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Treatment of chronic graft-versus-host disease with anti-CD20 chimeric monoclonal antibody
Biology of Blood and Marrow Transplantation 9:505-511 (2003) 䊚 2003 American Society for Blood and Marrow Transplantation 1083-8791/03/0908-0004$30.00/0 doi:10.1016/S1083-8791(03)00216-7
Treatment of Chronic Graft-versus-Host Disease with Anti-CD20 Chimeric Monoclonal Antibody Voravit Ratanatharathorn, Lois Ayash, Christopher Reynolds, Samuel Silver, Pavan Reddy, Michael Becker, James L. M. Ferrara, Joseph P. Uberti Blood and Marrow Stem Cell Transplantation Program, University of Michigan Health System, Ann Arbor, Michigan Correspondence and reprint requests: Voravit Ratanatharathorn, B1-207, Cancer Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 (e-mail: [email protected]). Received May 5, 2003; accepted June 17, 2003
ABSTRACT 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/m2 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. © 2003 American Society for Blood and Marrow Transplantation
KEY WORDS Chronic graft-versus-host disease ● Acute graft-versus-host disease ● Allogeneic transplantation ● Hematopoietic stem cell transplantation ● Anti-CD20 antibody ● B-cell depletion
INTRODUCTION Chronic graft-versus-host disease (GVHD) remains a formidable complication for long-term survivors of hematopoietic stem cell transplantation. The primary treatment of chronic GVHD has mainly relied on systemic corticosteroids. The addition of other immunosuppressive agents to corticosteroids has not resulted in improvement of efficacy [1,2]. Various agents have been studied for salvage therapy in the setting of corticosteroid failure, with some reported success [3]. However, the protean manifestations of chronic GVHD could confound the ability to accurately assess the efficacy of these agents, especially when they are used as salvage therapy. Conventional opinions regarding organ rejection, GVHD, and transplantation tolerance have centered on a primary role for T cells in mediating immunologic attacks on the target tissues [4]. However, there is evidence of B-cell dysregulation that might contribute to the pathogenesis of chronic GVHD. In a case report,
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thrombocytopenia associated with chronic GVHD was successfully treated with B-cell depletion by using an anti-CD20 monoclonal antibody (rituximab [Rituxan]; IDEC Pharmaceuticals Corp., San Diego, CA) [5]. Other clinical manifestations of chronic GVHD in this patient, including oral lichen planus, skin, and xerophthalmia, also became quiescent after rituximab use, allowing gradual discontinuation of immunosuppressants. Normalization of thrombocytopenia in this patient was durable despite B-cell recovery, suggesting that tolerance may be induced with B-cell depletion. In this article, we report a retrospective case series of 8 patients with refractory chronic GVHD treated with rituximab. The clinical responses observed in this article suggest a role of B-cell depletion in treating some manifestations of chronic GVHD.
PATIENTS AND METHODS From September 2000 to October 2002, we treated 8 adults who had undergone an allogeneic 505
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sibling stem cell transplantation for hematologic malignancies and who had refractory chronic GVHD treated with rituximab. The dose of rituximab was 375 mg/m2 given intravenously weekly for 4 weeks. The initial rate of infusion was 50 mg/h. If there was no reaction to the infusion, the rate was increased by 50 mg/h increments every 30 minutes to a maximum of 400 mg/h. All patients were premedicated with acetaminophen 650 mg and diphenhydramine 50 mg orally. We retrospectively reviewed the clinical data and outcome of these 8 patients. This study was approved by the institutional review board.
RESULTS All patients had extensive chronic GVHD with sclerodermoid involvement of skin/soft tissues and xerophthalmia. One other patient had limited sclerodermoid involvement of the lateral thoracic cage and abdominal wall but developed painful ischemic fingers on both hands because of cold agglutinins and the Raynaud phenomenon. All but 1 patient had progressive onset of chronic GVHD. Prior treatment for chronic GVHD included tacrolimus and methylprednisolone for all patients. Seven patients were taking at least 3 immunosuppressive agents before or during rituximab therapy. Six patients had received extracorporeal photopheresis (ECP) before rituximab, without response. With the exception of case 4, no patient received methylprednisolone or hydrocortisone during rituximab infusion. Patients who responded to rituximab had their immunosuppression tapered gradually. For nonresponders, the dose of immunosuppression was increased or additional agents were added as clinically indicated. The median age of the patients was 46 years (range, 28-58 years). The median time from transplantation to rituximab was 18 months (range, 13-90 months); the median duration of follow-up after rituximab was 265 days (range, 104-846 days). Patient demographics, prior therapy of chronic GVHD, and response to therapy are summarized in Table 1. A clinical response to rituximab was noted in 4 of 8 patients, as detailed below. Case 1
A 31-year-old woman developed progressive chronic GVHD that was unresponsive to tacrolimus, methylprednisolone, mycophenolate, hydroxychloroquine, thalidomide, acitretin, and ECP. The predominant clinical feature was generalized sclerodermoid chronic GVHD interspersed with ulcerating lichen planus. The most disabling sclerodermoid GVHD involved the anterior cervical fascia, resulting in a severe flexion contracture (Figure 1). After rituximab therapy, her immunosuppressive agents were able to 506
