Abstract
Introduction: We present a case of recurrent diffuse large B-cell lymphoma (DLBCL) in a lung transplant recipient. Case Report: A 62 year-old man underwent bilateral lung transplantation for chronic obstructive pulmonary disease; both donor and recipient were seropositive for Epstein Barr virus (EBV). The patient's posttransplant course was significant for heparin-associated thrombocytopenia, drug-induced leucopenia, steroid-induced diabetes, chronic nephropathy, and COVID, parainfluenza, and respiratory syncytial viral infections. Six years seven months later, the patient was given 2 doses of rituximab due to de-novo donor-specific antibodies. A few weeks later, he presented with bright red painless rectal bleeding; colonoscopy revealed an ulcerative mass in the cecum and ascending colon. Histopathology showed monomorphic EBV-negative DLBCL with a proliferation index of 80%; PET-CT showed no distant metastasis. The patient initially received 4 cycles of rituximab only chemotherapy; however, the patient reported progressively worsening right flank pain with poor oral intake and failure to thrive eight months after initial presentation; exam showed a mildly tender right mid-abdominal firm mobile mass without hepatosplenomegaly. CT demonstrated thick-walled cecum dilated to 9.5 cm with enlarging tumor infiltrating into the lateral abdominal wall. The patient underwent a robotic right colectomy with en-bloc resection of abdominal wall and end-ileostomy. Surgical pathology showed negative margins, 3 of 5 local lymph nodes were positive for lymphoma. A month later, the patient was admitted for shortness of breath and chest pain; exam showed a tender soft mass in the right mid-abdomen. Non-contrast CT was performed due to chronic kidney disease and showed a soft tissue collection in the same area suspicious for surgical site hematoma. Despite interruption of anticoagulation, the mass persisted and the patient continued to have dyspnea and failure to thrive. Contrast MRI was performed and showed right lateral abnormal wall heterogeneous enhancing lobulated mass extending into the extra-peritoneal and peritoneal space, suspicious for locally recurrent lymphoma. After extensive discussion with Oncology teams regarding the poor prognosis, the patient elected to pursue hospice care. Summary: EBV-negative posttransplant lymphoproliferative disorders, such as diffuse large B-cell lymphoma, are biologically distinct from their EBV+ counterparts, tend to occur much later after lung transplantation, frequently involve the gastrointestinal tract, and are more likely to be monomorphic. Modification of conventional chemotherapy is often needed given associated comorbidities. Despite aggressive and definitive therapy, early recurrence can occur and timely detection requires low threshold of clinical suspicion.