Posttransplantation lymphoproliferative disorder: manifestations in pediatric thoracic organ recipients

PURPOSE: To describe and correlate the clinical and imaging features of posttransplantation lymphoproliferative disorder (PTLD) in young thoracic organ transplant recipients. MATERIALS AND METHODS: The authors retrospectively reviewed the medical and imaging records of 31 PTLD episodes in 27 patients with PTLD out of 183 young patients who survived for at least 1 month after thoracic organ transplantation: 18 (14%) heart transplant recipients and nine (16%) lung or heart-lung transplant recipients. Four patients had two separate PTLD episodes. The distribution, timing, and imaging features of the disease were analyzed. RESULTS: Seventeen (55%) of 31 episodes involved intrathoracic PTLD manifesting as multiple pulmonary nodules (n = 10), a solitary nodule (n = 3), alveolar consolidation (n = 3), and/or mediastinal adenopathy (n = 8). Extrathoracic PTLD occurred in 21 (68%) of 31 episodes and involved the abdomen (n = 15), head and neck (n = 11), and/or central nervous system (n = 3). The imaging findings of these episodes included bowel wall thickening, lymphadenopathy, and focal masses. Intrathoracic PTLD occurred more commonly in lung transplant recipients (89%) than in heart transplant recipients (44%); no cases of lymphoma involved the thorax. The frequency of extrathoracic manifestations was higher in heart transplant recipients (83%) than in lung transplant recipients (33%). In lung transplant recipients, the prevalence of early-onset PTLD was significantly greater than that in heart transplant recipients (P <.05). Intrathoracic PTLD tended to manifest early. CONCLUSION: PTLD in young thoracic transplant recipients involves the lungs and extrathoracic organs, tends to have an early onset, and manifests predominantly in the thorax in lung transplant and heart-lung transplant recipients, as opposed to heart transplant recipients.     

Posttransplantation lymphoproliferative disorder of the head and neck: imaging features in seven adults

PURPOSE: To determine the cross-sectional imaging findings of posttransplantation lymphoproliferative disorder (PTLD) of the head and neck. MATERIALS AND METHODS: Computed tomographic (CT) scans (n = 6) and magnetic resonance (MR) images (n = 2) in seven patients with histopathologically proved PTLD of the Waldeyer (lymphoid) ring or cervical lymph nodes were retrospectively reviewed for abnormalities. RESULTS: The interval between transplantation and PTLD onset was 3.5-108 months (mean, 30 months). All patients had imaging abnormalities involving the Waldeyer ring, and focal 2.0-4. 5-cm masses were present in six patients (unilateral oropharyngeal tonsil in two, bilateral oropharyngeal tonsils in one, nasopharyngeal adenoids in three, unilateral pharyngeal tonsil and ipsilateral nasopharynx in one). In three patients, the mass was centrally low attenuating at CT or isointense to fluid at MR imaging, with enhancing solid peripheral lymphoid tissue. Three patients also had nodal findings: one with a 7-cm low-attenuating nodal mass in the right neck and two with numerous bilateral lymph nodes (mostly normal sized) in the anterior and posterior cervical lymph chains. One patient also had a small mass in the upper mediastinum. CONCLUSION: In the setting of organ transplantation, findings of masses in the Waldeyer ring or an excessive number of cervical nodes should increase the index of suspicion of PTLD.     

Posttransplantation lymphoproliferative disorder in children: clinical, histopathologic, and imaging features

Posttransplantation lymphoproliferative disorder (PTLD) is a condition in patients who receive transplants in which chronic immunosuppression leads to an unregulated expansion of lymphoid cells; the condition ranges from hyperplasia to malignant lymphoid proliferation. Risk factors affecting the incidence of PTLD include allograft type, Epstein-Barr virus infection, and immunosuppression. In this article, we review the clinical, histopathologic, and imaging features of PTLD in children. Because PTLD can affect nearly any organ system, a wide variety of clinical manifestations is possible. The heterogeneous nature of the disease is also reflected on imaging studies. The goals of imaging in patients with PTLD are to detect disease, guide biopsy, and direct appropriate follow-up imaging rather than to establish a specific diagnosis. Because the clinical and imaging manifestations of PTLD are nonspecific and are not reliably predictive of histopathologic subtype, tissue biopsy is necessary for final diagnosis.     

