CLINICAL RESEARCH
`
`ASBM1
`
`American Society for Blood
`and Marrow Transplantation
`
`Rituximab Administration within 6 Months
`of T Cell-Depleted Allogeneic SCT is Associated
`with Prolonged Life-Threatening Cytopenias
`
`Zachariah McIver, Nicole Stephens, Andrew Grim, A. John Barrett
`
`The monoclonal anti-CD20 antibody Rituximab (RTX) is increasingly used in allogeneic stem cell transplanta-
`tion (SCT) to treat lymphoproliferative disorders and chronic graft-versus-host disease (GVHD). RTX
`administration can be complicated by delayed and prolonged neutropenia, but the mechanism is unclear. We
`report the occurrence of profound cytopenias following RTX given in the conditioning regimen or early after
`T cell-deplete SCT to treat B cell lymphoproliferative disorders or chronic GVHD (cGVHD). Between 2006
`and 2009, 102 patients (median age: 43 years, range: 13-68 years), received a myeloablative matched-sibling T
`cell-deplete SCT for lymphoid or myeloid hematologic disorders. Neutropenia occurring within 4 weeks of
`treatment developed in 16 of 17 patients given RTX within the first 190 days after SCT. Fourteen patients de-
`veloped severe neutropenia (count\0.5 K/mL) lasting up to 10 months and 12 required hospitalization to treat
`severe neutropenic infections. Six of the 14 patients died of infection complicating GVHD treatment. Recovery
`of lymphocytes and immunoglobulins was also delayed, with a significantly lower absolute lymphocyte counts
`(ALC) at 9 months and 12 months post-SCT compared to patients with cGVHD not treated with early RTX
`(P \.02). In contrast, patients receiving RTX 1 year after SCTexperienced only moderate neutropenia 3 to 5
`months after treatment lasting 10 to 20 days while maintaining absolute neutrophil count (ANC) .1.0 109/L.
`Although RTX rapidly controlled cGVHD, we conclude that its administration early after T cell-deplete SCT is
`associated with prolonged profound and life-threatening cytopenias, and should be avoided.
`
`Biol Blood Marrow Transplant 16: 1549-1556 (2010) Published by Elsevier Inc. on behalf of American Society for Blood and
`
`Marrow Transplantation
`
`KEY WORDS: Allogeneic, T cell deplete, Stem cell transplant, Cytopenia, Neutrophenia, Transplant-related
`mortality
`
`INTRODUCTION
`
`Allogeneic hematopoietic stem cell transplantation
`(SCT) offers the possibility of a curative treatment for
`malignant and nonmalignant hematologic diseases.
`However, SCT is frequently complicated by graft-
`versus-host disease (GVHD), which remains a major
`cause of transplant-related morbidity and mortality
`(TRM). The anti-CD20 chimeric monoclonal antibody
`Rituximab (RTX) given prior to, or during, conditioning
`
`From the Stem Cell Allotransplantation Section, Hematology
`Branch, Heart Lung and Blood Institute, National Institutes
`of Health, Bethesda, Maryland.
`Financial disclosure: See Acknowledgments on page 1555.
`Correspondence and reprint requests: Zachariah McIver, DO, Stem
`Cell Allotransplantation Section, Hematology Branch, Heart
`Lung and Blood Institute, National Institutes of Health,
`Room 3-5288, 10 Center Drive, Bethesda, MD 20892 (e-mail:
`mciverza@nhibi.nih.gov).
`Received February 17, 2010; accepted May 12, 2010
`Published by Elsevier Inc. on behalf of American Society for Blood
`and Marrow Transplantation
`1083-8791/$36.00
`doi:10.1016/j.bbmt.2010.05.004
`
`for T cell-replete SCT has been reported to decrease
`acute GVHD, and chronic GVHD (aGVHD, cGVHD),
`and may decrease TRM [1–3]. Because of these
`promising results, RTX has been increasingly used to
`treat cGVHD [4].
`RTX induces response rates in about two-thirds of
`patients with cGVHD. Response varies by organ, with
`an estimated response rate of 60% for cGVHD of the
`skin compared to approximately 30% for cGVHD of
`the gastrointestinal (GI) tract, liver, or lung [5]. Apart
`from acute infusion reactions, RTX is well tolerated.
`However,
`late adverse effects are being identified
`with increased frequency. Late-onset neutropenia is
`estimated to occur in up to 35% of patients treated
`for B cell malignancies in the non-SCT setting [6].
