Transplant and Surgical Oncology

01Purpose and scope

• This manual supports the course Transplant and Surgical Oncology. It is written as a working reference for surgeons, transplant coordinators, oncology nurses, pathologists, radiologists, perfusionists, research staff and quality managers who take part in care for patients who have cancer and who either need a cancer resection in the same episode as an organ transplant or who are being evaluated for transplant after a cancer diagnosis.
• The field sits where two disciplines meet. Surgical oncology asks how completely a tumor can be removed with an acceptable functional outcome. Transplant medicine asks whether a patient can safely receive a donor organ, how long immunosuppression can be tolerated, and whether a recurrent malignancy could be accelerated by that immunosuppression. Each side brings its own vocabulary, timelines and risk tolerance, so the work depends on a shared plan that both sides can read.
• The scope covers the common situations in which these two streams overlap: resection of a tumor found in an explanted or donor organ, cancer surgery in a patient already on the transplant list or already transplanted, liver tumors evaluated for transplant, and the surveillance that follows. It does not cover general transplant surgery for non-malignant disease or routine chemotherapy management, except where those decisions change the surgical plan.
• This guidance does not replace qualified professional judgment, approved institutional procedures or required authorization. Donor organ allocation, candidate listing criteria and cancer-history waiting rules differ by country, by region and by transplant program, and they change over time. Where rules depend on jurisdiction, use the current authoritative source for your location, such as the national organ allocation network, the relevant regulator or the program's written policy approved by its governing committee.

02Core principles

• The first principle is that cancer status is a shared fact, not a surgeon's or transplant team's private judgment. A malignancy history, an incidental tumor or a suspicious imaging finding must be recorded in a form that every member of the team can read, and it must be reviewed by the group that will make the decision.
• The second principle is that transplant candidacy and cancer treatment are linked decisions. Immunosuppression that prevents graft rejection can also reduce the body's ability to control a tumor. Choosing a cancer operation before transplant, or accepting a transplant after cancer, therefore changes the expected outcome of both. The team should state which risk it is accepting and why.
• The third principle is that the oncologic goal must be defined before the operation begins. Surgeons should write down what a complete resection means for the specific tumor, including the target margin, the nodal basin to be addressed and the organs that must be preserved. A plan that says remove the tumor and see what we find is not sufficient for this work.
• The fourth principle is that the patient's own priorities matter and must be documented. Some patients prefer a shorter path to transplant, others prefer a longer period of cancer surveillance before listing. Shared decision making should be recorded with the options, the uncertainties and the patient's stated choice.

03Planning and preparation

• Planning starts with a complete oncologic history. Obtain pathology reports, not only the summary diagnosis, because histologic subtype, grade, stage, margin status and molecular markers all influence both surgical extent and transplant eligibility. Where a prior tumor was treated elsewhere, request the original slides or at least the pathology report and treatment summary before deciding anything.
• Next, confirm the imaging baseline. Cross-sectional imaging of the chest, abdomen and pelvis is standard for most solid tumors, but the protocol should be chosen with the reading radiologist, particularly for liver lesions, where contrast phase timing changes what can be seen. Positron emission tomography may be used in selected cases, and its role should be agreed in advance rather than ordered by default.
• Assemble the tumor board or multidisciplinary conference early. The board should include at least the operating surgeon, transplant hepatology or nephrology or cardiology as relevant, medical oncology, radiation oncology when applicable, pathology and radiology. A transplant coordinator should attend so that donor and recipient logistics are part of the conversation from the start.
• Prepare the logistics before the day of surgery. Confirm blood product availability, specify the anesthesia plan with attention to immunosuppression and vascular access, schedule frozen section pathology, and check that the operating room has equipment for any planned reconstruction. For transplant cases, confirm the organ offer, the donor cold ischemia estimate and the team's ability to hold the recipient if the donor organ changes.
• Obtain consent that covers both streams. A consent form for a transplant does not automatically cover cancer resection, and a cancer consent may not mention the immunosuppressive consequences. Patients should understand that a planned operation may change if frozen section results differ from expectations, and the consent should say what decisions can be made intraoperatively and what decisions require a phone call to the patient or a surrogate.

