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Su YY, Yu YF, Yan ZY, Zhao YJ, Lou JW, Xue F, Xu M, Feng Q, Ji XB, Dong XY, Wang W, Liu CF, Peng J, Liu XG. Post-transplant lymphoproliferative disorders after allogeneic hematopoietic stem cell transplantation: a case report, meta-analysis, and systematic review. Diagn Pathol 2024; 19:122. [PMID: 39244586 PMCID: PMC11380407 DOI: 10.1186/s13000-024-01544-8] [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: 05/20/2024] [Accepted: 08/28/2024] [Indexed: 09/09/2024] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorders (PTLD) are rare but severe complications that occur after solid organ or allogeneic hematopoietic stem cell transplantations (allo-HSCT), with rapid progression and high mortality. Primary central nervous system (CNS)-PTLD are rarely recognized histo-pathologically. In addition, the diagnostic value of the Epstein-Barr virus (EBV) DNA copies in CNS-PTLD remains poorly understood. OBJECTIVES We herein report a case of monomorphic EBV-associated CNS-PTLD (diffuse large B-cell lymphoma, DLBCL) after allo-HSCT and perform a meta-analysis to assess the efficacy of PTLD treatment strategies in recent years. METHODS We present the case report covering clinical manifestations, diagnosis, treatment, and outcomes of a patient with primary CNS-PTLD. Additionally, we include a systematic review and meta-analysis of the clinical characteristics of 431 patients with PTLD after allo-HSCT. We evaluate the main treatment options and outcomes of PTLD management, including rituximab, chemotherapies, and autologous or human leukocyte antigen (HLA)-matched EBV-specific cytotoxic T lymphocyte infusion (EBV-CTLs)/donor lymphocyte infusion (DLI). RESULTS The meta-analysis revealed an overall response rate of 69.0% for rituximab alone (95% CI: 0.47-0.84), 45.0% for rituximab plus chemotherapies (95% CI: 0.15-0.80), and 91.0% for rituximab plus EBV-CTLs/DLI (95% CI: 0.83-0.96). The complete response (CR) rate after treatments for PTLD was 67.0% (95% CI: 0.56-0.77). Moreover, the 6-month and 1-year overall survival (OS) rate was 64.0% (95% CI: 0.31-0.87) and 49.0% (95% CI: 0.31-0.68), respectively. CONCLUSIONS This case highlighted the urgent need for effective, low-toxic treatment regimens for CNS-PTLD. Our meta-analysis suggested that rituximab combined with EBV-CTLs/DLI could be a favorable strategy for the management of PTLD after allo-HSCT.
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Affiliation(s)
- You-Yuan Su
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Ya-Fei Yu
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Zhen-Yu Yan
- North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Ya-Jing Zhao
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China.
| | - Jian-Wei Lou
- Department of Neurology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Feng Xue
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Miao Xu
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Qi Feng
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Xue-Bin Ji
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Xiao-Yuan Dong
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Wen Wang
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Chuan-Fang Liu
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China
| | - Xin-Guang Liu
- Department of Hematology, Qilu Hospital of Shandong University, 107 West Wenhua Road, Jinan, Shandong, 250012, China.
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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Allen UD, L'Huillier AG, Bollard CM, Gross TG, Hayashi RJ, Höcker B, Maecker-Kolhoff B, Marks SD, Mazariegos GV, Smets F, Trappe RU, Visner G, Chinnock RE, Comoli P, Danziger-Isakov L, Dulek DE, Dipchand AI, Ferry JA, Martinez OM, Metes DM, Michaels MG, Preiksaitis J, Squires JE, Swerdlow SH, Wilkinson JD, Dharnidharka VR, Green M, Webber SA, Esquivel CO. The IPTA Nashville consensus conference on post-transplant lymphoproliferative disorders after solid organ transplantation in children: IV-consensus guidelines for the management of post-transplant lymphoproliferative disorders in children and adolescents. Pediatr Transplant 2024; 28:e14781. [PMID: 38808744 DOI: 10.1111/petr.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
The International Pediatric Transplant Association convened an expert consensus conference to assess current evidence and develop recommendations for various aspects of care relating to post-transplant lymphoproliferative disorders (PTLD) after pediatric solid organ transplantation. This report addresses the outcomes of deliberations by the PTLD Management Working Group. A strong recommendation was made for reduction in immunosuppression as the first step in management. Similarly, strong recommendations were made for the use of the anti-CD20 monoclonal antibody (rituximab) as was the case for chemotherapy in selected scenarios. In some scenarios, there is uncoupling of the strength of the recommendations from the available evidence in situations where such evidence is lacking but collective clinical experiences drive decision-making. Of note, there are no large, randomized phase III trials of any treatment for PTLD in the pediatric age group. Current gaps and future research priorities are highlighted.
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Affiliation(s)
- Upton D Allen
- Division of Infectious Diseases, Department of Paediatrics, Transplant and Regenerative Medicine Center, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Arnaud G L'Huillier
- Pediatric Infectious Diseases Unit and Laboratory of Virology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital, The George Washington University, Washington, District of Columbia, USA
| | - Thomas G Gross
- Center for Cancer and Blood Diseases, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Britta Höcker
- Department of Pediatrics I, Medical Faculty, University Children's Hospital, Heidelberg University, Heidelberg, Germany
| | | | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - George Vincent Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francoise Smets
- Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany
- Department of Internal Medicine II: Hematology and Oncology, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | | | - Patrizia Comoli
- Cell Factory & Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Junior Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judith A Ferry
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Olivia M Martinez
- Department of Surgery and Program in Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Diana M Metes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jutta Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven H Swerdlow
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension & Apheresis, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Michael Green
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
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3
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Hoyt D, Hughes J, Liu J, Ayyad H. Primary central nervous system post-transplantation lymphoproliferative disorder: A case report and systematic review of imaging findings. Radiol Case Rep 2024; 19:2168-2182. [PMID: 38515768 PMCID: PMC10950589 DOI: 10.1016/j.radcr.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/23/2024] Open
Abstract
Primary central nervous system post-transplant lymphoproliferative disease (PCNS-PTLD) is a rare subset of post-transplant lymphoproliferative disorder (PTLD) isolated to the CNS without nodal or extra-nodal organ involvement [1,2]. PCNS-PTLD occurs primarily in patients following either solid organ transplants or hematopoietic stem cell transplants and tends to be monomorphic DLBCL. The development of PCNS-PTLD is commonly associated with EBV infection [3]. Many intracranial pathologies can resemble the imaging appearance of PCNS-PTLD, including primary CNS lymphoma, glial tumors, metastatic disease, and intracranial abscesses. The purpose of this systematic review is to identify the most common imaging characteristics of PCNS-PTLD. Our review included 97 sources that describe the imaging appearance of PCNS-PTLD. Based on our review, PCNS-PTLD lesions are typically multifocal, ring-enhancing and diffusion-restricting. PCNS-PTLD lesions typically demonstrate focal FDG avidity. Despite advancement in medical imaging, PCNS-PTLD remains a diagnostic challenge due to its rare incidence. Limited data is available on advanced imaging with regards to PTLD, but techniques including DCE-MRI and fMRI demonstrate promising results that may help further delineate PCNS-PTLD.
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Affiliation(s)
- Dylan Hoyt
- Barrow Neurological Institute, Department of Neuroradiology, 350 W Thomas Road, Phoenix, AZ 85013
- Creighton University Arizona Diagnostic Radiology Residency, Department of Radiology, 350 W Thomas Road, Phoenix, AZ 85013
| | - Jeremy Hughes
- Barrow Neurological Institute, Department of Neuroradiology, 350 W Thomas Road, Phoenix, AZ 85013
| | - John Liu
- Creighton University School of Medicine, 2621 Burt St., Omaha, NE 68178
| | - Hashem Ayyad
- Department of Radiology, St. Josephs Hospital and Medical Center, Department of Pathology, 350 W Thomas Road, Phoenix, AZ 85013
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4
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Aslan F, Güler S, Sezgin Evim M, Aslier M, Yazici Z, Öztürk Nazlioğlu H, Meral Güneş A. Successful Treatment of Central Nervous System Involvement in Posttransplant EBV-related Lymphoproliferative Disease With Intrathecal Rituximab Therapy. J Pediatr Hematol Oncol 2023; 45:e628-e630. [PMID: 36730621 DOI: 10.1097/mph.0000000000002592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/13/2022] [Indexed: 02/04/2023]
Abstract
The posttransplant lymphoproliferative disease is a severe cause of morbidity and mortality following allogeneic hematopoietic stem cell transplantation. Central Nervous System involvement in EBV-related PTLD is rare, and there is no standard treatment recommendation. We present our patient and discuss other previously reported cases of EBV-associated PTLD with CNS involvement.