`Thrombocytopenia (platelets \75 K/mL) and anemia
`(hemoglobin \10 g/dL) have also been reported,
`with an incidence of approximately 12% and 6%,
`respectively [7].
`Since 2006, we have used RTX in the early trans-
`plant period after myeloablative SCT, either as part
`of the conditioning regimen for B cell malignancies,
`or to treat emerging cGVHD. Although patients
`
`1549
`
`

`

`1550
`
`Z. McIver et al.
`
`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`with cGVHD responded well to RTX, all patients who
`received RTX within 6 months after SCT had a high
`risk of developing severe cytopenias. Here, we describe
`the clinical outcome of RTX-treated patients and dis-
`cuss the possible etiology of RTX-induced cytopenias
`in this patient population.
`
`treat incipient rejection as documented by falling
`counts and falling donor T cell chimerism. CsA was
`continued or reinitiated if cGVHD developed, and
`patients were treated off protocol for cGVHD refrac-
`tory to CsA and prednisone.
`
`MATERIALS AND METHODS
`
`Patients and Controls
`
`Between February 2004 and April 2009, 102 con-
`secutive patients underwent a T cell-depleted SCT
`from an HLA-identical sibling in 3 successive National
`Heart, Lung and Blood Institute (NHLBI) institu-
`tional review board-approved protocols (04-H-0112,
`06-H-0248, and 07-H-0136). Patients and donors
`provided written informed consent before enrolling
`in the transplantation protocol.
`All patients received a conditioning regimen of
`fludarabine 125 mg/m2 over 5 days,
`fractionated
`total-body irradiation (TBI) 12 Gy (4.0 Gy if over
`55y) in 8 fractions over 4 days, followed by cyclophos-
`phamide 120 mg/kg over 2 days. All transplants were
`depleted of T lymphocytes with the Isolex system
`(protocol 04-H-0112), or with the Miltenyi CliniMacs
`system (Miltenyi Biotec Inc., Auburn, CA) (protocols
`06-H-0248 and 07-H-0136) as previously described
`[8,9]. In protocols 04-H-0112, 06-H-0248 patients
`received an infusion of donor lymphocytes between
`days 60 to 90 after SCT. In protocol 07-H-0136
`patients received 5  106 selectively depleted CD3
`1
`cells/kg on day 0, as previously described [10].
`Only patients surviving 6 months or longer after
`SCT were included in the analysis to allow sufficient
`time for the development of cGVHD, and to exclude
`patients that experienced early deaths because of unre-
`lated causes. Of the 95 patients surviving 6 months or
`longer after SCT, 17 received RTX within 6 months of
`SCT. Twenty-eight patients developed cGVHD but
`did not receive RTX early after SCT (4 received
`RTX 1-7 years after SCT), 18 of whom received an
`SCT prior to the use of RTX for treatment of cGVHD
`at our institution and were therefore considered the
`historic controls for this analysis. Fifty patients did
`not develop cGVHD and did not receive RTX at any
`time after SCT. Chronic GVHD was diagnosed and
`graded consistent with NIH consensus criteria [11].
`
`GVHD Prophylaxis
`
`All patients received low-dose (LD) cyclosporine
`(CsA) (target plasma level, 100-200 mg/mL), starting
`on day 24 and continuing according to protocol to
`day 121 or day 90 after SCT. CsA was reinitiated
`and continued for approximately 3 months after donor
`lymphocyte infusions (DLIs) given by protocol or to
`
`Infection Prophylaxis and Treatment
`
`Standard prophylaxis against infection included
`fluconazole and bactrim given for at least 6 months after
`transplantation, and twice weekly surveillance for
`cytomegalovirus (CMV) DNA by polymerase chain
`reaction (PCR). Treatment of infections was in accor-
`dance with the Guidelines for Management in Alloge-
`neic Hematopoietic Stem Cells Transplant Recipients
`published by the Center for Disease Control (CDC)
`(http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4
`910a1.htm). Granulocyte colony stimulating factor
`(G-CSF) was administered in all cases to maintain
`and absolute neutrophil count (ANC) .500/mL.
`
`RTX Administration and Response Criteria
`
`RTX given in the first 6 months after SCT was
`administered by intravenous infusions of RTX (375
`mg/m2 per infusion) at 2 to 4 weekly intervals posttrans-
`plant to treat cGVHD (15 patients), Epstein-Barr virus
`(EBV)
`lymphoproliferative disease (1 patient), and
`autoimmune hemolytic anemia (1 patient). Three pa-
`tients with B cell malignancies that received RTX for
`treatment of cGVHD also received RTX immediately
`prior to, or as part of, the SCT conditioning regimen.
