A retrospective review of patients with urothelial cancer in 3,370 recipients after renal transplantation: a single-center experience

The Evolution of Upper Tract Urothelial Carcinoma Management in Kidney Recipients

INTRODUCTION

Urothelial cancers were one of the most common malignancies in patients with kidney transplants. Although radical nephroureterectomy is still the standard of care in current guidelines, studies have shown that significantly improved perioperative outcomes can be achieved for patients who underwent bilateral nephroureterectomy. Our study provides evidence on the outcome of bilateral nephroureterectomy and unilateral nephroureterectomy in kidney recipients with upper tract urothelial carcinoma.

MATERIAL AND METHODS

In the study, the data of patients from a single center, Chang Gung Memorial Hospital Linkou branch, were collected retrospectively from 1981 to 2023. The patient's detailed information was collected through the medical records in the hospital.

RESULTS

A total of 44 cases of kidney recipients with upper urinary tract urothelial carcinoma were collected in this study. Of the patients, 19 nephroureterectomies were performed before 2008 and 24 afterward. Incidental findings of contralateral tumors were noted in 3 out of 6 patients who underwent bilateral nephroureterectomy before 2008 and 3 out of 12 after 2008. Contralateral upper urinary tract urothelial carcinoma after unilateral nephroureterectomy was noted in 3 patients within a median of 8.1 years. The progression-free survival of bilateral nephroureterectomy was significantly better compared with a unilateral group (not reached, 15.8 years, respectively).

DISCUSSION

Our study, along with previous studies, provides evidence that bilateral nephroureterectomy may be a better treatment option in kidney recipients with upper tract urothelial carcinoma. Our study has several limitations based on its retrospective nature.

A Novel Preoperative Prediction Model Based on Deep Learning to Predict Neoplasm T Staging and Grading in Patients with Upper Tract Urothelial Carcinoma

Objectives: To create a novel preoperative prediction model based on a deep learning algorithm to predict neoplasm T staging and grading in patients with upper tract urothelial carcinoma (UTUC). Methods: We performed a retrospective cohort study of patients diagnosed with UTUC between 2001 and 2012 at our institution. Five deep learning algorithms (CGRU, BiGRU, CNN-BiGRU, CBiLSTM, and CNN-BiLSTM) were used to develop a preoperative prediction model for neoplasm T staging and grading. The Matthews correlation coefficient (MMC) and the receiver-operating characteristic curve with the area under the curve (AUC) were used to evaluate the performance of each prediction model. Results: The clinical data of a total of 884 patients with pathologically confirmed UTUC were collected. The T-staging prediction model based on CNN-BiGRU achieved the best performance, and the MMC and AUC were 0.598 (0.592–0.604) and 0.760 (0.755–0.765), respectively. The grading prediction model [1973 World Health Organization (WHO) grading system] based on CNN-BiGRU achieved the best performance, and the MMC and AUC were 0.612 (0.609–0.615) and 0.804 (0.801–0.807), respectively. The grading prediction model [2004 WHO grading system] based on BiGRU achieved the best performance, and the MMC and AUC were 0.621 (0.616–0.626) and 0.824 (0.819–0.829), respectively. Conclusions: We developed an accurate UTUC preoperative prediction model to predict neoplasm T staging and grading based on deep learning algorithms, which will help urologists to make appropriate treatment decisions in the early stage.

Urological Cancers and Kidney Transplantation: a Literature Review

PURPOSE OF REVIEW

The aim of this review is to provide an overview of epidemiology, risk factors, and treatment of urological malignancies in renal transplant recipients (RTR).