be tapered gradually over 7 months, with improvement of skin GVHD. The range of motion of her neck had improved to near normal 1 year after treatment with rituximab (Figure 2). The dose of immunosuppression was tapered from tacrolimus 1.5 mg twice daily (BID) and methylprednisolone 32 mg daily at the initiation of rituximab to tacrolimus 0.5 mg daily and methylprednisolone 4 mg daily at the last follow-up visit. Case 2
A 38-year-old man had biopsy-proven liver GVHD (lobular hepatitis with mild bile duct damage compatible with GVHD) at day 60 after transplantation. He was treated with methylprednisolone and tacrolimus, with complete resolution of his liver disease. Eleven months after transplantation, he developed painful ischemic fingers consistent with the Raynaud phenomenon and was treated with nifedipine, without relief. He also had other signs and symptoms of chronic GVHD involving the eyes and mouth and limited sclerodermoid and fasciitis changes of the lower thoracic cage and abdomen. His fingertips had bluish discoloration and were very painful to touch and movement. He had a cold agglutinin titer of 1:40 and an absence of cryoglobulin. He was started on 2 mg/kg/d of methylprednisolone, which was reduced several weeks later because of a lack of improvement and steroid intolerance (Figure 3). Despite corticosteroids, ischemic changes of the fingertips became more pronounced, and early necrosis of his fingertips appeared. He was then started on rituximab. Three months after treatment with rituximab, his fingers returned to normal, without pain, despite the continuing taper of methylprednisolone (Figure 4). Cold agglutinins were not detectable after rituximab therapy was completed. Other manifestations of chronic GVHD involving the eyes, mouth, and soft tissue also improved, allowing methylprednisolone to be tapered from 32 mg BID to 10 mg daily. Case 3
A 48-year-old man with advanced immunoglobulin G myeloma developed a clinical grade 3 acute GVHD involving the skin and gastrointestinal tract early in the course of transplantation. His acute GVHD responded to methylprednisolone and tacrolimus, but at 1 year after transplantation, he was noted to have xerophthalmia, xerostomia, and eosinophilia. At the same time, because of concern for progression of his myeloma (indicated by an increasing M spike), his immunosuppression was gradually tapered. Several weeks later, he developed nephrotic syndrome, with proteinuria of 20 g/24 hours, and the renal biopsy showed membranous glomerulonephritis. There was
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Table 1. Patient Demographics, Prior Therapy, Response, and Status
Preparative Regimen
Source of Stem Cells
T/NK NHL
CVB
PB/Sis
Progressive
38/M
CML/AP
BAC
PB/Sis
Progressive
3
48/M
Myeloma
BuCyTMI
PB/Bro
Progressive
4
46/M
MDS
BAC
BM/Sis
Progressive
5
58/M
MCL
RI
PB/Sis
Progressive
6
41/F
CML
BuCy-2
PB/Sis
De novo
7
48/M
MDS
BAC
PB/Sis
Progressive
8
28/M
ALL
CY/TBI
PB/Bro
Progressive
Case No.
Age/ Sex
Diagnosis
1
31/F
2
Type of Onset
Organ Involvement Extensive sclerodermoid; lichen planus; eyes; chronic bronchitis; cervical flexion contracture Localized sclerodermoid involvement of the skin and soft tissue, eyes, and liver; cold agglutinin and Raynaud phenomenon Extensive sclerodermoid; eyes, kidney
Interval from Transplantation to Rituximab Therapy (mo)
Response
Status
Tacrolimus, MP, MMF, hydroxychloroquine, infliximab, thalidomide, acitretin, ECP
13
Responded
Alive at 42 mo after transplantation continuing response at 868 d
Tacrolimus, MP
13
Responded
Alive at 27 mo after transplantation continuing response at 369 d
Tacrolimus, MP, MMF
14
Responded
90
Responded
Alive at 29 mo after transplantation continuing response at 294 d Alive at 99 mo after transplantation continuing response at 265 d
19
NR
49
NR
33
NR
40
NR
Prior Therapy
Tacrolimus, CSA, MP, Extensive azathioprine, MMF, sclerodermoid ECP interspersed with lichen planus, eyes, liver; restrictive/obstructive lung disease Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid, ECP eyes Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid; thalidomide, lichen planus; acitretin, ECP eyes; chronic bronchitis Tacrolimus, MP, MMF, Extensive ECP sclerodermoid; eyes Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid; ECP eyes
Alive at 27 mo after transplantation Alive at 55 mo after transplantation
Alive at 39 mo after transplantation Alive at 45 mo after transplantation
MP indicates methylprednisolone; MMF, mycophenolate mofetil; ECP, extracorporeal photopheresis; MDS, myelodysplastic syndrome; CY, cyclophosphamide 60 mg/kg intravenously daily for 2 days; TBI, total body irradiation 2 Gy twice a day on 3 consecutive days; ALL, acute lymphocytic leukemia; AML, acute myeloid leukemia; CML, chronic myeloid leukemia; MCL, mantle cell lymphoma; BM, bone marrow; PB, peripheral blood; BAC, 3 agents given consecutively (busulfan 1 mg/kg every 6 hours orally for 16 doses, cytarabine 2 g/m2 every 12 hours for 4 doses, and cyclophosphamide 60 mg/kg daily for 2 days); BuCy-2, busulfan 1 mg/kg every 6 hours orally for 16 doses and cyclophosphamide 60 mg/kg daily for 2 days; RI, reduced-intensity regimen of fludarabine 25 mg/m2 intravenously daily for 5 days (days ⫺11 to ⫺7) followed by busulfan 0.5 mg/kg orally every 6 hours for 16 doses (days ⫺6 to ⫺3), MMF 750 mg orally twice per day for actual weight ⱕ80 kg and 1000 mg orally twice per day for weight ⱖ80 kg from day ⫺6 to day 0, and total lymphoid irradiation of 2 Gy on day 0; BuCyTMI, sequential busulfan 0.875 mg/kg orally every 6 hours for 16 doses, cyclophosphamide 60 mg/kg intravenously daily for 2 days, and total marrow irradiation to a total dose of 8.5 Gy; M, male; F, female; bro, brother; sis, sister; NR, no response; CSA, cyclosporine; CVB, regimen of cyclophosphamide 1800 mg/m2 intravenously on day ⫺7 to ⫺4, etoposide 200 mg/m2 intravenously q12h on day ⫺7 to ⫺4, BCNU 450 mg/m2 intravenously on day ⫺3; AP, accelerated phase.
