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Adverse Occurrence type:
Melanoma: Most recent risk assessment for melanoma (Council of Europe, 2018): donors with active melanoma represent an unacceptable risk for organ donation. Donors with a history of treated melanoma are generally considered to represent a high transmission risk. Opinions vary. The SaBTO/UK states that a superficial spreading melanoma with tumor thickness less than 1.5 mm and with curative surgery and cancer free interval of more than five years is associated with a low transmission risk, although this conclusion is based on a small number of cases. UNOS/DTAC considers all patients with a history of melanoma to represent a high risk for transmission.
Time to detection:
6 months after transplantation of the kidney
Alerting signals, symptoms, evidence of occurrence:
Severe fatigue and shortness of breath in kidney recipient with mild tenderness to palpation in the right lower quadrant along the allograft site. A computerized tomography (CT) scan noted innumerable punctate nodules in the lungs, a 1-3 cm hypoattenuating lesion in the right hepatic dome, and scattered nonenlarged para-aortic lymph nodes. A CT - guided percutaneous biopsy of a left lower lobe pleural-based nodule was performed; pathology revealed melanoma with a BRAF-V600E mutation. After allograft nephrectomy, findings demonstrated extensive tumor throughout the kidney allograft. Pathology consistent with melanoma with lymphovascular invasion. There was a liver recipient from the same donor that was also diagnosed with donor derived metastatic melanoma, but there is no further information on that case.
Demonstration of imputability or root cause:
HLA typing of the tumor cells matched that of the donor, indicating a diagnosis of donor-derived metastatic melanoma. A female liver recipient from the same donor (only other recipient) was also diagnosed with donor-derived metastatic melanoma, determined by identification of male karyotype in melanoma cells.
Suggest new keywords:
Kidney transplant/Kidney recipient/Kidney transplantation
Liver transplant/Liver recipient/Liver transplantation
Boyle SM, Ali N, Olszanski AJ, Park DJ, Xiao G, Guy S, et al. Donor-Derived Metastatic Melanoma and Checkpoint Inhibition. Transplant Proc. 2017;49(7):1551-4.
Clone record for liver recipient.
Expert comments for publication:
This is an interesting case report of a kidney recipient who was himself a previous donor who developed chronic glomerulonephritis. The donor for this patient had no evidence of malignancy and this case report emphasizes the need for clinicians to maintain a high index of suspicion for donor-derived disease in patients who have atypical presentations after a kidney transplant. Although melanoma transmission is typically associated with high mortality, this report highlights successful management with the use of targeted therapies following transplant nephrectomy. The tumor was shown to have a BRAF V600E mutation and the BRAF inhibitor dabrafenib was used along with the MEK inhibitor trametinib, leading to clinical response but noncompliance due to side effects. For that reason nivolumab was initiated with marked clinical response. The authors provide details regarding the use of these drugs in patients with compromised renal function. Context is important, and it should be remembered that the use of checkpoint inhibitors is likely to cause immune stimulation, increasing the likelihood of organ rejection.