The price of immunotherapy

When and How Is It Possible to Stop Therapy in Patients with Lupus Nephritis: A Narrative Review

Glucocorticoids and other immunosuppressants still represent the cornerstone drugs for the management of SLE and lupus nephritis. The refined use of these drugs over the years has allowed us to obtain stable disease remission and improvement of long-term kidney and patient survival. Nevertheless, a prolonged use of immunosuppressive agents may be accompanied by severe and even life-threatening side effects. Theoretically, a transient or even definitive withdrawal of immunosuppression could be useful to prevent iatrogenic morbidities. For many years, however, the risk of SLE reactivation has held clinicians back from trying to interrupt therapy. In this review, we report the results of the attempts to interrupt glucocorticoids and other immunosuppressive agents in lupus nephritis and in SLE. The available data suggest that therapy withdrawal is feasible at least in patients enjoying a complete clinical remission after a prolonged therapy. A slow and gradual reduction of treatment under medical surveillance is needed to prevent flares of activity. After therapy withdrawal, around one-quarter of patients may have kidney or systemic flares. However, most flares may respond to therapy if rapidly diagnosed. The other patients can enter stable remission for even 20 years or more. The use of antimalarials can help in maintaining the remission after the withdrawal of the immunosuppressive therapy. A repeated kidney biopsy could be of help in deciding to stop therapy, but given the few available data, it cannot be considered essential.

High rates of de novo malignancy compromise post-heart transplantation survival

BACKGROUND

Transplant patients are known to have increased risk of developing de novo malignancies (DNMs). As post-transplant survival increases, DNM represents an obstacle to further improving survival. We sought to examine the incidence, types, and risk factors for post-transplant DNM.

METHODS

We studied adult heart transplant recipients from the Organ Procurement and Transplantation Network database (1987-2018). Kaplan-Meier survival analysis was performed to determine annual probabilities of developing DNM, excluding squamous and basal cell carcinoma. Rates were compared to the general population in the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was performed to calculate hazard ratios for risk factors of DNM development, all-cause, and cancer-specific mortality.

RESULTS

Over median follow-up of 6.9 years, 18% of the 49,361 patients developed DNM, which correlated with an incidence rate 3.8 times that of the general population. The most common malignancies were lung, post-transplant lymphoproliferative disorder, and prostate. Risk was most increased for female genital, tongue/throat, and renal cancers. Male gender, older age, smoking history, and impaired renal function were risk factors for developing DNM, whereas the use of MMF for immunosuppression was protective. Cigarette use, increasing age, the use of ATG for induction and calcineurin inhibitors for maintenance were risk factors for cancer-specific mortality. The development of a DNM increased the risk of death by 40% (p < .001).

CONCLUSIONS

Heart transplant patients are at increased risk of malignancy, particularly rare cancers, which significantly increases their risk of death. Strict cancer surveillance and attention to immunosuppression are critical for prolonging post-transplant survival.

Are patients with inflammatory eye disease treated with systemic immunosuppressive therapy at increased risk of malignancy?

The purpose of this study is to review the literature on the risk of malignancy in patients with inflammatory eye disease (IED) treated with systemic immunosuppressive (IS) therapy. Relevant databases in transplant medicine, autoimmune diseases and literature regarding uveitis and scleritis were reviewed. Literature with regards systemic IS therapy in transplant recipients and patients with autoimmune diseases revealed a significant increase in malignancies, especially non-melanocytic skin cancers and lymphomas. Studies of patients with IED were limited in number and scope, with no studies adequately evaluating the incidence of malignancy in these patients. Difficulties associated with the evaluation of the risk of malignancy associated with IS therapy in patients with IED include the heterogeneity of the disease and treatment regimens as well as the low frequency of IED, its variable severity and the lack of adequate long-term follow-up studies. Systemic IS therapy is an important therapeutic option in the treatment of patients with severe IED. A well-designed, comprehensive, multi-centre long-term follow-up study is required to evaluate the risk of malignancy in patients with specific IED diseases treated with defined systemic IS therapy. Until such evidence is available, we recommend the adoption of preventative strategies to help minimise the risk of malignancy in such patients.

