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Prepublished online as a Blood First Edition Paper on May 22, 2003; DOI 10.1182/blood-2002-12-3908.
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Blood, 1 October 2003, Vol. 102, No. 7, pp. 2364-2372
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis
Richard A. Nash,
James D. Bowen,
Peter A. McSweeney,
Steven Z. Pavletic,
Kenneth R. Maravilla,
Man-soo Park,
Jan Storek,
Keith M. Sullivan,
Jinan Al-Omaishi,
John R. Corboy,
John DiPersio,
George E. Georges,
Theodore A. Gooley,
Leona A. Holmberg,
C. Fred LeMaistre,
Kate Ryan,
Harry Openshaw,
Julie Sunderhaus,
Rainer Storb,
Joseph Zunt, and
George H. Kraft
From the Fred Hutchinson Cancer Research Center, Seattle, WA; the University of Washington, Seattle, WA; the University of Colorado Health Sciences Center, Denver, CO; the University of Nebraska Medical Center, Omaha, NE; the City of Hope National Medical Center, Duarte, CA; Duke University Medical Center, Durham, NC; Washington University, St Louis, MO; and the Texas Transplant Institute, San Antonio, TX.
There were 26 patients enrolled in a pilot study of high-dose immunosuppressive therapy (HDIT) for severe multiple sclerosis (MS). Median baseline expanded disability status scale (EDSS) was 7.0 (range, 5.0-8.0). HDIT consisted of total body irradiation, cyclophosphamide, and antithymocyte globulin (ATG) and was followed by transplantation of autologous, granulocyte colony-stimulating factor (G-CSF)-mobilized CD34-selected stem cells. Regimen-related toxicities were mild. Because of bladder dysfunction, there were 8 infectious events of the lower urinary tract. One patient died from Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disorder (PTLD) associated with a change from horse-derived to rabbit-derived ATG in the HDIT regimen. An engraftment syndrome characterized by noninfectious fever with or without rash developed in 13 of the first 18 patients and was associated in some cases with transient worsening of neurologic symptoms. There were 2 significant adverse neurologic events that occurred, including a flare of MS during mobilization and an episode of irreversible neurologic deterioration after HDIT associated with fever. With a median follow-up of 24 (range, 3-36) months, the Kaplan-Meier estimate of progression ( 1.0 point EDSS) at 3 years was 27%. Of 12 patients who had oligoclonal bands in the cerebrospinal fluid at baseline, 9 had persistence after HDIT. After HDIT, 4 patients developed new enhancing lesions on magnetic resonance imaging of the brain. The estimate of survival at 3 years was 91%. Important clinical issues in the use of HDIT and stem cell transplantation for MS were identified; however, modifications of the initial approaches appear to reduce treatment risks. This was a heterogeneous high-risk group, and a phase 3 study is planned to fully assess efficacy. (Blood. 2003;102:2364-2372)
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