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Tsai DE, Bagley S, Reshef R, Shaked A, Bloom RD, Ahya V, Goldberg L, Chung A, Debonera F, Schuster SJ, Huntington SF. The changing face of adult posttransplant lymphoproliferative disorder: Changes in histology between 1999 and 2013. Am J Hematol 2018; 93:874-881. [PMID: 29659047 DOI: 10.1002/ajh.25116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/15/2018] [Accepted: 04/10/2018] [Indexed: 01/20/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) typically presents with either polymorphic or monomorphic histology. While both are the end result of immunosuppressive therapies, their origins are felt to be different with different prognoses and responsiveness to therapy, resulting in 2 different malignancies. We attempted to confirm reports suggesting that the relative frequency of these 2 histologies is shifting over time. We analyzed 3040 adult PTLD cases in the UNOS OPTN database from 1999 to 2013. Changes in PTLD cases over time were analyzed for histology, time from transplant to diagnosis, and patient EBV serostatus. We found that the relative proportion of polymorphic versus monomorphic histology has changed with an increase in the proportion of monomorphic cases with time (1999-2003, 54.9% vs. 45.1%; 2004-2008, 58.3% vs. 41.7%; 2009-2013, 69.7% vs. 30.3%; P = <.001). The change is driven by a gradual increase in the number of monomorphic PTLD with a steady number of polymorphic PTLD. The change is most strongly seen in transplant recipients who were EBV serostatus positive at the time of transplant. Potential causes are changes in immunosuppressive regimens with increased tacrolimus use (P = .009) and increased survival among transplant patients leading to later occurrence of PTLD (P = .001) that have occurred during the time frame analyzed. As organ transplantation has evolved over time, PTLD has coevolved. These changes in histology have important implications regarding the origin and clinical management of PTLD.
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Affiliation(s)
- Donald E. Tsai
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Stephen Bagley
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Ran Reshef
- Division of Hematology and Oncology and Columbia Center for Translational Immunology, Department of Medicine; Columbia University Medical Center; New York New York
| | - Abraham Shaked
- Department of Surgery, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Roy D. Bloom
- Department of Medicine, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Vivek Ahya
- Department of Medicine, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Lee Goldberg
- Department of Medicine, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Albert Chung
- Department of Biology; Georgia Southern University; Statesboro Georgia
| | - Fotini Debonera
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Stephen J. Schuster
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
| | - Scott F. Huntington
- Section of Hematology, Department of Internal Medicine; Yale University School of Medicine; New Haven Connecticut
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Rituximab therapy and reduction of immunosuppression to rescue graft function after renal posttransplantation lymphoproliferative disorder found by macrohematuria in a pancreas and kidney transplant recipient: a case report. Transplant Proc 2014; 43:3299-301. [PMID: 22099782 DOI: 10.1016/j.transproceed.2011.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Posttransplantation lymphoproliferative disorder (PTLD) remains an uncommon complication of solid organ transplantation, with a high mortality rate reported after conventional therapies. Epstein-Barr virus (EBV) may cause PTLD, but most EBV infections after transplantation are clinically silent reactivations, so the detection of PTLD is often delayed. Recently we experienced the rare case of intrarenal graft PTLD found by macrohematuria in a simultaneous pancreas and kidney transplant recipient. The grafts were saved by treatments with rituximab, cyclophosphamide, hydroxydaunorubicin, and prednisone-based chemotherapy (R-CHOP) after reduction of immunosuppression (IR). METHODS This 37-year-old man with insulin-dependent diabetes underwent simultaneous pancreas and kidney transplantation (SPK) with enteric drainage. Six months after transplantation, he displayed macrohematuria, which we investigated by blood tests, computer tomography (CT) scan, positron emission tomography (PET)-CT, and magnetic resonance imaging, recognizing a tumor in the transplanted renal graft. An open biopsy showed a CD20-positive PTLD. We started treatments with IR, rituximab (375 mg/m(2), weekly for 2 cycles) and R-CHOP therapy: rituximab (375 mg/m(2)) plus CHOP every 3 weeks for 6 cycles. RESULTS IR and R-CHOP therapy achieved a complete remission (CR). CR has continued for 14 months at the time of writing. The maximum level of EBV DNA was 259 copies/μg DNA, but 2 months after these therapies, the level had decreased to normal. The patient had no impairment of pancreas and kidney graft functions. CONCLUSIONS The outcome of intragraft PTLD in the kidney of an SPK recipient suggested that the negative impact of IR on graft function may be compensated by the immunosuppressive effects of rituximab, allowing reduced immunosuppression during chemotherapy.
