Etanercept treatment in Fanconi anaemia; combined US and Italian experience

Article (PDF Available)inBritish Journal of Haematology 158(6):809-11 · July 2012with23 Reads
DOI: 10.1111/j.1365-2141.2012.09250.x · Source: PubMed
(2011) BET bromodomain inhibition as a
therapeutic strategy to target c-Myc. Cell, 146,
Ferlay, J., Shin, H.R., Bray, F., Forman, D.,
Mathers, C. & Parkin, D.M. (2010) GLOBOCAN
2008, Cancer Incidence and Mortality Worldwide:
IARC CancerBase No. 10 [Internet]. International
Agency for Research on Cancer, Lyon, France.
International Myeloma Working Group. (2003)
Criteria for the classification of monoclonal
gammopathies, multiple myeloma and related
disorders: a report of the International Myeloma
Working Group. British Journal of Haematology,
Raab, M.S., Podar, K., Breitkreutz, I., Richardson,
P.G. & Anderson, K.C. (2009) Multiple
myeloma. Lancet, 374, 324339.
Richardson, P.G., Laubach, J., Mitsiades, C.S.,
Schlossman, R., Hideshima, T., Redman, K.,
Chauhan, D., Ghobrial, I.M., Munshi, N. &
Anderson, K.C. (2011) Managing multiple
myeloma: the emerging role of novel therapies
and adapting combination treatment for higher
risk settings. British Journal of Haematology, 154,
Etanercept treatment in Fanconi anaemia; combined US and
Italian experience
Fanconi Anaemia (FA) is an autosomal recessive disease
characterized by progressive bone marrow failure (BMF; the
major cause of morbidity and mortality), variable congenital
abnormalities and a predisposition to malignancy. Studies in
FANCC mice have shown that the cytokines tumour necrosis
factor alpha (TNF-a) and gamma interferon (IFN-c) play
key roles in the pathogenesis of BMF (Haneline et al, 1998;
Otsuki et al, 1999). Pang et al (2001) demonstrated that
inactivating mutations of FANCC lead to loss of interaction
with heat shock protein 70, which results in dysfunction of
the anti-apoptotic pathway and the characteristic hypersensi-
tivity of FANCC cells to TNF-a. Furthermore, TNF-a expo-
sure promotes outgrowth of TNF-resistant cytogenetically
abnormal clones from Fancc/ stem progenitors suggesting
an additional beneficial effect of neutralizing TNF-a (Li et al,
Clinical studies have shown that patients with FA and
other BMF syndromes produce increased serum levels of
TNF-a, which is thought to be one of the late effectors of
the haematopoietic stem cell damage that occurs in FA
(Rosselli et al, 1994; Dufour et al, 2001). A study of seven
children with FA showed increased intracytoplasmic TNF-a
in all marrow mononuclear cell subsets (compared to normal
children), and markedly reduced erythroid colony-forming
units (CFU-E) and burst-forming units (BFU-E), which
increased in number and size in response to in vitro etaner-
cept (Dufour et al, 2003).
We hypothesized that neutralization of TNF-a by etaner-
cept, a fusion protein of the extra cellular ligand-binding
domain of the human p75 TNF receptor linked to the Fc por-
tion of human IgG1, will ameliorate BMF in children with FA.
Etanercept is well tolerated in healthy normal volunteers
and was effective in disease modification in studies of adults
and children with arthritis, colitis and psoriasis (Moreland
et al, 1997; Lovell et al, 2000).
Two separate studies were performed in the United States
(Cincinnati) and Italy (Genova). Inclusion criteria (for the
US study) included, diagnosis of FA with evidence of early
BMF, i.e., reduction in at least one cell line on two separate
occasions at least 1 month apart e.g. platelet count of
<100 9 10
/l, haemoglobin <90 g/l and/or absolute neutro-
phil count of <10 9 10
/l. The Italian study allowed inclu-
sion of patients with advanced BMF (e.g., patients receiving
transfusion and growth factor support, on androgen ther-
apy). Both studies excluded patients with an abnormal
cytogenetic clone that involved chromosome 3 and/or 7,
patients with an available donor and clinically indicated need
for transplant, patients with any active infection, or with a
history of tuberculosis infection or exposure.
