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Nikiforow S, Whangbo JS, Reshef R, Tsai DE, Bunin N, Abu-Arja R, Mahadeo KM, Weng WK, Van Besien K, Loeb D, Nasta SD, Nemecek ER, Zhao W, Sun Y, Galderisi F, Wahlstrom J, Mehta A, Gamelin L, Dinavahi R, Prockop S. Tabelecleucel for EBV+ PTLD after allogeneic HCT or SOT in a multicenter expanded access protocol. Blood Adv 2024; 8:3001-3012. [PMID: 38625984 DOI: 10.1182/bloodadvances.2023011626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/27/2024] [Accepted: 03/31/2024] [Indexed: 04/18/2024] Open
Abstract
ABSTRACT Patients with Epstein-Barr virus (EBV)-positive posttransplant lymphoproliferative disease (EBV+ PTLD) in whom initial treatment fails have few options and historically low median overall survival (OS) of 0.7 months after allogeneic hematopoietic cell transplant (HCT) and 4.1 months after solid organ transplant (SOT). Tabelecleucel is an off-the-shelf, allogeneic EBV-specific cytotoxic T-lymphocyte immunotherapy for EBV+ PTLD. Previous single-center experience showed responses in patients with EBV+ PTLD after HCT or SOT. We now report outcomes from a multicenter expanded access protocol in HCT (n = 14) and SOT (n = 12) recipients treated with tabelecleucel for EBV+ PTLD that was relapsed/refractory (R/R) to rituximab with/without chemotherapy. The investigator-assessed objective response rate was 65.4% overall (including 38.5% with a complete and 26.9% with a partial response), 50.0% in HCT, and 83.3% in SOT. The estimated 1- and 2-year OS rates were both 70.0% (95% confidence interval [CI], 46.5-84.7) overall, both 61.5% (95% CI, 30.8-81.8) in HCT, and both 81.5% (95% CI, 43.5-95.1) in SOT (median follow-up: 8.2, 2.8, and 22.5 months, respectively). Patients responding to tabelecleucel had higher 1- and 2-year OS rates (94.1%) than nonresponders (0%). Treatment was well tolerated, with no reports of tumor flare, cytokine release syndrome, or rejection of marrow and SOT. Results demonstrate clinically meaningful outcomes across a broad population treated with tabelecleucel, indicating a potentially transformative and accessible treatment advance for R/R EBV+ PTLD after HCT or SOT. This trial was registered at www.ClinicalTrials.gov as #NCT02822495.
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Affiliation(s)
- Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer S Whangbo
- VOR Bio, Cambridge, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Ran Reshef
- Blood and Marrow Transplantation and Cell Therapy Program, Columbia University Irving Medical Center, New York, NY
| | - Donald E Tsai
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy Bunin
- Division of Pediatric Hematology/Oncology and Blood and Marrow Transplant, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rolla Abu-Arja
- Division of Pediatric Hematology/Oncology and Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, OH
| | - Kris Michael Mahadeo
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, NC
| | - Wen-Kai Weng
- BMT-Cellular Therapy, Department of Medicine, Stanford University, School of Medicine, Stanford, CA
| | - Koen Van Besien
- Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, OH
| | - David Loeb
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Sunita Dwivedy Nasta
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Eneida R Nemecek
- Pediatric Transplant & Cellular Therapy, Oregon Health and Science University, Portland, OR
| | | | - Yan Sun
- Atara Biotherapeutics, Thousand Oaks, CA
| | | | | | | | | | | | - Susan Prockop
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- VOR Bio, Cambridge, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Dana-Farber Cancer Institute/Boston Children's Hospital Cancer and Blood Disorders Center, Boston, MA
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2
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Guerra-García P, Bomken S, Ling R, Lazareva A, Gupte G, Amrolia P, Andrés M, Diez-Sebastián J, Taj MM. Management of paediatric monomorphic post-transplant lymphoproliferative disorders with low-intensity treatment: A multicentre international experience. Pediatr Blood Cancer 2024:e31053. [PMID: 38757407 DOI: 10.1002/pbc.31053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Monomorphic post-transplant lymphoproliferative disorder (mPTLD) is a major cause of morbidity/mortality following solid organ transplant (SOT), with infection, mPTLD progression and organ rejection presenting equal risks. Balancing these risks is challenging, and the intensity of therapy required by individual patients is not defined. Although an increasing body of evidence supports the use of a stepwise escalation of therapy through reduction in immunosuppression (RIS) to rituximab monotherapy and low-dose chemo-immunotherapy, many centres still use B-cell non-Hodgkin lymphoma (B-NHL) protocols, especially when managing Burkitt/Burkitt-like (BL) PTLD. This study sought to define outcomes for children managed in the UK or Spanish centres using low-intensity first-line treatments. PROCEDURE Retrospective data were anonymously collected on patients younger than 18 years of age, with post-SOT mPTLD diagnosed between 2000 and 2020. Only patients given low-intensity treatment at initial diagnosis were included. RESULTS Fifty-six patients were identified. Age range was 0.9-18 years (median 10.7). Most (62.5%) had early-onset PTLD. Haematopathological analysis showed 75% were diffuse large B-cell like, 14.3% were BL and nine of 33 (27%) harboured a MYC-rearrangement. Stage III-IV disease was present in 78.6%. All but one had RIS, 26 received rituximab monotherapy and 24 low-dose chemo-immunotherapy, mostly R-COP. Intensified B-NHL chemotherapy was required in 10/56 (17.9%). There were a total of 13 deaths in this cohort, three related to PTLD progression. The 1-year overall survival (OS), event-free survival (EFS) and progression-free survival (PFS) were 92.8%, 78.6% and 80.2%, respectively. CONCLUSIONS R-COP provides an effective low-dose chemotherapy option. Escalation to more intensive therapies in the minority of inadequately controlled patients is an effective strategy.
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Affiliation(s)
- Pilar Guerra-García
- Paediatric Haematology and Oncology Department, University Hospital La Paz, Madrid, Spain
- Translational Research in Paediatric Oncology, Haematopoietic Transplantation and Cell Therapy, University Hospital La Paz Institute for Health Research - IdiPAZ, Madrid, Spain
| | - Simon Bomken
- The Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Wolfson Childhood Cancer Research Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Ling
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Arina Lazareva
- Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Girish Gupte
- Liver Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Persis Amrolia
- Bone Marrow Transplantation, Great Ormond Street Hospital for Children, London, UK
| | - Mara Andrés
- Department of Paediatric Oncology, University Hospital La Fe, Valencia, Spain
| | | | - Mary M Taj
- The Royal Marsden Hospital, Sutton, London, UK
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3
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Jung H, Dhatt R, Rassekh SR, Heran MKS. Intra-arterial methylprednisolone for pediatric gastrointestinal post-transplant lymphoproliferative disorder. Pediatr Hematol Oncol 2024; 41:240-245. [PMID: 37861406 DOI: 10.1080/08880018.2023.2267612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Hoyoung Jung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ravjot Dhatt
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - S Rod Rassekh
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj K S Heran
- Department of Radiology, British Columbia's Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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4
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Mahadeo KM, Baiocchi R, Beitinjaneh A, Chaganti S, Choquet S, Dierickx D, Dinavahi R, Duan X, Gamelin L, Ghobadi A, Guzman-Becerra N, Joshi M, Mehta A, Navarro WH, Nikiforow S, O'Reilly RJ, Reshef R, Ruiz F, Spindler T, Prockop S. Tabelecleucel for allogeneic haematopoietic stem-cell or solid organ transplant recipients with Epstein-Barr virus-positive post-transplant lymphoproliferative disease after failure of rituximab or rituximab and chemotherapy (ALLELE): a phase 3, multicentre, open-label trial. Lancet Oncol 2024; 25:376-387. [PMID: 38309282 DOI: 10.1016/s1470-2045(23)00649-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/20/2023] [Accepted: 12/14/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND Survival in Epstein-Barr virus (EBV)-positive post-transplant lymphoproliferative disease following haematopoietic stem-cell transplant (HSCT) or solid organ transplant (SOT) is poor after failure of initial therapy, indicating an urgent need for therapies for this ultra-rare disease. With recent EU marketing authorisation, tabelecleucel is the first off-the-shelf, allogeneic, EBV-specific T-cell immunotherapy to receive approval for treatment of relapsed or refractory EBV-positive post-transplant lymphoproliferative disease. We aimed to determine the clinical benefit of tabelecleucel in patients with relapsed or refractory EBV-positive post-transplant lymphoproliferative disease following HSCT or SOT. METHODS In this global, multicentre, open-label, phase 3 trial, eligible patients (of any age) had biopsy-proven EBV-positive post-transplant lymphoproliferative disease, disease that was relapsed or refractory to rituximab after HSCT and rituximab with or without chemotherapy after SOT, and partially HLA-matched and appropriately HLA-restricted tabelecleucel available. Patients received tabelecleucel administered intravenously at 2 × 106 cells per kg on days 1, 8, and 15 in 35-day cycles and are assessed for up to 5 years for survival post-treatment initiation. The primary endpoint was objective response rate. All patients who received at least one dose of tabelecleucel were included in safety and efficacy analyses. This trial is registered with ClinicalTrials.gov, NCT03394365, and is ongoing. FINDINGS From June 27, 2018, to Nov 5, 2021, 63 patients were enrolled, of whom 43 (24 [56%] male and 19 [44%] female) were included, 14 had prior HSCT, 29 had SOT. Seven (50%, 95% CI 23-77) of 14 participants in the HSCT group and 15 (52%, 33-71) of 29 participants in the SOT group had an objective response, with a median follow-up of 14·1 months (IQR 5·7-23·9) and 6·0 months (1·8-18·4), respectively. The most common grade 3 or 4 treatment-emergent adverse events were disease progression (in four [29%] of 14 in HSCT and eight [28%] of 29 in SOT) and decreased neutrophil count (in four [29%] of 14 in HSCT and four [14%] of 29 in SOT). Treatment-emergent serious adverse events were reported in 23 (53%) of 43 patients and fatal treatment-emergent adverse events in five (12%); no fatal treatment-emergent adverse event was treatment-related. There were no reports of tumour flare reaction, cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, transmission of infectious diseases, marrow rejection, or infusion reactions. No events of graft-versus-host disease or SOT rejection were reported as related to tabelecleucel. INTERPRETATION Tabelecleucel provides clinical benefit in patients with relapsed or refractory EBV-positive post-transplant lymphoproliferative disease, for whom there are no other approved therapies, without evidence of safety concerns seen with other adoptive T-cell therapies. These data represent a potentially transformative and accessible treatment advance for patients with relapsed or refractory disease with few treatment options. FUNDING Atara Biotherapeutics.
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Affiliation(s)
| | - Robert Baiocchi
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospital Birmingham, Birmingham, UK
| | - Sylvain Choquet
- Clinical Hematology Unit, Groupe Hospitalier Pitié Salpêtrière, APHP, Sorbonne Université, Paris, France
| | | | | | | | | | - Armin Ghobadi
- Division of Oncology, Washington University, St Louis, MO, USA
| | | | | | - Aditi Mehta
- Atara Biotherapeutics, Thousand Oaks, CA, USA
| | | | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard J O'Reilly
- Transplant Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ran Reshef
- Blood and Marrow Transplantation and Cell Therapy Program, Columbia University Medical Center, New York, NY, USA
| | - Fiona Ruiz
- Atara Biotherapeutics, Thousand Oaks, CA, USA
| | | | - Susan Prockop
- Department of Pediatrics, Boston Children's Hospital-Dana Farber Cancer Institute, Boston, MA, USA.
