Posttransplant lymphoproliferative disorders of the central nervous system after kidney transplantation: single center experience over 40 years. Two case reports

Primary central nervous system post-transplantation lymphoproliferative disorder: A case report and systematic review of imaging findings

Primary central nervous system post-transplant lymphoproliferative disease (PCNS-PTLD) is a rare subset of post-transplant lymphoproliferative disorder (PTLD) isolated to the CNS without nodal or extra-nodal organ involvement [1,2]. PCNS-PTLD occurs primarily in patients following either solid organ transplants or hematopoietic stem cell transplants and tends to be monomorphic DLBCL. The development of PCNS-PTLD is commonly associated with EBV infection [3]. Many intracranial pathologies can resemble the imaging appearance of PCNS-PTLD, including primary CNS lymphoma, glial tumors, metastatic disease, and intracranial abscesses. The purpose of this systematic review is to identify the most common imaging characteristics of PCNS-PTLD. Our review included 97 sources that describe the imaging appearance of PCNS-PTLD. Based on our review, PCNS-PTLD lesions are typically multifocal, ring-enhancing and diffusion-restricting. PCNS-PTLD lesions typically demonstrate focal FDG avidity. Despite advancement in medical imaging, PCNS-PTLD remains a diagnostic challenge due to its rare incidence. Limited data is available on advanced imaging with regards to PTLD, but techniques including DCE-MRI and fMRI demonstrate promising results that may help further delineate PCNS-PTLD.

Spontaneous regression of central nervous system posttransplant lymphoproliferative disease: A case report

RATIONALE

Primary central nervous system (CNS) posttransplant lymphoproliferative disease (PTLD) is a very rare entity. Patients may respond to reduction of immunosuppression or other therapies, but the prognosis is still pessimistic.

PATIENT CONCERNS

Herein, we report a 40-year-old female with a history of renal transplantation developed brain masses 4 years ago. Although brain biopsy was performed, PTLD was underdiagnosed then. No relevant treatment was administered. However, the lesions resolved spontaneously. After 4 years, new lesion appeared in a different brain region.

DIAGNOSES

The history of renal transplantation raised the suspicion of PTLD. Reexamination of previous brain sections confirmed the diagnosis of polymorphic PTLD (P-PTLD). A second biopsy of the new lesion also demonstrated P-PTLD.

INTERVENTIONS

She was referred to hematology department to receive rituximab.

OUTCOMES

After 4 rounds of treatment, the lesion resolved satisfactorily.

LESSONS

This case demonstrates the natural history of primary CNS P-PTLD. Although self-remission and recurrence is possible, aggressive measures should be taken to this condition.

[EBV-positive central nervous system lymphoproliferative disease associated with immunosuppression after organ transplantation: Long-term remission without chemotherapy]

Primary central nervous system (CNS) lymphomas account for 13-20% of the posttransplant lymphoproliferative disorders (PTLD) and rank among the most aggressive conditions. Reduction of immunosuppressive therapy should be mandatory to treat PTLD, but this is rarely used as the only therapy option. Chemotherapy regimens for PTLD involving the CNS most commonly include high-dose rituximab and high-dose methotrexate and/or cytarabine. The efficiency only of discontinuation of immunosuppressive therapy for PTLD does not exceed 5-10%, but there are no literature data on its efficiency for PTLD involving the CNS. The paper describes a clinical case of achieving long-term remission in a female patient with Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma involving the central nervous system, associated with immunosuppression after kidney transplantation from a related donor, in the absence of chemotherapy during immunosuppressive therapy discontinuation and transplantectomy.

Primary brain lymphomas after kidney transplantation: an under-recognized problem?

Primary central nervous system post-transplant lymphoproliferative disease (CNS PTLD) is a serious complication after solid organ transplantation that has not received much attention so far. However, it could become a more frequent problem with the introduction of new biological agents.

METHODS

We identified five cases with CNS PTLD in our center who were transplanted between 1986 and 2007, three men and two women, with a mean age of 55.9 years (range 42-74). Three patients had received only kidney transplant and two patients had received a kidney-pancreas transplant.

RESULTS

The mean time from first symptoms until diagnosis was 3.5 months (2-6). One patient was diagnosed post-mortem in autopsy. The mean time from transplantation to onset of neurological symptoms was 73.8 months (31-144). The initial clinical manifestation was heterogeneous: all five cases showed headache, four cases presented with gait disturbance, one with dysarthria and two with a confusional state. Epstein-Barr virus (EBV) immunoglobulin (Ig)G serology was positive in four out of five cases; in situ hybridization for EBV in brain biopsy samples was positive in three cases, negative in one and not available in one. In four patients, EBV polymerase chain reaction (PCR) was positive in cerebrospinal fluid (CSF). After diagnosis, overall immunosuppressive load was lowered in all patients (n = 4). Three patients died at 8-104 weeks (mean 40 weeks) after diagnosis and one patient is still alive 20 months after diagnosis.

CONCLUSIONS

CNS PTLD is a complication difficult to diagnose, frequently diagnosed too late and often refractory to treatment. A more aggressive screening might be necessary in patients even with mild CNS symptoms.