1
|
Law SC, Hoang T, O'Rourke K, Tobin JWD, Gunawardana J, Loo-Oey D, Bednarska K, Merida de Long L, Sabdia MB, Hapgood G, Blyth E, Clancy L, Hennig S, Keane C, Gandhi MK. Successful treatment of Epstein-Barr virus-associated primary central nervous system lymphoma due to post-transplantation lymphoproliferative disorder, with ibrutinib and third-party Epstein-Barr virus-specific T cells. Am J Transplant 2021; 21:3465-3471. [PMID: 33942495 DOI: 10.1111/ajt.16628] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/30/2021] [Accepted: 04/23/2021] [Indexed: 01/25/2023]
Abstract
Primary central nervous system lymphoma (PCNSL) occurring following organ transplantation (post-transplantation lymphoproliferative disorder [PTLD]) is a highly aggressive non-Hodgkin lymphoma. It is typically treated with high-dose methotrexate-based regimens. Outcomes are dismal and clinical trials are lacking. It is almost always Epstein-Barr virus (EBV) associated. Two patients (CA1-2) presented with EBV-associated PCNSL after renal transplant. CA1 was on hemodialysis and had prior disseminated cryptococcus and pseudomonas bronchiectasis, precluding treatment with methotrexate. CA2 was refractory to methotrexate. Both were treated off-label with the first-generation Bruton's tyrosine kinase inhibitor ibrutinib for 12 months. Cerebrospinal fluid penetration at therapeutic levels was confirmed in CA1 despite hemodialysis. Both patients entered remission by 2 months. Sequencing confirmed absence of genetic aberrations in human leukocyte antigen (HLA) class I/II and antigen-presentation/processing genes, indicating retention of the ability to present EBV-antigens. Between Weeks 10 and 13, they received third-party EBV-specific T cells for consolidation with no adverse effects. They remain in remission ≥34 months since therapy began. The strength of these findings led to an ongoing phase I study (ACTRN12618001541291).
Collapse
Affiliation(s)
- Soi C Law
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Thanh Hoang
- Diamantina Institute, The University of Queensland, Brisbane, QLD, Australia.,Hue University of Medicine and Pharmacy, Hue, Vietnam
| | - Kacey O'Rourke
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Joshua W D Tobin
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Jay Gunawardana
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Dorothy Loo-Oey
- Proteomics Core Facility, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Karolina Bednarska
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Lilia Merida de Long
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Muhammed B Sabdia
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Greg Hapgood
- Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Emily Blyth
- Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Leighton Clancy
- Cellular Therapies, NSW Government Health Pathology, Westmead, NSW, Australia
| | - Stefanie Hennig
- Certara Inc., Princeton, New Jersey.,School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.,Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Colm Keane
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia.,Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Maher K Gandhi
- Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia.,Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| |
Collapse
|
2
|
Ehx G, Ritacco C, Hannon M, Dubois S, Delens L, Willems E, Servais S, Drion P, Beguin Y, Baron F. Comprehensive analysis of the immunomodulatory effects of rapamycin on human T cells in graft-versus-host disease prophylaxis. Am J Transplant 2021; 21:2662-2674. [PMID: 33512760 DOI: 10.1111/ajt.16505] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease (GVHD) is a major cause of toxicity after allogeneic hematopoietic cell transplantation (allo-HCT). While rapamycin (RAPA) is commonly used in GVHD prophylaxis in combination with a calcineurin inhibitor (CNI), the understanding of its mechanism of action on human T cells is still incomplete. Here, we performed an extensive analysis of RAPA effects on human T cells in a humanized mouse model of GVHD, in ex-vivo T cell cultures and in patients given RAPA plus tacrolimus as GVHD prophylaxis after nonmyeloablative allo-HCT. We demonstrate that RAPA mitigates GVHD by decreasing T cell engraftment and differentiation, inhibiting CD8+ T cell activation and increasing the long-term IL-2 secretion, thereby supporting regulatory T cell (Treg) proliferation. In contrast, graft-versus-leukemia effects were not abrogated, as RAPA-treated T cells had increased resistance to apoptosis and retained their effector function and proliferative capacity upon re-stimulation. Importantly, we found that RAPA impact on Treg and CD8+ T cells was closely dependent upon IL-2 signaling and that therapeutic options interfering with IL-2, such as calcineurin inhibitors, antagonize the IL-2-dependent promotion of Treg mediated by RAPA. Our results suggest that RAPA immunological efficacy could be improved in combination with drugs having possible synergistic effects such as the hypomethylating agent 5-azacytidine.
Collapse
Affiliation(s)
- Grégory Ehx
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Caroline Ritacco
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Muriel Hannon
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Sophie Dubois
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Loic Delens
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Evelyne Willems
- Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Sophie Servais
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Pierre Drion
- Experimental Surgery, GIGA-R & Credec, University of Liège, Liège, Belgium
| | - Yves Beguin
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Frédéric Baron
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| |
Collapse
|
3
|
Krishnamoorthy S, Ghobadi A, Santos RD, Schilling JD, Malone AF, Murad H, Bartlett NL, Alhamad T. CAR-T therapy in solid organ transplant recipients with treatment refractory posttransplant lymphoproliferative disorder. Am J Transplant 2021; 21:809-814. [PMID: 33089906 DOI: 10.1111/ajt.16367] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 01/25/2023]
Abstract
Chimeric antigen receptor T cells (CAR-T) are genetically modified T cells with a chimeric antigen receptor directed against a specific tumor-associated antigen like CD19 in lymphoma. CAR-T cells have shown encouraging activity against recurrent and refractory diffuse large B cell lymphomas (DLBCL). However concurrent use of immunosuppressive agents was prohibited in most CAR-T trials effectively excluding patients with prior solid organ transplantation (SOT) and posttransplant lymphoproliferative disorders (PTLD). We report the outcomes for three patients with PTLD refractory to immunochemotherapy 10-20 years after SOT who received CAR-T therapy between January 2018 and December 2019. One patient had an orthotopic heart transplant, the second had a deceased donor kidney transplant, and the third had a pancreas after kidney transplant (PAK). All patients developed complications of CAR-T therapy such as cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and acute kidney injury requiring renal replacement therapy in the two out of three patients. All patients expired after withdrawal of care due to lack of response to CAR-T therapy. In addition, the PAK patient developed acute pancreatitis after CAR-T therapy. This case series identifies the challenges of using CAR-T therapy to manage refractory PTLD in SOT recipients and its possible complications.
Collapse
Affiliation(s)
- Sambhavi Krishnamoorthy
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Armin Ghobadi
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Rowena D Santos
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Joel D Schilling
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew F Malone
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Haris Murad
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Nancy L Bartlett
- Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Tarek Alhamad
- Division of Nephrology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.,Transplant Epidemiology Research Collaboration (TERC), Institute of Public Health, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|