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5
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Atamna A, Yahav D, Hirzel C. Prevention of Oncogenic Gammaherpesvirinae (EBV and HHV8) Associated Disease in Solid Organ Transplant Recipients. Transpl Int 2023; 36:11856. [PMID: 38046068 PMCID: PMC10689273 DOI: 10.3389/ti.2023.11856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023]
Abstract
Long-term risk for malignancy is higher among solid organ transplant (SOT) recipients compared to the general population. Four non-hepatitis viruses have been recognized as oncogenic in SOT recipients-EBV, cause of EBV-associated lymphoproliferative diseases; human herpes virus 8 (HHV8), cause of Kaposi sarcoma, primary effusion lymphoma and multicentric Castleman disease; human papilloma virus, cause of squamous cell skin cancers, and Merkel cell polyomavirus, cause of Merkel cell carcinoma. Two of these viruses (EBV and HHV8) belong to the human herpes virus family. In this review, we will discuss key aspects regarding the clinical presentation, diagnosis, treatment, and prevention of diseases in SOT recipients associated with the two herpesviruses.
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Affiliation(s)
- Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dafna Yahav
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
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Portuguese AJ, Gauthier J, Tykodi SS, Hall ET, Hirayama AV, Yeung CCS, Blosser CD. CD19 CAR-T therapy in solid organ transplant recipients: case report and systematic review. Bone Marrow Transplant 2023; 58:353-359. [PMID: 36575360 DOI: 10.1038/s41409-022-01907-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a leading cause of cancer death in solid organ transplant recipients (SOTRs). Relapsed or refractory (R/R) PTLD portends a high risk of death and effective management is not well established. CD19-targeted CAR-T cell therapy has been utilized, but the risks and benefits are unknown. We report the first case of diffuse large B-cell lymphoma (DLBCL) PTLD treated with lisocabtagene maraleucel and present a systematic literature review of SOTRs with PTLD treated with CD19 CAR-T therapy. Our patient achieved a complete response (CR) with limited toxicity but experienced a CD19+ relapse 8 months after infusion despite CAR-T persistence. Literature review revealed 14 DLBCL and 2 Burkitt lymphoma PTLD cases treated with CD19 CAR-T cells. Kidney (n = 12), liver (n = 2), heart (n = 2), and pancreas after kidney (n = 1) transplant recipients were analyzed. The objective response rate (ORR) was 82.4% (14/17), with 58.5% (10/17) CRs and a 6.5-month median duration of response. Among kidney transplant recipients, the ORR was 91.7% (11/12). Allograft rejection occurred in 23.5% (4/17). No graft failure occurred. Our analysis suggests that CD19 CAR-T therapy offers short-term effectiveness and manageable toxicity in SOTRs with R/R PTLD. Further investigation through larger datasets and prospective study is needed.
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Affiliation(s)
- Andrew J Portuguese
- University of Washington, Seattle, WA, USA.
- Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Jordan Gauthier
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Scott S Tykodi
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Evan T Hall
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Alexandre V Hirayama
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Cecilia C S Yeung
- University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Christopher D Blosser
- University of Washington, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
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7
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Chaganti S, Barlev A, Caillard S, Choquet S, Cwynarski K, Friedetzky A, González-Barca E, Sadetsky N, Schneeberger S, Thirumalai D, Zinzani PL, Trappe RU. Expert Consensus on the Characteristics of Patients with Epstein-Barr Virus-Positive Post-Transplant Lymphoproliferative Disease (EBV + PTLD) for Whom Standard-Dose Chemotherapy May be Inappropriate: A Modified Delphi Study. Adv Ther 2023; 40:1267-1281. [PMID: 36681739 PMCID: PMC9988727 DOI: 10.1007/s12325-022-02383-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/17/2022] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Following hematopoietic stem cell transplantation or solid organ transplantation, patients are at risk of developing Epstein-Barr virus-positive post-transplant lymphoproliferative disease (EBV+ PTLD), which is an ultra-rare and potentially lethal hematologic malignancy. Common treatments for EBV+ PTLD include rituximab alone or combined with chemotherapy. Given specific considerations for this population, including severity of the underlying condition requiring transplant, the rigors of the transplant procedure, as well as risks to the transplanted organ, there is a group of patients with EBV+ PTLD for whom chemotherapy may be inappropriate; however, there is limited information characterizing these patients. This study aimed to reach expert consensus on the key characteristics of patients for whom chemotherapy may be inappropriate in a real-world setting. METHODS A two-round modified Delphi study was conducted to reach consensus among clinicians with expertise treating EBV+ PTLD. Articles identified in a targeted literature review guided the development of round 1 and 2 topics and related statements. The consensus threshold for round 1 statements was 75.0%. If consensus was achieved in round 1, the statement was not discussed further in round 2. The consensus thresholds for round 2 were moderate (62.5-75.0%), strong (87.5%), or complete (100.0%). RESULTS The panel was composed of a total of eight clinicians (seven hematologists/hemato-oncologists) from six European countries. The panel generated a final list of 43 consensus recommendations on the following topics: terminology used to describe patients for whom chemotherapy may be inappropriate; demographic characteristics; organ transplant characteristics; comorbidities that preclude the use of chemotherapy; EBV+ PTLD characteristics; and factors related to treatment-related mortality and morbidity. CONCLUSIONS This modified Delphi panel successfully achieved consensus on key topics and statements that characterized patients with EBV+ PTLD for whom chemotherapy may be inappropriate. These recommendations will inform clinicians and aid in the treatment of EBV+ PTLD.
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Affiliation(s)
- Sridhar Chaganti
- Centre for Clinical Haematology, University Hospital Birmingham, Birmingham, UK
| | - Arie Barlev
- Atara Biotherapeutics, South San Francisco, CA, USA
| | - Sophie Caillard
- Department of Nephrology Transplantation, Strasbourg University Hospitals, Strasbourg, France
| | - Sylvain Choquet
- Department of Hematology, Hospitalier Pitié Salpétrière, Paris, France
| | - Kate Cwynarski
- Department of Haematology, University College Hospital, London, UK
| | | | - Eva González-Barca
- Department of Hematology, Institut Català d'Oncologia, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | | | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Pier L Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia "Seràgnoli", Bologna, Italy.,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Hospital Bremen, Bremen, Germany
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Blosser CD, Portuguese AJ, Santana C, Murakami N. Transplant Onconephrology: An Update. Semin Nephrol 2022; 42:151348. [PMID: 37209580 PMCID: PMC10330527 DOI: 10.1016/j.semnephrol.2023.151348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Transplant onconephrology is a growing specialty focused on the health care of kidney transplant recipients with cancer. Given the complexities associated with the care of transplant patients, along with the advent of novel cancer therapies such as immune checkpoint inhibitors and chimeric antigen-receptor T cells, there is a dire need for the subspecialty of transplant onconephrology. The management of cancer in the setting of kidney transplantation is best accomplished by a multidisciplinary team, including transplant nephrologists, oncologists, and patients. This review addresses the current state and future opportunities for transplant onconephrology, including the roles of the multidisciplinary team, and related scientific and clinical knowledge.
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Affiliation(s)
- Christopher D Blosser
- Division of Nephrology, University of Washington, Seattle, WA; Division of Nephrology, Seattle Children's Hospital, Seattle, WA.
| | | | | | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.; Harvard Medical School, Boston, MA
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9
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Zimmermann H, Koenecke C, Dreyling MH, Pott C, Dührsen U, Hahn D, Meidenbauer N, Hauser IA, Rummel MJ, Wolf D, Heuser M, Schmidt C, Schlattmann P, Ritgen M, Siebert R, Oschlies I, Anagnostopoulos I, Trappe RU. Modified risk-stratified sequential treatment (subcutaneous rituximab with or without chemotherapy) in B-cell Post-transplant lymphoproliferative disorder (PTLD) after Solid organ transplantation (SOT): the prospective multicentre phase II PTLD-2 trial. Leukemia 2022; 36:2468-2478. [PMID: 35974101 PMCID: PMC9522585 DOI: 10.1038/s41375-022-01667-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/30/2022]
Abstract
The prospective multicentre Phase II PTLD-2 trial (NCT02042391) tested modified risk-stratification in adult SOT recipients with CD20-positive PTLD based on principles established in the PTLD-1 trials: sequential treatment and risk-stratification. After rituximab monotherapy induction, patients in complete remission as well as those in partial remission with IPI < 3 at diagnosis (low-risk) continued with rituximab monotherapy and thus chemotherapy free. Most others (high-risk) received R-CHOP-21. Thoracic SOT recipients who progressed (very-high-risk) received alternating R-CHOP-21 and modified R-DHAOx. The primary endpoint was event-free survival (EFS) in the low-risk group. The PTLD-1 trials provided historical controls. Rituximab was applied subcutaneously. Of 60 patients enrolled, 21 were low-risk, 28 high-risk and 9 very-high-risk. Overall response was 45/48 (94%, 95% CI 83–98). 2-year Kaplan–Meier estimates of time to progression and overall survival were 78% (95% CI 65–90) and 68% (95% CI 55–80) – similar to the PTLD-1 trials. Treatment-related mortality was 4/59 (7%, 95% CI 2–17). In the low-risk group, 2-year EFS was 66% (95% CI 45–86) versus 52% in the historical comparator that received CHOP (p = 0.432). 2-year OS in the low-risk group was 100%. Results with R-CHOP-21 in high-risk patients confirmed previous results. Immunochemotherapy intensification in very-high-risk patients was disappointing.
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Affiliation(s)
- Heiner Zimmermann
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany.,Pius-Hospital, University Medicine Oldenburg, Department of Hematology and Oncology, Oldenburg, Germany
| | - Christian Koenecke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Christiane Pott
- Department of Internal Medicine II: Hematology and Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ulrich Dührsen
- Department of Hematology, Essen University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Dennis Hahn
- Department of Hematology, Oncology and Palliative Care, Katharinenhospital, Stuttgart, Germany
| | - Norbert Meidenbauer
- Department of Medicine 5, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ingeborg A Hauser
- Department of Nephrology, UKF, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Mathias J Rummel
- Department of Hematology, Clinic for Haematology and Medical Oncology, Justus Liebig University Hospital, Gießen, Germany
| | - Dominik Wolf
- Internal Medicine 3, Hematology, Oncology, Immunooncology and Rheumatology, University Hospital Bonn, Bonn, Germany.,University Clinic V, Department of Hematology and Oncology, and Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Peter Schlattmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Matthias Ritgen
- Department of Internal Medicine II: Hematology and Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Reiner Siebert
- Institute of Human Genetics, Ulm University and Ulm University Medical Center, Ulm, Germany
| | - Ilske Oschlies
- Department of Hematopathology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus, Bremen, Germany. .,Department of Internal Medicine II: Hematology and Oncology, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany.
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10
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Pediatric Onco-Nephrology: Time to Spread the Word-Part II: Long-Term Kidney Outcomes in Survivors of Childhood Malignancy and Malignancy after Kidney Transplant. Pediatr Nephrol 2022; 37:1285-1300. [PMID: 34490519 DOI: 10.1007/s00467-021-05172-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 05/24/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022]
Abstract
Onco-nephrology is a recent and evolving medical subspecialty devoted to the care of patients with kidney disease and unique kidney-related complications in the context of cancer and its treatments, recognizing that management of kidney disease as well as the cancer itself will improve survival and quality of life. While this area has received much attention in the adult medicine sphere, similar emphasis in the pediatric realm has not yet been realized. As in adults, kidney involvement in children with cancer extends beyond the time of initial diagnosis and treatment. Many interventions, such as chemotherapy, stem cell transplant, radiation, and nephrectomy, have long-term kidney effects, including the development of chronic kidney disease (CKD) with subsequent need for dialysis and/or kidney transplant. Thus, with the improved survival of children with malignancy comes the need for ongoing monitoring of kidney function and early mitigation of kidney-related comorbidities. In addition, children with kidney transplant are at higher risk of developing malignancies than their age-matched peers. Pediatric nephrologists thus need to be aware of issues related to cancer and its treatments as they impact their own patients. These facts emphasize the necessity of pediatric nephrologists and oncologists working closely together in managing these children and highlight the importance of bringing the onco-nephrology field to our growing list of pediatric nephrology subspecialties.
