CEC Count Changes to Support GvHD Diagnosis. (ALLOCEC)

Evaluation of Circulating Endothelial Cells (CEC) as a Marker of Endothelial Damage in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation (Allo-HSCT): Correlation With the Occurrence of Graft-versus-Host Disease (GvHD)

In consideration of the fact that the vascular endothelium has been shown to be a target of GvHD in early stage and that the count of CEC may represent a marker of endothelial damage, we want to evaluate the changes in CEC counts of patients affected by hematological disorders undergoing allo-HSCT, as a function of endothelial damage. We will enroll 50 patients affected by hematologic disorders undergoing allo-HSCT. Peripheral blood will be drawn before (T1, baseline) and at the end of the conditioning regimen (T2, pre-transplant), upon confirmation of hematopoietic recovery (T3, engraftment) and thereafter at onset of GVHD (GVHD T4) and one week after the start of steroid therapy (T5, post-GvHD). All patients will also be checked for CEC at day + 28. CEC enumeration will be performed by using the CellSearch® System and a flowcytometry procedure.

Through the conduct of this study, we expect to confirm our preliminary results on a larger series of patients, and to evaluate the predictive role of CEC on the occurrence of GvHD and prognostic response to treatment of GvHD. The possibility of early identification of patients who do not respond to traditional treatments of GvHD, and for this reason at a higher risk of morbidity and mortality, may allow greater individualization of the therapeutic program, for example with the introduction as early as possible of alternative treatments. In addition, the identification of patients at higher risk of non-responsiveness to steroid treatment, would allow, through a closer monitoring, the early introduction of additional treatment before the development of resistance/refractoriness to treatment of GvHD.

The present study takes the form of a prospective study. The primary endpoint is the identification and enumeration of CECs in peripheral blood of patients with hematological disorder undergoing allo-HSCT, as a function of endothelial damage. The secondary endpoint is to define the prognostic and predictive value of the changes of CEC counts on the diagnosis of GvHD and response to treatment.

Study Overview

• Status: Completed
• Conditions: Endothelial Dysfunction; Graft vs Host Disease; Complications of Organ Transplant Stem Cells
• Intervention / Treatment: Other: Patients undergoing allo-HSCT, who manifest GvHD.

Detailed Description

The endothelial damage is a characteristic common to several complications of vascular origin that may occur in the course of allo-HSCT (GVHD, IPS, VOD, TMA). The diagnosis of vascular complications represents an interesting challenge, but unfortunately limited by the fact that the markers of endothelial damage are extremely scarce. In particular, the plasmatic dosage of von Willebrand factor, thrombomodulin and adhesion molecules generated results difficult to use for a potential application for routine diagnostics for the high degree of non-specificity and the potential influence on the assay by co-morbid conditions related to the recipient. Much more promising methods appear to be those that are based on the evaluation of microparticles derived from endothelial cells (EMP) or the direct counting of circulating endothelial cells (CEC). Recently, the EMP were assessed by flow cytometry (annexin V-FITC and anti-CD62-PE) in 19 patients undergoing allo-HSCT, showing an increase in patients with acute GvHD grade ≥ I, compared to patients that did not display GvHD. In addition, the evaluation of EMP did not appear to be affected by the radio-chemotherapy conditioning regimen. This method is, however, burdened with a procedural complexity and a certain degree of non-specificity due to the fact that the microparticles can be released by endothelial cells as well as also from platelets, red blood cells and leukocytes.

Currently, the direct counting of the CEC seems to be the most reliable ways to assess the degree of endothelial damage. The finding of elevated numbers of CEC has been shown to reflect the extent of endothelial damage in numerous pathologies of autoimmune nature, but are still preliminary data in the course of allo-HSCT. Woywodt et al. demonstrated in patients with ANCA-positive vasculitis a correlation between the number of CEC and the degree of disease activity and response to treatment. Moreover, the number of CEC correlates, in patients undergoing renal transplantation, with the risk of organ rejection. In the course of allo-HSCT, the same authors have shown a correlation between the number of CEC and endothelial damage induced by radio-chemotherapy conditioning regimen. However, the lack of a standardized method, the use of manual procedures of immunoselection, the lack of consensus on the identification of CEC represent limiting factors for routine application.

The present study takes the form of a prospective study. The primary endpoint is the identification and enumeration of CECs in peripheral blood of patients with hematological disorders undergoing allo-HSCT, as a function of endothelial damage. The secondary endpoint is to define the prognostic and predictive value of CEC counts changes on the diagnosis of GvHD and on the response to treatment.

