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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 29-37
CD20 antigen expression by lymphoma cells in lung allograft recipients is associated with higher remission rate and superior survival: A study on heart and lung transplant recipients


1 Guilan University of Medical Sciences, Rasht, Iran
2 Dr. Taheri Medical Research Group, Tehran, Iran

Click here for correspondence address and email

Date of Web Publication7-Jan-2014
 

   Abstract 

Post-transplant lymphoproliferative disorders (PTLD) are one of the fatal complications of transplantation, and there is scarcity of data on the relevance of antigen expression by tumor cells in PTLD. In the current study, we aimed to investigate the potential effects of CD20 antigen expression by PTLD lesions developing in heart/lung transplant recipients. A comprehensive search was performed for reports indicating CD20 antigen tests in PTLD lesions developing in heart and/or lung transplant recipients. For data accumulation, we developed a standard questionnaire and data of patients presented in different published reports were entered into it. Finally, data from 26 previously published reports from different centers around the world were included in the analysis. CD20-positive PTLD lesions are significantly more likely to be of the B cell type (P = 0.006). PTLD in patients with a CD20-positive test represented relevantly shorter time from transplantation to PTLD, although it did not reach a significance level (P = 0.08). At the last follow-up, 53% patients were dead. Survival analysis showed no prognosis difference regarding CD20 test. When data were reanalyzed separately for heart and lung transplant recipients, lung recipients developing PTLD with a CD20-positive test were significantly more likely to represent remission episodes (P = 0.03), and also represented a significantly better outcome than CD20-negative PTLD patients (P = 0.04). CD20-positive PTLD lesions in heart/lung recipients are more likely of the B cell type and develop PTLD lesions earlier than their CD20-negative counterparts. Lung recipients developing CD20-positive PTLD lesions represented higher remission rates and better outcome. Further studies with prospective follow-up of patients are needed for confirming our findings.

How to cite this article:
Gholipour-Shoiili A, Gholipour-Shoiili H, Taheri S. CD20 antigen expression by lymphoma cells in lung allograft recipients is associated with higher remission rate and superior survival: A study on heart and lung transplant recipients. Saudi J Kidney Dis Transpl 2014;25:29-37

How to cite this URL:
Gholipour-Shoiili A, Gholipour-Shoiili H, Taheri S. CD20 antigen expression by lymphoma cells in lung allograft recipients is associated with higher remission rate and superior survival: A study on heart and lung transplant recipients. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2014 Sep 1];25:29-37. Available from: http://www.sjkdt.org/text.asp?2014/25/1/29/124468

   Introduction Top


Development of post-transplant lymphoproliferative disorders (PTLD) is a well known and inauspicious complication in transplantation practice, which develops in the context of highly potent immunosuppression. The incidence of PTLD varies depending on the transplanted organ as well, and it usually occurs early after transplantation especially in patients with Epstein-Barr virus (EBV) infection. [1] Most PTLD lesions arise from B cell lineage, and the most common subtype is diffuse large B cell lymphoma. For the diagnosis of the disease, histopathological evaluations are needed, and such evaluations empower us to classify the pathology into three different groups with prognostic and severity grading, including early lesions, polymorphic PTLD and mono-morphic PTLD based on a categorization by the World Health Organization. [2]

The reported incidence of PTLD in different transplant recipients is highly different with regard to several factors, but most notable of them is the type of transplanted organ, with the lowest rate of occurrence in bone marrow graft recipients and the highest in multiviceral trans­plant patients. The incidence of PTLD in heart and lung transplant patients is considered high, and is up to 10%. [3],[4]

Human cells express various antigens on and within their cell membranes that can affect their resistance and weakness to several di­seases, including lymphomas. Although PTLD is genotypically considered a B-cell lymphoma in over 90% of the cases, the classical B-cell marker CD20 is expressed in a minority of such cases. CD20 is a membrane-embedded phosphorylated protein [5],[6],[7] that appears on the B-cell surface. [8] CD20 resembles a Ca [2] + ion channel [9] and is involved in signal transduction for B-cell differentiation and proliferation and cell cycle progression during human B-cell activation. [10],[11]

