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Patel JA, Daoud D, Jain A. Review of Standardized Incidence Ratios (SIR) of non-lymphoid de novo malignancies after liver transplantation: Structured analysis of global differences. Transplant Rev (Orlando) 2021; 36:100670. [PMID: 34688986 DOI: 10.1016/j.trre.2021.100670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION De Novo malignancy after liver transplantation (LTx) is the second most common cause of death in adult LTx recipients. The current report identifies differences in Standardized Incidence Ratios (SIR) for various non-lymphoid de novo malignancies by comparing and analyzing post LTx SIR for non-lymphoid de novo malignancies. MATERIAL AND METHODS A thorough search of PubMed and Web of Science databases was conducted; 25 publications describing de novo malignancies post-LTx with SIR were identified. RESULTS Overall SIR varied from 1.4 to 11.6 (median 2.4). Oropharyngeal/larynx (OPL), lung, colo-rectal, and kidney malignancies were more prevalent with higher SIR (median = 4.4, 1.9, 2.67, 2.5, respectively). Breast and prostate malignancies were also more prevalent with lower SIR (median = 0.9, 1.0, respectively). Pancreatic, central nervous system (CNS), melanoma, rare cancers and Kaposi's sarcoma were less prevalent (except in Italy and Sweden) but had much higher SIR (median = 2.6, 2.4, 2.02, 22.5 and 53.6, respectively). The overall higher SIR values are related to the age of the recipient, length of follow-up, the grouping of different organ systems, inclusion or exclusion of epidermal non-malacotic skin cancers, lymphoid malignancy, and occurrence of rare malignancies including Kaposi's sarcoma. CONCLUSION OPL, lung, gastrointestinal, kidney, and bladder malignancies were more prevalent with higher SIR. Breast and prostate cancers were more prevalent with lower SIR. Pancreatic, CNS, melanoma, rare cancers and Kaposi's sarcoma were less prevalent with higher SIR. Age of the recipients, length of follow-up, and rare cancer types influence overall SIR values with some global differences.
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Affiliation(s)
- Jay A Patel
- Department of General Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Deborah Daoud
- Division of Transplant Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA
| | - Ashokkumar Jain
- Department of General Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA; Division of Transplant Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA, USA.
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2
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Anderson TL, Brandts HM, Gunderson T, Fazzio RT, Hunt KN, Heimbach JK, Glazebrook KN. Breast cancers observed in transplant patients in a single institution. Clin Imaging 2021; 76:26-29. [PMID: 33548889 DOI: 10.1016/j.clinimag.2021.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Document occurrence of breast cancer in females after liver, kidney, or pancreas transplantation seen at a tertiary medical center. METHODS Medical records of adult female patients with liver, kidney, or pancreas transplants from 1/1/1995 to 4/4/2014 were retrospectively reviewed. Patients with a history of breast cancer, no mammogram post-transplant, or no research authorization were excluded. Mammogram findings and pathology results were reviewed and recorded. Cancer rates could not be measured in patients followed up outside the institution. Descriptive statistics summarized the cohort. Occurrence rates were estimated using Poisson regression. RESULTS 1095 women were included and 33 were diagnosed with breast cancer post-transplant. Median age at diagnosis was 58 years. Average interval from transplant to cancer diagnosis was 82.6 months. Observed occurrence of invasive and in-situ breast cancer (reported as per 100,000 person-years [95% confidence interval]) was 353 [243-496]. Liver transplant patients showed the lowest rate (181 [95% CI 73-372]), vs. kidney (476 [305-708]) or pancreas (467 [57-1688]). Patients with the highest breast density showed increased occurrence despite younger age (1001 [367-2178]) compared to those with lower breast density (range 239 [109-454] to 372 [186-666]). CONCLUSIONS Female patients after organ transplant experienced increased breast cancer occurrence in this observational study. Those who developed breast cancer also had increased breast density. The findings underscore the importance of breast cancer screening in this population.
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Affiliation(s)
- Tara L Anderson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America.
| | - Hannah M Brandts
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Tina Gunderson
- Division of Biostatistics and Infomatics, Mayo Clinic, 200 First Street SW, Rochester, MN, United States of America
| | - Robert T Fazzio
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Katie N Hunt
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Julie K Heimbach
- Department of Transplantation Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America
| | - Katrina N Glazebrook
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
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3
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Ardhani R, Ana ID, Tabata Y. Gelatin hydrogel membrane containing carbonate hydroxyapatite for nerve regeneration scaffold. J Biomed Mater Res A 2020; 108:2491-2503. [PMID: 32418269 DOI: 10.1002/jbm.a.37000] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/11/2020] [Accepted: 04/19/2020] [Indexed: 12/26/2022]
Abstract
A scaffold that mimics physicochemical structure of nerve and supplies calcium ions in axonal environment is an attractive alternative for nerve regeneration, especially when applied in critical nerve defect. Various scaffold material, design, including their combination with several growth-induced substances and cells application have been being investigated and used in the area of nerve tissue engineering. However, the development remains challenges today because they are still far from ideal concerning their stability, reproducibility, including complicated handling related to the poor mechanical strength. In view of the current basis, in this study, the introduction of carbonated hydroxyapatite (CHA) as promising candidate to increase mechanical properties of nerve scaffold is reported. The incorporation of CHA was not only expected to provide better mechanical properties of the scaffold. Under physiological condition, CHA is known to be the most stable phases of calcium phosphate compound. Therefore, CHA was expected to provide controlled release calcium for better axonal environment and promote fasten nerve regeneration. This study shows that CHA incorporated gelatin membrane has ideal microstructure to prevent fibrous tissue ingrowth into the injury site, while retaining its capability to survive nerve tissue by allowing adequate glucose and specific proteins diffusion. The provided Ca2+ release to the environment promoted neuronal growth, without suppressing acetylcholine esterase release activity. Neurite elongation was dramatically higher in the gelatin membrane incorporated with CHA. Introduction of CHA into gelatin membrane represents a new generation medical device for nerve reconstruction, with CHA was considered as a promising factor.
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Affiliation(s)
- Retno Ardhani
- Department of Dental Biomedical Sciences, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ika Dewi Ana
- Department of Dental Biomedical Sciences, Faculty of Dentistry, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Yasuhiko Tabata
- Laboratory of Biomaterials, Department of Regeneration Science and Engineering Institute for Frontier Life and Medical Sciences, Kyoto University, Kyoto, Japan
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4
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Singh A, De A, Singh V. Post-transplant malignancies in alcoholic liver disease. Transl Gastroenterol Hepatol 2020; 5:30. [PMID: 32258534 DOI: 10.21037/tgh.2019.11.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 11/21/2019] [Indexed: 01/20/2023] Open
Abstract
Post-transplant malignancy is emerging as an important cause of mortality in patients with cirrhosis undergoing liver transplant (LT). However, establishing the exact relationship between the two needs further evaluation. It has been observed that approximately 30% deaths after 10 years of hepatic transplantation occur due to de novo malignancies. Various known risk factors include immunosuppression, age of patient, alcoholic liver disease (ALD) or primary sclerosing cholangitis, smoking, and oncogenic viral infections. There is scanty literature on the post-transplant malignancy risk in patients with alcoholic cirrhosis. The current evidence suggests a particularly increased risk of oropharyngeal and lung cancers in patients transplanted for ALD. Abstinence from alcohol, smoking and other tobacco-containing products along with optimization of immunosuppression are paramount for decreasing the risk of post-transplant malignancies.
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Affiliation(s)
- Akash Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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5
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Bibee K, Swartz A, Sridharan S, Kurten CHL, Wessel CB, Skinner H, Zandberg DP. Cutaneous squamous cell carcinoma in the organ transplant recipient. Oral Oncol 2020; 103:104562. [PMID: 32065978 PMCID: PMC7217490 DOI: 10.1016/j.oraloncology.2019.104562] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/13/2019] [Accepted: 12/31/2019] [Indexed: 12/31/2022]
Abstract
One in twenty solid organ transplant recipients (SOTRs) will develop a highly morbid or fatal cutaneous carcinoma after transplantation. The majority of these cases develop on the head and neck and may require intervention on the part of dermatology, dermatologic surgery, otolaryngology, transplant medicine, radiation oncology, and medical oncology. In this review, we discuss the problem of cutaneous squamous cell carcinoma (cSCC) in SOTRs as well as the prognostic factors and management strategies to care for this population.
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Affiliation(s)
- Kristin Bibee
- Department of Dermatology, University of Pittsburgh, 3708 Fifth Ave #5, Pittsburgh, PA 15213, USA; Hillman Cancer Center, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA 15232, USA.
| | - Andrew Swartz
- Department of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA 15261, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Cornelius H L Kurten
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA 15232, USA; Department of Otorhinolaryngology, University Hospital Essen, University Duisburg-Essen, Hufelandstrabe 55, 45147 Essen, Germany
| | - Charles B Wessel
- Health Sciences Library, University of Pittsburgh, 200 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261, USA
| | - Heath Skinner
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA 15232, USA; Department of Radiation Oncology, University of Pittsburgh, 5115 Centre Ave, Pittsburgh, PA 15232, USA
| | - Dan P Zandberg
- Hillman Cancer Center, University of Pittsburgh Medical Center, 5115 Centre Ave, Pittsburgh, PA 15232, USA; Department of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA 15261, USA
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6
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Lopez J, Gourin CG, Tufaro AP. Aggressive Cutaneous Malignancies: A New and Dangerous Phenomenon in Transplant Patients. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0223-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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7
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Crouse L, McShane D, Morrell DS, Wu EY. Pyoderma gangrenosum in an infant: A case report and review of the literature. Pediatr Dermatol 2018; 35:e257-e261. [PMID: 29656404 DOI: 10.1111/pde.13471] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis that is rare in infancy, with only 20 cases reported in the literature. We present a case of infantile pyoderma gangrenosum refractory to topical steroids, tacrolimus, and dapsone as well as systemic steroids and infliximab that is currently well controlled with the addition of oral tacrolimus. To our knowledge, this is the first report of the effective, safe use of oral tacrolimus in combination with infliximab for infantile pyoderma gangrenosum. We review all current cases of infantile pyoderma gangrenosum, as well as tacrolimus and its role in the treatment of this condition.
