1.10
0.79, 1.56
0.56
Donor related
CMV donor status positivity
Donor sex (male)
Patient sex (male)
Disease remission status before
allo-HCT (uncontrolled vs.
controlled)2
1.03
1.02
1.23
1.14
1.33
0.73, 1.46
0.73, 1.44
0.88, 1.73
0.81, 1.61
0.86, 2.06
0.85
0.89
0.23
0.45
0.20
Disease remission status before
allo-HCT (untreated vs.
controlled)2
1.09
0.66, 1.81
0.72
Patients with prior lung disease
before allo-HCT
1.45
1.03, 2.04
0.03
Current or previous smokers
1.12
0.76, 1.66
0.55
CMV patient status positivity
0.81
0.57, 1.16
0.25
CMV reactivation
0.95
0.68, 1.34
0.79
HLA (A, B, DQB1, DRB1)
difference
HLA C difference
1.27
0.75, 2.14
0.37
1.35
0.90, 2.03
0.15
Acute GvHD3
2.00
1.41, 2.82
<0.0001
3
4
5
6
7
8
9
10
11
12
13
14
15
16
6
1
2
3
Supplementary table 5. Multivariate analysis of risk factors for cGvHD besides BOS
after reduced-intensity conditioning and allo-HCT.
cGvHD besides BOS
Clinical characteristics
HR
95% CI
p-value
GvHD prophylaxis without invivo T-cell depletion1
Acute GvHD2
1.89
1.23, 2.82
0.002
1.65
1.13, 2.41
0.009
Patients with prior lung disease
before allo-HCT
1.56
1.10, 2.20
0.01
Lung disease after allo-HCT
1.38
0.95, 2.01
0.09
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
7
1
2
3
4
5
Supplementary table 6. Carbon monoxide diffusion changes after reduced intensity
conditioning protocol with fludarabine, carmustine and melphalan.
A. Cumulative incidence rates of DLCOc SB < 60 % of predicted values after allo-HCT
≥ 55 years
< 55 years
6
7
8
9
10
11
Time after
allo-HCT
Cumulative
incidence rate
95% CI
Cumulative
incidence rate
95% CI
1 year
40.1 %
30.0, 53.8 %
18.5 %
13.7, 24.9 %
5 year
41.7 %
31.4, 55.4 %
21.8 %
16.6, 28.6 %
10 year
41.7 %
31.4, 55.4 %
23.8 %
17.8, 31.9 %
B. Cumulative incidence rates of DLCOc SB < 80 % of predicted after allo-HCT
≥ 55 years
< 55 years
Time after
allo-HCT
1 year
Cumulative
incidence rate
53.2 %
3 year
5 year
95% CI
42.2, 66.9 %
Cumulative
incidence rate
41.1 %
95% CI
34.5, 48.9 %
59.9 %
48.5, 73.9 %
50.3 %
43.2, 58.4 %
64.2 %
51.8 79.6 %
51.4 %
44.2, 59.8 %
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
8
1
2
3
Supplementary table 7. Impact of immunosuppression before and after diagnosis of
BOS on clinical response regarding FEV1.
n/total
Patients without immunosuppression before BOS
9/24
No change of immunosuppression after BOS
6/9
Decline of FEV1 > 10%
Stabilization
Improvement of FEV1 > 10%
Increase of immunosuppression after BOS
Decline of FEV1 > 10%
Stabilization
Improvement of FEV1 > 10%
3/9
1
0
2
15/24
Reduction in immunosuppression after BOS
5/15
Decline of FEV1 > 10%
Stabilization
1
2
Improvement of FEV1 > 10%
2
Inhalative beta-agonists
Oral steroids
Inhalative steroids
Oral steroids, CyA
Oral steroids, CyA
Oral steroids, CyA and MMF
Oral steroids, CyA
Oral steroids, MMF
4/15
Decline of FEV1 > 10%
2
Stabilization
Improvement of FEV1 > 10%
1
1
Increase in immunosuppression after BOS
Treatment
employed/increased
after BOS
1
3
2
Patients with immunosuppression before BOS
No change in immunosuppression after BOS
Treatment
before BOS
Oral steroids
Oral steroids, CyA and MMF
CyA
CyA
6/15
Decline of FEV1 > 10%
Stabilization
1
2
Improvement of FEV1 > 10%
3
Oral steroids and CyA
Oral steroids and CyA
Oral steroids and CyA
Oral steroids and CyA
Oral steroids and CyA
Oral steroids
Oral steroids
Oral steroids
Oral steroids
Oral steroids
Oral steroids
Oral steroids and CyA
4
5
6
9