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\begin{document}

\title{Ataxia-Telangiectasia and Refractory Peripheral T-cell Lymphoma:
Considerations for Therapy and Role of Bone Marrow Transplantation}



\author[1]{Saara Kaviany}%
\author[1]{Carrie Kitko}%
\author[2]{Cesar Rueda}%
\author[2]{Roshini Abraham}%
\author[1]{Debra Friedman}%
\author[1]{Sarah Neumann}%
\author[1]{Becky Manes}%
\author[1]{Sara Zarnegar-Lumley}%
\author[1]{James Connelly}%
\affil[1]{Monroe Carell Junior Children's Hospital at Vanderbilt}%
\affil[2]{Nationwide Children's Hospital}%


\vspace{-1em}



  
  \date{June 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Certain patients with inborn errors of immunity have defects in DNA
damage response, predisposing them to malignancy. Subsequent cancer
therapy may require substantial attenuation given defective DNA repair;
however, this carries risk of incomplete disease control. We describe a
5-year-old boy with peripheral T-Cell lymphoma with
ataxia-telangiectasia (A-T). After incomplete chemotherapeutic response,
he underwent allogenic hematopoietic cell transplantation (allo-HCT)
with an attenuated preparative regimen, but developed graft rejection
and relapse. Following remission with salvage chemotherapy, second
allo-HCT with reduced intensity conditioning (RIC) resulted in minimal
toxicity and short-term disease control. HCT with RIC can be considered
in patients with A-T.%
\end{abstract}%



\sloppy


\emph{Introduction}

Ataxia-telangiectasia (A-T) is an autosomal recessive disorder caused by
pathogenic variants in \emph{ATM} , which is critical for
double-stranded DNA break repair. Bi-allelic variants lead to
progressive cerebellar dysfunction, immunodeficiency, oculocutaneous
telangiectasias, and an increased risk of cancer, specifically
lymphoid\textsuperscript{1}. Peripheral T-Cell Lymphoma-Not Otherwise
Specified (PTCL-NOS), a predominantly nodal mature T-cell lymphoma, is
rare in children\textsuperscript{2}. Treatment in children is not
uniform, but reported outcomes are poor, with a 5-year event free
survival of 59\%\textsuperscript{3}. Hematopoietic cell transplant (HCT)
is considered a viable salvage option, with the majority receiving
allo-HCT.

Treatment planning for patients with inborn errors of immunity (IEI)
with impaired DNA damage response (DDR) has to accommodate this critical
limitation to aggressive approaches. Patients with A-T have demonstrated
worsening ataxia with vinca alkaloids, increased hemorrhagic cystitis
(including late-onset) with alkylators, and declining lung function with
bleomycin\textsuperscript{4--7}. Furthermore, patients with A-T are at
higher infection risk due to their intrinsic
immunodeficiency\textsuperscript{4--7}. HCT is rarely employed in A-T
with limited reports of survival\textsuperscript{8}. Herein, we discuss
a pediatric patient with A-T and PTCL-NOS who underwent a second HCT
following a tailored conditioning regimen and experienced minimal
transplant-related toxicity to provide a framework for transplant
consideration.

\emph{Results}

The patient presented at age five with fevers, diffuse lymphadenopathy,
and no prior diagnosis of A-T. An excisional lymph node biopsy revealed
CD30\textsuperscript{\textbf{neg}} PTCL-NOS, and bone marrow (BM)
involvement classified him with Stage IV disease\textsuperscript{9}. He
was treated with dose adjusted-EPOCH (etoposide, prednisone,
vincristine, cyclophosphamide, doxorubicin\textsuperscript{10}).
Interim-restaging demonstrated clinical and radiographic remission, with
no morphologic evidence of lymphoma in BM; however, molecular residual
disease was detected by polymerase chain reaction of rearrangement of
T-cell receptor (TCR) gamma chain leading to HCT evaluation.

