Amid a boom in organ donation, a heightened focus on cancer risk in transplant recipients

IF 2.6 3区 医学 Q3 ONCOLOGY
Bryn Nelson PhD, William Faquin MD, PhD
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Although it has happened only rarely, some donors’ metabolic disorders or nascent tumors have evaded detection before the transplant, the latter resulting in the documented transmission of glioblastoma multiforme and lung, breast, colorectal, kidney, and other cancers.</p><p>More commonly, donors can transmit parasitic, fungal, bacterial, or viral infections, including some cancer-linked pathogens such as <i>Helicobacter pylori</i>, hepatitis B, and hepatitis C, as well as more ubiquitous viruses such as Epstein–Barr virus and human papillomavirus (HPV). <i>H. pylori</i> has been linked to gastric cancer, chronic hepatitis, and liver cancer; Epstein–Barr to non-Hodgkin lymphoma; and HPV to cervical, anal, penile, and oropharyngeal cancers.</p><p>A 2021 study by OPTN’s Disease Transmission Advisory Committee (DTAC) suggested that donor-derived disease transmission occurs in less than 1% of all transplant recipients. Of the proven or probable donor transmission events, 67% involved infections, 29% included malignancies, and 6% involved other disease processes (a small percentage involved more than one kind of event).<span><sup>2</sup></span>\n </p><p>Gerald Berry, MD, a professor of surgical pathology at Stanford University in Palo Alto, California, and a cancer expert on the DTAC, says that the committee first tries to determine whether a transmissible event is donor-derived or originates in the recipient. “Then the subcategory is, even if it’s donor derived, was it there at the time of transplant and too small to actually detect?”</p><p>The DTAC’s work toward determining whether a malignancy can be traced back to the donor, even years after the fact, can help to establish the risk for the remaining cohort of transplant recipients. “Many times, the donor is providing organs for more than one recipient, so the biggest concern is when a recipient develops a malignancy, are the other recipients at risk?” Dr Berry says. The risk can be further characterized according to tumor type: A donor’s brain tumor that has metastasized, for example, would pose a considerably bigger danger than a far more treatable thyroid tumor.</p><p>The most significant cancer-related risk for organ transplant recipients, however, is associated with the very immunosuppressive medications that are required to prevent rejection of the organs but also can render the immune system less able to identify and kill tumor cells or battle cancer-linked infections. “The patients are so heavily immunosuppressed as part of the transplant protocol that the host versus the virus mechanisms are distorted, so things like that can then proliferate,” says Dr Berry.</p><p>Compared to the general population, transplant recipients face a 2- to 4-fold higher risk for multiple cancer types. A 30-year cohort study in Finland that examined roughly 6500 transplant recipients, for example, found that nearly 1 in 4 eventually contracted cancer; this translated to a 3.6-fold higher risk.<span><sup>3</sup></span>\n </p><p>For non-melanoma skin cancers, such as basal cell and squamous cell carcinomas, the rate is even higher: Studies have documented anywhere from a 25- to 250-fold increase in risk.<span><sup>4</sup></span> Although most of these cancers are relatively benign, transplant recipients also develop more locally advanced or advanced stage cutaneous malignancies, says Kevin Emerick, MD, director of the Division of Head and Neck Cancer Surgery at Massachusetts Eye and Ear in Boston.</p><p>“As we do more and more transplants, we’re going to have more and more of those patients,” says Dr Emerick, who also serves as codirector of the clinic’s Non-Melanoma Skin Cancer Multidisciplinary Clinic and Program. “So maybe a good trend is a recognition and acknowledgment of the special care that those patients need.” With more patients living longer after transplantation, more will require long-term follow-up. At many academic medical centers, he points out that dermatology departments are creating high-risk clinics that specifically cater to the growing number of solid organ transplant patients, some of whom need to be seen every 6 or 12 weeks.</p><p>According to one Italian study of more than 1300 heart or kidney transplant patients, “the overall risk of developing skin cancer increased from a cumulative incidence of 5.8% after 5 post-transplant years to an incidence of 10.8% after 10 years of graft survival.”<span><sup>5</sup></span> Studies from other countries have documented even higher rates.</p><p>One take-home message, Dr Emerick says, is the need for dedicated providers to conduct routine surveillance and for sufficient infrastructure and teams to care for those patients who develop skin cancer. Even more than the risk for other cancers, the risk for skin cancer is based overwhelmingly on recipients’ immunosuppression and the ability of cancerous lesions to evade immune surveillance. “Our immune system just plays such a critical role in helping to suppress and clean up DNA damage, and we all have a ton of DNA damage in our skin,” Dr Emerick says. “So, if you take away that surveillance effect of our immune system, this is why patients are getting a lot more skin cancers.”</p><p>Consequently, the cancer risk associated with a new liver may be high in comparison to the risk for the general public, but the risk is even greater with a new heart. Similarly, small bowel and lung transplant patients tend to have a higher incidence of post-transplant lymphoproliferative disorder, a life-threatening type of lymphoma also seen after hematopoietic stem cell transplantation in which white blood cells multiply uncontrollably.</p><p>Patients living with a transplanted kidney for years or decades may be able to decrease their immunosuppression regimen, and older patients generally have less active immune systems; conversely, living longer with a transplanted organ can increase the risk over time.</p><p>For some patients, switching immunosuppressants (e.g., from tacrolimus to sirolimus) may reduce the risk of developing skin cancer. “This is where partnering with people’s transplant teams is so important,” Dr Emerick says. “They’re the real experts at finding the right level of immunosuppression that [transplant recipients] need to maintain their organ, which is so important for these folks, especially our heart and lung transplant patients.”</p><p>Risk-reduction strategies, such as vaccinating patients against hepatitis B and HPV and prioritizing prevention messages (e.g., emphasizing the importance of avoiding more ultraviolet radiation from sun exposure), could benefit patients even when they are on an organ transplant wait list. Patients with more skin pigmentation have a lower risk of developing both non-melanoma and melanoma skin cancers, including after organ transplantation, because of the protective role of melanin against cumulative exposure to ultraviolet radiation. 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引用次数: 0

