Epstein-Barr Virus Post-transplant Lymphoproliferative Disorder Research Articles

1588. Epidemiology of Chronic High Level (CHL) Epstein-Barr virus (EBV) DNAemia in Pediatric Solid Organ Transplant Recipients (SOTR) at Texas Children’s Hospital (TCH)

Abstract Background EBV infections cause significant morbidity and mortality in pediatric SOTR and can be complicated by post-transplant lymphoproliferative disorder (PTLD). Contemporary data on CHL EBV DNAemia and the development of PTLD are limited. Methods A retrospective cohort study of patients ≤ 21 years of age who received heart, lung, liver, kidney, or multi-organ transplants at TCH between 2011–2018 was conducted. Primary outcome was CHL EBV DNAemia, defined as peripheral blood lymphocyte EBV values ≥ 500 copies/ug or whole blood EBV values ≥ 10,000 IU/mL for ≥ 6 months. Associations with CHL EBV DNAemia were measured using chi-squared or Fisher exact test and multivariate logistic regression. Time to CHL EBV DNAemia was assessed using Kaplan-Meier method. Results Among 687 SOTR (152 heart, 87 lung, 259 liver, 175 kidney, 14 multi-organ), 87 (13%) developed CHL EBV DNAemia; this included 15 (9%) heart, 9 (10%) lung, 59 (22%) liver, 2 (1%) kidney, and 2 (14%) multi-organ recipients. Receiving a heart [OR 2.1, 95% CI (2.1 – 62.4)], lung [7.7, 95% CI (1.5 – 39.3)], liver [OR 31.8, 95% CI (4.9 – 208.7)], or multi-organ [OR 18.3, 95% CI (2.0 – 170)] transplant and being 1–5 years of age [OR 4.0, 95% CI (1.6 – 9.8)] were associated with CHL EBV DNAemia. SOTR transplanted from 2015–2018 were less likely to develop CHL EBV DNAemia than those transplanted from 2011–2014 [OR 0.5, 95% CI (0.3 – 0.8)]. EBV risk status, CMV risk status, gender, and induction therapy were not associated with developing CHL EBV DNAemia. The median maximum peripheral blood lymphocyte and whole blood EBV values for those with CHL EBV DNAemia were 9475 (993 – 258151) copies/ug and 22093 (564 – 550000) IU/mL, respectively. Organ transplanted (p< 0.01), age (p< 0.01), and EBV risk status (p< 0.01) were associated with time to CHL EBV DNAemia (Figure 1). PTLD occurred in 28 (4%) of SOTR; 14 (50%) had preceding CHL EBV DNAemia (p< 0.01). Figure 1 Time to CHL EBV DNAemia. Conclusion This cohort of pediatric SOTR demonstrates a low prevalence of CHL EBV DNAemia and PTLD. Receiving a heart, lung, liver, or multi-organ transplant and being 1–5 years of age were associated with developing CHL EBV DNAemia. SOTR who developed CHL EBV DNAemia were more likely to develop PTLD, suggesting that further interventions targeting this group may be warranted. Disclosures Flor M. Munoz, MD, MSc, Gilead: Grant/Research Support Elizabeth A. Moulton, MD, PhD, Pfizer: Co-investigator for SARS-CoV-2 pediatric vaccine trials.

ABCL-542 Prevalence and Characterization of EBV-Negative Post-Transplant Lymphoproliferative Disorder

A common and potentially fatal post-solid organ transplant (SOT) complication is post-transplant lymphoproliferative disorder (PTLD). While the association of Epstein-Barr virus (EBV) with the development of PTLD is well recognized, little is known about the etiology of EBV-negative PTLD. To characterize the differences between EBV-positive and EBV-negative PTLD to better understand the pathogenesis of EBV-negative PTLD. This was a retrospective study that reviewed patients who developed PTLD after SOT. Data was collected on PTLD patients (>18 years) from 2011 to 2021. Data included demographics, SOT type, time from SOT to PTLD development, tumor EBV status, PTLD site, histopathological morphology, tumor markers, and overall survival. EBV tumor status was compared using χ2, Fisher's Exact, and Wilcoxon Rank Sum tests. A single, large academic center. A total of 99 patients met the inclusion criteria. Of those, 45.5% were EBV-positive and 54.5% were EBV-negative. Tumor EBV status did not differ by race, but males were more likely to be EBV-negative (63% v. 44.4% of females, p=0.065). EBV tumor status did not differ by SOT type. The interval between SOT and PTLD diagnosis was longer in EBV-negative patients (8.68 years) than EBV-positive patients (4.93 years) (p=0.001). There was a significant difference in EBV-negative PTLD site (p=0.046) and PTLD subtypes (p=0.002). Site of EBV-negative PTLD consisted of gastrointestinal (38.9%), head/neck (11.1%), liver/spleen (11.1%), CNS (3.7%), other lymph (24%), and other non-lymph (11.1%). Monomorphic (65.5%) and T-cell (90%) subtypes were more common in EBV-negative patients, compared to the polymorphic (15.4%) and plasmablastic/plasmacytic (27.3%) subtypes. Expression of CD20 did not differ by tumor EBV status. Those who were CD30-negative were more likely to be EBV-negative (90% v. 25%, p=<0.001). Those who were CD138-negative were more likely to be EBV-negative (75% v. 26.7%, p=0.012). There was no difference in overall survival by tumor EBV status. This single institution retrospective review shows that there are distinct differences between EBV-negative and EBV-positive PTLD. EBV-negative PTLD has a longer interval from SOT to PTLD development, is more likely to occur in the gastrointestinal tract, and is more likely to have a monomorphic morphology.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Third-party CMV- and EBV-specific T-cells for first viral reactivation after allogeneic stem cell transplant