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5
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Bhargava P, Hartung HP, Calabresi PA. Contribution of B cells to cortical damage in multiple sclerosis. Brain 2022; 145:3363-3373. [PMID: 35775595 DOI: 10.1093/brain/awac233] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/06/2022] [Accepted: 06/17/2022] [Indexed: 11/14/2022] Open
Abstract
Multiple sclerosis is associated with lesions not just in the white matter, but also involving the cortex. Cortical involvement has been linked to greater disease severity and hence understanding the factor underlying cortical pathology could help identify new therapeutic strategies for multiple sclerosis. The critical role of B cells in multiple sclerosis has been clarified by multiple pivotal trials of B cell depletion in people with multiple sclerosis. The presence of B cell rich areas of meningeal inflammation in multiple sclerosis has been identified at all stages of multiple sclerosis. Leptomeningeal inflammation is associated with greater extent of cortical demyelination and neuronal loss and with greater disease severity. Recent studies have identified several potential mechanisms by which B cells may mediate cortical injury including antibody production, extracellular vesicles containing neurotoxic substances and production of pro-inflammatory cytokines. Additionally, B cells may indirectly mediate cortical damage through effects on T cells, macrophages or microglia. Several animal models replicate the meningeal inflammation and cortical injury noted in people with multiple sclerosis. Studies in these models have identified BTK inhibition and type II anti-CD20 antibodies as potential agents that can impact meningeal inflammation. Trials of anti-CD20 monoclonal antibodies in people with multiple sclerosis have unsuccessfully attempted to eliminate B cells in the leptomeninges. New strategies to target B cells in multiple sclerosis include BTK inhibition and cell-based therapies aimed at B cells infected with Epstein Barr virus. Future studies will clarify the mechanisms by which B cells mediate cortical injury and treatment strategies that can target B cells in the leptomeninges and CNS parenchyma.
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Affiliation(s)
- Pavan Bhargava
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hans Peter Hartung
- Department of Neurology, Heinrich-Heine University, Dusseldorf, Germany.,Brain and Mind Center, University of Sydney, Sydney, Australia.,Department of Neurology, Medical University of Vienna, Vienna, Austria.,Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Anastasiou M, Mamez AC, Masouridi S, Vargas MI, Hadaya K, Egervari K, Chalandon Y. Successful treatment of central nervous system lymphoproliferative disorder in a kidney-pancreas and stem cell transplanted patient using intrathecal rituximab. BMJ Case Rep 2021; 14:14/8/e238236. [PMID: 34353823 PMCID: PMC8344276 DOI: 10.1136/bcr-2020-238236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Central nervous system lymphoproliferative disorder (CNS-PTLD) after organ transplant is a unique clinicopathological entity and is associated with poor survival rates. When the CNS is involved, intravenous rituximab might not be the treatment of choice, due to its poor CNS penetration. However, intrathecal (IT) administration of rituximab has shown to be safe and efficient in small studies and in case series. We report here the case of a patient with late development of CNS-PTLD after kidney-pancreas transplantation who achieved complete remission after surgical resection and four cycles of IT rituximab and we provide a review of the literature for this treatment option.
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Affiliation(s)
- Maria Anastasiou
- Oncology, Division Hematology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - Anne-Claire Mamez
- Oncology, Division Hematology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - Stavroula Masouridi
- Oncology, Division Hematology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | | | - Karine Hadaya
- Nephrology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - Kristof Egervari
- Service of Clinical Pathology, Department of Genetic Medicine, Laboratory and Pathology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
| | - Yves Chalandon
- Oncology, Division Hematology, Hopitaux Universitaires de Geneve, Geneva, Switzerland
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7
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Wen J, Cheever T, Wang L, Wu D, Reed J, Mascola J, Chen X, Liu C, Pegu A, Sacha JB, Lu Y, Haigwood NL, Chen ISY. Improved delivery of broadly neutralizing antibodies by nanocapsules suppresses SHIV infection in the CNS of infant rhesus macaques. PLoS Pathog 2021; 17:e1009738. [PMID: 34283885 PMCID: PMC8323878 DOI: 10.1371/journal.ppat.1009738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/30/2021] [Accepted: 06/22/2021] [Indexed: 12/31/2022] Open
Abstract
Broadly neutralizing antibodies (bNAbs) directed to HIV-1 have shown promise at suppressing viremia in animal models. However, the use of bNAbs for the central nervous system (CNS) infection is confounded by poor penetration of the blood brain barrier (BBB). Typically, antibody concentrations in the CNS are extremely low; with levels in cerebrospinal fluid (CSF) only 0.1% of blood concentrations. Using a novel nanotechnology platform, which we term nanocapsules, we show effective transportation of the human bNAb PGT121 across the BBB in infant rhesus macaques upon systemic administration up to 1.6% of plasma concentration. We demonstrate that a single dose of PGT121 encased in nanocapsules when delivered at 48h post-infection delays early acute infection with SHIVSF162P3 in infants, with one of four animals demonstrating viral clearance. Importantly, the nanocapsule delivery of PGT121 improves suppression of SHIV infection in the CNS relative to controls. In patients where HIV-1 is fully suppressed by antiretroviral drugs, HIV-1 still persists in reservoirs. If antiretroviral drugs are stopped, the virus will emerge from these reservoirs and re-seeds systemically. The central nervous system (CNS) is proposed to be a tissue compartment that harbors other HIV-1 reservoirs. A key obstacle that constrains the treatment for the CNS infection is the blood–brain barrier (BBB), a highly restrictive barrier separating the circulating blood from the brain and extracellular fluid in the CNS, which impedes ~98% of the small molecule therapeutics and almost all macromolecules including broadly neutralizing antibodies (bNAbs) directed to HIV-1. Our “nanocapsule” strategy is based on a nanotechnology wherein bNAb molecules are encapsulated within nanocapsules of which the surface contains abundant choline and acetylcholine analogues. This design allows the nanocapsules to effectively cross the BBB to deliver bNAbs into the CNS upon systemic administration and show an impact of bNAb on CNS reservoirs in SHIV infected infant macaques.
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Affiliation(s)
- Jing Wen
- Department of Microbiology, Immunology and Molecular Genetics, David Geffen School of Medicine, University of California Los Angeles (UCLA), UCLA AIDS Institute, Los Angeles, California, United States of America
| | - Tracy Cheever
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, United States of America
| | - Lan Wang
- Department of Microbiology, Immunology and Molecular Genetics, David Geffen School of Medicine, University of California Los Angeles (UCLA), UCLA AIDS Institute, Los Angeles, California, United States of America
| | - Di Wu
- Department of Chemical and Biomolecular Engineering, School of Engineering, UCLA, Los Angeles, California, United States of America
| | - Jason Reed
- Vaccine & Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, United States of America
| | - John Mascola
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda Maryland, United States of America
| | - Xuejun Chen
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda Maryland, United States of America
| | - Cuiping Liu
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda Maryland, United States of America
| | - Amarendra Pegu
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, NIH, Bethesda Maryland, United States of America
| | - Jonah B Sacha
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, United States of America.,Vaccine & Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, United States of America
| | - Yunfeng Lu
- Department of Chemical and Biomolecular Engineering, School of Engineering, UCLA, Los Angeles, California, United States of America
| | - Nancy L Haigwood
- Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, Oregon, United States of America
| | - Irvin S Y Chen
- Department of Microbiology, Immunology and Molecular Genetics, David Geffen School of Medicine, University of California Los Angeles (UCLA), UCLA AIDS Institute, Los Angeles, California, United States of America
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Abstract
OBJECTIVE We report a case of facial paresis and profound hearing loss from post-transplant lymphoproliferative disorder (PTLD) in a pediatric patient with neuroblastoma. PATIENT Three-year-old boy with rapidly progressive right facial paresis and sensorineural hearing loss. High-risk neuroblastoma had been diagnosed 1 year earlier, treated with chemotherapy and resection of the adrenal primary tumor. Two months after two autologous hematopoietic stem cell transplantations (HSCT), the patient developed facial paralysis. Magnetic resonance imaging (MRI) showed bilateral progressive internal auditory canal (IAC) enhancing lesions with a mass lesion on the right and wispy enhancement on the left and enhancement within the right cochlea. Lumbar puncture (LP) was positive for Epstein-Barr virus (EBV) making the diagnosis of PTLD most probable. Biopsy of the right IAC lesion was deferred because of potential procedural risks including intradural spread of tumor or fungus. The patient was treated with anti-fungal therapy and systemic rituximab without improvement. Subsequent intrathecal rituximab resulted in improvement of lesions on MRI and clearance of EBV from the cerebrospinal fluid (CSF). INTERVENTIONS Mastoidectomy for biopsies from the mastoid and middle ear. Intrathecal treatment with rituximab. MAIN OUTCOME MEASURES Imaging assessment of IAC lesion, CSF EBV titers, facial nerve function. RESULTS Gradual resolution of IAC mass lesions, remission of PTLD, and facial improvement from House-Brackmann score of 4 to 3. CONCLUSIONS PTLD causing facial paresis after autologous HSCT has not been previously reported and may be considered in the differential diagnosis of lesions causing facial paresis in patients who have received a stem cell or solid organ transplant.
