High-dose cyclophosphamide with stem cell rescue for severe rheumatoid arthritisShort-term efficacy correlates with reduction of macroscopic and histologic synovitis.код для вставкиСкачать
ARTHRITIS & RHEUMATISM Vol. 46, No. 3, March 2002, pp 837–839 © 2002, American College of Rheumatology CONCISE COMMUNICATION Table 1. Arthroscopic findings at baseline and following autologous stem cell transplantation DOI 10.1002/art.10093 High-dose cyclophosphamide with stem cell rescue for severe rheumatoid arthritis: short-term efficacy correlates with reduction of macroscopic and histologic synovitis Month Macroscopic synovitis VAS score* Microscopic findings† CD3 CD45RO CD4 CD8 Stroma Lining layer CD34 Number Intensity CD20 Vascularity Autologous stem cell transplantation (SCT) has been proposed as therapy for severe autoimmune diseases (1), and a small number of patients with rheumatoid arthritis (RA) have received such transplants (2). The European League Against Rheumatism and the European Bone Marrow Transplant Group have issued treatment guidelines (3) and established a registry of patients undergoing autologous SCT (4). The principle mechanism of action of autologous SCT is unclear, and there is no published information about its effects in the synovium, the principal target organ in RA. We now report the case of a patient who was diagnosed with seronegative RA in 1996 at age 21 years. Between 1996 and 1998, she was treated unsuccessfully with sulfasalazine, 1 gm twice daily (neutropenia), intramuscular gold, 50 mg/week (no response), oral and subcutaneous methotrexate, 20 mg/ week (no response), and cyclosporine, 350 mg/day (no response). In July 1998, she was referred to the General Infirmary at Leeds for evaluation for autologous SCT. Baseline assessment revealed very active disease, with impaired functional ability and quality of life. Following counseling regarding the risks and possible outcomes, consent was obtained for autologous SCT with arthroscopy at baseline, 3 months, and at relapse (for research purposes). Baseline arthroscopy revealed marked synovitis with villous formation and increased vascularity. Histologic examination showed infiltration with inflammatory cells (Tables 1 and 2 and Figure 1). Disease-modifying antirheumatic drugs (DMARDs) (except prednisolone, 10 mg) were stopped prior to mobilization. Stem cells were mobilized with cyclophosphamide (2 gm/m2) and granulocyte colony-stimulating factor (lenograstim, 263 g/day). The patient became neutro- 0 3 9 64 20 82 1 2 3 1 3 3 0 0 0 0 1 1 2 3–4 2 1 1 1 3 2 1 1 2 2 0 2 1 1 1 1 * VAS ⫽ visual analog scale; score 0–100 mm. † Graded as 0, no stained cells in sample; 1, ⬍25% cells stained; 2, 25–50% cells stained; 3, 50–75% cells stained; or 4, ⬎75% cells stained. penic during the mobilization phase (nadir 0.6 ⫻ 109 neutrophils/liter), and intravenous antibiotic therapy (gentamicin and piperacillin/tazobactam) was started following an episode of pyrexia. The graft contained 4.05 ⫻ 106 CD34⫹ cells/kg, resulting in a purified product containing 1.6 ⫻ 106 CD34⫹ cells/kg (95.3% pure CD34) following positive CD34⫹ and negative CD4/8 selection using the Isolex 300i cell selection system (Baxter, Norfolk, UK). Six weeks later, she was readmitted for conditioning with cyclophosphamide, 50 mg/kg, which was given on days 5, 4, 3, and 2 prior to stem cell reinfusion (total 200 mg/kg). Stem cells were reinfused on day 0, and reconstitution occurred rapidly (neutrophil count ⬎1.0 ⫻ 109 cells/liter, platelet count ⬎50 ⫻ 109 cells/liter by day 14). During this period, she had an Table 2. Laboratory and clinical findings at baseline and following autologous stem cell transplantation Month Laboratory C-reactive protein, mg/liter (normal ⬍10) Peripheral blood, cells ⫻ 109/liter CD3 (normal 0.77–2.68) CD4 (normal 0.53–1.76) CD8 (normal 0.30–1.03) B cell (normal 0.06–0.66) Clinical* Swollen joint count Tender joint count ACR response, % 0 1 3 6 9 12 15 18 105 15 13 15 114 303 249 94 0.8 0.56 0.23 0.12 0.34 0.11 0.31 0.18 0.42 0.15 0.22 0.15 0.37 0.12 0.22 0.01 0.66 0.3 0.34 0.43 0.74 0.43 0.28 0.46 0.85 0.51 0.31 0.43 0.57 0.31 0.24 0.15 16 21 – 9 7 20 6 14 20 7 10 50 3 10 0 14 11 0 37 32 0 12 18 0 * Swollen joint count based on 56 joints; tender joint count based on 58 joints; ACR response ⫽ response according to the American College of Rheumatology preliminary definition of rheumatoid arthritis improvement (5). 