C. Montecucco

C. Perotti

G. Da Prada

P. Pedrazzoli

R. Caporali

S. Bernuzzi

AIR Universita degli studi di Milano

106
haematologica vol. 86(1):January 2001
Cyclophosphamide plus granulocyte colony stimulating
factor (G-CSF) is more effective than G-CSF alone in mobi-
lizing hemopoietic progenitor cells in severe, refractory
rheumatoid arthritis
In seven patients with rheumatoid arthritis, candidates for
autologous hemopietic stem cell transplantation, cyclophos-
phamide (4 g/m2) plus G-CSF proved to be more effective
than G-CSF alone for stem cell mobilization allowing ex vivo
manipulations aimed at reducing T-cells in the graft. Fur-
thermore, cyclophosphamide induced a significant improve-
ment in arthritis, lasting 1 to19+ months.
Autologous hematopoietic stem cell transplantation (AHSCT)
has been proposed as a treatment for severe, refractory rheuma-
toid arthritis (RA).1 Although it needs to be clarified by con-
trolled studies in this setting, AHSCT with ex vivo T-cell deple-
tion might be more effective than an unmanipulated graft reduc-
ing the reinfusion of autoreactive T-cells.2 Peripheral blood stem
cells are now replacing bone marrow cells as a source of
hematopoietic progenitors. Release of a large number of hema-
topoietic stem cells as required for engraftment can be obtained
by granulocyte colony-stimulating factor (G-CSF) either alone or
in combination with chemotherapy.1,3 In patients with malig-
nancies, mobilization with cyclophosphamide and G-CSF allows
the collection of a larger number of stem cells than G-CSF alone.3
This may be useful when T-cell depletion is planned, as ex vivo
graft manipulation is associated with a reduction of stem cell
content.4 Previous studies have looked at the combination of
cyclophosphamide plus G-CSF in RA,1,5 however direct compar-
isons between combination treatment and G-CSF alone have
not been formally undertaken.
After signing informed consent, seven patients with severe
RA refractory to conventional therapy were enrolled in a clini-
cal trial approved by the ethical committee of the Maugeri Foun-
dation Institute for Clinical Research. Bone marrow examination
was normal in all cases; one patient (#6) had developed stage I
non-Hodgkin’s lymphoma (treated with surgery and radiother-
apy) 3 years before this study. Three patients (#1-3) received I.V.
cyclophosphamide (4 g/m2) followed by lenograstim 10 µg/kg/d
starting from day 4 until stem cell collection. Four patients (#4-
7), matched for sex, age, disease activity and duration, received
lenograstim 10 µg/kg/d until stem cell collection. CD34+ cell
count in the peripheral blood was monitored daily by Facscal-
ibur (Becton Dickinson Immunocytometry Systems, San José, CA,
USA); when CD34+ cells exceeded 20/µL, stem cell collection
was performed by a Cobe Spectra cell separator (Cobe, Denver,
CO, USA). Positive immunoselection was performed using a Isolex
300i cell separator device (Baxter Health Care, Deerfield, IL, USA).
Since the number of CD34+ cells required for  safe hematopoi-
etic recovery is ≥2.5×106/kg and considering that immunose-
lection may cause a loss of hematopoietic progenitors, this pro-
cedure was performed only in case of harvesting ≥5×106 CD34+
cells/kg. An aliquot of the CD34+ cells exceeding 5×106/kg was
stored unselected as a back-up graft.
Stem cell mobilization was highly effective in patients receiv-
ing cyclophosphamide plus growth factor as compared to G-CSF
alone, so that CD34+ cell immunoselection could be performed
only in the former patients (Table 1). No patient experienced
flares of the disease; neutropenic fever was observed in patient
#3 but no infections or bleeding were documented and no
patient required blood transfusions. Patients who received
cyclophosphamide had complete hair loss lasting 3 months. The
clinical outcomes of RA following mobilization are shown in
Table 2 according to the core set criteria of the American Col-
lege of Rheumatology.6
The number of CD34+ cells in the peripheral blood of RA
