Epstein–Barr virus-related lymphoproliferative disease complicating childhood acute lymphoblastic leukemia: no recurrence after unrelated donor bone marrow transplantation

Bone Marrow Transplantation (2001) 27, 93–95  2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt

Case report Epstein–Barr virus-related lymphoproliferative disease complicating childhood acute lymphoblastic leukemia: no recurrence after unrelated donor bone marrow transplantation C Pondarre´1, K Kebaili1, F Dijoud2, T Basset3, N Philippe1 and Y Bertrand1 Departments of 1Pediatric Hematology, 2Pathology and 3Surgery, Hoˆpital Debrousse, Lyon, France

Summary:

Case report

A 16-year-old boy in complete remission of ALL, undergoing oral maintenance therapy, developed intestinal perforation related to EBV-associated lymphoproliferative disease (LPD). He was successfully managed with surgical resection, acyclovir, immunoglobulins and discontinuation of maintenance therapy. Leukemic marrow relapse occurred 3 months later, treated by polychemotherapy followed by unmanipulated BMT from a matched unrelated EBV seropositive donor. Donor lymphocytes were infused twice after transplant because of delayed immunologic recovery and severe CMV colitis. This was followed by acute GVHD requiring prolonged immunosuppressive treatment. Despite intensive and prolonged immunosuppression, recurrence of LPD was not observed. Following EBV-related LPD, allogeneic BMT can be performed if indicated. Selection of an EBV seropositive donor is of major importance for the prevention of LPD recurrence as the recipient may be protected by passive transfer of EBV-specific cytotoxic T cells. Bone Marrow Transplantation (2001) 27, 93–95. Keywords: ALL; EBV; lymphoproliferative disease; BMT

A 16-year-old boy was diagnosed in October 1995 with pre-B cell ALL, with polyadenopathy, hepatosplenomegaly and a leukocyte count of 53 × 109/l. There was no other visceral or central nervous system involvement. Cytogenetic evaluation of the marrow lymphoblasts revealed an abnormal clone, 46XY/del 3q21, der 3 (t(3;11)), −17, der17. The patient had no history of familial or personal malignancy or immune deficiency. Ig profile was normal. Serological test for HIV was negative and EBV serology was positive for viral capsid antigen (VCA) and nuclear antigen (EBNA) IgG and negative for VCA IgM, consistent with a prior EBV infection. He was enrolled in the EORTC 58881 protocol, which is a Berlin–Frankfurt–Munster (BFM)-derived protocol but without prophylactic cranial irradiation. A good response was occurred after a 1-week prephase consisting of prenisolone plus intrathecal MTX on day 1. Complete remission was attained after induction and maintained with consolidation. Maintenance therapy was initiated in June 1996, consisting of daily 6-MP (50 mg/m2) and weekly MTX (20 mg/m2), administered orally on an outpatient basis. In September 1997, after 15 months of maintenance therapy the patient presented with a 3-week history of fever, asthenia, weight loss and abdominal pain. Physical examination was unremarkable except for abdominal tenderness in the right lower quadrant. Iatrogenic neutropenia and lymphopenia were present (neutrophils 0.8 × 109/l and lymphocytes 0.01 × 109/l) and his biochemical profile, including liver and renal function, was normal. Bone marrow aspirate was hypocellular without leukemic relapse. Abdominal ultrasonography and computed tomography revealed a thickening of the wall of the distal part of the small bowel surrounded by inflammatory mesentery and associated with a peritoneal effusion. Moreover, careful examination of the liver revealed a 10-mm low density nodular mass. Antibacterial therapy was first initiated for a presumptive diagnosis of peritoneal abscess but as the patient’s condition deteriorated further a laparoscopy was undertaken which revealed a retrovesical abscess surrounding an intestinal perforation of the terminal ileum. Intestinal resection was performed and continuity was re-established. Histological study showed transmural lymphoid prolifer-

Children with ALL receiving daily 6-mercaptopurine (6MP) and weekly MTX as maintenance therapy have a T cell immunodeficiency that can very occasionally lead to EBV-related lymphoproliferative disease (LPD).1–3 Following this complication, unrelated BMT may put the patient at high risk of LPD recurrence due to the use of intensive immunosuppression. We report the case of a boy who successfully received an unrelated BMT after developing an EBV-associated lymphoproliferative disorder following ALL.

Correspondence: Dr C Pondarre´, INSERM U474, Maternite´ Port Royal, 123 boulevard de Port Royal, 75014 Paris, France Received 5 June 2000; accepted 30 September 2000

