Donor-derived malignancy in a pancreas graft

Metastatic Donor-derived Malignancies Following Simultaneous Pancreas-kidney Transplant: Three Case Reports and Management Strategies

Stopping immunosuppression in a transplant patient with donor-derived malignancy offers the theoretical benefit that reconstitution of the patient's immune system will allow "rejection" of the malignancy, as the malignancy also originates from allogeneic tissue. However, this option exists with the caveat that the patient's allograft(s) will likely be rejected too. In simultaneous pancreas-kidney (SPK) recipients, the normal continued functioning and possible absence of malignancy in either the unaffected kidney or pancreas further complicate this decision.

Methods

The charts of 3 patients with donor-derived metastatic malignancies after SPK were retrospectively reviewed in detail. We provide treatment and management recommendations based on successful outcomes and a review of the existing literature.

Results

Consistent with a broad review of the literature, in all 3 cases, complete immunosuppression cessation, removal of both grafts, and in 1 case treatment with an immune checkpoint inhibitor to augment the immune response was successful. One patient is doing well 1 year after successfully undergoing kidney retransplantation, while a second patient is active on the waitlist for SPK retransplantation after no evidence of metastatic disease for 2 years.

Conclusion

The successful management of metastatic donor-derived malignancies requires allograft removal, immunosuppression cessation, and adjuvant therapy that includes occasional use of checkpoint inhibitors to augment the immune response.

Surgical aspects of human islet isolation

Islet transplantation is a safe and effective procedure; however, it depends on the critical step of isolating high quality of islets from whole pancreas. Human islet isolation requires considerable experience and expertise, and is frequently seen as 'an art rather than a science'. However, without scientific knowledge of pancreatic anatomy, real experience can not be gained. In particular, an understanding ductal anatomy is important to perform human islet isolation. This review is based on clinical experience of more than 900 human islet isolations performed over 10 years and aims to highlight pancreatic anatomy and surgical techniques in islet processing.