Patients treated in USA received etanercept (08 mg/kg/
dose, to a maximum dose of 50 mg) weekly, and those in
Italy were treated with 04 mg/kg/dose subcutaneously on a
twice- weekly schedule for a total of 6 months. These dosing
regimens are known to be safe, well-tolerated and equivalent
in adult and paediatric patients with rheumatoid arthritis
(Lovell et al, 2000; Keystone et al, 2004). Patients were fol-
lowed closely for adverse events and with weekly blood
counts, serial renal and liver function tests, along with bio-
marker studies (TNF- a concentration, etanercept concentra-
tion) on serial blood and bone marrow samples.
Six patients with FA in different stages of marrow failure
were enrolled and treated (three at each centre; Table 1). All
patients had a negative tuberculin test, and all female
patients of childbearing potential had a negative pregnancy
test before starting treatment.
Etanercept was well tolerated in all six patients. The
majority of adverse events reported (73%; n = 156 events)
were grade 1. Fourteen events (12 grade 1; 2 grade 3) were
potentially related to the study treatment; seven were pain
and five were bruising at the injection site. All injection
site reactions were mild and resolved without treatment.
Two grade 3 adverse events in the Italian study group
included a skin furunculous infection in a neutropenic
patient and vasculitis of the lower limbs responsive to ste-
ª 2012 Blackwell Publishing Ltd 809
British Journal of Haematology, 2012, 158, 798–814
roid treatment in another patient. Additional grade 2
adverse events not attributed to study drug, included epi-
staxis (4) and hypertension requiring treatment with anti-
hypertensive medication. In patients with early BMF, there
was a trend towards an immediate decrease in the blood
counts with initial treatment, followed by recovery or
improvement around 6 months after completion of treat-
ment. There were no other adverse events, and the study
stopping rules were not met. None of the patients devel-
oped anti-nuclear antibody, antibody to double-stranded
DNA or antibodies to etanercept.
At each centre, one patient opted to discontinue therapy
after 3 months one due to a transient small decrease in
platelet count, and the second because a matched unrelated
donor became available and the patient went on to receive
haematopoetic cell transplantation for progressive BMF.
None of the six subjects met the study definition for com-
plete or partial response in their blood counts. Marrow
responses were variable without any significant evidence of
improvement in haematopoiesis. Biomarker studies showed
increased plasma TNF-a levels (after initial treatment with
etanercept) in most cases studied as expected (etanercept
binds the ligand in the blood), confirming that the drug was
successfully administered. Pharmacokinetic data available
from the three Italian patients showed that, at the dosage
used, expected amounts of the drug reached the bone mar-
row. Changes in intracellular TNF-a level and the CFU assay
also showed variable results, with no clear evidence of change
in relation to the treatment. Of note, we observed improved
linear growth in one patient, similar to reports of growth
improvement in children with juvenile idiopathic arthritis
treated with etanercept (Keystone et al, 2004).
In contrast to increased risk of lymphoma in adult rheu-
matoid arthritis patients treated with etanercept, we have not
observed any malignancy in our study patients with up to
4 years post-therapy follow-up.
This combined report, from two independent centres,
concludes that etanercept is well tolerated and can be safely
administered to FA patients. There was no evidence of an
effect of etanercept on haematopoiesis. The small number of
cases treated at different stages of marrow failure, and only
for short duration (6 months) could be possible reasons for
this. Further exploration of anti-inflammatory therapies in
children with less advanced marrow failure will help identify
therapeutic approaches that can ameliorate or prevent mar-
row failure.
This work was funded by research grant from American
Society of Clinical Oncology (ASCO Young Investigator
Award to P. A. Mehta) and Translational Research Initiative,
University of Cincinnati (to S. M. Davies). The drug was
donated by Amgen.Inc (for the US study). The authors
would also like to acknowledge ERG s.p.a, Cambiaso & Ris-
so, Cantieri Mariotti, SAAR (all from Genova), for their sup-
port to the activities of the Haematology Unit of the G.
