A Population-Based Study of Cancer Incidence in Solid Organ Transplants From Donors at Various Risk of Neoplasia

[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.

Prevention and Management of Donor-transmitted Cancer After Liver Transplantation: Guidelines From the ILTS-SETH Consensus Conference

As with any other intervention in health, liver transplantation (LT) entails a variety of risks, including donor-transmitted cancers (DTCs). At present, 2%-4% of used deceased organ donors are known to have a current or past history of malignancy. The frequency of DTCs is consistently reported at 3-6 cases per 10 000 solid organ transplants, with a similar frequency in the LT setting. A majority of DTCs are occult cancers unknown in the donor at the time of transplantation. Most DTCs are diagnosed within 2 y after LT and are associated with a 51% probability of survival at 2 y following diagnosis. The probability of death is greatest for DTCs that have already metastasized at the time of diagnosis. The International Liver Transplantation Society-Sociedad Española de Trasplante Hepático working group on DTC has provided guidance on how to minimize the occurrence of DTCs while avoiding the unnecessary loss of livers for transplantation both in deceased and living donor LT. The group endorses the Council of Europe classification of risk of transmission of cancer from donor to recipient (minimal, low to intermediate, high, and unacceptable), classifies a range of malignancies in the liver donor into these 4 categories, and recommends when to consider LT, mindful of the risk of DTCs, and the clinical condition of patients on the waiting list. We further provide recommendations to professionals who identify DTC events, stressing the need to immediately alert all stakeholders concerned, so a coordinated investigation and management can be initiated; decisions on retransplantation should be made on a case-by-case basis with a multidisciplinary approach.

Follow-up Survey of Donor Candidates for Living Related Kidney Transplantation With Prostate Cancer

INTRODUCTION

With the increasing number of elderly kidney donor candidates due to the lack of available donors, prostate cancer has sometimes been detected in these candidates during pretransplant screening examinations. There are currently no guidelines or consensus on prostate cancer screening and treatment in donors. We retrospectively evaluated the clinical course of donor candidates with prostate cancer.

METHODS

Between January 2006 and December 2016, 9 donor candidates for living related kidney transplantation were incidentally diagnosed with prostate cancer at our institution. All male kidney transplant donor candidates routinely received prostate-specific antigen (PSA) testing. The patients with PSA levels > 4.0 ng/mL underwent prostate biopsies. For future kidney transplantation, treatment for localized prostate cancer was prostatectomy.

RESULTS

Seven low- or intermediate-risk patients according to the D'Amico risk classification underwent endoscopic prostatectomy, while 2 high-risk patients underwent high dose-rate brachytherapy to prioritize prostate cancer treatment. Of the 7 who underwent surgery, 3 patients ultimately became living related kidney transplantation donors for their wives. There was no recurrence of PSA elevation after treatment.

CONCLUSION

This study showed that donor candidates with prostate cancer could safely donate a kidney after a thorough evaluation to exclude those with high-risk prostate cancer. Transmission of prostate cancer through kidney transplantation seems unlikely and robot-assisted laparoscopic prostatectomy may be feasible for donor candidates with localized prostate cancer.

Renal donors with prostate cancer, no longer a reason to decline

OBJECTIVE

To fully assess the true risk of prostate cancer transmission in during renal transplantation.

METHODS

A full review of all existing literature relevant to the topic.

RESULTS

There has not been a single documented case of transmission of prostate cancer during renal transplant. Prostate cancer in deceased organ donors has an incidence estimated between 3% and 18.5% and over 100 transplants have been performed using organs from donor with proven prostate cancer without issue.

CONCLUSION

Transmission of prostate cancer through kidney transplantation seems very unlikely. The risks of remaining on the waiting list are outweighed by a transmission risk and the potential benefit makes the case to have clear guidelines about donor prostate malignancy when accepting potential organs.

Cancers after renal transplantation

For patients with end-stage kidney failure, kidney transplantation improves both their quality of life and overall life expectancy compared with dialysis, but it is not without adverse effects. Cancer is second to cardiovascular disease as one of the major causes of morbidity and mortality in renal transplant recipients. Prolonged use of modern immunosuppression, which leads to alteration of immune function and immune surveillance, is associated with increased cancer risk. There is now convincing evidence from observational studies and registry data to confirm a 3- to 5-fold increase in overall cancer incidence, with viral-related neoplasia incurring the greatest risk when compare with the general population. Despite the increased risk, little is known about the overall cancer prognosis, screening, treatment strategies, and effectiveness in this population. Cancers can recur, occur de novo, and be transmitted from donor organs posttransplantation. Uncertainties exist as to how modern immunosuppressive agents impact on cancer management and outcomes in these patients, with some agents such as calcineurin inhibitors and azathioprine, being more carcinogenic than others. The newer agents, proliferation signal/mammalian target of rapamycin inhibitors and mycophenolate mofitil, may have some antiproliferative and antitumor activities demonstrated in preclinical and clinical studies, but long-term well-powered trial data are needed to determine whether they are either protective or curative for cancers in renal transplant recipients. In this review, the incidence, etiology, prognosis, and potential approaches to cancer screening and management post-renal transplantation are discussed.