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11
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Santarsieri A, Rudge JF, Amin I, Gelson W, Parmar J, Pettit S, Sharkey L, Uttenthal BJ, Follows GA. Incidence and outcomes of post-transplant lymphoproliferative disease after 5365 solid-organ transplants over a 20-year period at two UK transplant centres. Br J Haematol 2022; 197:310-319. [PMID: 35235680 DOI: 10.1111/bjh.18065] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Post-transplant lymphoproliferative disease (PTLD) is a life-threatening complication of solid-organ transplantation (SOT). We present the incidence and outcomes of PTLD in a cohort of 5365 SOT recipients over a 20-year period at two UK transplant centres. With a median follow-up of 7.7 years, 142 of 5365 patients have developed PTLD. Cumulative incidence was 18% at five years after multivisceral transplant and 1%-3% at five years following the other SOT types. Twenty-year cumulative incidence was 2%-3% following liver and heart transplantation and 10% following kidney transplantation. Median overall survival (OS) following SOT was 16 years, which is significantly reduced compared with the age-adjusted UK population. There is relatively high early mortality following diagnosis of PTLD and only patients surviving two years regained a longer-term survival approaching the non-PTLD SOT cohort. Of 90 patients with monomorphic PTLD, diffuse large B-cell lymphoma, 66 were treated with first-line rituximab monotherapy and 24 received first-line rituximab plus chemotherapy. Up-front rituximab monotherapy does not appear to compromise OS, but the number of patients dying from non-lymphoma causes before and after treatment remains high with both treatment approaches. Multivariate analysis of all 90 monomorphic PTLD patients identified an International Prognostic Index (IPI) of 3+ as the strongest pretreatment variable associating with inferior one-year OS.
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Affiliation(s)
- Anna Santarsieri
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.,Anglia Ruskin University, Cambridge, UK
| | - John F Rudge
- Bullard Laboratories, University of Cambridge, Cambridge, UK
| | - Irum Amin
- Department of General Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Will Gelson
- Department of Hepatology, Addenbrooke's Hospital, Cambridge, UK
| | - Jasvir Parmar
- Cardio-Thoracic Transplant Unit, Royal Papworth Hospital, Cambridge, UK
| | - Stephen Pettit
- Cardio-Thoracic Transplant Unit, Royal Papworth Hospital, Cambridge, UK
| | - Lisa Sharkey
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, UK
| | | | - George A Follows
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.,Anglia Ruskin University, Cambridge, UK
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12
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Boyle S, Tobin JWD, Perram J, Hamad N, Gullapalli V, Barraclough A, Singaraveloo L, Han MH, Blennerhassett R, Nelson N, Johnston AM, Talaulikar D, Karpe K, Bhattacharyya A, Cheah CY, Subramoniapillai E, Bokhari W, Lee C, Hawkes EA, Jabbour A, Strasser SI, Chadban SJ, Brown C, Mollee P, Hapgood G. Management and Outcomes of Diffuse Large B-cell Lymphoma Post-transplant Lymphoproliferative Disorder in the Era of PET and Rituximab: A Multicenter Study From the Australasian Lymphoma Alliance. Hemasphere 2021; 5:e648. [PMID: 34651103 PMCID: PMC8505336 DOI: 10.1097/hs9.0000000000000648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022] Open
Abstract
There are limited data on post-transplant lymphoproliferative disorder (PTLD) in the era of positron emission tomography (PET) and rituximab (R). Furthermore, there is limited data on the risk of graft rejection with modern practices in reduction in immunosuppression (RIS). We studied 91 patients with monomorphic diffuse large B-cell lymphoma PTLD at 11 Australian centers: median age 52 years, diagnosed between 2004 and 2017, median follow-up 4.7 years (range, 0.5-14.5 y). RIS occurred in 88% of patients. For patients initially treated with R-monotherapy, 45% achieved complete remission, rising to 71% with the addition of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) for those not in complete remission. For patients initially treated with R-CHOP, the complete remission rate was 76%. There was no difference in overall survival (OS) between R-monotherapy and R-chemotherapy patients. There was no difference in OS for patients with systemic lymphoma (n = 68) versus central nervous system (CNS) involvement (n = 23) (3-y OS 72% versus 73%; P = 0.78). Treatment-related mortality was 7%. End of treatment PET was prognostic for patients with systemic lymphoma with longer OS in the PET negative group (3-y OS 91% versus 57%; P = 0.01). Graft rejection occurred in 9% (n = 4 biopsy-proven; n = 4 suspected) during the entire follow-up period with no cases of graft loss. RIS and R-based treatments are safe and effective with a low likelihood of graft rejection and high cure rate for patients achieving complete remission with CNS or systemic PTLD.
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Affiliation(s)
- Stephen Boyle
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Joshua W. D. Tobin
- University of Queensland, Brisbane, Queensland, Australia
- Department of Haematology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Jacinta Perram
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent’s Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Veena Gullapalli
- Department of Haematology, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Allison Barraclough
- Department of Haematology and Olivia Newton John Cancer Research Institute, The Austin Hospital, Melbourne, Victoria, Australia
| | | | - Min-Hi Han
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Richard Blennerhassett
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Niles Nelson
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Anna M. Johnston
- Royal Hobart Hospital, Hobart, Tasmania, Australia
- University of Tasmania, Hobart, Tasmania, Australia
| | - Dipti Talaulikar
- Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Krishna Karpe
- Department of Renal Medicine, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Abir Bhattacharyya
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Chan Yoon Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- University of Western Australia, Crawley, Western Australia, Australia
| | | | - Waqas Bokhari
- Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eliza A. Hawkes
- Department of Haematology and Olivia Newton John Cancer Research Institute, The Austin Hospital, Melbourne, Victoria, Australia
- Eastern Health, Box Hill, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Jabbour
- Department of Cardiology, St Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Simone I. Strasser
- University of Sydney, Sydney, New South Wales, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Steven J. Chadban
- University of Sydney, Sydney, New South Wales, Australia
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Kidney Node, Charles Perkins Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Christina Brown
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Peter Mollee
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Greg Hapgood
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
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13
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Pearse WB, Petrich AM, Gordon LI, Karmali R, Winter JN, Ma S, Kaplan JB, Behdad A, Klein A, Jovanovic B, Helenowski I, Smith SM, Evens AM, Pro B. A phase I/II trial of brentuximab vedotin plus rituximab as frontline therapy for patients with immunosuppression-associated CD30+ and/or EBV + lymphomas. Leuk Lymphoma 2021; 62:3493-3500. [PMID: 34338127 DOI: 10.1080/10428194.2021.1957867] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Treatment strategies for post-transplant lymphoproliferative disorders (PTLD) consist of response-adapted risk-stratified methods using immunosuppression reduction, immunotherapy, and chemotherapy. We investigated the efficacy of Brentuximab vedotin given concurrently with Rituximab (BV + R) once weekly for four weeks, followed by optional consolidation, and up to one year of maintenance. Among 20 assessable patients, BV + R therapy resulted in an overall response rate of 75% (95% CI 51 to 91, p = 0.044) with 60% achieving a complete response. Median time to best response was 28 days. Two-year progression-free survival and overall survival rates were 75 and 90%, respectively. Most common severe grade 3/4 treatment-related toxicities included neutropenia (40%), hypertension (30%), infection (25%), and peripheral neuropathy (15%). BV + R is a novel and effective therapeutic strategy that achieved rapid and durable remissions in previously untreated PTLD patients; however, this treatment platform requires further modification due to the high rates of treatment-related toxicity.Key pointsBrentuximab vedotin + Rituximab showed ORR and CR rates of 75 and 60% in patients with immunosuppression-associated lymphoid malignanciesHigh rates of treatment delay were attributed to treatment-related toxicity; further dosing optimization of this regimen is required.
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Affiliation(s)
- William B Pearse
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adam M Petrich
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leo I Gordon
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Reem Karmali
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane N Winter
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shuo Ma
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason B Kaplan
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amir Behdad
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andreas Klein
- Department of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - Borko Jovanovic
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Irene Helenowski
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Sonali M Smith
- Section of Hematology/Oncology, University of Chicago, Chicago, IL, USA
| | - Andrew M Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Barbara Pro
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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14
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Rubinstein JD, Shah R, Breese EH, Burns KC, Mangino JL, Norris RE, Lee L, Mizukawa B, O'Brien MM, Phillips CL, Perentesis JP, Pommert L, Absalon MJ. Treatment of posttransplant lymphoproliferative disorder with poor prognostic features in children and young adults: Short-course EPOCH regimens are safe and effective. Pediatr Blood Cancer 2021; 68:e29126. [PMID: 34019326 DOI: 10.1002/pbc.29126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 12/30/2022]
Abstract
No guidelines exist for which intensive chemotherapy regimen is best in pediatric or young adult patients with high-risk posttransplant lymphoproliferative disorder (PTLD). We retrospectively reviewed patients with PTLD who received interval-compressed short-course etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin (SC-EPOCH) regimens at our institution. Eight patients were included with median age of 12 years. All patients achieved a complete response with a manageable toxicity profile. Two patients developed second, clonally unrelated, EBV-positive PTLD and one patient had recurrence at 6 months off therapy. No graft rejection occurred during therapy. All eight patients are alive with median follow-up of 29 months.
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Affiliation(s)
- Jeremy D Rubinstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rachana Shah
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Erin H Breese
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Karen C Burns
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer L Mangino
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Robin E Norris
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lynn Lee
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Benjamin Mizukawa
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maureen M O'Brien
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christine L Phillips
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John P Perentesis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lauren Pommert
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael J Absalon
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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15
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Dang BN, Ch'ng J, Russell M, Cheng JC, Moore TB, Alejos JC. Treatment of post-transplant lymphoproliferative disorder (PTLD) in a heart transplant recipient with chimeric antigen receptor T-cell therapy. Pediatr Transplant 2021; 25:e13861. [PMID: 33002249 DOI: 10.1111/petr.13861] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/15/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) are a group of lesions that can complicate solid organ or hematopoietic stem cell transplantation and are often associated with Epstein-Barr virus (EBV). The treatment of PTLD is dependent on the type of lesion and includes a wide range of therapies, but chimeric antigen receptor (CAR) T-cell therapy has not previously been reported as a treatment option for PTLD. We present a patient who developed refractory PTLD in her right retroperitoneum, right inguinal and iliac chains, and right axillary region shortly after heart transplantation and was treated with CAR T-cell therapy. She could not tolerate complete discontinuation of immunosuppression due to the risk of rejection of a life-supporting graft. The patient's PTLD responded to CAR T-cell therapy, and her heart was monitored throughout the treatment course without any signs of rejection or ventricular dysfunction. CAR T-cell therapy may be a viable treatment option in patients who develop PTLD after a solid organ transplant.
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Affiliation(s)
- Brian N Dang
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - James Ch'ng
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Matthew Russell
- Division of Pediatric Cardiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jerry C Cheng
- Pediatric Hematology and Oncology, Southern California Kaiser Permanente Medical Group, Los Angeles, CA, USA
| | - Theodore B Moore
- Division of Pediatric Hematology and Oncology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Juan C Alejos
- Division of Pediatric Cardiology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
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16
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Saito H, Miyoshi H, Shibayama H, Toda J, Kusakabe S, Ichii M, Fujita J, Fukushima K, Maeda T, Mizuki M, Oritani K, Seto M, Yokota T, Kanakura Y, Hosen N, Ohshima K. High numbers of programmed cell death-1-positive tumor infiltrating lymphocytes correlate with early onset of post-transplant lymphoproliferative disorder. Int J Hematol 2021; 114:53-64. [PMID: 33765256 DOI: 10.1007/s12185-021-03129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/26/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening complication of transplantation. In addition to reactivation of Epstein-Barr virus in immunocompromised patients, impaired tumor immunity is suggested to be a risk factor for PTLD. However, it remains unclear whether immune suppressive tumor-infiltrating lymphocytes (TILs) correlate with the occurrence or prognosis of PTLD. We analyzed TILs in 26 patients with PTLD to elucidate the clinicopathological significance of the expression of PD-1 and FoxP3, which are associated with exhausted T-cells and regulatory T-cells (Tregs), respectively. Numbers of PD-1+ TILs in the PTLD specimens were significantly higher in patients who developed PTLD early after transplantation (P = 0.0040), while numbers of FoxP3+ TILs were not (P = 0.184). There was no difference in overall response rate regardless of the expression of PD-1 or FoxP3. FoxP3high patients tended to have a shorter time to progression compared with FoxP3low patients, especially in the case of FoxP3high patients with diffuse large B-cell lymphoma-subtype PTLD (P = 0.011), while PD-1high patients did not. These results suggest that T-cell exhaustion may be mainly associated with PTLD development, while immune suppression by Tregs may be dominant in enhanced progression of PTLD following disease occurrence.
