Lois Ayash

Chronic graft-versus-host disease: clinical manifestation and therapy

Chronic graft-versus-host disease (GVHD) is a major cause of morbidity and mortality in long-term survivors of allogeneic stem cell transplantation. The immunopathogenesis of chronic GVHD is, in part, TH-2 mediated, resulting in a syndrome of immunodeficiency and an autoimmune disorder. The most important risk factor for chronic GVHD is prior history of acute GVHD and strategies that prevent acute GVHD also decrease the risk of chronic GVHD. Other important risk factors are the use of a non-T cell-depleted graft, and older age of donor and recipient. Whether recipients of peripheral blood stem cells are at increased risk of chronic GVHD remains unsettled. There are no known pharmacologic agents which can specifically prevent development of chronic GVHD. Agents which have efficacy in the treatment of autoimmune disorders have been utilized as therapy for established chronic GVHD and are associated with response rates of 20% to 80%. Most responses are confined to skin, soft tissue, oral mucosa and occasionally liver. Bronchiolitis obliterans responds infrequently to therapy and is associated with a dismal prognosis. Newer, promising therapeutic strategies under investigation include thalidomide, photopheresis therapy, anti-tumor necrosis factor and B cell depletion with anti-CD20 monoclonal antibody. Bone Marrow Transplantation (2001) 28, 121–129.

Treatment of chronic graft-versus-host disease with anti-CD20 chimeric monoclonal antibody

We reviewed the clinical outcome of 8 patients with steroid-refractory chronic graft-versus-host disease (GVHD) who received an anti-CD20 chimeric monoclonal antibody (rituximab). Rituximab was given by intravenous infusion at a weekly dose of 375 mg/m(2) for 4 weeks. All patients had received extensive treatment with various immunosuppressive agents; 6 patients had also received extracorporeal photopheresis. All patients had extensive chronic GVHD with diffuse or localized sclerodermoid GVHD and xerophthalmia. Other extracutaneous involvements included cold agglutinin disease with the Raynaud phenomenon, membranous glomerulonephritis, and restrictive or obstructive lung disease. Four patients responded to treatment with ongoing resolution or improvement ranging from 265 to 846 days after therapy, despite recovery of B cells in 3 patients. Rituximab seems to have significant activity in the treatment of refractory chronic GVHD and should be considered for further study in patients with early disease. This study suggests a participating role of B cells in the pathogenesis of chronic GVHD.

Cyclophosphamide pharmacokinetics: correlation with cardiac toxicity and tumor response.

BACKGROUND Cyclophosphamide, which forms the nucleus for virtually all preparative regimens for autologous bone marrow transplantation (ABMT), is an alkylating agent of which cytotoxicity is not directly caused by the parent compound but by its biologically active metabolites. Its nonmyelosuppressive toxicity in the ABMT setting is cardiomyopathy. We attempted to determine any correlation between plasma levels of total cyclophosphamide and the subsequent development of cardiac dysfunction. PATIENTS AND METHODS Analyses of plasma levels and the derivation of plasma concentration-time curves (area under the curve [AUC]) were performed in 19 women with metastatic breast carcinoma, who received a continuous 96-hour infusion of cyclophosphamide, thiotepa, and carboplatin (CTCb) with ABMT. The assay for total cyclophosphamide measures the inactive parent compound; reliable assays of the active metabolites of cyclophosphamide are not yet available. RESULTS Six of 19 women developed moderate, but transient, congestive heart failure (CHF) as assessed by clinical and radiologic criteria. These patients had a significantly lower AUC of total cyclophosphamide (median, 2,888 mumol/L/h) than patients who did not develop CHF (median, 6,121 mumol/L/h) (P less than .002). Median duration of tumor response in these patients was also more durable; at least 22 months in patients with lower AUCs versus a median of 5.25 months in those with higher AUCs (P = .008). CONCLUSION These pharmacokinetic data support the premise that enhancement of cyclophosphamide activation may lead to both greater tumor cytotoxicity and increased but reversible end-organ toxicity. Early analysis of pharmacokinetic data may allow modulation of cyclophosphamide administration in an attempt to enhance therapeutic efficacy.

