(Subject Review): Donor cancer transmission in kidney transplantation (Melanoma) (2013)

The authors conclude with the general consensus that organs from donors with a history of melanoma or lung cancer should be rejected for transplantation but state that their review suggests that use of donor kidneys with a history of small incidental renal cell cancers may be reasonable. Council of Europe recommendations for major tumors reviewed in this article: Renal cell carcinoma (Council of Europe, 2018): To provide a valid assessment, complete tumour resection (R0) prior to transplantation is required for the acceptance of all organs; additionally, tumour-free margins are a prerequisite for transplant of the affected kidney. The contralateral kidney should always be examined for synchronous RCC. RCC < 1 cm (Stage T1a AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) can be considered minimal risk for transmission. RCC 1-4 cm (Stage T1a AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered low risk. RCC > 4-7 cm (Stage T1b AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered intermediate risk. RCC > 7 cm (Stage T2 AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered high risk. RCC with extension beyond the kidney (Stages T3 or T4 AJCC 8th ed.) is considered a contraindication to transplant. All RCC with nucleolar grade III/IV (Fuhrman grade III/IV) are considered high risk for transmission. Contralateral kidneys and other organs that are uninvolved by carcinoma are considered to represent minimal risk for transplantation when the RCC in the involved kidney is 4 cm or less and Fuhrman or nucleolar grade I-II. Followup surveillance is recommended. In the case of a donor with a history of renal cell carcinoma, the transmission risk of treated RCC depends on the 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. 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. Lymphoma: Most recent risk assessment for lymphoma (Council of Europe, 2018): donors with active lymphoma are considered to represent an unacceptable risk for tumor transmission. Insufficient data exist at present to discriminate among different lymphoma subtypes. Donors with a history of treated lymphoma after a disease-free interval of 5 to 10 years are assumed to represent a high risk for transmission. Lung cancer: Most recent risk assessment for Lung Cancer (Council of Europe, 2018): Any form of newly diagnosed lung cancer represents an Unacceptable Risk for organ donation. Treated lung cancer is considered to be High Risk, but this may be modified by curative therapy and recurrence-free time with increasing probability of cure. Sarcoma Most recent risk assessment for sarcoma (Council of Europe, 2018): Donors with active sarcoma are considered to represent an unacceptable risk for organ donation regardless of disease stage. Donors with a history of sarcoma are also generally considered to represent unacceptable risks for transmission. After curative therapy and recurrence free survival of more than five years, they are still assumed to be associated with a high risk for transmission. Gastrointestinal stromal tumors are not grouped with other sarcomas and are considered separately. Glioma and Astrocytoma (various WHO grades, in this study only WHO Grade IV considered): (Council of Europe, 2018): Potential donors with pilocytic astrocytoma (WHO grade I) may be considered for organ donation with minimal risk of transmission. Extra-neural 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 more aggressive malignancy are ruled out. Since astrocytomas have a tendency to relapse with a histologically higher grade of malignancy, new histological examinations should be performed where relapse occurs to regrade the tumour. If the tumor 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 extra-neural metastases of anaplastic astrocytomas and glioblastoma multiforme are rare, but have been observed, and 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 multiforme (WHO grade IV) are considered intermediate to high risk for transmission depending on the 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. Choricarcinoma: Most recent risk assessment for choriocarcinoma (Council of Europe, 2018): Potential donors with recently diagnosed choriocarcinoma represent an Unacceptable Risk for organ donation. Those with a history of choriocarcinoma represent a High or Unacceptable risk for organ donation due to the reported high transmission and mortality rates, depending upon recurrence free time, which is not clearly defined in the literature.