VOL.10, NO.2, 2021 DOI:10.18620/CTT-1866-8836-2021-10-2-45-53

AHSCT with
Low-Intensity conditioning regimens

Clinical outcomes and quality of life
The effect of autologous hematopoietic stem cell trans­plantation (AHSCT) with low-intensity conditioning regimens, in terms of clinical and patient-reported out­comes, was studied in patients with relapsing-remitting multiple sclerosis (RRMS). In total, 258 RRMS patients were enrolled in a single-center study. The median fol­low-up duration was 30 months. Low-intensity condi­tioning regimens (two based on reduced BEAM and one on cyclophosphamide) were applied. Outcomes of AHSCT were evaluated from both the physicians' and patients' perspectives. Reversal of the disability progres­sion, relapse-free survival (RFS), progression-free sur­vival (PFS), as well as changes in quality of life (QoL), and severity of symptoms were analyzed. Transplanta­tion procedure was well tolerated by the patients, and there were no cases of transplantation-related mortality. In addition, no deaths were registered throughout the follow-up period.
Multiple sclerosis (MS) is a severe inflammatory and demy­elinating autoimmune disease of the central nervous system

(CNS), which affects mainly young people and leads to pro­gressive quality of life (QoL) deterioration due to progres­sive disability [1, 2]. Relapsing remitting MS (RRMS) evolves into secondary progressive disease in 70-80% of cases during 10-15 years [3, 4]. Hence, this relatively favorable variant of MS seems to be a very difficult condition with high risk of disability. Thus, the goal of treatment is to prevent MS progression and disability, to provide better control of the symptoms and to improve patient's QoL [5]. Conventional DMT (Disease Modifying Therapies) does not provide sat­isfactory control of MS, due to inability to eradicate self-ag­gressive T- and B-cell clones. Immunosuppressive treatment including monoclonal antibodies, which are usually used as a second-line therapy, also have only partial beneficial effect [6, 7].

At present, high-dose immunosuppressive therapy with au­tologous hematopoietic stem cell transplantation (AHSCT) has been used with increasing frequency as a therapeutic option for MS patients [8-14]. The rationale for this method presumes that ablation of the impaired immune system fol­lowed by reconstitution of the new immune cell populations may alter the characteristics of the T - and B-cell respons­es and other immunological properties which can improve clinical course of MS [15, 16]. Previous studies demonstrated that AHSCT was associated with improvement in neurologi­cal disability and QoL in RRMS patients [17-21].

At the same time, in spite of promising clinical results, there are still several questions to be clarified before recommend­ing AHSCT as a treatment choice for MS patients, especial­ly for those with relapsing-remitting disease. For example, effectiveness and safety of different conditioning regimens (intermediate and low-intensity) should be analyzed careful­ly. Several clinical studies have addressed the issue of safety and effectiveness of AHSCT with BEAM as intermediate­intensity conditioning regimen in MS with certain promis­ing results [22-25]. On the other side, it was shown recently, that low-intensity regimens (BEAM-like or Cyclophospha­mide based) are associated with similar outcome results and less toxicity profile to compare with more intensive condi­tioning. Patients' selection for AHSCT is another core issue [26, 27]. Additionally, comprehensive treatment outcomes assessment is very important in all variants of AHSCT [28, 29]. Both disease-free period and improvement of patient's QoL are recognized as important treatment outcomes. Also, one of the key issues is the long-term follow-up and assess­ment of clinical and patient-reported outcomes [29-31].

Thus, we aimed to evaluate the effect of AHSCT with low- intensity conditioning regimens in patients with RRMS, in terms of clinical and patient-reported outcomes.
All the patients underwent AHSCT in the Transplantation Unit, Department of Haematology and Cellular Therapy, Pirogov National Medical and Surgical Centre (Moscow) from October 2006 to October 2018. The study was con­ducted according to the principles of Helsinki Declaration, and was approved by the Institute Research Board and local Ethics Committee before initiation. All the patients had giv­en their written informed consent. The patients were eligible if they were >15 years old and met the Poser and McDon­ald criteria for clinically defined MS [32]. Other criteria for patients' selection included normal mental status and ab­sence of severe concomitant diseases. The vast majority of patients was refractory to 2-4 different lines of conventional treatment including interferons, copaxone, mitoxantrone, cladribine, monoclonal antibodies therapy, azathioprine, in­travenous immunoglobulin, glucocorticosteroids etc.

Hematopoietic stem cells were mobilized with granulocyte colony-stimulating factor (G-CSF, 10 ig/kg) during 4-5 days. The mobilized cells were collected by apheresis after 4 days of stimulation until a yield of at least 2.0x106 CD34+ cells/kg.