There is a scarcity of data on the relevance of CD20 expression in the PTLD cells and its potential prognostic value. However, due to the very limited volume of its population size, only one study was found in the literature on CD20 relevance in PTLD and the inconsis­tencies in the study population; [12] findings from this study cannot be considered with confi­dence. In their study, pediatric recipients of different types of organ allograft were equally entered into analysis regarding their tumoral CD20 antigen test results. However, it is a very well known fact that prognosis of PTLD developing in recipients of different organs (e.g., kidney or liver versus heart or lung) are quite diverse. [13],[14],[15],[16] Therefore, we think that analysis of data gathered from a very limited number of patients who have received diffe­rent types of organ transplants cannot be considered trustable. In the current study, how­ever, conducting a very comprehensive review of the literature, we aimed to find and gather data on heart and lung allograft recipients who have developed a PTLD in their post-trans­plant era and had a documented a report on the CD20 antigen testing result to prepare and analyze the largest possible data on the disease and to reveal any potential specific feature, behavior or prognosis of CD20-positive PTLD lesions compared with their CD20-negative counterparts.


   Materials and Methods Top


Approach to the study

For searching the literature for reports indi­cating test results for CD20 antigen in PTLD lesions developing in heart and/or lung trans­plant recipients, we performed a very compre­hensive search using Pubmed and Google scholar. Keywords used for this purpose were "lymphoproliferative disorders + heart trans­plantation + CD20," "lymphoproliferative disorders + cardiac graft + CD20," "PTLD + CD20 + heart transplant," "PTLD + CD20 + cardiac graft," "lymphoproliferative disorders + lung transplantation + CD20," "lymphoproliferative disorders + pulmonary graft + CD20," "PTLD + CD20 + lung transplant" and "PTLD + CD20 + pulmonary graft". Wherever we failed to get the full text of the articles, we sent e-mails to the correspondent authors - and sometimes to other authors, when we did not receive a reply - requesting for the article. After completing the search, only studies in which data of each patient were presented separately were included. To minimize selec­tion bias, we only included series reporting their study of patients from single- or multi-center populations, and reports with any parti­cular selection criterion were excluded. For data accumulation, we developed a standard questionnaire and data of patients presented in different published reports were entered into it. Finally, data from 26 previously published reports from different centers around the world [17],,[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[34],[35],[36],[37],[38],[39],[40],[41],[42] were included in the analysis. The time to PTLD onset was defined as the period between the grafting and the first signs of PTLD or diagnosis, based on the studies' approaches.

Study population

Overall, 81 recipients of heart and/or lung allograft were included in the analysis. Eighty-six (93.8%) patients of the study population were patients with a positive result for CD20 antigen evaluation of their PTLD lesions, while the remaining five (6.2%) patients represented CD20-negative test results.

Because of the inconsistencies in the ap­proaches of different studies of patients en­rolled in this study, we were not able to get all required data from all the included patients, and in some cases we had to introduce new standardized measures to be able to cumulate data from different studies into a unique data­base. Disseminated lymphoma was diagnosed when it was declared by the authors or at least three different organs (excluding different lymph node areas) were involved by PTLD, reported in nine (14.1%; 17 unreported) patients. Multi-organ involvement, defined as involvement of more than a unique organ as well as more than one lymphatic region, was seen in 16 (23.9%; 14 unreported) patients.

At lymphoma diagnosis, all patients were re­ceiving and had received immunosuppressive regimens consisting of varying combinations of azathioprine, prednisone, cyclosporine, mycophenolate mofetil and antithymocyte/lymphocyte globulin (ATG/ALG) and OKT3. More or less, a rather uniform approach was used to manage all PTLD patients in the included reports. On diagnosis of PTLDs, the first step in almost all reports was to decrease or discontinue immunosuppressive therapy; different regimens of chemotherapy with or without surgical inter­ventions were also used for some of the patients.