Função sexual e reprodutiva em receptoras de transplante hepático

RACIONAL: Anormalidades na função sexual e reprodutiva são comuns em pacientes com hepatopatia crônica avançada e podem ser revertidas após transplante hepático bem-sucedido. OBJETIVO: Avaliar aspectos da função sexual e reprodutiva em mulheres submetidas a transplante de fígado no Serviço de Transplante Hepático do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR. PACIENTES E MÉTODOS: Entre setembro de 1991 e dezembro de 2001, 94 mulheres foram submetidas a transplante hepático. Vinte e oito delas (idade média 44,17 ± 13,60 anos) preencheram os seguintes critérios de inclusão: idade > 16 anos na época do transplante, sobrevida pós-transplante > 6 meses, estar em acompanhamento regular no Serviço na época do estudo e concordância em participar do mesmo. Os prontuários médicos foram revisados e as pacientes responderam a um questionário abordando padrão dos ciclos menstruais no pré e pós-transplante, gravidez no pós-transplante, métodos contraceptivos no pré e pós-transplante, freqüência de realização de citologia oncótica cervical no pré e pós-transplante, ocorrência de neoplasia ginecológica pós-transplante, além de questionário específico para o domínio da sexualidade no período pós-transplante. RESULTADOS: A mediana do tempo de seguimento pós-transplante das 28 pacientes foi de 36,5 meses (6-110 meses) e a principal indicação para o transplante foi cirrose associada à hepatite C (25%). Todas as pacientes apresentavam função normal do enxerto. Excluindo-se 6 pacientes em menopausa (natural ou cirúrgica), 13 das 22 pacientes (59,1%) com potencial de menstruar apresentavam amenorréia no ano anterior ao transplante. Dezenove dessas 22 pacientes (86,4%) reassumiram os ciclos menstruais após o transplante, com mediana de 1 mês pós-transplante (1 a 7 meses). Todas as pacientes com idade inferior a 45 anos voltaram a menstruar após o transplante. Quatro gestações bem-sucedidas ocorreram em três pacientes, sendo uma gestação gemelar. Cerca de 70% das transplantadas realizavam exame de citologia oncótica cervical pelo menos uma vez ao ano. Um caso de carcinoma adenoescamoso de endométrio foi identificado em uma paciente de 64 anos, 36 meses após o transplante, tratado cirurgicamente com sucesso. Cerca de 71,4% das pacientes referiram vida sexual ativa pós-transplante, sendo que 70% delas consideravam-na satisfatória. CONCLUSÕES: Após transplante hepático bem-sucedido, a maioria das mulheres em idade fértil reassumem os ciclos menstruais poucos meses após o transplante, tornando possível a ocorrência de gestações. Devido ao rápido retorno da libido e da fertilidade, as pacientes devem ser esclarecidas sobre métodos contraceptivos seguros após o transplante. A maioria das pacientes apresenta vida sexual ativa e satisfatória e realiza regularmente citologia oncótica cervical.

Urological complications after living-donor renal transplantation

OBJECTIVE

To determine the incidence and management of urological complications after 1200 consecutive live-donor renal transplantations, all of which were carried out in one centre; the possible risk factors and the effect on patient and graft survival were also assessed.

PATIENTS AND METHODS

Data were retrieved from an electronic database; the incidence of urological complications was determined, and correlated with relevant risk factors by univariate and multivariate analysis. The effect on patient and graft survival was assessed using Kaplan-Meier statistics.

RESULTS

There were 100 complications in 96 patients (8%); urinary leaks occurred in 37, ureteric strictures in 23 and lymphoceles causing ureteric obstruction in 17. Percutaneous needle biopsy was complicated by haematuria and clot anuria in six patients. Late complications included 11 cases of stones, four of bladder malignancy and two of haemorrhagic cystitis. There was evidence that the age of the recipients (< 10 years), method of establishing urinary continuity (uretero-ureteric anastomosis) and a high dose of steroids had an independent positive effect on the incidence of urological complications. However, their development did not influence graft or patient survival.

CONCLUSION

When there is meticulous attention to the technical details, renal transplantation should incur few urological complications. Early intervention with percutaneous drainage reduces morbidity and the likelihood loss of graft function. Proper and prompt management should not affect the graft and/or the patient's survival.