`In addition, 4 patients received RTX 1 to 7 years
`post-SCT at the same dose and schedule to treat
`cGVHD. Response of cGVHD to RTX was assessed
`1 month after the last infusion. Complete response
`(CR) was defined as resolution of all manifestations of
`cGVHD in involved organs. A partial response (PR)
`was defined as an improvement in 1 or more involved
`organ without any progression or new organ involve-
`ment. Resistance was defined as no response or worsen-
`ing cGVHD requiring alternative therapy.
`
`Statistical Analysis
`
`Survival was measured to the last contact date or
`death. Univariate and multivariate analyses were per-
`formed using Cox proportional-hazard regression
`model, including all factors associated with a P-value
`\.2 by univariate analysis, and all factors statistically
`different among the early RTX and other groups
`(P \.10). A stepwise backward procedure was then
`used with a cutoff significance level of .05 to remove
`factors from the model. P-values are 2 sided, with
`a type I error rate fixed at .05. Statistical analyses
`were performed with SPSS 15.0 and Prism 4 software.
`
`

`

`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`Rituximab after Allogeneic SCT and Prolonged
`Life-Threatening Cytopenias
`
`1551
`
`lymphocyticleukemia;NHL,non-HodgkinLeukemia;MDS,myelodysplasticsyndrome;Ph+,Philadelphiachromosome;NKorT-LGL,NKorTcell-largegranulocyticleukemia;GI,gastrointestinal.
`RTXindicatesRituximab;SCT,stemcelltransplantation;AML,acutemyelogenousleukemia;ALL,acutelymphoblasticleukemia;APL,acutepromyelocyticleukemia;CML,chronicmyelogenousleukemia;CLL,chronic
`
`528
`648
`1564
`1362
`703
`195
`759
`430
`1039
`414
`577
`443
`218
`214
`503
`959
`815
`
`NK-LGL,GIoverlapsyndromeDiedfungalpneumonia
`
`Alive
`
`Alive
`Alive
`Alive
`DiedIdiopathicPneumonitis
`Alive
`Alive
`Alive
`Diedfungalpneumonia
`Alive
`Diedfungalpneumonia
`DiedofRelapse
`DiedICH
`Diedfungalpneumonia
`Diedfungalpneumonia
`Alive
`
`ITP
`
`LGL
`
`T-
`
`GIoverlapsyndrome
`
`GIoverlapsyndrome
`GIoverlapsyndrome
`
`LGL
`
`T-
`
`Cellulitis
`None
`Pneumonia,septicemia
`Apergilluspneumonia
`None
`None
`Cellulitis
`None
`Pneumonia
`None
`Cellulitis
`None
`Cellulitis,bowelperforation,septicemiaNone
`None
`Cellulitis
`None
`None
`Aspergillus+Zygomycosispneumonia
`Cellulitis,septicemia
`None
`None
`Aspergilluspneumonia
`Pneumonia,septicemia
`None
`Cellulitis,septicemia
`Pneumonia,septicemia
`S.prolificans
`Zygomycosispneumonia
`Pneumonia,cellulitis,septicemia
`Zygomycosispneumonia
`Cellulitis,pneumonia,septicemia
`None
`Cellulitis
`
`3
`
`7
`
`5
`
`2
`
`3
`
`2
`
`3
`
`2
`
`3
`
`4
`
`3
`
`3
`
`2
`
`2
`
`3
`
`4
`
`2
`
`27
`23
`23
`22
`22
`20
`19
`16
`16
`15
`15
`13
`12
`10
`
`0
`
`25
`28
`
`post-SCT
`
`DaysSurvival
`
`Outcome
`
`AutoimmuneDisorders
`
`Infections
`
`Fungal
`
`BacterialInfections
`
`within30WeeksofSCT
`
`No.ofdosesofRTX
`
`DoseofRTX
`WeekofFirst
`
`CML
`APL
`APL
`ALLPh2
`ALLPh+
`AML
`MDS/AML
`AML
`AML
`MDS
`AML
`ALLPh+
`AML
`ALLPh+
`CLL
`MCL
`MCL
`
`Diagnosis
`
`Table1.OutcomesofPatientsTreatedwithRTXwithin30WeeksofSCT
`
`RESULTS
`
`cGVHD Response to RTX
`
`Eight of the 15 patients who received RTX for
`treatment of cGVHD during the first 6 months after
`SCT experienced complete remission of all cGVHD
`symptoms shortly after RTX administration, 4 pa-
`tients developed a PR but continued to require first-
`line cGVHD treatment, and 3 patients required
`further second-line treatment (Table 1). All 4 patients
`receiving RTX 1 to 7 years after SCT responded, 3
`with CR and 1 with PR.
