Transmission of Cancer With Cadaveric Donor ... - Beaumont Hospital

EDITORIAL

Tomas Denver,

Berl, CO

William Toledo,

Editor

OVERVIEW

Henrich OH

COMMITIEE Mark

Fred Silva Oklahoma

Paller

Minneapolis,

MN

OF THE NEPHROLOGY TRAINING PROGRAM DUKE UNIVERSITY MEDICAL CENTER

City,

OK

AT

The nephrology training program at the Duke University School of Medicine provides comprehensive training in clinical nephrology. dialysis. renal transplantation. and hypertension. Fellowship options include a 3-yr clinical investigator pathway. a 3-yr basic science investigator pathway. and a 2-yr clinical training track. Of the 14 fellows completing training over the past 5 yr. 10 have pursued academic careers and 4 have entered private practice. Each fellow completes a clinical program that includes rotations on three services: the transplant service. the acute nephrology service. and the VA consult service. During the transplant rotation, the fellow is involved in the evaluation of donor and recipient candidates for kidney and simultaneous kidney-pancreas transplant. Posifransplant care is primarily the responsibility of the nephrology division. The acute service provides interventional support to Duke University Medical Center’s intensive care units, an inpatient renal ward, and a general renal consultation service. Outpatient activities include the longitudinal management of the fellow’s own renal transplant. dialysis. chronic renal failure. and nephrology referral patients. Clinical facilities include the 1.100-bed Duke University Medical Center and the 450-bed Durham Veterans Medical Center. The division directs five outpatient dialysis facilities, providing care for over 375 dialysis patients. peritoneal and home hemodialysis programs are included. The renal transplant program at Duke averages 70 and simultaneous kidney-pancreas transplants per year. The Duke Hypertension Center provides the opportunity clinical experience in refractory hypertension. An NIH-supported General Clinical Research Center is often used division. The basic science investigator pathway includes 2 yr of research under currently has a Transplantation Program Project Grant with three faculty investigation is also ongoing in areas including metabolic bone disease. transduction, and receptor regulation.

the direction of a faculty sponsor. The division members involved. NIH-funded basic science genetic predisposition for hypertension. signal

Advanced training in biostatistics, study design. and epidemiology (including Health Science degree) is available to fellows choosing the clinical investigator in the dietary modification of hypertension. morbidity and mortality in dialysis and cardiovascular disease in patients with renal failure are ongoing.

the opportuniiy to pursue a Masters of pathway. NIH- and industry-funded trials patients, hemodialysis vascular access,

The straight clinical pathway includes 18 months of intensive clinical training nephrology including the management of outpatient hemodialysis and significant tension experience with a brief exposure to clinical research. In addition, structured histocompatibility are available.

Transmission Peter

J. Conlon2

of Cancer and Stephen

Affairs Active kidney for by the

that encompasses all areas of outpatient transplant and hyperexposures to renal pathology and

With Cadaveric

Donor

Organs1

R. Smith ABSTRACT

P,J. Conlon,

S.R. Smith,

sion of Durham,

Nephrology.

(J. Am.

Soc.

1 Received

June

2

NC

Durham, 1 046-6673/0601

of Medicine,

University

Medical

30, 1994.

1995;

Accepted

to Dr. P.J. conlon,

October Box

3014.

is presented of cadaveric

minisatellite University

NC 27710. -0054$03.00/0

One

in which each of the recipients of kidneys developed metastatic

of the recipients

died,

and

the other

demonstrated involution of metastatic deposits after graft nephrectomy and withdrawal of immunosuppression. By the use of polymerase chain reaction of

26. 1994. Duke

A case a pair carcinoma.

#{243}:54-#{243}O)

Journal of the American society of Nephroiogy Copyright © 1995 by the American Society of Nephrology

54

DiviCenter,

1

Nephrol.

correspondence

Department Duke

Medical

Center.

regions

of donor

and

recipient

donor origin of the tumor was conclusively strated. Although a relatively uncommon tion sion

of cadaveric of cancer

with

renal transplantation, cadaveric organs Volume

6

DNA,

the may ‘

the

demoncomplica-

Number

transmisbecome 1

‘

1995

Conlon

more organ

frequent donation.

