COLUMN ONE : Prognosis Slips From Joy to Grief : A kidney transplant gave a woman new life, then led to the cancer that killed her. Her death, and those of others who received organs from one donor, offers a cautionary tale on hopes, risks of modern medicine.
Ruth Glor’s family was devastated, her doctor baffled. Just months after receiving a transplanted kidney that revitalized the life of the 57-year-old social worker, Glor was dying of metastatic melanoma, a particularly virulent form of skin cancer.
Around the country, other transplant recipients--at first unknown to one another--were making similarly grim and mysterious discoveries: They, too, were dying of metastatic melanoma. Their new organs, all from the donor who provided Glor’s kidney, were not life-sustaining; they were lethal.
Glor’s transplant and recovery had gone so smoothly that only 11 days after the operation, the mother of three was able to leave Kansas University Medical Center and return home to the small farming community of Buffalo in southwest Missouri.
“She was real happy,” said her son, Danny, 35, a dairy maintenance man in Buffalo. “She built flower beds outside. . . She got a bicycle. . . . She just thought it was a new lease on life.”
Then, 15 weeks later, Glor grew weak and felt excruciating pain in her back. Her doctor sent her to a small, nearby hospital, which quickly airlifted her to the university medical center in Kansas City, Kan. On Aug. 17, 1991, five months after the transplant, Glor died.
Within a year of her operation, lawyers on both sides of the resulting lawsuit say, a number of people died from melanoma traced to the donor, a 42-year-old Northern California woman. Attorneys for the doctors, hospital and local organ bank say four died; lawyers for the Glor family insist the total is more than a dozen.
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Experts say the risk of getting cancer from a transplant is rare, and is counteracted by the overwhelming number of successes under extreme circumstances.
Doctors now are able to rapidly transport and transplant organs with almost routine success, thanks in part to new drugs that combat rejection. In today’s high-tech world, the concept of walking around with someone else’s heart or kidney is almost taken for granted. As a result, major organ transplants are no longer considered experimental by some insurance companies.
But medical technology has its limits, as the Glor case illustrates, with some glaring--if rare--shortcomings.
Transplant donors are screened for HIV, hepatitis and other blood-borne organisms, but oncologists and transplant experts say there is no fast, routine way to screen organs and tissues for most cancers, even in living patients. Early blood screening tests exist for only a few malignancies, such as prostate and certain types of uterine cancer, and those results are not universally accepted. Major undiagnosed diseases are found in 20% of autopsies, experts say.
The medical journal Transplantation called cancer risk, although small, “a well-known and greatly feared problem” within the transplant community, warning that “it is inevitable that occasionally tumors or infectious agents will be transplanted with a lethal outcome.”
For the Glors, statistics and warnings are academic. “Someone’s made a terrible mistake,” said Danny Glor, explaining why the family has sued two surgeons, one transplant organization and a hospital. “Somebody’s killed more than one person.”
A review of medical literature reveals three cases in the United States in the last seven years in which cancerous organs and tissues from a single donor resulted in multiple malignancies among recipients.
“We run every laboratory test we can think of that might give us information on the suitability of the donor,” said Daniel M. Ferree, director of policy development for Virginia-based United Network for Organ Sharing, the national coordinating organization for transplant programs.
There is little prospect anytime soon for a screening procedure that would catch undiagnosed malignancies, Ferree added.
“You either stop doing transplants or you accept the risk,” said Dr. Steven A. Armentrout, professor of hematology and oncology at UC Irvine. “It’s an unavoidable complication of transplants that you have to accept. . . . You save far more lives than you’ve lost.”
Some facts and reports involved in the Northern California transplant case are being withheld by attorneys for various parties to the lawsuit, which is scheduled to go to trial next spring. The Glor family declined to comment outside of depositions. The doctors involved in the case have either declined to comment or did not return phone calls.
However, the broad outlines of this emerging medical tale can be sketched through legal filings, depositions and limited revelations from the lawyers.