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9
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Zimmermann H, Nitsche M, Pott C, Reinke P, Babel N, Hermann RM, Hauser IA, Hahn D, Ritgen M, Pietschmann C, Klapper W, Anagnostopoulos I, Trappe RU. Reduction of immunosuppression combined with whole-brain radiotherapy and concurrent systemic rituximab is an effective yet toxic treatment of primary central nervous system post-transplant lymphoproliferative disorder (pCNS-PTLD): 14 cases from the prospective German PTLD registry. Ann Hematol 2021; 100:2043-2050. [PMID: 33973053 DOI: 10.1007/s00277-021-04548-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/01/2021] [Indexed: 01/10/2023]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) exclusively affecting the central nervous system-primary CNS-PTLD (pCNS-PTLD)-are rare. There is no standard therapy, and previous case series have included heterogeneous treatment approaches. We performed a retrospective, multi-centre analysis of 14 patients with pCNS-PTLD after solid organ transplantation (SOT) treated in the prospective German PTLD registry with reduction of immunosuppression (RI), whole-brain radiotherapy (WBRT), and concurrent systemic rituximab between 2001 and 2018. Twelve of fourteen patients were kidney transplant recipients and median age at diagnosis was 65 years. Thirteen of fourteen cases (93%) were monomorphic PTLD of the diffuse large B-cell lymphoma type, and 12/13 were EBV-associated. The median dose of WBRT administered was 40 Gy with a median fraction of 2 Gy. The median number of administered doses of rituximab (375 mg/m2) IV was four. All ten patients evaluated responded to treatment (100%). Median OS was 2.5 years with a 2-year Kaplan-Meier estimate of 63% (95% confidence interval 30-83%) without any recorded relapses after a median follow-up of 2.6 years. Seven of fourteen patients (50%) suffered grade III/IV infections under therapy (fatal in two cases, 14%). During follow-up, imaging demonstrated grey matter changes interpreted as radiation toxicity in 7/10 evaluated patients (70%). The combination of RI, WBRT, and rituximab was an effective yet toxic treatment of pCNS-PTLD in this series of 14 patients. Future treatment approaches in pCNS-PTLD should take into account the significant risk of infections as well as radiation-induced neurotoxicity.
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Affiliation(s)
- Heiner Zimmermann
- Department of Haematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Gröpelinger Heerstr. 406-408, 28239, Bremen, Germany
| | | | - Christiane Pott
- Department of Internal Medicine II: Haematology and Oncology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nina Babel
- Center for Translational Medicine and Department of Internal Medicine I, Marien Hospital Herne, Ruhr-University Bochum University Hospital, Herne, Germany
| | - Robert M Hermann
- Center of Radiotherapy, Bremen, Germany
- Department of Radiotherapy and Special Oncology, Hannover Medical School, Hannover, Germany
| | - Ingeborg A Hauser
- Department of Nephrology, UKF, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Dennis Hahn
- Department of Haematology, Oncology and Palliative Care, Katharinen hospital, Stuttgart, Germany
| | - Matthias Ritgen
- Department of Internal Medicine II: Haematology and Oncology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Wolfram Klapper
- Department of Haematopathology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Ralf U Trappe
- Department of Haematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Gröpelinger Heerstr. 406-408, 28239, Bremen, Germany.
- Department of Internal Medicine II: Haematology and Oncology, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany.
- Department of Haematology and Oncology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
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10
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Czyzewski K, Dziedzic M, Salamonowicz M, Fraczkiewicz J, Zajac-Spychala O, Zaucha-Prazmo A, Gozdzik J, Galazka P, Bartoszewicz N, Demidowicz E, Styczynski J. Epidemiology, Outcome and Risk Factors Analysis of Viral Infections in Children and Adolescents Undergoing Hematopoietic Cell Transplantation: Antiviral Drugs Do Not Prevent Epstein-Barr Virus Reactivation. Infect Drug Resist 2019; 12:3893-3902. [PMID: 31908501 PMCID: PMC6925545 DOI: 10.2147/idr.s224291] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/05/2019] [Indexed: 12/28/2022] Open
Abstract
Objective The analysis of epidemiology, risk factors and outcome of viral infections in children and adolescents after hematopoietic cell transplantation (HCT). Methods In this multicenter nationwide study a total of 971 HCT procedures (741 allo-HCT; 230 auto-HCT) over a period of 6 years were analyzed. Results During this period 801 episodes of viral infections were diagnosed in 442 patients. The incidence of viral infections was 57.9% in allo-HCT and 4.8% in auto-HCT patients. The most frequent infections after allo-HCT were caused by cytomegalovirus (CMV), polyoma BK virus (BKV) and Epstein-Barr virus (EBV). The majority of infections occurred within the first 4 months after allo-HCT and over 80% required pharmacotherapy or symptomatic therapy. The median time of treatment of specific viral infection ranged from 7 (for EBV) to 24 (for CMV) days. The highest mortality was observed in case of CMV infection. The risk factors for viral infections were allo-HCT, acute leukemia, acute and chronic graft versus host disease (a/cGVHD), and matched unrelated donor (MUD)/mismatched unrelated donor (MMUD)-HCT. The risk factor for death from viral infection were CMV-IgG seropositivity in acute lymphoblastic leukemia recipient, and MUD/MMUD-HCT. The incidence of EBV infection requiring pre-emptive treatment with rituximab in allo-HCT children was 19.3%. In 30.8% cases of EBV infection, these episodes were preceded by other viral infection and treated with antivirals, which did not prevent development of EBV-DNA-emia with need of rituximab treatment in 81.5% cases. In 47.7% of these cases, GVHD was a factor enabling development of significant EBV-DNA-emia during antiviral therapy of other infection. Conclusion We have shown that antiviral drugs do not prevent EBV reactivation in allo-HCT pediatric patients.
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Affiliation(s)
- Krzysztof Czyzewski
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Malgorzata Salamonowicz
- Department of Pediatric Transplantation, Oncology and Hematology, Medical University, Wroclaw, Poland
| | - Jowita Fraczkiewicz
- Department of Pediatric Transplantation, Oncology and Hematology, Medical University, Wroclaw, Poland
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - Agnieszka Zaucha-Prazmo
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - Jolanta Gozdzik
- Stem Cell Transplant Center, University Children's Hospital, Department of Clinical Immunology and Transplantology, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Przemyslaw Galazka
- Department of General and Oncological Surgery for Children and Adolescents, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Natalia Bartoszewicz
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Ewa Demidowicz
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
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11
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Abstract
Bing-Neel syndrome (BNS) is an uncommon presentation of Waldenström macroglobulinaemia (WM), seen during the course of the disease in about 1% of patients. BNS occurs when WM cells gain access to the central nervous system (CNS) causing neurological deficits. The diagnosis of BNS is suggested by the presence of radiological abnormalities, such as leptomeningeal enhancement on magnetic resonance imaging and confirmed by the presence of clonal lymphoplasmacytic cells and MYD88 L265P in the cerebrospinal fluid. The treatment of BNS requires agents with good penetration into the CNS, such as fludarabine, methotrexate and cytarabine. The novel Bruton Tyrosine Kinase inhibitor ibrutinib has shown CNS-penetrating properties, and recent data suggest a therapeutic role in BNS. In this review, we will discuss the clinical and pathological features, diagnostic criteria, treatment options and outcomes of patients with BNS.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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12
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Sustained delivery and molecular targeting of a therapeutic monoclonal antibody to metastases in the central nervous system of mice. Nat Biomed Eng 2019; 3:706-716. [PMID: 31384008 PMCID: PMC6736720 DOI: 10.1038/s41551-019-0434-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/26/2019] [Indexed: 11/24/2022]
Abstract
Approximately 15–40% of all cancers develop metastases in the
central nervous system (CNS), yet few therapeutic options exist to treat them.
Cancer therapies based on monoclonal antibodies are widely successful, yet have
limited efficacy against CNS metastases, owing to the low levels of the drug
reaching the tumour site. Here, we show that the encapsulation of rituximab
within a crosslinked zwitterionic polymer layer leads to the sustained release
of rituximab as the crosslinkers are gradually hydrolyzed, enhancing by
approximately 10-fold the CNS levels of the antibody with respect to the
administration of naked rituximab. When the nanocapsules are functionalized with
CXCL13, the ligand for the chemokine receptor CXCR5 frequently found on B-cell
lymphoma, a single dose led to improved control of CXCR5-expressing metastases
in a murine xenograft model of non-Hodgkin lymphoma, and eliminated lymphoma in
a xenografted humanized bone-marrow–liver–thymus mouse model.