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ation with large areas of necrosis. The cells were pleomorphic and consisted mainly of large, basophilic lymphoid cells with more mature plasmocytoid cells. Immunohistochemistry indicated a B cell phenotype with expression of CD20 and CD79a and absence of a T cell marker. In situ hybridization with a biotinylated oligonucleotide probe complementary to EBV-encoded RNA-1 (EBER-1) showed heavy positive staining consistent with a diagnosis of EBVrelated LPD. Clonality and cytogenetic analysis of the lymphoproliferation could unfortunately not be performed. Chest X-ray, head MRI, CSF analysis and bone marrow study showed no evidence of LPD. Hepatic involvement by LPD was suspected but a biopsy was not performed. A diagnosis of localized EBV-related LPD was made, chemotherapy was discontinued and therapy with daily intravenous acyclovir (30 mg/kg) and weekly immunoglobulin (300 mg/kg) was initiated. Ten days later, the patient became afebrile with a better appetite. His lymphocyte count increased to 0.5 × 109/l and he was discharged with no further treatment. The liver infiltrate resolved slowly and he remained well until 3 months after cessation of maintenance therapy when a marrow relapse of his leukemia was diagnosed. A second CR was achieved and the patient was transplanted with unmanipulated bone marrow (3.5 × 108 nuclear cells/kg) from a matched unrelated EBV seropositive donor. Conditioning included fractionated TBI of 12 Gy, Ara-c (12 g/m2), melphalan (140 mg/m2) and thymoglobulin (5 mg/kg) once daily on days −7, −5, −3 and −1. Prophylactic i.v. weekly immunoglobulin (200 mg/kg) was started on day −1. GVHD prophylaxis included CsA and i.v. MTX on day 1, 3, 6 and 11 after transplant. The patient’s course was complicated by delayed immunologic recovery with histologically proven CMV ulcerative colitis refractory to ganciclovir and foscarnet. This prompted us to give two escalating doses (5 × 105 and 1 × 106 T cells/kg) of donor lymphocytes with a 4-week interval. The CMV infection resolved but acute grade II GVHD occurred while he responded to corticosteroids. The patient later developed extensive GVHD requiring prolonged immunosuppressive treatment. In spite of this high level of immunosuppression, recurrence of the LPD did not occur. Throughout this period, EBV genome copy number in PBMC and plasma, estimated by semi-quantitative PCR, remained undetectable (⬍20 copies/106 PBMC). The patient is now 27 months after BMT, in continuous complete remission. Discussion EBV has been associated with a spectrum of B cell lymphoproliferative diseases in severely immunosuppressed patients. In the immunocompetent host, primary EBV infection induces a massive CD8 positive T cell response and is followed by a persistent infection, which is maintained at a subclinical level. The key role in maintaining a stable host–virus balance in persistent EBV infection is provided by EBV-specific CTL. In severely immunosuppressed patients such as allogeneic solid organ or BMT recipients, the absence of EBV-specific CTL may lead to expansion of EBV-infected B lymphocytes and to the development of LPD. Children receiving maintenance therapy for ALL

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have a T cell immunodeficiency rendering them susceptible to a wide range of life-threatening infections but rarely resulting in EBV-related LPD. However, increasing numbers of cases of EBV-related LPD occurring in this setting are reported in the literature. All reported cases (six children and one adult)1–3 and two other pediatric cases presented at the Paediatric Pathology Society at Leeds in 1997 were in remission of their leukemia. All had extranodal involvement but the clinical presentation was diverse and usually aggressive. All LPDs have occurred during maintenance therapy, including MTX which is known to induce a T cell defect and might play a major role in the development of EBV-related LPD in this setting.4 However, the majority of children receiving maintenance therapy for ALL never develop EBV-related LPD suggesting that additional predisposing factors are required to promote infected B cell proliferation. Our patient had an extremely low lymphocyte count that might have predisposed to the LPD and one infant had received polychemotherapy in the early months of life that might have hampered maturation of the immune system.1 This case describes the only patient reported who received allogeneic bone marrow transplantation following EBV-related LPD. In spite of severe and prolonged immunosuppression following BMT, the LPD did not recur. The patient may have been protected by passive transfer of EBV-specific cytotoxic T cells in donor marrow and later in the donor peripheral lymphocytes. The optimum treatment is difficult to define, given the diverse clinical presentation, the morphological heterogeneity and the rarity of EBV-related LPD. Reduction or withdrawal of immunosuppressive therapy should be undertaken whenever possible to allow reactivation of EBVspecific CTL and cause regression of the tumors. One must balance discontinuation of immunosuppressive agents against any potential benefit of these drugs in controlling the underlying disease. The discontinuation of maintenance therapy in our patient was easy as the LPD occurred at the very end of the chemotherapy regimen. However, one can not prove that this did not contribute to the leukemic relapse. Surgical excision may be required in addition to the reduction of immunosuppressive therapy especially for rapidly growing or obstructive tumors. Chemotherapy and radiotherapy have been administered to patients refractory to withdrawal of immunosuppression with varying success.5 However, chemotherapy carries a high morbidity and mortality and should be considered as a last resort treatment. The anti-viral drugs acyclovir and ganciclovir may be used in conjunction with modulation of immunosuppression. They are not effective against the latent form of EBV found in LPD, but might reduce EBV-replication dependent B cell proliferation. MoAb against B cell surface molecules (CD20, CD21 and CD24)6,7 and interferon-alpha8 have been shown to be effective and represent a reasonable treatment option if reduction of immunosuppressive drugs proves unsuccessful. These treatments are often attractive, in that they may obviate the need for cytotoxics. Finally, adoptive transfer of T cell immunity (donor lymphocyte infusion) is an alternative treatment for EBV-related LPD arising after allo-

Allogeneic BMT following EBV-related lymphoproliferative disease C Pondarre´ et al

geneic BMT but any benefit must be balanced against the increased risk of GVHD.9 Preventive or therapeutic infusions of EBV-specific donor-CTL grown in vitro have been reported but the procedure is still under investigation.10 In conclusion, increasing observations of EBV-related LPD arising during maintenance therapy for ALL are being reported. Pediatricians caring for children with ALL must be aware of this serious complication as early recognition and management with reduced levels of immunosuppression can lead to resolution of LPD. Following EBV-related LPD, allogeneic unrelated BMT can be performed although the high cumulative dose of immunosuppressive agents further increases the risk of LPD development. The search for an EBV seropositive donor is fundamental as the recipient may be protected by passive transfer of donor EBV-specific cytotoxic T cells after bone marrow and lymphocyte infusions.

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