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Ross LA, Stropp LM, Cohen JA. Autologous Hematopoietic Stem Cell Transplantation to Treat Multiple Sclerosis. Neurol Clin 2024; 42:165-184. [PMID: 37980114 DOI: 10.1016/j.ncl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
In aggregate, the available data suggest autologous hematopoietic stem cell transplantation (AHSCT) has potent, durable efficacy to treat relapsing multiple sclerosis (MS). Safety issues and financial costs are significant but largely associated with the procedure itself. AHSCT is a reasonable option for patients with highly active relapsing MS and an inadequate response to the available disease therapies. The key question is where to place AHSCT in the overall relapsing MS algorithm relative to other high-efficacy therapies. Ongoing randomized trials will better characterize the benefit and risk of AHSCT compared with currently available high-efficacy disease therapies.
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Affiliation(s)
- Lindsay A Ross
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Lisa M Stropp
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jeffrey A Cohen
- Mellen Center, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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2
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Bellanca CM, Augello E, Mariottini A, Bonaventura G, La Cognata V, Di Benedetto G, Cantone AF, Attaguile G, Di Mauro R, Cantarella G, Massacesi L, Bernardini R. Disease Modifying Strategies in Multiple Sclerosis: New Rays of Hope to Combat Disability? Curr Neuropharmacol 2024; 22:1286-1326. [PMID: 38275058 PMCID: PMC11092922 DOI: 10.2174/1570159x22666240124114126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/21/2023] [Accepted: 09/22/2023] [Indexed: 01/27/2024] Open
Abstract
Multiple sclerosis (MS) is the most prevalent chronic autoimmune inflammatory- demyelinating disorder of the central nervous system (CNS). It usually begins in young adulthood, mainly between the second and fourth decades of life. Usually, the clinical course is characterized by the involvement of multiple CNS functional systems and by different, often overlapping phenotypes. In the last decades, remarkable results have been achieved in the treatment of MS, particularly in the relapsing- remitting (RRMS) form, thus improving the long-term outcome for many patients. As deeper knowledge of MS pathogenesis and respective molecular targets keeps growing, nowadays, several lines of disease-modifying treatments (DMT) are available, an impressive change compared to the relative poverty of options available in the past. Current MS management by DMTs is aimed at reducing relapse frequency, ameliorating symptoms, and preventing clinical disability and progression. Notwithstanding the relevant increase in pharmacological options for the management of RRMS, research is now increasingly pointing to identify new molecules with high efficacy, particularly in progressive forms. Hence, future efforts should be concentrated on achieving a more extensive, if not exhaustive, understanding of the pathogenetic mechanisms underlying this phase of the disease in order to characterize novel molecules for therapeutic intervention. The purpose of this review is to provide a compact overview of the numerous currently approved treatments and future innovative approaches, including neuroprotective treatments as anti-LINGO-1 monoclonal antibody and cell therapies, for effective and safe management of MS, potentially leading to a cure for this disease.
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Affiliation(s)
- Carlo Maria Bellanca
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Egle Augello
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Alice Mariottini
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Gabriele Bonaventura
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Valentina La Cognata
- Institute for Biomedical Research and Innovation (IRIB), Italian National Research Council, 95126 Catania, Italy
| | - Giulia Di Benedetto
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
| | - Anna Flavia Cantone
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppe Attaguile
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Rosaria Di Mauro
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Giuseppina Cantarella
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
| | - Luca Massacesi
- Department of Neurosciences Drugs and Child Health, University of Florence, Florence, Italy
| | - Renato Bernardini
- Department of Biomedical and Biotechnological Sciences (BIOMETEC), Section of Pharmacology, University of Catania, 95123 Catania, Italy
- Clinical Toxicology Unit, University Hospital, University of Catania, 95123 Catania, Italy
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3
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Hematopoietic Stem Cell Transplantation for the Treatment of Autoimmune Neurological Diseases: An Update. Bioengineering (Basel) 2023; 10:bioengineering10020176. [PMID: 36829670 PMCID: PMC9952685 DOI: 10.3390/bioengineering10020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Over the last two decades, haematopoietic stem cell transplantation (HSCT) has been explored as a potential therapeutic strategy for autoimmune diseases refractory to conventional treatments, including neurological disorders. Although both autologous (AHSCT) and allogeneic HSCT (allo-HSCT) were investigated, AHSCT was preferentially developed due to a more favourable safety profile compared to allo-HSCT. Multiple sclerosis (MS) represents the most frequent neurological indication for AHSCT, but increasing evidence on the potential effectiveness of transplant in other autoimmune neurological diseases is emerging, although with a risk-benefit ratio overall more uncertain than in MS. In the present work, the rationale for the use of HSCT in neurological diseases and the experimental models that prompted its clinical application will be briefly covered. Case series and prospective studies exploring the use of HSCT in autoimmune diseases other than MS will be discussed, covering both frequent and rare neurological disorders such as myasthenia gravis, myopathies, and stiff-person syndrome. Finally, an updated summary of ongoing and future studies focusing on this issue will be provided.
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Patti F, Chisari CG, Toscano S, Arena S, Finocchiaro C, Cimino V, Milone G. Autologous Hematopoietic Stem Cell Transplantation in Multiple Sclerosis Patients: Monocentric Case Series and Systematic Review of the Literature. J Clin Med 2022; 11:jcm11040942. [PMID: 35207216 PMCID: PMC8875789 DOI: 10.3390/jcm11040942] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple sclerosis (MS) is a chronic, inflammatory and immune-mediated disease of the central nervous system (CNS), commonly affecting young adults and potentially associated with life-long disability. About 14 disease-modifying treatments (DMTs) are currently approved for the treatment of MS. However, despite the use of highly effective therapies, some patients exhibit a highly active disease with an aggressive course from onset and a higher risk of long-term disability accrual. In the last few years, several retrospective studies, clinical trials, meta-analyses and systematic reviews have investigated autologous hematopoietic stem cell transplantation (AHSCT) as a possible therapeutic option in order to address this unmet clinical need. These studies demonstrated that AHSCT is a highly efficacious and relatively safe therapeutic option for the treatment of highly active MS. Particularly, over recent years, the amount of evidence has grown, with significant improvements in the development of patient selection criteria, choice of the most suitable transplant technique and clinical experience. In this paper, we present six patients who received AHSCT in our MS center and we systematically reviewed recent evidence about the long-term efficacy and safety of AHSCT and the placement of AHSCT in the rapidly evolving therapeutic armamentarium for MS.