Encapsulation and molecular targeting of therapeutic antibodies could become an
option for the treatment of cancers with CNS metastases.
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13
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Clinical utility of measuring Epstein–Barr virus-specific cell-mediated immunity after HSCT in addition to virological monitoring: results from a prospective study. Med Microbiol Immunol 2019; 208:825-834. [DOI: 10.1007/s00430-019-00629-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/29/2019] [Indexed: 12/11/2022]
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14
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Gui RR, Zu YL, Zhang Y, Han LJ, Zhao HF, Li Z, Yu FK, Wang J, Zhao JJ, Fu YW, Song YP, Zhou J. [Successful treatment of Epstein-Barr virus associated central nervous system diseases after allogeneic hematopoietic stem cell transplantation with intrathecal donor lymphocytes infusion: three cases report and literatures review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:333-335. [PMID: 31104448 PMCID: PMC7343007 DOI: 10.3760/cma.j.issn.0253-2727.2019.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 11/24/2022]
Affiliation(s)
- R R Gui
- Department of Hematology Affiliated Cancer Hospital Zhengzhou University, Henan Tumor Hospital, Institute of Hematology, Zhengzhou 450008, China
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15
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Zhu CY, Zhao SS, Wang XK, Wang L, Wang FY, Fang S, Liu ZX, Guan LX, Liu YC, Ding Y, Dou LP, Wang LL, Gao CJ. Outcome of Rituximab-Based Treatment for Post-Transplant Lymphoproliferative Disorder After Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Experience. Ann Transplant 2019; 24:175-184. [PMID: 30940797 PMCID: PMC6463616 DOI: 10.12659/aot.914101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Post-transplant lymphoproliferative disorder (PTLD) is a rare complication following solid organ transplantation and allogeneic hematopoietic stem cell transplantation (Allo-HSCT), which gives rise to high mortality rates. Material/Methods This was a single-center retrospective analysis based on 27 patients who were diagnosed with PTLD following Allo-HSCT between January 1, 2007 and June 2018 at the Chinese PLA General Hospital. The purpose of this analysis was to investigate responses and prognostic factors of rituximab-based treatment. Results Twenty-seven patients were treated with rituximab. Among them, 20 of 27 patients (74.07%) had a complete response, 2 of 27 patients (7.41%) had a partial response, 5 of 27 patients (18.52%) had no response, and 22 of 27 patients (81.48%) cleared Epstein-Barr virus (EBV) copies. There were no obvious side effects. The 1-year overall survival (OS) estimate was 46.8% (95% CI, 23.1–65.5%). Univariate analysis revealed that lower OS was correlated with Eastern Cooperative Oncology Group (ECOG) score standard (3–4), Epstein-Barr virus (EBV) viral load (≥106 copies/mL), bacteria or fungal infection, and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab (P<0.05). Multivariate analysis showed that each of the following were independently associated with lower OS (P<0.05): female, ECOG score standard (3–4), and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab. Conclusions Our results demonstrated that rituximab-based treatment was a safe and effective strategy for patients who were diagnosed with PTLD following Allo-HSCT. The identified prognostic factors may help to detect which PTLD patients are at a higher risk of mortality.
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Affiliation(s)
- Cheng-Ying Zhu
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Sha-Sha Zhao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xiao-Kai Wang
- Department of Orthopedics, Xiqing Hospital, Tianjin, China (mainland)
| | - Li Wang
- Department of Hematology and Oncology, Laoshan Branch, No. 401 Hospital of Chinese People's Liberation Army (PLA), Qingdao, Shandong, China (mainland)
| | - Fei-Yan Wang
- School of Medicine, Nankai University, Tianjin, China (mainland)
| | - Shu Fang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Zhan-Xiang Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Xun Guan
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yu-Chen Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yi Ding
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Ping Dou
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Li Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chun-Ji Gao
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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16
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Bhargava P, Wicken C, Smith MD, Strowd RE, Cortese I, Reich DS, Calabresi PA, Mowry EM. Trial of intrathecal rituximab in progressive multiple sclerosis patients with evidence of leptomeningeal contrast enhancement. Mult Scler Relat Disord 2019; 30:136-140. [PMID: 30771580 DOI: 10.1016/j.msard.2019.02.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/01/2019] [Accepted: 02/09/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Leptomeningeal inflammation is associated with increased cortical damage and worse clinical outcomes in MS. It may be detected on contrast-enhanced T2-FLAIR imaging as focal leptomeningeal contrast-enhancement (LME). OBJECTIVE To assess the safety of intrathecal (IT) rituximab in progressive MS (PMS) and to assess its effects on LME and CSF biomarkers. METHODS PMS patients had a screening MRI to detect LME. Participants satisfying eligibility criteria underwent two IT administrations of 25 mg rituximab 2 weeks apart. Follow-up lumbar puncture and MRI were performed at 8 and 24 weeks after the first treatment. RESULTS Of 36 patients screened 15 had LME, 11 consented, and 8 received study treatment. Mean age was 56.7 years and number of LME lesions ranged from 1 to 3. No serious adverse effects occurred. We noted profound reductions in peripheral B cells from baseline to week 2 and 8 with some return at week 24. We also observed transient reductions in CSF B cells and CXCL-13 levels with an increase in BAFF levels. However, the number of LME did not change following treatment. CONCLUSIONS IT rituximab was well tolerated in PMS patients and had transient effects on CSF biomarkers but did not change LME.
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Affiliation(s)
- Pavan Bhargava
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA.
| | - Cassie Wicken
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA
| | - Matthew D Smith
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA
| | - Roy E Strowd
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA
| | - Irene Cortese
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Daniel S Reich
- Translational Neuroradiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Peter A Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA
| | - Ellen M Mowry
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe St, Pathology 627, Baltimore, MD 21287, USA
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17
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Velvet AJJ, Bhutani S, Papachristos S, Dwivedi R, Picton M, Augustine T, Morton M. A single-center experience of post-transplant lymphomas involving the central nervous system with a review of current literature. Oncotarget 2019; 10:437-448. [PMID: 30728897 PMCID: PMC6355190 DOI: 10.18632/oncotarget.26522] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 12/13/2018] [Indexed: 12/13/2022] Open
Abstract
Background Central Nervous System (CNS) lymphoma is a rare presentation of post-transplantation lymphoproliferative disorder (PTLD). Methods This single center retrospective study reviewed presentations, management and outcomes of CNS lymphomas in kidney transplant patients transplanted 1968 to 2015, and reviews relevant current literature. Results We identified 5773 adult kidney transplant recipients of who 90 had a PTLD diagnosis confirmed. CNS disease was diagnosed in 6/90 (7%). Median age at presentation was 60 years and time from transplant 4.5 years. Immunosuppression at diagnosis included mycophenolate mofetil and prednisolone without calcineurin inhibitor in 5/6 patients. Histological analysis diagnosed monomorphic disease in 5/6, and one polymorphic case with tissue positive for Epstein-barr virus (EBV) in 5/6 cases. Despite this 2/4 EBV positive cases had no detectable EBV in peripheral blood or CSF at diagnosis. Treatment strategies included reduction in immunosuppression in all, chemotherapy (n=5), radiotherapy (n=3), Cytotoxic T-Lymphocytes and Craniotomy (n=2). Patient survival was 40% at 1 year with CTL treated patients surviving beyond three years from diagnosis. Conclusion This study supports observational data suggesting MMF treated patients without CNI may have increased risk of disease. Peripheral blood screening for EBV DNAemia does not seem helpful in early identification of those at risk.
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Affiliation(s)
- Anju John John Velvet
- Department of Renal and Pancreas Transplantation, Division of Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Shiv Bhutani
- Department of Renal Medicine and Transplant Nephrology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stavros Papachristos
- Department of Renal and Pancreas Transplantation, Division of Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Reena Dwivedi
- Department of Radiology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Michael Picton
- Department of Renal Medicine and Transplant Nephrology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Titus Augustine
- Department of Renal and Pancreas Transplantation, Division of Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK.,Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Muir Morton
- Department of Renal Medicine and Transplant Nephrology, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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18
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Treatment of Epstein-Barr virus associated central nervous system diseases after allogeneic hematopoietic stem cell transplantation with intrathecal donor lymphocyte infusion. Bone Marrow Transplant 2018; 54:821-827. [PMID: 30518982 DOI: 10.1038/s41409-018-0409-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 11/15/2018] [Accepted: 11/17/2018] [Indexed: 11/08/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective measure for the treatment of hematological disease. With the progress and widespread use of allo-HSCT, Epstein-Barr virus (EBV) related central nervous system (CNS) diseases have gotten more and more attention because of its poor prognosis and overall survival. Since currently there is no standard treatment for patients with EBV-associated CNS diseases and reported therapies are heterogeneous with mixed results, we attempted to develop a novel therapeutic method. We applied a regimen of intrathecal donor lymphocyte infusion (IDLI) in three patients with EBV-associated CNS diseases after allo-HSCT in addition to immunosuppressants reduction and combined antiviral therapy. All of three patients were responsive to this therapy: all clinical symptoms and EBV load in CSF were resolved 10, 17, and 12 days after initial IDLI, respectively, and magnetic resonance imaging (MRI) showed that lesions of case 1 and 2 disappeared 15 and 19 days after initial IDLI, respectively. Even more appealing, there were no acute or chronic adverse reactions during the infusion and up to 23 months of follow-up. In conclusion, IDLI seems to be an effective and safe method for EBV-associated CNS diseases in allo-HSCT recipients. We recommend this treatment modality for further investigation.
