Solid tumors after liver transplantation

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.

De novo cancers arising in organ transplant recipients are associated with adverse outcomes compared with the general population

BACKGROUND

Transplant recipients are at increased risk of malignancy; however, the influence of transplantation on cancer outcomes has not been rigorously defined. The purpose of this study was to examine the influence of transplantation on the outcomes of individual cancers.

METHODS

De novo nonsmall cell lung cancer, colon cancer, breast cancer, prostate cancer, bladder cancer, renal cell cancer (RCC), and malignant melanoma data in 635 adult (>18 years of age) transplant recipients (from the Israel Penn International Transplant Tumor Registry) were compared with data from 1,282,984 adults in the general population (from the Surveillance, Epidemiology, and End Results database).

RESULTS

Compared with the general population, transplant patients were more likely to have early stage (AJCC stage 0-II) RCC, but more advanced (AJCC stage >II) colon cancer, breast cancer, bladder cancer, and malignant melanoma. Compared with the general population, disease-specific survival was worse in the transplant population for colon cancer (all stages), nonsmall cell lung cancer (stage II), breast cancer (stage III), prostate cancer (stage II, III, and IV), bladder cancer (stage III), and RCC (stage IV). Multivariate analyses demonstrated transplantation to be a negative risk factor for survival for each cancer studied, and transplantation and cancer stage at diagnosis to be the most profound negative survival predictors.

CONCLUSIONS

These analyses indicate that, for several common cancers, transplant patients experience worse outcomes than the general population. The data also suggest that cancers in transplant recipients are more aggressive biologically at the time of diagnosis.

Risk of malignant neoplasms after liver transplantation: a population-based study

Posttransplant malignancies have become a serious long-term complication after liver transplantation. Our aim was to compare the incidence of posttransplant cancers with national cancer incidence rates. The study included all Finnish liver transplant patients transplanted at the Helsinki University Central Hospital between 1982 and 2005. The cohort was linked with the nationwide Finnish Cancer Registry. Observed numbers of cancers were compared to site-specific expected numbers based on national cancer incidence rates stratified by age, sex, and calendar time. The standardized incidence ratios (SIRs) were calculated as observed-to-expected ratios. Thirty-nine posttransplant de novo cancers and 11 basal cell carcinomas were found in the cohort of 540 patients during 3222 person years of follow-up. The overall SIR was 2.59 (95% confidence interval 1.84-3.53). SIR was higher for males (SIR 4.16) than for females (SIR 1.74), higher among children (SIR 18.1) than among adults (SIR 5.77 for ages of 17-39 years and 2.27 for ages >/= 40 years), and more elevated in the immediate posttransplant period (SIR 3.71 at < 2 years) compared to later periods (SIR 2.46 at 2-10 years and 1.53 at >10 years). The most common cancer types were nonmelanoma skin cancer (SIR 38.5) and non-Hodgkin lymphoma (SIR 13.9). Non-Hodgkin lymphoma was associated with male gender, young age, and the immediate posttransplant period, whereas old age and antibody induction therapy increased skin cancer risk. In conclusion, cancer incidence is increased among liver transplant patients compared to the general population. This study points out the importance of cancer surveillance after liver transplantation.

De novo esophageal neoplasia after liver transplantation

The purpose of the study was to determine the incidence, risk factors, treatment, and influence on survival of patients with de novo esophageal cancer after liver transplantation (LT). From 1988 to 2006, 1,926 patients underwent LT in our institution. A total of 9 patients (0.5%) developed a de novo esophageal cancer and 1 patient a cancer of the cardia (0.05%). A retrospective analysis was performed to reveal underlying diseases, timeframes between LT and appearance of cancer, predisposing factors, cancer therapy, complications, immunosuppressive regimens, and survival. Of our 10 patients, 7 (70%) suffered from esophageal squamous cell carcinoma (SCC) and 3 patients (30%) developed an adenocarcinoma, including the patient with cancer of the cardia. A total of 9 patients were transplanted due to alcoholic cirrhosis; 1 patient suffered from hepatocellular carcinoma in nonA-nonB hepatitis-related cirrhosis. Median time to tumor diagnosis was 51 months after transplantation. A total of 5 patients were treated conservatively with combined radiochemotherapy and 5 underwent surgical resection. Patients with radiochemotherapy showed a mean survival of 14.8 months vs. 24.8 months for the patients of the surgery group. No major postoperative complication has been observed. A total of 2 patients of the surgery group are still alive after a follow-up of 15 and 89 months. In conclusion, de novo esophageal and cancer of the cardia after LT is a rare event. In spite of immunosuppression, no increased complication rate has been observed. Patients may have a survival benefit from surgical resection.