AbstractVirus-specific T-cells (VSTs) from third-party donors mediate short- and long-term antiviral effects in allogeneic hematopoietic stem cell transplant (HSCT) recipients with relapsed or refractory viral infections. We investigated early administration of third-party VSTs, together with antiviral therapy in patients requiring treatment for first cytomegalovirus (CMV) or Epstein-Barr virus (EBV) infection. Thirty HSCT patients were treated with 1 to 4 VST infusions (2 × 107 cells/m2; CMV n=27, EBV n=3) at a median of 4 days after initiation of antiviral treatment. The overall viral response rate was 100%, with a complete response (CR) rate of 94%. Of the 28 patients who achieved a CR, 23 remained virus PCR negative (n=9) or below quantitation limit (n=14) for the duration of follow-up. Four patients had brief episodes of quantifiable reactivation not requiring additional therapy, and one required a second infusion after initial CR, remaining PCR negative thereafter. All 3 patients treated for EBV post-transplant lymphoproliferative disorder achieved sustained CR. Rates of aGVHD and cGVHD after infusion were 13% and 23%, respectively. There were no serious infusion-related adverse events. VST infusion was associated with rapid recovery of CD8+CD45RA−CD62L− and a slower recovery of CD4+CD45RA−CD62L− effector memory T-cells; CMV-specific T-cells comprised up to 13% of CD8+ cells. At 1 year post-transplant, non-relapse mortality was 10%, cumulative incidence of relapse was 7%, overall survival was 88% and 25 of 27 patients had ECOG status of 0 or 1. Early administration of third-party VSTs in conjunction with antiviral treatment appears safe and leads to excellent viral control and clinical outcomes. Registered on Australian New Zealand Clinical Trials Registry as #ACTRN12618000343202.

Epstein-Barr virus posttransplant lymphoproliferative disorder: update on management and outcomes.

Management of Epstein-Barr virus posttransplant lymphoproliferative disorder (EBV PTLD) is complex, involving risk stratification, prevention and/or preemptive measures involving monitoring EBV DNAemia and balancing treatment options, using a combination of reduction of immune suppression, anti-B cell therapy, and cytotoxic T lymphocytes (CTLs). The highest risk factor for the development of EBV PTLD in hematopoietic cell transplant (HCT) remains T cell depletion, with increasing use of antithymocyte globulin (ATG) or alemtuzumab in conditioning. In solid organ transplantation (SOT), the incidence of PTLD is highest among EBV seronegative recipients who are at risk for primary EBV infection following transplant in the first 12 months. Prevention is a critical component of the management of EBV PTLD. Although preemptive therapy remains standard of care, there continues to be heterogenicity and debate over the optimal choice of EBV DNA quantification and the threshold to use. Novel therapies such as donor-derived multipathogen and EBV specific CTLs for the prevention and third party CTLs for the treatment of EBV PTLD are promising, with rapidly expanding evidence, including large scale Phase III trials currently underway. With an increasing number of risk groups for developing EBV PTLD in HCT and SOT, management strategies using prophylaxis or preemptive therapy remain standard of care, however the use of prophylactic or preemptive EBV specific or multipathogen CTLs show promising results and safety profiles.

Novel Risk Factors for Epstein-Barr Virus (EBV) Reactivation and Post-Transplant Lymphoproliferative Disorder (PTLD) after Allogeneic Hematopoietic Stem Cell Transplant

Background: Epstein-Barr virus (EBV) reactivation and EBV-positive post-transplant lymphoproliferative disorder (EBV+PTLD) are often fatal complications following allogeneic hematopoietic stem cell transplant (HSCT). Risk factors for the development of EBV+PTLD after HSCT include human leukocyte antigen (HLA) mismatches, T cell depletion (TCD) and older age, among others. It has been proposed that specific HLA haplotypes are associated with the development of EBV+PTLD after solid organ transplant (SOT) and that pre-emptive use of Rituximab can reduce the risk of EBV+PTLD. We present a retrospective analysis of patients who underwent HSCT in order to determine the impact of donor source, TCD, age, HLA-A1 haplotypes and use of Rituximab prior to HSCT on the development of EBV reactivation and EBV+PTLD after HSCT.Methods: We retrospectively reviewed patients who had undergone allogeneic HSCT at our Institution between January 2012 and December 2016. We analyzed the cumulative incidence of EBV reactivation and EBV+PTLD and the impact of known and novel risk factors.Results: Of 474 patients, 10% developed EBV reactivation and 6% were diagnosed with EBV+PTLD. The cumulative incidence of EBV reactivation and EBV+PTLD was 15% and 11%, respectively, after haplo-cord HSCT, compared to 3% and 2% after MRD HSCT and 8% and 5% after MUD HSCT (p=0.0004 and p=0.02, respectively). EBV reactivation was associated with receipt of ATG compared to Alemtuzumab (p=0.03) and age older than 60 years (p=0.004). The presence of HLA-A1 haplotype in the recipient did not affect the incidence of EBV reactivation and EBV+PTLD (p=0.2 and p=0.9, respectively). The cumulative incidence of EBV reactivation and EBV+PTLD was lower in patients with Rituximab exposure prior to HSCT, although this did not reach statistical significance (p=0.2 and p=0.15, respectively). In a multivariate analysis, donor source (haplo-cord vs HLA-matched) and age older than 60 were found to be independent risk factors for the development of EBV reactivation (HR 1.9; p=0.038 and HR 2.6; p=0.002, respectively) and EBV+PTLD (HR 1.9; p=0.020 and HR 3.5; p=0.004, respectively). PTLD was fatal in 8 of 27 patients (29%) with PTLD and 17% of all patients with EBV reactivation. One patient died of disseminated EBV disease without PTLD.Conclusions: The cumulative incidence of EBV viremia and PTLD after allogeneic HSCT was 10% and 6%, respectively, and led to death in 2% of the patients. Haplo-cord grafts and age older than 60 years were independent risk factors for EBV reactivation and EBV+PTLD. Rituximab use prior to HSCT may confer protection against EBV reactivation and its use in the conditioning regimen of patients undergoing HSCT, at high risk for EBV reactivation, should be studied prospectively. Further studies are needed to determine the impact of HLA haplotypes on the incidence of EBV reactivation in patients after HSCT. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Identification of Epstein-Barr Virus Related Risk Factors for the Occurrence of Post-Transplant Lymphoproliferative Disorder in Lung Transplant Recipients

