Neoplastic PTLD. Case 4.
Posttransplant Hodgkin's Disease
This young male received a liver transplant for relief of
sclerosing cholangitis. His underlying disease was a complication
of Crohn’s disease which had been diagnosed 8 years earlier.
His family history was positive for ulcerative colitis,
Hodgkin’s disease, leukemia, and diabetes in close family
members. Following uncomplicated liver transplant, he was
discharged under Cyclosporine/steroid immunosuppression. His only
complication was a tooth abscess two months posttransplant. Five
months after transplant he complained of throbbing flank pain,
and developed fever to 103F without chills, anorexia and fatigue.
Ultrasonography revealed paraaortic nodes in the distal aorta and
pelvis, with no adenopathy elsewhere. Urine was positive for CMV.
A lymph node biopsy was consistent with mixed cellularity
Hodgkin’s disease. A trial of reduced imunosuppression was
initiated. The patient returned to his home state and was
apparently well for another 4 years, at which time recurrence of
a histologically similar tumor occurred. Few details of this
hospitalization are available at present, but he apparently
received chemotherapy for Hodgkin’s disease. The patient
expired 3.5 years following the original tumor diagnosis. The
slide series is taken from the original node biopsy and shows
effacement by a mixed cell infiltrate consistent with
Hodgkin’s disease. The infiltrate extended beyond the
capsule, and in some areas residual node elements were
identifiable. Reed-Sternberg and Hodgkin cells were easily
identified. Focal necrosis was observed (the patient had not
received chemotherapy prior to this biopsy). Eosinophils were
focally prominent and an example is given here. The large
atypical cells were positive for EBV by the EBER stain. These
cells were also among the replicating cells according to
immunostain for cell cycle-associated antigens. Molecular clonal
studies were not available.
Posttransplant Hodgkin’s disease is unusual in comparison to
posttransplant non-Hodgkin’s lymphoma. The family history of
Hodgkin’s disease is of interest in this case and it would
also be of interest to know if other transplant patients with
Hodgkin’s disease had a positive family history. In our
experience it is more common to see PTLDs with
"Hodgkin’s-like" features, rather than frank
Hodgkin’s disease. These "Hodgkin's-like" tumors
are also characterized by a minor population of
neoplastic-appearing large cells which have an appearance and
phenotype similar or identical to Reed-Sternberg cells. These
cells also contain EBV. The background cells are lymphoid, many
with an "activated" appearance. The few tumors of this
type have contained monoclonal B cells, which likely correspond
to the large cell population.
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