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Goiffon RJ, Depetris J, Dageforde LA, Kambadakone A. Radiologic evaluation of the kidney transplant donor and recipient. Abdom Radiol (NY) 2024:10.1007/s00261-024-04477-4. [PMID: 38985292 DOI: 10.1007/s00261-024-04477-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/11/2024]
Abstract
The kidney is the most common solid organ transplant globally and rates continue to climb, driven by the increasing prevalence of end stage renal disease (ESRD). Compounded by advancements in surgical techniques and immunosuppression leading to longer graft survival, radiologists evermore commonly evaluate kidney transplant patients and candidates, underscoring their role along the transplant process. Multiphase computed tomography (CT) with multiplanar and 3D reformatting is the primary method for evaluating renal donor candidates, detailing renal size, vascular/collecting system anatomy, and identifying significant pathologies such as renal vascular diseases and nephrolithiasis. Ultrasound is the preferred initial postoperative imaging modality for graft evaluation due to its low cost, accessibility, noninvasiveness, and lack of radiation. CT and magnetic resonance imaging (MRI) may be useful adjunctive imaging techniques in diagnosing transplant pathology when ultrasound alone is not diagnostic. Kidney transplant complications are categorized by an approximate timeline framework, aiding in differential diagnosis based on onset, duration, and severity and include perinephric fluid collections, graft compression, iatrogenic injuries, vascular compromise, graft rejection, and neoplastic processes. This review discusses imaging strategies and important findings along the transplant timeline, from donor assessment to long-term recipient complications.
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Affiliation(s)
- Reece J Goiffon
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA.
| | - Jena Depetris
- Department of Radiological Sciences, University of California Los Angeles Health, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Suite 1621, Los Angeles, CA, 90095, USA
| | - Leigh Anne Dageforde
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 511, Boston, MA, 02114-2696, USA
| | - Avinash Kambadakone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, White 270, Boston, MA, 02114-2696, USA
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2
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Pociupany M, Snoeck R, Dierickx D, Andrei G. Treatment of Epstein-Barr Virus infection in immunocompromised patients. Biochem Pharmacol 2024; 225:116270. [PMID: 38734316 DOI: 10.1016/j.bcp.2024.116270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
Epstein-Barr Virus (EBV), is a ubiquitous γ-Herpesvirus that infects over 95% of the human population and can establish a life-long infection without causing any clinical symptoms in healthy individuals by residing in memory B-cells. Primary infection occurs in childhood and is mostly asymptomatic, however in some young adults it can result in infectious mononucleosis (IM). In immunocompromised individuals however, EBV infection has been associated with many different malignancies. Since EBV can infect both epithelial and B-cells and very rarely NK cells and T-cells, it is associated with both epithelial cancers like nasopharyngeal carcinoma (NPC) and gastric carcinoma (GC), with lymphomas including Burkitt Lymphoma (BL) or Post-transplant Lymphoproliferative Disorder (PTLD) and rarely with NK/T-cell lymphomas. Currently there are no approved antivirals active in PTLD nor in any other malignancy. Moreover, lytic phase disease almost never requires antiviral treatment. Although many novel therapies against EBV have been described, the management and/or prevention of EBV primary infections or reactivations remains difficult. In this review, we discuss EBV infection, therapies targeting EBV in both lytic and latent state with novel therapeutics developed that show anti-EBV activity as well as EBV-associated malignancies both, epithelial and lymphoproliferative malignancies and emerging therapies targeting the EBV-infected cells.
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Affiliation(s)
- Martyna Pociupany
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Laboratory of Experimental Hematology, Department of Oncology, KU Leuven, Leuven, Belgium; Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
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3
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Jin L, Lu D, Yan F, Han J, Wei P, Zhou Y, Wang Y, Shan Y, Zhao G. A disease warranting attention from neurosurgeons: primary central nervous system post-transplant lymphoproliferative disorder. Front Neurol 2024; 15:1392691. [PMID: 38813246 PMCID: PMC11133574 DOI: 10.3389/fneur.2024.1392691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024] Open
Abstract
Background Primary central nervous system post-transplant lymphoproliferative disorder (PCNS-PTLD) is a rare condition, posing diagnostic and treatment challenges, with histological biopsy essential for diagnosis. Standardized treatment protocols are lacking. This disease requires urgent attention due to the increasing number of organ transplant surgeries and the use of immunosuppressive agents. Methods From 2020 to 2023, our center diagnosed five patients with PCNS-PTLD. We reviewed their clinical records and conducted a comprehensive analysis of 22 literatures on PCNS-PTLD cases following renal transplantation or allogeneic hematopoietic stem cell transplantation (HSCT). Results Four patients had previously received a kidney transplant, one had undergone allogeneic HSCT. The median time from the last transplant surgery to the diagnosis of PCNS-PTLD differs between kidney transplant (21.5 years) and allogeneic HSCT (9 months). Common symptoms included motor weakness (n = 4), headache (n = 2), confusion (n = 2), and nausea (n = 2), with ring-enhancing (n = 5), typically solitary (n = 3) and supratentorial (n = 3) lesions on imaging. Diagnosis involved robot-assisted stereotactic brain biopsy (n = 4) or craniotomy (n = 1), all showing Epstein-Barr virus and CD20 positivity. Most cases (n = 4) were monomorphic diffuse large B-cell lymphoma. Treatment included rituximab (n = 3), surgical resection (n = 2), zanubrutinib (n = 1), whole-brain radiation (n = 1), and methotrexate (n = 1). At the last follow-up, the median duration of follow-up for all patients was 19 months. During this time, 3 patients had died and 2 patients were still alive. Conclusion In patients with a history of kidney transplantation or allogeneic HSCT who are on long-term immunosuppressive therapy, any neurological symptoms, particularly the presence of supratentorial ring-enhancing masses in the brain on imaging, whether solitary or multiple, should raise high suspicion for this disease, warranting a timely brain biopsy. Additionally, we found that besides reducing immunosuppressants, zanubrutinib may be a potential, safe, and effective treatment for this condition. Moreover, post-surgical administration of rituximab in conjunction with whole-brain radiotherapy also appears to be a potentially safe and effective approach.
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Affiliation(s)
- Lei Jin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Di Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Feng Yan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Jinkun Han
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Penghu Wei
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
| | - Yiqiang Zhou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yaming Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Yongzhi Shan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
| | - Guoguang Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Clinical Research Center for Epilepsy, Capital Medical University, Beijing, China
- Beijing Municipal Geriatric Medical Research Center, Beijing, China
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Ergisi M, Ooi B, Salim O, Papalois V. Post-transplant lymphoproliferative disorders following kidney transplantation: A literature review with updates on risk factors, prognostic indices, screening strategies, treatment and analysis of donor type. Transplant Rev (Orlando) 2024; 38:100837. [PMID: 38430887 DOI: 10.1016/j.trre.2024.100837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) is a devastating complication of kidney transplantation with an insidious presentation and potential to disseminate aggressively. This review delineates the risk factors, prognostic indexes, screening, current management algorithm and promising treatment strategies for PTLD. Kidneys from both extended criteria donors (ECD) and living donors (LD) are being increasingly used to expand the donor pool. This review also delineates whether PTLD outcomes vary based on these donor sources. While Epstein-Barr virus (EBV) is a well-known risk factor for PTLD development, the use of T-cell depleting induction agents has been increasingly implicated in aggressive, monomorphic forms of PTLD. Research regarding maintenance therapy is sparse. The international prognostic index seems to be the most validate prognostic tool. Screening for PTLD is controversial, as annual PET-CT is most sensitive but costly, while targeted monitoring of EBV-seronegative patients was more economically feasible, is recommended by the American Society of Transplantation, but is limited to a subset of the population. Other screening strategies such as using Immunoglobulin/T-cell receptor require further validation. A risk-stratified approach is taken in the treatment of PTLD. The first step is the reduction of immunosuppressants, after which rituximab and chemotherapy may be introduced if unsuccessful. Some novel treatments have also shown potential benefit in studies: brentuximab vedotin, chimeric antigen receptor T-cell therapy and EBV-specific cytotoxic T lymphocytes. Analysis of LD v DD recipients show no significant difference in incidence and mortality of PTLD but did reveal a shortened time to development of PTLD from transplant. Analysis of SCD vs ECD recipients show a higher incidence of PTLD in the ECD group, which might be attributed to longer time on dialysis for these patients, age, and the pro-inflammatory nature of these organs. However, incidence of PTLD overall is still extremely low. Efforts should be focused on optimising recipients instead. Minimising the use of T-cell depleting therapy while encouraging research on the effect of new immunosuppressants on PTLD, screening for EBV status are essential, while enabling shared decision-making during counselling when choosing kidney donor types and individualised risk tailoring are strongly advocated.
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Affiliation(s)
- Mehmet Ergisi
- Norfolk and Norwich University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Department of Medicine, Norwich, United Kingdom.
| | - Bryan Ooi
- Department of Medicine, Imperial College London, London, United Kingdom.
| | - Omar Salim
- Isle of Wight NHS Trust, Parkhurst Road, Newport, United Kingdom
| | - Vassilios Papalois
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, Department of Transplant and General Surgery, London, United Kingdom.
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5
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Jung H, Dhatt R, Rassekh SR, Heran MKS. Intra-arterial methylprednisolone for pediatric gastrointestinal post-transplant lymphoproliferative disorder. Pediatr Hematol Oncol 2024; 41:240-245. [PMID: 37861406 DOI: 10.1080/08880018.2023.2267612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Hoyoung Jung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ravjot Dhatt
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - S Rod Rassekh
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj K S Heran
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Taborelli M, Serraino D, Cimaglia C, Furian L, Biancone L, Busnach G, Bossini N, Citterio F, Veroux M, Iaria M, Argiolas D, Todeschini P, Manzia TM, Pisani F, Cantaluppi V, Simone S, Mangino M, Campise M, Ambrosini A, Caputo F, Piselli P. Cancer mortality after kidney transplantation: A multicenter cohort study in Italy. Int J Cancer 2024; 154:842-851. [PMID: 37924271 DOI: 10.1002/ijc.34787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Kidney transplant (KT) recipients are known to be at risk of developing several cancer types; however, cancer mortality in this population is underinvestigated. Our study aimed to assess the risk of cancer death among Italian KT recipients compared to the corresponding general population. A cohort study was conducted among 7373 individuals who underwent KT between 2003 and 2020 in 17 Italian centers. Date and cause of death were retrieved until 31 December 2020. Indirect standardization was used to estimate standardized mortality ratios (SMRs) and corresponding 95% confidence intervals (CIs). Cancer was the most common cause of death among the 7373 KT recipients, constituting 32.4% of all deaths. A 1.8-fold excess mortality (95% CI: 1.59-2.09) was observed for all cancers combined. Lymphomas (SMR = 6.17, 95% CI: 3.81-9.25), kidney cancer (SMR = 5.44, 95% CI: 2.97-8.88) and skin melanoma (SMR = 3.19, 95% CI: 1.03-6.98) showed the highest excess death risks. In addition, SMRs were increased about 1.6 to 3.0 times for cancers of lung, breast, bladder and other hematopoietic and lymphoid tissues. As compared to the general population, relative cancer mortality risk remained significantly elevated in all age groups though it decreased with increasing age. A linear temporal increase in SMR over time was documented for all cancers combined (P < .01). Our study documented significantly higher risks of cancer death in KT recipients than in the corresponding general population. Such results support further investigation into the prevention and early detection of cancer in KT recipients.