837 838 CONCISE COMMUNICATION Figure 1. Arthroscopic findings before and after autologous stem cell transplantation in a patient with seronegative rheumatoid arthritis. Left panels, Macroscopic appearance of synovium. a, Before therapy, the synovium is hyperemic, and marked villous formation is apparent. b, At 3 months, when patient showed a dramatic clinical response, most villi are avascular and white (arrowheads), although 1 villus remains vascularized and swollen (arrow). c, At 9 months, the synovial villous vascularity has become confluent again. Right panels, Microscopic appearance of synovium stained immunohistochemically with a monoclonal antibody to CD3, showing d, synovial tissue with abundant CD3⫹ T cells, e, synovial tissue devoid of CD3⫹ cells, and f, reappearance of a dense CD3⫹ T cell infiltrate. episode of neutropenic sepsis related to the Hickman line insertion site and was treated with intravenous vancomycin and aztreonam. She had no other complications, apart from mild mucositis, and was discharged on day 24. Immediately following SCT, a dramatic reduction in disease activity occurred, and the patient was able to discontinue all DMARDs. Three months after SCT, planned arthroscopy of her left knee revealed very little inflammation and reduced vascularity compared with baseline (Tables 1 and 2 and Figure 1). However, a single villus remained inflamed and vascular. Immunohistochemical staining revealed a marked reduction in all T cell subsets (CD3, CD4, CD8, CD45RO), B cells (CD20), and macrophages (CD68), and a reduction in CD34 staining predominantly related to endothelial cell expression in the synovium (Table 1 and Figure 1). At the 6-month review, the dramatic reduction in disease activity was maintained, and the patient reached 50% response according to American College of Rheumatology criteria (5). CONCISE COMMUNICATION Nine months after SCT, the patient experienced widespread relapse of disease. Arthroscopy of her left knee revealed increased synovitis and early invasive pannus (Figure 1). Immunohistochemistry studies revealed increased infiltration of CD3⫹, CD4⫹, CD45RO⫹, and, to a lesser extent, CD8⫹ cells (Tables 1 and 2 and Figure 1). Treatment with oral cyclosporine (350 mg/day) was started, followed by oral methotrexate (20 mg/week) because of continued disease activity. At the 15-month assessment, the level of disease activity was still unacceptable, and anti–tumor necrosis factor therapy was started. However, this treatment was accompanied by an exacerbation of arthritis and was discontinued after 2 infusions. The patient is currently receiving leflunomide, 20 mg/ day. This patient received a manipulated graft that had undergone positive CD34 and negative T cell selection. It is possible that purification of the graft may reduce the rate of relapse, but some clinicians fear that this may be at the expense of poor reconstitution and increase the risk of subsequent infection. Although peripheral blood CD3, CD4, and CD8 levels did not return to the normal range until 15 months after autologous SCT, the patient had no infectious complications following discharge. High-dose chemotherapy and highly selected autologous SCT with double selection did induce a dramatic reduction in disease activity, both clinically and on macroscopic and histologic evaluation of the synovium. When relapse occurred at 9 months, arthroscopy revealed florid synovitis consistent with clinical disease, and histologic evaluation of synovium showed increased numbers of CD3 and CD4 cells despite flow cytometry of peripheral blood lymphocytes showing prolonged cell depletion. A correlation between synovial lymphocyte infiltration and clinical disease, along with disparity between circulating and synovitic lymphocyte repopulation suggests either synovitic T cell proliferation or ongoing recruitment from significantly depleted peripheral blood. In our patient, increased numbers of CD45RO⫹ cells indicated the presence of memory or primed rather than naive T cells. These results suggest a pathogenic role for T cells, even in established RA. 839 Sarah Bingham, MA, MRCP Douglas Veale, MD, FRCP, FRCPI Ursula Fearon, PhD John D. Isaacs, PhD, FRCP Gareth Morgan, MB BS, PhD, MRCP, MRCPath Paul Emery, MA, MD, FRCP University of Leeds Leeds, UK Dennis McGonagle, MRCPI Halifax General Hospital and University of Leeds Leeds, UK Richard Reece, MB BCh, MRCP Huddersfield Royal Infirmary University of Leeds Leeds, UK Roy Clague, MD, FRCP Nobles Hospital Isle of Man, UK John A. Snowden, BSc (Hons), MD, MRCP, MRCPath Leicester Royal Infirmary Leicester, UK 1. 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