Blood cancers

Blood cancer patients at risk from CMV beyond HCT setting

Clinicians are advised to be vigilant following Australian research showing that cytomegalovirus (CMV) infection or disease is common in patients with haematological malignancies outside the haematopoietic cell transplant setting.

A retrospective review of patients with haematological and solid organ cancers at the Peter MacCallum Cancer Centre between 2013 and 2020 found 25% of 953 patients who had CMV PCR testing returned positive tests.

After excluding allogeneic HCT patients, the study identified 62 patients with CMV DNAemia or disease.

Most patients (81%) had a haematological cancer including B-cell lymphoproliferative disease (31%), T cell lymphoproliferative disease (21%), chronic lymphocytic leukaemia (11%), and multiple myeloma (10%).

“CMV DNAemia and/or disease was detected in patients receiving conventional chemotherapy, fludarabine-containing chemotherapy, autologous transplantation, idelalisib, bispecific T-cell engager (BiTE) antibody therapy, CAR T-cell therapy, brentuximab vedotin, and monoclonal antibody therapy such as rituximab, obinutuzumab, and alemtuzumab,” the study said.

The study, published in the Internal Medicine Journal, said alemtuzumab therapy was associated with an overall 48% cumulative incidence of CMV.

“This was higher than the cumulative incidence among patients taking idelalisib (15.4%), CAR T-cell therapy (6.5%), brentuximab vedotin (4%), BiTE therapy (3.8%), and fludarabine- containing therapy (2.9%).”

The investigators noted that recognition of CMV infection following alemtuzumab and idelalisib has led to clinical guidelines for prospective monitoring of CMV DNA during treatment.

“Apart from these therapies with known CMV risk, the magnitude of risk for CMV infection among other novel therapies is still largely undetermined and thus needs to be further evaluated.”

The study found co-infections were common within one month of CMV diagnosis and included bacterial (45%), viral (21%), and fungal disease (18%).

Invasive fungal disease occurred in heavily pretreated patients with a median of three previous treatment. All cases had received steroid therapy; all were lymphopenic at the time of IFD diagnosis and 78% died within 3 months of CMV diagnosis.

Overall, no deaths were directly attributed to CMV infection.

The study said anti-CMV therapies were mostly valganciclovir (83%) or ganciclovir (17%).

“Anti-CMV therapy could be considered when the patient becomes symptomatic, having high CMV viral load or rising trends of viral load.”

The study concluded that haematological malignancy with lymphopenia, multiple cancer therapies, co-infection and treatment with high doses of systemic corticosteroids potentially posed an increased risk for CMV DNAemia and disease.

“Presence of these features should prompt testing for CMV.”

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