POST TRANSPLANT LYMPHOPROLIFERATIVE DISORDER AFTER SOLID ORGAN TRANSPLANT

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POST TRANSPLANT LYMPHOPROLIFERATIVE
DISORDERAFTER SOLID ORGAN TRANSPLANT

• ADEMOLA ADEROJU

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OVERVIEW

• PTLD is most common malignancy following solid
  organ transplant (except non melanoma skin ca and
  cervical ca)
• 21 post transplant vs 5 in general population
• NHL 95 vs 65 in general population
• Seen in heart gt lung gt liver gt kidney transplant
  patients
• Risk factors include duration/intensity of
  immunosupression and EBV seropoitivity

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OVERVIEW

• Mostly B cell lymphomas, but occasionally T-cell
  and NK cell
• Thought to involve EBV mediated transformation of
  B cells
• Immunosupression may deplete T cells, allowing
  these B cells to escape control by cytotoxic T
  cells
• Also seen after hematopoietic transplants

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Pathogenesis

• PTLD cells may originate in donor or recipient
  (more commonly donor)
• EBV infected B cells proliferate in absence of
  adequate T cell control
• EBV negative PTLD occurs, but not as common
  (20)
• EBV negative T cell disease seen in late onset
  PTLD (more aggressive).

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Presentation

• More than 50 present with extra-nodal masses
• Involved organs include GI tract, lungs, skin,
  and liver
• Allograft may also be involved (up to 25)
• CNS involvement in up to 25 (rare in non
  transplant population)

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DIAGNOSIS

• Requires high index of suspicion
• Radiographic evidence of mass
• Increased LDH
• PET scan
• Bone marrow biopsy
• Biopsy of focal lesions

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Pathology

• Disruption of tissue architecture
• EBV infected cells
• Flow cytometry
• Cytogenetics

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Treatment

• Reduction in immunosupression
• Chemotherapy CHOP
• Antiviral questionable evidence
• Rituximab anti CD20 antibody
• Interferon alpha case reports/series
• Surgery for focal masses
• Re-transplantation

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Prevention

• Limit aggressive immunosupression
• Prophylaxis with gangiclovir for high risk
  patients

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Take home point

• High degree of suspicion in our patient
  population of post transplant patients