<h3>Purpose</h3> Post-transplant lymphoproliferative disorder (PTLD) is the second most common malignancy in solid organ transplantation. Based on recent registry data, ≈ 1.1% of lung transplants (LTx) develop PTLD within the first year. PTLD confers significant morbidity and mortality and has been associated with Epstein-Barr virus (EBV) infection. The threshold for EBV viremia predictive of PTLD is unknown. In the current study we examined risk factors for PTLD development and the relationship between EBV viremia and PTLD in LTx was assessed. <h3>Methods</h3> A single-center, retrospective review of all LTx recipients from 1/1/2009 - 7/31/2019 with EBV viremia was conducted. All patients (pts) with at least one positive EBV PCR test were reviewed for EBV viremia progression and PTLD occurrence. PTLD was confirmed by review of oncology notes, biopsy results, computed tomography and positron emission tomography scans. <h3>Results</h3> One hundred and forty-seven pts were included. Thirty-four (24.8%) underwent work-up for PTLD, of whom ten were diagnosed with PTLD. Median time from transplant to EBV viremia was 368 days (IQR 111-1201) with PTLD diagnosis occurring at a median of 521 days (IQR 150-741) after LTx. The PTLD(+) group had a higher baseline median EBV PCR of 2613 copies/mL (IQR 680-6099) vs 528 copies/mL (IQR 369-930) in PTLD(-) pts and an increased number of positive PCRs; 3.5 (IQR 2-10) vs 1 (IQR 1-2). In patients with EBV IgG data available, (<i>n</i>=66), Donor(+)/Recipient(-) pts were more likely to develop PTLD than other groups, RR = 18.3 (95% CI 3.93, 85.32); p<0.001. A cut-point analysis of EBV viral load determined that pts with a baseline EBV viral load >1930 copies/mL had a significantly higher risk of PTLD development, RR = 31.03 (95 %CI 9.44, 102.02); p<0.001. <h3>Conclusion</h3> EBV mismatch, higher viral loads, and persistence of viremia may be indicative of PTLD development. Patients with an EBV viral load >1930 copies/ml may benefit from closer surveillance.

Peripheral Blood Monoclonal B-Cell and/or Plasma Cell Detection By Flow Cytometry in Screening and Monitoring EBV-Positive Post-Transplant Lymphoproliferative Disorders

Background Post-transplant lymphoproliferative disorder (PTLD) is a serious complication that can occur following an allogenic hematopoietic stem cell transplant (allo-HSCT). PTLD occurs in approximately 0.8% to 20% of patients following an allo-HSCT and is associated with Epstein-Barr virus (EBV) infection in about 60% to 80% of patients. EBV positive (EBV+) PTLD generally arises early, several months following transplantation. The routine methods to diagnose EBV+ PTLD are clinical symptoms, EBV copy number, imageological examination, and pathological diagnosis, of which pathological diagnosis is the gold standard. Yet obtaining a biopsy is not possible with some patients and is not applicable for post-therapy monitoring. Therefore, there is an urgent need to find a simple, highly efficient, feasible, sensitive, and specific diagnostic and monitoring tool. Flow cytometry (FCM) has been established as a highly cost-effective method to diagnose lymphoma over the past several decades, and particularly for screening monoclonal B and/or plasma cells (MC B/P). Several recent publications as well as our own published and unpublished data have found that MC B/P are present in the peripheral blood of most PTLD patients. To this end, FCM detection of MC B/P in PB is a promising screening and monitoring method for EBV(+) PTLD. Objective To investigate the effectiveness of detecting MC B/P in PB by FCM for EBV+ PTLD screening and monitoring. Methods A total of 1470 patients received allo-HSCT at the Hebei Yanda Ludaopei Hospital, China from January 2018 through December 2019. We conducted a retrospective study of 481 patients with fever and lymphadenopathy following allo-HSCT. Patient PB was extracted for FCM MC B/P analysis. Plasma EBV viral loads were detected by PCR. The median fellow-up time was 6 months (range: 2 days to 21 months). The relationships of PB MC B/P, EBV load and clinical EBV-associated PTLD symptoms were investigated. Results: MC B/Ps were detected in the PB of 47 patients, of which 29 cases had monoclonal B cells, 14 cases had detectable co-existence of monoclonal B cells and monoclonal plasma cells, and 4 cases had detectable monoclonal plasma cells. The median time to PTLD onset following allo-HSCT was 70 days (range: 33 days to 491 days). The median percentage of monoclonal B cells was 0.43% (range: 0.1% to 23.41%. The median percentage of monoclonal plasma cells was 0.25%). Forty of 47 patients (85.1%) were finally diagnosed with PTLD using clinical comprehensive examination of symptoms. The incidence of clinical EBV+ PTLD was 2.9% (44 of 1470 cases). By FCM, MC B/Ps were observed in the PB of 91% of the patients (40 of 44 cases). No MC B/Ps were found in the PB of 4 patients. MC B/P detection in PB by FCM screening could effectively predict the incidence of EBV+ PTLD with a sensitivity of 90.91% and specificity of 98.40%. The positive predictive value was 85.17% and the negative predictive value was 99.08%. There was no significant correlation between EBV viral copy number and percentage of MC B/P. The median fellow-up time was 6 months (range: 2 days to 21 months) for all patients. The therapeutic response rate was 87.5% (35 of 40 patients) for MC B/P positive EBV+ PTLD patients. In those patients with a therapeutic response, clinical symptoms improved, lymph nodes significantly shrank, EBV viral loads decreased, MC B/Ps decreased or vanished, and CD20+ cell proportion decreased or vanished. Among the 7 patients who had MC B/Ps in PB but were not diagnosed with PTLD , their clinical symptoms recovered after treatment with immunosuppressive therapy. Conclusion By detecting PB MC B/Ps using FCM, we can successfully screen for EBV+ PTLD and monitor patient therapeutic responses in most cases. FCM to detect MC B/Ps in PB is a new, promising method for the diagnosis and monitoring of EBV+ PTLD. Compared to a biopsy, this appears to be a more simple, easier and more applicable tool to diagnose and monitor EBV+ PTLD. Disclosures No relevant conflicts of interest to declare.

Biological Difference Between Epstein-Barr Virus Positive and Negative Post-transplant Lymphoproliferative Disorders and Their Clinical Impact.