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Affiliation(s)
- Martina Taborelli
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Diego Serraino
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Claudia Cimaglia
- Department of Epidemiology and Pre-Clinical Research, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy
| | - Lucrezia Furian
- Unit of Kidney and Pancreas Transplantation, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center "A. Vercellone," Città della Salute e della Scienza University Hospital, Turin, Italy
| | | | - Nicola Bossini
- Unit of Nephrology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Franco Citterio
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimiliano Veroux
- Organ Transplantation Unit, Department of Medical and Surgical Sciences and Advanced Technologies, University Hospital of Catania, Catania, Italy
| | - Maurizio Iaria
- Department of General and Specialized Surgery, Division of General Surgery, Transplant Surgery Unit, Parma University Hospital, Parma, Italy
| | - Davide Argiolas
- Renal Transplant Unit, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Paola Todeschini
- Department of Experimental Diagnostic and Specialty Medicine (DIMEC), Nephrology, Dialysis and Renal Transplant Unit, IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Francesco Pisani
- General and Transplant Surgery Department, University of L'Aquila, L'Aquila, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), "Maggiore della Carità" University Hospital, Novara, Italy
| | - Simona Simone
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Margherita Mangino
- Nephrology, Dialysis, Transplantation Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Mariarosaria Campise
- Unit of Nephrology, Dialysis, and Renal Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Andrea Ambrosini
- Renal Transplant Unit, Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Flavia Caputo
- Nephrology Dialysis and Renal Transplant Department, Civico and Di Cristina Hospital, Palermo, Italy
| | - Pierluca Piselli
- Department of Epidemiology and Pre-Clinical Research, National Institute for Infectious Diseases "L. Spallanzani" IRCCS, Rome, Italy
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7
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McGlynn MC, Brady K, Healey JM, Dharnidharka VR, Ybarra AM, Stoll J, Sweet S, Hayashi RJ. Late effects in survivors of post-transplant lymphoproliferative disease. Pediatr Blood Cancer 2024; 71:e30777. [PMID: 37988230 DOI: 10.1002/pbc.30777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/12/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Treatment of post-transplant lymphoproliferative disease (PTLD) varies, with only some patients receiving chemotherapy. Concern for chemotherapy toxicities may influence treatment decisions as little is known regarding the late effects (LE) in PTLD survivors. This report characterizes LE in PTLD survivors at our institution. PROCEDURE Pediatric patients (0-18 years old) diagnosed with PTLD from 1990 to 2020 were examined. All patients included survived 6 months after completing chemotherapy or were 6 months from diagnosis if received no chemotherapy. Treatment with anti-CD20 antibody (rituximab) alone was not considered chemotherapy. Toxicities were classified per Common Terminology Criteria for Adverse Events Version 5.0. Chi-square tests assessed differences between categorical groups, or Fischer's exact test or the Fischer-Freeman-Halton exact test for limited sample sizes. RESULTS Of the 44 patients included, 24 (55%) were treated with chemotherapy. Twenty-four (55%) were alive at last follow-up. Chemotherapy was not associated with differences in survival (odds ratio [OR] 1.40, confidence interval [CI]: 0.42-4.63; p = .31). All patients experienced LE. Grade 3 toxicity or higher was experienced by 82% of patients with no difference in incidence (OR 1.20, CI: 0.27-5.80; p > .99) or median toxicity grade (3.00 vs. 4.00, p = .21) between treatment groups. Patients who received chemotherapy were more likely to experience blood and lymphatic toxicity (58% vs. 25%, p = .03) and cardiac toxicity (46% vs. 15%, p = .03), but less likely to have infections (54% vs. 85%, p = .03). CONCLUSIONS Survivors of PTLD experience LE including late mortality regardless of chemotherapy exposure. Further investigation to better understand LE could optimize upfront therapy for children with PTLD and improve outcomes.
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Affiliation(s)
- Mary Claire McGlynn
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Kassidy Brady
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Jessica M Healey
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - A Marion Ybarra
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Janis Stoll
- Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stuart Sweet
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Robert J Hayashi
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Order KE, Rodig NM. Pediatric Kidney Transplantation: Cancer and Cancer Risk. Semin Nephrol 2024; 44:151501. [PMID: 38580568 DOI: 10.1016/j.semnephrol.2024.151501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Children with end-stage kidney disease (ESKD) face a lifetime of complex medical care, alternating between maintenance chronic dialysis and kidney transplantation. Kidney transplantation has emerged as the optimal treatment of ESKD for children and provides important quality of life and survival advantages. Although transplantation is the preferred therapy, lifetime exposure to immunosuppression among children with ESKD is associated with increased morbidity, including an increased risk of cancer. Following pediatric kidney transplantation, cancer events occurring during childhood or young adulthood can be divided into two broad categories: post-transplant lymphoproliferative disorders and non-lymphoproliferative solid tumors. This review provides an overview of cancer incidence, types, outcomes, and preventive strategies in this population.
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Affiliation(s)
- Kaitlyn E Order
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Nancy M Rodig
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
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9
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Massicotte-Azarniouch D, Noel JA, Knoll GA. Epidemiology of Cancer in Kidney Transplant Recipients. Semin Nephrol 2024; 44:151494. [PMID: 38538455 DOI: 10.1016/j.semnephrol.2024.151494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Kidney transplantation is the ideal treatment modality for patients with end-stage kidney disease, with excellent outcomes post-transplant compared with dialysis. However, kidney transplant recipients are at increased risk of infections and cancer because of the need for immunosuppression. Kidney transplant recipients have approximately two to three times greater risk of developing cancer than the general population, and cancer is a major contributor to morbidity and mortality. Most of the increased risk is driven by viral-mediated cancers such as post-transplant lymphoproliferative disorder, anogenital cancers, and Kaposi sarcoma. Nonmelanoma skin cancer is the most frequent type of cancer in kidney transplant recipients, likely due to an interaction between ultraviolet radiation exposure and decreased immune surveillance. Occurrence of the more common types of solid organ cancers seen in the general population, such as breast, prostate, lung, and colorectal cancers, is not, or is only mildly, increased post-transplant. Clinical care and future research should focus on prevention and on improving outcomes for important immunosuppression-related malignancies, and treatment options for other cancers occurring in the transplant setting.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - J Ariana Noel
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Greg A Knoll
- Division of Nephrology, Department of Medicine and Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
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10
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Dharnidharka VR, Ruzinova MB, Marks LJ. Post-Transplant Lymphoproliferative Disorders. Semin Nephrol 2024; 44:151503. [PMID: 38519279 PMCID: PMC11213680 DOI: 10.1016/j.semnephrol.2024.151503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Post-transplant lymphoproliferative disorders (PTLDs) are a heterogenous set of unregulated lymphoid cell proliferations after organ or tissue transplant. A majority of cases are associated with the Epstein-Barr virus and higher intensity of pharmacologic immunosuppression. The clinical presentations are numerous. The diagnosis is ideally by histology, except in cases where the tumor is inaccessible to biopsy. While some pre-emptive therapies and treatment strategies are available have reasonable success are available, they do not eliminate the high morbidity and significant mortality after PTLD.
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Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Apheresis, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
| | - Marianna B Ruzinova
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Lianna J Marks
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Stanford University School of Medicine, Palo Alto, CA
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11
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Atamna A, Yahav D, Hirzel C. Prevention of Oncogenic Gammaherpesvirinae (EBV and HHV8) Associated Disease in Solid Organ Transplant Recipients. Transpl Int 2023; 36:11856. [PMID: 38046068 PMCID: PMC10689273 DOI: 10.3389/ti.2023.11856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
Long-term risk for malignancy is higher among solid organ transplant (SOT) recipients compared to the general population. Four non-hepatitis viruses have been recognized as oncogenic in SOT recipients-EBV, cause of EBV-associated lymphoproliferative diseases; human herpes virus 8 (HHV8), cause of Kaposi sarcoma, primary effusion lymphoma and multicentric Castleman disease; human papilloma virus, cause of squamous cell skin cancers, and Merkel cell polyomavirus, cause of Merkel cell carcinoma. Two of these viruses (EBV and HHV8) belong to the human herpes virus family. In this review, we will discuss key aspects regarding the clinical presentation, diagnosis, treatment, and prevention of diseases in SOT recipients associated with the two herpesviruses.
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Affiliation(s)
- Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dafna Yahav
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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12
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Papalexandri A, Gavriilaki E, Vardi A, Kotsiou N, Demosthenous C, Constantinou N, Touloumenidou T, Zerva P, Kika F, Iskas M, Batsis I, Mallouri D, Yannaki E, Anagnostopoulos A, Sakellari I. Pre-Emptive Use of Rituximab in Epstein-Barr Virus Reactivation: Incidence, Predictive Factors, Monitoring, and Outcomes. Int J Mol Sci 2023; 24:16029. [PMID: 38003218 PMCID: PMC10671524 DOI: 10.3390/ijms242216029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Post-transplant lymphoproliferative disease (PTLD) is a fatal complication of hematopoietic cell transplantation (HCT) associated with the Epstein-Barr virus (EBV). Multiple factors such as transplant type, graft-versus-host disease (GVHD), human leukocyte antigens (HLA) mismatch, patient age, and T-lymphocyte-depleting treatments increase the risk of PTLD. EBV reactivation in hematopoietic cell transplant recipients is monitored through periodic quantitative polymerase chain reaction (Q-PCR) tests. However, substantial uncertainty persists regarding the clinically significant EBV levels for these patients. Guidelines recommend initiating EBV monitoring no later than four weeks post-HCT and conducting it weekly. Pre-emptive therapies, such as the reduction of immunosuppressive therapy and the administration of rituximab to treat EBV viral loads are also suggested. In this study, we investigated the occurrence of EBV-PTLD in 546 HCT recipients, focusing on the clinical manifestations and risk factors associated with the disease. We managed to identify 67,150 viral genomic copies/mL as the cutoff point for predicting PTLD, with 80% sensitivity and specificity. Among our cohort, only 1% of the patients presented PTLD. Anti-thymocyte globulin (ATG) and GVHD were independently associated with lower survival rates and higher treatment-related mortality. According to our findings, prophylactic measures including regular monitoring, pre-emptive therapy, and supportive treatment against infections can be effective in preventing EBV-related complications. This study also recommends conducting EBV monitoring at regular intervals, initiating pre-emptive therapy when viral load increases, and identifying factors that increase the risk of PTLD. Our study stresses the importance of frequent and careful follow-ups of post-transplant complications and early intervention in order to improve survival rates and reduce mortality.
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Affiliation(s)
- Apostolia Papalexandri
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Anna Vardi
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Nikolaos Kotsiou
- 2nd Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Christos Demosthenous
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Natassa Constantinou
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Tasoula Touloumenidou
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Panagiota Zerva
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Fotini Kika
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Michalis Iskas
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Ioannis Batsis
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Despina Mallouri
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Evangelia Yannaki
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Achilles Anagnostopoulos
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
| | - Ioanna Sakellari
- Hematology Department, BMT Unit, General Hospital “George Papanicolaou”, 57010 Thessaloniki, Greece; (A.P.); (A.V.); (C.D.); (T.T.); (P.Z.); (F.K.); (M.I.); (I.B.); (D.M.); (E.Y.); (A.A.); (I.S.)
