Management of de-novo urothelial carcinoma in transplanted patients

Incidence of De Novo Post-Transplant Malignancies in Thai Adult Kidney Transplant Recipients: A Single-Center, Population-Controlled, Retrospective Cohort Study at the Highest Volume Kidney Transplant Center in Thailand

Kidney transplant recipients (KTRs) are at increased risk of developing de novo post-transplant malignancies (PTMs), with regional differences in types with excess risk compared to the general population. A single-center, population-controlled, retrospective cohort study was conducted at a tertiary care center in Thailand among all adults who underwent their first kidney transplant from 1986 to 2018. Standardized incidence ratios (SIRs) of malignancy by age, sex, and place of residence were obtained using data from the National Cancer Registry of Thailand as population control. There were 2,024 KTRs [mean age, 42.4 years (SD 11.4); female patients, 38.6%] during 16,495 person-years at risk. Of these, 125 patients (6.2%) developed 133 de novo PTMs. The SIR for all PTMs was 3.85 (95% CI 3.22, 4.56), and for pooled solid and hematologic PTMs, it was 3.32 (95% CI 2.73, 3.99). Urothelial malignancies had the largest excess risk, especially in women [female SIR 114.7 (95% CI 66.8, 183.6); male SIR 17.5 (95% CI 8.72, 31.2)]. The next two most common cancers were non-Hodgkin's lymphoma and skin cancer [SIR 20.3 (95% CI 13.6, 29.1) and 24.7 (95% CI 15.3-37.8), respectively]. Future studies are needed to identify the risk factors and assess the need for systematic screening among PTMs with excess risk in KTRs.

Between the Hammer and Anvil: Resolution of unresectable muscle invasive bladder cancer in a renal transplant patient after cessation of immunosuppressive therapy

Multimodal immunosuppression is the backbone of modern solid organ transplantation. However, immunosuppression itself is an independent risk factor for post-transplant malignancy. Although skin malignancy is the most common post-transplant malignancy, genitourinary cancers are also described. Dose reduction or cessation of immunosuppression has a beneficial role in the management of transplant patients with concomitant malignancy, but only limited data exist with respect to bladder cancer (BCa). We describe a patient who developed metastatic muscle invasive bladder cancer (MIBC) after diseased donor kidney transplant (DDKT) who was successfully managed with dose reduction and elimination of an immunosuppression regimen.

Clinical characteristics and treatment outcomes of kidney transplant recipients with de novo urothelial carcinoma: thirty years of experience from a single center

BACKGROUND

De novo urothelial carcinoma (UC) is a leading cause of death after kidney transplant (KT). The efficacy of various treatments, apart from surgery, and the prognosis for patients with urothelial carcinoma after kidney transplantation remain unclear.

METHODS

We retrospectively reviewed the efficacy of chemotherapy with gemcitabine + cisplatin (GC) or gemcitabine + carboplatin (GCa), bladder infusion chemotherapy, and immunosuppression therapy for de novo UC in kidney transplantation recipients at different sites and T stages. We evaluated the prognosis and compared the difference using Kaplan-Meier analysis and the log-rank test.

RESULTS

Of the 97 kidney transplantation recipients with de novo UC, 51 (52.6%) were diagnosed with upper urinary tract carcinoma (UTUC), 17 (17.5%) with bladder carcinoma (BC), and 29 (29.9%) with both UTUC and BC. The five-year survival rates for BC, UTUC, and BC + UTUC with ≤ T1 stage were 100%, 88.2%, and 57.7%, respectively, while the survival rates for UTUC, BC + UTUC with ≥ T2 stage were 90.2% and 48.2%. Cyclosporine A significantly improved progression-free survival (PFS) in UTUC with ≤ T1 stage (p = 0.017). Rapamycin significantly improved PFS in UTUC with ≥ T2 stage (p = 0.026). Bladder infusion chemotherapy and GC/GCa chemotherapy had no significant effect on each T stage and site. Patients with UTUC + BC had the poorest overall survival (OS) compared with those with BC and UTUC.

CONCLUSION

The prognosis of UC in different sites varies. GC/GCa chemotherapy and bladder infusion chemotherapy appear to have no effect on prognosis. Rapamycin can delay the progression of advanced UTUC.

Systematic review on oncologic outcomes on adjuvant endovesical treatment for non-muscle invasive bladder cancer in patients with solid organ transplant

PURPOSE

Urothelial carcinoma has a higher incidence in renal transplanted patients according to several registries (relative risk × 3), and the global prognosis is inferior to the general population. The potential impact of immunosuppressive therapy on the feasibility, efficacy, and complications of endovesical treatment, especially Bacillus Calmette-Guerin, has a low level of evidence. We performed a systematic review that aimed to assess the morbidity and oncological outcomes of adjuvant endovesical treatment in solid organ transplanted patients.

METHODS

Medline was searched up to December 2021 for all relevant publications reporting oncologic outcomes of endovesical treatment in solid organ transplanted patients with NMIBC. Data were synthesized in light of methodological and clinical heterogeneity.

RESULTS

Twenty-three retrospective studies enrolling 238 patients were included: 206 (96%) kidney transplants, 5 (2%) liver transplants, and 2 (1%) heart transplants. Concerning staging: 25% were pTa, 62% were pT1, and 22% were CIS. 140/238 (59%) patients did not receive adjuvant treatment, 50/238 (21%) received mitomycin C, 4/238 (2%) received epirubicin, and 46/238 (19%) received BCG. Disease-free survival reached 35% with TURBT only vs. 47% with endovesical treatment (Chi-square test p = 0.08 OR 1.2 [0.98-1.53]). The complication rate of endovesical treatment was 12% and was all minor (Clavien-Dindo I).

CONCLUSION

In solid organ transplanted patients under immunosuppressive treatment, both endovesical chemotherapy and BCG are safe, but the level of evidence concerning efficacy in comparison with the general population is low. According to these results, adjuvant treatment should be proposed for NMIC in transplanted patients as in the general population.

[TREATMENT OF BLADDER UROTHELIAL CARCINOMA WITH LUNG METASTASIS AFTER RENAL TRANSPLANTATION]

We report a case of bladder cancer in a 54-year-old woman who underwent renal transplantation for chronic renal failure. Six years after the transplantation, she was diagnosed with muscle-invasive bladder cancer with multiple lung metastases. She received gemcitabine/cisplatin therapy for Stage IV bladder cancer, and the dose of the immunosuppressants was reduced to prevent adverse effects. Since lung metastatic lesions disappeared after four courses of chemotherapy and no new lesions were found, we performed radical cystectomy and right nephroureterectomy with ileal conduit construction. Although she was followed closely without therapy, multiple lung metastases appeared 6 months after the radical cystectomy. Gemcitabine/carboplatin therapy was administered, and the lung metastasis improved slightly until the end of the 4th course, but aggressive growth was observed after the 5th course. She switched to palliative treatment without requesting additional treatment and died of cancer 1 year and 9 months after total cystectomy.There is no evidence-based treatment strategy for advanced bladder cancer after kidney transplantation. It is necessary to recognize that the patient had renal dysfunction and was in an immunosuppressed state. Thus, it is crucial to select appropriate drug and surgical treatments for each patient.

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.