Anti-CD20 Chimeric Monoclonal Antibody Treatment of Refractory Immune-Mediated Thrombocytopenia in a Patient with Chronic Graft-versus-Host Disease

Chronic graft-versus-host disease occurs in approximately 50% of long-term survivors of transplantation with marrow from HLA-identical donors (1); the risk for this disease increases with use of peripheral blood stem cells (2). Chronic graft-versus-host disease shares many of the clinical manifestations of autoimmune collagen vascular diseases, including oral ulceration, lichen planus, xerostomia, keratoconjunctivitis sicca, polyserositis, esophagitis and esophageal stricture, vaginal ulceration and stricture, intrahepatic obstructive liver disease, obstructive pulmonary disease, scleroderma, morphea, fasciitis, and myositis (3). Cytopenias, particularly thrombocytopenia, are a common feature of both chronic graft-versus-host disease and collagen vascular disease, and thrombocytopenia in chronic graft-versus-host disease is associated with poorer survival (4, 5). Antiplatelet antibodies are frequently detected in patients with thrombocytopenia associated with chronic graft-versus-host disease (6). Most patients with chronic graft-versus-host disease have evidence of B-cell dysregulation, with a high prevalence of autoantibodies to several cell surface and intracellular antigens (7). The role of these autoantibodies in the pathogenesis of chronic graft-versus-host disease is unclear. Autoimmune thrombocytopenia in chronic graft-versus-host disease may represent an instance of B-cell dysregulation leading to clinical disease. Rituximab is a humanized murine monoclonal antibody commonly used to treat B-cell lymphomas (8). This antibody is highly effective for in vivo depletion of B cells. Circulating B cells become undetectable after a single 375-mg/m2 infusion of rituximab; recovery of B cells begins at 6 to 9 months after treatment, and counts normalize by 9 to 12 months (9). Because of these biological properties of rituximab and the association of antiplatelet autoantibody with thrombocytopenia in patients with chronic graft-versus-host disease (6), we hypothesized that rituximab might have clinically significant activity in the treatment of refractory immune-mediated thrombocytopenia. We describe a patient with chronic graft-versus-host disease who developed severe refractory thrombocytopenia that responded to anti-CD20 chimeric antibody therapy. The rationale for this treatment was to eliminate B cells producing autoantibodies and thereby reverse the thrombocytopenia. Case Report A 32-year-old woman, gravida 3 para 1, presented with blurred vision and was found to have retinal hemorrhages. Complete blood count showed a leukocyte count of 451 109 cells/L with 2% basophils. A diagnosis of chronic myelogenous leukemia was confirmed by the presence of the Philadelphia chromosome in the marrow sample. The patient began receiving hydroxyurea to reduce her leukocyte count and was referred for stem-cell transplantation. She received 16 doses of busulphan (1 mg/kg of body weight every 6 hours) followed by cyclophosphamide (60 mg/kg daily for 2 days) in preparation for transplantation. Filgrastim-mobilized peripheral blood stem cells were harvested from an HLA-matched brother and were infused into the patient 3 months after diagnosis. The patients blood group was A+, and she was seropositive for cytomegalovirus; the donors blood group was O+, and he was seronegative for cytomegalovirus. Prophylaxis against graft-versus-host disease consisted of tacrolimus and methotrexate (10). The patient had prompt hematologic reconstitution, with an absolute neutrophil count of 0.5 109 cells/L on day 12 after transplantation and a platelet count greater than 100 109 cells/L on day 16 after transplantation. Therapy with ganciclovir, 5 mg/kg twice weekly, was started on day 16 as prophylaxis against cytomegalovirus infection. On day 28 after transplantation, the patient developed a maculopapular rash of the upper torso and diarrhea. Skin biopsy confirmed acute graft-versus-host disease, and she began receiving methylprednisolone, 1 mg/kg daily. The ganciclovir dose was increased prophylactically to 5 mg/kg 5 times per week. Bone marrow aspirate on day 100 after transplantation showed a normal male karyotype, and full donor chimerism was confirmed by polymerase chain reaction of microsatellite markers. The patient responded well to steroid therapy for the skin and gastrointestinal symptoms of graft-versus-host disease, but symptoms of xerophthalmia and xerostomia developed and steroid therapy was continued through day 127. On day 142, she underwent punctal occlusion of both eyes for severe xerophthalmia. Other manifestations of chronic graft-versus-host disease were progressive xerostomia with lichenoid changes of the oral mucosa. During the patients course of therapy with steroids and the increased dose of ganciclovir, her platelet count remained greater than 100 109 cells/L. On day 211, a complete blood count showed an absolute neutrophil count of 2.7 