Incidence and Long-Term Prognosis of Cancer After Kidney Transplantation

Everolimus Use in Lung Transplant Recipients

BACKGROUND

Most lung transplantation centers prefer triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil, and corticosteroids. However, to prevent complications and comorbidities caused by tacrolimus, replacing the drug with everolimus has been considered.

METHODS

This is a retrospective observational study investigating everolimus switch for different reasons. The population was divided into 3 groups: chronic lung allograft dysfunction (CLAD), kidney impairment, and malignant neoplasm groups. We investigated whether we achieved the goal of the switch and the frequency of rejection, cytomegalovirus and fungal infections, and everolimus adverse effects.

RESULTS

Nineteen patients received everolimus therapy, and 5 of these were for CLAD, 7 for tacrolimus nephrotoxicity, and 7 for explant/de novo malignant neoplasm. The patients were followed up for a mean (SD) of 30 (16.7) months under the therapy. The number of acute cellular rejection, cytomegalovirus infection, and aspergillosis infection cases before switch were 7, 13, and 2, respectively, and 7, 2, and 3 after that. The mean values of creatinine and estimated glomerular filtration rate of the whole population after the switch improved with no statistical significance, whereas it was significant in tacrolimus nephrotoxicity group. Three patients in the CLAD group remained stable after switching, whereas 2 progressed. Only 1 of the 7 patients with malignant neoplasms had a recurrence during 31.1 (16.5) months of median follow-up. Eleven cases of everolimus adverse effects occurred in 9 patients (47.3%), with 2 (10.5%) withdrawal events. Kidney impairment (P = .02) and age (P = .05) stood out as significant risk factors for drug adverse effects.

CONCLUSIONS

After lung transplant, everolimus can be a safe alternative for immunosuppression with acceptable adverse effects.

Transplanted kidney loss during colorectal cancer chemotherapy: A case report

BACKGROUND

The overall risk of de novo malignancies in kidney transplant recipients (KTRs) is higher than that in the general population. It is associated with long-lasting exposure to immunosuppressive agents and impaired oncological vigilance due to chronic kidney disease. Colorectal cancer (CRC), frequently diagnosed in an advanced stage, is one of the most common malignancies in this cohort and is associated with poor prognosis. Still, because of the scarcity of data concerning adjuvant chemotherapy in this group, there are no clear guidelines for the specific management of the CRCs in KTRs. We present a patient who lost her transplanted kidney shortly after initiation of adjuvant chemotherapy for colon cancer.

CASE SUMMARY

A 36-year-old woman with a medical history of kidney transplantation (2005) because of end-stage kidney disease, secondary to chronic glomerular nephritis, and long-term immunosuppression was diagnosed with locally advanced pT_4AN_1BM₀ (clinical stage III) colon adenocarcinoma G2. After right hemicolectomy, the patient was qualified to receive adjuvant chemotherapy that consisted of oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX-4). The deterioration of kidney graft function after two cycles caused chemotherapy cessation and initiation of hemodialysis therapy after a few months. Shortly after that, the patient started palliative chemotherapy because of cancer recurrence with intraperitoneal spread.

CONCLUSION

Initiation of adjuvant chemotherapy for colon cancer increases the risk of rapid kidney graft loss driven also by under-immunosuppression.

Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature

BACKGROUND

Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared with conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA.

METHODS

We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥3 years follow-up, were included.

RESULTS

The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first-year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively.

CONCLUSIONS

Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression-related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.

Radical prostatectomy outcomes in renal transplant recipients: a retrospective case series of Thai patients

Background

The incidence of prostate cancer in renal transplant recipients (RTR) is similar to the general population. Radical prostatectomy (RP) is the standard of care in the management of clinically localized cancer, but is considered complicated due to the presence of adhesions, and the location of transplanted ureter/kidney. To date, a few case series or studies on RP in RTR have been published, especially in Asian patients. This study aimed to evaluate the efficacy and safety and report the experience with RP on RTR.

Methods

We retrospectively reviewed data of 1270 patients who underwent RP from January 2008 to March 2020, of which 5 patients were RTR. All available baseline characteristics, perioperative and postoperative data (operative time, estimated blood loss (EBL), complications, length of hospital stay, complication), pathological stage, Gleason score, surgical margin status, and pre/postoperative creatinine were reviewed.