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Affiliation(s)
- Lauren Crouse
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diana McShane
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dean S Morrell
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eveline Y Wu
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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8
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Ohtsuki M, Morimoto H, Nakagawa H. Tacrolimus ointment for the treatment of adult and pediatric atopic dermatitis: Review on safety and benefits. J Dermatol 2018; 45:936-942. [PMID: 29927498 PMCID: PMC6099320 DOI: 10.1111/1346-8138.14501] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/07/2018] [Indexed: 12/26/2022]
Abstract
Atopic dermatitis (AD) requires long-term management, mainly with topical anti-inflammatory agents. Topical corticosteroids (TCS) and tacrolimus ointment (TAC-O) are recommended as first-line treatments for AD. However, the long-term use of TCS is limited by cutaneous adverse events such as skin atrophy. For TAC-O, Japanese and US labelings were updated in 2003 and 2006, respectively, to include a boxed warning about a theoretical risk of skin cancer and lymphoma in patients treated with topical calcineurin inhibitors. However, TAC-O has been used worldwide for longer than 15 years to treat adult and pediatric patients with AD. Available data suggest that TAC-O is effective and well tolerated, and can improve quality of life. TAC-O has successfully been used in the proactive management of AD consisting of long-term intermittent use to prevent, delay or reduce the occurrence of AD flares. Systemic drug absorption after TAC-O application is negligible and unlikely to result in systemic immunosuppression. There is currently no strong evidence of an increased rate of malignancy in treated patients, and observational data from postmarketing surveillance studies have shown no safety concerns. In the absence of robust evidence, the warning about the carcinogenic potential in the Japanese labeling for TAC-O does not appear justified and should be reconsidered. This mitigation of description would allow adult and pediatric patients with AD to receive the effective treatment more appropriately.
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Affiliation(s)
| | | | - Hidemi Nakagawa
- Department of DermatologyThe Jikei University School of MedicineTokyoJapan
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9
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Acuna SA. Etiology of increased cancer incidence after solid organ transplantation. Transplant Rev (Orlando) 2018; 32:218-224. [PMID: 30017342 DOI: 10.1016/j.trre.2018.07.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/28/2018] [Accepted: 07/05/2018] [Indexed: 01/15/2023]
Abstract
Over the past decades, there has been an encouraging increase in survival after solid organ transplantation. However, with longer life spans, more transplant recipients are at risk of dying with functioning grafts from illnesses such as cancer and cardiovascular conditions. Malignancy has emerged as an important cause of death in transplant recipients and is expected to become the leading cause of death in transplanted patients within the next decade. While it is known that solid organ transplant recipients have a three to five-fold increased risk of developing cancer compared with the general population, the mechanisms that lead to the observed excess risk in transplant recipients are less clear. This review explores the etiology of the increased cancer incidence in solid organ transplant including the effect of immunosuppressants on immunosurveillance and activation of oncogenic viruses, and carcinogenic effects of these medications; the role of chronic stimulation of the immune system on the development of cancer; and the impact of pre-existing cancer risk factors and factors related to end-stage organ disease on the cancer excess incidence in solid organ transplant recipients.
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Affiliation(s)
- Sergio A Acuna
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; Department of Surgery, St. Michael's Hospital, Toronto, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
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10
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Castellsague J, Kuiper JG, Pottegård A, Anveden Berglind I, Dedman D, Gutierrez L, Calingaert B, van Herk-Sukel MP, Hallas J, Sundström A, Gallagher AM, Kaye JA, Pardo C, Rothman KJ, Perez-Gutthann S. A cohort study on the risk of lymphoma and skin cancer in users of topical tacrolimus, pimecrolimus, and corticosteroids (Joint European Longitudinal Lymphoma and Skin Cancer Evaluation - JOELLE study). Clin Epidemiol 2018; 10:299-310. [PMID: 29559812 PMCID: PMC5856050 DOI: 10.2147/clep.s146442] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background There is a concern that topical tacrolimus and pimecrolimus, indicated for second-line treatment of atopic dermatitis, may increase the risk of lymphoma and skin cancer, particularly in children. Objective The aim of this study was to compare incidence rates (IRs) of lymphoma and skin cancer between new users of topical tacrolimus or pimecrolimus and users of moderate- to high-potency topical corticosteroids (TCSs) and untreated subjects. Methods This is a multicenter cohort study with frequency matching by strata of propensity scores in population databases in the Netherlands, Denmark, Sweden, and the UK. IR ratios (IRRs) were estimated using Mantel–Haenszel methods for stratified analysis. Results We included 19,948 children and 66,127 adults initiating tacrolimus, 23,840 children and 37,417 adults initiating pimecrolimus, 584,121 users of TCSs, and 257,074 untreated subjects. IRs of lymphoma per 100,000 person-years were 10.4 events in children and 41.0 events in adults using tacrolimus and 3.0 events in children and 27.0 events in adults using pimecrolimus. The IRR (95% confidence interval [CI]) for lymphoma, tacrolimus versus TCSs, was 3.74 (1.00–14.06) in children and 1.27 (0.94–1.71) in adults. By lymphoma type, the highest IRR was 3.17 (0.58–17.23) for Hodgkin lymphoma in children and 1.76 (95% CI, 0.81–3.79) for cutaneous T-cell lymphoma (CTCL) in adults. For pimecrolimus versus TCSs, the highest IRR was 1.31 (95% CI, 0.33–5.14) for CTCL in adults. Compared with untreated subjects, adults using TCSs had a higher incidence of CTCL (IRR, 10.66; 95% CI, 2.60–43.75). Smaller associations were found between tacrolimus and pimecrolimus use and the risk of malignant melanoma or nonmelanoma skin cancer. Conclusion Use of topical tacrolimus and pimecrolimus was associated with an increased risk of lymphoma. The low IRs imply that even if the increased risk is causal, it represents a small excess risk for individual patients. Residual confounding by severity of atopic dermatitis, increased monitoring of severe patients, and reverse causation could have affected the results.
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Affiliation(s)
| | - Josephina G Kuiper
- Department Research, PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ingegärd Anveden Berglind
- Centre for Pharmacoepidemiology, Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Dedman
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lia Gutierrez
- Department of Epidemiology, RTI Health Solutions, Barcelona, Spain
| | - Brian Calingaert
- Department Epidemiology, RTI Health Solutions, Research Triangle Park, NC
| | | | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anders Sundström
- Centre for Pharmacoepidemiology, Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Arlene M Gallagher
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - James A Kaye
- Department of Epidemiology, RTI Health Solutions, Waltham, MA, USA
| | - Carolina Pardo
- Pharmacovigilance Department, Astellas Pharma Europe B.V., Leiden, the Netherlands
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11
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Bajetta E, Platania M, Catena L, Bichisao E, Fabbri A, Procopio G, De Dosso S, Buzzoni R. Merkel Cell Carcinoma after Liver Transplantation: A Case Report. TUMORI JOURNAL 2018; 93:323-6. [PMID: 17679476 DOI: 10.1177/030089160709300321] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Merkel cell carcinoma is a rare and aggressive neuroendocrine skin cancer with a very low incidence in the general population. MCC seems to be common in transplant recipients and 52 cases have been reported in the literature. Methods and results This report describes a Merkel cell carcinoma which developed in a liver transplant recipient. To our knowledge, this is the second such case reported, as Merkel cell carcinoma most commonly occurs after kidney and heart transplants. The treatment approach is described and the literature on the subject is reviewed. Conclusion There is currently no consensus regarding the optimal therapeutic approach to Merkel cell carcinoma. In transplant recipients, such tumors are more common and more aggressive but their treatment does not differ from the treatment of Merkel cell carcinomas in the general population.
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Affiliation(s)
- Emilio Bajetta
- Unit of Medical Oncology 2, Centro di Riferimento per lo Studio e la Cura del Carcinoide e dei Tumori Neuroendocrini (CeRiCa), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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12
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Campos GR, Boin IDFSF, Campos IDD, Cintra ML. Study of factors affecting the incidence of skin cancer in patients after liver transplant. An Bras Dermatol 2017; 92:492-498. [PMID: 28954097 PMCID: PMC5595595 DOI: 10.1590/abd1806-4841.20175946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 12/10/2016] [Indexed: 01/08/2023] Open
Abstract
Background Many factors are currently being identified as potential inductors of skin
cancer in patients after a liver transplant, among them, immunosuppressive
regimen. Objective To study the factors that influence the incidence of skin cancer in patients
after liver transplant. Methods We have carried out a retrospective and observational study with 170
transplanted patients who had undergone transplantation from 1997 to 2010.
We have adjusted the multiple logistic regression model (saturated model) to
the ensemble of collected data using skin cancer as dependent variable,
indicated in anatomopathological analysis between 1997 and 2014. Results Incidence of skin cancer was 9.4%. Predictors were incidence of diabetes in
the third year after the transplantation (p=0.047), not using tacrolimus in
the first year after the transplantation (p=0.025) and actinic keratosis
(p=0.003). Study Limitations An important limitation is that the interpretation of the results was based
on information collected of patients undergoing transplantation at a single
center. Future research, multicentric and involving larger and more diverse
populations, are needed. Conclusions Factors found might contribute to Brazilian surveillance programs associated
with decreased incidence of skin cancer.
