Multifocal aggressive lymphoma of the gastrointestinal tract in a renal transplant patient treated with cyclosporin A and prednisone

Role of fine-needle aspiration in the clinical management of solid organ transplant recipients: a review

BACKGROUND

We evaluated the clinical course of the solid-organ transplant population at our institutions to determine the role of fine-needle aspiration (FNA) in the clinical management of this subgroup of patients.

METHODS

1196 allograft recipients (522 liver, 288 cardiac, 250 renal, 131 lung, 5 heart and lung) were reviewed. A total of 62 (5.2%) (32 liver, 23 heart, 6 lung, and 1 renal) transplant patients underwent an FNA procedure. Thirty-seven males and 25 females were included, ranging in age from 18 to 71 years (mean 50 years).

RESULTS

Of the 62 fine-needle aspirates, 29 (47%) were neoplastic. The most common malignancies aspirated were malignant solid tumors (15 cases)-including 8 epithelial malignancies, 5 hepatocellular carcinomas, and 2 mesenchymal neoplasms-followed by posttransplant lymphoproliferative disorders (14 cases). Thirteen (21%) aspirates were inflammatory. The remaining 20 (32%) cases were benign aspirates from various sites (9 liver, 3 breast, 2 thyroid, 2 soft tissue, 2 lung, and 2 vertebral body). Surgical and/or autopsy material was available in 34 cases (55%). There was agreement between the tissue diagnosis and FNA material in 33 cases (97%). One case (3%) was a false negative. No false-positive cases were recorded.

CONCLUSIONS

This study showed that over 50% of the aspirates were benign, justifying a conservative approach in the clinical management of these patients. Histologic correlation was available in 54% of the cases with an overall specificity of 100% and a sensitivity of 97%. We conclude that FNA is a highly sensitive and specific technique in the evaluation of lesions occurring in posttransplant patients. Cancer (Cancer Cytopathol)

Role of fine-needle aspiration in clinical management of transplant patients

Fine-needle aspiration (FNA) of superficial and deep seated lesions has been used with high sensitivity and specificity in the diagnosis of neoplastic and non-neoplastic entities. However, studies of FNA in post-transplant patients are virtually absent. Six hundred and seventy-four allograft recipients (cardiac 288, renal 250, lung 131 and heart-lung 5) were reviewed. A total of 30 (25 heart, 4 lungs and 1 renal transplant) patients underwent an FNA procedure. There were 26 males and 4 females. Ages ranged from 18-63 yr (mean 48 yr). The most common entity aspirated was post-transplant lymphoproliferative disorder (PTLD) in 12 cases, followed by inflammatory lesions in 10 cases, malignant epithelial neoplasms in 3 cases, and 1 case each of malignant mesenchymal tumor, pulmonary infarction, hamartoma of liver, fatty changes of liver, and a benign vascular lesion. Surgical or autopsy tissue was available in 19 cases (63.3%). There was an agreement between tissue diagnosis and FNA material in 18 cases (94.7%). One (5.2%) false negative case was recorded. This was a liver aspirate showing benign liver elements, which a surgical biopsy proved to be a bile duct hamartoma. No false positive cases were recorded. FNA is a highly sensitive and specific diagnostic tool in the management of post-transplant patients.

Posttransplant lymphoproliferative disorders: a fine-needle aspiration biopsy study

Fine-needle aspiration biopsy (FNAB) has been used with high sensitivity and specificity in the diagnosis of both Hodgkin's and non-Hodgkin's lymphoma. However, studies of FNAB of posttransplant lymphoproliferative disorders (PTLDs) are rare. The clinical course of 593 allograft recipients (cardiac, 288; renal, 250; lung, 50; and heart/lung, 5) was reviewed. Twenty-six patients developed PTLD with an overall incidence of 4.4%. Of these patients, 12 underwent FNAB. Their age ranged from 33-67 yr (mean, 55 yr). The interval between transplantation and FNAB ranged between 2-14 mo (average, 8.4 mo). The lungs were the most common site aspirated (7 cases), followed by lymph nodes (3 cases) and other extranodal sites (2 cases, liver and paraspinal mass). The cytologic features of these aspirates could be classified into two categories: a polymorphous smear composed of a spectrum of mature and immature lymphocytes with scattered plasma cells and histiocytes; and a monotonous population of large lymphoid cells consistent with malignant lymphoma, large-cell type. Surgical biopsies were available in 10 (83.3%) cases and confirmed the FNAB diagnosis. In summary, FNAB appears to be a highly sensitive and specific diagnostic tool in patients with PTLD.