Results

Of the 5 RTR who underwent RPs (1 open radical prostatectomy (ORP), 1 laparoscopic radical prostatectomy (LRP), 2 robotic-assisted laparoscopic radical prostatectomies (RALRP), and 1 Retzius-sparing RALRP (RS-RALRP)) prostatectomy, the mean age (± SD) was 70 (± 5.62) years. In LRP and RALRP cases, the standard ports were moved slightly medially to prevent graft injury. The mean operative time ranged from 190 to 365 min. The longest operative time and highest EBL (630 ml) was the ORP case due to severe adhesion in Retzius space. For LRP and RALRP cases, the operative times seemed comparable and had EBL of ≤ 300 ml. All RPs were successful without any major intra-operative complication. There was no significant change in graft function. The restorations of urinary continence were within 1 month in RS-RALRP, approximately 6 months in RALRP, and about 1 year in ORP and LRP. Three patients with positive surgical margins had prostate-specific antigen (PSA) persistence at the first follow-up and 1 had later PSA recurrence. Two patients with negative margins were free from biochemical recurrence at 47 and 3 months after their RP.

Conclusions

Our series suggested that all RP techniques are safe and feasible mode of treatment for localized prostate cancer in RTR.

Post-transplant lymphoproliferative disorder in adult renal transplant recipients: case series and review of literature

Post-transplant lymphoproliferative disorder (PTLD) is serious life-threating complication of transplantation. The clinical picture differs from lymphomas observed in the general population, with different manifestation, histopathology, higher aggressiveness with involvement of sites beyond the primary lymph node, and poorer outcome.

The objective of the study was to present nine cases of PTLD observed in our centre among the kidney transplant recipient population and discuss the results with up-to-date literature. We performed a retrospective single-centre assessment of PTLD incidence in the cohorts of kidney transplant recipients followed by our centre. We found nine cases of PTLD, five men and four woman, aged from 26 to 67 years at the time of diagnosis (mean [SD] 48 [5] years), transplanted between 1997 and 2013.

The disease was diagnosed between 2002 and 2017, from 6 to 440 months after transplantation (mean [SD] 96 [137] months). A diffuse large B-cell lymphoma was found in seven cases early as well as late after transplantation, and two patients presented T-cell lymphoma. Five patients achieved complete remission with no relapses after 6 to 13 months of treatment. In three cases the remission was achieved by switching to mammalian target of rapamycin inhibitors (mTORi) only. Four recipients died from 2 weeks to 15 months after PTLD was diagnosed.

Although the diagnostic criteria of different forms of PTLD are commonly known, rapid and correct diagnosis is not easy. PTLD is a relatively a rare disease, so there are too few studies and little consensus on the optimal treatment.

De-novo malignancies after kidney transplantation: A long-term observational study

Background

De-novo malignancies after kidney transplantation represent one major cause for mortality after transplantation. However, most of the studies are limited due to small sample size, short follow-up or lack of information about cancer specific mortality.

Methods

This long-term retrospective analysis included all adult patients with complete follow-up that underwent kidney transplantation between 1995 and 2016 at our centre. All patients with diagnosis of malignancy excluding non-melanoma skin cancer (NMSC) were identified and a matched control group was assigned to the kidney transplant recipients with post-transplant malignancies.

Results

1417 patients matched the inclusion criteria. 179 malignancies posttransplant were diagnosed in 154 patients (n = 21 with two, n = 2 patients with three different malignancies). Mean age at cancer diagnosis was 60.3±13.3 years. Overall incidence of de-novo malignancies except NMSC was 1% per year posttransplant. Renal cell carcinoma was the most common entity (n = 49, incidence 4.20 per 1000 patient years; cancer specific mortality 12%), followed by cancer of the gastro-intestinal tract (n = 30, 2.57; 50%), urinary system (n = 24, 2.06; 13%), respiratory system (n = 18, 1.54; 89%), female reproductive system (n = 15, 1.29; 13%), posttransplant lymphoproliferative disorders and haematological tumours (n = 14, 1.20; 21%), cancers of unknown primary (n = 7, 0.60 100%) and others (n = 22, 1.89; 27%). Male sex, re-transplantation and time on dialysis were associated with de-novo malignancies after transplantation.

Conclusion

De-novo malignancies continue to be a serious problem after kidney transplantation. To improve long-term outcome after Kidney transplantation, prevention and cancer screening should be more tailored and intensified.

Pelvic radiation therapy with volumetric modulated arc therapy and intensity-modulated radiotherapy after renal transplant: A report of 3 cases

Aim

Describe characteristics and outcomes of three patients treated with pelvic radiation therapy after kidney transplant.

