Liver transplantation in the setting of extra-hepatic malignancy: two case reports

Cryoablation for Renal Cell Carcinoma Prior to Liver Transplantation: A Case Report

Extrahepatic malignancies are a relatively rare incidental finding during liver transplant work-up that provides a significant barrier to continued transplant evaluation and requires treatment to limit the risk of recurrence. There have only been 11 previously reported cases of pre-liver transplant renal cell carcinoma (RCC), of which all underwent partial or radical nephrectomy. Percutaneous cryoablation therapy has been gaining acceptance as a curative treatment alternative for RCC and is a new therapeutic standard for patients who are poor candidates for surgical resection. Recent studies have demonstrated the safety and efficacy of cryoablation for RCC in native kidneys and in solid masses in kidney allografts, but there is no data on the efficacy or recurrence of RCC when cryoablation is used for the treatment of RCC in a native kidney prior to solid organ transplantation. The patient underwent percutaneous cryoablation therapy of a T1a RCC of the native kidney 10 months prior to orthotopic liver transplant (OLT) without subsequent partial or radical nephrectomy. At seven years post-ablation therapy, the patient has no evidence of tumor recurrence despite immunosuppressive therapy post-transplantation. Cryoablation is potentially a safe and highly effective means of treating RCC in patients who are not candidates for nephrectomy secondary to complications associated with end-stage liver disease. In our case, the patient was treated with cryoablation and received standard post-transplant immunosuppression without recurrence of RCC at seven years. More studies are needed to determine inclusion and exclusion criteria for cryoablation and to confirm long-term efficacy as well as a strategy for duration and frequency of surveillance in these patients.

Transplant of Elderly Patients: Is There an Upper Age Cutoff?

Increased life expectancy and advances in the care of chronic liver disease has increased the number of elderly patients needing liver transplant. Organ donation policies prioritize transplant to the sickest. There is an ongoing debate with regard to balancing the principles of equity and utility. Several hospitals have adopted center-specific policies and there has been an increased trend of transplant in elderly patients since 2002. Appropriate patient selection and long-term outcomes in the setting of limited organ availability pose several challenges. This article reviews the data and discusses the pros and cons of transplants in the elderly.

Possible association between hepatitis C virus and malignancies different from hepatocellular carcinoma: A systematic review

AIM: To summarize the current knowledge about the potential relationship between hepatitis C virus (HCV) infection and the risk of several extra-liver cancers.

METHODS: We performed a systematic review of the literature, according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) Statement. We extracted the pertinent articles, published in MEDLINE and the Cochrane Library, using the following search terms: neoplasm/cancer/malignancy/tumor/carcinoma/adeno-carcinoma and non-Hodgkin lymphomas, kidney/renal-, cholangio-, pancreatic-, thyroid-, breast-,oral-, skin-, prostate-, lung-, colon-, stomach-, haematologic. Case series, case-series with control-group, case-control, cohort-studies as well as meta-analyses, written in English were collected. Some of the main characteristics of retrieved trials, which were designed to investigate the prevalence of HCV infection in each type of the above-mentioned human malignancies were summarised. A main table was defined and included a short description in the text for each of these tumours, whether at least five studies about a specific neoplasm, meeting inclusion criteria, were available in literature. According to these criteria, we created the following sections and the corresponding tables and we indicated the number of included or excluded articles, as well as of meta-analyses and reviews: (1) HCV and haematopoietic malignancies; (2) HCV and cholangiocarcinoma; (3) HCV and pancreatic cancer; (4) HCV and breast cancer; (5) HCV and kidney cancer; (6) HCV and skin or oral cancer; and (7) HCV and thyroid cancer.

RESULTS: According to available data, a clear correlation between regions of HCV prevalence and risk of extra-liver cancers has emerged only for a very small group of types and histological subtypes of malignancies. In particular, HCV infection has been associated with: (1) a higher incidence of some B-cell Non-Hodgkin-Lymphoma types, in countries, where an elevated prevalence of this pathogen is detectable, accounting to a percentage of about 10%; (2) an increased risk of intra-hepatic cholangiocarcinoma; and (3) a correlation between HCV prevalence and pancreatic cancer (PAC) incidence.

CONCLUSION: To date no definitive conclusions may be obtained from the analysis of relationship between HCV and extra-hepatic cancers. Further studies, recruiting an adequate number of patients are required to confirm or deny this association.

Chronic hepatitis C infection as a risk factor for renal cell carcinoma

BACKGROUND

Chronic hepatitis C virus (HCV) infection causes cirrhosis and hepatocellular carcinoma but is also etiologically linked to several extrahepatic medical conditions including renal disorders. HCV is also associated with extrahepatic malignancies and may be oncogenic. Whether HCV confers an increased risk of renal cell carcinoma (RCC) remains controversial.

