Epstein-Barr Virus (EBV) complications following HSCT:from viremia to post transplant lymphoproliferativep p y p p

disease (PTLD) and lymphoma

Laurie A. Milner, MDLaurie A. Milner, MD

Associate Professor,Pediatric Hematology / Oncology / HSCTPediatric Hematology / Oncology / HSCT

Pathology and Laboratory MedicineMedical Oncology and the Wilmot Cancer Center

Medical Director, Stem Cell Processing Laboratoryg yUniversity of Rochester Medical Center

February 12, 2009

No conflicts of interest or financial disclosures

Diseases Associated with EBV

1. Mononucleosis

2. Burkitt Lymphoma

3. Nasopharyngeal carcinoma

4. Hemophagocytic lymphohistiocytosis (HLH)

5. Lymphoproliferative Syndromes, e.g. Juvenile Myelomonocytic Leukemia (JMML)Juvenile Myelomonocytic Leukemia (JMML)

Post-Transplant Lymphoproliferative Disease (PTLD)

Epstein Barr Virus: aka EBV or HHV-4

1. γ Herpes virus

2. Once you’ve had it…..you have it “forever”(virus becomes latent in memory B cells)( y )

B B

3. Expansion of infected B cells is controlled by CD 8+ cytotoxic T cells (CTL)by CD 8 cytotoxic T cells (CTL)

and NK/LAK cells

B TT

B TT

EBV Infection Post-HSCT

1 Viral Reactivation B B1. Viral Reactivation B B

2. T cell immunosuppressionT

TT

BT

3. Expansion of infected B cells

B B BB

BB B

BB

B

Clinical Manifestations of EBV Infection

1. Asymptomaticy p2. Fever3. Tonsillar enlargement4. Lymphadenopathy5. Hepatosplenomegaly6 Bowel obstruction6. Bowel obstruction7. Respiratory symptoms due to pulmonary

infiltration or airway compressioninfiltration or airway compression8. “B” symptoms: sweats, weight loss9. CNS symptoms10. Cytopenias due to BM involvement

Spectrum of EBV infections in the immunocompetent hostimmunocompetent host

Asymptomatic Common

(Fever, LAD, HSM, Fatigue)Mononucleosis

Chronic EBV Infection

RareLymphoproliferative syndromes RareLymphoproliferative syndromesHLH, Malignancies

Spectrum of EBV infections in the immunocompromised hostimmunocompromised host

Ct ti“R ti ti ” Common

Nonspecific

asymptomatic“Reactivation”

Nonspecific (fever, rash, fatigue)

Viremia

focal ordisseminatedPTLD

HLH

disseminated

l h

PTLD

Malignancies lymphomaleukemia Uncommon

Natural history of EBV infections in the immunocompromised hostimmunocompromised host

low copy number spontaneous“Reactivation” low copy number(viral genome)

spontaneousresolution

Reactivation

rapid

Viremiahigh copy number rapid

progression

PTLDHLH

high cop n mberPTLD high copy number& cellular proliferation

FatalMalignancy

Fatal (~90% MR)

Development of EBV-associated PTLD requires:

1. EBV reactivation

2. T cell suppression T

3 Presence of B cells3. Presence of B cells

B BBB B B

BB

B B B B

Factors that influence the development of PTLD

1. EBV reactivationSerologic status of donor and recipient

2 T cell suppression

g pAge: children > adults

2. T cell suppressionT cell depletion of the stem cell productT ll di t d i i f th ti tT cell directed immunosuppression of the patient- especially antibody therapy: ATG, OKT3, α-CD3

3. Presence of B cellsStem cell product - “early” PTLD (< 1 year) almostalways involves proliferation of donor B cellsCell dose

EBV infections post HSCT: therapeutic options

1 Virus

Target Agents Response

Antiviral drugs Mixed1. VirusGanciclovir

Antiviral drugs Mixed (not usually sufficient)

2. B cells Very good (if used early)

Rituximab(α-CD20 MoAb)

3. T cells

chemotherapy anecdotal responses

Discontinue3. T cells

Donor Lymphocyte Infusions (DLI)

immunosuppression Mixed(limited by GVHD)

EBV specific cytotoxic T cells (CTL)

Infusions (DLI)Very good (if available)

Monitoring HSCT patients for EBV infection/PTLD

Pre-transplant Post-transplantp p

Clinical symptoms

generally not helpful(non-specific too late)

helpful (postpone transplant)

Serologieshelpful to NOT h l f l

symptoms (non-specific, too late)(postpone transplant)

Serologies(recipient and donor)

helpful to assess risk of “reactivation”

