Death from metastatic donor-derived ovarian cancer in a male kidney transplant recipient

Donors risk assessment in transplantation: From the guidelines to their real-world application

Transplantation of an organ from a donor carries an unavoidable risk of tumor transmission. The need to extend the donor pool increases the use of organs from donors with malignancies and potential disease transmission is a constant tension influencing donor suitability decisions. Current classification systems for the assessment of donor malignancy transmission risk have evolved from reports of potential transmission events in recipients to national donation and transplant surveillance agencies. Although the risk of malignancy transmission is very low in the general transplant setting it must constantly be balanced with the transplant benefits. Guidelines are mainly based on large registries and sparse case reports of transmission, so they cannot cover all the possible situations. For this reason, in 2004 in Italy, the National Transplant Center gave rise to the Second Opinion Service, charged by the Ministry of Health, by structuring expertise in diagnostic oncology and risk transmission and making it available to the Italian Transplant Centers. In this paper the registry of the Italian Oncological Second Opinion was reviewed, from 2016 to 2018, to detail the most frequent and problematic neoplastic topics addressed, those are separately reported and discussed. Furthermore, a review of the most recent strategies and risk stratification is provided, according to the most recent literature evidence and to the European Guidelines.

[Breast cancer and organ transplantation: Systematic review and meta-analysis]

OBJECTIVES

Our main objective was to investigate donor-transmitted epithelial cancers of all origins in comparison with breast cancers, with analysis of the carcinological outcome of recipients. Our secondary objective was to define medical check-up to be performed before any organ procurement from a donor with a history of breast cancer.

METHODOLOGY

We performed a systematic review of the literature up to June 1st 2022 by including all original articles (including clinical cases) reporting cases of epithelial cancer transmitted from donor to recipient, followed by a meta-analysis of epidemiological and survival data.

RESULTS

In total, we included 52 articles (31 clinical cases and 21 cohort studies), representing 91,388 donors, 236,142 recipients, and 2591 cases of transmitted cancer. The risk of transmitted cancer was significantly higher with a history of breast cancer compared with a history of other cancer (RR=9.48 P=0.0025). In clinical cases, the pre-donation check-up was specified in only 33.3% of publications. The time between transplantation and cancer occurrence was longer in cases of breast cancer transmission compared to other epithelial cancers: 1435.8 days versus 297.6 (P<0.001).

CONCLUSION

Organ donation from a person previously treated for breast cancer or having a risk of occult breast cancer is possible in some situations but requires an adapted pre-donation assessment, the respect of good practice guidelines and an expert opinion in complex situations.

Donor-Derived Ovarian Cancer in a Male Recipient After Kidney Transplant: A Case Report

BACKGROUND

Patients who receive kidney transplants and experience long-term immunosuppressive therapy are tied to higher risk of developing cancers. Reports concerning about donor-associated cancers are rarely reported, especially for male ovarian cancer.

CASE REPORT

Here we report a case of donor-derived ovarian malignancy of a man after 3 years of renal transplantation. This case complied with the Helsinki Congress and the Istanbul Declaration. The donor is the recipient's mother who developed ovarian malignancy 6 months after the transplantation surgery and died 1.5 years later after diagnosis due to tumor progression. The patient devolved into abnormal renal function 3 years after the transplantation. The transplanted kidney lost its function and was subsequently surgically removed. The ovary cancer was confirmed as high-grade serous ovarian cancer by pathology and had potentially metastasized to donor kidney. Then the male patient received regular maintenance and dialysis. Four years after transplantation, he gradually developed the symptoms of coughing and sputum and computed tomography examination revealed a lung space-occupying lesion that was confirmed to be a metastatic tumor with the same pathology as before. Platinum-based combination chemotherapy can effectively control the condition; by the last follow-up evaluation, the progression-free survival of the patient was 23.5 months, and the overall survival was 36 months.

CONCLUSIONS

This case demonstrates that donor-derived ovarian tumor can be transferred into the recipient via the transplanted kidney even in the male recipient. This observation provides clinicians with effective treatment options for this rare type of patient population.

Long-term survival after choriocarcinoma transmitted by liver graft: A successful report in pediatric transplantation

BACKGROUND

LT is the standard of care for many pediatric liver disorders. Although long-term outcomes have improved, some rare complications such as transmission of occult donor tumors have been reported.