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Affiliation(s)
- Hideaki Saito
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Hiroaki Miyoshi
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Hirohiko Shibayama
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan.
| | - Jun Toda
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Shinsuke Kusakabe
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Michiko Ichii
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Jiro Fujita
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Tetsuo Maeda
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
- Department of Hematology, Suita Municipal Hospital, Osaka, Japan
| | - Masao Mizuki
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Kenji Oritani
- Department of Hematology, Graduate School of Medical Sciences, International University of Health and Welfare, Chiba, Japan
| | - Masao Seto
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Takafumi Yokota
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
- Department of Hematology, Sumitomo Hospital, Osaka, Japan
| | - Naoki Hosen
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
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17
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Patil R, Prashar R, Patel A. Heterogeneous Manifestations of Posttransplant Lymphoma in Renal Transplant Recipients: A Case Series. Transplant Proc 2021; 53:1519-1527. [PMID: 34134932 DOI: 10.1016/j.transproceed.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/05/2021] [Accepted: 04/19/2021] [Indexed: 01/07/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) occurs in 1% to 3% of adult renal transplant recipients (RTRs). PTLD has a heterogeneous presentation and is often associated with Epstein-Barr virus (EBV) and immunosuppression. We present a descriptive case series of 16 RTRs who demonstrate a variety of PTLD manifestations. Fifty-six percent received rabbit antithymocyte globulin induction, and 37.5% received basiliximab. Maintenance immunosuppression included glucocorticoids, tacrolimus, and mycophenolate mofetil. Median time from transplantation to PTLD diagnosis was 96.5 months. PTLD involved a single site in 44% of RTRs and multiple sites in 56%. PTLD was localized to the gastrointestinal tract in 9 RTRs, in lymph nodes in 9, central nervous system in 4, bone marrow in 3, skin in 3, lungs in 2, perinephric space in 2, mediastinum in 1, and native kidney in 1. PTLD was EBV positive in 8 RTRs, monomorphic/monoclonal in 14, and of B-cell lineage in 13. Three RTRs had T-cell PTLD. Immunosuppressive agents, except glucocorticoids, were discontinued at diagnosis. Treatment was chemotherapy either alone (in 14 RTRs) or in combination with radiation. Complete remission was achieved in 62.5% of RTRs. Renal dysfunction developed in 62.5% of RTRs, and 4 received dialysis. The overall mortality rate was 62.5%, with median time of death 6.5 months after diagnosis. PTLD that was EBV negative and had T-cell involvement presented with aggressive disease and a higher mortality. Clinicians should be aware of the various PTLD manifestations. Early diagnosis and a multidisciplinary approach to treatment is crucial for improved patient outcomes.
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Affiliation(s)
- Rujuta Patil
- Wayne State University School of Medicine, Detroit, Michigan
| | - Rohini Prashar
- Kidney and Pancreas Transplant Program, Henry Ford Transplant Institute, Detroit, Michigan
| | - Anita Patel
- Kidney and Pancreas Transplant Program, Henry Ford Transplant Institute, Detroit, Michigan.
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18
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Shah N, Eyre TA, Tucker D, Kassam S, Parmar J, Featherstone C, Andrews P, Asgari E, Chaganti S, Menne TF, Fox CP, Pettit S, Suddle A, Bowles KM. Front-line management of post-transplantation lymphoproliferative disorder in adult solid organ recipient patients - A British Society for Haematology Guideline. Br J Haematol 2021; 193:727-740. [PMID: 33877688 DOI: 10.1111/bjh.17421] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Nimish Shah
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Shireen Kassam
- King's College Hospital NHS Foundation Trust, London, UK
| | - Jasvir Parmar
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Peter Andrews
- Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Elham Asgari
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Tobias F Menne
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Stephen Pettit
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Abid Suddle
- King's College Hospital NHS Foundation Trust, London, UK
| | - Kristian M Bowles
- Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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19
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Reappraisal of the prognostic value of Epstein-Barr virus status in monomorphic post-transplantation lymphoproliferative disorders-diffuse large B-cell lymphoma. Sci Rep 2021; 11:2880. [PMID: 33536508 PMCID: PMC7859229 DOI: 10.1038/s41598-021-82534-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/14/2021] [Indexed: 12/13/2022] Open
Abstract
The role of the Epstein-Barr virus (EBV) status in the blood for predicting survival in post-transplantation lymphoproliferative disorders-diffuse large B-cell lymphoma (PTLD-DLBCL) is unknown. We evaluated the prognostic values of pre-treatment EBV-encoded small RNA (EBER) detected with in situ hybridization in tissues and EBV DNA in the whole blood (WB) and plasma in 58 patients with monomorphic PTLD-DLBCL after solid organ transplantation. There were no significant differences in the rates of overall response, complete response, and survival according to EBER EBV and WB EBV status. In contrast, patients with positive plasma EBV DNA had significantly lower rates of overall response (60.0% vs. 94.4%, P = 0.043) and complete response (40.0% vs. 88.9%, P = 0.019) as well as worse progression-free survival (PFS) (P = 0.035) and overall survival (OS) (P = 0.039) compared with patients with negative plasma EBV DNA. In multivariate analysis, plasma EBV DNA positivity was a significantly unfavorable prognostic factor for PFS [hazard ratio (HR) 4.92, 95% confidence interval (CI) 1.22-19.86, P = 0.025] and OS (HR 4.48, 95% CI 1.14-17.63, P = 0.032). Despite small number of 6 patients with plasma EBV positivity, plasma EBV DNA positivity might be more prognostic for survival than EBER or WB EBV DNA positivity in patients with monomorphic PTLD-DLBCL.
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Leeaphorn N, Thongprayoon C, Chewcharat A, Hansrivijit P, Jadlowiec CC, Cummings LS, Katari S, Mao SA, Mao MA, Cheungpasitporn W. Outcomes of kidney retransplantation in recipients with prior posttransplant lymphoproliferative disorders: An analysis of the 2000-2019 UNOS/OPTN database. Am J Transplant 2021; 21:846-853. [PMID: 33128832 DOI: 10.1111/ajt.16385] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/13/2020] [Accepted: 10/25/2020] [Indexed: 01/25/2023]
Abstract
This study utilized the UNOS database to assess clinical outcomes after kidney retransplantation in patients with a history of posttransplant lymphoproliferative disease (PTLD). Among second kidney transplant patients from 2000 to 2019, 254 had history of PTLD in their first kidney transplant, whereas 28,113 did not. After a second kidney transplant, PTLD occurred in 2.8% and 0.8% of patients with and without history of PTLD, respectively (p = .001). Over a median follow-up time of 4.5 years after a second kidney transplant, 5-year death-censored graft failure was 9.5% vs. 12.6% (p = .21), all-cause mortality was 8.3% vs. 11.8% (p = .51), and 1-year acute rejection was 11.0% vs. 9.3% (p = .36) in the PTLD vs. non-PTLD groups, respectively. There was no significant difference in death-censored graft failure, mortality, and acute rejection between PTLD and non-PTLD groups in adjusted analysis and after propensity score matching. We conclude that graft survival, patient survival, and acute rejection after kidney retransplantation are comparable between patients with and without history of PTLD, but PTLD occurrence after kidney retransplantation remains higher in patients with history of PTLD.
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Affiliation(s)
- Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Api Chewcharat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, Pennsylvania
| | | | - Lee S Cummings
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri
| | - Sreelatha Katari
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri
| | - Shennen A Mao
- Division of Transplant Surgery, Mayo Clinic, Jacksonville, Florida
| | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Neelapu SS, Adkins S, Ansell SM, Brody J, Cairo MS, Friedberg JW, Kline JP, Levy R, Porter DL, van Besien K, Werner M, Bishop MR. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of lymphoma. J Immunother Cancer 2020; 8:e001235. [PMID: 33361336 PMCID: PMC7768967 DOI: 10.1136/jitc-2020-001235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
The recent development and clinical implementation of novel immunotherapies for the treatment of Hodgkin and non-Hodgkin lymphoma have improved patient outcomes across subgroups. The rapid introduction of immunotherapeutic agents into the clinic, however, has presented significant questions regarding optimal treatment scheduling around existing chemotherapy/radiation options, as well as a need for improved understanding of how to properly manage patients and recognize toxicities. To address these challenges, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts in lymphoma to develop a clinical practice guideline for the education of healthcare professionals on various aspects of immunotherapeutic treatment. The panel discussed subjects including treatment scheduling, immune-related adverse events (irAEs), and the integration of immunotherapy and stem cell transplant to form recommendations to guide healthcare professionals treating patients with lymphoma.
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Affiliation(s)
- Sattva S Neelapu
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry Adkins
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen M Ansell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Joshua Brody
- Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Mitchell S Cairo
- Department of Pediatrics, Medicine, Pathology, Microbiology and Immunology and Cell Biology, New York Medical College At Maria Fareri Children's Hospital, New York City, New York, USA
| | - Jonathan W Friedberg
- Department of Medicine, Hematology-Oncology Division, Wilmot Cancer Institute University of Rochester Medical Center, Rochester, New York, USA
| | - Justin P Kline
- Department of Medicine Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Ronald Levy
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David L Porter
- Cell Therapy and Transplant and Division of Hematology Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Koen van Besien
- Division of Hematology/Oncology, Weill Cornell Medical College, New York City, New York, USA
| | | | - Michael R Bishop
- Department of Medicine Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
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22
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Zhu F, Li Q, Liu T, Xiao Y, Pan H, Liu X, Wu G, Zhang L. Primary central nervous system lymphoma after heart transplantation: A case report and literature review. Medicine (Baltimore) 2020; 99:e21844. [PMID: 32871907 PMCID: PMC7458240 DOI: 10.1097/md.0000000000021844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 06/16/2020] [Accepted: 07/21/2020] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The heart transplantation is the most important treatment for patients with end-stage severe heart disease who failed to conventional therapy. Post-transplant lymphoproliferative disorder is the second most common malignancy in heart transplant recipients. However, primary central nervous system lymphoma (PCNSL) after heart transplantation is an extremely rare condition. PATIENTS CONCERNS This report described a 53-year-old male who was diagnosed as PCNSL 17 months after heart transplantation. DIAGNOSES The patient was admitted to the local hospital presenting with dizziness, headache, and reduced left-sided power and sensation for 1 week. He had a medical history of heart transplantation because of the dilated cardiomyopathy 17 months ago and had a 17-month history of immunosuppressive therapy with tacrolimus. A computed tomography scan of the brain revealed a bulky mass in the right temporal lobe. The emergency intracranial mass resection and cerebral decompression were performed in our hospital. The histopathology of the brain lesions showed diffuse large B-cell lymphoma. A further FDG positron emission tomography-computed tomography scan of the whole body showed no significantly increased metabolic activity in other regions. The final diagnosis of this patient was PCNSL after heart transplantation. INTERVENTIONS Given the poor health condition, with the patient's consent, the whole brain radiotherapy was performed with supportive care. OUTCOMES The disease deteriorated rapidly during the period of receiving radiotherapy, and he died within 2 months from the diagnosis. LESSONS PCNSL after heart transplantation is an extremely rare phenomenon with extremely poor prognosis. We should pay close attention to the heart recipients, especially when the patients present with neurological symptoms and signs. The available treatment options for PCNS-post-transplant lymphoproliferative disorder include the reduction of immunosuppressive drugs, immune-chemotherapy, operation, radiotherapy. However, individual treatments for heart transplant recipients with PCNSL should be based on the performance status and tolerance to treatment, combined with the doctor's experience and supportive care.