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Affiliation(s)
- Gabriela Rached Campos
- Post-Graduation Program in Surgery Sciences of School of Medical Sciences of Universidade Estadual de Campinas (FCM-Unicamp) - Campinas (SP), Brazil
| | | | - Ivan Dias de Campos
- Post-Graduation Program in Surgery Sciences of School of Medical Sciences of Universidade Estadual de Campinas (FCM-Unicamp) - Campinas (SP), Brazil
| | - Maria Letícia Cintra
- Department of Pathologic Anatomy of School of Medical Sciences of Universidade Estadual de Campinas (FCM-Unicamp) - Campinas (SP), Brazil
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Risk Factors and Outcomes of De Novo Cancers (Excluding Nonmelanoma Skin Cancer) After Liver Transplantation for Primary Sclerosing Cholangitis. Transplantation 2017; 101:1859-1866. [PMID: 28272287 DOI: 10.1097/tp.0000000000001725] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with primary sclerosing cholangitis (PSC) may be at higher risk of malignancy after liver transplantation (LT) compared to other LT recipients. We aimed to determine the cumulative incidence of/risk factors for long-term cancer-related mortality in patients with PSC after LT. METHODS All adult patients underwent LT for PSC without cholangiocarcinoma from 1984 to 2012, with follow-up through June 2015. We estimated cumulative incidence, risk factors, and mortality from de novo malignancies after LT. RESULTS Two hundred ninety-three patients were identified (mean [SD] age, 47 [12] years; 63.3% males; 2.4% smoking at LT). Over a median of 11.5 years (range, 6.4-18.6 years), 64 patients (21.8%) developed 73 nonskin cancers, including 46 solid-organ cancers (renal, 11; colorectal, 11; prostate, 7; breast, 5; pancreas, 5; ovarian/endometrial/vulvar cancers, 3; and de novo cholangiocarcinoma, 4). Twenty-two patients developed hematologic malignancies (posttransplant lymphoproliferative diseases, 18; Hodgkin disease, 2; and myelodysplastic syndrome, 2). Five patients developed melanoma. The 1-, 5-, 10-, and 20-year cumulative incidences of cancer were 2.1%, 8.6%, 18.7%, and 27%, respectively. Mortality of patients with PSC who developed cancer was higher than that of patients with PSC without cancer (hazard ratio, 2.2; P < 0.01). On multivariate analysis, recipient's age and elevated pre-LT international normalized ratio were associated with increased risk of de novo (nonskin) malignancy. CONCLUSION The 10-year cumulative risk of cancer after LT for advanced-stage PSC was 18.7%, with posttransplant lymphoproliferative diseases, colorectal cancer, and renal cell cancer being the most common. Post-LT de novo nonskin cancer decreased overall posttransplant survival. Only recipient's age and elevated international normalized ratio at LT were associated with increased nonskin cancer risk.
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14
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Komaki Y, Komaki F, Micic D, Ido A, Sakuraba A. Risk of colorectal cancer in chronic liver diseases: a systematic review and meta-analysis. Gastrointest Endosc 2017; 86:93-104.e5. [PMID: 28011280 DOI: 10.1016/j.gie.2016.12.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The risk of colorectal cancer (CRC) in various chronic liver diseases compared with the general population remains unclear. We performed a systematic review and meta-analysis to assess the risk of CRC in patients with chronic liver diseases before and after liver transplantation. METHODS Electronic databases were searched for studies assessing the risk of CRC in patients with chronic liver diseases. The primary outcome was the pooled risk of CRC among studies that reported the risk as standardized incidence rate (SIR). RESULTS Fifty studies that included 55,991 patients were identified. Among studies that included hepatitis and cirrhotic patients, the pooled SIR was 2.06 (P < .0001; 95% confidence interval (CI), 1.46-2.90) with moderate heterogeneity (I2 = 49.2%), which appeared to be because of the difference between subgroup of diseases and the power of studies. Three studies reported an increased risk of CRC in primary sclerosing cholangitis patients (pooled SIR 6.70; P < .0001; 95% CI, 3.48-12.91) with moderate heterogeneity (I2 = 36.3%), which appeared to be because of the difference between the power of studies. Among studies that included post-transplant patients, the pooled SIR was 2.16 (P < .0001; 95% CI, 1.59-2.94) with moderate heterogeneity (I2 = 56.4%). Meta-regression showed a correlation between the proportion of autoimmune-related liver diseases and the risk of CRC. CONCLUSIONS Patients with chronic liver diseases had an increased risk of CRC compared with the general population, which persisted after liver transplantation. A more intensive surveillance for CRC is warranted in this population.
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Affiliation(s)
- Yuga Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Fukiko Komaki
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Dejan Micic
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Akio Ido
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Atsushi Sakuraba
- Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois, USA
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15
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Liu ZN, Wang WT, Yan LN. De Novo Malignancies After Liver Transplantation With 14 Cases at a Single Center. Transplant Proc 2016; 47:2483-7. [PMID: 26518956 DOI: 10.1016/j.transproceed.2015.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To analyze the clinical characteristics, risk factors, and prevention of de novo malignant tumors after liver transplantation. METHODS Fourteen patients who underwent liver transplantation were identified as having de novo malignancies. The clinical characteristics and survival of these patients were retrospectively reviewed. RESULTS Fourteen cases of de novo malignancies after liver transplantation occurred for an incidence rate of 1.94% (14/722), including 11 men (78.6%, mean age, 48 y) and 3 women (21.4%, mean age, 50 y). The mean period from transplantation to cancer diagnosis was 55 ± 35 months. The distribution of tumor histologic types included colon cancer, lung cancer, esophageal cancer, nasopharyngeal cancer, liver cancer, parotid carcinoma, bone cancer, post-transplantation lymphoproliferative disorder, stomach cancer, bladder cancer, and laryngeal cancer. Twelve cases (85.7%) had hepatitis B. Five patients (35.7%) underwent operations, and the other 9 patients underwent chemotherapy or radiotherapy. During a mean follow-up period of 37 ± 26 months after the diagnosis of de novo malignancy, 8 patients (57.1%) died, with only 1 dying of causes not related to the de novo malignancy. The survival analysis showed 1-, 5-, and 7-year survival rates of 85.7%, 71.4%, and 42.9%, respectively. CONCLUSIONS De novo malignancies after organ transplantation have been suggested to be a major cause of late mortality. De novo malignancy after orthotopic liver transplantation was found to be related to smoking, sex, and low immune function due to immunosuppressive agents. Solid tumors should be removed, and the patient should receive chemotherapy or radiotherapy as early as possible. Early diagnosis and treatment are very important for improving the prognosis.
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Affiliation(s)
- Z-N Liu
- Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - W-T Wang
- Liver Surgery, West China Hospital of Sichuan University, Chengdu, China.
| | - L-N Yan
- Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
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16
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Abikhair M, Mitsui H, Yanofsky V, Roudiani N, Ovits C, Bryan T, Oberyszyn TM, Tober KL, Gonzalez J, Krueger JG, Felsen D, Carucci JA. Cyclosporine A immunosuppression drives catastrophic squamous cell carcinoma through IL-22. JCI Insight 2016; 1:e86434. [PMID: 27699266 PMCID: PMC5033893 DOI: 10.1172/jci.insight.86434] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/21/2016] [Indexed: 12/27/2022] Open
Abstract
Immune-suppressed organ transplant recipients (OTRs) can develop catastrophic squamous cell carcinoma (SCC), characterized by multiple primary tumors, extensive body surface area involvement, or metastases. There are currently no curative systemic therapies available. We previously showed that IL-22 enhances SCC proliferation. Herein, we examined links between cyclosporine (CSA), IL-22, and SCC in patients, cell lines, and mice with UV light-induced SCC. Eighteen of 114 OTRs developed catastrophic SCC, which was strongly associated with CSA treatment. We found that CSA drives T cell polarization toward IL-22-producing T22 cells, and CSA treatment increased IL-22 receptor in SCC cells. SCC tissue from OTRs showed increased expression of IL-22RA1. CSA potentiated rescue by IL-22 of serum-starved SCC cells; treatment of SCC cells with IL-22 and CSA increased both their migratory and invasive capacity. In a UV-induced model of SCC in SKH-1 immunocompetent mice, treatment with anti-IL-22 antibody reduced tumor number and tumor burden. We found that catastrophic SCC in OTRs is associated with CSA use, which may be acting by favoring T22 polarization. Since anti-IL-22 antibody administration decreased tumor number and tumor burden in vivo, blockade of the IL-22 axis may be developed as a viable therapeutic option for catastrophic SCC.
