Cancer chemotherapy after solid organ transplantation

Current and Future States of Natural Killer Cell-Based Immunotherapy in Hepatocellular Carcinoma

Natural killer (NK) cells are innate lymphoid cells that exhibit high levels of cytotoxicity against NK-specific targets. NK cells also produce various cytokines, and interact with T cells, B cells, and dendritic cells to effectively serve as frontliners of the innate immune system. Produce various cytokines, and interact with T cells, B cells, and dendritic cells to effectively serve as frontliners of the innate immune system. Moreover, NK cells constitute the second most common immune cell in the liver. These properties have drawn significant attention towards leveraging NK cells in treating liver cancer, especially hepatocellular carcinoma (HCC), which accounts for 75% of all primary liver cancer and is the fourth leading cause of cancer-related death worldwide. Notable anti-cancer functions of NK cells against HCC include activating antibody-dependent cell cytotoxicity (ADCC), facilitating Gasdermin E-mediated pyroptosis of HCC cells, and initiating an antitumor response via the cGAS-STING signaling pathway. In this review, we describe how these mechanisms work in the context of HCC. We will then discuss the existing preclinical and clinical studies that leverage NK cell activity to create single and combined immunotherapies.

Pilot study to determine the safety and feasibility of deceased donor liver natural killer cell infusion to liver transplant recipients with hepatocellular carcinoma

Liver transplantation (LT) is a viable treatment option for cirrhosis patients with hepatocellular carcinoma (HCC). However, recurrence is the rate-limiting factor of long-term survival. To prevent this, we conducted the phase I study of the adoptive transfer of deceased donor liver-derived natural killer (NK) cells. Liver NK cells were extracted from donor liver graft perfusate and were stimulated in vitro with IL-2. The patient received an intravenous infusion of NK cells 3-5 days after LT. Eighteen LT recipients were treated. There were no severe cell infusion-related adverse events or acute rejection episodes. One patient withdrew from the study because the pathological observation revealed sarcoma instead of HCC. All patients who received this immunotherapy completed the follow-up for at least 2 years without evidence of HCC recurrence (median follow-up, 96 months [range, 17-121 months]). Considering that 9 (52.9%) of the 17 patients pathologically exceeded the Milan criteria, liver NK cell infusion is likely to be useful for preventing HCC recurrence after LT. This is the first-in-human immunotherapy study using deceased donor liver-derived NK cells to prevent HCC recurrence after LT. This treatment was well tolerated and resulted in no HCC recurrence after LT.Clinical trial registration www.clinicaltrials.gov ; NCT01147380; registration date: June 17, 2010.

Recurrent Cardiac Myxoma Treated by Orthotopic Heart Transplantation: A Case Report and Literature Review of Heart Transplantation for Primary Cardiac Tumor

Primary cardiac myxoma is the most common primary cardiac tumor. Tumor resection is the treatment of choice and overall long-term prognosis is good and recurrence is rare. This report presents a case of a young girl who presented with multiple recurrent cardiac myxoma. She underwent 3 sternotomy surgeries of 3 separated episodes of cardiac myxoma resection. On the fourth recurrence, the patient underwent orthotopic heart transplant. The patient tolerated the procedure well and is alive 6 months after the procedure with NYHA class I. We reviewed evidences and summarized reported cases of orthotopic heart transplant operation for primary cardiac tumor in the literature.

Stereotactic ablative radiotherapy for early-stage lung cancer following double lung transplantation

BACKGROUND

Development of primary lung cancer in donor lung post-lung transplantation is very rare, with few described cases. The safety of stereotactic ablative radiotherapy (SABR) for early-stage lung cancer arising from donor lung is unclear.

CASE PRESENTATION

Herein, we present a case of a patient with a Stage IB adenocarcinoma arising from donor lung 8 years post-double lung transplantation, which was performed due to advanced emphysema. The patient was ineligible for surgical management due to chronic lung allograft dysfunction, which significantly compromised pulmonary function. Full dose SABR was delivered with curative intent after a discussion with the patient. The patient tolerated the treatment well, with one episode of subacute toxicity that resolved with treatment. There was no evidence of recurrence at 15 months post-treatment and the patient's pulmonary function did not deviate from the pre-SABR baseline.

CONCLUSIONS

SABR appears feasible for medically-inoperable early-stage primary lung adenocarcinoma in the setting of previous double-lung transplantation.