no light chain proteinuria and no detectable monoclonal spike on serum protein electrophoresis. He initially responded to increasing immunosuppression with methylprednisolone and the addition of mycophenolate. Over the ensuing 3 months, his proteinuria improved and plateaued at 13 to 14 g/24 hours, whereas his creatinine clearance declined, and tacrolimus was replaced with sirolimus. His skin also showed mottled sclerodermoid changes, particularly over the
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distal extremities and lateral torso; his xerophthalmia was increasingly symptomatic. Five months after the diagnosis of membranous glomerulonephritis, his proteinuria remained unchanged, and rituximab was initiated. Both his proteinuria and other manifestations of chronic GVHD gradually improved despite the tapering of immunosuppressants (Figure 5). Nine months after rituximab, a 24-hour urinary protein was measured at 4 g. His renal function and proteinuria 507
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Figure 3. Painful cyanotic fingers in a patient (case 2) with cold agglutinin.
Case 4
Figure 1. This patient (case 1) showed cervical flexion contracture (caused by dense fibrosis of the anterior cervical fascia), blotchy hyperpigmentation, hidebound facial skin, and circumoral stricture.
continued to improve despite the reduction of immunosuppression. At the last follow-up visit, he was taking methylprednisolone 8 mg every other day and sirolimus 1 mg daily.
Figure 2. Resolution of the cervical flexion contracture and improvement of the sclerodermoid changes of the facial skin. 508
A 49-year-old man who had received allogeneic marrow stem cell transplantation developed progressive-onset chronic GVHD. The prominent feature was slowly progressive sclerodermoid skin changes over the entire torso, limiting chest wall compliance and resulting in severe restrictive lung disease. Pulmonary function studies also indicated obstructive physiology. Seven years after transplantation, ECP was initiated. After 5 months of ECP therapy, there was minimal softening of the skin of both lower distal extremities but no significant improvement of his respiratory dysfunction. Ninety months after transplantation, with increasing oxygen requirements, the patient was given rituximab. He experienced severe respiratory difficulty with the first rituximab infusion and required a single intravenous dose of methylprednisolone 40 mg and aerosolized albuterol. The subsequent 3 doses of rituximab were given without further difficulty after premedication with hydrocortisone 100
Figure 4. Resolution of painful cyanotic fingers after antibody therapy.
Rituximab Treatment for Chronic GVHD
Figure 5. Response of proteinuria in a patient with membranous glomerulonephritis.
mg intravenously. Two weeks after he completed a course of rituximab, his lung capacity had improved sufficiently to become oxygen independent, and he was able to participate in household chores. His forced vital capacity and forced expiratory volume in 1 second improved from 28% and 33% before rituximab therapy to 57% and 63%, respectively, after rituximab therapy. Serial pulmonary function studies and treatments given are summarized in Figure 6. The patient was maintained on tacrolimus 1 mg BID and mycophenolate 1 g BID. Cases 5 to 8
Four patients did not respond to rituximab therapy. Three of 4 patients had a rapid onset of diffuse inflammatory changes of the skin associated with edema of both upper extremities. The involved skin was tender to pressure, and there was a limited range of motion of the involved extremities. The inflammatory changes were most pronounced over the distal extremities. Fibrosis and postinflammatory hyperpigmentation of the skin ensued within 8 weeks of onset. Progressive fibrosis later involved the lower lateral thoracic cage, with restricted respiratory movement. One patient (case 6) had slowly progressive fibrosis of the distal upper extremities associated with lichen planus clustering over the wrists, palmar surfaces, and shoulders, with scattered lesions on the trunk and axillary folds. Patchy areas of dense fibrosis were limited to the volar surfaces of the forearms, axillary folds, and scattered lesions over the neck. There was severe pain and tenderness of the ulcerating lesions of lichen planus.
manifestations of chronic GVHD, eg, skin involvement and dry eyes, also improved despite discontinuation of immunosuppressive therapy. This observation suggested that other organ manifestations of chronic GVHD may also respond to B-cell depletion. The role of B cells in the pathogenesis of autoimmune disorders is a subject of debate. There is mounting evidence that hyperactivity of B cells may be the defining event in systemic lupus erythematosus, leading to production of pathogenic autoantibodies that results in end-organ damage [6]. Similarly, in a murine model of chronic GVHD, parent into F1 model (C57BL/6 ⫻ DBA2), the expansion of host B cells in response to donor CD4⫹ was thought to play a central role in the development of chronic GVHD with autoantibody production and glomerulonephritis [7,8]. It is uncertain whether this nonradiation model of GVHD bears any relevance to the human GVHD, because until recently most preparative regimens used in clinical stem cell transplantation were myeloablative. However, the clinical resemblance of this murine model to chronic GVHD in humans with autoantibody production would suggest the pathogenetic role of B cells in some of the manifestations of this syndrome. Recently, depletion of B cells by using rituximab [9] has shown efficacy in the treatment of several autoimmune disorders [10], including chronic idiopathic thrombocytopenia [11], autoimmune polyneuropathy [12], autoimmune hemolytic anemia [13], cold agglutinin disease [14], pure red cell aplasia [15], Wegener granulomatosis [16], idiopathic membranous nephropathy [17], and rheumatoid arthritis [18]. Rituximab has also been shown to be effective in the treatment of various immune-mediated complications related to chronic GVHD or allogeneic transplantation, eg, thrombocytopenia [5], myasthenia gravis [19], and autoimmune hemolytic anemia [20]. It is interesting to note that other manifestations of chronic GVHD were also noted to be responding to
