Rituximab in the management of post-transplantation lymphoproliferative disorder after solid organ transplantation: proceed with caution

The introduction of single-agent rituximab has markedly changed the approach to therapy of patients with post-transplantation lymphoproliferative disorder (PTLD), but response to treatment varies substantially between patients. In the current report, we analyze long-term efficacy of single-agent rituximab in 60 patients and present factors predictive of progression-free and overall survival. Twelve months after completing first-line treatment, 34 of 60 patients (57%) had progressive disease, resulting in a median progression-free survival of 6.0 months at a median followup of 16.3 months. Using multivariate Cox regression analysis, the following factors were identified as significantly predictive of overall survival: age at diagnosis, performance status, lactate dehydrogenase (LDH), and time from transplantation to PTLD. Stage of disease and Epstein-Barr virus association of PTLD did not influence overall survival. LDH and time from transplantation to PTLD were also predictive of progression-free survival. The international prognostic index was shown to be of limited predictive value in these patients, but a PTLD-specific prognostic index separated low-, intermediate-, and high-risk patients with high significance: 2-year overall survival rates after first-line treatment with single-agent rituximab were 88, 50, and 0%, respectively. Thus, prognostic indices can be useful tools for prediction of treatment outcome and for the development of risk-adapted treatment strategies in patients with PTLD and may also provide the basis for interstudy comparisons.