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19
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Kassa C, Reményi P, Sinkó J, Kállay K, Kertész G, Kriván G. Successful nivolumab therapy in an allogeneic stem cell transplant child with post-transplant lymphoproliferative disorder. Pediatr Transplant 2018; 22:e13302. [PMID: 30345623 DOI: 10.1111/petr.13302] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/06/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
Primary CNS PTLD is an extremely rare complication after allogeneic HSCT. At our centre, an 11-year-old patient developed nausea, vomiting, and diplopy on day +82 following HSCT. On brain MRI, multiple white matter lesions were seen. Histology showed a diffuse large B-cell lymphoma with high load of EBV in tissue. Despite stopping immunosuppression, treatment with EBV-specific cytotoxic T cells, systemic rituximab, HD-MTX, and intrathecal chemotherapy, progression was observed. With a combination of HD-MTX and cytarabine, only a partial response could be achieved. Having all conventional modalities not only failed but resulted in significant toxicity, a salvage monotherapy with biweekly nivolumab has been instituted. The starting dose was 1.1 mg/kg, later escalated to 2.2 mg/kg. After 8 months of nivolumab therapy, PET-CT showed complete metabolic remission. Subsequently, the patient has been switched to a maintenance dosage of 1.1 mg/kg. No cytopenias, graft failure, GvHD, or any other alloimmune complications were seen during nivolumab therapy. In conclusion, nivolumab may be considered as an effective and safe option for CNS PTLD therapy when all other modalities have failed.
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Affiliation(s)
- Csaba Kassa
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Péter Reményi
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - János Sinkó
- Department of Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Krisztián Kállay
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Gabriella Kertész
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Gergely Kriván
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
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20
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Wicken C, Nguyen J, Karna R, Bhargava P. Leptomeningeal inflammation in multiple sclerosis: Insights from animal and human studies. Mult Scler Relat Disord 2018; 26:173-182. [DOI: 10.1016/j.msard.2018.09.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/16/2018] [Accepted: 09/21/2018] [Indexed: 12/17/2022]
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21
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Management of Non-Diffuse Large B Cell Lymphoma Post-Transplant Lymphoproliferative Disorder. Curr Treat Options Oncol 2018; 19:33. [DOI: 10.1007/s11864-018-0549-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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22
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Rubenstein JL. Biology of CNS lymphoma and the potential of novel agents. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:556-564. [PMID: 29222305 PMCID: PMC6053314 DOI: 10.1182/asheducation-2017.1.556] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Primary and secondary CNS lymphomas are aggressive brain tumors that pose an immense challenge to define in terms of molecular pathogenesis, as well as to effectively treat. During the past 10 years improvements in survival have been achieved with the implementation of anti-CD20 immunotherapy and optimization of dose-intensive consolidation strategies. The applications of whole-exome sequencing, comparative genomic hybridization, transcriptional profiling, and examination of the tumor microenvironment, particularly in the context of clinical investigation, provide insights that create a roadmap for the development and implementation of novel targeted agents for this disease. A body of genetic evidence strongly suggested that primary CNS lymphomas (PCNSLs) are likely largely dependent on NF-κB prosurvival signals, with enrichment of mutations involving the B-cell receptor pathway, in particular myeloid differentiation primary response 88 and cluster of differentiation 79B. The first set of early-phase investigations that target NF-κB in PCNSL have now been completed and support the NF-κB hypothesis but at the same time reveal that much work needs to be done to translate these results into meaningful advances in survival for a large fraction of patients. Insights into secondary prosurvival pathways that mediate drug resistance is a priority for investigation. Similarly, further evaluation of the immune-suppressive mechanisms in the CNS lymphoma tumor microenvironment is requisite for progress. Combinatorial interventions that promote the antitumor immune response have significant potential. With increasing availability of targeted agents, there is also a need to develop more sensitive imaging tools, not only to detect this highly invasive brain neoplasm but also potentially to define an evolving molecular phenotype to facilitate precision medicine.
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Affiliation(s)
- James L Rubenstein
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, CA
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23
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Xu LP. [How I diagnose and treat post-transplant lymphoproliferative disorders after allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:923-929. [PMID: 29224312 PMCID: PMC7342797 DOI: 10.3760/cma.j.issn.0253-2727.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Indexed: 11/05/2022]
Affiliation(s)
- L P Xu
- Peking University, People' s Hospital, Peking University Institute of Hematology, Beijing 100044, China
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24
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Liu L, Feng SZ. [Advances on Epstein-Barr virus related post-transplant lymphoproliferative disorders after allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:817-821. [PMID: 29081206 PMCID: PMC7348362 DOI: 10.3760/cma.j.issn.0253-2727.2017.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/13/2022]
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25
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Ke P, Ma X, Bao XB, Liu YJ, Wu XJ, Xue SL, Hu XH, He XF, Wu DP. [Clinical analysis of 7 patients with Epstein-Barr virus encephalitis after allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:685-689. [PMID: 28954347 PMCID: PMC7348247 DOI: 10.3760/cma.j.issn.0253-2727.2017.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Indexed: 11/05/2022]
Abstract
Objective: To summarize the clinical features, treatment and prognosis of patients with Epstein Barr virus (EBV) encephalitis after allogeneic hematopoietic stem cell transplantation (allo-HSCT) . Methods: The clinical data of 7 patients with EBV encephalitis who had undergone allo-HSCT in the First Affiliated Hospital of Soochow University from January 2012 to December 2015 were reviewed. Results: The incidence of EBV encephalitis was 0.70% (7/998) , and the median time was 63 (10-136) d after allo-HSCT. Seven patients had fever and mental disorder, of whom 4 cases of brain MRI were positive. Two patients received HLA-matched unrelated transplantation, while other 5 ones received haploidentical allo-HSCT. In conditioning regimen process, 7 patients were combined with anti-thymocyte globulin (ATG) to prevent graft versus host disease (GVHD) , of whom 6 patients had grade Ⅱ-Ⅳ acute GVHD. All patients of EBV-DNA were negative in CSF after taking anti-virus agent Rituximab. Until the last follow-up, a total of 3 patients died, 2 died of leukemia recurrence, 1 EBV encephalitis progression. Conclusion: Once suspected EBV encephalitis after allo-HSCT, brain MRI and EBV-DNA in CSF should be detected, which could improve early diagnosis of EBV encephalitis. The usage of Rituximab was effective and well tolerated.
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Affiliation(s)
- P Ke
- First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis under Ministry of Health, Collaborative Innovation Center of Hematology, Institute of Blood and Marrow Transplantation, Soochow University, Suzhou 215006, China
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Styczynski J, van der Velden W, Fox CP, Engelhard D, de la Camara R, Cordonnier C, Ljungman P. Management of Epstein-Barr Virus infections and post-transplant lymphoproliferative disorders in patients after allogeneic hematopoietic stem cell transplantation: Sixth European Conference on Infections in Leukemia (ECIL-6) guidelines. Haematologica 2017; 101:803-11. [PMID: 27365460 DOI: 10.3324/haematol.2016.144428] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/21/2016] [Indexed: 12/11/2022] Open
Abstract
Epstein-Barr virus-related post-transplant lymphoproliferative disorders are recognized as a significant cause of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation. To better define current understanding of post-transplant lymphoproliferative disorders in stem cell transplant patients, and to improve its diagnosis and management, a working group of the Sixth European Conference on Infections in Leukemia 2015 reviewed the literature, graded the available quality of evidence, and developed evidence-based recommendations for diagnosis, prevention, prophylaxis and therapy of post-transplant lymphoproliferative disorders exclusively in the stem cell transplant setting. The key elements in diagnosis include non-invasive and invasive methods. The former are based on quantitative viral load measurement and imaging with positron emission tomography; the latter with tissue biopsy for histopathology and detection of Epstein-Barr virus. The diagnosis of post-transplant lymphoproliferative disorder can be established on a proven or probable level. Therapeutic strategies include prophylaxis, preemptive therapy and targeted therapy. Rituximab, reduction of immunosuppression and Epstein-Barr virus-specific cytotoxic T-cell therapy are recommended as first-line therapy, whilst unselected donor lymphocyte infusions or chemotherapy are options as second-line therapy; other methods including antiviral drugs are discouraged.