Epstein–Barr virus (EBV) infection is correlated with several lymphoproliferative disorders, including Hodgkin disease, Burkitt lymphoma, diffuse large B-cell lymphoma (DLBCL), and post-transplant lymphoproliferative disorder (PTLD). The oncogenic EBV is present in 80% of PTLD. EBV infection influences immune response and has a causative role in the oncogenic transformation of lymphocytes. The development of PTLD is the consequence of an imbalance between immunosurveillance and immunosuppression. Different approaches have been proposed to treat this disorder, including suppression of the EBV viral load, reduction of immune suppression, and malignant clone destruction. In some cases, upfront chemotherapy offers better and durable clinical responses. In this work, we elucidate the clinicopathological and molecular-genetic characteristics of PTLD to clarify the biological differences of EBV(+) and EBV(–) PTLD. Gene expression profiling, next-generation sequencing, and microRNA profiles have recently provided many data that explore PTLD pathogenic mechanisms and identify potential therapeutic targets. This article aims to explore new insights into clinical behavior and pathogenesis of EBV(–)/(+) PTLD with the hope to support future therapeutic studies.

Calcineurin Inhibitors Replacement by Ruxolitinib as Graft-versus-Host Disease Prophylaxis for Patients after Allogeneic Stem Cell Transplantation

Graft-versus-host disease (GVHD) is a common complication of allogeneic stem cell transplantation (allo-SCT) that carries a high mortality. Although calcineurin inhibitors (CNIs) have been widely used in GVHD prophylaxis, the incidence of acute GVHD (aGVHD) remains at roughly 30% to 50%. Moreover, some allo-SCT recipients cannot tolerate CNI. Thus, improved GVHD prevention methods are needed. Our study aimed to determine the prophylactic value of ruxolitinib for GVHD in CNI-intolerant patients after allo-SCT. Between September 2017 and March 2019, 10 patients with hematopoietic malignancies after allo-SCT who were intolerant to CNI at our center were enrolled in this study. The regimens were based on a myeloablative busulfan and cyclophosphamide regimen. Antithymocyte globulin was administered to patients with an HLA-haploidentical related donor (HRD) at a dosage of 6 mg/kg. All received ruxolitinib to replace CNI as GVHD prophylaxis. Ruxolitinib was initiated at 5 to 10 mg twice daily until 2 to 3 months post-transplantation and then tapered gradually, and in the absence of GVHD, discontinued by day +180. Eight patients had acute leukemia, 1 patient had myeloproliferative neoplasm, and 1 patient had natural killer T cell (NK/T) lymphoma. The donor type was a matched sibling donor in 3 patients and an HLA-haploidentical related donor (HRD) in 7 patients. All patients received CNI plus short-course of methotrexate as GVHD prophylaxis, but showed intolerance to CNI within 45 days post-transplantation. After ruxolitinib replacement, only 1 patient (10%) developed grade II skin aGVHD within 100 days, and only 1 patient developed severe aGVHD after 100 days. Two patients developed moderate/severe chronic GVHD (cGVHD) after tapering or stopping ruxolitinib, resulting in a 1-year cumulative incidence of moderate/severe cGVHD of 21.4%. Cytomegalovirus (CMV) reactivation occurred in 4 patients (40%), and Epstein-Barr virus (EBV) reactivation occurred in 3 patients (30%). None of the patients developed CMV disease or EBV post-transplantation lymphoproliferative disorder. After a median follow-up of 11 months (range, 2 to 15.5 months), 2 patients (20%) relapsed and 7 (70%) were alive, of whom 6 (60%) were negative for minimal residual disease and 4 were off immunosuppressant therapy. The prophylactic application of ruxolitinib for CNI-intolerant patients after allo-SCT appears to be safe and effective in preventing GVHD, but this awaits further study in larger cohorts.

ABO Blood Type Incompatibility Is Not a Risk Factor of Outcomes for Acute Myeloid Leukemia (AML) Patients After Unmanipulated Haplo-identical Peripheral Blood Hematopoietic Stem Cell Transplantation.

BackgroundHaplo-identical hematopoietic stem cell transplantation (HSCT) has provided potential donors for patients lacking available HLA-matched donors. ABO blood type compatibility has been reported to be associated with HSCT outcomes. However, few studies have investigated the role of ABO compatibility in haplo-identical HSCT of AML patients.Material/MethodsWe retrospectively analyzed 42 adult acute myeloid leukemia (AML) patients who received unmanipulated haplo-identical peripheral blood HSCT at the Chinese PLA General Hospital between Jan 2013 and Dec 2017. We analyzed the role of ABO compatibility in engraftment, transfusion requirements, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) viremia, acute graft-versus-host disease (GVHD), overall survival (OS), transplantation-related mortality (TRM), relapse, chronic GVHD, and post-transplant lymphoproliferative disorder (PTLD).ResultsThere were no significant differences between the ABO-matched group and the ABO-mismatched group in terms of engraftment, transfusion requirements, CMV and EBV viremia, OS, TRM, relapse, PTLD, and chronic GVHD. Univariate analysis revealed ABO incompatibility is not an independent risk factor of engraftment, transfusion requirements, CMV and EBV viremia, OS, TRM, relapse, PTLD, and chronic GVHD. We found a significantly higher cumulative incidence of aGVHD in the matched group compared with the mismatched group (80.95% vs. 42.86%, p=0.020). In multivariate analysis, ABO mismatch was associated with decreased risk of acute GVHD within 100 days after transplant (hazard ratio 0.492, 95% confidence interval 0.2123–1.14). However, the difference was not statistically significant (p=0.099).ConclusionsThis study demonstrated ABO incompatibility is not an independent risk factor of outcomes for AML patients who received unmanipulated haplo-identical peripheral blood HSCT. ABO compatibility might have limited value in haplo-identical donor selection.

