1
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Ergisi M, Ooi B, Salim O, Papalois V. Post-transplant lymphoproliferative disorders following kidney transplantation: A literature review with updates on risk factors, prognostic indices, screening strategies, treatment and analysis of donor type. Transplant Rev (Orlando) 2024; 38:100837. [PMID: 38430887 DOI: 10.1016/j.trre.2024.100837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/31/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Post-transplant lymphoproliferative disorders (PTLD) is a devastating complication of kidney transplantation with an insidious presentation and potential to disseminate aggressively. This review delineates the risk factors, prognostic indexes, screening, current management algorithm and promising treatment strategies for PTLD. Kidneys from both extended criteria donors (ECD) and living donors (LD) are being increasingly used to expand the donor pool. This review also delineates whether PTLD outcomes vary based on these donor sources. While Epstein-Barr virus (EBV) is a well-known risk factor for PTLD development, the use of T-cell depleting induction agents has been increasingly implicated in aggressive, monomorphic forms of PTLD. Research regarding maintenance therapy is sparse. The international prognostic index seems to be the most validate prognostic tool. Screening for PTLD is controversial, as annual PET-CT is most sensitive but costly, while targeted monitoring of EBV-seronegative patients was more economically feasible, is recommended by the American Society of Transplantation, but is limited to a subset of the population. Other screening strategies such as using Immunoglobulin/T-cell receptor require further validation. A risk-stratified approach is taken in the treatment of PTLD. The first step is the reduction of immunosuppressants, after which rituximab and chemotherapy may be introduced if unsuccessful. Some novel treatments have also shown potential benefit in studies: brentuximab vedotin, chimeric antigen receptor T-cell therapy and EBV-specific cytotoxic T lymphocytes. Analysis of LD v DD recipients show no significant difference in incidence and mortality of PTLD but did reveal a shortened time to development of PTLD from transplant. Analysis of SCD vs ECD recipients show a higher incidence of PTLD in the ECD group, which might be attributed to longer time on dialysis for these patients, age, and the pro-inflammatory nature of these organs. However, incidence of PTLD overall is still extremely low. Efforts should be focused on optimising recipients instead. Minimising the use of T-cell depleting therapy while encouraging research on the effect of new immunosuppressants on PTLD, screening for EBV status are essential, while enabling shared decision-making during counselling when choosing kidney donor types and individualised risk tailoring are strongly advocated.
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Affiliation(s)
- Mehmet Ergisi
- Norfolk and Norwich University Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Department of Medicine, Norwich, United Kingdom.
| | - Bryan Ooi
- Department of Medicine, Imperial College London, London, United Kingdom.
| | - Omar Salim
- Isle of Wight NHS Trust, Parkhurst Road, Newport, United Kingdom
| | - Vassilios Papalois
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, Department of Transplant and General Surgery, London, United Kingdom.
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2
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Ehrsam JP, Meier Adamenko O, Pannu M, Markus Schöb O, Inci I. Lung transplantation in children. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2024; 32:S119-S133. [PMID: 38584780 PMCID: PMC10995684 DOI: 10.5606/tgkdc.dergisi.2024.25806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 04/09/2024]
Abstract
Lung transplantation is a well-established treatment for children facing advanced lung disease and pulmonary vascular disorders. However, organ shortage remains highest in children. For fitting the small chest of children, transplantation of downsized adult lungs, lobes, or even segments were successfully established. The worldwide median survival after pediatric lung transplantation is currently 5.7 years, while under consideration of age, underlying disease, and peri- and posttransplant center experience, median survival of more than 10 years is reported. Timing of referral for transplantation, ischemia-reperfusion injury, primary graft dysfunction, and acute and chronic rejection after transplantation remain the main challenges.
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Affiliation(s)
- Jonas Peter Ehrsam
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | | | | | - Othmar Markus Schöb
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
| | - Ilhan Inci
- School of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Klinik Hirslanden Zurich, Zurich, Switzerland
- Klinik Hirslanden Zurich, Centre for Surgery, Zurich, Switzerland
- University of Nicosia Medical School, Nicosia, Cyprus
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3
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Franco A, Hernandez D, Zarraga S, Fructuoso AS, Crespo M, Mazuecos A, Corte CD, Benot AR, Ruiz JC, Beneyto I. Lymphoproliferative disorders after renal transplantation along 2 decades: a large longitudinal study of 21.546 recipients. Nefrologia 2023; 43:427-434. [PMID: 37813738 DOI: 10.1016/j.nefroe.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Post transplant lymphoproliferative disorders (PTLD) are heterogeneous lymphoid proliferations in recipients of solid organs which seem to be related to Epstein Barr Virus (EBV). The use of antilymphocyte antibodies, EBV seronegativity in the recipient,acute rejection and CMV infection have been identified as classical risk factors. MATERIAL Y METHODS We have studied in a retrospective observational study, the incidence of PTLD in a period of 22 years, its relationship with EBV, presence of classical risk factors and outcome in 21546 simple adult renal transplant recipients from cadaveric and living donors, transplanted in 21 hospitals from 1990 to 2009. RESULTS A total of 275 recipients developed PTLD (1,2%),195 males (70,9%), 80 females (29,1%) aged 59.2 (p25 44.7 p75 68)years. Two hundred forty-five (89.0%) were 1st transplant recipients and 269 (97,8%) from cadaveric donors. EBV in the tissue was reported in 94 out of the 155 studied recipients (60.6%) and 86.0% of the proliferations were due to B lymphocytes. PTLD median appearance after transplant were 42.months (p25, 75, 12, 77, 5). One hundred eighty-eight recipients out of 275 patients (68.3%) had any classical risk factor and the use of antilymphocyte antibodies was the most frequent. During the follow-up, 172 patients died (62,5%) and 103 (37,5%) had a complete remission. The main cause of death was PTLD progression (n = 91, 52,9%), followed by sepsis (n = 24, 13,9%). The follow-up period post-transplant of the recipients was between 3 and 22 years. The incidence was 0,14% during the first year post-trasplant and 0.98% the cumulative incidence at 10 years. Patient survival after diagnosis was 51%, 44% and 39% after 1, 2 and 5 years, respectively. Finally, overall graft survival was 48%, 39% and 33% at the same periods. CONCLUSION PTLD has a low incidence in renal transplant recipients. Most of the proliferations are due to B lymphocytes and seem to have a close relationship with EBV. PTLD can develop in the absence of classical risk factors. The prognosis is poor, mainly due to PTLD progression, but the survivors can even maintain their grafts.
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Affiliation(s)
- Antonio Franco
- Servicio de Nefrología, Hospital General de Alicante, Alicante, Spain.
