Cancers of new appearance in liver transplant recipients: incidence and evolution

Lessons Learned From a Case of Gastric Cancer After Liver Transplantation for Hepatocellular Carcinoma: A Case Report and Literatures Review

Nowadays, de novo malignancies have become an important cause of death after transplantation. According to the accumulation of cases with liver transplantation, the incidence of de novo gastric cancer is anticipated to increase among liver transplant recipients in the near future, especially in some East Asian countries where both liver diseases requiring liver transplantation and gastric cancer are major burdens. Unfortunately, there is limited information regarding the relationship between de novo gastric cancer and liver transplantation. Herein, we report a case of stage IIIc gastric cancer after liver transplantation for hepatocellular carcinoma, who was successfully treated by radical distal gastrectomy with D2 lymphadenectomy but died 15 months later due to tumor progression. Furthermore, we extract some lessons to learn from the case and review the literatures. The incidence of de novo gastric cancer following liver transplantations is increasing and higher than the general population. Doctors should be vigilant in early detection and control the risk factors causing de novo gastric cancer after liver transplantation. Curative gastrectomy with D2 lymphadenectomy is still the mainstay of treatment for such patients. Preoperative assessments, strict postoperative monitoring, and managements are mandatory. Limited chemotherapy could be given to the patients with high risk of recurrence. Close surveillance, early detection, and treatment of posttransplant cancers are extremely important and essential to improve the survival.

De novo malignancy after liver transplantation: a single-center experience of 14 cases

PURPOSE

The aim of this study is to evaluate the incidence of de novo malignancy after liver transplantation (LT) and compare with those among the general Chinese population.

METHODS

A total of 466 patients who had a minimum follow-up time of 6 months were enrolled in the study. All data of medical records and follow up were retrospectively reviewed.

RESULTS

The incidence rate of de novo malignancy was 3.0% (14 in 466 patients). The median elapsed time from transplant to the diagnosis of de novo malignancy was 42 months (range, 6 to 106 months). The cumulative risk for development of de novo malignancy was 1.6%, 2.7%, and 8.2% at 3, 5 and 10 years after LT, respectively. The patients were all male. The types of de novo tumors included digestive system tumor (8 in 14), lung cancer (2 in 14), urologic neoplasm (2 in 14), and hematologic malignant tumor (2 in 14). Over a mean follow-up of 24 months after diagnosis of de novo malignancy, 7 patients (50.0%) died; the overall 5-year patient survival rate was 54.5%. The relative risk of malignancy following LT was 9.5 folds higher than the general Chinese population.

CONCLUSION

The relative risk of malignancy following LT was much higher than the general Chinese population. Digestive system tumor is the most common type of de novo malignancy after LT in China.

Early and late de novo tumors after liver transplantation in adults: the late onset of bladder tumors in men

Background

De novo tumors (DNT) after liver transplantation (LT) represent a growing concern.

Patients and Methods

We analyzed the incidence of DNT, type, time of onset, risk factors and mortality (as of 2010) in 494 adult patients transplanted in the last 26 years (1983–2009).

Results

DNT occurred in 41 (8.3%) of the patients. The Standardized Incidence Ratio (SIR) compared with the Italian population was 1.8. There was a higher incidence in males (SIR 2.0), an expected extremely high rate of Kaposi’s sarcoma (SIR 127.95) and unexpected higher rates of tumors of the bladder in males (SIR 3.3). The incidence of DNT was higher within the first two years of LT (SIR 2.7) for Kaposi’s sarcoma (SIR 393.3) and after 10 years (SIR 1.7) for bladder tumors (SIR 10.6). Multivariate analysis identified alcoholic cirrhosis (HR = 3.0, 95% CI = 1.2–7.8) and sclerosing cholangitis (HR = 3.5, 95% CI = 1.1–11.3) in the recipient as main risk factors for the occurrence of DNT.

