title: Chemoimmunotherapy and withdrawal of immunosuppression for monomorphic posttransplant lymphoproliferative disorders.
abstract: BACKGROUND
  Monomorphic PTLDs are the most aggressive type of PTLD occurring after SOT. Current guidelines for treatment suggest a stepwise approach that includes a reduction of immunosuppression (RIS) with or without rituximab, followed by chemotherapy if there is no response. Nevertheless, recommendations regarding the extent and duration of RIS are nonstandardized and RIS as an initial strategy might be associated with an unacceptably high frequency of graft loss and disease progression.
  
  
  METHODS
  We reviewed the outcome of a combination program of aggressive chemoimmunotherapy and complete withdrawal of immunosuppression in treating 22 patients with monomorphic PTLD between January 1995 and August 2012.
  
  
  RESULTS
  Twelve of 22 patients (55%) received CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) every 2 weeks (dose-dense CHOP-R) and 10 patients received other doxorubicin-based regimens. There was no treatment-related mortality. Complete response was seen in 91% of patients. Median OS was 9.61 years (95% confidence interval (CI), 5.21-10.74). Median progression-free survival was 5.39 years (95% CI, 2.10-10.74). The graft rejection rate was 18% (95% CI, 0.03-0.34).
  
  
  CONCLUSIONS
  The use of aggressive chemoimmunotherapy in combination with the withdrawal of immunosuppression approach yields excellent results and should be prospectively studied in a multi-institutional setting.
authors.affiliation: Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT. Electronic address: nikolai.podoltsev@yale.edu.
authors.forename: Nikolai
authors.initials: N
authors.lastname: Podoltsev
authors.forename: Bingnan
authors.initials: B
authors.lastname: Zhang
authors.forename: Xiaopan
authors.initials: X
authors.lastname: Yao
authors.forename: Ivan
authors.initials: I
authors.lastname: Bustillo
authors.forename: Yanhong
authors.initials: Y
authors.lastname: Deng
authors.forename: Dennis L
authors.initials: DL
authors.lastname: Cooper
mesh_terms: D000328:Adult; D000368:Aged; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D003520:Cyclophosphamide / Q000627:therapeutic use; D004317:Doxorubicin / Q000627:therapeutic use; D005260:Female; D006084:Graft Rejection / Q000517:prevention & control; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects; D007167:Immunotherapy; D008232:Lymphoproliferative Disorders / Q000209:etiology* / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016377:Organ Transplantation / Q000009:adverse effects*; D011241:Prednisone / Q000627:therapeutic use; D000069283:Rituximab; D016896:Treatment Outcome; D014750:Vincristine / Q000627:therapeutic use; D028761:Withholding Treatment; D055815:Young Adult
chemical_list: D058846:Antibodies, Monoclonal, Murine-Derived; C571759:R-CHOP protocol; D000069283:Rituximab; D014750:Vincristine; D004317:Doxorubicin; D003520:Cyclophosphamide; D011241:Prednisone
keywords: Graft loss; Organ rejection; Rituximab; Solid organ transplantation; Treatment-related mortality
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