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Post‐TransplantLymphoproliferativeDisorders(PTLD)withEmphasisonEBV‐PositiveMucocutaneousUlcer
RobertMcKenna,M.D.
IllustrationsandTablesareProvidedbyBeenuThakral,M.D.
PTLDwithEmphasisonEBV‐PositiveMucocutaneousUlcer
• ReviewofPTLD– Riskfactors– Epidemiologyandincidence– Classificationandpathology
• RoleofEBVinPTLD• EBVviralloadmonitoringasasurveillancetool
• EBV‐positivemucocutaneousulcer(EBVMCU)
• EBVMCUinorgantransplantrecipients
Post‐transplantlymphoproliferativedisorders
• Lymphoidorplasmacyticproliferationsasaconsequenceofimmunosuppressioninorganorstem‐celltransplantrecipients
• Insolidorgantransplantrecipientsmostareofhostorigin– donororiginisseeninliverandlungallografts
• InBMtransplantrecipientsPTLDismostlyofdonororigin
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RiskFactorsforDevelopingPTLD
• Children>adults• EBVorCMVseronegativerecipientwithEBVseropositivedonor
LorenAWetal.BMT2003;31:145‐155
RiskFactorsforDevelopingPTLD
• Solidorgantransplant– Typeoftransplant
• Heart,heart‐lungandGI– Timefromtransplant
• Medianintervalaftertransplantis6months
– Typeandintensityofimmunosuppression
• OKT3(21.5%),ATG(4.9%),IL‐2receptorantagonist(7.8%),Campath(noassociation)
• Intensity(triplevs.quadruple),andduration
RiskFactorsforDevelopingPTLD
• Allogeneicstemcelltransplant– T‐celldepletion– HLAmismatchandsomeHLAtypes
• Relatedvs.unrelated (synergisticwithT‐celldepletion)
• HLAtype:A25,B38vs.A1,8andDR3– Timefromtransplant
• MediantimeintervalafterHSCTis2‐3months
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RiskFactorsforDevelopingPTLD
• Allogeneicstemcelltransplant(cont.)• 17%riskofEBV‐associatedPTLDwithumbilicalcordbloodtransplantsandATGorspecificanti‐lymphocytetherapy
• Primaryimmunodeficiencyasanindicationoftransplantation
LorenAWetal.BMT2003;31:145‐155
Epidemiology
PTLDdevelopsin~2%oftransplantrecipients
OrganTx Incidence% References
Kidney 0.3‐1.4 Caillardetal,2006
Liver 2‐5 Jainetal,2002
Heart 0.7‐6.8 Swerdlowetal,2000
Lung 3.3‐10.0 Reamsetal,2003
Heart‐lung 4.6‐12.5 Swerdlowetal,2000
GI/multi 10toupto25 Holmanetal,2012
Pancreas 2.1 Paraskevasetal,2005
Bonemarrow 0.5‐6.9 Holmanetal,2012
LocationandfrequencyofPTLDinSOT
IncidenceofPTLDinthetransplantedorganitselfishighforallSOTexceptheart,thereby,raisingthedifferentialofPTLDvs.rejection
Muchaetal.NephrolDialTransplant2010;25:2089‐2098
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WHOClassificationofPTLD
Category
• Earlylesions
• PolymorphicPTLD
• MonomorphicPTLD(classifyaccordingtothelymphomatheyresemble)
• ClassicalHodgkinlymphoma‐typePTLD
Sub‐type• Plasmacytichyperplasia• Infectiousmononucleosis‐like
lesion
• Bcellneoplasms– DiffuselargeBcelllymphoma– Burkittlymphoma– Plasmacellmyeloma– Plasmacytoma‐likelesion– other
• Tcellneoplasms– PeripheralTcellLymphoma,NOS– HepatosplenicTcelllymphoma– Other
Architecture Preserved,butoftenamasslesion
Clinical YoungerageSolidorganrecipientswithoutpriorEBVLN,tonsilsandadenoids,stage1E
Majorfindings
Hyperplasticfollicles¶corticalexpansionSmalllymphocytes,plasmacells,±immunoblasts
Immuno‐phenotype
PolyclonalB‐cells,T‐cells&plasmacellsOftenEBV+
Genetics Polyclonaloroligoclonal
Earlylesion
SwerdlowSandCraigF(In)JaffeEetal.Hematopathology.1sted.2011.
