Pediatr Blood Cancer 2009;52:522–550 BRIEF REPORTS Etanercept as a Salvage Treatment for Refractory Aplastic Anemia Carlo Dufour, MD, 1 * Raffaella Giacchino, MD, 2 Pietro Ghezzi, PhD, 3 Rossella Tonelli, PhD, 3 Elisa Ferretti, PhD, 4 A. Pitto, PhD, 5 Vito Pistoia, MD, 4 Tiziana Lanza, PhD, 1 and Johanna Svahn, MD 1 INTRODUCTION Standard treatment of acquired aplastic anemia (AAA) includes hematopoietic stem cell transplantation (HCST) from HLA matched family donor that improves long-term hematopoiesis in about 75% of cases [1]. In the absence of an identical family donor, first line treatment is combined immunosuppression (IS) with anti- thymocyte globulin (ATG) and cyclosporin A (CyA), which increases hematopoietic activity in 70 – 90% of patients [1,2]. Both IS and HSCT, including that from unrelated donors tend to have better outcome in pediatric populations [1 – 5]. All these options have drawbacks. An HLA identical donor may not be available for all patients. IS implies risks of recurrence or lack of response in about 30% of cases [6]. In spite of recent improvements [5], alternative donor HSCT can still be associated with important complications like infections and GVHD [3,6] particularly in patients with pre-transplant organ dysfunction. Overall it can be estimated that 10–15% of AAA have resistant/ refractory disease with no satisfactory treatment options. We report the case of a 17-year-old male with a long history of AAA, transfusion-dependence, refractoriness to platelet trans- fusions, HCV infection and iron overload, who responded to treatment with anti-TNF agent Etanercept after having failed two courses of IS. CASE PRESENTATION The patient was diagnosed with non-severe AAA [7] in his native country, Ukraine, at the age of 6 years due to WBC 3.6 Â 10 9 /L, polymorphonuclear cells (PMN) 1.0 Â 10 9 /L, Hb 7 g/dl, reticulo- cytes 0.2%, platelets 10 Â 10 9 /L and a hypocellular marrow with no excess blasts. Since a suitable family HSC donor was not available, he received red cell and platelet transfusions and a first course of IS with horse ATG 1.5 vial/10 kg/day for 5 days and CyA (5 mg/Kg/day orally) to which he did not respond. He was given a second IS course (rabbit ATG) which induced transfusion independence. Two years later HCV infection, most likely of post-transfusional origin, was detected. Hematological remission persisted for 8 years after which transfusion dependent pancytopenia re-appeared. A suitable HSC donor was not available and the patient received only red cell and platelet transfusions. At the age of 16 years the patient was referred to our Unit for further evaluation. On admission WBC were 2.6 Â 10 9 /L, PMN 0.70 Â 10 9 /L, Hb 6.1 g/dl (pre-transfusion), reticulocytes 0.2% and platelets 12 Â 10 9 /L. He was on oral CyA (3 mg/kg/day; serum trough level 130 ng/ml), red cell transfusion-dependent, severely thrombocytopenic but not receiving platelet concentrates due to positive test for HLA class I serum antibodies detected 2 years before. HCV infection was shown to be caused by genotype 1B virus. No anti-HCV treatment was given and a fortnightly HCV load and liver function test monitoring was started. The patient had iron overload measured by increased serum ferritin (2,670 ng/ml) and confirmed by MRI T2* weighted images. Desferoxamine (40 mg/ Kg/day/5 days a week) was given intravenously because of hemorrhagic risk of subcutaneous administration. Clinical and laboratory data on admission are shown in Table I. To assess if the hematopoietic progenitor growth was decreased by TNF-a, one of the final mediators of hematopoiesis inhibition in AAA [8,9], we blocked TNF-a in patient bone marrow cultures with the anti-TNF molecule Etanercept (10 mg/ml) [10]. Although absolute colony numbers were low, we observed a substantial percentage increment (66.6%) of BFU-e and of CFU-GM progenitors after in vitro blockade of TNF (Table I). Given this in vitro effect, the patient was enrolled in a pilot study currently ongoing at G.Gaslini Institute that is testing the use of Etanercept in AAA patients failing other IS regimens (Study CD 001, Eudract Code 2005-003096-20). This decision was also supported by the previous demonstration that Etanercept can reduce the viral load, improve liver function and slow down the progression of disease in patients with HVC infection [11]. Thus, after informed consent and demonstration of negativity of TB skin test and chest X-ray, the patient was started on Etanercept 0.4 mg/Kg/dose subcutaneously, About 10–15% of patients with acquired aplastic anemia (AAA) have resistant/recurrent disease not eligible for standard treatment like hematopoietic stem cell transplantation and/or combined immunosuppression. We report a 17-year-old male with an 11 years history of AAA who, after two courses of immunosuppression, was red cell transfusion-dependent, severely thrombocytopenic, refrac- tory to platelet transfusion, had iron overload and post-transfusion HCV infection. This patient achieved transfusion independence from platelets and normalized Hb after treatment with the anti-TNF agent Etanercept. Over a 12 months follow-up he experienced only transient increase of liver transaminases. Pediatr Blood Cancer 2009; 52:522–525. ß 2008 Wiley-Liss, Inc. Key words: anti-TNF; complicated aplastic anemia; HCV infection ß 2008 Wiley-Liss, Inc. DOI 10.1002/pbc.21886 Published online 5 December 2008 in Wiley InterScience (www.interscience.wiley.com) —————— 1 Haematology Unit, G.Gaslini Children’s Hospital, Genova, Italy; 2 Infectious Disease Unit, G.Gaslini Children’s Hospital, Genova, Italy; 3 Neuroimmunolgy Laboratory, Mario Negri Institute for Pharmacological Research, Milan, Italy; 4 Oncology Laboratory, G.Gaslini Children’s Hospital, Genova, Italy; 5 Haematology and HCS Transplantation Unit, Ospedale San Martino, Genova, Italy Grant sponsor: Compagnia di San Paolo, ERG s.p.a.; Grant sponsor: Fondazione Banca Popolare di Novara. *Correspondence to: Carlo Dufour, Haematology Unit, G.Gaslini Children’s Hospital, Largo G.Gaslini 5, 16147 Genova, Italy. E-mail: carlodufour@ospedale-gaslini.ge.it Received 4 June 2008; Accepted 5 November 2008