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Jurasz University Hospital, Bydgoszcz, Poland
| | - Walter van der Velden
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Christopher P Fox
- Center for Clinical Hematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dan Engelhard
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Catherine Cordonnier
- Department of Hematology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, and University Paris-Est-Créteil, Créteil, France
| | - Per Ljungman
- Karolinska University Hospital, Departments of Hematology and Allogeneic Stem Cell Transplantation, Karolinska Institutet, Division of Hematology, Department of Medicine, Huddinge, Stockholm, Sweden
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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Zhou J, Han LJ, Zu YL, Zhang Y, Yu FK, Fu YW, Wang Q, Liang LJ, Zhou H, Fang BJ, Wei XD, Song YP. [EBV related post-transplantation lymphoproliferative diseases in patients with severe aplastic anemia after allogeneic hematopoietic stem cell transplantation: five cases report and literatures review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:998-1000. [PMID: 27995889 PMCID: PMC7348515 DOI: 10.3760/cma.j.issn.0253-2727.2016.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 11/05/2022]
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29
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Ceppi F, Weitzman S, Woessmann W, Davies K, Lassaletta A, Reismüller B, Mellgren K, Uyttebroeck A, Maia I, Abdullah S, Miakova N, Glaser D, Cohn R, Abla O, Attarbaschi A, Alexander S. Safety and efficacy of intrathecal rituximab in children with B cell lymphoid CD20+ malignancies: An international retrospective study. Am J Hematol 2016; 91:486-91. [PMID: 26872652 DOI: 10.1002/ajh.24329] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 01/21/2016] [Accepted: 02/08/2016] [Indexed: 01/11/2023]
Abstract
Central nervous system (CNS) involvement in patients with mature B non-Hodgkin lymphoma, post-transplantation proliferative disorder and acute lymphoblastic leukemia confers a significantly inferior prognosis as compared to patients without CNS disease. Intrathecal (IT) or intraventricular administration of rituximab is an option for this group of patients. We report 25 children with CNS involvement of CD20+ B lymphoid malignancies who received in total 163 IT/intraventricular rituximab doses. The median number of doses received by each patient was 6, with a median dose of 25 mg. The most common adverse events were Grades 1 and 2 peripheral neuropathies in five patients (20%), allergy in two patients, and headache in two patients. These events were self-limited, occurring in the 48 hours after treatment and resolving within 24 hr. Three patients presented with more severe though transient side effects, one with a Grade III neuropathy and two with seizure. Eighteen patients (72%) of those treated with IT/intraventricular rituximab, with or without other CNS directed treatment, achieved a CNS remission. This case series suggests that IT/intraventricular rituximab has therapeutic efficacy and relatively limited toxicity. Prospective trials of IT/intraventricular rituximab for patients with CNS involvement of CD20 + B lymphoid malignancies are warranted.
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Affiliation(s)
- Francesco Ceppi
- Department of Pediatrics, Division of Hematology/Oncology; Hospital for Sick Children; Ontario Toronto Canada
| | - Sheila Weitzman
- Department of Pediatrics, Division of Hematology/Oncology; Hospital for Sick Children; Ontario Toronto Canada
| | - Wilhelm Woessmann
- Department of Pediatric Hematology and Oncology; University Children's Hospital and Justus-Liebig-University; Giessen Germany
| | - Kimberly Davies
- Department of Pediatric Oncology; Dana-Farber/Boston Children's Cancer and Blood Disorders Center; Boston
| | - Alvaro Lassaletta
- Department of Pediatric Hematology/Oncology; Hospital Infantil Universitario Niño Jesús; Madrid Spain
| | - Bettina Reismüller
- Department of Pediatric Hematology and Oncology; Medical University of Vienna, St. Anna Children's Hospital; Vienna Austria
| | - Karin Mellgren
- Department of Paediatrics; Institution for Clinical Sciences, Sahlgrenska University Hospital; Gothenburg Sweden
| | - Anne Uyttebroeck
- Department of Pediatric Hemato-Oncology; University Hospitals of Leuven; Leuven Belgium
| | - Iris Maia
- Pediatric Service, Portuguese Institute of Oncology; Porto Portugal
| | - Shaker Abdullah
- Pediatric Oncology, King Abdulaziz Medical City - National Guard Health Affairs; Jeddah Kingdom of Saudi Arabia
| | - Natasha Miakova
- Department of Hematology/Oncology; Federal Center for Pediatric Hematology, Oncology and Immunology Named by D. Rogachev; Moscow Russia
| | - Darryl Glaser
- Division of Hematology/Oncology, Department of Pediatrics; University of Hawai‘I John a. Burns School of Medicine; Honolulu Hawai‘i
| | - Richard Cohn
- Kids Cancer Centre, Sydney Children's Hospital and School of Women's and Children's Health; University of New South Wales; Sydney Australia
| | - Oussama Abla
- Department of Pediatrics, Division of Hematology/Oncology; Hospital for Sick Children; Ontario Toronto Canada
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology; Medical University of Vienna, St. Anna Children's Hospital; Vienna Austria
| | - Sarah Alexander
- Department of Pediatrics, Division of Hematology/Oncology; Hospital for Sick Children; Ontario Toronto Canada
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Rouphael B, Lankireddy S, Lazaryan A, Kukla A, Ibrahim HN, Matas AJ, Issa N. Outcomes of kidney retransplantation in recipients with prior post-transplant lymphoproliferative disorder. Clin Transplant 2016; 30:60-5. [DOI: 10.1111/ctr.12659] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Bassem Rouphael
- Division of Renal Diseases and Hypertension; Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Srilakshmi Lankireddy
- Division of Renal Diseases and Hypertension; Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Aleksandr Lazaryan
- Division of Hematology, Oncology and Transplantation; Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Aleksandra Kukla
- Division of Renal Diseases and Hypertension; Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Hassan N. Ibrahim
- Division of Renal Diseases and Hypertension; Department of Medicine; University of Minnesota; Minneapolis MN USA
| | - Arthur J. Matas
- Division of Transplant Surgery; Department of Surgery; University of Minnesota; Minneapolis MN USA
| | - Naim Issa
- Division of Renal Diseases and Hypertension; Department of Medicine; University of Minnesota; Minneapolis MN USA
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31
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Intrathecal rituximab for EBV-associated post-transplant lymphoproliferative disorder with central nervous system involvement unresponsive to intravenous rituximab-based treatments: a prospective study. Bone Marrow Transplant 2015; 51:456-8. [DOI: 10.1038/bmt.2015.281] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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32
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Styczynski J, Czyzewski K, Wysocki M, Gryniewicz-Kwiatkowska O, Kolodziejczyk-Gietka A, Salamonowicz M, Hutnik L, Zajac-Spychala O, Zaucha-Prazmo A, Chelmecka-Wiktorczyk L, Siewiera K, Fraczkiewicz J, Malas Z, Tomaszewska R, Irga-Jaworska N, Plonowski M, Ociepa T, Pierlejewski F, Gamrot Z, Urbanek-Dadela A, Gozdzik J, Stolpa W, Dembowska-Baginska B, Perek D, Matysiak M, Wachowiak J, Kowalczyk J, Balwierz W, Kalwak K, Chybicka A, Badowska W, Szczepanski T, Drozynska E, Krawczuk-Rybak M, Urasinski T, Mlynarski W, Woszczyk M, Karolczyk G, Sobol-Milejska G, Gil L. Increased risk of infections and infection-related mortality in children undergoing haematopoietic stem cell transplantation compared to conventional anticancer therapy: a multicentre nationwide study. Clin Microbiol Infect 2015; 22:179.e1-179.e10. [PMID: 26493843 DOI: 10.1016/j.cmi.2015.10.017] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 10/06/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
Abstract
This nationwide multicentre study analysed the epidemiology of bacterial, viral and fungal infections in paediatric haematopoietic stem cell transplantation (HSCT) and paediatric haematology and oncology (PHO) patients over a period of 24 consecutive months, including incidence, hazard risk and outcome of infections as well as occurrence of multidrug-resistant bacteria. During this period, 308 HSCTs were performed and 1768 children were newly diagnosed for malignancy. Compared to PHO, the risk in HSCT patients was significantly higher for all infections (hazard ratio (HR) 2.7), bacterial (HR 1.4), fungal (HR 3.5) and viral (HR 15.7) infections. The risk was higher in allo- than auto-HSCT for bacterial (HR 1.4), fungal (HR 3.2) and viral (HR 17.7) infections. The incidence of resistant bacteria was higher in HSCT than in PHO patients for both G-negative (72.5% vs. 59.2%) and G-positive (41.4% vs. 20.5%) strains. Cumulative incidence of bacterial, fungal and viral infections in HSCT patients was 33.9, 22.8 and 38.3%, respectively. Cumulative incidence of viral infections in allo-HSCT was 28.0% for cytomegalovirus, 18.5% for BK virus, 15.5% for Epstein-Barr virus, 9.5% for adenovirus, 2.6% for varicella zoster virus, 0.9% for influenza, 0.9% for human herpesvirus 6 and 0.3% for hepatitis B virus. Survival rates from infections were lower in HSCT than in PHO patients in bacterial (96.0 vs. 98.2%), fungal (75.5 vs. 94.6%) and most viral infections. In conclusion, the risk of any infections and the occurrence of resistant bacterial strains in allo-HSCT patients were higher than in auto-HSCT and PHO patients, while the outcome of infections was better in the PHO setting.
