Features and outcomes of renal cell carcinoma of native kidneys in renal transplant recipients

Genitourinary malignancies in kidney transplant recipients

Advances in immunosuppressive therapy and postoperative management have greatly improved the graft and patient survival rates after kidney transplantation; however, the incidence of post-transplant malignant tumors is increasing. Post-renal transplantation malignant tumors are associated with renal failure, immunosuppression, and viral infections. Moreover, the risk of developing cancer is higher in kidney transplant recipients than in the general population, and the tendency to develop cancer is affected by the background and environment of each patient. Recently, cancer after kidney transplantation has become the leading cause of death in Japan. Owing to the aggressive nature and poor prognosis of genitourinary malignancies, it is crucial to understand their epidemiology, risk factors, and best practices in kidney transplant recipients. This review has a special emphasis on the epidemiology, risk factors, and treatment protocols of genitourinary malignancies in kidney transplant recipients to enhance our understanding of the appropriate management strategies. Optimal immunosuppressive therapy and cancer management for these patients remain controversial, but adherence to the general guidelines is recommended.

Testicular tumor in a case of, undescended testes, persistent mullerian duct syndrome and transverse testicular ectopia: Report of a case and review of the literature

A 20-year-old with normal male body features and secondary sexual characteristics presented with a right testicular swelling. Imaging revealed a right testicular mass, leading to a diagnosis of classical seminoma. During inguinal orchiectomy, a solid testicular mass was found on the right side along with two spermatic cords, one attached to the mass and the other to a structure resembling a testes. Examination showed the presence of other testes and a rudimentary uterus, indicating a rare case of a testicular tumor coexisting with undescended testes and transverse testicular ectopia (TTE) in a Pseudohermaphrodite with "persistent mullerian duct syndrome" (PMDS).

Clinical characteristics of renal cell carcinoma in the transplanted kidney in renal transplant recipients: a systematic scoping review

Background

Renal transplant recipients confront a substantially elevated susceptibility to renal cell carcinoma (RCC), particularly in their native kidneys as opposed to allografts.

Methods

In this systematic scoping review, exhaustive searches were conducted of the MEDLINE and EMBASE databases. Information was gathered on clinical manifestations, donor demographics, diagnostic intervals, tumor dimensions, histopathological characteristics, and therapeutic outcomes associated with RCC arising in allograft kidneys.

Results

The searches yielded a corpus of 42 case reports and 11 retrospective cohorts, encompassing a cohort of 274 patients. The majority of cases (75.4%) were clinically latent, discerned primarily through imaging modalities. Symptomatic presentations encompassed manifestations such as hematuria, elevated serum creatinine levels, abdominal discomfort, and graft-related pain. The mean temporal interval between renal transplantation and RCC diagnosis was calculated at 11.6 years, albeit displaying considerable variance. Notably, papillary and clear cell RCC emerged as the prevailing histopathological subtypes. However, the paucity of longitudinal follow-up data represents a notable caveat.

Conclusion

This investigation underscores the imperative of rigorous posttransplant surveillance regimes owing to the substantial prevalence of asymptomatic RCC instances. Future research should focus on clinical outcomes and cost-effectiveness of screening practices to develop preventive strategies.

Metastatic Translocated Renal Cell Carcinoma in a Kidney Transplant Patient - a Case Report and Review of the Literature

TFEB-altered renal cell carcinomas are rare tumours. Here, we report the exceptional case of such a tumour in the setting of solid organ transplantation and with already metastatic disease at the time of diagnosis. The primary tumour occurred in the native kidney and only focally showed biphasic morphology whereas the metastasis, among others to the transplant kidney, showed nonspecific, albeit different morphology, but both had consistent TFEB translocation. Treatment with the immune checkpoint inhibitor pembrolizumab together with the multi-kinase inhibitor lenvatinib achieved partial response 14 months after diagnosis.

How to manage renal masses in kidney transplant recipients? A collaborative review by the EAU-YAU kidney transplantation and renal cancer working groups

INTRODUCTION

Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate.

OBJECTIVE

To explore the current management of the native kidney masses in KT patients.

ACQUISITION OF EVIDENCE

We performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review.

SYNTHESIS OF EVIDENCE

In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft.

CONCLUSIONS

Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented.

Characteristics and Outcomes of De Novo Genitourinary Malignancy in Solid Organ Transplant Recipients at the University of Minnesota

BACKGROUND

Studies examining outcomes of genitourinary malignancy (GU) in the solid organ transplant (SOT) population predominantly focus on renal transplant recipients and consist of relatively small cohorts. We aimed to expand knowledge of the characteristics and outcomes of de novo GU malignancies in all patients with SOT at a large tertiary center.

