Female Transplant Recipients at Risk for High-Grade Genital Tract Dysplasia

By Marilynn Larkin

July 17, 2019

NEW YORK (Reuters Health) - One in eight women who receive an organ transplant may develop lower genital tract dysplasia, a retrospective study reveals.

"High-grade non-cervical lesions appear to be as common as high-grade cervical lesions (3.3% vs. 3.6% of women)," Dr. Kimberly Levinson of Johns Hopkins University School of Medicine in Baltimore told Reuters Health by email.

"Providers taking care of women who have undergone transplantation should be aware of the risk of vulvar, vaginal and anal dysplasia," she said. "Furthermore, given this incidence, comprehensive lower genital tract exams should be performed, with biopsy as indicated, in order to diagnose lesions at a precancerous state."

Dr. Levenson and colleagues analyzed data from women who underwent organ transplantation at Johns Hopkins between 2000 and 2015 to identify risk factors for lower genital tract dysplasia.

As reported online July 9 in Obstetrics and Gynecology, 394 patients with a median age of 41 were included in the analysis; 47 (11.9%) developed lower genital tract dysplasia over a median follow-up of 7.8 years.

Thirty-eight (9.6% of the entire cohort) developed cervical intraepithelial neoplasia (CIN), with 14 (3.6%) diagnosed with CIN 2 or worse, including one cervical carcinoma.

Nineteen women (4.8%) developed noncervical lower genital tract dysplasia; 13 (3.3%) had high-grade dysplasia or worse, including five with lower genital tract carcinoma (three anal, one vulvar, and one vaginal).

Ten women (2.5%) developed both cervical and noncervical lower genital tract dysplasia.

High-grade cervical dysplasia was diagnosed at a median of 3.18 years after transplant; noncervical high-grade lower genital tract dysplasia was diagnosed at a median of 3.94 years.

Black race was significantly associated with development of dysplasia (odds ratio 2.86), as was hydroxychloroquine use (OR 5.95).

Dr. Nicole Ali, a nephrologist at NYU Langone's Transplant Institute in New York City, commented by email, "This paper brings to light an important issue facing immunosuppressed patients. While the overall incidence of malignancy is low, treatment of these in the setting of immunosuppression can be challenging. Therefore, early detection and intervention prior to malignant conversion is most effective."

"At NYU, all female patients are referred pre-transplant for gynecological screening and are strongly encouraged to continue close follow-up post-transplant annually," she said. "Unfortunately, with new guidelines and insurance coverage, we have encountered some patients whose insurance will only screen with a Pap test every three years. However, we fully support annual screening in this high-risk population."

"This article will be important to share with (a patient's) gynecological team, as it points out that anal Pap is also important to detect early disease," Dr. Ali noted. "Education for patients and their primary care and gynecology providers is important for getting appropriate screening for this population," she added.

SOURCE: http://bit.ly/2YPGVno

Obstet Gynecol 2019.