Background

The incidence of pelvic cancers in kidney transplant (KT) recipients is rising. Currently it is the leading cause of death. Moreover, treatment is challenging because anatomical variants, comorbidities, and associated treatments, which raises the concern of using radiotherapy (RT). RT has been discouraged due to the increased risk of urethral/ureteral stricture and KT dysfunction.

Materials and methods

We reviewed the electronic health records and digital planning system of patients treated with pelvic RT between December 2013 and December 2018 to identify patients with previous KT.

Cases description

We describe three successful cases of KT patients in which modern techniques allowed full standard RT for pelvic malignances (2 prostate and 1 vaginal cancer) with or without elective pelvic nodal RT, without allograft toxicity at short and long follow-up (up to 60 months).

Conclusion

When needed, RT modern techniques remain a valid option with excellent oncologic results and acceptable toxicity. Physicians should give special considerations to accomplish all OAR dose constraints in the patient's specific setting. Recent publications recommend KT mean dose <4 Gy, but graft proximity to CTV makes this unfeasible. We present 2 cases where dose constraint was not achieved, and to a short follow-up of 20 months renal toxicity has not been documented. We recommend the lowest possible mean dose to the KT, but never compromising the CTV coverage, since morbimortality from recurrent or progressive cancer disease outweighs the risk of graft injury.

Early Complications After Kidney Transplantation in Patients Aged 60 Years and Older: A Single-Center, Paired-Kidney Analysis

OBJECTIVES

As the population ages, the number of people suffering from cardiovascular diseases (CVD) and diabetes mellitus (DM) increases. The coexistence of these diseases can affect the results of kidney transplantation (KT) in the elderly. The aim of this study was to analyze surgical and nonsurgical complications in the early period after KT and to identify the factors that influence their development in recipients aged ≥ 60 years compared to younger recipients < 60 years.

METHODS

One hundred seventy-five recipients of KT ≥ 60 years and 175 recipients of KT < 60 years who received kidneys from the same deceased donor were enrolled into the study. The incidence of surgical and nonsurgical complications, factors that may influence their development, early graft function, and patient and kidney-graft survival were analyzed during a 3-month follow-up period. Donor sources complied with the Helsinki Congress and Istanbul Declaration and organs were not procured from prisoners and individuals who were coerced or paid.

RESULTS

Older recipients were characterized by higher body mass index ± SD (26.1 ± 3.5 vs 24.7 ± 3.4 kg/m²) and suffered more often from pretransplant DM (20.6% vs 11.4%) and CVD (34.3% vs 10.3%) and less frequently underwent previous KT (6.3% vs 20.0%). There were no differences between the ≥ 60 year old and < 60 year old groups in reference to surgical (20.6% vs 24%) and nonsurgical complications (28.6% vs 27.4%), early graft function, serum creatinine, and proteinuria. Recipients (95.4% vs 97.1%) and kidney-graft survival (93.1% vs 95.4%) were similar in both groups. The recipient factors that influenced the development of infectious complications were age, dialysis duration, pretransplant DM, and CVD.

CONCLUSIONS

Despite higher co-incidence of CVD and DM, the risk of surgical and nonsurgical complications in elderly recipients is comparable to younger recipients in the early period after KT.

Oral carcinoma development after 23 years of renal transplantation

Renal transplant patients are treated with immunosuppressive drugs that decrease the effectiveness of the immune system, making them more prone to developing cancer. Skin and lip carcinomas are common malignancies encountered after transplantation, whereas oral carcinomas are rare. We report the case of a 51-year-old female Caucasian patient, with no history of smoking, who presented white lesions on the tongue and an ulcerated lesion on the lower lip beginning 4 months prior. Diagnosis of squamous cell carcinoma for both lesions was made following incisional biopsies. Interestingly, the patient reported a renal transplantation 23 years prior, and was maintained on a combination of cyclosporine, mycophenolate sodium and prednisone. The patient also presented a history of several basal and squamous cell carcinomas on sun-exposed areas of the skin. Both lesions were surgically excised. No sign of recurrence or new lesions in the oral cavity have been observed; however, new skin lesions are frequently diagnosed. This case report highlights that oral cancers may occur in transplant patients in the absence of classical risk factors. Thus, clinicians must be aware of the importance of thorough oral examination in transplant patients in routine follow-up.

