Post-transplant lymphoproliferative disease in heart and lung transplantation: Defining risk and prognostic factors.
BACKGROUND
Heart and lung transplant recipients have among of the highest incidence rates of post-transplant lymphoproliferative disease (PTLD). Despite this, there is a paucity of data specific to this group. We collated data on heart, lung and heart-lung transplant recipients with PTLD to identify disease features and prognostic factors unique to this group of patients.


METHODS
Seventy cases of PTLD were identified from a single institution (41 heart, 22 lung, 6 heart-lung and 1 heart-kidney transplant) from 1984 to 2013. Demographics, immunosuppression, treatment, response, complications and survival data were analyzed. Uni- and multivariate Cox regression analyses were performed to identify prognostic factors.


RESULTS
The incidence of PTLD was 7.59% in heart-lung, 5.37% in heart and 3.1% in lung transplant recipients. Extranodal disease (82%) with diffuse large B-cell lymphoma (72%) was the most common presentation. Bone marrow involvement (13%) and central nervous system disease (3%) were uncommon. Heart transplant recipients had later onset of PTLD (>1 year post-transplant), with less allograft involvement, compared with lung and heart-lung recipients. Poor prognostic markers were bone marrow involvement (HR 6.75, p < 0.001) and serum albumin <30 g/liter (HR 3.18, p = 0.006). Improved survival was seen with a complete response within 3 months of treatment (HR 0.08, p < 0.001). Five-year overall survival was 29%.


CONCLUSIONS
This analysis is the largest to date on PTLD in heart and lung transplant recipients. It provides a detailed analysis of the disease in this group of patients and identifies unique prognostic features to aid risk stratification and guide treatment allocation.
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Gayathri
G
Kumarasinghe
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Orly
O
Lavee
Department of Anatomical Pathology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Andrew
A
Parker
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Ian
I
Nivison-Smith
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Samuel
S
Milliken
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Anthony
A
Dodds
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Joanne
J
Joseph
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
Keith
K
Fay
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia.
David D
DD
Ma
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Monique
M
Malouf
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Marshall
M
Plit
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Adrian
A
Havryk
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Ann M
AM
Keogh
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Christopher S
CS
Hayward
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Eugene
E
Kotlyar
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Andrew
A
Jabbour
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Allan R
AR
Glanville
Heart Lung Transplant Unit, St Vincent's Hospital, Sydney, New South Wales, Australia.
Peter S
PS
Macdonald
Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia. Electronic address: john.moore@svha.org.au.
John J
JJ
Moore
D000293:Adolescent; D000328:Adult; D000368:Aged; D001706:Biopsy; D002648:Child; D005260:Female; D006084:Graft Rejection / Q000150:complications* / Q000175:diagnosis / Q000517:prevention & control; D006333:Heart Failure / Q000601:surgery; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D015994:Incidence; D008171:Lung Diseases / Q000601:surgery; D016040:Lung Transplantation / Q000009:adverse effects*; D008232:Lymphoproliferative Disorders / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009517:New South Wales / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014184:Transplantation, Homologous; D055815:Young Adult
PTLD; heart transplant; lung transplant; post-transplant malignancies