| | | | - Sofia Zarraga
- Servicio de Nefrologia, Hospital de Cruces, Baracaldo, Vizcaya, Spain
| | | | - Marta Crespo
- Servicio de Nefrologia, Hospital del Mar, Barcelona, Spain
| | | | | | | | - Juan Carlos Ruiz
- Servicio de Nefrologia, Hospital Marque de Valdecilla, Santander, Cantabria, Spain
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4
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Incidence of Lymphoproliferative Disorders After Renal Transplantation is Down, but the Poor Prognosis Remains. Multicenter 32-Year Cohort Study. Transplant Proc 2022; 54:2462-2466. [DOI: 10.1016/j.transproceed.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/01/2022] [Indexed: 11/15/2022]
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5
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Enfermedad linfoproliferativa difusa postrasplante renal: estudio longitudinal de 21.546 receptores durante 2 décadas en España. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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6
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D'Costa MR, King RL, Alexander MP, Zhang P, Issa N, Dingli D, Amer H, Singh D, Leung N, Sukov WR, Dean PG, Habermann TM, Kukla A. Epstein Barr Virus-Negative Lymphoplasmacytic Proliferation Limited to the Renal Allograft: A Unique Presentation of a Rare Disease. Kidney Int Rep 2021; 6:2223-2227. [PMID: 34386673 PMCID: PMC8343792 DOI: 10.1016/j.ekir.2021.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/20/2021] [Accepted: 05/17/2021] [Indexed: 10/25/2022] Open
Affiliation(s)
- Matthew R D'Costa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Rebecca L King
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Pingchuan Zhang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naim Issa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - David Dingli
- Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Devender Singh
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Department of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Sukov
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick G Dean
- Department of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aleksandra Kukla
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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7
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Montes de Jesus F, Dierickx D, Vergote V, Noordzij W, Dierckx RAJO, Deroose CM, Glaudemans AWJM, Gheysens O, Kwee TC. Prognostic superiority of International Prognostic Index over [ 18F]FDG PET/CT volumetric parameters in post-transplant lymphoproliferative disorder. EJNMMI Res 2021; 11:29. [PMID: 33738643 PMCID: PMC7973341 DOI: 10.1186/s13550-021-00769-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/03/2021] [Indexed: 11/19/2022] Open
Abstract
Background Post-transplant lymphoproliferative disorders (PTLDs) are a spectrum of hematological malignancies occurring after solid organ and hematopoietic stem cell transplantation. [18F]FDG PET/CT is routinely performed at PTLD diagnosis, allowing for both staging of the disease and quantification of volumetric parameters, such as whole-body metabolic tumor volume (MTV) and total lesion glycolysis (TLG). In this retrospective study, we aimed to determine the prognostic value of MTV and TLG in PTLD patients, together with other variables of interest, such as the International Prognostic Index (IPI), organ transplant type, EBV tumor status, time after transplant, albumin levels and PTLD morphology. Results A total of 88 patients were included. The 1-, 3-, 5- year overall survival rates were 67%, 58% and 43% respectively. Multivariable analysis indicated that a high IPI (HR: 1.56, 95% CI: 1.13–2.16) and an EBV-negative tumor (HR: 2.71, 95% CI: 1.38–5.32) were associated with poor overall survival. Patients with a kidney transplant had a longer overall survival than any other organ recipients (HR: 0.38 95% CI: 0.16–0.89). IPI was found to be the best predicting parameter of overall survival in our cohort. Whole-body MTV, TLG, time after transplant, hypoalbuminemia and PTLD morphology were not associated with overall survival. Conclusion [18F]FDG PET/CT whole-body volumetric quantitative parameters were not predictive of overall survival in PTLD. In our cohort, high IPI and an EBV-negative tumor were found to predictors of worse overall survival while kidney transplant patients had a longer overall survival compared to other organ transplant recipients
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Affiliation(s)
- F Montes de Jesus
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - D Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - V Vergote
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - W Noordzij
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - R A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - C M Deroose
- Department of Nuclear Medicine, University Hospitals Leuven, Leuven, Belgium
| | - A W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - O Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - T C Kwee
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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8
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Di Napoli ML, Rohan V, Nadig SN, Lin A. Small Bowel Perforation as the Initial Manifestation of Post-Transplant Lymphoproliferative Disorder in a Kidney and Pancreas Transplant Recipient: A Case Report. Transplant Proc 2020; 52:2827-2830. [PMID: 32900475 DOI: 10.1016/j.transproceed.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/16/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) comprises a broad spectrum of diseases and is a rare but serious complication of solid organ transplantation. We report the case of a 45-year-old simultaneous pancreas and kidney (SPK) transplant recipient with diffuse, early-onset PTLD, manifesting as jejunal perforation at 6 months after transplantation. The patient underwent urgent small bowel resection of the affected portion of jejunum. The surgical pathology report was significant for diffuse large B-cell lymphoma. Subsequently, the patient underwent a full workup, including upper and lower endoscopy and whole-body positron emission tomography that revealed involvement of the axial skeleton and multiple abdominal organs with sparing of the grafts. He was treated with rituximab and intrathecal methotrexate for central nervous system prophylaxis. The patient experienced complete resolution of disease by positron emission tomography 8 months after initial presentation. We found no previous report in the literature of intestinal perforation as the initial presentation of PTLD in SPK transplant recipients.
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Affiliation(s)
- Marissa L Di Napoli
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Vinayak Rohan
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Satish N Nadig
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Angello Lin
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States.
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9
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Ose N, Minami M, Funaki S, Kanou T, Fukui E, Morii E, Shintani Y. Late-Onset Central Nervous System Posttransplant Lymphoproliferative Disorder After Lung Transplantation:A Case Report. Transplant Proc 2019; 51:3163-3166. [PMID: 31619339 DOI: 10.1016/j.transproceed.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/28/2019] [Indexed: 11/26/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is caused by uncontrolled proliferation of lymphoid cells after a hematopoietic stem cell or solid organ transplant procedure related to the Epstein-Barr virus (EBV) infection. A primary central nervous system (CNS) PTLD (CNS-PTLD) is rare and important to distinguish from an intracranial lesion after transplantation. A 66-year-old man with pulmonary arterial hypertension who underwent living-donor lung transplantation 9 years prior noticed disorientation regarding route and dates. Brain magnetic resonance imaging revealed multiple white matter lesions and fluorodeoxyglucose (FDG) positron emission tomography showed FDG uptake in the brain and skin. CNS-PTLD was diagnosed by craniotomy biopsy and EBV-encoded RNA was positive in in situ hybridization findings and elevated in brain tissue. The treatment was started with immunosuppressant reduction and whole brain radiotherapy. But the condition progressed rapidly over 2 months after the first symptom and the patient was passed away 25 days after hospitalization. CNS-PTLD can occur several years after transplantation and it is necessary to keep in mind to distinguish brain disease because early diagnosis and treatment are important.
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Affiliation(s)
- Naoko Ose
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Masato Minami
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Kanou
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eriko Fukui
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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10
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Post-transplant lymphoproliferative disorder manifesting as lymphomatoid granulomatosis: report of two cases and review of the literature highlighting current challenges in pathologic classification. J Hematop 2019. [DOI: 10.1007/s12308-019-00364-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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11
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Korf JA, Jesse MK, Schultheiss TC. Post-transplant lymphoproliferative disorder presenting with multifocal aggressive osseous lesions. BJR Case Rep 2019; 5:20180045. [PMID: 31131123 PMCID: PMC6519495 DOI: 10.1259/bjrcr.20180045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 12/02/2022] Open
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) encompasses a broad category of lymphoid and plasmacytic proliferations that occur following solid organ and/or allogeneic stem cell transplantation. PTLD manifests in the setting of chronic immunosuppression and is thought to be associated with the Epstein Barr Virus, although Epstein Barr Virus infection or reactivation is not required for the process to occur. Pathologic correlation is necessary for diagnosis with B-cell lymphocytes the most commonly isolated cellular etiology. There is a broad range of clinical and imaging presentations of PTLD with intestinal and nodal involvement being the most common. Imaging plays an integral part in the diagnosis and management of PTLD, as it is utilized in the initial diagnosis and staging, guiding biopsy of lesions, and gauging treatment response. Presenting symptoms of PTLD are often vague and nonspecific and depend on the organ systems affected. Musculoskeletal involvement is especially rare, with only a few cases described in the literature. We present a case with multifocal osseous manifestations of PTLD occurring years after a renal living donor transplant.