PS1532 RISK FACTORS AND CLINICAL OUTCOMES OF EPSTEIN–BARR VIRUS DNAEMIA AND POST‐TRANSPLANT LYMPHOPROLIFERATIVE DISORDERS AFTER UNMANIPULATED ALLOGENEIC PBSCT IN PATIENTS WITH HEMATOLOGIC MALIGNANCIES

Background:In allogeneic hematopoietic stem cell transplantation recipients reactivation of Epstein‐Barr virus (EBV) can cause post‐transplantation lymphoproliferative disorder (PTLD), which may rapidly progress to multi‐organ failure and even death. Development of EBV PTLD correlates very closely with use of anti‐thymocyte globulin (ATG) and type of transplant.Aims:To assess the incidences and clinical features of EBV DNAemia and PTLD in the setting of stem cell transplantation using unmanipulated G‐CSF‐primed allogeneic peripheral blood stem cells as graft (PBSCT), we performed a retrospective analysis of stem cell transplantation from HLA‐matched (MSD) or haploidentical (HID‐SCT) sibling donors in patients with high‐risk hematological malignancies.Methods:The clinical characteristics of patients and donors were described in Table 1. EBV DNA were monitored by real‐time quantitative PCR on plasma samples weekly. The EBV DNAemia was defined as DNA loads more than 1,000 copies/mL of plasma. The diagnosis of EBV‐associated PTLD was defined as proven or probable according to the published definition. Probable PTLD was defined as significant lymphadenopathy, hepatosplenomegaly or other end‐organ manifestations accompanied by significant EBV DNAemia and the absence of other documented cause. Proven PTLD was defined as the detection of EBV in tissue specimen accompanied by symptoms and/or signs from the affected organ. Morphological classification of PTLD was based on histological WHO 2016 classification.Results:One‐year cumulative incidence of EBV DNAemia was 44.1%, ranging from 4.8% in MSD‐SCT recipients not using ATG to 20.0% in MSD‐SCT recipients using ATG, and 73.7% in HID‐SCT recipients. Risk factors for EBV reactivation included use of ATG (p = 0.008), male donor (p = 0.034), and reactivation of cytomegalovirus DNAemia (p &lt; 0.001). One‐year incidence of EBV PTLD was 11.9%, ranging from 1.8% in recipients of MSD‐SCT not using ATG to 4.4% in recipients of MSD‐SCT using ATG, and 23.5% in recipients of HID‐SCT. Risk factors for PTLD included in fludarabine‐based conditioning regimen (p = 0.010), cytomegalovirus DNAemia (p = 0.036) and patient's age &lt;40‐yr (p = 0.032). The 1‐yr relapse‐free survival and overall survival among the 19 patients with PTLD were 40.2% and 44.9%, respectively, as opposed to 63.4% and 68.4% among patients without PTLD (p &lt; 0.05). In multivariate analyses, EBV DNAemia was associated with a lower risk of relapse (p = 0.025), while PTLD was marginally associated with a higher risk of relapse (p = 0.092). Neither EBV DNAemia nor PTLD independently predict inferior relapse‐free survival, overall survival and non‐relapse mortality (p&gt;0.05).Summary/Conclusion:This study confirmed higher incidences of EBV DNAemia and PTLD after HID‐SCT than MSD‐SCT in the setting of unmanipulated with PBSCs as graft. Risk factors associated with reactivation of EBV were included in use of ATG, male donor, and CMV DNAemia. EBV PTLD developed mainly in HID‐SCT recipients with EBV DNAemia. The risk factor associated with EBV PTLD after HID‐SCT was fludarabine‐containing conditioning regimens. Although patients with EBV DNAemia did not have an inferior survival, they did have an increased risk of developing EBV PTLD, which was associated with worse RFS and OS after HID‐SCT.image

Prophylactic rituximab prevents EBV PTLD in haplo-cord transplant recipients at high risk

Epstein–Barr virus (EBV) reactivation and post-transplant lymphoproliferative disorders (PTLD) are common and potentially fatal complications after allogeneic transplantation with mismatched donors and T-cell depletion. Haplo-cord transplantation combines a mismatched UCB graft with third-party cells. Conditioning involves thymoglobulin. EBV reactivation and PTLD were common in initial patients. As of March 2017, we administered a prophylactic dose of rituximab 375 mg/m2 pre-transplant. Among 147 patients who did not receive rituximab, the cumulative incidence of post-transplant EBV reactivation and of EBV PTLD was 13% and 8%, respectively. Among 51 who received pre-transplant rituximab, the incidences were 2% (p = .0017) and 0% (p = .04), respectively. There was no difference in time to hematopoietic recovery, in the incidence of CMV reactivation, of invasive blood stream infections or of proven or probable invasive fungal infections. Pre-transplant administration of rituximab is an effective and nontoxic intervention that drastically reduces EBV reactivation and PTLD in high-risk patients.

Epstein-Barr virus DNA load kinetics analysis in allogeneic hematopoietic stem cell transplant recipients: Is it of any clinical usefulness?

BackgroundThere is a lack of clinical information regarding the usefulness of plasma Epstein-Barr virus (EBV) DNA load kinetics analyses in the management of EBV infections in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Namely, it remains unknown whether this type of analysis can help physicians to anticipate the development of high-level EBV DNAemia episodes requiring rituximab treatment or predict the risk of recurrent EBV DNAemia or post-transplant lymphoproliferative disorders (PTLDs). Study designUnicentric, retrospective, observational study including 142 consecutive patients undergoing T-cell replete allo-HSCT. The plasma EBV DNA load was monitored on a weekly basis using the artus® EBV PCR kit. ResultsFifty-five of the 142 patients (38.7%) developed at least one episode of EBV DNAemia; 13 of the 55 initial EBV DNAemia episodes (23.6%) were preemptively treated with rituximab, 7 patients had a recurrent episode of EBV DNAemia, and biopsy-proven PTLDs were diagnosed in 4 patients. The initial plasma EBV DNA load was not significantly different (P=0.269) in episodes of self-resolving EBV DNAemia, those requiring rituximab treatment, or those leading to PTLDs. The plasma EBV DNA load doubling times were similar across all the groups (P=0.799), and the EBV DNA-load half-life was not associated with the occurrence of recurrent EBV DNAemia (P=0.550). ConclusionPlasma EBV DNA-load kinetics analyses are unlikely to be useful in predicting the occurrence of high-level EBV DNAemia, PTLD, or recurrent EBV DNAemia.

