Ball, L.M.
Citation
Ball, L. M. (2010, March 4). Clinical and laboratory features of mesenchymal
stromal cells in pediatric stem cell transplantation. Retrieved fromhttps://hdl.handle.net/1887/15035
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Chapter 8
Third party mesenchymal stromal cell infusions fail to induce tissue repair despite successful control of severe grade IV acute graft versus host disease in a child with juvenile myelomonocytic leukemia.
LM Ball
RGM Bredius
AC Lankester
JJ Schweizer
M van der Heuvel-Ebbrink JC Escher
WE Fibbe
RM Egeler
LEUKEMIA 2008; 22, 1256–1298
Progressive steroid refractory grade IV graft versus host disease (GvHD) is generally considered to be a fatal disease. The use of allogeneic bone marrow derived
expanded mesenchymal stromal cells (MSCs) has been reported as a novel treatment for this condition.1 Recently, Ringden et al reported potential tissue repair during MSC infusions in patients undergoing allogeneic stem cell transplanation.2 We found a dissimilar outcome within the gastrointestinal tract of a child treated with MSCs for steroid refractory GvHD and thus express caution in the interpretation of these findings.
A 15 month old girl underwent a 6/6 matched unrelated cord blood transplant for a diagnosis of juvenile myelo-monocytic leukemia. Conditioning consisted of
intravenous Busulfex® 120mg /m2 daily with targeted drug dosing (day -9 to -6), cyclophosphamide 60 mg/kg daily (day -5 and -4) with Mesna® prophylaxis,
melphalan 140 mg/m2 (day -1) and antithymocyte globulin (ATG-Sangstat Imtix® day -6 to -2) at a dose of 2.5 mg/kg/day. GvHD prophylaxis consisted of cyclosporine 2 mg/kg/day from day –1 given intravenously with dose adjustment according to the results of regular blood sampling. Prednisolone 1 mg/kg/day was administered from day +5 onwards.
She developed systemic adenoviral infection detected by quantitative RT-PCR and gastrointestinal (GI) infection detected by excretion of adenovirus type 31 in the feces.
Although the duration of therapy was prolonged in light of her poor immune reconstitution, she was successfully treated with cidofovir (1 mg/kg; 3 times per week) and with probenecid for renal protection.
Leucocyte recovery (≥ 0.5 x 109/l) was observed at day +31 post transplantation and was confirmed by VNTR polymorphic chimerism analysis of circulating peripheral blood mononuclear cells (PBMCs) as well as bone marrow,which demonstrated 100%
donor signal in both PBMCs and granulocytes.
She simultaneously developed profuse watery diarrhea, hematemesis and severe rectal bleeding requiring massive blood and platelet support. There were no evident skin or liver abnormalities. Endoscopic examination of the rectosigmoid colon
demonstrated severe mucosal sloughing. No biopsy was undertaken because of the risk of perforation. However the overall appearance was consistent with a diagnosis of severe GvHD. She was started on methyl-prednisolone 2 mg/kg/day, resulting in a marked reduction in diarrhea and blood loss, which further supported our clinical diagnosis. The improvement was not maintained and despite further immune suppression, namely additional steroids, tacrolimus and mycophenolate mofetil, the severe diarrhea and massive blood losses became almost uncontrollable.
Intravenous mesenchymal stromal cells (MSCs) from a third party, unrelated 25 year old female donor, at a dose of 1.76x 106/kg recipient weight, were given two months after the onset of GvHD, according to an ethically approved phase II study. These were administered without acute side effects and no evident worsening of her adenoviral infection.
Her GI symptoms resolved completely over a period of two weeks and following a cautious reduction of her immune suppression, she received a further infusion of MSCs from the same donor (one month after the 1st infusion) to successfully control a rebound of her diarrhea. Further reduction of immune suppression was uneventful.
Despite this, she developed persistent obstructive upper GI problems with severe gastric retention and bilious aspirates. Upper GI endoscopy was performed, which showed loss of folds and atrophic, scarred duodenal mucosa and a marked stenosis in the distal duodenum (Figure 1a). Dynamic radiological examination showed thinning, marked reduction in the caliber, stenosis and stricturing of the small bowel (Figure 1b).
Peristaltic activity was not evident in the jejunum and ileum. Histopathological examination revealed areas of severe widespread disorganization and atrophy of the villi, fibrosis of the lamina propria and edema (Figure 2a). These were interspersed by areas of relatively normal mucosa. No lymphocyte infiltration or apoptosis was evident confirming the resolution of GvHD. The rectum was relatively normal.
At three months post MSC infusion repeated examination of the GI tract was undertaken. Her clinical condition remained stable with no evident underlying hematological disease or GvHD. Small intestinal pathology persisted with evident fibrosis of the muscularis mucosa and submucosa (Figure 2b).
Figure 1. a) Endoscopic apperance shortly afterward b) radiological appearance after 2nd MSC infusion.
