AHSCT in CD

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8

From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

TRANSPLANTATION

Autologous hematopoietic stem cell transplantation in refractory celiac disease


with aberrant T cells
Abdulbaqi Al-toma,1 Otto J. Visser,2 Hyacintha M. van Roessel,2 B. Mary E. von Blomberg,3 Wieke H. M. Verbeek,1
Petra E. T. Scholten,3 Gert J. Ossenkoppele,2 Peter C. Huijgens,2 and Chris J. J. Mulder1
Departments of 1Gastroenterology, 2Hematology, and 3Clinical Pathology, VU University Medical Center, Amsterdam, The Netherlands

Autologous hematopoietic stem cell trans- fludarabine and melphalan, ASCT was and biochemical markers (mean follow-
plantation (ASCT) is an increasingly ac- performed. Patients were monitored for up, 15.5 months; range, 7-30 months).
cepted treatment for refractory autoim- response, adverse effects, and hema- One patient died 8 months after trans-
mune diseases. Refractory celiac disease topoietic reconstitution. All 7 patients plantation from progressive neuroce-
with aberrant T cells (RCD type II) is completed the mobilization and leuka- liac disease. These preliminary results
unresponsive to available therapies and pheresis procedures successfully and showed that high-dose chemotherapy
carries a high risk of transition into enter- subsequently underwent conditioning followed by ASCT seems feasible and
opathy associated T-cell lymphoma and transplantation. Engraftment oc- safe and might result in long-term im-
(EATL). This study reports on the feasibil- curred in all patients. No major nonhe- provement of patients with RCD type II
ity, safety, and efficacy of ASCT in pa- matologic toxicity or transplantation- whose condition did not respond
tients with RCD type II. Thirteen patients related mortality was observed. There promptly to available drugs. (Blood.
with RCD type II were evaluated. Seven was a significant reduction in the aber- 2007;109:2243-2249)
patients (4 men, 3 women, mean age 61.5 rant T cells in duodenal biopsies associ-
years [range, 51-69 years]) underwent ated with improvement in clinical well-
transplantation. After conditioning with being and normalization of hematologic © 2007 by The American Society of Hematology

Introduction
Autologous hematopoietic stem cell transplantation (ASCT) is an monoclonal neoplastic T-cell population may emerge from IELs in
increasingly accepted effective treatment option for patients with RCD. Clonal expansion of this monoclonal T-cell population
severe autoimmune diseases refractory to conventional treatment1 eventually leads to frank EATL. The genesis and expansion of these
and has been used successfully in patients with multiple sclerosis,2 monoclonal T cells involve both inappropriate immune responses
rheumatoid arthritis,3 systemic sclerosis,4 systemic lupus erythem- to gluten and acquisition of genetic abnormalities. Although the
atosus,5 and Crohn disease.6 The rationale for this strategy is based monoclonal IELs in patients with RCD are neoplastic, they are
on the concept of immunoablation by intense immunosuppression not cytologically abnormal and do not form tumor masses,
using high-dose chemotherapy, with subsequent regeneration of which differentiate these patients from those with EATL, in
naı̈ve T lymphocytes derived from reinfused hematopoietic progeni- addition to the absence of radiologic and bone marrow evidence
tor cells.7 of lymphoma.10,12-14
In celiac disease (CD), HLA-DQ molecules bind and present RCD II is usually resistant to any known therapy, including
gluten peptides to antigen-specific T cells. These HLA-DQ–peptide azathioprine/prednisone, cyclosporine, and IL-10 therapy15-18 and
complexes induce inflammatory responses in the small intestine has a high risk of developing EATL (60%-80% within 5 years).10,19
consisting of lymphocytic infiltration of the lamina propria, This specific type of peripheral T-cell lymphomas has a very poor
expansion of the intraepithelial lymphocyte population, hyperpla- outcome with 1- and 5-year survival rates in the range of 31% to
sia of the crypts, and atrophy of the villi.8 In a small percentage 39% and 11% to 20%, respectively.19-21 In a prospective multi-
(2%-5%) of adult patients with CD diagnosed as adults, a center study of 35 patients with EATL treated with 6 cycles of
refractory state develops despite strict adherence to a gluten-free cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP),
diet (GFD).9 In refractory celiac disease (RCD) the number of the cumulative 2-year survival was only 28%.11 Therefore, new
intraepithelial lymphocytes (IELs) is markedly raised and it is from treatment strategies for patients with “premalignant” CD (RCD II)
these IELs that enteropathy associated T-cell lymphoma (EATL) are urgently needed to improve their clinical condition with the
may arise.9,10 Immunophenotyping of the IELs identifies 2 groups ultimate goal of resetting the immune response, which might
of RCD patients: those with normal IELs (RCD I) and those with prevent or delay development of overt EATL.
aberrant IELs, lacking surface expression of CD3 and CD8 (RCD This study reports on the feasibility, safety, and efficacy
II).10,11 RCD II can be regarded as a “cryptic” lymphoma.9 Strong of high-dose chemotherapy followed by ASCT in patients
molecular and immunophenotypic evidence now shows that a with RCD II.

Submitted August 24, 2006; accepted October 11, 2006. Prepublished online payment. Therefore, and solely to indicate this fact, this article is hereby
as Blood First Edition Paper, October 26, 2006; DOI 10.1182/blood-2006-08- marked ‘‘advertisement’’ in accordance with 18 USC section 1734.
042820.