Posttransplant primary cutaneous T-cell lymphoma

A patient with posttransplant cutaneous lymphoma is described. Although most posttransplant lymphomas are of B-cell origin, this patient's lymphoma is a primary cutaneous lymphoma of T-cell origin. Another report exists of the first case of posttransplant primary cutaneous T-cell lymphoma localized to the lower extremities. Our patient's involvement was generalized with tumor nodules on the face and anterior chest. Reduced immune surveillance, chronic antigenic stimulation caused by transplant grafts, and the direct oncogenic effects of immunosuppressive drugs have all been suggested as mechanisms. Prompt recognition of this condition and initiation of appropriate therapy with reduction of high-dose immunosuppression can lead to better patient outcomes.

Swine composite tissue allotransplant model for preclinical hand transplant studies

Our laboratory previously developed and used an orthotopic radial forelimb osteomyocutaneous flap in the pig as a preclinical composite tissue allograft (CTA) model. To ensure that it mimicked the clinical situation as closely as possible we developed this model taking many immunologic and reconstructive considerations into account. While our original pig CTA model was ideal for studying the methods of preventing skin, muscle, bone, vessel and nerve rejection, and systemic toxicity, it did not include specialized tissues/structures of a joint and digit. Therefore, we were unable to evaluate rejection of these specialized tissues and their functional properties. Recognizing the importance of assessing joint rejection and function in hand transplantation research we developed a new swine forelimb CTA model that included the animal's medial digit. The present study describes the anatomy and the transplantation technique used in this new preclinical CTA model. We transplanted a radial osteomyocutaneous flap that included the medial digit between two size- (17-21 kg) and age- (6-8-week) matched farm pigs. We removed the digit from the recipient pig's forelimb in continuity with a section of the radial bone and replaced it with the same structure transplanted from a donor pig. After transplantation, a full-length cast was placed on the recipient pig's operated limb and changes in flap color, temperature and the presence of edema were monitored continuously for 6 h, and then regularly at predetermined intervals over 4 days. No weight bearing restrictions were placed on the animal's operated limb. After 4 days, the animal was euthanized. Direct visual monitoring of the allograft during 4 days revealed it was viable with no signs of graft failure due to technical complications associated with the transplant procedure. Upon waking from anesthesia, the animal stood and wandered freely about its cage with no apparent difficulty. Based on the animal's high level of activity at this time, we concluded that the procedure caused it minimal morbidity. At 4 days after the operation, early signs of rejection (skin erythema and edema) were observed. By incorporating a digit into our original CTA pig forelimb model we have made it a better model for performing preclinical hand transplant studies. The added advantage of being able to assess methods of preventing rejection in the specialized joint/digital tissues (articular cartilage, digital flexor and extensor systems, the nail complex) and assess long-term function of these structures is important. The fact that the procedure does not cause major morbidity to the animal makes it possible to conduct long-term graft survival and functional studies.

Lymphoproliferative disorders after organ transplantation in children

BACKGROUND

After organ transplant, patients are at risk of posttransplant lymphoproliferative disorders (PTLD). The purpose of this study was to analyze 26 pediatric cases of PTLD observed at our institution between 1988 and 1996, and to evaluate the validity of the Society for Hematopathology Workshop (SHPW) 1997 classification in our patient population.

METHODS

Charts were reviewed for analysis of incidence, clinical course, and outcome. Tissue samples were classified by a pathologist according to SHPW recommendations.

RESULTS

By morphology, 20 were monomorphic, 5 polymorphic, and 1 hyperplastic. Assessment of lineage by morphology, molecular studies, and immunophenotyping did not correlate in six cases. By immunophenotyping, 12 were B cell, 4 T cell, 8 mixed B/T cells, and 2 undetermined. The 20 patients evaluable for treatment efficacy were treated with various therapeutic combinations, including immunosuppressive drug reduction, acyclovir/ganciclovir, interferon-alpha, immunoglobulins, surgery, and local irradiation. No patient received systemic chemotherapy. Thirteen patients achieved complete remission and 3, partial; 1 died 5 days after starting therapy, and 3 of progressive disease. Adverse prognostic factors included low platelet or neutrophil counts; stage III-IV and SHPW morphology were marginally significant.

