Case report: Donor choriocarcinoma transmission by liver and kidney transplants from a single donor (2021)

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Most recent risk assessment for choriocarcinoma (Council of Europe, 2022): 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.
Time to detection: 
2 months
Alerting signals, symptoms, evidence of occurrence: 
An ultrasound was done at the time that the kidney recipient had a urinary tract infection and was being treated. A renal lesion was seen and a biopsy showed a neoplasm. The information was passed to the liver center, and the liver recipient underwent CT scan showing liver lesions and metastatic foci. hCG levels were elevated in both patients.
Demonstration of imputability or root cause: 
The histology of a germ cell tumor and elevated hCG levels were consistent with choriocarcinoma. Retrospective analysis of donor blood (17 year old female who died of cerebral hemorrhage attributed to arteriovenous malformation) showed elevated hCG level.
Imputability grade: 
3 Definite/Certain/Proven
Groups audience: 
Suggest new keywords: 
Case Report
Deceased donor
Kidney transplant
Kidney recipient
Kidney transplantation
Liver transplant
Liver recipient
Liver transplantation
Histologic analysis
Germ cell, sex cord and related tumors
Therapy discussed
Suggest references: 
de Queiroz Moura D, Rawache R, Garcia MFG, Vasconcelos NF, Santos P, Coelho GR, Luis da Paz Santos T, Reis da Rocha Filho D, Leite da Silva S, Barbosa de Almeida ER, Fernandes PFCBC, Cerqueira JB, Parente Garcia JH, Costa de Oliveira CM. Donor Choriocarcinoma Transmission From Solid Organ Transplantation: A Case Report. Transplant Proc. 2021 May;53(4):1345-1349. doi: 10.1016/j.transproceed.2020.10.034. Epub 2020 Dec 29. PMID: 33384179
Uploaded MN 5/13/22 Please clone for liver transplant First review done 5/13/22 MN Second review KM 4/13/23 fully agree
Expert comments for publication: 
Although the danger of choriocarcinoma transmission is well documented, cases unfortunately continue to occur. In this case later information obtained revealed that the patient had an abortion 2 years earlier and pathology showed a partial hydatidiform mole. As a result of this experience, the center now (as of 2020) measures beta hCG levels in potential female donors of childbearing age. Both recipients died a short time after initiation of chemotherapy and, in the kidney recipient, transplant nephrectomy.