American Journal of Transplantation 2014; 14: 472–476 Wiley Periodicals Inc.
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Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12555
Case Report
Isolated Peritoneal Donor-Related Plasmacytoma 3 Years After Liver Transplantation: A Case Report M. Sosin, S. R. Nassif, R. Girlanda*, C. S. Desai, R. Satoskar, B. Kallakury, T. Cermak and T. Fishbein MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC Corresponding author: Raffaele Girlanda, [email protected]
Organ transplantation carries a risk of disease transmission from donor to recipient, primarily infection or malignancy. Although donors are thoroughly screened, donor-related malignancies are reported to occur in 0.01% of solid organ transplants. Plasma cell neoplasm, to the best of our knowledge, has not been reported as a donor-transmitted malignancy in liver transplantation. We describe a liver transplant from a donor with unrecognized plasmacytoma requiring retransplantation. Three years after the first transplant a single peritoneal mass was detected on surveillance imaging and radically excised; HLA phenotyping confirmed the mass to be an isolated extra-medullary plasmacytoma of chimeric donor and recipient origin. Keywords: Donor-related malignancy, liver transplant, plasmacytoma, posttransplant lymphoproliferative disorder Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; EBV, Epstein-Barr virus; HCC, hepatocellular carcinoma; INR, international normalized ratio; MRI, magnetic resonance imaging; PTLD, posttransplant lymphoproliferative disorder Received 08 October 2013, revised 15 October 2013 and accepted for publication 19 October 2013
Introduction Organ transplantation inevitably carries a risk of disease transmission from donor to recipient, primarily infection or malignancy. Although donors are thoroughly screened, donor-related malignancies occur in 0.01% of transplants according to Registry data from the United States Organ Procurement and Transplantation Network/United Network for Organ Sharing and the Israel Penn International Transplant Tumor Registry (1,2). The most commonly 472
reported donor-related malignancies in solid organ transplant recipients are melanoma, renal cell carcinoma, and lung, breast and central nervous system cancer (2). Plasma cell neoplasm, to the best of our knowledge, has not been reported as a donor-transmitted malignancy in liver transplantation. We describe a unique case in which an isolated peritoneal deposit of donor-derived plasmacytoma developed 3 years after liver transplantation.
Case Report A 73-year-old Asian male with chronic hepatitis C virus and recurrent hepatocellular carcinoma (HCC; single nodule of 2.4 cm in diameter in the right lobe) underwent liver transplantation at our institute following a partial liver resection for HCC performed at another institution 4 years prior. The donor was a 73-year old, blood type B AfricanAmerican male with history of hypertension who suffered brain death secondary to intracranial hemorrhage. Routine laboratory panel revealed normal liver function tests, leukocytosis (peak 22 000/dL on the second day of admission, with 15% bands), chronic anemia (Hb 8 g/dL, Hct 23%), thrombocytopenia (72 000/dL) and renal failure (BUN 45 mg/dL and creatinine 5.4 mmol/dL). There was no history of kidney disease nor of hematologic disorders. The liver was procured with standard technique: the graft weighed 1500 g and had normal color, texture and perfusion. A frozen section biopsy obtained at the donor’s hospital during procurement demonstrated minimal macrosteatosis (65 years) rarely constitutes an exclusion criterion for liver transplantation. Nevertheless, since advanced age increases the cumulative lifetime risk of cancer, transplanting grafts from older donors, as in the case presented here, inevitably increases the risk of donor-transmitted malignancy and requires a higher level of suspicion compared to standard donors. Furthermore, mild to moderate peripheral blood leukocytosis is a common finding in brain-dead donors following American Journal of Transplantation 2014; 14: 472–476
intracranial hemorrhage or infarct, and benign histologic abnormalities in frozen sections from older donor livers (such as mild portal inflammation, deposits of lipofuscin, micro/macrosteatosis) are not unusual; therefore, such findings should not be used as exclusion criteria. However, the abnormal peripheral blood findings noted for the first donor (available only after transplant) and the atypical infiltrate seen in the liver frozen section (only after review by a dedicated liver pathologist) should have raised suspicion for malignancy in this case. Since frozen section liver biopsies are often more difficult to interpret and more prone to artifacts than permanent section, we believe it is preferable that such biopsies be evaluated by dedicated hepatopathologists, whenever possible. As a result, following the occurrence of this case, our protocol for liver biopsies from local older or ‘‘nonideal’’ donors has changed as we now submit the donor biopsy for review by the liver-histology service before proceeding with the transplant. Also, we believe that our case, in which a mass developed 3 years after transplant, highlights the importance of continuous and prolonged surveillance of transplant recipients in order to detect posttransplant malignancies or recurrences at an early stage. In conclusion, we report a case of donor-derived plasmacytoma after liver transplant, the first occurrence of such a case in the literature that made us change our protocol for handling donor liver biopsies prior to transplant. Early retransplant at short interval (9 days) after recognition of the donor malignancy still leaves a risk of late disease transmission.