Daunting but Worthy Goal: Reducing the De Novo Cancer Incidence After Transplantation

Solid-organ transplant recipients are at increased risk of developing de novo malignancies compared with the general population, and malignancies become a major limitation in achieving optimal outcomes. The prevention and the management of posttransplant malignancies must be considered as a main goal in our transplant programs. For these patients, immunosuppression plays a major role in oncogenesis by both impairement of immunosurveillance, enhancement of chronic viral infection, and by direct prooncogenic effects. It is essential to manage the recipient with a long-term adapted screening program beginning before transplantation to use a prophylaxis to decrease infection-related cancer, to propose a viral monitoring, and to modulate the immunosuppression toward lower doses especially for calcineurin inhibitors. Indeed, strategies to induce tolerance or to allow a dramatic reduction of the immunosuppression burden are the more promising approaches for the reduction of the posttransplant malignancies.

Survival after heart transplantation for non-metastatic primary cardiac sarcoma

Background

Heart transplantation is an uncommon treatment for unresectable and non-metastatic primary cardiac sarcomas, and the role of it is unclear. This study aims to offer a survival analysis of it.

Methods

This study consists of 6 patients from our institution and 40 patients identified in a literature search who underwent heart transplantation for non-metastatic primary cardiac sarcomas. Seven patients with unresectable cardiac angiosarcoma who received palliative therapies at our institution were included for comparison. All the clinicopathologic data were collected, retrospectively reviewed and statistically analyzed.

Results

Among the 46 patients receiving heart transplantation for primary cardiac sarcomas, the overall median survival was 16 months (2–112 months). The most common histologic type receiving heart transplantation was angiosarcoma. Its median survival time after heart transplantation (n = 14) was much less than that of other histologic types (n = 31) (9 vs 36 months; P = 0.002), which means it was not different from the median survival of 8 months for patients (n = 7) receiving palliative therapies (P = 0.768). The patients with grade 2 cardiac sarcomas (n = 5) survived much longer after heart transplantations than patients with grade 3 tumors (n = 15) (mean survival: 85 vs 18 months; P = 0.006). Neoadjuvant or adjuvant chemotherapy didn’t provide survival benefits after heart transplantation.

Conclusions

Cardiac angiosarcoma seems to be not the proper indication of heart transplantation. The role of heart transplantation in other histologic subtypes still remains undefined. Lower grade and less aggressive histologic subtypes benefit more from heart transplantation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-016-0540-x) contains supplementary material, which is available to authorized users.

Clinical-scale isolation of interleukin-2-stimulated liver natural killer cells for treatment of liver transplantation with hepatocellular carcinoma

Tumor recurrence is the main limitation of liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) and can be promoted by immunosuppressants. However, there is no prevention or treatment for HCC recurrence after LT. Here we describe a clinical-scale method for an adoptive immunotherapy approach that uses natural killer (NK) cells derived from deceased donor liver graft perfusate to prevent tumor recurrence after LT. Liver mononuclear cells (LMNCs) that were extracted from deceased donor liver graft perfusate contained a high percentage of NK cells (45.0 ± 4.0%) compared with peripheral blood mononuclear cells (PBMCs) (21.8 ± 5.2%) from the same donor. The CD69 activation marker and the natural cytotoxicity receptors, NKp44 and NKp46, were expressed at high levels in freshly isolated liver NK cells. Furthermore, interleukin-2 (IL-2)-stimulated NK cells showed greater upregulation of activation markers and the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), which is critical for NK cell-mediated antitumor cell death and increased production of interferon. Moreover, IL-2 stimulation induced LMNCs to exhibit a strong cytotoxicity against NK-susceptible K562 target cells compared with PBMCs (p < 0.01). Finally, we also showed that the final product contained a very low T-cell contamination (0.02 ± 10(6) cells/kg(-1)), which reduces the risk of graft-versus-host disease (GVHD). Collectively, our results suggest that the adoptive transfer of IL-2-stimulated NK cells from deceased donor liver graft perfusate could be a promising treatment for LT patients with HCC.

Combined heart and lung transplantation for unresectable primary cardiac sarcoma

OBJECTIVE

The prognosis for patients with primary cardiac sarcoma is poor. Median survival is less than 10 months, especially when complete surgical excision is not feasible. Removal of all cardiopulmonary structures involved by tumor followed by orthotopic allotransplantation has been proposed to improve long-term survival.