Three low-intensity conditioning regimens were applied in the patients. Two regimens were based on reduced BEAM protocol: (1) BM schedule (BCNU 300 mg/m2, Melphalan 100 mg/m2 + horse ATG at the dose of 30 mg/kg on days 1 and 2 for in vivo T cell-depletion); (2) BEAM-like regimen (BCNU 300 mg/m2, Etoposide 100 mg/m2, Ara-C 100 mg/m2, Melphalan 100 mg/m2 + horse ATG at the dose of 30 mg/kg on days 1 and 2 for in vivo T cell-depletion). The third con­ditioning regimen included high-dose cyclophosphamide (200 mg/kg) + Rituximab (500 mg/m2) on D+11-12 (one infusion).

G-CSF (5 ig/kg) was administered on D+1 to D+2 until gran­ulocyte recovery. For infection prophylaxis, oral levofloxacin, fluconazole, co-trimoxazole and acyclovir were used.

Toxicity of treatment was evaluated in accordance with Na­tional Cancer Institute Common Toxicity Criteria (version 2) [33]. The terms of posttransplant neutrophil engraftment were defined since the first day when absolute neutrophil count was >500 cells/mL. Platelet engraftment was registered since the first day when the platelet count was >20,000 plate- lets/mL (without platelet transfusions). Transplant-related mortality (TRM) included every death occurring within 100 days of transplantation [34].

The primary end point was disability level defined by the EDSS score [35]. Other studied end-points included safety, relapse-free survival (no acute relapses) and quality of life (QoL) changes. To evaluate clinical outcomes, neurological assessment and MRI scans were performed. Neurological assessment using EDSS was performed at baseline, at dis­charge, at 3, 6, and 12 months after transplantation, every 6 months thereafter up to 48 months, and, later, at the an­nual basis. EDSS decrease of 1.0 or more was considered a significant improvement, and an increase of 1.0 or greater was viewed as significant worsening. MRI scans of brain and cervical spinal cord with gadolinium enhancement were per­formed at baseline, at 3, 6, and 12 months after transplan­tation, every 6 months up to 48 months, and then at yearly intervals. QoL was assessed using RAND SF-36 [36], com­mon symptoms, by CSP-MS-42 [37]. The SF-36 is generic tool for QoL assessment widely used in patients with chronic diseases, including MS [38, 39]. The Comprehensive Symp­tom Profile-MS-42 (CSP-MS-42) was developed in 2007 by New Jersey Center for Quality of Life and Health Outcome Research (USA) and Multinational Center for QoL Research (Russia) to assess the severity of 42 symptoms which are common and most disturbing for MS patients. It consists of numerical analogous scales, scored from "0" (no symptom) to "10" (most expressed symptom). The measurements were conducted before AHSCT, at 6 and 12 months after AHSCT, then every 6 months during 2 years after AHSCT and every 12 months after 2 years during 5 years after AHSCT.

For statistical evaluation, paired t-test, Wilcoxon test and ANOVA were used. Progression-free survival (PFS) and relapse-free survival (RFS) after AHSCT were evaluated using Kaplan-Meyer method. To compare survival rates, log-rank criterion and Tarone-Ware criterion were applied. Mc-Nemar's test was used in order to compare the propor­tions of patients according to symptom prevalence before AHSCT and 12 months following transplant. P values of <0.05 will be used as a cut-off point for statistical signifi­cance, and all statistical tests will be two-sided.
General characteristics:

A total of 258 patients with RRMS were enrolled in the study. Mean age was 36.5 years old; male/female ratio, 73/185. Me­dian EDSS value before transplantation was 2.0 (range 1.5­6.5). Mean duration of the disease was 4.9 years (median 3.0, range 0.5-24). Patients' chara
Table 1. Characteristics of the patients with multiple sclerosis
Abbreviations: EDSS, Expanded Disability Status Scale score; ND, no data.
The procedure of autologous HSCT was well tolerated by the patients. There were no cases of transplantation-related mortality. Mobilization was successful in all cases with me­dian number of 2.1x106/kg (range 2-10.9x106/kg) collected CD34+cells; no major clinical adverse events were observed during this phase.

The mean time of neutropenia (grade 4) was 8.0 days. The mean time of thrombocytopenia (grade 3-4) was 7.0 days. Neutrophil engraftment was registered on D+8- D+11. No differences in hematological toxicity between the three con­ditioning regimens were found (P>0.05).