04Recommended workflow

1. 1
   : Confirm the diagnosis and the transplant question in one sentence. Write the question as a single line, for example whether a recipient with a resected colorectal liver metastasis is a candidate for liver transplant under the program's current criteria, so the tumor board has a clear decision to make.
2. 2
   : Review the pathology and imaging together. Look for discordance between the radiology read and the biopsy, and for lesions that are small enough to be missed on one modality. Record any unresolved question as an open item rather than resolving it silently.
3. 3
   : Hold the multidisciplinary review and record the decision. The record should state the recommended operation, the oncologic goal, the transplant plan, the immunosuppression consideration and the conditions that would change the plan. Assign an owner to each follow-up item.
4. 4
   : Confirm the patient's decision and consent. Walk the patient through the options with written materials that match the chart. Document questions asked and answered, and note any decision that was deferred.
5. 5
   : Perform the operation with a defined intraoperative decision tree. Agree before incision on which findings trigger a change in extent, such as unexpected vascular involvement, peritoneal spread or a second lesion. Name the surgeon who makes each call and the person who must be notified.
6. 6
   : Send intraoperative specimens promptly and label them clearly. Mark orientation on the specimen where needed, document the time of removal and the time of fixation, and keep a specimen log that the pathologist and surgeon both sign. For explanted organs with an unexpected tumor, notify the transplant team at once because the donor or recipient decision may depend on the finding.
7. 7
   : Review final pathology and adjust the plan. Margin status, lymph node count, lymphovascular invasion and tumor deposits should be reported in the structured format the program uses. Bring the final report back to the tumor board, and document whether the transplant decision, the surveillance schedule or the adjuvant plan changed.
8. 8
   : Set the surveillance and handoff plan. Specify the imaging interval, tumor markers if used, the lab schedule for immunosuppression, the name of the clinician who owns each part of follow-up, and the trigger for early reassessment. The handoff should be written and sent to the primary care physician and to the receiving oncology team.

05Quality checks, risk controls and compliance

• Quality checks should be built into each stage rather than applied only at the end. Before surgery, a second clinician should confirm the cancer history, the laterality and site of the lesion, and the consent. During surgery, a time out should include the oncologic goal and the decision tree. After surgery, the team should confirm that specimens reached pathology, that the report was received and that the final result was reviewed.
• Risk controls focus on three areas. The first is tumor transmission, where a donor or recipient carries an occult malignancy that was not detected before transplant. Program policy should define donor screening, the review of donor history and the handling of incidental findings in the explant. The second is immunosuppression-related progression, where the team tracks recurrence signals and adjusts immunosuppression with the transplant physician. The third is surgical risk, where extended resections in a recently transplanted or immunosuppressed patient carry higher infection and healing risks.
• Compliance differs across jurisdictions. In the United States, organ allocation for transplant is governed by the Organ Procurement and Transplantation Network and by federal rules for transplant programs, and patient records are subject to the Health Insurance Portability and Accountability Act privacy rule. Other countries have their own allocation and privacy frameworks. Teams should confirm the current requirements with their compliance office and the national authority, because the details change and this manual cannot list them reliably.
• Clinical practice guidelines from recognized professional bodies are useful references for cancer staging, surveillance and treatment selection. Use the most current version available to your team and note the version date in the chart. Where guidelines do not address a combined transplant and cancer question, the decision belongs to the multidisciplinary board, and the reasoning should be recorded in the note.
• Research participation adds another layer. Any protocol that enrolls a transplant recipient with cancer or collects tumor tissue from a donor organ needs approval from the institutional review board or ethics committee and proper consent. Do not start data collection on these patients under a general quality project without confirming the approval scope.

06Collaboration and documentation

• Good documentation makes the shared plan visible. The operative note should state the planned operation, the actual operation, the reason for any deviation and the specimens sent. The transplant note should state the organ, the donor history relevant to malignancy, the immunosuppression plan and any change to the recipient's candidacy. Use the same terms in both notes, such as margin positive rather than close, so that the reader can compare them.
• Establish a single point of contact for each patient. In many programs this is the transplant coordinator for transplant timing and the surgical oncology nurse navigator for cancer timing. The two should share a running list of open items, including pending pathology, pending imaging, pending donor information and pending consent discussions.
• Communication with the patient should be consistent. When the plan changes, the patient should hear the change from a clinician who understands both streams, and the conversation should be documented with the date in the chart and the questions raised. Avoid relying on a single message in a patient portal to communicate a major change.
• Tumor board minutes should record attendance, the case presented, the question asked, the recommendation, dissent if any, and the action owner. Keep these minutes in a format that can be audited. Where a case is revisited after new pathology or imaging, link the new record to the original decision so that the reasoning chain is clear.

