To the Editor:
In the January issue of this journal, Harbell et al. reported the transmission of a T-cell non-Hodgkin lymphoma (NHL) from a donation after cardiac death (DCD) donor to the four recipients of his organs (1). This report is the second published case of cancer transmission from a DCD organ donor, the first case being the transmission of an undiagnosed sarcoma to the recipients of a liver and a kidney (2). With the widening acceptance of the DCD donors, it is likely that some other cases will occur in the future.
In the case described by Harbell et al. (1), the origin of the transmitted lymphoma might be a matter of debate; it could be either a primary central nervous system (CNS) NHL with systemic metastases or systemic NHL with CNS involvement. As Harbell stated, T-cell primary CNS NHL are extremely rare (1). Moreover, spontaneous systemic metastases of primary CNS NHL are also rare, despite the fact that the neurosurgical procedures that this donor underwent, and particularly the decompression craniotomy, may have promoted breaking of the blood-brain barrier and the passage of lymphoma cells in the blood stream (3). To our knowledge, only one case of transmission of CNS NHL from donor to organ recipients was reported so far (4). It is more likely, but not sure, that the young donor described by Harbell et al. did not suffer from a CNS NHL but from an undiagnosed systemic T-cell NHL and died from cerebral metastases.
In their report, Harbell et al. discussed the role of post-harvesting donor autopsy in the diagnosis of potential cancer in the donor (1). We advised systematic autopsy of the organ donors, after the occurrence of such a tumor transmission in 1993 (5), but in the real life, permission for this autopsy is difficult to obtain from the donor's family. This case reported by Harbell et al., added to all the reports of cancer transmission in the organ transplant literature, emphasizes the importance of the knowledge of this rare but possible complication of organ transplantation for the organ recovery team. Careful surgical exploration of the donor, with visual inspection and palpation of the thoracic and abdominal organs, including lymph nodes, and immediate frozen section of any suspicious tissue at the time of organ recovery, is the key to limit the incidence of this dreadful complication. However, even with this policy, transmission of undiagnosed cancer with organ transplantation will always occur, and the organ transplant candidates should be informed of this possible complication.