INTENSIVE IMMUNOSUPPRESSION WITH HIGH-DOSE CYCLOPHOSPHAMIDE AND AUTOLOGOUS CD34+ SELECTED HEMATOPOIETIC CELL SUPPORT FOR CHRONIC REFRACTORY AUTOIMMUNE THROMBOCYTOPENIA (AITP): A FOLLOW-UP REPORT

Patrick F. Fogarty1, Richard D. Huhn2, Ryotaro Nakamura1, Elizabeth J. Read3, Margaret Rick4, Susan F. Leitman3, Adeira Greene1, Alois Gratwahl5, Neal S. Young1, A. John Barrett1, and Cynthia E. Dunbar1. 1Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD; 2Corriell Institute for Medical Research, Camden, NJ; 3Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD; 4Department of Clinical Pathology, National Institutes of Health, Bethesda, MD and 5University of Basel, Basel, Switzerland.
We assessed the safety and efficacy of intensive immunosuppression with high-dose cyclophosphamide (50 mg/kg/day x 4 days) and hematopoietic progenitor cell support using filgrastim-mobilized (10mg/kg/day IV x 4-5 days) immunomagnetic (Isolex)-selected autologous CD34+ enriched peripheral stem cells highly depleted of CD3+ T cells for treatment of patients with chronic refractory AITP. To date, 15 patients have been enrolled. All had failed multiple prior therapies including steroids, splenectomy and IVIg, and had a history of clinically significant bleeding with chronic platelet counts of <20,000/ml. Ages ranged from 17-53 yrs (median 42 yr). Four patients had concomitant immune hemolytic anemia (Evans syndrome). Peak mobilization of CD34+ stem cells occurred after the fifth dose of filgrastim. Median (ranges) of CD34+ and CD3+ cell doses in the grafts were 3.65 x 106/kg (2.31- 8.59 x 106/kg) and 23.8 x 103/kg (5.58 - 177.9 x 103/kg), respectively. Of the fifteen patients, fourteen are evaluable for response at greater than six months post-transplantation. Four have had sustained responses with platelet counts >100,000/ml at 38, 24, 17, and 14 months, respectively. One patient who had a sustained post-transplant platelet count of >100,000/ml was diagnosed with myeloma and died 14 months post-transplant. Four patients have had sustained, unsupported platelet counts greater than 50,000/ml at 19, 17, 6 and 6 months post-transplant, respectively. Six patients had no sustained response. Neutrophil engraftment occurred by post-transplant day 10 in all patients. A median of 63 single-donor apheresis-derived platelets per patient was required to maintain platelet counts >10,000ml during the peritransplant period (including pretransplant line placement and apheresis). One patient with recent intracranial hemorrhage aggressive prophylactic platelet transfusions (total 564 units). A median of 4 (range 0-27) units of RBC transfusions per patient was required. One patient who had indirect Coombs test positivity and bleeding required 27 units. There were no protocol-related deaths; toxicity was mild-moderate. Thirteen patients had febrile neutropenia, effectively managed with empiric or targeted antibiotics. One patient developed hemorrhagic cystitis. Five patients had vaginal bleeding, one had epistaxis requiring nasal packing, and two had evidence of mild GI bleeding. We are encouraged at the overall 57% response rate in patients with very severe refractory AITP, with no relapses to date, and several patients now followed for over 2-3 years post-protocol entry.






[All patient s receive IVIg at 1 gm/kg prior to progenitor mobilization and CTX/PBSC reinfusion.]
[Three] patients needed to undergo second mobilization and apheresis because doses of CD34+ cells did not reach the minimal dose after CD34-selection (2 x 106/kg) required for this study with the first mobilization.

(One patient died from sepsis related to an indwelling central venous catheter 19 months post transplant.)
“Specific serum anti-platelet glycoprotein antibodies, flow cytometry data, and T lymphocyte subsets are being analyzed for possible correlation with clinical response”.
*** One patient had improvement of transfusion and IVIg requirements and of clinical bleeding though platelet counts remained less than 20,000/ml (Mark Come, in which case could change “six patients” with no response to “Five patients”).