109 cells/L, hemoglobin value of 131 g/L, and platelet count of 178 109 cells/L. On day 230, the patients platelet count decreased to 88 109/cells/L. On day 238, it decreased further to 28 109 cells/L. No microangiopathic changes were seen on peripheral smear. Bone marrow aspiration and biopsy showed normal trilineage hematopoietic maturation with an adequate number of megakaryocytes. Flow cytometry showed the presence of platelet-associated IgG on washed, formalin-fixed platelets. Intravenous immunoglobulin, 500 mg/kg, was administered daily for 3 days; the platelet count increased to 159 109 cells/L, but for only 2 weeks. The patient then received 5 doses of intravenous immunoglobulins with methylprednisolone, 64 mg/d. On day 278, therapy with mycophenolate was started to provide additional immunosuppression. The combination of intravenous immunoglobulins, steroids, and mycophenolate resulted in an increase in platelet count to 114 109 cells/L by day 299. On day 308, the patients platelet count decreased to 51 109 cells/L. A dose of anti-D antibody (50 g/kg) was given, and the platelet count increased to 127 109 cells/L. However, the patient experienced significant hemolysis; her hemoglobin value decreased from 131 g/L to 78 g/L, an expected side effect related to the destruction of Rho (D)positive red cells. On day 337, she underwent laparoscopic splenectomy; an accessory spleen was also removed. By day 341, the platelet count increased to 139 109 cells/L but decreased to 2 109 cells/L 1 week later. Intravenous vincristine, 2 mg, was administered in four weekly doses starting on day 356, but it did not produce a response. The patient subsequently received intravenous cyclophosphamide, 1.5 g/m2, on day 384, again without response. On day 404, the patient received the first of four weekly doses of anti-CD20 antibody (rituximab [Rituxan, Genentech/IDEC, South San Francisco, California]). Peripheral blood flow cytometry on day 377 showed a CD19+ cell count (B cells) of 0.116 109 cells/L; by day 474, after rituximab therapy, CD19+ cells were absent. A gradual but sustained increase in the platelet count was noted after 2 doses of rituximab. The dose of mycophenolate mofetil was tapered and therapy was discontinued 3 weeks after initiation of rituximab therapy. At the time of this report, the patient has no clinically significant signs or symptoms of chronic graft-versus-host disease despite continued tapering of the tacrolimus dose and discontinuation of this therapy on day 667. The platelet-associated antibody assay remained weakly positive at day 485 and became negative on day 532. The patient has now been followed for 11 months since initiation of rituximab therapy, and the platelet count has not decreased (Table and Figure). Table. Chronological Clinical Course of the Patient Figure. Clinical course of a patient with chronic graft-versus-host disease in whom severe refractory immune-mediated thrombocytopenia responded to treatment with anti-CD20 monoclonal antibody. Discussion The reversal of our patients immune-mediated thrombocytopenia was especially noteworthy because of the lack of a sustained response to intensive immunosuppression, including treatment with steroids, mycophenolate, tacrolimus, vincristine, cyclophosphamide, intravenous immunoglobulins, anti-D antibody, and splenectomy. The improvement of thrombocytopenia was also associated with decreased levels of platelet-associated antibody and lack of progression of chronic graft-versus-host disease despite the discontinuation of immunosuppression. It is possible that cyclophosphamide therapy contributed in part to the platelet response. Reiner and colleagues (11) reported a series of 20 cases of refractory idiopathic thrombocytopenia purpura treated with pulse cyclophosphamide (1 to 1.5 g/m2), with complete remission in 65% of patients and partial remission in 20%. However, most patients required multiple pulses (mean, 2; maximum, 4), and the mean time to response was 7 weeks. Considering the intensity of the immunosuppressive therapy that our patient received and the lack of platelet response at the time of neutrophil recovery, it is unlikely that cyclophosphamide contributed substantially. Studies of B cells in patients with chronic graft-versus-host disease have not convincingly explained the clinical abnormalities, including reduced B-cell count, decreased Ig production, and increased spontaneous Ig production (12), seen in this condition. Clonal dysregulation of B cells in chronic graft-versus-host disease has been suggested by the presence of monoclonal gammopathy (13, 14) and elevated serum IgG and IgM levels (15). Antibody production is a prominent feature of many animal models of chronic graft-versus-host disease (16, 17). Mechanistic studies showed that secretion of Th2 cytokines, such as interleukin-4 and interleukin-5, by donor CD4+ cells are critical to B-cell activation and autoantibody production. Most of the autoantibodies are of the IgG subclass (16), and abnormal cross-linking of IgG receptors on t