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Affiliation(s)
- James Anthony Korf
- Department of Radiology, University of Colorado at Denver-Anschutz Medical Campus, Denver, CO, USA
| | - Mary-Kristen Jesse
- Department of Radiology, University of Colorado at Denver-Anschutz Medical Campus, Denver, CO, USA
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12
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Zhu CY, Zhao SS, Wang XK, Wang L, Wang FY, Fang S, Liu ZX, Guan LX, Liu YC, Ding Y, Dou LP, Wang LL, Gao CJ. Outcome of Rituximab-Based Treatment for Post-Transplant Lymphoproliferative Disorder After Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Experience. Ann Transplant 2019; 24:175-184. [PMID: 30940797 PMCID: PMC6463616 DOI: 10.12659/aot.914101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Post-transplant lymphoproliferative disorder (PTLD) is a rare complication following solid organ transplantation and allogeneic hematopoietic stem cell transplantation (Allo-HSCT), which gives rise to high mortality rates. Material/Methods This was a single-center retrospective analysis based on 27 patients who were diagnosed with PTLD following Allo-HSCT between January 1, 2007 and June 2018 at the Chinese PLA General Hospital. The purpose of this analysis was to investigate responses and prognostic factors of rituximab-based treatment. Results Twenty-seven patients were treated with rituximab. Among them, 20 of 27 patients (74.07%) had a complete response, 2 of 27 patients (7.41%) had a partial response, 5 of 27 patients (18.52%) had no response, and 22 of 27 patients (81.48%) cleared Epstein-Barr virus (EBV) copies. There were no obvious side effects. The 1-year overall survival (OS) estimate was 46.8% (95% CI, 23.1–65.5%). Univariate analysis revealed that lower OS was correlated with Eastern Cooperative Oncology Group (ECOG) score standard (3–4), Epstein-Barr virus (EBV) viral load (≥106 copies/mL), bacteria or fungal infection, and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab (P<0.05). Multivariate analysis showed that each of the following were independently associated with lower OS (P<0.05): female, ECOG score standard (3–4), and EBV reactivation were positive after treatment with 1 or 2 doses of rituximab. Conclusions Our results demonstrated that rituximab-based treatment was a safe and effective strategy for patients who were diagnosed with PTLD following Allo-HSCT. The identified prognostic factors may help to detect which PTLD patients are at a higher risk of mortality.
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Affiliation(s)
- Cheng-Ying Zhu
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Sha-Sha Zhao
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Xiao-Kai Wang
- Department of Orthopedics, Xiqing Hospital, Tianjin, China (mainland)
| | - Li Wang
- Department of Hematology and Oncology, Laoshan Branch, No. 401 Hospital of Chinese People's Liberation Army (PLA), Qingdao, Shandong, China (mainland)
| | - Fei-Yan Wang
- School of Medicine, Nankai University, Tianjin, China (mainland)
| | - Shu Fang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Zhan-Xiang Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Xun Guan
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yu-Chen Liu
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Yi Ding
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Ping Dou
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Li-Li Wang
- Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
| | - Chun-Ji Gao
- School of Medicine, Nankai University, Tianjin, China (mainland).,Department of Hematology, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China (mainland)
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13
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Cassol CA, Hod-Dvorai R, Hubbell C, Aggarwal V, Sinha S, Gentile T, Hutchison RE. Donor-derived Philadelphia chromosome-positive B cell lymphoblastic leukemia presenting with renal allograft involvement in the first year posttransplant. Am J Transplant 2019; 19:956-957. [PMID: 30222902 DOI: 10.1111/ajt.15117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Clarissa A Cassol
- Renal Pathology Division, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Reut Hod-Dvorai
- Department of Pathology, State University of New York - Upstate Medical University, Syracuse, NY, USA
| | - Charlene Hubbell
- Department of Pathology, State University of New York - Upstate Medical University, Syracuse, NY, USA
| | - Vikram Aggarwal
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shreya Sinha
- Department of Hematology-Oncology, State University of New York - Upstate Medical University, Syracuse, NY, USA
| | - Teresa Gentile
- Department of Hematology-Oncology, State University of New York - Upstate Medical University, Syracuse, NY, USA
| | - Robert E Hutchison
- Department of Pathology, State University of New York - Upstate Medical University, Syracuse, NY, USA
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14
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Rausch L, Koenecke C, Koch HF, Kaltenborn A, Emmanouilidis N, Pape L, Lehner F, Arelin V, Baumann U, Schrem H. Matched-pair analysis: identification of factors with independent influence on the development of PTLD after kidney or liver transplantation. Transplant Res 2016; 5:6. [PMID: 27486513 PMCID: PMC4970231 DOI: 10.1186/s13737-016-0036-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) adversely affects patients' long-term outcome. METHODS The paired t test and McNemar's test were applied in a retrospective 1:1 matched-pair analysis including 36 patients with PTLD and 36 patients without PTLD after kidney or liver transplantation. Matching criteria were age, gender, indication, type of transplantation, and duration of follow-up. All investigated PTLD specimen were histologically positive for EBV. Risk-adjusted multivariable regression analysis was used to identify independence of risk factors for PTLD detected in matched-pair analysis. The resultant prognostic model was assessed with ROC-curve analysis. RESULTS Patients suffering with PTLD had shorter mean survival (p = 0.004), more episodes of CMV infections or reactivations (p = 0.042), and fewer recipient HLA A2 haplotypes (p = 0.007), a tacrolimus-based immunosuppressive regimen (p = 0.052) and higher dosages of tacrolimus at hospital discharge (Tac dosage) (p = 0.052). Significant independent risk factors for PTLD were recipient HLA A2 (OR = 0.07, 95 % CI = 0.01-0.55, p = 0.011), higher Tac dosages (OR = 1.29, 95 % CI = 1.01-1.64, p = 0.040), and higher numbers of graft rejection episodes (OR = 0.38, 95 % CI = 0.17-0.87, p = 0.023). The following prognostic model for the prediction of PTLD demonstrated good model fit and a large area under the ROC curve (0.823): PTLD probability in % = Exp(y)/(1 + Exp(y)) with y = 0.671 - 1.096 × HLA A2-positive recipient + 0.151 × Tac dosage - 0.805 × number of graft rejection episodes. CONCLUSIONS This study suggests prognostic relevance for recipient HLA A2, CMV, and EBV infections or reactivations and strong initial tacrolimus-based immunosuppression. Patients with risk factors may benefit from intensified screening for PTLD.
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Affiliation(s)
- Lisa Rausch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Christian Koenecke
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hans-Friedrich Koch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Trauma and Orthopedic Surgery, Federal Armed Forces Hospital Westerstede, Westerstede, Germany
| | - Nikos Emmanouilidis
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Lars Pape
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Nephrology, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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15
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Ishihara H, Shimizu T, Unagami K, Hirai T, Toki D, Omoto K, Okumi M, Imai Y, Ishida H, Tanabe K. Post-Transplant Lymphoproliferative Disorder in Kidney Transplant Recipients: A Single-Center Experience in Japan. Ther Apher Dial 2016; 20:165-73. [DOI: 10.1111/1744-9987.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 09/07/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroki Ishihara
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | | | - Kohei Unagami
- Department of Nephrology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Toshihito Hirai
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Daisuke Toki
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Kazuya Omoto
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Yoichi Imai
- Department of Hematology; Tokyo Women's Medical University; Tokyo Japan
| | - Hideki Ishida
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology, Kidney Center; Tokyo Women's Medical University; Tokyo Japan
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16
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Gifford G, Fay K, Jabbour A, Ma DD. Primary central nervous system posttransplantation lymphoproliferative disorder after heart and lung transplantation. Intern Med J 2016; 45:583-6. [PMID: 25955465 DOI: 10.1111/imj.12735] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 02/28/2015] [Indexed: 11/28/2022]
Abstract
Primary central nervous system posttransplantation lymphoproliferative disorder (PCNS-PTLD) is uncommon, especially after heart or lung transplantation. Database analysis from a single heart and lung transplantation centre and a literature review pertaining to PCNS-PTLD was performed. In this study, the prevalence of PCNS-PTLD was 0.18% after heart and/or lung transplants. Of 1674 transplants, three cases of PCNS-PTLD developed 14 months, 9 years and 17 years posttransplant, and all were Epstein-Barr virus driven malignancies. Literature review of the topic revealed predominantly retrospective studies, with most reported cases after renal transplantation. The overall survival is poor, and it may be improved by early diagnosis and treatment. There are no published guidelines on the management of PCNS-PTLD; immune-chemotherapy in conjunction with reduction of immune suppression is preferred based on available evidence.
