[Characterization of de novo malignancies in liver transplantation]

Cigarette smoking and liver diseases

Cigarette smoking is a preventable risk factor for premature morbidity and mortality. A history of smoking is observed in approximately 40% of patients with liver disease, while a growing number of studies are investigating the potential impact of smoking in chronic liver diseases. This review discusses the effects of smoking on liver diseases, at multiple levels, with a focus on its potential causal role. Clinical evidence indicates that cigarette smoking negatively impacts the incidence and severity of fatty liver disease, fibrosis progression, hepatocellular carcinoma development, and the outcomes of patients with advanced liver disease. The underlying mechanisms are complex and involve different pathophysiological pathways including oxidative stress and oncogenic signals. Importantly, smoking promotes cardiovascular disease and extrahepatic cancers in patients with steatohepatitis and in transplant recipients. We discuss how promoting smoking cessation could improve the rates of treatment response (in clinical trials) and fibrosis regression, while reducing the risk of hepatocellular carcinoma and improving liver transplant outcomes. Finally, we discuss current challenges such as the referral of smokers to specialised units for smoking cessation.

Liver metastasis from colorectal cancer 12 years after liver transplantation

Liver transplantation is an effective treatment for many liver diseases, with a 5-year survival of about 70 %. However, development of de novo malignancies in these immunocompromised patients is becoming a frequent complication medium term. The annual risk of developing a malignant tumor after a solid organ transplant is 2% . We report the case of a liver transplant patient who developed colorectal neoplasia at 12 years after transplantation , and then a metachronous metastases in the liver transplanted.

De novo malignancies after liver transplantation: a single-center experience

BACKGROUND AND OBJECTIVES

The recipients of liver transplantation (LT) are subjected to lifelong immunosuppression with its many drawbacks. De novo and recurrent malignancy in transplant recipients are attributed to attenuation of immunosurveillance. In the present study, we present our experience with de novo malignancies encountered after both deceased and living donor liver transplantations.

DESIGN AND SETTING

Retrospective study of patients referred to LT center between April 2001 and January 2010.

PATIENTS AND METHODS

Various data were collected including type of malignancy and histopathologic features, immunosuppression regimen, and patient survival.

RESULTS

Of 248 LT procedures performed in 238 patients (10 retransplants), 8 patients (3.4%) developed de novo post-LT malignancies. De novo malignancies included post-LT lymphoproliferative disorders (PTLD) in 5 patients who were all Epstein-Barr virus (EBV) positive, and who were treated successfully with anti-CD20 monoclonal antibody therapy, reduction of immunosuppression, and control of EBV activity; urinary bladder cancer in 1 patient who was treated with radical surgical resection and chemotherapy but died of bone and lung metastasis within 1 year of diagnosis; endometrial carcinoma in 1 patient who was treated with radical surgical resection; and Kaposi sarcoma in 1 patient who was successfully treated with surgical excision and reduction of immunosuppression.

CONCLUSION

EBV-associated PTLD is the most frequently encountered de novo malignancy after LT and is easily treatable by chemotherapy and reduction of immunosuppression.

Evolution and management of de novo neoplasm post-liver transplantation: a 20-year experience from a single European centre

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.

Causes and predisposing factors of de novo tumors in our series of liver transplant recipients

INTRODUCTION

Liver transplant recipients suffer a high risk of developing cancer, mainly as a consequence of immunosuppressant treatment, although a variety of other factors are involved. Our purposes were to evaluate the frequency of de novo tumours and to determine predisposing factors.

MATERIAL AND METHODS

We analyzed all of the transplantations performed during 1990, with a total of almost 700 cases. We analyzed the frequency of de novo tumors, their location, time since transplantation, survival, and recurrence rates and factors that may influence their appearance.

RESULTS

The series included 64 cases in 50 patients with a frequency of 7%. Skin tumors were the most frequent (39.06%), followed by those in the otolaryngologic (ear, nose, and throat) region (15.62%) and the lung (14.06%). The average time to progression between the transplantation and diagnosis was less than 4 years (47.74 months). The recurrence rate was 16%. The factors with the greatest influence on their appearance were age and gender of the recipient, alcohol consumption, and Child-Pugh score. Plasma transfusion was statistically, although not clinically, significant.

DISCUSSION

Our frequency of de novo tumors was consistent with that described in the literature. Despite some factors that influence their appearance, the main predisposing factor was immunosuppression and its duration.

Long-term probability of and mortality from de novo malignancy after liver transplantation

BACKGROUND & AIMS

Information about malignancies that arise in patients after liver transplantation comes from volunteer registry databases and single-center retrospective studies. We analyzed a multicenter, prospectively obtained database to assess the probabilities of and risk factors for de novo malignancies in patients after liver transplantation.

METHODS

We analyzed the National Institute of Diabetes and Digestive and Kidney Diseases' liver transplantation database of 798 adults who received transplants from April 1990 to June 1994 and long-term follow-up data through January 2003. In this patient population, 171 adult patients developed 271 de novo malignancies. Of these malignancies, 147 were skin-related, 29 were hematologic, and 95 were solid organ cancers; we focused on nonskin malignancies.