Double dose-intensive chemotherapy with autologous marrow and peripheral-blood progenitor-cell support for metastatic breast cancer: a feasibility study.

PURPOSE Twenty-seven percent of responding metastatic breast cancer patients remain progression-free a median 29 months following one intensification course of cyclophosphamide (6,000 mg/m2), thiotepa (500 mg/m2), and carboplatin (800 mg/m2) (CTCb) with autologous bone marrow transplantation (ABMT). European investigators report high complete response (CR) rates with melphalan for breast cancer. This trial studied the feasibility of two tandem high-dose intensification therapies in an attempt to optimize disease response and duration. PATIENTS AND METHODS Women with at least partial responses (PRs) to induction therapy received melphalan (140 to 180 mg/m2), followed 24 hours later by chemotherapy and granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral-blood progenitor cells (PBPCs) and subsequent G-CSF until WBC recovery. The women were monitored as outpatients. After recovery, patients were hospitalized for CTCb with marrow, PBPC, and G-CSF support. RESULTS Twenty women were assessable. Fourteen (70%) required admission for fever (10% infection) or mucositis (35%) after melphalan (median stay, 5 days). Median days of absolute neutrophil count (ANC) less than 500/microL and platelet count less than 20,000/microL were 6 and 5.5, respectively. Patients received CTCb 25 days after starting melphalan and had a hospital stay of 25 days. After CTCb, median days of ANC less than 500/microL and platelet count less than 20,000/microL were 11.5 and 24, respectively. Grade 3 toxicities included venoocclusive disease (VOD) (10%), mucositis (45%), and infection (20%). Toxicities were reversible without mortality. CONCLUSION With mobilized PBPCs and growth factors, double dose-intensive chemotherapy is feasible with acceptable toxicity. When compared with trials using marrow alone, these supportive adjuncts decrease sepsis and organ toxicity. The concepts of dose and dose-intensity may now be more effectively and safely studied in chemosensitive tumors, including breast cancer.

Prognostic factors for prolonged progression-free survival with high-dose chemotherapy with autologous stem-cell support for advanced breast cancer.