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Affiliation(s)
- G Gifford
- Haematology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - K Fay
- Haematology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,Cardiology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - A Jabbour
- Haematology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Clinical Faculty, Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia
| | - D D Ma
- Haematology Department, St Vincent's Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,St Vincent's Centre for Applied Medical Research, Sydney, New South Wales, Australia
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17
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Abstract
Post-transplant lymphoproliferative disorders (PTLDs) are a group of conditions that involve uncontrolled proliferation of lymphoid cells as a consequence of extrinsic immunosuppression after organ or haematopoietic stem cell transplant. PTLDs show some similarities to classic lymphomas in the non-immunosuppressed general population. The oncogenic Epstein-Barr virus (EBV) is a key pathogenic driver in many early-onset cases, through multiple mechanisms. The incidence of PTLD varies with the type of transplant; a clear distinction should therefore be made between the conditions after solid organ transplant and after haematopoietic stem cell transplant. Recipient EBV seronegativity and the intensity of immunosuppression are among key risk factors. Symptoms and signs depend on the localization of the lymphoid masses. Diagnosis requires histopathology, although imaging techniques can provide additional supportive evidence. Pre-emptive intervention based on monitoring EBV levels in blood has emerged as the preferred strategy for PTLD prevention. Treatment of established disease includes reduction of immunosuppression and/or administration of rituximab (a B cell-specific antibody against CD20), chemotherapy and EBV-specific cytotoxic T cells. Despite these strategies, the mortality and morbidity remains considerable. Patient outcome is influenced by the severity of presentation, treatment-related complications and risk of allograft loss. New innovative treatment options hold promise for changing the outlook in the future.
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18
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Lampe A, Duddalwar VA, Djaladat H, Aron M, Gulati M. Contrast-enhanced ultrasound findings of post-transplant lymphoproliferative disorder in a transplanted kidney: A case report and literature review. J Radiol Case Rep 2015; 9:26-34. [PMID: 26629291 DOI: 10.3941/jrcr.v9i10.2602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Post-transplant lymphoproliferative disorder occurs in approximately one percent of kidney transplant recipients. We evaluated a seventy-seven year-old man with a solid mass in his transplant kidney. On contrast enhanced ultrasound, the mass enhanced but remained persistently hypovascular throughout exam. The enhancement pattern of the mass differed from that typical of clear cell renal cell carcinoma, the main differential diagnosis. Final pathology after partial nephrectomy confirmed post-transplant lymphoproliferative disorder. This is the first report of contrast enhanced ultrasound findings in a renal mass diagnosed as post-transplant lymphoproliferative disorder. Contrast enhanced ultrasound has a promising role in imaging of renal masses, particularly relevant in transplant patients due to the lack of nephrotoxicity.
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Affiliation(s)
- Alyssa Lampe
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vinay A Duddalwar
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Hooman Djaladat
- Department of Urology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Manju Aron
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Mittul Gulati
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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19
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Thomas de Montpréville V, Le Pavec J, Le Roy Ladurie F, Crutu A, Mussot S, Fabre D, Mercier O, Dorfmuller P, Ghigna MR, Fadel É. Lymphoproliferative Disorders after Lung Transplantation: Clinicopathological Characterization of 16 Cases with Identification of Very-Late-Onset Forms. Respiration 2015; 90:451-459. [PMID: 26506523 DOI: 10.1159/000441064] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/11/2015] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND The incidence of posttransplant lymphoproliferative disorders (PTLD) has recently declined, but late cases are increasingly reported in lung transplant recipients. OBJECTIVES We present our experience with PTLD after lung transplantation, attempting to examine the distinguishing characteristics of early versus late cases. METHODS We have reviewed clinical and pathological data of all cases occurring in our institution between 2001 and 2014. RESULTS Patients, aged 15-63 years, were mostly (12/16) Epstein-Barr virus (EBV) seropositive at the time of transplantation. Eleven early cases, occurring 9.4 ± 5.2 months after transplantation and mostly (9/11) prior to 2010, had EBV+ diffuse large B-cell lymphomas. Lungs and/or thoracic lymph nodes were often involved (n = 8). Treatments included reduction of immune suppression (n = 11), rituximab (n = 8) and chemotherapy (n = 7). Two patients are in complete remission at 26 and 216 months. Nine patients died 8.0 ± 6.5 months after PTLD diagnosis. Of the 5 cases with late PTLD occurring 4-23 years (mean ± SD: 10.4 ± 7.7) after transplantation (and 3/5 after 2009), 1 had pulmonary lymphomatoid granulomatosis (only endothoracic case), 1 cutaneous large T-cell lymphoma, 2 had anaplastic large cell lymphomas, and 1 Hodgkin's disease. Two of the 5 cases were EBV-, including one followed by a second EBV+ PTLD after 8 years of complete remission. Two patients were alive and well (follow-up: 44 and 151 months), one having suffered from EBV-related cholestatic hepatitis 6 years after the PTLD. CONCLUSION Our small experience shows a trend toward (very) late occurrence, associated with more unusual clinicopathologic features, but not with a worse prognosis.
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20
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Abbas M, Dämmrich M, Braubach P, Kramer M, Grünwald V, Merseburger A, Herrmann T, Becker J, Kreipe H. Role of immunohistochemistry and fluorescence in-situ hybridization (FISH) in the diagnosis of spindle and round cell tumors of the kidney. J Egypt Natl Canc Inst 2015; 27:173-8. [DOI: 10.1016/j.jnci.2015.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 04/09/2015] [Accepted: 04/18/2015] [Indexed: 12/26/2022] Open
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21
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Clajus C, Blasi F, Welte T, Greer M, Fuehner T, Mantero M. Therapeutic approach to respiratory infections in lung transplantation. Pulm Pharmacol Ther 2014; 32:149-54. [PMID: 25038552 PMCID: PMC7110868 DOI: 10.1016/j.pupt.2014.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 07/09/2014] [Indexed: 01/22/2023]
Abstract
Lung transplant recipients (LTRs) are at life-long risk for infections and disseminated diseases owing to their immunocompromised state. Besides organ failure and sepsis, infection can trigger acute and chronic graft rejection which increases mortality. Medical prophylaxis and treatment are based on comprehensive diagnostic work-up including previous history of infection and airway colonisation to reduce long-term complications and mortality. Common bacterial pathogens include Pseudomonas and Staphylococcus, whilst Aspergillus and Cytomegalovirus (CMV) are respectively the commonest fungal and viral pathogens. Clinical symptoms can be various in lung transplant recipients presenting an asymptomatic to severe progress. Regular control of infection parameters, daily lung function testing and lifelong follow-up in a specialist transplant centre are mandatory for early detection of bacterial, viral and fungal infections. After transplantation each patient receives intensive training with rules of conduct concerning preventive behaviour and to recognize early signs of post transplant complications. Early detection of infection and complications are important goals to reduce major complications after lung transplantation.
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Affiliation(s)
- Carolina Clajus
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, IRCCS Fondazione Ospedale Maggiore, Policlinico Cà Granda Milano, Italy
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22
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23
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Ramos E, Hernández F, Andres A, Martínez-Ojinaga E, Molina M, Sarría J, Lopez-Santamaria M, Prieto G. Post-transplant lymphoproliferative disorders and other malignancies after pediatric intestinal transplantation: incidence, clinical features and outcome. Pediatr Transplant 2013; 17:472-8. [PMID: 23730927 DOI: 10.1111/petr.12103] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 12/22/2022]
Abstract
PTLDs are a well-recognized and potentially fatal complication after intestinal transplantation. We analyzed the incidence, clinical features, and outcome in a 63 intestinal transplantation series performed in our unit between October 1999 and July 2011. Types of graft included ISB (n = 23), LSB (n = 20), and MV (n = 20). Patients were categorized into three groups of immunosuppression: I (n = 43) received basiliximab, tacrolimus, and steroids; II (n = 11) thymoglobulin and tacrolimus, and III (n = 9) alemtuzumab and tacrolimus. EBV status was serially assessed. All PTLD cases were biopsied to establish histopathological diagnosis. The incidence of PTLD was 14.2% (9/63). Median onset of PTLD after transplant was four months (range: 0.5-28), within first postoperative year in 6 (66.6%) patients. Fever was the most common symptom. Graft removal was needed in four patients (44%). The patient survival rate was 66.6% (6/9). We have not found any association between PTLD and immunosuppression regimen or transplant type. However, there was a statistical association with EBV active infection.
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Affiliation(s)
- Esther Ramos
- Intestinal Rehabilitation Unit, University Hospital La Paz, Madrid, Spain.
