The Farooq, not the Lerner, grading system predicts disease-specific and overall survival in duodenal graft-versus-host disease.

Histopathological evaluation of graft-versus-host disease (GVHD) is crucial in its diagnosis. In the upper gastrointestinal tract, the duodenum has been reported as the most affected site. However, studies characterizing the features of duodenal GVHD (dGVHD) are sparse and no study to date have compared the utility of the traditionally use Lerner grading system and the recently proposed Farooq grading system. 130 cases were included with a median age of 40 years (range: 0.8-73) and 50.8% of the patients were men. The median follow-up time was 32 months (range: 0-185), 83.1% of patients received treatment for GVHD with a treatment response seen in 63.1%, and the overall mortality and GVHD-specific mortality within 6 months of biopsy was 48.1% and 10.4%, respectively. Apoptotic bodies, crypt dropout and ulceration were seen in 58.5%, 12.3% and 6.2% of the cases, respectively. In 50% of cases there were 1-6 apoptotic bodies in 10 continuous crypts and in 8.5% there were >6. No apoptotic bodies, crypt dropout or ulceration were seen in 53 cases (no histologic evidence of GVHD), for the remaining 77 cases a Lerner and Farooq grade was assigned. Utilizing the Lerner grade system cases were considered as grade 1 (46.2%), grade 2 (2.3%), grade 3 (4.6%) and grade 4 (6.2%); and using the Farooq grade cases were considered as indeterminate for GVHD (71.4%), low grade (18.2%), intermediate grade (6.5%) and high grade (2.3%). Treatment response was associated with Farooq grade (p = 0.003) but not with Lerner grade (p = 0.440). Only age and the Farooq grade were independently associated with overall survival (p = 0.004 and 0.005, respectively) and GVHD-specific survival (p = 0.013 and 0.026, respectively) within 6 months of biopsy. The Farooq grading system should be utilized over the Lerner system in dGVHD.