`
`Blood Counts and Immunoglobulin Levels
`during the First 12 Months after SCT
`
`Onset of cytopenias occurred a median of 4 weeks
`after administration of RTX and led to a significant
`difference in blood counts between the 3 groups (early
`RTX, cGVHD without early RTX, no cGVHD) dur-
`ing the first year after SCT (Figure 1A-C). Patients
`treated within 6 months after SCT with RTX experi-
`enced lower absolute neutrophil counts at 6 months
`and 9 months (P \.01). These patients also experi-
`enced lower absolute lymphocyte counts throughout
`the first posttransplant year (P \.01 at 6, 9, and 12
`months), a lower median platelet count at 6 months af-
`ter SCT (P \.01), and lower immunoglobulin levels
`for up to 2 years post-SCT. The median level of IgM
`was lowest at 9 months after SCT, and occurred 12
`months or later for IgG and IgA (Figure 1E). Clinically
`significant anemia requiring red blood cell (RBC)
`transfusions was infrequently noted. However, no
`difference in erythropoeitic activity was noted between
`the 3 groups as represented by equivalent absolute
`reticulocyte counts during the first year after SCT,
`and anemia requiring RBC transfusions occurred
`infrequently (Figure 1D).
`
`Timing of RTX Administration and Severity of
`Lymphopenia Correlates with Duration of
`Neutropenia
`
`The earlier RTX was given after SCT, the longer
`was the duration of cytopenias. Patients receiving their
`first dose of RTX at least 20 weeks after SCT experi-
`enced relatively short episodes of cytopenias with
`a mean duration of moderate neutropenia (ANC
`\1000 cells/mL) of 1.3 months, and of severe neutrope-
`nia (ANC \500 cells/mL, G-CSF dependence) of 0.6
`months. In contrast, patients receiving RTX between
`10 and 20 weeks after SCT experienced prolonged
`neutropenia (mean duration 3.3 months of moderate
`neutropenia, and 1.7 months of severe neutropenia).
`Patients treated with RTX within 10 weeks of SCT
`experienced the longest cytopenias (mean duration of
`13.7 months of moderate neutropenia, and 5 months
`of severe neutropenia) (Figure 2). In total, 16 of the
`
`

`

`1552
`
`Z. McIver et al.
`
`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`A
`
`5
`
`4.5
`
`4
`
`3.5
`
`3
`
`2.5
`
`2
`
`1.5
`
`1
`
`0.5
`
`0
`
`B
`
`2.5
`
`2
`
`1.5
`
`1
`
`Neutrophil Count x 10
`
`3
`/mL
`
`. .,.
`
`.,.
`
`t ~
`l
`
`T
`
`·,1. - . - .
`1
`
`Platelet Count x 10
`
`3
`/mL
`
`C
`
`250
`
`200
`
`150
`
`100
`
`50
`
`0
`
`3 months
`
`6 months 9 months
`
`12 months
`
`3 months 6 months 9 months 12 months
`
`Lymphocyte Count x 10
`
`3
`/mL
`
`Reticulocyte Count x 10
`
`3
`/mL
`
`~-
`
`D
`
`140
`
`120
`
`100
`
`80
`
`60
`
`40
`
`0.5
`
`0
`
`..... . --
`
`-- .
`
`·-f- ·
`
`20
`
`0
`
`3 months
`
`6 months 9 months 12 months
`
`3 months 6 months 9 months 12 months
`
`E
`
`IgG Immunoglobulin Levels (mg/dL)
`
`1200
`
`1000
`
`800
`
`600
`
`400
`
`200
`
`0
`
`3
`
`6
`
`9
`
`12
`
`24
`
`months
`
`months
`
`months
`
`months
`
`months
`
`Figure 1. (A-E) Median absolute peripheral counts during the first year after SCT, and median absolute IgG immunoglobulin levels during the first 2
`years after SCT. – – – No cGVHD; ––– cGVHD without early RTX; –  – Early RTX.
`
`17 patients developed severe neutropenia, 5 of which
`experienced only a minimal responsive to prolonged
`G-CSF administration. All 4 patients receiving RTX
`1 to 7 years after SCT experienced only moderate neu-
`tropenia 3 to 5 months after treatment lasting 10 to 20
`days while maintaining ANC .1.0  109/L.