Key Words:

I

t was

Renal not

era

that from

nancy major

as

long

older

transplant. after

malignancy

the

eric

transplantation

A

frequency

accepted

for

cancer

of the

transplantation

transmission of maligwas recognized as a

this first report by McPhaul and more than 1 50 cases of donorhave

malignancy transmitted eric kidneys from the literature is reviewed,

CASE

dawn

the problem of the donors to recipients

how

are

transplated

the

problem. Since McIntosh ( 1 ) In 1 965, transmitted

donors

been

reported.

A case

of

with each of a pair of cadavsame donor is presented. the and suggestions are made on

of this

devastating

might

be

result

of cadav-

lowered.

REPORT white man with end-stage diabetic neunderwent cadaveric renal transplantation antigen-matched kidney at Duke University Center after 2 yr on peritoneal dialysis. He

30-yr-old

phropathy of a six Medical

was

initially

treated

with

triple

immunosuppression

consisting of cycbosporlne. azathioprine, and prednisone. No induction antilymphocyte preparation was used. The kidney functioned immediately, and he was discharged with a creatinine level of 2. 1 mg/dL. His initial posttransplant course was complicated by two biopsy-confirmed episodes of acute cellular rejection, for which he received a total of nine daily pulses of 500 mg of methylprednisolone and one 10-day course of

Figure

repeat

Journal

OKT3.

5 mg/day.

He

also

subsequently

of the

American

Society

of Nephrology

Smith

developed

a

fever associated with cytomegalovirus seroconvension, for which he was treated with a 10-day course gancichovir. Over the subsequent 7 months, he developed slowly deteriorating renal transplant function. transplant biopsy performed 9 months after transplantation demonstrated marked interstitial fibrosis and arteriohar thickening. There was no evidence malignancy in any of the transplant biopsies. Eleven months after transplantation. he developed shortness of breath and pain over the transplanted kidney. The serum creatinine was 4.8 mg/dL. and chest x-ray demonstrated a reticuhonodular pattern (Figure restrictive predicted. arterial

1A).

Po2

Pulmonary pattern with With was

function a diffusing

the patient 53 mm Hg

tests

breathing and the

demonstrated capacity of 35% Pco2

room was

air, 25

of A

of

a a of

the mm

Hg. Bronchoscopy showed a grossly normal endobronchial tree; however, four out of four tnansbronchial biopsies demonstrated poorly differentiated non-small cell carcinoma with some squamous characteristics (Figure 2A). A computed tomography scan of the chest, abdomen, and pelvis demonstrated neticular/nodubar parenchymab lung lesions. but no mediastinal adenopathy. There were mildly enlarged penaortic nodes, and the transplanted kidney was enlarged. A bone scan and brain magnetic resonance imaging scans were negative for metastatic disease. A transplant nosuppression nation of

nephrectomy was performed, and was discontinued. A histologic the excised transplanted kidney

1 (A) Chest radiograph of Recipient A on presentation with dyspnea showing an interstitial reticulonodular radiograph 6 wk after transplant nephrectomy and the cessation of immunosuppressive therapy. .

and

immuexamidemon-

pattern;

(B)

55

Transmission

of Cancer

Figure 2. Photomicrograph (original magnification, x250) of tissue obtained from: (A) transbronchial biopsy, Recipient A; (B) graft nephrectomy, Recipient A. Arrowhead demonstrates areas oftumor with similar appearance to transbronchial biopsy; (C) Tumor biopsy, Recipient B. strated throughout

areas

tumor the

present kidney,

adjacent

In small mainly

to arteries.

to medium-sized in lymphatics

The

tumor

was

nests and In

quite

pbeo-

morphic (Figure 2B) in its appearance; some tumor nodules had a clear cell pattern, but the majority of the tumor was composed of poorly differentiated car-

cinoma

and

that of biopsies. dyspnea

the malignant By 6 wk after was markedly

showed

resolution

1B).