RESULTS

The probability of developing any nonskin malignancy was highest in patients with primary sclerosing cholangitis (PSC; 22% at 10 years) or alcohol-related liver disease (ALD; 18% at 10 years); all other diagnoses had a 10% probability. Multivariate analysis indicated that increased age by decade (hazard ratio [HR] = 1.33, P = .01), a history of smoking (HR = 1.6, P = .046), PSC (HR = 2.5, P = .001), and ALD (HR = 2.1, P = .01) were associated with development of solid malignancies after liver transplantation. The probabilities of death after diagnosis of hematologic and solid malignancy were 44.0% and 38.0% at 1 year and 57.6% and 53.1% at 5 years, respectively.

CONCLUSIONS

De novo malignancy primarily affects patients with PSC or ALD, compared to other transplant recipients, with a significant impact on long-term survival.

Health maintenance issues in cirrhosis

Caring for patients with cirrhosis requires special consideration. The role of the hepatologist is to assist the primary care physician in caring for such patients. This involves an active role in immunizations, lifestyle modifications, and providing instructions on when to go to the emergency room (ER). There are also specific recommendations geared toward the patient with cirrhosis relating to slowing down the disease process, maintaining quality of life, and improving survival.

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.

[Microcytic and hypochromic anemia due to a high-grade undifferentiated, embryonal, pleomorphic sarcoma]

Undifferentiated (embryonal) sarcoma (UES) of the liver is a primary malignant tumor, rarely diagnosed in adults. Because of the absence of specific symptoms, rapid tumor growth, and normality of the common tumor markers, this neoplasm has a poor prognosis. Histologically, UES of the liver is characterized by anaplastic cells within myxoid matrix. Histological, immunohistochemical and chromosomic alterations are similar in UES and in mesenchymal hamartoma, suggesting a relation between these entities. The mainstay of treatment is surgery, while adjuvant treatment could increase survival.

Esophageal squamous cell carcinoma after liver transplantation

The occurrence of an oesophageal squamous cell carcinoma following liver transplantation is very infrequent. Such an event has been related to a history of alcohol-induced cirrhosis, as in other squamous cell tumours of the oropharynx. We report the case of a 64-year-old male patient diagnosed as having oesophageal squamous cell carcinoma six years after having had a liver transplant due to alcohol-induced cirrhosis. The tumour was treated surgically and consisted of an Ivor-Lewis oesophagectomy. The patient is disease-free 17 months after surgery. A review of the cases reported in the literature indicated treatment with chemotherapy and radiation therapy, and with excision in some cases. Generally, despite aggressive treatment the prognosis is poor.

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.

Nonmelanoma skin cancer after liver transplantation. Study of risk factors

Nonmelanoma skin cancer (NMSC) is a frequent complication after liver transplantation, but the risk factors of posttransplant NMSC have not been well defined. In a prospectively followed series of 170 liver transplant recipients, we assessed the incidence of NMSC, compared it with the expected incidence in the general population, and investigated which risk factors were related to NMSC. After a median follow-up of 62 months, 27 patients developed 43 NMSC. The relative risk of NMSC was 20.26 (95% confidence interval: 14.66-27.29) as compared with sex- and age-matched population. In univariate analysis, older age, male sex, Child-Turcotte-Pugh A or B at transplantation, treatment with mycophenolate mofetil, skin type, and total pretransplant sun burden were associated to the development of NMSC. In multivariate analysis, only skin type and total sun burden were independently related to NMSC. In conclusion, risk of posttransplant NMSC may be estimated combining skin type and an easy estimation of total sun burden. No individual immunosuppression regimen seems to be related to a higher risk of NMSC.

De Novo neoplasia after liver transplantation: an analysis of risk factors and influence on survival

Immunosuppression increases the risk of posttransplant malignancy and it may increase posttransplant mortality. The finding of factors related to the development of posttransplant malignancy may serve as a guide to avoid those risk factors and to develop strategies of posttransplant surveillance. The incidence and risk factors of malignancy were studied in 187 consecutive liver transplant recipients surviving more than 3 months. None of the 12 patients surviving less than 3 months had de novo neoplasia. The impact of malignancy on survival was studied in a case-control study. After a median follow-up of 65 months, 49 patients developed 63 malignancies: 25 patients had 35 cutaneous neoplasias and 27 patients had 28 noncutaneous malignancies. The 5- and 10-year actuarial rates of cutaneous neoplasia were 14 and 24% and the rates of noncutaneous neoplasia were 11 and 22%, respectively. Risk factors for the development of cutaneous malignancy were older age and Child-Turcotte-Pugh A status. Risk factors for the development of noncutaneous malignancy were older age, alcoholism, and smoking. Cutaneous neoplasia had no effect on survival, whereas patients with noncutaneous malignancy had a significant reduction of survival. The overall relative risk of cutaneous and noncutaneous neoplasia, as compared with the general population were 16.91 (95% confidence interval: 11.78-23.51) and 3.23 (95% confidence interval: 2.15-4.67), respectively. The relative risk of cancer-related mortality (after excluding recurrent malignancy) was 2.93 (95% confidence interval: 1.56-5.02). Multivariate analysis showed that noncutaneous malignancy was an independent risk factor for posttransplant mortality. In conclusion, liver transplant recipients have a higher risk of cancer-related mortality than the general population. This increased risk is due to the development of noncutaneous neoplasia. Older age, alcoholism, and smoking increase the risk of de novo noncutaneous neoplasia.