`
`RTX administration was associated with a profound
`nadir in absolute lymphocyte counts (ALC) occurring
`within 4 weeks after the administration of the last
`dose. Patients developing an ALC nadir less than the
`median of 140 lymphocytes/mL experienced the longest
`duration of neutropenia (ANC \1000/mL, median 7
`
`Mean Duration of Neutropenia
`
`Mean Duration of Lymphopenia
`
`Months
`10 ~ - -~ - - - - - - - - - - - - - - -
`■ AN( < S00/µl
`ANC < 1000/µl
`
`8
`
`4
`
`2
`
`0
`
`Month•
`14 ~ - - - - - - - - - - - - - - - -
`
`12
`
`10
`
`8
`
`6
`
`4
`
`2
`
`0
`
`< lOweeks 10-20weeks 20-30weeks
`
`<lOweeks 10-20weeks 20-30weeks
`
`Week Rltuxlmab elven after SCT
`
`Week Rltuxlmab elven afterSCT
`
`Figure 2. Timing of RTX administration and duration of neutropenia. Mean duration of cytopenias experienced by patients when treated with their first
`dose of RTX within various time periods in relation to SCT. Duration of cytopenias inversely correlated with the time interval between RTX adminis-
`tration and SCT; patients that received RTX within 10 weeks of SCT experiencing the longest duration of neutropenia and lymphopenia.
`
`

`

`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`Rituximab after Allogeneic SCT and Prolonged
`Life-Threatening Cytopenias
`
`1553
`
`Table 2. Patients with cGVHD Who Received RTX within 30 Weeks of SCT
`
`Disease
`
`Indication
`for RTX
`
`Week of
`First Dose
`of RTX
`
`Week of
`Chronic
`GVHD Onset
`
`Organs Involved
`with Chronic
`GVHD
`
`cGVHD Severity
`(NIH Consensus
`Criteria)
`
`Treatment of
`Chronic GVHD
`Prior to RTX
`
`No. of Doses
`within 30 weeks
`of SCT
`
`Other Second-
`Line Treatments
`after RTX
`
`MCL
`MCL
`
`NHL, GVHD
`NHL, GVHD
`
`28
`25
`
`CLL , GVHD
`CLL
`ALL Ph+ GVHD
`AML
`GVHD
`ALL Ph+ GVHD
`
`GVHD
`AML
`GVHD
`MDS
`EBV LPD
`AML
`GVHD
`AML
`MDS/AML GVHD
`AML
`GVHD
`ALL Ph+ GVHD
`ALL Ph2 GVHD
`APL
`GVHD
`APL
`GVHD
`
`CML
`
`AIHA
`
`0
`10
`12
`13
`
`15
`15
`16
`16
`19
`20
`22
`22
`23
`23
`
`27
`
`13
`14
`
`19
`10
`12
`12
`
`13
`13
`*
`14
`16
`19
`16
`16
`18
`14
`
`*
`
`Skin, Joints
`Skin, Joints, GI
`
`Mild
`Moderate
`
`Pred, CsA
`Pred, CsA, MMF
`
`Skin, Liver, GI
`Skin, Liver, GI
`Skin
`Skin, GI
`
`Skin, Joints
`Skin, Joints
`*
`Skin, Joints, Lung
`Skin, Liver, GI
`Skin, Lung
`Skin, Joints
`Skin, Joints
`Skin, Joints, Liver
`Skin, Joints, Liver
`
`Moderate
`Moderate
`Mild
`Moderate
`
`Moderate
`Moderate
`*
`Moderate
`Moderate
`Moderate
`Moderate
`Moderate
`Moderate
`Moderate
`
`Pred, CsA, Tacro, MMF
`Pred, CsA
`Pred, CsA
`Pred, CsA, MMF
`
`Pred, CsA, MMF
`Pred, CsA
`*
`Pred, CsA, MMF
`Pred, CsA, Tacro, MMF
`Pred, CsA, MMF
`Pred, CsA, MMF
`Pred, CsA, MMF
`Pred, CsA, Tacro, MMF
`Pred, CsA, Tracro, MMF
`
`*
`
`*
`
`*
`
`3
`7
`
`5
`2
`3
`2
`
`3
`2
`3
`4
`3
`3
`2
`2
`3
`4
`
`2
`
`Daclizumab and
`Infliximab, PhotoPh
`
`Daclizumab
`and Infliximab
`
`Imatinib
`
`Imatinib
`
`Daclizumab
`and Infliximab
`
`RTX indicates rituximab; SCT, stem cell transplantation; AML, acute myelogenous leukemia; ALL, acute lymphoblastic leukemia; APL, acute promyelo-
`cytic leukemia; CML, chronic myelogenous leukemia; CLL, chronic lymphocytic leukemia; NHL, non-Hodgkin leukemia; MDS, myelodysplastic syndrome;
`Ph+, Philadelphia chromosome; EBV, Epstein-Barr virus; AIHA, autoimmune hemolytic anemia; PhotoPh, Photopheresis; CsA, cyclosporine; Tacro,
`tacrolimus; Pred, prednisone; GVHD, graft-versus-host disease.