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Affiliation(s)
- Francesco Patti
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Clara Grazia Chisari
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
- Correspondence: (F.P.); (C.G.C.); Tel.: +39-09-5378-2620 (F.P.)
| | - Simona Toscano
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Sebastiano Arena
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Chiara Finocchiaro
- Department of Medical, Surgical Sciences and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95125 Catania, Italy; (S.T.); (S.A.); (C.F.)
| | - Vincenzo Cimino
- IRCCS Centro Neurolesi “Bonino Pulejo”, 98124 Messina, Italy;
| | - Giuseppe Milone
- Hematology and Bone Marrow Transplant Unit, Azienda Policlinico-Vittorio Emanuele, 95124 Catania, Italy;
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5
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Moraes DA, Oliveira MC. Life after Autologous Hematopoietic Stem Cell Transplantation for Systemic Sclerosis. J Blood Med 2021; 12:951-964. [PMID: 34785969 PMCID: PMC8590726 DOI: 10.2147/jbm.s338077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/26/2021] [Indexed: 12/29/2022] Open
Abstract
Stem cell transplantation has been investigated as treatment for severe and progressive systemic sclerosis (SSc) for the past 25 years. To date, more than 1000 SSc patients have been transplanted worldwide. Overall and event-free survival have increased over the years, reflecting stricter patient selection criteria and better clinical management strategies. This review addresses long-term outcomes of transplanted SSc patients, considering phase I/II and randomized clinical trials, as well as observational studies and those assessing specific aspects of the disease. Clinical outcomes are discussed comparatively between studies, highlighting advances, drawbacks and controversies in the field. Areas for future development are also discussed.
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Affiliation(s)
- Daniela A Moraes
- Division of Clinical Immunology, Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Maria Carolina Oliveira
- Center for Cell-Based Therapy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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6
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Chatterton S, Withers B, Sutton IJ, Milliken ST, Ma DD, Moore JJ, Massey JC. Pregnancy post autologous stem cell transplant with BEAM conditioning for multiple sclerosis. Mult Scler 2021; 27:2112-2115. [PMID: 33870788 DOI: 10.1177/13524585211005660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Given the increasing numbers of multiple sclerosis (MS) patients undergoing autologous haematopoietic stem cell transplant (AHSCT) worldwide, and with women of childbearing age overrepresented in the target population, it is increasingly important to review fertility and pregnancy outcomes following AHSCT. OBJECTIVE To evaluate the rate of pregnancy and complications post-AHSCT for MS. METHOD Retrospective evaluation of the rate of pregnancy and associated complications in a cohort of patients post-AHSCT with BEAM conditioning for MS since 2010 in a tertiary referral centre. RESULTS In our ongoing Phase 2 trial of AHSCT for MS, 55 patients have undergone AHSCT with 30 females being of childbearing age at time of transplantation. Four pregnancies occurred following AHSCT. Two pregnancies were carried to term. No maternal or neonatal complications were reported in either case. Two pregnancies were not carried to term due to elective terminations. Both of these patients became pregnant unexpectedly 2 years following AHSCT. Of the 21 male patients, one patient has fathered three children since his AHSCT. There were no newborn complications. CONCLUSIONS This is the first report to our knowledge on fertility outcomes in both sexes post-AHSCT for MS. Patients of both sexes should be counselled prior to treatment on infertility and contraceptive use.
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Affiliation(s)
- Sophie Chatterton
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia/St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia
| | - Barbara Withers
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia/Department of Haematology and Bone Marrow Transplantation, St Vincent's Health Network, Darlinghurst, NSW, Australia/Kinghorn Cancer Centre and St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Ian J Sutton
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Samuel T Milliken
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia/Department of Haematology and Bone Marrow Transplantation, St Vincent's Health Network, Darlinghurst, NSW, Australia/Kinghorn Cancer Centre and St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - David Df Ma
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia/Department of Haematology and Bone Marrow Transplantation, St Vincent's Health Network, Darlinghurst, NSW, Australia/Kinghorn Cancer Centre and St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - John J Moore
- St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia/Department of Haematology and Bone Marrow Transplantation, St Vincent's Health Network, Darlinghurst, NSW, Australia/Kinghorn Cancer Centre and St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Jennifer C Massey
- Department of Neurology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia/St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW, Australia/Department of Haematology and Bone Marrow Transplantation, St Vincent's Health Network, Darlinghurst, NSW, Australia; Kinghorn Cancer Centre and St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
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7
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Massarotti C, Sbragia E, Boffa G, Vercelli C, Zimatore GB, Cottone S, Frau J, Raiola A, Varaldo R, Mancardi G, Inglese M, Anserini P. Menstrual cycle resumption and female fertility after autologous hematopoietic stem cell transplantation for multiple sclerosis. Mult Scler 2021; 27:2103-2107. [PMID: 33709839 DOI: 10.1177/13524585211000616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data on fertility after autologous hematopoietic stem cell transplantation (aHSCT) in women with multiple sclerosis (MS) are inconclusive. This study aims to report on post-aHSCT menstrual resumption in a multi-center MS-women cohort. Out of 43 women, 30 (70%) recovered menses after a mean time of 6.8 months. Older age (odds ratio (OR) = 0.5, p < 0.0001) and previous pulsed cyclophosphamide (OR = 0.44, p = 0.005) were independently associated with a reduced menstrual recovery probability. Conditioning regimens' intensity resulted not associated with post-procedure amenorrhea. Our results highlight younger age as significantly associated with menses recovery; proper fertility counseling for MS women candidated to aHSCT both prior- and post-transplantation is therefore warranted.
