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CASEREPORT Transmissionofbreastcancerbyasinglemultiorgandonorto4transplantrecipients 2 LiteraturesSource Americanjournaloftransplantation YvetteA H Matser1 MattyL Terpstra2 SilvioNadalin3 GeorgeD Nossent4 JandeBoer5 BarbaraC vanBemmel6 SusannevanEeden7 KlemensBudde8 SusanneBrakemeier8 FrederikeJ Bemelman2 Author IF 6 493 3 1 INTRODUCTION Thiscasereportdescribesthetransmissionofbreastcancerfromasingleorgandonorto4recipientsmanyyearsafterdonation Atthetimeofdonation itwasunknownthatthedonorsufferedfromamalignancy 2 CASEREPORT The53 year olddonorinthiscasehadnorelevantmedicalhistoryanddonatedherkidneys lungs liver Theother4recipientsdevelopeddonor derivedbreastcancer provenbyDNAmicrosatellite within16monthsto6yearsaftertransplantation Unfortunately thedouble lungrecipient left kidneyrecipient andliverrecipientdiedduetothedonor derivedbreastcancer Theright kidneyrecipientremainsalive Afterthediagnosisofbreastcancerinthetransplantedkidney thepatientunderwenttransplantnephrectomy hisimmunosuppressionwasstopped chemotherapywasinitiated andheachievedcompleteremissiondespitewidelymetastasizeddisease 4 5 FIGURE11 6 Double lungrecipient Thelungswereallocatedtoa42 year oldfemalewhosufferedfromend stagelungdiseaseduetosarcoidosiswithremittingpneumothoraces InAugust2008 16monthsaftertransplantation thepatientwasadmittedtothehospitalbecauseoftransplantdysfunction AchestX rayshowedmediastinallymphadenopathy Amediastinallymphnodebiopsyshowedestrogenreceptorandprogesterone receptorpositive ER PR adenocarcinoma TheFES PETscanrevealedabnormalitiesinthelungsandbones Thepatient simmunosuppressionwasreduced InSeptember aCTscanshowedlesionsintheliverandbonesthatwerecompatiblewithmetastases Sixmonthslater shepresentedwithincreasingthoracicpain hypercalcemia andrenalinsufficiency InAugust2009 palliativecarewasstarted andafterafewdays thepatientpassedaway Extensiveresearchwith5independentDNAmicrosatellitemarkersrevealedthatthisbreastcancerwasdonorderived 2020 1 7 7 8 Left kidneyrecipien Theleft kidneyrecipientwasa62 year oldfemale SheunderwentapostmortemdonorkidneytransplantationinApril2007underhighlyurgentstatusbecauseofanimminentlackofvascularaccess whichwaslimitingdialysisoptions WhenEurotransplantreportedthedeathofthelungrecipientin2010duetodonor derivedmetastaticbreastcancer thesituationwasdiscussedwiththepatient Itseemedthatremovalofthetransplantwasnotanoptionbecauseofalackofaccess ACTscanofthetransplantedkidneywasperformed whichmajorpathology Prophylacticantihormonaltreatmentwasconsidered However becausetherewerenodataintheliteraturesupportingthistreatment itwasfinallydecidednottostartantihormonaldrugs Fiveyearslater thepatientpresentedwithhypercalcemia weightloss andmalaise ACTscanoftheabdomenshowedmultiplelesionsintheliver AliverbiopsyrevealedER PR adenocarcinoma whichappearedtohavespreadtothekidney liver bone Liverrecipient Thelivergraftwasallocatedtoa59 year oldfemalerecipientsuf feringfromdecompensatedprimarybiliarycirrhosis Fouryearslater in2011 atumorwasdetectedinsegmentVIIIofthelivergraftandhistologicallyproventobedonor derivedmetastasizedER breastcancer Aretransplantationwasimmediatelyproposedtotherecipient whichsherefused Shefeltwellandwasafraidofpotentialpostoperativecomplicationsshehadexperiencedin2007afterthelivertransplantation Shedecidedtoundergoanablativeprocedurebymeansofextracorporealprotonradiationatanothercenter andtherewereradiologicalsignsofcompleteresponse Afteralong termstabledisease in2014 7yearsafterthetransplant thepatientdevelopedextrahepatictumorprogressionthatwasmainlylocalizedatthehilarregion Sherefusedanyfurtheroncologicaltreatmentanddiedafewmonthslaterduetodiffusetumorprogression 9 10 Right kidneyrecipient A32 year oldmalereceivedtherightkidney Afterhewasinformedofthetransmissionofbreastcancertothelungrecipientin2010 regulartumorscreeninginvestigationswereperformed includingachestX rayandultrasoundoftheabdomen Inaddition aCTscanofthechestwasperformedinJanuary2011 Allofthefindingswereunremarkable InJuly2011 thepatientdevelopedmassiveproteinuria 3g d andantibody mediatedrejectionwassuspectedduetoweakHLA classIIantibodies AbiopsyshowedwidespreadinvasionoftherenalallograftbyER PR adenocarcinoma whichappearedtobehumanepidermalgrowthfactorreceptor2positive ACTscanofthetransplantedkidneyrevealedseveralfocalhypodenseareasandaheterogeneouscortex 11 4 DISCUSSION It snotthefirsttimethatacancerhasmetastasizedbetweenanorgandonorandanorganrecipient buttheoddsofthathappeningareverylow somewherebetween1in10 000and5in10 000 andinthiscase it sthefirsttimeadonorhastransferredcancercellstofourreceptors Whywouldapersonwhoshowsnosignsofcancer infect organrecipientsafteranorgantransplant Whydopatientswithdifferentorganshavethesamekindofcancer Atpresent theresearchershaveonlysomespeculationaboutthecause thedefinitivereasonisunknown Onehypothesisisthatdonorbreastcancerhasmetastasizedormetastasizedineverytransplantorgan andpreviousstudieshaveshownthatcirculatingtumorcellswerefoundinthefirststageofbreastcancer Recipientsoforgantransplantsrequirelong termuseofimmunosuppressants whichallowcancercellsinorgansthatdonotnormallydevelop Anotherpossiblereasonisthatischemia reperfusioninjuryassociatedwithorgantransplantationmaystimulate