He is now

some

areas

had

of the 6 months

an

appearance

cells from transplant Improved

interstitial after

similar

to

the transbronchial nephrectomy, the and the chest x-ray

transplant

changes

(Figure

nephrectomy

and has shown no evidence ofrecurrence oftumor. He continues to have a reduced diffusing capacity at 48% of predicted and a restrictive pattern on pubmonary function testing. The kidney donor was a 64-yr-old man who was declared brain dead after an apparently spontaneous intracranial hemorrhage. Apart from some evidence of chronic obstructive airways disease, he had been in good x-ray was

56

health before taken in the on a ventilator

his sudden death. intensive care unit showed bulbous

A portable while the changes

chest patient In the

night lung, but no evidence of a mass lesion. At the time of organ harvesting, the kidneys appeared normal and there was no indication of any intra-abdominal malignancy. A subcapsubar biopsy of the kidney at the time of transplantation surgery demonstrated changes of artenionephroscberosis only. No autopsy was performed. The other kidney from the same donor was transplanted into a female recipient at another hospital (Recipient B). A needle biopsy of this graft performed because of a rise in creatinine 10 months

after larger

transplantation subsequent

sent for recipient

karyotyping origin.

biopsy

revealed (Figure

malignant 2C) of the

to determine if it was Karyotyping of this larger

cebls. A tumor was of donor or biopsy sug-

gested that the tumor contained female cell types and, thus, was of recipient origin. In retrospect, the sungeon who performed the procedure noted that the tumor tissue was surrounded by fat and omental tissue, and thus, the sampbe that was karyotyped may have contained this uninvolved recipient tissue. The patient decbined either graft nephrectomy or chemotherapy and died of metastatic carcinoma a few weeks later.

Volume

6

‘

Number

1

.

1995

Conlon

In order

to confirm

that

the

malignant

tumor

in our

chain

from the donor, we performed DNA on tissue taken from: the tumor in the graft in our patient (Recipient A), the graft transplanted into Recipient A, a biopsy of Recipient A, and peripheral Recipient A. DNA was extracted, and six

hod

reaction

with

primers

AL).

on gel

amplified In

obtained

(Huntsville, resed dried

were

(PCR)

6% was

the

from

The

PCR

loci

are

netic Thus,

variability in DNA obtained

yield

PCR

were M film

x-ray

urea for

unequivocal

donor

gels. 16 h.

The The

with

ge-

polymorphic, tandem individuals

products

of the tumor lymphocyte

repeats. will

of different

DNA fingerprint DNA (Figure

determination

Inc.

ehectropho-

Analysis of multiple microsatellite loci distinctive pattern of bands (corresponding varying sizes of DNA fragments) that can “DNA fingerprint” to distinguish individual

comparison the recipient’s

(32PIdCTP,

Genetics,

number of from different

amplification

polymenase of

products

highly

the

the

Research

polyacrylamide-7.7 exposed to

microsatelhite

by presence

that

Smith

BCTL

patient arose “fIngerprinting” transplanted cortex of the transbronchiab

blood of microsatelhite

and

sizes.

produces

a the as a A

to be used samples.

with that of 3) allowed the

the

tumor

was

of

origin.

DISCUSSION In this

cancer

report.

from

we

have

described

an apparently

the

healthy

transmission

organ

of

donor

to two

recipients of renal transplants with devastating results for both recipients. Although the organ donor did not have an autopsy, with the use of DNA fingerprint-

ing

technology.

we

have

been

able

unequivocally that the tumor donor, and we suspect arose chial carcinoma. The recipient able to recover from histologically

to

demonstrate

arose from the organ from metastatic bronof one of the grafts was documented wide-

spread metastatic cancer with withdrawal of immunosuppression and transplant nephrectomy. The transmission of cancer from a donor to the recipient of a cadaveric organ is a catastrophic result of transplantation. In the early days of cadavenic

transplantation, of donors

it was who

died

not

uncommon

of cerebral

for transplantation. After a series development of metastatic cancer these organs (2), the use of organs recognized malignant disease was

theless,

despite

the

of donors known to be reports of being

planted in

one

modern

to

can

of three

ways.

