Contralateral Nephroureterectomy for Renal Transplant Recipients With Unilateral Upper Urinary Tract Transitional Cell Carcinoma: A Report of 12 Cases

De novo upper tract urothelial carcinoma after renal transplantation: a single-center experience in China

BACKGROUND

Long-term prognosis and risk factors of de novo upper tract urothelial carcinoma after renal transplantation were rarely studied. Thus, the aim of this study was to investigate the clinical features, risk factors, and long-term prognosis of de novo upper tract urothelial carcinoma after renal transplantation, especially the impact of aristolochic acid on tumor, using a large sample.

METHODS

106 patients were enrolled in retrospective study. The endpoints included overall survival, cancer-specific survival, bladder or contralateral upper tract recurrence-free survival. Patients were grouped according to aristolochic acid exposure. Survival analysis was performed using Kaplan-Meier curve. Log-rank test was used to compare the difference. Multivariable cox regression was conducted to evaluate the prognostic significance.

RESULTS

Median time from transplantation to development of upper tract urothelial carcinoma was 91.5 months. Cancer-specific survival rate at 1, 5, 10 years was 89.2%, 73.2%, 61.6%. Tumor staging (≥ T2), lymph node status (N +) were independent risk factors for cancer-specific death. Contralateral upper tract recurrence-free survival rate at 1, 3, 5 years was 80.4%, 68.5%, 50.9%. Aristolochic acid exposure was independent risk factor for contralateral upper tract recurrence. The patients exposed to aristolochic acid had more multifocal tumors and higher incidence of contralateral upper tract recurrence.

CONCLUSION

Both higher tumor staging and positive lymph node status were associated with a worse cancer-specific survival in patients with post-transplant de novo upper tract urothelial carcinoma, which highlighted the importance of early diagnosis. Aristolochic acid was associated with multifocality of tumors and higher incidence of contralateral upper tract recurrence. Thus, prophylactic contralateral resection was suggested for post-transplant upper tract urothelial carcinoma, especially for patients with aristolochic acid exposure.

Significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

OBJECTIVES

To investigate the significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma.

METHODS

Between January 2001 and December 2015, 548 patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy in a single institution were included in this retrospective cohort study. Several clinicopathological characteristics and outcomes were explored. The crucial end-point was the diagnosis of contralateral upper tract recurrence after radical nephroureterectomy.

RESULTS

Of the 548 patients, the median age was 68 years (range 24-93 years), and the median follow-up time after radical nephroureterectomy was 41 months (range 8-191 months). Contralateral upper tract recurrence occurred in 28 patients (5.1%). The median time period between radical nephroureterectomy and contralateral upper tract recurrence was 15.4 months (range 3.4-52.4 months). In the multivariate analysis, preoperative estimated glomerular filtration rate <30 mL/min/1.73 m² (hazard ratio 3.08, P = 0.003) and tumor multifocality (hazard ratio 2.16, P = 0.043) were independent risk factors.

CONCLUSION

Preoperative estimated glomerular filtration rate <30 and tumor multifocality are significant predictors of contralateral upper tract recurrence after radical nephroureterectomy for upper tract urothelial carcinoma.

Bilateral Nephroureterectomy Versus Unilateral Nephroureterectomy for Treating De Novo Upper Tract Urothelial Carcinoma After Renal Transplantation: A Comparison of Surgical and Oncological outcomes

Background:

There is currently no consensus on the optimal management of de novo unilateral upper tract urothelial carcinoma (UTUC) in renal transplant recipients. We aimed to compare the surgical and oncological outcomes of simultaneous bilateral radical nephroureterectomy (SBRNU) and unilateral radical nephroureterectomy (URNU) to determine the appropriate surgical method.

Methods:

Patients who developed de novo UTUC after renal transplantation and underwent surgical treatment at our center were included in the study. Outcomes were compared between the SBRNU group (underwent bilateral RNU within 3 months) and the URNU group using the Mann–Whitney U-test for continuous variables, Pearson’s chi-square test for categorical variables, and the log-rank test for survival data.