Progress of EB virus related post-transplantation lymphoproliferative diseases

Epstein-Barr virus (EBV) related post-transplant lymphoproliferative diseases (EBV-PTLD) is a rare and deadly complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical manifestations often show the unexplained fever, swollen lymph nodes, hepatosplenomegaly, pharyngitis, and central nervous system symptoms, with rapid disease progression and high fatality rate. As allo-HSCT for treatment of complex and refractory hemopathy has made a great progress, the prevention of graft versus host disease (GVHD) requires more application of immune inhibitors, resulting in an increasing incidence rate of PTLD. In addition to conventional treatments, such as antiviral therapy, reduction of immune suppression, local surgery and traditional chemotherapy, monoclonal antibodies and adoptive immunotherapy with T-cells for treatment of PTLD have brought a profound influence. This paper reviews the latest progress of treatment of EBV-PTLD. Key words: Epstein-Barr virus post-transplant lymphoproliferative disorder; Allogeneic hematopoietic stem cell transplantation; Treatment progress

Primary Epstein-Barr virus infection, seroconversion, and post-transplant lymphoproliferative disorder in seronegative renal allograft recipients: a prospective cohort study.

Epstein-Barr virus (EBV)-seronegative renal transplant recipients are at risk of post-transplant lymphoproliferative disorder (PTLD). We compared primary EBV infection, seroconversion, and PTLD in EBV-seronegative patients who received renal allograft from seropositive or seronegative donors (D+/R- and D-/R-, respectively). We prospectively followed 25 D+/R- and 8 D-/R- recipients. We followed patients from January 1999 to June 2009 with clinical visits, monthly EBV polymerase chain reaction tests, and serologic tests for a period of 1 year after kidney transplantation and on an individual basis thereafter. Three patients (9%) developed PTLD including 2 early-onset (<12 months) and 1 late-onset (>12 months) disease. In D+/R- and D-/R- patients, the frequencies of PTLD (8% vs. 12.5%, P = 0.7), EBV seroconversion (64% vs. 50%, P = 0.4), and EBV viremia (40% vs. 25%, P = 0.6) were not significantly different. Clinical, serologic, and virologic surveillance as well as reduction in immunosuppression after evidence of primary EBV infection resulted in a PTLD rate of 9%, despite a seroconversion rate of 60.6%. Rate of graft loss after reduction in immunosuppression was 10% (2 of 20), which was not significantly different from 13 patients without EBV seroconversion (no graft loss, P = 0.5). Rates of viremia, seroconversion, and PTLD in D+/R- and D-/R- patients appear to be similar. The incidence of PTLD in renal transplants ranges from 0.5% to 2.9%. Our data show a significantly higher rate in EBV-seronegative renal allograft recipients, suggesting the need for close surveillance. Our data also suggest that donors for EBV-seronegative recipients may be accepted irrespective of positive or negative serostatus, with ongoing surveillance important in either circumstance.

Infection Burden of Double Stranded DNA (dsDNA) Viruses after CD34+ Selected, T-Cell Depleted (TCD) Hematopoietic Cell Transplantation (HCT) for Myeloid Malignancies at Memorial Sloan Kettering Cancer Center (MSK)

Background: Ex vivo T-cell depletion (TCD) by CD34+ selection has been used successfully for graft-versus-host disease prevention alleviating the need for additional pharmacologic immunosuppressants. TCD has been associated with higher rates of viral infections and cytomegalovirus (CMV) disease in particular compared to conventional (CONV) HCT. Modern methods of TCD achieve up to 5 log reduction of T-cells. At MSK, TCD HCT recipients (R) are routinely monitored for CMV, adenovirus (ADV), Epstein-Barr virus (EBV), and human herpes virus 6 (HHV6) in the blood by quantitative polymerase chain reaction (qPCR) assays. We report the incidence of viremia and end organ disease (EOD) by these viruses in TCD HCT recipients.Methods: Retrospective review of adults with acute leukemia (AL) and myelodysplastic syndrome (MDS) patients (pts) who received TCD HCT at MSK from June 2010 -December 2014. TCD was performed by the FDA approved CliniMACS CD34+ reagent system (Miltenyi Biotec, Gladbach, Germany). CMV was monitored at least weekly from day 14-100 and at least every 14 days until day 180. EBV was monitored through day 180. Monitoring for CMV and EBV was performed by the Clinical Microbiology Laboratory at MSK using Roche analyte specific reagents, and since March 2013, the Cobas Ampliprep/Cobas Taqman (CAP/CTM) CMV qPCR in plasma. Monitoring for ADV/HHV6 was performed by Viracor-IBT laboratories (Lenexa, KS). Preemptive treatment for CMV was started for ≥2 consecutive PCR >500copies/ml in whole blood or >300 IU/ml in plasma. Treatment of ADV/HHV6 viremia was at clinician's discretion. EBV post-transplant lymphoproliferative disorder (PTLD) was treated with rituximab as primary therapy. During the study, 11 pts were enrolled in CMV prevention trials of brincidofovir (BCV), and 5 pts received BCV for treatment of ADV. EOD was scored by standard criteria. Follow up was through June 2015. The cumulative incidence (CI) was estimated for viremia at 180 days and EOD at 365 days for CMV, ADV, HHV6, and EBV. Kaplan-Meier method and log-rank test were used to compare CI between groups. P <0.05 was deemed statistically significant.Results: Of239 pts (median age 56.3 years, range 19.6-73.3), 161 (67%) pts had AL and 78 (33%) pts had MDS. Donors were matched-related 76 (32%), matched unrelated 116 (48%), or mismatched (related or unrelated) 47(20%); CMV R+ 148 (62%) or R- 91 (38%). CMV infection had the earliest onset post HCT at a median of 28 days (d) (IQR: 25-33), followed by HHV6 33d (25-52), ADV 71d (44-89), and EBV 85d (58-107). 188 (79%) pts had ≥1 dsDNA viral infection with 182 (76%) pts experiencing infection prior to d100. The CIs of viremia were: CMV 42% (68% in R+ vs 0% in R-, P <0.0001), ADV 7% (10% in R+ vs 5% in R-, P =0.02), EBV 19%, and HHV6 61%. The CI of EBV and HHV6 viremia were similar between R+ and R- (P =NS). Among 100 pts with CMV viremia, 62 (62%) had dsDNA viral coinfections; including 40 (40%) with 1 coinfection, 19 (19%) with 2 coinfections, and 3 (3%) with 3 coinfections. Antiviral treatment was given to 99 pts for CMV (99% of CMV viremic pts, 67% of R+, 41% of total pts), 9pts for ADV (56% of ADV viremic pts; 4% of total), and 19 for HHV6 (16% of HHV6 viremic pts; 8% of total). In total, 42 (18%) pts developed EOD by dsDNA viruses. The most common EOD was EBV PTLD (20 pts, 9%), followed by CMV (14 pts, 7%; but 11% among CMV R+ pts), ADV (8 pts, 4%), and HHV6 (2 pts, 1%). Among 14 pts with CMV disease, 6 had pneumonitis, 5 colitis, 3 duodenitis, and 3 retinitis. Three pts had 2 sites of CMV EOD. Among 8 pts with ADV disease, 3 had colitis, 3 pneumonitis, 1 nephritis, and 1 hepatitis/colitis. Two pts had HHV6 pneumonitis.Conclusions: 1) Viremias by dsDNA viruses occurred frequently and early post TCD HCT: 189 (79%) pts had at least 1 dsDNA viral infection, with onset of first infection before d100 in 183 (77%) pts. Around 58% of pts with CMV had coinfections with additional dsDNA virus(es). 2) Two thirds (67%) of CMV R+ and 41% of total pts received CMV antiviral treatment. 3) Overall, 18% of patients developed end organ disease by dsDNA viruses. 4) Viremias were managed effectively with intense monitoring and antiviral treatment, and rates of EOD were comparable to those of CONV HCT. Our data highlights the need for effective strategies to reduce the total burden of dsDNA viruses after TCD HCT. [Display omitted] [Display omitted] [Display omitted] DisclosuresPerales:Merck: Membership on an entity's Board of Directors or advisory committees; Astellas: Membership on an entity's Board of Directors or advisory committees. Giralt:TAKEDA: Consultancy, Honoraria, Research Funding; JAZZ: Consultancy, Honoraria, Research Funding, Speakers Bureau; AMGEN: Consultancy, Research Funding; SANOFI: Consultancy, Honoraria, Research Funding; CELGENE: Consultancy, Honoraria, Research Funding.