Oral presentation of posttransplantation lymphoproliferative disorders. An unusual manifestation

Cyclosporine, an immunosuppressive agent widely used in organ transplantation, has several undesirable side effects, including gingival hyperplasia, which occurs in up to 70% of patients. Another complication associated with use of cyclosporine and other immunosuppressants is an increased incidence of malignancies. Long-term use of cyclosporine also is associated with a spectrum of hyperproliferative disorders ranging from reactive lymphoid hyperplasia to aggressive malignant lymphomas. While cyclosporine-related lymphoproliferative disorders have been widely reported, they have not been described in the oral cavity as the first manifestation of this disease. We report on two cardiac transplantation patients with a history of cyclosporine use who presented initially with oral symptoms of lymphoproliferative disorder. Both had erythematous to cyanotic and hyperplastic gingiva. On gingivectomy, the fixed tissue was soft, glistening, and tan colored, in contrast to the usual firm, white, cyclosporine-associated, benign gingival fibrous hyperplasia. Histologically, a dense, diffuse infiltrate of lymphoplasmacytoid cells with vesicular nuclei, prominent nucleoli, a moderate amount of cytoplasm, and high mitotic activity was observed. Immunocytochemical studies confirmed that the cells were monoclonal for lambda light chains in one patient and kappa light chains in the other. The cells from one patient were positive for CD45, while both patients were negative for CD20 and all nonhematopoietic antigens tested. Both tissues were strongly positive for Epstein-Barr virus. Morphology and immunocytochemistry findings are consistent with a posttransplant lymphoproliferative disorder. These are the first two reported cases of cyclosporine-associated posttransplant lymphoproliferative disorders presenting as gingival hyperplasia.

Primary extramedullary plasmacytoma in cyclosporine-induced gingival overgrowth. A case report

An unusual solitary extramedullary plasmacytoma developed in the gingiva of a 28 year-old male renal transplant patient with cyclosporine (CyA)-induced gingival overgrowth. On initial presentation, there was no suspicion of a tumor within the lesion. One year later, however, the lesion had increased progressively in size, and its surface was ulcerated. At this time, the lesion was excised by gingivectomy, and histopathological examination revealed plasmacytoma. CyA was discontinued and the patient has been closely observed for 4 years with no recurrence of the gingival lesion.

High-grade T-cell lymphoma following treatment with cyclosporin A

A 47-year-old man with persistent severe oropharyngeal ulceration developed a high-grade T-cell lymphoma soon after commencing treatment with cyclosporin A. Using Southern blotting to identify T-cell beta-chain gene rearrangements, evidence of clonal restriction was found both in blood and lymph node DNA samples. Two BamH1 rearranged bands were demonstrated in both samples. In the blood a 16 Kb band predominated, with a weaker 28 kb band. In the lymph node sample this pattern was reversed. The findings suggest that a bi-clonal population of T-lymphocytes or clonal evolution of an existing T-cell monoclone had developed, and that cyclosporin contributed to the emergence of a high-grade T-cell lymphoma.

Malignant lymphoma in a renal transplant patient on cyclosporin A therapy

Cyclosporin A has been associated with an apparent increased incidence of non Hodgkins lymphoma, most often in conjunction with multiple immunosuppressive agents. We report a patient who developed a non Hodgkins lymphoma arising in the right tonsillar fossa six months following renal transplantation. The development of the lymphoma was associated with seroconversion for the Epstein Barr capsid antigen and nuclear antigen. The patient was receiving cyclosporin A alone as immunosuppression.

HTLV-I-associated lymphoma involving the entire alimentary tract and presenting with an acquired immune deficiency

A patient with HTLV-I-associated adult T cell lymphoma presented like a patient with the acquired immune deficiency syndrome (AIDS) with peripheral lymphadenopathy, profuse diarrhea, weight loss, night sweats, and multiple opportunistic infections. Infections included cytomegalovirus, Pneumocystis, Histoplasma, Strongyloides, Giardia, and Staphylococcus aureus. Histoplasma has not previously been associated with this lymphoma. The lymphoma involved the entire alimentary tract from pharynx to rectum, which has not previously been reported for adult T cell lymphoma, and is rare for any lymphoma, with only one case reported in this century. Despite extensive gastrointestinal involvement, steatorrhea was not present, perhaps due to preservation of normal intestinal villous architecture.

Cyclosporin A does not inhibit epidermal cell growth at therapeutic levels

The direct effect of cyclosporin A on epidermal cells was examined by using a pig skin explant culture system. A dose-response study using cyclosporin concentration from one-tenth the expected serum level to 100 times the expected serum level was done, and epidermal outgrowth and the number of mitotic figures were measured. Cyclosporin inhibited epidermal cell outgrowth at concentrations of 60 and 100 times the expected serum level, but it did not inhibit epidermal cell outgrowth at the serum level or even at 30 times the serum level. Cyclosporin did not inhibit mitotic figures significantly. These results suggest that cyclosporin does not inhibit epidermal cells directly.