POST – TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD)
PTLD is a common cancer that occurs after an organ or stem cell transplant. In almost every case, this type of cancer is associated with Epstein-Barr virus or EBV. The virus can be acquired after the transplant procedure is done, known as a primary infection or can get re-activated if the patient already had the virus prior to the transplant. Primary infection of this virus can be acquired through the donor of the organ or from the environment.
Most cases of PTLD occur within the first year of the transplant. This is because the most intense immunosuppression is given right after the transplant procedure in order to prevent rejection. This unfortunately causes the virus to proliferate and cause PTLD. There is a higher incidence in children who receive a transplant compared to adults. Higher rates are also seen after heart, heart-lung or small bowel transplants. Approximately 0.6 to 1.5 percent of kidney transplant recipients will develop PTLD compared to approximately 5 percent in heart transplant recipients.
Clinically, there is a wide range of features that PTLD can present with, from a rapidly spreading disease to a localized, painless lump, usually in the armpit, neck or groin. General symptoms of malaise, fever and night sweats can occur.
When a suspicious lesion is found, a biopsy is usually performed which will then confirm the diagnosis of PTLD.
Treatment of PTLD involves the transplant team and the cancer specialist. It involves lowering the dose of the immunosuppressive medications and monitoring the condition of the transplant and the PTLD. In early cases, lowering the dose is usually enough. This will give the body’s immune system to fight the PTLD. If lowering immunosuppression is not working or not possible for fear of rejection of the organ, other treatment options are employed.
a) Rituximab, an antibody drug, which is part of treatment for a type of lymphoma, known as B-cell non-Hodgkin lymphoma.
b) Chemotherapy, this is either given alone or in combination with rituximab
c) Radiotherapy, for localized PTLD or if PTLD is in the brain or spinal cord
d) Surgery, when it is localized and can be removed