Overview

HSCT has been implemented in (inter)national treatment guidelines for diffuse cutaneous systemic sclerosis (dcSSc) and is offered in clinical care and reimbursed by national health insurance in several European countries. However, data and specific guidelines on the best timing of HSCT in the course of dcSSc are lacking. In particular, it is unclear whether HSCT should be positioned as upfront therapy or as rescue treatment for patients not responding to conventional immunosuppressive therapy.

This multicentre, randomized, open label trial aims to compare two treatment strategies used in usual care: upfront autologous HSCT versus usual care with (intravenous (i.v.) cyclophosphamide (CYC) pulse therapy followed by mycophenolate mofetil (MMF) and HSCT as rescue option).

Eligibility

Inclusion Criteria:

1. Age between 18 and 65 years.
2. Fulfilling the 2013 ACR-EULAR classification criteria for SSc

   Either: 3.1 or 3.2 3.1. Disease duration ≤ 3 years (from onset of first non-Raynaud's symptoms) and diffuse cutaneous disease with

   • progressive skin involvement with a mRSS ≥ 15 (in a diffuse pattern: involvement of skin on the upper limbs, chest and/or abdomen)

and/or

• major organ involvement as defined by either:
  1. clinically significant respiratory involvement = i. DLCO and/or (F)VC ≤ 85% (of predicted) and evidence of interstitial lung disease on HR-CT scan with clinically relevant obstructive disease and emphysema excluded. ii. Patients with a DCLO and/or FVC > 85%, but with a progressive course of lung disease: defined as rela-tive decline of >10% in FVC predicted and/or TLC predicted, or >15% in DLCO predicted and evidence of interstitial lung disease on HR-CT scan with clinically relevant obstructive disease and emphysema ex-cluded, within 12 months. Intercurrent infections excluded.
  2. clinically significant renal involvement = i. new renal insufficiency (serum creatinine > upper limit of normal) AND
     1. persistent urinalysis abnormalities (proteinuria, haematuria, casts), AND/OR
     2. microangiopathic haemolytic anaemia AND/OR
     3. hypertension (two successive BP readings of either systolic ≥ 160 mm Hg or diastolic > 110 mm Hg, at least 12 hours apart), ; non-scleroderma related causes (e.g. medication, infection etc.) must be reasonably excluded.
  3. clinically significant cardiac involvement = any of the following criteria: i. reversible congestive heart failure, ii. atrial or ventricular rhythm disturbances such as atrial fibrillation or flutter, atrial paroxysmal tachycar-dia or ventricular tachycardia, 2nd or 3rd degree AV block, iii. pericardial effusion (not leading to hemodynamic problems), myocarditis; non-scleroderma related causes must have been reasonably excluded

             3.2. Disease duration ≤ 1 year (from onset of first non-Raynaud's symptoms) and
             diffuse cutaneous disease with mRSS ≥ 10 and
               1. High risk ANA for organ based disease: ATA or ARA positivity and/ or
               2. Acute phase response (ESR > 25 mm/h and/or CRP > 10.0 mg/L )
        4. Written Informed consent
        Exclusion Criteria:
          1. Pregnancy or unwillingness to use adequate contraception during study
          2. Concomitant severe disease =
               1. respiratory: resting mean pulmonary artery pressure (mPAP) > 25 mmHg (by right
                  heart catheterisation), DLCO < 40% predicted, respiratory failure as defined by
                  the primary endpoint
               2. renal: creatinine clearance < 40 ml/min (measured or estimated)
               3. cardiac: clinical evidence of refractory congestive heart failure; LVEF < 45% by
                  cardiac echo or cardiac MR; chronic atrial fibrillation necessitating oral
                  anticoagulation; uncontrolled ventricular arrhythmia; pericardial effusion with
                  hemodynamic consequences
               4. liver failure as defined by a sustained 3-fold increase in serum transaminase or
                  bilirubin, or a Child-Pugh score C
               5. psychiatric disorders including active drug or alcohol abuse
               6. concurrent neoplasms or myelodysplasia
               7. bone marrow insufficiency defined as leukocytopenia < 4.0 x 109/L,
                  thrombocytopenia < 50x 10^9/L, anaemia < 8 gr/dL, CD4+ T lymphopenia < 200 x
                  106/L
               8. uncontrolled hypertension
               9. uncontrolled acute or chronic infection, including HIV, HTLV-1,2 positivity
              10. ZUBROD-ECOG-WHO Performance Status Scale > 2
          3. Previous treatments with immunosuppressants > 12 months including MMF, methotrexate,
             azathioprine, rituximab, tocilizumab, glucocorticosteroids.
          4. Previous treatments with TLI, TBI or alkylating agents including CYC.
          5. Significant exposure to bleomycin, tainted rapeseed oil, vinyl chloride,
             trichlorethylene or silica;
          6. eosinophilic myalgia syndrome; eosinophilic fasciitis.
          7. Poor compliance of the patient as assessed by the referring physicians.