NOT helpful

Quantitativemay be helpful in Helpful(if done correctlyPCR for viral DNAspecific cases (if done correctly& standardized)

Studies using Q-PCR to evaluate EBV viremia &PTLD have been limited by numerous factorsy

Relatively low incidence of PTLDunrecognized and unreported casesunrecognized and unreported cases

Single institution and retrospective analyses

few cases in any given study

Ch i t h l i t d t t i i

Single institution and retrospective analysesvariable treatment regimens & patient populations

Changing technologies to detect viremialack of standardization and variable sensitivityuse of different patient samples & unit basis

Evolving transplant regimens and the use of new immunosuppressive agents

use of different patient samples & unit basis

new immunosuppressive agentsespecially the increasing use of reduced intensity (RIC) and nonmyeloablative (NMA) regimens

Despite the complicating factors, Q-PCR studies have led to important insights into the incidence and risk

factors for EBV viremia & PTLD following HSCT

Th f ll i lid t bi d d t fThe following slides represent combined data from multiple studies; they are intended to illustrate

trends and consensus observationstrends and consensus observations.

Variable patient populations transplantVariable patient populations, transplant regimens, and other factors unique to each

study preclude direct comparisons in most cases.y p p

Incidence of EBV Viremia & PTLD post HSCT

Type of HSCT Viremia PTLD

MyeloablativeMyeloablative< 1%

MUDMatched sib 8-10%

25-30% 4-6%MUD 25 30% 4 6%

Non myeloablative

UCB 2-5%

Non-myeloablativeor reduced intensity 30-50% 10-15%

The increased incidence of EBV reactivation and PTLD in NMA/RIC transplants is likely due to the highly

Immunosuppressive regimens employed, particularly Fludarabine + ATG

Incidence of EBV PTLD post UCBT

Low incidence of EBV reactivation & PTLD with UCBTreflects the lower numbers of mature lymphocytes

& decreased probability of EBV in the product& decreased probability of EBV in the product

However, UCB recipients treated with NMA/RIC regimensth t i l d ATG t i ifi t i k f PTLDthat include ATG are at significant risk for PTLD

Myeloablative

Brunstein. Blood. 2006

5/240 (2%)

6/95 (7%)Non-myeloablative1/65 (1 5%)without ATG

with ATG 5/30 (17%)1/65 (1.5%)without ATG

Impact of T cell depletion on EBV Viremia & PTLD

Ex vivo treatment Viremia PTLD

Unmanipulated graft 25 30% 0 5%Unmanipulated graft

T cell depleted graft

25-30%

30-65%

0-5%

10-20%risk depends on method of depletion: highest risk with ATG, α-T cell Abslower with Campath, CD34 selection

15 25%in vivo T cell depletion 50 65%

p ,In vivo treatment

15-25%

1 7%

in vivo T cell depletion (ATG, OKT3, α-CD3)

i i T & B ll d l ti

50-65%

15% 1-7%in vivo T & B cell depletion (Campath)

15%

Cohen, et.al. Leukemia & Lymphoma. 2007

Viremia PTLDPediatric Patients

Viremia PTLDConditioning Regimen

Reduced Intensity (RIC)Conventional (myeloablative)

35.4%8 8%

15.4%0%Conventional (myeloablative) 8.8%

34 9%In vivo T-cell depletion

ATG

0%

11 6%34.9%16.4%11.8%

ATGCampathNone

11.6%6.8%

0%

32.0%Disease

1o Immunodeficiency 12.0%15.7%All Others

Acute GVHD

4.8%

32.0%15.7%

PresentAbsent

16.0%2.4%

Changing the natural history of EBV infections in HSCT patientsinfections in HSCT patients

low copy number t“R ti ti ” low copy number(viral genome)

spontaneousresolution

“Reactivation”

progression

Viremia

high copy number

monitoring

progression

PTLDHLH

high copy number

preemptive orprompt therapy

PTLDhigh copy number

& cellular proliferation

prompt therapy

fatalMalignancy& cellular proliferation

Using Q-PCR to predict progression of viremia to PTLD

Van Esser, et.al. Blood. 2001

Viremia (>1000 gEq/ml) → 39% PPV 100% NPV for PTLDViremia (>1000 gEq/ml) → 39% PPV, 100% NPV for PTLD

Wagner, et.al. Blood. 2004

Viremia (>4000 gEq/μg DNA) x 2 → 50% PPV, 100% NPV

Ki h t l S d J I f Di 2007Kinch, et.al. Scand.J.Inf.Dis. 2007

Viremia >1000 gEq/ml plasma distinguished asymptomatici i f EBV di b t t EBV di f PTLDviremia from EBV disease, but not EBV disease from PTLD