Architecture Effaced,destructiveextranodalmasses
Clinical 20‐80%,MCinchildren,usuallyafterEBV‐infection,lung,GI,LN,tonsils,stage1E‐IV
Majorfindings
Fullspectrumoflymphoidmaturation,+/‐geographicnecrosis,scatteredatypicalimmunoblastswithRS‐likecells
Immuno‐phenotype
PolyormonoclonalB‐cells,admixedT‐cells,RS‐likecells:CD30+,CD20+,CD15‐EBER‐positive
Genetics Clonallyrearranged:monoclonalB‐cells(75%),non‐clonalT,somewithBCL‐6somatichypermutation(43%)
PolymorphicPTLD
SwerdlowSandCraigF(In)JaffeEetal.Hematopathology.1stedn2011.
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Architecture Effaced
Clinical Extranodalmasses,olderage(56years);LN,BM,skin,softtissue,IIIE,IV
Majorfindings
MonomorphicSomehavebizarreormultinucleatedcells~RScells
Immuno‐phenotype
ClonalB‐cells(CD20,CD79a,CD19),mostarenon‐GCtype(CD10‐,BCL6‐,MUM+,CD138‐)EBVpositivein70%
Genetics ClonalB‐cellsand/orT‐cells,somaticallymutatedIGH,p53,RAS,MYCrearrangements,BCL6somatichypermutationcommon(90%),multiplegains(trisomies2,7,9,11,22,X),losses,breaks(1qregion),lackp16expression
MonomorphicPTLD
Monomorphic PTLD, Burkitt lymphoma
Monomorphic PTLD, plasma cell myeloma
JaffeEetal.Hematopathology.1stedn2011.
Architecture Effaced
Clinical <1%ofallPTLD;Mostcommoninrenaltransplant,m=32years(6‐54years)and63monthspostTX,30M:1F,stage1‐2,nodal,donotregresswithreductionofISand75%alive
Majorfindings
FulfillscriteriaforCHL(MC>NS>LD)
Immuno‐phenotype
~100%EBER‐positive(latenttypeII)likeinCHL
Genetics IgHclonalityisnoteasytodemonstrateandnoothergeneticabnormalities
PTLD,classicalHodgkinlymphoma
JaffeEetal.Hematopathology.1stedn2011.
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Architecture Effaced
Clinical <15%allPTLD,usuallyextranodal,pooroutcome,60%deadat2monthsofDx
Majorfindings
PeripheralT‐celllymphoma,NOS;hepatosplenicT‐celllymphoma,aggressiveNK/Tcelllymphoma
Immuno‐phenotype
LossofsomeT‐cellantigens,1/3EBER‐positive
Genetics ClonalTCRrearrangementi7(q10,+8(HSTL)P53andotheroncogenemutationscommon
PTLD,T/NK‐celltype
SwerdlowSandCraigF(In)JaffeEetal.Hematopathology.1sted.,2011.
EBVnegativePTLD
• 25‐30%ofPTLD• 2/3rdofT‐cellPTLDareEBVnegative
Characteristics EBV+PTLD EBV‐PTLD
Age 40years 50years
TimefromTx 10months 50months
Morphology(monomorphic)
43% 65%
Immunophenotype(GCtype)
15% 60%
Prognosis(died) 20% 40%
EBVMLP‐1
EBVviralloadmonitoring:Surveillancetool
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• EBVDNAwasmeasuredinsolidorgan(SOT)andhematopoieticcelltransplants(HCT)usingreal‐timeTaqManEBVPCR
• TheproportionofpatientswhohadEBVDNAviremiapost‐transplantwassignificantlyhigherinSOTvs.HCT(p<0.001)
• SOTrecipientsdevelopedPTLDsignificantlylaterthanHCTrecipients(median,2.8yearsvs.121days;p<0.001)
• PTLDriskinviremicpatientsincreasedwiththepeakquantityofEBVDNAemia(p<0.001)
• EBVPCRwaspredictivein29(78%)of37patientstestedwithinthreeweekspriortotissuediagnosisofPTLD,andthus,theauthorsconcludedthatEBVPCRwithcarefulattentionpaidtochangesinEBVDNAemiacouldleadtoearlierdiagnosisandtreatmentofPTLD
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AmJClinPathol2014;141:268‐274
RetrospectivereviewofEBVDNAquantitationdataof9,779bloodsamplesfrom740transplantpatients(233SOTand507HSCT)andtheirassociationswithPTLD