Gaslini Children’s Hospital.
Table 1. Patient characteristics.
USA patients Italian patients
Age (years)
at enrollment
Sex Male Female Female Male Male Female
Duodenal atresia,
supernumerary left
thumb, undescended
left testis,
Duodenal/jejunal atresia,
absent thumbs, modest
microphtalmia, small
kidneys, PDA/VSD
(self-resolved), septo-optic
None None Horse-shoe
Baseline ANC
1615128 090714
Hb (g/l) 97 96 120 76 80 80
Platelet count
58 35 47 36 22 24
Baseline BM
cellularity (%)
123040 30 20 2025 30
Transfusions (n)
None None None 1/1 5/3 8/2
Other therapies
prior to enrollment
None None None None Epo 9 6 months Epo + GCSF
10 years ago
PDA, patent ductus arteriosus; VSD, ventricular septal defect; ANC, absolute neutrophil count; Hb, haemoglobin; BM, bone marrow; PRBC,
packed red blood cells; Epo, erythropoietin; GCSF, granulocyte colony-stimulating factor.
ª 2012 Blackwell Publishing Ltd
British Journal of Haematology, 2012, 158, 798–814
Author contributions
P. A. Mehta and J. Svahn designed the study, performed
the research, analysed the data and wrote the paper. S. M.
Davies and C. Dufour designed the research study, analy-
sed the data and reviewed the paper. Q. Pang provided
preclinical animal data, contributed to analysis of correlative
studies and reviewed the paper. R. Harris participated in
performance of research and reviewed the paper. P. Ghezzi
performed the research and Pharmacokinetics and reviewed
the paper. P. Barabino performed the research and
reviewed the paper, R. Mueller coordinated patient enroll-
ment and follow-up, and reviewed the paper. T. Lanza per-
formed the experiments and data management. E. Ferretti
performed the experiments and data management.
Parinda A. Mehta
Johanna Svahn
Stella M. Davies
Qishen Pang
Richard Harris
Pietro Ghezzi
Tiziana Lanza
Elisa Ferretti
Paola Barabino
Robin Mueller
Carlo Dufour
Division of Bone Marrow Transplantation and Immune Deficiency,
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA,
Department of Paediatric Haemato-Oncology, G. Gaslini Children’s
Hospital, Genova, Italy,
Division of Experimental Hematology, Cincin-
nati Children’s Hospital Medical Center, Cincinnati, OH, USA and
Trafford Centre for Medical Research, Brighton & Sussex Medical
School, Brighton, East Sussex, UK
Keywords: Fanconi Anaemia, marrow failure, cytokine therapy,
etanercept, tumour necrosis factor-a
First published online 27 July 2012
doi: 10.1111/j.1365-2141.2012.09250.x
Dufour, C., Corcione, A., Svahn, J., Haupt, R.,
Battilana, N. & Pistoia, V. (2001) Interferon
gamma and tumour necrosis factor alpha are
overexpressed in bone marrow T lymphocytes
from paediatric patients with aplastic anaemia.
British Journal of Haematology, 115, 10231031.
Dufour, C., Corcione, A., Svahn, J., Haupt, R.,
Poggi, V., Beka’ssy, A.N., Scime, R., Pistorio, A.
& Pistoia, V. (2003) TNF-alpha and IFN-gamma
are overexpressed in the bone marrow of Fan-
coni anemia patients and TNF-alpha suppresses
erythropoiesis in vitro. Blood, 102, 20532059.
Haneline, L.S., Broxmeyer, H.E., Cooper, S., Han-
goc, G., Carreau, M., Buchwald, M. & Clapp, D.
W. (1998) Multiple inhibitory cytokines induce
deregulated progenitor growth and apoptosis in
hematopoietic cells from Fac/ mice. Blood,
91, 40924098.