Common adverse effects after AHSCT were as follows: he­patic toxicity (grade 2 and 3) - 20.5%; mucositis (grade 2), 1.6%; temporary neurological worsening, 6.4%; neutropen­ic fever, 27%; local infection, 6.2%; anemia (grade 3), 1.9%; allergic reactions, 2.3%. No differences in toxicity were ob­served among the patients who received different condition­ing regimens. No deaths were registered throughout the en­tire follow-up period.
Median follow-up after AHSCT was 30 months (3.7-110.9). The vast majority of patients (99%) responded to treatment. The decrease of EDSS score from median 2.0 to 1.5 was ob­served at 12 months after AHSCT, and it remained at this level during the follow-up of more than 60 months (Fig. 1). The EDSS score improved significantly for the entire group (P <0.001) at all the time intervals, as compared with base­line. EDSS changes in patients with RRMS prior to and at dif­ferent time-points after AHSCT are presented in Table 2. The proportion of patients with change of >1.0 in EDSS score was 36% (86 patients) with index of improvement at 12 months, and 0.4% (1 patient) with an index of the disease progres­sion. At 2 years post-transplant, 47 (32%) patients showed improvement, 1 patient (0.7%) became worse, and others presented with stable disease. At 3 years posttransplant, im­provement was observed in 23 (25%) patients, worsening - in 1 (1.1%) patient, the others were in stable clinical state. At 4 years posttransplant, the majority (83.1%) of patients were stable, there was no further worsening, and 10 patients (16.9%) exhibited improvement. Hence, the vast majority of patients was stable during the continuous follow-up; clinical deterioration took place in 6% of patients.
Figure 1.
EDSS medians in patients with RRMS before and at different time-points after AHSCT
After AHSCT, the vast majority of patients with RRMS were relapse-free (245 out of 258). The mean term until relapse was 30.4 months (95% CI 18.24-42.52). Estimated relapse-free survival (RFS) at the median follow-up of 29.5 months was 95% (95% CI: 92.3-97.7) (Fig. 2A).

Estimated RFS at the follow-up of 36 months was 95.6% (95% CI: 92.4-98.8), at the follow-up of 60 months, 88.2% (95% CI: 80.2-96.2); at the follow-up of 84 months, 83.3%

Table 2.
EDSS changes in patients with RRMS before and at different time-points after AHSCT

Figure 1.
Relapse-free (a)
and progression free (b) survival Kaplan-Meyer curves in RRMS patients after AHSCT

(95% CI: 71.3-95.3). Estimated progression-free survival (PFS) at the follow-up of 36 months was 98% (95% CI: 95.6­100.0), at the follow-up of 60 months, 91.2% (95% CI: 81.9­100.0), at the follow-up of 84 months, 86.2% (95% CI: 73.1­99.3), as seen from Fig. 2B.

Separate analysis of RFS probability in the groups of patients with different conditioning regimen was also performed. Comparison was made between the conditioning regimens based on BEAM-like and Cyclophosphamide+Rituximab protocols. Previously, it was shown that the outcomes for mini-BEAM and BM were similar [24]. Thus, the BEAM­like group included mini-BEAM and BM conditioning reg­imens. No differences in RFS were found between patients who received BEAM-like and these who received high-dose cyclophosphamide+Rituximab (log-rank, P=0.92), as shown in Fig
Figure 3.
Relapse-free survival Kaplan-Meyer curves for patients who received BEAM-like vs who received high-dose Cyclophosphamide+Rituximab

Table 3.
Quality of life mean values in RRMS patients at baseline and 12 months after AHSCT
Notes: *Wilcoxon test
Abbreviations: RRMS, relapsing-remitting multiple sclerosis; AHSCT, autologous hematopoietic stem cell transplantation; SD, standard deviation; PF, physical functioning; RPF, Role physical functioning; BP, Bodily pain; GH, General health; V, Vitality; SF, Social functioning; REF, Role emotional functioning; MH, Mental health; IQoLI, Integral QoL Index.

Figure 4.
QoL changes in RRMS patients at 12 months
after AHSCT as compared to baseline (before ASCT)
Figure 5.
QoL changes in RRMS patients at long-term follow-up
after AHSCT as compared to baseline (before ASCT)
Mean QoL values in RRMS patients before AHSCT and 12 months after AHSCT (n=78) are presented in Table 3. QoL changes (Д) of scores according to all the SF-36 scales in 12 mo after AHSCT were compared to the baseline levels (Fig. 4).