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Affiliation(s)
- Melody Abikhair
- Ronald O. Perelman Department of Dermatology, New York University (NYU) Langone Medical Center, New York, New York, USA
| | - Hiroshi Mitsui
- Laboratory for Investigative Dermatology, Rockefeller University, New York, New York, USA
| | - Valerie Yanofsky
- Ronald O. Perelman Department of Dermatology, New York University (NYU) Langone Medical Center, New York, New York, USA
| | - Nazanin Roudiani
- Ronald O. Perelman Department of Dermatology, New York University (NYU) Langone Medical Center, New York, New York, USA
| | - Channa Ovits
- Institute for Pediatric Urology, Department of Urology, Weill Cornell Medicine, New York, New York, USA
| | - Teddy Bryan
- Ronald O. Perelman Department of Dermatology, New York University (NYU) Langone Medical Center, New York, New York, USA
| | | | - Kathleen L. Tober
- Department of Pathology, The Ohio State University, Columbus, Ohio, USA
| | - Juana Gonzalez
- Translational Immunomonitoring Resource Center, Rockefeller University, New York, New York, USA
| | - James G. Krueger
- Laboratory for Investigative Dermatology, Rockefeller University, New York, New York, USA
| | - Diane Felsen
- Institute for Pediatric Urology, Department of Urology, Weill Cornell Medicine, New York, New York, USA
| | - John A. Carucci
- Ronald O. Perelman Department of Dermatology, New York University (NYU) Langone Medical Center, New York, New York, USA
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17
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Rahman S, Farooque A, Anjum S, Ansari RA, Adhikari JS, Dwarakanath BS, Raisuddin S. Nordihydroguiaretic acid attenuates skin tumorigenesis in Swiss albino mice with the condition of topical co-administration of an immunosuppressant. Chem Biol Interact 2015; 233:106-14. [PMID: 25770929 DOI: 10.1016/j.cbi.2015.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 02/17/2015] [Accepted: 03/03/2015] [Indexed: 10/23/2022]
Abstract
Drug and chemically-induced immunosuppression has been implicated as a confounding factor for cancer development. Management of cancer in such situation is often a challenging task. We tested the efficacy of nordihydroguiaretic acid (NDGA) against immunosuppressant tacrolimus-induced augmentation of mouse skin tumorigenesis. It was observed that topical administration of tacrolimus significantly accelerated the tumor promotion events in dimethylbenz(a)anthracene (DMBA)-initiated and 12-O-tetradecanoylphorbol-13-acetate (TPA) promoted two-stage mouse skin carcinogenesis, which were accompanied by reduced CD4(+)/CD8(+) ratio of lymph nodes and serum IL-2 level. NDGA pre-treatment before each TPA application reduced the tumor incidence, its multiplicity and volume together with improvement in histopathological alterations and decrease in proliferating cell nuclear antigen (PCNA) labeling index (LI). However, NDGA had no significant influence on the immunosuppressive effect of tacrolimus. The present study demonstrates chemopreventive effect of NDGA in normal as well as in the condition of immunosuppression. Thus, NDGA has the potential to inhibit or delay the onset of tumor development during immunosuppressive regimen.
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Affiliation(s)
- Shakilur Rahman
- Department of Medical Elementology and Toxicology, Jamia Hamdard (Hamdard University), New Delhi 110 062, India
| | - Abdullah Farooque
- Division of Radiation Biosciences, Institute of Nuclear Medicine and Allied Sciences, Brig. SK Mazumdar Road, Delhi 110 054, India
| | - Sameya Anjum
- Department of Medical Elementology and Toxicology, Jamia Hamdard (Hamdard University), New Delhi 110 062, India
| | - Rizwan Ahmad Ansari
- Department of Medical Elementology and Toxicology, Jamia Hamdard (Hamdard University), New Delhi 110 062, India
| | - Jawahar S Adhikari
- Division of Radiation Biosciences, Institute of Nuclear Medicine and Allied Sciences, Brig. SK Mazumdar Road, Delhi 110 054, India
| | - Bilikere S Dwarakanath
- Division of Radiation Biosciences, Institute of Nuclear Medicine and Allied Sciences, Brig. SK Mazumdar Road, Delhi 110 054, India
| | - Sheikh Raisuddin
- Department of Medical Elementology and Toxicology, Jamia Hamdard (Hamdard University), New Delhi 110 062, India.
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Grewal AS, Padera RF, Boukedes S, Divo M, Rosas IO, Camp PC, Fuhlbrigge A, Goldberg H, El-Chemaly S. Prevalence and outcome of lung cancer in lung transplant recipients. Respir Med 2015; 109:427-33. [PMID: 25616348 DOI: 10.1016/j.rmed.2014.12.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/20/2014] [Accepted: 12/30/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lung transplant is the only available therapy for patients with advanced lung disease. The goal of this study was to examine the prevalence, origin, management and outcome of lung cancer in recipients of lung transplant at our institution. METHODS After institutional review board approval, we conducted a retrospective chart review of all lung transplantations in our institution from January 1990 until June 2012. RESULTS The prevalence of lung cancer in the explanted lung was 6 (1.2%) of 462 and all cases were in subjects with lung fibrosis. All 4 subjects with lymph node involvement died of causes related to the malignancy. Nine (1.9%) of 462 patients were found to have bronchogenic carcinoma after lung transplant. The most common location was in the native lung in recipients of a single lung transplant (6 out of 9 patients). In one case, the tumor originated in the allograft and was potentially donor related. The median time to diagnosis after lung transplant was 28 months with a range from 9 months to 10 years. Median survival was 8 months, with tumors involving lymph nodes or distant metastases associated with a markedly worse prognosis (median survival 7 months) than stage I disease (median survival 27 months). CONCLUSIONS The prevalence of lung cancer in lung transplant recipients is low. Using accepted donor screening criteria, donor derived malignancy is exceptionally rare. While stage I disease is associated with improved survival in this cohort, survival is still not comparable to that of the general population, likely influenced by the need for aggressive immune suppression.
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Affiliation(s)
| | | | - Steve Boukedes
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA
| | - Miguel Divo
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA
| | - Ivan O Rosas
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA
| | - Phillip C Camp
- Department of Thoracic Surgery Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Anne Fuhlbrigge
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA
| | - Hilary Goldberg
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA
| | - Souheil El-Chemaly
- Division of Pulmonary and Critical Care Medicine, Boston, MA 02115, USA.
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19
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Management of de novo malignancies after liver transplantation. Transplant Rev (Orlando) 2015; 29:38-41. [DOI: 10.1016/j.trre.2014.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/21/2014] [Accepted: 11/13/2014] [Indexed: 12/19/2022]
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20
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Lim SM, Jung M, Shin SJ, Baek SJ, Hur H, Min BS, Baik SH, Kim NK, Ahn JB. Clinical implications from a single-center study of colorectal adenocarcinoma in transplant recipients. Oncology 2014; 88:195-200. [PMID: 25502286 DOI: 10.1159/000369254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 10/20/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND With the increasing burden of organ transplant recipients and improvements in allograft outcome, the incidence of neoplasms rising from these patients is an important issue. OBJECTIVE In this study, we investigated transplant recipients with colorectal cancer to determine its incidence, clinicopathological characteristics, and prognosis. METHODS The database of Severance Hospital was queried for all cases of colorectal adenocarcinoma among transplant recipients from August 2005 to January 2013. RESULTS A total of 29 patients were diagnosed with colorectal adenocarcinoma after transplantation, and the median age at diagnosis was 58.6 years. As for primary tumor stage, 17 (58.6%) patients had stage ≥3, and distant metastasis was found in 10 (34.4%) patients. The mean time from transplantation to tumor detection was 13.7 years. The median disease-free survival was 11.0 months and the median overall survival (OS) was 18.1 months. In multivariate analysis of prognostic factors for OS, surgical resection was a positive prognostic factor (HR 1.357, p = 0.010) and the presence of distant metastasis at diagnosis was a negative prognostic factor (HR 1.047, p = 0.006). CONCLUSION The behavior of colorectal cancer in posttransplant patients is more aggressive and refractory to treatment. A separate guideline for the colorectal screening program for the posttransplant patients needs to be established.
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Affiliation(s)
- Sun Min Lim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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21
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Olland AB, Falcoz PE, Santelmo N, Kessler R, Massard G. Primary Lung Cancer in Lung Transplant Recipients. Ann Thorac Surg 2014; 98:362-71. [DOI: 10.1016/j.athoracsur.2014.04.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 02/03/2023]
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22
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Penninga L, Wettergren A, Wilson CH, Chan A, Steinbrüchel DA, Gluud C. Antibody induction versus corticosteroid induction for liver transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD010252. [PMID: 24880007 PMCID: PMC10577808 DOI: 10.1002/14651858.cd010252.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Liver transplantation is an established treatment option for end-stage liver failure. To date, no consensus has been reached on the use of immunosuppressive T-cell specific antibody induction compared with corticosteroid induction of immunosuppression after liver transplantation. OBJECTIVES To assess the benefits and harms of T-cell specific antibody induction versus corticosteroid induction for prevention of acute rejection in liver transplant recipients. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 30 September 2013 together with reference checking, citation searching, contact with trial authors and pharmaceutical companies to identify additional trials. SELECTION CRITERIA We included all randomised clinical trials assessing immunosuppression with T-cell specific antibody induction versus corticosteroid induction in liver transplant recipients. Our inclusion criteria stated that participants within each included trial should have received the same maintenance immunosuppressive therapy. DATA COLLECTION AND ANALYSIS We used RevMan for statistical analysis of dichotomous data with risk ratio (RR) and of continuous data with mean difference (MD), both with 95% confidence intervals (CIs). We assessed risk of systematic errors (bias) using bias risk domains with definitions. We used trial sequential analysis to control for random errors (play of chance). MAIN RESULTS We included 10 randomised trials with a total of 1589 liver transplant recipients, which studied the use of T-cell specific antibody induction versus corticosteroid induction. All trials were with high risk of bias. We compared any kind of T-cell specific antibody induction versus corticosteroid induction in 10 trials with 1589 participants, including interleukin-2 receptor antagonist induction versus corticosteroid induction in nine trials with 1470 participants, and polyclonal T-cell specific antibody induction versus corticosteroid induction in one trial with 119 participants.Our analyses showed no significant differences regarding mortality (RR 1.01, 95% CI 0.72 to 1.43), graft loss (RR 1.12, 95% CI 0.82 to 1.53) and acute rejection (RR 0.84, 95% CI 0.70 to 1.00), infection (RR 0.96, 95% CI 0.85 to 1.09), hepatitis C virus recurrence (RR 0.89, 95% CI 0.79 to 1.00), malignancy (RR 0.59, 95% CI 0.13 to 2.73), and post-transplantation lymphoproliferative disorder (RR 1.00, 95% CI 0.07 to 15.38) when any kind of T-cell specific antibody induction was compared with corticosteroid induction (all low-quality evidence). Cytomegalovirus infection was less frequent in patients receiving any kind of T-cell specific antibody induction compared with corticosteroid induction (RR 0.50, 95% CI 0.33 to 0.75; low-quality evidence). This was also observed when interleukin-2 receptor antagonist induction was compared with corticosteroid induction (RR 0.55, 95% CI 0.37 to 0.83; low-quality evidence), and when polyclonal T-cell specific antibody induction was compared with corticosteroid induction (RR 0.21, 95% CI 0.06 to 0.70; low-quality evidence). However, when trial sequential analysis regarding cytomegalovirus infection was applied, the required information size was not reached. Furthermore, diabetes mellitus occurred less frequently when T-cell specific antibody induction was compared with corticosteroid induction (RR 0.45, 95% CI 0.34 to 0.60; low-quality evidence), when interleukin-2 receptor antagonist induction was compared with corticosteroid induction (RR 0.45, 95% CI 0.35 to 0.61; low-quality evidence), and when polyclonal T-cell specific antibody induction was compared with corticosteroid induction (RR 0.12, 95% CI 0.02 to 0.95; low-quality evidence). When trial sequential analysis was applied, the trial sequential monitoring boundary for benefit was crossed. We found no subgroup differences for type of interleukin-2 receptor antagonist (basiliximab versus daclizumab). Four trials reported on adverse events. However, no differences between trial groups were noted. Limited data were available for meta-analysis on drug-specific adverse events such as haematological adverse events for antithymocyte globulin. No data were available on quality of life. AUTHORS' CONCLUSIONS Because of the low quality of the evidence, the effects of T-cell antibody induction remain uncertain. T-cell specific antibody induction seems to reduce diabetes mellitus and may reduce cytomegalovirus infection when compared with corticosteroid induction. No other clear benefits or harms were associated with the use of T-cell specific antibody induction compared with corticosteroid induction. For some analyses, the number of trials investigating the use of T-cell specific antibody induction after liver transplantation is small, and the numbers of participants and outcomes in these randomised trials are limited. Furthermore, the included trials are heterogeneous in nature and have applied different types of T-cell specific antibody induction therapy. All trials were at high risk of bias. Hence, additional randomised clinical trials are needed to assess the benefits and harms of T-cell specific antibody induction compared with corticosteroid induction for liver transplant recipients. Such trials ought to be conducted with low risks of systematic error and of random error.