Three New Transplant patients:

Perlman(34-86-69-2): Had 7 months of menorrhagia prior to transplant, Syneril nasal spray started with addition of OCP x 2 5 months prior to transplant; these meds continued into transplant. Admitted on pred 40mg used primarily to control Evans syndrome (had lab evidence of hemolysis on admission )., steroids continued through transplant. Had moderate vaginal bleeding post pheresis (plts 8K, missed OCP dose), goal was to keep plts over 30K. Hb dropped to 6.6 and transfused RBC’s D-7. R thigh hematoma D-3 (had had R fem line placed D-6; Hb dropped 9.6à8.7 D-4 to D-3). Continued mild vaginal bleeding throughout hospitalization. D 0 + 1/29/01. Required more RBC’s D 0 for Hb 7.5. Migraine HA D+1 (had past history). Neutropenic fever D+5, placed n Ceftaz, vanc added when urine came back with +enterococcus. D+6 cx come back with port cx growing coag neg staph. Anc recovered d+9, ceftaz stopped and ID recommended keeping Vanc for 14d from last + culture. Continued to have migraines after counts recovered, treated effectively with sumatriptan.

Brandy (34-93-56-8): Prior to transplant had uterine fibroids and menorrhagia resulting in placement on Lupron 3 mo pretransplant and Hb 5.6 2 months pretransplant which resulted in D&C plus aborted uterine ablation secondary to not having the appropriately sized “roller-ball” instrument 2 months pretransplant. Seen by Gyn pre-everything and OCP changed to BID with plt recommendation >30K. On day 1 of pheresis had a platelet reaction with chills and abd cramps and nausea, better with benadryl and Zantac. Mild vaginal bleeding (1-3 pads/day) throughout the remainder of hospital stay. Vomiting D0. D0 = 2/12/01, received two products. Neutropenic fever D+5, meropenem started due to possible sinus source. Developed epistaxis D+7, seen by ENT, rec’d Bacitracin and plt recommendation 50K; epistaxis stopped then resumed D+8 for 4 hours à anterior nasal packing at that jucture (but can’t find record of this in the chart). Non-neutropenic D+10, antbx changed to po Augmentin

Frederick (35-48-54-5): pretranspant had significant vaginal bleeding which was largely controlled just prior to transplant on 2 OCP’s, I think, per day. Started in INH prophylaxis for +ppd pre-transplant. Required second day of apheresis (1.7 x 106 collection first day). Day 0 = 7/16/01. Day 0: reed jelly stools and vaginal spotting did not drop Hb at this point). Mild rectal bleeding for 2-3 days. Neutropenic fever D+3, Ct sinuses with chronic maxillary sinusitis, ceftaz switched to meropenem after Ct report came back 1 day after initial fever; meropenem continued x 5-6 days until ANC recovered (D+9). Cx negative throughout. .Mild vag bleeding through D+6 and D+7. Was on Nicoderm patch and Xanax for smoking cessation throughout transplant.

ITP patient update 7/31/01:

Come: at last look (8/22/00?) had platelets < 20K but needed little or no IVIG, etc. à PR?

Albert: Giveb 2nd course (?3rd) of rituximab 3/01 for plt count 9K. Serial counts: 5/7 66K à 6/20 61K à 7/- 101K à 7/24 161K à 7/31 205K. Developed cirrhotic picture with bilirubin 55 by 5/00, however, bx showing vanished bile ducts and postulated primary biliary cirrhosis vs rmonoclonal Ab drug toxicity, thought that he may require transplant (other thought: with autoimmune activation could he have a biphenotypic phenomenon of ITP and autoimmune hepatitis?). As of 7/31/01, hospitalized with FUO of two weeks duration, on Ampho. Still on pred 20mg/day.

Springer: Transplanted 10/99 à CR; had abdominal pain and underwent cholecystectomy 1/01 and intraoperatively, an abnormal distal pancreas was noted; bx of this and an area of omentum taken which revealed metaststic poorly differentiated pancreatic CA, plt count at that time =342K. 2/6/01 = 396K, weekly 5-FU started on this date. Next plt count was 2/20/01 = 65K, indicating loss of CR status (this being at 16 mo post transplant). Through 7/11/01, plt counts were widely fluctuating (117K down to 6K post chemo).