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

Abstract

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.(Transplantation 2022;106: e12-e29).

Machine Perfusion for Extended Criteria Donor Livers: What Challenges Remain?

“…The heterogenous group of ECD livers covers two main groups: first, livers with the risk for poor graft function, and second, livers from donors with a specific disease with the potential for transmission to the recipient. With the increasing experience with donor infections and tumors, fairly clear guidelines on what to accept are available and widely respected [ 24 , 25 , 26 , 27 ]. In contrast, specific criteria to describe donor parameters with the potential to trigger high levels of IRI with more complications and impaired graft and patient survival appear less well-defined.…”

Malignancies in Deceased Organ Donors: The Spanish Experience

“…[4][5][6][7] A comparison of existing classifications has been recently published. 8 The Council of Europe considers 4 levels of risk of malignancy transmission: (1) minimal (eg, basalioma, central nervous system [CNS] neoplasia of the World Health Organization [WHO] grades 1-2, renal cell carcinoma [RCC] <1 cm and Fuhrman I-II);…”

“…8 The Council of Europe considers 4 levels of risk of malignancy transmission: (1) minimal (eg, basalioma, central nervous system [CNS] neoplasia of the World Health Organization [WHO] grades 1–2, renal cell carcinoma [RCC] <1 cm and Fuhrman I–II); (2) low to intermediate (eg, colorectal cancer pT2N0 in complete remission ≥5–10 y, RCC 1–4 cm and Fuhrman I–II); (3) high (breast cancer in complete remission ≥5–10 y, glioblastoma); (4) unacceptable (eg, metastatic cancer). 7,8 Although a minimal risk of transmission is acceptable for any patient on the waiting list, a high risk is only considered acceptable after an individualized risk-benefit assessment and informed consent. 7 Although this guidance is of high value, there has been no prospective and standardized follow-up of recipients of organs obtained from donors with malignancies that could validate existing recommendations.…”

Organ donation and the dermatologist

“…Careful attention must also be paid to scars that may indicate previous skin surgeries, and a collateral history should be obtained where there is uncertainty regarding previous excisions 2 . If a lesion is suspicious for malignancy, it may be appropriate to excise and conduct histopathological examination on frozen sections 2 . However, the time to transplant is limited and diagnosis of melanocytic pathology can be challenging on frozen sections 3 …”

“…If a lesion of concern is identified, the SNOD must seek expertise from a medical practitioner, at which point dermatology colleagues may be consulted 1 . Careful attention must also be paid to scars that may indicate previous skin surgeries, and a collateral history should be obtained where there is uncertainty regarding previous excisions 2 . If a lesion is suspicious for malignancy, it may be appropriate to excise and conduct histopathological examination on frozen sections 2 .…”