Transplantation of a liver graft from a living donor with early gastric cancer
Olivier Detry, Arnaud Deroover, Pierre Honoré, Michel Meurisse
Dpt of Abdominal Surgery and Transplantation University of Liège
CHU Sart Tilman B35 B4000 Liège
We read with great interest the paper of Fujiwara et al., published in the March issue of this journal (1). This case report described the life-saving liver transplantation of a 9-month-old Japanese baby with a partial liver graft from the only potential parental living donor, who was diagnosed with early gastric cancer during the pre donation work-up. Curative partial gastrectomy was performed just before partial liver retrieval, during the same anesthesia. Both the donor and the recipient were reported alive and well at one-year follow-up. We believe that this interesting case might raise several important issues and might deserve some comments.
It has been determined that (cadaveric and living) organ donors with past history of cancer should be denied from donation because of a significant risk of cancer transmission to the recipient (2). Transmission of donor cancer to organ recipient is favored by the post transplant immunosuppression, and particularly by the calcineurin inhibitors that are reported to enhance cancer cell development (3). However, due to the organ donor shortage, the use of organs harvested from donors with primary central nervous system tumor or with in situ cancer is generally admitted, as these cancers have a very low risk of transmission to the recipient (2,4). However, the risk of transmission of cancer with the graft is not null, and has always to be balanced with the risk of dying on the waiting lists.
In this particular case, Fujiwara et al. estimated that the risk of transmission of the early gastric cancer was lower that the recipient’s risk of dying. As the clinical status of the recipient was desperate and that this living donor was the only possibility in Japan where cadaveric donation is generally not accepted for cultural reasons, the risk of cancer transmission was clearly much lower that the natural history of the recipient’s disease. Even if the results were good in this case, the risk of cancer transmission was not null. The rate of hepatic metastasis of early gastric cancer was reported to be between 0.8 to 1.7% in
non-immunosuppressed patients (1). Even if the authors performed donor liver intra operative ultrasonography and multiple frozen sections, these measures did not totally exclude the possibility of the presence of undiagnosed cancer cells in the liver or in the peritoneum. For these reasons the authors chose to renew all the surgical instruments between partial gastrectomy and partial hepatectomy. Moreover it was demonstrated that surgical manipulation increases the rate of circulating cancer cells in gastric cancer (5). As the liver is the first filter for these gastric cancer cells, there was a potential risk of circulating cancer cell migration to the liver graft, and post transplant immunosuppression could have promoted development of these cells.
Another ethical issue is the increased risk imposed to the donor by the combination of partial gastrectomy to the procurement of a part of the liver. This risk was acceptable for this donor who largely benefited from donation work up that diagnosed curable early gastric cancer. Moreover it was also demonstrated that combined bowel and liver surgery was possible with acceptable morbidity and mortality (6). In the case reported by Fujiwara et al., the risk for the donor may be estimated low as the lateral segment procurement consists in a minor hepatectomy. However this risk may be much higher in right liver lobe procurement for living liver transplantation in adult recipient.
Therefore we consider that in the particular case reported by Fujiwara et al., the use of such a marginal living donor was fully justified, both for the donor and the recipient. However the use of a donor with a (small or not) cancer should always be avoided, as the risk of transmission of this cancer to the recipient is real, as described by multiple case reports. Moreover adding any surgical procedure to the procurement of part of the liver for organ donation is highly controversial, especially in right liver lobe harvesting, a procedure with demonstrated morbidity and mortality.
1. Fujiwara T, Sakuma Y, Hosoya Y, Hojyo N, Yasuda Y, Nagai H, et al. Liver transplantation from a donor with early gastric cancer. Am J Transplant 2005; 5: 627-629. 2. Detry O, Detroz B, D'silva M, Pirenne J, Defraigne Jo, Meurisse M, et al. Misdiagnosed malignancy in transplanted organs. Transpl Int 1993; 6: 50-54.
3. Guba M, Graeb C, Jauch KW, Geissler. Pro- and anti- cancer effects of immunosuppressive agents used in organ transplantation. Transplantation 2004; 77: 1777-1782.
4. Detry O, Honore P, Hans MF, Delbouille MH, Jacquet N, Meurisse M. Organ donors with primary central nervous system. Transplantation 2000; 70: 244-248.
5. Miyazono F, Natsugoe S, Takao S, Tokuda K, Kijima F, Aridome K, et al. Surgical maneuvers enhance molecular detection of circulating tumor cells during gastric cancer surgery. Ann Surg 2001; 233: 189-194.
6. Elias D, Detroz B, Lasser P, Plaud B, Jerbi G. Is simultaneous hepatectomy and intestinal anastomosis safe? Am J Surg 1995; 169: 254-260.