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Affiliation(s)
| | | | | | | | - Huaxiong Pan
- Department of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Long-term follow-up of a prospective phase 2 clinical trial of extended treatment with rituximab in patients with B cell post-transplant lymphoproliferative disease and validation in real world patients. Ann Hematol 2020; 100:1023-1029. [PMID: 32367180 DOI: 10.1007/s00277-020-04056-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/23/2020] [Indexed: 12/12/2022]
Abstract
The purpose of this report is to provide long-term follow-up of 38 patients diagnosed of post-transplant lymphoproliferative disease (PTLD) included in a phase 2 clinical trial of first line therapy with rituximab and to evaluate the same therapy in a real world cohort of 21 consecutive patients treated once the trial was closed. Eligible patients were ≥ 18 years of age with a biopsy-proven CD20 positive B cell PTLD and treatment naive except for reduction of immunosuppression. Treatment consisted in four weekly infusions of rituximab at the standard dose of 375 mg/m2. Patients in complete remission (CR) were followed without further treatment, and those in partial remission (PR) were treated with another four cycles of weekly rituximab. Median follow-up in the clinical trial was 13.0 years. Disease-specific survival (DSS) at 10 years was 64.7% [95% confidence interval (CI) 48.2-81.2%]. For those patients who achieved CR (61%), DSS at 5 and 10 years was 94.4% (95% CI 83.8-100%) and 88.1% (95% CI 72.6-100%), respectively, and only 1 patient progressed beyond 5 years. The median follow-up of the real world patients was 6.5 years. DSS at 5 years was 75.2% (95% CI 56.4-94.0%). DSS at 5 years of patients who achieved CR (38%) was 87.5% (95% CI 64.6-100%). In conclusion, PTLD patients in CR after rituximab have an excellent long-term outcome. These results not only apply in the clinical trial setting but are also reproducible in the real world. However, those patients who do not respond represent an unmet clinical need and should be included in prospective clinical trials.
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Burns DM, Clesham K, Hodgson YA, Fredrick L, Haughton J, Lannon M, Hussein H, Shin JS, Hollows RJ, Robinson L, Byrne C, McNamara C, Vydianath B, Lennard AL, Fields P, Johnson R, Wright J, Fox CP, Cwynarski K, Chaganti S. Real-world Outcomes With Rituximab-based Therapy for Posttransplant Lymphoproliferative Disease Arising After Solid Organ Transplant. Transplantation 2020; 104:2582-2590. [DOI: 10.1097/tp.0000000000003183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Jain MD, Lam R, Liu Z, Stubbins RJ, Kahlon A, Kansara R, Goswami R, Humar A, Prica A, Sehn LH, Slack GW, Crump M, Savage KJ, Peters AC, Kuruvilla J. Failure of rituximab is associated with a poor outcome in diffuse large B cell lymphoma‐type post‐transplant lymphoproliferative disorder. Br J Haematol 2020; 189:97-105. [DOI: 10.1111/bjh.16304] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/23/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Michael D. Jain
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
- H. Lee Moffitt Cancer Center University of South Florida Morsani College of Medicine Tampa FL USA
| | - Ryan Lam
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
| | - Zhihui Liu
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
| | - Ryan J. Stubbins
- Cross Cancer Institute University of Alberta Edmonton Canada
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
| | - Amrit Kahlon
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
| | - Roopesh Kansara
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
- Cancer Care Manitoba Winnipeg Canada
| | - Rashmi Goswami
- Sunnybrook Research Institute and Department of Laboratory Medicine and Pathobiology University of Toronto Toronto Canada
| | - Atul Humar
- Toronto General Hospital University Health Network University of Toronto Toronto Canada
| | - Anca Prica
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
| | - Laurie H. Sehn
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
| | - Graham W. Slack
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
| | - Michael Crump
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
| | - Kerry J. Savage
- British Columbia Cancer Centre for Lymphoid Cancer Vancouver Canada
| | | | - John Kuruvilla
- Princess Margaret Cancer Centre University Health Network University of Toronto Toronto Canada
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Koganti S, Burgula S, Bhaduri-McIntosh S. STAT3 activates the anti-apoptotic form of caspase 9 in oncovirus-infected B lymphocytes. Virology 2019; 540:160-164. [PMID: 31928997 DOI: 10.1016/j.virol.2019.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/05/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
The cancer-causing Epstein-Barr virus (EBV) activates the transcription factor STAT3 upon infecting B-lymphocytes. STAT3 then activates caspase 7 to degrade cellular claspin, resulting in impaired Chk1 phosphorylation. This blockade of ATR-Chk1 signaling allows EBV-transformed cells to proliferate despite DNA lesions from virus-induced replication stress. In addressing the mechanism of caspase 7 activation, we now report that in newly-infected B-cells, STAT3 transcriptionally activates the initiator caspase, caspase 9. Caspase 9 then activates caspase 7 to impair phosphorylation of Chk1 at S345. Importantly, although cleaved products of caspase 9 are detectable in infected cells, there is simultaneous increase in the alternatively-spliced dominant-negative form of caspase 9 - and - expression of dominant-negative caspase 9 is abrogated when STAT3 activation is impaired. Thus EBV, via STAT3, activates caspase 9 but also shifts the balance of transcripts towards its dominant-negative form to allow activation of caspase 7 while avoiding death of EBV-infected cells.
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Affiliation(s)
- Siva Koganti
- Division of Infectious Diseases, Department of Pediatrics, Stony Brook University, NY, USA
| | - Sandeepta Burgula
- Division of Infectious Diseases, Department of Pediatrics, Stony Brook University, NY, USA
| | - Sumita Bhaduri-McIntosh
- Division of Infectious Diseases, Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL, USA.
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27
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Allen UD, Preiksaitis JK. Post-transplant lymphoproliferative disorders, Epstein-Barr virus infection, and disease in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13652. [PMID: 31230381 DOI: 10.1111/ctr.13652] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 02/06/2023]
Abstract
PTLD with the response-dependent sequential use of RIS, rituximab, and cytotoxic chemotherapy is recommended. Evidence gaps requiring future research and alternate treatment strategies including immunotherapy are highlighted.
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Affiliation(s)
- Upton D Allen
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jutta K Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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28
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Piening N, Saurabh S, Munoz Abraham AS, Osei H, Fitzpatrick C, Greenspon J. Sterile necrotizing and non-necrotizing granulomas in a heart transplant patient with history of PTLD: A unique finding. Int J Surg Case Rep 2019; 60:8-12. [PMID: 31185455 PMCID: PMC6556822 DOI: 10.1016/j.ijscr.2019.05.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/07/2019] [Accepted: 05/27/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Posttransplant lymphoproliferative disease (PTLD) is a known complication in patients with solid organ transplant. It can present as localized or disseminated tumor. The cornerstone of management consists of reduced immunosuppression (RI). In select cases, localized disease can potentially be curative with surgical excision. PRESENTATION OF CASE Here we present a case of a 19-year-old female with orthotopic heart transplant with two episodes of recurrent PTLD. After the second episode she was found to have asymptomatic splenic lesions which were refractory to RI and chemotherapy. She subsequently underwent splenectomy that showed sterile necrotizing and non-necrotizing granulomas with no evidence of PTLD. DISCUSSION Based on our literature search this is the first ever reported case of sterile granulomas in a patient with recurrent PTLD which could potentially be diagnosed with minimally invasive biopsy rather than diagnostic splenectomy. CONCLUSION This report is an attempt to create awareness regarding potential for presence of sterile granulomas in patients with recurrent PTLD and discuss the use of percutaneous biopsy before splenectomy.
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Affiliation(s)
| | - Saxena Saurabh
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center, United States
| | | | - Hector Osei
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center, United States
| | - Colleen Fitzpatrick
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center, United States
| | - Jose Greenspon
- Department of Pediatric Surgery, Cardinal Glennon Children's Medical Center, United States
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Performance of advanced imaging modalities at diagnosis and treatment response evaluation of patients with post-transplant lymphoproliferative disorder: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2018; 132:27-38. [DOI: 10.1016/j.critrevonc.2018.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/20/2018] [Accepted: 09/11/2018] [Indexed: 01/03/2023] Open
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Kawano N, Yoshida S, Kawano S, Kuriyama T, Tahara Y, Toyofuku A, Manabe T, Doi A, Terasaka S, Yamashita K, Ueda Y, Ochiai H, Marutsuka K, Yamano Y, Shimoda K, Kikuchi I. The clinical impact of human T-lymphotrophic virus type 1 (HTLV-1) infection on the development of adult T-cell leukemia-lymphoma (ATL) or HTLV-1-associated myelopathy (HAM) / atypical HAM after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and renal transplantation. J Clin Exp Hematop 2018; 58:107-121. [PMID: 30089749 PMCID: PMC6408177 DOI: 10.3960/jslrt.18011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Because there are limited clinical reports on the impact of human T-lymphotropic virus
type 1 (HTLV-1) on organ transplantation, its effects on the development of adult T-cell
leukemia-lymphoma (ATL), post-transplantation lymphoproliferative disorder (PTLD) and
HTLV-1–associated myelopathy (HAM) or atypical HAM after organ transplantation remain
unclear. We retrospectively analyzed the impact of HTLV-1 in 54 allogeneic hematopoietic stem cell
transplantation (allo-HSCT) cases and 31 renal transplantation cases between January 2006
and December 2016. Among the 54 allo-HSCT cases, nine recipients with ATL tested positive for HTLV-1, and
one was found to be an HTLV-1 carrier. All donors tested negative for HTLV-1. Only one
HTLV-1 carrier did not present with ATL or HAM development after allo-HSCT. Among nine ATL
cases after allo-HSCT, four eventually relapsed due to proliferation of recipient-derived
ATL cells. However, in one ATL case, atypical HAM developed rapidly at 5 months after
allo-HSCT. Among the 31 renal transplantation cases, all donors tested negative for HTLV-1, and only
recipients tested positive. Only one HTLV-1 carrier recipient did not present with ATL or
HAM development after renal transplantation. However, one HTLV-1-negative recipient
developed PTLD in the brain 10 years after renal transplantation. In clinical practice, careful follow-up of HTLV-1 infected recipients after organ
transplantation is important because atypical HAM can develop in ATL patients after
allo-HSCT. Furthermore, to clarify the risk of ATL or HAM development in HTLV-1 infected
recipients, we prospectively followed up our cohort.
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31
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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: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Hotta M, Nakaya A, Fujita S, Satake A, Nakanishi T, Azuma Y, Tsubokura Y, Konishi A, Yoshimura H, Ito T, Ishii K, Nomura S. Blastic Epstein-Barr virus associated post-transplant lymphoproliferative disorder after allogeneic stem cell transplantation for severe aplastic anemia. Hematol Rep 2018; 10:7527. [PMID: 30046412 PMCID: PMC6036979 DOI: 10.4081/hr.2018.7527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 05/15/2018] [Indexed: 11/23/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized complication of organ transplantation. Progress has recently been made in the pathological classification of PTLD. However, the clinical course has not been clarified because of the rarity of this disease. We experienced a case of PTLD with a fulminant clinical course. The patient had been under longterm immunosuppressive treatment for aplastic anemia. He received related allogeneic hematopoietic stem cell transplantation. Soon after transplantation, he developed PTLD. According to the guidelines, we reduced immunosuppression. However, the disease course was so fulminant that there was no time for the patient to respond, and he died of multi-organ failure. There may be various clinical types of PTLD, which may include some fulminant cases. In such a case, it is not sufficient to reduce immunosuppression. The patient should be carefully observed and an appropriate individual treatment should be chosen.