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Affiliation(s)
- Luit Penninga
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812Blegdamsvej 9CopenhagenDenmarkDK‐2100
- Rigshospitalet, Copenhagen University HospitalDepartment of Surgery and Transplantation C2122Blegdamsvej 9CopenhagenDenmarkDK‐2100 Ø
| | - André Wettergren
- Surgical Clinic HvidovreHvidovrevej 342, 1. floorHvidovreDenmark2650
| | - Colin H Wilson
- The Freeman HospitalInstitute of TransplantationFreeman RoadHigh HeatonNewcastle upon TyneTyne and WearUKNE7 7DN
| | - An‐Wen Chan
- University of TorontoWomen's College Research Institute790 Bay St, Rm 735TorontoONCanada
| | - Daniel A Steinbrüchel
- Rigshospitalet, Copenhagen University HospitalDepartment of Cardiothoracic SurgeryBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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23
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EXP CLIN TRANSPLANTExp Clin Transplant 2014; 12. [DOI: 10.6002/ect.25liver.p11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Chen K, Man K, Metselaar HJ, Janssen HLA, Peppelenbosch MP, Pan Q. Rationale of personalized immunosuppressive medication for hepatocellular carcinoma patients after liver transplantation. Liver Transpl 2014; 20:261-9. [PMID: 24376158 DOI: 10.1002/lt.23806] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 11/24/2013] [Indexed: 12/12/2022]
Abstract
Liver transplantation is the only potentially curative treatment for hepatocellular carcinoma (HCC) that is not eligible for surgical resection. However, disease recurrence is the main challenge to the success of this treatment. Immunosuppressants that are universally used after transplantation to prevent graft rejection could potentially have a significant impact on HCC recurrence. Nevertheless, current research is exclusively focused on mammalian target of rapamycin inhibitors, which are thought to be the only class of immunosuppressive agents that can reduce HCC recurrence. In fact, substantial evidence from the bench to the bedside indicates that other classes of immunosuppressants may also exert diverse effects; for example, inosine monophosphate dehydrogenase inhibitors potentially have antitumor effects. In this article, we aim to provide a comprehensive overview of the potential effects of different types of immunosuppressants on HCC recurrence and their mechanisms of action from both experimental and clinical perspectives. To ultimately improve the outcomes of HCC patients after transplantation, we propose a concept and approaches for developing personalized immunosuppressive medication to be used either as immunosuppression maintenance or during the prevention/treatment of HCC recurrence.
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Affiliation(s)
- Kan Chen
- Bio-X Center, College of Life Sciences, Zhejiang Sci-Tech University, Hangzhou, China; Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
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25
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Yu S, Gao F, Yu J, Yan S, Wu J, Zhang M, Wang W, Zheng S. De novo cancers following liver transplantation: a single center experience in China. PLoS One 2014; 9:e85651. [PMID: 24475047 PMCID: PMC3901656 DOI: 10.1371/journal.pone.0085651] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 11/28/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND De novo cancers are a growing problem that has become one of the leading causes of late mortality after liver transplantation. The incidences and risk factors varied among literatures and fewer concerned the Eastern population. AIMS The aim of this study was to examine the incidence and clinical features of de novo cancers after liver transplantation in a single Chinese center. METHODS 569 patients who received liver transplantation and survived for more than 3 months in a single Chinese center were retrospectively reviewed. RESULTS A total of 18 de novo cancers were diagnosed in 17 recipients (13 male and 4 female) after a mean of 41 ± 26 months, with an overall incidence of 3.2%, which was lower than that in Western people. Of these, 8 (3.32%) cases were from 241 recipients with malignant liver diseases before transplant, while 10 (3.05%) cases were from 328 recipients with benign diseases. The incidence rates were comparable, p = 0.86. Furthermore, 2 cases developed in 1 year, 5 cases in 3 years and 11 cases over 3 years. The most frequent cancers developed after liver transplantation were similar to those in the general Chinese population but had much higher incidence rates. CONCLUSIONS Liver transplant recipients were at increased risk for developing de novo cancers. The incidence rates and pattern of de novo cancers in Chinese population are different from Western people due to racial and social factors. Pre-transplant malignant condition had no relationship to de novo cancer. Exact risk factors need further studies.
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Affiliation(s)
- Songfeng Yu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Feng Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Jun Yu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Min Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Weilin Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, Zhejiang Province, Hangzhou, China
- * E-mail: .
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26
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Singh S, Varayil JE, Loftus EV, Talwalkar JA. Incidence of colorectal cancer after liver transplantation for primary sclerosing cholangitis: a systematic review and meta-analysis. Liver Transpl 2013; 19:1361-9. [PMID: 24019127 DOI: 10.1002/lt.23741] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/08/2013] [Accepted: 08/27/2013] [Indexed: 12/15/2022]
Abstract
Patients with primary sclerosing cholangitis (PSC) and associated inflammatory bowel disease (IBD) have an increased risk of colorectal cancer (CRC). We estimated the pooled incidence of CRC after liver transplantation (LT) in patients with PSC as well as in a subset of patients with associated IBD (PSC-IBD). Through a systematic review of major bibliographic databases up to April 1, 2013, we identified cohort studies reporting the incidence of de novo CRC after LT for PSC. The main outcome measure was CRC incidence rate (IR) per 1000 person-years after LT in all patients with PSC and in a subset of patients with PSC-IBD with an intact colon. According to a meta-analysis of 18 independent cohorts (69 cases of CRC among 1987 patients), the pooled IR of de novo CRC in patients with PSC after LT was 5.8 per 1000 person-years [95% confidence interval (CI) = 3.8-7.8]. According to a meta-analysis of 16 independent cohort studies (66 cases of CRC among 1017 patients), the IR of CRC in patients with PSC-IBD and an intact colon at the time of LT was 13.5 per 1000 person-years (95% CI = 8.7-18.2). A long duration of IBD and extensive colitis were identified as risk factors for CRC. Specific transplant-related factors that can increase the risk of CRC have not been identified. In conclusion, the risk of CRC remains high for patients who undergo LT for PSC, particularly in the subset of patients with associated IBD and an intact colon at the time of LT. Aggressive colonoscopic surveillance for CRC would be prudent for patients with PSC-IBD even after LT.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester MN
| | | | - Edward V. Loftus
- Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester MN
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27
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Ong KWK, Joseph B, Gyomber DV, Bolton DM, Lawrentschuk N. Nephrectomy for a renal metastasis of undiagnosed hepatocellular carcinoma arising from an orthotopic liver transplant undertaken for cryptogenic cirrhosis. Korean J Urol 2013; 54:715-7. [PMID: 24175048 PMCID: PMC3806998 DOI: 10.4111/kju.2013.54.10.715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/14/2012] [Indexed: 01/07/2023] Open
Abstract
Urological involvement of hepatocellular carcinoma (HCC) is rare; HCC arising in an orthotopic liver transplant (OLT) is exceptionally rare. Here we report the case of a 70-year-old man who was incidentally found to have metastatic HCC in the right kidney arising from his OLT undertaken for cryptogenic cirrhosis 10 years previously. Adding to the complexity of this case was the lack of an obvious liver primary HCC at the time of the radical nephrectomy, thus making the final diagnosis all but impossible. We believe this report represents the first report of HCC metastasizing to the kidney after OLT and adds to the few reports in the literature of HCC arising in transplanted livers.
