Part 2: Post-transplant Lymphoproliferative Disorders
Namrata M. Shah, MD, MPH
Hematology/Oncology Fellow, Medical College of Wisconsin, Milwaukee, WI
Timothy S. Fenske, MD
Associate Professor of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
A 52-year-old man who underwent cadaveric renal transplantation 6 years earlier for polycystic kidney disease is admitted with a 2-week history of progressive fatigue, night sweats, and low-grade fever. On admission, he is found to have extensive adenopathy. Laboratory evaluation shows a white blood cell (WBC) count of 2800/μL, hemoglobin of 8.9 g/dL, and platelet count of 88,000/μL. Serum creatinine is normal at 1.0 mg/dL. LDH is elevated at 865 U/L (normal range, 140–280 U/L), alanine aminotransferase at 86 U/L (normal range, 7–56 U/L), and aspartate aminotransferase at 77 U/L (normal range, 5–40 U/L); alkaline phosphatase and total bilirubin are normal. An excisional lymph node biopsy shows diffuse large B-cell lymphoma. EBER (EBV-encoded small nuclear RNA ) stain is negative. Staging PET/CT scan shows widespread FDG-avid lymphadenopathy as well as multiple 1- to 2-cm lung and liver lesions felt to be most consistent with lymphoma. A staging bone marrow biopsy shows 50% cellularity with 20% involvement by large cell lymphoma. What is the most appropriate treatment plan?