CONCLUSIONS

The majority of patients eligible for treatment can be cured with immunosuppressive drug reduction and antiviral drugs, along with surgery and irradiation when indicated. Systemic chemotherapy or innovative approaches may have a role in unresponsive cases. Morphologic SHPW grouping is feasible and seems to have clinical relevance. However, correlation with clonality and immunophenotyping is not always possible, necessitating modifications including segregation of descriptive morphology from clonality and cell origin.

Epstein-Barr virus lymphoproliferative disorders after liver transplantation

Post-transplant lymphoproliferative disorders (PTLD) represent a spectrum of histological and immunological abnormalities, ranging from benign polyclonal B-cell hyperplasia to monoclonal malignant lymphoma. The important role of Epstein-Barr virus (EBV) in PTLD in liver transplant patients, particularly in pediatric recipients, is reviewed. Understanding the risks of EBV infection, the clinical presentations and diagnosis of PTLD, and its pathophysiology are crucial to the management of these disorders. Current treatment methods have resulted in better outcomes of these disorders, which in the past were uniformly fatal.

Gynecological and reproductive function after liver transplantation

Women of reproductive age who underwent orthotopic liver transplantation were surveyed to determine timing and pattern of menstruation, sexual activity, contraception, and incidence of pregnancy and gynecological disorders. Eighty two female recipients of liver transplantation at the University of Michigan between August 1985 and January 1992 were surveyed about menstrual function and gynecological and obstetrical histories before and after transplantation. Additional information was retrieved from medical records regarding their liver disease and details of pregnancies and gynecological care. In the year before transplantation, 27 women (42%) reported regular menstrual cycles, 18 (28%) irregular and unpredictable bleeding, and 19 (30%) amenorrhea. After transplantation, 30 women (48%) experienced regular menses, 16 (26%) irregular bleeding, and 16 (26%) amenorrhea. In women less than 46 years old, 27 (53%) had regular menses before and after transplant. Most women with acute liver disease had regular periods before (82%) and after transplant (73%). A total of 95% of women under the age of 46 had return of menstrual bleeding within the first year after transplantation. Of these women 49% had normal liver function tests at the time of survey, 33% mildly abnormal, and 18% severely abnormal. Liver function was not correlated with menstrual patterns. A total of 72% of women were sexually active after transplantation. Of 24 women under age 46 who had not undergone sterilization or hysterectomy, six women conceived seven pregnancies. Seven women reported abnormal cervical cytology results after transplantation. Six underwent colposcopy and 4 required some form of destructive therapy for cervical dysplasia. In women with liver disease, menstrual patterns may change after orthotopic liver transplantation. This is more common in women with chronic liver disease than in those with acute liver disease. There was no correlation between liver function and menstrual regularity after transplant. Return to sexual activity can be expected and pregnancies are not rare in a population of young women after liver transplantation. Regular cervical cytology is critical due to a recognized increase in cervical neoplasia in immunocompromised patients.

Invasive bladder cancer following cardiac transplantation

Iatrogenic immunosuppression following renal transplantation has been associated with the development and progression of multiple neoplasms, including transitional cell carcinoma (TCC). We present the first report of invasive TCC of the bladder managed with radical cystectomy in a cardiac transplant recipient. The short survival of this patient, despite organ-confined disease at the time of cystectomy, illustrates the necessity of early diagnosis and aggressive treatment of malignancy following organ transplantation.

Radical cystectomy and lower urinary tract reconstruction after cardiac allograft transplantation

The risk of a malignancy developing as a consequence of long-term immunosuppression after allograft transplantation is well documented. To our knowledge we report on the first cardiac allograft recipient to undergo radical cystectomy with lower urinary tract reconstruction using a continent Kock ileal reservoir with bilateral ureteroileal urethrostomy for squamous cell carcinoma that developed 4 years after transplantation.

Malignant Melanoma Following Heart Transplantation: A Cautionary Tale

A Nandi, AR Groves. Malignant melanoma following heart transplantation: A cautionary tale. Can J Plast Surg 1994;2(4): 173-174. The incidence of neoplasia in patients on immunosuppression after organ transplantation is 100 times greater than that of the general population. Skin tumours and malignant lymphomas are most common. Such tumours are more aggressive than their counterparts in the general population. A higher incidence may be expected in patients receiving heart transplants since they receive the most vigorous immunosuppressive regimes. A case of malignant melanoma developing five years after cardiac transplantation is reported. The need for increased vigilance towards detection of skin cancers in this risk group is highlighted.