Peripheral blood (PB) will be drawn before (T1, baseline) and at the end of the conditioning regimen (T2, pre-transplant), upon confirmation of hematopoietic recovery (T3, engraftment) and thereafter at onset of GVHD (GVHD T4) and one week after the start of steroid therapy (T5, post-GvHD) for the control of GvHD. All patients will also be checked for CEC at day + 28.

The peripheral blood for counting CEC will be collected, respectively, in the CellSave Preservative Tube (Veridex, J & J, USA), containing a preservative for the stabilization of the cells at room temperature, for counting with the CellSearch® System and in CBC tube containing K2EDTA, for counting by flow cytometry.

By the CellSearch® System an event will be classified as CEC when its morphology is consistent with that of a cell and simultaneously shows the following phenotype: CD146+, CD105+, DAPI+ and CD45-. By the flowcytometry procedure, after staining of cells with lyophilized antibodies of the Endo Panel tube (CD146, 7-AAD, CD34, CD309, CD45) 4x106 events in the lympho-monocyte gate will be immediately aquired at flowcytometry.

• Study Type: Observational
• Enrollment (Actual): 50

Contacts and Locations

Study Locations

• Italy
  • Brescia, Italy, 25123
    • A.O. Spedali Civili of Brecia

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients, affected by hematologic disorders, undergoing allo-HSCT.

Description

Inclusion Criteria:

• Patients with hematological disorders undergoing allo-HSCT,
• Age 18-65 years.
• Sign of written informed consent form at the time of study entry.

Exclusion Criteria:

• No candidates to allo-HSCT.
• Patients under the age of 18 years.

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Patients undergoing allo-HSCT, who manifest GvHD.; Patients undergoing allo-HSCT, that manifest GvHD. Patients undergoing allo-HSCT will have CEC count performed at the following timepoints: T1 (baseline), T2 (pre-transplant), T3 (engraftment), T4 (GvHD onset) and T5 (post-GvHD). All patients will also be checked for CEC at day + 28.	Other: Patients undergoing allo-HSCT, who manifest GvHD.; Changes in CEC counts in relation to GvHD ONSET

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes from baseline (Timepoint 1) in Circulating Endothelial Cell (CEC) count at GvHD onset (Timepoint 4)	CEC count changes will be evaluated between baseline and time of GvHD onset, within day + 100 post-transplant. In our preliminary series of 40 patients GvHD have manifested at a median of 27 days post-transplant (range 15-103).	Basal (Timepoint 1) versus GvHD onset (Timepoint 4)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes from baseline (Timepoint 1) in Circulating Endothelial Cell (CEC) count at time of transplant (Timepoint 2)	CEC count changes will be evaluated between baseline and pre-transplant, which usually is in the range of 5-8 days.	Basal (Timepoint 1) versus pre-transplant (Timepoint 2)
Changes from baseline (Timepoint 1) in Circulating Endothelial Cell (CEC) count at time of engraftment (Timepoint 3).	CEC count changes will be evaluated between baseline and time of engraftment. In our preliminary series of 40 patients engraftment occurred at a median of 22 days post-transplant (range 14-31).	Basal (Timepoint 1) versus engraftment (Timepoint 3)
Changes from GvHD onset (Timepoint 3) in Circulating Endothelial Cell (CEC) count at one week after the start of steroid therapy (Timepoint 5).	CEC count changes will be evaluated between GVHD onset and one week after steroid therapy	GvHD onset (Timepoint 3) versus one week after the start of steroid therapy (Timepoint 5)

Collaborators and Investigators

• Sponsor: Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia
• Collaborators: Janssen Diagnostics, LLC
• Investigators: Principal Investigator: Camillo Almici, M.D., Transfusion Medicine, Spedali Civili Brescia, Italy

