Case report: Medulloblastoma (1987)

Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Most recent risk assessment for medulloblastoma (Council of Europe, 2022): Childhood medulloblastomas are the CNS primitive tumours that metastasize most frequently outside the CNS. The risk may be increased if prior ventriculo-peritoneal or ventricular-atrial shunts, tumour resection or cranial chemo-/radiotherapy have been performed. Organs from potential donors with medulloblastomas (WHO grade IV) are considered intermediate to high risk for tumour transmission, depending on different international recommendations, which will be adjusted with increasing evidence. They should be used exclusively for transplants where the recipient’s risk of dying while on the waiting list is greater than the risk of tumour transmission.
Time to detection: 
5 months
Alerting signals, symptoms, evidence of occurrence: 
Kidney, kidney-pancreas and heart recipients developed disseminated tumors resulting in the death of two. The kidney-pancreas recipients had the pancreas graft removed 3 days after the transplant due to arterial thrombosis. The patient died 5 months later due to tumoral infiltration of the kidney graft and lymph nodes. The kidney recipient had the graft removed due to the evolution of the first recipient. The graft had tumoral infiltration and there were diffuse lymphatic metastasis. The patient received chemotherapy and was alive and disease-free 12 months after the transplant.
Demonstration of imputability or root cause: 
Condition known in the donor whose cause of death was medulloblastoma after placement of a ventriculo - atrial shunt, surgery, radiotherapy and chemotherapy. More than one recipient affected.
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