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Dharnidharka VR, Ruzinova MB, Marks LJ. Post-Transplant Lymphoproliferative Disorders. Semin Nephrol 2024; 44:151503. [PMID: 38519279 PMCID: PMC11213680 DOI: 10.1016/j.semnephrol.2024.151503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Post-transplant lymphoproliferative disorders (PTLDs) are a heterogenous set of unregulated lymphoid cell proliferations after organ or tissue transplant. A majority of cases are associated with the Epstein-Barr virus and higher intensity of pharmacologic immunosuppression. The clinical presentations are numerous. The diagnosis is ideally by histology, except in cases where the tumor is inaccessible to biopsy. While some pre-emptive therapies and treatment strategies are available have reasonable success are available, they do not eliminate the high morbidity and significant mortality after PTLD.
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Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, Hypertension and Apheresis, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
| | - Marianna B Ruzinova
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Lianna J Marks
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Stanford University School of Medicine, Palo Alto, CA
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Menon J, Vij M, Hakeem AR, Gopi KR, Bibi A, Shanmugam N, Reddy MS, Rela M. Late-Onset Peripheral T-Cell Lymphoma Not Otherwise Specified in a Liver Transplant Recipient: A Rare Subtype of Posttransplant Lymphoproliferative Disorder. J Clin Exp Hepatol 2021; 11:511-514. [PMID: 34276157 PMCID: PMC8267348 DOI: 10.1016/j.jceh.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Posttransplant lymphoproliferative disorder (PTLD) is a rare complication seen in the period after liver transplant. The commonest subtype is B-cell PTLD which is usually associated with Epstein-Barr virus (EBV) infection. T-cell PTLD is rare and the association with EBV is again rarer. CASE Our patient, a 21-year-old young adult, presented to us with generalized lymphadenopathy, 5 years after liver transplantation. The biopsy of the lymph node was suggestive of peripheral T-cell lymphoma not otherwise specified, which was associated with EBV infection. The Positron emission tomography and computerised tomography (PET-CT) scan showed stage 3 disease. He was treated with standard cyclophosphamide, doxorubicin, etoposide, vincristine, and prednisolone chemotherapy and is currently in remission. CONCLUSION Peripheral T-cell lymphoma not otherwise specified is a rare subtype of PTLD and its association with EBV is even more rare. A few patients can achieve complete remission with standard chemotherapy.
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Key Words
- CHOEP, Cyclophosphamide, Doxorubicin, Etoposide, Vincristine, Prednisolone
- EBV, Epstein-Barr Virus
- Epstein-Barr virus
- NK, Natural Killer Cells
- PET, Positron Emission Tomography
- PTLD NOS, Posttransplant Lymphoproliferative Disorder Not Otherwise Specified
- PTLD, Posttransplant Lymphoproliferative Disorder
- chemotherapy
- liver transplantation
- peripheral T-cell lymphoma not otherwise specified
- remission
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Affiliation(s)
- Jagadeesh Menon
- Department of Pediatric Gastroenterology & Hepatology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
- Address for correspondence. Jagadeesh Menon, Consultant, Department of Pediatric gastroenterology & hepatology , Dr Rela Institute & medical center, Bharat Institute of Higher Education and research, Chennai, India.
