Admissions for posttransplant lymphoproliferative disorder: a 9-year longitudinal analysis of the National (Nationwide) Inpatient Sample

Background

Posttransplant lymphoproliferative disorder (PTLD), a term that encompasses a wide array of malignancies that occur after transplant, can be one of the most devastating transplant complications. While there have been major advancements in care, especially after the landmark PTLD-1 trial in 2012, there is a paucity of information on hospitalizations for PTLD and the changes in hospitalizations over time.

Methods

This retrospective cohort study used the National Inpatient Sample to identify hospitalizations for PTLD that occurred between 2009 and 2018. We extracted data for hospitalizations with a primary or secondary diagnosis of PTLD and examined a range of variables, including age, gender, race, hospital type, hospital location, and disposition status. We also collected data on hospital region, median household income, insurance status, and bed size.

Results

There was a statistically significant increase in the number of hospitalizations from 2009 to 2019 and an increasing rate of hospitalizations over the study period. Hypertension, electrolyte imbalances, renal failure, and anemia were among the most common comorbidities. We found an increased mortality rate, but this was not statistically significant.

Conclusion

Our study provides insight into the changes in hospitalizations for PTLD over nearly a decade, showing an increase in hospitalizations and reports of comorbidities.

Post-transplant Lymphoproliferative Disease (PTLD) of The Larynx in an Adult With Kidney Transplant; A Case Report

Post-transplant lymphoproliferative disease (PTLD) is a clinicopathologic entity characterized by an abnormal lymphocytic proliferation that occurs in immunosuppressed patients following organ transplantation. Several sites in the head and neck may be affected by PTLD with rare involvement of the larynx. Affected patients often present with symptoms and signs suggestive of a malignant lesion. Early diagnosis using histopathologic examination is paramount to prevent life-threatening airway compromise. The authors of this manuscript report a 52-year-old women, diagnosed case of renal failure for which she had undergone kidney transplant, who presented with symptoms of laryngeal PTLD. The clinical work-up and management of these cases is reviewed.

Posttransplant Lymphoproliferative Disorder in Children: A 360-degree Perspective

An earlier incorrect version of this article appeared online. This article was corrected on December 17, 2019.

Airway plaque presenting after alteration of immunosuppression in a pediatric patient remote from heart transplantation

Success after solid organ transplantation is dependent on the proper balance of immunosuppression to prevent rejection of the allograft while limiting the risk of developing infections and malignancy. We present a 9-year-old girl, remote from transplant, who presented with airway plaque after a change in immunosuppression to include the mTOR inhibitor sirolimus. Differential diagnosis included direct medication side effect, infection, and neoplasia.

Posttransplant Lymphoproliferative Disorder: Otolaryngological Manifestations and Management

Objective

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

Data Sources

PubMed/Medline.

Review Methods

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

Conclusion

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

Implications for Practice

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

Airway inflammation and symptoms in children following liver and heart transplantation

OBJECTIVES

To describe the upper airway endoscopic findings of children with upper airway symptoms after liver transplantation (LT) or heart transplantation (HT).

METHODS

Review of children undergoing airway endoscopy after LT or HT from 2011 to 2015 at a tertiary care pediatric hospital. Airway findings, biopsy results, immunosuppression, and Epstein-Barr virus (EBV) levels were recorded.

RESULTS

Twenty-three of 158 LT (111) and HT (47) recipients underwent endoscopy. Median time from LT to endoscopy was 9 months (range 4-25) and 31 months (range 1-108) for HT. Thirteen of 23 patients presented with upper airway symptoms, and 10/23 presented with respiratory failure or for surveillance. Thirteen patients with upper airway symptoms had abnormal findings (7 LT; 6 HT), most commonly arytenoid edema (13 patients). There were five EBV-positive biopsies (four with post-transplant lymphoproliferative disorder), and six EBV-negative biopsies with lymphocytic inflammation. One biopsy demonstrated fungal infection. Immunosuppression was decreased in seven patients, and three received steroids. There were no episodes of allograft rejection. No patients had airway symptoms at last follow-up.