The publication costs of this article were defrayed in part by page charge © 2007 by The American Society of Hematology

BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5 2243


From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

2244 AL-TOMA et al BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5

and follow-up) in addition to checking serology (antiendomysial [EMA]


and anti–tissue transglutaminase antibody [anti-tTG], both of which usually
Patients, materials, and methods revert to negative after strict adherence to the GFD); and evaluation by
Patients upper gastrointestinal endoscopy (UGIE), video capsule endoscopy (VCE),
and double balloon enteroscopy (DBE). Duodenal biopsies (4 biopsies)
Between March 2004 and March 2006, 13 patients were evaluated for were classified according to the modified Marsh criteria.24,25 T-cell receptor
ASCT. The 4 men and 3 women (mean age, 61.5 years; range, 51-69 years) (TCR) gene rearrangement study,12-14 T-cell flow cytometry, and IEL
with RCD II underwent ASCT. Six other patients were excluded because of phenotyping were performed.15,26,27 Laboratory evaluation included whole
the presence of coexistent coronary artery disease and heart failure (New blood cell counts and serum levels of creatinine, bilirubin, liver enzymes,
York Heart Association classification III in 2 patients), EATL found on lactate dehydrogenase, albumin, electrolytes, iron, ferritin, folic acid, and
evaluation before transplantation (3 patients), and low performance status vitamin B12 were determined. EMA and anti-tTG assays, HLA-DQ typing,
(1 patient). One patient could not be treated due to unsuccessful leukaphere- thyroid function tests, stool examination for Giardia and other parasites,
sis; she developed EATL and died subsequently despite chemotherapy and and HIV serology were also performed.28 For radiologic evaluation, the
immunotherapy with anti-CD52 (alemtuzumab).22 The 2 patients with patients underwent whole-body CT scanning and whole-body PET to
congestive heart failure died from progressive disease and cachexia (first exclude intestinal and extraintestinal localization of EATL.29,30
patient) and bronchiectasis (second patient). The 3 patients with EATL all
died within few months, whereas the patient with low performance status
Immunophenotyping of IELs
died from cachexia.
The baseline characteristics of the patients are shown in Table 1. All IELs were isolated from 3 duodenal biopsies by passing them through nylon
patients received therapy with prednisone and cladribine (2-CDA) several filters (1 ⫻ 100 ␮m, 1 ⫻ 40 ␮m, BD Biosciences, Discovery Labware,
months before undergoing ASCT (not within 6 months of transplantation). Bedford, MA). Cells were stained with fluorescent-labeled monoclonal
The first 3 patients (patients A, B, and C) were diagnosed with CD at antibodies to CD3, CD7, CD8, CD45, CD103, and TCR␥␦, as well as with
relatively advanced age, had persistent diarrhea and weight loss and failed relevant isotype controls.
to respond to GFD, steroids, and immunosuppressives. Because of the All monoclonal antibodies were from BD (BD Biosciences, San Jose,
presence of active disease and high percentage of aberrant T cells in the CA), except for CD103, which was from IQ Products (Groningen, The
small bowel mucosa, they were included in this study protocol. At the age of Netherlands) and analyzed by 4-color flow cytometry (FACSCalibur, BD
48 years, patient D was diagnosed with CD in association with dermatitis Biosciences, San Jose, CA). Leukocyte common antigen (CD45) was
herpetiformis. Furthermore, he had a clinical picture of neuroceliac disease always included to identify the lymphocyte population. In some tubes cell
with ataxia. After exclusion of structural brain and infectious disorders, he surface CD3 staining (anti–CD3-APC) was followed by permeabilization
underwent ASCT at the age of 63.5 years. Patient E has, in addition to CD (Cytofix/Cytoperm, BD Biosciences PharMingen, San Diego, CA) and
with ulcerative jejunitis, Hashimoto thyroiditis, and patient F has CD with subsequent cytoplasmic staining with anti–CD3-FITC or isotype control.
ulcerative jejunitis. One patient (patient G) was included because of the Aberrant T cells were defined either as CD7⫹ surface CD3⫺ cells
presence of very extensive ulcerative jejunitis with multiple small bowel (expressed as percent of CD103⫹ lymphocytes) or as cytoplasmic CD3⫹,
strictures necessitating repeated resections although initially biopsies surface CD3⫺ cells (expressed as percent of CD103⫹ lymphocytes).12,26
showed a low percentage of aberrant T cells. He had clinically short bowel All flow cytometry analyses were performed by an analyst and
syndrome (remaining small bowel approximately 100-150 cm) requiring interpreted by the same medical immunologist; histopathology was per-
total parenteral nutrition (TPN). formed by the same pathologist to ensure uniformity, reproducibility, and
consistency of results.
Criteria for diagnosis of RCD