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Affiliation(s)
- Kevin W K Ong
- Department of Surgery (Urology), Austin Hospital, University of Melbourne, Heidelberg, Australia
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28
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Singh S, Loftus EV, Talwalkar JA. Inflammatory bowel disease after liver transplantation for primary sclerosing cholangitis. Am J Gastroenterol 2013; 108:1417-25. [PMID: 23896954 DOI: 10.1038/ajg.2013.163] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023]
Abstract
The course of inflammatory bowel disease (IBD) after liver transplantation (LT) for primary sclerosing cholangitis (PSC) is complex, with several IBD-, PSC-, and transplant-related factors interplaying with each other. Approximately one-third of patients with known IBD improve, and one-third paradoxically worsen, after LT for PSC. Active IBD, discontinuation of 5-aminosalicylates (5-ASA) at time of LT and tacrolimus-based immunosuppression may be associated with an unfavorable course of IBD after LT. Approximately 14-30% patients with PSC may develop de novo IBD 10 years after LT. LT confers a high risk of pouchitis after ileal pouch-anal anastomosis, although it may not be higher than baseline rates for PSC patients. The risk of colorectal cancer continues to be high after LT for PSC, and is higher in this cohort of patients with PSC-IBD, compared with patients undergoing LT for other indications. IBD does not adversely affect patient survival after LT, although the risk of recurrent PSC in the allograft may be higher in patients with IBD and an intact colon at time of LT. Standard therapy with 5-ASA and/or azathioprine may be appropriate for treatment of active IBD after LT and maintenance of remission. Anti-tumor necrosis factor-α agents are effective, but should be used with caution because of high risk of adverse events. The management of IBD after LT requires close coordination between transplant hepatologists and IBD experts.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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29
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Wimmer CD, Angele MK, Schwarz B, Pratschke S, Rentsch M, Khandoga A, Guba M, Jauch KW, Bruns C, Graeb C. Impact of cyclosporine versus tacrolimus on the incidence of de novo malignancy following liver transplantation: a single center experience with 609 patients. Transpl Int 2013; 26:999-1006. [PMID: 23952102 DOI: 10.1111/tri.12165] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 05/05/2013] [Accepted: 07/21/2013] [Indexed: 12/18/2022]
Abstract
De novo malignancies are a major cause of late death after liver transplantation. Aim of the present study was to determine whether use of cyclosporine versus tacrolimus affects long-term tumor incidence considering potential confounders. De novo malignancies in 609 liver transplant recipients at Munich Transplant Centre between 1985 and 2007 were registered. In 1996, the standard immunosuppressive regimen was changed from cyclosporine to tacrolimus. Different effects of those drugs on long-term tumor incidence were analyzed in multivariate analysis. During 3765 patient years of follow-up (median 4.78 years), 87 de novo malignancies occurred in 71 patients (mean age 47.5 ± 13.3 years, mean time after liver transplantation 5.7 ± 3.7 years). The cumulative incidence of de novo malignancies was 34.7% for all tumor entities after 15 years as compared to 8.9% for a nontransplanted population. The most frequent tumors observed were nonmelanoma skin cancers (44.83%). Moreover, post-transplant lymphoid disease, oropharyngeal cancer (n = 6, 6.9%), upper gastrointestinal tract cancer (n = 4, 4.6%), lung cancer (n = 4, 4.6%), gynecological malignancies (n = 4, 4.6%), and kidney cancer (n = 3, 3.45%) were detected. Multivariate analysis revealed recipient age [hazards ratio (HR) 1.06], male gender (HR 1.73), and tacrolimus-based immunosuppression (HR 2.06) as significant risk factors. Based on those results, a tacrolimus-based immunosuppression should be discussed especially in older male patients. Whether reducing tacrolimus target levels may reduce the risk for de novo malignancies has yet to be determined in prospective trials.
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Affiliation(s)
- Cosmas D Wimmer
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, Munich, Germany
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30
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Apel H, Walschburger-Zorn K, Häberle L, Wach S, Engehausen DG, Wullich B. De novo malignancies in renal transplant recipients: experience at a single center with 1882 transplant patients over 39 yr. Clin Transplant 2012; 27:E30-6. [PMID: 23278453 DOI: 10.1111/ctr.12050] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2012] [Indexed: 12/15/2022]
Abstract
PURPOSE Cancers complicating organ allografts are a major cause of morbidity and mortality after renal transplantation. Different registries have described an overall three to eightfold increase in cancer risk compared with the general population. This retrospective study investigated the incidence and outcome of de novo malignancies following kidney transplantation in a single German kidney transplantation center. MATERIALS AND METHODS Between 1966 and 2005, 1882 patients underwent kidney transplantation at the Erlangen-Nuremberg kidney transplantation center. The incidence and types of post-transplant malignancies were retrospectively analyzed according to the patients' records and the database of the local cancer registry. RESULTS We identified 257 malignancies in 231 patients, an overall incidence of 13.7%. The mean follow-up time was 9.9 yr (range, 0.4-25.5 yr). The observed incidence data corresponded to a 12.1-fold increase in the overall risk of developing a malignant nonskin tumor compared with the nontransplanted population. Urinary tract malignancies represented the most frequent malignancies among the nonskin tumors (32.1%), followed by gastrointestinal tract (30.7%) and gynecological (14%) cancers. When we considered the duration from renal transplantation to tumor detection and tumor-specific survival, there was no difference between patients treated with or without a cyclosporine A-based regimen. CONCLUSIONS In our study, the overall risk of developing a post-transplant nonskin malignancy was 12.1-fold higher compared with the age-matched general population. Development of solid organ malignancies is one of the most frequent causes of morbidity and mortality in renal transplant recipients; thus, close tumor screening in patients after kidney transplantations is warranted.
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Affiliation(s)
- Hendrik Apel
- Department of Urology, University Hospital Erlangen, Friedrich Alexander University, Erlangen-Nuremberg, Germany.
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31
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Lim KBL, Schiano TD. Long-term outcome after liver transplantation. ACTA ACUST UNITED AC 2012; 79:169-89. [PMID: 22499489 DOI: 10.1002/msj.21302] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Liver transplantation is a life-saving therapy for patients with end-stage liver disease, acute liver failure, and liver tumors. Over the past 4 decades, improvements in surgical techniques, peritransplant intensive care, and immunosuppressive regimens have resulted in significant improvements in short-term survival. Focus has now shifted to addressing long-term complications and improving quality of life in liver recipients. These include adverse effects of immunosuppression; recurrence of the primary liver disease; and management of diabetes, hypertension, dyslipidemia, obesity, metabolic syndrome, cardiovascular disease, renal dysfunction, osteoporosis, and de novo malignancy. Issues such as posttransplant depression, employment, sexual function, fertility, and pregnancy must not be overlooked, as they have a direct impact on the liver recipient's quality of life. This review summarizes the latest data in long-term outcome after liver transplantation.
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Rostaing L, Saliba F, Calmus Y, Dharancy S, Boillot O. Review article: use of induction therapy in liver transplantation. Transplant Rev (Orlando) 2012; 26:246-60. [PMID: 22863028 DOI: 10.1016/j.trre.2012.06.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 06/12/2012] [Indexed: 02/07/2023]
Abstract
Induction therapy is used relatively infrequently in liver transplantation, but developments in induction regimens and strategies for their use are prompting a re-examination of its benefits. Rabbit antithymocyte globulin (rATG) induces protracted, dose-dependent lymphocytopenia with preferential reconstitution of regulatory T-lymphocytes. Non-depleting interleukin-2 receptor antagonists (IL-2RA) act selectively on activated T-lymphocytes with a shorter duration of effect. IL-2RA induction with delayed and reduced calcineurin inhibitor (CNI) exposure appears to preserve efficacy, while more aggressive CNI minimisation has been attempted successfully using rATG. Steroid-free tacrolimus monotherapy with rATG or IL-2RA induction is effective if adequate tacrolimus exposure is maintained. Early concerns that addition of induction to a conventional maintenance regimen could lead to accelerated progression of hepatitis C disease, or to an increased risk of hepatocellular cancer recurrence, now appear unfounded using modern regimens. Similarly, with routine use of systemic prophylaxis, recent prospective and retrospective data have not shown a higher rate of infections overall, or cytomegalovirus infection specifically, using rATG or IL-2RA induction. Historical evidence that lymphocyte-depleting agents increased the risk of non-Hodgkin lymphoma has not been confirmed for rATG. Wider use of induction in liver transplantation is now merited, using individualized strategies to support reduced CNI exposure or steroid-free immunosuppression.
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Affiliation(s)
- Lionel Rostaing
- Nephrology, Dialysis and Organ Transplantation Service, CHU Rangueil, Toulouse, France.
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33
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Yan S, Jiang X, Yang J, Yan D, Wang YXJ. Radiotherapy for nasopharyngeal carcinoma and combined capecitabine and nimotuzumab treatment for lung metastases in a liver transplantation recipient: a case experience of sustained complete response. Cancer Biother Radiopharm 2012; 27:519-23. [PMID: 22834655 DOI: 10.1089/cbr.2012.1206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The primary treatment for nasopharyngeal carcinoma (NPC) is external beam radiotherapy. However, until now, there is little experience with the management of NPC occurred after solid organ transplantation. In this report, a 60-year-old man was found to have NPC (T2N1M0; stage III) 3 years after orthotopic liver transplantation treatment for hepatocellular carcinoma. Intensity-modulated radiotherapy (IMRT) was performed for NPC. One month after IMRT, complete response of NPC was achieved. However, multiple lung metastases occurred 18 months after the IMRT with the largest lesion measuring 4.1×5.5 cm and confirmed to be originated from NPC. Combined chemo-/targeted therapy consisted of capecitabine, and nimotuzumab was administered for four cycles. One month after initiation of capecitabine plus nimotuzumab treatment, a near-complete response was achieved for lung metastases. A repeat CT scan 1 year later showed sustained resolution of the lung metastases. The patient is still alive 16 months after the combined chemo-/targeted therapy.