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Affiliation(s)
- Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Aya Nakaya
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Takahisa Nakanishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Yoshiko Azuma
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Yukie Tsubokura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Kazuyoshi Ishii
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
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33
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DeStefano CB, Desai SH, Shenoy AG, Catlett JP. Management of post-transplant lymphoproliferative disorders. Br J Haematol 2018; 182:330-343. [DOI: 10.1111/bjh.15263] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
| | - Sanjal H. Desai
- Department of Hematology; MedStar Washington Hospital Center; Washington DC USA
| | - Aarthi G. Shenoy
- Department of Hematology; MedStar Washington Hospital Center; Washington DC USA
| | - Joseph P. Catlett
- Department of Hematology; MedStar Washington Hospital Center; Washington DC USA
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Ready E, Chernushkin K, Partovi N, Hussaini T, Luo C, Johnston O, Shapiro RJ. Posttransplant Lymphoproliferative Disorder in Adults Receiving Kidney Transplantation in British Columbia: A Retrospective Cohort Analysis. Can J Kidney Health Dis 2018; 5:2054358118760831. [PMID: 29636980 PMCID: PMC5888818 DOI: 10.1177/2054358118760831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/06/2017] [Indexed: 01/31/2023] Open
Abstract
Background: Posttransplant lymphoproliferative disorder (PTLD) is a major complication following kidney transplantation. Objective: We undertook this study to characterize PTLD in kidney transplant patients in British Columbia with regard to incidence, patient and graft survival, histological subtypes, treatment modalities, and management of immunosuppression. Design: Retrospective cohort analysis. Setting: British Columbia. Patients: All adult patients who underwent kidney transplantation in British Columbia between January 1, 1996, and December 31, 2012, were included. Patients less than 18 years of age at the time of first transplant and multiple organ transplant recipients were excluded from analysis. Measurements: Patients with lymphoproliferative disorders that occurred subsequent to kidney transplantation were considered to have developed PTLD. Methods: Cases of PTLD were identified by cross-referencing data abstracted from the provincial transplant agency’s clinical database with the provincial cancer agency’s lymphoma registry. Patients were followed up for the development of PTLD until December 31, 2012, and for outcomes of death and graft failure until December 31, 2014. Data collection was completed via an electronic chart review. Results: Of 2217 kidney transplant recipients, 37 (1.7%) developed PTLD. Nine cases were early-onset PTLD, occurring within 1 year of transplant; of these cases, 6 were known/presumed Epstein-Barr virus mismatch, compared with only 2 of 28 late-onset cases. Patient survival for early-onset PTLD was 100% at 2 years post diagnosis. Late-onset PTLD had survival rates of 71.4% and 67.9% at 1 and 2 years, respectively. PTLD was associated with significantly decreased patient survival (P = .031) and graft survival (uncensored for death, P = .017), with median graft survival of PTLD and non-PTLD patients being 9.5 and 16 years, respectively. Immunosuppressant therapy was reduced in the majority of patients; additional therapies included rituximab monotherapy, CHOP-R, radiation, and surgery. Limitations: Limitations to this study include its retrospective nature and the unknown adherence of patients to prescribed immunosuppressant regimens. In addition, cumulative doses of immunosuppression received and the degree of immunosuppression reduction for PTLD management were not effectively captured. Conclusions: The incidence of PTLD in British Columbia following kidney transplantation was low and consistent with rates reported in the literature. The incidence of late-onset PTLD and its association with reduced patient and graft survival warrant further analysis of patients’ long-term immunosuppression.
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Affiliation(s)
- Erin Ready
- Department of Pharmaceutical Sciences, Vancouver General Hospital, British Columbia, Canada
| | - Kseniya Chernushkin
- Department of Pharmaceutical Sciences, Vancouver General Hospital, British Columbia, Canada
| | - Nilufar Partovi
- Department of Pharmaceutical Sciences, Vancouver General Hospital, British Columbia, Canada
| | - Trana Hussaini
- Department of Pharmaceutical Sciences, Vancouver General Hospital, British Columbia, Canada
| | - Cindy Luo
- Department of Pharmaceutical Sciences, Vancouver General Hospital, British Columbia, Canada
| | - Olwyn Johnston
- Division of Nephrology, Gordon and Leslie Diamond Centre, The University of British Columbia, Vancouver, Canada
| | - R Jean Shapiro
- Division of Nephrology, Gordon and Leslie Diamond Centre, The University of British Columbia, Vancouver, Canada
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Koff JL, Li JX, Zhang X, Switchenko JM, Flowers CR, Waller EK. Impact of the posttransplant lymphoproliferative disorder subtype on survival. Cancer 2018; 124:2327-2336. [PMID: 29579330 DOI: 10.1002/cncr.31339] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/25/2018] [Accepted: 02/12/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication of solid organ transplantation. Histologic heterogeneity and a lack of treatment standards have made evaluating clinical outcomes in specific patient populations difficult. This systematic literature review investigated the impact of the PTLD histologic subtype on survival in a large data set. METHODS Case series were identified on PubMed with the search terms post-transplant lymphoproliferative disorder/disease, PTLD, and solid organ transplantation, with additional publications identified through reference lists. The patient characteristics, immunosuppressive regimen, treatment, survival, and follow-up time for 306 cases were extracted from 94 articles, and these cases were combined with 11 cases from Emory University Hospital. Patients with a recorded subtype were included in a Kaplan-Meier survival analysis (n = 234). Cox proportional hazards regression analyses identified predictors of overall survival (OS) for each subtype and B-cell subgroup. RESULTS OS differed significantly between monomorphic T-cell neoplasms (median, 9 months) and polymorphic, monomorphic B-cell, and Hodgkin-type neoplasms, for which the median OS was not reached (P = .0001). Significant differences in OS among B subgroups were not detected, but there was a trend toward decreased survival for patients with Burkitt-type PTLD. Kidney transplantation and a reduction of immunosuppression were associated with increased OS for patients with B-cell neoplasms in a multivariate analysis. Immunosuppression with azathioprine was associated with decreased OS for patients with T-cell neoplasms, whereas radiotherapy was associated with improved OS for patients with that subtype. CONCLUSIONS The histologic subtype represents an important prognostic factor in PTLD, with patients with T-cell neoplasms exhibiting very poor OS. Possibly lower survival for certain subsets of patients with B-cell PTLD should be explored further and suggests the need for subtype-specific therapies to improve outcomes. Cancer 2018;124:2327-36. © 2018 American Cancer Society.
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Affiliation(s)
- Jean L Koff
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jing-Xia Li
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
- Hematology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xinyan Zhang
- Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Biostatistics and Bioinformatics, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Christopher R Flowers
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Edmund K Waller
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Dharnidharka VR. Comprehensive review of post-organ transplant hematologic cancers. Am J Transplant 2018; 18:537-549. [PMID: 29178667 DOI: 10.1111/ajt.14603] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 11/17/2017] [Accepted: 11/17/2017] [Indexed: 01/25/2023]
Abstract
A higher risk for a variety of cancers is among the major complications of posttransplantation immunosuppression. In this part of a continuing series on cancers posttransplantation, this review focuses on the hematologic cancers after solid organ transplantation. Posttransplantation lymphoproliferative disorders (PTLDs), which comprise the great majority of hematologic cancers, represent a spectrum of conditions that include, but are not limited to, the Hodgkin and non-Hodgkin lymphomas. The oncogenic Epstein-Barr virus is a key pathogenic driver in many PTLD cases, through known and unknown mechanisms. The other hematologic cancers include leukemias and plasma cell neoplasms (multiple myeloma and plasmacytoma). Clinical features vary across malignancies and location. Preventive screening strategies have been attempted mainly for PTLDs. Treatments include the chemotherapy regimens for the specific cancers, but also include reduction of immunosuppression, rituximab, and other therapies.
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Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine, Saint Louis, MO, USA
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Affiliation(s)
- Daan Dierickx
- From the Department of Hematology, University Hospitals Leuven, and the Laboratory for Experimental Hematology, Department of Oncology, University of Leuven, Leuven, Belgium (D.D.); and the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN (T.M.H.)
| | - Thomas M Habermann
- From the Department of Hematology, University Hospitals Leuven, and the Laboratory for Experimental Hematology, Department of Oncology, University of Leuven, Leuven, Belgium (D.D.); and the Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN (T.M.H.)
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Alderuccio JP, Stefanovic A, Dammrich D, Chapman JR, Vega F, Selvaggi G, Tzakis A, Lossos IS. Decreased survival in hepatitis C patients with monomorphic post-transplant lymphoproliferative disorder after liver transplantation treated with frontline immunochemotherapy. Leuk Lymphoma 2017; 59:2096-2104. [PMID: 29252057 DOI: 10.1080/10428194.2017.1413187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) develops in 1-3% of liver transplant recipients and no consensus exists about therapeutic management. From 2006 to 2016, 1489 liver transplants were performed at our institution with 20 patients (incidence 1.3%) developing PTLD. Hepatitis C virus (HCV) was the leading cause (n = 10) of liver transplant in PTLD patients. Diffuse large B-cell lymphoma was the most frequent histologic subtype (n = 17), and we report our experience in the management of these patients. Patients were treated with frontline immunochemotherapy without immunosuppression reduction. All evaluable patients achieved a complete remission. Statistically significant decreased survival was identified in HCV-positive patients. Six patients (60%) exhibited increases in HCV RNA levels during therapy. Four patients (40%) developed graft failure and three of them (30%) died from liver dysfunction. This is the first study providing evidence of decreased survival in HCV-positive PTLD patients after liver transplant receiving immunochemotherapy.
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Affiliation(s)
- Juan Pablo Alderuccio
- a Department of Medicine, Division of Hematology , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Alexandra Stefanovic
- a Department of Medicine, Division of Hematology , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Daniel Dammrich
- a Department of Medicine, Division of Hematology , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Jennifer R Chapman
- b Department of Pathology and Laboratory Medicine, Division of Hematopathology , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Francisco Vega
- b Department of Pathology and Laboratory Medicine, Division of Hematopathology , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Gennaro Selvaggi
- c Department of Surgery, Division of Transplantation , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Andreas Tzakis
- c Department of Surgery, Division of Transplantation , University of Miami Miller School of Medicine , Miami , FL , USA
| | - Izidore S Lossos
- a Department of Medicine, Division of Hematology , University of Miami Miller School of Medicine , Miami , FL , USA.,d Department of Molecular and Cellular Pharmacology , University of Miami Miller School of Medicine , Miami , FL , USA.,e Sylvester Comprehensive Cancer Center , Miami , FL , USA
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Nagle SJ, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder in Solid Organ and Hematopoietic Stem Cell Transplantation. Clin Chest Med 2017; 38:771-783. [DOI: 10.1016/j.ccm.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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40
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Fararjeh FA, Mahmood S, Tachtatzis P, Yallop D, Devereux S, Patten P, Agrawal K, Suddle A, O'Grady J, Heaton N, Marcus R, Kassam S. A retrospective analysis of post-transplant lymphoproliferative disorder following liver transplantation. Eur J Haematol 2017; 100:98-103. [PMID: 29094407 DOI: 10.1111/ejh.12988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate response rates and survival in adults developing post-transplant lymphoproliferative disorder (PTLD) following liver transplantation. METHODS Patients were identified retrospectively and data collected through local liver and haematology electronic databases and pharmacy records. RESULTS Forty-five patients were identified. The median age at first transplant and at development of PTLD was 48 and 54 years, respectively, with the median time from transplant to PTLD diagnosis of 56 months. The majority of cases (76%) were monomorphic B-cell lymphomas, and 36% of tumours were EBV positive. Treatment involved reduction in immune-suppression (RIS) in 30 (67%) with RIS the only treatment in 3. Ten (22%) patients were treated with rituximab alone, 13 (29%) with chemotherapy alone and 14 (31%) patients were treated with rituximab and chemotherapy. Twenty-six (58%) patients achieved a complete response (CR). At a median follow-up of 27 months, the median overall survival (OS) was 50 months. Response and OS were not associated with clinical factors or the use of rituximab. CONCLUSION Outcomes reported in this study are favourable and comparable to those reported previously. The addition of rituximab did not appear to have improved outcomes in this series, although a significant proportion of patients were able to avoid chemotherapy.