Abstract

In 2023, the United States set a record for organ transplants, with more than 46,00 transplants performed with organs procured from more than 16,000 deceased donors and nearly 7000 living ones.1 With this encouraging trend reported by the Organ Procurement and Transplantation Network (OPTN), though, experts have stressed that the lifesaving operations can carry a tradeoff. Although it has happened only rarely, some donors’ metabolic disorders or nascent tumors have evaded detection before the transplant, the latter resulting in the documented transmission of glioblastoma multiforme and lung, breast, colorectal, kidney, and other cancers.

More commonly, donors can transmit parasitic, fungal, bacterial, or viral infections, including some cancer-linked pathogens such as Helicobacter pylori, hepatitis B, and hepatitis C, as well as more ubiquitous viruses such as Epstein–Barr virus and human papillomavirus (HPV). H. pylori has been linked to gastric cancer, chronic hepatitis, and liver cancer; Epstein–Barr to non-Hodgkin lymphoma; and HPV to cervical, anal, penile, and oropharyngeal cancers.

A 2021 study by OPTN’s Disease Transmission Advisory Committee (DTAC) suggested that donor-derived disease transmission occurs in less than 1% of all transplant recipients. Of the proven or probable donor transmission events, 67% involved infections, 29% included malignancies, and 6% involved other disease processes (a small percentage involved more than one kind of event).2

Gerald Berry, MD, a professor of surgical pathology at Stanford University in Palo Alto, California, and a cancer expert on the DTAC, says that the committee first tries to determine whether a transmissible event is donor-derived or originates in the recipient. “Then the subcategory is, even if it’s donor derived, was it there at the time of transplant and too small to actually detect?”

The DTAC’s work toward determining whether a malignancy can be traced back to the donor, even years after the fact, can help to establish the risk for the remaining cohort of transplant recipients. “Many times, the donor is providing organs for more than one recipient, so the biggest concern is when a recipient develops a malignancy, are the other recipients at risk?” Dr Berry says. The risk can be further characterized according to tumor type: A donor’s brain tumor that has metastasized, for example, would pose a considerably bigger danger than a far more treatable thyroid tumor.

The most significant cancer-related risk for organ transplant recipients, however, is associated with the very immunosuppressive medications that are required to prevent rejection of the organs but also can render the immune system less able to identify and kill tumor cells or battle cancer-linked infections. “The patients are so heavily immunosuppressed as part of the transplant protocol that the host versus the virus mechanisms are distorted, so things like that can then proliferate,” says Dr Berry.