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Barnett ANR, Hadjianastassiou VG, Mamode N. Rituximab in renal transplantation. Transpl Int 2013; 26:563-75. [PMID: 23414100 DOI: 10.1111/tri.12072] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/09/2012] [Accepted: 01/07/2013] [Indexed: 12/17/2022]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that leads to B cell depletion. It is not licensed for use in renal transplantation but is in widespread use in ABO blood group incompatible transplantation. It is an effective treatment for post-transplant lymphoproliferative disorder, and is also used in both HLA antibody incompatible renal transplantation and the treatment of acute rejection. Recent evidence suggests rituximab may prevent the development of chronic antibody mediated rejection. The mechanisms underlying its effects are likely to relate both to long-term effects on plasma cell development and to the impact on B cell modulation of T cell responses. Rituximab (in multiple doses or in combination with other monoclonal antibodies and/or other immunosuppressants) may lead to an increase in infectious complications, although the evidence is not clear. Rarely, the drug can cause a cytokine release syndrome, thrombocytopenia and neutropenia. It has been related to an increased risk of progressive multifocal leucoencephalopathy and, recently, deaths from cardiovascular causes. Trials examining the effects of rituximab in induction therapy for compatible renal transplantation and the treatment of chronic antibody mediated rejection are ongoing. These trials should aid greater understanding of the role of B-cells in the alloresponse to renal transplantation.
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Affiliation(s)
- A Nicholas R Barnett
- Renal and Transplant Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Khedmat H, Taheri S. Very late onset lymphoproliferative disorders occurring over 10 years post-renal transplantation: PTLD.Int. Survey. Hematol Oncol Stem Cell Ther 2011; 4:73-80. [DOI: 10.5144/1658-3876.2011.73] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Nakamichi N, Wada N, Kohara M, Fukuhara S, Sugiyama H, Ogawa H, Hino M, Kanamaru A, Kanakura Y, Morii E, Aozasa K. Polymorphous lymphoproliferative disorder: a clinicopathological analysis. Virchows Arch 2010; 456:269-76. [DOI: 10.1007/s00428-010-0880-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/02/2009] [Accepted: 01/03/2010] [Indexed: 12/19/2022]
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O'Mahony D, Morris JC, Stetler-Stevenson M, Matthews H, Brown MR, Fleisher T, Pittaluga S, Raffeld M, Albert PS, Reitsma D, Kaucic K, Hammershaimb L, Waldmann TA, Janik JE. EBV-related lymphoproliferative disease complicating therapy with the anti-CD2 monoclonal antibody, siplizumab, in patients with T-cell malignancies. Clin Cancer Res 2009; 15:2514-22. [PMID: 19293260 DOI: 10.1158/1078-0432.ccr-08-1254] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We report an increased incidence of EBV-induced B-cell lymphoproliferative disease (LPD) in patients treated with siplizumab, an anti-CD2 antibody. The development of EBV-LPD has been associated with the use of immunosuppressive agents used in solid organ, bone marrow, and stem cell transplantation and in certain congenital immunodeficiencies. EXPERIMENTAL DESIGN We conducted a single-institution phase I dose-escalation trial of siplizumab, a humanized monoclonal antibody to CD2, in 29 patients with T-cell malignancies. RESULTS Although initial responses were encouraging, 4 (13.7%) patients developed EBV-LPD and the trial was stopped. Reductions in CD4(+) and CD8(+) cell count numbers in response to therapy were seen in all patients, but in those patients developing EBV-LPD a significantly greater reduction in natural killer (NK) cell number and CD2 expression on T cells was seen. These findings highlight the importance of NK-cell depletion and CD2 expression in addition to T-cell depletion in the etiology of EBV-LPD. CONCLUSIONS The emergence of EBV-LPD may be associated with the ability of siplizumab to deplete both T and NK cells without affecting B cells. Agents that deplete T- and NK-cell populations without affecting B cell number should be screened for this potentially serious adverse event.