An

malignancy unrecognized

cell carcinoma in the graft may appears to be the least common perhaps

of the

recipients

transfer

because

these

tumors

used

of reports of the in the recipients of from donors with abandoned. None-

practice

graft

organs

to be

to carry malignancy, unrecognized tumors

transmitted

organ

for the

metastases

there in

continue the donor

(3,4).

A trans-

to the

recipient renal

be transplanted. This mode of transmission, often

be

recog-

nized at the time of organ harvest. Second, the transplanted kidney may contain metastatic cells from a

Journal

of the

American

Society

of Nephrology

distant primary tumor that may subsequently tasize further in the organ recipient, as was the the patients presented here. Table 1 summarizes

primary

malignancies

transmitted

with

TABLE 1 Primary .

reported

organs

by Penn

that organ

have

been

transplants.

malignancies that to be transmitted

metascase in the

reported Third,

have with

the

to be trans-

been cadaveric

(23)

exclusion

primary

can

Figure 3. DNA fingerprint analysis comparing: B, peripheral blood lymphocytes from Recipient A; C, cortex of transplanted kidney not involved with tumor; T, tumor from transplanted kidney; L, malignant cells from transbronchial lung biopsy. Tumor samples and kidney cortex show distinct differences from recipient blood lymphocytes, confirming that the tumor arose from the donor.

Lung

Breast Carcinoma Colorectal Cutaneous Lymphoma Bronchial

Carcinoma Malignant

Melanoma

Carcinoma

Renal Carcinoma Choriocarcinoma

Glioma Hepatocellular

Carcinoma

57

Transmission

planted

of Cancer

organ

may

contain

passenger

leukocytes

that

donor.

Recently.

Starzb

et al.

have

donors

occur after renal transplantation occur in the albograft itself; it is possible that many of these are derived from the donor (22). The outcome of patients who receive a transplanted

with

primary

brain

tumors

comprise

up

to 7%

of the organ donors in some series, there have been only four reports of the development of a metastasis from a primary brain tumor in alhograft recipients (8-1 1 ). Factors that traditionally have been associated with an increased risk of extraneural spread include a

high

grade

of malignancy,

a history

of craniotomy,

ventniculosystemic drainage, and a long disease. Medullobbastoma and glioblastoma forme tumors together represent the vast tumors that are anecdotal

spread reports

outside the suggesting

toneal shunting may metastasis, a recent

increase review

CNS. that

the of 415

duration

of multimajority of

Although there ventricuboperi-

risk of extracranial children with ma-

lignant CNS tumors found no difference in the occurrence of extracranial metastasis between children with or without a previous shunting procedure. Of the

four

previous

cases

of donor-transmitted

CNS

malig-

nancy, three occurred in the absence of a shunt. Currently, the United Network for Organ Sharing (UNOS) standards exclude potential donors who died of a primary CNS malignancy if they have undergone a previous shunting procedure. Given the rarity of transmission of malignancy from patients with histologically confirmed primary CNS malignancies, it may be inappropriate to exclude these donors, whether or

not

they

have

had

a shunting

procedure

previously.

neous

Intracerebral

hemorrhage

that,

fer

of

strated the

group

58

biologically

by

cases

production

antigens

active

of hemolytic by “passenger”

the as

anemia against

lymphocytes.

Between

malignancy

is not

15 and

30%

entirely

ofbymphomas

clear.

Penn

that

has

reported

the development of malignancy in 78 (45%) of 142 patients who received a cadaveric graft from a donor who was subsequently found to have had a malignancy (23). The tumor was confined to the graft or surrounding

static

in 36.

tissue

in

Figure

4 summarizes

28

cases

these 36 patients. Sixteen ing received chemotherapy

munosuppression. had withdrawal nephrectomy.

went

into

became

the

time of the report to Penn’s report.

