Case report: Melanoma after heart transplant (2000)

Record number:

292

Adverse Occurrence type:

MPHO Type:

Estimated frequency:

Most recent risk assessment for melanoma (Council of Europe, 2022): Due to the very aggressive behaviour of this tumour, it is considered an unacceptable risk for organ donation. Malignant melanoma in the donor history: Due to the lack of exhaustive data, transplanting organs from donors with treated malignant melanoma must still be considered to be associated with a high transmission risk. If precise donor data about staging, therapy, follow-up and recurrence-free survival are available, and evaluation by the dermato-oncologist concludes there is a low probability of recurrence and metastasis, organ donation might be considered for selected recipients.

Time to detection:

10, 15, 15, 17 months (4 recipients)

Alerting signals, symptoms, evidence of occurrence:

Kidney recipient 1: urinary infection complicated with sepsis and poor renal function leading to graft removal 15 months after Tx. Graft removed contained malignant melanoma. Dies 17 months after Tx the autopsy revealing widespread malignant melanoma. Kidney recipient 2: Physician in charge is allerted of rest of the cases 17 months after Tx. CT reveals masses in kidneys, liver and lungs. IS was discontinued but died 30 months after Tx. Liver: Shortness of breath 15 months after Tx, Xray reveals lung infiltrates and CT multiple lung and liver lessions. Biopsy of liver compatible with malignant melanoma. IS withdrawn and chemotherapy started, but dies a few days later. Autopsy reveals metastatic malignant melanoma. Heart:10 months after Tx, routine x-ray shows multiple lung nodules. Further studies reveal lesions in liver and brain. Biopsy of a lung nodule compatible with malignant melanoma. IS reduced, but dies 13 months after Tx. No autopsy.

Demonstration of imputability or root cause:

Donor with no previous history of cancer, dead due to intracraneal hemorrhage. Four recipients of the same donor developed a histologically identical metastatic malignant melanoma. Donor origin of tumor cells confirmed by polymerase chain reaction-based DNA analysis for polymorphic short tandem tetrameric repeats. DNAs from nontumorous donor tissue and tumor tissue available from three recipients tested positive for CSF1P0 alleles 10 and 12 and for TH01 alleles 6 and 7, although DNAs from nonneoplastic recipient tissues all exhibited different allelotypes.

Imputability grade:

3 Definite/Certain/Proven

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