Patients with CD were considered to be refractory when symptoms of Assessment of TCR gene rearrangement by PCR
malabsorption due to villous atrophy persisted or recurred after a former TCR␥ gene rearrangements studies were performed in separate 3 to 4
good response despite strict adherence to a GFD for at least 1 year. duodenal specimens that were preserved on Histocon (Polysciences Europe,
Furthermore, possible underlying diseases such as autoimmune enteritis, Eppelheim, Germany) and frozen at ⫺20°C. DNA was extracted from
bacterial overgrowth, giardiasis, amyloidosis, intestinal lymphangiectasia, cryosections of duodenal specimens by a standard procedure using protein-
Whipple disease, hypogammaglobulinemia, eosinophilic enteritis, EATL, ase-K digestion and ethanol precipitation of the gDNA. TCR-␥ gene
and inflammatory bowel disease were excluded.11 The diagnosis of RCD was rearrangements were analyzed by multiplex polymerase chain reaction (PCR)
established as type II when 20% or more aberrant T cells were present.10,11,15 amplification under standardized conditions. A monoclonal and polyclonal
control was included in each experiment. Clonality assessment for TCR-␥ gene
Inclusion criteria rearrangements was done according to the Biomed-2 concerted action BM
Patients were included only when the diagnosis of true RCD with aberrant T H4-CT98-3936 on PCR-based clonality studies for early diagnosis of lymphopro-
cells was confirmed (except for patient G who was included based on the liferative disorders.12-14
extensive ulcerative jejunitis with short bowel syndrome despite having
only 10% aberrant T cells), after verifying their strict adherence to a GFD. Peripheral blood stem cells mobilization and collection
Performance status according to the World Health Organization (WHO)
criteria had to be 0 to 2, and no severe concomitant cardiac, pulmonary, Mobilization of hematopoietic progenitor cells from the bone marrow into
renal or hepatic disease could be present. EATL was excluded by the peripheral blood was achieved using granulocyte colony-stimulating
endoscopic examination with multiple biopsies, computed tomography factor (G-CSF) 2 ⫻ 5 ␮g/kg by subcutaneous injection for at least 4 days.
(CT) scan, positron emission tomography (PET), and a trephine bone Hematopoietic stem cells were harvested from the peripheral blood by
marrow biopsy. Furthermore, neither active uncontrolled infection nor HIV leukapheresis and kept frozen until ASCT. The target CD34⫹ count was
positivity was permitted. more than 2 ⫻ 106/kg.

Evaluation Conditioning and ASCT

Before proceeding to ASCT, the patients were extensively evaluated as to The conditioning regimen consisted of fludarabine given orally for 5 days
their performance status, the presence of concomitant diseases, and (40 mg/m2/d) and melphalan (given intravenously, 2 days, 70 mg/m2/d) as
extraintestinal disease or EATL. This evaluation included clinical assess- shown in Figure 1. At day 0, the frozen stem cell suspension was thawed
ment noting particularly signs and symptoms of malabsorption, body mass and reinfused. The rationale for this conditioning regimen was based on
index (BMI), and performance according to the WHO score23; evaluation of T-cell depletion by a purine analog combined with a modified dose of
adherence to a GFD including frequent consultation with dietitian (advice melphalan (total dose 140 mg/m2) for myeloablation.
Table 1. Baseline characteristics of the patients
Characteristic Patient A Patient B Patient C Patient D Patient E Patient F Patient G

Age, y/sex 62/M 70/M 65/F 63/M 64/F 59/F 51/M


BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5

Age at CD diagnosis, y 56 62 61 48 44 47 50
Age at RCD II diagnosis, y 59 64 63 63 56 58 51
Age at ASCT, y 60 68 64 63 64 59 51
Date of ASCT Mar 2004 Aug 2004 May 2005 Aug 2005 Nov 2005 Dec 2005 Mar 2006
HLA-DQ2 Homozygous Homozygous Heterozygous Homozygous Heterozygous Heterozygous Homozygous
Marsh at RCD diagnosis III-A III-B III-A III-A III-C III-C III-A
BMI, kg/m2 19.4 18.9 17.1 24.1 20.1 21.3 20.5
Performance 1 1 1 1 1 1 2
Symptoms/associations Diarrhea, pain, weight Pain, diarrhea Diarrhea, weight loss, Diarrhea, weight loss, dermatitis, Weight loss, skin rash, Weight loss, Diarrhea, hypocalcemia, weight
loss hypocalcemia herpetiformis, neurologic Hashimoto diarrhea loss, extensive small bowel
symptoms (ataxia) thyroiditis resection
Serology at CD diagnosis EMA⫹, anti-tTG⫹ EMA⫹, anti-tTG⫹ EMA⫹, anti-tTG⫹ EMA⫹, anti-tTG⫹ EMA⫹, anti-tTG⫹ EMA⫹, EMA⫹, anti-tTG⫹
anti-tTG⫹
Serology at RCD EMA⫺, anti-TTG⫺ EMA⫺, anti-tTG⫺ EMA⫺, anti-tTG⫺ EMA⫺, anti-tTG⫺ EMA⫺, anti-tTG⫺ EMA⫺, EMA⫺, anti-tTG⫺
diagnosis anti-tTG⫺
Endoscopy* Nodular mucosa Mosaic mucosa, Mosaic mucosa, Nodular mucosa, disappearance Ulcerative jejunitis Ulcerative Ulcerative jejunitis with multiple
erosions, and visible vessels, no of folds, erosions jejunitis stenoses
ulcerations ulcerations
CT scan Splenic atrophy, Thickened SI loops Splenic atrophy, Splenic atrophy No abnormality No abnormality SI ileus
thickened SI wall dilated SI loops
PET scan Increased uptake in SI Increased uptake in SI Increased uptake in SI No abnormality No abnormality No abnormality No abnormality

All patients were treated with prednisone and 2-CDA (cladribine).


SI indicates small intestine; tTG, tissue transglutaminase; and EMA, endomysial antibody.
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

*Gastroduodenoscopy (GDS), video capsule enteroscopy (VCE), or double balloon enteroscopy (DBE).
STEM CELL TRANSPLANTATION IN RCD
2245
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

