Epstein-Barr virus-associated lymphoproliferative disease following allogeneic stem cell transplantation Dr Christopher Fox Consultant Haematologist Nottingham University Hospitals NHS Trust
The Herpesvirus Evolutionary tree
Epstein Barr Virus Human 1-herpes virus 95% adult population latently infected Predominantly B lymphotropic Entry via CD21 & HLA class II Potent in-vitro growth transforming properties
Epstein Barr Virus Human 1-herpes virus 95% adult population latently infected Predominantly B lymphotropic Entry via CD21 & HLA class II Potent in-vitro growth transforming properties + EBV
EBV can adopt different latency states in vivo memory B cells in healthy persistence BL HL ENKTL NPC PTLD
EBV can adopt different latency states in vivo memory B cells in healthy persistence BL HL ENKTL NPC PTLD
Primary infection Epithelium Latency III Naïve B Lytic cycle 80 proteins EBNA1 EBNA2 EBNA-LP EBNA3A EBNA3B EBNA3C LMP1 LMP2 ncrnas
Primary infection Epithelium Latency III Naïve B Lytic cycle 80 proteins EBNA1 EBNA2 EBNA-LP EBNA3A EBNA3B EBNA3C LMP1 LMP2 ncrnas PTLD biopsy
EBV-infected cells in infectious mononucleosis tonsil EBER EBNA2 LMP1 From Gerald Niedobitek
Primary infection Epithelium Latency III Naïve B Lytic cycle Plasma cell T T T T T T T T T T Lytic Ag specific T Latent Ag specific 1 o CTL response
Primary infection Epithelium Latency III Latency I/II Latency 0 Naïve B GC Memory B Lytic cycle Plasma cell Persistent infection T T T T T T T T T Tm Tm T T Tm Tm Lytic Ag specific Latent Ag specific Lytic Ag specific Latent Ag specific 1 o CTL response memory CTL response
EBV-specific responses in IM PBMC 46.71% Tonsil 13.13% CD8 Lytic epitope response RAK lytic 2.16% 1.61% CD8 Latent epitope response QAK latent From Prof Martin Rowe
EBV-specific responses in healthy carriers PBMC Tonsil 1.31% 3.87% CD8 Lytic epitope response RAK lytic 1.16% 12.18% CD8 Latent epitope response FLR latent From Prof Martin Rowe
SCT-PTLD history Donor-derived immunoblastic sarcomas in the early months following allosct reported in the late 1970s and early 1980s 15 patients with a histological spectrum of EBV-associated lymphomas (median D+77) following myeloablative SCT reported 1988 Majority of cases arose from donor B cells Mortality rate was almost 90% Gossett TC et al NEJM 1979, Zutter MM et al Blood 1988
SCT-PTLD history Donor-derived immunoblastic sarcomas in the early months following allosct reported in the late 1970s and early 1980s 15 patients with a histological spectrum of EBV-associated lymphomas (median D+77) following myeloablative SCT reported 1988 Majority of cases arose from donor B cells Mortality rate was almost 90% Despite diagnostic and therapeutic advances, SCT-PTLD remains an important cause of mortality PTLD risk increases with the degree of T cell impairment ~ 1-15% Gossett TC et al NEJM 1979, Zutter MM et al Blood 1988
Definitions EBV-DNA-emia detection of EBV-DNA in the blood. Probable EBV disease significant lymphadenopathy (or other end-organ disease) with high EBV-DNA load in the blood. Proven EBV disease EBV detected from an organ by biopsy together with symptoms and/or signs from the affected organ Styczynski J et al. Bone Marrow Transplant 2009; 43:757-770.
Definitions EBV-DNA-emia detection of EBV-DNA in the blood. Probable EBV disease significant lymphadenopathy (or other end-organ disease) with high EBV-DNA load in the blood. Proven EBV disease EBV detected from an organ by biopsy together with symptoms and/or signs from the affected organ Styczynski J et al. Bone Marrow Transplant 2009; 43:757-770.
Incidence of EBV DNAemia following in vivo T-depleted allosct
Cumulative Incidence EBV >10,000 copies/ml Cumulative Incidence EBV >500 copies/ml Cumulative 1.25.5 Incidence of EBV DNAemia following in vivo T-depleted allosct.75.5 0.25 0 6 12 Time from Transplant (Mon 0 0 6 12 18 24 Time from Transplant (Months) Campath ATG 1.75.5.25 Figure 1. Incidence of EBV Reactivation by TCD 0 0 6 12 18 24 Time from Transplant (Months) From David Burns
Cumulative In.25.5 Incidence of high-level EBV Reactivation by Risk Factors 0.75 1 0 6 12 18 24 Time from Transplant (Months) AML/MDS NHL Other.5.25 0 0 6 12 18 24 Time from Transplant (Months) From David Burns
.25 Incidence of high-level EBV Reactivation by Risk Factors 0 1 0 6 12 18 24 Time from Transplant (Months) No Rituximab Rituximab.75.5.25 0 0 6 12 18 24 Time from Transplant (Months) From David Burns
40 30 EBV qpcr Positivity Alemtuzumab ATG Kinetics of EBV Reactivation Frequency 20 10 0 0-4 4-8 8-12 12-16 16-20 18-24 24-28 28-32 32-36 36-40 Time post transplant (weeks) 40-44 44-48 48-52 >52 20 High Level EBV 15 Frequency 10 5 0 0-4 4-8 8-12 12-16 16-20 18-24 24-28 28-32 32-36 36-40 Time post transplant (weeks) 40-44 44-48 48-52 >52 30 Interval to High Level EBV Frequency 20 10 0 0 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 Time from EBV qpcr positivity to 10 4 copies/ml (weeks) 11-12 >12 From David Burns
40 30 EBV qpcr Positivity Alemtuzumab ATG Kinetics of EBV Reactivation Frequency 20 10 0 0-4 4-8 8-12 12-16 16-20 18-24 24-28 28-32 32-36 36-40 Time post transplant (weeks) 40-44 44-48 48-52 >52 20 High Level EBV 15 Frequency 10 5 0 0-4 4-8 8-12 12-16 16-20 18-24 24-28 28-32 32-36 36-40 Time post transplant (weeks) 40-44 44-48 48-52 >52 30 Interval to High Level EBV Frequency 20 10 0 0 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 Time from EBV qpcr positivity to 10 4 copies/ml (weeks) 11-12 >12 From David Burns
Definitions EBV-DNA-emia detection of EBV-DNA in the blood. Probable EBV disease significant lymphadenopathy (or other end-organ disease) with high EBV-DNA load in the blood. Proven EBV disease EBV detected from an organ by biopsy together with symptoms and/or signs from the affected organ Styczynski J et al. Bone Marrow Transplant 2009; 43:757-770.
