Donor-transmitted Melanoma Case Study

Donor-transmitted malignant melanoma gaffe StudyLakshmi Rangaswamy, D.O., Kim Jordan, MD., FACP, Ronald deAndrade, MDIntroduction pipe organ channel pass receivers are at an increased risk of developing malignancy, estimated to number in 15-20% of graft recipients by and by 10 years. Most malignancies occur de novo or as recurrence of previously treated disease, related to immunosuppression and oncogenic viruses.Donor-transmitted tumors are rare. From 1994 2001, the US Transplant tumor registry reported 18 donor-related bathcers in 108,062 recipients.Case PresentationHistoryA 66-year-old female presents with abdominal fullness, fevers, chills and malaise for 1 weeks time. Admitted to displace service to rule out rejection. former(prenominal) Medical HistoryEnd Stage Renal Disease military position post cadaveric renal transplant 3 months prior heights blood pressureDiabetes Mellitus Type 2 -Anemia of chronic diseaseSocial HistoryNo tobacco, alcohol, or drug abuseMedication s (do I really need specialty and frequency?)Amlodipine 10 mg occasionalAspirin 81 mg routineBactrim 160 mg dailyCarvedilol 25 mg in two ways dailyClotrimazole 10 mg troche three times dailyInsulin Lispro 10 units with mealsLantus 20 units in AMMyofortic 360 mg 2 tablets twice dailyPrednisone 10 mg dailyTacrolimus 2mg twice dailyValcyte 450 mg 2 tablets dailyPhysical examVITALS T 100.1, BP 133/60, HR 71, Resp 18, SpO2 99% on RA, nonoliguricNeck no lymphadenopathy, no carotid bruitsCardiovascular regular rate and rhythm, no clicks, gallops, rubs, no lower phallus edemaLungs clear to auscultation bilaterally, no rales or wheezes breadbasket soft, well heal Gibson incision in RLQ, no graft tenderness, no organomegalySkin no rashes or lesions noted on skinLaboratory and Diagnostic Studies (insert images) white blood electric cell 3.94 K/mcl Hgb 9.8 g/dL (patients baseline) platelets 104 K/mclLDH 747 U/LCreatinine 1.72 mg/dL on the day of admission (baseline 1.02 two months prior, after transplant). During the hospital course, her renal failure worsened with creatinine reaching 8.08 mg/dL and patient requiring intermittent hemodialysisCT of the abdomen with contrast and front-runner scanFindings compatible with metastatic disease to the liver, spleen, bones, and probably lungs.MRI Abdomen/pelvisA few indeterminate T1 and T2 hyperintense lesions in the periphery of the transplant kidney, suspicious for neoplasm. Innumerable bone halfwayfield and splenic lesions, suspicious for hemorrhagic metastasisMRI of brainDiffuse bony metastases, no signs of intraparenchymal metastasisPET confident(p) for multiple lesions in the transplant kidney, bone, and spleen.CT guided Bone marrow biopsyMetastatic malignant neoplasm, quite consistent with metastatic malignant malignant malignant malignant melanoma**Within days of patients admission, it was discovered that the recipient of the liver from the same donor developed melanoma within the transplanted liver and the r ecipient of the mate kidney had developed melanoma in the renal allograft.**The transplant center reported no known history of donor melanoma and commonplace visual inspection of donor organs at time of transplant.clinical CoursePatient elected to undergo allograft nephrectomy. Surgical pathology of take donor kidney confirmed malignant melanoma that was BRAF-V600E mutation positive (insert histo playground slide of melanoma in kidney)Patient was taken off of all immunosuppressor therapy and was started on chemotherapy with zelboraf and immunotherapy with ipilimumab (completed 4 months of zelboraf and 4 cycles of ipilimumab)Patient currently off of chemotherapy, and undergoes twin imaging every month.At 6 months, CT body from 6 months demonstrates basically stable disease.This patient is now undergoing hemodialysis for her end exhibit renal diseaseThe two other recipients died from metastatic melanoma prepare in the transplanted liver and renal allograft this patient is the s ole subsister of the transplanted melanoma.Transmission of melanoma by organ transplantation (VIPER)Not whole is melanoma the well-nigh common fatal form of skin cancer, it is the most common tumor responsible for donor-derived malignancy.The late disease recurrence of melanoma is related to the dormancy of melanoma. Major theories for the dormancy of melanoma include cell-cycle complete and blocked angiogenesis. Per Lancet article entitled Transmission of donor melanoma by organ transplantation, late recurrence of dormant melanoma can occur because of micrometastases or solitary dormant cells. Dormant micrometastasis occurs because of the softness for angiogenesis thereof there is an equilibrium between cell proliferation and apoptosis and thus an inability of malignant cell growth. In dormant solitary cells, there is an absence of proliferation or apoptosis, in essence a pause in cell growth. Because of these theories, it is possible that these dormant cells stay latent in immunocompetent individuals for decades and even forever, barely the immunosuppression of the organ recipient can reactivate the melanoma cells.Transplantation for end-stage organ disease has become routine care with resultant increased take for donor organs.With increased public awareness and donor pool expansion, m each an(prenominal) transplant programs are easing criteria for selection by accepting sr. donors and those with remote history of low-grade skin cancers and/or remote aged cancers.A late study reported 23 cases of donor-transmitted melanoma from 12 separate donors between 1972 and 2006. Only 2 donors had known history of melanoma and one case of fatal melanoma occurred from a donor who had surgically removed melanoma sixteen years prior to donation.History of melanoma system a contraindication to organ donation given melanoma high transmission rate of 74% and mortality of 58%.Treatment of donor-related melanoma involves withdrawing immunosuppression and allowing the body to reject the transplanted organ, followed by explantation of the allograft carrying the melanoma cells.SummaryMelanoma incidence in the general population is increasing, but whether this will empathize into increased incidence of donor-transmitted melanoma and resultant increased mortality remains to be determined.Physicians must not only discuss risks of malignancy with transplant candidates, but also carefully question all donors and their family about recent and remote malignancy, particularly melanoma, given its high transmission rate and mortality.Patients with any history of melanoma, whether it be in the ahead of time stages or cured, showed not be considered as organ donors.ReferencesGeller, A.,et al (2013). Melanoma Epidemic An Analysis of sixsome Decades of Data From the Connecticut Tumor Registry.Journal of Clinical Oncology,31, 4172-4178.Geller, A.,et al (2014). Screening and early detection of melanoma. Retrieved January 1,2014, from http//www.uptodate.com/ Morris-Stiff, G.,et al (2004). Transmission of Donor Melanoma to Multiple organTransplant Recipients.American Journal of Transplantation,10, 444-446.Strauss, D. (2010). Transmission of donor melanoma by organ transplantation. LancetOncology, 11, 790-796. Retrieved from www.thelancet.com/oncology