Compared to the general population, transplant recipients face a 2- to 4-fold higher risk for multiple cancer types. A 30-year cohort study in Finland that examined roughly 6500 transplant recipients, for example, found that nearly 1 in 4 eventually contracted cancer; this translated to a 3.6-fold higher risk.3

For non-melanoma skin cancers, such as basal cell and squamous cell carcinomas, the rate is even higher: Studies have documented anywhere from a 25- to 250-fold increase in risk.4 Although most of these cancers are relatively benign, transplant recipients also develop more locally advanced or advanced stage cutaneous malignancies, says Kevin Emerick, MD, director of the Division of Head and Neck Cancer Surgery at Massachusetts Eye and Ear in Boston.

“As we do more and more transplants, we’re going to have more and more of those patients,” says Dr Emerick, who also serves as codirector of the clinic’s Non-Melanoma Skin Cancer Multidisciplinary Clinic and Program. “So maybe a good trend is a recognition and acknowledgment of the special care that those patients need.” With more patients living longer after transplantation, more will require long-term follow-up. At many academic medical centers, he points out that dermatology departments are creating high-risk clinics that specifically cater to the growing number of solid organ transplant patients, some of whom need to be seen every 6 or 12 weeks.

According to one Italian study of more than 1300 heart or kidney transplant patients, “the overall risk of developing skin cancer increased from a cumulative incidence of 5.8% after 5 post-transplant years to an incidence of 10.8% after 10 years of graft survival.”5 Studies from other countries have documented even higher rates.

One take-home message, Dr Emerick says, is the need for dedicated providers to conduct routine surveillance and for sufficient infrastructure and teams to care for those patients who develop skin cancer. Even more than the risk for other cancers, the risk for skin cancer is based overwhelmingly on recipients’ immunosuppression and the ability of cancerous lesions to evade immune surveillance. “Our immune system just plays such a critical role in helping to suppress and clean up DNA damage, and we all have a ton of DNA damage in our skin,” Dr Emerick says. “So, if you take away that surveillance effect of our immune system, this is why patients are getting a lot more skin cancers.”

Consequently, the cancer risk associated with a new liver may be high in comparison to the risk for the general public, but the risk is even greater with a new heart. Similarly, small bowel and lung transplant patients tend to have a higher incidence of post-transplant lymphoproliferative disorder, a life-threatening type of lymphoma also seen after hematopoietic stem cell transplantation in which white blood cells multiply uncontrollably.

Patients living with a transplanted kidney for years or decades may be able to decrease their immunosuppression regimen, and older patients generally have less active immune systems; conversely, living longer with a transplanted organ can increase the risk over time.

For some patients, switching immunosuppressants (e.g., from tacrolimus to sirolimus) may reduce the risk of developing skin cancer. “This is where partnering with people’s transplant teams is so important,” Dr Emerick says. “They’re the real experts at finding the right level of immunosuppression that [transplant recipients] need to maintain their organ, which is so important for these folks, especially our heart and lung transplant patients.”

Risk-reduction strategies, such as vaccinating patients against hepatitis B and HPV and prioritizing prevention messages (e.g., emphasizing the importance of avoiding more ultraviolet radiation from sun exposure), could benefit patients even when they are on an organ transplant wait list. Patients with more skin pigmentation have a lower risk of developing both non-melanoma and melanoma skin cancers, including after organ transplantation, because of the protective role of melanin against cumulative exposure to ultraviolet radiation. Even so, Dr Emerick says, their risk for other cancers remains elevated, and constant vigilance is required.

One cruel irony of advanced skin cancers that develop after organ transplantation is that immunotherapy is a key anticancer treatment. “Skin cancers are the most treatable cancer by immunotherapy,” Dr Emerick says. “Unfortunately, immunotherapy comes with a significant risk of losing your transplanted organ.” Anticancer immunotherapy can be used for some renal transplant patients, he says, “largely because if their organ fails, you do have an option to consider dialysis.” That same option is not available to lung, heart, and most liver transplant patients because losing the organ would kill them.