Immunosuppression and cancer: the ciclosporin case

Experimental and clinical data relevant for the evaluation of the carcinogenic potential of the immunosuppressant ciclosporin are reviewed. Ciclosporin binds reversibly to the cytosolic receptor protein ciclophilin. Ciclophilin is likely involved in the blockade of lymphocyte activation-induced gene transcription of various growth factors, especially interleukin-2. The drug has no effect on the transcription of housekeeping genes nor does it activate any gene. Ciclosporin may inhibit tumor cell growth, notably those which are growth factor dependent. At high concentration virus-transformed cells, especially Epstein-Barr-infected B-lymphocytes, may escape the control of specific cytotoxic T-lymphocytes. Ciclosporin has no genotoxic activity, and has no DNA-binding property. In experimental studies ciclosporin did not cause cancer in the absence of an initiating event (e.g. chemical mutagen). However, by its immunosuppressive property, the drug may allow the growth of initiated tumor cells in vivo, an effect which is dose-dependent. In clinical use ciclosporin immunosuppression is associated with an increased incidence of lymphoproliferative disorders and other malignancies particularly of the skin when compared with a normal, not immunosuppressed population. Conventional immunosuppression (azathioprine, antilymphocyte globulin, prednisone) also demonstrates comparable risks to develop tumors. Lymphoproliferative lesions regress after dose reduction or cessation of treatment. Furthermore, combinations of various immunosuppressants with associated 'over-immunosuppression' may result in a higher incidence of viral infection and malignancy. In summary, chemical immunosuppression carries the intrinsic risk of tumor growth. In the case of ciclosporin this effect is dose dependent. Thus, the risk may be reduced by low dosage and by avoiding combination therapies with additional immunosuppressants.

The carcinogenicity of ciclosporin

Experimental data relevant for the evaluation of the carcinogenic potential of the immunosuppressant ciclosporin are reviewed: Firstly, the mode of action of ciclosporin at the level of lymphocyte gene transcription, secondly, the main adverse effects especially nephrotoxicity and thirdly, the results of the chronic bioassays. The experimental data are discussed together with the clinical evidence of increased incidence of tumors, especially lymphoproliferative disorders under ciclosporin immunosuppression. Conventional immunosuppression (azathioprine, anti-lymphocyte globulin, prednisone) also demonstrates comparable risks to develop tumors. Lympho-proliferative lesions regress after dose reduction or cessation of treatment. Furthermore, combinations of various immunosuppressants may result in a higher incidence of viral infection and malignancy. In summary, chemical immunosuppression carries the intrinsic risk of tumor growth. In the case of ciclosporin, which has no direct genotoxic effect, tumor promotion is probably dose-dependent. Thus, the risk may be reduced by low dosage and by avoiding combination therapies with additional immunosuppressants.

Fatal transitional cell carcinoma of bladder in renal transplant recipient

The risk of development of a malignancy as a consequence of long-term immunosuppression is well documented. Herein, we report the course of a renal allograft recipient in whom a fatal transitional cell carcinoma of the bladder developed eighteen years following transplantation.