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Affiliation(s)
- Senxiang Yan
- Department of Radiation Oncology, The First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China.
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34
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Stravitz RT, Carl DE, Biskobing DM. Medical management of the liver transplant recipient. Clin Liver Dis 2011; 15:821-43. [PMID: 22032531 DOI: 10.1016/j.cld.2011.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Long-term survival of liver transplant recipients has become the rule rather than the exception. As a result, the medical complications of long-term survival, including atherosclerotic cardiovascular disease, metabolic bone disease, and de novo malignancy, have accounted for an increasing proportion of late morbidity and mortality. Risk factors for these complications begin before transplant and are potentially modifiable but are exacerbated by the requirement for immunosuppressive medications after transplantation. Surveillance and early intervention programs administered by transplant hepatologists and other medical subspecialists may improve long-term outcomes in liver transplant recipients by ameliorating risk factors for atherosclerosis, bone fractures, and cancer.
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Affiliation(s)
- R Todd Stravitz
- Section of Hepatology, Division of Gastroenterology, Hepatology, and Nutrition, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA 23298-0341, USA.
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35
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De novo lung cancer diagnosed 32 months after liver transplantation: report of a case. Surg Today 2011; 41:1280-3. [PMID: 21874431 DOI: 10.1007/s00595-010-4473-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 06/30/2010] [Indexed: 10/17/2022]
Abstract
Patients who undergo organ transplantation are now known to be at increased risk of the development of de novo malignant tumors. This is primarily a consequence of immunosuppression, which may promote tumor development and progression by a variety of mechanisms. It was also reported recently that the relative ratio of lung tumors developing in orthotopic liver transplantation patients was 3.7 times greater than in the general population. We report a case of de novo lung cancer diagnosed in a 65-year-old man 32 months after he underwent liver transplantation for hepatocellular carcinoma secondary to hepatitis C virus cirrhosis. He had received tacrolimus as immunosuppressive therapy after the liver transplantation. The tumor was resected, and he remains well almost 3 years later. Previous reports provide evidence that immunosuppressive therapy is a risk factor for de novo lung cancer; thus, it is important to reduce immunosuppression for orthotropic liver transplantation patients, and to screen them carefully to detect the tumor at an early stage.
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36
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Leblanc KG, Hughes MP, Sheehan DJ. The role of sirolimus in the prevention of cutaneous squamous cell carcinoma in organ transplant recipients. Dermatol Surg 2011; 37:744-9. [PMID: 21605234 DOI: 10.1111/j.1524-4725.2011.01973..x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Skin cancers are common in organ transplant recipients (OTRs). In this review, we discuss the epidemiology of and risk factors for cutaneous neoplasms, particularly squamous cell carcinoma (SCC) in OTRs. The pathogenesis of SCC is reviewed, as well as the potential mechanisms for tumor progression and metastasis associated with two commonly used immunosuppressive medications: tacrolimus and cyclosporine. Finally, we discuss the mechanism of action and potential preventative use of sirolimus, a member of a newer class of immunosuppressants, the mammalian target of rapamycin inhibitors. The authors have indicated no significant interest with commercial supporters.
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Affiliation(s)
- Keith G Leblanc
- Section of Dermatology, Augusta, Georgia Medical College of Georgia, Augusta, Georgia 30904, USA.
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37
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One thousand consecutive primary liver transplants under tacrolimus immunosuppression: a 17- to 20-year longitudinal follow-up. Transplantation 2011; 91:1025-30. [PMID: 21378604 DOI: 10.1097/tp.0b013e3182129215] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Tacrolimus has proven to be a potent immunosuppressive agent in orthotopic liver transplantation (OLT). The aim of this study is to examine its long-term efficacy and safety. METHODS AND RESULTS One thousand consecutive primary OLTs performed between August 1989 and December 1992 and maintained under tacrolimus-based immunosuppression were followed up until January 2009. Patient and graft survivals with corresponding causes of death and retransplantation, maintenance immunosuppression, and adverse effects were examined. The study population includes 600 males and 400 females comprising 166 children, 630 adults, and 204 seniors. The mean follow-up was 17.83 (range, 16.1-19.50) years. The overall 20-year actuarial patient and graft survivals were 35.8% and 32.6%, respectively. At the last follow-up, 442 patients were alive; 133 (77.1%) children, 265 (34.5%) adults, and 44 (16.1%) seniors (P=0.0001). After the first post-OLT year, cardiopulmonary events, recurrence of primary disease, and malignancy were the main causes of death. Overall, 183 recipients underwent retransplants; mainly for primary nonfunction, hepatic artery thrombosis, and recurrent primary disease, 180 required dialysis, and 45 underwent kidney transplant. A total of 97.7% of the survivors were on tacrolimus and 26.2% were also receiving adjunctive immunosuppressants at the last follow-up. CONCLUSIONS The overall 20-year actuarial patient and graft survivals were 35.8% and 32.6%, respectively, with significantly better survival among children. Age-related complications, recurrence of primary disease, and malignancy were the major causes of late graft loss. Graft loss related to immunologic reasons was rare. The prevention of recurrent disease and newer immunosuppressive regimen will further improve these results.
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38
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Yokota A, Ozawa S, Masanori T, Akiyama H, Ohshima K, Kanda Y, Takahashi S, Mori T, Nakaseko C, Onoda M, Kishi K, Doki N, Aotsuka N, Kanamori H, Maruta A, Sakamaki H, Okamoto S. Secondary solid tumors after allogeneic hematopoietic SCT in Japan. Bone Marrow Transplant 2011; 47:95-100. [PMID: 21358690 DOI: 10.1038/bmt.2011.23] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
To evaluate the incidence and risk factors for secondary solid tumors in Japan after allogeneic hematopoietic SCT (allo-HSCT), 2062 patients who had received allo-HSCT between 1984 and 2005 were retrospectively analyzed. Twenty-eight patients who developed 30 solid tumors were identified a median of 5.6 years after transplantation. The risk for developing tumors was 2.16-fold higher than that of the age- and sex-adjusted general population. The cumulative incidence of solid tumors at 10 years after allo-HSCT was 2.4%. The risk was significantly higher for tumors of the skin, oral cavity and esophagus (standard incidental ratio 40.23, 35.25 and 10.73, respectively). No increase in gastric, colon or lung cancer, despite being the most prevalent neoplasm in the Japanese, was observed. In multivariate analysis, occurrence of chronic GVHD and malignant lymphoma as a primary disease was associated with a higher risk for developing solid tumors. Eighteen patients are still alive, and their 5-year probability of survival since diagnosis of solid tumors is 59.7%. Our data suggest that the incidence and risk factors of secondary solid tumors in Japanese allo-HSCT recipients are comparable to those reported in Western countries and emphasize that the early detection of solid tumors has a crucial role in improving OS.
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Affiliation(s)
- A Yokota
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan.
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39
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Evolution and management of de novo neoplasm post-liver transplantation: a 20-year experience from a single European centre. Hepatol Int 2010; 5:707-15. [PMID: 21484107 DOI: 10.1007/s12072-010-9231-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 11/26/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE Survival post-liver transplantation (LT) has improved; however, patients are considered at the, risk of malignancy due to prolonged immunosuppression. The long-term outcome of patients developing de novo neoplasm (DN) at our centre was evaluated. METHODS Between October 1988 and December 2007, 800 LT were performed in 742 patients. Patients were divided into two study periods according to the time of LT; first: October 1988-December 1995; second: January 1996-December 2007. RESULTS After a mean follow-up of 5 ± 4.6 years, 71 DN (9.5%) were detected in 742 patients. The cumulative risk of DN development increased with the time from LT although no differences at 3, 5, and 10 years were found when first and second periods were compared (3, 7, 16% vs. 2, 4, 11%, respectively; p = 0.4). DN incidence was higher in the first compared with the second period (10.7 vs. 7.8%; p < 0.04); no significant differences were observed in mortality rate (50 vs. 27%; p = 0.052). Actuarial patient survival post-DN at 1, 3, and 5 years: 67, 48, 45% versus 82, 71, 65%, in the first versus second period, respectively, p < 0.04. CONCLUSIONS DN incidence has decreased in recent years; however, as survival post-LT increases, so does the incidence of DN. Surveillance programmes are necessary to diagnose DN at early stages.
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40
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Bakulev AL, Bakulev AL. Tacrolimus: 10 years of successful clinical application. VESTNIK DERMATOLOGII I VENEROLOGII 2010. [DOI: 10.25208/vdv775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Tacrolimus (FK506) is the first drug from the new class of drugs - calcineurin inhibitors. It has a great potential and can change
the current approaches to treatment of different dermatoses. Topical forms of Tacrolimus are activated due to the effect on T-lymphocyte
signal transduction, and they also inhibit gene transcription. As a result, the T-cell response to antigens is alleviated.
Percutaneous absorption of Tacrolimus in affection foci is higher than in healthy skin. Due to this a smaller amount of the drug
is absorbed by the skin as long as the skin is healed. Systemic absorption of Tacrolimus is low in the course of treatment. The
maximum clinical experience has been gained in the field of applying Tacrolimus for treatment of atopic dermatitis. In a number of
clinical studies, 0.03-0.3% Tacrolimus ointment efficiently reduced the severity of symptoms and course of atopic dermatitis in
adults and children. Moreover, topical treatment with Tacrolimus did not involve any substantial toxic effects. The patients most often
complained of local irritations in the area where the ointment was applied, which were transient by nature and did not demand
the drug withdrawal. Today Tacrolimus is a valuable and safer alternative to glucocorticosteroids for treatment of atopic dermatitis.
It can also be used for treating other dermatoses, which demands additional all-round examination.