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Affiliation(s)
- Deirdre O'Mahony
- Metabolism Branch, Center for Cancer Research, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland and MedImmune, Inc, Gaithersburg, Maryland, USA
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Primary cutaneous diffuse large B-cell lymphoma (leg type) after renal allograft: case report and review of the literature. Int J Hematol 2008; 89:113-117. [PMID: 19109733 DOI: 10.1007/s12185-008-0201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 09/17/2008] [Accepted: 09/19/2008] [Indexed: 10/21/2022]
Abstract
We report a case of a 58-year-old man who presented with a rapidly growing proliferative lesion on the left lower limb, clinically resembling a soft tissue sarcoma 3 years after renal allograft. There was no evidence of systemic involvement on bone marrow needle aspiration and computed tomography (CT) scans of the chest and abdomen. The lesion turned out to be primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL LT), as defined in the recent World Health Organization-European Organization for Research and Treatment of Cancer (WHO-EORTC) classification of cutaneous lymphomas by skin biopsy. Immunosuppression reduction, chemotherapy with CHOP regimen and local radiotherapy induced complete remission of the tumor.
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Ocheni S, Kroeger N, Zabelina T, Sobottka I, Ayuk F, Wolschke C, Muth A, Lellek H, Petersen L, Erttmann R, Kabisch H, Zander AR, Bacher U. EBV reactivation and post transplant lymphoproliferative disorders following allogeneic SCT. Bone Marrow Transplant 2008; 42:181-6. [PMID: 18516079 DOI: 10.1038/bmt.2008.150] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Fatal problems encountered in allogeneic stem cell transplantation include EBV reactivation and post transplant lymphoproliferative disorders (PTLDs) with high mortality rates. We performed a retrospective analysis in all consecutive adult and pediatric EBV reactivations and PTLD during a period of 8.5 years. There were 26 patients with EBV reactivation/PTLD out of a total of 854 transplantations giving an overall incidence of 3.0%. Specifically, the incidence of EBV-PTLD was 1.3%, whereas that of EBV reactivation was 1.8%. Median age was 46.0 and 11.0 years in the adult and pediatric patients, respectively. There were high rates (54%) of concomitant bacterial, viral, fungal and parasitic infections at the time of EBV manifestation. Variable treatment regimens were applied including in most cases an anti-CD20 regimen often in combination with virustatic compounds, polychemotherapy or donor lymphocytes. The mortality rates were 9 of 11 (82%) in patients with EBV-PTLD and 10 of 15 (67%) in patients with reactivation. Only 7 of 26 patients (27%) are alive after a median follow-up of 758 days (range 24-2751). The high mortality rates of EBV reactivation and of EBV-PTLD irrespective of multimodal treatment approaches emphasize standardization and optimization of post transplant surveillance and treatment strategies to improve control of these often fatal complications.