Quality and safety in the Italian donor evaluation process

BACKGROUND

The shortage of available organs, has increasingly prompted the use of elderly donors, with a consequent growth of possible risk factors. In this context the risk of donor-recipient transmission of infectious or neoplastic pathologies may be considered as a major issue; in each case for each organ potentially available, acceptable quality must be provided and unacceptable risks must be avoided.

METHODS

We are presenting here the process of risk management followed by the Italian centers. In 2001, the Italian National Transplant Centre created a national commission of experts, with the mission of defining guidelines for the evaluation process of the potential organ donor. As a supplement to these measures, the Italian National Transplant Centre has supported transplant network health workers through ad hoc developed information tools and an expert task force (second opinion) for evaluation of doubtful cases.

RESULTS

Starting from the date of guidelines application and second opinion start up, 9519 potential cadaveric donors were reported in Italy. Of these, 1611 presented a neoplastic or infectious risk. Over this period, 4861 donors were used for transplantation, equal to 48.5% of reported donors. Among the 1611 donors, who had been diagnosed at risk, 674 were neoplastic-disease affected donors and 937 infection-disease affected donors.

CONCLUSIONS

At the European level, several new activities have been recently implemented to increase organ safety. In Italy, new guidelines and actions to ensure organ safety have been implemented. The evaluation of the impact of these actions will be performed in the near future.

The Italian multiorgan donor cancer screening protocol: 2002-2005 experience

BACKGROUND

We describe the results of the application of the Italian donor cancer screening protocol to all the 7608 candidate multiorgan donors presented in Italy in 2002-2005.

METHODS

All suspect findings raised in the two presurgical and surgical phases of the protocol were investigated by extemporary pathologic evaluation. Donors were classified as standard risk (no transmissible risk); nonstandard risk (low-risk of transmission, eligibility restricted to certified clinical emergencies pending informed consent); and unacceptable risk (unconditional exclusion because of high-risk pathologies).

RESULTS

The protocol was successfully implemented for all 7608 candidates. In addition to 8 (0.1%) independent exclusions, clinical suspicion of cancer was raised for 337 (4.6%) donors. According to pathological examination 198 donors (2.6%) were judged at unacceptable risk of tumor transmission; 80 (1%) were included in the "standard risk". Used standard risk and nonstandard risk donors provided a total of 241 organs in 231 recipients. Although no suspect was raised after implementation of the protocol, a malignant tumor was discovered after organ transplantation in 14 (0.2%) donors. All the recipients transplanted with organs from ascertained nonstandard risk donors or from neoplastic donors who donated by accident have been carefully followed. At the time of most recent follow-up no donor/recipient tumor transmission has been reported.

CONCLUSIONS

Implementation of the multiorgan cancer screening protocol is feasible at a national level in Italy. In view of the increasing demand for organs our protocol provides a useful tool for rationalization of the use of organs from neoplastic marginal donors.

Last resort for renal transplant recipients, 'restored kidneys' from living donors/patients

Because of the grave shortage of deceased kidney allografts in Japan, we have embarked on a new source of organs, 'Restored kidneys' from living patients. From January 1991 through September 2006, 42 kidneys (eight benign pathology, eight small renal cancers, eight ureteral cancers, six aneurysms, eight severe nephrotic syndrome from four patients and four ureteral stenosis) were obtained from 38 patients/donors after extensive discussion of treatment modalities and risks. All patients/donors agreed to undergo total nephrectomy. The lesions were removed/repaired ex vivo on the back table, then transplanted. All recipients were notified of all possible risks including donor disease recurrence. One, 5 and 10-year patient survival rates of restored transplant patients were 92.9%, 79.3% and 63.8%, respectively. One, 5 and 10-year graft survival rates of restored kidney transplant patients were 78.6%, 51.8% and 42.7%, respectively. There were no recurrences of small renal cell carcinomas. There was one recurrence of ureteral cancer in the transplanted kidney 15 months after operation. In countries where deceased donors are scarce, such as Japan, the restored kidneys can be a last resort for renal allografts.