The fact that immunosuppression helps to prevent the rejection of a donated organ but raises the risk of a host of other diseases reinforces the crucial importance of long-term cancer surveillance and early detection for transplant patients, says Dr Emerick and other experts. So does the possibility that a transmitted malignancy may not present itself clinically until years after the transplant, Dr Berry adds. “It’s not only looking at the survival risk or morbidity-mortality risk to the poor recipient who is unfortunately the one who has developed the tumor, but then we also look at risk stratification for the remainder,” he says.

Fortunately, most such patients are seen at regular intervals after transplantation, and these visits provide ample—and crucial—opportunities for screening and risk evaluation.

Abstract Image

随着器官捐赠的蓬勃发展,对移植受者癌症风险的高度关注:免疫抑制、传染性感染和肿瘤,以及器官受者长期生存率的提高,要求对皮肤癌和其他恶性肿瘤提高警惕。
2023年,美国创下了器官移植的纪录,从1.6万多名已故捐赠者和近7000名活着的捐赠者那里获得的器官进行了4.6万多例移植尽管器官获取和移植网络(OPTN)报告了这一令人鼓舞的趋势,但专家们强调,挽救生命的手术可能会带来权衡。虽然这种情况很少发生,但一些供体的代谢紊乱或新生肿瘤在移植前没有被发现,后者导致多形性胶质母细胞瘤和肺癌、乳腺癌、结肠直肠癌、肾癌和其他癌症的传播。更常见的是,捐赠者可以传播寄生虫、真菌、细菌或病毒感染,包括一些与癌症相关的病原体,如幽门螺杆菌、乙型肝炎和丙型肝炎,以及更普遍的病毒,如爱泼斯坦-巴尔病毒和人类乳头瘤病毒(HPV)。幽门螺旋杆菌与胃癌、慢性肝炎和肝癌有关;Epstein-Barr到非霍奇金淋巴瘤;HPV对宫颈癌、肛门癌、阴茎癌和口咽癌的影响。OPTN疾病传播咨询委员会(DTAC) 2021年的一项研究表明,供体来源的疾病传播发生在所有移植受者的不到1%。在已证实或可能的供体传播事件中,67%涉及感染,29%包括恶性肿瘤,6%涉及其他疾病过程(一小部分涉及一种以上事件)Gerald Berry医学博士是加州帕洛阿尔托斯坦福大学的外科病理学教授,也是DTAC的癌症专家,他说该委员会首先试图确定传播事件是源自供体还是源自受体。“那么子类别是,即使它来自供体,在移植时是否存在并且太小而无法实际检测?”DTAC的工作是确定恶性肿瘤是否可以追溯到捐赠者,甚至在事实发生多年之后,这有助于确定移植接受者的剩余队列的风险。“很多时候,捐赠者为不止一个接受者提供器官,所以最大的担忧是,当一个接受者患上恶性肿瘤时,其他接受者是否有风险?”贝里博士说。风险可以根据肿瘤类型进一步确定:例如,供体的脑肿瘤已经转移,比可治疗得多的甲状腺肿瘤造成的危险要大得多。然而,对于器官移植受者来说,最重要的癌症相关风险与免疫抑制药物有关,这些药物是防止器官排异反应所必需的,但也会降低免疫系统识别和杀死肿瘤细胞或对抗癌症相关感染的能力。贝瑞博士说:“作为移植方案的一部分,患者的免疫受到严重抑制,宿主对抗病毒的机制被扭曲,因此类似的事情就会扩散。”与一般人群相比,移植受者患多种癌症的风险高出2至4倍。例如,芬兰一项为期30年的队列研究对大约6500名移植接受者进行了调查,发现近四分之一的人最终患上了癌症;这意味着风险增加了3.6倍对于非黑色素瘤皮肤癌,如基底细胞癌和鳞状细胞癌,发病率甚至更高:研究表明,其风险增加了25至250倍波士顿马萨诸塞州眼耳科头颈癌外科主任Kevin Emerick医学博士说,虽然这些癌症大多是相对良性的,但移植受者也会发展成更多的局部晚期或晚期皮肤恶性肿瘤。“随着我们做越来越多的移植手术,我们将会有越来越多的这样的病人,”埃默里克博士说,他也是诊所非黑色素瘤皮肤癌多学科临床和项目的联合主任。“因此,也许一个好的趋势是对这些患者需要的特殊护理的认可和承认。”