Post-transplant lymphoproliferative disorder in adult liver transplant recipients: a South American multicenter experience

Epstein-Barr Virus-Associated Latent Malignant Lymphoma With Acute Exacerbation After Living Donor Liver Transplantation: Case Report

Concomitant malignant lymphoma at the time of transplantation is usually considered a contraindication to liver transplantation (LT). We report a case of Epstein-Barr virus (EBV)-associated malignant lymphoma that was latent preoperatively and rapidly became aggravated after LT. A 69-year-old man was referred to our hospital with an exacerbation of abdominal distension due to polycystic liver. As cystic infection, ascites, and deteriorated liver reserve function occurred after hepatic artery embolization, he underwent living-donor LT with his daughter as the donor. His respiratory condition worsened, and he was moved to the intensive care unit on postoperative day 34. Histopathologic examination of the excised liver returned around the same time revealed findings suggestive of EBV-associated malignant lymphoma in lymph nodes near the gallbladder. Subsequent computed tomography scans showed apparent neoplastic lesions in the abdominal cavity and worsening pleural effusion and ascites. Numerous atypical lymphocytes were observed in the pleural effusion and ascites, and the patient was diagnosed with exacerbation of EBV-associated malignant lymphoma. He was treated unsuccessfully with rituximab and died 66 days after LT. Caution should be exercised in elderly immunocompromised transplant candidates who may have comorbid EBV-associated lymphoproliferative disease.

Diagnosis and treatment of adult patients with PTLD at different sites after liver transplantation: A three-case report and literature review

Post-transplant lymphoproliferative disease (PTLD) is a rare complication accompanying organ transplantation. Herein, we presented 3 cases of PTLD with different primary sites. All three patients presented with symptoms in the corresponding organs or sites and the latter two patients started with atypical symptoms of infections. The first two patients who developed the disease about a year after liver transplantation both had EBV infections. All three patients received immunosuppressant reduction and antiviral therapy. In case 2, remission occurred midway. Adult liver transplantation recipients are at high risk for PTLD, and screening for EBV infection should be intensified in such recipients within 1 year after liver transplantation. Patients should be highly alert for the development of PTLD when new unidentified masses appear, for whom enhanced CT and tissue biopsy should be performed as early as possible.

Single-center "Argentine" analysis of post-transplant lymphoproliferative disorders: incidence, histopathological characteristics and EBV status

INTRODUCTION

Post-transplant lymphoproliferative disorders (PTLDs) are a heterogeneous group of lymphoid proliferations occurring after solid organ or bone marrow transplantation. The primary aims of our study were to characterize cumulative incidence of PTLDs, clinical and pathological features according to the Epstein-Barr virus (EBV) status and survival.

METHODS

This was a retrospective cohort study on adult and pediatric patients, from January 2001 to December 2017. The cumulative incidence of PTLD was calculated by analyzing all the patients transplanted at our hospital, based on the database of the Organ Donation and Ablation Authority of Argentina (INCUCAI). The Kaplan-Meier method was used to plot the survival.

RESULTS

Fifty-eight cases of biopsy-confirmed PTLD were identified and 12 cases of clinical data were incomplete and these patients were excluded. The median age at the time of the PTLD diagnosis was 17.5 years (interquartile range [IQR] 9 - 57). The median interval between transplant and PTLD diagnosis was 39 months (IQR 9 - 113). The most commonly transplanted organ was the liver (24 cases, 52.2%), followed by kidney (20 cases, 43.5%). The Epstein-Barr encoding region in situ hybridization (EBER ISH) was positive in 29 (69.8%) of the 43 evaluable biopsies. The PTLD cumulative incidence was 1.84% (95%CI 1.77 - 1.91) for solid organ and 0.84% (95%CI 0.48 - 1.2) for bone marrow transplant patients. The overall survival rate at 5 years was 0.77 (95%CI 0.61 - 0.87). Subgroups by the EBV EBER status, transplant type, PTLD subtype and age group (adult vs. pediatric) showed no statistically significant association with the overall survival.

CONCLUSION

The PTLD incidence was similar to that of previous series and the EBER did not appear as a relevant factor in our patient survival.

Post-transplant lymphoproliferative disorders in a cohort of adult patients with a liver transplant from a reference hospital in Bogotá, Colombia

Introduction: The post-transplant lymphoproliferative disorders (PTLD) are characterized by an uncontrolled pathological lymphoid proliferation as a consequence of transplant immunosuppression therapy. Objective: To characterize the clinical and pathological characteristics of PTLD in a cohort of adult patients with liver transplant during a 15 year period at the Hospital Universitario Fundación Santa Fe de Bogota. Materials and methods: We conducted an observational retrospective study by searching for the PTLD cases diagnosed during the study period in the databases of the Liver Transplantation Unit and the Pathology Department. We collected the epidemiological, clinical, and pathological information and performed the corresponding statistics analyses. Results: During the research period, 572 patients were transplanted; the incidence of PTDL was 2.44%; 79% of them were man and the average age at the time of diagnosis was 62.5 years; 71% of the cases were diagnosed during the first year after the transplant and the same percentage EBV-seropositive patients. The most frequent pathological phenotype was monomorphic and the majority of tumors was detected in the hepatic hilum. The one-year survival was 50%. Conclusion: The high proportion of early cases and the high frequency of Epstein-Barr virus seropositivity both in donors and receptors drewour attention. More studies are necessary to have a better understanding of this condition in Colombia. This is the first PTLD clinical and pathological analysis in liver-transplant patients from Colombia to date.

