Open Access
J Oral Med Oral Surg
Volume 26, Number 1, 2020
Article Number 2
Number of page(s) 4
Section Cas clinique et revue de la littérature / Up-to date review and case report
Published online 23 December 2019

© The authors, 2019

Licence Creative CommonsThis is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Among malignant lesions of the head and neck, lymphomas are the second most common lesion [1], with an incidence rate of 0.1–5% [2]. They form a heterogeneous group of malignant haematology pathology. Lymphomas are more likely to develop in immunosuppressed patients like transplant recipients forming the post-transplant lymphoproliferative disorders (PTLD). These are a well-recognized complication of solid organ transplantation and need to be found out during the tracking of patients in order to be cured prematurely [3]. Lesions affect commonly the vestibule, gingival, or posterior hard palate and develop slowly as non-tender swellings, mimicking a dental abscess of endodontic or periodontal origin [4].


A 68 years-old woman was referred to the unit of the oral medicine of the Hospital University Center of Nice with growing swelling over her left lip since six weeks. She was toothless and she initially thought this swelling was due to an accidental blow. Before the persistence, she consulted her dentist, who prescribed antibiotics (amoxicillin/clavulanic acid) without any improvement. The patient did not report any systemic symptoms including weight loss or fever. She gave history of kidney transplantation 4 years ago, with tacrolimus 6 mg/day like treatment.

The extraoral examination disclosed a firm, painful swelling that is fixed into superficial and deep tissue. It was an unique homogeneous subcutaneous mass, measuring 5 × 5 × 3 cm. The overlaying mucosa was smooth and slightly erythematous (Fig. 1). There was no lymph node enlargement. Contrast computed tomography (CT) confirmed the presence of the enlarged mass in left lip, without bone lesion and without involvement of nasal cavity and metastasis, just a sub-mandibular lymph node aspecific (Fig. 2). Punch biopsy was performed under local anaesthesia and histopathological analyses showed diffuse infiltrate by atypical lymphoid cells (Fig. 3). Immunohistochemical staining was positive for CD20 and CD79a, and negative for CD3, CD5 and CD138. Fluorescence in situ hybridization depicted an absence of rearrangement of loci MYC and BCL6. The proliferative rate by Ki-67 was superior to 95% (Fig. 4). The laboratory investigation revealed a normal hemogram and a positive serology for Epstein-Barr Virus (EBV). A diagnosis of non-Hodgkin lymphoma (diffuse large B-cell lymphoma) was rendered.

The patient received one cycle concurrent chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), at the same time nephrologists switched PROGRAFT by EVEROLIMUS. Unfortunately a week later, she died of a pulmonary embolism due to pro-thrombotic treatments such as EVEROLIMUS, hematopoietic growth factors and the absence of antithrombotic prophylaxis, which was impossible in her case on account of her renal deficiency.

thumbnail Fig. 1

Local examination on the lymphoma of the left lip.

thumbnail Fig. 2

CT scan of the face with lymphoma of the left lip without bone lesion (axial and coronal slices).

thumbnail Fig. 3

Proliferation of large lymphoid cells (HES, X400).

thumbnail Fig. 4

The Ki-67 cell proliferation index was approximately 95% (X ;400).


The PTLD is a heterogeneous group of diseases occurring after solid organ transplantation or allogenic hematopoietic stem cell transplantation. It may present various clinical manifestations, from non-specific mononucleosis-like syndrome to lymphomas. The first cases were reported in 1968 by DOAK and al. for kidney recipient [3]. This is a well-known complication for transplant recipient due to the immunosuppressive treatment used to prevent graft rejecting. In Kasisks study, they analysed rates of malignancies after kidney transplantation (n = 35 765), non-Hodgkin lymphoma is increased 20-fold compared to general population [5]. Post-transplant non-Hodgkin lymphomas differ from lymphomas of the general population with more aggressive clinical course, poorer response to conventional therapies and poorer outcomes. The most common malignant PTLD subtype is diffuse large B-cell lymphoma, with only 5% of T cell or T/NK cell origin [6].

Immunosuppression is considered as the most important risk factor, as it decreases the immunologic control of oncogenic viral infection and cancer immunosurveillance. The other risk factors of PTLD are EBV infections, age, transplant type and immunosuppressive therapy provided. The mean age correlated with diagnosis is about 46/48 years in many studies [3,7,8,9], but the risk is linked to the age at the moment of the transplantation: the younger the recipient is, the higher the risk gets. For the transplant type, PTLD prevails most often (20% of patients) for bowel recipients; less often for liver and kidney recipients 2.4–8% vs 1-10%, and even less for bone marrow recipients (1%) [10].