We have also performed analysis of QoL changes at long­term follow-up after AHSCT (>18 months) as compared to baseline values (n=41). Median follow-up was 22.9 months (interquartile range: 16.8-35.7 mo; mean±SD, 23.9±5.05 mo;95% CI: 22.3 to 25.5 mo). The mean QoL values in RRMS patients before AHSCT and in the course of long-term fol­low-up after AHSCT are presented in Table 4. QoL changes (Д) of scores for all SF-36 scales over long-term follow-up after AHSCT were compared to baseline scores (Fig. 5).

Prevalence of the most common symptoms by CSP-MS42 in RRMS patients at 12 mo after ASCT against appropriate baseline values is shown in Fig. 6. Before AHSCT, the ten most common symptoms were present in more than half of the patients. Such symptoms as constant tiredness feeling, early exhaustion after physical activity, decreased energy, fa­tigue, heaviness in legs, loss of balance, lack of working coor­dination, difficulty walking and poor tolerance of hot water were reported by the vast majority of patients. As seen from the Fig. 6, their prevalence decreased 12 months post-trans­plant. The number of patients who experienced these symp­toms except of heaviness in legs was significantly less after AHSCT as compared with baseline prevalence (P<0.05). The severity of all these symptoms also decreased after AHSCT (P<0.05).

AHSCT was accompanied by a significant improvement in patient's QoL and decrease of symptom burden. Improved QoL was preserved during the entire period of follow-up. AHSCT is beneficial in unfavorable group of MS patients, those with progressive MS, with high disability and long last­ing disease.
Figure 6.
Prevalence of common MS symptoms before and at 12 months posttransplant
We have analyzed a cohort of 258 patients with RRMS un­dergoing AHSCT, with a median follow-up of 30 months. Low-intensity conditioning regimens based on BEAM and cyclophosphamide were applied. Outcomes of AHSCT were evaluated both from physician's and patient's perspective. Transplantation procedure was well tolerated by the patients. There were no cases of transplantation-related mortality. In our cohort, the vast majority of patients responded to treat­ment and exhibited clinical improvement, or were stable during the entire period of follow-up. Significant decrease of EDSS score was observed after transplantation; the EDSS score improved (decreased by >1.0 point), with 32% and 17% of patients demonstrating improvement at 2 years and 4 years, respectively. In our cohort, relapse-free survival and progression-free survival at 7-year follow-up were 83% and 86%, respectively. These results are in line with previously published data by R. Burt [18, 19].

Moreover, AHSCT was accompanied by significant im­provement in patient's QoL. The analysis of QoL demon­strated benefits of AHSCT with low-intensity conditioning regimens in this patient population. QoL is an important outcome of MS treatment and its assessment provides the patient's perspective on the overall effect of treatment and allows evaluating patient benefits. Our results definitely show that AHSCT resulted in significant and sustained im­provement of patient's QoL. Also, prevalence and severity of common symptoms of MS decreased after transplantation. Thus, noticeble decrease of symptom burden after AHSCT was demonstrated.

For the first time to our knowledge, we report the AHSCT outcomes in MS patients after different low-intensity condi­tioning regimens and long-term follow-up. We did not find any differences in RFS between the patients who received BM/BEAM-like+ATG, and those who received high-dose cyclophosphamide+Rituximab. These data are in line with the results we have published previously [29]. Our study also demonstrated that RFS did not differ between various age groups, and between the groups with different duration of the disease.

On the contrary, disability status was an important factor influencing the outcomes of transplantation: RFS was dra­matically better in patients with EDSS<4 as compared to pa­tients with EDSS=4-6.5. This finding supports the idea that AHSCT is beneficial for patients with highly active relaps­ing-remitting MS and moderate disability.

This study has several important limitations. Firstly, the study was conducted at a single academic institution, which may introduce some bias. However, all patients had clinical continuity and were monitored for in terms of relapses or need for additional treatment. Secondly, a large number of patients were treated on a compassionate basis rather than within a study protocol. Thirdly, a long-term follow-up (i.e, for >4 years) was not available for a substantial proportion of patients. Fourth, this was an observational cohort lacking a control group. Therefore, any inferences about causal effects of AHSCT can't be made.

Thus, the risk/benefit ratio of AHSCT with low-intensity conditioning regimens in our population of RRMS patients is rather favorable. The consistency of our clinical and QoL results, together with persistent improvement suggest clini­cal efficacy of AHSCT strategy in RRMS patients. In general, the results of our study support the feasibility of AHSCT with low-intensity conditioning in RRMS patients. To optimize the mentioned treatment protocols of AHSCT in RRMS, multicenter cooperative studies are necessary in future.
None reported

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