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Affiliation(s)
- J Styczynski
- Department of Paediatric Haematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland.
| | - K Czyzewski
- Department of Paediatric Haematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - M Wysocki
- Department of Paediatric Haematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | | | | | - M Salamonowicz
- Department of Paediatric Haematology and Oncology, Medical University, Warszawa, Poland
| | - L Hutnik
- Department of Paediatric Haematology and Oncology, Medical University, Warszawa, Poland
| | - O Zajac-Spychala
- Department of Paediatric Oncology, Haematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - A Zaucha-Prazmo
- Department of Paediatric Haematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - L Chelmecka-Wiktorczyk
- Department of Paediatric Oncology and Haematology, University Children's Hospital, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - K Siewiera
- Department of Paediatric Stem Cell Transplantation, Haematology and Oncology, Medical University, Wroclaw, Poland
| | - J Fraczkiewicz
- Department of Paediatric Stem Cell Transplantation, Haematology and Oncology, Medical University, Wroclaw, Poland
| | - Z Malas
- Division of Paediatric Haematology and Oncology, Children Hospital, Olsztyn, Poland
| | - R Tomaszewska
- Department of Paediatric Haematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - N Irga-Jaworska
- Department of Paediatrics, Haematology and Oncology, Medical University, Gdansk, Poland
| | - M Plonowski
- Department of Paediatric Oncology and Haematology, Medical University, Bialystok, Poland
| | - T Ociepa
- Department of Paediatric Haematology and Oncology, Pomeranian Medical University, Szczecin, Poland
| | - F Pierlejewski
- Department of Paediatric Oncology, Haematology and Diabetology, Medical University, Lodz, Poland
| | - Z Gamrot
- Division of Paediatric Haematology and Oncology, Chorzow Paediatric and Oncology Center, Chorzow, Poland
| | - A Urbanek-Dadela
- Division of Paediatric Haematology and Oncology, Children Hospital, Kielce, Poland
| | - J Gozdzik
- Stem Cell Transplant Center, University Children's Hospital, Department of Clinical Immunology and Transplantology, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - W Stolpa
- Division of Paediatric Oncology, Haematology and Chemotherapy, Department of Paediatric, Silesian Medical University, Katowice, Poland
| | | | - D Perek
- Department of Oncology, Children's Memorial Health Institute, Warszawa, Poland
| | - M Matysiak
- Department of Paediatric Haematology and Oncology, Medical University, Warszawa, Poland
| | - J Wachowiak
- Department of Paediatric Oncology, Haematology and Transplantology, University of Medical Sciences, Poznan, Poland
| | - J Kowalczyk
- Department of Paediatric Haematology, Oncology and Stem Cell Transplantation, Medical University, Lublin, Poland
| | - W Balwierz
- Department of Paediatric Oncology and Haematology, University Children's Hospital, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - K Kalwak
- Department of Paediatric Stem Cell Transplantation, Haematology and Oncology, Medical University, Wroclaw, Poland
| | - A Chybicka
- Department of Paediatric Stem Cell Transplantation, Haematology and Oncology, Medical University, Wroclaw, Poland
| | - W Badowska
- Division of Paediatric Haematology and Oncology, Children Hospital, Olsztyn, Poland
| | - T Szczepanski
- Department of Paediatric Haematology and Oncology, Silesian Medical University, Zabrze, Poland
| | - E Drozynska
- Department of Paediatrics, Haematology and Oncology, Medical University, Gdansk, Poland
| | - M Krawczuk-Rybak
- Department of Paediatric Oncology and Haematology, Medical University, Bialystok, Poland
| | - T Urasinski
- Department of Paediatric Haematology and Oncology, Pomeranian Medical University, Szczecin, Poland
| | - W Mlynarski
- Department of Paediatric Oncology, Haematology and Diabetology, Medical University, Lodz, Poland
| | - M Woszczyk
- Division of Paediatric Haematology and Oncology, Chorzow Paediatric and Oncology Center, Chorzow, Poland
| | - G Karolczyk
- Division of Paediatric Haematology and Oncology, Children Hospital, Kielce, Poland
| | - G Sobol-Milejska
- Division of Paediatric Oncology, Haematology and Chemotherapy, Department of Paediatric, Silesian Medical University, Katowice, Poland
| | - L Gil
- Department of Haematology, University of Medical Sciences, Poznan, Poland
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Styczyński J, Czyżewski K, Siewiera K, Frączkiewicz J, Zając-Spychała O, Goździk J, Zaucha-Prażmo A, Kałwak K, Gorczyńska E, Chybicka A, Wachowiak J, Kowalczyk J, Wysocki M. Zakażenia wirusowe u dzieci po przeszczepieniu komórek krwiotwórczych. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.achaem.2015.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Siegal T. Primary central nervous system lymphoma: current state of anti-CD20 therapy and appraisal of reported response criteria. J Clin Neurosci 2014; 21:709-15. [PMID: 24725453 DOI: 10.1016/j.jocn.2014.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 02/02/2014] [Indexed: 12/30/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is an aggressive non-Hodgkin's lymphoma which is confined to the central nervous system and may also affect intraocular structures. Despite high initial rates of response to methotrexate-based chemotherapy, more than 50% of patients will experience relapse and about 10% have disease that is refractory to chemotherapy. Outcome in patients who fail treatment is very poor, and therefore new therapeutic approaches that may increase the rate of complete response and the proportion of durable remission are sought. Based on the pivotal role that anti-CD20 therapy now plays in the treatment outcome of aggressive systemic B-cell lymphomas, a similar approach is commonly being adapted for PCNSL despite the lack of evidence for its effectiveness. This review examines the current status and level of evidence for the use of monoclonal antibodies against the CD20 surface antigen, which is present on normal and malignant B-cells in PCNSL. The review covers both systemic and local (intracerebrospinal fluid or intravitreal) administration of CD20 monoclonal antibodies in PCNSL. In addition, it scrutinizes the response criteria commonly reported for evaluation of treatment outcome. The importance of differentiating unconfirmed complete response from partial response is outlined and the lack of consensus on response criteria for atypical imaging presentations of PCNSL is delineated.
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Affiliation(s)
- Tali Siegal
- Center for Neuro-Oncology, Davidoff Institute of Oncology, Rabin Medical Center, Campus Beilinson, 49100 Petach Tikva, Israel.
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35
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Lauro A, Arpinati M, Pinna AD. Managing the challenge of PTLD in liver and bowel transplant recipients. Br J Haematol 2014; 169:157-72. [DOI: 10.1111/bjh.13213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/01/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Augusto Lauro
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Mario Arpinati
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Antonio D. Pinna
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
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36
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Imashuku S. Hemophagocytic lymphohistiocytosis: Recent progress in the pathogenesis, diagnosis and treatment. World J Hematol 2014; 3:71-84. [DOI: 10.5315/wjh.v3.i3.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 05/09/2014] [Accepted: 06/18/2014] [Indexed: 02/05/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome that develops as a primary (familial/hereditary) or secondary (non-familial/hereditary) disease characterized in the majority of the cases by hereditary or acquired impaired cytotoxic T-cell (CTL) and natural killer responses. The molecular mechanisms underlying impaired immune homeostasis have been clarified, particularly for primary diseases. Familial HLH (familial hemophagocytic lymphohistiocytosis type 2-5, Chediak-Higashi syndrome, Griscelli syndrome type 2, Hermansky-Pudlak syndrome type 2) develops due to a defect in lytic granule exocytosis, impairment of (signaling lymphocytic activation molecule)-associated protein, which plays a key role in CTL activity [e.g., X-linked lymphoproliferative syndrome (XLP) 1], or impairment of X-linked inhibitor of apoptosis, a potent regulator of lymphocyte homeostasis (e.g., XLP2). The development of primary HLH is often triggered by infections, but not in all. Secondary HLH develops in association with infection, autoimmune diseases/rheumatological conditions and malignancy. The molecular mechanisms involved in secondary HLH cases remain unknown and the pathophysiology is not the same as primary HLH. For either primary or secondary HLH cases, immunosuppressive therapy should be given to control the hypercytokinemia with steroids, cyclosporine A, or intravenous immune globulin, and if primary HLH is diagnosed, immunochemotherapy with a regimen containing etoposide or anti-thymocyte globulin should be started. Thereafter, allogeneic hematopoietic stem-cell transplantation is recommended for primary HLH or secondary refractory disease (especially EBV-HLH).