CASE REPORT

An adolescent diagnosed with tyrosinemia was submitted to LT from a previous healthy donor due to HCC. Almost 8 months after LT, the patient presented a nodular hepatic lesion. Clinically, he had mild weight loss, lower limb edema, and gynecomastia. Thorax CT found lesions in the left lung parenchyma, which showed no increased uptake in PET SCAN. Liver biopsy revealed a carcinoma with desmoplastic stroma. ISS was withdrawn, and palliative chemotherapy was started for presumptive HCC relapse. AFP remained normal, but HCG had reached unexpected values of 1984 IU/L. As we requested detailed information about the other organ recipients from the same donor, we found that one of them passed away due to disseminated tumor. Five months after the beginning of chemotherapy, the patient underwent resection of liver segments V and VI. Histological examination confirmed liver metastatic choriocarcinoma. At the time of writing, with 11 years of follow-up, the patient had sustained remission with no signs of relapse.

DISCUSSION

This case reports a diagnostic challenge in an adolescent with a particular unique background and a very rare pattern of tumor transmission. The authors aim to highlight the risk of cancer-bearing organs reveled post-LT and to testimony the experience of the successful outcome after a choriocarcinoma transmitted by liver graft.

Immunologic Clearance of a BK Virus-associated Metastatic Renal Allograft Carcinoma

BACKGROUND

Metastatic carcinoma of a renal allograft is a rare but life threatening event with a difficult clinical management. Recent reports suggested a potential role of BK polyomavirus (BKPyV) in the development of urologic tract malignancies in kidney transplant recipients.

METHODS

We investigated a kidney-pancreas female recipient with an history of BKPyV nephritis who developed a rapidly progressive and widely metastatic donor-derived renal carcinoma 9 years after transplantation.

RESULTS

Histology and fluorescence in situ hybridization analysis revealed a donor-derived (XY tumor cells) collecting (Bellini) duct carcinoma. The presence of BKPyV oncogenic large tumor antigen was identified in large amount within the kidney tumor and the bowel metastases. Whole genome sequencing of the tumor confirmed multiple genome BKPyV integrations. The transplanted kidney was removed, immunosuppression was withdrawn, and recombinant interleukin-2 (IL-2) was administered for 3 months, inducing a complete tumor clearance, with no evidence of disease at 6-year follow-up. The immunological profiling during IL-2 therapy revealed the presence of donor-specific T cells and expanded cytokine-producing bright natural killer cells but no donor-specific antibodies. Finally, we found persistently elevated anti-BK virus IgG titers and a specific anti-BKPyV T cell response.

CONCLUSIONS

This investigation showed evidence for the potential oncogenic role of BKPyV in collecting duct carcinoma in renal allografts and demonstrated that immunosuppression withdrawal and IL-2 therapy can lead to an efficient antitumor cellular mediated rejection possibly via 3 distinct mechanisms including (1) host-versus-graft, (2) host-versus-tumor, and (3) anti-BKPyV responses.

Transformed bone marrow cells generate neoplasms of distinct histogenesis. a murine model of cancer transplantation

The last several years have witnessed renewed interest regarding the contribution of cancer stem cells in tumorigenesis and neoplastic heterogeneity. It has been reported that patients who undergo bone marrow transplantation are more prone to develop a malignancy during their life time; usually hematological tumors, but solid neoplasms may also develop, which in certain instances are donor-derived. It has also been well documented that multipotent bone marrow derived cells can migrate to diverse organs, differentiating into various histological lineages. The present study reports an experimental syngeneic transplantation model, using fluorescently tagged bone marrow cells from p53 null male mice into female wild-type counterparts. We found that transplanted non-neoplastic mutant bone marrow cells can generate tumors of distinct histogenesis, including thymic lymphomas, sarcomas, and carcinomas after carcinogen induction, providing evidence that multipotent cancer-prone stem cells can reside in the bone marrow and are transplantable.

Transmission of breast cancer by a single multiorgan donor to 4 transplant recipients

We report 4 cases of breast cancer transmission to transplant recipients from a single organ donor that occurred years after donation. The diagnosis of breast cancer was occult at the time of donation. All of the recipients developed a histologically similar type of breast cancer within 16 months to 6 years after transplantation. Three out of 4 recipients died as a result of widely metastasized disease. One of the recipients survived after transplant nephrectomy followed by cessation of immunosuppression and chemotherapy. This extraordinary case points out the often fatal consequences of donor-derived breast cancer and suggests that removal of the donor organ and restoration of immunity can induce complete remission.