Posttransplantation lymphoproliferative disorder of the paranasal sinuses mimicking invasive fungal sinusitis: case report

Posttransplantation lymphoproliferative disorder (PTLD) is a challenging complication associated with organ transplantation and is usually fatal if untreated. We describe the case of a transplant recipient who presented with rapidly progressive cranial nerve palsies due to PTLD that originated in the sphenoid sinus. In this case, the clinical and radiologic presentation of PTLD mimicked invasive fungal disease. Because the management of PTLD and the management of invasive fungal infection are vastly different, prompt pathologic diagnosis is required.     

儿童移植术后淋巴增生性疾病:造血细胞移植受体与肝移植受体表现比较

目的比较儿科病人造血细胞移植后与肝移植后淋巴组织增生性疾病(PTLD)的临床和影像学表现。材料与方法该研究经学院伦理委员会批准,并免除病人知情同意。回     

Posttransplantation lymphoproliferative disorder in pediatric recipients of solid organ transplants: timing and location of disease

OBJECTIVE: The objective of our study was to correlate the location of radiologic presentation and time to onset of posttransplantation lymphoproliferative disorder (PTLD) with the allograft type received in a population of pediatric heart, lung, liver, kidney, and bone marrow transplant recipients. CONCLUSION: Symptomatic PTLD in children manifests earliest in lung recipients and can involve any organ system. However, PTLD in the thorax is most common after lung transplantation, and PTLD in the abdomen most commonly follows kidney transplantation.     

Posttransplantation cyclosporine-induced lymphoproliferative disorders: clinical and radiologic manifestations

Fifteen allograft transplant recipients acquired lymphoproliferative disorders after immunosuppressive therapy with cyclosporine and steroids. Many of these lymphoproliferative disorders regressed or disappeared completely after reduction of cyclosporine dose. This disease has several aspects that distinguish it from usual posttransplantation lymphomas that occur with regimens that do not contain cyclosporine. The time course from transplantation to onset of lymphoma is relatively short, with an average of approximately 8 months. Organs show a wide spectrum of abnormalities typical of other immunosuppression-associated lymphomas, but there is unique sparing of the central nervous system. The tumor is also unique in that it responds to a decrease in the cyclosporine dose.     

Tailored helical CT evaluation of acute abdomen.

Helical computed tomography (CT) allows rapid, cost-effective evaluation of patients with acute abdominal pain. Tailoring the examination to the working clinical diagnosis by optimizing constituent factors (eg, timing of acquisition, contrast material used, means and rate of contrast material administration, collimation, pitch) can markedly improve diagnostic accuracy. Rapid (>/=3 mL/sec) intravenous injection of contrast material is required for optimal assessment of acute pancreatitis, ischemic bowel, aortic aneurysm, and aortic dissection. Narrow collimation and small reconstruction intervals can help detect calculi in the biliary system and genitourinary tract. Tailored helical CT in patients with acute pyelonephritis usually involves several acquisitions through the kidneys during various phases of renal enhancement. In patients with suspected renal infarction, CT protocol must include an acquisition during the corticomedullary phase. Helical CT with 5-mm collimation through the lower abdomen and pelvis is used to evaluate patients with suspected diverticulitis. Use of both oral and intravenous contrast material can help localize small bowel perforation and characterize related complications. Tailored helical CT for assessment of abdominal hemorrhage consists of initial unenhanced CT followed by optional contrast material-enhanced CT. Clear communication between the radiologist, the patient, and the referring physician is essential for narrowing the differential diagnosis into a working diagnosis prior to helical CT.     