METHODS

From 1996 through 1999, we performed combined heart and lung resection followed by en bloc heart and bilateral lung transplantation in 4 patients (2 men and 2 women): 2 with inoperable pulmonary arterial sarcoma and 2 with left atrial sarcoma extending into the pulmonary vein.

RESULTS

Median age at diagnosis was 39 years (range 37-45 years). All 4 patients were given chemotherapy before transplantation: doxorubicin and ifosfamide in 2 cases, and doxorubicin, ifosfamide, mesna, and dacarbazine in 2 cases. There were no operative deaths. Median survival after transplantation was 31 months (range 5-49 months). All patients had tumor recurrence: local recurrence in the chest (n = 1) and distant metastases in the brain (n = 2) and abdomen (n = 1). One patient remains alive 49 months after disease progression with cerebral metastasis as the only site of recurrence treated with whole-brain irradiation, resection, and stereotactic radiosurgery.

CONCLUSIONS

Combined heart and lung transplantation is a technically feasible treatment for highly selected patients with localized advanced primary cardiac sarcomas. The high incidence of metastatic disease, however, limits its utility.

Heart transplantation: an approach to treating primary cardiac sarcoma?

Treating rare, primary cardiac soft-tissue sarcomas (C-STS) with heart transplantation (HTx) is controversial. Conventional tumor resection only partially alleviates the disease, and patients die of local recurrence of the tumor or of distant metastases. Heart transplantation offers the opportunity to eradicate the primary malignancy completely. In our experience of 4 patients with C-STS indicates, HTx followed by post-operative chemotherapy does not affect the long-term outcome. However, pre-operative chemotherapy can regress tumors in chemosensitive C-STS and potentially eradicate early micrometastases. Consecutive HTx for responders may then offer a chance of long-term survival.

Atrial transplantation for recurrent cardiac sarcoma

Cardiac transplantation for sarcomas has met with little success and the surgical treatment remains controversial. We describe the case of a 56-year-old woman who was referred for transplantation after two procedures in which undifferentiated atrial sarcoma was locally excised successfully. The patient underwent atrial homograft transplantation, the first reported to date. Advantages of the procedure include wide atrial resection and no need for immune suppression.

Therapy for primary cardiac tumors: is there a role for heart transplantation?

Primary cardiac tumors are rare clinical entities. Benign tumors are often amenable to surgical excision, whereas malignant tumors are seldom resectable. The literature has reported that 28 patients have undergone orthotopic heart transplantation for inoperable primary cardiac tumors. The results of these transplants are presented in this article. Of the 28 patients who underwent orthotopic heart transplantation for primary cardiac neoplasms, 7 patients had benign histology (fibroma-5, rhabdomyoma-1, and pheochromocytoma-1) and 21 patients had malignant histology (sarcoma-15, malignant fibrohistiocytoma-3, and lymphoma-3). Mean survival in the patients with benign histology was 46 months, and the mean survival in the patients with malignant histology was 12 months. However, there were seven patients with malignant histology who had survived for a mean of 27 months without evidence of recurrent disease. An awareness by clinicians of the presenting clinical picture of these tumors is warranted in view of the potential for cure by resection or transplantation. Patients with benign primary cardiac tumors appear to benefit from the complete resection afforded by cardiectomy and transplantation. The role of transplantation for patients with malignant tumors remains unclear. Further experience and continued follow-up of these patients is necessary to ascertain the role of cardiac transplantation, radiation, and chemotherapy in the management of patients with primary tumors of the heart.

[Cardiac tumors (II). Malignant primary tumors. Metastatic tumors. Carcinoid tumor]

Heart neoplasms are of increasing interest among clinicians and surgeons. A review of primary malignant cardiac tumors, secondary cardiac tumors and carcinoid heart tumors is presented, with special reference to their pathological and surgical aspects. Primary malignant heart tumors represent about 25% of all cardiac tumors, the great majority are sarcomas and the whole family of this group is described including angiosarcoma, rhabdomyosarcoma, fibrosarcoma, leiomyosarcoma, liposarcoma, neurogenic sarcoma, synovial sarcoma and osteosarcoma; mesothelioma, lymphoma, malignant teratoma and thymoma are also included. Metastatic heart tumors are 20-40 times more common than primary malignancies, their behavior and more relevant aspects in diagnostic and surgical therapy are mentioned. Carcinoid heart tumors represent a distinctive entity and are discussed individually.

