Breast Reconstruction After Solid Organ Transplant

Biomarkers from subcutaneous engineered tissues predict acute rejection of organ allografts

Invasive graft biopsies assess the efficacy of immunosuppression through lagging indicators of transplant rejection. We report on a microporous scaffold implant as a minimally invasive immunological niche to assay rejection before graft injury. Adoptive transfer of T cells into Rag2-/- mice with mismatched allografts induced acute cellular allograft rejection (ACAR), with subsequent validation in wild-type animals. Following murine heart or skin transplantation, scaffold implants accumulate predominantly innate immune cells. The scaffold enables frequent biopsy, and gene expression analyses identified biomarkers of ACAR before clinical signs of graft injury. This gene signature distinguishes ACAR and immunodeficient respiratory infection before injury onset, indicating the specificity of the biomarkers to differentiate ACAR from other inflammatory insult. Overall, this implantable scaffold enables remote evaluation of the early risk of rejection, which could potentially be used to reduce the frequency of routine graft biopsy, reduce toxicities by personalizing immunosuppression, and prolong transplant life.

De Novo Malignancy After Liver Transplantation: Risk Assessment, Prevention, and Management-Guidelines From the ILTS-SETH Consensus Conference

De novo malignancies (DNMs) following liver transplantation (LT) have been reported as 1 of the major causes of late mortality, being the most common cause of death in the second decade after LT. The overall incidence of DNMs is reported to be in the range of 3.1% to 14.4%, and the incidence is 2- to 3-fold higher in transplant recipients than in age- and sex-matched healthy controls. Long-term immunosuppressive therapy, which is the key in maintaining host tolerance and achieving good long-term outcomes, is known to contribute to a higher risk of DNMs. However, the incidence and type of DNM also depends on different risk factors, including patient demographics, cause of the underlying chronic liver disease, behavior (smoking and alcohol abuse), and pre-existing premalignant conditions. The estimated standardized incidence ratio for different DNMs is also variable. The International Liver Transplantation Society-Spanish Society of Liver Transplantation Consensus Conference working group on DNM has summarized and discussed the current available literature on epidemiology, risk factors, management, and survival after DNMs. Recommendations for screening and surveillance for specific tumors, as well as immunosuppression and cancer-specific management in patients with DNM, are summarized.

Liver transplantation does not increase morbidity or mortality in women undergoing surgery for breast cancer

Purpose:

The incidence of breast cancer following solid organ transplantation is comparable to the age-matched general population. The rate of de novo breast cancer following liver transplantation varies. Furthermore, there is limited information on the management and outcomes of breast cancer in liver transplant recipients. We aim to evaluate the impact of liver transplantation on breast cancer surgery outcomes and compare the outcomes after breast cancer surgery in liver transplant recipient in transplant versus non-transplant centers.

Methods:

National Inpatient Sample database was accessed to identify liver transplant recipient with breast cancer. Mortality, complications, hospital charges, and total length of stay were evaluated with multivariate logistic regression testing. Weighted multivariate regression models were employed to compare outcomes at transplant and non-transplant centers.

Results:

Ninety-nine women met inclusion criteria for liver transplantation + breast cancer and were compared against women with breast cancer without liver transplantation (n = 736,527). Liver transplantation + breast cancer had lower performance status as confirmed via higher Elixhauser Comorbidity Index (20.5% vs 10.2%, p < 0001). There were significantly more complications in the liver transplantation cohort when compared to the non-liver transplant recipient (15.0% vs 8.2%, p = 0.012). However, on multivariate analysis, liver transplantation was not an independent risk factor for post-operative complications following breast cancer surgery (odd ratio, 1.223, p = 0.480). Cost associated with breast cancer care was significantly higher in those with liver transplantation (2.621, p < 0.001). Breast conservation surgery in liver transplantation had shorter length of stay as compared to breast cancer alone (odds ratio, 0.568, p = 0.027) in all hospitals.

Conclusion:

Liver transplantation does not increase short-term mortality when undergoing breast cancer surgery. Although there were significantly more complications in the liver transplantation cohort when compared to the non-liver transplant recipient (15.0% vs 8.2%, p = 0.012), on multivariate analysis, liver transplantation was not an independent risk factor for postoperative complications following breast cancer surgery. Breast cancer management in liver transplant recipient at non-transplant centers incurred higher charges but no difference in complication rate or length of stay when compared to transplant centers.

Is Aesthetic Surgery Safe in the Solid Organ Transplant Patient? An International Survey and Review

BACKGROUND

Improved immunosuppression and lifespans have afforded solid organ transplant (SOT) recipients the opportunity to seek aesthetic surgery.

OBJECTIVES

To determine current trends in the provision of aesthetic in the SOT patient population, we polled the international plastic surgery community. We specifically sought to evaluate their experiences with this patient population, as well as to perform a review of the literature to provide updated guidelines for practitioners who may consider performing surgery in the SOT patient population.

METHODS

A web-based survey was sent to national and international colleagues to query the experiences and complication rates of performing aesthetic surgery in this patient population.

RESULTS

Thirty percent of the 1308 respondents performed surgery in SOT patients. Three hundred and forty practitioners performed 552 procedures with a 4.3% complication rate. Over 68% of all procedures were performed on kidney transplant recipients.

CONCLUSIONS

SOT patients can safely undergo elective aesthetic procedures. We recommend working closely with the medical team to assure the best outcomes.

How Do Previous Solid Organ Transplant Recipients Fare After Primary Total Knee Arthroplasty?

INTRODUCTION

Total knee arthroplasty (TKA) has been proven to increase knee outcome scores after solid organ transplantation (SOT), but many authors are concerned about a higher complication rate. The purpose of this study is to evaluate the complication profile of TKA after previous SOT.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease, version 9, codes to identify 3339 patients who underwent TKA after 1 or more solid organ transplants including the kidney (2321), liver (772), lung (129), heart (412), and pancreas (167). A cohort of 1,685,295 patients served as a control with minimum 2-year follow-up. Postoperative complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts.

RESULTS

Patients with any SOT were younger (age: <65, odds ratio [OR]: 6.58, P < .001), male (OR: 1.88, P < .001), and medically complex (significant increase in 28 of 29 Elixhauser comorbidities, P < .05). There was a significant increase (P < .05) in 11 of 13 (84.6%) recorded postoperative medical complications rates at 90 days. There was a significant increase overall in periprosthetic infection (OR: 2.11, P < .001), periprosthetic fracture (OR: 1.78, P < .001), and TKA revision (OR: 1.36, P < .001). When analyzed by individual organ, heart and lung transplants carried the fewest medical and surgical complications.

CONCLUSION

The results of this study demonstrate that patients with previous SOT who undergo elective primary TKA have more postoperative complications in the global period and at short-term follow-up. Yet, complication profiles by individual organ varied significantly.

Addressing inherited predisposition for breast cancer in transplant recipients

Consideration of prophylactic mastectomy surgery following transplantation requires complex medical decision-making, and bias against elective surgery exists because of concern for post-operative complications. Prevention of cancer in transplant recipients is of utmost importance, given the risks of treating malignancy in an immunosuppressed patient. We present a patient case and review of the literature to support a thorough pre-transplantation evaluation of family history and consideration of prophylactic interventions to safeguard the quality of life of transplant recipients. J. Surg. Oncol. 2016;113:605-608. © 2016 Wiley Periodicals, Inc.