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41
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Channabasappa N, Johnson-Welch S, Mittal N. De novo cholangiocarcinoma after liver transplantation in a pediatric patient. Pediatr Transplant 2010; 14:E110-4. [PMID: 19659806 DOI: 10.1111/j.1399-3046.2009.01220.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To date, no child has been reported to develop de novo CCA after liver transplantation although patients with transplants have a significantly higher risk of malignancy than the general population. CCA is extremely rare in the pediatric age group, seen mostly in patients with a history of choledochal cysts, Caroli's disease, or PSC. We report the first case of pediatric de novo CCA in the liver allograft 12 yr after liver transplantation.
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Affiliation(s)
- Nandini Channabasappa
- Departments of Pediatrics Pathology, University of Texas Southwestern Medical Center and Children's Medical Center of Dallas, Dallas, TX, USA.
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42
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Malignancies in pediatric solid organ transplant recipients: epidemiology, risk factors, and prophylactic approaches. Curr Opin Organ Transplant 2010; 15:621-7. [DOI: 10.1097/mot.0b013e32833e1673] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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43
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Chak E, Saab S. Risk factors and incidence of de novo malignancy in liver transplant recipients: a systematic review. Liver Int 2010; 30:1247-58. [PMID: 20602682 DOI: 10.1111/j.1478-3231.2010.02303.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Orthotopic liver transplant (OLT) is an established life saving procedure for both acute and chronic liver failure, but incidences and risk factors for development of these malignancies are yet to be established. To determine the incidences and risk factors associated with de novo malignancy after OLT. We performed a systematic review of relevant epidemiological studies available on MEDLINE, which provided information on the incidences and risk factors for the development malignancies in adult OLT recipients published from 1983 to 2009. All data was compiled from retrospective studies. Independent risk factors for the development of de novo malignancy in adult OLT recipients were identified to be statistically significant including immunosuppression, hepatitis C virus infection, smoking, alcoholic cirrhosis and sun exposure. OLT recipients with smoking and alcohol history are of particular risk for head and neck and lung cancers. Primary sclerosing cholangitis and inflammatory bowel disease were found to be independent risk factors for colon cancer. Adult OLT recipients are at increased risk for the development of post-transplant malignancies and obviates the need for surveillance protocols that are safe and cost-effective. OLT recipients should be advised on taking proper precautions in the sun, smoking cessation, and eliminating alcohol consumption. Given the emergence of alcoholic cirrhosis as a leading indication for liver transplantation, the early detection of lung and head and neck cancers is of particular importance.
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Affiliation(s)
- Eric Chak
- Department of Medicine, UCLA-Oliver View Medical Center, Pfleger Liver Institute, Sylmar, Los Angeles, CA 90095, USA
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Abstract
In this article there were regarded the most frequent side effects that appear in the patients who have been treated with topical tacrolimus, and the association between topical tacrolimus and the development of tumors is unfolded. The irritation in the site of application of the tacrolimus can manifiest as pruritus, sensation of burning and/or eritema located to the area of the application. It is the most frequent side effect, independently of the duration of the study. The cutaneous infections, especially the viral ones, tend to be more numerous in patients with atopic dermatitis that receive topic tacrolimus. After reviewing the medical literature one concludes that nowadays there doesn t exist scientific evidence of an increase of skin cancer, lymphomas or systemic immunosuppression in those patients that use or have used topical tacrolimus. Nevertheless, it is not possible to exclude the possibility that there appear cutaneous and/or systemic long-term side effects.
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45
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Tjon ASW, Sint Nicolaas J, Kwekkeboom J, de Man RA, Kazemier G, Tilanus HW, Hansen BE, van der Laan LJW, Tha-In T, Metselaar HJ. Increased incidence of early de novo cancer in liver graft recipients treated with cyclosporine: an association with C2 monitoring and recipient age. Liver Transpl 2010; 16:837-46. [PMID: 20583092 DOI: 10.1002/lt.22064] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The goal of this study was to determine the risk factors for de novo cancer after liver transplantation (LTx). Retrospective analyses were performed in 385 LTx patients who underwent transplantation between 1986 and 2007. In total, 50 (13.0%) recipients developed de novo malignancy. The cumulative incidence of de novo cancer at 1, 5, 10, and 15 years after LTx was 2.9% +/- 0.9%, 10.5% +/- 1.8%, 19.4% +/- 3.0%, and 33.6% +/- 6.8%, respectively. The standardized incidence ratio of malignancy in LTx patients compared to the general population was 2.2 (95% confidence interval: 1.6-2.8). After excluding posttransplant lymphoproliferative disorder and skin cancer, patients with de novo cancer had a significantly lower survival rate compared to recipients who remained cancer-free. The identified univariate risk factors for de novo cancer were cyclosporine A (CsA) treatment, time period of LTx, and recipient age. In multivariate analysis, only CsA treatment emerged as an independent risk factor for de novo cancer, which was attributed to more aggressive cancer types. A surprising finding was that CsA treatment specifically enhanced cancer risk in patients who underwent transplantation after 2004, when C(2) monitoring (blood concentration at 2 hours postdose) was introduced. In addition, these patients showed a significantly lower acute rejection rate, which might reflect a more robust immunosuppressive status caused by the CsA-C(2) regimen. When age was considered, only patients < or =50 years had a higher cancer rate when treated with CsA compared to treatment with tacrolimus. Our data suggest that, compared to tacrolimus treatment, CsA treatment with C(2) monitoring or in younger patients of < or =50 years is associated with a higher early de novo cancer risk after LTx.
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Affiliation(s)
- Angela S W Tjon
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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46
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Nicolaas JS, De Jonge V, Steyerberg EW, Kuipers EJ, Van Leerdam ME, Veldhuyzen-van Zanten SJO. Risk of colorectal carcinoma in post-liver transplant patients: a systematic review and meta-analysis. Am J Transplant 2010; 10:868-876. [PMID: 20420641 DOI: 10.1111/j.1600-6143.2010.03049.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Liver transplant patients (LTx) have an increased risk for developing de novo malignancies, but for colorectal cancer (CRC) this risk is less clear. We aimed to determine whether the CRC risk post-LTx was increased. A systematic search was performed in MEDLINE and Cochrane databases to identify studies published between 1986 and 2008 reporting on the risk of CRC post-LTx. The outcomes were (1) CRC incidence rate (IR per 100,000 person-years (PY)) compared to a weighted age-matched control population using SEER and (2) relative risk (RR) for CRC compared to the general population. If no RR data were available, the RR was estimated using SEER. Twenty-nine studies were included. The overall post-LTx IR was 119 (95% CI 88-161) per 100,000 PY. The overall RR was 2.6 (95% CI 1.7-4.1). The non-primary sclerosing cholangitis (PSC) IR was 129 per 100,000 PY (95% CI 81-207). Compared to SEER (71 per 100,000 PY), the non-PSC RR was 1.8 (95% CI 1.1-2.9). In conclusion, the overall transplants and the subgroup non-PSC transplants have an increased CRC risk compared to the general population. However, in contrast to PSC, non-PSC transplants do not need an intensified screening strategy compared to the general population until a prospective study further defines recommendations.
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Affiliation(s)
| | | | | | - E J Kuipers
- Gastroenterology and Hepatology.,Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Marqués Medina E, Jiménez Romero C, Gómez de la Cámara A, Rota Bernal A, Manrique Municio A, Moreno González E. Malignancy after liver transplantation: cumulative risk for development. Transplant Proc 2010; 41:2447-9. [PMID: 19715947 DOI: 10.1016/j.transproceed.2009.06.153] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Solid organ recipients are at high risk to develop malignancies due to the complex interactions of several factors, constituting a major cause of late death after transplantation. PATIENTS AND METHODS We retrospectively reviewed an historic cohort of adult liver recipients from cadaveric donors (multiorgan recipients excluded) performed from 1986-2002 with a minimum follow-up of 36 months. The Kaplan-Meier method was used to assess cumulative risk to develop malignancy and survival analyses. RESULTS Among the 528 patients undergoing orthotopic liver transplantation (OLT) with a mean follow-up of 2400 days, 98 developed cancer among which 25% were skin malignancies. Sixty-seven patients developed at least 1 noncutaneous malignancy, an overall incidence of 12.7%. Eighteen percent suffered from posttransplant lymphoproliferative disease; 14%, lung cancer; 4%, Kaposi's sarcoma; 7%, genitourinary malignancies; and 17%, oropharyngeal or laryngeal cancer. The cumulative patient risks to develop noncutaneous malignancies at 5, 10, and 15 years posttransplantation were 9% (confidence interval [CI]: 0.06-0.11), 18% (CI: 0.14-0.23), and 25% (CI: 0.18-0.31), respectively. CONCLUSIONS OLT recipients are at higher risk to develop malignancies after transplantation, reaching a cumulative risk of 25% at 15 years. Long-term surveillance measures and screening programs must be seriously conducted for selected groups.
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Affiliation(s)
- E Marqués Medina
- Department of General and Digestive Surgery and Abdominal Organ Transplantation, Hospital Universitario Doce de Octubre, Madrid, Spain.
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Stoebner PE, Fabre C, El Kabbaj N, Bismuth M, Pageaux GP, Meunier L. Koebnerizing Kaposi's sarcoma mimics a laparotomic hypertrophic scar in a liver transplant recipient. Liver Transpl 2009; 15:994-6. [PMID: 19642134 DOI: 10.1002/lt.21739] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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49
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Weaver J, Grenade LL, Kwon H, Avigan M. Finding, evaluating, and managing drug-related risks: approaches taken by the US Food and Drug Administration (FDA). Dermatol Ther 2009; 22:204-15. [DOI: 10.1111/j.1529-8019.2009.01233.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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50
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Affiliation(s)
- Jean Kanitakis
- Department of Dermatology, Edouard Herriot Hospital, 60437 Lyon Cedex 03, France
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