Keystone, E.C., Schiff, M.H., Kremer, J.M., Kafka,
S., Lovy, M., DeVries, T. & Burge, D.J. (2004)
Once-weekly administration of 50 mg etanercept
in patients with active rheumatoid arthritis:
results of a multicenter, randomized, double-
blind, placebo-controlled trial. Arthritis and
Rheumatism, 50, 353363.
Li, J., Sejas, D.P., Zhang, X., Qiu, Y., Nattamai, K.
J., Rani, R., Rathbun, K.R., Geiger, H., Williams,
D.A., Bagby, G.C. & Pang, Q. (2007) TNF-alpha
induces leukemic clonal evolution ex vivo in
Fanconi anemia group C murine stem cells. The
Journal of Clinical Investigation, 117, 32833295.
Lovell, D.J., Giannini, E.H., Reiff, A., Cawkwell, G.
D., Silverman, E.D., Nocton, J.J., Stein, L.D.,
Gedalia, A., Ilowite, N.T., Wallace, C.A., Whit-
more, J. & Finck, B.K. (2000) Etanercept in chil-
dren with polyarticular juvenile rheumatoid
arthritis. Pediatric Rheumatology Collaborative
Study Group. New England Journal of Medicine,
Moreland, L.W., Baumgartner, S.W., Schiff, M.H.,
Tindall, E.A., Fleischmann, R.M., Weaver, A.L.,
Ettlinger, R.E., Cohen, S., Koopman, W.J., Moh-
ler, K., Widmer, M.B. & Blosch, C.M. (1997)
Treatment of rheumatoid arthritis with a recom-
binant human tumor necrosis factor receptor
(p75)-Fc fusion protein. New England Journal of
Medicine, 337, 141147.
Otsuki, T., Nagakura, S., Wang, J., Bloom, M.,
Grompe, M. & Liu, J.M. (1999) Tumor necrosis
factor-alpha and CD95 ligation suppress eryth-
ropoiesis in Fanconi anemia C gene knockout
mice. Journal of Cellular Physiology, 179,7986.
Pang, Q., Keeble, W., Christianson, T.A., Faulkner,
G.R. & Bagby, G.C. (2001) FANCC interacts
with Hsp70 to protect hematopoietic cells from
IFN-gamma/TNF-alpha- mediated cytotoxicity.
EMBO Journal, 20, 44784489.
Rosselli, F., Sanceau, J., Gluckman, E., Wietzerbin,
J. & Moustacchi, E. (1994) Abno rmal lympho-
kine production: a novel fea ture of the genetic
disease Fanconi anemia. II. In vitro and in vivo
spontaneous overproduction of tumor necrosis
factor alpha. Blood, 83, 12161225.
Venous thromboembolism and coagulation activity in patients
with immune thrombocytopenia treated with
thrombopoietin receptor agonists
Thrombopoietin receptor agonists (Tpo-RAs) are new agents
developed for the treatment of immune thrombocytopenia
(ITP) that have demonstrated high efficacy and safety in clin-
ical trials (Bussel et al, 2007; Kuter et al, 2008; Bussel et al,
ª 2012 Blackwell Publishing Ltd 811
British Journal of Haematology, 2012, 158, 798–814
    • "This raises the possibility that treatment with RT inhibitors, which inhibit the accumulation of immunogenic nucleic acids responsible for initiating pro-inflammatory cytokines production, may delay or prevent the onset of bone marrow failure in FA. In support, immunotherapy aiming at neutralizing a single pro-inflammatory cytokine (TNFα) has shown promising positive effects in patients (Mehta et al., 2012; Miehsler et al., 2010 ). Accordingly , we observed that treatment with TenoF weakly decreased the cell death of SLX4-deficient cells following treatment with TNFα or DNA damaging drugs. "
    [Show abstract] [Hide abstract] ABSTRACT: Chronic inflammation favors tumorigenesis, negatively influencing patient prognosis. Yet, the underlying molecular mechanisms are poorly understood. Here, we show that increased endogenous retroelement-associated reverse transcriptase activity contributes to generate immunogenic cytoplasmic nucleic acids susceptible of triggering a pro-inflammatory response in the Fanconi Anemia (FA) cancer susceptibility syndrome. In addition, treatment of FA cells or of cells exposed to replication stress inducing drugs, with a reverse transcriptase inhibitor, decreases pro-inflammatory signals. Altogether our data suggest the involvement of endogenous reverse transcriptase activities in sustaining pervasive chronic inflammation, opening therapeutic perspectives for preventing its impact on tumorigenesis.