| | - Mukul Vij
- Department of Histopathology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Abdul R. Hakeem
- Department of Hepatobiliary Surgery and Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Kakumudi Rajagopal Gopi
- Department of Medical Oncology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Asma Bibi
- Department of Hematopathology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Naresh Shanmugam
- Department of Pediatric Gastroenterology & Hepatology, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Mettu S. Reddy
- Department of Hepatobiliary Surgery and Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Mohamed Rela
- Department of Hepatobiliary Surgery and Liver Transplantation, Dr Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
- Liver Transplant Unit, Kings College Hospital, London, United Kingdom
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Rogers TS, McGevna L, Cook DL. Pediatric cutaneous T-cell post-transplant lymphoproliferative disorder: Case report and review of the literature. J Cutan Pathol 2018; 45:858-863. [DOI: 10.1111/cup.13331] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 06/28/2018] [Accepted: 07/24/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Thomas S. Rogers
- Department of Pathology and Laboratory Medicine; University of Vermont Medical Center; Burlington Vermont
- The Robert Larner MD College of Medicine; The University of Vermont; Burlington Vermont
| | - Laura McGevna
- The Robert Larner MD College of Medicine; The University of Vermont; Burlington Vermont
- Division of Dermatology; University of Vermont Medical Center; Burlington Vermont
| | - Deborah L. Cook
- Department of Pathology and Laboratory Medicine; University of Vermont Medical Center; Burlington Vermont
- The Robert Larner MD College of Medicine; The University of Vermont; Burlington Vermont
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Immunodeficiency-associated lymphoproliferative disorders: time for reappraisal? Blood 2018; 132:1871-1878. [PMID: 30082493 DOI: 10.1182/blood-2018-04-842559] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/27/2018] [Indexed: 12/14/2022] Open
Abstract
Immunodeficiency-associated lymphoproliferative disorders (IA-LPDs) are pathologically and clinically heterogeneous. In many instances, similar features are shared by a spectrum of IA-LPDs in clinically diverse settings. However, the World Health Organization (WHO) classifies IA-LPDs by their immunodeficiency setting largely according to the paradigm of posttransplant lymphoproliferative disorders but with inconsistent terminology and disease definitions. The field currently lacks standardization and would greatly benefit from thinking across immunodeficiency categories by adopting a common working vocabulary to better understand these disorders and guide clinical management. We propose a 3-part unifying nomenclature that includes the name of the lesion, associated virus, and the specific immunodeficiency setting for all IA-LPDs. B-cell lymphoproliferative disorders (LPDs) are usually Epstein-Barr virus (EBV)+ and show a spectrum of lesions, including hyperplasias, polymorphic LPDs, aggressive lymphomas, and, rarely, indolent lymphomas. Human herpes virus 8-associated LPDs also include polyclonal and monoclonal proliferations. EBV- B-cell LPDs and T- and NK-cell LPDs are rare and less well characterized. Recognition of any immunodeficiency is important because it impacts the choice of treatment options. There is an urgent need for reappraisal of IA-LPDs because a common framework will facilitate meaningful biological insights and pave the way for future work in the field.
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Absalon MJ, Khoury RA, Phillips CL. Post-transplant lymphoproliferative disorder after solid-organ transplant in children. Semin Pediatr Surg 2017; 26:257-266. [PMID: 28964482 DOI: 10.1053/j.sempedsurg.2017.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The post-transplant lymphoproliferative disorders (PTLD) are a diverse group of potentially life-threatening conditions affecting organ transplant recipients. PTLD arises in the setting of an attenuated host immunologic system that is manipulated to allow a foreign graft but then fails to provide adequate immune surveillance of transformed malignant or premalignant lymphocytes. The diversity of biological behavior and clinical presentation makes for a challenging clinical situation for those involved in the care of children with PTLD occurring after solid-organ transplantation. This review details a large transplant center's multidisciplinary approach to monitoring for PTLD and systematic approach to intervention, which has been essential for early recognition and successful treatment.
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Affiliation(s)
- Michael J Absalon
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229.
| | - Ruby A Khoury
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229
| | - Christine L Phillips
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 7018, Cincinnati, Ohio 45229
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.25liver.p29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Kraus TS, Twist CJ, Tan BT. Angioimmunoblastic T cell lymphoma: an unusual presentation of posttransplant lymphoproliferative disorder in a pediatric patient. Acta Haematol 2013; 131:95-101. [PMID: 24157860 DOI: 10.1159/000353783] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 06/17/2013] [Indexed: 11/19/2022]
Abstract
Posttransplant lymphoproliferative disorders (PTLD) are a potentially life-threatening complication of immunosuppression in transplant recipients. The majority of cases are Epstein-Barr virus-associated lesions of B cell origin. T cell PTLD is rare, particularly in pediatric patients. We present an unusual case of monomorphic T cell PTLD with features of angioimmunoblastic T cell lymphoma in an 8-year-old heart transplant patient, presenting with cranial nerve palsy.
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Affiliation(s)
- Teresa S Kraus
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla., USA
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Posttransplant lymphoproliferative disease after pediatric solid organ transplantation. Clin Dev Immunol 2013; 2013:814973. [PMID: 24174972 PMCID: PMC3794558 DOI: 10.1155/2013/814973] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 02/06/2023]
Abstract
Patients after solid organ transplantation (SOT) carry a substantially increased risk to develop malignant lymphomas. This is in part due to the immunosuppression required to maintain the function of the organ graft. Depending on the transplanted organ, up to 15% of pediatric transplant recipients acquire posttransplant lymphoproliferative disease (PTLD), and eventually 20% of those succumb to the disease. Early diagnosis of PTLD is often hampered by the unspecific symptoms and the difficult differential diagnosis, which includes atypical infections as well as graft rejection. Treatment of PTLD is limited by the high vulnerability towards antineoplastic chemotherapy in transplanted children. However, new treatment strategies and especially the introduction of the monoclonal anti-CD20 antibody rituximab have dramatically improved outcomes of PTLD. This review discusses risk factors for the development of PTLD in children, summarizes current approaches to therapy, and gives an outlook on developing new treatment modalities like targeted therapy with virus-specific T cells. Finally, monitoring strategies are evaluated.