DISCUSSION In our initial observation in a patient with chronic GVHD-associated thrombocytopenia, there was a dramatic response of her thrombocytopenia to treatment with rituximab [5]. Furthermore, other clinical
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Figure 6. Response of restrictive or obstructive pulmonary physiology to antibody therapy; (f) forced vital capacity, (䉬) forced expiratory volume in 1 second. 509
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this treatment in some patients. Furthermore, the response seemed to be durable despite recovery of B cells, suggesting that tolerance may be achieved with this therapy. Numerous treatment strategies for chronic GVHD with varying degrees of success have been reported [5,21-23]. Among the treatments studied, ECP is by far the most effective, with 38% to 80% complete resolution of skin involvement, 48% to 70% improvement of liver involvement, and 39% improvement of lung involvement [24,25]. In our series, 6 patients had received prior ECP therapy, and only 2 of these patients responded. It is not likely that prior ECP affected the outcome of rituximab therapy. Of the 4 patients who responded to rituximab therapy, 2 patients had predominantly skin and soft tissue involvement (sclerodermoid chronic GVHD and lichen planus). The remaining 2 patients had membranous glomerulonephritis and Raynaud phenomenon related to cold agglutinins. The temporal relationship of cold agglutinin disease and glomerulonephritis with the ongoing activity of chronic GVHD in our patients suggested that the immunopathogenesis of these chronic GVHD manifestations might be similar to that in patients with autoimmune diseases. Objective responses to rituximab included disappearance of cold agglutinin titers and resolution of the Raynaud phenomenon (case 2), decline in urinary protein excretion (case 3), and improvement of sclerodermatous changes of the thoracic cage with a marked improvement in the pulmonary spirogram (case 4). The remaining patient (case 1) had resolution of the severe cervical flexion contracture from diffuse scleroderma and healing of the ulcerating lichen planus. The time to clinical and laboratory improvement ranged from 1 month in a patient (case 2) with cold agglutinin disease to 4 months in a patient with diffuse scleroderma and lichen planus. In patients with membranous glomerulonephritis and cold agglutinin disease, the presence of autoantibody may be implicated as the cause of the unique manifestations of chronic GVHD. Depletion of CD20⫹ B cells, the potential precursors of the autoantibody-producing cells, might explain the efficacy of rituximab in treatment of autoimmune manifestations. However, depletion of B cells alone may not be the only mechanism responsible for rapid recovery from thrombocytopenia [5,11]. Fc receptor blockade by opsonized B cells may also play a role in rapid clinical improvement [26]. Similar mechanisms involving depletion of autoantibody-producing B cells might be operating in patients with sclerodermoid chronic GVHD and patients with systemic sclerosis and related fibrosing disorders [27]. Furthermore, higher levels of B-cell activation in the granulocyte colonystimulating factor mobilized peripheral blood stem cell may be an important contributing factor in the 510
increased incidence of chronic GVHD in recipients of allogeneic stem cell transplants [28]. The role of T cells in mediating endothelial injury in patients with chronic GVHD has also been described. Compromised tissue perfusion resulting from endothelialitis eventually leads to tissue hypoxia and fibrosis, which is the hallmark of chronic GVHD pathology [29]. It is unclear how T and B cells interact to sustain the immunologic assaults on target tissues. One of the mechanisms might involve antigen presentation by interaction of dendritic cells with B cells, leading to generation of peptide/major histocompatibility complex complexes by B cells that then presented to T cells [30,31]. A clinical example of the collaboration of T and B cells in chronic GVHDassociated bullous pemphigoid was recently reported [32]. Furthermore, Miklos et al. [33] have demonstrated B-cell responses to DBY (a minor H-Y minor histocompatibility antigen) in 48% of male recipients from female grafts, indicating the collaboration of T and B cells to produce specific antibodies against host antigens. Four patients in this series did not respond to B-cell depletion. Serial peripheral blood CD19⫹ cell counts obtained in 4 patients (3 responders and 1 nonresponder) demonstrated no detectable CD19⫹ cells after rituximab therapy (data not shown). It is possible that some autoantibody-producing cells or their precursors were not depleted because of the absence or low expression of CD20. Other mechanisms of antigen presentation not involving B cells might also be dominant in sustaining the dysregulated immune response. In these situations, treatment with rituximab, a highly effective agent for B-cell depletion, would not be sufficient in eliminating pathogenic autoantibodies. The efficacy of rituximab in patients with chronic GVHD demonstrated in this retrospective study suggests a pathogenetic role of B cells in this disease. Depletion of B cells with rituximab resulted in clinical and laboratory improvement of chronic GVHD in 4 of 8 patients with refractory chronic GVHD. Sustained improvement of clinical signs and symptoms of chronic GVHD, despite B-cell recovery, may indicate that the induction of tolerance may have occurred. This novel therapy should be tested in a prospective study in patients with earlier stages of chronic GVHD.
