Important Considerations in the Diagnosis and Management of Post-transplant Lymphoproliferative Disorder

Abstract

Purpose of review: A relative lack of molecular and clinical studies compared to other lymphoid cancers has historically made it difficult to determine optimal management approaches in post-transplant lymphoproliferative disorder (PTLD). We sought to better define the "state of the science" in PTLD by examining recent advances in risk assessment, genomic profiling, and trials of PTLD-directed therapy.

Recent findings: Several major clinical trials highlight risk-stratified sequential therapy incorporating rituximab with or without chemotherapy as a rational treatment strategy in patients with CD20+ PTLD who do not respond to reduction of immunosuppression alone. Epstein Barr virus (EBV)-targeted cytotoxic lymphocytes are a promising approach in patients with relapsed/refractory EBV+ PTLD, but dedicated clinical trials should determine how autologous chimeric antigen receptor T cell therapy (CAR-T) may be safely administered to PTLD patients. Sequencing studies underscore the important effect of EBV infection on PTLD pathogenesis, but comprehensive genomic and tumor microenvironment profiling are needed to identify biomarkers that predict response to treatment in this clinically heterogeneous disease.

Keywords: Epstein-Barr virus; Hematopoietic stem cell transplant; Post-transplant lymphoproliferative disorder; Solid organ transplant.

Fig. 1

Histopathologic features of post-transplant lymphoproliferative disorder (PTLD) subtypes. Left panels are representative H&E slides. Right panels highlight immunohistochemistry stains of interest (brown). A, B Non-destructive PTLD, infectious mononucleosis-like type. Brain tissue with mild small lymphocytic infiltrate and admixed scattered plasma cells (green arrow, A, 200 ×) and CD3+ T cells (B, 200 ×). C, D Polymorphic PTLD. Colonic mucosa heavily infiltrated by lymphoplasmacytic cells (C, 100 ×) that are predominantly small in size and composed of CD3+ T cells (D, 100 ×). E, F Monomorphic PTLD, diffuse large B cell lymphoma type. Diffuse infiltration of large, atypical lymphocytes (E, 200 ×) that are exclusively CD20+ (F, 200×). G, H Hodgkin-like PTLD, Reed-Sternberg (green arrow), and Hodgkin cells in the background of lymphohistiocytic infiltrate (G, 200 ×). Neoplastic cells are CD30+ (H, 200 ×)