RECENT FINDINGS

Although optimal immunosuppressive therapy and cancer management in these patients remain controversial, adherence to general guidelines is recommended. Kidney transplantation is recognized as the standard of care for the treatment of end-stage renal disease (ESRD) as it offers prolonged survival and better quality of life. In the last decades, survival of RTRs has increased as a result of improved immunosuppressive therapy; nonetheless, the risk of developing cancer is higher among RTRs compared to the general population. Urological malignancies are the second most common after hematological cancer and often have more aggressive behavior and poor prognosis.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

Sex differences in cancer risk and outcomes after kidney transplantation

Kidney transplant recipients (KTRs) experience a two- to four-fold increased risk of developing and dying from cancer compared with the general population. High cancer risk results from the interaction of both modifiable and non-modifiable factors. This mapping review explores the impact of sex disparity on cancer's increased incidence and mortality after kidney transplantation (KT). In terms of age, population-based studies indicate that younger recipients of both sexes experience a higher risk of cancer, but this is more pronounced in young women. On the contrary, older men are more likely to be diagnosed with cancer, although their increased risk is not statistically significant compared with the general population. Regarding cancer type, studies show an increased risk of Kaposi sarcoma, gynecologic and lung cancer in women, and bladder and kidney cancer in men. Immune-related cancers such as pos-transplant lymphoproliferative disorders and melanoma are increased in both sexes. Mortality also shows differences between sexes. Although cancer is the second cause of death in both male and female KTRs, studies show higher overall mortality in men and elderly recipients. However, the relative risk of cancer mortality compared with the general population is higher at a younger age, with disparate results regarding sex. Female KTRs appear to die at a younger age than males when compared with the general population. Differences in cancer rates by sex after renal transplantation need further studies. A better understanding of sex-specific differences in cancer epidemiology after KT could help nephrologists to better address pre-transplant counseling, to establish early surveillance programs, and to plan modifiable risk factors such as immunosuppression.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

Endometrial cancer in a renal transplant recipient: A case report

As the most effective treatment for end-stage renal diseases, renal transplantation can improve the quality of life of patients and prolong the survival time. However, during the prolonged survival time, malignancy has become one of the main causes of death of recipients, which vary geographically. Tumors in the digestive system and urothelial tumors have been highly reported in Asia. In general, the gynecological malignant tumors have been rarely reported, especially the endometrial carcinoma. Herein, a 63-year-old female renal transplant recipient diagnosed with endometrial carcinoma (15 years after transplantation) was reported. The patient had suffered irregular postmenopausal bleeding for a short time before hospitalization. She underwent abdominal hysterectomy, bilateral salpingo-oophorectomy, right pelvic lymphadenectomy, right para-aortic lymphadenectomy and omental excision. Postoperative pathology showed ovarian and pelvic lymph node metastasis and pathological stage IIIC. After six courses of chemotherapy with paclitaxel 270 mg + carboplatin 500 mg, the patient’s renal function was normal. During the third cycle of chemotherapy, the patient suffered a third-degree bone marrow suppression and returned to normal soon when treated with the recombinant human granulocyte stimulating factor. In conclusion, early screening of gynecologic tumors is important for female patients after renal transplantation, which has a positive significance for the prognosis improvement.

Role of glucocorticoid signaling in urothelial tumorigenesis: Inhibition by prednisone presumably through inducing glucocorticoid receptor transrepression

Glucocorticoids, including dexamethasone (DEX) and prednisone (PRED), have been prescribed in patients with neoplastic disease as cytotoxic agents or comedications. Nonetheless, it remains uncertain whether they have an impact on the development of bladder cancer. We, therefore, assessed the functional role of the glucocorticoid-mediated glucocorticoid receptor (GR) signaling in urothelial tumorigenesis. Tumor formation was significantly delayed in xenograft-bearing mice with implantation of control bladder cancer UMUC3 cells or nonneoplastic urothelial SVHUC cells undergoing malignant transformation induced by a chemical carcinogen 3-methylcholanthrene (MCA), compared with respective GR knockdown xenografts. Using the in vitro system with MCA-SVHUC cells, we screened 11 GR ligands, including DEX, and found significant inhibitory effects of PRED on their neoplastic transformation. The effects of PRED were restored by a GR antagonist RU486 in GR-positive MCA-SVHUC cells, while PRED failed to inhibit the neoplastic transformation of GR knockdown cells. Significant decreases in the expression levels of oncogenes (c-Fos/c-Jun) and significant increases in those of a tumor suppressor UGT1A were seen in MCA-SVHUC-control cells (vs GR-short hairpin RNA) or PRED-treated MCA-SVHUC-control cells (vs mock). In addition, N-butyl-N-(4-hydroxybutyl) nitrosamine induced bladder cancer in all of eight mock-treated mice vs seven (87.5%) of DEX-treated (P = .302) or four (50%) of PRED-treated (P = .021) animals. Finally, DEX was found to considerably induce both transactivation (activation of glucocorticoid-response element mediated transcription and expression of its targets) and transrepression (suppression of nuclear factor-kappa B transactivation and expression of its regulated genes) of GR in SVHUC cells, while PRED more selectively induced GR transrepression. These findings suggest that PRED could prevent urothelial tumorigenesis presumably via inducing GR transrepression.

