Donor‐derived malignancy in a pancreas graft

Donor-transmitted tumors may occur in about 0.02% of solid organ recipients [1]. Considering the rarity of these events, the case of a patient who developed malignancy in a pancreatic graft derived from a donor with a malignant glioma as the cause of brain death is reported. A 11-year-old white female child who had died from a malignant glioma was the organ donor. She had been diagnosed with malignant glioma by the age of 4 when a first craniotomy was performed and the tumor removed. Histological findings revealed a grade III pleomorphic xanthoastrocytoma. She was followed for 6 years asymptomatically up to the age of 10. By this time, she presented with seizures and headache episodes and a new surveillance showed recurrent cerebral tumor. Three consecutive craniotomies were performed within a period of 6 months for removal of the recurrent tumor. After the fourth craniotomy, she was evaluated for intracranial hypertension and progression to brain death. No ventriculo-peritoneal shunt, chemoor radiotherapy was performed during the follow-up. By the time of recovery of organs, no intra-abdominal or intra-thoracic abnormalities were noticed. Heart, liver, one kidney and pancreas were recovered for transplant in different recipients. One kidney was not used because of anatomical problems. Macroscopic appearance of the pancreas was normal. A pancreas transplant alone (PTA) was performed in a 21-year-old male patient, who had been diabetic for 19 years. The indication of the transplant was based on the presence of two secondary complications of the diabetes, including an advanced retinopathy and moderate nephropathy (proteinuria of 1.14 g/24 h and a creatinine clearance of 66 ml/min). Surgical technique consisted of bladder and systemic venous drainage with a total ischemia time of 6 h and 10 min. A quadruple sequential immunosuppression regimen was employed with thymoglobulin, mycophenolate mofetil, tacrolimus and prednisone. Early postoperative outcome was uneventful and the patient was discharged insulin-free 12 days post-transplant. No imaging study was performed until the 4th postoperative month according to our routine protocol for uncomplicated pancreas transplant recipients. By this time, the patient developed abdominal pain and an allograft pancreatic mass was diagnosed in an ultrasonography and confirmed by a CT scan. An ultrasoundguided biopsy was performed and revealed a malignant anaplastic tumor, compatible with glioma. A retrospective comparison between donorand recipient histological findings was carried out and this study confirmed the same malignant glioma in both patients, classified as a grade III pleomorphic xanthoastrocytoma by immunohistochemical staining. A graft pancreatectomy was performed and the surgical finding was a tumor limited to the head of the pancreas with no suspected infiltrative tissues or lymph nodes surrounding the graft (Fig. 1). Immunosuppression was promptly discontinued and the patient was restored to insulin. A strict follow-up has been done, with thoracic and abdominal CT scans performed every 6 months. His clinical evolution has been uneventful and the patient is stable and malignancy-free 5 years after graft removal.