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Zaffiri L, Chambers ET. Screening and Management of PTLD. Transplantation 2023; 107:2316-2328. [PMID: 36949032 DOI: 10.1097/tp.0000000000004577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) represents a heterogeneous group of lymphoproliferative diseases occurring in the setting of immunosuppression following hematopoietic stem cells transplant and solid organ transplantation. Despite its overall low incidence, PTLD is a serious complication following transplantation, with a mortality rate as high as 50% in transplant recipients. Therefore, it is important to establish for each transplant recipient a personalized risk evaluation for the development of PTLD based on the determination of Epstein-Barr virus serostatus and viral load following the initiation of immunosuppression. Due to the dynamic progression of PTLD, reflected in the diverse pathological features, different therapeutic approaches have been used to treat this disorder. Moreover, new therapeutic strategies based on the administration of virus-specific cytotoxic T cells have been developed. In this review, we summarize the available data on screening and treatment to suggest a strategy to identify transplant recipients at a higher risk for PTLD development and to review the current therapeutic options for PTLD.
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Affiliation(s)
- Lorenzo Zaffiri
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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Kolijn PM, Langerak AW. Immune dysregulation as a leading principle for lymphoma development in diverse immunological backgrounds. Immunol Lett 2023; 263:46-59. [PMID: 37774986 DOI: 10.1016/j.imlet.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 10/01/2023]
Abstract
Lymphoma is a heterogeneous group of malignancies arising from lymphocytes, which poses a significant challenge in terms of diagnosis and treatment due to its diverse subtypes and underlying mechanisms. This review aims to explore the shared and distinct features of various forms of lymphoma predisposing conditions, with a focus on genetic, immunological and molecular aspects. While diseases such as autoimmune disorders, inborn errors of immunity and iatrogenic immunodeficiencies are biologically and immunologically distinct, each of these diseases results in profound immune dysregulation and a predisposition to lymphoma development. Interestingly, the increased risk is often skewed towards a particular subtype of lymphoma. Patients with inborn errors of immunity in particular present with extreme forms of lymphoma predisposition, providing a unique opportunity to study the underlying mechanisms. External factors such as chronic infections and environmental exposures further modulate the risk of lymphoma development. Common features of conditions predisposing to lymphoma include: persistent inflammation, recurrent DNA damage or malfunctioning DNA repair, impaired tumor surveillance and viral clearance, and dysregulation of fundamental cellular processes such as activation, proliferation and apoptosis. Our growing understanding of the underlying mechanisms of lymphomagenesis provides opportunities for early detection, prevention and tailored treatment of lymphoma development.
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Affiliation(s)
- P Martijn Kolijn
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Anton W Langerak
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center, Rotterdam, the Netherlands.
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Amengual JE, Pro B. How I treat posttransplant lymphoproliferative disorder. Blood 2023; 142:1426-1437. [PMID: 37540819 PMCID: PMC10731918 DOI: 10.1182/blood.2023020075] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/03/2023] [Accepted: 07/21/2023] [Indexed: 08/06/2023] Open
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is an important and potentially life-threatening complication of solid organ transplant and hematopoietic stem cell transplant (HSCT). Given the heterogeneity of PTLD and the risk of infectious complications in patients with immunosuppression, the treatment of this disease remains challenging. Monomorphic PTLD and lymphoma of B-cell origin account for the majority of cases. Treatment strategies for PTLD consist of response-adapted, risk-stratified methods using immunosuppression reduction, immunotherapy, and/or chemotherapy. With this approach, ∼25% of the patients do not need chemotherapy. Outcomes for patients with high risk or those who do not respond to frontline therapies remain dismal, and novel treatments are needed in this setting. PTLD is associated with Epstein-Barr virus (EBV) infection in 60% to 80% of cases, making EBV-directed therapy an attractive treatment modality. Recently, the introduction of adoptive immunotherapies has become a promising option for refractory cases; hopefully, these treatment strategies can be used as earlier lines of therapy in the future.
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Affiliation(s)
- Jennifer E. Amengual
- Division of Hematology and Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | - Barbara Pro
- Division of Hematology and Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
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Ruiz E, Moreno P, Gonzalez FJ, Fernandez AM, Cantador B, Parraga JL, Salvatierra A, Alvarez A. Influence of De Novo Malignancies on Long-Term Survival after Lung Transplantation. Cancers (Basel) 2023; 15:4011. [PMID: 37568825 PMCID: PMC10417357 DOI: 10.3390/cancers15154011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 08/13/2023] Open
Abstract
(1) Background: Malignancies are an important cause of mortality after solid organ transplantation. The purpose of this study was to analyze the incidence of malignancies in patients receiving lung transplants (LT) and their influence on patients' survival. (2) Methods: Review of consecutive LT from 1994 to 2021. Patients with and without malignancies were compared by univariable and multivariable analyses. Survival was compared with Kaplan-Meier and Cox regression analysis. (3) Results: There were 731 LT malignancies developed in 91 patients (12.4%) with related mortality of 47% (n = 43). Native lung cancer, digestive and hematological malignancies were associated with higher lethality. Malignancies were more frequent in males (81%; p = 0.005), transplanted for emphysema (55%; p = 0.003), with cyclosporine-based immunosuppression (58%; p < 0.001), and receiving single LT (65%; p = 0.011). Survival was worse in patients with malignancies (overall) and with native lung cancer. Risk factors for mortality were cyclosporine-based immunosuppression (OR 1.8; 95%CI: 1.3-2.4; p < 0.001) and de novo lung cancer (OR 2.6; 95%CI: 1.5-4.4; p < 0.001). (4) Conclusions: Malignancies are an important source of morbidity and mortality following lung transplantation that should not be neglected. Patients undergoing single LT for emphysema are especially at higher risk of mortality due to lung cancer in the native lung.
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Affiliation(s)
| | | | | | | | | | | | | | - Antonio Alvarez
- Department of Thoracic Surgery and Lung Transplantation, University Hospital Reina Sofia, 14004 Cordoba, Spain; (E.R.); (P.M.); (F.J.G.); (A.M.F.); (B.C.); (J.L.P.); (A.S.)
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Lee M, Abousaud A, Harkins RA, Marin E, Balasubramani D, Churnetski MC, Peker D, Singh A, Koff JL. Important Considerations in the Diagnosis and Management of Post-transplant Lymphoproliferative Disorder. Curr Oncol Rep 2023; 25:883-895. [PMID: 37162742 PMCID: PMC10390257 DOI: 10.1007/s11912-023-01418-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE OF REVIEW A relative lack of molecular and clinical studies compared to other lymphoid cancers has historically made it difficult to determine optimal management approaches in post-transplant lymphoproliferative disorder (PTLD). We sought to better define the "state of the science" in PTLD by examining recent advances in risk assessment, genomic profiling, and trials of PTLD-directed therapy. RECENT FINDINGS Several major clinical trials highlight risk-stratified sequential therapy incorporating rituximab with or without chemotherapy as a rational treatment strategy in patients with CD20+ PTLD who do not respond to reduction of immunosuppression alone. Epstein Barr virus (EBV)-targeted cytotoxic lymphocytes are a promising approach in patients with relapsed/refractory EBV+ PTLD, but dedicated clinical trials should determine how autologous chimeric antigen receptor T cell therapy (CAR-T) may be safely administered to PTLD patients. Sequencing studies underscore the important effect of EBV infection on PTLD pathogenesis, but comprehensive genomic and tumor microenvironment profiling are needed to identify biomarkers that predict response to treatment in this clinically heterogeneous disease.
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Affiliation(s)
| | - Aseala Abousaud
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Ellen Marin
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | | | - Michael C Churnetski
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Deniz Peker
- Department of Pathology, Emory University, Atlanta, GA, USA
| | - Ankur Singh
- Georgia Institute of Technology, Atlanta, GA, USA
| | - Jean L Koff
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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Warley F, Jauk F, Otero V, Rivello HG. Single-center "Argentine" analysis of post-transplant lymphoproliferative disorders: incidence, histopathological characteristics and EBV status. Hematol Transfus Cell Ther 2023; 45 Suppl 2:S119-S125. [PMID: 36411235 PMCID: PMC10433319 DOI: 10.1016/j.htct.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/17/2022] [Accepted: 08/12/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Post-transplant lymphoproliferative disorders (PTLDs) are a heterogeneous group of lymphoid proliferations occurring after solid organ or bone marrow transplantation. The primary aims of our study were to characterize cumulative incidence of PTLDs, clinical and pathological features according to the Epstein-Barr virus (EBV) status and survival. METHODS This was a retrospective cohort study on adult and pediatric patients, from January 2001 to December 2017. The cumulative incidence of PTLD was calculated by analyzing all the patients transplanted at our hospital, based on the database of the Organ Donation and Ablation Authority of Argentina (INCUCAI). The Kaplan-Meier method was used to plot the survival. RESULTS Fifty-eight cases of biopsy-confirmed PTLD were identified and 12 cases of clinical data were incomplete and these patients were excluded. The median age at the time of the PTLD diagnosis was 17.5 years (interquartile range [IQR] 9 - 57). The median interval between transplant and PTLD diagnosis was 39 months (IQR 9 - 113). The most commonly transplanted organ was the liver (24 cases, 52.2%), followed by kidney (20 cases, 43.5%). The Epstein-Barr encoding region in situ hybridization (EBER ISH) was positive in 29 (69.8%) of the 43 evaluable biopsies. The PTLD cumulative incidence was 1.84% (95%CI 1.77 - 1.91) for solid organ and 0.84% (95%CI 0.48 - 1.2) for bone marrow transplant patients. The overall survival rate at 5 years was 0.77 (95%CI 0.61 - 0.87). Subgroups by the EBV EBER status, transplant type, PTLD subtype and age group (adult vs. pediatric) showed no statistically significant association with the overall survival. CONCLUSION The PTLD incidence was similar to that of previous series and the EBER did not appear as a relevant factor in our patient survival.
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Affiliation(s)
| | - Federico Jauk
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Otero
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Lückemeier P, Radujkovic A, Holtick U, Kurch L, Monecke A, Platzbecker U, Herling M, Kayser S. Characterization and outcome of post-transplant lymphoproliferative disorders within a collaborative study. Front Oncol 2023; 13:1208028. [PMID: 37427100 PMCID: PMC10326719 DOI: 10.3389/fonc.2023.1208028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Background Post-transplant lymphoproliferative disorders (PTLD) are heterogeneous lymphoid disorders ranging from indolent polyclonal proliferations to aggressive lymphomas that can arise after solid organ transplantation (SOT) and allogeneic hematopoietic transplantation (allo-HSCT). Methods In this multi-center retrospective study, we compare patient characteristics, therapies, and outcomes of PTLD after allo-HSCT and SOT. Twenty-five patients (15 after allo-HSCT and 10 after SOT) were identified who developed PTLD between 2008 and 2022. Results Median age (57 years; range, 29-74 years) and baseline characteristics were comparable between the two groups (allo-HSCT vs SOT), but median onset of PTLD was markedly shorter after allo-HSCT (2 months vs. 99 months, P<0.001). Treatment regimens were heterogeneous, with reduction of immunosuppression in combination with rituximab being the most common first-line treatment strategy in both cohorts (allo-HSCT: 66%; SOT: 80%). The overall response rate was lower in the allo-HSCT (67%) as compared to the SOT group (100%). Consequently, the overall survival (OS) trended towards a worse outcome for the allo-HSCT group (1-year OS: 54% vs. 78%; P=0.58). We identified PTLD onset ≤150 days in the allo-HSCT (P=0.046) and ECOG >2 in the SOT group (P=0.03) as prognostic factors for lower OS. Conclusion PTLD cases present heterogeneously and pose unique challenges after both types of allogeneic transplantation.