In early childhood the patient developed lower extremity weakness
prompting a neurology evaluation, including a non-informative brain
magnetic resonance imaging (MRI). Increased drooling, decreased grip,
and wobbly gait out of proportion to expected toxicities, and diagnosis
of a rare lymphoma at a young age led to evaluation for predisposing
conditions. Targeted genetic sequencing revealed compound heterozygous
variants \emph{in trans:} (1) a pathogenic variant
(c.2921+1G\textgreater{}A) and (2) a variant of uncertain significance
(VUS) (c.8041G\textgreater{}A; p.V2681M) in \emph{ATM} . To establish
the functional significance of the variants, a flow cytometric assay
assessing DNA repair defects demonstrated completely absent ATM
phosphorylation along with decreased gamma-H2AX (Figs. 1A and 1B), one
hour after induction of DNA double-strand breaks, which is typically
when maximal phosphorylation is expected\textsuperscript{11--13}. This
result revealed a functional defect in the ATM protein, indicating that
the VUS is pathogenic. A Western immunoblot revealed absent ATM protein
(not shown). These results confirmed a diagnosis of A-T, and further
dose-escalation of EPOCH was halted.

Consideration of myeloablative autologous transplant was abandoned for a
minimally-intensive allo-HCT. The patient received a matched unrelated
donor HCT (MUD-HCT) following ``Fanconi-style'' preparative regimen of
anti-thymocyte globulin (ATG), fludarabine and very low dose busulfan
(estimated cumulative area under the curve (AUC) exposure: 1.9 mg*h/L).
Unfortunately, the patient had primary graft failure with autologous
reconstitution. ~His BM evaluation at day +100 was negative for residual
disease by morphology; however, TCR-gamma chain rearrangement was
detectable. On day +147 he presented with lymphadenopathy and
biopsy-proven recurrence. In conjunction with family preference, we
pursued a curative approach based on the anaplastic large cell lymphoma
(ALCL)-99 backbone\textsuperscript{14} (methotrexate, ifosfamide,
cytarabine, etoposide, dexamethasone, doxorubicin). Enhanced supportive
care measures included mesna and hydration with alkylators, and
methylene blue with ifosfamide to mitigate mucosal and neurologic
toxicities, respectively. No dose reductions were made given previous
tolerance and the refractory nature of his disease. Following two
cycles, disease evaluation demonstrated clinical, radiographic and
molecular remission.

Our patient received a MUD-HCT from a different donor with reduced
intensity fludarabine and busulfan (estimated cumulative AUC: 57.3
mg*h/L). He had minimal toxicity including grade II mucositis,
neutrophil engraftment on day +13 and discharge home on day +18. His day
+30 marrow demonstrated 100\% donor myeloid engraftment with no residual
lymphoma but persistent recipient T-cells (38\% donor). The patient had
no graft-vs-host disease (GvHD) and tacrolimus taper was initiated at
day +58. He had improving peripheral blood T-cell chimerism on day +86
(100\% donor myeloid cells, 60\% donor T-cells.) He developed no
post-engraftment adverse events until day +94 when he presented with
headache and diplopia, revealing lymphomatous involvement of his left
optic nerve and cerebral spinal fluid consistent with PTCL-NOS relapse.
He was also noted to have Epstein-Barr virus (EBV) viremia (41,200
copies/mL), presumed to be primary EBV as he had no documentation of
prior infection. The family chose symptomatic management with
dexamethasone and hospice enrollment for end-of-life care.

\emph{Discussion}

Patients with A-T have a lifetime cancer incidence of
10-20\%\textsuperscript{15}. Dose reduction of chemotherapy may be
considered, based on the premise that cancer cells may have increased
susceptibility due to germline defects in DNA
repair\textsuperscript{16}. The role of HCT is not well established. HCT
in pediatric cancer typically employs myeloablative dosing of
DNA-damaging chemotherapy to reduce disease burden and permit
engraftment which can cause severe toxicity and higher grade
GvHD\textsuperscript{17} in patients with A-T. It remains unclear if
hematopoietic cells in A-T have increased sensitivity to conditioning
agents.