6.5%(48/740)werediagnosedwithPTLD,8.6%(20/233)inSOTand5.5%(28/507)inHSCTpatients.PTLDdiagnosiswasbiopsyprovenin82.3%ofpatients
• 41.8%(306/740patients)hadEBVviremia
• 13.4%(41/306)ofviremicpatientsdevelopedPTLDascomparedto1.6%(7/306)innon‐viremicpatients
• EBVviremiaoccurredmorefrequentlyinpatientswithPTLD(85.4%)incomparisontopatientswithoutPTLD(38.3%;P<.0001)
• WholebloodEBVDNAviremia:103‐105:6.9%developedPTLDand>105:40%developPTLD
PatientswithPTLDdemonstratedsignificantlyhigherfirstpositiveresults,higherpeaklevels,andahigherrateofincreaseinEBVviralloadcomparedwithpatientswithoutPTLD(P=.002)
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EBVviralloadmonitoring:Surveillancetool
• IdentifiespatientsatriskforEBV‐associatedPTLD– Nointernationalreference,?optimalsample
– Thresholdsdefiningriskandspecifictriggerpointsforpreemptiveinterventionarenotwelldefined
– Comparisonbetweencentersisdifficult
– EBVnegativePTLDwillnotbedetected• IntransplantrecipientsathighriskofearlyEBV‐associatedPTLD,EBVviralloadmonitoringhas:– Goodnegativepredictivevalue(>90%)– Poorpositivepredictivevalue(25‐65%)
MonomorphicB‐cellPTLD:TreatedassystemicpolymorphicPTLD
• Recentlydescribedentitycharacterizedbyisolatedwell‐circumscribed,ulcersthatoccurinthemucocutaneouslocations
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• Majorityoflesionsoccurredinoralcavity(16),theskin(6)orgastrointestinaltract(4)inpatientswith:• Iatrogenicimmunosuppression(MTXorAZA,CYAinduced):n=8
• Agerelatedimmunosuppression(63‐101years):n=17
• Hematopoieticstemcelltransplantpatient:n=1
60 year female with RA, on standard methotrexate therapy
Presentation
4 weeks
2 weeks
8 weeks
MorphologicandIHCcharacteristicsofEBVMCU
• Polymorphousinfiltrate• Lymphocytesandimmunoblasts• Scatteredplasmacells,histiocytes,eosinophils,anddispersed“plasmacytoid”apoptoticcells
• ScatteredlargepleomorphiccellsreminiscentofHodgkincells,oftenReedSternberg‐likecells
• R‐S‐likecellsco‐expressB‐cellantigensCD20(88.5%),CD30(100%)andsomeCD15expression(43%)
• Backgroundnecrosisandulceration
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IHCCharacteristicsofEBVMCU
• ProminentrimofT‐lymphocytesattheulcerbaseinallcaseswithabundantCD8positiveT‐cells
• EBVpositivityinboththelargeandsmallcells
CD3 CD8
DiseaseCourseandFollow‐up• Alliatrogenicimmunosuppressedpatientsachievedcomplete
remissionwithreductioninimmunosuppression
• 30%ofagerelatedEBV‐MCUreceivedaggressivetherapy(CT+/‐RT)
• Nodiseaseassociateddeathoveramedianfollow‐upof22months(3‐72months)
• Recommendation:EBVMCUisanewlyrecognizedclinicopathologicentitywithHodgkinlikefeaturesandaselflimitedindolentcourserespondingwelltoconservativemanagement
EBV-Positive Mucocutaneous Ulcer in Organ Transplant Recipients
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CaseSelection
• RetrospectivereviewofallPTLDsurgicalexcisionorbiopsyspecimensfrom12/03to4/13
• IdentifedlocalizedMCUshistologicallycompatiblewithEBVMCU
• Patientswereexcludedifphysicalexamination,imagingstudies(includingCT/PETscans)orstagingbonemarrowbiopsieswerepositiveorsuspiciousforotherlesionsadjacenttoordistantfromtheMCU
Clinicalinformation
• Ageandgender• Typeoftransplant• Medicationsandpresentingsymptoms
• Imagingcharacteristics
• EBVDNAquantificationresults• TreatmentforEBVMCUandoutcome