Approximately 50 to 70% of PTLD are EBV related [11]. Once EBV infects B-lymphocytes, it achieves latent infection. This virus is a well-known oncogenic virus, with protein like latent membrane protein-1 (LMP-1) mimics CD40, activates the nuclear factor-kappa B and induces BCL-2 to escape from apoptosis and provide a proliferation [12]. Most cases of PTLD have been linked to unrestrained proliferation of EBV infected B cells caused by suppression of normal immune system mechanisms on account of immunosuppressive therapy [13].

In the study of Opelz et al. [14], among 18 682 kidney transplant recipients, the risk of lymphoma post transplantation was significantly increased for patients with a seronegative EBV status in all age groups in comparison with patients with seropositive EBV status. This is due to the primary EBV infection caused by transplanted infected organs [15]. These explain the higher risk of PTLD for transplanted children, naive of this infection and the association between early-onset disease and seronegative EBV recipient status [16]. These findings provide the need for an EBV serology before a graft [14] as well as a screen for EBV DNA in blood in high-risk recipients for 1 year after transplantation like recommended actual guidelines [17].

PTLD treatment has to guaranteee the complete remission as well as the preservation of the transplantation. The universal initial step is the reduction of immunosuppression [9,18]. Then, current treatment strategies used antiviral therapy, monoclonal antibodies, chemotherapy and local therapy (surgery and radiation) [19]. The most common is Rituximab (chimeric monoclonal antibody directed against the B cell antigen CD20) associated with chemotherapy CHOP (Cyclophosphamide, Hydroxy Adriamycine, Oncovin, Prednisone) [20]. Overall patient survival at 1, 5, and 10 years was 66%, 50%, and 37% respectively [15] and mean survival is 5.6 years [20].

Survival rate lowers, as well as graft survival rate for transplanted patients with PTLD compared to patients without.


PTLD is a complication following transplantation that can seriously threaten long-term outcomes, overall survival patient and graft survival. Screening for malignant lesions should continue to be a major focus in all transplanted patients. Dentists, oral surgeons and oral pathologists need to be vigilant about all oral lesions, realizing a biopsy for histopathologic examination and starting early treatments.

Conflict of interest

The authors declare that they have no conflicts of interest in relation to this article.