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Affiliation(s)
- Claudia Massarotti
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Health (DiNOGMI), University of Genova, Genova, Italy/Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elvira Sbragia
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Giacomo Boffa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Health (DiNOGMI), University of Genova, Genova, Italy
| | | | - Giovanni Bosco Zimatore
- Department of Neurology, Ospedale Generale Regionale "F. Miulli," Acquaviva delle Fonti, Puglia, Italy
| | | | - Jessica Frau
- Multiple Sclerosis Centre, Binaghi Hospital, ASSL Cagliari, ATS Sardegna, Cagliari, Italy
| | - Annamaria Raiola
- Division of Hematology and Bone Marrow Transplantation, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Riccardo Varaldo
- Division of Hematology and Bone Marrow Transplantation, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Gianluigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Health (DiNOGMI), University of Genova, Genova, Italy/Scientific Clinical Institutes Maugeri IRCCS, Pavia, Italy
| | - Matilde Inglese
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Child Health (DiNOGMI), University of Genova, Genova, Italy/Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Paola Anserini
- Physiopathology of Human Reproduction Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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8
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Mariottini A, De Matteis E, Muraro PA. Haematopoietic Stem Cell Transplantation for Multiple Sclerosis: Current Status. BioDrugs 2021; 34:307-325. [PMID: 32166703 DOI: 10.1007/s40259-020-00414-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a treatment option for aggressive forms of multiple sclerosis (MS) that has been derived from haematological indications and repurposed for treatment of refractory autoimmune diseases. In the present review, a search for clinical studies on AHSCT was performed on the PubMed website and ClinicalTrials.gov databases. Papers were selected according to the following criteria: text written in English language, publication date between 2014 and August 2019, and reports including more than five patients. Prospective randomised and uncontrolled trials and retrospective case series were reviewed to examine the safety and efficacy of the procedure. Treatment protocols, pathological data and economic aspects of AHSCT were also succinctly covered. Growing evidence suggests that long-term suppression of inflammatory activity with stabilization or improvement of disability can be achieved in a high proportion of properly selected patients. More sophisticated outcome measures recently adopted, including effect on brain atrophy and disease biomarkers, are giving further insight into the effectiveness of transplant. The risks of the procedure have decreased to levels that can be considered acceptable for treatment of individuals with aggressive forms of MS. Careful selection of patients with an expected good benefit/risk profile, which is maximal when AHSCT is performed in early phases of the disease, and the expertise of transplant centres are critical to the success of treatment. Higher efficacy of AHSCT than with conventional treatments has recently been demonstrated by one randomised trial and further evidence is awaited from ongoing and planned trials comparing AHSCT with the most effective disease-modifying therapeutic agents.
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Affiliation(s)
- Alice Mariottini
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Drug and Child Health, University of Florence, Florence, Italy
| | - Eleonora De Matteis
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.,Department of Neurosciences, Mental Health and Sensory Organs, Faculty of Medicine and Psychology, Centre for Experimental Neurological Therapies, Sapienza University, Rome, Italy
| | - Paolo A Muraro
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Burlington Danes Building, Du Cane Road, Hammersmith Hospital Campus, London, W12 0NN, UK.
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9
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Bose G, Freedman MS. Recent advances and remaining questions of autologous hematopoietic stem cell transplantation in multiple sclerosis. J Neurol Sci 2021; 421:117324. [PMID: 33497951 DOI: 10.1016/j.jns.2021.117324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The judicious use of autologous hematopoietic stem cell transplantation (AHSCT) for MS requires understanding the potential benefits, identifying the most appropriate patient, and acknowledging the risks and differences between different protocols. Recently, AHSCT for MS is occurring more frequently, with a better safety profile than earlier studies. This review assesses recently published studies to determine the advances that have been made and remaining questions that future studies are poised to answer. We included studies from January 2016 to November 2020 with 20 or more patients. The benefits of AHSCT, including "no evidence of disease activity", functional and patient-reported outcomes, novel biomarkers such as brain atrophy or neurofilament light chain, and cost-effectiveness were assessed. The patient selection, treatment protocols, and safety outcomes differ between reports. The overall efficacy of AHSCT is better than standard treatments. Younger patients with highly active disease have greater chance for improvement, while patients who have comorbidities, failed more treatments, and are transitioning to a more progressive phase may not respond as well to AHSCT. The safety profiles for all AHSCT protocols is improving, however the durability of treatment response may not be the same for all protocols. The goal of AHSCT is to stop disease activity, avoid worsening disability, and obviate the need for further disease-modifying treatment, while improving patient quality of life and minimizing treatment-related risk. Results from currently enrolling randomized controlled trials, as well as ongoing registries, will provide more evidence for the safe and appropriate use of AHSCT.
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Affiliation(s)
- Gauruv Bose
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital Civic Campus, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada.
| | - Mark S Freedman
- University of Ottawa, The Ottawa Hospital Research Institute, Department of Medicine, The Ottawa Hospital General Campus, 501 Smyth Road, Box 606, Ottawa, ON K1H 8L6, Canada.
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10
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Roberts F, Hobbs H, Jessop H, Bozzolini C, Burman J, Greco R, Ismail A, Kazmi M, Kirgizov K, Mancardi G, Mawson S, Muraro PA, Puyade M, Saccardi R, Withers B, Verhoeven B, Sharrack B, Snowden JA. Rehabilitation Before and After Autologous Haematopoietic Stem Cell Transplantation (AHSCT) for Patients With Multiple Sclerosis (MS): Consensus Guidelines and Recommendations for Best Clinical Practice on Behalf of the Autoimmune Diseases Working Party, Nurses Group, and Patient Advocacy Committee of the European Society for Blood and Marrow Transplantation (EBMT). Front Neurol 2020; 11:556141. [PMID: 33362684 PMCID: PMC7759663 DOI: 10.3389/fneur.2020.556141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 11/06/2020] [Indexed: 12/29/2022] Open
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is increasingly used to treat people with multiple sclerosis (MS). Supported by an evolving evidence base, AHSCT can suppress active inflammation in the central nervous system and induce long-term changes in immune cell populations, thereby stabilizing, and, in some cases, reversing disability in carefully selected MS patients. However, AHSCT is an intensive chemotherapy-based procedure associated with intrinsic risks, including profound cytopenia, infection, and organ toxicity, accompanied by an on-going degree of immuno-compromise and general deconditioning, which can be associated with a transient increase in functional impairment in the early stages after transplantation. Although international guidelines and recommendations have been published for clinical and technical aspects of AHSCT in MS, there has been no detailed appraisal of the rehabilitation needed following treatment nor any specific guidelines as to how this is best delivered by hospital and community-based therapists and wider multidisciplinary teams in order to maximize functional recovery and quality of life. These expert consensus guidelines aim to address this unmet need by summarizing the evidence-base for AHSCT in MS and providing recommendations for current rehabilitation practice along with identifying areas for future research and development.