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Lin R, Liu Q. Diagnosis and treatment of viral diseases in recipients of allogeneic hematopoietic stem cell transplantation. J Hematol Oncol 2013; 6:94. [PMID: 24341630 PMCID: PMC3878524 DOI: 10.1186/1756-8722-6-94] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 11/30/2013] [Indexed: 11/11/2022] Open
Abstract
Viral infections are important causes of morbidity and mortality after allogeneic stem cell hematopoietic transplantation (allo-HSCT). Although most viral infections present with asymptomatic or subclinical manifestations, viruses may result in fatal complications in severe immunocompromised recipients. Reactivation of latent viruses, such as herpesviruses, is frequent during the immunosuppression that occurs with allo-HSCT. Viruses acquired from community, such as the respiratory and gastrointestinal viruses, are also important pathogens of post-transplant viral diseases. Currently, molecular diagnostic methods have replaced or supplemented traditional methods, such as viral culture and antigen detection, in diagnosis of viral infections. The utilization of polymerase chain reaction facilitates the early diagnosis. In view of lacking efficacious agents for treatment of viral diseases, prevention of viral infections is extremely valuable. Application of prophylactic strategies including preemptive therapy reduces viral infections and diseases. Adoptive cellular therapy for restoring virus-specific immunity is a promising method in the treatment of viral diseases.
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Affiliation(s)
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, 1838, Guangzhou China.
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Kadoch C, Li J, Wong VS, Chen L, Cha S, Munster P, Lowell CA, Shuman MA, Rubenstein JL. Complement activation and intraventricular rituximab distribution in recurrent central nervous system lymphoma. Clin Cancer Res 2013; 20:1029-41. [PMID: 24190981 DOI: 10.1158/1078-0432.ccr-13-0474] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To elucidate the mechanistic basis for efficacy of intrathecal rituximab. We evaluated complement activation as well as the pharmacokinetics of intraventricular rituximab in patients who participated in two phase 1 multicenter studies. EXPERIMENTAL DESIGN We evaluated complement activation as a candidate mediator of rituximab within the central nervous system (CNS). Complement C3 and C5b-9 were quantified by ELISA in serial cerebrospinal fluid (CSF) specimens after intraventricular rituximab administration. We determined rituximab concentration profiles in CSF and serum. A population three- compartment pharmacokinetic model was built to describe the disposition of rituximab following intraventricular administration. The model was derived from results of the first trial and validated with results of the second trial. RESULTS Complement C3 and C5b-9 were reproducibly activated in CSF after intraventricular rituximab. Ectopic expression of C3 mRNA and protein within CNS lymphoma lesions was localized to myeloid cells. Constitutive high C3 activation at baseline was associated with adverse prognosis. A pharmacokinetic model was built, which contains three distinct compartments, to describe the distribution of rituximab within the neuroaxis after intraventricular administration. CONCLUSIONS We provide the first evidence of C3 activation within the neuroaxis with intraventricular immunotherapy and suggest that complement may contribute to immunotherapeutic responses of rituximab in CNS lymphoma. Penetration of rituximab into neural tissue is supported by this pharmacokinetic model and may contribute to efficacy. These findings have general implications for intraventricular immunotherapy. Our data highlight potential innovations to improve efficacy of intraventricular immunotherapy both via modulation of the innate immune response as well as innovations in drug delivery.
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Affiliation(s)
- Cigall Kadoch
- Authors' Affiliations: Division of Hematology/Oncology, Genentech, South San Francisco; Helen Diller Comprehensive Cancer Center; and Department of Radiology, Laboratory Medicine, University of California, San Francisco, San Francisco, California
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Said-Conti V, Amrolia PJ, Gaze MN, Stoneham S, Sebire N, Shroff R, Marks SD. Successful treatment of central nervous system PTLD with rituximab and cranial radiotherapy. Pediatr Nephrol 2013; 28:2053-6. [PMID: 23743853 DOI: 10.1007/s00467-013-2499-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 04/10/2013] [Accepted: 04/12/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary central nervous system (PCNS) post-transplant lymphoproliferative disorder (PTLD) is a rare complication of solid organ transplantation and is typically an Epstein-Barr virus (EBV)-induced B-cell CD20+ lymphoma. The modalities of treatment include reduction in immunosuppression, cranial radiotherapy (CRT), intravenous and intrathecal rituximab when CD20 is expressed on B-lymphocytes and PTLD cells, and chemotherapy. CASE-DIAGNOSIS/TREATMENT We report the successful treatment of EBV-driven PCNS PTLD by reduction in immunosuppression (RI), CRT, and intravenous rituximab. Our patient was an 11-year-old boy with a living-related renal transplant for end-stage renal failure (ESRF) secondary to posterior urethral valves (PUV) and bilateral renal dysplasia (BRD) and on triple immunosuppression with prednisolone, tacrolimus, and azathioprine who had a rising EBV load, which was managed with reduction in tacrolimus dose, withdrawal of azathioprine, and introduction of mycophenolate mofetil (MMF). CONCLUSIONS The patient presented 7 years post-transplant with a seizure and abnormal neurology secondary to polymorphous hyperplastic lesions in the brain, which responded to rituximab and CRT.
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MESH Headings
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antigens, CD20/metabolism
- Antineoplastic Agents/administration & dosage
- Biopsy
- Central Nervous System Neoplasms/diagnosis
- Central Nervous System Neoplasms/immunology
- Central Nervous System Neoplasms/therapy
- Central Nervous System Neoplasms/virology
- Chemoradiotherapy
- Child
- Cranial Irradiation
- Drug Therapy, Combination
- Epstein-Barr Virus Infections/diagnosis
- Epstein-Barr Virus Infections/virology
- Humans
- Immunohistochemistry
- Immunosuppressive Agents/adverse effects
- Infusions, Intravenous
- Kidney Failure, Chronic/surgery
- Kidney Transplantation/adverse effects
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/immunology
- Lymphoma, B-Cell/therapy
- Lymphoma, B-Cell/virology
- Magnetic Resonance Imaging
- Male
- Rituximab
- Seizures/virology
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Valerie Said-Conti
- Department of Paediatric Nephrology, Great Ormond Street Hospital NHS Trust, London, UK.
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Posttransplant lymphoproliferative disease after pediatric solid organ transplantation. Clin Dev Immunol 2013; 2013:814973. [PMID: 24174972 PMCID: PMC3794558 DOI: 10.1155/2013/814973] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 02/06/2023]
Abstract
Patients after solid organ transplantation (SOT) carry a substantially increased risk to develop malignant lymphomas. This is in part due to the immunosuppression required to maintain the function of the organ graft. Depending on the transplanted organ, up to 15% of pediatric transplant recipients acquire posttransplant lymphoproliferative disease (PTLD), and eventually 20% of those succumb to the disease. Early diagnosis of PTLD is often hampered by the unspecific symptoms and the difficult differential diagnosis, which includes atypical infections as well as graft rejection. Treatment of PTLD is limited by the high vulnerability towards antineoplastic chemotherapy in transplanted children. However, new treatment strategies and especially the introduction of the monoclonal anti-CD20 antibody rituximab have dramatically improved outcomes of PTLD. This review discusses risk factors for the development of PTLD in children, summarizes current approaches to therapy, and gives an outlook on developing new treatment modalities like targeted therapy with virus-specific T cells. Finally, monitoring strategies are evaluated.
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Abstract
UNLABELLED Recurrent CNS lymphoma continues to be associated with poor outcomes in the rituximab era. Although IV rituximab mediates superior disease control of systemic non-Hodgkin lymphoma (NHL), it fails to completely eliminate the risk of meningeal recurrence, likely due to minimal CNS penetration. Given that rituximab acts synergistically with chemotherapy, we conducted the first phase 1 study of intraventricular immunochemotherapy in patients with recurrent CNS NHL. Fourteen patients received 10 mg or 25 mg intraventricular rituximab twice weekly for 4 weeks, with rituximab administered as monotherapy during the first treatment each week and rituximab administered in combination with methotrexate (MTX) during the second treatment each week. More than 150 doses were administered without serious toxicity. In a population with high-refractory CNS NHL, 75% of patients achieved complete cytologic responses and 43% achieved an overall complete response in CSF and/or brain parenchyma. Two patients achieved a first complete response of CNS NHL with intraventricular rituximab/MTX, including 1 with CNS lymphoma refractory to high-dose systemic and intrathecal MTX plus IV rituximab. We conclude that intraventricular rituximab in combination with MTX is feasible and highly active in the treatment of drug-resistant CNS NHL that is refractory or unresponsive to IV rituximab. KEY POINTS Phase I study showed that intraventricular rituximab plus methotrexate is feasible and active in the treatment of refractory CNS lymphoma.
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