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Affiliation(s)
- Feras Al Fararjeh
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Shameem Mahmood
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Phaedra Tachtatzis
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Deborah Yallop
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Stephen Devereux
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Piers Patten
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Kosh Agrawal
- Department of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Abid Suddle
- Department of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - John O'Grady
- Department of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Nigel Heaton
- Department of Hepatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Robert Marcus
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
| | - Shireen Kassam
- Department of Haematology, King's College Hospital NHS Foundation Trust, London, UK
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Prockop SE, Vatsayan A. Epstein-Barr virus lymphoproliferative disease after solid organ transplantation. Cytotherapy 2017; 19:1270-1283. [PMID: 28965834 DOI: 10.1016/j.jcyt.2017.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/10/2017] [Indexed: 12/18/2022]
Abstract
Epstein-Barr virus (EBV) was the first identified human oncovirus and is also one of the most ubiquitous viral infections known with established infections in more than 90% of individuals by early adulthood. EBV establishes latency by controlling expression of the viral genome making it silent to immune surveillance. In immunocompetent individuals, up to 1% of circulating T cells are directed at maintaining control over EBV replication. In addition to being involved in oncogenesis of lymphoid and epithelial tumors in immune-competent individuals, loss of immune surveillance over EBV predisposes individuals to EBV malignancies. Lymphoid proliferations from EBV-infected B cells arise in up to 20% of recipients of solid organ transplants (SOTs). One question not answered is why, when EBV requires such active immune surveillance, EBV malignancies are not even more prevalent in severely immune-compromised individuals. A better understanding of who develops complications related to EBV and what the immunologic risks are will ultimately make it feasible to perform prophylactic trials in those at highest risk. This review summarizes our current understanding of factors in SOT recipients that predispose them to the development of an EBV malignancy and that predict response to initial therapy. We then review the current landscape of those therapies, focusing on the goal of restoring long-term EBV-directed immunity to patients at risk.
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Affiliation(s)
- Susan E Prockop
- Pediatric BMT Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Anant Vatsayan
- Pediatric BMT Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Bishnoi R, Bajwa R, Franke AJ, Skelton WP, Wang Y, Patel NM, Slayton WB, Zou F, Dang NH. Post-transplant lymphoproliferative disorder (PTLD): single institutional experience of 141 patients. Exp Hematol Oncol 2017; 6:26. [PMID: 29021921 PMCID: PMC5622441 DOI: 10.1186/s40164-017-0087-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/20/2017] [Indexed: 02/08/2023] Open
Abstract
Background Post-transplant lymphoproliferative disorder is a well-recognized but rare complication of hematopoietic stem cell and solid organ transplant. Due to rarity of this disease, retrospective studies from major transplant centers has been the main source to provide treatment guidelines, which are still in evolution. The sample size of this study is among one of the largest study on PTLD till date reported throughout the world. Methods This study was performed at University of Florida which is one of the largest transplant center in South East United States. We performed treatment and survival analysis along with univariate and multivariate analysis to identify prognostic factors. Results We reviewed 141 patients diagnosed with PTLD over last 22 years with median follow-up of 2.4 years. The estimated median overall survival of the entire group was 15.0 years. Sub group analysis showed that 5-year overall survival rates of pediatric population were 88% (median not reached). For adults, median OS was 5.35 years while for elderly patients it was 1.32 years. The estimated median OS of patients with monomorphic PTLD was 9.0 years while in polymorphic PTLD was 19.3 years. Univariate analysis identified gender, age at transplant and PTLD diagnosis, performance status, IPI score, allograft type, recipient EBV status, multiple acute rejections prior to PTLD diagnosis, PTLD sub-type, extra-nodal site involvement, immunosuppressive drug regimen at diagnosis, initial treatment best response were statistically significant prognostic factors (p < 0.05). On multivariate analysis, age at PTLD diagnosis, recipient EBV status, bone marrow involvement, and initial best response were statistically significant prognostic factors (p < 0.05). Surprisingly, use of Rituximab alone as upfront therapy had poor hazard ratio in the cumulative group as well less aggressive PTLD subgroup comprising of early lesions and polymorphic PTLD. Conclusions Our experience with treatment and analysis of outcomes does challenge current role of Rituximab use in treatment of PTLD. Currently as we define role of immunotherapy in cancer treatment, the role of acute rejections and immunosuppressant in PTLD becomes more relevant as noticed in our study. This study was also able to find new prognostic factors and also verified other known prognostic factors.
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Affiliation(s)
- Rohit Bishnoi
- Department of Medicine, University of Florida, PO Box 100238, Gainesville, FL 32610-0238 USA
| | - Ravneet Bajwa
- Department of Medicine, University of Florida, PO Box 100278, 1600 SW Archer Rd, Gainesville, FL 32610 USA
| | - Aaron J Franke
- Department of Medicine, University of Florida, PO Box 100277, Gainesville, FL 32610-0277 USA
| | - William Paul Skelton
- Department of Medicine, University of Florida, PO Box 100277, Gainesville, FL 32610-0277 USA
| | - Yu Wang
- Department of Biostatistics, University of Florida, PO Box 117450, Gainesville, FL 32611 USA
| | - Niraj M Patel
- Department of Medicine, University of Florida, PO Box 100277, Gainesville, FL 32610-0277 USA
| | - William Birdsall Slayton
- Division of Pediatric Hematology/Oncology, University of Florida, PO Box 100298, Gainesville, FL 32610-0298 USA
| | - Fei Zou
- Department of Biostatistics, University of Florida, PO Box 117450, Gainesville, FL 32611 USA
| | - Nam H Dang
- Department of Medicine, University of Florida, PO Box 100278, 1600 SW Archer Rd, Gainesville, FL 32610 USA
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Peters A, Olateju T, Deschenes J, Shankarnarayan SH, Chua N, Shapiro AMJ, Senior P. Posttransplant Lymphoproliferative Disorder After Clinical Islet Transplantation: Report of the First Two Cases. Am J Transplant 2017; 17:2474-2480. [PMID: 28390107 DOI: 10.1111/ajt.14303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/27/2017] [Accepted: 04/01/2017] [Indexed: 01/25/2023]
Abstract
We report the first two cases of posttransplant lymphoproliferative disorder (PTLD) in recipients of islet transplants worldwide. First, a 44-year-old recipient of three islet infusions developed PTLD 80 months after his initial transplantation, presenting with abdominal pain and diffuse terminal ileum thickening on imaging. He was treated with surgical excision, reduction of immunosuppression, and rituximab. Seven months later, he developed central nervous system PTLD, presenting with vertigo and diplopia; immunosuppression was discontinued, resulting in graft loss, and he was given high-dose methotrexate and underwent consolidative autologous stem cell transplantation. He remains in remission 37 months after the initial diagnosis. Second, a 58-year-old female recipient of two islet infusions developed PTLD 24 months after initial islet infusion, presenting with pancytopenia secondary to extensive bone marrow involvement. Immunosuppression was discontinued, resulting in graft loss, and she received rituximab and chemotherapy, achieving complete remission. Both patients were monomorphic B cell PTLD subtype by histology and negative for Epstein-Barr virus in tissue or blood. These cases document the first occurrences of this rare complication in islet transplantation, likely secondary to prolonged, intensive immunosuppression, and highlight the varying clinical manifestations of PTLD. Further studies are needed to determine incidence rate and risk factors in islet transplantation.
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Affiliation(s)
- A Peters
- Division of Clinical Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - T Olateju
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Canada
| | - J Deschenes
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - S H Shankarnarayan
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Canada
| | - N Chua
- Department of Oncology, University of Alberta, Edmonton, Canada
| | - A M J Shapiro
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Canada
| | - P Senior
- Clinical Islet Transplant Program, University of Alberta, Edmonton, Canada.,Division of Endocrinology, Department of Medicine, University of Alberta, Edmonton, Canada
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Schultz TD, Zepeda N, Moore RB. Post-transplant lymphoproliferative disorder and management of residual mass post chemotherapy: Case report. Int J Surg Case Rep 2017; 38:115-118. [PMID: 28756359 PMCID: PMC5537377 DOI: 10.1016/j.ijscr.2017.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/29/2017] [Accepted: 07/03/2017] [Indexed: 11/17/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD). Residual mass post rituximab therapy. Surgical management.
Introduction Post-transplant lymphoproliferative disorder (PTLD) is a rare complication. It represents a spectrum of lymphoid proliferations which occur in the setting of immunosuppression and organ transplantation. There are no reported cases or recommendations for the treatment of residual masses post rituximab of PTLD. Presentation of case A patient with a long standing history of immunosuppression due to multiple kidney transplants starting in 1979, presented with a very large palpable hard abdominal mass (2004) after a fourth renal transplant. There was a past history of heavy immune suppression. CT scans revealed a conglomerate mass involving the right native kidney and two prior right sided renal allografts that crossed the midline. Biopsy of the large right retroperitoneal mass revealed large B cell lymphoma (CD 20 positive); consistent with post-transplant lymphoproliferative disorder (PTLD). Discussion Management of bulky PTLD, in a highly sensitized, heavily immune suppressed patient is not well described in the literature. The mainstay of therapy is IR and Ritixumab (R) monotherapy and combination R-CHOP. CHOP chemotherapy has an associated mortality rate of up to 38%. Radiotherapy is often considered over surgery and surgery has been most frequently used when associated with bowel complications. In this case report we describe upfront Ritiximab followed by consolidation resection and cytotoxic chemotherapy as a management strategy to reduce toxicity. Conclusion The approach taken by our surgical team illustrates the benefits of disease debulking in certain cases of PTLD, by guiding further therapy and spacing and reducing chemotherapy in immune suppressed patients.
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Affiliation(s)
- Troy D Schultz
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nubia Zepeda
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ronald B Moore
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
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de Jong D, Roemer MGM, Chan JKC, Goodlad J, Gratzinger D, Chadburn A, Jaffe ES, Said J, Natkunam Y. B-Cell and Classical Hodgkin Lymphomas Associated With Immunodeficiency: 2015 SH/EAHP Workshop Report-Part 2. Am J Clin Pathol 2017; 147:153-170. [PMID: 28395108 DOI: 10.1093/ajcp/aqw216] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The 2015 Workshop of the Society for Hematopathology/European Association for Haematopathology submitted small and large B-cell lymphomas (BCLs), including classical Hodgkin lymphoma (CHL), in the context of immunodeficiency. METHODS Clinicopathologic and molecular features were studied to explore unifying concepts in malignant B-cell proliferations across immunodeficiency settings. RESULTS Cases submitted to the workshop spanned small BCLs presenting as nodal or extranodal marginal zone lymphoma and lymphoplasmacytic lymphoma, Epstein-Barr virus (EBV) positive in 75% of cases. Submitted large BCLs formed a spectrum from diffuse large B-cell lymphoma (DLBCL) to CHL across immunodeficiency settings. Additional studies demonstrated overexpression of PD-L1 and molecular 9p24 alterations in the large BCL spectrum and across different immunodeficiency settings. CONCLUSIONS Small BCLs occur in all immunodeficiency settings, and EBV positivity is essential for their recognition as immunodeficiency related. Large BCLs include a spectrum from DLBCL to CHL across all immunodeficiency settings; immunohistochemical and molecular features are suggestive of shared pathogenetic mechanisms involving PD-L1 immune checkpoints.