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Affiliation(s)
| | - Helen Hobbs
- Hobbs Rehabilitation, Winchester, United Kingdom
| | - Helen Jessop
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | | | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), San Raffaele Scientific Hospital, Milan, Italy
| | - Azza Ismail
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, United Kingdom
| | - Kirill Kirgizov
- Institute of Paediatric Oncology and Haematology, N.N. Blokhin National Medical Research Center of Oncology, Moscow, Russia
| | - Gianluigi Mancardi
- Department of Neuroscience, University of Genova and Clinical Scientific Institutes Maugeri, Genoa, Italy
| | - Susan Mawson
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Mathieu Puyade
- CHU de Poitiers, Service de Médecine Interne et Maladies Infectieuses, Poitiers, France.,CHU de Poitiers, CIC-1402, Poitiers, France
| | | | - Barbara Withers
- Department of Haematology and Blood Stem Cell Transplantation, St Vincent's Health Network Sydney and Senior Lecturer, St Vincent's Clinical School, University of New South Wales Medicine, Sydney, NSW, Australia
| | - Bregje Verhoeven
- Patient Advocacy Committee, EBMT Executive Office, Barcelona, Spain
| | - Basil Sharrack
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.,School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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11
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Selective cognitive dysfunction and physical disability improvement after autologous hematopoietic stem cell transplantation in highly active multiple sclerosis. Sci Rep 2020; 10:21286. [PMID: 33277590 PMCID: PMC7718237 DOI: 10.1038/s41598-020-78160-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/18/2020] [Indexed: 12/29/2022] Open
Abstract
The aim was to assess the cognitive dysfunction and physical disability after autologous hematopoietic stem cell transplantation (AHSCT), to explore the potential factors influencing disability regression after AHSCT and to estimate the safety of low-dose immunosuppressive therapy in highly active Multiple Sclerosis (MS) patients. In single-center prospective study patients who failed to conventional therapies for highly active relapsing MS underwent the AHSCT. The disability was followed up with Expanded Disability Status Scale and cognition with Brief International Cognitive Assessment for Multiple Sclerosis. Twenty four patients [18 (72.0%) female] underwent AHSCT. Two patients of 13 had one relapse during the first year and three patients-during the second year after AHSCT. Disability regression was found in 84.6% of patients. The scores of information processing speed and verbal learning were significantly higher at month 12 after AHSCT. The clinical variable that explained the disability regression at months 6 and 12 after AHSCT was the disability progression over 6 months before AHSCT. No transplant related-deaths were observed. Selective cognitive improvement was found after AHSCT in MS patients. The disability may be temporarily reversible after AHSCT in a significant proportion of highly active RMS patients if AHSCT is well-timed performed.
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12
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Bertolotto A, Martire S, Mirabile L, Capobianco M, De Gobbi M, Cilloni D. Autologous Hematopoietic Stem Cell Transplantation (AHSCT): Standard of Care for Relapsing-Remitting Multiple Sclerosis Patients. Neurol Ther 2020; 9:197-203. [PMID: 32548740 PMCID: PMC7606396 DOI: 10.1007/s40120-020-00200-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 12/24/2022] Open
Abstract
Autologous hematopoietic stem cell transplantation (AHSCT) has been used in the treatment of highly active multiple sclerosis (MS) for over two decades. It has been demonstrated to be highly efficacious in relapsing-remitting (RR) MS patients failing to respond to disease-modifying drugs (DMDs). AHSCT guarantees higher rates of no evidence of disease activity (NEDA) than those achieved with any other DMDs, but it is also associated with greater short-term risks which have limited its use. In the 2019 updated EBMT and ASBMT guidelines, which review the clinical evidence of AHSCT in MS, AHSCT indication for highly active RRMS has changed from "clinical option" to "standard of care". On this basis, AHSCT must be proposed on equal footing with second-line DMDs to patients with highly active RRMS, instead of being considered as a last resort after failure of all available treatments. The decision-making process requires a close collaboration between transplant hematologists and neurologists and a full discussion of risk-benefit of AHSCT and alternative treatments. In this context, we propose a standardized protocol for decision-making and informed consent process.
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Affiliation(s)
- Antonio Bertolotto
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy.
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy.
| | - Serena Martire
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Luca Mirabile
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco Capobianco
- Neurologia-CRESM (Centro Riferimento Regionale Sclerosi Multipla), AOU San Luigi Gonzaga, Orbassano, TO, Italy
- Clinical Neurobiology Unit, Neuroscience Institute Cavalieri Ottolenghi, Orbassano, TO, Italy
| | - Marco De Gobbi
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
| | - Daniela Cilloni
- SSD Terapia oncoematologica intensiva e trapianto CSE, AOU San Luigi Gonzaga, Dipartimento di Scienze Cliniche e Biologiche, University of Turin, Turin, Italy
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Autologous Haematopoietic Stem Cell Transplantation in Multiple Sclerosis: a Review of Current Literature and Future Directions for Transplant Haematologists and Oncologists. Curr Hematol Malig Rep 2020; 14:127-135. [PMID: 30828772 PMCID: PMC6510794 DOI: 10.1007/s11899-019-00505-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review We summarise the current development of autologous haematopoietic stem cell transplantation (AHSCT) in treating multiple sclerosis (MS) and discuss future directions for the general neurologist, transplant haematologist and oncologist. Recent Findings AHSCT was initially performed to treat MS over 20 years ago. Over recent years, the evidence base has grown, especially in relapsing-remitting MS (RRMS), with significant improvements in safety and efficacy through better patient selection, choice of transplant technique and increase in centre experience. Summary AHSCT is now a treatment option in very carefully selected patients with severe, treatment-resistant RRMS. However, it is important for transplant haematologists and oncologists to work closely with specialist MS neurologists in patient selection, during transplant and in long-term follow-up of patients. Data should be registered into international transplant registries and, ideally, patients should be enrolled on prospective clinical trials in order to build the evidence base and refine transplant techniques.
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14
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Bose G, Thebault S, Rush CA, Atkins HL, Freedman MS. Autologous hematopoietic stem cell transplantation for multiple sclerosis: A current perspective. Mult Scler 2020; 27:167-173. [PMID: 32364422 DOI: 10.1177/1352458520917936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The most effective treatment at halting inflammation in patients with highly active multiple sclerosis (MS) is immune ablation followed by autologous hematopoietic stem cell transplantation (AHSCT). Better patient selection and supportive management, as well as advances in conditioning regimens have resulted in improved safety with AHSCT. However, which comorbidities or prior therapies increase the risks associated with AHSCT still need to be determined. In addition, there is still debate as to which AHSCT conditioning regimen offers the best balance of long-term efficacy and safety. New studies comparing AHSCT with highly effective disease-modifying therapies will help to inform on the ideal placement of AHSCT in the treatment algorithm. Currently, many centers are experienced and use AHSCT to treat select patients with MS, contributing to ongoing registries and clinical trials which will help answer these questions.
