Surgical Treatment of Renal Cell Carcinoma in the Immunocompromised Transplant Patient

Renal Cell Carcinoma in End-Stage Kidney Disease and the Role of Transplantation

Kidney transplant patients have a higher risk of renal cell carcinoma (RCC) compared to non-transplanted end-stage kidney disease (ESKD) patients. This increased risk has largely been associated with the use of immunosuppression; however, recent genetic research highlights the significance of tissue specificity in cancer driver genes. The implication of tissue specificity becomes more obscure when addressing transplant patients, as two distinct metabolic environments are present within one individual. The oncogenic potential of donor renal tissue is largely unknown but assumed to pose minimal risk to the kidney transplant recipient (KTR). Our review challenges this notion by examining how donor and recipient microenvironments impact a transplant recipient's associated risk of renal cell carcinoma. In doing so, we attempt to encapsulate how ESKD-RCC and KTR-RCC differ in their incidence, pathogenesis, outcome, and approach to management.

Small renal masses in kidney transplantation: overview of clinical impact and management in donors and recipients

Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended.

Management of Urological Malignancy in Heart and Lung Transplant Recipients: An Irish National Cohort Study

OBJECTIVES

Following the first hearttransplantin Ireland in 1985, there have been almost 700 deceased donor heart and lung transplants carried out in Ireland at a single institution. In this retrospective study, our aim was to assess the incidence and management of urological malignancies arising in this national cohort.

MATERIALS AND METHODS

Our retrospective analysis included all heart and lung transplant recipients identified as having a urological malignancy. Primary outcome variables included incidence, management, and clinical outcomes following cancer diagnosis.

RESULTS

A total of 28 patients (4.1%) had radiologically or histologically confirmed urological malignancies. Fourteen patientswere diagnosedwith prostate cancer, with 13 who underwent radical treatment. Eight renal cell carcinomas were diagnosed in heart transplant recipients, with 5 who underwent nephrectomies. Two bladder cancers and 1 uppertract urothelial carcinoma were diagnosed and managed with endoscopic resection, radiotherapy, and nephroureterectomy, respectively. Two patients were diagnosed with penile squamous cell carcinoma and managed with radical surgery and lymph node dissection/sampling, with 1 patient receiving adjuvant chemoradiotherapy.

CONCLUSIONS

Urological malignancies are not common in heart and lung transplant recipients; however, standard management options can be safely used, including radical surgery. Prospective monitoring of these patients and potential considerations for screening should be maintained.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Long-Term Outcome of Zero-Ischemia Partial Nephrectomy for the Treatment of Multifocal Renal Cell Carcinoma in Renal Transplant Allograft: A Case Report

Multifocal synchronous renal cell carcinoma in the functioning allograft is a rare disease; there is no consensus regarding its treatment, and few cases have been reported. In isolated masses, some authorities advocate graft nephrectomy, and some recommend partial nephrectomy. To our knowledge, we describe the first experience of nephron-sparing surgery in multifocal synchronous renal cell carcinoma in an allograft with its long-term outcome. A 42-year-old male patient with a history of living related-donor kidney transplant from his brother (18 years previously) presented with a history of gross hematuria over the past few months. Imaging studies revealed a 5.5-cm exophytic cystic mass lesion in lower pole and an 11-mm solid mass in the upper pole of the renal allograft. Both graft nephrectomy and nephronsparing surgery were offered to him. After the patient provided written informed consent, zero-ischemia partial nephrectomy of lower pole and enucleation of upper pole mass were performed. Pathology reports for both lesions indicated clear cell carcinoma, and margins were free of tumor. Twelve months after surgery, the patient was free of tumor, and his creatinine level was 1.6 mg/dL. At 29 months after surgery, his creatinine level was 2.4 mg/dL, and imaging revealed a tumor-free allograft. Nephronsparing surgery in multifocal renal cell carcinoma in the functioning renal allograft was feasible in our patient, and the long-term outcome was satisfactory. This surgical option provided dialysis-free and longterm tumor-free survival to the patient.

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.

De novo renal tumors arising in kidney transplants: midterm outcome after percutaneous thermal ablation

PURPOSE

To retrospectively evaluate the midterm outcome of patients treated for primary renal cell carcinomas arising in kidney transplants with minimally invasive techniques.

MATERIALS AND METHODS

The institutional review board of each participating institution approved this retrospective study and waived informed consent. This study was HIPAA compliant. A request for cases through the European Society of Urogenital Radiology network was made to institutions for patients who fit the requirements outlined by the authors, and a prospective follow-up of recipients was performed. Twenty-four tumors were identified that developed in the renal allograft of 20 patients from 11 institutions who were treated with radiofrequency ablation (n = 19) or cryoablation (n = 5) between 2003 and 2010. Maximal diameter of masses was 6-40 mm (median, 19.5 mm). Twenty masses were solid, and four were type 4 cystic masses. Preablation biopsy was performed for solid tumors only. All images and biologic and biopsy reports were retrospectively reviewed. Significant differences were determined by using a paired t test before and after ablation.

RESULTS

Mean follow-up was 27.9 months (range, 7-71 months). Histopathologic examination revealed papillary carcinoma in 17 patients and clear cell carcinoma in three. Tumors were successfully treated with ultrasonographic guidance in six patients, with computed tomographic guidance in 10 patients, and with both in four patients. One case of infection of the tumor site and one case of transitory genitofemoral nerve injury were the only reported complications. No significant change of renal function was noted. Subsequent imaging follow-up did not reveal any case of recurrence in the ablative site.

CONCLUSION

Percutaneous thermal ablation of renal tumors occurring in renal grafts is effective, with low morbidity. .