2246 AL-TOMA et al BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5

patient G, whose performance status was 2. Patients B, E, F, and G


had ulcerative jejunitis. Patients A, C, and D had splenic atrophy on
CT scan. PET scan showed an increased uptake in the small
intestine in patients A, B, and C. At the time of diagnosis of CD, all
patients were positive for anti-tTG and EMA, but all reverted to
negative after GFD. Before and after ASCT all patients remained
negative for anti-tTG and EMA. There was no transplantation-
Figure 1. Scheme of transplantation protocol. related mortality. The conditioning regimen seems feasible in this
group of patients. The mean duration of hospitalization was 19.5
Supportive care days (range, 18-22 days). ASCT-related toxicity was relatively
mild. Patient B had transient diarrhea and fever of undetermined
Patients A, C, and D were supported with parenteral feeding during the
origin, which was treated with intravenous antibiotics. Three weeks
2-week period of oral mucositis after ASCT; patient G was receiving
after discharge from the hospital, he suffered from a transient visual
parenteral nutritional support before receiving the transplant. After dis-
charge, all patients except patient G were able to be fed enterally. Patient G disturbance caused by minor retinal bleeding, which was not
was supported to gain weight for several months with a duodenal feeding related to thrombocytopenia. Patient D experienced fever of
tube and limited TPN (twice a week). During admission, all patients undetermined origin and recovered after administration of intrave-
received standard antibacterial and antifungal prophylaxis. Pneumocystis nous antibiotics. One month after ASCT, patient E developed
jiroveci pneumonia prophylaxis was initiated (trimethoprim-sulfamethox- self-limiting erythematous plaque skin lesions with central necro-
azole gluten-free syrup 480-960 mg daily) until 6 months after sis. Detailed histopathologic tests excluded EATL and showed
transplantation. No patient received antidiarrheal or narcotic medica- aberrant T-lymphocyte infiltration (CD8⫺CD7⫹CD30⫹).
tions in the peritransplantation period. Blood and platelet transfusions The mean time from the day of transplantation to neutrophil
were given as indicated.
recovery was 17.8 days (range, 10-21 days). Only one patient
(patient B) had a transient 5-day period of severe thrombocytope-
Follow-up and criteria of response
nia of 5 ⫻ 109/L; all other patients had nadir platelet counts
During follow-up, WHO performance status, nutritional status, and changes between 17 and 32 ⫻ 109/L without need for platelet transfusions.
in weight and stool frequency were noted, as well as relevant biochemical Clinical and laboratory tests before and after ASCT are shown
markers. An endoscopic and histologic examination of the small intestine in Table 2. Patients A, C, and D were supported with parenteral
was performed (3, 12, and 24 months after ASCT). From the second part of
feeding during the period of oral mucositis. No patient received
the duodenum, 4 biopsies were taken for histologic assessment and 4 to 6
antidiarrheal or long-term narcotic medications. Within 3 months
specimens for T-cell flow cytometry study. Hematologic data (hemoglobin,
white blood cell [WBC] count, differential, and platelets) were registered after ASCT, all patients showed impressive clinical improvement
before inclusion, after preconditioning, and after transplantation until with normalization of stool frequency, disappearance of abdominal
recovery. The nadir WBC count, duration of neutropenia, infectious pain, and improvement of biochemical markers. In addition,
complications, bleeding tendency, and need for supportive therapies such as improvement of BMI was documented (from mean 20.2 at baseline
blood and platelet transfusions were documented. to 24.1 after ASCT). Mean serum albumin level increased from 29
g/L to 40.7 g/L. Patient G showed a remarkable clinical improve-
Ethics approval and informed consent ment 3 to 4 months after ASCT and was able to be fed partly
Approval of the medical ethics committee was obtained, and all treated enterally with parenteral nutritional support twice a week.
patients signed an informed consent in accordance with the Declaration Table 3 shows the endoscopic and immunologic results. All
of Helsinki. patients were monoclonal for the TCR-␥. Endoscopically there
was disappearance of erosions and ulcerations in the jejunum in
all patients (patients B, E, F, and G) who had ulcerative jejunitis
Results before ASCT, and histology of the small intestine showed
significant regeneration as documented by down-staging of the
Table 1 summarizes the demographic and clinical characteristics of Marsh class (patients A, B, C, E, F, and G). Overall, the aberrant
the patients before ASCT. The mean age at diagnosis of CD was (CD7⫹CD3⫺) T-cell percentage of CD103⫹ lymphocytes de-
52.5 years (range, 47-62 years) and for RCD II 59 years (range, creased from a mean of 63% (range, 11%-95%) at baseline to
51-64 years). Four patients were DQ2 homozygous and 3 were 38% (range, 7%-68%) 3 to 4 months after transplantation.
heterozygous.31 The mean follow-up was 15.5 months (range, 7-30 Aberrant cytoplasmic CD3⫹ surface CD3⫺ T-cell percentage of
months). All patients had a WHO performance status of 1 except CD103⫹ lymphocytes decreased from a mean of 61% (range,

Table 2. Clinical and laboratory tests before and at the last follow-up after ASCT
Patient A Patient B Patient C Patient D Patient E Patient F Patient G
Characteristic Before After Before After Before After Before After Before After Before After Before After

BMI, kg/m2 19.4 25.6 18.9 26.1 22 24.1 24 24.1 20.1 22 22.1 23 20.5 25.8
Diarrhea Yes No Yes No Yes Yes Yes No Yes No Yes No Yes No
Performance status 1 0 1 0 1 1 1 0 1 0 1 0 2 0
Albumin, g/L 32 43 33 41 30 46 32 41 20 41 30 44 26 46
Serum iron, ␮M 18 26 11 18 14 10 14 15 17 13 7 17 13 18
Serum calcium, mM 2.20 2.36 2.33 2.45 2.26 2.26 2.26 2.32 2.33 2.41 2.02 2.35 2.00 2.29
Serum folic acid, nM 10 44 10.4 24 14 91 14 15 14 78 4.4 35 29 18
Serum B12, pM 470 560 169 307 440 290 440 790 206 666 107 317 269 221

