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A Pilot Study of Chemoimmunotherapy (Cyclophosphamide, Prednisone, and Rituximab) in Patients with Post-Transplant Lymphoproliferative Disorder following Solid Organ Transplantation¹

Departments of Pediatrics [M. O., E. M., M. S. C.], Biostatistics [Y-K. C.], and Pathology [B. A.], Columbia University, New York, New York 10032, and Department of Pediatrics, Ohio State University, Columbus, Ohio 43205 [T. G. G.]

Purpose: We have previously demonstrated a >80% complete response (CR) rate with cyclophosphamide/prednisone (Cy/Pred) chemotherapy alone in patients with post-transplant lymphoproliferative disease (PTLD) after solid organ transplantation (SOT), but only a 58% 2-year event-free survival. The response rate to immunotherapy (rituximab) is only about 46% with a 54% relapse/progression rate. In this study, we investigated the use of a combination of Cy/Pred with rituximab as treatment for this disease.

Experimental Design: Patients received two to six courses of cyclophosphamide (600 mg/m², on day 1 of each course) and prednisone (1 mg/kg, every 12 h x 10 doses), given every 3 weeks. The first two courses were given in combination with 4–6 weekly doses of rituximab (375 mg/m², i.v.). Imaging studies were done every 2 months to document response.

Results: There were six PTLD patients (two fulminant); age, 4–23 year; sex, male:female (3:3); status post SOT (two cardiac, two liver, two renal); median onset, 39 months (10–144 months). Fifty percent were polyclonal, 100% were CD20+, and 83% were EBV+. The overall response rate was 100% (five CRs and one PR). All five CRs showed no evidence of disease, and one PR eventually progressed and died of fulminant disease. All allografts in surviving patients were functional. There was no grade III/IV toxicity and/or no infectious complications related to the combination of Cy/Pred with rituximab. Median follow-up was 12.5 months (range, 4–29 months).

Conclusions: These preliminary results suggest that the combination of Cy/Pred and targeted immunotherapy (rituximab) is well tolerated and may be more efficacious in patients with PTLD after SOT. Future prospective larger trials with longer follow-up investigating this combination will be required to confirm these preliminary results.

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