died

in

and

hayof im-

20 patIents who and or graft

of metastatic

remission, with there

meta-

experience

patients died without or discontinuance

1 0 patients

complete

resolution normalization

and

In the case of the of immunosuppression

cancer,

1 was

alive

9

at the

evidence of cancer. In addition are several case reports of the

of metastatic of the

disease patients’

associated with immune mechanisms

the

by either cessation or reduction in immunosuppression and/or removal of the transplanted graft (24,25). How frequently a metastatic tumor will resolve after the discontinuation of Immunosuppression is unclear, because undoubtedly, cases in which a good

is obtained

pression apparent

cells

are for

are

subjects,

TABLE

the

likely than

transplanted

they however,

When,

from

more more are

cessation

to 30

be yr

into

It has been malignant

nonimmunosuppressed

2. Recommendations

occurrence

of immunosup-

reported. that when

frequenfly rejected they are transplanted

compbetely into an

to reduce

of donor-transmitted

transdemon-

resulting

from

recipient

lymphocytes

Exclude donors with known histologically

confirmed

(26). immu-

the

malignancy

blood

from

history of malignancy primary

and low-grade skin carcinoma. Exclude women of child-bearing apparently

spontaneous

13-HCG is elevated,

(15,16). with

B lymphocytes,

of antibodies

printing of tumor cells have been able to demonstrate that a number of these malignant lymphomas arise from lymphocytes derived from the organ donor (182 1 ). Just as the immunosuppressed state can induce recipient lymphocytes to undergo malignant transformation, so also can they similarly Influence donor

on subsequent

autopsy after the organs had been transplanted, turned out to be a hemorrhage into a cerebral metastasis ( 13, 14). Choriocarcinoma with cerebral metasta515 has been mistaken for a primary intracerebral hemorrhage. with the subsequent transmission of

choniocarcinoma to organ recipients Renal transplantation is associated

and lymph received an

( 1 7). It is well established that transplant are at increased risk for the development of hymphomas. HLA typing and DNA finger-

result

It is important that donors with a suspected primary Intracerebral neoplasm have a histologic diagnosis before organ donation because there are a number of case reports of tumors with the radiobogic appearance of a primary brain tumor that later prove to be a metastatic deposit of a different primary tumor (12). Similarly, cases have been reported in which the donor died of what appeared to have been a sponta-

29

in skin patients

the

presence of donor-derived node tissue more than

albograft recipients malignant

cells yr after

demonstrated

may have already undergone malignant change or subsequently undergo malignant change to form a malignant lymphoma. In 1926. Bailey and Cushing reported that primary central nervous system (CNS) malignancies never give rise to extracranial metastasis (5). Consequently. when clinical transplantation began. patients who died of primary CNS malignancies were considered suitable candidates for organ donation. Subsequently, it became apparent that primary CNS malignancies can rarely metastasize with an estimated frequency of between 0.4 and 2.3% (6,7). Although

cerebral

age who die of

intracerebral

unless

except

neoplasms

hemorrhage

pregnancy

can

if

be confirmed

by ultrasound. Meticulous examination at the time of organ

of any suspicious Mandatory

postmortem

of abdominal viscera and lungs harvest with frozen section histology

tissue. examination

of older

donors.

the

Volume

6

‘

Number

1

‘

1995

Conlon

patients

36

with

metastatic

cancer

I 16 died

I 20 had

treatment

without

graft

immunosupression

discontinued±

nephrectomy

sound assay exclude

examinations of the abdominal of human chorionic gonadotrophin the possibility of metastatic

noma

or other

quently

I

I

10 Ded

9 complete

I remission

1 alive

with

ney

are

no

clear

guidelines

on

the

use

of

chemotherapy tion. Although

or radiotherapy in this patient populathe discontinuation of immunosuppression and graft nephrectomy can frequently be achieved in a renal graft recipient. the situation is much more difflcubt with heart or liver graft recipients. In modern practice. a single donor can provide organ tissue for as many as six different recipients, each of which could be potentially Infected with malignant cells. Because older donors are increasingly being that

accepted for organ donation, it is to be expected an increased number of clinically occult malignancies will be transplanted from them. It is essential therefore to intensify efforts to exclude patients with

malignancy

from

Penn

and

important of

the

others

donor

recommendations

made

to reduce

donor-transmitted

with

2) have

malignancy

a history

of any

a number

the

other

of any

suspicious

able

24

of

within

potentially

h

malignant

gross

examination

neophasm when the histologically.

clinician older

team died

the

made

Journal

should

organs.

and

of an

young

American

Even

angiographic malformation, a metastasis

Society

identified

if an

occult

The

of Nephrology

in whom

unsuspected

ago,

and

the

graft

McIntosh

is an

experiment

with

the

undertaken

and bethan

that will nephrecfollow-up is neces-

discovered,

McPhaul

a

can-

( 1) in hu-

best

interest

of

moribund patients have consequences

Only this

in mind. That this experiment may far beyond technical hazards, perdiscomfort and economic extravagance is quite “ This statement has some truth even today. through careful selection of organ donors can unexpected consequence of organ transphanta-

tion

be minimized.

sonal clear.