Response to treatment

Response to treatment was defined as any fa­vorable change in the cancer measures as well as patients' clinical condition; data of PTLD response to treatment was reported by authors for 44 (54.3%) patients, of whom 31 (70.5%; 37 unreported) patients responded to anti-malignancy treatment. However, we developed new criteria for defining remission rates for the study population; while remission episode was defined when patients were alive after their 24 th month of PTLD diagnosis (because all reported cases having this criterion had at least one confirmed remission episode) and no remission was defined when a patient dies within the first month post-PTLD diagnosis (because among the reported cases there were no patients dying at the first post-transplant month and reported to have any remission epi­sodes). According to the abovementioned cri­teria, 20 patients were added to the list and the remission rate reached to 44 (74.6%; 22 mis­sing) cases. Overall mortality was 39 (54.2% of the reported cases; nine unreported) pa­tients, of whom 23 (59%) were reportedly due to PTLD progression.


   Statistical Analysis Top


Software used for data analyses was SPSS v.13.0. Statistical differences between patients' subgroups were performed using the χ2 and Fishers' exact tests for proportions and the Student's t test for continuous data. Survival analysis was performed with life tables and Kaplan-Meier methods and log-rank test. All statistical tests were performed at the 0.05 significance level. P-values below 0.1 were considered relevant.


   Results Top


Data of an overall of 81 recipients of heart and/or lung allograft developing PTLD were entered into analysis. There were 57 (73.1%) male and 21 (26.9%) female patients (three unreported). Mean ± SD age at diagnosis of PTLD was 40.3 ± 19.3 years. The mean inter­val between transplantation and the diagnosis of PTLD was 50.6 ± 50.7 months, whereas the follow-up time after diagnosis of PTLD was 32.8 ± 40.4 months.

Characteristics of the patients regarding their malignancy site are summarized in [Table 1]. Chi square test showed that CD20-positive PTLD lesions are significantly more likely to be of the B cell type (P = 0.006). PTLD in patients with a CD20-positive test had a rele­vantly shorter time from transplantation to PTLD, although it did not reach a significance level (P = 0.08). CD20-positive PTLD patients were comparable with their CD20-negative counterparts regarding age, gender, immunosuppression types, histopathological pattern of PTLD lesions, remission rates, multiorgan involvement and disseminated PTLD rates. The EBV positivity rate was also comparable between the two patient groups. [Table 2] sum­marizes the organ involvement frequencies in the two patient groups. As is evident in [Table 2], no preponderance was found in organ com­plication regarding CD20 positivity.
Table 1: Characteristics of PTLD heart/lung recipients regarding CD20-positive and -negative results.

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Table 2: PTLD organ involvement with respect to their CD20 test result.

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At the last follow-up, 41 (52.6%) patients were dead (nine unreported). When death irrespective of the reason was used as the final outcome, the log-rank test showed comparable survival for heart/lung graft recipients re­garding CD20 antigen expression (P = 0.998) [Figure 1]. The 1- and 5-year survival rates for PTLD patients with CD20-positive results were 70% and 45%, respectively, compared with 63% and 38%, respectively, for CD20 negative-PTLD patients.
Figure 1: Survival curves of heart/lung graft recipients in relation to their CD20 test result.

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Then, the data were reanalyzed separately for heart and lung transplant recipients. For heart recipients, no change in the above-mentioned findings was detected; however, after splitting data of the two types of organ grafts, lung recipients developing PTLD with the CD20-positive test were significantly more likely to represent remission episodes (P = 0.026), and also represented a significantly better outcome than CD20-negative PTLD patients (P = 0.041; [Figure 2].
Figure 2: Survival curve of the lung transplant recipients regarding their CD20 antigen expression by their PTLD lesions.