  1. Scherfler S, Freier K, Seeberger R, Bacon C, Hoffmann J, Thiele OC. Cranio-maxillofacial non-Hodgkin's lymphoma: clinical and histological presentation. J Craniomaxillofac Surg 2012;40:e211–e213. [CrossRef] [PubMed] [Google Scholar]
  2. Reddy I, Sreenath G, Reddy YR, Prakash AR, Swathi TR. Non-Hodgkin's lymphoma in buccal vestibule − case report. J Clin Diagn Res 2014;8:QD01–QD02. [Google Scholar]
  3. Romero S, Montoro J, Guinot M, Almenar L, Andreu R, Balaguer A, et al. Post-transplant lymphoproliferative disorders after solid organ and hematopoietic stem cell transplantation. Leuk Lymphoma 2018;1–9. [Google Scholar]
  4. Malaguarnera M, Giordano M, Russo C, Puzzo L, Trainiti M, Consoli AS, et al. Lymphoma of cheek: a case report. Eur Rev Med Pharmacol Sci 2012;16 Suppl 4:4–7. [PubMed] [Google Scholar]
  5. Kasiske BL, Snyder JJ, Gilbertson DT, Wang C. Cancer after kidney transplantation in the United States. Am J Transplant 2004;4:905–913. [Google Scholar]
  6. Abdelrahim LM, Peh SC, Kallarakkal TG. Epstein-Barr virus infection in B-cell Non-Hodgkin's Lymphomas of the oral and maxillofacial region: Is there any evidence? Malays J Pathol 2018;40:49–56. [PubMed] [Google Scholar]
  7. Ready E, Chernushkin K, Partovi N, Hussaini T, Luo C, Johnston O, et al. Posttransplant Lymphoproliferative Disorder in Adults Receiving Kidney Transplantation in British Columbia: A Retrospective Cohort Analysis. Can J Kidney Health Dis. 2018;5:2054358118760831. [CrossRef] [PubMed] [Google Scholar]
  8. Wójciak M, Gozdowska J, Dęborska-Materkowska D, Perkowska-Ptasińska A, Kosieradzki M, Nazarewski S, et al. Posttransplant lymphoproliferative disorder in kidney and liver transplant recipients: a single-center experience. Transplant Proc 2018;50: 2154–2158. [CrossRef] [PubMed] [Google Scholar]
  9. Shapiro R, Nalesnik M, McCauley J, Fedorek S, Jordan ML, Scantlebury VP, et al. Posttransplant lymphoproliferative disorders in adult and pediatric renal transplant patients receiving tacrolimus-based immunosuppression. Transplantation 1999;68: 1851–1854. [CrossRef] [PubMed] [Google Scholar]
  10. Krasuska-Sławińska E, Minko-Chojnowska I, Pawłowska J, Dembowska-Bagińska B, Pronicki M, Olczak-Kowalczyk D. Post-Transplant Lymphoproliferative Disorder (PTLD) Manifesting in the Oral Cavity of a 13-Year-Old Liver Transplant Recipient (LTx). Ann Transplant 2015;20:478–482. [CrossRef] [PubMed] [Google Scholar]
  11. Kinch A, Baecklund E, Backlin C, Ekman T, Molin D, Tufveson G, et al. A population-based study of 135 lymphomas after solid organ transplantation: The role of Epstein-Barr virus, hepatitis C and diffuse large B-cell lymphoma subtype in clinical presentation and survival. Acta Oncol 2014;53:669–679. [CrossRef] [PubMed] [Google Scholar]
  12. Ok CY, Li L, Young KH. EBV-driven B-cell lymphoproliferative disorders: from biology, classification and differential diagnosis to clinical management. Exp Mol Med 2015;47:e132. [Google Scholar]
  13. Hanto DW, Frizzera G, Gajl-Peczalska KJ, Simmons RL. Epstein-Barr virus, immunodeficiency, and B-cell lymphoproliferation. Transplantation 1985;39:461–472. [CrossRef] [PubMed] [Google Scholar]
  14. Opelz G, Daniel V, Naujokat C, Döhler B. Epidemiology of pretransplant EBV and CMV serostatus in relation to posttransplant non-Hodgkin lymphoma. Transplantation 2009;88:962–967. [CrossRef] [PubMed] [Google Scholar]
  15. Morton M, Coupes B, Roberts SA, Klapper PE, Byers RJ, Vallely PJ, et al. Epidemiology of posttransplantation lymphoproliferative disorder in adult renal transplant recipients. Transplantation 2013;95:470–478. [CrossRef] [PubMed] [Google Scholar]
  16. Ojha J, Islam N, Cohen DM, Marshal D, Reavis MR, Bhattacharyya I. Post-transplant lymphoproliferative disorders of oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:589–596. [CrossRef] [PubMed] [Google Scholar]
  17. Morton M, Coupes B, Roberts SA, Johnson SL, Klapper PE, Vallely PJ, et al. Epstein-Barr virus infection in adult renal transplant recipients. Am J Transplant 2014;14:1619–1629. [Google Scholar]
  18. Opelz G, Döhler B. Lymphomas after solid organ transplantation: a collaborative transplant study report. Am J Transplant 2004;4: 222–230. [Google Scholar]
  19. Renard N, Canonica M, Piral T, Princ G. Lymphomes malins non hodgkiniens buccaux: À propos de 18 cas. Med Buccale Chir Buccale 2015;21:77–83. [CrossRef] [Google Scholar]
  20. Morton M, Coupes B, Ritchie J, Roberts SA, Klapper PE, Byers RJ, et al. Post-transplant lymphoproliferative disorder in adult renal transplant recipients: survival and prognosis. Leuk Lymphoma 2016;57:299–305. [PubMed] [Google Scholar]

All Figures

thumbnail Fig. 1

Local examination on the lymphoma of the left lip.

In the text
thumbnail Fig. 2

CT scan of the face with lymphoma of the left lip without bone lesion (axial and coronal slices).

In the text
thumbnail Fig. 3

Proliferation of large lymphoid cells (HES, X400).

In the text
thumbnail Fig. 4

The Ki-67 cell proliferation index was approximately 95% (X ;400).

In the text

Current usage metrics show cumulative count of Article Views (full-text article views including HTML views, PDF and ePub downloads, according to the available data) and Abstracts Views on Vision4Press platform.

Data correspond to usage on the plateform after 2015. The current usage metrics is available 48-96 hours after online publication and is updated daily on week days.

Initial download of the metrics may take a while.