ITP in solid organ transplant patient by jennyyingdi


									        Post transplant
lymphoproliferative disorder:
  Risk factors and prognosis
      Melissa Schapiro, MD
       September 1, 2011
PTLD: description
• Spectrum of disease ranging from benign
  polyclonal B cell hyperplasia to malignant
  monoclonal non-Hodgkin’s lymphoma that
  develops in transplant recipients
• Can be localized or disseminated
PTLD: pathophysiology
• EBV-associated PTLD:
  – Cytotoxic T cell response is blunted by
  – EBV-infected B cells proliferate
  – Clonal outgrowth and malignant transformation
PTLD: pathophysiology
• EBV-associated PTLD:

                         (Tanner and Alfieri, 2001)
PTLD: pathophysiology
• EBV-negative PTLD may be a distinct clinical
  entity from EBV-associated PTLD (Leblond et
                                   al., 1998)
PTLD: EBV associated vs. negative
• Leblond et al. (1998) compared 11 patients with EBV-
  negative PTLD (group 1) to 21 patients with EBV-
  associated PTLD (group 2)
   – Time between transplantation and PTLD diagnosis was
     180-10220 days (median 1800) in group 1 versus 60-2100
     days (median 180) in group 2 (P=0.02)
PTLD: EBV associated vs. negative
• 8/8 B-cell PTLDs in group 1 were monomorphic diffuse
  large B-cell lymphomas versus 8/20 in group 2
• Overall median survival was 1 month in group 1 and
  37 months in group 2 (P<0.01)
• Probability of survival was 14% at 44 months in group
  1 versus 41% at 96 months in group 2

                                                 (Leblond et
                                                 al., 1998)
PTLD: EBV associated vs. negative
• Nelson et al. (2000) compared the clinic features of
  EBV-negative PTLDs with those of EBV-positive cases
   – 17/80 patients had EBV-negative PTLD
   – Compared to the EBV-positive cases of PTLD, the EBV-
     negative cases were often late appearing (statistical
     significance unknown) and were more likely to be
     monomorphic (p<0.05)
A case of late-presenting non-EBV-
  associated PTLD in a pediatric
    cardiac transplant patient
Clinical case
• J.B. is a 14 y.o. boy with a history of orthotopic
  heart transplant at 2.5 m.o. due to severe aortic
• He has been on tacrolimus (Prograf) and
  azathioprine (Imuran) for the past several years.
• At a routine lab check on 7/5/11, he was found
  to have a platelet count of 51,000; CBC was
  otherwise within normal limits.
• No recent viral symptoms, bruising, bleeding,
  fatigue, night sweats.
Clinical case, continued
• On 7/9, he presented to an OSH ED with
  hemorrhagic bullae in mouth, epistaxis x 1, and
  scattered petechiae on his chest and thighs.
  Platelet count 2,000.
• Imuran (75mg daily) discontinued on 7/10.
• He received WinRho on 7/11, and was
  discharged with a platelet count of 16,000.
• He received IVIG on 7/15. Follow up platelet
  count was 3,000.
Clinical case, continued
• Scheduled for bone marrow biopsy on 7/22,
  with plan to start steroids and Rituximab.
• On 7/22, he admitted that he had been having
  black stools and periumbilical pain since the
  week before. His hemoglobin was 6.0.
• Admitted, transfused with PRBCs, GI consulted,
  started on IV pantoprazole and IV steroids,
  tranfused with platelets.
Clinical case, continued
• Abdominal CT on 7/23 showed markedly
  enlarged mesenteric lymph nodes (up to 5 cm).
• Bone marrow aspiration on 7/26 showed no
  signs of malignancy.
• Lymph node biopsy on 7/26 showed large B cell
  lymphoma CD20+.
• CSF on 8/9 was negative for malignancy.
Clinical case, continued
• He was started on COG ANHL0221 on 7/28.
  – Prednisone
  – Low-dose cytoxan
  – Rituximab
• Tacrolimus was discontinued.
• Most recent endomyocardial biopsy on 8/9
  showed no evidence of rejection.
• He is currently on week 3 of cycle 2 of
What are the risk factors for PTLD
 in pediatric cardiac transplant
PTLD: risk factors
• In a case-control study that included 22 cases of PTLD
  in 179 pediatric solid organ transplant patients, Allen et
  al. (2005) found:
   – PTLD cases occurred in 13/39 liver transplants, 5/57 heart
     transplants, 3/77 kidney transplants, and 1/5 lung transplants
   – Cases occurred 1-131 months post-transplant (median 22.8)
   – Cases had higher post-transplant mean baseline EBV load
     than controls, but were not more likely to be EBV-
     seronegative pre-transplant than controls
   – 1 in 4 PTLD cases were EBV seropositive pre-transplantation
   – Occurrence of PTLD was not associated with any specific
     immunosuppressive medication
PTLD: risk factors
• In a case-control study that included 9 cases of PTLD in
  95 pediatric cardiac transplant recipients, Katz et al.
  (2007) identified risk factors:
PTLD: risk factors
• In a retrospective study that included 12 cases of PTLD
  in 146 pediatric heart transplant patients, Schubert et
  al. (2009) identified risk factors:
 What is the prognosis for
pediatric cardiac transplant
   patients with PTLD?
PTLD: prognosis
• Highly variable (Aull et al., 2004)