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19. Zaja F, Russo D, Fuga G, Perella G, Baccarani M. Rituximab for myasthenia gravis developing after bone marrow transplant. Neurology. 2000;55:1062-1063. 20. Ship A, May W, Lucas K. Anti-CD20 monoclonal antibody therapy for autoimmune hemolytic anemia following T celldepleted, haplo-identical stem cell transplantation. Bone Marrow Transplant. 2002;29:365-366. 21. Vogelsang GB, Farmer ER, Hess AD, et al. Thalidomide for the treatment of chronic graft-versus-host disease. N Engl J Med. 1992;326:1055-1058. 22. Parker PM, Chao N, Nademanee A, et al. Thalidomide as salvage therapy for chronic graft-versus-host disease. Blood. 1995;86:3604-3609. 23. Koc S, Leisenring W, Flowers ME, et al. Thalidomide for treatment of patients with chronic graft-versus-host disease. Blood. 2000;96:3995-3996. 24. Dall’Amico R, Messina C. Extracorporeal photochemotherapy for the treatment of graft-versus-host disease. Ther Apher. 2002; 6:296-304. 25. Greinix HT, Volc-Platzer B, Kalhs P, et al. Extracorporeal photochemotherapy in the treatment of severe steroid-refractory acute graft-versus-host disease: a pilot study. Blood. 2000; 96:2426-2431. 26. Stasi R, Stipa E, Forte V, Meo P, Amadori S. Variable patterns of response to rituximab treatment in adults with chronic idiopathic thrombocytopenic purpura. Blood. 2002;99:3872-3873. 27. Clements PJ. Systemic sclerosis (scleroderma) and related disorders: clinical aspects. Baillieres Best Pract Res Clin Rheumatol. 2000;14:1-16. 28. Tayebi H, Lapierre V, Saas P, et al. Enhanced activation of B cells in a granulocyte colony-stimulating factor-mobilized peripheral blood stem cell graft. Br J Haematol. 2001;114:698700. 29. Biedermann BC, Sahner S, Gregor M, et al. Endothelial injury mediated by cytotoxic T lymphocytes and loss of microvessels in chronic graft versus host disease. Lancet. 2002;359:20782083. 30. Dustin ML, Dustin LB. The immunological relay race: B cells take antigen by synapse. Nat Immunol. 2001;2:480-482. 31. Batista FD, Iber D, Neuberger MS. B cells acquire antigen from target cells after synapse formation. Nature. 2001;411: 489-494. 32. Szabolcs PR. Combination treatment of bullous pemphigoid with anti-CD20 and anti-CD25 antibodies in a patient with chronic graft-versus-host disease. Bone Marrow Transplant. 2002;30:327-329. 33. Miklos DB, Kim HT, Zorn E, et al. Antibody response to H-Y minor histocompatibility antigen DBY is detected in male patients after allogeneic stem cell transplantation and in normal female donors. Blood. 2003;100:213a-214a.
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Treatment of Chronic Graft-versus-Host Disease with Anti-CD20 Chimeric Monoclonal Antibody Voravit Ratanatharathorn, Lois Ayash, Christopher Reynolds, Samuel Silver, Pavan Reddy, Michael Becker, James L. M. Ferrara, Joseph P. Uberti Blood and Marrow Stem Cell Transplantation Program, University of Michigan Health System, Ann Arbor, Michigan Correspondence and reprint requests: Voravit Ratanatharathorn, B1-207, Cancer Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109 (e-mail: [email protected]). Received May 5, 2003; accepted June 17, 2003
ABSTRACT 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/m2 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. © 2003 American Society for Blood and Marrow Transplantation
KEY WORDS Chronic graft-versus-host disease ● Acute graft-versus-host disease ● Allogeneic transplantation ● Hematopoietic stem cell transplantation ● Anti-CD20 antibody ● B-cell depletion
INTRODUCTION Chronic graft-versus-host disease (GVHD) remains a formidable complication for long-term survivors of hematopoietic stem cell transplantation. The primary treatment of chronic GVHD has mainly relied on systemic corticosteroids. The addition of other immunosuppressive agents to corticosteroids has not resulted in improvement of efficacy [1,2]. Various agents have been studied for salvage therapy in the setting of corticosteroid failure, with some reported success [3]. However, the protean manifestations of chronic GVHD could confound the ability to accurately assess the efficacy of these agents, especially when they are used as salvage therapy. Conventional opinions regarding organ rejection, GVHD, and transplantation tolerance have centered on a primary role for T cells in mediating immunologic attacks on the target tissues [4]. However, there is evidence of B-cell dysregulation that might contribute to the pathogenesis of chronic GVHD. In a case report,
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thrombocytopenia associated with chronic GVHD was successfully treated with B-cell depletion by using an anti-CD20 monoclonal antibody (rituximab [Rituxan]; IDEC Pharmaceuticals Corp., San Diego, CA) [5]. Other clinical manifestations of chronic GVHD in this patient, including oral lichen planus, skin, and xerophthalmia, also became quiescent after rituximab use, allowing gradual discontinuation of immunosuppressants. Normalization of thrombocytopenia in this patient was durable despite B-cell recovery, suggesting that tolerance may be induced with B-cell depletion. In this article, we report a retrospective case series of 8 patients with refractory chronic GVHD treated with rituximab. The clinical responses observed in this article suggest a role of B-cell depletion in treating some manifestations of chronic GVHD.
PATIENTS AND METHODS From September 2000 to October 2002, we treated 8 adults who had undergone an allogeneic 505
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sibling stem cell transplantation for hematologic malignancies and who had refractory chronic GVHD treated with rituximab. The dose of rituximab was 375 mg/m2 given intravenously weekly for 4 weeks. The initial rate of infusion was 50 mg/h. If there was no reaction to the infusion, the rate was increased by 50 mg/h increments every 30 minutes to a maximum of 400 mg/h. All patients were premedicated with acetaminophen 650 mg and diphenhydramine 50 mg orally. We retrospectively reviewed the clinical data and outcome of these 8 patients. This study was approved by the institutional review board.