Post-transplantation lymphoproliferative disease in pediatric liver recipients in Taiwan

BACKGROUND

Post-transplantation lymphoproliferative disorder (PTLD) is a heterogeneous, potentially life-threatening complication after liver transplantation in children. In this study, the disease characteristics, outcomes, and prognostic factors of PTLD were investigated.

METHODS

A retrospective, observational study was conducted on 16 pediatric liver transplant (LT) recipients who developed PTLD between February 2001 and December 2013 at a tertiary referral center in Taiwan. The disease characteristics and treatment outcomes of the patients were analyzed.

RESULTS

The median time from liver transplantation to the development of PTLD was 8 months. Early onset (<1 year post-transplantation) PTLD constituted 62.5% of the cases. PTLD location was frequently extranodal (81.3%) and mostly involved the gastrointestinal tract (68.8%). Histopathologic findings showed polymorphic PTLD in six cases (37.5%), diffuse large B-cell lymphoma in five cases (31.3%), and Burkitt's PTLD in two cases (12.5%). Early lesions in PTLD, T-cell lymphoma, and Hodgkin's lymphoma were observed in one case each (6.3%). Overall survival at 1- and 5-years post-PTLD diagnosis was 87.5% and 79.5%, respectively. St Jude's classification stage IV disease was associated with poor survival (hazard ratio [HR] = 13.37, P = 0.037). Two patients (12.5%) had chronic rejection after the treatment for PTLD and one patient (6.3%) developed graft failure.

CONCLUSION

PTLD is a major complication in pediatric LT recipients, but long-term survival is possible in most cases with an adequate treatment strategy. Stage IV disease is a major risk factor for poor survival in pediatric PTLD patients. During the management of PTLD, the possibility of chronic rejection and even graft failure should be considered.

Developing multicenter consortia in liver disease in Latin America: Challenges and opportunities

The development of consortia has been useful for exploring challenging scenarios and uncharted territories in liver disease treatments. Several consortia already developed in the United States and Europe have become key factors in patient care decision-making processes and medical education, and they have also impacted policy makers' decisions. In Latin America, the situation is different. As a result of a combination of different factors, our region has not been able to develop networking advantages in research and education in liver diseases. Thus far, most of the initial experiences focused on the development of collaborative groups established to investigate a particular topic, which were dissolved once the questions were answered. It is the aim of this review to describe those difficulties we confront in developing multicenter liver consortia in Latin America, to identify those challenges we face, and also to describe the opportunities we have for improvement. Liver Transplantation 23 1210-1215 2017 AASLD.

Post-transplant lymphoproliferative disorders: from epidemiology to pathogenesis-driven treatment

Post-transplant lymphoproliferative disorders (PTLDs) represent the most severe complication of both solid organ and hematopoietic stem cell transplantation. The Epstein-Barr Virus (EBV) is the main driver of PTLD, particularly those occurring early after transplantation. EBV-driven malignancies are associated with selective expression of latent viral proteins, but uncontrolled lytic replication may favor early phases of cell transformation. Besides immunodepression, persistent immune activation and chronic inflammation play an important role in both virus reactivation and expansion of EBV-infected B cells. EBV-induced immortalization requires the expression of telomerase. TERT, the rate-limiting component of the telomerase complex, is central in the switch from the lytic to the latent viral program, and TERT inhibition induces the EBV lytic cycle and cell death. Immunotherapy and combination of EBV lytic cycle inducers with antiviral drugs are promising strategies to improve the treatment of PTLD patients. This review is aimed at providing an update on the intriguing association between EBV and PTLD, mainly focusing on cases arising after kidney and liver transplantation, which account for the vast majority of transplants.

Rituximab, Dexamethasone, Cytarabine, and Cisplatin as Effective Platinum-Based Salvage Chemotherapy for Periportal Posttransplant Lymphoproliferative Disorder After an Orthotopic Liver Transplant

Posttransplant lymphoproliferative disorder is a group of heterogenous disorders that occur after solid-organ transplant. The overall incidence is between 1% and 20%. In orthotopic liver transplant recipients, the reported incidence ranges from 2% to 10%, while the incidence is greater in children (9.7%-11%) and lesser in adults (1.7%-3%). The following treatment options are considered for patients with posttransplant lymphoproliferative disorder: reduction of immunosuppression, single-agent rituximab, rituximab and chemotherapy, surgery and radiation, antivirals targeted at the Epstein-Barr virus, and cytotoxic T-lymphocytes targeting the Epstein-Barr virus. This report describes a 61-year-old man who presented after an orthotopic liver transplant with a large periportal soft tissue mass that was shown on biopsy to be a monomorphic, CD20+, diffuse, large B-cell lymphoma, nongerminal center type. He was treated with reduced immunosuppression, followed by single-agent rituximab, then with an anthracycline-based chemotherapy regimen: rituximab, etoposide, prednisone, vincristine, doxorubicin, and then a platinum-based salvage chemotherapy with rituximab, dexamethasone, cytarabine, and cisplatin with a good response.