Cyclosporin A renders target cells resistant to immune cytolysis

Exposure of cytolytically susceptible human target cells with therapeutic concentrations of the immunosuppressive drug cyclosporin A renders these cells highly resistant to T cell-mediated, natural killer (NK) cell-mediated, and complement-mediated cytolysis. The resistance is dose dependent, time dependent and reversible. The resistance is accompanied by target cell growth inhibition as measured by thymidine uptake. Surprisingly, target cell growth inhibition induced by serum depletion is associated with cell-mediated cytolytic resistance. These data suggest that cyclosporin A (CsA) may block some target cell biochemical pathway(s) important in the suicidal cytolytic process which is (are) linked to some G0/G1 cell cycle events. In addition, these results suggest that the increased risk of Epstein-Barr virus (EBV)-associated lymphoproliferative disease in human organ transplant recipients may be contributed to by CsA-induced resistance of EBV-transformed B lymphocytes to immune cytolysis. In the post-transplant setting, CsA probably blocks T cell-dependent responses to EBV-transformed B lymphocytes (Bird, A.G., McLachlan, S.M. and Britton, S., Nature 1981, 289: 300) yet leaving the NK cell and antibody-dependent responses intact (Shao-Hsien, C. et al. Transplantation 1983. 35: 127). However, given the direct effect of CsA upon EBV-transformed B lymphocytes, these cells would be rendered resistant to nearly all forms of cytolytic immune control (cytotoxic T lymphocyte, natural killer, antibody-dependent cell-mediated cytotoxicity, complement). Unregulated EBV-transformed B lymphocytes may then proliferate in the CsA-treated host thus leading to a polyclonal B cell hyperplasia. Our data would suggest that this early pre-malignant process is likely to be reversible following CsA dose reduction. Indeed, EBV-dependent polyclonal B cell hyperplasia is seen in early post-transplant lymphoproliferative disorders (Hanto, D.W., et al., Transplantation 1989, 47: 458). Furthermore, in some cases CsA dose reduction does lead to disease regression (Starzl, T., et al., Lancet 1984. i: 583). However, further progression of the disease probably occurs following chromosomal changes leading to oncogene activation and might be resistant to CsA dose reduction.

Hodgkin disease in a patient with common variable immunodeficiency

Extensive extralymphatic Hodgkin disease developed in a young man with common variable immunodeficiency manifested by hypogammaglobulinemia, recurrent sinopulmonary infections, and multiple autoimmune phenomena. Both humoral and cell-mediated immune dysfunction were present prior to treatment. After two cycles of chemotherapy, irreversible shock developed, and death occurred secondary to overwhelming infection in spite of prophylactic gammaglobulin replacement. The unusual features of this patient's case of extralymphatic Hodgkin disease in association with a primary immunodeficiency disorder have not been previously reported.

Neoplasms in dialysis patients: a population-based study

Cancer incidence was assessed in 4,161 end-stage renal disease (ESRD) patients on dialysis to determine whether there was any excess risk of cancer in this population. Records from the Michigan Kidney Registry (MKR) for 1973 to 1984 were linked to those of the Michigan Cancer Foundation's Metropolitan Detroit Cancer Surveillance System (MDCSS) to identify cases in the dialysis cohort. The expected number of cancers in the ESRD population was calculated using the race-, sex-, age- and calendar year-specific incidence rates of the tricounty metropolitan Detroit region of 4 million residents. The standardized incidence ratio (observed:expected) was significantly increased for all in situ tumors combined, as well as for invasive tumors of the kidney, the corpus uteri, and the prostate. The four-fold to five-fold excess (P less than 0.005) observed for renal and endometrial cancers, in addition to the significantly elevated (P less than 0.05) risk of prostate cancer indicates that patients maintained on dialysis should be evaluated for these tumors when they experience even minor symptoms. Population-based cancer and renal disease registries provide excellent opportunities for investigating etiologic hypotheses and future studies should incorporate potential risk factors when analyzing these data.

Management of heart transplant recipients: guidelines for the obstetrician-gynecologist

As the number and survival time of heart transplant recipients continue to increase, their quality of life, including sexuality and childbearing, have become important issues. Reproduction is possible for both male and female patients after the transplant. Counseling for contraception when sterilization is not desired must take into account the increased risk of infection and genital carcinoma associated with immunosuppressant drug therapy. Teratogenicity has not been reported either with traditional immunosuppressive agents (prednisone, azathioprine) or with cyclosporine. Osteoporosis prophylaxis is particularly important in the female heart transplant recipient, because the chronic use of prednisone increases this risk. Guidelines are provided to counsel patients in these areas.

Long-term survival and late development of bladder cancer in renal transplant patient with progressive multifocal leukoencephalopathy

We describe a renal transplant recipient in whom progressive multifocal leukoencephalopathy and transitional cell carcinoma of the bladder developed. Despite these potentially fatal sequelae of chronic immunosuppression the patient remains free of recurrent disease.