Gunshot wounds of abdomen: evaluation of stable patients with triple-contrast helical CT

PURPOSE: To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy. MATERIALS AND METHODS: The study was conducted for 19 months. All patients met the following inclusion criteria: age of 16 years or older, hemodynamic stability, no clinical signs of peritoneal irritation, and signed consent to participate. Patients with obvious indications for laparotomy, such as gastrointestinal bleeding or evisceration, were excluded from the study. Forty-seven patients fulfilled the criteria and underwent abdominal triple-contrast helical CT. CT findings were evaluated by one of four radiologists for evidence of peritoneal penetration and injury to solid organs or hollow viscera. Patients were followed up clinically for 13 weeks. CT findings were compared with those at surgery and/or clinical follow-up. RESULTS: CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%. CONCLUSION: In stable patients with gunshot wounds to the abdomen in whom there is no indication for immediate surgery, triple-contrast helical CT can help reduce the number of cases of unnecessary or nontherapeutic laparotomy (negative laparotomy) and can help identify patients with injuries that may be safely treated without surgery.     

Distribution of metastases in breast carcinoma: CT evaluation of the abdomen

To determine the frequency and distribution of extrahepatic and extraskeletal metastases in patients with breast carcinoma, the abdominal CT scans of 260 consecutive patients were systematically evaluated. Extrahepatic and extraskeletal metastases were demonstrated in 26 patients (10%). Confirmation of findings was made by biopsy, autopsy, or by demonstration of progression or regression of disease. Twelve patients (4.6%) demonstrated metastases to the stomach, eleven of whom presented with a linitis plastica pattern. Retroperitoneal and/or mesenteric adenopathy was noted in 10 patients (3.8%), of whom three demonstrated associated hydronephrosis and one demonstrated associated biliary obstruction. Ascites was seen in 14 (5.4%) and peritoneal carcinomatosis in 7 (2.6%). Genitourinary involvement included metastases to the kidney (one case), ureter (one), and uterus (one). Direct invasion of the diaphragm by adjacent pleural metastases (two cases) as well as a soft tissue metastasis (one case) was also demonstrated. Metastases to the ovaries, adrenals, or pancreas could not be identified. Although lesions to the liver and skeleton account for the largest group of metastases from breast carcinoma seen in the abdomen, one should be aware of the potential for other locations of metastatic disease.     

Posttransplant lymphoproliferative disorder: intrathoracic manifestations.

Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation and immunosuppression. Early diagnosis and treatment greatly affect prognosis. Chest radiographs (n = 13), chest computed tomographic (CT) scans (n = 2), or both (n = 20) from 35 patients with intrathoracic PTLD were retrospectively studied to define the intrathoracic manifestations of this disorder. Intrathoracic abnormalities consisted of pulmonary nodules (16 patients), patchy air-space consolidation (three patients), mediastinal and hilar adenopathy (17 patients), thymic enlargement (two patients), pericardial thickening and/or effusions (two patients), and pleural effusions (four patients). Multiple, well-circumscribed pulmonary nodules with or without mediastinal adenopathy are highly suggestive of PTLD. However, pathologic examination is usually necessary for a definitive diagnosis.     

CT of posttransplantation lymphoproliferative disorder in pediatric recipients of lung allograft

OBJECTIVE: The purpose of this study was to determine the CT and clinical findings of posttransplantation lymphoproliferative disorder in pediatric lung allograft recipients. MATERIALS AND METHODS: We reviewed the medical records and CT examinations of 260 lung transplantations in pediatric patients and found 26 recipients who had 29 episodes of histologically proven posttransplantation lymphoproliferative disorder. The clinical and CT features of the disease, the time to diagnosis, and the outcomes were assessed. RESULTS: The clinical presentation of posttransplantation lymphoproliferative disorder varied from asymptomatic pulmonary nodules (14/29 [48%]) detected on chest CT to specific (organ-related) and nonspecific symptoms (15/29 [52%]). Intrathoracic posttransplantation lymphoproliferative disorder occurred in 20 (69%) of 29 cases and manifested as multiple pulmonary nodules (n = 17), alveolar infiltrates (n = 2), and combined nodules and infiltrates (n = 1). In eight (28%) of 29 cases, there was extraparenchymal disease, including adenopathy, pleural effusion, and esophageal thickening and erosions. Extrathoracic posttransplantation lymphoproliferative disorder occurred in 13 cases and involved the abdomen (n = 10), paranasal sinuses (n = 2), and brain (n = 1). In the abdomen, extranodal disease was more common than nodal disease and presented as bowel wall thickening, focal mass lesions, and splenomegaly. In 18 of 29 episodes of posttransplantation lymphoproliferative disorder, the histologic diagnosis was lymphoma. The median time to diagnosis after transplantation for the 29 episodes of posttransplantation lymphoproliferative disorder was 10 months. Thirteen of the 26 patients died. The median time of survival after the diagnosis of posttransplantation lymphoproliferative disorder was 17 months. CONCLUSION: Posttransplantation lymphoproliferative disorder in pediatric lung transplant recipients occurs with relatively high frequency in both the chest and abdomen, tends to have lymphomatous features, and results in substantial mortality rates.     