RESULTS All patients had extensive chronic GVHD with sclerodermoid involvement of skin/soft tissues and xerophthalmia. One other patient had limited sclerodermoid involvement of the lateral thoracic cage and abdominal wall but developed painful ischemic fingers on both hands because of cold agglutinins and the Raynaud phenomenon. All but 1 patient had progressive onset of chronic GVHD. Prior treatment for chronic GVHD included tacrolimus and methylprednisolone for all patients. Seven patients were taking at least 3 immunosuppressive agents before or during rituximab therapy. Six patients had received extracorporeal photopheresis (ECP) before rituximab, without response. With the exception of case 4, no patient received methylprednisolone or hydrocortisone during rituximab infusion. Patients who responded to rituximab had their immunosuppression tapered gradually. For nonresponders, the dose of immunosuppression was increased or additional agents were added as clinically indicated. The median age of the patients was 46 years (range, 28-58 years). The median time from transplantation to rituximab was 18 months (range, 13-90 months); the median duration of follow-up after rituximab was 265 days (range, 104-846 days). Patient demographics, prior therapy of chronic GVHD, and response to therapy are summarized in Table 1. A clinical response to rituximab was noted in 4 of 8 patients, as detailed below. Case 1
A 31-year-old woman developed progressive chronic GVHD that was unresponsive to tacrolimus, methylprednisolone, mycophenolate, hydroxychloroquine, thalidomide, acitretin, and ECP. The predominant clinical feature was generalized sclerodermoid chronic GVHD interspersed with ulcerating lichen planus. The most disabling sclerodermoid GVHD involved the anterior cervical fascia, resulting in a severe flexion contracture (Figure 1). After rituximab therapy, her immunosuppressive agents were able to 506
be tapered gradually over 7 months, with improvement of skin GVHD. The range of motion of her neck had improved to near normal 1 year after treatment with rituximab (Figure 2). The dose of immunosuppression was tapered from tacrolimus 1.5 mg twice daily (BID) and methylprednisolone 32 mg daily at the initiation of rituximab to tacrolimus 0.5 mg daily and methylprednisolone 4 mg daily at the last follow-up visit. Case 2
A 38-year-old man had biopsy-proven liver GVHD (lobular hepatitis with mild bile duct damage compatible with GVHD) at day 60 after transplantation. He was treated with methylprednisolone and tacrolimus, with complete resolution of his liver disease. Eleven months after transplantation, he developed painful ischemic fingers consistent with the Raynaud phenomenon and was treated with nifedipine, without relief. He also had other signs and symptoms of chronic GVHD involving the eyes and mouth and limited sclerodermoid and fasciitis changes of the lower thoracic cage and abdomen. His fingertips had bluish discoloration and were very painful to touch and movement. He had a cold agglutinin titer of 1:40 and an absence of cryoglobulin. He was started on 2 mg/kg/d of methylprednisolone, which was reduced several weeks later because of a lack of improvement and steroid intolerance (Figure 3). Despite corticosteroids, ischemic changes of the fingertips became more pronounced, and early necrosis of his fingertips appeared. He was then started on rituximab. Three months after treatment with rituximab, his fingers returned to normal, without pain, despite the continuing taper of methylprednisolone (Figure 4). Cold agglutinins were not detectable after rituximab therapy was completed. Other manifestations of chronic GVHD involving the eyes, mouth, and soft tissue also improved, allowing methylprednisolone to be tapered from 32 mg BID to 10 mg daily. Case 3
A 48-year-old man with advanced immunoglobulin G myeloma developed a clinical grade 3 acute GVHD involving the skin and gastrointestinal tract early in the course of transplantation. His acute GVHD responded to methylprednisolone and tacrolimus, but at 1 year after transplantation, he was noted to have xerophthalmia, xerostomia, and eosinophilia. At the same time, because of concern for progression of his myeloma (indicated by an increasing M spike), his immunosuppression was gradually tapered. Several weeks later, he developed nephrotic syndrome, with proteinuria of 20 g/24 hours, and the renal biopsy showed membranous glomerulonephritis. There was
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Table 1. Patient Demographics, Prior Therapy, Response, and Status
Preparative Regimen
Source of Stem Cells
T/NK NHL
CVB
PB/Sis
Progressive
38/M
CML/AP
BAC
PB/Sis
Progressive
3
48/M
Myeloma
BuCyTMI
PB/Bro
Progressive
4
46/M
MDS
BAC
BM/Sis
Progressive
5
58/M
MCL
RI
PB/Sis
Progressive
6
41/F
CML
BuCy-2
PB/Sis
De novo
7
48/M
MDS
BAC
PB/Sis
Progressive
8
28/M
ALL
CY/TBI
PB/Bro
Progressive
Case No.
Age/ Sex
Diagnosis
1
31/F
2
Type of Onset
Organ Involvement Extensive sclerodermoid; lichen planus; eyes; chronic bronchitis; cervical flexion contracture Localized sclerodermoid involvement of the skin and soft tissue, eyes, and liver; cold agglutinin and Raynaud phenomenon Extensive sclerodermoid; eyes, kidney
Interval from Transplantation to Rituximab Therapy (mo)
Response
Status
Tacrolimus, MP, MMF, hydroxychloroquine, infliximab, thalidomide, acitretin, ECP
13
Responded
Alive at 42 mo after transplantation continuing response at 868 d
Tacrolimus, MP
13
Responded
Alive at 27 mo after transplantation continuing response at 369 d
Tacrolimus, MP, MMF
14
Responded
90
Responded
Alive at 29 mo after transplantation continuing response at 294 d Alive at 99 mo after transplantation continuing response at 265 d
19
NR
49
NR
33
NR
40
NR
Prior Therapy
Tacrolimus, CSA, MP, Extensive azathioprine, MMF, sclerodermoid ECP interspersed with lichen planus, eyes, liver; restrictive/obstructive lung disease Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid, ECP eyes Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid; thalidomide, lichen planus; acitretin, ECP eyes; chronic bronchitis Tacrolimus, MP, MMF, Extensive ECP sclerodermoid; eyes Tacrolimus, MP, MMF, Extensive hydroxychloroquine, sclerodermoid; ECP eyes
Alive at 27 mo after transplantation Alive at 55 mo after transplantation
Alive at 39 mo after transplantation Alive at 45 mo after transplantation
MP indicates methylprednisolone; MMF, mycophenolate mofetil; ECP, extracorporeal photopheresis; MDS, myelodysplastic syndrome; CY, cyclophosphamide 60 mg/kg intravenously daily for 2 days; TBI, total body irradiation 2 Gy twice a day on 3 consecutive days; ALL, acute lymphocytic leukemia; AML, acute myeloid leukemia; CML, chronic myeloid leukemia; MCL, mantle cell lymphoma; BM, bone marrow; PB, peripheral blood; BAC, 3 agents given consecutively (busulfan 1 mg/kg every 6 hours orally for 16 doses, cytarabine 2 g/m2 every 12 hours for 4 doses, and cyclophosphamide 60 mg/kg daily for 2 days); BuCy-2, busulfan 1 mg/kg every 6 hours orally for 16 doses and cyclophosphamide 60 mg/kg daily for 2 days; RI, reduced-intensity regimen of fludarabine 25 mg/m2 intravenously daily for 5 days (days ⫺11 to ⫺7) followed by busulfan 0.5 mg/kg orally every 6 hours for 16 doses (days ⫺6 to ⫺3), MMF 750 mg orally twice per day for actual weight ⱕ80 kg and 1000 mg orally twice per day for weight ⱖ80 kg from day ⫺6 to day 0, and total lymphoid irradiation of 2 Gy on day 0; BuCyTMI, sequential busulfan 0.875 mg/kg orally every 6 hours for 16 doses, cyclophosphamide 60 mg/kg intravenously daily for 2 days, and total marrow irradiation to a total dose of 8.5 Gy; M, male; F, female; bro, brother; sis, sister; NR, no response; CSA, cyclosporine; CVB, regimen of cyclophosphamide 1800 mg/m2 intravenously on day ⫺7 to ⫺4, etoposide 200 mg/m2 intravenously q12h on day ⫺7 to ⫺4, BCNU 450 mg/m2 intravenously on day ⫺3; AP, accelerated phase.
