A Rare Case of Classical Hodgkin Lymphoma 10 Years After Liver Transplantation

Posttransplant lymphoproliferative disorders (PTLDs) are rare and potentially life-threatening complications that may arise from solid organ transplantation or allogeneic hematopoietic stem cell transplantation. PTLD risk is associated with Epstein-Barr virus (EBV) infection. Among possible PTLD disorders, classical Hodgkin lymphoma (cHL) occurs in only 1.8% to 3.4% of cases. In addition, the incidence of PTLD following liver transplantation is relatively low at only 2% to 3% compared to other transplants.

A recently published study in Case Reports in Oncology describes a rare case of EBV-positive cHL occurring 10 years after liver transplantation. “To our knowledge, this is the first report of cHL occurring with such a long interval after liver transplantation,” report the authors. The study follows a 61-year-old male, with a history of previous hepatitis B, chronic obstructive pulmonary disease (COPD) with pulmonary emphysema related to tobacco use and frequent alcohol consumption. He also had a chronic hepatitis C virus infection (HVC), which lead to cirrhosis and hepatocellular carcinoma, for which he was treated with a liver transplantation. Ten years following the transplant, the patient presented with superficial lymphadenopathies and a weight loss of 15 kg.

Upon presentation, the patient tested positive for EBV DNA by PCR, but tested negative before the start of treatment. He tested negative for hepatitis B surface antigen, hepatitis C RNA, and human immunodeficiency virus, but positive for hepatitis B core antibody. Lymphadenopathy was confirmed via a whole-body CT scan. A biopsy of an axillary lymph node revealed subverted architecture and the existence of Hodgkin and Reed Sternberg cells among inflammatory cells. Upon immunohistochemistry analysis, a diagnosis of cHL PTLD stage IVB was made.

PTLDs may also be caused by intense immunosuppression. Consequently, the first course of PTLD treatment is to reduce immunosuppressive agents. In the present case, following the suspension of immunosuppressant drugs, the patient underwent an ABVD chemotherapy regimen with reduced bleomycin for the first 2 cycles and without bleomycin for cycles 3 to 6, to prevent bleomycin-induced lung toxicity in consideration of the patient’s COPD, lung emphysema, and smoking. Seven months following chemotherapy the patient was in complete remission.

Incidence of PTLD is related to a variety of factors including the type of organ transplantation, the level of immunosuppression, the occurrence of viral infections, and the patient’s age at transplantation. Due to the heterogeneity of PTLD disorders and the rarity of PTLD cHL there is no standard treatment. According to the authors, there are a number of factors to consider when making treatment decisions including pathological subtype, grade, and site of the tumor as well as on adequate assessment of the patient’s clinical state, including transplanted organ function. “Treatment of cHL PTLD is compatible with consideration of the agent’s toxicity, the patient’s graft function, and his/her capacity to tolerate therapy,” conclude the authors. “The development of individual risk-adapted treatments may improve long-term outcomes for cHL patients.”

Reference

Zhang L, Pereira Mestre R, Bihl F, et al. A rare case of classical Hodgkin lymphoma diagnosed 10 years after liver transplant. Case Rep Oncol. 2017;10(3):923-927.