Successful treatment of EBV-associated posttransplantation lymphoma after cord blood transplantation using third-party EBV-specific cytotoxic T lymphocytes

Abstract

Cellular therapy of Epstein-Barr virus (EBV)(+) posttransplantation lymphoproliferative diseases (PTLD) in cord blood transplant (CBT) recipients is limited by lack of donor access and the donor's naive neonatal immune system. We therefore used partially human leukocyte antigen-matched third-party in vitro expanded EBV-specific cytotoxic T lymphocytes (CTLs) to treat 2 CBT recipients with life-threatening, donor-derived monoclonal EBV(+) diffuse large B-cell lymphomas with extranodal involvement developing in the context of graft-versus-host disease. Both patients had failed immunosuppression taper and Rituximab. After 5 and 9 infusions of 10(6) EBV-CTL/kg, respectively, each patient achieved a sustained complete remission without toxicity or graft-versus-host disease. Each is alive without recurrence at 20 and 15 months, respectively, post-EBV-PTLD diagnosis. This approach demonstrates the efficacy of using "off-the-shelf," virus-specific third-party CTLs restricted by human leukocyte antigens expressed by the tumor to treat otherwise lethal EBV-PTLD. Such therapy may also be applicable to the treatment of other infections and residual or recurrent malignancy after CBT.

Figure 1

EBV-CTL administration timeline, EBV-specific CTL precursor (CTLp) blood levels, and the EBV-qPCR and FDG-PET disease course. (A) Patient #1. Top panel: T cells generated from the third-party donor were restricted by the B*0801 and C*0701 HLA-alleles presented on the EBV⁺ tumor of the patient and were EBV-specific. The HLA-typing of the engrafting unit is shown. The HLA-typing of the other unit was A*0101, A*0101; B*0801, B*2705; C*0701, C*0102; DRB1*0101, DRB1*0404; DQ*0501, DQ*0302. However, this unit did not engraft. Middle panel: EBV DNA increased on day 253 after CBT (red line) and partially responded to 10 doses of Rituximab. EBV viremia resolved completely after EBV-specific T-cell administration with partial clinical remission after 3 infusions and complete remission after 5 infusions. Peripheral blood EBV-specific CTLp measured by limiting dilution analysis (LDA) rose after each administration indicating transient in vivo expansion (green line) with subsequent decrease in frequencies after 10 days. Bottom panel: PET images demonstrating extensive abdominal and cervical lesions, persistence of abdominal and lesions as well as pulmonary lesions, marked resolution in abdominal lesions at 24 days, near resolution of abdominal and pulmonary lesions at 107 days, and complete remission 176 days after CTL initiation. (B) Patient #2. Top panel: The cytotoxic EBV-specific CTL activity was restricted by the HLA-B*3501 and DRB1*13 HLA-antigens shared with the CB donor. Middle panel: Increased EBV DNA was first detected in the blood 244 days after CBT (red line). This resolved after 7 doses of Rituximab. However, because of relapsed lymphoma in the intestine the patient received EBV-CTLs on day 347. LDA demonstrated 4-fold increase in EBV-CTLp frequency (green line) by day 7 that remained high until 18 days after the first CTL dose. The second course of 3 infusions resulted in a 10-fold increase of EBV-CTLp for another 30 days. T cells binding an HLA-B35-EBNA3A tetramer (purple line), which were the major class I restricted T cells in the T-cell adoptive therapy, were not detectable before CTL infusion, but increased 4-5 logs by 16 days after CTL initiation. Bottom panel: Extensive abdominal and cervical lymphoma 244 days after CBT largely resolved after the 8 doses of Rituximab (day +305). However, abdominal disease recurred that was successfully treated with EBV-CTLs that induced partial remission by 56 days and complete remission by 106 days after CTL initiation.