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Affiliation(s)
- Gauruv Bose
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Simon Thebault
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Carolina A Rush
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Harold L Atkins
- Department of Medicine, Division of Hematology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Mark S Freedman
- Department of Medicine, Division of Neurology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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15
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[Autologous hematopoietic stem cell transplantation for systemic sclerosis : Position statement of the stem cell therapy working party of the German Society of Rheumatology]. Z Rheumatol 2020; 79:429-436. [PMID: 32322977 DOI: 10.1007/s00393-020-00789-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There have been three randomized controlled trials on autologous hematopoietic stem cell transplantation (AHSCT) in systemic sclerosis (SSc) that demonstrated significant superiority with respect to survival, improvement of cutaneous fibrosis, lung function and quality of life compared to standard treatment; however, these advantages must be carefully weighed against the transplantation-related risks. For this reason, an expert group from the stem cell therapy working party of the German Society for Rheumatology (DGRh) has now developed recommendations for the use of AHSCT in SSc. Based on the high-quality evidence, AHSCT is considered as the standard option for the treatment of selected SSc patients. Potential candidates for AHSCT are those with early, rapidly progressive, diffuse cutaneous SSc with visceral manifestations who have not yet developed severe damage to internal organs. A close cooperation between rheumatologists and transplantation centers is crucial for optimizing patient selection and treatment outcomes.
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16
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Autologous hematopoietic stem cell transplantation with reduced-intensity conditioning regimens in refractory Takayasu arteritis: a retrospective multicenter case-series from the Autoimmune Diseases Working Party (ADWP) of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2020; 55:2109-2113. [DOI: 10.1038/s41409-020-0907-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/10/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
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17
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Sharrack B, Saccardi R, Alexander T, Badoglio M, Burman J, Farge D, Greco R, Jessop H, Kazmi M, Kirgizov K, Labopin M, Mancardi G, Martin R, Moore J, Muraro PA, Rovira M, Sormani MP, Snowden JA. Autologous haematopoietic stem cell transplantation and other cellular therapy in multiple sclerosis and immune-mediated neurological diseases: updated guidelines and recommendations from the EBMT Autoimmune Diseases Working Party (ADWP) and the Joint Accreditation Committee of EBMT and ISCT (JACIE). Bone Marrow Transplant 2020; 55:283-306. [PMID: 31558790 PMCID: PMC6995781 DOI: 10.1038/s41409-019-0684-0] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
These updated EBMT guidelines review the clinical evidence, registry activity and mechanisms of action of haematopoietic stem cell transplantation (HSCT) in multiple sclerosis (MS) and other immune-mediated neurological diseases and provide recommendations for patient selection, transplant technique, follow-up and future development. The major focus is on autologous HSCT (aHSCT), used in MS for over two decades and currently the fastest growing indication for this treatment in Europe, with increasing evidence to support its use in highly active relapsing remitting MS failing to respond to disease modifying therapies. aHSCT may have a potential role in the treatment of the progressive forms of MS with a significant inflammatory component and other immune-mediated neurological diseases, including chronic inflammatory demyelinating polyneuropathy, neuromyelitis optica, myasthenia gravis and stiff person syndrome. Allogeneic HSCT should only be considered where potential risks are justified. Compared with other immunomodulatory treatments, HSCT is associated with greater short-term risks and requires close interspeciality collaboration between transplant physicians and neurologists with a special interest in these neurological conditions before, during and after treatment in accredited HSCT centres. Other experimental cell therapies are developmental for these diseases and patients should only be treated on clinical trials.
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Affiliation(s)
- Basil Sharrack
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- NIHR Neurosciences Biomedical Research Centre, University of Sheffield, Sheffield, UK
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Firenze, Italy
| | - Tobias Alexander
- Klinik fur Rheumatologie und Klinische Immunologie, Charite-Universitatsmedizin, Berlin, Germany
| | - Manuela Badoglio
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Dominique Farge
- Unité de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire (UF 04), Hôpital St-Louis, AP-HP, Paris, France
- Centre de Référence des Maladies Auto-Immunes Systémiques Rares d'Ile-de-France, Filière, FAI2R, Paris, France
- EA 3518, Université Denis Diderot, Paris, France
- Department of Internal Medicine, McGill University, Montreal, QC, Canada
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - Helen Jessop
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, UK
| | - Kirill Kirgizov
- N.N. Blokhin National Medical Center of Oncology, Institute of Pediatric Oncology and Hematology, Moscow, Russia
| | - Myriam Labopin
- EBMT Paris study office, Department of Haematology, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Gianluigi Mancardi
- Department of Neuroscience, University of Genova and Clinical Scientific Institutes Maugeri, Genoa, Italy
| | - Roland Martin
- Neuroimmunology and MS Research, Neurology Clinic, University Hospital, Zurich, Switzerland
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | - Paolo A Muraro
- Department of Brain Sciences, Imperial College London, London, UK
| | - Montserrat Rovira
- BMT Unit, Department of Hematology, IDIBAPS, Hospital Clinic, Institut Josep Carreras, Barcelona, Spain
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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18
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Autologous haematopoietic stem cell therapy for multiple sclerosis: a review for supportive care clinicians on behalf of the Autoimmune Diseases Working Party of the European Society for Blood and Marrow Transplantation. Curr Opin Support Palliat Care 2019; 13:394-401. [PMID: 31599815 PMCID: PMC6867671 DOI: 10.1097/spc.0000000000000466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW In this review, we summarize the recently published literature that demonstrates the efficacy and safety of autologous haematopoietic stem cell therapy (AHSCT) in multiple sclerosis (MS) and highlight the importance of supportive care required for the safe and well-tolerated delivery of AHSCT. RECENT FINDINGS MS is an autoimmune inflammatory and degenerative disorder of the central nervous system (CNS). In the majority of patients, the illness runs a relapsing remitting course (RRMS), culminating in a secondary progressive phase with gradual accumulation of fixed disabilities. Currently available disease-modifying therapies suppress CNS inflammation but have a limited effect on preventing disease progression for which there remains no effective therapy. Over the last two decades, there has been increasing evidence that AHSCT is a highly effective therapeutic strategy for treatment-resistant inflammatory types of MS, especially RRMS. Concerns about the safety of AHSCT in MS, usually a nonlife-threatening disease, have previously limited its use. However, AHSCT can now be delivered safely with major long-term benefits because of increasing transplant centre experience, judicious patient selection and good supportive care. SUMMARY MS is currently the fastest growing indication for AHSCT in Europe. Supportive care before, during and after the transplant period is key to the successful delivery of AHSCT.
