Oral Manifestations of Post-transplant Lymphoproliferative Disorder

Lymphomas represent the third most common group of malignant lesions found in the oral and maxillofacial region, after Squamous Cell Carcinoma (SCCa) and salivary gland neoplasms.  One subset of lymphomas, Posttransplantation Lymphoproliferative Disorder(PTLD), is becoming more prevalent as the number of organ recipients increases.  It is thought that his occurs as a result of the interaction between EBV and the state of chronic immunosuppression.  The most common clinical presentation is localized swelling, with or without ulceration.  The nonspecific nature of this disease process makes differentiation from other malignant or benign processes difficult.  As it is a true malignancy commonly misdiagnosed as a benign lesion, PTLD necessitates early recognition and biopsy by a knowledgeable OMS in order to procure a diagnosis and improve outcomes.

A PubMed literature review of all cases of PTLD was conducted.  The data collected included the clinical presentation and location of the lesion, original diagnosis, treatment and outcome.  Also included was a recent case at Thomas Jefferson University Hospital in which a 52 year old lady post renal transplant presented with oral ulcerations and migraine who was misdiagnosed as having viral ulcers.  She was discharged on acyclovir after her first admission only to return for re-admission two more times.  On her third admission, the OMFS team was consulted, resulting in biopsies of the lesions, which with immunohistochemistry was found to be a diffuse large B-Cell Lymphoma.  This aided in the identification of the mass effect lesion in her brain, which carried the same diagnosis.

At this point in time, 11 cases of PTLD were found in the literature.  PTLD was recorded to be present in the lip, healing extraction socket, tongue, parotid gland and most commonly as ulcers on the gingiva.  Nearly half of the patients with PTLD presented with oral ulcers as their chief complaint (5 cases).  As so, the most common preliminary diagnosis was that of simple viral ulcers.  These patients were commonly treated with antivirals, subsequently failed treatment and then re-presented after further clinical deterioration.  Successful resolution of the lesion is possible with reduction of immunosupression in combination with antivirals, surgical excision and possibly chemotherapy.  Thus, it is paramount that these lesions are correctly identified in a timely fashion.

 

Over the past twenty years, tissue and hematopoietic transplantation has become increasingly more common.  As rare as PTLD is, clinicians need to be vigilant in examining post-transplant patients.  Any persistent oral lesion in a patient that is posttransplantation should alert the practitioner to possible PTLD.  Early detection of this disorder by the OMS yields the opportunity for oncologic surveillance in a patient that may otherwise be misdiagnosed, causing undo morbidity and mortality.       

Triantafillidou, K, et al. ”Extranodal NHL of Oral Cavity and Maxillofacial Region: A Clinical Study of 58 Cases and Review of the Literature.” JOMSDecember 2012. 2776-2784.

Elad, S., C. Meyerowitz, M. Shapira, M. Glick, M. Bitan, and G. Amir. "Oral Posttransplantation Lymphoproliferative Disorder: An Uncommon Site for an Uncommon Disorder." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 105.1 (2008): 59-64. Print.