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• W2057342114 abstract "Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of liver transplantation with an incidence of 2.2–3.6% in the first posttransplantation year. The syndrome typically reflects a wide range of B-cell proliferation and is strongly associated with concomitant Epstein-Barr virus (EBV) infection. In this case report we draw attention to abdominal complications after rapid chemotherapeutic lysis of PTLD. To our knowledge, this is the first report of intestinal perforations after CD20 antibody therapy. A 66-year-old patient suffering from chronic hepatitis C virus-induced liver cirrhosis underwent liver transplantation in May 2000. Six months later the patient had a primary EBV infection (IgM positive, DNA positive on polymerase chain reaction). After verification of the diagnosis, immunosuppression was reduced to cyclosporine levels between 50 and 75 ng/ml (from levels of 200 ng/ml before). Additionally, antiviral therapy (acyclovir 10 mg/kg, three times daily) was initiated (1). Because symptoms and EBV infection persisted, a thoracoabdominal computed tomography scan was performed and showed a tumor mass with involvement of the respiratory and gastrointestinal tract. Fine-needle aspiration led to the diagnosis of a CD20-positive polymorphic B-cell lymphoma (PTLD). According to previously reported studies, therapy with a chimeric humanized anti-CD20 monoclonal antibody (375 mg/m2; Rituximab-MABTHERA, Roche, Basel, Switzerland) was given as a single shot only (2,3). Prednisolone (100 mg, once a day) was added for 3 days, because previous studies showed that glucocorticoids are able to induce apoptosis of lymphocytes and to sensitize B cells to cell killing via anti-CD20 antibodies (4). Four days after Rituximab infusion, the patient complained of acute abdominal pain. On clinical examination, generalized abdominal tenderness was found with signs of peritoneal irritation. Emergency laparotomy revealed three intestinal perforations, two in the terminal ileum and one in the transverse colon. Correspondingly, segmental resections of the ileum and transverse colon with primary anastomoses were performed. Postoperatively, cyclosporine therapy was continued at a level of 50–75 ng/ml. Histology revealed perforations due to transmural infiltration of PTLD, with destruction of all bowel wall layers. A control computed tomography scan 15 days after Rituximab infusion exhibited partial remission (more than 50% reduction of tumor size). The patient continued to do well under reduced immunosuppression 6 months postoperatively. Anti-CD20 antibody therapy is a successful treatment modality of B-cell lymphoma with a reported response rate of 65% and a 1-year projected survival of 73% in recipients of solid organs (2). Compared with cytotoxic chemotherapeutic regimens, the risk of life-threatening complications is expected to be lower. The majority of adverse events occur within the first few hours after antibody infusion and frequently include allergic symptoms. Rituximab has not been reported to induce alopecia, myelosuppression, or other side effects characteristic of chemotherapy. Overall toxicity was reported to be mild and applicable in an outpatient setting. The strong therapeutic effect of a single shot of Rituximab was obvious, probably due to high levels of CD20 antigen expression by the tumor. Correspondingly, this rapid response resulted in intestinal perforations due to transmural tumor necrosis. Caution and close clinical monitoring in cases of gastrointestinal wall involvement are recommended (5) because PTLD itself, but especially under treatment with Rituximab, can cause intestinal perforation. Because of its high efficacy and, hence, potential for complications, rituximab should not be recommended as an outpatient therapy for PTLD. Otto Kollmar1 Sandra Becker Martin K. Schilling1 Christoph A. Maurer1 2" @default.
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• W2057342114 title "Intestinal lymphoma perforations as a consequence of highly effective anti-CD20 antibody therapy" @default.
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• W2057342114 doi "https://doi.org/10.1097/00007890-200202270-00038" @default.
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