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19
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Del Papa N, Pignataro F, Zaccara E, Maglione W, Minniti A. Autologous Hematopoietic Stem Cell Transplantation for Treatment of Systemic Sclerosis. Front Immunol 2018; 9:2390. [PMID: 30386340 PMCID: PMC6198074 DOI: 10.3389/fimmu.2018.02390] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/26/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic Sclerosis (SSc) is a complex autoimmune disease, characterized by high mortality and morbidity. The heterogeneity in terms of extent, severity, and rate of progression of skin and internal organ involvement gives rise to many difficulties in finding the optimal therapeutic interventions for SSc and, to date, no disease-modifying agents are available. In this scenario, it is not surprising that SSc was one of the first autoimmune diseases challenged with high-dose immunosuppressive treatment followed by autologous hematopoietic stem cell transplantation (AHSCT). In the last decades, AHSCT has emerged as a treatment option for refractory SSc through a reduction of the aberrant immune cells, followed by re-constitution of a new, self-tolerant immune system. After several case series and pilot studies, more recently three randomized controlled trials have shown a benefit in skin involvement, organ functions and quality of life measures in AHSCT compared to monthly cyclophosphamide. In addition, although AHSCT presents a certain risk of mortality, it has been shown that the overall survival is better, compared to the cyclophosphamide group. Current evidence suggests that SSc patients who are most likely to benefit from AHSCT are early, active, with rapidly progressing diffuse skin disease, and mild involvement of internal organs. As the studies have progressed, it has become evident the need for a more rigorous patient selection, the optimization of transplant and post-transplant procedures, and the intervention of multidisciplinary teams of specialists to increase the safety and efficacy of AHSCT in SSc.
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Affiliation(s)
- Nicoletta Del Papa
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Francesca Pignataro
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Eleonora Zaccara
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Wanda Maglione
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
| | - Antonina Minniti
- Dipartimento di Fisiatria e Reumatologia, Istituto Ortopedico Gaetano Pini, Milan, Italy
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20
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Snowden JA, Panés J, Alexander T, Allez M, Ardizzone S, Dierickx D, Finke J, Hasselblatt P, Hawkey C, Kazmi M, Lindsay JO, Onida F, Salas A, Saccardi R, Vermeire S, Rovira M, Ricart E. Autologous Haematopoietic Stem Cell Transplantation (AHSCT) in Severe Crohn's Disease: A Review on Behalf of ECCO and EBMT. J Crohns Colitis 2018; 12:476-488. [PMID: 29325112 DOI: 10.1093/ecco-jcc/jjx184] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 01/04/2018] [Indexed: 02/06/2023]
Abstract
Despite the major recent progress in the treatment of Crohn's disease [CD], there is a subset of patients in whom the disease runs an aggressive course with progressive tissue damage requiring early and repeated surgical management. Increasing evidence supports sustained and profound improvement in gastrointestinal parameters and quality of life following high-dose immunosuppressive therapy and autologous haematopoietic stem cell transplantation [AHSCT] compared to standard therapy in this context. In addition, international transplant registry data reflect the use of AHSCT in CD outside of trials in selected patients. However, AHSCT may be associated with significant treatment-related complications with risk of transplant-related mortality. In a joint initiative, the European Crohn's and Colitis Organisation [ECCO] and the European Society for Blood and Marrow Transplantation [EBMT] have produced a state-of-the-art review of the rationale, evaluation, patient selection, stem cell mobilization and transplant procedures and long-term follow up. Given the unique spectrum of issues, we recommend that AHSCT should only be performed in experienced centres with expertise in both haematological and gastroenterological aspects of the procedure. Where possible, patients should be enrolled on clinical trials and data registered centrally. Future development should be coordinated at both national and international levels.
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Affiliation(s)
- John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Julián Panés
- Department of Gastroenterology, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine, Berlin, Germany
| | - Matthieu Allez
- Department of Gastroenterology, Hôpital Saint Louis, APHP, INSERM U1160, Paris Diderot, Sorbonne Paris-Cité University, Paris, France
| | - Sandro Ardizzone
- DIBIC - ASST Fatebenefratelli Sacco - University of Milan, Italy
| | - Daan Dierickx
- Department of Haematology, University Hospitals, Leuven, Belgium
| | - Jürgen Finke
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Peter Hasselblatt
- Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Chris Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Majid Kazmi
- Department of Haematology, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - James O Lindsay
- The Royal London Hospital, Barts Health NHS Trust, London UK & Centre for Immunobiology, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Francesco Onida
- Hematology-BMT Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico - University of Milan, Italy
| | - Azucena Salas
- Department of Gastroenterology, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Riccardo Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - Severine Vermeire
- Department of Gastroenterology - University Hospitals, Leuven, Belgium
| | - Montserrat Rovira
- BMT Unit, Hematology Department, IDIBAPS, Hospital Clinic. Josep Carreras Leukaemia Research Institute (IJC), Barcelona, Spain
| | - Elena Ricart
- Department of Gastroenterology, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, Spain
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21
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Snowden JA, Badoglio M, Labopin M, Giebel S, McGrath E, Marjanovic Z, Burman J, Moore J, Rovira M, Wulffraat NM, Kazmi M, Greco R, Snarski E, Kozak T, Kirgizov K, Alexander T, Bader P, Saccardi R, Farge D. Evolution, trends, outcomes, and economics of hematopoietic stem cell transplantation in severe autoimmune diseases. Blood Adv 2017; 1:2742-2755. [PMID: 29296926 PMCID: PMC5745133 DOI: 10.1182/bloodadvances.2017010041] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/27/2017] [Indexed: 02/06/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) has evolved for >20 years as a specific treatment of patients with autoimmune disease (AD). Using European Society for Blood and Marrow Transplantation registry data, we summarized trends and identified factors influencing activity and outcomes in patients with AD undergoing first autologous HSCT (n = 1951; median age, 37 years [3-76]) and allogeneic HSCT (n = 105; median age, 12 years [<1-62]) in 247 centers in 40 countries from 1994 to 2015. Predominant countries of activity were Italy, Germany, Sweden, the United Kingdom, The Netherlands, Spain, France, and Australia. National activity correlated with the Human Development Index (P = .006). For autologous HSCT, outcomes varied significantly between diseases. There was chronological improvement in progression-free survival (PFS, P < 10-5), relapse/progression (P < 10-5), and nonrelapse mortality (P = .01). Health care expenditure was associated with improved outcomes in systemic sclerosis and multiple sclerosis (MS). On multivariate analysis selecting adults for MS, systemic sclerosis, and Crohn disease, better PFS was associated with experience (≥23 transplants for AD, P = .001), learning (time from first HSCT for AD ≥6 years, P = .01), and Joint Accreditation Committee of the International Society for Cellular Therapy and European Society for Blood and Marrow Transplantation accreditation status (P = .02). Despite improved survival over time (P = .02), allogeneic HSCT use remained low and largely restricted to pediatric practice. Autologous HSCT has evolved into a treatment modality to be considered alongside other modern therapies in severe AD. Center experience, accreditation, interspecialty networking, and national socioeconomic factors are relevant for health service delivery of HSCT in AD.
