Amara Dominic, Wisel Steven A, Braun Hillary J, Collisson Eric A, Friedlander Terence, Worner Giulia, Roll Garret R, Hirose Ryutaro, Stock Peter G
School of Medicine, University of California, San Francisco, San Francisco, CA.
Department of Surgery, University of California, San Francisco, San Francisco, CA.
Transplant Direct. 2020 Dec 8;7(1):e636. doi: 10.1097/TXD.0000000000001090. eCollection 2021 Jan.
Stopping immunosuppression in a transplant patient with donor-derived malignancy offers the theoretical benefit that reconstitution of the patient's immune system will allow "rejection" of the malignancy, as the malignancy also originates from allogeneic tissue. However, this option exists with the caveat that the patient's allograft(s) will likely be rejected too. In simultaneous pancreas-kidney (SPK) recipients, the normal continued functioning and possible absence of malignancy in either the unaffected kidney or pancreas further complicate this decision.
The charts of 3 patients with donor-derived metastatic malignancies after SPK were retrospectively reviewed in detail. We provide treatment and management recommendations based on successful outcomes and a review of the existing literature.
Consistent with a broad review of the literature, in all 3 cases, complete immunosuppression cessation, removal of both grafts, and in 1 case treatment with an immune checkpoint inhibitor to augment the immune response was successful. One patient is doing well 1 year after successfully undergoing kidney retransplantation, while a second patient is active on the waitlist for SPK retransplantation after no evidence of metastatic disease for 2 years.
The successful management of metastatic donor-derived malignancies requires allograft removal, immunosuppression cessation, and adjuvant therapy that includes occasional use of checkpoint inhibitors to augment the immune response.
对于患有供体来源恶性肿瘤的移植患者，停止免疫抑制理论上有益，因为患者免疫系统的重建将使“排斥”该恶性肿瘤，因为该恶性肿瘤也源自异体组织。然而，这种选择存在一个问题，即患者的同种异体移植物也可能被排斥。在胰肾联合移植（SPK）受者中，未受影响的肾脏或胰腺的正常持续功能以及可能不存在恶性肿瘤使这一决定更加复杂。
对3例SPK术后发生供体来源转移性恶性肿瘤患者的病历进行了详细的回顾性研究。我们根据成功的结果和对现有文献的回顾提供治疗和管理建议。
与对文献的广泛回顾一致，在所有3例病例中，完全停止免疫抑制、切除两个移植物，并且在1例病例中使用免疫检查点抑制剂增强免疫反应治疗是成功的。1例患者在成功进行肾脏再次移植1年后情况良好，而另1例患者在2年无转移性疾病证据后正在积极等待SPK再次移植。
成功管理供体来源的转移性恶性肿瘤需要切除同种异体移植物、停止免疫抑制以及辅助治疗，包括偶尔使用检查点抑制剂增强免疫反应。