Normal ranges: albumin, 34-50 g/L; iron, 10-32 ␮M; calcium, 2.20-2.60 mM; folic acid, ⬎ 5.9 nM; B12, 156-672 pM. Duration of follow-up for each patient: A, 30 mo; B, 27
mo; C, 16 mo; D, 8 mo; E, 11 mo, F, 10 mo; and G, 7 mo.
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5 STEM CELL TRANSPLANTATION IN RCD 2247

Table 3. Histological and phenotypical flow cytometric analysis of IELs in duodenal biopsies before (1-6 mo) and after ASCT
Marsh category CD7ⴙCD3ⴚ, % of CD103ⴙ ly Cyt CD3ⴙ surf CD3ⴚ, % of CD103ⴙ ly CD8ⴙ, % of CD103ⴙ ly
After After After After
Patient Before 3 mo 12 mo 24 mo Before 3 mo 12 mo 24 mo Before 3 mo 12 mo 24 mo Before 3 mo 12 mo 24 mo

Patient A III-A III-A III-A I 95 47 48 15 94 89 86 3 1 20 7 52


Patient B III-B I I I 51 7 4 8 51 2 6 4 28 68 62 67
Patient C III-C III-A III-A — 62 33 24 — 59 34 27 — 15 41 36 —
Patient D III-A III-A — — 54 47 — — 81 78 — — 7 13 — —
Patient E III-B I — — 44 68 — — 30 36 — — 22 2 — —
Patient F III-B III-A — — 71 40 — — 50 31 — — 23 11 — —
Patient G III-C III-A — — 11 30 — — 10 27 — — 63 52 — —
Mean — — — — 63 38 — — 61 42 — — 23 30 — —

Mean was calculated for values at 3 mo after ASCT. Normal range for Cyt CD3⫹ surf CD3⫺% of lymphocytes is 10% or less. TCR␥-PCR analysis showed monoclonality in
all patients.
Ly indicates lymphocytes; —, not applicable; TCR␥-PCR analysis, T-cell receptor ␥–polymerase chain reaction rearrangement.

10%-94%) to 42% (range, 2%-89%). Furthermore, the mean we assumed that progressive disease of RCD II with oligoclonal
percentage of CD8⫹ cells increased from 23% to 30% after T lymphocytes infiltrating the brain was the cause of death in
ASCT. This was particularly noticeable in the first 3 patients. this particular patient. EATL could not be detected. Autopsy
Patient D did not show a significant increase in CD8⫹ cells and confirmed the presence of chronic encephalitis of the right
the last 3 patients have not yet shown a significant change. temporal lobe with T-lymphocyte infiltration. Immunohistochem-
Individual responses to ASCT differed from each patient as istry showed that the lymphocyte infiltrate was CD3⫹ and the
shown in Table 3. Patient B showed the most impressive majority of cells expressed CD8 positivity. TCR gene analysis
response with a virtual complete disappearance of aberrant T showed that the T cells were oligoclonal.
cells. The fluorescent-activated cell sorting (FACS) data from
patient B are shown in Figure 2. The trend of aberrant T cells
and body weight for the first 4 patients who have a follow-up
period of at least 1 year is shown in Figure 3. Follow-up of Discussion
patients E, F, and G is as yet limited. Two years after
transplantation, our first patient (patient A) is showing further In this pilot study, ASCT in patients with RCD II was shown to be
improvement in his immunopathology status as demonstrated in feasible. The conditioning regimen was well tolerated in all
further decline in the percentage of aberrant T cells to 3% and patients and there was a substantial clinical improvement. The
histologically improved from Marsh III-A to Marsh I and the rapid initial response (within 3 months) and the duration (2 years in
second patient (patient B) is still showing persistent complete patient A and B and 14 months in patient C) of the remission up to
clinical and histologic response. Patient D had no significant now are promising. Complications included the occurrence of
change in the percentage of aberrant T cells and showed no neutropenic fever in 2 patients and retinal bleeding not related to
histologic improvement and no significant improvement in thrombocytopenia in one patient, all with full recovery. The nadir
CD8⫹ percentage; he died 8 months after transplantation. After leukocyte and platelet counts and the duration of leukopenia and
ruling out structural and infectious (bacterial and viral) causes, thrombocytopenia were comparable to our experience in patients
with non-Hodgkin lymphomas and multiple myeloma undergoing
ASCT after a combination of carmustine, etoposide, cytarabine,
and melphalan (BEAM) or high-dose melphalan (HDM; 200
mg/m2).32 Because there is no standard conditioning regimen for
ASCT used in autoimmune disease,33 a standard regimen from our
institution was used. Fludarabine induces T-cell depletion and the
alkylating agent melphalan was used to achieve myeloablation.
One patient was excluded due to unsuccessful leukapheresis.
Although we could achieve successful leukapheresis in all patients
despite earlier 2-CDA therapy, it is possible that the reason for
failure of stem cell mobilization in one particular patient might be
related to the use of 2-CDA.34 T cells play an essential role in the
pathogenesis of CD and RCD II/EATL.8,10,15 Through the activity
of the enzyme tissue transglutaminase (tTG) glutamine residues in
gluten are converted into glutamic acid.35,36 Subsequently a multi-
tude of gluten-derived peptides is generated that, when bound to
either HLA-DQ2 or -DQ8 can induce T-cell responses in patients
with CD.8,24 A particular glutamine- and proline-rich 33-mer
␣-gliadin peptide that contains 6 different T-cell stimulatory
Figure 2. Flow cytometric analysis of duodenal cells obtained from patient B, sequences and is resistant to gastric and duodenal proteolysis might
showing the change in the percentage of aberrant T-cell population before and be the primary initiator of the inflammatory response to gluten. In
after ASCT. Aberrant population is shown as CD7⫹CD3⫺ within CD103⫹ lympho-
the large majority of patients, even in children with CD, inflamma-
cytes (left) or as cytoplasmic (cyt) CD3⫹ surface (surf) CD3⫺ within lymphocyte gate
(right). Normal range for cyt CD3⫹ surf CD3⫺ % of CD103⫹ lymphocytes is 10% or tory T-cell responses to other gluten peptides are also observed,
less. implicating multiple gluten peptides in the disease process.26,27
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

2248 AL-TOMA et al BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5

Figure 3. The trend of aberrant T cells and body weight per patient. Ly indicates lymphocytes; before, 1 to 3 months. Normal range for cyt CD3⫹ surf CD3⫺ % of
lymphocytes is 10% or less.