NOTE ADDED

IN PROOF after

months

A was

found

transplant

to have

the right acetabalum. beam radiation and

therapy with interleukan-2, plant nephrectomy.

1 . McPhaul

nephrectomy.

an

isolated He is

14

bony

Re-

metas-

was treated with currently receiving

months

posttrans-

McIntosh DA Tissue transplantation still J Med 1965:272:105. 2. Martin DG, Rubini M, Rosen VJ: Cadavenic renal homotransplantation with inadvertent transplantation of carcinoma. JAMA 1965; 192:752-754. 3. Osterwitz H, Lucius K, Blank W: Transmission of cancer with cadavenic donor kidneys. mt Urol Nephrol 1990;

vexes.

harof

age

intracerebral

do not demeffort should

screening

donor

a kid-

be promptly removed should be discontinued, suggest that there is a greater

transplantation

immunology

if an

When

REFERENCES

on

of child-bearing

by

man

what

Dr. H. Erlanger. Dr. E. Walstrom. and Dr. D. Weeks of Loma Linda University Medical Center, Los Angeles. CA. who cared for and provided the histologic material from Recipient B. We also acknowledge the support of Dr. Sandra Bigner and the technical excellence of Ahmed Rashaed in performing the DNA fingerprint studies and Dr. David Howell, who reviewed the histology.

Most

suspicious

studies every

tojudge

excluded

should

years

Renal

We acknowledge

be avail-

recipient.

spontaneous

Twenty-nine wrote

ACKNOWLEDGMENTS

until some days later. tissues are examined information for the

women

a cadaver

a previously

If a tumor is subsequently be excised.

primary

donors.

particularly

apparently

to exclude

of the

be

should be

from

Patients

than

older

transplant to

hemorrhage. When onstrate a vascular be

tissue

of the

needs

donors

who

on

is not discovered paraffin-embedded this is important

treating

vesting

tissue

death

sary. should

tasis in external

cerebral malignancies or bow-grade cutaneous malignancy should be excluded. At the time of organ harvest. a rigorous laparotomy should be performed with meticulous abdominal examination and bung examination. A compulsory necropsy with frozen section

examination

be

frequency

(3,4.23).

malignancy

would requirement.

reveals

UNOS

45% chance that it contains tumor cells metastasize (23). If the patient refuses graft tomy or it is technically Impossible, close with appropriate radiobogic investigations

dipient

of

so it is difficult

donors

cer, the albograft immunosuppression cause registry data

Currently,

on organ donors, nor does of donors who subse-

a mandatory

autopsy

Smith

organs and (f3-HCG) to chonionic card-

malignancies.

autopsy,

is transplanted

Twelve

pooh.

(Table

was

later

nosuppressed patient, the tumor cells divide and spread rapidly. It has been suggested that if the donor and recipient are mismatched for HLA boci, the reciplent is more likely to recover than if the graft is well matched, because there will be a more vigorous immunobogic rejection of the transplanted malignancy

an

of organ

autopsy

Figure 4. Outcome of 36 renal transplant recipients who developed metastatic cancer of donor origin, as reported by Penn (23).

There

have

proportion

tumor

( 1 3).

occult

does not require an autopsy it keep data on the number

and

ultra-

JJ,

N Engl

22:581-583. Baquero

A, Penn I. Bannett A, et at.: Misdiagnosis of metastatic cerebral choniocarcinoma in female cadaver donors. Transplant Proc 1988:20:776-777. 5. Bailey P. Cushlng P: A classification of the tumors of the glioma group on a histogenic basis with a correlated study of prognosis. Philadelphia: J.B. Lippincott; 1926: 175. 6. Pasquier B, Pasquier D, N’Gohet A, et at.: Extraneural 4,

59

Transmission

metastases l980;45:

of Cancer

of astrocytomas 112-125.

and

glioblastomas.

