BOF: Malignant (NHL/PTLD)

Which ONE of the following statements regarding treatment of post-transplant immunosuppressive disorder (PTLD) is TRUE?

a) First line treatment for patients with PTLD should be single agent rituximab where not contraindicated.

b) High dose methotrexate is required in most cases of PTLD affecting the central nervous system,

c) In PTLD affecting the central nervous system which has responded fully to immunosuppression reduction, radiotherapy is essential.

d) Patients relapsing with PTLD following an initial complete remission to rituximab and chemotherapy should not receive further rituximab-based chemotherapy.

e) Patients with high clinical risk PTLD whose disease has progressed despite immunosuppression and a course of rituximab and chemotherapy should be offered second line chemotherapy.

Answer:

c) In PTLD affecting the central nervous system which has responded fully to immunosuppression reduction, radiotherapy is essential.

Explanation:

First line treatment for PTLD is reduction of immunosuppression. Should this fail, patients should be offered single agent rituximab if the disease is of low clinical risk, and rituximab with chemotherapy if the disease is clinically aggressive or they have organ compromise.

CNS PTLD is relatively common and its prognosis extremely poor however it may be treated. Treatment goals and priorities should be set carefully based on toxicity of therapy and likelihood of success. Reasonable outcomes have been reported using radiotherapy consolidation following initial reduction of immunosuppression. The use of high dose methotrexate is limited in these patients by its renal excretion, and by poor tolerance of toxicity in the post-transplant population in general. However, this option may be preferred by some oncologists.

Patients relapsing having achieved a remission with rituximab based chemotherapy should receive another rituximab based course of chemotherapy. However, intensifying chemotherapy following progression after rituximab based chemotherapy is usually not beneficial and generally the disease should be palliated rather than pursuing an aggressive treatment course.

Reference:

Parker A, Bowles K, Bradley JA, et al. Management of post-transplant lymphoproliferative disorder in adult solid organ transplant recipients - BCSH and BTS Guidelines. Br J Haematol 2010; 149:693.