14th International Small Bowel Transplant Symposium
Outcome
Use of Everolimus After Multivisceral Transplantation: A Report of Two Cases

https://doi.org/10.1016/j.transproceed.2015.11.034Get rights and content

Highlights

  • Single-center experience of using everolimus in MVT for NET.

  • The first case emphasizes issues with delayed wound healing.

  • The second case was complicated by CMV infection and ACR.

  • Everolimus use can help preserve renal function and may prevent recurrence of NET.

Abstract

Inhibitors of mechanistic target of rapamycin are used in solid organ transplant procedures to avoid calcineurin inhibitor complications, including nephrotoxicity and malignancy. We present 2 cases of multivisceral transplantation for neuroendocrine tumor (NET) for which everolimus was implemented for its potential to prevent NET recurrence as well as preserve renal function. The first case was complicated by NET recurrence in the liver before initiation of everolimus. After initiation of everolimus, the patient developed a ventral hernia and elevated aminotransferase levels with nonspecific biopsy findings. The second case was complicated by cytomegalovirus infection with elevated everolimus trough levels as well as acute cellular rejection. Everolimus was reinitiated in both cases in addition to decreasing the dosage of tacrolimus, and there were no further complications. Everolimus was beneficial in stabilizing renal function in both patients and has the theoretical potential to prevent recurrence of NET.

Section snippets

Case Report 1

A 58-year-old white male subject diagnosed with metastatic NET underwent gastrectomy for a primary tumor as well as multiple transarterial chemoembolization procedures for hepatic spread. Due to continued hepatic decompensation, he ultimately underwent MVT. The patient's immediate postoperative course was complicated by an ileocolic anastomotic leak requiring repair and formation of an end-ileostomy. He began treatment with tacrolimus, basiliximab, and prednisone for immunosuppression.

Case Report 2

A 44-year-old African American female patient with a history of metastatic NET underwent a right hemicolectomy for primary tumor followed by multiple transarterial chemoembolization procedures. She underwent MVT with explant demonstrating tumor in the pancreas, liver, and 5 of 14 removed lymph nodes. Her initial regimen included tacrolimus and prednisone for immunosuppression. One month posttransplantation, the patient developed grade 1 acute cellular rejection (ACR) involving the intestine,

Discussion

Our experience in the first case (Table 1) highlights a common concern regarding delays in wound healing with the use of everolimus [10]. This outcome was problematic because the patient required posttransplantation surgical intervention both for his ostomy reversal and the ventral hernia, thus requiring postponement and temporary discontinuation of everolimus. Everolimus has the potential to contribute to hernia formation and may have been the culprit in this case. The second patient (Table 2)

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    EVR did not affect the intestinal anastomosis. Rao et al reported that a patient who underwent multivisceral transplantation developed persistent CMV viremia [13]. In our patients, there were no severe infections although valganciclovir was administered prophylactically and maintained at a immunosuppressive level lower than in their patient.

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    Five months after MvTx a routine octreotide scan showed recurrent disease in the right lobe of the liver. This was treated with microwave ablation (MWA) and the patient was alive 3 years post-transplant. [25] Two patients from the Miami group developed recurrent disease: one 61-year-old male patient who received a MvTx for a well-differentiated G2 tumor of the pancreas had tumor recurrence in the liver 28 months post-transplant and was treated with irreversible electroporation.

  • Liver transplantation in patients with liver metastases from neuroendocrine tumors: A systematic review

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    Overall, 4 studies presented data from registries, namely the European Liver Transplant Registry (ELTR)22 and the United Network for Organ Transplantation (UNOS)/Organ Procurement and Transplantation Network databases.25-27 Three were multicenter studies,28-30 while the majority of studies were single center reports (57 out of 64).31-87 In turn, the largest cohort of data on patients undergoing LT for NET liver metastasis indication were from single center studies comprising a total of 279 patients (Supplemental Table III).

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