Organ transplantation from donors (cadaveric or living) with a history of malignancy: Review of the literature

Organ Transplants From Deceased Donors With Primary Brain Tumors and Risk of Cancer Transmission

Importance

Cancer transmission is a known risk for recipients of organ transplants. Many people wait a long time for a suitable transplant; some never receive one. Although patients with brain tumors may donate their organs, opinions vary on the risks involved.

Objective

To determine the risk of cancer transmission associated with organ transplants from deceased donors with primary brain tumors. Key secondary objectives were to investigate the association that donor brain tumors have with organ usage and posttransplant survival.

Design, Setting, and Participants

This was a cohort study in England and Scotland, conducted from January 1, 2000, to December 31, 2016, with follow-up to December 31, 2020. This study used linked data on deceased donors and solid organ transplant recipients with valid national patient identifier numbers from the UK Transplant Registry, the National Cancer Registration and Analysis Service (England), and the Scottish Cancer Registry. For secondary analyses, comparators were matched on factors that may influence the likelihood of organ usage or transplant failure. Statistical analysis of study data took place from October 1, 2021, to May 31, 2022.

Exposures

A history of primary brain tumor in the organ donor, identified from all 3 data sources using disease codes.

Main Outcomes and Measures

Transmission of brain tumor from the organ donor into the transplant recipient. Secondary outcomes were organ utilization (ie, transplant of an offered organ) and survival of kidney, liver, heart, and lung transplants and their recipients. Key covariates in donors with brain tumors were tumor grade and treatment history.

Results

This study included a total of 282 donors (median [IQR] age, 42 [33-54] years; 154 females [55%]) with primary brain tumors and 887 transplants from them, 778 (88%) of which were analyzed for the primary outcome. There were 262 transplants from donors with high-grade tumors and 494 from donors with prior neurosurgical intervention or radiotherapy. Median (IQR) recipient age was 48 (35-58) years, and 476 (61%) were male. Among 83 posttransplant malignancies (excluding NMSC) that occurred over a median (IQR) of 6 (3-9) years in 79 recipients of transplants from donors with brain tumors, none were of a histological type matching the donor brain tumor. Transplant survival was equivalent to that of matched controls. Kidney, liver, and lung utilization were lower in donors with high-grade brain tumors compared with matched controls.

Conclusions and Relevance

Results of this cohort study suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors was lower than previously thought, even in the context of donors that are considered as higher risk. Long-term transplant outcomes are favorable. These results suggest that it may be possible to safely expand organ usage from this donor group.

Case Report: An Unusual Course of Angiosarcoma After Lung Transplantation

A 35-year-old woman underwent bilateral lung transplantation for primary ciliary dyskinesia and developed vascular tumors over a slow time course. Initial presentation of non-specific vascular tumors in the lungs and liver for up to 6 years after transplantation evolved toward bilateral ovarian angiosarcoma. Tumor analysis by haplotyping and human leukocyte antigen typing showed mixed donor chimerism, proving donor origin of the tumoral lesions. In retrospect, the donor became brain dead following neurosurgical complications for a previously biopsy-proven cerebral hemangioma, which is believed to have been a precursor lesion of the vascular malignancy in the recipient. Donor-transmitted tumors should always be suspected in solid organ transplant recipients in case of uncommon disease course or histology, and proper tissue-based diagnosis using sensitive techniques should be pursued.

The 3-T Model of Informed Consent for Nonstandard Risk Donors: A Proposal for Transplant Clinical Practice

Background

The risk of disease transmission from nonstandard risk donors (NSRDs) is low, and outcomes are similar or better relative to transplants performed with standard criteria donors. However, NSRDs have posed new ethical challenges to the informed consent (IC) process. Based on the shared decision-making model, coinciding with the 3 main timings of the IC process ([1] pretransplant assessments and waiting list registration, [2] time on the waiting list, and [3] time of the organ offer), we put forward a model (3-T Model) to summarize the knowledge on IC for NSRDs and to deliver conceptual and practical support to transplant providers on this emergent issue.

Methods

We searched PubMed and analyzed data from our area to provide evidence and ethical arguments to promote standardization of the timing of patient information, degree of patient participation, and disclosure of donor risk factors throughout the 3 stages of the time continuum leading to the potential acceptance of NSRDs.

Results

Each of the 3 timings carries special ethical significance and entails well-defined duties for transplant providers relative to patient involvement and information of the benefits and risks associated with NSRDs. Based on our framework, experience, and interpretation of the literature, we put forward a list of recommendations to combine standardization (ie, timing, content, and degree of patient participation) and individualization of IC.

Conclusions

The 3-T Model may enable the prevention of physicians' arbitrariness and the promotion of patient-centered care. Future studies will assess the effectiveness of the 3-T Model in transplant clinical practice.

Donor history of malignancy: A limited risk for heart transplant recipients

Organ donor contraindications are frequently reassessed for impact on recipient outcomes in attempt to meet demand for transplantation. This study retrospectively analyzed the United Network for Organ Sharing (UNOS) registry for adult heart transplants from 1987 to September 2016 to characterize the impact of donor malignancy history in heart transplantation. Kaplan-Meier estimates illustrated 10-year survival. Propensity score matching was utilized for 1:1 matching of donors with and without history of malignancy, and Cox proportional hazards and logistic regressions were used to analyze the matched population. Of 38 781 heart transplants, 622 (1.6%) had a donor history of malignancy. Cox regressions demonstrated that donor malignancy predicted increased 10-year mortality (HR = 1.16 [1.01-1.33]), but this difference did not persist when conditioned upon 1 year post-transplant survival (log-rank = 0.643). Cox regressions of the propensity score-matched population (455 pairs) found no association between donor malignancy and 10-year mortality (HR = 1.02 [0.84-1.24]). Older age and higher rates of hypertension were observed in donors with a history of malignancy whose recipients died within the first year post-transplant. Therefore, increased recipient mortality is likely due to donor characteristics beyond malignancy, creating the potential for expanded donor selection.