07Measures and continuous improvement

• Track a small set of indicators that reflect both oncologic and transplant outcomes. Useful examples include the proportion of cases with a documented oncologic goal before surgery, the rate of unplanned change in operative extent, the proportion of final margin reports reviewed at tumor board within a set period, the time from specimen removal to fixation, and the rate of documented consent discussions that cover both transplant and cancer risks. Each program should set its own targets based on local baseline data rather than adopting published numbers without context.
• Review outcomes with a standard method. A monthly or quarterly review of a sample of cases, with a structured template, is more useful than a single annual summary. Look for patterns, such as a recurring gap between frozen section and final pathology, or a delay in notifying the transplant team of an explant finding.
• Improvement projects should have a clear owner and a measurable change. For example, a team might add a required field to the transplant listing form for prior malignancy with a pathology reference, then measure whether the field is complete at the next review. Avoid making several changes at once, because the effect of each becomes impossible to isolate.
• Share results with the people who do the work. Surgeons, coordinators, pathologists and nurses see different parts of the process, and the review should include all of them. Feedback that identifies a problem without suggesting a fix tends to be ignored, so pair each finding with a proposed action.

08Common mistakes and how to prevent them

• One common mistake is treating the cancer history as incidental. A prior melanoma or breast cancer may be treated as remote and then turn out to matter greatly for listing or immunosuppression. Prevent this by requiring a pathology-based oncologic summary in every transplant and cancer case, reviewed before the board meets.
• A second mistake is deciding the operation without a shared oncologic goal. When the goal is vague, the surgeon may remove more or less tissue than the transplant team expected. Prevent this by writing the goal in the plan and reading it aloud at the time out.
• A third mistake is delayed communication about explant findings. An unexpected tumor in a donor organ can change the recipient plan within hours, but the message may be sent by a resident or left until the next morning. Prevent this with a written notification pathway that names who calls whom and within what period.
• A fourth mistake is inconsistent consent. The patient signs one form for transplant and another for surgery, and neither describes the combined risk. Prevent this by using a joint consent discussion, documented in one note, with a summary that the patient receives in writing.
• A fifth mistake is losing track of follow-up after discharge. Surveillance lists become outdated, and the person who owned the plan changes roles. Prevent this with a named owner for each follow-up item, a date-independent reminder system in the chart and a review at each clinic visit.
• A sixth mistake is treating published criteria as universal. Cancer-history rules and surveillance intervals differ by program and by jurisdiction. Prevent this by checking the local policy and the current national source before finalizing any plan, and by recording which source was used.

09Practical checklist

• Confirm the cancer history with the original pathology report and, where needed, the slides or a pathology review.
• Record a single transplant question and a single oncologic question in the chart before the board meets.
• Confirm the imaging protocol with the radiologist and note any modality that was not performed and why.
• Hold the multidisciplinary review with surgery, transplant, oncology, pathology and radiology present, and record the decision with its conditions.
• Document a shared consent discussion that covers both the cancer operation and the transplant risks, and provide a written summary to the patient.
• Agree on the oncologic goal and the intraoperative decision tree before incision, and name the decision maker for each change.
• Label specimens with orientation, time of removal and time of fixation, and confirm receipt by pathology.
• Notify the transplant team immediately of any unexpected tumor finding in an explanted or donor organ, and document the call.
• Review the final pathology at tumor board and document whether the transplant plan, surveillance or adjuvant plan changed.
• Hand off to primary care and the receiving oncology team with a written surveillance plan and a named owner for each item.
• Confirm local allocation, privacy and research approval requirements with the compliance office and the current authoritative source before acting.

★Learning sources

• Micro Degree: Transplant and Surgical Oncology
• Micro Degree: Healthcare Administration Practice
• Micro Degree: Physiotherapy Assistant Operations
• Micro Degree: Cardiac Care Support