Acknowledgments Washington Regional Transplant Community (WRTC)
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Myron Kauffman H, McBride MA, Cherikh WS, Spain PC, Marks WH, Roza AM. Transplant tumor registry: Donor related malignancies. Transplantation 2002; 74: 358–362. 2. Buell JF, Beebe TM, Trofe J, et al. Donor transmitted malignancies. Ann Transplant 2004; 9: 53–56. 3. Soutar R, Lucraft H, Jackson G, et al. Guidelines on the diagnosis and management of solitary plasmacytoma of bone and solitary extramedullary plasmacytoma. Br J Haematol 2004; 124: 717–726. 4. Hughes M, Soutar R, Lucraft H, Bird J. Guidelines on the diagnosis and management of solitary plasmacytoma of bone, extramedullary plasmacytoma and multiple solitary plasmacytomas: 2009 update.
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Sosin et al London, UK: British Committee for Standards in Haematology 2009, 2009, 14 pp. 5. Schrem H, Kurok M, Kaltenborn A, et al. Incidence and long-term risk of de novo malignancies after liver transplantation with implications for prevention and detection. Liver Transpl 2013; doi: 10.1002/ lt.23722 [Epub ahead of print]. 6. Kremers WK, Devarbhavi HC, Wiesner RH, Krom RA, Macon WR, Habermann TM. Post-transplant lymphoproliferative disorders
476
following liver transplantation: Incidence, risk factors and survival. Am J Transplant 2006; 6: 1017–1024. 7. Richendollar BG, Hsi ED, Cook JR. Extramedullary plasmacytomalike posttransplantation lymphoproliferative disorders: Clinical and pathologic features. Am J Clin Pathol 2009; 132: 581–588. 8. McKenna RW, Kyle RA, Kuehl RA, Grogan TM, Harris NL, Coupland RW. Plasma cell neoplasms. In: Jaffe ES, Harris NL, Vardiman JW, Campo E, Arber DA, eds. Hematophathology. Lyon: IARC, 2008, 200–213.
American Journal of Transplantation 2014; 14: 472–476
C
Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12555
Case Report
Isolated Peritoneal Donor-Related Plasmacytoma 3 Years After Liver Transplantation: A Case Report M. Sosin, S. R. Nassif, R. Girlanda*, C. S. Desai, R. Satoskar, B. Kallakury, T. Cermak and T. Fishbein MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC Corresponding author: Raffaele Girlanda, [email protected]
Organ transplantation carries a risk of disease transmission from donor to recipient, primarily infection or malignancy. Although donors are thoroughly screened, donor-related malignancies are reported to occur in 0.01% of solid organ transplants. Plasma cell neoplasm, to the best of our knowledge, has not been reported as a donor-transmitted malignancy in liver transplantation. We describe a liver transplant from a donor with unrecognized plasmacytoma requiring retransplantation. Three years after the first transplant a single peritoneal mass was detected on surveillance imaging and radically excised; HLA phenotyping confirmed the mass to be an isolated extra-medullary plasmacytoma of chimeric donor and recipient origin. Keywords: Donor-related malignancy, liver transplant, plasmacytoma, posttransplant lymphoproliferative disorder Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; EBV, Epstein-Barr virus; HCC, hepatocellular carcinoma; INR, international normalized ratio; MRI, magnetic resonance imaging; PTLD, posttransplant lymphoproliferative disorder Received 08 October 2013, revised 15 October 2013 and accepted for publication 19 October 2013
Introduction Organ transplantation inevitably carries a risk of disease transmission from donor to recipient, primarily infection or malignancy. Although donors are thoroughly screened, donor-related malignancies occur in 0.01% of transplants according to Registry data from the United States Organ Procurement and Transplantation Network/United Network for Organ Sharing and the Israel Penn International Transplant Tumor Registry (1,2). The most commonly 472
reported donor-related malignancies in solid organ transplant recipients are melanoma, renal cell carcinoma, and lung, breast and central nervous system cancer (2). Plasma cell neoplasm, to the best of our knowledge, has not been reported as a donor-transmitted malignancy in liver transplantation. We describe a unique case in which an isolated peritoneal deposit of donor-derived plasmacytoma developed 3 years after liver transplantation.
