Pretransplant malignancy in candidates and posttransplant malignancy in recipients of cardiac transplantation

Characteristics and outcomes of heart transplant recipients with a pretransplant history of malignancy

We aimed to investigate the characteristics and outcomes of HTx recipients with a history of pretransplant malignancy (PTM). Among 1062 HTx recipients between 1997 and 2013, 73 (7.1%) patients had PTMs (77 cancer cases). We analyzed post-HTx outcome, recurrence of PTM, and development of de novo malignancies. Post-HTx outcome included overall survival, 10-year survival, 10-year freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Four most common PTMs were lymphoproliferative disorders (18.2%), prostate cancers (18.2%), non-melanoma skin cancers (18.2%), and breast cancers (13.0%). Median time from PTM and HTx was 9.0 years. During a median follow-up of 8.6 years after HTx, patients with PTM, compared to those without, showed significantly higher incidence of posttransplant malignancies (43.8% vs. 20.8%, p < .001) including 9.6% (n = 7) of PTM recurrences. However, patients with PTM, compared to those without, showed comparable overall survival, 10-year survival, 10-year freedom from CAV, NF-MACE, ATR, ACR, and AMR. Therefore, a history of PTM should not disqualify patients from HTx listing, while further research is necessary for early detection of posttransplant malignancies in these patients.

Deep Neural Network-Based Survival Analysis for Skin Cancer Prediction in Heart Transplant Recipients

Heart-transplant recipients are at high risk of developing skin cancer, while Squamous Cell Carcinoma (SCC) and Basal Cell Carcinoma (BCC) are commonly detected. This paper utilized the database from the United Network for Organ Sharing (UNOS) to study the incidence rate of SCC and BCC among heart transplant recipients. Cox proportional hazards model and two deep neural network-based models were studied, and their performance were compared. In addition, Lasso regression, Chi-square test, and Wilcoxon signed-rank test were applied to identify key risk factors. The neural network-based survival models showed better accuracy compared to the standard Cox regression model, which indicates the advantage of deep learning approaches in survival analysis and risk prediction for post-transplant skin cancer.This study investigates the performance of deep learning (DL) models in clinical applications for predicting the risk of skin cancer in heart transplant recipients. The DL models outperform the standard models in assessing the incidence rate of skin cancer across different time spans.

Long-term outcomes of living donor liver transplantation in patients with a prior history of nonhepatic malignancy

Posttransplant malignancy has become a significant cause of mortality. Data on the long-term outcomes of patients with pretransplant nonhepatic malignancy (PTM) after living donor liver transplantation (LDLT) are scarce, although the recipients of other organs with PTM have been reported to have a poor survival. Fifteen patients with PTM (4.4%) among the 342 adult recipients were identified in our LDLT programs. The outcomes of the patients with PTM after LDLT were compared to those of patients without PTM in terms of the all-cause mortality and cancer-specific mortality (defined as mortality related to malignancy expect for hepatocellular carcinoma, cholangiocarcinoma, or neuroendocrine tumor). The sites of PTM included the breast in six, stomach in two, and colon, lung, kidney, uterine, thyroid, larynx, and acute myelogenous leukemia in one each. The median interval from the PTM treatment to LDLT was 57 months (range, 2-298). The patients who received the curative treatment for PTM were selected as the recipients. No patients with PTM had recurrence during the follow-up period. The 1-, 5-, and 10-year patient survival rates were 100%, 92.9%, and 92.9% in the PTM group and 86.2%, 76.7%, and 68.5% in the non-PTM group, respectively (p = 0.142). Likewise, there was no significant difference between the two groups in the cancer-specific mortality. In conclusion, the patients with PTM had comparable outcomes with regard to mortality and cancer-specific mortality compared with those without PTM. This study showed that the patients with PTM can obtain an acceptable outcome after LDLT when carefully selected.

Malignancies After Heart Transplant

Along with graft vasculopathy, malignancies comprise a major complication after heart transplant, with a rate of occurrence of 39.1% in 10 years. Skin cancers and posttransplant lymphoproliferative disorder are more common in adults, whereas lymphoma is more often shown in children. A major cause of malignancies after heart transplant is the use of increased doses of prophylactics needed during immunosuppressive therapy. Data, however, are scarce regarding the association between a particular immunosuppressive drug and a posttransplant malignancy. Compared with the general population, recipients have a higher incidence of malignancies after heart transplant, with an early onset and more aggressive disease. Solid tumors known to occur in heart transplant recipients include lung cancer, bladder and prostate carcinoma, adenocarcinoma of the oral cavity, stomach cancer, and bowel cancer, although the incidence is rare. The risk factors for development of a malignancy after heart transplant are the same as for the nontransplant population.