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24
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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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25
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Neuringer IP. Posttransplant lymphoproliferative disease after lung transplantation. Clin Dev Immunol 2013; 2013:430209. [PMID: 23533455 PMCID: PMC3603163 DOI: 10.1155/2013/430209] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 01/10/2013] [Indexed: 12/23/2022]
Abstract
Posttransplant lymphoproliferative disease (PTLD) after lung transplantation occurs due to immunosuppressant therapy which limits antiviral host immunity and permits Epstein-Barr viral (EBV) replication and transformation of B cells. Mechanistically, EBV survives due to latency, escape from cytotoxic T cell responses, and downregulation of host immunity to EBV. Clinical presentation of EBV may occur within the lung allograft early posttransplantation or later onset which is more likely to be disseminated. Improvements in monitoring through EBV viral load have provided a means of earlier detection; yet, sensitivity and specificity of EBV load monitoring after lung transplantation may require further optimization. Once PTLD develops, staging and tissue diagnosis are essential to appropriate histopathological classification, prognosis, and guidance for therapy. The overall paradigm to treat PTLD has evolved over the past several years and depends upon assessment of risk such as EBV-naïve status, clinical presentation, and stage and sites of disease. In general, clinical practice involves reduction in immunosuppression, anti-CD20 biologic therapy, and/or use of plasma cell inhibition, followed by chemotherapy for refractory PTLD. This paper focuses upon the immunobiology of EBV and PTLD, as well as the clinical presentation, diagnosis, prognosis, and emerging treatments for PTLD after lung transplantation.
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Affiliation(s)
- Isabel P Neuringer
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA 02114, USA.
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26
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Fedrigo M, Poli F, Esposito G, Feltrin G, Toscano G, d'Agostino C, Schiavon B, Gerosa G, Amadori A, Valente M, Thiene G, Angelini A. HLA-DRB1 typing by micro-bead array assay identifies the origin of early lymphoproliferative disorder in a heart transplant recipient. Am J Transplant 2013; 13:802-7. [PMID: 23331771 DOI: 10.1111/ajt.12063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/01/2012] [Accepted: 11/19/2012] [Indexed: 01/25/2023]
Abstract
We report the case of a 68-year-old woman who underwent heart transplantation for hypertrophic cardiomyopathy. Two months after the transplant she developed mild fever and dyspnea with a marked drop in left ventricle ejection fraction of 31%. Coronary angiography was negative for cardiac allograft vasculopathy. Endomyocardial biopsy revealed ischemic damage with no evidence of acute cellular rejection, antibody-mediated rejection or viral myocarditis. A neoplastic process was suspected even though full-body computerized tomography was negative for malignancy. The patient died 4 months after transplantation. The autopsy showed acute antero-septal myocardial infarction due to a nodular epicardial EBV-related posttransplant lymphoproliferative disorder (PTLD) infiltrating the left anterior descending coronary artery with occlusive neoplastic thrombosis. We highlight two major aspects of this case: (1) the unusual occurrence of early PTLD involving the cardiac allograft and causing a fatal outcome, (2) the application of an immunological technique for HLA-DRB1 typing to posttransplant paraffin-embedded autopsy material to identify the recipient origin of this early malignancy, thus excluding a possible donor-transmitted neoplasm.
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Affiliation(s)
- M Fedrigo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
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27
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Michonneau D, Suarez F, Lambert J, Adam J, Brousse N, Canioni D, Anglicheau D, Martinez F, Snanoudj R, Legendre C, Hermine O, Mamzer-Bruneel MF. Late-onset post-transplantation lymphoproliferative disorders after kidney transplantation: a monocentric study over three decades. Nephrol Dial Transplant 2012; 28:471-8. [PMID: 23129824 DOI: 10.1093/ndt/gfs476] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Late-onset post-transplantation lymphoproliferative disorders (PTLDs) occur 1 year after transplantation and are associated with poor prognosis. Initial treatment usually involves a reduction in immunosuppressive treatment. While early-onset PTLDs have a good prognosis following RI, this approach is generally inadequate for late-onset PTLDs. We assessed the specific outcome of late-onset PTLDs after kidney transplantation during the past three decades. METHODS We reviewed the clinical and biological data of 52 kidney transplant recipients who developed late-onset PTLDs at our centre between 1980 and 2010. We compared clinical features, long-term outcome and renal prognosis of late-onset PTLDs both before and after the era of rituximab. RESULTS Before 2000, 38% of the patients underwent surgery and 76% received chemotherapy either immediately or after surgery. After 2000, rituximab was administrated to 70% of the patients either alone (23%) or in combination with chemotherapy (77%). Chemotherapy alone was administrated in 26% of the cases. Before and after 2000, complete remission was achieved in 38 and 87% of the cases, respectively (P = 0.0005). The 5-year overall survival (OS) was 33.3 and 69% (P = 0.003), and 5-year disease-free survival was 37.5 and 80%, respectively (P = 0.19). Renal function was preserved in 70% of the cases at the end of the follow-up. CONCLUSIONS This study shows an increase in OS and low graft loss for patients with late-onset PTLDs during the last decade, which may be attributed to multiple changes in clinical practice, including a more standardized treatment and the use of rituximab in combination with chemotherapy.
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Affiliation(s)
- David Michonneau
- Service de Transplantation Rénale Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
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28
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Nelson BP, Wolniak KL, Evens A, Chenn A, Maddalozzo J, Proytcheva M. Early posttransplant lymphoproliferative disease: clinicopathologic features and correlation with mTOR signaling pathway activation. Am J Clin Pathol 2012; 138:568-78. [PMID: 23010712 DOI: 10.1309/ajcpqyye04avgvyi] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Early posttransplant lymphoproliferative disorders (EPTLDs) represent the first changes in posttransplant lymphoproliferative disorders (PTLDs) morphologic spectrum. EPTLD data are available mostly from case reports and series that include other types of PTLD. Fifteen EPTLDs were reviewed retrospectively. Clinical data, histopathology, clonality, and Epstein- Barr virus (EBV) status were correlated with staining intensity to an antibody for phosphorylated S6 (pS6) ribosomal protein, a downstream effector of mammalian target of rapamycin (mTOR). Median time from transplantation to EPTLD was 50 months (range, 7-135 mo). EPTLDs involved tonsil and/or adenoids (n = 11) and lymph nodes (n = 4), all of which were nonclonal and EBV-encoded RNA-positive. Most (n = 11) were plasmacytic hyperplasia and florid follicular hyperplasia (n = 4). All regressed with reduced immunosuppression, and had increased pS6 staining compared with normal tonsil (P = .002, F test). EPTLDs developed later than previously reported, involved mostly tonsils/adenoids, were EBV-encoded RNA (EBER) positive, showed increased pS6, and had excellent clinical outcome with reduction of immunosuppression.
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Affiliation(s)
- Beverly P. Nelson
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Kristy L. Wolniak
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Andrew Evens
- Division of Hematology/Oncology, University of Massachusetts Medical School, Worcester
| | - Anjen Chenn
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - John Maddalozzo
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
- Department of Pathology and Laboratory Medicine and Division of Otolaryngology–Head and Neck Surgery, Children's Memorial Hospital, Chicago
| | - Maria Proytcheva
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
- Department of Pathology and Laboratory Medicine and Division of Otolaryngology–Head and Neck Surgery, Children's Memorial Hospital, Chicago
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30
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Izumiya S, Ishida M, Hodohara K, Yoshida T, Okabe H. Epstein-Barr virus-associated lymphoproliferative disorder developed following autologous peripheral blood stem cell transplantation for relapsing Hodgkin's lymphoma. Oncol Lett 2012; 3:1203-1206. [PMID: 22783418 DOI: 10.3892/ol.2012.670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/27/2012] [Indexed: 01/24/2023] Open
Abstract
Post-transplant lymphoproliferative disorders (PTLDs) are lymphoid or plasmacytic proliferations that develop as a consequence of immunosuppression in a recipient of a solid organ, bone marrow or stem cell allograft. The development of PTLDs is usually associated with Epstein-Barr virus (EBV) and the disorder is also termed EBV-associated lymphoproliferative disorder (LPD). The development of PTLD is a rare complication in autologous bone marrow/peripheral blood stem cell transplantation. In the present study, we report a case of EBV-associated LPD which developed following autologous peripheral blood stem cell transplantation for relapsing Hodgkin's lymphoma. A 51-year-old male presented with swelling of the left cervical lymph nodes. A biopsy revealed nodular sclerosis classical Hodgkin's lymphoma. Following four courses of ABVd (adriamycin, bleomycin, vinblastine, dacarbazine) therapy, the Hodgkin's lymphoma relapsed. CHASE (cyclophosphamide, etoposide, cytarabine, dexamethasone) therapy and autologous peripheral blood stem cell transplantation were performed. In the 128 days following the transplantation, lymph node swelling was noted and a biopsy specimen demonstrated EBV-associated LPD. The serum copy number of EBV-DNA was 2.7×10(3) copies/ml. The occurrence of EBV-associated LPD may be on the rise due to the increased number of patients undergoing immunosuppression therapy. The measurement of the serum EBV-DNA copy number and the detection of EBV-infected atypical lymphocytes using in situ hybridization are significant in establishing an early accurate diagnosis and initiating the correct treatment for EBV-associated LPD in patients with immunosuppression.