De Novo Cancer Incidence and Prognosis After Kidney Transplantation: A Single Center Analysis

BACKGROUND

Malignancy is an important cause of mortality in renal transplants recipients. The aim of this study was to evaluate the incidence, prognosis, and survival of patients developing a de novo post-transplant cancer.

METHODS

Using a retrospective cohort design, we evaluated the incidence of de novo cancers among kidney transplants patients in our hospital from January 2000 to December 2012. We also evaluated the patient survival after tumor diagnosis.

RESULTS

We included 535 kidney transplants recipients with a mean follow-up of 7.8 years; among them, 39 (7.2%) developed malignancies. Median time from transplant to cancer diagnosis was 3 years, with a median age at diagnosis of 60 years. Male patients were significantly older at time of cancer diagnosis (68.5 years) compared with women (38 years, P < .05), and cancer diagnosis occurred significantly earlier in men (3.5 years since transplantation) than in women (8.5 years, P < .05). Among 39 patients affected by a de novo post-transplant cancer, 18 patients (46.2%) died, with an average age at death of 58.5 years. The average time from cancer diagnosis to death was 1.5 years. Among the group of patients who did not develop a post-transplant cancer, 83 patients (16.7%) died, with a median age at time of death of 54.5 years (P < .05).

CONCLUSIONS

Kidney transplant recipients are at higher risk of developing a post-transplant cancer. Prognosis after cancer diagnosis is poor, probably as a consequence of a more aggressive behavior of cancer in transplant recipients. Intensive screening protocols could allow for an earlier diagnosis thereby improving the long-term outcome of these patients.

Antitumor pharmacotherapy of colorectal cancer in kidney transplant recipients

Renal transplantation has become the sole most preferred therapy modality for end-stage renal disease patients. The growing tendency for renal transplants, and prolonged survival of renal recipients, have resulted in a certain number of post-transplant colorectal cancer patients. Antitumor pharmacotherapy in these patients is a dilemma. Substantial impediments such as carcinogenesis of immunosuppressive drugs (ISDs), drug interaction between ISDs and anticancer drugs, and toxicity of anticancer drugs exist. However, experience of antitumor pharmacotherapy in these patients is limited, and the potential risks and benefits have not been reviewed systematically. This review evaluates the potential impediments, summarizes current experience, and provides potential antitumor strategies, including adjuvant, palliative, and subsequent regimens. Moreover, special pharmaceutical care, such as ISDs therapeutic drug monitoring, metabolic enzymes genotype, and drug interaction, are also highlighted.

Chemotherapy in patient with colon cancer after renal transplantation: A case report with literature review

RATIONALE

Experience of pharmacotherapy in posttransplantation colorectal cancer (CRC) patients is inadequate.

PATIENT CONCERNS

A Chinese man had right renal transplantation and began immunosuppressive treatment at the age of 31 in 2009. He was diagnosed with colon cancer and underwent anterior resection in 2014. He was diagnosed with metastatic colon carcinoma by abdomen computed tomography (CT) and positron emission tomography-computed tomography in April 2017.

DIAGNOSIS

Metastatic colon carcinoma in posttransplantation patient.

INTERVENTIONS

Three cycles of FLOFOX (5-fluorouracil and leucovorin and oxaliplatin) chemotherapy were given since April 2017.

OUTCOMES

Plasma concentrations of immunosuppressant and kidney function were within normal during the chemotherapy. Abdomen CT revealed the progress of colon cancer at the end of the third course of chemotherapy.

LESSONS

A few cases about monochemotherapy of posttransplantation CRC have been reported, whereas experience of doublet chemotherapy was currently unavailable. We shared the experience of FOLFOX in a patient with posttransplantation colon cancer. Neither of incompatibility with immunosuppressant nor serious adverse drug reaction was observed. It provides evidence for the pharmacotherapy of posttransplantation CRC.

Trichoblastoma Cutis in a Renal Transplant Recipient: A Case Report

Trichoblastoma is rare, benign skin neoplasm that may be difficult to distinguish from malignant baso-cellular skin cancer. Renal transplant recipients are at increased risk for development of skin malignancies. Resection and histopathological evaluation of a suspicious lesion is mandatory to determine malignant skin changes. We present the first reported case of trichoblastoma in a renal transplant recipient. Proper diagnosis enables less aggressive resection and maintenance of the same immunosuppressive protocol.