PTLD following Alemtuzumab-based allosct Retrospective multicentre UK study Characteristics of disease and outcome Relationship with viral load 69 cases of PTLD 15 BMT centres, 2001-2010 Inclusion based on published diagnostic criteria EBV reactivations without evidence of end-organ disease, irrespective of viral load, were not included Most were biopsy proven Fox et al BMT 2014
7 cases presented with other end-organ disease or fulminant multi-organ failure
The majority of cases (n=62) presented with features characteristic of aggressive lymphoma
EBV copy number per ml EBV DNA levels at SCT-PTLD clinical presentation 10 8 10 7 10 6 10 5 10 4 10 3 10 2 10 1 PTLD patients Marked variation in magnitude of EBV DNAemia
EBV copy number per ml EBV copy number per ml EBV DNA levels at SCT-PTLD clinical presentation 10 8 10 7 10 6 10 5 10 4 10 8 10 7 10 6 10 5 10 4 10 3 10 2 10 1 PTLD patients 10 3 10 2 10 1 1 2 3 4 5 6 7 8 9 10 1112 13 14 15 Transplant centre Marked variation in magnitude of EBV DNAemia Not explained simply by inter-laboratory variability
PTLD-free Survival (%) Overall Survival (%) 100 SCT-PTLD survival 80 60 40 20 0 0 6 12 18 24 100 80 60 40 20 0 0 6 12 18 24 Months from PTLD onset
Survival (%) Absence of lymphadenopathy associated with inferior survival 100 80 60 40 20 0 24 Month Survival Rate (95% CI) Lymphadenopathy No Lymphadenopathy 85.9% (76.5%, 96.4%) 40.3% (32.6%, 49.9%) Log-rank p<0.0001 0 6 12 18 24 Months from PTLD onset
Survival (%) A modified IPI score is predictive for survival in SCT-PTLD 100 80 60 40 20 0 IPI score 0-2 IPI score 3-4 24 Month Survival Rate (95% CI) 83.3% (74.3%, 93.3%) 31.3% (25.0%, 39.0%) Log-rank p<0.0001 0 6 12 18 24 Months from PTLD onset
Conclusions - PTLD following Alemtuzumab-alloSCT Raw estimate of PTLD risk ~4% Some patients have a fulminant course Markedly variable EBV DNA loads at PTLD onset 23% and 45% of cases, respectively, had <10 000 and <40 000 copies/ml. Lymphadenopathy may not be clinically apparent Up to a third of patients will fail R-monotherapy Chemotherapy ineffective at salvage Donor lymphocyte infusion can salvage Rituximab-refractory cases Fox et al BMT 2014
Case study 42 year old woman Flu-BEAM-Campath MUD for LPL (A mismatch) Early graft failure Reconditioned with Flu/Cy/ATG D+55 High-level EBV reactivation D+44/D+99 Initial fall in EBV qpcr with Rituximab But. severe oropharyngeal ulceration with progressive (absolute) dysphagia
EBV+ Diffuse large B cell lymphoma EBER CD20
In vivo kinetics of adoptively transferred T cells HSCT Rituximab DLI 1x10 6 /kg PTLD patient NUHEBV0013
Response to Donor Lymphocyte infusion: PET-CT D-1 DLI 6 weeks 6 months
Donor Lymphocytes Pre-DLI From Heather Long
From Heather Long Donor Lymphocytes Pre-DLI 3 Weeks 1 Month 3 Months 1 Year
NUHEBV0013 CD4+ T cell response From Heather Long
NUHEBV0013: EBV antigen expression in tumour cells A B EBER EBNA1 LMP1 BZLF1 CD20 EBNA2 LMP2 gp350
Equivalent efficacy of: Unselected DLI GVHD risk Donor-derived ex-vivo expanded EBV-CTLs Time constraints Third-party EBV-CTLs Availability and cost
Acknowledgements UHB David Burns Sridhar Chaganti Charlie Craddock Contributing UK BMT centres BSBMT Patients University of Birmingham Heather Long Gordon Ryan Paul Murray Martin Rowe Alan Rickinson Nottingham University Hospitals Nigel Russell Jenny Byrne Emma Das-Gupta Caroline Harvey Lynne Watson Simon Hughes