Single center series: Prostate adenocarcinoma/carcinoma and liver transplant (2003)

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Record number: 
1950
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Prostate cancer: Most recent risk assessment for prostate cancer (Council of Europe, 2022): If Gleason score is available, e.g., prostate diagnostics have been initiated a few days before organ procurement, then small intra-prostatic, low-grade (Gleason score ≤ 6) tumours are considered minimal-risk; intra-prostatic tumours with Gleason score 7 are considered low-to-intermediate risk; and intra-prostatic (pT2c) tumours with Gleason score > 7 are considered high-risk. Histological examination of the entire prostate with a valid grading of the tumour is time-consuming and the results might not always be available before an organ is transplanted. Donors with extra-prostatic tumour extension should be unequivocally excluded from the donation process as an unacceptable risk. Prostate cancer in the donor history: The acceptable time intervals for complete remission of prostate cancer are strongly correlated with stage and Gleason grade of the tumour. Donors with a history of curatively treated prostate cancer ≤ pT2 (tumour confined to prostate) and Gleason 3 + 3, as well as donors with very small prostate cancers and Gleason 3 + 3 under ‘active surveillance’, can be accepted for organ donation as minimal transmission risk at any time after diagnosis with the prerequisite of a frequently performed and non-suspicious follow-up. Prostate cancer < pT2 (confined to the prostate) and Gleason grade < 7 after curative treatment and cancer-free period > 5 years is considered minimal-risk. Higher stages/grades and/or shorter cancer-free periods require an individual risk assessment. A history of extra-¬prostatic tumour extension poses a high risk for transmission. In any case, current PSA values should be obtained to compare to former ones and to assess the actual situation. Renal cell carcinoma: Most recent risk assessment for renal cell carcinoma (Council of Europe, 2022): To provide valid histological staging, complete tumour resection (R0) is required for acceptance of all organs; additionally, tumour-free margins are a prerequisite for transplant of the affected kidney. Paraffin section is superior to frozen section for the assessment of such biopsies. The contralateral kidney should always be examined for synchronous RCC (5 % of patients). RCC < 1 cm (stage T1a AJCC 8th ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) can be considered minimal-risk for transmission; RCC 1-4 cm (stage T1a AJCC 8th ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered low-risk; RCC > 4-7 cm (stage T1b AJCC 8th ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered intermediate-risk; RCC > 7 cm (stage T2 AJCC 8th ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered high-risk; RCC with extension beyond the kidney (stages T3/T4 AJCC 8th ed) is considered a contraindication to transplant; All RCC with WHO/ISUP grade III/IV (Fuhrman grade III/IV) are considered high-risk for transmission; Contralateral kidneys and other organs that are un¬involved in carcinoma are considered to represent minimal risk for transplantation when the RCC in the involved kidney is 4 cm or less and WHO/ISUP grade I-II. In all cases, follow-up surveillance is desirable. RCC in the donor history: The transmission risk of treated RCC depends on the histological type of tumour [159] and its recurrence-free follow-up period. In general, in the first 5 years after initial diagnosis, risk categories correspond to those stated above (RCC diagnosed during donor procurement) if there is no suspicion of tumour recurrence in the donor. After this time, the risk of advanced stages may decrease. Astrocytoma and glioblastoma: Most recent risk assessment for astrocytoma and glioblastoma (Council of Europe, 2022): Potential donors with pilocytic astrocytoma (WHO grade I) may be considered for organ donation with minimal risk of transmission. Extraneural metastases from low-grade astrocytomas (WHO grade II) are rare and have been associated with resection and ventriculo-peritoneal shunts. In the absence of these risk factors, the donor may be considered minimal risk. Risk may increase with the extent of performed interventions. A complete histological examination of the tumour should be performed so that areas of transformation into a more aggressive malignancy can be ruled out. Since astrocytomas tend to relapse with a histologically higher grade of malignancy, new histological examinations to regrade the tumour should be performed where relapse occurs. If the tumour co-exists with histological areas of greater malignancy or is very invasive locally, it should be considered high-grade and will be associated with an increased risk of transmission. Spontaneous extraneural metastases of anaplastic astrocytomas and glioblastoma are rare, but such metastases have been observed, and seem to occur more frequently when associated with prior surgical treatment and/or ¬ventriculo-peritoneal drainage, or chemo-/radiotherapy. Potential donors with anaplastic astrocytomas (WHO grade III) can be accepted as organ donors. Transmission risk is considered low to intermediate for tumours without any risk factors. Potential donors with glioblastoma (WHO grade IV) are considered intermediate to high risk for transmission, depending on different national recommendations, which are expected to be adjusted with increasing evidence. The transmission risk is increased (high risk) in all cases with previous interventions such as tumour resection, ¬ventriculo-peritoneal/-atrial drainage and/or cranial chemo-/radiotherapy.
Time to detection: 
Related to procurement and post donation autopsy T1 or T2 renal cell carcinoma (RCC) have been detected in 6 of 582 donors where at a single Center the liver had been transplanted as well as 2 prostate cancer (T1; one with Glioblastoma in comibnation) at autopsy.
Alerting signals, symptoms, evidence of occurrence: 
Histologic findings at back table surgery of kidney procurement and/or autopsy. It has to be noted that the 4 small RCC were detected after liver Implantation has started while kidney procurement was not finished (without early inspection of the kidney) and/or autopsy of unsuscipious prostate before autopsy. Not well explained is the diagnosis of the incidental detection of a glioblastoma. In summary here carefully applied cancer screening protocols would contriubte to earlier diagnosis while Implantation of the liver should not be delayed inappropriately. The study covers a period from 1996 to 2001 in a single Center, where in 6 of 582 liver Transplantation a delayed report of donor malignancy became availabe as well as 11 events of unsuspected detection of malignancy during 684 procurement despite careful pre-procurement donor examination. Since all tumors are of T1 or T2 for RCC without invasive growth beyond the capsule or vessels as well as small RCC (and not papillary RCC) and/or T1 prostate cancers the authors conclude that it is not necessary to remove the liver graft in case of such findings. They followed up their recipients for 51+7-20 months with two patient dead due to HCV recurrence at month 14 and 55. Still the authors prefer to have as many autopsies post donation as possible (which is in contrast to notify record n.1864 where the authors conclude that after application of a strict cancer screening protocol this will be of a limited contribution)
Demonstration of imputability or root cause: 
Histology of space-occupying lesion at procurement, autopsy finding.
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Suggest new keywords: 
malignancy
Single Center Series
deceased donor
Liver transplant/Liver recipient/Liver transplantation
Astrocytoma/glioblastoma multiform E. (WHO grade 4)
Prostate adenocarcinoma/carcinoma
Renal cell carcinoma
Reference attachment: 
Suggest references: 
Serralta AS, Orbis FC, Sanjuan FR, Moya AH, López-Andújar R, Pareja EI, et al. If the donor had an early-stage genitourinary carcinoma and the liver has already been implanted, should we perform the transplantectomy? Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2003;9(12):1281-5.
Note: 
should be linked in addition to prostate cancer, glioblastoma --> ok (EP)
Expert comments for publication: 
Please note that this study covers a period from 1996 to 2001 and current evidence confirms the conclusion of the authors while careful donor examination pre-, during procurement and post procurement is in 2018 best practice.