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Aggressive treatment for postcardiac transplant lymphoproliferation
LJ Swinnen, GM Mullen, TJ Carr, MR Costanzo and RI Fisher
Division of Hematology/Oncology, Loyola University Chicago, Maywood, IL
60153, USA.
Posttransplant lymphoproliferative disorder (PTLD) is a frequently fatal
complication of organ transplantation, occurring in 2% to 6% of cardiac
recipients. Treatment remains poorly defined. Reduction in
immunosuppression is effective in a proportion of cases, but mortality on
the order of 80% is reported for patients requiring chemotherapy. The
reason for such poor outcomes is unclear, but may be partly caused by the
concomitant use of immunosuppressives. Nineteen consecutive cardiac
recipients with PTLD were studied retrospectively in terms of clinical
features and outcome. Patients were managed according to a uniform
treatment approach. Initial therapy was a trial of reduced
immunosuppression with concomitant acyclovir followed, if unsuccessful, by
aggressive combination chemotherapy. The regimen used was predominantly
ProMACE-CytaBOM. Six patients with phenotypically polyclonal PTLD presented
less than 6 months after transplantation (median 6 weeks). Only 1 of 4
(25%) treated patients responded to reduced immunosuppression; the
remainder died of multiorgan failure. Thirteen patients presented with
phenotypically monoclonal disease > or = 6 months after transplantation.
In 8 of 12 (75%) treated patients initial therapy was reduction in
immunosuppression. None achieved complete remission (CR) and 2 experienced
fatal rejection. Two patients achieved durable surgical CR. The remaining 8
patients received chemotherapy; 2 of 8 (25%) died during treatment, 6 of 8
(75%) achieved CR. None have relapsed, at a median duration of follow-up of
38 months. Neutropenic sepsis and subclinical doxorubicin cardiotoxicity at
a mean cumulative dose of 63 mg/m2 were the principal toxicities. Our data
indicate that aggressive chemotherapy is both feasible and effective in
phenotypically monoclonal PTLD refractory to reduced immunosuppression.
ProMACE-CytaBOM is well suited to cardiac recipients, minimizing
doxorubicin exposure and obviating the need for concurrent
immunosuppressives.
Volume 86,
Issue 9,
pp. 3333-3340,
11/01/1995
Copyright © 1995 by The American Society of Hematology
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