    Full-text · Article · May 2016
    • "As with any other immunosuppressant, etanercept increases the risk of infections, lupus, systemic sclerosis and congestive heart failure. Etanercept may also increase risk of lymphoma, central nervous system disease such as multiple sclerosis, vasculitis and autoimmune hepatitis but in clinical trials appears to have a favorable risk-benefit ratio373839. In the patient mentioned in this report, dramatic improvement in mucosal disease as well as in the systemic complications of fatigue an arthralgia was convincing enough to allow her to stay on etanercept, though the long term safety and efficacy are unknown and need to be evaluated before firm recommendations on such use could be recommended. "
    [Show abstract] [Hide abstract] ABSTRACT: Celiac disease is a common autoimmune disease triggered by gluten-containing foods (wheat, barley and rye) in genetically predisposed individuals. We present a patient with celiac disease complicated by severe aphthous stomatitis resulting in impairing swallowing, chewing and speaking. This led to weight loss, psychosocial problems as well as inability to perform her work. A variety of topical and systemic medications used resulted in either no improvement or only partial alleviation of the patient's symptoms. After informed consent, etanercept was initiated and resulted in complete remission of aphthous stomatitis, decrease in arthralgia and fatigue and considerable improvement in her quality of life. The use of newer biological agents for selected and severe manifestations of celiac disease may lead to improved morbidity in these patients, but more studies are needed to determine long-term efficacy as well as safety of these drugs in the mucosal and/or systemic complications of this disease.
    Full-text · Article · Dec 2013
    • "Furthermore, T-cell receptor excision circle analysis should provide useful information on the presence of newly selected T-cells (Somech, 2011). Based on the previous study that showed T-cells overproduce TNF-a (Dufour et al, 2003), etanercept, a TNF-a inhibitor, was administered to patients with FA in a clinical trial to ameliorate bone marrow failure (Mehta et al, 2012), a study which failed to demonstrate patient benefit. Our data, which showed no evidence of TNF-a overproduction by activated T cells, were consistent with that null result. "
    [Show abstract] [Hide abstract] ABSTRACT: Fanconi anaemia (FA), dyskeratosis congenita (DC), Diamond-Blackfan anaemia (DBA), and Shwachman-Diamond syndrome (SDS) are characterized by the progressive development of bone marrow failure. Overproduction of tumour necrosis factor-α (TNF-α) from activated bone marrow T-cells has been proposed as a mechanism of FA-related aplasia. Whether such overproduction occurs in the other syndromes is unknown. We conducted a comparative study on bone marrow mononuclear cells to examine the cellular subset composition and cytokine production. We found lower proportions of haematopoietic stem cells in FA, DC, and SDS, and a lower proportion of monocytes in FA, DC, and DBA compared with controls. The T- and B-lymphocyte proportions were similar to controls, except for low B-cells in DC. We did not observe overproduction of TNF-α or IFN-γ by T-cells in any patients. Induction levels of TNF-α, interleukin (IL)-6, IL-1β, IL-10, granulocyte colony-stimulating factor, and granulocyte-macrophage colony-stimulating factor in monocytes stimulated with high-dose lipopolysaccharide (LPS) were similar at 4 h but lower at 24 h when compared to controls. Unexpectedly, patient samples showed a trend toward higher cytokine level in response to low-dose (0·001 μg/ml) LPS. Increased sensitivity to LPS may have clinical implications and could contribute to the development of pancytopenia by creating a chronic subclinical inflammatory micro-environment in the bone marrow.
    Article · Jul 2013
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