Multiple Neoplastic Lesions of the Lower Genital Tract in a Human Papilloma Virus-Infected Kidney-Pancreas Allograft Recipient: A Case Report

Preneoplastic Lesion in a Pancreas Allograft: Dilemma for the Pancreas Transplant Surgeon

Although the relationship between immunosuppression and cancer risk is well-documented, the association between immunosuppression and the development of preneoplastic lesions (PNL) is less clear. PNLs pose a unique clinical conundrum in the transplanted pancreas because their prevalence in the general population is not infrequent. We present the case of a 58-year-old man with a history of diabetes mellitus type 1 who underwent successful pancreas transplantation with bladder drainage. His kidney function failed 13 years after his transplant and he developed recurrent painful hematuria with symptomatic anemia 2 years after initiating hemodialysis. Upon work-up, he was found to have a 4 cm intraductal papillary mucinous neoplasm in his pancreas allograft. At his enteric conversion, the intraductal papillary mucinous neoplasm was removed through a distal pancreatectomy due to concern for its malignant potential. He recovered well from surgery and continues to be insulin-free. With the rising incidence of PNLs from improved detection and the improved survival of pancreas allografts, the implications of PNLs may be more pronounced in the future. This case raises several important considerations for the pancreas transplant surgeon regarding adequate allograft surveillance protocols, treatment, and follow-up.

HPV-related (pre)malignancies of the female anogenital tract in renal transplant recipients

Renal transplantations (RTs) are performed routinely in many countries. After RT, the administration of lifelong immunosuppressive therapy is required. As a consequence, renal transplant recipients (RTRs) have a high risk to develop virus-associated (pre)malignancies, such as Human papillomavirus (HPV) related anogenital (pre)malignancies. It is known that the majority of the RTRs are infected with HPV and that these women have a 14-fold increased risk of cervical cancer, up to 50-fold of vulvar cancer and up to 100-fold of anal cancer. Often, treatment of these lesions requires concessions and may be suboptimal as radiation therapy and extensive surgery may damage the renal transplant. Therefore, prognosis may be compromised due to inadequately treated malignancies. Especially for these immunocompromised patients prevention is of utmost importance. Yearly cervical cancer screening for RTRs is advised, but appears to be executed poorly. For the future, optimizing screening and prevention of anogenital (pre)malignancies is an important issue for women after RT. This review gives a broad overview of all aspects regarding HPV-related (pre)malignancies of the female anogenital tract in RTRs.

Multiple types of high-risk human papilloma virus in the lower genital tract of a female kidney recipient: a case report

We present a case of a female kidney recipient who was infected with 3 types of high-risk human papilloma viruses. An infection in the lower genital tract led to the development of both neoplastic cervical lesions and vulvar cancer.

Cidofovir: clinical experience and future perspectives on an acyclic nucleoside phosphonate analog of cytosine in the treatment of refractory and premalignant HPV-associated anal lesions

BACKGROUND

Cidofovir, a nucleotide analog with antiviral activity against a broad range of DNA viruses including human papilloma viruses (HPV), is available off label to clinicians.

OBJECTIVE

To provide a better knowledge of pharmacology and effects when topically applied.

METHODS

After reviewing the chemistry, physiology, and animal studies, an overview of clinical studies is provided.

RESULTS/CONCLUSIONS

Cidofovir, as a result of its antiviral and antiproliferative activity and its ability to induce apoptosis, can offer a solution for the treatment of severe recurrent HPV-induced lesions. It can also be used to attempt to treat dysplastic lesions and as an adjuvant treatment. The long-lasting antiviral activity allows infrequent dosing. As a rule, cidofovir applied on the skin is well tolerated, even in long-term treatment. The dose-limiting nephrotoxicity of the drug is not a concern in patients with a glomerular filtration rate within the normal range. Cidofovir has clearly influenced the landscape of refractory and dysplastic anogenital condylomata acuminata and its use has increased over the last decade. However, further controlled clinical trials are needed to assess the role of cidofovir and its derivatives.

Increased risk of cervical dysplasia in long-term survivors of allogeneic stem cell transplantation--implications for screening and HPV vaccination

As more women survive allogeneic stem cell transplantation (SCT), the development of genital human papilloma virus (HPV)-related squamous intraepithelial lesions (SIL) warrants study. Thirty-five of 38 females followed prospectively long-term after SCT for hematological malignancies (median: 7 years posttransplant) were adults and had cervical cytology testing. Acute graft-versus-host-disease (aGVHD) occurred in 9 and chronic (cGVHD) in 34 patients. Six (17%) continued receiving systemic immunosuppressive therapy (IST) for cGVHD >3 years after SCT. Of 15 (43%) with abnormal cytology, 12 (34%) patients had HPV-related SIL (median time to SIL 51 months, range: 22-108) including high-grade SIL in 7 (20%). Patients requiring continued IST had the highest risk (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.1-16.4; P = .019). This high incidence of SIL in long-term SCT survivors underscores the importance of gynecologic assessment after transplantation, especially in those requiring IST. This may portend an increased risk of genital or other HPV-related malignancies.

Local administration of cidofovir for human papilloma virus associated skin lesions in transplant recipients

Human papilloma virus (HPV)-associated diseases are increasingly diagnosed in solid organ recipients. Cidofovir (CDV) is a broad-spectrum antiviral agent with activity against all human herpes viruses and HPV. From 2000-2004, a total of 1303 solid organ transplants (SOT) were performed at our center. Six transplant recipients were treated with topical CDV for HPV-associated lesions. One cardiac recipient responded to a single injection of CDV into his recurrent anal condylomata. In a renal recipient with recurrent penile condylomata CDV was injected into the lesions four times (2 week interval) until lesions regressed. One renal recipient developed multiple vaginal and anal intradermal neoplasias, which relapsed after laser ablation. The lesions were repeatedly injected with CDV and completely disappeared. Two renal recipients with widespread verrucae vulgares were treated with CDV gel, which resulted in regression of the lesions. One patient developed donor derived verrucae vulgares on both transplanted hands, which responded to CDV gel. Four of the six patients were switched from calcineurin inhibitors (CNIs) to Sirolimus (SIR). CDV was found effective in the treatment of HPV-associated skin lesions in SOT recipients. It needs to be determined whether switch from CNIs to SIR might have contributed to the beneficial effect of CDV.