`*Received RTX for PTLD and AIHA.
`months versus 1.5 months, P \.01). Death because of
`infection only occurred in this group.
`
`Outcomes
`
`All patients received anti-Candida prophylaxis with
`fluconazole initiated at time of SCT, and all patients
`were switched to voriconazole for anti-Aspergillus
`prophylaxis at the time of cGVHD diagnosis with
`introduction of steroid therapy. Fourteen of the 17
`patients treated with RTX within 6 months of SCT de-
`veloped recurrent bacterial infections, with superficial
`cellulitis, bacterial pneumonia, and septicemia occur-
`ring in the majority of cases (Table 1). Additionally, 6
`patients developed significant fungal infections and
`5 died with invasive fungal pneumonia (2 Apergillus,
`3 Zygomyces). Four patient developed evidence of
`autoimmune disorders; 2 with T cell large granular
`lymphoproliferative disease (T-LGL), with .30%
`1
`1
`CD57
`cytotoxic T cells by flow cytometry of
`CD8
`peripheral blood, 1 patient with natural killer (NK)-
`LGL (.90% NK dominance of lymphocytes in bone
`marrow specimen), and 1 patient with immune throm-
`bocytopenic purpura diagnosed clinically and by in-
`creased megakaryocytes in the bone marrow biopsy.
`Three patients developed aGVHD overlap syndrome
`of the gastrointestinal tract, which occurred up to 2.5
`years after SCT and was documented by biopsy.
`Patients with cGVHD treated with RTX early after
`SCT had higher TRM (64% versus 18%, P 5 .03) when
`compared to all other patients with cGVHD. To
`exclude selection bias and the possibility that RTX
`was used only to treat the most recalcitrant forms of
`
`cGVHD, we compared results with historic cGVHD
`controls not treated with RTX at our institution
`(Tables 2, 3, and 4). Again, patients with cGVHD
`treated with RTX within 6 months of SCT had
`significantly higher TRM compared with the
`cGVHD historic controls (64% versus 17%, P 5 .02),
`suggesting that
`the early administration of RTX
`increased the risk of TRM independent of cGVHD
`status. In univariate and multivariate analysis only
`RTX administration was associated with increased
`TRM (hazard ratio [HR] 5 5.54, 95% confidence
`interval [CI] 1.12-27.2, P 5 .03, Figure 3).
`
`DISCUSSION
`
`cGVHD is a major cause of SCT-related morbid-
`ity and mortality, and steroid dependent or resistant
`patients have a worse prognosis. RTX is effective in
`the treatment of steroid refractory cGVHD and has
`been used increasingly early after SCT to treat
`cGVHD in addition to its use in controlling lympho-
`proliferative disorders. This report highlights a poten-
`tial risk of RTX administration within 6 months of T
`cell-depleted SCT.
`Although cytopenias are known to occur following
`RTX administration, severe RTX-induced cytopenias
`have not been described in the context of allogeneic
`SCT [6,12]. Previous reports describe only limited
`cytopenias when RTX is administered early after T
`cell-replete SCT [13,14]. A possible explanation for
`the worse outcomes in our patients receiving RTX is
`that the risk of cytopenias is related to the T cell
`
`

`

`1554
`
`Z. McIver et al.