PURPOSE With a median observation time of 50 months from transplant, 13 (22%) of 62 women with metastatic breast cancer treated with high-dose chemotherapy at the Dana-Farber Cancer Institute (DFCI)/Beth Israel Hospital (BIH) remain progression-free. This study determined factors prognostic for prolonged progression-free survival (PFS). METHODS From June 1988 to January 1992, women who responded to standard chemotherapy received high-dose cyclophosphamide, thiotepa, and carboplatin with autotransplantation. Data encompassing initial breast cancer diagnosis, metastatic presentation, and response to induction treatment were examined for correlations with improved PFS. RESULTS The 5-year PFS rate for the entire group is estimated to be 21% (95% confidence interval [CI], 10% to 32%). For those patients who attained a complete response (CR) to induction therapy, the 5-year PFS rate is estimated to be 31% (95% CI, 0% to 63%). In univariate analyses, a single metastatic site, CR to induction therapy, prolonged interval from primary diagnosis to first metastases, estrogen receptor (ER)-negative tumors, and older age (> or = 40 years) were associated with prolonged PFS. In multivariate analyses, single metastatic site (P = .002) and attainment of a CR to induction chemotherapy (P = .04) were the most significant predictors for PFS, with a strong trend observed for an interval from primary diagnosis to onset of metastatic disease of 24+ months (P = .066). CONCLUSION We and others have shown that 10% to 25% of women with metastatic breast cancer are progression-free after high-dose chemotherapy with autotransplantation. Those with chemosensitive disease, minimal tumor bulk, and a prolonged disease-free interval appear to benefit most. Emphasis should continue to focus on the development of more effective cytotoxic regimens and biologic approaches to increase the percentage of patients who may benefit from this approach.

Lowered-intensity preparative regimen for allogeneic stem cell transplantation delays acute graft-versus-host disease but does not improve outcome for advanced hematologic malignancy.

Reduced conditioning intensity has extended the option of allogeneic hematopoietic stem cell transplantation to patients who cannot tolerate fully myeloablative regimens. However, relapse and graft-versus-host disease (GVHD) continue to be major causes of morbidity and mortality. We prospectively tested whether a moderate reduction of the intensity of the preparative regimen would lead to significant reduction in regimen-related toxicity without compromising tumor control in a cohort of 44 patients ineligible for conventional hematopoietic stem cell transplantation. Patients were conditioned with fludarabine, busulfan, mycophenolate, and total lymphoid irradiation. Tacrolimus and methotrexate were given as prophylaxis for GVHD. Donors were 5 of 6 or 6 of 6 matched family members. The median age was 61 years. Eleven patients had comorbid conditions that precluded conventional myeloablative transplantation. Fatal regimen-related organ toxicity occurred in 3 patients. The cumulative incidence of grade 2 to 4 or grade 3 to 4 acute GVHD by day 100 was 38% (95% confidence interval [CI] = 25%, 55%) and 20% (95% CI = 10%, 39%), respectively, with a median time to onset of 66 days. For the entire cohort, 1-year overall survival, disease-free survival, and relapse rates were 54% (95% CI = 41%, 71%), 47% (95% CI = 35%, 65%), and 37% (95% CI = 19%, 51%), respectively. Outcomes differed based on stage of disease at time of transplantation, advanced (n = 19) versus nonadvanced (n = 25). Median survival times were 138 days and 685 days for subjects with advanced and nonadvanced disease, respectively (P =.005). After adjusting for age and comorbidity, disease stage continued to be significantly associated with overall survival (P =.005). In conclusion, a moderate reduction in conditioning dose intensity resulted in delayed onset of acute GVHD (compared with historical controls). A reduction in conditioning intensity is associated with poor survival for patients with advanced-stage disease, highlighting the importance of the conditioning regimen for tumor control.