According to a lawsuit filed last spring in Sacramento on behalf of Glor’s survivors, the chain of events began March 11, 1991, when the donor, a Yolo County woman, suffered a brain hemorrhage while taking a shower. She was taken, comatose, to Sutter Davis Hospital in Davis.
At the 48-bed hospital, the husband agreed to allow his wife’s organs to be transplanted. He filled out the standard screening form, marking none of the risk factors that would bar transplants, including cancer, intravenous drug use and high-risk sexual activity.
The attending surgeons, Dr. John K. Yen and Dr. Peter K. Droubay, approved the harvesting--including kidneys, heart, liver, corneas, bone marrow and skin--and notified Golden State Transplant Services’ coordinator, Vicky Mirtle. This triggered a fast-moving sequence of events.
Transplant organs and tissues are allocated according to state and federal guidelines. Various local and regional medical groups, such as Golden State and United Network for Organ Sharing, have drawn up additional regulations. Priorities, which vary by type of organ and tissue, are based on a complex, computerized point system that takes into account the level of organ compatibility, the survival prospects of the recipient, and geography--the distance between the transplanted organ and the recipient.
After organs are screened for HIV, hepatitis and other blood-borne organisms, potential recipients around the nation are notified, in some cases given only an hour to accept or reject the organ.
When the information about the Northern California organs went out on the UNOS computer, one of the kidneys was matched to Glor. She was suffering from a debilitating kidney ailment known as Bright’s disease, which ultimately leads to renal failure. As the kidney was being flown to the Midwest Organ Bank in Kansas City, the local UNOS affiliate, Glor and her 63-year-old husband, Elwayne, were making a frantic, four-hour drive from Buffalo to the university medical center.
After the operation, Dr. George E. Pierce, a vascular surgeon, and other members of the transplant team emerged from the operating room to tell family members how well it had gone, recalled her daughter, Ramona D. Mizell.
Pierce declined to comment on the case.
Over the next few weeks, Mizell, 39, spoke with her mother daily and visited frequently. Glor, she said, “seemed stronger every day. She had more energy than the rest of the family could keep up with.”
In late June, Glor felt strong enough to take a car trip to visit Atlanta to see her son Robert, a 33-year-old high school music teacher. At the end of her two-week stay, she experienced severe back pain, which continued after she returned to Missouri.
At first, Elwayne Glor said, doctors told the family they thought his wife’s sudden decline might be the result of leukemia. The same drugs, called immunosuppressants, given to prevent rejection of the foreign organs, lower the body’s resistance to a variety of cancers, including lymphoma and leukemia. They can also allow cancers that have been treated and are in remission in the recipient’s body to return. (Glor’s doctors suspected leukemia, although she had had cervical cancer 20 years earlier.)
When medication did not ease the pain, Glor was admitted to a local hospital and then airlifted to the university medical center. She was examined, tested and released, only to be readmitted for surgery a few days later--for the last time.
In early August, when Pierce performed exploratory surgery, he saw that Glor’s transplanted kidney was full of metastasized melanoma, according to the Glors’ depositions. In the next 10 days, doctors operated again, first removing her colon and then her kidney. By this time, Glor had lost consciousness, and died a few days later.
As soon as he saw the kidney, Pierce told family members he suspected that the malignancy did not occur naturally. He told Elwayne Glor that “they knew where the cancer had come from, but they had to prove it. They would run the tests that would prove it,” according to the husband’s deposition.
The vascular surgeon used the relatively new technique of DNA tissue typing to confirm that the melanoma that killed her came from the Northern California donor, according to the Glors’ depositions and sources familiar with the case.
Two weeks after Glor died, Pierce called the family back to Kansas City. The autopsy revealed that the cancer had spread throughout her body. In his deposition, Elwayne Glor said Pierce told him the next day that the DNA tests “proved it was not Ruth’s cancer, it belonged to another person.”