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Affiliation(s)
- John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Manuela Badoglio
- European Society for Blood and Marrow Transplantation (EBMT) Paris Study Office and
| | - Myriam Labopin
- Department of Haematology, Saint Antoine Hospital, INSERM Unité Mixte de Recherche 938, Université Pierre et Marie Curie, Paris, France
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie Institute-Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Eoin McGrath
- Joint Accreditation Committee of the International Society for Cellular Therapy and EBMT (JACIE) Office, Barcelona, Spain
| | - Zora Marjanovic
- Service d'Hematologie clinique et Therapie Cellulaire, Hopital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Joachim Burman
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - John Moore
- Haematology Department, St. Vincent's Health Network, Darlinghurst, NSW, Australia
| | | | - Nico M Wulffraat
- Divisie Kinderen, Cluster Immunologie, Reumatologie, Hematologie en Infectiologie, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands
| | - Majid Kazmi
- Kings Health Partners, Department of Haematology, Guys Hospital, London, United Kingdom
| | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Emilian Snarski
- Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Tomas Kozak
- Přednosta Interní hematologické kliniky, Univerzity Karlovy a Fakultní nemocnice Královské Vinohrady, Prague, Czech Republic
| | - Kirill Kirgizov
- Department of Scientific Studies and Clinical Technologies, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Tobias Alexander
- Klinik für Rheumatologie und Klinische Immunologie, Charité-Universitätsmedizin, Berlin, Germany
| | - Peter Bader
- Stammzelltransplantation und Immunologie Klinik für Kinder und Jugendmedizin, Frankfurt am Main, Germany
| | - Riccardo Saccardi
- Haematology Department, Careggi University Hospital, Florence, Italy
| | - Dominique Farge
- Unité Clinique de Médecine Interne, Maladies Auto-immunes et Pathologie Vasculaire, Unité Fonctionnelle 04, Hôpital Saint-Louis, AP-HP, INSERM Unité Mixte de Recherche Scientifique 1160, Paris Denis Diderot University, Paris, France; and
- Centre de Référence des Maladies auto-immunes systémiques Rares d'Ile-de-France (site constitutif), Filière FAI2R, Paris, France
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Mancardi G, Sormani MP, Muraro PA, Boffa G, Saccardi R. Intense immunosuppression followed by autologous haematopoietic stem cell transplantation as a therapeutic strategy in aggressive forms of multiple sclerosis. Mult Scler 2017; 24:245-255. [DOI: 10.1177/1352458517742532] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the majority of relapsing multiple sclerosis patients, the disease can be quite easily controlled by already available, approved therapies. There are, however, some aggressive cases who continue to have clinical and magnetic resonance imaging (MRI) activity in spite of the treatment. These are the cases who may now receive benefit from intense immunosuppression followed by autologous haematopoietic stem cell transplantation (aHSCT). In this review, we describe the method and the rationale of aHSCT, the more recently published studies that demonstrate its efficacy in selected multiple sclerosis cases, the problems related to safety and the transplant-related mortality risk of the procedure. A description of the ideal patient who can take advantage of aHSCT is outlined and, finally, the ongoing studies which are near to completion or are close to starting are briefly reported.
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Affiliation(s)
- Gianluigi Mancardi
- Neurological Clinic, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa and Ospedale Policlinico San Martino, Genova, Italy
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Paolo A Muraro
- Division of Brain Sciences, Imperial College London, London, UK
| | - Giacomo Boffa
- Neurological Clinic, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa and Ospedale Policlinico San Martino, Genova, Italy
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy
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23
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Muraro PA, Martin R, Mancardi GL, Nicholas R, Sormani MP, Saccardi R. Autologous haematopoietic stem cell transplantation for treatment of multiple sclerosis. Nat Rev Neurol 2017; 13:391-405. [PMID: 28621766 DOI: 10.1038/nrneurol.2017.81] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Autologous haematopoietic stem cell transplantation (AHSCT) is a multistep procedure that enables destruction of the immune system and its reconstitution from haematopoietic stem cells. Originally developed for the treatment of haematological malignancies, the procedure has been adapted for the treatment of severe immune-mediated disorders. Results from ∼20 years of research make a compelling case for selective use of AHSCT in patients with highly active multiple sclerosis (MS), and for controlled trials. Immunological studies support the notion that AHSCT causes qualitative immune resetting, and have provided insight into the mechanisms that might underlie the powerful treatment effects that last well beyond recovery of immune cell numbers. Indeed, studies have demonstrated that AHSCT can entirely suppress MS disease activity for 4-5 years in 70-80% of patients, a rate that is higher than those achieved with any other therapies for MS. Treatment-related mortality, which was 3.6% in studies before 2005, has decreased to 0.3% in studies since 2005. Current evidence indicates that the patients who are most likely to benefit from and tolerate AHSCT are young, ambulatory and have inflammatory MS activity. Clinical trials are required to rigorously test the efficacy, safety and cost-effectiveness of AHSCT against highly active MS drugs.
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Affiliation(s)
- Paolo A Muraro
- Division of Brain Sciences, Imperial College London, Burlington Danes Building, 190 Du Cane Road, London W12 0NN, UK
| | - Roland Martin
- Neuroimmunology and Multiple Sclerosis Research, Neurology Clinic, University Hospital Zurich, University Zurich, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
| | - Giovanni Luigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Largo Paolo Daneo 3, 16145 Genova, Italy
- Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132 Genoa, Italy
| | - Richard Nicholas
- Division of Brain Sciences, Imperial College London, Burlington Danes Building, 190 Du Cane Road, London W12 0NN, UK
| | - Maria Pia Sormani
- Biostatistics Unit, Department of Health Sciences (DISSAL), University of Genoa, Via Pastore 1, 16132, Genova, Italy
| | - Riccardo Saccardi
- Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Largo Brambilla, 3-50134 Firenze, Italy
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Zeher M, Papp G, Nakken B, Szodoray P. Hematopoietic stem cell transplantation in autoimmune disorders: From immune-regulatory processes to clinical implications. Autoimmun Rev 2017; 16:817-825. [PMID: 28572052 DOI: 10.1016/j.autrev.2017.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/28/2017] [Indexed: 12/29/2022]
Abstract
Autoimmune diseases are characterized by the development of autoreactive T- and B-cells targeting self-antigens, which eventually can result in chronic and persistent organ damage. The autologous hematopoietic stem cell transplantation (AHSCT) opened new avenues in the treatment of patients with severe, treatment-resistant autoimmune diseases. This paper reviews the immune-regulatory mechanisms behind AHSCT, and also summarizes the experiences of clinical practice related to the therapy in organ-specific and systemic autoimmune diseases. It seems that the intricate interplay of various immune competent cells with regulatory capacity control in a synergistic manner the repopulated immune system after AHSCT, which potentially leads to a significant clinical improvement in certain autoimmune diseases. However, the widespread use of AHSCT was intrinsically limited, due to the serious side-effects of conditioning treatment and relatively high treatment-related mortality; moreover, the development of new effective and safe therapeutic approaches and the dawn of biological agents further limited its indications in the last decade. Nevertheless, with an appropriate patient selection and increased experience of transplant centres, the risks can be minimized, and AHSCT remained still a reasonable choice in multiple sclerosis and systemic sclerosis when the conventional therapy failed and further progression of disease is inevitable.