StudiesPerformed
• Immunohistochemical:CD3,CD20,MUM‐1,BCL2,BCL6,CD15,CD30,CD23andCD10
• EBV‐encodedRNA(EBER)byin‐situhybridization• WholebloodEBVDNAquantification• Pre‐transplantEBVserologicstatusofdonorandpatientincludingIgMandIgGantibodiestoEBVVCAwhenavailable
• IgHandTCRgenerearrangementstudies
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Results
• 7/70(10%)transplantrecipientswithEBV‐positivePTLDhadisolatedEBVMCU
• All7wererecipientsofsolidorgans:5renal,1heart,1lung• NocasesofEBVMCUamongthe14HSCTrecipients
• Patientsrangedfrom18‐70years(median=61);5weremale
• 4/7hadanoralulcer;theother3wereinesophagus,terminalileumandrectum
• Themeandurationofimmunosuppressivetherapypriortosymptomswas0.6‐13years(median=6.3years)
Results
• Diagnosisinthe3mostrecentpatientswasEBVMCU
• 4patientswereoriginallydiagnosedwithmonomorphic(n=3)andpolymorphic(n=1)PTLD–Thediagnosisinthese4caseswaschangedtoEBVMCUonretrospectivereview
• ReedSternberg‐likecellswerepresentin5/7patients
Esophagealulcer(2X) 20X
20X20X
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CD20 CD30
EBER
EBVMCUresemblingmonomorphicPTLD,largecellsubtype
Lipulcer
EBVMCUresemblingmonomorphicPTLD,largecellsubtype
SmallBowelulcerativelesion
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CD20
CD30EBER
CD15
InallcasesthelargeB‐cellswereCD20,CD30andEBERpositive
MUM‐1+(80%) CD23+(28%)
CD3andCD8immunostain
CD3 CD8
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WholeBloodEBVDNAquantification
• NoneofthepatientshadEBVDNAdetectableinblood(<1000copies/mL)atdiagnosisorfollow‐upof16.5months
• ThiscontrastswiththefindingofEBVDNAinbloodspecimensin35of44(80%)solidorgantransplantpatientswithsystemicPTLDreportedfromourinstitutionduringthesameobservationperiod(P<0.001,Fisherexacttest,2‐sided)
EBVserology:Donorandpatient
• Pre‐transplantrecipientanddonorEBVantibodiesresultswereavailableinfourpatients
• ThreeEBVnaivepatientsreceivedorgansfromEBVnaivedonorsandlackedEBVantibodiesatthetimeofdiagnosisofEBVMCU
• OneEBVantibodynegativerecipientreceivedahearttransplantfromanEBVantibodypositivedonorandatthetimeofpresentationwithEBV‐MCUhadseroconvertedwithapositiveEBVVCAIgGantibodybutnegativeVCAIgMresult
Age/Sex
OriginalDiagnosis
EBERISH
EBVserology EBVDNAquantification IgHclonality
BeforeTx(IgM,IgG)
Atulcerpresentation(IgM/IgG)
Atulcerpresentation
Atfollowup
44/M EBVMCU, Positive Unknown ‐/+ Neg Negx4 Clonal
61/M EBVMCU, Positive Unknown NP Neg Negx2 NP
18/M PTLD,polymorphic
Positive Neg ‐/+ Neg Negx5 Equivocal
63/F EBVMCU, Positive Unknown NP Neg NP Polyclonal
70/F PTLD,monomorphiclargeB‐cell
Positive Neg ‐/‐ Neg Neg NP
70/M PTLD,monomorphiclargeB‐cell
Positive Neg ‐/‐ Neg Negx5 Clonal
32/M PTLD,monomorphiclargeB‐cell
Positive Neg ‐/‐ Neg NP Clonal
EBERISH,EBVserology,EBVDNAquantification,andB‐cellclonality
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ClinicalCourse
• Alllesionsresolvedwith– Reductionofimmunosuppression(7/7)
– Changeofimmunosuppressiveagent(2/7)
– Rituximab(3/7)
• Fivepatientsareliving– 4healthy– 1awaitingsecondrenaltransplant
• Twopatientsdied17and60mos.followingresolutionofEBVMCU
• NopatientsrecurredwithEBVMCUorotherPTLD
Age / Sex
Original Diagnosis
Transplant type
Ulcer site Treatment Resolution (wks)
Follow up duration (mo.)