Spiral CT of the abdomen: increased diagnostic potential.

Over the last 10 years, spiral CT has become the optimal method of performing all CT within the abdomen and pelvis. Not only has the technique improved the quality of individual examinations, it has also opened up many new diagnostic possibilities which are currently being evaluated and compared with the concurrent advances in ultrasound and MRI. These new diagnostic possibilities are discussed in this review article. So too are the economic advantages of the shorter data-acquisition times which also make the examination much better tolerated by the patient.     

FDG PET imaging in the evaluation of post-transplant lymphoproliferative disorder following renal transplantation

OBJECTIVES: To assess the usefulness of fluorodeoxyglucose positron emission tomography (FDG PET) in the evaluation of post-transplant lymphoproliferative disorder (PTLD) following renal transplantation. METHODS: Staging FDG PET examinations were reviewed in five patients with biopsy proven post-renal allograft PTLD and compared with conventional imaging. Follow-up PET examinations of three patients at various points during their therapy for PTLD were also reviewed and compared with clinical outcome. RESULTS: PET imaging identified all disease sites seen at cross-sectional imaging, clarified sites of uncertain significance and detected additional disease in two out of five patients. Early follow-up imaging impacted PTLD management in two of three patients. CONCLUSION: In this limited series FDG PET was an effective imaging modality in the staging and follow-up of PTLD.     

Usefulness of F-18 FDG PET/CT in the evaluation of neck swelling in polymorphic posttransplant lymphoproliferative disorder after renal transplantation

A 38-year-old man with a history of renal transplantation presented with a 3-month history of bilateral neck swelling. Ultrasonography of the neck showed multiple enlarged lymph nodes at the bilateral neck. Histologic examination of a specimen from an excisional biopsy at right level II cervical lymph node revealed polymorphic posttransplant lymphoproliferative disorder. F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography scan was performed for further evaluation. The scan revealed marked enlargement and intense hypermetabolism of the lymph nodes along the bilateral cervical lymph node chains (Fig. 1). Several reports have described that diverse infectious or inflammatory disorders and malignant diseases show various degree of FDG uptake of cervical lymph nodes. This case illustrates that the possibility of posttransplant lymphoproliferative disorder should be considered in renal transplant patients with increased FDG uptake of cervical lymph nodes on F-18 FDG positron emission tomography/computed tomography scan.     

Terson syndrome: CT evaluation in 12 patients.

PURPOSETerson syndrome may be overlooked in the acute setting and often requires ophthalmologic intervention to prevent long-term visual loss. In this syndrome, vitreous or retinal hemorrhage results from an abrupt rise in intracranial pressure, leading to retinal venous hypertension and intraocular hemorrhage. Our objective was to determine whether imaging findings could be discovered that might facilitate an earlier diagnosis.METHODSOur inpatient medical record data base for 1991-1996 listed 11 patients with Terson syndrome. The medical records of these 11 patients were reviewed retrospectively and compared with their noncontrast head CT scans and with scans of 10 control subjects. One additional case was discovered prospectively, for a total of 12 patients. Three radiologists unaware of the patients'' history evaluated CT scans of the orbits for evidence of intraocular hemorrhage.RESULTSCT findings in eight patients were suggestive of retinal hemorrhage manifested by a retinal crescent or nodule that was slightly hyperdense relative to the vitreous humor. There was a high degree of concordance between the retrospective and independent reviews.CONCLUSIONRetinal nodularity and crescentic hyperdensities are evident on CT scans in the majority of patients with Terson syndrome. Although findings are subtle and not present in all cases, in the setting of subarachnoid hemorrhage they suggest retinal hemorrhage and warrant detailed fundoscopic evaluation.