Reply: Liver grafts from donors with central nervous system tumors: A single-center perspective

Abstract

I read with interest the thoughtful article entitled “Liver Grafts from Donors with Central Nervous System Tumors: A Single-Center Perspective.”1 This report raises a few questions and invites comments. The authors note that in their 42 cases, the diagnosis of a central nervous system (CNS) tumor in the donor was made by histological examination and not solely by imaging. However, although 26 patients underwent either craniotomy or biopsy (see Table 2 in their article), 8 underwent no procedure, and the other 8 patients underwent procedures that do not typically yield a tissue diagnosis of neoplasm. How was the diagnosis of a CNS tumor made in these 16 patients, and how were these CNS tumors graded without the tissue mandated to permit grading? Of additional concern is the statement in the Discussion section that “a donor with a low-grade CNS malignancy (astrocytoma, glioblastoma, or medulloblastoma)…carries a 7% risk of tumor transmission.” Glioblastoma and medulloblastoma in fact represent the highest grade of CNS malignancy. The authors perpetuate the belief that surgical violation of the blood-brain barrier is an important risk factor for spreading a primary brain tumor extracranially and potentially increasing the small risk of contaminating a donable organ. I have argued previously that this belief may be fallacious.2 A recent well-documented case of a previously healthy donor dying of sudden intracranial hemorrhage supports my contention; this donor was found to have an undiagnosed glioblastoma at autopsy, and the recipient of his lungs succumbed to pulmonary glioblastoma.3 Low-grade primary brain tumors do appear to carry a lower risk of extraneural metastasis than high-grade tumors such as medulloblastoma and glioblastoma2, 4; of course, these tumors are less likely to be fatal unless they transform into high-grade tumors. These observations do not contradict Kashyap et al.'s1 conclusion that patients with CNS tumors represent a potentially underused group of donors. They do argue both for the careful examination of transplanted organs and locoregional lymph nodes, cervical lymph nodes, craniotomy sites, and shunts and for the creation of a registry of recipients of organs from donors with CNS tumors to ascertain the true risk of transmission of these generally fatal malignancies. David Schiff M.D.*, * Neuro-Oncology Center, University of Virginia, Charlottesville, VA.