Conclusions

Surveillance protocols for DNT must be specifically oriented to patients transplanted for alcoholic cirrhosis and sclerosing cholangitis. They should focus on early detection of Kaposi’s sarcomas, and more remarkably, on late development bladder tumors in men after LT.

Incidence, risk factors, and preventative management of skin cancers in organ transplant recipients: a review of single- and multicenter retrospective studies from 2006 to 2010

BACKGROUND

Organ transplant recipients (OTRs) taking immunosuppressants are at high risk of skin cancer, which is the most common malignant condition in OTRs, so dermatologic surveillance is important for OTRs.

OBJECTIVES

To characterize the most common skin cancers arising from chronic immunosuppression in OTRs.

METHODS

A PubMed search for retrospective single- and multicenter studies reporting skin cancer incidence from 2006 to 2010 was undertaken. Data regarding each study's immunosuppressive regimen, affected skin cancer cohort, and associated risk factors were extracted.

RESULTS

Thirty-six articles that met our inclusion criteria reported incidences of nonmelanoma skin cancer (NMSC), Kaposi's sarcoma, melanoma, and Merkel cell carcinoma. NMSC was the most commonly reported cancer of all skin cancers after transplantation. Common risk factors were sex, age, sunlight exposure, and immunosuppressive agent-related (duration, type).

CONCLUSION

Sun education programs and frequent screenings in organ transplant clinics have provided the best preventative strategies after transplantation, although the characteristics of the immunosuppressive regimen also play an important role. Thus, the adjuvant strategy of modifying immunosuppression may be effective when confronting severe transplant-associated skin cancer. Although the decision-making process for curbing levels of immunosuppression is difficult, further long-term, randomized controlled studies should assess the effect of using less immunosuppressant medication while preserving graft function.

Risk of colorectal carcinoma in post-liver transplant patients: a systematic review and meta-analysis

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.

Skin Cancer Education in Transplant Recipients

In the past 20 years, long-term survival for solid-organ transplant recipients has improved dramatically; about 223 000 patients are alive in the United States with organ transplants today. As survival rates improve, however, the morbidity and mortality associated with lifelong immunosuppressive therapy is increasing in significance. Skin cancer is common among recipients of all major organ transplants, including the kidney, liver, heart, lung, and pancreas. Although skin cancer is the most common cancer in transplant recipients, many cases can be prevented by sun protection, skin self-examinations, and physician examinations. Because transplant recipients visit the transplant clinic frequently, clinicians have ample opportunities to teach patients about the importance of prevention and detection of skin cancer. At a routine visit, the clinician should inquire about sun protection practices, especially for tanned, light-skinned, or freckled patients or patients who are planning a warm-weather vacation or time in the sun during the summer. Skin cancer education should be integrated into the care of transplant patients as part of their numerous visits to the transplant clinic. Although some transplant recipients may resist adopting new behaviors at first, use of the ample clinic opportunities for patient education can dramatically reduce their risk of skin cancer.

De novo posttransplantation nonlymphoproliferative malignancies in liver transplant recipients

The risk of developing de novo malignancies after liver transplantation is around 1% per year. The incidence varies from 3% to 15%; it is greater than that in the general population. The potential causes for cancer after solid organ grafting are: chronic immunosuppression and human herpes viral infection. The objective of this paper was to review the medical literature about the subject to verify the incidence of de novo malignancies in our service. We performed retrospective analysis of the medical files of 325 successive patients undergoing orthotopic liver transplantation from September 1991 to December 2006. We analyzed the type of tumor, the risk factors, the treatment modality, and the patient survivals. Recurrences of hepatocellular carcinoma were excluded. There were 5 (1.54%) men of average age 50.2 years, and an 80% mortality rate. Their survival time was affected by the nature of the tumor and by the late manifestations of intestinal obstruction allowing adequate surgical treatment. Four of the patients displayed heavy alcohol and tobacco consumption before transplantation. Screening for premalignant lesions must be strongly encouraged to achieve better postoperative results.