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Affiliation(s)
- Philipp Lückemeier
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | | | - Udo Holtick
- Department I of Internal Medicine, Medical Faculty and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Lars Kurch
- Department of Nuclear Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Astrid Monecke
- Department of Pathology, University Hospital Leipzig, Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Marco Herling
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Kayser
- Department of Hematology, Cellular Therapy, and Hemostaseology, University Hospital Leipzig, Leipzig, Germany
- NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, Heidelberg University, Germany
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Gross TG, Rubinstein JD. Post-transplant lymphoproliferative disease in children, adolescents, and young adults. Hematol Oncol 2023; 41 Suppl 1:48-56. [PMID: 37294957 DOI: 10.1002/hon.3139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Post-transplant lymphoproliferative disease (PTLD) remains a major complication of transplantation. PTLD is a rare entity and very heterogenous making consensus on diagnosis and treatment very challenging. The majority are Epstein-Barr virus (EBV) driven, CD20+ B-cell proliferations. PTLD does occur following hematopoietic stem cell transplant (HSCT), but due to the relative short risk period and efficacy of pre-emptive therapy, PTLD following HSCT will not be discussed in this review. This review will focus on the epidemiology, role of EBV, clinical presentation, diagnosis and evaluation and the current and emerging treatment strategies for pediatric PTLD following solid organ transplantation.
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Affiliation(s)
- Thomas G Gross
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado, USA
| | - Jeremy D Rubinstein
- Department of Pediatric, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Atallah-Yunes SA, Salman O, Robertson MJ. Post-transplant lymphoproliferative disorder: Update on treatment and novel therapies. Br J Haematol 2023; 201:383-395. [PMID: 36946218 DOI: 10.1111/bjh.18763] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/23/2023]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is rare and heterogeneous lymphoid proliferations that occur as a result of immunosuppression following solid organ transplant (SOT) and haematopoietic stem cell transplant (HSCT) with the majority being driven by EBV. Although some histologies are similar to lymphoid neoplasms seen in immunocompetent patients, treatment of PTLD may be different due to difference in pathobiology and higher risk of treatment complications. The most common treatment approach in SOT PTLD after failing immunosuppression reduction (RIS) takes into consideration a risk-stratified sequential algorithm with rituximab +/- chemotherapy based on phase 2 studies. In HSCT PTLD, RIS alone and chemotherapy are usually ineffective making rituximab +/- RIS as the gold standard of frontline treatment. In this review, we give an update on the treatment of PTLD beyond RIS. We highlight the most recent studies that attempted to incorporate more aggressive chemotherapy regimens and novel treatments into the traditional risk-stratified sequential approach. We also discuss the role of EBV-cytotoxic T lymphocytes in treatment of EBV-driven PTLD. Other novel agents with potential role in PTLD will be discussed in addition to the challenges that could arise with chimeric antigen receptor T-cell therapy and immune checkpoint inhibitors in this population.
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Affiliation(s)
- Suheil Albert Atallah-Yunes
- Division of Hematology and Medical Oncology - Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Omar Salman
- Division of Hematology and Medical Oncology - Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Michael J Robertson
- Lymphoma Program, Division of Hematology and Medical Oncology - Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Liu Y, Wang BC, Zuppan CW, Chau P, Fitts J, Chinnock R, Wang J. Relationship of Post-Transplant Lymphoproliferative Disorders (PTLD) Subtypes and Clinical Outcome in Pediatric Heart Transplant Recipients: A Retrospective Single Institutional Analysis/Experience of 558 Patients. Cancers (Basel) 2023; 15:cancers15030976. [PMID: 36765933 PMCID: PMC9913467 DOI: 10.3390/cancers15030976] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/19/2023] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are heterogenous lymphoproliferative disorders that develop as a consequence of immunosuppression in transplant recipients. We sought to determine if subtypes of PTLD correlated with different outcomes. We performed a retrospective review of PTLD occurring in pediatric heart transplant recipients. A total of 558 children and infants underwent cardiac transplantation at our institution between 1985 and 2019 and were followed until March 2021. Forty-nine of 558 patients developed PTLD (8.8%). As compared to older children (>one year of age), infant recipients (<three months of age) were less likely to develop PTLD. Monomorphic PTLDs (M-PTLD, 61%) was the most common subtype at initial diagnosis, followed by non-destructive (21%), polymorphic (14%), and classic Hodgkin lymphoma (cHL, 4%). Patients who underwent transplantation at a young age (<three months) had significantly lower rates of M-PTLD or cHL and a longer time from transplant to PTLD diagnosis as compared to children older than one year at transplant (p = 0.04). Although not reaching statistical significance, patients with a shorter time to PTLD diagnosis showed a trend toward higher rates of M-PTLD or cHL. As expected, the overall survival (OS) of patients with M-PTLD or cHL was significantly lower than patients with non-destructive or polymorphic PTLD.
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Affiliation(s)
- Yan Liu
- Department of Pathology and Laboratory Medicine, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
| | - Billy C. Wang
- Division of Pediatric Critical Care, Department of Pediatrics, University of Illinois College of Medicine Peoria, Peoria, IL 61605, USA
- Department of Cancer Biology and Pharmacology, University of Illinois College of Medicine Peoria, Peoria, IL 61605, USA
| | - Craig W. Zuppan
- Department of Pathology and Laboratory Medicine, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
| | - Peter Chau
- Division of Pediatric Cardiology, Department of Pediatrics, University of California San Diego, San Diego, CA 92123, USA
| | - James Fitts
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
| | - Richard Chinnock
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
| | - Jun Wang
- Department of Pathology and Laboratory Medicine, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Correspondence:
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Arı D, Turan D, Gökcan H, Özdemir M, Akdoğan Kayhan M. Complete Recovery After Immunosuppressive Treatment Change in a Patient With Posttransplant Lymphoproliferative Disorder. EXP CLIN TRANSPLANT 2023; 21:76-79. [PMID: 34981706 DOI: 10.6002/ect.2021.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Posttransplant lymphoproliferative diseases are a rare but important cause of morbidity and mortality secondary to immunosuppression after solid-organ or bone marrow transplant. Generally, posttransplant lymphoproliferative diseases develop in the first 2 years after transplant, when immunosuppressive therapy is the most intense. Change or reduction in immunosup - pressive treatment is an option for treatment of posttransplant lymphoproliferative diseases. We evaluated the treatment of a patient with posttransplant lymphoproliferative disease after liver transplant. A 64-year-old man underwent liver transplant from a living donor (the patient's son) in 2011 to treat hepatocellular cancer secondary to chronic hepatitis B. Tacrolimus and mycophenolate mofetil were used for immunosuppression through 9 years after liver transplant. In the abdominal computed tomography performed in response to abdominal pain during follow-up in March 2019, multiple solid lesions were observed. A liver biopsy revealed posttransplant lymphoproliferative disease with diffuse large B-cell lymphoma. Fluorine-18 positron emission tomography/computed tomography imaging of the patient showed no pathology in favor of primary lymphoproliferative disease. Mycophenolate mofetil and tacrolimus treatment was changed to everolimus. In the follow-up dynamic magnetic resonance imaging examination that was performed at 3 months after treatment change, we observed that the lesion at liver segment 6 had regressed to 30 mm and several lesions with similar features were observed in the right lobe of the liver. Additional liver biopsy results were compatible with complete remission. The patient's clinical symptoms had fully regressed at 18 months after the diagnosis of PTLD, at the time of this writing. Ongoing radiological and clinical follow-up has shown complete remission. Change from calcineurin treatment to treatment with an inhibitor of the mechanistic target of rapamycin may be an essential and new option for treatment of posttransplant lymphoproliferative disease after liver transplant.
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Affiliation(s)
- Derya Arı
- From the Ankara City Hospital, Department of Gastroenterology, Ankara, Turkey
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Vergote VKJ, Deroose CM, Fieuws S, Laleman W, Sprangers B, Uyttebroeck A, Van Cleemput J, Verhoef G, Vos R, Tousseyn T, Dierickx D. Characteristics and Outcome of Post-Transplant Lymphoproliferative Disorders After Solid Organ Transplantation: A Single Center Experience of 196 Patients Over 30 Years. Transpl Int 2022; 35:10707. [PMID: 36589262 PMCID: PMC9794588 DOI: 10.3389/ti.2022.10707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a rare but life-threatening complication after transplantation. In this retrospective, monocentric study we aimed to collect real life data regarding PTLD and determine the role of Epstein Barr Virus (EBV) status and year of diagnosis on prognosis. We identified 196 biopsy-proven PTLD after solid organ transplantation (SOT) diagnosed at the University Hospitals Leuven (Belgium) from 1989 to 2019. EBV status was positive in 61% of PTLD. The median overall survival (OS) was 5.7 years (95% CI: 2.99-11.1). Although EBV positivity was not significantly correlated with OS in multivariate analyses (HR: 1.44 (95% CI: 0.93-2.24); p = 0.10), subgroup analysis showed a significantly better median OS for EBV negative post-transplant diffuse large B-cell lymphoma (DLBCL) compared to EBV positive post-transplant DLBCL (8.8 versus 2.5 years respectively; p = 0.0365). There was a significant relation between year of PTLD diagnosis and OS: the more recent the PTLD diagnosis, the lower the risk for death (adjusted HR: 0.962 (95% CI: 0.931-0.933); p = 0.017). In conclusion, the prognosis of PTLD after SOT has improved in the past decades. Our analysis shows a significant relation between EBV status and OS in post-transplant DLBCL.
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Affiliation(s)
- Vibeke K. J. Vergote
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium,*Correspondence: Vibeke K. J. Vergote, , orcid.org/0000-0003-1100-5600
| | | | - Steffen Fieuws
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven—University of Leuven, Leuven, Belgium
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Laboratory of Molecular Immunology, Department of Microbiology, Immunology and Transplantation, Rega Institute, KU Leuven, Leuven, Belgium,Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Pediatric Hemato-Oncology, Department of Oncology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Gregor Verhoef
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium,BREATHE, KU Leuven, Leuven, Belgium
| | - Thomas Tousseyn
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
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Thieme CJ, Schulz M, Wehler P, Anft M, Amini L, Blàzquez-Navarro A, Stervbo U, Hecht J, Nienen M, Stittrich AB, Choi M, Zgoura P, Viebahn R, Schmueck-Henneresse M, Reinke P, Westhoff TH, Roch T, Babel N. In vitro and in vivo evidence that the switch from calcineurin to mTOR inhibitors may be a strategy for immunosuppression in Epstein-Barr virus-associated post-transplant lymphoproliferative disorder. Kidney Int 2022; 102:1392-1408. [PMID: 36103953 DOI: 10.1016/j.kint.2022.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 01/12/2023]
Abstract
Post-transplant lymphoproliferative disorder is a life-threatening complication of immunosuppression following transplantation mediated by failure of T cells to control Epstein-Barr virus (EBV)-infected and transformed B cells. Typically, a modification or reduction of immunosuppression is recommended, but insufficiently defined thus far. In order to help delineate this, we characterized EBV-antigen-specific T cells and lymphoblastoid cell lines from healthy donors and in patients with a kidney transplant in the absence or presence of the standard immunosuppressants tacrolimus, cyclosporin A, prednisolone, rapamycin, and mycophenolic acid. Phenotypes of lymphoblastoid cell-lines and T cells, T cell-receptor-repertoire diversity, and T-cell reactivity upon co-culture with autologous lymphoblastoid cell lines were analyzed. Rapamycin and mycophenolic acid inhibited lymphoblastoid cell-line proliferation. T cells treated with prednisolone and rapamycin showed nearly normal cytokine production. Proliferation and the viability of T cells were decreased by mycophenolic acid, while tacrolimus and cyclosporin A were strong suppressors of T-cell function including their killing activity. Overall, our study provides a basis for the clinical decision for the modification and reduction of immunosuppression and adds information to the complex balance of maintaining anti-viral immunity while preventing acute rejection. Thus, an immunosuppressive regime based on mTOR inhibition and reduced or withdrawn calcineurin inhibitors could be a promising strategy for patients with increased risk of or manifested EBV-associated post-transplant lymphoproliferative disorder.