In his deposition, Danny Glor recalled Pierce apologizing, saying: “Somebody’s made a terrible mistake here.”
Attorneys for Golden State told The Times they were certain that the cancer in the kidney came from the donor, and as soon as they were informed of the DNA results, they notified all other patients who had received organs from that donor.
Pierce later learned that another recipient had died the day before Glor, according to the Glors’ deposition transcripts. A third person, who received a kidney, was informed of the melanoma but declined to have the kidney removed and later died, according to the depositions.
The Glor family’s attorneys--on the basis of conversations with doctors involved in the transplants--contend that more than a dozen recipients around the country died as a result of the tainted transplants. But the Glor lawyers said they could not give names and death certificates because they said Golden State has refused to provide a complete list of recipients from the donor.
In its lawsuit, the family claimed that the hospital, the two surgeons and the transplant coordinator for Golden State Transplant Services failed to spot the melanoma during the required visual inspection.
Golden State Transplant Services acknowledges that the transplants resulted in the deaths of four recipients, including Glor, said Thomas A. Minder, the company’s attorney.
“It is a tragedy with no villains, and we recognize it as tragedy, and we feel sorry for the families of the recipients,” Minder said.
However, in a legal response to the Glors’ suit, the transplant company denied any negligence, maintaining that it followed all state, federal and professional guidelines in handling the transplant.
Neither the two Sutter Davis surgeons nor their attorneys responded to numerous telephone inquiries for their official response to the charges.
Sutter Davis, in its court papers, likewise denied any negligent handling of the Sacramento transplant case. David Bills, an attorney for Sutter Davis, said: “We’re certainly sad for the Glor family,” but added that the hospital acted in good faith under the provisions of the state’s Uniform Anatomical Gift Act.
But the Glor family claims that the doctors did not heed the warning of a hospital radiologist who raised the possibility of cancer. The report was based on a CT scan to determine the donor’s brain activity the day before the transplant.
Minder, Golden State’s attorney, says the radiologist’s report “was not available in the chart when the harvesting was approved,” and thus not seen by the two surgeons or by Golden State’s transplant coordinator before the transplants were approved.
Whether or not the two California surgeons saw the report, “those organs should not have left Sutter Davis until that report was in their hands,” said Joseph Dunn, the Glors’ Costa Mesa attorney.
The case comes at a time when the demand for organs is skyrocketing.
As of Oct. 13, there were 32,709 people in the United States on the waiting list for transplants, according to UNOS. In 1992, there were 16,580 transplants performed, including 2,519 from living donors.
Multiple deaths as a result of transplanted malignancies “have been a very rare, uncommon occurrence,” said Dr. Israel Penn, professor of surgery at the University of Cincinnati Medical Center.
Penn, who oversees a worldwide transplant tumor registry, estimated that of the 200,000 to 300,000 transplants performed worldwide over the past 30 years, no more than 60 cases involved the harvesting of organs or tissues with cancers.
Before blood and tissue screening procedures became more sophisticated in the late 1980s, Penn said, there were a number of cases in which AIDS-infected organs were transplanted into otherwise healthy patients, resulting in death.
Although there are cases of a single malignant organ being transplanted, medical experts report only a few cases like Glor’s of multiple malignancies resulting from transplanting cancer-involved organs or tissue from a single donor.
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Two years later, Ruth Glor’s death weighs heavily on her tightknit family.
“I am upset that a diseased kidney could be transplanted into my mother and be the cause of her death,” said her daughter, Ramona. “I feel like I have been cheated out of 15, 20 years. I feel like my son has been denied his grandmother. I feel like my whole family has been denied a lot of joy.”
Asked by lawyers at the deposition how his life had changed since his wife’s death, Elwayne Glor, who is the town’s barber, said: “Well. . .it’s terrible. She was the nicest person I ever knew.”
Her son Danny said: “With that transplant, she could have made another 15 or 20 years easy. It was such a good match. It was supposed to be a perfect match. That’s what everybody’s looking for.”