Figure 1a) shows endoscopic appearance of the distal duodenum with atrophic mucosa, scarring and stenosis, in the absence of acute graft versus host disease (see 2 a for histology). Figure 1b) is the simultaneous radiographic appearance of severely constricted small bowel.
Figure 2. a) Histology of small bowel at one month post 2nd MSC infusion & b) three months after 2nd MSC infusion. Distal duodenal biopsies (40 x magnification H&E)
Figure 2a) sampled post 2nd MSC infusion, demonstrating the severe atrophic mucosa, lack of normal villous pattern and scarring, interspersed with relatively normal mucosal architecture. Figure 2b) taken at three months shows no evident tissue repair.
One year following MSC’s, she remains dependent on total parenteral feeding with no evident functional small bowel tissue or regeneration. In light of these findings she has been appraised and accepted as a possible candidate for future small bowel
transplantation.
Despite advances in pre-transplant immune suppression and donor HLA typing methods (and thus donor selection), acute GvHD remains a significant cause of transplant related mortality and morbidity following allogeneic HSCT.3 The initial management of acute GvHD comprises of steroid treatment.
Approximately 50% of patients will remit or improve with this treatment but the remainder requires second-line treatment, of which the outcome to date remains unsatisfactory.4
There is presently no consensus as to salvage treatment in steroid refractory acute GvHD. Acute GvHD is generally considered steroid refractory when there is no response to methyl-prednisolone at 2.0 mg/kg/day for one week, or when there is progressive disease at 72 hours with this dose.3
Recently, the infusion of third party MSC's has been described which effectively controlled steroid refractory GvHD that had failed all other attempts at treatment.1 A multi-center analysis has confirmed this initial report, with the majority of children treated, inclusive of this child, showing either complete or partial resolution of symptoms.5
MSC’s are multi-potent bone marrow cells and may play a role in modulating a variety of immune responses.6 The mechanisms underlying the possible in-vivo immunomodulatory effects of MSCs remain unknown. MSCs may influence GvHD by secretion of soluble factors, by suppressing dendritic cell function or direct cell-to-cell contact with alloreactive T cells. The provision of soluble factors, trans-differentiation or cell fusion have all been suggested as the possible means by which MSCs may play a role in tissue healing.7
In our patient, despite evident control of GvHD, presumed to be due to the
immunomodulatory nature of the infused MSC’s, repair of the small bowel injury was not affected by this strategy. However, the timing of MSC infusion related to the onset of refractory GvHD may be an important factor. Our patient was treated with alternative immune suppression before MSC infusions and persistent GvHD combined
with GI adenoviral infection may have contributed to her long-term outcome.
Similarly we were unable to determine MSC donor cells in biopsy material and can make no comment as to trafficking to the site of tissue damage as was demonstrated in the case presented by Ringden et al.2
This case, the first to report such extensive tissue damage unrelated to chronic GvHD, highlights the need for further studies of long term outcome, as new forms of therapy to overcome GvHD become more widespread. MSC’s have been shown to provide an excellent alternative strategy for the control of acute steroid refractory GvHD but our patient demonstrates that additional medical problems may result as survival rates improve following such treatments. More studies are needed to assess the most effective way to administer MSCs, not only for the control of GvHD but also how best to maximize the long term health of affected individuals.
The authors wish to acknowledge the medical and ancillary staff of the LUMC Leiden and the Sophia Children’s Hospital, Rotterdam for contributing to the overall
excellent care of the patient, Prof. Dr. Johannes Morreau for the pathological preparations, the Medical Photography Department of the LUMC for preparing the illustrations and Dr. Helene Roelofs of the Stem Cell Laboratory for the MSC cultures.
This work is partly supported by grants from the Dutch Program for Tissue Engineering.
References
1. Le Blanc K, Rasmusson I, Sundberg B, et al. Treatment of severe acute graft- versus-host disease with third party haploidentical mesenchymal stem cells.
Lancet. 2004; 363: 1439-1441.
2. Ringden O, Uzunel M, Sundberg B, et al. Tissue repair using allogeneic mesenchymal stem cells for hemorrhagic cystitis, pneumomediastinum and perforated colon. Leukemia. 2007; 21: 2271-2276.
3. Couriel A, Caldera H, Champlin R, Komanduri K. Acute graft versus host disease: pathophysiology, clinical manifestations, and management. Cancer.
2004; 101: 1936-1946.
4. Martin PJ, Schoch G, Fisher L, et al. A retrospective analysis of severe acute graft-versus-host disease. Blood. 1990; 76: 1464-1472.
5. Le Blanc K, Frassoni F, Ball LM, et al. Mesenchymal stem cells for treatment of severe acute graft-versus-host disease. Blood. 2006; 180: abstract 753.
6. Nauta A, Fibbe WE. Immunomodulatory properties of mesenchymal stromal cells. Blood. 2007; 110: 3499-3506.
7. Prockop DJ, Gregory CA, Spees JL. One strategy for cell and gene therapy:
harnessing the power of adult stem cells to repair tissues. Proc Natl Acad Sci U S A. 2003; 100 Suppl 1: 11917-11923.