The predictive value of Q-PCR can be increased by combining it with an assessment of T cell immunitycombining it with an assessment of T cell immunity

1. Absolute lymphocyte counts

2 EBV specific CTL– tetramer analysis2. EBV specific CTL tetramer analysis

QPCR + EBV specific CTLQPCRPPV40% 100%PPV40% 100%

Patients with very low T cell / EBV CTL numbers in the context of EBV viremia have an extremely

high risk of developing PTLD

Preemptive therapy for EBV infections post HSCT

Van Esser, et.al. Blood. 2002

T Cell depleted Allo-HSCT Preemptive TX Historical

17/49 (35%)Viremia >1000 gEq/ml 26/85 (31%)

Preemptive TX(Rituximab x 1)

Historicalcontrols

PTLD 3/17 (18%)PTLD mortality 0

10/26 (38%)5

Cohen, et.al. Leuk&Lymph. 2007RIC Allo-HSCT

Viremia >1000 gEq/ml 23/65 (35%)26/52 (50%)

Preemptive TX Prompt TXRIC Allo HSCT

PTLD PTLD mortality

10/23 (43%)02/10 (20%)

Preemptive vs prompt therapy for post HSCT EBV

Brunstein, et.al. Blood. 2006

UCBT1 /33 (4 %)

Prompt TX(Rituximab x 4)15/335 (4.5%)Viremia

PTLD 11/15 (73%)PTLD mortality 6/11 (55%)PTLD mortality

Comoli, et.al. Amer.J.Transplant. 2007

6/11 (55%)

Viremia 3/65 (35%)12/27 (44%)

Preemptive TX Prompt TXPediatric Haplo -HSCT

ViremiaPTLD PTLD mortality

3/65 (35%)3/12 (25%)4/12 (33%)3/3 (100%)

12/27 (44%)

0/4 (0%)

4 patients developed PTLD resistant to Rituximab and were salvaged with CTL

Preemptive therapy: unresolved issues

Untreated PTLD has a very high MR: >90%

Rituximab is highly effective if used early:

But many patients get treated unnecessarily to

Rituximab is highly effective if used early: 70-100% RR

But…many patients get treated unnecessarily to prevent PTLD in a single patient

EBV infected B cells may become CD20− and

EBV CTLs are highly effective

EBV infected B cells may become CD20 andthus resistant to rituximab

EBV-CTLs are highly effective

But…are also time consuming, expensive, & req ire a GMP facilit& require a GMP facilityCannot be derived for all patients

Bottom Line?

1. Monitor at risk patients by weekly Q-PCR

2. Pre-emptive treatment when viremia reaches threshold

Rituximab (+/- ganciclovir, IVIG)

3 Di ti i i (if ibl )3. Discontinue immunosuppression (if possible)

4 Consider DLI (Donor Lymphocyte Infusion)- or EBV specific CTL, if available

4. Consider DLI (Donor Lymphocyte Infusion)

5. Chemotherapy for evidence of clonal malignancy

Risk Factors for developing PTLD: Summary

T ll d l i f h ll dT cell depletion of the stem cell productHaploidentical HSCTHLA mismatched donors

T cell immunosuppressionATG OKT3 α-CD3

HLA mismatched donors

NMA / RIC regimens

ATG, OKT3, α CD3

EBV serologic status of donor and recipient

Grade III-IV GVHD

Primary immunodeficiency disorders

EBV serologic status of donor and recipientseropositive donor and naïve recipient

Primary immunodeficiency disorders

Age: children at higher risk than adults

References

1. Brunstein, et.al. Blood. 2006;108:2874.2. Cohen, et.al. Leukemia & Lymphoma. 2007;48:256.y p3. Comoli, et.al. Amer.J.Transplantation. 2007;7:1648.4. Juvonen, et.al. Bone Marrow Transplantation. 2003;32:97.5. Kinch, et.al. Scandinavian J.Infectious Disease. 2007;39:235. 6. Ocheni, et.al. Bone Marrow Transplantation. 2008;42:189.7 M b h t l J M d Vi l 2008 80 4417. Meerbach, et.al. J.Med.Virology. 2008;80:441.8. Van Esser, et.al. Blood. 2001; 98:972.9 Van Esser et al Blood 2002; 99:43649. Van Esser, et.al. Blood. 2002; 99:4364.10.Wagner, et.al. Blood. 2004;103:3979.11.Weinstock, et.al. Bone Marrow Transplantation. 2006;37:539., p ;