Cancer

16. Detry 0. D’Silva M, Defrainge JO. et at: Misdiagnosed malignancy in transplanted organs. Transplant Int 1993:6:50-54. 1 7. Starzl TE, Demetris AJ. Trucco M, et aL: Chimenism and donor-specific nonreactivity 27 to 29 years after kidney alhotransphantation. Transplantation 1993:55: 1272-1277. 18. Gassel AM, Westphal E, Hansmann ML, et at.: Malignant lymphoma of donor origin after renal transplantation: A case report. Human Pathol 199 1 ;22: 1291-1293. 19. Gambacorta M, Bonacina E, Fahini B, et at: Malignant lymphoma in the recipient of a heart transplant from a donor with malignant hymphoma. Transplantation 1991; 51:920-922. 20. Spiro U. Yandell DW, Li C, et al.: Brief report: Lymphoma of donor origin occurring in the ponta hepatitis of a transplanted liver. N Engl J Med 1993:329:27-29. 2 1 . Hjelle B, Evans-helm M, Yen TSB, et aL: A poorly differentiated lymphoma of donor origin in a renal allograft recipient. Transplantation 1989:47:945-948. 22. Penn I: Lymphomas complicating organ transplantation. Transplant Proc 1983; l5lSupph 11:2790. 23. Penn I: Donor transmitted disease: Cancer. Transplant

7. Campbell AN, Chan HSL. Becker LE, et at: Extracranial metastases in childhood primary intracranial tumors. Cancer 1984:53:974-981. 8. Lefrancois N, Touraine JL, Cantarovich D, et aL: Transmission of meduloblastoma from cadaver donor to three organ transplant recipients. Transplant Proc 1987; 19: 2242. 9. Morse JH, Turcotte JG, Merion RM, et aL: Development of a malignant tumor In a liver transplant graft procured from a donor with a cerebral neoplasm. Transplantation 1990:50:875-877. 10. Ruiz JC, Cotorruelo JG, Tudela V. et aL: Transmission of glioblastoma multiforme to two kidney transplant recipients from the same donor in the absence of yentnicular

shunt.

Transplantation

b993;55:682-683.

1 1 . Cohquhoun SD, Robert ME, Shaked A, et al.: Transmission of CNS malignancy by organ transplantation. Transplantation 1994:57:970-978. 1 2. Konigsrainer A, Steurer W, Schumer J, et at.: Transmission of non-Hodgkins lymphoma through renal allogralts-dilsastrous result of false diagnosis and madequate information. Transplant Proc 1993:25:30753076. 13. Homburg A, Kindler J, Hofstadter F, et at.: Regression of an adenocarcinoma transmitted by a cadaver kidney graft. Transplantation 1988;46:777-779. 14. Detroz B. Detry 0. D’Silva M, et aL.: Organ transplantation with undetected donor neoplasm. Transplant Proc 1991:23:2657. 15. Knoop C. Jacobovitz D, Antoine M. et at.: Donortransmitted tumors in lung allograft recipients: Report on two cases. Transplantation 1994:57:1679-1680.

A MESSAGE

TO

Proc

24.

199 1 ;23:2629-263

ent: Complete 25. 26.

OUR

remission

OF THE

AMERICAN

F, et at.: Lymphoprohiferain a liver transplant redipiafter drastic reduction of immugraft loss. Transplantation 1993;

nosuppression without 56:1023-1026. Zukoski CF, Killen DA, Ginn carcinoma In an immunosuppressed tation 1970;9:71-74. Southam CM, Moore AE, Rhoads tion of human cell lines. Science

E, et

at.: Transplanted patient. Transphan-

CP: Homotransplanta1957; 125:158-160.

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Cherqui D, Duvoux C, Plassa tive disorder of donor origin

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OF NEPHROLOGY

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ALMA J. WILLS President Periodical

60

Publishing

Volume

6

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Number

1

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1995