Results:

A total of 48 patients were identified, including 21 and 27 patients in the SBRNU and URNU groups, respectively. Comparison of perioperative data showed that the SBRNU group had a significantly longer operative time (P < .001) and hospital stay (P = .040) than the URNU group but no statistically significant difference in the blood loss (P = .171) and morbidity rate (P = .798). After a median follow-up of 65 months, the SBRNU group had a significantly longer disease-free survival (P = .009), longer cancer-specific survival (P = .032), marginally longer overall survival (P = .066), and similar intravesical recurrence-free survival (P = .274) than the URNU group.

Conclusions:

Our data suggest that SBRNU contributes to improved survival without significantly compromising the perioperative outcomes compared with URNU. SBRNU can be considered a feasible option for de novo UTUC after renal transplantation in specialized centers. Prospective studies should be conducted to further explore the best treatment options for this group of patients.

Urologic malignancies in kidney transplantation

With advances in immunosuppression, graft and patient outcomes after kidney transplantation have improved considerably. As a result, long-term complications of transplantation, such as urologic malignancies, have become increasingly important. Kidney transplant recipients, for example, have a 7-fold risk of renal cell carcinoma (RCC) and 3-fold risk of urothelial carcinoma (UC) compared with the general population. While extrapolation of data from the general population suggest that routine cancer screening in transplant recipients would allow for earlier diagnosis and management of these potentially lethal malignancies, currently there is no consensus for posttransplantation RCC or UC screening as supporting data are limited. Further understanding of risk factors, presentation, optimal management of, and screening for urologic malignancies in kidney transplant patients is warranted, and as such, this review will focus on the incidence, surveillance, and treatment of urologic malignancies in kidney transplant recipients.

Characteristics and treatment outcomes of pan-urothelial cell carcinoma: a descriptive analysis of 45 patients

The incidence of pan-urothelial cell carcinoma (panUCC), which refers to the presence of both bilateral (UTUC) and bladder tumor (BT), is relatively low. However, the profile of a panUCC cohort of patients remains to be elucidated. We reviewed the data of consecutive UTUC patients who received treatment at our center from 1999 to 2012. Overall, 45 patients were included in this study, with a median age of 64.5 years. Fourteen patients initially presented with unilateral UTUC, 11 initially with BT, and the remainder with multiple tumors. Patients with UTUC were more likely to manifest higher rates of muscle invasion and larger-sized tumors. Five patients were treated with complete urinary tract exenteration (CUTE), and most patients (73.3%) received combined management with conservative and radical surgery. After a median follow-up of 77 months, 18 patients (40%) died including 15 (33.3%) due to cancer. Higher tumor stage was the only risk factor predictive of worse survival. Nineteen patients experienced local recurrence after conservative surgery. This study indicated that PanUCC involves either synchronous or metachronous presentation of tumors with a high risk of tumor recurrence, progression, and dissemination after conservative surgery.

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.

Risk factors and treatment outcomes of new contralateral upper urinary urothelial carcinoma after nephroureterectomy: the experiences of a large Chinese center

OBJECTIVE

To explore the risk factors and treatment outcomes of contralateral new upper tract urothelial carcinoma (UTUC) after nephroureterectomy in a large single-center cohort of UTUC patients.

METHODS

A retrospective analysis of the clinicopathological data of 509 consecutive patients treated by nephroureterectomy from 2000 to 2010 at a high-volume center in China was conducted.

RESULTS

Thirty-five patients (6.9%) were found to develop contralateral UTUC. Gross hematuria was a common symptom, and aristolochic acid (AA) containing Chinese herbs was identified as an underlying cause. In multivariate analysis, renal transplant recipients (HR = 16.507) and preoperative renal insufficiency (HR = 2.523) were independent risk factors. No correlation was found in the clinical and pathological characteristics of primary and subsequent contralateral UTUC. A second round of nephroureterectomy should be performed on renal transplant patients, whereas patients who are older, exhibit relatively better renal function, and have tumors that are single, located in the ureter and small size could be treated with nephron-sparing surgery. No survival difference was detected between the two treatment groups, and developing contralateral UTUC was not associated with worse survival.

CONCLUSION

Contralateral UTUC is comparatively rare, and gross hematuria is a common symptom. Renal transplant history and renal insufficiency are independent risk factors, and prophylactic contralateral nephroureterectomy is considered for uremic UTUC patients with proper renal replacement treatment or renal transplant recipients. These features are likely related to the mechanisms of multifocality of UTUC, and the potential correlation with AA remains to be elucidated. Tumor characteristics and renal function are informative for the decisions concerning surgical options for contralateral UTUC.