AIMS

Prospectively determine whether chronic HCV is associated with an increased risk of RCC.

METHODS

At an integrated medical center in Detroit, Michigan, adult patients with suspected RCC or newly diagnosed colon cancer (controls) were screened for hepatitis C antibody (HCAB) and HCV RNA. Renal or colon cancers were confirmed histologically. The proportion of patients with HCAB and HCV RNA in each group was compared, and risk factors for renal cell carcinoma were determined by multivariable logistic regression analysis.

RESULTS

RCC patients had a higher rate of HCAB positivity (11/140, 8 %) than colon cancer patients (1/100, 1 %) (p < 0.01). Of the HCAB-positive patients, 9/11 RCC and 0/1 controls had detectable HCV RNA. HCV RNA positivity was a significant risk factor for RCC (OR 24.20; 95 % CL 2.4, >999.9; p = 0.043). Additionally, viremic RCC patients were significantly younger than RCC patients who were HCV RNA negative (p = 0.013).

CONCLUSIONS

Patients with chronic HCV are at heightened risk of RCC.

Risk for renal cell carcinoma in chronic hepatitis C infection

BACKGROUND

Chronic infection with hepatitis C virus (HCV) confers increased risk for chronic renal disease, and numerous reports suggest an association with renal cell carcinoma (RCC), a cancer with rapidly rising global incidence. We sought to determine whether HCV infection confers an increased risk for developing RCC.

METHODS

With the use of administrative data from a large, integrated, and ethnically diverse healthcare system, we did a cohort study of 67,063 HCV-tested patients between 1997 and 2006 who were followed for the development of RCC until April 2008.

RESULTS

A search of the health system cancer registry for patients with the diagnosis of kidney cancer showed that RCC was diagnosed in 0.6% (17 of 3,057) of HCV-positive patients versus 0.3% (177 of 64,006) of HCV-negative patients. The mean age at RCC diagnosis was much younger in HCV-positive individuals (54 versus 63; P < 0.001). The univariate hazard ratio for RCC among HCV patients was 2.20 (95% confidence interval, 1.32-3.67; P = 0.0025). In a multivariate model that included the risk factors age, African-American race, male gender, and chronic kidney disease, the overall hazard ratio for RCC among HCV patients was 1.77 (95% confidence interval, 1.05-2.98; P = 0.0313).

CONCLUSION

Chronic HCV infection confers a risk for the development of RCC.

IMPACT

Clinicians should consider newly identified renal lesions in patients with chronic HCV infection with a heightened suspicion for neoplasm, and newly diagnosed cases of RCC may require more careful surveillance for the presence of HCV infection. Additional studies are required to confirm these findings and to explore potential mechanisms of oncogenesis.

Recurrent nonhepatic and de novo malignancies after liver transplantation

INTRODUCTION

After Liver transplantation (LTx), recurrence of hepatic cancer, de novo cancers, and donor-transmitted cancers have been described. However, the data for patients with a prior history of nonhepatic malignancy and its recurrence post-LTx are limited.

AIM

Aim of this study was to examine the patient with nonhepatic pre-LTx malignancies, and their recurrence post-LTx along with de novo cancers and recurrence of hepatic malignancy in the population.

PATIENTS AND METHOD

Between March 1996 and July 2006, 1127 patients underwent LTx at our institution. Thirty patients (2.7%) (15 men and 15 women, mean age 56.9+/-12.8 years) had documented nonhepatic malignancies. There were seven colorectal, three prostatic, three cervical, three bladder, six breast, and other nine miscellaneous cancers (one patient had two cancers). Four patients had hepatocellular carcinoma at the time of LTx. All patients were followed up until 2008 with a mean follow-up period of 34.1+/-35.3 months.

RESULTS

One patient with oropharyngeal cancer (3.3%), who was recurrence-free pre-LTx for 77.3 months, developed recurrence 36 months post-LTx and subsequently died 11 months postrecurrence. Two patients developed de novo cancer. One developed renal cell carcinoma 46.6 months post-LTx and other developed de novo intra-abdominal metastatic adenocarcinoma of unknown origin. Three of four patients developed recurrent hepatocellular carcinoma.

CONCLUSION

The rate of recurrence of nonhepatic malignancy was 3% and de novo cancer was 6% in the present series. There is a need to develop a guideline for recurrence-free survival period for nonhepatic malignancies before LTx, based on the type and stage of cancer.