Post-transplant lymphoproliferative disorders (PTLD) are rare, but significant complications following transplantation. Although organ-specific cases have been reported, primary presentation in the thoracic cavity has not been fully characterized.
11 cases of PTLD with a primary thoracic presentation were identified among solid organ or bone marrow (BM) transplant patients from 1990-2002.
Patients include 8 men and 3 women (mean age of 49 years). Transplant cases were as follows: 1 heart, 3 lung, 2 kidney/pancreas, 3 kidney, 2 BM, and 0 liver. Time to presentation ranged from 1 to 97 months and was <1 year in 6 and >1 year in 5 cases. Pre-transplant EBV and CMV status were negative in 8/10 and 9/10 cases, respectively. Patients presented with mediastinal adenopathy (7/11) or pulmonary parenchymal lesions (5/11). 6/11 also had extra-thoracic involvement. 8 presented with constitutional symptoms. Pathologic diagnosis was achieved by CT-guided fine needle aspiration (FNA) in 8 patients or by an open biopsy procedure in 3 patients. Pathologic analysis revealed B-cell lymphoproliferative disorder in 9/11 cases, anaplastic large cell lymphoma in 1, and Hodgkin’s lymphoma in 1. 5/6 specimens evaluated for EBV were positive by in situ hybridization or immunohistochemistry. All patients were initially treated with reduction in immunosuppresion and 6 received adjuvant chemotherapy. Overall, mortality was 64%: 4/7 patients died from complications of PTLD (1 heart, 1 BM, 2 kidney), and 3/7 (3 lung) died from rejection. The mean interval from diagnosis to death was 13 months.CONCLUSIONS: PTLD may present in the thoracic cavity regardless of organ transplanted and must be considered as a potentially fatal complication in immuno-suppressed transplant patients. Long-term survival remains poor and is worse for heart or lung recipients who will not tolerate rejection associated with suboptimal drug regimens.
Most diagnoses can be obtained via CT-guided FNA. Earlier diagnosis and improvements in chemotherapy and immunosuppresion may improve survival for these high-risk patients.
M.E. Halkos, None.