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Affiliation(s)
- Daphne de Jong
- From the VU University Medical Center, Amsterdam, the Netherlands
| | - Margaretha G M Roemer
- From the VU University Medical Center, Amsterdam, the Netherlands
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - John Goodlad
- HMDS, St James's University Hospital, Leeds, United Kingdom
| | | | - Amy Chadburn
- Weill Medical College of Cornell University, New York
| | | | - Jonathan Said
- University of California Los Angeles Medical Center, Los Angeles
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Trappe RU, Dierickx D, Zimmermann H, Morschhauser F, Mollee P, Zaucha JM, Dreyling MH, Dührsen U, Reinke P, Verhoef G, Subklewe M, Hüttmann A, Tousseyn T, Salles G, Kliem V, Hauser IA, Tarella C, Van Den Neste E, Gheysens O, Anagnostopoulos I, Leblond V, Riess H, Choquet S. Response to Rituximab Induction Is a Predictive Marker in B-Cell Post-Transplant Lymphoproliferative Disorder and Allows Successful Stratification Into Rituximab or R-CHOP Consolidation in an International, Prospective, Multicenter Phase II Trial. J Clin Oncol 2016; 35:536-543. [PMID: 27992268 DOI: 10.1200/jco.2016.69.3564] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose The Sequential Treatment of CD20-Positive Posttransplant Lymphoproliferative Disorder (PTLD-1) trial ( ClinicalTrials.gov identifier, NCT01458548) established sequential treatment with four cycles of rituximab followed by four cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy as a standard in the management of post-transplant lymphoproliferative disorder (PTLD) and identified response to rituximab induction as a prognostic factor for overall survival. We hypothesized that rituximab consolidation might be sufficient treatment for patients with a complete response after rituximab induction. Patients and Methods In this prospective, international, multicenter phase II trial, 152 treatment-naive adult solid organ transplant recipients, with CD20+ PTLD unresponsive to immunosuppression reduction, were treated with four weekly doses of rituximab induction. After restaging, complete responders continued with four courses of rituximab consolidation every 21 days; all others received four courses of rituximab plus CHOP chemotherapy every 21 days. The primary end point was treatment efficacy measured as the response rate in patients who completed therapy and the response duration in those who completed therapy and responded. Secondary end points were frequency of infections, treatment-related mortality, and overall survival in the intention-to-treat population. Results One hundred eleven of 126 patients had a complete or partial response (88%; 95% CI, 81% to 93%), of whom 88 had a complete response (70%; 95% CI, 61% to 77%). Median response duration was not reached. The 3-year estimate was 82% (95% CI, 74% to 90%). Median overall survival was 6.6 years (95% CI, 5.5 to 7.6 years). The frequency of grade 3 or 4 infections and of treatment-related mortality was 34% (95% CI, 27% to 42%) and 8% (95% CI, 5% to 14%), respectively. Response to rituximab induction remained a prognostic factor for overall survival despite treatment stratification. Conclusion In B-cell PTLD, treatment stratification into rituximab or rituximab plus CHOP consolidation on the basis of response to rituximab induction is feasible, safe, and effective.
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Affiliation(s)
- Ralf U Trappe
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Daan Dierickx
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Heiner Zimmermann
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Franck Morschhauser
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Peter Mollee
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Jan M Zaucha
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Martin H Dreyling
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Ulrich Dührsen
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Petra Reinke
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Gregor Verhoef
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Marion Subklewe
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Andreas Hüttmann
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Thomas Tousseyn
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Gilles Salles
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Volker Kliem
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Ingeborg A Hauser
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Corrado Tarella
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Eric Van Den Neste
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Olivier Gheysens
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Ioannis Anagnostopoulos
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Veronique Leblond
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Hanno Riess
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
| | - Sylvain Choquet
- Ralf U. Trappe and Heiner Zimmermann, DIAKO Evangelisches Diakonie-Krankenhaus Bremen, Bremen; University Medical Centre Schleswig-Holstein, Kiel; Ralf U. Trappe, Petra Reinke, Ioannis Anagnostopoulos, and Hanno Riess, Charité-Universitätsmedizin Berlin, Berlin; Martin H. Dreyling and Marion Subklewe, University of Munich, Munich; Ulrich Dührsen and Andreas Hüttmann, University of Duisburg-Essen, Essen; Volker Kliem, Nephrological Centre Lower Saxony, Hann. Münden; Ingeborg A. Hauser, J.W. Goethe University Hospital, Frankfurt, Germany; Daan Dierickx, Gregor Verhoef, Thomas Tousseyn, and Olivier Gheysens, Catholic University Leuven, Leuven; Eric Van Den Neste, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Franck Morschhauser, Hôpital Claude Huriez, Lille; Gilles Salles, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite; Veronique Leblond and Sylvain Choquet, Université Pierre et Marie Curie, Paris, France; Peter Mollee, University of Queensland, Brisbane, Queensland, Australia; Jan M. Zaucha, Medical University of Gdansk, Gdansk; Polish Lymphoma Research Group, Warsaw, Poland; and Corrado Tarella, European Institute of Oncology, Milan, Italy
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Law MF, Chan HN, Lai HK, Ha CY, Ng C, Yeung YM, Yip SF. Post-transplant lymphoproliferative disorder presenting with skin ulceration in a renal transplant recipient who achieved sustained remission with rituximab therapy: A case report. Mol Clin Oncol 2016; 5:610-612. [PMID: 27900097 DOI: 10.3892/mco.2016.1024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/18/2016] [Indexed: 11/06/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is associated with a variety of clinical presentations, but rarely involves the skin. We herein report a case of PTLD presenting with skin ulceration in a renal transplant recipient. A biopsy of the ulcer confirmed the diagnosis of diffuse large B-cell lymphoma. The patient was initially treated with immunosuppression reduction, but the skin ulcer persisted. He was then treated with two courses of chemotherapy, but his condition was complicated with cryptococcal infection. Antifungal agents were administered to control the fungal infection. The patient later developed lymphoma recurrence and was successfully treated with single-agent rituximab. The patient remains well 6 years after treatment, with no evidence of disease relapse. Therefore, PTLD may manifest as skin lesions and physicians must be aware of this rare presentation.
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Affiliation(s)
- Man Fai Law
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China; Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR 999077, P.R. China
| | - Hay Nun Chan
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Ho Kei Lai
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Chung Yin Ha
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Celia Ng
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Yiu Ming Yeung
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
| | - Sze Fai Yip
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR 999077, P.R. China
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Rosenberg AS, Ruthazer R, Paulus JK, Kent DM, Evens AM, Klein AK. Survival Analyses and Prognosis of Plasma-Cell Myeloma and Plasmacytoma-Like Posttransplantation Lymphoproliferative Disorders. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2016; 16:684-692.e3. [PMID: 27771291 PMCID: PMC5402751 DOI: 10.1016/j.clml.2016.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 09/08/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple myeloma/plasmacytoma-like posttransplantation lymphoproliferative disorder (PTLD-MM) is a rare complication of solid organ transplantation. Case series have shown variable outcomes, and survival data in the modern era are lacking. PATIENTS AND METHODS A cohort of 212 PTLD-MM patients was identified in the Scientific Registry of Transplant Recipients between 1999 and 2011. Overall survival (OS) was estimated by the Kaplan-Meier method, and the effects of treatment and patient characteristics on OS were evaluated by Cox proportional hazards models. OS in 185 PTLD-MM patients was compared to 4048 matched controls with multiple myeloma (SEER-MM) derived from Surveillance, Epidemiology, and End Results (SEER) data. RESULTS Men comprised 71% of patients; extramedullary disease was noted in 58%. Novel therapeutic agents were used in 19% of patients (more commonly during 2007-2011 vs. 1999-2006; P = .01), reduced immunosuppression in 55%, and chemotherapy in 32%. Median OS was 2.4 years and improved in the later time period (adjusted hazard ratio [aHR], 0.64, P = .05). Advanced age, creatinine > 2 g/dL, white race, and use of OKT3 were associated with inferior OS in multivariable analysis. OS of PTLD-MM patients is significantly inferior to SEER-MM patients (aHR, 1.6, P < .001). Improvements in OS over time differed between PTLD-MM and SEER-MM. Median OS of patients diagnosed from 2000 to 2005 was shorter for PTLD-MM than SEER-MM patients (18 vs. 47 months, P < .001). There was no difference among those diagnosed from 2006 to 2010 (44 months vs. median not reached, P = .5; interaction P = .08). CONCLUSION Age at diagnosis, elevated creatinine, white race, and OKT3 were associated with inferior survival in patients with PTLD-MM. Survival of PTLD-MM is inferior to SEER-MM, although significant improvements in survival have been documented.
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Affiliation(s)
- Aaron S Rosenberg
- Division of Hematology/Oncology, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Department of Internal Medicine, Tufts Cancer Center, Boston, MA; Department of Internal Medicine, Tufts Medical Center, Boston, MA.
| | - Robin Ruthazer
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Sciences Institute, Tufts University, Boston, MA
| | - Jessica K Paulus
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Sciences Institute, Tufts University, Boston, MA
| | - David M Kent
- Division of Hematology/Oncology, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA; Department of Internal Medicine, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Sciences Institute, Tufts University, Boston, MA
| | - Andrew M Evens
- Division of Hematology/Oncology, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Department of Internal Medicine, Tufts Cancer Center, Boston, MA; Department of Internal Medicine, Tufts Medical Center, Boston, MA
| | - Andreas K Klein
- Division of Hematology/Oncology, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Department of Internal Medicine, Tufts Cancer Center, Boston, MA; Department of Internal Medicine, Tufts Medical Center, Boston, MA
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49
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Lee JJ, Lam MSH, Rosenberg A. Role of Chemotherapy and Rituximab for Treatment of Posttransplant Lymphoproliferative Disorder in Solid Organ Transplantation. Ann Pharmacother 2016; 41:1648-59. [PMID: 17848421 DOI: 10.1345/aph.1k175] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the role of chemotherapy and/or rituximab for treatment of posttransplant lymphoproliferative disorder (PTLD) in solid organ transplantation. Data Sources: A MEDLINE search (1966–May 2007) was conducted using the key words posttransplant lymphoproliferative disorder, solid organ transplantation, chemotherapy, and rituximab. References of relevant articles and abstracts from recent hematology, oncology, and transplantation scientific meetings (2004–May 2007) were also reviewed. Study Selection and Data Extraction: Prospective and retrospective studies identified from the data sources were evaluated, and all information deemed relevant was included for this review. Data Synthesis: Overall response rates ranged from 53% to 68%, 25% to 83%, and 74% to 100% for rituximab monotherapy, chemotherapy, and chemotherapy plus rituximab, respectively. Positive response to treatment was influenced by prognostic factors, including presence of Epstein-Barr virus in tumor cells, normal lactate dehydrogenase levels, good performance status, early disease onset after transplantation, and early disease stages. These factors in study patients likely contribute to the variability in response rates seen between treatment options. Severe adverse effects, ranging from grade 3 neutropenia to infection resulting in death, occurred more frequently in patients receiving chemotherapy than in patients receiving only rituximab. Conclusions: Although reduction in immunosuppressive medications remains the first-line therapy for PTLD treatment, many cases do not respond to this treatment alone, especially monomorphic or more aggressive cases of lymphoma. Therefore, it is reasonable to begin active treatment including rituximab and/or chemotherapy initially, along with reduction in immunosuppression in many cases. Further prospective, comparative studies are urgently needed to confirm the efficacy of these treatment strategies as well as to clarify which subset of patients may benefit most from them.
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Affiliation(s)
- Jin-Joo Lee
- College of Pharmacy, University of Florida, Gainesville, FL, USA
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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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