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Herreman A, Dierickx D, Morscio J, Camps J, Bittoun E, Verhoef G, De Wolf-Peeters C, Sagaert X, Tousseyn T. Clinicopathological characteristics of posttransplant lymphoproliferative disorders of T-cell origin: single-center series of nine cases and meta-analysis of 147 reported cases. Leuk Lymphoma 2013; 54:2190-9. [PMID: 23402267 DOI: 10.3109/10428194.2013.775436] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
T-cell or natural killer (NK)-cell posttransplant lymphoproliferative disorder (T-PTLD) is a rare but severe complication after transplant. Here we present the clinicopathological features of a single-center series of nine cases. Additionally, we summarize the clinicopathological findings of 147 cases of T/NK-cell PTLD reported in the literature in an attempt to define subtype-specific characteristics. T/NK-cell PTLD occurs in patients of all ages, usually extranodally, and most frequently after kidney transplant. Organ specific incidence, however, is highest following heart transplant. Approximately one-third of T-cell PTLDs are Epstein-Barr virus (EBV)-related, with peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) being the most prevalent EBV-associated T-cell PTLD. A male predominance is observed, which is most striking in the EBV(+) group, particularly in PTCL, NOS. With a median posttransplant interval of 72 months, T-cell PTLDs are among the late-occurring PTLDs. Of the most common T-cell PTLDs, anaplastic large cell lymphoma (ALCL) has the best prognosis, whereas PTCL, NOS and hepatosplenic T-cell lymphoma (HSTCL) have the worst prognosis. EBV(+) cases seem to have a longer survival than EBV(-) cases, suggesting a different pathogenetic mechanism.
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Affiliation(s)
- An Herreman
- KU Leuven, Translational Cell and Tissue Research , Leuven , Belgium
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Effect of Cytomegalovirus Immunoglobulin on the Incidence of Lymphoproliferative Disease After Lung Transplantation. Transplantation 2013; 95:766-72. [DOI: 10.1097/tp.0b013e31827df7a7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Risk Factors and Prognosis in T-Cell Posttransplantation Lymphoproliferative Diseases. Transplantation 2013; 95:479-88. [DOI: 10.1097/tp.0b013e3182762e07] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
BACKGROUND Peripheral T-cell lymphoma (PTCL) is rare in pediatric patients and is associated with worse outcome compared with other pediatric non-Hodgkin lymphomas. We report our institutional experience over a 10-year period. METHODS Patients were identified through the institutional oncology database. Data were abstracted through a detailed retrospective review of patient charts. Those with isolated cutaneous T-cell lymphoma were excluded from this analysis. RESULTS Thirteen patients were diagnosed with PTCL during the 10-year period. All presented with advanced disease. According to the WHO PTCL classification, 7 patients had PTCL not otherwise specified, 3 had hepatosplenic T-cell lymphoma and 3 had T-cell posttransplant lymphoproliferative disease. Six of the patients had previously received or were receiving immunosuppressive therapy at the time of their diagnosis. Patients were treated with various chemotherapeutic regimens, including B-cell non-Hodgkin lymphomas and T-cell acute lymphoblastic leukemia-like therapy. Patients who had refractory or recurrent disease were changed to alternative therapy. Eight patients underwent stem cell transplantation, 7 allogeneic and 1 autologous. Of the 13 patients, 7 died. Three patients died from disease progression, 3 died from treatment-related mortality, and 1 patient died from cardiac rejection. Six patients (46%) are alive and disease free at a median of 21 months (2 to 79 mo). CONCLUSIONS Children with PTCL have an unfavorable outcome. A standard approach to management of pediatric PTCL needs to be established to improve outcome. Because of the rarity of this condition, this will require collaborative studies.