• Median survival time was 1 month in EBV-negative
  PTLD patients and 37 months in EBV-positve PTLD
  patients (p<0.01) (Leblond et al., 1998)
• Most EBV-negative PTLDs with monomorphic
  histology do not have a favorable outcome even
  with aggressive treatment (Nelson et al., 2000)
PTLD: prognosis
• In a multicenter study of 274 cardiac transplant
  recipients with PTLD, Aull et al. (2004) found low long-
  term survival rates
• Overall, 80% of patients died (median follow up was 53
  months after transplantation)
• Common causes of death included PTLD (51%),
  cardiovascular collapse due to withdrawal of
  immunosuppression (21%), and infection (10%)
PTLD: prognosis
• Figure 2a (left) shows overall survival after cardiac
  transplantation: 81%, 68%, 47%, and 20% at 1, 2, 5,
  and 10 years
• Figure 2b (right) shows survival after PTLD diagnosis:
  45%, 33%, 30%, and 13% at 1, 3, 5, and 10 years

                                      • (Aull et al., 2004)
PTLD: prognosis
• Aull et al. (2004) identified factors associated with
   – Single PTLD site (P<0.001)
   – Receiving immunosuppression reduction as a component of
     treatment (P<0.001)
   – Receiving surgery for PTLD (P=0.02)
   – Transplant 1991-1998 (P<0.001)
• Factors not associated with survival:
   – Polyclonal vs. monoclonal
   – Receiving chemotherapy
   – Diagnosis within one year of transplant
 PTLD: prognosis
• In a retrospective study of 30 pediatric and adult patients
  with late-presenting PTLD, Dotti et al. (2002) found that
  survival was significantly influenced by treatment
   – Three patients died before any patients initiated
   – 26/27 patients underwent reduction of immunosuppresion
     (cyclosporin reduced; tacrolimus and azathioprine
   – 8/27 patients underwent surgery or radiotherapy for localized
     disease – all attained complete remission
   – 18/27 patients received chemotherapy – clinical response was
     attained in 6
      • 9 patients died of toxicity, 3 died of PTLD, 6 died of infectious
 PTLD: prognosis
• In a retrospective multicenter study of 80 PTLD patients,
  Evens et al. (2010) found
PTLD: prognosis
• In a multicenter retrospective study of pediatric cardiac
  transplant patients, Webber et al. (2006) found:
   – PTLD developed in 56 of 1184 (5%) patients
   – Probability of survival was 75% at 1 year, 68% at 3 years, and
     67% at 5 years after diagnosis
   – Death from graft loss was as frequent as death from PTLD
   – No significant predictors of survival
PTLD: prognosis
• In a retrospective study of 12 cases of PTLD in pediatric
  heart transplant patients, Schubert et al. (2009) found
  that all patients demonstrated full remission without
  death related to PTLD or treatment (median follow-up
  time 3.9 years)
PTLD: prognosis
• In a case-control study that included 9 cases of PTLD in
  95 pediatric cardiac transplant recipients, Katz et al.
  (2007) found that patients who developed PTLD were
  at no greater risk of death than control patients
What is the best management for
  pediatric cardiac transplant
      patients with PTLD?
PTLD: management
• Reduction in immunosuppresive medications is
  typically the first-line treatment
  – many patients do not respond or initially respond and then
    relapse (e.g., Reshef et al., 2011)
• Surgery and radiotherapy are options for some
  patients with localized disease
• There is no standard chemotherapy regimen for PTLD
  – CHOP is frequently used in adult patients (e.g., Choquet et
    al., 2007)
PTLD: management
• In a retrospective study of 35 adult patients with
  PTLD who were treated with rituximab,
  chemotherapy, or both, Elstrom et al. (2006) found:
   – 32 patients were initially treated with reduction of
   – 22 patients were treated with rituximab – overall response
     rate 68% - median overall survival 31 months
   – 23 patients received chemotherapy – overall response rate
     74% - median overall
     survival 42 months
PTLD: management
• In a prospective multicenter study of rituximab
  treatment including 46 adult patients with B cell
  PTLD, Choquet et al. (2006) found:
   – 32/43 patients completed the full course of rituximab
   – Overall response rate 44% at day 80
   – Normal LDH level was the only factor predictive of
     response at day 80