Donor transmitted and de novo cancer after liver transplantation

Cancers in solid organ recipients may be classified as donor transmitted, donor derived, de novo or recurrent. The risk of donor-transmitted cancer is very low and can be reduced by careful screening of the donor but cannot be abolished and, in the United Kingdom series is less than 0.03%. For donors with a known history of cancer, the risks will depend on the nature of the cancer, the interventions given and the interval between diagnosis and organ donation. The risks of cancer transmission must be balanced against the risks of death awaiting a new graft and strict adherence to current guidelines may result increased patient death. Organs from selected patients, even with high-grade central nervous system (CNS) malignancy and after a shunt, can, in some circumstances, be considered. Of potential donors with non-CNS cancers, whether organs may be safely used again depends on the nature of the cancer, the treatment and interval. Data are scarce about the most appropriate treatment when donor transmitted cancer is diagnosed: sometimes substitution of agents and reduction of the immunosuppressive load may be adequate and the impact of graft removal should be considered but not always indicated. Liver allograft recipients are at increased risk of some de novo cancers, especially those grafted for alcohol-related liver disease and hepatitis C virus infection. The risk of lymphoproliferative disease and cancers of the skin, upper airway and bowel are increased but not breast. Recipients should be advised to avoid risk behavior and monitored appropriately.

Cancer transmission from organ donors-unavoidable but low risk

BACKGROUND

Donor origin cancer (DOC) in transplant recipients may be transmitted with the graft (donor-transmitted cancer [DTC]) or develop subsequently from the graft (donor-derived cancer [DDC]).

METHODS

Recipients with DOC between January 1, 2001, and December 31, 2010, were identified from the United Kingdom Transplant Registry and database search at transplantation centers.

RESULTS

Of 30,765 transplants from 14,986 donors, 18 recipients developed DOC from 16 donors (0.06%): 3 were DDC (0.01%) and 15 were DTC (0.05%). Of the 15 DTCs, 6 were renal cell cancer; 5, lung cancer; 2, lymphoma; 1, neuroendocrine cancer; and 1, colon cancer. Recipients with DTC underwent explant/excision (11), chemotherapy (4), and radiotherapy (1). Of 15 recipients, 3 (20%) recipients with DTC died as a direct consequence of cancer. Early DTC (diagnosed ≤6 weeks of transplantation) showed a better outcome (no DTC-related deaths in 11 cases) as opposed to late DTC (DTC-related deaths in 3 of 4 cases). Five-year survival was 83% for kidney recipients with DTC compared with 93% for recipients without DTC (P=0.077). None of the donors resulting in cancer transmission was known to have cancer at donation.

CONCLUSIONS

DTC is rare but frequently results in graft loss and death. The risk of cancer transmission cannot be eliminated because, in every case, the presence of cancer was not known at donation. This information will allow informed consent for prospective recipients. Explantation/excision is likely to benefit recipients with localized cancer, but in transplants other than kidney/pancreas, the benefits should be balanced against the risks of retransplantation.

Gestational choriocarcinoma transmission following multiorgan donation

An accidental transmission of placental choriocarcinoma (CC) from a multiorgan donor to four recipients is reported. The donor was a 26-year-old pregnant woman, died from a cerebral hemorrhage. Histological examination demonstrated the presence of a placental CC. Diagnosis of CC transmission was established on the basis of an increase of human chorionic gonadotrophin hormone (hCG) level. The recipient of combined pancreas-kidney is still in complete remission 2 years after the beginning of chemotherapy without removal of the grafted organs which show optimal function. The recipient of a single kidney was rapidly transplantectomized and treated with actinomycin. At 2 years, she remains in remission. Liver recipient showed intestinal metastasis and died from digestive hemorrhage after an initial response to chemotherapy. Heart recipient had an initial remission under EMA-CO, but at the last report, he showed diffuse metastasis. Published reports on CC transmission are rare. The long-lasting remission of our pancreas-kidney recipient and her good outcome after 2 years make our observation original. Moreover, the high rate of transmission demonstrates the high malignant potential of CC in immunosuppressed patients. Chemotherapy combined or not with transplantectomy in case of nonvital organ, should be discussed.