Malignancies in the acquired immunodeficiency syndrome

Aside from opportunistic infections, several neoplasms have been identified as part of the spectrum of acquired immunodeficiency syndrome (AIDS) as defined by the Centers for Disease Control. Kaposi's sarcoma (KS) was the first such neoplasm to be recognized within the spectrum of AIDS. Although the classic form of Kaposi's sarcoma had been well recognized prior to the epidemic of AIDS, it was quite distinct from the illness that was seen in its "epidemic" form in young homosexual males. In this setting, Kaposi's sarcoma is an aggressive disease, with extensive involvement of skin and mucous membranes, early dissemination to lymph nodes, impressive development of extreme lymphedema, even in the absence of bulky adenopathy, and rapid spread to visceral organs, including lungs and gastrointestinal tract, among others. Although rapid clinical progression and short median survival have been the rule, a spectrum of disease has been seen such that some patients have survived for many years with disease limited to the skin. Certain clinical and laboratory features, such as presence of unexplained fever, night sweats, weight loss ("B" symptoms), or significant T-4-lymphocytopenia, have been identified as indicators of poor prognosis. Various therapeutic interventions have been employed in epidemic KS, and although partial and complete remissions have occurred, no regimen yet reported has significantly improved the survival of treated patients. High-dose recombinant alpha interferon has produced response rates in approximately 30% of treated patients, although toxicity has been observed in approximately 30% as well. Likewise, vinblastine has produced similar response rates with no evidence of long-term efficacy or "cure." Aside from Kaposi's sarcoma, lymphoma primary to the central nervous system was recognized early in the AIDS epidemic as a criterion for inclusion within AIDS in patients less than sixty years of age. Several years after the initial reports of disease, it became apparent that specific types of systemic lymphoma were also quite extraordinary, and the definition of AIDS was amended in June 1985 to include high-grade B-cell lymphomas in individuals who had positive serology or virology for the human immunodeficiency virus (HIV). The AIDS-related lymphomas are characteristic, both pathologically and clinically. The vast majority of these cases have been high-grade B-lymphoid tumors of either immunoblastic or small-non-cleaved type (also known as "undifferentiated," Burkitt, or Burkitt-like).(ABSTRACT TRUNCATED AT 400 WORDS)

Post-transplantation T cell lymphoblastic lymphoma

Immunosuppressed renal transplant recipients are at increased risk for large cell lymphoma of B cell phenotype. This report describes a case of post-transplantation lymphoma presenting with a mediastinal mass causing superior vena cava syndrome, tracheal obstruction, and pleural effusion. Cytospin preparations of pleural fluid documented high-grade lymphoblastic lymphoma morphology and immature T cell (cortical thymocyte) phenotype: Leu 1-6-positive, Leu 9-positive, Tdt-positive, B-negative, Calla-positive. The occurrence of post-transplantation lymphoma of T cell lineage is inconsistent with the postulated Epstein-Barr virus origin and raises important questions regarding the development of lymphoproliferative disorders in immunosuppressed organ transplant recipients.

Immunosuppression and other nonsurgical factors in the improved results of liver transplantation

During the last 5 years, liver transplantation has become a service as opposed to an experimental operation. The most important factor in making this possible has been the introduction of cyclosporine-steroid therapy. At the same time, liver transplantation has been made more practical by improvements in diagnosing and managing other causes of postoperative hepatic dysfunction. Tissue typing and matching have played no role in improving the results of liver transplantation. With the demonstration that performed antibody states are irrelevant, even avoidance of positive cross-matches caused by cytotoxic antibodies and observance of ABO blood group barriers have become unnecessary if the recipient's needs are great. With the exceptions of malignancy and cirrhosis, the nature of the underlying hepatic disease has not profoundly influenced the results. Retransplantation has played an important role in improving survival, although the costs of retransplantation have been extremely high.

