Recipients of liver transplantation (LT) have a higher overall risk (2-3 times on average) of developing de novo malignancies than the general population, with standardized incidence ratios ranging from 1.0 for breast and prostate cancers to 3-4 for colon cancer and up to 12 for esophageal and oropharyngeal cancers. Aside from immunosuppression, other identified risk factors for de novo malignancies include the patient's age, a history of alcoholic liver disease or primary sclerosing cholangitis, smoking, and viral infections with oncogenic potential. Despite outcome studies showing that de novo malignancies are major causes of mortality and morbidity after LT, there are no guidelines for cancer surveillance protocols or immunosuppression protocols to lower the incidence of de novo cancers. Patient education, particularly for smoking cessation and excess sun avoidance, and regular clinical follow-up remain the standard of care. Further research in epidemiology, risk factors, and the effectiveness of screening and management protocols is needed to develop evidence-based guidelines for the prevention and treatment of de novo malignancies. Liver Transpl 18:1277-1289, 2012. V C 2012 AASLD.Received March 29, 2012; accepted July 4, 2012.The all-cause mortality rates of adult recipients after liver transplantation (LT) have incrementally improved in the last 4 decades, with current recipient survival rates in the United States and elsewhere approximating 90% at 1 year and 70% at 5 years. 1,2 However, the greatest reduction in recipient mortality in the last 2 decades has occurred largely in the first year after transplantation, and survival rates beyond 1 year have been relatively stagnant during the same period. 3,4 For the recipient who survives hepatic transplantation without allograft or postoperative complications, malignancies are among the most frequent causes of morbidity and death. 3,5,6 Malignancies account for 3 of the top 10 causes of death in developed countries, and they are a tremendous global burden. 7 Multiple observational studies have shown a 2-fold increase in the rate of solid organ malignancies and a 30-fold or higher increase in the rate of lymphoproliferative malignancies in comparison with the general population. [8][9][10][11] The higher incidence of de novo malignancies in the post-LT population may not be surprising because recipients receive long-term immunosuppression therapy on top of other risk factors associated with carcinogenesis.This review briefly summarizes our current understanding of the epidemiology, risk factors, pathogenesis, and management of post-LT malignancies. In addition, we aim to identify the gaps in medical knowledge that warrant prospective studies when they are feasible. LYMPHOPROLIFERATIVE MALIGNANCIESPosttransplant lymphoproliferative disorder (PTLD) refers to uncontrolled lymphoproliferation in an immunocompromised host after solid organ transplantation.
This story of collaboration in a distributed team calls into question two premises underpinning current models of IPC and IPE: the notion that stable professional roles exist, and the ideal of a unifying objective of 'caring for the patient'. We suggest important elaborations to these premises as they are used to conceptualise and teach IPC in order to better represent the intricacy of everyday collaborative work in health care.
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