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Affiliation(s)
- Constantin J Thieme
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Malissa Schulz
- Hochschule für Technik und Wirtschaft Berlin (HTW), Berlin, Germany
| | - Patrizia Wehler
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Anft
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Leila Amini
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arturo Blàzquez-Navarro
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Ulrik Stervbo
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Jochen Hecht
- Centre for Genomic Regulation (CRG), Barcelona Institute of Science and Technology, Barcelona, Spain; Experimental and Health Sciences Department, Universitat Pompeu Fabra, Barcelona, Spain
| | - Mikalai Nienen
- Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Panagiota Zgoura
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Richard Viebahn
- Department of Surgery, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Michael Schmueck-Henneresse
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Petra Reinke
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin Center for Advanced Therapies (BeCAT), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Timm H Westhoff
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Toralf Roch
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | - Nina Babel
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany; Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany.
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Markouli M, Ullah F, Omar N, Apostolopoulou A, Dhillon P, Diamantopoulos P, Dower J, Gurnari C, Ahmed S, Dima D. Recent Advances in Adult Post-Transplant Lymphoproliferative Disorder. Cancers (Basel) 2022; 14:cancers14235949. [PMID: 36497432 PMCID: PMC9740763 DOI: 10.3390/cancers14235949] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
PTLD is a rare but severe complication of hematopoietic or solid organ transplant recipients, with variable incidence and timing of occurrence depending on different patient-, therapy-, and transplant-related factors. The pathogenesis of PTLD is complex, with most cases of early PLTD having a strong association with Epstein-Barr virus (EBV) infection and the iatrogenic, immunosuppression-related decrease in T-cell immune surveillance. Without appropriate T-cell response, EBV-infected B cells persist and proliferate, resulting in malignant transformation. Classification is based on the histologic subtype and ranges from nondestructive hyperplasias to monoclonal aggressive lymphomas, with the most common subtype being diffuse large B-cell lymphoma-like PTLD. Management focuses on prevention of PTLD development, as well as therapy for active disease. Treatment is largely based on the histologic subtype. However, given lack of clinical trials providing evidence-based data on PLTD therapy-related outcomes, there are no specific management guidelines. In this review, we discuss the pathogenesis, histologic classification, and risk factors of PTLD. We further focus on common preventive and frontline treatment modalities, as well as describe the application of novel therapies for PLTD and elaborate on potential challenges in therapy.
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Affiliation(s)
- Mariam Markouli
- Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Fauzia Ullah
- Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Najiullah Omar
- Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Anna Apostolopoulou
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Puneet Dhillon
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Panagiotis Diamantopoulos
- Department of Internal Medicine, Laikon General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Joshua Dower
- Department of Hematology and Medical Oncology, Tufts Medical Center, Boston, MA 02111, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Sairah Ahmed
- Department of Lymphoma-Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, OH 44195, USA
- Correspondence:
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Epstein-Barr virus-associated posttransplant lymphoproliferative disorders: new insights in pathogenesis, classification and treatment. Curr Opin Oncol 2022; 34:413-421. [PMID: 35900750 DOI: 10.1097/cco.0000000000000885] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Posttransplant lymphoproliferative disorder (PTLD) is a serious complication following transplantation from an allogeneic donor. Epstein-Barr Virus (EBV) is involved in a substantial number of cases. In this review, we aim to summarize recent knowledge on pathogenesis, classification and treatment of EBV + PTLD. RECENT FINDINGS New insights in the complex oncogenic properties of EBV antigens noncoding Ribonucleic acids (RNAs), especially EBV MicroRNA (miRNAs), have increased our knowledge of the pathogenesis of EBV + PTLD. In addition the potential influence of EBV on the tumor microenvironment is becoming clearer, paving the way for new types of immunotherapy. Currently PTLD is classified according to the World Health Organization classification together with other lymphoproliferative disorders, based on the specific immunosuppression. However, a new framework integrating all types of lymphoproliferative disorders in all different settings of immune deficiency and dysregulation is needed. Although treatment of EBV + and EBV - PTLD was largely similar in the past, EBV-directed therapies are currently increasingly used. SUMMARY The use of EBV-directed therapies and new agents, based on better understanding of pathogenesis and classification of PTLD, will change the treatment landscape of EBV + PTLD in the next era.
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Reiche W, Tauseef A, Sabri A, Mirza M, Cantu D, Silberstein P, Chandan S. Gastrointestinal manifestations, risk factors, and management in patients with post-transplant lymphoproliferative disorder: A systematic review. World J Transplant 2022; 12:268-280. [PMID: 36159076 PMCID: PMC9453293 DOI: 10.5500/wjt.v12.i8.268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/24/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with a history of solid organ transplantation (SOT) or hematopoietic stem cell transplantation (HSCT) are at an increased risk of developing post-transplant lymphoproliferative disorder (PTLD). The gastrointestinal (GI) tract is commonly affected as it has an abundance of B and T cells.
AIM To determine typical GI-manifestations, risk factors for developing PTLD, and management.
METHODS Major databases were searched until November 2021.
RESULTS Non-case report studies that described GI manifestations of PTLD, risk factors for developing PTLD, and management of PTLD were included. Nine articles written within the last 20 years were included in the review. All articles found that patients with a history of SOT, regardless of transplanted organ, have a propensity to develop GI-PTLD.
CONCLUSION GI tract manifestations may be nonspecific; therefore, consideration of risk factors is crucial for identifying GI-PTLD. Like other lymphoma variants, PTLD is very aggressive making early diagnosis key to prognosis. Initial treatment is reduction of immunosuppression which is effective in more than 50% of cases; however, additional therapy including rituximab, chemotherapy, and surgery may also be required.
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Affiliation(s)
- William Reiche
- Department of Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Abubakar Tauseef
- Department of Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Ahmed Sabri
- Department of Pathology, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Mohsin Mirza
- Department of Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - David Cantu
- Department of Pathology, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Peter Silberstein
- Division of Hematology and Oncology, Department of Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, Department of Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
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Pediatric Onco-Nephrology: Time to Spread the Word-Part II: Long-Term Kidney Outcomes in Survivors of Childhood Malignancy and Malignancy after Kidney Transplant. Pediatr Nephrol 2022; 37:1285-1300. [PMID: 34490519 DOI: 10.1007/s00467-021-05172-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 05/24/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
Onco-nephrology is a recent and evolving medical subspecialty devoted to the care of patients with kidney disease and unique kidney-related complications in the context of cancer and its treatments, recognizing that management of kidney disease as well as the cancer itself will improve survival and quality of life. While this area has received much attention in the adult medicine sphere, similar emphasis in the pediatric realm has not yet been realized. As in adults, kidney involvement in children with cancer extends beyond the time of initial diagnosis and treatment. Many interventions, such as chemotherapy, stem cell transplant, radiation, and nephrectomy, have long-term kidney effects, including the development of chronic kidney disease (CKD) with subsequent need for dialysis and/or kidney transplant. Thus, with the improved survival of children with malignancy comes the need for ongoing monitoring of kidney function and early mitigation of kidney-related comorbidities. In addition, children with kidney transplant are at higher risk of developing malignancies than their age-matched peers. Pediatric nephrologists thus need to be aware of issues related to cancer and its treatments as they impact their own patients. These facts emphasize the necessity of pediatric nephrologists and oncologists working closely together in managing these children and highlight the importance of bringing the onco-nephrology field to our growing list of pediatric nephrology subspecialties.
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Comparison of Post-Transplantation Lymphoproliferative Disorder Risk and Prognostic Factors between Kidney and Liver Transplant Recipients. Cancers (Basel) 2022; 14:cancers14081953. [PMID: 35454860 PMCID: PMC9024969 DOI: 10.3390/cancers14081953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 01/10/2023] Open
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) is a life-threatening complication of solid organ transplantation (SOT). Its development risk varies among organ graft recipients. In this study, retrospective data were analyzed to compare PTLD’s risk and prognostic factors between adult kidney and liver transplant recipients (KTRs and LTRs, respectively). Over 15 years, 2598 KTRs and 1378 LTRs were under observation at our center. Sixteen KTRs (0.62%) and twenty-three LTRs (1.67%) were diagnosed with PTLD. PTLD developed earlier in LTRs (p < 0.001), SOT patients > 45 years old (p = 0.002), and patients receiving tacrolimus (p < 0.001) or not receiving cyclosporin (p = 0.03) at diagnosis. Tacrolimus use, male sex, and age > 45 years old significantly affected the time of PTLD onset in KTRs (hazard ratio (HR) = 18.6, 7.9 and 5.2, respectively). Survival was longer in LTRs < 45 years old (p < 0.009). LTRs were more likely than KTRs to achieve complete remission (p = 0.039). Factors affecting PTLD development and outcome differ between KTRs and LTRs; thus, these populations should be separately evaluated in future studies.
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Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients. Biomedicines 2022; 10:biomedicines10030701. [PMID: 35327510 PMCID: PMC8944970 DOI: 10.3390/biomedicines10030701] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution.
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Murakami N, Webber AB, Nair V. Transplant Onconephrology in Patients With Kidney Transplants. Adv Chronic Kidney Dis 2022; 29:188-200.e1. [PMID: 35817526 PMCID: PMC9326185 DOI: 10.1053/j.ackd.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/10/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
Cancer is a leading cause of death in patients with kidney transplantation. Patients with kidney transplants are 10- to 200-times more likely to develop cancers after transplant than the general population, depending on the cancer type. Recent advances in cancer therapies have dramatically improved survival outcomes; however, patients with kidney transplants face unique challenges of immunosuppression management, cancer screening, and recurrence of cancer after transplant. Patients with a history of cancer tend to be excluded from transplant candidacy or are required to have long cancer-free wait time before wait-listing. The strategy of pretransplant wait time management may need to be revisited as cancer therapies improve, which is most applicable to patients with a history of multiple myeloma. In this review, we discuss several important topics in transplant onconephrology: the current recommendations for pretransplant wait times for transplant candidates with cancer histories, cancer screening post-transplant, post-transplant lymphoproliferative disorder, strategies for transplant patients with a history of multiple myeloma, and novel therapies for patients with post-transplant malignancies. With emerging novel cancer treatments, it is critical to have multidisciplinary discussions involving patients, caregivers, transplant nephrologists, and oncologists to achieve patient-oriented goals.