Double dose-intensive chemotherapy with autologous stem cell support for relapsed and refractory testicular cancer: The University of Michigan experience and literature review

Testicular cancer patients refractory or in relapse after primary chemotherapy have ⩽25% 5-year progression-free survival with salvage. To improve prognosis, patients entered a phase I/II tandem dose-escalation trial of carboplatin (1500–2100 mg/m2) and etoposide (1200–2250 mg/m2) with ABMT. Patients were eligible for a second cycle if disease progression was absent and performance status allowed. From August 1990 to June 1998, 29 males (25 NSGCT) were treated. At the time of ABMT, 10 were chemosensitive, four were chemoresistant, and 10 were absolutely refractory to platinum. Disease status (no. patients) at transplant: primary refractory disease (six), first relapse (10), second relapse (eight), third relapse (five). Fifteen (52%) received both transplants. Treatment-related mortality was 10%. Best response after ABMT included: two CR, one CR surgically NED, five PR, three PR surgically NED, seven SD, and eight PD. Eight (28%) patients are continuously progression-free a median 60 months (range, 31–93) from first ABMT. Three seminoma patients remain progression-free. Of five long-term NSGCT survivors, four were treated in first relapse with platinum-sensitive disease. Eighteen relapses occurred a median of 4 months after ABMT I (two late relapses at 28 and 44 months). The median PFS and OS for the whole group are 4 and 14 months, respectively. Patients with relapsed/ refractory testicular cancer benefit most from ABMT if they have platinum-sensitive disease in first relapse. Patients who do poorly despite ABMT have a mediastinal primary site, true cisplatin-refractory disease, disease progression prior to ABMT, and/or markedly elevated βHCG at ABMT. New treatment modalities are needed for the latter group. Bone Marrow Transplantation (2001) 27, 939–947.

Tacrolimus as monotherapy or combined with minidose methotrexate for graft-versus-host disease prophylaxis after allogeneic peripheral blood stem cell transplantation: long-term outcomes

Summary:We report long-term outcomes for allogeneic peripheral blood stem cell (PBSC) recipients, evaluating cumulative incidence (CI) of acute and chronic graft-versus-host disease (GVHD), after use of tacrolimus with or without minidose methotrexate for GVHD prophylaxis. From April 1996 to April 1998, 97 adults underwent allogeneic PBSC transplantation. The first 49 received tacrolimus monotherapy as GVHD prophylaxis and the subsequent 48 received combination therapy. The median follow-up for survivors was 67 months. Compared to combination therapy, tacrolimus monotherapy resulted in enhanced neutrophil engraftment, shortened hospitalization, comparable rates of GVHD, and equivalent 100-day survival. The CI of grades II–IV acute GVHD was 35% with tacrolimus and 23% with the combination (P=0.19). The CI of III–IV GVHD was 22% for tacrolimus and 19% for the combination. CI of chronic GVHD was similar between the two groups (P=0.5). Patients with good-risk disease had superior overall survival (OS) when compared to those with poor-risk features (P<0.001). Within the good-risk disease category, patients receiving methotrexate had a trend towards improved OS (P=0.07). Multivariate analysis indicated good-risk disease status and methotrexate were independently associated with improved OS, progression-free survival (PFS), and relapse. In addition, patients developing chronic GVHD had a significantly reduced risk of relapse and improved PFS.

West Nile virus encephalitis causing fatal CNS toxicity after hematopoietic stem cell transplantation.

Summary:We describe here a patient who died of progressive CNS deterioration following allogeneic stem cell transplant with West Nile virus as the sole pathogen on the cerebrospinal fluid and brain tissue analysis. A 50-year-old male with Philadelphia chromosome-positive acute lymphocytic leukemia (ALL) underwent allogeneic PBSCT from his HLA identical sister. After engraftment, the patient developed fever with progressive and ultimately fatal neurological deterioration. Imaging studies of the brain including CT and MRI scans were remarkable for mild low attenuation lesions of the white matter. CSF analysis was negative for neoplastic cells, bacteria, AFB, CMV, HSV, fungal infections and leukemic relapse. However, serological analysis of both the serum and CSF was positive for West Nile virus-specific IgM antibodies. At autopsy, West Nile virus PCR and cultures were positive in the mid-brain tissue. Electron micrographs showed evidence of viral particles. Given the recent increase in the spread of West Nile virus infections and the increased susceptibility of BMT patients to infectious complications, West Nile virus encephalitis should be considered in patients undergoing transplantation.