Urothelial carcinoma of an allograft ureter 10 years after deceased donor kidney transplantation

The incidence of urothelial carcinoma (UC; formerly transitional cell carcinoma) is higher among renal transplant recipients compared with the general population. Upper urinary tract UC (UUT-UC) of allograft urothelium is a rare event with approximately 40 cases reported in the literature. Herein, we describe the clinical presentation and management of UUT-UC in a transplant ureter 10 years after deceased donor kidney transplantation.

Solid Organ Cancer and Melanoma in Kidney Transplant Recipients: TumorTx Base Preliminary Results

BACKGROUND

Incidence of malignancy in transplant recipients is higher than in the general population. Malignancy is a major cause of mortality following solid organ transplantation and a major barrier to long-term survival for the kidney. The aim of this study was to estimate the incidence of solid organ malignancy (SOM) and melanoma in renal transplant recipients (RTR) transplanted at 2 representative transplant centers in Poland based on data from the Polish Tumor Registry.

MATERIAL AND METHODS

We analyzed the medical data of 3069 patients who underwent kidney transplantation (KTx) between 1995 and 2015.

RESULTS

In our study 112 SOM (3.6%) were diagnosed. The majority of patients were male (n = 71; 63.4%; P < .01). The mean age at KTx was 48.0 ± 13.1 years and the mean age at the time of cancer diagnosis was 55.9 ± 12.7 years. The average time of malignancy occurrence was 5.9 ± 5.0 years after KTx. SOM was the cause of death in 60 patients (53%). The most common were malignancies of gastrointestinal tract (25%), urinary tract tumors (23.2%), lung cancer (n = 18; 16%), and lymphoma (13.4%). We found an increase in the percentage of chronic glomerular nephropathy in the group of SOM (n = 56; 50%) compared with renal insufficiency of other etiologies.

CONCLUSIONS

RTR in Poland are at a significant risk of malignancy development in a variety of organs, primarily urinary tract tumors and lymphoma. Cancers most frequently occurring in the general population such as lung and colorectal cancer are common in our RTR. On this basis an appropriate tumor screening schedule can be developed in individual countries.

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis

OBJECTIVES

Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence.

MATERIAL AND METHODS

We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed.

RESULTS

A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%.

CONCLUSIONS

Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.

Profiling of mRNA and long non-coding RNA of urothelial cancer in recipients after renal transplantation