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Affiliation(s)
- Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Allison B. Webber
- Divisino of Nephrology, Kidney Transplant Service, University of California San Francisco, San Francisco, CA
| | - Vinay Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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EBV+ lymphoproliferative diseases: opportunities for leveraging EBV as a therapeutic target. Blood 2022; 139:983-994. [PMID: 34437680 PMCID: PMC8854679 DOI: 10.1182/blood.2020005466] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 11/20/2022] Open
Abstract
Epstein-Barr virus (EBV) is a ubiquitous human tumor virus, which contributes to the development of lymphoproliferative disease, most notably in patients with impaired immunity. EBV-associated lymphoproliferation is characterized by expression of latent EBV proteins and ranges in severity from a relatively benign proliferative response to aggressive malignant lymphomas. The presence of EBV can also serve as a unique target for directed therapies for the treatment of EBV lymphoproliferative diseases, including T cell-based immune therapies. In this review, we describe the EBV-associated lymphoproliferative diseases and particularly focus on the therapies that target EBV.
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34
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An Essential Guide for Managing Post-Liver Transplant Patients: What Primary Care Physicians Should Know. Am J Med 2022; 135:157-166. [PMID: 34508700 DOI: 10.1016/j.amjmed.2021.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022]
Abstract
With long-term survival after liver transplantation becoming the rule, care for medical problems arising over time in liver-transplanted patients gained increasing importance. The most common causes of death occurring more than 1 year after liver transplantation are unrelated to liver diseases and facilitated by immunosuppressive treatments; examples are malignancies, renal failure, and cardiovascular, metabolic, and infectious diseases. Recipients receive life-long follow-up care at transplant centers, however, the increasing number of liver-transplanted patients is saturating the health care supply that transplant centers have to offer. Primary care physicians are increasingly exposed to liver-transplanted patients, even in the early periods after transplant, and an understanding of the most common risks and complications faced by these patients would enhance their care. This article reviews the long-term care of liver transplant recipients, emphasizing the key internal medicine-related issues that should be known by primary care physicians. A specific section is devoted to implementing strategies to involve these physicians in the long-term follow-up of liver-transplanted patients in close collaboration with transplant hepatologists.
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35
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Masset C, Gautier-Vargas G, Cantarovich D, Ville S, Dantal J, Delbos F, Walencik A, Kerleau C, Hourmant M, Garandeau C, Meurette A, Giral M, Benotmane I, Caillard S, Blancho G. Occurrence of de novo Donor Specific Antibodies after Covid-19 in kidney transplant recipients is low despite immunosuppression modulation. Kidney Int Rep 2022; 7:983-992. [PMID: 35155848 PMCID: PMC8818557 DOI: 10.1016/j.ekir.2022.01.1072] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 02/07/2023] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Christophe Masset
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Correspondence: Christophe Masset, Service de Néphrologie et Immunologie Clinique, 30 bd Jean Monnet, 44093 Nantes Cedex 01, France.
| | - Gabriela Gautier-Vargas
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Diego Cantarovich
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Simon Ville
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Jacques Dantal
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | | | | | - Clarisse Kerleau
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Maryvonne Hourmant
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Claire Garandeau
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Aurélie Meurette
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Magali Giral
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
| | - Ilies Benotmane
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, Centre Hospitalier Universitaire, Strasbourg, France
| | - Gilles Blancho
- Service de Néphrologie et Immunologie Clinique Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, France
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Fulchiero R, Amaral S. Post-transplant lymphoproliferative disease after pediatric kidney transplant. Front Pediatr 2022; 10:1087864. [PMID: 36568415 PMCID: PMC9768432 DOI: 10.3389/fped.2022.1087864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
Post-transplant lymphoproliferative disease (PTLD) is the most common malignancy complicating solid organ transplantation (SOT) in adults and children. PTLD encompasses a spectrum of histopathologic features and organ involvement, ranging from benign lymphoproliferation and infectious-mononucleosis like presentation to invasive neoplastic processes such as classical Hodgkin lymphoma. The predominant risk factors for PTLD are Epstein-Barr virus (EBV) serostatus at the time of transplant and the intensity of immunosuppression following transplantation; with EBV-negative recipients of EBV-positive donor organs at the highest risk. In children, PTLD commonly presents in the first two years after transplant, with 80% of cases in the first year, and over 90% of cases associated with EBV-positive B-cell proliferation. Though pediatric kidney transplant recipients are at lower risk (1-3%) for PTLD compared to their other SOT counterparts, there is still a significant risk of morbidity, allograft failure, and an estimated 5-year mortality rate of up to 50%. In spite of this, there is no consensus for monitoring of at-risk patients or optimal management strategies for pediatric patients with PTLD. Here we review pathogenesis and risk factors for the development of PTLD, with current practices for prevention, diagnosis, and management of PTLD in pediatric kidney transplant recipients. We also highlight emerging concepts, current research gaps and potential future developments to improve clinical outcomes and longevity in these patients.
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Affiliation(s)
- Rosanna Fulchiero
- Department of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sandra Amaral
- Department of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States
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Dahle DO, Skauby M, Langberg CW, Brabrand K, Wessel N, Midtvedt K. Renal Cell Carcinoma and Kidney Transplantation: A Narrative Review. Transplantation 2022; 106:e52-e63. [PMID: 33741842 PMCID: PMC8667800 DOI: 10.1097/tp.0000000000003762] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/08/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
Kidney transplant recipients (KTRs) are at increased risk of developing renal cell carcinoma (RCC). The cancer can be encountered at different steps in the transplant process. RCC found during work-up of a transplant candidate needs treatment and to limit the risk of recurrence usually a mandatory observation period before transplantation is recommended. An observation period may be omitted for candidates with incidentally discovered and excised small RCCs (<3 cm). Likewise, RCC in the donor organ may not always preclude usage if tumor is small (<2 to 4 cm) and removed with clear margins before transplantation. After transplantation, 90% of RCCs are detected in the native kidneys, particularly if acquired cystic kidney disease has developed during prolonged dialysis. Screening for RCC after transplantation has not been found cost-effective. Treatment of RCC in KTRs poses challenges with adjustments of immunosuppression and oncologic treatments. For localized RCC, excision or nephrectomy is often curative. For metastatic RCC, recent landmark trials in the nontransplanted population demonstrate that immunotherapy combinations improve survival. Dedicated trials in KTRs are lacking. Case series on immune checkpoint inhibitors in solid organ recipients with a range of cancer types indicate partial or complete tumor response in approximately one-third of the patients at the cost of rejection developing in ~40%.
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Affiliation(s)
- Dag Olav Dahle
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Morten Skauby
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Knut Brabrand
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Nicolai Wessel
- Department of Urology, Oslo University Hospital, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Nonhepatic Cancer in the Pediatric Liver Transplant Population: Guidelines From the ILTS-SETH Consensus Conference. Transplantation 2022; 106:e46-e51. [PMID: 34905761 DOI: 10.1097/tp.0000000000003996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The incidence and geographical distribution of cancers in children are dramatically different from the adult population. Consequent to improvements in postcancer survival, there is a progressive increase in the number of patients requiring liver transplantation (LT) who are in remission from pretransplant malignancy (PTM). Conventionally, however, PTM has been considered a relative contraindication to LT. Furthermore, with improving post-LT survival now extending beyond decades, the cumulative effect of immunosuppression and the increasing risk of de novo cancers need to be acknowledged. A working group was formed to evaluate, discuss, and retrieve all the evidence and provide guidelines with regards to best practices surrounding nonhepatic cancer in the pediatric LT (PLT) population. Further subsections of research included (a) extrahepatic solid tumors, leukemia, lymphoma, and other hematological disturbances before PLT and (b) malignancies following PLT (including posttransplant lymphoproliferative disorders). This guidance provides a collection of evidence-based expert opinions, consensus, and best practices on nonhepatic cancers in PLT.
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Abstract
Cancer remains a significant cause of morbidity and mortality in kidney transplant recipients, due to long-term immunosuppression. Salient issues to consider in decreasing the burden of malignancy among kidney transplant recipients include pretransplant recipient evaluation, post-transplant screening and monitoring, and optimal treatment strategies for the kidney transplant recipients with cancer. In this review, we address cancer incidence and outcomes, approaches to cancer screening and monitoring pretransplant and post-transplant, as well as treatment strategies, immunosuppressive management, and multidisciplinary approaches in the kidney transplant recipients with cancer.
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Vazirani J, Crowhurst T, Morrissey CO, Snell GI. Management of Multidrug Resistant Infections in Lung Transplant Recipients with Cystic Fibrosis. Infect Drug Resist 2021; 14:5293-5301. [PMID: 34916813 PMCID: PMC8670859 DOI: 10.2147/idr.s301153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is an inherited multisystem disease characterised by bronchiectasis and chronic respiratory infections which eventually cause end stage lung disease. Lung transplantation (LTx) is a well-established treatment option for patients with CF-associated lung disease, improving survival and quality of life. Navigating recurrent infections in the setting of LTx is often difficult, where immune suppression must be balanced against the constant threat of infection. Sepsis/infections are one of the major contributors to post-LTx mortality and multiresistant organisms (eg, Burkholderia cepacia complex, Mycobacterium abscessus complex, Scedosporium spp. and Lomentospora spp.) pose a significant threat to survival. This review will summarize current and novel therapies to assist with the management of multiresistant bacterial, mycobacterial, viral and fungal infections which threaten the CF LTx cohort.
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Affiliation(s)
- Jaideep Vazirani
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Thomas Crowhurst
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
- Department of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - C Orla Morrissey
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
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Zanelli M, Sanguedolce F, Palicelli A, Zizzo M, Martino G, Caprera C, Fragliasso V, Soriano A, Gozzi F, Cimino L, Masia F, Moretti M, Foroni M, De Marco L, Pellegrini D, De Raeve H, Ricci S, Tamagnini I, Tafuni A, Cavazza A, Merli F, Pileri SA, Ascani S. EBV-Driven Lymphoproliferative Disorders and Lymphomas of the Gastrointestinal Tract: A Spectrum of Entities with a Common Denominator (Part 3). Cancers (Basel) 2021; 13:6021. [PMID: 34885131 PMCID: PMC8656853 DOI: 10.3390/cancers13236021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/27/2021] [Accepted: 11/28/2021] [Indexed: 12/28/2022] Open
Abstract
EBV is the first known oncogenic virus involved in the development of several tumors. The majority of the global population are infected with the virus early in life and the virus persists throughout life, in a latent stage, and usually within B lymphocytes. Despite the worldwide diffusion of EBV infection, EBV-associated diseases develop in only in a small subset of individuals often when conditions of immunosuppression disrupt the balance between the infection and host immune system. EBV-driven lymphoid proliferations are either of B-cell or T/NK-cell origin, and range from disorders with an indolent behavior to aggressive lymphomas. In this review, which is divided in three parts, we provide an update of EBV-associated lymphoid disorders developing in the gastrointestinal tract, often representing a challenging diagnostic and therapeutic issue. Our aim is to provide a practical diagnostic approach to clinicians and pathologists who face this complex spectrum of disorders in their daily practice. In this part of the review, the chronic active EBV infection of T-cell and NK-cell type, its systemic form; extranodal NK/T-cell lymphoma, nasal type and post-transplant lymphoproliferative disorders are discussed.