Table 1. Stem cell mobilization, collection and immunoselec-
tion in seven patients with severe, refractory rheumatoid
arthritis after cyclophosphamide plus G-CSF (patients #1-3) or
G-CSF alone (patients #4-7). CD34+ cell positive selection to
obtain partial T-cell depletion was performed only in case of
harvesting at least 5x106 CD34+ cells/kg.
Pts. Sex/ Disease Circulating CD34+ CD34+ CD34+ T-cells Log of 
age duration CD34+ cells cells cells stored as cells stored after T-cell
(years) (years) (peak collected unselected after selection depletion
value/µL) graft selection
(x106/kg) (x106/kg) (x106/kg) (x104/kg)   
1 F/ 58 7.2 512 53.5 20.1 23.5 1.38 3.5
2 F/ 47 4.5 402 51.8 17.4 15.3  1.7 3.34
3 F/ 55 10 334 31.6 11.6 14.5 0.82 3.82
4 F/ 49 7.7 24 2.56 2.56 — — —
5 F/ 58 8 29 3.13 3.13 — — —
6 F/ 56 5.1 11 — — — — —
7 F/ 53 3.8 37 4.22 4.22 — — —
Table 2. Clinical outcome in patients with severe refractory
rheumatoid arthritis following stem cell mobilization. Patients
#1-3, who received cyclophosphamide plus G-CSF, experi-
enced a significant clinical improvement lasting 13 months,
19+ months and 1 month, respectively. Patients #4-6, who
received G-CSF alone, did not show any change in disease
activity.
Assessment
Pt. Time of Current Swollen/tender HAQ CRP Pain by by
assessment therapy joint count mg/L pts. phys.
1 mobilization Mtx, HCQ, P 15 mg 10/28 2.0 140 8.7 10 8.5
1 month HCQ, P 5 mg 0/2 1.5 19 2.1 2.0 4.5
13 months HCQ, P 5 mg 0/2 1.5 23 2.2 2.2 4.6
19 months Mtx, HCQ, P 10 mg 10/22 1.8 98 8.9 8.5 7.5
2 mobilization Mtx, HCQ, CyA 5mg/kg, P10mg 20/38 1.8 133 7.2 9.1 6.9
1 month None 0/7 0.6 11 1.5 1.7 0.5
19 months CyA 3mg/Kg, P 5mg 0/7 0.6 14 2.3 1.5 1.0
3 mobilization Mtx,HCQ,CyA,P10mg 13/29 1.5 30 4.5 5.3 5.7
1 month P 5mg 0/0 0 2 0.7 1.1 0
3 months CyA, P5mg,IA steroids 4/6 0.6 9 3.9 4.8 2.9
5 months Mtx, CyA, P 5mg 4/14 0.8 11 4.3 4.5 3.0
15 months Mtx,HCQ,CyA,P10mg 8/26 1.1 48 6.5 7.1 4.9
4 mobilization Mtx,HCQ,CyA,P10mg 24/34 2.1 172 8.1 8.2 6.8
1 month Mtx,HCQ,CyA,P10mg 20/29 2.0 114 7.7 8.1 6.7
5 mobilization Mtx, HCQ, CyA, P 10 mg 14/23 1.8 131 5.3 6.4 6.1
1 month Mtx, HCQ, SSZ, P 10 mg 14/24 1.8 135 6.1 6.0 6.3
6 mobilization HCQ, SSZ, P 15 mg 12/25 1.6 38 5.5 4.9 5.9
1 month HCQ, SSZ, P 15 mg 12/18 1.5 44 3.8 4.5 5.5
7 mobilization Mtx, HCQ, CyA, P 10 mg 15/28 1.3 147 6.6 7.5 6.0
1 month Mtx, HCQ, CyA, P 10 mg 16/26 1.3 113 6.3 7.5 6.2
Pts.= patients; phys.= physicians; Mtx= methotrexate; HCQ= hydroxychloroquine;
P=prednisone; CyA=cyclosporin A; SSZ=sulphasalazine; IA=intra-articular; HAQ=health
assessment questionnaire; CRP=C-reactive protein.
haematologica 2001; 86:106-107 [http://www.haematologica.it/2001_01/0106.htm]
scientific correspondence
haematologica vol. 86(1):January 2001
107
patients after cyclophosphamide + G-CSF mobilization is very
high compared with the numbers observed in cancer patients by
our group7 and others.3 Breban et al.5 recently reported CD34+
cell collections of up to 35×106/kg in four RA patients treated
with 4 g/m2 cyclophosphamide and 5 µg/kg/d G-CSF. In our study
stem cell mobilization was even more marked, probably due to
the higher doses of G-CSF. 
Mobilization with G-CSF alone, as also reported by Snowden
et al.,8 allows the collection of about 3.0-3.5×106 stem cells /kg
hampering any ex vivo graft manipulation. G-CSF appears to be
less effective in RA patients than in healthy donors;7 this is in
accordance with the evidence of markedly affected myelopoiesis
in advanced RA.9 Stem cell mobilization by G-CSF alone was
unsuccessful in one of our RA patients who had had lymphoma.
At present there is no definite proof that AHSCT may cure RA.
High-dose cyclophosphamide is often effective in refractory
autoimmune rheumatic diseases, and a recent study has shown
that clinical improvement after unmanipulated AHSCT is depen-
dent on the dose of cyclophosphamide used as conditioning reg-
imen.10 Our results show that 4 g/m2 cyclophosphamide may
induce a sustained clinical improvement in some patients with