Epidemiology and Comorbidity Burden of Organ Donor Referrals in Australia: Cohort Study 2010-2015

Increasing organ donation rates in Australia have been exceeded by a rise in potential donor referrals not proceeding to donate. Referral evaluation is resource-intensive. We sought to characterize organ donor referrals in New South Wales, Australia, and identify predictors of referrals not proceeding to donation.

Safety of Donation From Brain-dead Organ Donors With Central Nervous System Tumors: Analysis of Transplantation Outcomes in Korea

BACKGROUND

This study aims to verify the condition of recipients of solid organs from donors with central nervous system (CNS) tumors and determine the risk of disease transmission due to transplantation.

METHODS

Twenty-eight brain-dead organ donors with CNS tumors and 91 recipients who received solid organs from January 1, 2005, to December 31, 2014 in Korea were investigated using the Korean Network of Organ Sharing data.

RESULTS

Of the 36 recipients of organs from the 11 donors whose pathological results were not verified, 4 developed the following tumors: renal cell carcinoma, carcinoma in situ of the cervix uteri, B-cell lymphoma, and colon cancer. Among 51 recipients from 17 donors with CNS tumor, no recipient had the same tumor as the donors. Six were classified as high-risk donors according to the World Health Organization classification, and 14 recipients from these donors did not develop tumor after transplantation. The remaining 11 donors were classified as low-risk donors according to the World Health Organization classification but as high-risk donors according to the Malignancy Subcommittee of the Disease Transmission Advisory Committee of the Organ Procurement and Transplantation Network/United Network for Organ Sharing. Of the 37 recipients, 3 had recurring hepatocellular carcinoma with lung and bone metastases, thyroid cancer, and Kaposi's sarcoma after transplantation.

CONCLUSIONS

The risk of disease transmission due to organ transplantation from donors with CNS tumors was very low. Thus, organ donation from such donors should be promoted actively to expand the donor range.

The Process of Kidney Donation in the Northern Macroregional Area of Paraná, Brazil

INTRODUCTION

The high morbidity and mortality caused by chronic kidney disease, and consequently, the increase in the need for kidney transplants, makes the evaluation of the kidney donation process relevant to verifying the service's fragility with the goal of optimizing this process.

OBJECTIVE

This study analyzed the process of kidney donation in the Northern Macroregional area of Paraná, Brazil.

METHOD

This was a cross-sectional and retrospective evaluation study based on 586 reports of deaths provided by the Intra-Hospital Organ Donation and Transplant Tissue Commissions to the Organ Procurement Organization of the Northern Macroregional area of Paraná in Brazil between 2011 and 2015. Data were analyzed by descriptive statistics, prevalence ratio, and Poisson regression.

RESULTS

The prevalence of kidney donation was higher among the deaths of individuals younger than 61 years of age (P = .018) due to traumatic brain injury and hemorrhagic cardiovascular accident (P < .001), assisted in private institutions (P = .037), and occurring in the second half of the year (P = .015).

CONCLUSION

The process of kidney donation was mainly compromised due to the refusal of the family and was associated with clinical and organizational aspects.

Single-Center Case Series of Donor-Related Malignancies: Rare Cases With Tremendous Impact

BACKGROUND

Donor-related malignancy is a rare complication of organ transplantation.

METHODS

In this case series, we discuss three cases of donor-related cancers in kidney transplant recipients who were registered in our center between 1979 and 2015. They account for an incidence of 0.29% of donor-related malignancies of a total of 1015 transplanted kidney grafts (deceased and living donors). The three cases that we describe presented in different ways and with different severity, although the response to the initiated treatment was comparable.

RESULTS

All three patients not only survived their cancer episode but also had a complete oncological remission and underwent successful second kidney transplantation, accounting for a 100% survival rate in our small cohort.

CONCLUSIONS

Despite the very low incidence of this complication, transplant clinicians must be aware of the occurrence of donor-related malignancies when selecting a donor and should be able to diagnose and treat a case of donor-related cancer.

[Deceased donation in renal transplantation]

OBJECTIVES

To review epidemiologic data's and medical results of deceased donation in renal transplantation.

MATERIAL AND METHODS

Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "brain death; cardiac arrest; deceased donation; organ procurement; transplantation". Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 2498 articles, 8 official reports and 17 newspaper articles were identified; after careful selection 157 publications were eligible for our review.

RESULTS

Deceased donation may involve either brain death or non-heartbeating donors (NHBD). Organ shortage led to the procurement of organs from expanded-criteria donors, with an increased age at donation and extended vascular disease, leading to inferior results after transplantation and underlining the need for careful donor management during brain death or cardiac arrest. Evolution of French legislation covering bioethics allowed procurement from Maastricht categories II and recently III non-heartbeating donors.

CONCLUSION

The increase of organ shortage emphasizes the need for a rigorous surgical technique during procurement to avoid loss of transplants. A history or current neoplasm in deceased-donors, requires attention to increase the pool of organs without putting the recipients at risk for cancer transmission. French NHBD program, especially from Maastricht category III, may stand for a potential source of valuable organs.