High Incidence of Late, Sustained and Clinically Inconsequential Epstein Barr Virus (EBV) Reactivation Following Combined Unrelated Cord Blood and Haploidentical CD34+ Cell Transplantation

Introduction: Unrelated cord blood (UCB) transplantation is a useful alternative for patients (pts) with malignant or non-malignant hematological disorders who lack an HLA matched donor. However, because UCB is devoid of memory T-cells, viral infections are more problematic following this transplant approach. EBV is a latent γ-herpesvirus that infects more than 90% of the world’s population. Following UCB transplantation, early (<100 days) reactivation of latent EBV is common and is associated with a high risk of post-transplant lymphoproliferative disorder (PTLD). The likelihood of PTLD following late EBV reactivation (>100 days) is less well characterized. We investigated EBV reactivation and PTLD development in early vs late post-transplant periods in severe aplastic anemia (SAA) pts undergoing combined UCB and haploidentical CD34+ cell transplantation.Methods: Pts with SAA and life-threatening neutropenia (ANC <500/uL) refractory to ≥2 immunosuppressive agents were eligible for treatment if they lacked an HLA-matched donor. Conditioning consisted of cyclophosphamide (120 mg/kg), fludarabine (125 mg/m2), equine ATG (160 mg/kg) and a single dose of 200 cGy of total body irradiation. Graft-vs-host disease (GVHD) prophylaxis consisted of tacrolimus and mycophenolate mofetil. Pts received a single ³4/6 HLA antigen matched UCB unit co-infused with a G-CSF mobilized, T-cell depleted CD34+ selected (Miltenyi CliniMacs system) allograft collected by apheresis of a haploidentical relative. EBV copy numbers were measured weekly for the first six months post-transplant and thereafter as clinically warranted.Results: 18 pts with treatment refractory SAA (median age 18 years; range 4-30), including 4 with SAA evolved to myelodysplastic syndrome (MDS) were transplanted. All pts were platelet and RBC transfusion-dependent. 11 pts received a ≥4/6 HLA matched UCB unit and 7 received a 5/6 HLA-matched unit. UCB units contained a median 2.8 x 107 TNCs/kg (range 1.7- 5.2) and 2.1 x 105CD34+cells/kg (range 0.5- 4.7) and haploidentical peripheral blood grafts contained a median 3.2 x106 CD34+cells/kg (range 3- 4.1) and 2.3 x 103 CD3+cells/kg (range 0.8- 5). All 18 pts were EBV IgG seropositive pretransplant. With a median follow-up of 689 days (range 160-2022), 16 pts survive, all disease free and transfusion independent. 16/18 (89%) pts developed EBV reactivation (EBV copy number >1000 copies/ml of whole blood or >150 genome equivalents/million PBMC) at a median 42 days post-transplant (range 2-1165). 12 pts (67%) had EBV reactivation before transplant day 100 (defined as early reactivation). Among those with early reactivation, 10/12 (83%) were treated preemptively with rituximab while 2/12 (17%) did not receive treatment and cleared the EBV viremia without intervention. Late EBV reactivation (defined as reactivation occurring after day 100) occurred in 15/18 (83%) pts. Among those with late reactivation, 12/15 (80%) were not treated while 3/15 (20%) received rituximab, which was given preemptively for PTLD in 2 pts and used to treat biopsy-confirmed PTLD on day 343 in one pt. The median time to first rituximab use was 37 days (range 8-343). Among the 12 pts with late EBV reactivation not given treatment, 9 (50% of those transplanted) had sustained viremia of >1000 copies lasting >30 days (defined as late and sustained EBV reactivation). All pts with late and sustained EBV reactivation remained asymptomatic despite high viral copy numbers, including 4 who had peak EBV copy numbers >30,000 copies/ml (Figure). There was no statistically significant difference in immune reconstitution, as determined by quantitative serum IgG levels and absolute numbers of CD4+ and CD8+ T-cells on day 100, 6 months, 1 year and > 1 year post-transplant in those with vs without late and sustained EBV reactivation.Conclusion: We observed that late and sustained EBV reactivation occurs commonly following combined UCB/haploidentical selected CD34+ cell transplantation, even in pts off immunosuppressive therapy and without CD4 and/or CD8 lymphopenia. In most cases, it was clinically inconsequential, and did not require rituximab treatment. The factors contributing to late sustained EBV reactivation including potential defects in viral-specific immunity remain under investigation.Figure: [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Reconstitution Of EBV-Specific Immunity In Adult Recipients Of Double Cord Blood Transplantation Depends On SCF and IL-7 Levels and Maintenance Of a Diverse TCR Repertoire

