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Rituximab and autologous stem cell transplantation for malignant lymphoma after liver transplantation

Bone Marrow Transplantation volume 33, pages 1071–1072 (2004)Cite this article

Post transplant lymphoproliferative disorders (PTLDs) occur in 0.7–32% of solid organ transplant (SOT) patients.1 Most PTLDs are derived from B-lineage lymphocytes and are associated with active Epstein–Barr virus (EBV) infection.1,2 As these disorders are aggressive, the prognosis for patients with PTLDs is poor, and 50–80% of patients who have monoclonal PTLDs after undergoing SOTs die.1 In fact, PTLDs are the main cause of morbidity and mortality among high-risk transplant recipients.2 Among the factors predictive of survival in patients with PTLDs are performance status and the number of involved sites.3 The occurrence of PTLD depends on the type, degree, and duration of the immunosuppressive therapy administered. The restoration of immunocompetence is the first-line treatment for PTLDs, but many patients also require: surgery, radiotherapy, chemotherapy, or immunotherapy.4 The following case study describes a patient diagnosed with diffuse large B-cell lymphoma (DLBCL) 14 years after a liver transplant who was successfully treated with chemotherapy, monoclonal antibodies, and autologous stem cell transplantation (ASCT).

The patient, Caucasian woman, at the age of 35 years received an orthotopic liver transplant for biliary cirrhosis and remained asymptomatic with cyclosporine alone. After 14 years, the patient was admitted to our hospital with malaise, fever, and abdominal pain. Computed tomography and laparotomy revealed an abdominal mass about 9 cm in diameter involving the small bowel. Histological study revealed DLBCL (CD20 positive). The tumor cells were negative for EBV (latent membrane protein 1 was negative by immunohistochemical analysis). BCL-2 was negative by immunohistochemical analysis. The patient's clinical characteristics comprised the following: Ann Arbor stage IV disease, performance status 2, normal lactate dehydrogenase, and the involvement of more than two extranodal sites (intestine, bone marrow, and central nervous system (CNS)). Involvement of the CNS was confirmed by the presence of tumor cells in the cerebrospinal fluid and was associated with meningeal symptoms. Cyclosporine was stopped, and the patient was given eight cycles of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone), anti-CD20 antibody (rituximab), and 10 intrathecal therapies (methotrexate, cytarabine, and hydrocortisone). Rituximab was administered with each chemotherapy cycle on day 1. The patient's disease went into complete remission but because of her poor prognosis (low performance status and disseminated disease), we decided to administer intensification treatment with ASCT. The conditioning regimen comprised carmustine, etoposide, cytarabine, and melphalan (BEAM), and the source of hematopoietic stem cells was the peripheral blood. She suffered no significant complications and soon recovered adequate neutrophil (day 15 after progenitor cell infusion) and platelet (day 16 after progenitor cell infusion) levels. Her liver function remained normal, and hepatic rejection did not occur. At 18 months after ASCT, the patient's disease remains in complete remission and she has started tacrolimus (FK506) treatment.

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  1. Department of Haematology, Hospital General Universitario de Alicante and Hospital General de Elda, Spain

    B Sánchez-González, P Fernández-Abellán, MC Garcia Garay, B Villarrubia, M F Palmero & C Rivas

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Sánchez-González, B., Fernández-Abellán, P., Garay, M. et al. Rituximab and autologous stem cell transplantation for malignant lymphoma after liver transplantation. Bone Marrow Transplant 33, 1071–1072 (2004). https://doi.org/10.1038/sj.bmt.1704468

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