Incidence and Outcomes of Malignancy Following Adult Intestinal Transplantation: A National Cohort Study

Introduction: Malignancies are a frequent complication following solid organ transplantation due to chronic immunosuppression. The risk may be particularly pronounced in intestinal transplantation (ITx) because the intestine is highly immunogenic due to its significant lymphoid tissue, necessitating higher levels of immunosuppression. Despite this theoretical risk, the incidence and characteristics of malignancy following ITx remains poorly defined. This study aimed to evaluate the incidence and outcomes of malignancy following adult ITx in both UK adult intestinal transplant centres.
Method: A retrospective cohort study was conducted including all adult ITx performed at Cambridge and Oxford transplant centres from 2007 onwards (representing all UK adult ITx activity). Clinical records were reviewed to identify cases of post-transplant malignancy, rejection episodes, post-transplant lymphoproliferative disorder (PTLD), patient survival and graft outcomes. The incidence of malignancy and associated clinical outcomes were analysed.
Results: A total of 240 intestinal transplants were performed during the study period. Twenty-one patients developed malignancy, representing an overall malignancy rate of 8.75%. Several patients developed more than one malignancy, resulting in 26 total malignancy events depicted in figure 1.

Four patients developed PTLD and seven patients had documented episodes of rejection requiring treatment. Thirteen patients died during follow-up, with 12 deaths attributable to malignancy. There was no graft loss reported. The median time from transplantation to malignancy diagnosis was 5.1 years (range 0.2–16.5 years). Median overall patient survival following transplantation was 6.3 years (range 0.8–17.3 years).
Conclusion: Malignancy represents a significant long-term complication following ITx and may occur at a higher frequency than that reported for other solid organ transplants. A notable proportion of patients developed multiple malignancies, highlighting the potential cumulative impact of long-term immunosuppression. These findings suggest that enhanced pre-transplant malignancy screening and more rigorous post-transplant surveillance are warranted for early diagnosis and improved outcomes. Larger international cohort studies are required to better define the true risk and inform optimal screening strategies in this population.