Immunotherapy in Patients Receiving Organ Transplantation
A discussion of the possibility of managing organ transplant populations with immunotherapy.
PUBLISHED June 15, 2020
Anthony Rossi, MD, FAAD: If we are presented with a very aggressive squamous cell carcinoma, we do talk to their transplant team or their oncologist to see if we can lower the immunosuppression if they’re on certain types of like calcineurin inhibitors for the solid organ transplant patients. But is there a role for immunotherapy in these organ transplant patients or CLL [chronic lymphoblastic leukemia] patients?
Anna C. Pavlick, DO: The jury is out. For the organ transplant patients, if we look at the melanoma population that has gotten metastatic melanoma, we try to lower their immunosuppressive agents. In the limited amount of literature out there, most patients who get anti-PD-1 inhibitors do have organ rejection, so it really is what organ have they had transplanted.
If you’ve got a patient who has had a kidney transplant but has diffuse metastatic disease, have a heart-to-heart conversation with the patient, saying, “We might be able to turn this metastatic disease around if we give you these immunotherapies. But you need to understand there’s a very, very high chance that you’re going to reject your kidney and wind up back on dialysis.”
Many patients will say, “If it’s my life or my kidney, I’m going to sacrifice this kidney. Hopefully you can get my cancer under control, and then I can be reconsidered for another transplant.” But I have a number of patients who have liver transplants. I’m stuck. I can’t give them anti-PD-1 therapy. Interestingly, you can give them anti-CTLA4 therapy with absolutely no issues. Why there’s that difference, I wish we knew, but we don’t. Then again, the efficacy of a single-agent CTLA4 therapy is far less, 50% less, than that of a PD-1 inhibitor. So I wouldn’t say no, but you really have to weigh the risk to benefits with the patient.
Anthony Rossi, MD, FAAD: For sure. Those are excellent points.