In patients with A-T, minimal intensity ``Fanconi-based'' conditioning
has been the most accepted\textsuperscript{8}. Slack et. al reported
survival without GvHD in only two of eight patients with A-T following
HCT after modified ``Fanconi conditioning'' without GvHD. Of the 6
patients who died, 67\% experienced grade 2-4 GvHD despite well-matched
donors and myeloablative conditioning in 5. Mortality causes included
GvHD, multi-organ failure, viral re-activation or post-transplant
lymphoproliferative disorder (PTLD). The underlying defective repair
mechanisms may predispose to GvHD, as demonstrated in patients with
Fanconi anemia and dyskeratosis congenita\textsuperscript{18}.

Mixed chimerism seen in modified German Fanconi protocols, allowed for
autologous hematopoietic cells to coexist with allogeneic
hematopoiesis\textsuperscript{19}. Remaining recipient A-T hematopoietic
cells with prior exposure to conditioning agents have reduced capacity
to correct genotoxic stress, and thus higher theoretical risk of
secondary malignancies.

The rate of PTLD appears higher in post-HCT patients with
A-T\textsuperscript{14} and may be due to the role of ATM in the EBV
life cycle. In the EBV lytic cycle, ATM~recruits~DDR proteins to viral
double-stranded linear DNA to promote viral
replication\textsuperscript{18}.~ Less is known about ATM in latency,
but ATM limits early hyperproliferation of infected B-cells~\emph{in
vitro,} ~which may inhibit expression of viral oncogenes and
promote~the~EBV latency~program~away~from lymphoma and PTLD. Loss of ATM
function may therefore directly contribute to a higher incidence of
EBV-driven lymphoma and PTLD in patients with A-T. As our patient did
not have complete lymphoid replacement, EBV reactivation may have been
driven by recipient B-cell infection and impaired regulation of B-cell
hyperproliferation. Full donor lymphoid engraftment may prevent
post-transplant viral reactivation in recipient cells reducing
mortality.

We propose that RIC be preferred when balancing risk of graft failure,
disease relapse and risks imposed by residual recipient chimerism
including secondary myeloid malignancy, recipient-derived PTLD, and
defects in immune reconstitution. While our patient ultimately had
disease relapse and EBV infection, we wish to highlight the challenges
in treating aggressive disease in this cohort and suggest consideration
of alternative therapeutic strategies to potentially improve outcomes.

\emph{Conflict of Interest Statement:}

There are no affiliations that are relevant and important with any
organization that to any author's knowledge has a direct interest,
particularly a financial interest, in the subject matter discussed.

\emph{Acknowledgements}

Research reported in this publication was supported by the Department of
Health and Human Services National Institutes of Health National Cancer
Institute under award number~5K12 CA090625-21. The assessment of the DNA
repair defect was supported by the Department of Pathology and
Laboratory Medicine, Nationwide Children's Hospital, Columbus.

We also acknowledge Laura Hall PharmD and Sarah Timaeus PharmD for their
input on therapeutic and supportive care regimens.

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\emph{Figure Legend:}

\textbf{Figure 1A and 1B.} ~ Flow cytometric analysis of the DNA damage
response (DDR) in A-T. Peripheral blood mononuclear cells (PBMCs) from a
healthy control and the patient were rested overnight and then either
subjected to low-dose irradiation (2Gy, IR) or were not irradiated
(unirradiated control, non-IR), and the phosphorylation of ATM (pATM)
and the histone, H2AX (gH2AX) was assessed in T, B and NK cells at 1h
(top panel) and 24h (bottom panel) post-irradiation with appropriate
unirradiated controls for each time point. In contrast to the healthy
control, the patient T, B and NK cells do not demonstrate pATM at 1h or
24h post-irradiation. Since H2AX is phosphorylated by several kinases,
including ATM, there is some level of residual~gH2AX detected (median
fluorescence intensity --MFI- ratio of irradiated to unirradiated) in
the patient lymphocyte subsets, though it is lower than the healthy
control, especially for T and NK cells at 1h post-irradiation, and more
importantly, the MFI ratio does not show the normal kinetics of
dephosphorylation at 24h post-irradiation, like the healthy control. The
frequency (\%) of T, B and NK cells expressed as a delta value
(irradiated -- unirradiated) at 1h post-irradiation is decreased
for~gH2AX in T cells, and NK cells compared to the control, but not in B
cells.\selectlanguage{english}
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