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Affiliation(s)
- Sakura Izumiya
- Department of Hematology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Post-transplantation lymphoproliferative disorder in living-donor liver transplantation: a single-center experience. Surg Today 2012; 42:741-51. [DOI: 10.1007/s00595-012-0127-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 06/27/2011] [Indexed: 12/18/2022]
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Moir JAG, Simms RJ, Wood KM, Talbot D, Kanagasundaram NS. Posttransplant lymphoproliferative disorder presenting as multiple cystic lesions in a renal transplant recipient. Am J Transplant 2012; 12:245-9. [PMID: 22244123 DOI: 10.1111/j.1600-6143.2011.03761.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a case of a 67-year-old man who experienced allograft dysfunction following a renal transplantation from a donation after cardiac death. The postoperative course was initially complicated by episodes of E. coli urinary sepsis causing pyrexia and a raised creatinine level. Ultrasound scanning 5 weeks posttransplant revealed mild hydronephrosis with several parenchymal cystic areas measuring up to 2 cm with appearances suggestive of fungal balls. Aspirated fluid again grew Escherichia coli, and this was treated with the appropriate antimicrobial therapy. The patient continued to have episodes of culture-negative sepsis; therefore, a computed tomography scan was performed 6 months posttransplant, which revealed multiple lesions in the renal cortex as well as liver and spleen. Subsequent biopsy revealed an Epstein-Barr virus-driven lymphoproliferation consistent with a polymorphic posttransplantation lymphoproliferative disorder (PTLD). This rare case of PTLD presenting as multiple renal, hepatic and splenic lesions emphasizes the need for a high index of clinical suspicion for this condition. Abnormal para-renal allograft masses should be biopsied to allow swift and effective management of a disease that can disseminate and become significantly more challenging to manage.
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Affiliation(s)
- J A G Moir
- Renal Transplant Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK.
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Gholipour-Shoiili A, Gholipour-Shoiili H, Taheri S. An approach to finding indications and contraindications for nephrectomy in post-transplant renal graft lymphomas: PTLD.Int survey. Hematol Oncol Stem Cell Ther 2011; 4:167-72. [PMID: 22198192 DOI: 10.5144/1658-3876.2011.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Allograft involvement can occur in some renal transplant recipients who develop post-transplant lymphoproliferative disorders (PTLD). We aimed to find indications and/or contraindications for nephrectomy in renal allograft PTLD based on an outcome analysis of previous reports. DESIGN AND SETTING A comprehensive search of Pubmed and Google scholar was performed to find reports of different treatment strategies addressing PTLD occurring within the allograft after renal transplantation. PATIENTS AND METHODS Patients who underwent nephrectomy due to kidney allograft localization by PTLD were categorized as the case group, and renal recipients with kidney PTLD for whom nonsurgical treatment modalities were used served as controls. RESULTS Survival analysis demonstrated that patients with renal allograft involvement who underwent allograft nephrectomy had a significantly better outcome compared to patients for whom a non-surgical approach was used (P=.03). In patients with disseminated PTLD, nephrectomy was not useful (P>.1). Patients with simultaneous kidney and lung complications by PTLD benefitted from nephrectomy. CONCLUSIONS We found that patients with renal graft complication with disseminated PTLD do not benefit from nephrectomy, which can be considered the only contraindication. However, some particular PTLD co-localizations were not as likely to adversely affect the benefit of nephrectomy in these patients, and these can be considered indications for the procedure. Future multicenter studies are needed to confirm our results.
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Post-transplant lymphoproliferative disorder after lung transplantation: a review of 35 cases. J Heart Lung Transplant 2011; 31:296-304. [PMID: 22112992 DOI: 10.1016/j.healun.2011.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 09/08/2011] [Accepted: 10/22/2011] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a complication of organ transplantation. The risk of developing PTLD varies depending on a number of factors, including the organ transplanted and the degree of immunosuppression used. METHODS We report a retrospective analysis of 35 patients with PTLD treated at our center after lung transplantation. Of 705 patients who received allografts, 34 (4.8%) developed PTLD. One patient underwent transplantation elsewhere and was treated at our center. RESULTS PTLD involved the allograft in 49% of our patients and the gastrointestinal (GI) tract lumen in 23%. Histologically, 39% of tumors were monomorphic and 48% polymorphic. The time to presentation defined the location and histology of disease. Of 17 patients diagnosed within 11 months of transplantation, PTLD involved the allograft in 12 (71%) and the GI tract in 1 (p = 0.01). This "early" PTLD was 85% polymorphic (p = 0.006). Conversely, of the 18 patients diagnosed more than 11 months after transplant, the lung was involved in 5 (28%) and the GI tract in 7 (39%; p = 0.01). "Late" PTLD was 71% monomorphic (p = 0.006). Median overall survival after diagnosis was 18.57 months. Overall survival did not differ between all lung transplant recipients and those who developed PTLD. CONCLUSIONS PTLD is an uncommon complication after lung transplantation, and its incidence declined remarkably in the era of modern immunosuppression. We report several factors that are important for predisposition toward, progression of, and treatment of PTLD after lung transplantation.
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Adult post-transplant lymphoproliferative disease in the liver graft in patients with recurrent hepatitis C. Eur J Gastroenterol Hepatol 2011; 23:559-65. [PMID: 21555941 DOI: 10.1097/meg.0b013e3283474ac9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM The aim of this study is to clarify the association between hepatitis C virus (HCV) infection and post-transplant lymphoproliferative disease (PTLD) in the liver allograft. METHODS Of the 933 adults who underwent liver transplantation (LT) between 1990 and 2005, 10 patients developed PTLD. Seven of the 10 patients that were HCV(+) (group 1) were compared with three HCV-negative recipients (group 2). RESULTS The mean time between LT and PTLD was 24.5 months. There were no differences between in Epstein-Barr virus antibody status or tumor lymphocyte subsets. In five of the seven HCV-positive recipients who developed PTLD, PTLD recurred preferentially in the liver allograft, whereas none of the three HCV-negative patients who developed PTLD did so in the liver (71.4 vs. 0%, respectively, P=0.038). In all five patients with graft PTLD, HCV recurred within 12 months followed by PTLD. There were significant differences between groups 1 and 2 in mean lymphocyte infiltrate scores (6.0±2.1 vs. 2.0±0.7, P=0.037), fibrosis stage (2.4±0.5 vs. 0.7±0.5, P=0.029), and frequency of lymphoid follicles in portal areas (33.6±14.8% vs. 1.1±2.3%, P=0.0002). CONCLUSION When PTLD occurs in patients with HCV recurrence after LT, it does so preferentially in the liver allograft.
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Abstract
Malignancy is an important complication of thoracic organ transplantation and is associated with significant morbidity and mortality. Lung transplant recipients are at greater risk for cancer than immunocompetent persons, with cancer-specific incidence rates up to 60-fold higher than the general population. The increased risk for cancer is attributed to neoplastic properties of immunosuppressive medications, oncogenic viruses, and cancer-specific risk factors. This article addresses the epidemiology, presentation, and treatment of the most common malignancies after lung transplantation, including skin cancer, posttransplant lymphoproliferative disorder, and bronchogenic carcinoma.