METHODS

The SOT database was queried for recipients with de novo bladder, renal cell, and prostate malignancy, and a retrospective chart review was performed. Descriptive statistics and Kaplan-Meier survival estimates were calculated. Cox proportional hazards regression was used for multivariate modeling of predictive factors in the development of GU malignancy.

RESULTS

Solid organ transplant recipients with de novo bladder malignancy comprised 64.3% with high grade and 38.1% with advanced stage (≥T2) disease at initial diagnosis. Only 3.7% of patients with de novo renal cell carcinoma presented with metastatic disease, and 13.6% with localized disease developed recurrences. The most common stage in de novo prostate cancer patients was pT3 (52.2%). Kaplan-Meier estimates (95% CI) for 5-year overall (OS) and cancer-specific survival (CSS) were 44.12% (31.13-62.52) and 80.80% (68.85-94.81) for bladder, 78.90% (68.93-90.30) and 96.61% (92.10-100.00) for renal cell, and 81.18% (72.01-91.51) and 96.16% (90.95-100.00) for prostate cancer, respectively. Age at transplant and time from transplant to cancer diagnosis were predictive of de novo bladder cancer OS (P = .042 and .021, respectively).

CONCLUSION

To our knowledge, this is the largest single-center cohort examined for GU malignancy after SOT. Bladder and renal cell cancer had worse OS but similar CSS as historical rates for nontransplant patients. De novo prostate cancer had similar CSS.

Renal cell carcinoma in native kidneys before transplantation - When will we stop waiting?

INTRODUCTION

Kidney transplantation requires immunosuppression, traditionally regarded as a risk factor for progression in all malignancies. Based on the Cincinnati Registry, a waiting period before transplantation is therefore mandatory. However, recent evidence suggests this increased risk is restricted to particular tumors, whereas others like renal cell carcinoma (RCC) are not negatively affected. We aimed to compare oncological outcomes of RCC in native kidneys of end-stage renal disease (ESRD) patients, according to their transplantation or dialysis status.

MATERIAL AND METHODS

Retrospective analysis of all ESRD patients diagnosed with RCC between 2010 and 2020 in our center. Recurrence-free survival (RFS) and overall survival (OS) were estimated with Kaplan-Meier curves. Multivariable Cox regression model was used to evaluate their association with kidney transplantation.

RESULTS

Clinical and pathological characteristics were similar between groups. Kidney transplant recipients had similar risk of recurrence (hazard ratio [HR] 0.40, 95% confidence interval [CI) 0.04-4.46, p = 0.458) and overall survival (HR 0.34, 95%CI 0.07-1.77, p = 0.202) as dialyzed patients. On multivariable Cox regression model, presence or absence of transplantation was not significantly associated with RFS (p = 0.479) or OS (p = 0.236). Time on dialysis was the only independent predictor of worse survival (HR 1.86, 95%CI 1.18-2.93, p = 0.008).

CONCLUSIONS

Most RCC in native kidneys of ESRD patients are low-grade, low-stage and exhibit favourable pathological and outcome features. Immunosuppression does not seem to have an impact on oncological outcomes, but an increased time on dialysis seems to be associated with worse overall survival. Therefore, waiting time for transplantation for these tumors could be reduced.

Renal cell carcinoma of different pathological types in bilateral native kidneys of a kidney transplant recipient: A case report and literature review

Patients after kidney transplantation have a much higher risk of developing malignant tumors than the general population. And the native kidney is an organ relatively susceptible to malignant tumors after renal transplantation. However, the simultaneous development of bilateral renal tumors is very rare; especially the bilateral native kidneys harbor different pathological types of renal cell carcinoma (RCC). We report a case of a patient who developed malignant tumors in both native kidneys nearly 19 years after renal transplantation. This patient underwent bilateral laparoscopic radical nephrectomy, and postoperative pathological examination showed clear cell RCC on the left native kidney and papillary RCC on the right one. And the early detection and surgical treatment resulted in a good prognosis. The literature related to the diagnosis and treatment of bilateral RCC after renal transplantation is also reviewed.

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.

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.

[Bilateral papillary renal cell carcinoma following kidney transplantation: A case report]