Modification of immunosuppressive therapy as risk factor for complications after liver transplantation

Management of complications post-liver transplantation (LT) includes immunosuppressive manipulations with the aim to reduce the overall burden of immunologic suppression and compensate for renal, cardiovascular, metabolic toxicities, and for the increased oncologic risk. Two approaches can be implemented to reduce immunosuppression-related adverse events: upfront schedules tailored to the pretransplant individual patient's risk profile versus downstream modifications in the event of immunosuppression-related complications. Upfront strategies are supported by evidence originating from prospective randomized trials and consist of triple/quadruple schedules whereby calcineurin inhibitors (CNI)-exposure is reduced with combination of anti-CD25 monoclonal antibodies, antimetabolites and corticosteroids. Quadruple regimens allow for staggering of CNI introduction and higher renal function in the early term, but their superiority in the long term has not yet been established. A more recent upfront schedule contemplates early (4 weeks) introduction of mammalian target of rapamycin inhibitor (mTORi) everolimus and allows for reduction of CNI up to 4 years posttransplantation. Incorporation of mTORi has the potential to prolong time to recurrence for patients with hepatocellular carcinoma. However, as suggested by the available evidence, downstream immunosuppressive manipulations are more frequently adopted in clinical practice. These encompass CNI replacement and immunosuppression withdrawal. Switching CNI to mTORi monotherapy is the option most commonly adopted to relieve renal function and compensate for posttransplant malignancies. Its impact is dependent on interval from transplantation and underlying severity of renal impairment. Introduction of mTORi is associated with longer overall survival for patients with extrahepatic posttransplant malignancies, but results are awaited for recurrences of hepatocellular carcinoma. Immunosuppression withdrawal seems feasible (70%) in very long term survivors (>10 years), but is not associated with reversal of immunosuppression-related complications. Awaiting novel immunosuppressive drug categories, integration of upfront strategies with the aim to reduce CNI-exposure and a low threshold for adjustment in the posttransplant course are both advisable to improve long-term outcomes of LT.

Prostate Cancer Metastatic to the Renal Allograft: A Case Report

Malignancy is a leading cause of morbidity and mortality in organ transplant recipients who receive immunosuppression. Cancers associated with viruses such as nonmelanotic skin cancer and Kaposi sarcoma occur in allograft recipients at rates that far exceed that in the general population. The increased risk and tumor type may depend not only on degree of immune system modulation but also on the type of organ transplanted. In kidney transplant recipients, the risk of cancers such as prostate and breast does not seem to be increased. However, these cancers tend to be advanced and aggressive. The management of these cancers is similar to the general population with the additional consideration for reduction in immunosuppression and conversion to sirolimus. Given the increased survival of both transplanted organs as well as organ recipients along with the increased number of older recipients, the diagnosis of prostate cancer in the older male organ recipient is increasing. The long-term outcomes using current treatment guidelines for prostate cancer in these individuals are not clear. We report a case of known localized prostate cancer in a renal transplant recipient presenting with metastasis diagnosed as tumor infiltration of the allograft. Our patient, upon initial diagnosis of cancer, opted for radiation with eventual androgen-deprivation therapy. This unusual site of prostate cancer spread heightens the need for awareness among providers as well as the need for further studies of the outcomes in these patients undergoing treatments designed using guidelines developed for those with normally functioning immunity.

Everolimus and Malignancy after Solid Organ Transplantation: A Clinical Update

Malignancy after solid organ transplantation remains a major cause of posttransplant mortality. The mammalian target of rapamycin (mTOR) inhibitor class of immunosuppressants exerts various antioncogenic effects, and the mTOR inhibitor everolimus is licensed for the treatment of several solid cancers. In kidney transplantation, evidence from registry studies indicates a lower rate of de novo malignancy under mTOR inhibition, with some potentially supportive data from randomized trials of everolimus. Case reports and small single-center series have suggested that switch to everolimus may be beneficial following diagnosis of posttransplant malignancy, particularly for Kaposi's sarcoma and nonmelanoma skin cancer, but prospective studies are lacking. A systematic review has shown mTOR inhibition to be associated with a significantly lower rate of hepatocellular carcinoma (HCC) recurrence versus standard calcineurin inhibitor therapy. One meta-analysis has concluded that patients with nontransplant HCC experience a low but significant survival benefit under everolimus monotherapy, so far unconfirmed in a transplant population. Data are limited in heart transplantation, although observational data and case reports have indicated that introduction of everolimus is helpful in reducing the recurrence of skin cancers. Overall, it can be concluded that, in certain settings, everolimus appears a promising option to lessen the toll of posttransplant malignancy.