Tonsil enlargement after liver transplantation in adults--reason enough for tonsillectomy? Two cases of tonsillar posttransplantation lymphoproliferative disease

Posttransplant Lymphoproliferative Disorder: Otolaryngological Manifestations and Management

Objective

Posttransplant lymphoproliferative disorder (PTLD) is a unifying term for a spectrum of lymphoid expansion entities brought about by immunosuppression and is strongly associated with Epstein-Barr virus (EBV). Otolaryngological findings tend to present early in the clinical course; therefore, disease awareness among otolaryngologists is of utmost importance. This review synthesizes the body of literature pertaining to PTLD involving the head and neck, summarizes contemporary management, and highlights areas for future research.

Data Sources

PubMed/Medline.

Review Methods

Primary literature search of the Medline database was performed for all titles published in the past 10 years pertaining to PTLD. The database search included PTLD combined with a collection of otolaryngological MeSH terms. Full manuscripts were reviewed based on relevance of their title and abstract. Selection into this review was according to clinical and scientific relevance.

Conclusion

Adenotonsillar focus is common in children in whom adenotonsillectomy may be diagnostic and prevents potentially morbid airway obstruction. Sinonasal PTLD may mimic fungal infection. Laryngotracheal involvement predominately presents in children with symptoms of airway obstruction. PTLD limited to the esophagus is rare. Oral PTLD is rare and phenotypically varied. Cutaneous presentation of PTLD is infrequent, yet one-third of cases affects the head and neck. PTLD may present as cervical lymphadenopathy.

Implications for Practice

PTLD consideration is vital when evaluating posttransplant patients. Children and EBV-seronegative patients should receive otolaryngological follow-up after transplant. PTLD treatment is multidisciplinary and typically led by lymphoma specialists. Formal partnerships between otolaryngologists and transplant centers may improve patient care and research quality.

The Importance and Place of Adenotonsillectomy in Syndromic Children

Objective

Upper airway obstruction and sleeping disorders are important issues in syndromic children, including mouth, lower-upper jaw, or all facial abnormalities. Tonsillectomy and/or adenoidectomy is required because of systemic problems and upper airway obstruction that increase the existing systemic problems, except those anomalies. However, tonsillectomy and/or adenoidectomy are mostly avoided because of the tendency to cause both intubation/perioperative systemic problems and respiratory complications in the postoperative period and in delays in the oral intake. However, these surgeries are sometimes required. In this context, we present our experience related with performing tonsillectomy and/or adenoidectomy in syndromic children admitted to our hospital.

Methods

We retrospectively examined the data on tonsillectomy and/or adenoidectomy performed in syndromic patients in our clinic between 2001 and 2011.

Results

We did not observe any postoperative complications in adenoidectomy and/or tonsillectomy performed by the same surgeon in 14 syndromic cases.

Conclusion

It should be noted that respiratory problems may arise from many different anatomical regions in syndromic patients. Therefore, surgery should be performed taking into consideration all of these factors in these patients. These patients must be hospitalized in the postoperative period.

Reduction of immunosuppression as initial therapy for posttransplantation lymphoproliferative disorder(★)

Reduction of immunosuppression (RI) is commonly used to treat posttransplant lymphoproliferative disorder (PTLD) in solid organ transplant recipients. We investigated the efficacy, safety and predictors of response to RI in adult patients with PTLD. Sixty-seven patients were managed with RI alone and 30 patients were treated with surgical excision followed by adjuvant RI. The response rate to RI alone was 45% (complete response-37%, partial response-8%). The relapse rate in complete responders was 17%. Adjuvant RI resulted in a 27% relapse rate. The acute rejection rate following RI-containing strategies was 32% and a second transplant was feasible without relapse of PTLD. The median survival was 44 months in patients treated with RI alone and 9.5 months in patients who remained on full immunosuppression (p = 0.07). Bulky disease, advanced stage and older age predicted lack of response to RI. Survival analysis demonstrated predictors of poor outcome-age, dyspnea, B symptoms, LDH level, hepatitis C, bone marrow and liver involvement. Patients with none or one of these factors had a 3-year overall survival of 100% and 79%, respectively. These findings support the use of RI alone in low-risk PTLD and suggest factors that predict response and survival.

Post-transplant lymphoproliferative disorder in view of the new WHO classification: a more rational approach to a protean disease?

Post-transplant lymphoproliferative disorders (PTLDs) are serious, life-threatening complications of solid-organ transplantation (SOT) and bone marrow transplantation leading to a high mortality (30-60%). PTLD represents a heterogeneous group of lymphoproliferative diseases. They become clinically relevant because of the expansion of transplantation medicine together with the development of potent immunosuppressive drugs. Although the diagnostic morphological criteria of different forms of PTLD are commonly known, rapid and correct diagnosis is not always easy. Because of the limited number of clinical trials, a consensus is lacking on the optimal treatment of PTLD. This review focuses on incidence, risk factors, clinical picture of the disease and diagnostic tools including histopathology relating to the new classification introduced in 2008 by the World Health Organisation (WHO) and treatment of PTLD.