Ask the Experts - Donor With Pulmonary Carcinomatosis?
Ask the Experts - Donor With Pulmonary Carcinomatosis?
During organ procurement from a 35-year-old brain-dead (secondary to intracranial bleed due to hypertension) male, a lesion (approximately 2 cm) was noted in the lower lobe of the left lung. The lesion was wedged and brought back with the liver and kidneys to the center. Frozen section revealed an old infarct, but no malignancy. An autopsy was not performed. The liver and both kidneys were transplanted. A few days later the permanent histopathology slides of the lung lesion revealed pulmonary carcinomatosis throughout the normal-looking lung tissue. The most likely primary is adenocarcinoma. The liver recipient and the 2 kidney recipients are well now at about 3 weeks posttransplantation. What is the advisable course of action?
A-Majeed A-Kareem, MD, FRCSC
The most authoritative information on this subject comes from the writings of Dr. Israel Penn (now deceased). Dr. Penn spent several decades collecting data on donor-derived tumors for the Cincinnati Transplant Tumor Registry. The risk that the organs used in this instance contain tumor cells has been estimated to be 45%. The pathologist's description that he is dealing with a carcinomatosis rather than a localized neoplasm is even more disconcerting in this instance. The risk involved should be explained to the patients and serious consideration given to removing the kidney grafts. This will allow the recipients to return to dialysis and be taken off immunosuppression. The possibility that any tumor remaining in the circulation might result in clinical disease would be minimized. Regular clinical follow-up would, of course, still be required.
The hepatic allograft recipient faces a bigger dilemma since artificial livers are not yet accepted therapy, and another donor organ may not be immediately available. Immunosuppression should be reduced, but doing that too drastically might precipitate rejection. If retransplantation is not an option, the patient could be simply monitored with serial computerized tomography scans or magnetic resonance imaging. When clinically detectable tumor does appear, radiotherapy or chemotherapy could be considered in consultation with oncologists.
During organ procurement from a 35-year-old brain-dead (secondary to intracranial bleed due to hypertension) male, a lesion (approximately 2 cm) was noted in the lower lobe of the left lung. The lesion was wedged and brought back with the liver and kidneys to the center. Frozen section revealed an old infarct, but no malignancy. An autopsy was not performed. The liver and both kidneys were transplanted. A few days later the permanent histopathology slides of the lung lesion revealed pulmonary carcinomatosis throughout the normal-looking lung tissue. The most likely primary is adenocarcinoma. The liver recipient and the 2 kidney recipients are well now at about 3 weeks posttransplantation. What is the advisable course of action?
A-Majeed A-Kareem, MD, FRCSC
The most authoritative information on this subject comes from the writings of Dr. Israel Penn (now deceased). Dr. Penn spent several decades collecting data on donor-derived tumors for the Cincinnati Transplant Tumor Registry. The risk that the organs used in this instance contain tumor cells has been estimated to be 45%. The pathologist's description that he is dealing with a carcinomatosis rather than a localized neoplasm is even more disconcerting in this instance. The risk involved should be explained to the patients and serious consideration given to removing the kidney grafts. This will allow the recipients to return to dialysis and be taken off immunosuppression. The possibility that any tumor remaining in the circulation might result in clinical disease would be minimized. Regular clinical follow-up would, of course, still be required.
The hepatic allograft recipient faces a bigger dilemma since artificial livers are not yet accepted therapy, and another donor organ may not be immediately available. Immunosuppression should be reduced, but doing that too drastically might precipitate rejection. If retransplantation is not an option, the patient could be simply monitored with serial computerized tomography scans or magnetic resonance imaging. When clinically detectable tumor does appear, radiotherapy or chemotherapy could be considered in consultation with oncologists.
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