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Affiliation(s)
- Margit Zeher
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Gábor Papp
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Britt Nakken
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Peter Szodoray
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Liu J, Li J, Chen M, Kuang L. Bortezomib followed by autologous stem cell transplantation in a patient with rheumatoid arthritis: A case report and review of the literature. Medicine (Baltimore) 2016; 95:e5760. [PMID: 28033292 PMCID: PMC5207588 DOI: 10.1097/md.0000000000005760] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE AND PATIENTS CONCERNS Despite the introduction of varied disease-modifying antirheumatic drugs and biological agents, a substantial proportion of patients remain untreatable. We report a 56-year-old Chinese female patient with a case of refractory rheumatoid arthritis (RA) complicated with multiple myeloma (MM) who was treated successfully with Bortezomib followed by autologous stem cell transplantation (ASCT). DIAGNOSIS AND INTERVENTIONS We report a 56-year-old Chinese female patient who was diagnosed as RA complicating with MM. She received 4 cycles of Bortezomib-based chemotherapy followed by ASCT. The response of her RA and MM were evaluated after every cycle of Bortezomib-based chemotherapy. INTERVENTIONS AND OUTCOMES After the first Bortezomib-based chemotherapy cycle, this patient's symptoms were significantly alleviated and thereafter the RA activity continued to improve. After the 4 courses of Bortezomib-based chemotherapy, the C-reactive protein was <0.5 mg/dL and the disease activity score 28-erythrocyte sedimentation rate was 2.0. No hematological or nonhematological side effects were observed during the treatment of Bortezomib. LESSONS Bortezomib might be a new safe and promising drug for refractory RA patients.
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Rebeiro P, Moore J. The role of autologous haemopoietic stem cell transplantation in the treatment of autoimmune disorders. Intern Med J 2016; 46:17-28. [PMID: 26524106 DOI: 10.1111/imj.12944] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 07/14/2015] [Accepted: 10/19/2015] [Indexed: 12/29/2022]
Abstract
Autologous haemopoietic stem cell transplantation (HSCT) has been used for over 30 years for malignant haematological diseases, such as myeloma and lymphoma, with considerable success. More recently this procedure has been adopted as a form of high dose immunosuppression in selected patients with autoimmune diseases that are resistant to conventional therapies. Animal models have previously outlined the rationale and validity of HSCT in patients with these non-malignant, but in many cases, life-threatening conditions. Recent data have that deletion of putative autoreactive immune clones with reconstitution of a thymic driven, tolerant immune system occurs in HSCT for auto-immune patients. Two randomised control trials have confirmed that HSCT is superior to monthly cyclophosphamide in systemic sclerosis with a highly significant disease free and overall survival benefit demonstrated in the Autologous Stem cell Transplantation International Scleroderma trial. Over 2000 patients worldwide with autoimmune conditions have been treated with HSCT - the commonest indications being multiple sclerosis (MS) and systemic sclerosis. Encouraging relapse free survival of 70-80% at 4 years, in heavily pre-treated MS patients, has been demonstrated in Phase II trials. A Phase III trial in MS patients who have failed interferon is currently accruing patients. Future challenges include improvements in safety of HSCT, particularly in cardiac assessment of systemic sclerosis patients, cost-benefit analyses of HSCT compared to standard therapy and establishment of centres of excellence to continue to enhance the safety and benefit of this exciting new therapy.
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Affiliation(s)
- P Rebeiro
- Haematology Department, St Vincents Hospital, Sydney, New South Wales, Australia
| | - J Moore
- Haematology Department, St Vincents Hospital, Sydney, New South Wales, Australia
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Maciejewska M, Snarski E, Wiktor-Jędrzejczak W. A Preliminary Online Study on Menstruation Recovery in Women After Autologous Hematopoietic Stem Cell Transplant for Autoimmune Diseases. EXP CLIN TRANSPLANT 2016; 14:665-669. [PMID: 27310497 DOI: 10.6002/ect.2015.0336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Autologous hematopoietic stem cell transplant has become a successful treatment option in aggressive autoimmune diseases. Young women who are consulted before this treatment are faced with an absence of data on the transplant's effect on their fertility. The aim of our study was to analyze information on menstruation recovery after autologous hematopoietic stem cell transplant for autoimmune diseases. MATERIALS AND METHODS An anonymous online questionnaire was distributed among members of an international Web forum of patients who had autologous hematopoietic stem cell transplant for autoimmune disease. Data were collated and analyzed. RESULTS We obtained responses from 28 female patients to the questionnaire. The conditioning regimens used in this population were cyclophosphamide ± antibodies or BCNU (carmustine), etoposide, Ara-C (cytarabine), and melphalan chemotherapy. All patients who were transplanted at the age of 32 years or younger showed restored menstruation after an average (standard deviation) of 5.38 months (5.34 mo). In patients aged 33 to 41 years, menstruation was restored in 38%. We found that 73% of patients already had children before autologous hematopoietic stem cell transplant, and only 15% of responders declared desire for pregnancy after transplant. CONCLUSIONS Our online analysis showed feasibility as a questionnaire for assessing fertility after autologous hematopoietic stem cell transplant. The results show that menstruation is restored in all patients of 32 years of age or younger, regardless of the conditioning regimen. Many of these women are likely to maintain fertility and may eventually become pregnant. However, a significant number of responders who underwent autologous hematopoietic stem cell transplant for autoimmune diseases already had children before transplant and indicated no desire for pregnancy after transplant; the data on pregnancy occurrence in this group should be interpreted in this context.
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Affiliation(s)
- Martyna Maciejewska
- From the Department of Hematology, Oncology and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Currò D, Mancardi G. Autologous hematopoietic stem cell transplantation in multiple sclerosis: 20 years of experience. Neurol Sci 2016; 37:857-65. [DOI: 10.1007/s10072-016-2564-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/17/2016] [Indexed: 12/29/2022]
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