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   Discussion Top


Although introduction of new and potent immunosuppressive agents to transplant medi­cine brought several optimisms for enhancing both graft and patient survival, it has resulted in an increased incidence of diseases associa­ted with immunosuppression, including infec­tions and malignancies. [43],[44] PTLD is one of the most frequent neoplasms developing in the post-transplant period, and causes a higher morbidity and mortality burden to the reci­pients. Thus, the definition of various aspects of this neoplasm and their relevance in solid organ recipients seems to be of outmost prio­rity. However, due to the very limited number of PTLD cases diagnosed in individual trans­plant centers, and the inconsistent approaches in them, investigations on distinctive areas of the disease and revealing hidden factors that may affect disease behavior and outcome have been performed very rarely.

Previous studies have proposed some factors having roles for their presentation and out­come in PTLD patients, from which we have focused on CD20 antigen expression by lymphomatoid lesions in heart/lung allograft reci­pients. CD20 protein expression, as deter­mined by flow cytometry, could be considered as a predictor for several drug resistance or responsive cases. [45],[46] However, almost all these studies have been conducted in a non-transplant context and, to the best of our knowledge, the present study represents the first data on the relevance of CD20 antigen expression in heart and lung graft recipients developing PTLD.

The only finding of our initial analyses was that CD20-positive lesions were more fre­quently of the B cell type and represented a shorter time to PTLD development, although in the latter case a significance level was not achieved. It is a known fact that CD20 is a marker of normal B lymphocytes. Therefore, it is expected that B cell lymphomas also, to some degree, present it on their cell mem­brane, as previously reported in lymphoma cells. [47] On the other hand, the finding that pa­tients with CD20-positive PTLD lesions have relatively shorter time from transplant to neo­plasm development has been previously repor­ted by Orjuela et al in their study on pediatric solid organ recipients. [12]

The prognostic value of CD20 antigen ex­pression in PTLD lesions has been investigated before. In a non-transplant context, Tzankov et al [48] have demonstrated a better outcome for patients with CD20+ Hodgkin's lymphoma. In transplantation practice, Orjuela et al [12] have similarly suggested a better survival for CD20-positive PTLD patients compared with their CD20-negative counterparts. On the other hand, Rassidakis et al [49] reported no prognostic significance for CD20 antigen expression in patients treated with equivalent regimens. Molot et al [50] also reported the same findings that there was no relevance for CD20 expres­sion on clinical outcome. In an unpublished study, we found an exactly adverse finding for renal recipients, with a relatively lower out­come for patients developing CD20-positive PTLD lesions. In the current study, however, when analysis pooled data of heart and lung recipients, no significant role for CD20 positivity was detected regarding patients' outcome [Figure 1]. But, when the analyses were re­peated separately for heart or lung graft reci­pients, lung transplant patients with CD20-positive lesions showed a better survival and higher remission rates than CD20-negative patients [Figure 2]. This finding is in accor­dance with the findings of Tzankov et al [48] and Orjuela et al. [12]

This study has some limitations. Firstly, the data for this study was gathered from different reports, which more or less had inconsistent approaches. In order to resolve this problem, we tried standardizing our data to be able to present the data in a unique way to insert them into one database. For example, different studies have used dissimilar methods for de­fining a "remission episode"; while some of them had used terms like "complete" or "par­tial" remission, others only talk about a remis­sion episode, favorable changes in tumor size, general conditions and so on. In such cases, we categorized the term to two sub-categories; for this case: "remission" and "no remission." When authors had reported any positive reac­tion to therapy, we used the term "remission" and when disease progressed, we used the se­cond term. Some other standardization policies have been employed that have been described in the methods section.

In conclusion, this study is most probably is the first and only data on the relevance of CD20 antigen expression by PTLD lesions ari­sing in heart and lung transplant recipients. According to our analyses, CD20-positive PTLD lesions are significantly of the B cell type and relatively develop earlier in time post-transplantation than their CD20-negative counterparts. When analyses were separately performed for heart and lung graft recipients, lung recipients developing CD20-positive PTLD lesions represented higher remission rates and better outcome. Further studies with prospective follow-up of patients are needed for confirming our findings.

 
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Correspondence Address:
Hani Gholipour-Shoiili
Department of Medicine, Guilan University of Medical Sciences, Rasht
Iran
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PMID: 24434379

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