Umbilical cord blood (UCB) is an alternative source of hematopoietic stem cells (HSC) for allogeneic HSC transplantation but reconstitution of T cell immunity remains problematic even with double UCB transplantation (dUCBT). This is related to the small T cell numbers of the UCB graft, the naïve nature of these T cells and often the use of ATG as part of the conditioning regimen. Consequently, UCBT recipients are susceptible to viral infections that require intact T cell immunity for their containment. Epstein Barr virus (EBV) is a gammaherpes virus that is transmitted orally. EBV initially replicates in a lytic cycle in the epithelium of the oropharynx and then establishes a latent state in memory B cells. Reactivation of EBV from latent to lytic cycle is mediated by physiologic stress of the memory B cell pool and by defects in antiviral T cell immunity, and can cause aggressive lymphomas known as post transplant lymphoproliferative disorder (PTLD) in immunocompromised hosts. The specific immunological correlates of EBV reactivation in adult UCBT recipients have not been examined. In the present study we attempted to distinguish immune reconstitution profiles in UCBT recipients who developed EBV viremia from those who did not, in order to better understand the immune profile of UCBT recipients who control gammaherpes virus reactivation. Thirty-one patients with hematologic malignancies received dUCBT with melphalan, fludarabine, ATG conditioning and tacrolimus plus sirolimus for GvHD prophylaxis. EBV viral load was determined on a weekly basis after dUCBT. Immunophenotype of peripheral blood lymphocytes, serum cytokine levels and T cell receptor excision circle analysis (TREC) values, were examined prior to and at 1, 2, 3, 6 and 12 months after UCBT and were compared between EBV viremic and non-viremic patients using the Wilcoxon-rank sum test. During the first 12 months after dUCBT, 14 of 31 (45%) patients developed EBV viremia and four (13%) developed PTLD. At one month after dUCBT, patients who developed EBV viremia displayed higher numbers of CD19+ B cell numbers (p=0.04) and CD4+CD25+ T regulatory cells (p=0.03) compared with patients who never became viremic. Surprisingly, development of EBV viremia correlated with increased numbers of CD3+ (p=0.04), CD4+ (p=0.015) and CD8+ (p=0.021) T cells. This finding was counterintuitive, as one might expect better quantitative peripheral T cell reconstitution in patients with recovering immunity and no EBV reactivation. One mechanism of impaired immune reconstitution after UCBT is skewing towards a late effector memory T cell phenotype, a stage in which T cells are incapable of mounting protective immune responses. We examined whether development of EBV viremia was associated with altered naïve versus memory T cell distribution. We determined that patients who developed EBV reactivation had higher numbers of memory cell subsets (CD4+CD45RO+, p=0.0023; CD8+CD45RO+, p=0.019) at two months after dUCBT. Neither development nor control of EBV viremia correlated with TREC recovery, which occurred after the time period of EBV viremia. We were unable to identify EBV-specific T cells in any patient group due to the very low T cell numbers during the time of viremia. However, analysis of repertoire diversity by deep-sequencing on PCR-amplified CDR3 regions of the TCRb gene using the ImmunoSEQ assay showed a more diverse TCR repertoire, as determined by higher entropy (p=0.03) and lower clonality (p=0.03), among patients who did not develop EBV reactivation, compared with those who developed EBV viremia and PTLD. Assessment of serum levels of SCF (a c-kit ligand), IL-7, thrombomodulin, VEGF and angiopoetin-1 showed that patients without EBV viremia had significantly higher levels of SCF (p=0.0001) and IL-7 (p=0.05), at 1 and 2 months after dUCBT, compared with patients who developed EBV reactivation and PTLD. SCF-mediated signaling via c-kit is integral to the homing and longevity of uncommitted hematopoietic stem cells whereas IL-7 is a critical factor for survival and homeostasis of naïve T cells. Together our findings suggest that control of EBV reactivation after dUCBT might be linked to the support of naïve T cell homeostasis, which enables maintenance of a diverse TCR repertoire.▪ Disclosures:No relevant conflicts of interest to declare.

Does CMV Mismatch Status Modify the Risk of PTLD Due to EBV Mismatch Status in Lung and Heart Transplant Recipients?

Purpose Epstein-Barr virus (EBV) mismatch is a known risk factor for posttransplant lymphoproliferative disorders (PTLD) in lung and heart transplant recipients (LTx and HTx). We evaluated the potential modifying effect of cytomegalovirus (CMV) mismatch on the relation between EBV mismatch and PTLD in LTx and HTx. Methods and Materials We performed a study of U.S. LTx and HTx recipients from 2000-2011 in the Scientific Registry of Transplant Recipient (SRTR). Adjustment for sextiles of the propensity score (based on the probability of being an EBV mismatch) was used to account for confounding in Cox proportional hazards models stratified for organ type. Results The study population included 5957 LTx (61 PTLDs; 1.02%) and 7870 HTx (39 PTLDs; 0.5%) with complete data on CMV and EBV serostatus. A total of 272 LTx and 457 HTx were concurrently CMV and EBV mismatches. After adjustment for sextiles of the propensity score, the hazard ratio (HR) for PTLD was 4.4 (95% CI: 2.9-6.7) and 1.6 (95% CI: 1.1-2.5) in EBV and CMV mismatch recipients, respectively. When compared to patients who were neither CMV nor EBV mismatch, the adjusted HR for PTLD in patients who were CMV mismatch only, EBV mismatch only, and both CMV/EBV mismatch were 1.8 (95% CI: 1.1-3.3), 4.8 (95% CI: 2.9-8.1), and 7.0 (95% CI: 3.9-12.7), respectively. However, the HRs for the association of EBV mismatches and PTLD in CMV mismatch and non-mismatch patients did not significantly differ (P value for interaction=0.6). [ figure 1 ] Conclusions EBV mismatch status is significantly associated with risk for PTLD in LTx and HTx. Concomitant CMV mismatch status in EBV mismatch patients does not significantly modify the relative hazard of PTLD.