Outcome
44 / M EBV MCU, Kidney Tongue Reduction of IS 2 15 No rec.
61 / M EBV MCU, Kidney Esophagus Reduction of IS 4 16.5 No rec.
18 / M PTLD, polymorphic
Heart Right palatine tonsil and left buccal cavity
Reduction of IS, R x 2 doses
4 14 No rec.
63 / F EBV MCU, Kidney Left mandibular mucosa
Reduction of IS 5 8 No rec.
70 / F PTLD, monomorphic large B-cell
Kidney Rectum Reduction of IS, R x 2 doses, and V started
12 17 Dead, renal failure & sepsis
70 / M PTLD, monomorphic large B-cell
Kidney Lip Reduction of IS Lesion excised
111 Norec.
32 / M PTLD, monomorphic large B-cell
Lungs, bilateral
Terminal ileum
Reduction of IS, R x 4 doses
4 60 Dead, lung infection & sepsis, autopsy performed
Clinicalpresentation&followupofEBVMCUpts
Characteristics AJSP2010;34:405‐417 Presentstudy
Patientcharacteristics Agerelated,iatrogenicIS,PBSCT
Organtransplantrecipients
Inclusionandexclusioncriteria
Similar Similar
Morphology Predominantlypolymorphousinfiltratewith30%originallyreportedasDLBCL
PredominantlypolymorphousinfiltratewithRSlikecellsand42%werereportedasmonomorphiclargeB‐cellPTLD
Immunophenotype CD20+(88.5%),CD30+(100%)CD15+(43%)MUM‐1(100%)
CD20+(100%)CD30+(100%)CD15+(0%)MUM‐1(80%)
BloodEBVDNA Notperformed Negative
ComparisonofEBVMCU
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Characteristics AJSP2010;34:405‐417 Presentstudy
Tcellsatthebaseoflesion(CD8>CD4)
Present Present
IgHclonality 38.9% 42.8%
Treatment Conservativemanagement,30%treatedwithchemotherapy
Conservativetreatment,Rituximabin42%
Follow‐up Completeremissioninallpatientswithf/u22months
Completeremissioninallpatientswithf/u111months
ComparisonofEBVMCU
Discussion
• EBVMCUintransplantrecipientsappearstobeanisolatedmucosalEBV‐drivenlymphoproliferationratherthanaresponsetoageneralizedsystemicinfectionasisusuallyobservedinotherPTLDandimmunodeficiencystates
• EBVMCUmaydevelopinpatientswithsufficientimmuneresponsetocontrolasystemicinfectionbutalevelofimmunedysregulationthatallowsforalocalizedself‐limitedlymphoproliferativedisorderinresponsetoEBVinfection
• ItfollowsthatpatientswithEBVMCUcontaintheirEBVinfectionbecausetheyarelessimmunosuppressed,comparedwithpatientswithotherPTLDs,whichhavemoreEBVDNAsheddingduetoagreaterdegreeofimmunosuppression
Discussion
• EBVMCUappearstobeadistinctiveformofEBV‐drivenPTLDnotassociatedwithincreasedwhole‐bloodEBVDNAandlikelytoresolvewithconservativemanagement
• AwarenessofEBVMCUintheposttransplantsettingandthevalueofEBVwhole‐bloodquantificationstudiesareimportantforappropriatediagnosisandmanagement.
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Conclusions
• EBVMCUshouldbeconsideredinthedifferentialdiagnosisofPTLDpresentingasamucosalulceration
• ClinicopathologiccorrelationandstagingwithmodernimagingareessentialtoexcludesystemicPTLD
• EBVMCUmaymorphologicallymimicamoreaggressivecategoryofPTLD
• DifferentiationisimportantbecausechemotherapyseemstobeexcessivetreatmentforEBVMCU
• EBVMCUmaywarrantconsiderationasadistinctcategoryintheclassificationofPTLD
Acknowledgement
• BeenuThakral,M.D.• MelissaHart,M.D.
• HenryHBalfourJr.,M.D.
• SophiaYohe,M.D.
• CharanjeetSingh,M.D.
• MichaelSpears,M.D.
Thankyou
Questions?