refractory RA. Recurrence of the disease was found in all 3 cas-
es but in two of them it was successfully controlled by low-dose
conventional therapy for 13 and 19+ months.
In conclusion cyclophosphamide plus G-CSF is superior to G-
CSF alone for stem cell mobilization in RA. Furthermore, clinical
improvement can be obtained in some patients after mobilizing
cyclophosphamide therapy, allowing a wait-and-see policy
before AHSCT.
Roberto Caporali, Cesare Perotti,* Paolo Pedrazzoli,° Gian Antonio
Da Prada,° Stefano Bernuzzi,* Carlomaurizio Montecucco
Cattedra di Reumatologia dell’Università di Pavia and *Servizio
di Immunoematologia e Trasfusione, IRCCS Policlinico
S. Matteo, Pavia, Italy; °Divisione di Oncologia Medica, IRCCS
Fondazione S. Maugeri, Istituto di Pavia, Italy
Key words:  rheumatoid arthritis, hematopoietic stem cell trans-
plantation, CD34+ cells, cyclophosphamide, granulocyte-colony
stimulating factor.
Correspondence: Carlomaurizio Montecucco, M.D., Cattedra di
Reumatologia, Policlinico S. Matteo, 27100 Pavia, Italy. Phone:
international +39.0382.502419 – Fax: international +39.0382.
526341 – E-mail: montecucco@smatteo.pv.it
References
1. Tyndall A, Gratwohl A. Blood and marrow stem cell trans-
plants in autoimmune disease: a consensus report written
on behalf of the European League against Rheumatism
(EULAR) and the European Group for Blood and Marrow
Transplantation (EBMT). Bone Marrow Transplant 1997;
19:643-5.
2. Euler HH, Marmont AM, Bacigalupo A, et al. Early recur-
rence or persistence of autoimmune diseases after unma-
nipulated autologous stem cell transplantation. Blood
1996; 88:3621-5.
3. Bensinger W, Appelbaum F, Rowley S, et al. Factors that
influence collection and engraftment of autologous periph-
eral-blood stem cells. J Clin Oncol 1995; 13:2547-55.
4. Locatelli F, Perotti C, Torretta L, et al. Mobilization and
selection of peripheral blood hematopoietic progenitors in
children with systemic sclerosis. Haematologica 1999;
84:839-43.
5. Breban M, Dougados M, Picard F, et al. Intensified-dose (4
g/m2) cyclophosphamide and granulocyte colony-stimu-
lating factor administration for hematopoietic stem cell
mobilization in refractory rheumatoid arthritis. Arthritis
Rheum 1999; 42:2275-80.
6. Felson DT, Anderson JJ, Boers M, et al. American College of
Rheumatology. Preliminary definition of improvement in
rheumatoid arthritis. Arthritis Rheum 1995; 38:727-35.
7. Torretta L, Perotti C, Dornini G, et al. Circulating progeni-
tor cell collection: experience from 275 leukaphereses in
various malignancies and in healthy donors. Haematologi-
ca 1996; 81:208-15.
8. Snowden JA, Biggs JC, Milliken ST, et al. A randomised,
blinded, placebo-controlled, dose-escalation study of the
tolerability and efficacy of filgrastim for haemopoietic stem
cell mobilisation in patients with severe active rheumatoid
arthritis. Bone Marrow Transplant 1998; 22:1035-41.
9. Danova M, Caporali R, Rosti V, et al. Apoptosis and cell
cycle status of hematopoietic progenitor cells in patients
with severe refractory rheumatoid arthritis candidates to
autografting. Blood 1999; 94 (Suppl 1):318b.
10. Snowden JA, Biggs JC, Milliken ST, Fuller A, Brooks PM. A
phase I/II dose escalation study of intensified cyclophos-
phamide and autologous blood stem cell rescue in severe,
active rheumatoid arthritis. Arthritis Rheum 1999; 42:
2286-92.
haematologica 2001; 86:106-107 [http://www.haematologica.it/2001_01/0106.htm]
scientific correspondence


Cyclophosphamide plus granulocyte colony stimulating factor (G-CSF) is more effective than G-CSF alone in mobilizing hemopoietic progenitor cells in severe, refractory rheumatoid arthritis

https://air.unimi.it/retrieve/handle/2434/665106/1308167/106.full.pdf

Cyclophosphamide plus granulocyte colony stimulating factor (G-CSF) is more effective than G-CSF alone in mobilizing hemopoietic progenitor cells in severe, refractory rheumatoid arthritis

Abstract

Similar works

Full text

Available Versions

AIR Universita degli studi di Milano