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Affiliation(s)
- Hilary Y Robbins
- Lung Transplantation Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY 10032, USA
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37
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Quinlan SC, Pfeiffer RM, Morton LM, Engels EA. Risk factors for early-onset and late-onset post-transplant lymphoproliferative disorder in kidney recipients in the United States. Am J Hematol 2011; 86:206-9. [PMID: 21264909 DOI: 10.1002/ajh.21911] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Solid-organ transplant recipients have an elevated risk for some malignancies because of the requirement for immunosuppression [1]. In particular, non-Hodgkin's lymphoma (NHL) is common and comprises one end of a spectrum of post-transplant lymphoproliferative disorder (PTLD) ranging from benign hyperplasia to lymphoid malignancy [2]. PTLD risk is influenced by the type of organ transplanted, the age and Epstein-Barr virus (EBV) serostatus of the transplant recipient, and the intensity of immunosuppression [3-9]. PTLD incidence is high immediately after transplantation, decreases subsequently, and then rises again 4-5 years from transplantation [10,11]. This incidence pattern suggests the presence of separate early-onset and late-onset PTLD subtypes. Early-onset PTLDs tend to be EBV-positive and, when extranodal, are more likely than late-onset PTLDs to be localized to the transplanted organ [12,13]. Late-onset PTLD is less likely to be associated with EBV and, overall, is more likely than early-onset PTLD to be extranodal [13,14]. The Scientific Registry of Transplant Recipients (SRTR) includes data on a large number of solid-organ transplant recipients in the United States and information on malignancies diagnosed post-transplantation. We used these data to conduct a retrospective cohort study among kidney transplant recipients to examine differences in risk factors between early-onset PTLD and late-onset PTLD.
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Affiliation(s)
- Scott C. Quinlan
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Lindsay M. Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
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Yoon SO, Yu E, Cho YM, Suh C, Kim KM, Han DJ, Lee SG, Huh J. Post-transplant lymphoproliferative disorders: clinicopathological analysis of 43 cases in a single center, 1990-2009. Clin Transplant 2011; 26:67-73. [DOI: 10.1111/j.1399-0012.2010.01392.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Végso G, Hajdu M, Sebestyén A. Lymphoproliferative disorders after solid organ transplantation-classification, incidence, risk factors, early detection and treatment options. Pathol Oncol Res 2010; 17:443-54. [PMID: 21193979 DOI: 10.1007/s12253-010-9329-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 10/26/2010] [Indexed: 12/12/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous disease group of benign and malignant entities. The new World Health Organisation classification introduced in 2008 distinguishes early lesions, polymorphic, monomorphic and classical Hodgkin lymphoma-type PTLD. Based on the time of appearance, early and late forms can be identified.PTLDs are the second most frequent posttransplantation tumors in adulthood, and the most frequent ones in childhood. The incidence varies with the transplanted organ-from 1%-2% following kidney transplantation to as high as 10% following thoracic organ transplantation-due to different intensities in immunosuppression. Immunocompromised state and Epstein-Barr virus (EBV) infection are the two major risk factors.In Europe and the US approximately 85% of PTLDs are of B-cell origin, and the majority are EBV-associated. Symptoms are often unspecific; extranodal, organ manifestations and central nervous system involvement is common. Early lesions respond well to a decrease in immunosuppression. Malignant entities are treated with rituximab, chemotherapy, radiotherapy and surgical therapy. Adoptive T-cell transfer represents a promising therapeutic approach. The prognosis is favorable in early PTLD, and poor in late PTLD. Five-year survival is 30% for high-grade lymphomas. The prognosis of EBV-negative lymphomas is worse.Lowering the risk of PTLD may be achieved by low dose maintenance immunosuppression, immunosuppressive drugs inhibiting cell proliferation, and special immunotherapy (e.g. interleukin-2 inhibitors). Early detection is especially important for high risk-e.g. EBV-negative-patients, where the appearance of EBV-DNA and the increase in its titer may help.
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Affiliation(s)
- Gyula Végso
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
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40
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Wudhikarn K, Holman C, Linan M, Blaes A, Dunitz J, Hertz M, Peterson B. Post-transplant lymphoproliferative disorders in lung transplant recipients: 20-yr experience at the University of Minnesota. Clin Transplant 2010; 25:705-13. [DOI: 10.1111/j.1399-0012.2010.01332.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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41
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Mucha K, Foroncewicz B, Ziarkiewicz-Wróblewska B, Krawczyk M, Lerut J, Paczek L. Post-transplant lymphoproliferative disorder in view of the new WHO classification: a more rational approach to a protean disease? Nephrol Dial Transplant 2010; 25:2089-98. [PMID: 20576725 DOI: 10.1093/ndt/gfq231] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Krzysztof Mucha
- Transplantation Institute, Department of Immunology, Transplantology and Internal Medicine, Warsaw Medical University, Warsaw, Poland.
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42
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Malhotra V, Kaul S, Arora DS. Post Transplant Malignancy – A Brief Review. APOLLO MEDICINE 2010. [DOI: 10.1016/s0976-0016(11)60100-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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43
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Bone marrow involvement in patients with posttransplant lymphoproliferative disorders: incidence and prognostic factors. Hum Pathol 2010; 41:1150-8. [DOI: 10.1016/j.humpath.2009.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 11/13/2009] [Accepted: 11/19/2009] [Indexed: 11/24/2022]
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Quinlan SC, Morton LM, Pfeiffer RM, Anderson LA, Landgren O, Warren JL, Engels EA. Increased risk for lymphoid and myeloid neoplasms in elderly solid-organ transplant recipients. Cancer Epidemiol Biomarkers Prev 2010; 19:1229-37. [PMID: 20406959 DOI: 10.1158/1055-9965.epi-09-1220] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND By assessing the spectrum of hematologic malignancies associated with solid-organ transplantation in the elderly, we provide information on the pathogenesis of lymphoid and myeloid neoplasms and the clinical manifestations of immunosuppression. METHODS Using data from the U.S. Surveillance, Epidemiology, and End Results Medicare database, we identified 83,016 cases with a hematologic malignancy (age 66-99 years) and 166,057 population-based controls matched to cases by age, sex, and calendar year. Medicare claims were used to identify a history of solid-organ transplantation. We used polytomous logistic regression to calculate odds ratios (OR) comparing transplantation history among cases with various hematologic malignancy subtypes and controls, adjusting for the matching factors and race. RESULTS A prior solid-organ transplant was identified in 216 (0.26%) cases and 204 (0.12%) controls. Transplantation was associated with increased risk for non-Hodgkin lymphomas [OR, 2.13; 95% confidence interval (95% CI), 1.67-2.72], especially diffuse large B-cell lymphoma (OR, 3.29; 95% CI, 2.28-4.76), marginal zone lymphoma (OR, 2.48; 95% CI, 1.17-5.22), lymphoplasmacytic lymphoma (OR, 3.32; 95% CI, 1.41-7.81), and T-cell lymphoma (OR, 3.07; 95% CI, 1.56-6.06). Transplantation was also associated with elevated risk of Hodgkin lymphoma (OR, 2.53; 95% CI, 1.01-6.35) and plasma cell neoplasms (OR, 1.91; 95% CI, 1.24-2.93). Risks for myeloid neoplasms were also elevated (OR, 1.99; 95% CI, 1.41-2.81). CONCLUSION Solid-organ transplantation is associated with a wide spectrum of hematologic malignancies in the elderly. Risk was increased for four specific non-Hodgkin lymphoma subtypes for which a viral agent has been implicated, supporting an added role for immunosuppression. IMPACT Our results support monitoring for a wide spectrum of hematologic malignancies following solid-organ transplant.
