Third malignant brain tumor transmitted by liver transplant raises concern in U.K.

The third confirmed case of a malignant brain tumor transmitted via a liver transplant, reported in the July 4 issue of the British medical journal The Lancet, raises new questions about organ donation policies. The donor was a 47-year-old German woman who died from recurrent glioblastoma multiforme. Five months after receiving her liver, the 29-year-old recipient died, with autopsy showing multiple liver, adrenal gland, lymph node, and brain and spinal cord metastases of a gliomatous tumor. Both kidney recipients, by contrast, continue to do well four years after receiving their transplants. Cancer is a general contraindication to organ donation. The only exceptions are low-grade skin cancers and primary central nervous system (CNS) tumors, both of which have low metastatic rates. Glioblastoma multiforme accounts for about one-quarter of all primary CNS cancers in US adults. Biologically, it is the most malignant of glial tumors and also is the most likely to metastasize, primarily to the lymph nodes, lung, bone, and liver. Neither the true incidence nor risk of CNS tumor transmission via transplants is known. But since 1 994, when the United Network for Organ Sharing (UNOS) began recording primary brain tumors as a cause of brain death, between 33 and 47 liver transplants per year have been donated by individuals who died of primary CNS tumors. None has transmitted the disease to a recipient. Whether patients with CNS tumors should be organ donors is a difficult clinical and ethical problem. Currently, over 9,000 patients are on US liver transplant waiting lists. In 1 996, the median waiting time was 366 days, and 953 patients died without ever receiving a suitable organ. Prohibiting all individuals with primary CNS cancers from organ donation would, each year, deny up to 0.5% of this waiting list--30% of status I patients--the opportunity for life, write Drs. Patrick Healey and Connie Davis in a commentary accompanying the case report. If only persons with glioblastomas were ineligible to become donors, approximately 10 patients per year would not receive an allograft. Excluding just those with metastatic disease would cause perhaps two to three patients to miss out on a transplant each year. To maintain the donor pool while at the same time limiting CNS tumor transmission, Healey and Davis suggest that liver donors with CNS cancers, especially a glioblastoma, be considered "marginal" donors." Their organs would be offered only to patients who would die without an immediate transplant. To increase safety, the authors recommend that the transplant team review donor records with special attention to physical and radiologic evidence of metastatic disease and seek out asymptomatic liver metastases radiologically or by lymph node biopsy preoperatively, intraoperatively, or both. The commentators conclude that while the case report justifies caution with and further investigation of the use of patients with brain tumors as organ donors, transplant policy should not be changed without more specific data on the risk tumor transmission. "There are too few organs for transplantation," they write, "for 1% of the total organ donor pool to be dispensed with."