Retrospective review of malignancy in liver transplant recipients

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Background: Multiple studies demonstrate an increased incidence of malignancy following solid organ transplantation. Due to steady improvements in post-transplant survival, the proportion of recipient deaths secondary to these malignancies is increasing. While cancer in kidney recipients is well researched, studies of cancer in liver recipients are relatively few and limited by small numbers of patients. In this study, we analyze the frequencies, treatments, and outcomes of different malignancies in adult liver transplant recipients from a single high-volume transplant center and suggest appropriate management strategies. Methods: A retrospective review was performed of all adult liver transplant recipients at a single liver transplant center between January 2002 and December 2016. Data regarding treatment, outcome, and survival was collected and analyzed from a previously established institutional database. Results: We identified 1221 adult liver transplants, of which 108 developed at least one post-transplant malignancy, with 45 cases of cutaneous malignancy and 67 cases of solid organ malignancy. Three patients developed recurrent hepatocellular carcinoma and one developed de novo hepatocellular carcinoma. A history of cancer prior to transplant was positive in 85/1061 (8.0%) patients that did not develop cancer and 14/108 (13.0%) patients that did (p = 0.10). Overall 1-, 3- and 5- and 10-year survival were 96.3%, 87.9%, 80.1% and 50.7% for the patients who developed cancer and 90.1%, 83.5%, 77.7% and 67.2% for those who did not (p = 0.0209). For patients who developed cutaneous cancer only, corresponding survival was 100%, 100%, 97.1% and 86.4% compared to 94.3%, 81.4%, 71.0% and 32.1% for patients developing other cancers. (p < 0.0001). 24 (22.2%) patients that developed cancer experienced biopsy-proven rejection, compared to 227 (21.4%) for patients without cancer (p = NS). 41 patients with cutaneous malignancy received local excision, while four developed local invasion and required invasive surgery or radiation. Only one of these patients developed metastatic disease. 50 patients with solid organ tumors received surgery, chemotherapy, radiation, hormone therapy, and/or targeted therapy while the rest received hospice, surveillance, or were lost to follow up. Lung, colorectal, and hematologic cancer patients that received chemotherapy (n = 17) tolerated treatment poorly with 14/17 (82.4%) regimens reduced or stopped due to toxicity and progression. Those with other cancers (n = 7) tolerated chemotherapy well and completed their prescribed courses. One patient treated with surgery required re-operation for a hematoma, one with radiation developed a bleeding ulcer, and one with targeted therapy developed a GI bleed. Conclusion: Outcomes varied based on the type of malignancy and degree of systemic involvement. Cancer patients demonstrated significantly worse 10-year survival relative to those without cancer but comparable 1-, 3-, and 5-year rates, indicating risk of mortality due to cancer does not increase until well after transplantation. As expected, patients with solid organ cancers had significantly worse survival than those with cutaneous cancer, whose survival was similar to those without cancer. There were no differences in rates of rejection, suggesting a judicious reduction of immunosuppression is an appropriate component of oncologic treatment. Patients with non-metastatic disease amenable to local surgery or radiation tolerated treatment well, while patients with hematologic, lung, and colorectal cancer requiring chemotherapy developed higher rates of toxicity than patients with other cancers.