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Affiliation(s)
- Scott C Quinlan
- Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Department of Health and Human Services, 6120 Executive Boulevard, EPS 7076, Rockville, MD 20892, USA
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45
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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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46
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Trappe R, Hinrichs C, Appel U, Babel N, Reinke P, Neumayer HH, Budde K, Dreyling M, Dührsen U, Kliem V, Schüttrumpf S, Hauser IA, Mergenthaler HG, Schlattmann P, Anagnostopoulos I, Doerken B, Riess H. Treatment of PTLD with rituximab and CHOP reduces the risk of renal graft impairment after reduction of immunosuppression. Am J Transplant 2009; 9:2331-7. [PMID: 19663889 DOI: 10.1111/j.1600-6143.2009.02772.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We addressed the effect of post-transplant lymphoproliferative disorder (PTLD) treatment with rituximab monotherapy or CHOP-based chemotherapy (+/- rituximab) after upfront immunosuppression reduction (IR) on renal graft function in a longitudinal analysis of 58 renal transplant recipients with PTLD and 610 renal transplant controls. Changes in the estimated glomerular filtration rate over time were calculated from a total of 6933 creatinine measurements over a period of >1 year using a linear mixed model with random and fixed effects. Renal graft function significantly improved with treatment of PTLD, especially in the chemotherapy subgroup. Patients treated with IR+chemotherapy +/- rituximab had a noninferior graft function compared with untreated controls suggesting that the negative impact of IR on the renal graft function can be fully compensated by the immunosuppressive effect of CHOP. The immunosuppressive effect of single agent rituximab may partially compensate the negative impact of IR on the graft function. Thus, it is possible to reduce immunosuppression when using chemotherapy to treat PTLD.
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Affiliation(s)
- R Trappe
- Department of Hematology, Campus Virchow-Klinikum, Charite-Universitatsmedizin Berlin, Berlin, Germany.
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47
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Bakker NA, van Dijk JMC, Slart RHJA, Coppes MH, van Imhoff GW, Verschuuren EAM. Extradural thoracic spinal cord compression: unusual initial presentation of post-transplant lymphoproliferative disorder. J Heart Lung Transplant 2009; 27:1165-8. [PMID: 18926411 DOI: 10.1016/j.healun.2008.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Revised: 05/27/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a serious complication after solid-organ transplantation. We report a lung transplant recipient presenting with lower limb weakness as a result of extradural cord compression from PTLD. Diagnosis was made by laminectomy of T-3 with partial removal of the epidural mass. Further treatment consisted of chemoradiotherapy. The patient recovered completely. To our knowledge, this is the first reported case of PTLD presenting with signs and symptoms of spinal cord compression. The differential diagnosis of spinal cord compression in a patient who has had a transplant should include primary presentation of PTLD.
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Affiliation(s)
- Nicholas A Bakker
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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48
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Schubert S, Abdul-Khaliq H, Lehmkuhl HB, Yegitbasi M, Reinke P, Kebelmann-Betzig C, Hauptmann K, Gross-Wieltsch U, Hetzer R, Berger F. Diagnosis and treatment of post-transplantation lymphoproliferative disorder in pediatric heart transplant patients. Pediatr Transplant 2009; 13:54-62. [PMID: 18518912 DOI: 10.1111/j.1399-3046.2008.00969.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PTLD is a severe complication in transplant recipients. Detection of increased EBV load in the peripheral blood acts as a surrogate marker for increased risk of PTLD development. We analyzed the time course of the disease, its severity, the organs involved, and mortality rates in our institutional experience of pediatric heart transplantation. This paper identifies risk factors for PTLD and describes the different ways of diagnosing and treating the disease. PTLD was screened for in 146 pediatric heart transplant patients using a retrospective analysis in patients who received transplantation before 1998. Prospective determination was performed in 72/146 patients transplanted after 1998 within the post-transplant follow-up. The occurrence of PTLD with all interventions, including tapering of immunosuppression, surgery, viral monitoring, and antiviral interventions, was recorded. PTLD was diagnosed in 12/147 (8.2%) children at a mean age of 7.2 +/- 3.3 yr after a mean post-transplant period of 3.2 +/- 2.2 yr. PTLD manifested in: lymph nodes (n = 4), intestine (n = 3), tonsils and adenoids (n = 2), eye (n = 2), and lung (n = 1). It was diagnosed in 7/12 as a monomorphic B-cell lymphoma and in four patients as a monomorphic Burkitt lymphoma, a polymorphic B-cell lymphoma, a T-cell rich or angiocentric lymphoma (Liebow) and as reactive plasmacytic hyperplasia (early lesion), respectively. Histology was not possible in one patient with ocular manifestation. EBV association was 83%. Risk factors in the comparison with patients without PTLD were age at time of Tx, primary EBV infection after Tx, use of Azathioprine and >or=3 doses of ATG. CMV mismatch and CMV infection, rejection episodes and steroids were not risk factors. Despite reduction of immunosuppression, treatment consisted of surgical procedures to remove tumor masses (n = 6), Rituximab (n = 5), polychemotherapy (n = 3), antiviral (n = 1) and autologous T-cell therapy (n = 1). All patients demonstrated full remission without death related to PTLD or treatment at 3.9 (1.3-6.2) yr median follow-up time. The manifestation of PTLD in pediatric heart transplant recipients is associated with EBV infection and is predominantly in the form of a B-cell lymphoma. A tight and specific follow-up including early assessment of immunity status and specific therapeutic intervention to improve cellular immunity is warranted and may contribute to a significant reduction of PTLD-related morbidity and mortality.
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Affiliation(s)
- S Schubert
- Department of Congenital Heart Defects/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.
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Primary cutaneous diffuse large B-cell lymphoma (leg type) after renal allograft: case report and review of the literature. Int J Hematol 2008; 89:113-117. [PMID: 19109733 DOI: 10.1007/s12185-008-0201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 09/17/2008] [Accepted: 09/19/2008] [Indexed: 10/21/2022]
Abstract
We report a case of a 58-year-old man who presented with a rapidly growing proliferative lesion on the left lower limb, clinically resembling a soft tissue sarcoma 3 years after renal allograft. There was no evidence of systemic involvement on bone marrow needle aspiration and computed tomography (CT) scans of the chest and abdomen. The lesion turned out to be primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL LT), as defined in the recent World Health Organization-European Organization for Research and Treatment of Cancer (WHO-EORTC) classification of cutaneous lymphomas by skin biopsy. Immunosuppression reduction, chemotherapy with CHOP regimen and local radiotherapy induced complete remission of the tumor.
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50
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Oton AB, Wang H, Leleu X, Melhem MF, George D, Lacasce A, Foon K, Ghobrial IM. Clinical and pathological prognostic markers for survival in adult patients with post-transplant lymphoproliferative disorders in solid transplant. Leuk Lymphoma 2008; 49:1738-44. [PMID: 18798108 DOI: 10.1080/10428190802239162] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We sought to determine the clinical and immunohistopathological prognostic factors for overall survival (OS) in adult patients with post-transplant lymphoproliferative disorders (PTLDs). Eighty-four patients diagnosed with PTLDs between 1980 and 2004 at the University of Pittsburgh Medical Center were identified. Immunohistochemical staining was performed on tumor tissue at the time of diagnosis for the following proteins: Bcl-2, Bcl-6, c-myc and p53. The median survival for all patients was 20.8 months, 95% CI: (7.4-77.6). On univariate analysis for OS, the following poor prognostic factors were identified: age at transplant >60 years (p = 0.024), multiorgan transplant (p = 0.019), ECOG > 2 (p < 0.0001), grafted organ involvement (p < 0.0001), extranodal disease (p = 0.011), early (<1 year) PTLDs (p < 0.0001), stage IV (p = 0.0017), EBV positive (p = 0.012) and elevated white blood count (p = 0.010). Good prognostic factors included ECOG<2 (p < 0.0001), late (>1 year) PTLDs (p = 0.002), early stage at diagnosis (stages I and II, p = 0.005), nodal disease (p = 0.0053), monomorphic disease (0.0034), initial immunosuppression reduction (p = 0.0015) and use of rituximab (p = 0.045). Bcl-2 but not Bcl-6, c-myc, or p53 correlated with poor survival, p = 0.0036. This study identifies new clinical and pathological markers for poor survival in PTLDs.
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Affiliation(s)
- Ana B Oton
- Department of Internal Medicine, Division of Hematology/Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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