The molecular mechanism and signal transduction pathways involved in urothelial cancer (UC) after renal transplantation (RTx) remain unknown. In this study, we investigated the profiling of messenger RNA (mRNA) and long non-coding RNA (lncRNA) in RTx recipients with UC. The mRNA and lncRNA of six pairs of UC and corresponding normal urothelial tissues in RTx recipients were profiled using Arraystar Human lncRNA Microarray V3.0, which is designed for the global profiling of 26,109 coding transcripts and 30,586 lncRNAs. Quantitative real-time PCR (qRT-PCR) was used to validate the differentially expressed mRNAs and lncRNAs. Molecular function classification and biological process classification for the differentially expressed mRNAs were analyzed with Gene Ontology. The key pathways that were associated with UC after RTx were analyzed using the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. Compared to normal urothelial tissues, 1597 mRNAs were upregulated and 1032 mRNAs were downregulated in UC; 2107 lncRNAs were upregulated and 1794 lncRNAs were downregulated (greater than twofold). Further qRT-PCR analysis of mRNA and lncRNA expression showed well consistency with the data of microarray analysis. The expression of matrix metalloprotease (MMP)-3, MMP-10, MMP-12, and MMP-13 was significantly increased, while the expression of CD36 was decreased in UC after RTx. Co-expression analysis of lncRNAs and their nearby coding genes showed that lncRNAs may play critical roles in regulating nearby genes in the carcinogenesis of UC. Our results also suggest that peroxisome proliferator-activated receptor (PPAR) signaling may be involved in UC after RTx. Moreover, several cytokines and their receptors were also significantly upregulated in UC after RTx, suggesting that cytokines might be modulated and participated in the carcinogenesis of UC after RTx. We analyzed the potential molecular mechanism and pathways involved in the UC of RTx recipients. Our results revealed that several key regulatory pathways and lncRNAs play critical roles in the carcinogenesis of UC, and suggest that UC in RTx recipients may be more likely to invade and metastasis. However, the detailed functional analysis of these mechanisms should be further performed in the future.

[Urological follow-up and development of cancer after renal transplantation]

BACKGROUND

The number of renal transplant recipients is rising, as well as graft and recipient survival. The mainstay of urological follow-up is to ensure urine transport and voiding function; also, the diagnosis and treatment of urological malignancies following renal transplantats is growing in importance. As urological malignancies are one of the three most common tumors following renal transplantation (RT), meticulous and regular urological evaluation is a central part of follow-up care after RT.

RECOMMENDATIONS

Urological evaluation following RT must ensure correct urine transport and voiding function. Transplant ureter strictures, relevant ureteral reflux and voiding dysfuntion (e.g., neurologic dysfunction, benign prostate hypeplasia) must be excluded or treated. Urinary tract infection (UTI), which can be life threatening in the immunosuppressed transplant recipient, must be diagnosed and treated consequently and for an adequate period of time. Prophylaxis of UTIs is indicated in patients with recurrent symptomatic UTI as well as in the initial 6 months following renal transplantation. Asymptomatic bacteriuria must not necessarily be treated. The incidence of urological malignancies like renal cell carcinoma, urothelial cancer of the bladder, and penile carcinoma is increased following RT, while the incidence of prostate and testis cancer is the same as in the nontransplant population. Surgical and nonsurgical treatment options do not differ from the normal population. Adaptation, cessation, or switching of the immunosuppressive regimen in case of urologic malignancy must be decided on the individual recipient basis.

Chemotherapy for urothelial carcinoma in renal transplantation patients: Initial results from a single center

The aim of this study was to assess the safety and efficacy of gemcitabine plus cisplatin/carboplatin (GC/GCa) chemotherapy in renal transplantation (RT) patients with urothelial carcinoma (UC). We reviewed the records of 12 RT patients with metastatic or locally advanced UC who received chemotherapy at our institution since January, 2013. All the patients received intravenous gemcitabine (800 mg/m²) on days 1, 8 and 15, plus cisplatin (70 mg/m²) or carboplatin (area under the curve = 5) on day 2, every 28 days. A total of 10 patients completed all the cycles, while 1 patient discontinued treatment due to disease progression and 1 patient discontinued due to non-medical reasons. In total, 12 patients received a median of four cycles of chemotherapy. The overall response rate was 50% (4/8 cases) in patients with measurable lesions. At the time of the study, 5 patients had succumbed to the disease (overall survival, 9.2 months), while 7 patients remained alive (follow-up time, 13.3 months). The most common toxicities were myelosuppression and gastrointestinal effects. Therefore, the GC/GCa regimen was found to be effective and tolerable in RT patients with UC. However, further studies involving more patients and control groups are required to confirm our results.