随着更多的患者在移植后存活时间延长,更多的患者需要长期随访。他指出,在许多学术医疗中心,皮肤科正在开设高风险诊所,专门为越来越多的实体器官移植患者提供服务,其中一些患者需要每6或12周看一次。根据意大利一项对1300多名心脏或肾脏移植患者的研究,“患皮肤癌的总体风险从移植后5年的累计发病率5.8%增加到移植后10年的发病率10.8%。”其他国家的研究记录了更高的比例。埃默里克博士说,一个重要的信息是,需要专门的提供者进行常规监测,并需要足够的基础设施和团队来照顾那些患皮肤癌的患者。 与其他癌症的风险相比,皮肤癌的风险主要是基于受体的免疫抑制和癌症病变逃避免疫监视的能力。“我们的免疫系统在帮助抑制和清除DNA损伤方面起着至关重要的作用,我们的皮肤上都有大量的DNA损伤,”埃默里克博士说。“所以,如果你把我们免疫系统的监视作用拿走,这就是为什么患者患皮肤癌的几率要高得多。”因此,与普通大众相比,与新肝脏相关的癌症风险可能更高,但与新心脏相关的风险甚至更高。同样,小肠和肺移植患者往往有更高的移植后淋巴增殖性疾病发病率,这是一种危及生命的淋巴瘤,也见于造血干细胞移植后,白细胞不受控制地增殖。移植肾患者生活数年或数十年可能会减少他们的免疫抑制方案,老年患者通常免疫系统活性较低;相反,随着时间的推移,移植器官的寿命延长会增加风险。对于一些患者,转换免疫抑制剂(例如,从他克莫司到西罗莫司)可能会降低患皮肤癌的风险。“这就是为什么与人们的移植团队合作是如此重要,”埃默里克博士说。“他们是找到合适的免疫抑制水平的真正专家,(移植受者)需要维持他们的器官,这对这些人来说非常重要,尤其是我们的心脏和肺移植患者。”降低风险的策略,例如为患者接种乙型肝炎和人乳头瘤病毒疫苗,并优先宣传预防信息(例如,强调避免更多阳光照射的紫外线辐射的重要性),即使患者在器官移植等待名单上,也可能使他们受益。皮肤色素较多的患者患非黑色素瘤和黑色素瘤皮肤癌的风险较低,包括在器官移植后,因为黑色素对紫外线辐射的累积暴露具有保护作用。即便如此,埃默里克博士说,他们患其他癌症的风险仍然很高,需要时刻保持警惕。器官移植后发生的晚期皮肤癌的一个残酷的讽刺是,免疫疗法是一种关键的抗癌治疗方法。“皮肤癌是免疫疗法最容易治疗的癌症,”埃默里克博士说。“不幸的是,免疫疗法伴随着失去移植器官的巨大风险。”抗癌免疫疗法可以用于一些肾移植患者,他说,“很大程度上是因为如果他们的器官衰竭,你可以考虑透析。”同样的选择不适用于肺、心脏和大多数肝脏移植患者,因为失去器官会杀死他们。埃默里克博士和其他专家说,免疫抑制有助于防止对捐赠器官的排斥,但会增加许多其他疾病的风险,这一事实加强了对移植患者进行长期癌症监测和早期检测的重要性。因此,一种传播性恶性肿瘤可能直到移植后数年才在临床上表现出来,贝里博士补充道。他说:“我们不仅要研究那些不幸患上肿瘤的贫穷受者的生存风险或发病率-死亡率风险,而且还要研究其余受者的风险分层。”幸运的是,大多数这样的患者在移植后定期就诊,这些就诊为筛查和风险评估提供了充足和关键的机会。
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来源期刊
Cancer Cytopathology
Cancer Cytopathology 医学-病理学
CiteScore
7.00
自引率
17.60%
发文量
130
审稿时长
1 months
期刊介绍: Cancer Cytopathology provides a unique forum for interaction and dissemination of original research and educational information relevant to the practice of cytopathology and its related oncologic disciplines. The journal strives to have a positive effect on cancer prevention, early detection, diagnosis, and cure by the publication of high-quality content. The mission of Cancer Cytopathology is to present and inform readers of new applications, technological advances, cutting-edge research, novel applications of molecular techniques, and relevant review articles related to cytopathology.
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