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Cleper R, Ben Shalom E, Landau D, Weissman I, Krause I, Konen O, Rahamimov R, Mor E, Bar-Nathan N, Frishberg Y, Davidovits M. Post-transplantation lymphoproliferative disorder in pediatric kidney-transplant recipients - a national study. Pediatr Transplant 2012; 16:619-26. [PMID: 22708682 DOI: 10.1111/j.1399-3046.2012.01731.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PTLD is the most common malignancy in pediatric kidney-transplant recipients. We examined the prevalence, clinical features, and outcome of PTLD in Israel. Twelve (4.4%) of 272 pediatric (<19 yr) kidney-transplant recipients retrieved from a search of the NIKTR for 1991-2008 had acquired PTLD at a median of 3.2 yr post-transplantation. PTLD-affected patients were younger at transplantation (4.2 vs. 12.5 yr, p = 0.02), had a higher rate of OKT3 therapy for acute rejection (25% vs. 4%, p = 0.015), and 5/12 were EBV-seropositive at transplantation. Graft dysfunction was the presenting sign in six (50%). PTLD was predominantly abdominal (83%) and B-cell type (67%); T-cell PTLD occurred exclusively in EBV-seropositive patients. Treatment consisted of immunosuppression cessation (6/12, 50%), antiviral agents (7/12, 58%), anti-CD20 monoclonal antibodies (4/12, 33%), and chemotherapy (6/12, 50%). Survival was 100% in the EBV-naïve patients and 40% in the EBV-seropositive patients. Graft loss occurred in three of eight survivors (37.5%). PTLD-associated mortality risk was older age: 11.2 vs. 3.4 yr, longer dialysis: 15 vs. 6.5 months, T-cell type disease (75%), later PTLD onset: 6.35 vs. 1.9 yr post-transplantation and era of transplantation (43% mortality before vs. 20% after 2001). Pretransplantation EBV-seronegative status might confer a survival benefit with early detected PTLD. EBV-seropositive patients are at risk for aggressive late-onset lethal PTLD.
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Affiliation(s)
- Roxana Cleper
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
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Abstract
Transplantation of solid organs and haematopoietic stem cells requires immunosuppressive drug therapy in order to prevent rejection or graft-versus-host disease. Depending on dosage and type of drug, the risk of developing an Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disease (PTLD) is increased. The lesion spectrum ranges from hyperplastic lesions to manifest lymphomas, the latter being classified as monomorphic PTLD. Hyperplastic changes, which are not distinguishable from viral reactions, comprise early or mononucleosis-like lesions. Those with effaced lymph node architecture or extranodal manifestation without a lymphoma-like phenotype are designated polymorphic PTLD. Monomorphic PTLD are either high grade B cell lymphomas, plasma cell neoplasms or Hodgkin lymphomas and only very rarely T cell lymphomas. Low grade B cell lymphomas do not occur. In a subfraction of cases, including even monomorphic PTLD, reduction of immunosuppression alone is sufficient to induce remission of the pathological process.
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Gross TG, Savoldo B, Punnett A. Posttransplant lymphoproliferative diseases. Pediatr Clin North Am 2010; 57:481-503, table of contents. [PMID: 20371048 DOI: 10.1016/j.pcl.2010.01.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The risk of developing cancer after solid organ transplantation (SOT) is about 5- to 10-fold greater than that of the general population. The cumulative risk of cancer rises to more than 50% at 20 years after transplant and increases with age, and so children receiving transplants are at high risk of developing a malignancy. Posttransplant lymphoproliferative disease (PTLD) is the most common cancer observed in children following SOT, accounting for half of all such malignancies. PTLD is a heterogeneous group of disorders with a wide spectrum of pathologic and clinical manifestations and is a major contributor to long-term morbidity and mortality in this population. Among children, most cases are associated with Epstein-Barr virus infection. This article reviews the pathology, immunobiology, epidemiology, and clinical aspects of PTLD, underscoring the need for ongoing systematic study of complex biologic and therapeutic questions.
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Affiliation(s)
- Thomas G Gross
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, OSU School of Medicine, Columbus, OH 43205, USA
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Ohta H, Fukushima N, Ozono K. Pediatric post-transplant lymphoproliferative disorder after cardiac transplantation. Int J Hematol 2009; 90:127-136. [DOI: 10.1007/s12185-009-0399-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/19/2009] [Accepted: 07/23/2009] [Indexed: 11/28/2022]
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Successful use of alemtuzumab in a child with refractory peripheral T-cell posttransplant lymphoproliferative disorder. J Pediatr Hematol Oncol 2008; 30:787-8. [PMID: 19011483 DOI: 10.1097/mph.0b013e318182e799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Where there are no randomized, phase 3 trials: what is a doctor to do? J Pediatr Hematol Oncol 2008; 30:719-20. [PMID: 19011465 DOI: 10.1097/mph.0b013e318182e774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Afify Z. T-cell post-transplantation lymphoproliferative disorder, a rare and challenging late complication of solid organ transplantation. Pediatr Transplant 2008; 12:617-8. [PMID: 18346038 DOI: 10.1111/j.1399-3046.2008.00915.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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