   – Overall survival rate 67% at day 360
   – Number of PTLD sites was the only factor predictive of
     overall survival
PTLD: management
• In a pilot study of 6 pediatric PTLD patients treated
  with rituximab, prednisone, and low-dose cytoxan,
  Orjuela et al. (2003) found an overall response rate
  of 100% (5 complete remissions, 1 partial remission)
PTLD: management
• In a retrospective study of 30 pediatric PTLD
  patients, Gupta et al. (2010) compared
  rituximab/low-dose chemotherapy with interferon,
  rituximab/prednisone, and other chemotherapy
PTLD: management
• Gross et al. (unpublished) enrolled 55 pediatric
  patients in the COG ANHL0221 study
   – All patients had CD20+ and EBV+ disease that had been
     refractory to reduction of immunosuppression
   – Six 3-week cycles of therapy
      • Cycles 1-2: Low-dose cytoxan, prednisone, weekly rituximab
      • Cycles 3-6: Low-dose cytoxan, prednisone
   – Event free survival 64% at 2 years
   – Overall survival 81% (median follow up 3.6 years)
•   Allen UD, et al. (2005). Risk factors for post-transplant lymphoproliferative disorder in pediatric patients: A case
    control study. Pediatr Transplant. 9(4):450-5.
•   Aull MJ, et al. (2004). Experience with 274 cardiac transplant recipients with posttransplant lymphoproliferative
    disorder: a report from the Israel Penn International Transplant Tumor Registry. Transplantation. 78(11):1676-82.
•   Choquet S, et al. (2006). Efficacy and safety of rituximab in B-cell post-transplantation lymphoproliferative
    disorders: results of a prospective multicenter phase 2 study. Blood. 107(8):3053-7.
•   Choquet S, et al. (2007). CHOP-21 for the treatment of post-transplant lymphoproliferative disorders (PTLD)
    following solid organ transplantation. Haematologica. 92(2):273-4.
•   Dotti G, et al. (2002). Lymphomas occurring late after solid-organ transplantation: influence of treatment on the
    clinical outcome. Transplantation. 74(8):1095-102.
•   Elstrom RL, et al. (2006). Treatment of PTLD with rituximab or chemotherapy. Am J Transplant. 6(3):569-76.
•   Evens AM, et al. (2010). Multicenter analysis of 80 solid organ transplantation recipients with post-transplantation
    lymphoproliferative disease: outcomes and prognostic factors in the modern era. J Clin Oncol. 28(6):1038-46.
•   Gross TG, et al. (unpublished). Low-dose chemotherapy and rituximab for post-transplant lymphoproliferative
    disease (PTLD): Children’s Oncology Group report.
•   Gupta S, et al. (2010). Post-transplant lymphoproliferative disorder in children: recent outcomes and response to
    dual rituximab/low-dose chemotherapy combination. Pediatr Transplant. 14(7):896-902.
•   Katz BZ, et al. (2007). Case-control study of risk factors for the development of post-transplant
    lymphoproliferative disease in a pediatric heart transplant cohort. Pediatr Transplant. 11(1):58-65.
•   Leblond V, et al. (1998). Posttransplant lymphoproliferative disorders not associated with Epstein-Barr virus: a
    distinct entity? J Clin Oncol. 16(6):2052-9.
•   Nelson BP, et al. (2002). Epstein-Barr virus-negative post-transplant lymphoproliferative disorders: a distinct
    entity? Am J Surg Pathol. 24(3):375-85.
•   Orjuela M, et al. (2003). A pilot study of chemoimmunotherapy (cyclophosphamide, prednisone, and rituximab) in
    patients with post-transplant lymphoproliferative disorder following solid organ transplantation. Clin Cancer Res.
    9(10 Pt 2):3945S-52S.
•   Reshef R, et al. (2011). Reduction of immunosuppression as initial therapy for posttransplantation
    lymphoproliferative disorder. Am J Transplant. 11(2):336-347.
•   Schubert S, et al. (2009). Diagnosis and treatment of post-transplantation lymphoproliferative disorder in
    pediatric heart transplant patients. Pediatr Transplant. 13(1):54-62.
•   Tanner JE, Alfieri C. (2001). The Epstein-Barr virus and post-transplant lymphoproliferative disease: interplay of
    immunosuppression, EBV, and the immune system in disease pathogenesis. Transpl Infect Dis. 3(2):60-9.
•   Webber SA, et al. (2006). Lymphoproliferative disorders after paediatric heart transplantation: a multi-
    institutional study. Lancet. 367(9506):233-9.

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