The definition of RCD I/II has undergone refinement in recent immune response that might prevent or delay development of overt
years. It seems that the most reliable available method to differenti- EATL. On follow-up, our patients showed improvement in the small
ate between RCD I and RCD II is flow cytometry of intestinal intestinal histology, together with impressive clinical improvement as
biopsies revealing the presence of aberrant T cells. Detection of a demonstrated by disappearance of diarrhea and abdominal pain; normal-
clonal T-cell population by testing for TCR rearrangement was ization of serum albumin, electrolytes, and hemoglobin; increase in
thought to be highly predictive of EATL development. However, BMI; and improvement of the performance status. Two years after
oligoclonal or monoclonal IEL populations can be detected in the transplantation, our first patient is showing further improvement in his
large majority of both RCD I and RCD II patients and also in immunopathology status as demonstrated by further decline in the
patients who do not develop an EATL. Clonality is therefore of percentage of aberrant T cells to 3% and histologic improvement from
limited use in establishing the diagnosis of RCD and to predict the Marsh III-Ato Marsh I. We propose that enhanced apoptosis of activated
development of EATL.14,37,38 but aberrant T cells has led to this late but remarkable decline.41 One
RCD II is usually resistant to any known immunosuppressive patient died 8 months after ASCT from progressive neurologic manifes-
therapy, including azathioprine/prednisone,15 cyclosporine,16 and tations in association with CD. Autopsy excluded any structural or
IL-10 therapy.17 Recently, we treated 17 patients with 2-CDA on infectious cause. One patient developed self-limiting erythematous
intention to induce remission. Within a mean follow-up period of plaque skin lesions with central necrosis 2 months after ASCT. Detailed
22 months (range, 7-67 months) 47% had a significant decrease in analysis excluded the presence of EATL. Our most recent patient with
aberrant T-cell percentages with or without clinical response.39 clinically short bowel syndrome is showing remarkable clinical, endo-
However, another 41% did not respond clinically, histologically, scopic, and immunologic improvement. All our patients had negative
nor immunopathologically and subsequently died from EATL. serology before inclusion, confirming their strict adherence to GFD, and
Remissions of autoimmune diseases have been described in adults after ASCT all patients remained negative for anti-tTG and EMA.
after both allogenic and autologous ASCT1-7 most probably due to the Furthermore, the first 3 patients showed a significant increase in the
extreme immunosuppressive effects of these strategies,1 resulting in percentage of CD8⫹ lymphocytes, which is seen as a marker of
immunoablation with subsequent regeneration of naı̈ve T lymphocytes lymphocyte regeneration after ASCT.42 Patient D did not show a
derived from reinfused hematopoietic progenitor cells.7 Furthermore, significant increase in CD8⫹ cells and the last 3 patients have
recently, interesting insights into possible unsuspected mechanisms by not yet shown a significant change. Absence of a demonstrable
which stem cell transplantation could affect the gut have emerged. In improvement in the surface expression of CD8 on the IEL might
both animal and patient studies, sex-mismatched allogeneic stem cell be regarded as a poor prognostic indicator of response; this is
transplantations have shown in both mice and women that a population only to be proved or disproved on longer-term follow-up.
of myofibroblasts derived from the donor populates the intestinal Although the short-term results in these patients are promising,
mucosa. Given the importance of myofibroblasts in orchestrating the follow-up at present is too short to permit firm conclusions as to
function of epithelial cells, these data suggest a mechanism other than efficacy. The selection of patients for this treatment should be
one targeted at immunosuppression that could beneficially reset patient restricted to those patients with a substantial population of aberrant
functions, for example, enhancing barrier function following stem cell T cells, even after therapy with 2-CDA, who have a greater
transplantation.40 tendency to progress to highly lethal EATL. High-dose chemo-
These positive results, the high risk of transforming into EATL, and therapy followed by ASCT seems feasible and safe and might result
the absence of effective therapy for RCD with aberrant T cells led us to in long-term improvement of disease activity in RCD patients with
introduce this new strategy with the ultimate goal of resetting the aberrant T cells whose condition previously did not respond to
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

BLOOD, 1 MARCH 2007 䡠 VOLUME 109, NUMBER 5 STEM CELL TRANSPLANTATION IN RCD 2249

available treatments. Longer-term follow-up and additional pilot B.M.E.v.B. and P.E.T.S. performed T-cell flow cytometry; G.J.O.,
studies with larger groups of patients are needed to confirm the P.C.H., and C.J.J.M. revised and gave final approval of the
efficacy of this therapy. manuscript; and C.J.J.M. supervised the management of patients
before and after transplantation.
Conflict of interest disclosure: The authors declare no compet-
Authorship ing financial interests.
Correspondence: Chris J. J. Mulder, VU University Medical
Contribution: A.A.-t., O.J.V., and W.H.M.V. drafted the manuscript Center, Department of Gastroenterology, PO Box 7057, 1005 MB
and provided patient care; H.M.v.R. collected and analyzed data; Amsterdam, The Netherlands; e-mail: cjmulder@vumc.nl.

