title: Reduction in immunosuppression as initial therapy for posttransplant lymphoproliferative disorder: analysis of prognostic variables and long-term follow-up of 42 adult patients.
abstract: BACKGROUND
  Posttransplant lymphoproliferative disorder (PTLD) is an Epstein-Barr virus-associated malignancy that occurs in the setting of pharmacologic immunosuppression after organ transplantation. With the increased use of organ transplantation and intensive immunosuppression, this disease is becoming more common. We explore reduction in immunosuppression as an initial therapy for PTLD.
  
  
  METHODS
  We analyzed our organ transplant patient database to identify patients with biopsy-proven PTLD who were initially treated with reduction of their immunosuppressive medications with or without surgical resection of all known disease.
  
  
  RESULTS
  Forty-two adult patients were included in this study. Thirty patients were treated with reduction in immunosuppression alone. Twelve patients were treated with both reduction in immunosuppression and surgical resection of all known disease. Thirty-one of 42 patients (73.8%) achieved a complete remission. Of those patients who were treated with reduction in immunosuppression alone, 19 of 30 (63%) responded with a median time to documentation of response of 3.6 weeks. Multivariable analysis showed that elevated lactate dehydrogenase (LDH) ratio, organ dysfunction, and multi-organ involvement by PTLD were independent prognostic factors for lack of response to reduction in immunosuppression. In patients with none of these poor prognostic factors, 16 of 18 (89%) responded to reduction in immunosuppression in contrast to three of five (60%) with one risk factor and zero of seven (0%) with two to three factors present. The analysis also showed that increased age, elevated LDH ratio, severe organ dysfunction, presence of B symptoms (fever, night sweats, and weight loss), and multi-organ involvement by PTLD at the time of diagnosis are independent prognostic indicators for poor survival. With median follow-up of 147 weeks, 55% of patients are alive with 50% in complete remission.
  
  
  CONCLUSIONS
  Reduction in immunosuppression is an effective initial therapy for PTLD. Clinical prognostic factors may allow clinicians to identify which patients are likely to respond to reduction in immunosuppression.
authors.affiliation: Hematologic Malignancies Program, University of Pennsylvania Cancer Center, Philadelphia 19104, USA. detsai@mail.med.upenn.edu
authors.forename: D E
authors.initials: DE
authors.lastname: Tsai
authors.forename: C L
authors.initials: CL
authors.lastname: Hardy
authors.forename: J E
authors.initials: JE
authors.lastname: Tomaszewski
authors.forename: R M
authors.initials: RM
authors.lastname: Kotloff
authors.forename: K M
authors.initials: KM
authors.lastname: Oltoff
authors.forename: B G
authors.initials: BG
authors.lastname: Somer
authors.forename: S J
authors.initials: SJ
authors.lastname: Schuster
authors.forename: D L
authors.initials: DL
authors.lastname: Porter
authors.forename: K T
authors.initials: KT
authors.lastname: Montone
authors.forename: E A
authors.initials: EA
authors.lastname: Stadtmauer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000627:therapeutic use; D044383:Black People; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D008232:Lymphoproliferative Disorders / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016377:Organ Transplantation; D010414:Pennsylvania; D011183:Postoperative Complications / Q000517:prevention & control*; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D044465:White People; D001741:Black or African American
chemical_list: D000998:Antiviral Agents; D007166:Immunosuppressive Agents