no light chain proteinuria and no detectable monoclonal spike on serum protein electrophoresis. He initially responded to increasing immunosuppression with methylprednisolone and the addition of mycophenolate. Over the ensuing 3 months, his proteinuria improved and plateaued at 13 to 14 g/24 hours, whereas his creatinine clearance declined, and tacrolimus was replaced with sirolimus. His skin also showed mottled sclerodermoid changes, particularly over the
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distal extremities and lateral torso; his xerophthalmia was increasingly symptomatic. Five months after the diagnosis of membranous glomerulonephritis, his proteinuria remained unchanged, and rituximab was initiated. Both his proteinuria and other manifestations of chronic GVHD gradually improved despite the tapering of immunosuppressants (Figure 5). Nine months after rituximab, a 24-hour urinary protein was measured at 4 g. His renal function and proteinuria 507
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Figure 3. Painful cyanotic fingers in a patient (case 2) with cold agglutinin.
Case 4
Figure 1. This patient (case 1) showed cervical flexion contracture (caused by dense fibrosis of the anterior cervical fascia), blotchy hyperpigmentation, hidebound facial skin, and circumoral stricture.
continued to improve despite the reduction of immunosuppression. At the last follow-up visit, he was taking methylprednisolone 8 mg every other day and sirolimus 1 mg daily.
Figure 2. Resolution of the cervical flexion contracture and improvement of the sclerodermoid changes of the facial skin. 508
A 49-year-old man who had received allogeneic marrow stem cell transplantation developed progressive-onset chronic GVHD. The prominent feature was slowly progressive sclerodermoid skin changes over the entire torso, limiting chest wall compliance and resulting in severe restrictive lung disease. Pulmonary function studies also indicated obstructive physiology. Seven years after transplantation, ECP was initiated. After 5 months of ECP therapy, there was minimal softening of the skin of both lower distal extremities but no significant improvement of his respiratory dysfunction. Ninety months after transplantation, with increasing oxygen requirements, the patient was given rituximab. He experienced severe respiratory difficulty with the first rituximab infusion and required a single intravenous dose of methylprednisolone 40 mg and aerosolized albuterol. The subsequent 3 doses of rituximab were given without further difficulty after premedication with hydrocortisone 100
Figure 4. Resolution of painful cyanotic fingers after antibody therapy.
Rituximab Treatment for Chronic GVHD
Figure 5. Response of proteinuria in a patient with membranous glomerulonephritis.
mg intravenously. Two weeks after he completed a course of rituximab, his lung capacity had improved sufficiently to become oxygen independent, and he was able to participate in household chores. His forced vital capacity and forced expiratory volume in 1 second improved from 28% and 33% before rituximab therapy to 57% and 63%, respectively, after rituximab therapy. Serial pulmonary function studies and treatments given are summarized in Figure 6. The patient was maintained on tacrolimus 1 mg BID and mycophenolate 1 g BID. Cases 5 to 8
Four patients did not respond to rituximab therapy. Three of 4 patients had a rapid onset of diffuse inflammatory changes of the skin associated with edema of both upper extremities. The involved skin was tender to pressure, and there was a limited range of motion of the involved extremities. The inflammatory changes were most pronounced over the distal extremities. Fibrosis and postinflammatory hyperpigmentation of the skin ensued within 8 weeks of onset. Progressive fibrosis later involved the lower lateral thoracic cage, with restricted respiratory movement. One patient (case 6) had slowly progressive fibrosis of the distal upper extremities associated with lichen planus clustering over the wrists, palmar surfaces, and shoulders, with scattered lesions on the trunk and axillary folds. Patchy areas of dense fibrosis were limited to the volar surfaces of the forearms, axillary folds, and scattered lesions over the neck. There was severe pain and tenderness of the ulcerating lesions of lichen planus.