CONCLUSIONS

In pediatric solid organ transplant recipients, symptoms of airway obstruction are not uncommon and should be evaluated with endoscopy. Endoscopy without symptoms is low-yield. Treatment with decreased immunosuppression improved airway symptoms.

Post-transplant lymphoproliferative disorder of the pediatric airway: Presentation and management

OBJECTIVE

Post-transplant lymphoproliferative disorder (PTLD) is a rare complication of immunosuppression with little consensus on its evaluation and management. The purpose of this contemporary review is to describe a pediatric patient with PTLD of the airway and review the literature to provide multidisciplinary recommendations regarding management.

DATA SOURCES

Retrospective chart and literature review.

REVIEW METHODS

A pediatric patient with PTLD of the airway is described. An extensive literature search to review the existing data on pediatric PTLD of the upper airway was also performed.

RESULTS

A pediatric patient with mixed fetal/embryonal hepatoblastoma developed laryngo-tracheal PTLD following liver transplantation. Diagnostic positron emission tomography (PET) scan demonstrated multiple sites of abnormal fluorodeoxyglucose (FDG) uptake within the larynx, distal esophagus, cervical lymph nodes, and abdomen concerning for PTLD. Laryngeal biopsy demonstrated Epstein-Barr virus (EBV) positive cells confirming the diagnosis. Rituximab therapy and reduction of immunosuppression resulted in resolution of his laryngeal disease in 3 months. An extensive literature search to review the existing data on pediatric PTLD of the larynx and trachea revealed 14 reported cases.

CONCLUSIONS

PTLD of the pediatric airway is an EBV-associated disease that requires a high index of suspicion as patients can often present with non-specific signs and symptoms but progress to have significant airway compromise. Evaluation consists of peripheral blood polymerase chain reaction (PCR) assays, biopsy, and PET/CT imaging. Management options include reduction of immunosuppression and/or systemic therapies.

Posttransplant Lymphoproliferative Disorder involving the Larynx

Aim:

Our goal is to present an unusual case of posttransplant lymphoproliferative disorder (PTLD) involving the larynx. We aim to expand the literature regarding head and neck manifestations involving PTLD and for otolaryngologists to include PTLD in their differential diagnosis of laryngeal lesions in patients who have a history of solid organ transplantation.

Background

Posttransplant lymphoproliferative disorder occurs in immunocompromised patients following solid organ transplantation. Head and neck manifestations most commonly involve Waldeyer's ring with the larynx and trachea being relatively uncommon sites of disease. However, lesions of the larynx can cause acute airway obstruction and rare fatalities have been reported in the literature.

Case report

We present the case of a 51-year-old female with a history of renal transplantation, who presented to the office after an incidental supraglottic lesion was discovered during intubation for cochlear implant placement. A mucosalized lesion arising from the right aryepiglottic fold with dynamic obstruction of the airway was noted on office endoscopic examination. Imaging revealed extension of the mass into the right posterolateral hypopharynx. The patient was taken to the operating room for microdirect laryngoscopy and CO2 laser excision of the mass. The lesion was excised with negative gross margins. Final pathology revealed plasmacytoma-like PTLD and the patient was referred back to her transplant team for modulation of her immunosuppressive therapy.

Conclusion

We present the case of an incidental supraglottic lesion in a posttransplant patient. Special emphasis should be given to the tissues of Waldeyer's ring and larynx.

Clinical significance

Posttransplant lymphoproliferative disorder, while rare, should be kept in the differential diagnosis of pharyngeal and airway lesions in patients with a history of solid organ transplantation. Expansile lesions can cause acute airway obstruction. Urgent evaluation and treatment of theses lesions is necessary in these circumstances.

How to cite this article

Kohli N, Wasserman JM. Posttransplant Lymphoproliferative Disorder involving the Larynx. Int J Head Neck Surg 2016;7(1):53-56.