`
`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`Table 3. Historical Controls, Patients with cGVHD Who Did Not Received RTX Early after SCT
`
`Disease
`
`Week of
`cGVHD Onset
`
`Organs Involved
`with cGVHD
`
`cGVHD Severity
`(NIH Consensus Criteria)
`
`Treatment of cGVHD
`
`Other Second-Line
`Treatments
`
`AML
`AML
`CLL
`AML
`ALL
`MDS
`CML
`AML
`AML
`AML
`ALL
`CML
`AML
`AML
`AML
`AML
`MDS
`AML
`
`16
`31
`23
`19
`14
`16
`22
`14
`14
`16
`13
`15
`10
`14
`16
`12
`15
`26
`
`Skin, Joints
`Skin, Liver, Eyes
`Skin, Joints
`Skin, Eyes
`Liver
`Skin, Liver, Mouth
`Skin, Joints
`Skin, Lungs
`Skin, Joints
`Skin, Joints
`Skin
`Skin, Mouth, Eyes
`Skin, Liver, GI
`Skin, Joints, Lung
`Skin, Joints
`Skin, Liver
`Skin, Renal
`Skin, Joints, Eyes
`
`moderate
`moderate
`mild
`mild
`moderate
`moderate
`moderate
`moderate
`moderate
`mild
`moderate
`moderate
`severe
`moderate
`moderate
`moderate
`moderate
`moderate
`
`Pred, CsA, MMF
`Pred, CsA, MMF
`Pred, CsA
`Pred, CsA
`Pred, CsA, Tacro
`Pred, CsA, Tacro
`Pred, CsA, MMF
`Pred, CsA
`Pred, CsA
`Pred, CsA
`Pred, CsA
`Pred, CsA, MMF
`Pred, CsA, Tacro
`Pred, CsA, MMF
`Pred, CsA, MMF
`Pred, CsA, Tracro
`Pred, CsA
`Pred, CsA, MMF
`
`Daclizumab and Infliximab
`
`Imatinib
`Daclizumab and Infliximab
`
`AML indicates acute myelogenous leukemia; ALL, acute lymphoblastic leukemia; APL, acute promyelocytic leukemia; CML, chronic myelogenous leuke-
`mia; CLL, chronic lymphocytic leukemia; NHL, non-Hodgkins Leukemia; MDS, myelodysplastic syndrome; CsA, cyclosporine; Tacro, tacrolimus; Pred,
`prednisone; GVHD, graft-versus-host disease; RTX indicates Rituximab.
`
`depletion of the graft, which delivers only a limited
`quantity of B cells to the recipient. In our patients
`whose allografts were manipulated to remove T
`lymphocytes, \1  103 B cells/kg were infused at the
`time of transplantation, rendering them profoundly B
`cell depleted. Additionally, the reduced inoculum of T
`cells in the lymphopenic milieu at time of SCT may
`have contributed to the risk of cytopenias by
`predisposing our patients to clonal expansions of small
`1
`T cells, which further
`numbers of residual CD8
`enhanced the immune imbalance induced by RTX
`[15,16].
`The mechanism of increased TRM with early
`RTX administration after T cell-deplete SCT in our
`patient population appears multifactorial
`involving
`impaired B-lymphocyte, neutrophil, and T cell
`function. Although the half-life of RTX ranges from
`2 to 3 weeks, detectable levels may persist 3 to 6
`months after administration [17,18]. Previous studies
`have demonstrated that RTX administration within 1
`year prior to SCT significantly impaired B cell
`reconstitution and resulted in a significant B cell
`deficiency lasting up to 2 years after T cell-replete
`SCT [19]. Similar to our experience, the duration of
`B cell deficiency was also inversely correlated with
`the time interval between RTX administration and
`SCT, indicating a profound B cell depleting effect of
`RTX when given in close proximity to SCT. Com-
`pared to other patients, including those with cGVHD,
`we found that early RTX recipients had reduced levels
`of immunoglobulins and an increased risk of infection.
`It was notable that early RTX recipients had lower me-
`dian neutrophil counts in the first 9 months after SCT
`compared with other patients (including those devel-
`oping cGVHD who did not receive early RTX).