Incidence and risk factors for cancer after liver transplantation

De novo tumors (DNT) are a serious complication after orthotopic liver transplantation (OLT), showing a higher overall incidence ranging from 4.7% to 15.7% in non-selected series. Skin cancer (SC) is the most frequent malignancy observed, ranging from 6% to 70% of the tumors observed, followed by post-transplant lymphoproliferative disorders (PTLD) (4.3-30%). Different immunosuppressive protocols do not seem to influence DNT appearance. Colon and upper aerodigestive cancer after OLT seems to be more prone to develop when there are associated risk factors, such as primary sclerosing cholangitis (PSC) and alcoholic liver cirrhosis (ALC). Some risk factors, such as age, smoking, alcohol and others seem to play a role in higher risk for malignancy, but the presence of a long-term immunosuppressive state, more than the specific regimen used, is the basis for this higher incidence. Ethnic and demographic factors are also important variables influencing the heterogeneity of the results, especially influencing Kaposi's sarcoma and skin tumors.

Malignancy after liver transplantation in patients with premalignant conditions

GOALS

Liver transplant recipients are at increased risk of developing nonhepatic malignant tumors. The aim of the current study was to evaluate the role of premalignant states, not associated with the liver disease prior to transplantation, in the development of posttransplantation malignancy.

STUDY

One hundred seventy-five patients who had undergone liver transplantation were retrospectively evaluated for the development of malignant conditions. Each of the patients who developed malignancy following transplantation was evaluated for the presence of premalignant conditions before transplantation.

RESULTS

Post-liver transplantation malignancy was identified in 13 patients (7.4%). Five patients developed non-Hodgkin lymphoma: four had posttransplantation lymphoproliferative diseases, and one had B cell lymphoma of the stomach. Eight patients developed solid tumors. In five of these patients, evidence of a premalignant state was identified: ulcerative colitis was diagnosed in 1 patient with carcinoma of the colon; colonic polyp, 1 patient with carcinoma of the colon; Barrett esophagus, 1 patient with esophageal carcinoma; Caroli disease, 1 patient with anaplastic cholangiocarcinoma; and cervical atypia, 1 patient with carcinoma of the cervix.

CONCLUSIONS

Premalignant conditions existing before transplantation, which are not associated with the primary liver disease, are major risk factors for posttransplantation malignancy. Screening for premalignant conditions should be included in pretransplantation evaluation. Liver transplant patients with evidence of a premalignant state should be followed after transplantation for detection of malignancy.

Imaging of hepatic transplantation

Hepatic transplantation has become the treatment of choice for advanced irreversible liver disease. More than 4,000 hepatic transplantations were performed in the United States in 1997 and more than 11,000 are awaiting transplantation. Graft endurance and overall patient survival has been steadily improving, and between 1992 and 1994, 82% of the patients who received a liver transplant survived for at least a year. Today, liver transplant patients have a five-year survival rate of approximately 75%. The improvement in survival can be attributed to better patient selection and preparation, advances in organ preservation, improved immunosuppressive therapy agents and refinement of surgical techniques. In this article, we will address the hepatic parenchyma and vascular structures that should be evaluated prior to and following liver transplantation, the range of expected anomalies and abnormalities, and the utility of each of the three main imaging modalities, namely ultrasonography, computed tomography and magnetic resonance imaging in this assessment.