Rabbit antithymocyte globulin induction and risk of post-transplant lymphoproliferative disease in adult and pediatric solid organ transplantation: An update

The most modifiable risk factor for post-transplant lymphoproliferative disease (PTLD) is the type and dose of induction and maintenance immunosuppressive therapy. It is challenging to identify the contribution of a single agent such as rabbit antithymocyte globulin (rATG) in the setting of multidrug therapy. Registry analyses can be helpful but are limited by methodological restrictions and inclusion of historical patient cohorts. These are typically from eras when rATG dosing was markedly higher than current dosing (e.g. total dose 14 mg/kg versus 6 mg/kg now), accompanied by higher exposure to maintenance therapies, and often an absence of antiviral prophylaxis. The largest registry analysis to assess rATG specifically found no risk of PTLD after kidney transplantation, but conflicting results have been reported, highlighting the difficulty of interpreting this type of analysis. The relative rarity of PTLD means that individually controlled trials are underpowered to assess its occurrence, but the available data do not suggest an effect of rATG. A pooled analysis of data from studies of rATG induction in kidney and heart transplantation found the incidence of PTLD to be comparable to published reports in the overall transplant population. Data on the effect of rATG dose are inconclusive, but in patients receiving antiviral prophylaxis it does not appear to be influential. Nevertheless, it would seem reasonable to employ the lowest dose of rATG compatible with effective induction, particularly in EBV-seronegative recipients and other high-risk groups such as heart-lung transplant recipients. Overall, the risk of PTLD following rATG induction therapy with modern dosing regimens and under current management conditions appears unlikely to make an important contribution to the risk:benefit balance.

Pre-transplant malignancy: an analysis of outcomes after thoracic organ transplantation

BACKGROUND

Pre-transplant malignancy (PTM) is a relative contraindication to organ transplantation. Studies examining the effect of PTM on outcomes after lung transplantation (LTx) or orthotopic heart transplantation (OHT) are limited. We evaluated the effect of PTM on outcomes after LTx and OHT.

METHODS

We retrospectively reviewed primary adult LTx and OHT recipients in the United Network for Organ Sharing database. Primary stratification was by PTM and secondary stratification by tumor type. Matched cohorts (2:1) and multivariable Cox proportional hazards regression models were used to evaluate mortality.

RESULTS

From 2000 to 2011, 13,613 adults underwent LTx and 19,817 underwent OHT. PTM was present in 740 LTx patients (5.4%) and in 1,117 OHT patients (5.6%). On unadjusted analysis, LTx patients and OHT patients with PTM had similar 30-day, 1-year, and 5-year survivals (p<0.05) compared with patients with no PTM. These findings persisted after risk-adjustment . No tumor types were associated with increased mortality in LTx patients. OHT patients with leukemia, lymphoma, or myeloma (LLM) had a significant increase in univariate mortality at 30 days (hazard ratio [HR], 1.82; p = 0.04), 1 year (HR, 1.93; p<0.001), and 5 years (HR, 1.54; p = 0.01). Matched cohort analysis revealed comparable outcomes in LTx patients but confirmed increased univariate 1-year mortality (HR, 1.89; p = 0.006) in OHT patients with LLM.

CONCLUSIONS

This large study evaluating the effects of PTM found the incidence of PTM was in LTx 5.4% and in OHT 5.6%. In general, PTM does not increase mortality in either cohort; however, OHT patients with LLM have an increased hazard of mortality. Therefore, carefully selected patients with PTM should not be excluded from LTx or OHT.

Low incidence of malignancy after transplantation in Chinese heart allograft recipients

This study sought to assess the incidence of neoplastic disease after transplantation in Chinese heart allograft recipients. A total of 156 patients (130 male and 26 female; mean age, 45.8 +/- 15.7 years), surviving more than 30 days after transplantation, were enrolled in this study. The mean follow up duration was 51.2 +/- 33.0 months. Six patients (3.8%) developed neoplastic diseases after transplantation: post-transplant lymphoproliferative diseases in four and solid tumors in two patients. There was no skin cancer or Kaposi's sarcoma. Solid tumors affected the prostate, liver and urinary bladder in two patients. The cumulative incidence of neoplastic disease was 2.1% at 1 year, 3.6% at 5 years, and 10.1% at 10 years after transplantation. The incidence of post-transplant neoplastic disease was low in Chinese heart allograft recipients. It resulted from a relative paucity of Kaposi's sarcoma and skin cancers in Chinese population.

Management of squamous cell carcinoma in organ transplant recipients

The number of skin cancers continues to rise with well over one million cases of skin cancer expected in the United States this year. Optimal management depends on early detection and treatment. The consequences of skin cancer may be particularly devastating in organ transplant recipients. In this article, management of squamous cell carcinoma in the organ transplant recipient is discussed.