`
`Clearly, the prolonged neutropenia contributed to
`the infectious complications encountered after early
`RTX administration despite the aggressive use of
`G-CSF, which provided only temporary improvement
`of the neutrophil count. The profound lymphopenia
`
`Table 4. Univariate Analysis of Risk Factors for TRM in
`Patients with cGVHD
`
`cGVHD Not
`Receiving
`Early RTX
`
`0/18 patients
`Median 34
`(range: 19-48)
`
`Patients with
`cGVHD Treated
`with RTX <6
`Months of SCT
`
`15/15 patients
`Median 41
`(range: 30-58)
`
`12
`1
`2
`1
`2
`
`7
`2
`9
`
`6
`12
`0
`
`10
`4
`4
`11
`
`5
`4
`0
`3
`2
`
`1
`9
`12
`
`3
`11
`0
`
`2
`7
`5
`3
`
`Univariate
`Analysis
`P-Value
`
`.02
`.09
`
`.73
`
`.69
`
`.18
`
`.80
`
`.10
`
`Covariable
`
`RTX administration
`Age
`
`Reason for SCT
`AML
`ALL
`CML
`NHL
`MDS
`Disease risk
`Low
`Intermediate
`High
`Severity of cGVHD
`prior to RTX
`administration
`Mild
`Moderate
`Severe
`Number of organs
`involved
`1
`2
`3+
`DLI given
`
`RTX indicates Rituximab; cGVHD, chronic graft-versus-host disease; SCT,
`stem cell transplantation; AML, acute myelogenous leukemia; ALL, acute
`lymphoblastic leukemia; CML, chronic myelogenous leukemia; NHL,
`non-Hodgkin leukemia; MDS, myelodysplastic syndrome; DLI, donor lym-
`phocyte infusion.
`
`

`

`Biol Blood Marrow Transplant 16:1549-1556, 2010
`
`Rituximab after Allogeneic SCT and Prolonged
`Life-Threatening Cytopenias
`
`1555
`
`In conclusion, RTX is a powerful immune modu-
`latory agent that is effective in the treatment of
`cGVHD. However, prolonged and life-threatening
`cytopenias can occur when RTX is administered
`within 6 months of T cell-depleted SCT. Although
`the mechanism remains unclear, the increased inci-
`dence of auto- and alloimmune diseases after RTX
`administration suggests immune dysregulation. We
`recommend avoiding RTX administration within 6
`months of T cell-deplete SCT to minimize the risk
`of
`life-threatening cytopenias and other immune
`mediated adverse events.
`
`TRM after SCT
`
`100
`
`Cox proportional hazard p = 0.03
`
`Early RTX
`
`No Early RTX
`
`0
`
`500
`
`1000
`
`1500
`
`2000
`
`2500
`
`Days after SCT
`
`80
`
`60
`
`40
`
`20
`
`0
`
`Percent TRM
`
`Figure 3. Administration of RTX to treat cGVHD within 6 months of
`SCT was associated with higher TRM.
`
`ACKNOWLEDGMENTS
`
`accompanying the neutropenia in our patients was
`striking, and was associated with more severe cytope-
`nias and worse outcome.
`The neutropenia and lymphopenia following RTX
`administration is not easily explained. The cytopenias
`we observed appear distinct
`from the effects of
`cGVHD because neutrophil, platelet, and lymphocyte
`counts were significantly lower than in patients devel-
`oping cGVHD who did not receive RTX early after
`SCT. In mice, short-term B cell depletion reduces ex-
`pansion, activation, and effector cell differentiation of
`1
`1
`T cells, whereas CD8
`activation is not affected
`CD4
`1
`T cells from the
`[20]. A decreased conversion of CD4
`naı¨ve to a central memory phenotype is also observed,
`suggesting that a significant functional and matura-
`1
`compartment in
`tional deficiency exists in the CD4
`1
`T
`the absence of B cell and antigen-specific CD4
`1
`cell interactions. Similarly in humans, lower CD4
`1
`1
`and CD4
`Foxp3
`regulatory T cells are noted in
`patients with diseases of defective B cell differentia-
`tion, and are associated with an inversion of the
`1
`1
`/CD8
`ratio and a higher incidence of autoim-
`CD4
`mune disorders [21]. Consequently,
`the immune
`dysregulation occurring after B cell depletion suggests
`an immune-mediated mechanism in the pathogenesis
`of RTX-associated cytopenias. A recent report demon-
`strates that patients who develop RTX-associated late
`1
`1
`/CD8
`ratios
`onset neutropenia have inverted CD4
`and more pronounced T cell expansions. Proliferation
`of T-large granular lymphocytes with increased ex-
`pression and secretion of Fas and Fas ligand was also
`noted, and bone marrow evaluation demonstrated
`dyshematopoiesis with extensive hypoplasia of the
`granulocytic series, consistent with findings seen in
`immune-mediated T-LGL [22]. The occurrence of
`LGL and ITP in 4 patients treated with RTX supports
`the possibility that RTX induced clonal expansion of
`1
`T cells, which suppressed neutro-
`autoreactive CD8
`phil production. We are now searching for expanded
`1
`T cell clones in all neutropenic RTX
`LGL CD8
`recipients.
`
`Financial disclosure: The authors have nothing to
`disclose.
`
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