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Affiliation(s)
- Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | | | - Andrea Palicelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Maurizio Zizzo
- Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Giovanni Martino
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Cecilia Caprera
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Valentina Fragliasso
- Laboratory of Translational Research, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Alessandra Soriano
- Gastroenterology Division, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Fabrizio Gozzi
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (F.G.); (L.C.)
| | - Luca Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (F.G.); (L.C.)
| | - Francesco Masia
- Dipartimento di Medicina, Università degli Studi di Perugia, 05100 Terni, Italy; (F.M.); (M.M.)
| | - Marina Moretti
- Dipartimento di Medicina, Università degli Studi di Perugia, 05100 Terni, Italy; (F.M.); (M.M.)
| | - Moira Foroni
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Loredana De Marco
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - David Pellegrini
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
| | - Hendrik De Raeve
- Pathology, University Hospital Brussels, 1090 Brussels, Belgium;
- Pathology, O.L.V. Hospital Aalst, 9300 Aalst, Belgium
| | - Stefano Ricci
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Ione Tamagnini
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Alessandro Tafuni
- Pathology Unit, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Alberto Cavazza
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.P.); (M.F.); (L.D.M.); (S.R.); (I.T.); (A.C.)
| | - Francesco Merli
- Hematology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Stefano A. Pileri
- Haematopathology Division, European Institute of Oncology-IEO IRCCS Milan, 20141 Milan, Italy;
| | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, 05100 Terni, Italy; (G.M.); (C.C.); (D.P.); (S.A.)
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Boyle S, Tobin JWD, Perram J, Hamad N, Gullapalli V, Barraclough A, Singaraveloo L, Han MH, Blennerhassett R, Nelson N, Johnston AM, Talaulikar D, Karpe K, Bhattacharyya A, Cheah CY, Subramoniapillai E, Bokhari W, Lee C, Hawkes EA, Jabbour A, Strasser SI, Chadban SJ, Brown C, Mollee P, Hapgood G. Management and Outcomes of Diffuse Large B-cell Lymphoma Post-transplant Lymphoproliferative Disorder in the Era of PET and Rituximab: A Multicenter Study From the Australasian Lymphoma Alliance. Hemasphere 2021; 5:e648. [PMID: 34651103 PMCID: PMC8505336 DOI: 10.1097/hs9.0000000000000648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022] Open
Abstract
There are limited data on post-transplant lymphoproliferative disorder (PTLD) in the era of positron emission tomography (PET) and rituximab (R). Furthermore, there is limited data on the risk of graft rejection with modern practices in reduction in immunosuppression (RIS). We studied 91 patients with monomorphic diffuse large B-cell lymphoma PTLD at 11 Australian centers: median age 52 years, diagnosed between 2004 and 2017, median follow-up 4.7 years (range, 0.5-14.5 y). RIS occurred in 88% of patients. For patients initially treated with R-monotherapy, 45% achieved complete remission, rising to 71% with the addition of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) for those not in complete remission. For patients initially treated with R-CHOP, the complete remission rate was 76%. There was no difference in overall survival (OS) between R-monotherapy and R-chemotherapy patients. There was no difference in OS for patients with systemic lymphoma (n = 68) versus central nervous system (CNS) involvement (n = 23) (3-y OS 72% versus 73%; P = 0.78). Treatment-related mortality was 7%. End of treatment PET was prognostic for patients with systemic lymphoma with longer OS in the PET negative group (3-y OS 91% versus 57%; P = 0.01). Graft rejection occurred in 9% (n = 4 biopsy-proven; n = 4 suspected) during the entire follow-up period with no cases of graft loss. RIS and R-based treatments are safe and effective with a low likelihood of graft rejection and high cure rate for patients achieving complete remission with CNS or systemic PTLD.
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Affiliation(s)
- Stephen Boyle
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Joshua W. D. Tobin
- University of Queensland, Brisbane, Queensland, Australia
- Department of Haematology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Jacinta Perram
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Veena Gullapalli
- Department of Haematology, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Allison Barraclough
- Department of Haematology and Olivia Newton John Cancer Research Institute, The Austin Hospital, Melbourne, Victoria, Australia
| | | | - Min-Hi Han
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Richard Blennerhassett
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Niles Nelson
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Anna M. Johnston
- Royal Hobart Hospital, Hobart, Tasmania, Australia
- University of Tasmania, Hobart, Tasmania, Australia
| | - Dipti Talaulikar
- Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Krishna Karpe
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Abir Bhattacharyya
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Chan Yoon Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- University of Western Australia, Crawley, Western Australia, Australia
| | | | - Waqas Bokhari
- Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliza A. Hawkes
- Department of Haematology and Olivia Newton John Cancer Research Institute, The Austin Hospital, Melbourne, Victoria, Australia
- Eastern Health, Box Hill, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Jabbour
- Department of Cardiology, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Simone I. Strasser
- University of Sydney, Sydney, New South Wales, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Steven J. Chadban
- University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Christina Brown
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Peter Mollee
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Greg Hapgood
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
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Füreder A, Kropshofer G, Benesch M, Dworzak M, Greil S, Huber W, Hubmann H, Lawitschka A, Mann G, Michel‐Behnke I, Müller‐Sacherer T, Pichler H, Simonitsch‐Klupp I, Schwinger W, Szepfalusi Z, Crazzolara R, Attarbaschi A. Characteristics, management, and outcome of pediatric patients with post-transplant lymphoproliferative disease-A 20 years' experience from Austria. Cancer Rep (Hoboken) 2021; 4:e1375. [PMID: 33755341 PMCID: PMC8551996 DOI: 10.1002/cnr2.1375] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Management of pediatric post-transplantation lymphoproliferative disorder (PTLD) after hematopoietic stem cell (HSCT) and solid organ transplantation (SOT) is challenging. AIM This study of 34 PTLD patients up to 19-years old diagnosed in Austria from 2000 to 2018 aimed at assessing initial characteristics, therapy, response, and outcome as well as prognostic markers of this rare pediatric disease. METHODS AND RESULTS A retrospective data analysis was performed. Types of allografts were kidney (n = 12), liver (n = 7), heart (n = 5), hematopoietic stem cells (n = 4), lungs (n = 2), multi-visceral (n = 2), small intestine (n = 1), and vessels (n = 1). Eighteen/34 were classified as monomorphic PTLD, with DLBCL accounting for 15 cases. Polymorphic disease occurred in nine, and non-destructive lesions in six cases. One patient had a non-classifiable PTLD. Thirteen/34 patients are surviving event-free in first remission (non-destructive, n = 4/6; polymorphic, n = 4/9; monomorphic, n = 6/18). Fourteen/34 patients lacked complete response to first-line therapy, of whom seven died. Four/34 patients relapsed, of whom two died. In 3/34 patients, death occurred as a first event. The 5-year overall and event-free survival rates were 64% ± 9% and 35% ± 9% for the whole cohort. Among all parameters analyzed, only malignant disease as the indication for transplantation had a significantly poor influence on survival. CONCLUSIONS This study shows PTLD still to be a major cause of mortality following SOT or HSCT in children. A continued understanding of the molecular biology of the disease shall allow to decrease treatment intensity for lower risk patients and to identify patients who may benefit from newer therapy approaches to improve outcome and decrease morbidity.
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Affiliation(s)
- Anna Füreder
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Gabriele Kropshofer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent MedicineMedical University of InnsbruckInnsbruckAustria
| | - Martin Benesch
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent MedicineMedical University of GrazGrazAustria
| | - Michael Dworzak
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Sabine Greil
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Pediatric Heart CenterMedical University of ViennaViennaAustria
| | - Wolf‐Dietrich Huber
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Holger Hubmann
- Division of General Pediatrics, Department of Pediatrics and Adolescent MedicineMedical University of GrazGrazAustria
| | - Anita Lawitschka
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Georg Mann
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
| | - Ina Michel‐Behnke
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Pediatric Heart CenterMedical University of ViennaViennaAustria
| | - Thomas Müller‐Sacherer
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Herbert Pichler
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | | | - Wolfgang Schwinger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent MedicineMedical University of GrazGrazAustria
| | - Zsolt Szepfalusi
- Division of Pediatric Pulmonology, Allergy and Endocrinology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center PediatricsMedical University of ViennaViennaAustria
| | - Roman Crazzolara
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent MedicineMedical University of InnsbruckInnsbruckAustria
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and OncologySt. Anna Children's HospitalViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
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Katz-Greenberg G, Ghimire S, Zhan T, Mallari K, Whitaker-Menezes D, Gong J, Uppal G, Martinez-Outschoorn U, Martinez Cantarin MP. Post-transplant lymphoproliferative disorders (PTLD)-from clinical to metabolic profiles-a single center experience and review of literature. Am J Cancer Res 2021; 11:4624-4637. [PMID: 34659910 PMCID: PMC8493408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/07/2021] [Indexed: 06/13/2023] Open
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are among the most serious complications after solid organ transplantation (SOT). Monomorphic diffuse large B-cell lymphoma (DLBCL) is the most common subtype of PTLD. Historically, outcomes of PTLD have been poor with high mortality rates and allograft loss, although this has improved in the last 10 years. Most of our understanding about PTLD DLBCL is extrapolated from studies in non-PTLD DLBCL, and while several clinical factors have been identified and validated for predicting non-PTLD DLBCL outcomes, the molecular profile of PTLD DLBCL has not yet been characterized. Compartment-specific metabolic reprograming has been described in non-PTLD DLBCL with a lactate uptake metabolic phenotype with high monocarboxylate transporter 1 (MCT1) expression associated with worse outcomes. The aim of our study was to compare the outcomes of PTLD in our transplant center to historic cohorts, as well as study a subgroup of our PTLD DLBCL tumors and compare metabolic profiles with non-PTLD DLBCL. We performed a retrospective single institution study of all adult patients who underwent a SOT between the years 1992-2018, who were later diagnosed with PTLD. All available clinical information was extracted from the patients' medical records. Tumor metabolic markers were studied in a subgroup of PTLD DLBCL and compared to a group of non-PTLD DLBCL. Thirty patients were diagnosed with PTLD following SOT in our center. Median time from SOT to PTLD diagnosis was 62.8 months (IQR 7.6; 134.4), with 37% of patients diagnosed with early PTLD, and 63% with late PTLD. The most common PTLD subtype was DLBCL. Most patients were treated with reduction of their immunosuppression (RIS) including a group who were switched from calcineurin inhibitor (CNI) to mTOR inhibitor based IS, in conjunction with standard anti-lymphoma chemoimmunotherapy. Progression free survival of the PTLD DLBCL cohort was calculated at 86% at 1 year, and 77% at 3 and 5-years, with overall survival of 86% at 1 and 3-years, and 75% at 5 years. Death censored allograft survival in the kidney cohort was 100% at 1 year, and 93% at 3, 5 and 10 years. MCT1 H scores were significantly higher in a subset of the non-PTLD DLBCL patients than in a PTLD DLBCL cohort. Our data is concordant with improved PTLD outcomes in the last 10 years. mTOR inhibitors could be an alternative to CNI as a RIS strategy. Finally, PTLD DLBCL may have a distinct metabolic profile with reduced MCT1 expression compared to non-PTLD DLBCL, but further studies are needed to corroborate our limited cohort findings and to determine if a specific metabolic profile is associated with outcomes.