Publications and helpful links

General Publications

• Penack O, Socie G, van den Brink MR. The importance of neovascularization and its inhibition for allogeneic hematopoietic stem cell transplantation. Blood. 2011 Apr 21;117(16):4181-9. doi: 10.1182/blood-2010-10-312934. Epub 2011 Jan 21.
• Lanuti P, Rotta G, Almici C, Avvisati G, Budillon A, Doretto P, Malara N, Marini M, Neva A, Simeone P, Di Gennaro E, Leone A, Falda A, Tozzoli R, Gregorj C, Di Cerbo M, Trunzo V, Mollace V, Marchisio M, Miscia S. Endothelial progenitor cells, defined by the simultaneous surface expression of VEGFR2 and CD133, are not detectable in healthy peripheral and cord blood. Cytometry A. 2016 Mar;89(3):259-70. doi: 10.1002/cyto.a.22730. Epub 2015 Aug 25.
• Almici C, Skert C, Verardi R, Di Palma A, Bianchetti A, Neva A, Braga S, Malagola M, Turra A, Marini M, Russo D. Changes in circulating endothelial cells count could become a valuable tool in the diagnostic definition of acute graft-versus-host disease. Transplantation. 2014 Oct 15;98(7):706-12. doi: 10.1097/TP.0000000000000385.
• Rowand JL, Martin G, Doyle GV, Miller MC, Pierce MS, Connelly MC, Rao C, Terstappen LW. Endothelial cells in peripheral blood of healthy subjects and patients with metastatic carcinomas. Cytometry A. 2007 Feb;71(2):105-13. doi: 10.1002/cyto.a.20364.
• Woywodt A, Scheer J, Hambach L, Buchholz S, Ganser A, Haller H, Hertenstein B, Haubitz M. Circulating endothelial cells as a marker of endothelial damage in allogeneic hematopoietic stem cell transplantation. Blood. 2004 May 1;103(9):3603-5. doi: 10.1182/blood-2003-10-3479. Epub 2004 Jan 8.
• Damani S, Bacconi A, Libiger O, Chourasia AH, Serry R, Gollapudi R, Goldberg R, Rapeport K, Haaser S, Topol S, Knowlton S, Bethel K, Kuhn P, Wood M, Carragher B, Schork NJ, Jiang J, Rao C, Connelly M, Fowler VM, Topol EJ. Characterization of circulating endothelial cells in acute myocardial infarction. Sci Transl Med. 2012 Mar 21;4(126):126ra33. doi: 10.1126/scitranslmed.3003451.
• Chen YB, Cutler CS. Biomarkers for acute GVHD: can we predict the unpredictable? Bone Marrow Transplant. 2013 Jun;48(6):755-60. doi: 10.1038/bmt.2012.143. Epub 2012 Aug 6.
• Carreras E, Diaz-Ricart M. The role of the endothelium in the short-term complications of hematopoietic SCT. Bone Marrow Transplant. 2011 Dec;46(12):1495-502. doi: 10.1038/bmt.2011.65. Epub 2011 Apr 4.
• Almici C, Neva A, Skert C, Bruno B, Verardi R, Di Palma A, Bianchetti A, Braga S, Piovani G, Cancelli V, Omede P, Baeten K, Rotta G, Russo D, Marini M. Counting circulating endothelial cells in allo-HSCT: an ad hoc designed polychromatic flowcytometry-based panel versus the CellSearch System. Sci Rep. 2019 Jan 14;9(1):87. doi: 10.1038/s41598-018-36442-9.
• Almici C, Skert C, Bruno B, Bianchetti A, Verardi R, Di Palma A, Neva A, Braga S, Piccinelli G, Piovani G, Malagola M, Bernardi S, Giaccone L, Brunello L, Festuccia M, Baeten K, Russo D, Marini M. Circulating endothelial cell count: a reliable marker of endothelial damage in patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant. 2017 Dec;52(12):1637-1642. doi: 10.1038/bmt.2017.194. Epub 2017 Sep 11.

Study record dates

Study Major Dates

• Study Start: April 1, 2014
• Primary Completion (Actual): March 1, 2016
• Study Completion (Actual): March 1, 2016

Study Registration Dates

• First Submitted: February 13, 2014
• First Submitted That Met QC Criteria: February 14, 2014
• First Posted (Estimate): February 17, 2014

Study Record Updates

• Last Update Posted (Actual): May 29, 2019
• Last Update Submitted That Met QC Criteria: May 28, 2019
• Last Verified: May 1, 2019

More Information

Terms related to this study

• Keywords: Hematopoietic Stem Cell Transplant; Graft vs Host Disease; Endothelial Dysfunction; Circulating Endothelial Cells; Biological Marker
• Additional Relevant MeSH Terms: Immune System Diseases; Graft vs Host Disease
• Other Study ID Numbers: NP 1574

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The datasets used and analysed during the current study will be available from the corresponding author on reasonable request after the publication of results.
• IPD Sharing Time Frame: After publication of results
• IPD Sharing Access Criteria: Request to Principal Investigator
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; ICF