Case Report A 73-year-old Asian male with chronic hepatitis C virus and recurrent hepatocellular carcinoma (HCC; single nodule of 2.4 cm in diameter in the right lobe) underwent liver transplantation at our institute following a partial liver resection for HCC performed at another institution 4 years prior. The donor was a 73-year old, blood type B AfricanAmerican male with history of hypertension who suffered brain death secondary to intracranial hemorrhage. Routine laboratory panel revealed normal liver function tests, leukocytosis (peak 22 000/dL on the second day of admission, with 15% bands), chronic anemia (Hb 8 g/dL, Hct 23%), thrombocytopenia (72 000/dL) and renal failure (BUN 45 mg/dL and creatinine 5.4 mmol/dL). There was no history of kidney disease nor of hematologic disorders. The liver was procured with standard technique: the graft weighed 1500 g and had normal color, texture and perfusion. A frozen section biopsy obtained at the donor’s hospital during procurement demonstrated minimal macrosteatosis (65 years) rarely constitutes an exclusion criterion for liver transplantation. Nevertheless, since advanced age increases the cumulative lifetime risk of cancer, transplanting grafts from older donors, as in the case presented here, inevitably increases the risk of donor-transmitted malignancy and requires a higher level of suspicion compared to standard donors. Furthermore, mild to moderate peripheral blood leukocytosis is a common finding in brain-dead donors following American Journal of Transplantation 2014; 14: 472–476
intracranial hemorrhage or infarct, and benign histologic abnormalities in frozen sections from older donor livers (such as mild portal inflammation, deposits of lipofuscin, micro/macrosteatosis) are not unusual; therefore, such findings should not be used as exclusion criteria. However, the abnormal peripheral blood findings noted for the first donor (available only after transplant) and the atypical infiltrate seen in the liver frozen section (only after review by a dedicated liver pathologist) should have raised suspicion for malignancy in this case. Since frozen section liver biopsies are often more difficult to interpret and more prone to artifacts than permanent section, we believe it is preferable that such biopsies be evaluated by dedicated hepatopathologists, whenever possible. As a result, following the occurrence of this case, our protocol for liver biopsies from local older or ‘‘nonideal’’ donors has changed as we now submit the donor biopsy for review by the liver-histology service before proceeding with the transplant. Also, we believe that our case, in which a mass developed 3 years after transplant, highlights the importance of continuous and prolonged surveillance of transplant recipients in order to detect posttransplant malignancies or recurrences at an early stage. In conclusion, we report a case of donor-derived plasmacytoma after liver transplant, the first occurrence of such a case in the literature that made us change our protocol for handling donor liver biopsies prior to transplant. Early retransplant at short interval (9 days) after recognition of the donor malignancy still leaves a risk of late disease transmission.
Acknowledgments Washington Regional Transplant Community (WRTC)
Disclosure The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.
References 1. Myron Kauffman H, McBride MA, Cherikh WS, Spain PC, Marks WH, Roza AM. Transplant tumor registry: Donor related malignancies. Transplantation 2002; 74: 358–362. 2. Buell JF, Beebe TM, Trofe J, et al. Donor transmitted malignancies. Ann Transplant 2004; 9: 53–56. 3. Soutar R, Lucraft H, Jackson G, et al. Guidelines on the diagnosis and management of solitary plasmacytoma of bone and solitary extramedullary plasmacytoma. Br J Haematol 2004; 124: 717–726. 4. Hughes M, Soutar R, Lucraft H, Bird J. Guidelines on the diagnosis and management of solitary plasmacytoma of bone, extramedullary plasmacytoma and multiple solitary plasmacytomas: 2009 update.
475
Sosin et al London, UK: British Committee for Standards in Haematology 2009, 2009, 14 pp. 5. Schrem H, Kurok M, Kaltenborn A, et al. Incidence and long-term risk of de novo malignancies after liver transplantation with implications for prevention and detection. Liver Transpl 2013; doi: 10.1002/ lt.23722 [Epub ahead of print]. 6. Kremers WK, Devarbhavi HC, Wiesner RH, Krom RA, Macon WR, Habermann TM. Post-transplant lymphoproliferative disorders
476
following liver transplantation: Incidence, risk factors and survival. Am J Transplant 2006; 6: 1017–1024. 7. Richendollar BG, Hsi ED, Cook JR. Extramedullary plasmacytomalike posttransplantation lymphoproliferative disorders: Clinical and pathologic features. Am J Clin Pathol 2009; 132: 581–588. 8. McKenna RW, Kyle RA, Kuehl RA, Grogan TM, Harris NL, Coupland RW. Plasma cell neoplasms. In: Jaffe ES, Harris NL, Vardiman JW, Campo E, Arber DA, eds. Hematophathology. Lyon: IARC, 2008, 200–213.
American Journal of Transplantation 2014; 14: 472–476