References
1. Tyndall A, Gratwohl A. Bone marrow transplanta- 16. Wahab PJ, Meijer JWR, Crusius BA, Uil JJ, Mul- 30. Hoffmann M, Vogelsang H, Kletter K, Zettinig G,
tion in the treatment of autoimmune diseases. der CJ. Cyclosporin in the treatment of adults with Chott A, Raderer M. 18F-fluoro-deoxy-glucose
Br J Rheumatol. 1997;36:1-5. refractory coeliac disease: an open pilot study. positron emission tomography (18F-FDG-PET)
2. Fassas A, Anagnostopulos A, Kazis A, et al. Pe- Aliment Pharmacol Ther. 2000;14:767-775. for assessment of enteropathy-type T cell lym-
ripheral blood stem cell transplantation in the 17. Mulder CJ, Wahab PJ, Meijer JW, Metselaar E. A phoma. Gut. 2003;52:347-351.
treatment of progressive multiple sclerosis: first pilot study of recombinant human interleukin-10 31. Al-toma A, Goerres MS, Meijer JWR, Peña AS,
results of a pilot study. Bone Marrow Transplant. in adults with refractory coeliac disease. Eur J Crusius JBA, Mulder CJJ. HLA-DQ2 homozygos-
1997;20:631-638. Gastroenterol Hepatol. 2001;13:1183-1188. ity and the development of refractory coeliac dis-
3. van Laar JM, Verburg RJ, Fibbe WE, Breedveld 18. Maurino E, Niveloni S, Chernavsky A, et al. Aza- ease and enteropathy associated T-cell lym-
FC. Intensive immunosuppression and autolo- thioprine in refractory sprue: results from a pro- phoma. Clin Gastroenterol Hepatol. 2006;4:315-
gous stem cell transplantation for patients with spective, open-label study. Am J Gastroenterol. 319.
severe rheumatoid arthritis: the Leiden experi- 2002;97:2595-2602. 32. Jonkhoff AR, De Kreuk AM, Franschman G, et al.
ence. J Rheumatol Suppl. 2001;64:25-27. 19. Gale J, Simmonds PD, Mead GM, Sweetenham Granulocyte colony-stimulating factor mobilized
4. Tyndall A, Black C, Finke J, et al. Treatment of JW, Wright DH. Enteropathy-type intestinal T-cell whole blood containing over 0.3 ⫻ 106/kg CD34⫹
systemic sclerosis with autologous haemopoi- lymphoma: clinical features and treatment of 31 cells is a sufficient graft in autologous transplan-
etic stem cell transplantation. Lancet. 1997; patients in a single center. J Clin Oncol. 2000;18: tation for relapsed non-Hodgkin’s lymphoma. Br J
349:254. 795-803. Haematol. 2002;118:90-100.
5. Marmont A, Bacigalupo A, van Lint MT, Occhini 20. Egan LJ, Walsh SV, Stevens FM, Connolly CE, 33. Tyndall A, Daikeler T. Autologous hematopoietic
D, Gualandi F. Autologous marrow stem cell Egan EL, McCarthy CF. Celiac-associated lym- stem cell transplantation for autoimmune dis-
transplantation for severe systemic lupus ery- phoma: a single institution experience of 30 eases. Acta Haematol. 2005;114:239-247.
thematosus of long duration. Lupus. 1997;6: cases in the combination chemotherapy era.
545-548. J Clin Gastroenterol. 1995;21:123-129. 34. Micallef IN, Apostolidis J, Rohatiner AZ, et al.
6. Oyama Y, Craig RM, Traynor AE, et al. Autolo- Factors which predict unsuccessful mobilisation
21. Daum S, Ullrich R, Heise W, et al. Intestinal non-
gous hematopoietic stem cell transplantation in of peripheral blood progenitor cells following G-
Hodgkin’s lymphoma: a multicenter prospective
patients with refractory Crohn’s disease. Gastro- CSF alone in patients with non-Hodgkin’s lym-
clinical study from the German Study Group on
enterology. 2005;128:552-563. phoma. Hematology. 2000;1:367-373.
Intestinal non-Hodgkin’s Lymphoma. J Clin On-
7. Verburg RJ, Toes RE, Fibbe WE, Breedveld FC, col. 2003;21:2740-2746. 35. Dieterich W, Ehnis T, Bauer M, et al. Identification
van Laar JM. High dose chemotherapy and au- 22. Verbeek WH, Mulder CJ, Zweegman S. Alemtu- of tissue transglutaminase as the autoantigen of
tologous hematopoietic stem cell transplantation zumab for refractory celiac disease. N Engl celiac disease. Nat Med. 1997;3:797-801.
for rheumatoid arthritis: a review. Hum Immunol. J Med. 2006;355:1396-1397; author reply 1397. 36. van de Wal Y, Kooy Y, van Veelen P, et al. Selec-
2002;63:627-637. 23. Zubrod CG, Schneiderman M, Frei E, et al. Ap- tive deamidation by tissue transglutaminase
8. Vader W, Stepniak D, Kooy Y, et al. The HLA- praisal of methods for the study of chemotherapy strongly enhances gliadin-specific T cell reactiv-
DQ2 gene dose effect in celiac disease is directly of cancer in man: comparative therapeutic trial of ity. J Immunol. 1998;161:1585-1588.
related to the magnitude and breadth of gluten- nitrogen mustard and thio-phosphoamide. 37. Bagdi E, Diss TC, Munson P, Isaacson PG. Mu-
specific T cell responses. Proc Natl Acad Sci J Chron Dis. 1960;11:7-33. cosal intra-epithelial lymphocytes in enteropathy-
U S A. 2003;100:12390-12395. 24. When is a coeliac a coeliac? Report of a working associated T-cell lymphoma, ulcerative jejunitis,
9. Wahab PJ, Meijer JW, Goerres MS, Mulder CJ. group of the United European Gastroenterology and refractory celiac disease constitute a neo-
Coeliac disease: changing views on gluten-sensi- Week in Amsterdam, 2001. Eur J Gastroenterol plastic population. Blood. 1999;94:260-264.
tive enteropathy. Scand J Gastroenterol Suppl. Hepatol. 2001;13:1123-1128.
2002;236:60-65. 38. Blumberg RS, Yockey CE, Gross GG, Ebert EC,
25. Rostami K, Mulder CJ, Werre JM, et al. High Balk SP. Human intestinal intraepithelial lympho-
10. Cellier C, Delabesse E, Helmer C, et al. Refrac- prevalence of celiac disease in apparently cytes are derived from a limited number of T cell
tory sprue, coeliac disease, and enteropathy-as- healthy blood donors suggests a high prevalence clones that utilize multiple V beta T cell receptor
sociated T-cell lymphoma. Lancet. 2000;356:203- of undiagnosed celiac disease in the Dutch popu- genes. J Immunol. 1993;150:5144-5153.
208. lation. Scand J Gastroenterol. 1999;34:276-279.
39. Al-toma A, Goerres MS, Meijer JWR, et al.
11. Biagi F, Corazza GR. Defining gluten refractory 26. Eiras P, Roldan E, Camarero C, Olivares F,
enteropathy. Eur J Gastroenterol Hepatol. 2001; Cladribine therapy in refractory coeliac disease
Bootello A, Roy G. Flow cytometry description of
with aberrant T-cells. Clin Gastroenterol Hepatol.
13:561-565. a novel CD3⫺/CD7⫹ intraepithelial lymphocyte
2006;4:1322-1327.
12. Cellier C, Patey N, Mauvieux L, et al. Abnormal subset in human duodenal biopsies: potential di-
intestinal intraepithelial lymphocytes in refractory agnostic value in coeliac disease. Cytometry. 40. Brittan M, Hunt T, Jeffery R, et al. Bone marrow
sprue. Gastroenterology. 1998;114:471-481. 1998;34:95-102. derivation of pericryptal myofibroblasts in the
27. Patey-Mariaud DS, Cellier C, Jabri B, et al. Dis- mouse and human small intestine and colon. Gut.
13. Diss TC, Watts M, Pan LX, BurkeM, Linch D,
tinction between coeliac disease and refractory 2002;50:752-757.
Isaacson PG. The polymerase chain reaction in
the demonstration of monoclonality in T-cell lym- sprue: a simple immunohistochemical method. 41. Te Boekhorst PA, Lamers CH, Schipperus MR, et
phomas. J Clin Pathol. 1995;48:1045-1050. Histopathology. 2000;37:70-77. al. T-lymphocyte reconstitution following rigor-
14. Murray A, Cuevas D, Jones B, Wright DH. Study 28. Daum S, Cellier C, Mulder CJ. Refractory coeliac ously T-cell-depleted versus unmodified autolo-
of the immunohistochemistry and T-cell clonality disease. Best Pract Res Clin Gastroenterol. gous stem cell transplants. Bone Marrow Trans-
of enteropathy associated T-cell lymphoma. Am J 2005;19:413-424. plant. 2006;37:763-772.
Pathol.1995;146:509-519. 29. Meijer JW, Mulder CJ, Goerres MG, Boot H, 42. Rutella S, Rumi C, Laurenti L, et al. Immune re-
15. Goerres MS, Meijer JW, Wahab PJ, et al. Azathio- Schweizer JJ. Coeliac disease and (extra)intesti- constitution after transplantation of autologous
prine and prednisone combination therapy in re- nal T-cell lymphomas: definition, diagnosis and peripheral CD34⫹ cells: analysis of predictive fac-
fractory coeliac disease. Aliment Pharmacol Ther. treatment [review]. Scand J Gastroenterol Suppl. tors and comparison with unselected progenitor
2003;18:487-494. 2004;241:78-84. transplants. Br J Haematol. 2000;108:105-115.
From www.bloodjournal.org by guest on October 5, 2018. For personal use only.