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Affiliation(s)
- S Ocheni
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Kaposztas Z, Etheridge W, Kahan B. Case Report: Successful Treatment of Posttransplant Lymphoproliferative Disorder and Quiescence of Dermatomyositis With Rituximab and Sirolimus. Transplant Proc 2008; 40:1744-6. [DOI: 10.1016/j.transproceed.2007.11.072] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 11/07/2007] [Indexed: 10/21/2022]
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Tsao L, Hsi ED. The clinicopathologic spectrum of posttransplantation lymphoproliferative disorders. Arch Pathol Lab Med 2007; 131:1209-18. [PMID: 17683183 DOI: 10.5858/2007-131-1209-tcsopl] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2007] [Indexed: 11/06/2022]
Abstract
CONTEXT Posttransplantation lymphoproliferative disorders (PTLDs) are a heterogeneous group of lymphoid proliferations occurring in the setting of solid organ or bone marrow transplantation. They show a clinical, morphologic, and molecular genetic spectrum ranging from reactive polyclonal lesions to frank lymphomas. The close association with Epstein-Barr virus has been established and the pathogenetic role of this virus is becoming better understood. Although they are relatively uncommon, PTLDs are a significant cause of morbidity and mortality in transplant patients. OBJECTIVE To review the incidence, risk factors, clinical features, pathogenesis, and classification of PTLDs. DATA SOURCES We reviewed relevant articles indexed in PubMed (National Library of Medicine), with emphasis on more recent studies. The classification of PTLDs is based on the most current World Health Organization classification text. CONCLUSIONS Posttransplantation lymphoproliferative disorders are a heterogeneous group of disorders showing a wide clinical and morphologic spectrum. Although relatively uncommon, PTLDs represent a serious complication after transplantation. Many risk factors for PTLD are well established, including transplanted organ, age at transplant, and Epstein-Barr virus seronegativity at transplant. However, other factors have been implicated and still require additional examination. Recent studies are shedding some light on the pathogenesis of PTLDs and defining relevant pathways related to Epstein-Barr virus. As the pathogenesis of PTLDs is further elucidated, the classification of PTLDs will most likely evolve.
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Affiliation(s)
- Lawrence Tsao
- Department of Pathology, University of New Mexico, Albuquerque, USA
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Haque T, Wilkie GM, Jones MM, Higgins CD, Urquhart G, Wingate P, Burns D, McAulay K, Turner M, Bellamy C, Amlot PL, Kelly D, MacGilchrist A, Gandhi MK, Swerdlow AJ, Crawford DH. Allogeneic cytotoxic T-cell therapy for EBV-positive posttransplantation lymphoproliferative disease: results of a phase 2 multicenter clinical trial. Blood 2007; 110:1123-31. [PMID: 17468341 DOI: 10.1182/blood-2006-12-063008] [Citation(s) in RCA: 456] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We present the results of a multicenter clinical trial using Epstein-Barr virus (EBV)-specific cytotoxic T lymphocytes (CTLs) generated from EBV-seropositive blood donors to treat patients with EBV-positive posttransplantation lymphoproliferative disease (PTLD) on the basis of the best HLA match and specific in vitro cytotoxicity. Thirty-three PTLD patients who had failed on conventional therapy were enrolled. No adverse effects of CTL infusions were observed and the response rate (complete or partial) in 33 patients was 64% at 5 weeks and 52% at 6 months. Fourteen patients achieved a complete remission, 3 showed a partial response, and 16 had no response at 6 months (5 died before completing treatment). At 5 weeks, there was a significant trend toward better responses with higher numbers of CD4(+) cells in infused CTL lines (P = .001) that were maintained at 6 months (P = .001). Patients receiving CTLs with closer HLA matching responded better at 6 months (P = .048). Female patients responded better than male patients, but the differences were not statistically significant. Our results show that allogeneic CTLs are a safe and rapid therapy for PTLD, bypassing the need to grow CTLs for individual patients. The response rate in this poor prognosis patient group is encouraging.
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Affiliation(s)
- Tanzina Haque
- Clinical and Molecular Virology Laboratory, University of Edinburgh, Edinburgh, United Kingdom.
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