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© 2003 American Society for Clinical Oncology
Patients Presenting With CNS LesionsCASE 3. SEQUENTIAL MYELOPROLIFERATIVE DISEASE AND GLIOBLASTOMA MULTIFORME IN A RENAL TRANSPLANT RECIPIENTDepartments of Medicine, Neurosurgery, and Pathology, Queen Mary Hospital, Hong Kong
A 55-year-old woman received a liver related renal transplant from her son for chronic glomerulonephritis, with cyslosporine and steroids used for immunosuppression. Eight years after transplantation, she developed persistent leukocytosis for 6 months that was unresponsive to empirical antimicrobial therapy (hemoglobin 15.6 g/dL, WBC 22.4 x 109/L, 86% neutrophils, 3% eosinophils, 4% basophils, platelet count 297 x 109/L). There was concurrent hepatosplenomegaly (Fig 1A
Because of chronic immunosuppression and alkylator exposure, renal transplant recipients are at increased risk of second malignancies. Data from the Cincinnati Transplant Tumor Registry showed 20-fold to 500-fold increases in risk for PTLD, skin cancer, hepatocellular carcinoma, and cervical carcinoma, respectively.2 We present a unique case of sequential myeloproliferative disease and GBM in a renal transplant recipient, which illustrated several interesting points. First, secondary malignancy in renal transplant recipients can have varied histology, and presentation and may disguise as infective and reactive causes. Multiple primary malignancies are not uncommon, and a high degree of vigilance is needed.3 Second, in our experience, raised EBV-DNA levels are not uncommonly found in these patients, especially in the presence of concurrent malignancy, and are of limited use in the diagnosis of EBV-related PTLD. In addition to histologic and genetic characterization, chimerism data is prudent for post-transplant malignancies, because donor derived lesions have been described for both myeloid leukemia4 and GBM.5 Finally, the risk for rare malignancies in transplant recipients is being increasingly recognized. Myeloproliferative diseases, especially chronic myeloid leukemia, often occur prematurely after renal transplantation.6,7 There is also evidence suggesting that the incidence of aggressive GBM is disproportionately increased.8 Given that second malignancies are becoming a major cause of late mortality in transplant recipients, the use of immunosuppression and alkylating agents should be rationalized.3 AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest.
REFERENCES 1. Bain B, Vardiman JW, Imbert M, et al: Myelodysplastic/myeloproliferative disease, in Jaffe ES, Harris NL, Stein H, et al (eds): Tumours of Haematopoietic and Lymphoid Tissues: World Health Organization Classification of Tumors. Lyon, France, IARC Press, 2001, pp 58–59 2. Penn I: Occurrence of cancers in immunosuppressed organ transplant recipients. Clin Transpl 147–158, 1998 3. Penn I: Cancers in renal transplant recipients. Adv Ren Replace Ther 7:147–156, 2000[Medline]
4. Bodo I, Peters M, Radich JP, et al: Donor-derived acute promyelocytic leukemia in a liver-transplant recipient. N Engl J Med 341:807–813, 1999 5. Val-Bernal F, Ruiz JC, Cotorruelo JG, et al: Glioblastoma multiforme of donor origin after renal transplantation: Report of a case. Hum Pathol 24:1256–1259, 1993[Medline] 6. Stein AM, Anthone R, Anthone S, et al: Chronic myelocytic leukemia in a young renal allografted patient. Transplantation 26:271–273, 1978[Medline] 7. Mignozzi M, Picca S: Chronic myelogenous leukemia following kidney transplantation in a pediatric patient. Pediatr Nephrol 16:852–853, 2001[Medline]
8. Schiff D, O’Neill B, Wijdicks E, et al: Gliomas arising in organ transplant recipients: An unrecognized complication of transplantation? Neurology 57:1486–1488, 2001
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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