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Affiliation(s)
- Goni Katz-Greenberg
- Department of Medicine, Division of Nephrology, Duke UniversityDurham, NC 27710, USA
- Department of Medicine, Division of Nephrology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Sushil Ghimire
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Tinging Zhan
- Department of Pharmacology and Experimental Therapeutics, Division of Biostatistics, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Kashka Mallari
- Sidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Diana Whitaker-Menezes
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Jerald Gong
- Department of Pathology, Anatomy and Cell Biology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Guldeep Uppal
- Department of Pathology, Anatomy and Cell Biology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Ubaldo Martinez-Outschoorn
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
- Sidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
| | - Maria P Martinez Cantarin
- Department of Medicine, Division of Nephrology, Sidney Kimmel Cancer Center, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
- Sidney Kimmel Medical College, Thomas Jefferson UniversityPhiladelphia, PA 19107, USA
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Characteristics of T- and NK-cell Lymphomas After Renal Transplantation: A French National Multicentric Cohort Study. Transplantation 2021; 105:1858-1868. [PMID: 33560724 DOI: 10.1097/tp.0000000000003568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorders (PTLDs) encompass a spectrum of heterogeneous entities. Because the vast majority of cases PTLD arise from B cells, available data on PTLD of T or NK phenotype (T/NK-cell PTLD) are scarce, which limits the quality of the management of these patients. METHODS All adult cases of PTLD diagnosed in France were prospectively recorded in the national registry between 1998 and 2007. Crosschecking the registry data with 2 other independent national databases identified 58 cases of T/NK-cell PTLD. This cohort was then compared with (i) the 395 cases of B-cell PTLD from the registry, and of (ii) a cohort of 148 T/NK-cell lymphomas diagnosed in nontransplanted patients. RESULTS T/NK-cell PTLD occurred significantly later after transplantation and had a worse overall survival than B-cell PTLD. Two subtypes of T/NK-cell PTLD were distinguished: (i) cutaneous (28%) and (ii) systemic (72%), the latter being associated with a worse prognosis. Compared with T/NK-cell lymphomas of nontransplanted patients, overall survival of systemic T/NK-cell PTLD was worse (hazard ratio: 2.64 [1.76-3.94]; P < 0.00001). CONCLUSIONS This difference, which persisted after adjustment on tumoral mass, histological subtype, and extension of the disease at diagnosis could be explained by the fact that transplanted patients were less intensively treated and responded less to chemotherapy.
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Robinson C, Chanchlani R, Kitchlu A. Malignancies after pediatric solid organ transplantation. Pediatr Nephrol 2021; 36:2279-2291. [PMID: 33057766 DOI: 10.1007/s00467-020-04790-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/28/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022]
Abstract
As life expectancy among pediatric solid organ transplant recipients (SOTRs) improves, the risk of comorbid conditions such as malignancy post-transplantation has also increased. SOTRs are at elevated risks of post-transplantation lymphoproliferative disorders (PTLDs), and skin and solid cancers. PTLDs typically occur early following transplantation, while skin and solid cancers frequently arise in young adulthood (25-40 years). By 30 years following transplantation, 26-41% of pediatric SOTRs have developed cancer. Different risk factors exist for PTLD, and skin and solid cancers, which are modified by cumulative immunosuppression, infections, transplanted organ, and the underlying disease process associated with initial organ failure (e.g., kidney failure). Optimal cancer treatment strategies depend on the specific cancer type, stage, and patient comorbidities. Immunosuppression reduction may be beneficial for certain cancers but must be considered against the risks of acute and chronic rejection and allograft loss. Lifestyle counseling regarding smoking avoidance and sun protection, as well as human papillomavirus vaccination, is an important aspect of cancer prevention. Currently, no cancer screening guidelines exist specifically for pediatric SOTRs. Adult population screening guidelines have not been validated in transplant populations. Therefore, an individualized approach should be taken to cancer screening for pediatric SOTRs, accounting for other cancer risk factors.
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Affiliation(s)
- Cal Robinson
- Division of Paediatric Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES McMaster, Hamilton, Ontario, Canada
| | - Abhijat Kitchlu
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, 200 Elizabeth Street, 8 Eaton North, 8 N-842, Toronto, Ontario, M5G 2C4, Canada.
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Dang BN, Ch'ng J, Russell M, Cheng JC, Moore TB, Alejos JC. Treatment of post-transplant lymphoproliferative disorder (PTLD) in a heart transplant recipient with chimeric antigen receptor T-cell therapy. Pediatr Transplant 2021; 25:e13861. [PMID: 33002249 DOI: 10.1111/petr.13861] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/15/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are a group of lesions that can complicate solid organ or hematopoietic stem cell transplantation and are often associated with Epstein-Barr virus (EBV). The treatment of PTLD is dependent on the type of lesion and includes a wide range of therapies, but chimeric antigen receptor (CAR) T-cell therapy has not previously been reported as a treatment option for PTLD. We present a patient who developed refractory PTLD in her right retroperitoneum, right inguinal and iliac chains, and right axillary region shortly after heart transplantation and was treated with CAR T-cell therapy. She could not tolerate complete discontinuation of immunosuppression due to the risk of rejection of a life-supporting graft. The patient's PTLD responded to CAR T-cell therapy, and her heart was monitored throughout the treatment course without any signs of rejection or ventricular dysfunction. CAR T-cell therapy may be a viable treatment option in patients who develop PTLD after a solid organ transplant.
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Affiliation(s)
- Brian N Dang
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - James Ch'ng
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Matthew Russell
- Division of Pediatric Cardiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jerry C Cheng
- Pediatric Hematology and Oncology, Southern California Kaiser Permanente Medical Group, Los Angeles, CA, USA
| | - Theodore B Moore
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Juan C Alejos
- Division of Pediatric Cardiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
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Shahid S, Prockop SE. Epstein-Barr virus-associated post-transplant lymphoproliferative disorders: beyond chemotherapy treatment. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2021; 4:646-664. [PMID: 34485854 PMCID: PMC8415721 DOI: 10.20517/cdr.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/10/2021] [Accepted: 05/19/2021] [Indexed: 12/30/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a rare but life-threatening complication of both allogeneic solid organ (SOT) and hematopoietic cell transplantation (HCT). The histology of PTLD ranges from benign polyclonal lymphoproliferation to a lesion indistinguishable from classic monoclonal lymphoma. Most commonly, PTLDs are Epstein-Barr virus (EBV) positive and result from loss of immune surveillance over EBV. Treatment for PTLD differs from the treatment for typical non-Hodgkin lymphoma because prognostic factors are different, resistance to treatment is unique, and there are specific concerns for organ toxicity. While recipients of HCT have a limited time during which they are at risk for this complication, recipients of SOT have a lifelong requirement for immunosuppression, so approaches that limit compromising or help restore immune surveillance are of high interest. Furthermore, while EBV-positive and EBV-negative PTLDs are not intrinsically resistant to chemotherapy, the poor tolerance of chemotherapy in the post-transplant setting makes it essential to minimize potential treatment-related toxicities and explore alternative treatment algorithms. Therefore, reduced-toxicity approaches such as single-agent CD20 monoclonal antibodies or bortezomib, reduced dosing of standard chemotherapeutic agents, and non-chemotherapy-based approaches such as cytotoxic T cells have all been explored. Here, we review the chemotherapy and non-chemotherapy treatment landscape for PTLD.
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Affiliation(s)
| | - Susan E. Prockop
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Kinch A, Baecklund E, Molin D, Pauksens K, Sundström C, Tufveson G, Enblad G. Prior antithymocyte globulin therapy and survival in post-transplant lymphoproliferative disorders. Acta Oncol 2021; 60:771-778. [PMID: 33793378 DOI: 10.1080/0284186x.2021.1904520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Treatment with antithymocyte globulin (ATG) is a well-recognized risk factor for the development of post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation, but it is unknown how its use affects overall survival after PTLD.Methods: A total of 114 patients with PTLD and available data on immunosuppressive regimen were included from a nation-wide case series of solid organ transplant recipients in Sweden. Prior use of ATG was correlated to clinical features, PTLD subtype, and survival.Results: A total of 47 (41%) patients had received ATG prior to the diagnosis of PTLD. The ATG-treated patients were more likely to be recipients of hearts or lungs, and less likely of kidneys (p < 0.01). They had experienced more acute rejections (p = 0.02). The PTLDs arose earlier, median 2.0 vs. 6.6 years post-transplant (p = 0.002) and were more often situated in the allograft (32% vs. 7%, p < 0.001) in patients with prior ATG vs. no ATG treatment. The PTLDs in the ATG group were more often Epstein-Barr virus-positive (80% vs. 40%, p < 0.001). There were more polymorphic PTLDs (17% vs. 1.5%, p = 0.004) and less T-cell PTLDs (4% vs. 19%, p = 0.02) in the ATG group than in the no ATG group. Diffuse large B-cell lymphoma was equally common in patients with and without prior ATG therapy, but the non-germinal center subtype was more frequent in the ATG group (p = 0.001). In an adjusted Cox proportional hazards regression model, prior ATG treatment and better performance status were associated with superior overall survival, whereas older age, T-cell subtype of PTLD, presence of B symptoms, and elevated lactate dehydrogenase were associated with inferior overall survival. Patients receiving ATG solely as rejection therapy had superior overall survival compared with those receiving ATG as induction therapy or both (p = 0.03).Conclusions: ATG therapy, especially rejection therapy, prior to PTLD development is an independent prognostic factor for superior overall survival after PTLD diagnosis.
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Affiliation(s)
- Amelie Kinch
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Daniel Molin
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Karlis Pauksens
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Christer Sundström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Gunnar Tufveson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunilla Enblad
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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50
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McDonald L, O' Doherty R, Ryan E, Enright H, Dunlea E, Kelliher S, Fortune A, Fay M, Maung SW, Desmond R, Wall C, Kumar S, O' Shea D, Fadalla K, Connaghan DG, Smyth L. Posttransplant Lymphoproliferative Disorder After Solid Organ Transplant: A Heterogeneous, Aggressive Disorder. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:694-700. [PMID: 34148849 DOI: 10.1016/j.clml.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 11/17/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplant. We identified 40 patients diagnosed with PTLD between 2009 and 2020 and analyzed their presentation, treatment strategies, and outcomes. Median age at diagnosis was 52.5 years (range 21.3 to 79). Median duration of immunosuppression was 95 months (range 4 to 292). Diffuse large B cell lymphoma (n = 16, 40%) and Burkitt lymphoma (n = 6, 15%) were the most common histological subtypes. First-line therapy varied. The median number of treatment lines was 1 (range 0 to 4). Sixteen patients (40%) achieved complete response after first-line therapy. Nineteen patients (47.5%) relapsed or progressed and received salvage therapy; 45% were alive at the end of the study period (median survival 52 months; range 1 to 266; 95% confidence interval 0 to 104). Causes of death included lymphoma-related (45.5%), therapy-related (27.3%), and other (27.3%). Five (22.7%) died within 3 months of diagnosis. Pearson's r test identified disease stage (P = .045) and proliferation index (P = .005) as negative predictors of response to frontline therapy. Bone marrow involvement (P = .033) and increased age (P = .018) were significant predictors of survival. Early mortality and poor response to frontline therapy are common, outlining the need for improved treatment strategies.
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Affiliation(s)
- Laura McDonald
- Department of Haematology, St Vincent's University Hospital, Elm Park, Dublin, Ireland.
| | - Roseann O' Doherty
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Eileen Ryan
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Helen Enright
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - Eoghan Dunlea
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Sarah Kelliher
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Anne Fortune
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Michael Fay
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - S W Maung
- Department of Haematology, Mater Misericordiae University Hospital, Eccles St, Dublin, Ireland
| | - Ronan Desmond
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - Catherine Wall
- Department of Haematology, Tallaght University Hospital, Dublin, Ireland
| | - Senthil Kumar
- Department of Haematology, University Hospital Waterford, Waterford, Ireland
| | - Derville O' Shea
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Kamal Fadalla
- Department of Haematology, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - D G Connaghan
- Department of Haematology, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Liam Smyth
- Department of Haematology, St Vincent's University Hospital, Elm Park, Dublin, Ireland
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