Non-Hodgkin's lymphoma after liver transplantation: response to chemotherapy

An increased incidence of lymphoproliferative disorders in immunosuppressed organ transplant recipients has long been recognised. Lymphoproliferative disorders occur in 2% of orthotopic liver transplant patients. Different therapies have been used, but the optimal treatment remains unknown. Relatively little information is available on experience with cytotoxic chemotherapy. Three children who developed Burkitt-like, non-Hodgkin's lymphomas after liver transplantation are described. The disease failed to regress after initial management, which included a reduction in immunosuppression. With cytotoxic chemotherapy all three achieved complete remission, which continued 36+, 35+, and 16+ months after diagnosis. Results suggest that in selected cases chemotherapy can be safe in late-onset lymphomas appearing after solid organ transplantation.

De novo solid malignancies after cardiac transplantation

BACKGROUND

As long-term survival after cardiac transplantation improves, neoplastic complications are increasingly being discovered. Although lymphoproliferative disorders predominate, the incidence and clinical spectrum of solid tumors in a uniform population of heart transplant recipients remains uncertain.

METHODS

We reviewed our experience with 712 patients who underwent cardiac transplantation. Clinical charts were reviewed and telephone interviews were conducted, when possible.

RESULTS

De novo solid malignancies were identified in 3.3% of patients at risk (21 of 633 patients). Twenty patients were male; mean age was 51.5 +/- 8.6 years. Most patients reported a significant smoking history. Pulmonary, urologic, and Kaposi's sarcoma were the most common malignancies identified. Mean interval from transplantation to diagnosis was 35 months. Six patients were diagnosed within 6 months of transplantation. One-year and 5-year survival after transplantation were 90% and 49%, respectively. One-year and 3-year survival after cancer diagnosis were 60% and 52%, respectively.

CONCLUSIONS

De novo solid malignancy after transplantation occurred with about half the frequency of lymphoproliferative disorders. A striking male predominance was noted. The interval from transplantation to the appearance of cancer is variable, and no clustering was identified. A significant smoking history warrants aggressive search for occult malignancy during pretransplantation evaluation of potential heart recipients.

Radical excisional therapy and total cardiac transplantation for recurrent atrial myxoma

We describe the management of a recurrent atrial myxoma extending to the pulmonary veins and superior vena cava. Deep hypothermia and circulatory arrest with left atrial and caval excision was required to achieve complete resection of the tumor. The patient is alive and well without evidence of tumor recurrence 18 months after transplantation. Radical en bloc cardiac resection is feasible in selected cases of cardiac tumors.

Primary bronchogenic carcinoma in the heart transplant recipient

An increased risk of neoplasia is a well-recognized complication of chronic immunosuppression. Although lung cancer has been sporadically reported in the transplant population, it has not been recognized widely as a specific risk among heart transplant recipients. We present 3 cases of bronchogenic carcinoma in cardiac transplant patients, discuss possible risk factors, and outline recommendations for diagnosis and management of new lung lesions discovered during routine follow-up.

Cyclophosphamide toxicity. Characterising and avoiding the problem

Cyclophosphamide, an orally active alkylating agent, is widely used to treat a variety of malignant and nonmalignant disorders. Although it has some tumour selectivity, it also possesses a wide spectrum of toxicities. The requirement of metabolic activation before cyclophosphamide exerts either its therapeutic or toxic effects is well established, but has not led to effective counter-measures. Clinically, damage to the bladder (haemorrhagic cystitis), immunosuppression (when not desired) and alopecia are the most significant toxicities associated with cyclophosphamide. Cardiotoxicity is also a possibility when very high doses are given. Preventing these toxicities has focused on modifications of the treatment regimens and, in the case of haemorrhagic cystitis, the administration of a drug which is excreted in the urine where it inactivates the bladder-toxic species. As treatment regimens for cancer become more effective in prolonging a patient's life, and as cyclophosphamide receives increasing use for nonmalignant disorders, the potential for cyclophosphamide-induced cancers, particularly in the bladder, must be recognised. Although the toxicities associated with cyclophosphamide are serious, this agent remains a highly effective drug in many situations. Research on the pathways which play an important role in activating this drug may improve our ability to target particular diseases and decrease unwanted side effects.