manifestations of chronic GVHD, eg, skin involvement and dry eyes, also improved despite discontinuation of immunosuppressive therapy. This observation suggested that other organ manifestations of chronic GVHD may also respond to B-cell depletion. The role of B cells in the pathogenesis of autoimmune disorders is a subject of debate. There is mounting evidence that hyperactivity of B cells may be the defining event in systemic lupus erythematosus, leading to production of pathogenic autoantibodies that results in end-organ damage [6]. Similarly, in a murine model of chronic GVHD, parent into F1 model (C57BL/6 ⫻ DBA2), the expansion of host B cells in response to donor CD4⫹ was thought to play a central role in the development of chronic GVHD with autoantibody production and glomerulonephritis [7,8]. It is uncertain whether this nonradiation model of GVHD bears any relevance to the human GVHD, because until recently most preparative regimens used in clinical stem cell transplantation were myeloablative. However, the clinical resemblance of this murine model to chronic GVHD in humans with autoantibody production would suggest the pathogenetic role of B cells in some of the manifestations of this syndrome. Recently, depletion of B cells by using rituximab [9] has shown efficacy in the treatment of several autoimmune disorders [10], including chronic idiopathic thrombocytopenia [11], autoimmune polyneuropathy [12], autoimmune hemolytic anemia [13], cold agglutinin disease [14], pure red cell aplasia [15], Wegener granulomatosis [16], idiopathic membranous nephropathy [17], and rheumatoid arthritis [18]. Rituximab has also been shown to be effective in the treatment of various immune-mediated complications related to chronic GVHD or allogeneic transplantation, eg, thrombocytopenia [5], myasthenia gravis [19], and autoimmune hemolytic anemia [20]. It is interesting to note that other manifestations of chronic GVHD were also noted to be responding to
DISCUSSION In our initial observation in a patient with chronic GVHD-associated thrombocytopenia, there was a dramatic response of her thrombocytopenia to treatment with rituximab [5]. Furthermore, other clinical
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Figure 6. Response of restrictive or obstructive pulmonary physiology to antibody therapy; (f) forced vital capacity, (䉬) forced expiratory volume in 1 second. 509
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this treatment in some patients. Furthermore, the response seemed to be durable despite recovery of B cells, suggesting that tolerance may be achieved with this therapy. Numerous treatment strategies for chronic GVHD with varying degrees of success have been reported [5,21-23]. Among the treatments studied, ECP is by far the most effective, with 38% to 80% complete resolution of skin involvement, 48% to 70% improvement of liver involvement, and 39% improvement of lung involvement [24,25]. In our series, 6 patients had received prior ECP therapy, and only 2 of these patients responded. It is not likely that prior ECP affected the outcome of rituximab therapy. Of the 4 patients who responded to rituximab therapy, 2 patients had predominantly skin and soft tissue involvement (sclerodermoid chronic GVHD and lichen planus). The remaining 2 patients had membranous glomerulonephritis and Raynaud phenomenon related to cold agglutinins. The temporal relationship of cold agglutinin disease and glomerulonephritis with the ongoing activity of chronic GVHD in our patients suggested that the immunopathogenesis of these chronic GVHD manifestations might be similar to that in patients with autoimmune diseases. Objective responses to rituximab included disappearance of cold agglutinin titers and resolution of the Raynaud phenomenon (case 2), decline in urinary protein excretion (case 3), and improvement of sclerodermatous changes of the thoracic cage with a marked improvement in the pulmonary spirogram (case 4). The remaining patient (case 1) had resolution of the severe cervical flexion contracture from diffuse scleroderma and healing of the ulcerating lichen planus. The time to clinical and laboratory improvement ranged from 1 month in a patient (case 2) with cold agglutinin disease to 4 months in a patient with diffuse scleroderma and lichen planus. In patients with membranous glomerulonephritis and cold agglutinin disease, the presence of autoantibody may be implicated as the cause of the unique manifestations of chronic GVHD. Depletion of CD20⫹ B cells, the potential precursors of the autoantibody-producing cells, might explain the efficacy of rituximab in treatment of autoimmune manifestations. However, depletion of B cells alone may not be the only mechanism responsible for rapid recovery from thrombocytopenia [5,11]. Fc receptor blockade by opsonized B cells may also play a role in rapid clinical improvement [26]. Similar mechanisms involving depletion of autoantibody-producing B cells might be operating in patients with sclerodermoid chronic GVHD and patients with systemic sclerosis and related fibrosing disorders [27]. Furthermore, higher levels of B-cell activation in the granulocyte colonystimulating factor mobilized peripheral blood stem cell may be an important contributing factor in the 510
increased incidence of chronic GVHD in recipients of allogeneic stem cell transplants [28]. The role of T cells in mediating endothelial injury in patients with chronic GVHD has also been described. Compromised tissue perfusion resulting from endothelialitis eventually leads to tissue hypoxia and fibrosis, which is the hallmark of chronic GVHD pathology [29]. It is unclear how T and B cells interact to sustain the immunologic assaults on target tissues. One of the mechanisms might involve antigen presentation by interaction of dendritic cells with B cells, leading to generation of peptide/major histocompatibility complex complexes by B cells that then presented to T cells [30,31]. A clinical example of the collaboration of T and B cells in chronic GVHDassociated bullous pemphigoid was recently reported [32]. Furthermore, Miklos et al. [33] have demonstrated B-cell responses to DBY (a minor H-Y minor histocompatibility antigen) in 48% of male recipients from female grafts, indicating the collaboration of T and B cells to produce specific antibodies against host antigens. Four patients in this series did not respond to B-cell depletion. Serial peripheral blood CD19⫹ cell counts obtained in 4 patients (3 responders and 1 nonresponder) demonstrated no detectable CD19⫹ cells after rituximab therapy (data not shown). It is possible that some autoantibody-producing cells or their precursors were not depleted because of the absence or low expression of CD20. Other mechanisms of antigen presentation not involving B cells might also be dominant in sustaining the dysregulated immune response. In these situations, treatment with rituximab, a highly effective agent for B-cell depletion, would not be sufficient in eliminating pathogenic autoantibodies. The efficacy of rituximab in patients with chronic GVHD demonstrated in this retrospective study suggests a pathogenetic role of B cells in this disease. Depletion of B cells with rituximab resulted in clinical and laboratory improvement of chronic GVHD in 4 of 8 patients with refractory chronic GVHD. Sustained improvement of clinical signs and symptoms of chronic GVHD, despite B-cell recovery, may indicate that the induction of tolerance may have occurred. This novel therapy should be tested in a prospective study in patients with earlier stages of chronic GVHD.
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