2007 109: 2243-2249


doi:10.1182/blood-2006-08-042820 originally published
online October 26, 2006

Autologous hematopoietic stem cell transplantation in refractory celiac


disease with aberrant T cells
Abdulbaqi Al-toma, Otto J. Visser, Hyacintha M. van Roessel, B. Mary E. von Blomberg, Wieke H. M.
Verbeek, Petra E. T. Scholten, Gert J. Ossenkoppele, Peter C. Huijgens and Chris J. J. Mulder

Updated information and services can be found at:


http://www.bloodjournal.org/content/109/5/2243.full.html
Articles on similar topics can be found in the following Blood collections
Clinical Trials and Observations (4833 articles)
Immunobiology and Immunotherapy (5625 articles)
Transplantation (2316 articles)

Information about reproducing this article in parts or in its entirety may be found online at:
http://www.bloodjournal.org/site/misc/rights.xhtml#repub_requests

Information about ordering reprints may be found online at:


http://www.bloodjournal.org/site/misc/rights.xhtml#reprints

Information about subscriptions and ASH membership may be found online at:
http://www.bloodjournal.org/site/subscriptions/index.xhtml

Blood (print ISSN 0006-4971, online ISSN 1528-0020), is published weekly by the American Society
of Hematology, 2021 L St, NW, Suite 900, Washington DC 20036.
Copyright 2011 by The American Society of Hematology; all rights reserved.

You might also like