In vitro analysis of the Epstein-Barr virus: host balance in long-term renal allograft recipients

Four indices of the EB virus carrier state, for which quantitative in vitro assays now exist, have been monitored in 55 renal allograft recipients under long-term immunosuppression, each patient being tested on a single occasion. By comparison with parallel data from healthy control donors, the results indicate the extent to which virus replication in the throat and virus-infected B cells in the blood are increased as a result of immunosuppression; the concordance between these two independent indices of the level of EB virus infection in vivo, first noted with healthy donors, was again observed within this large group of patients. Immunosuppression also leads to an impairment of virus-specific memory T-cell responsiveness and to an increase in anti-viral antibody titres, but the results show that the level of virus infection prevailing in any one individual cannot be inferred directly from these immunological indices of the virus:host balance. In allograft patients on stable levels of immunosuppression, virus and host appear to establish a new equilibrium. Limited prospective studies suggest that the position of this new equilibrium depends critically upon the virus:host balance prevailing in the same individuals before immunosuppression began. This may be an important consideration in identifying patients for whom immunosuppression may carry a particularly high risk of developing EB virus genome-positive lymphoma.

Melanoma masquerading as Spitz nevus following acute lymphoblastic leukemia

A malignant melanoma originally diagnosed as a Spitz nevus led to the death of a 10-year-old boy. The melanoma developed four years after therapy was begun for acute lymphoblastic leukemia. Melanomas in children are rare. Melanomas histologically resembling Spitz nevi have been reported. Deep contiguous growth and melanization are suspicious features. Lymphoproliferative malignancies are most commonly reported to occur in patients surviving treatment for acute lymphoblastic leukemia. Melanoma following acute lymphoblastic leukemia has not been described previously.

Reversibility of lymphomas and lymphoproliferative lesions developing under cyclosporin-steroid therapy

Post-transplant lymphomas or other lymphoproliferative lesions, which were usually associated with Epstein-Barr virus infections, developed in 8, 4, 3, and 2 recipients, respectively, of cadaveric kidney, liver, heart, and heart-lung homografts. Reduction or discontinuance of immunosuppression caused regression of the lesions, often without subsequent rejection of the grafts. Chemotherapy and irradiation were not valuable. The findings may influence policies about treating other kinds of post-transplantation neoplasms.

Dermatomyositis and multiple malignancies in a patient treated with methotrexate

Dermatomyositis (DM) has been linked to internal malignancy but this relationship is quite variable in respect to tumor type and time sequence. The occurrence of multiple cancers in an individual with DM is rare. Immunosuppressive agents, particularly methotrexate have been used increasingly in corticosteroid resistant cases or for their corticosteroid sparing effects. These agents have not been implicated in the development of malignancy in patients with DM. A patient with a uterine adenocarcinoma developed DM that despite tumor removal was not responsive to corticosteroids. She was successfully treated with methotrexate for 18 months. She has subsequently developed an adenocarcinoma of the breast. The relationship of malignancy and DM as well as the role of methotrexate in the development of the second primary will be discussed.

Epstein-Barr virus (EBV) induced polyclonal and monoclonal B-cell lymphoproliferative diseases occurring after renal transplantation. Clinical, pathologic, and virologic findings and implications for therapy

Nineteen renal allograft recipients developed B-cell lymphoproliferative diseases. Clinically there were two groups: a) young patients (mean age, 23 years) who presented soon (mean, 9 months) after transplantation or antirejection therapy with fever, pharyngitis, and lymphadenopathy resembling infectious mononucleosis, and b) older patients (mean age, 48 years) who presented later (mean, 6 years) after transplantation with localized tumor masses. Histologically, the diseases were classified as polymorphic diffuse B-cell hyperplasia (PDBH) or polymorphic B-cell lymphoma (PBL). Immunologic cell typing revealed either polyclonal or monoclonal B-cell proliferations. Malignant transformation of polyclonal proliferations in two patients was suggested by the finding of clonal cytogenetic abnormalities. Epstein-Barr virus (EBV) specific serology, staining of biopsy specimens for the Epstein-Barr nuclear antigen, and EBV DNA molecular hybridization studies implicated EBV as the cause of both PDBH and PBL. Acyclovir, an antiviral agent that blocks EBV replication in vitro, inhibited oropharyngeal shedding of EBV and caused complete remission in four patients with polyclonal B-cell proliferations. The monoclonal tumors were acyclovir resistant. We suggest that surgical treatment, radiotherapy, or chemotherapy may be more appropriate therapy in selected patients with acyclovir resistant tumors. Therapeutic decisions require not only documentation of the viral etiology of these tumors, but also immunologic and cytogenetic analysis to determine the stage of tumor evolution in individual patients.