With the continuous development of kidney transplantation technique, the survival time after kidney transplantation is gradually prolonged. Thus, the malignant tumor has been the important influencing factor on the long-term survival for kidney transplantation patients. Renal cell carcinoma is a relatively common tumor after kidney transplantation. Besides, clear cell renal cell carcinoma and papillary renal cell carcinoma are the relatively common pathological types for renal cell carcinoma following kidney transplantation. However, bilateral renal cell carcinoma following kidney transplantation is comparatively rare. In this article, we presented a case of bilateral papillary renal cell carcinoma, which occurred after kidney transplantation. And the diagnosis and treatment were introduced in detail. The patient was 37 years old, and he underwent kidney transplantation 13 years ago in our hospital, because of kidney failure. After kidney transplantation, he had regular medical check-up every year. In this year, his urological ultrasound results indicated bilateral renal tumors. And then, he received abdominal and pelvic computed tomography, and the result also showed bilateral renal tumors, which were likely to be malignant tumors. After adequate consultation, the patient chose surgical treatment. The patient received long-term immunosuppressive therapy, because of kidney transplantation. Considering this, the surgeon decided to choose a staging surgical treatment, in order to reduce the bad influence of one-stage surgery. Then, the patient first underwent retroperitoneal laparoscopic radical nephrectomy for right renal tumor in our hospital, and he had no complications after operation. The pathological results showed papillary renal cell carcinoma. He was discharged successfully. He underwent retroperitoneal laparoscopic radical nephrectomy for left renal tumor in our hospital one month later, and he had no complications after operation. The pathological results also showed papillary renal cell carcinoma. He was discharged successfully two days after surgery. In the 3-month follow-up, the patient was recovering well. To sum up, the incidence of bilateral renal cell carcinoma following kidney transplantation is relatively rare, and bilateral radical nephrectomy is effective and safe treatment. Above all, it is the patient's condition that determines the choice of staging surgery or simultaneous surgery.

Outcome of advanced renal cell carcinoma arising in end-stage renal disease: comparison with sporadic renal cell carcinoma

BACKGROUND

The data regarding oncological outcome in advanced renal cell carcinoma (RCC) arising in end-stage renal disease (ESRD) are limited.

METHODS

Patients diagnosed with advanced RCC on maintenance dialysis therapy (ESRD-RCC) and treated with tyrosine kinase inhibitors (TKIs) were retrospectively evaluated. Progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) after initiation of first-line TKI therapy in ESRD-RCC patients were compared to those in RCC arising in the general population (sporadic RCC).

RESULTS

A total of 36 and 240 patients were diagnosed with advanced ESRD-RCC and sporadic RCC, respectively. PFS and OS were significantly shorter in patients with ESRD-RCC than in those with sporadic RCC (p = 0.0004 and p = 0.0045). After adjusting for histopathological type, MSKCC risk and liver metastasis status, ESRD status (ESRD-RCC vs. sporadic RCC) was not an independent risk factor for PFS or OS (both, p > 0.05). The ORR tended to be lower in patients with ESRD-RCC than in those with sporadic RCC (11% vs. 28%, p = 0.0833). In 34 patients with ESRD-RCC treated with sorafenib, longer duration of dialysis was an independent prognostic factor for shorter OS (hazard ratio 3.21, p = 0.0370).

CONCLUSIONS

Outcome of advanced ESRD-RCC was poorer than that of sporadic RCC, but this finding was affected by other prognostic factors. Nevertheless, the study suggested that advanced ESRD-RCC was not an indolent disease. Additionally, patients with a longer duration of dialysis therapy might require careful monitoring.

[Renal cell carcinoma in candidates for renal transplantation and recipients of a kidney transplant: The French guidelines from CTAFU]

OBJECTIVE

To define guidelines for the management of renal cell carcinoma of the native kidney (NKRCC) in kidney transplant (KTx) recipients and renal cell carcinoma (RCC) in end-stage renal disease (ESRD) patients candidates for renal transplantation.

METHOD

A review of the literature following a systematic approach (Medline) was conducted by the CTAFU to report renal cell carcinoma epidemiology, screening, diagnosis and management in KTx candidates and recipients. References were assessed according to a predefined process to propose recommendations with the corresponding levels of evidence.

RESULTS

ESRD patients are at higher risk of RCC with a standardized incidence ratio of approximately 4,5 as compared with general population. NKRCC tumors occur in 1 to 3 % of KTx recipients with a 10 to 15-fold increased risk as compared with general population, especially in patients with acquired multicystic kidney disease. Most authors suggest yearly monitoring of the native kidneys using ultrasound imaging. Radical nephrectomy (either open or laparoscopic approach) is the preferred treatment of NKRCC in KTx recipients and RCC in ESRD. Surveillance in a valid option in small or cystic renal masses. In the localized setting, change in immunosuppressive therapy is not recommended besides perioperative avoidance of mTOR inhibitor to limit morbidity. CTAFU does not recommend a mandatory waiting time after nephrectomy for RCC in ESRD patients candidates for renal tranplantation when tumor stage<T3 and low ISUP grade. Follow-up modalities should follow recommendations in general population.

CONCLUSION

The French recommendations should contribute to improve management of NKRCC in KTx recipients and RCC in ESRD candidates for KTx, integrating oncological objectives in the context of kidney transplantation.

Characteristics and Graft Survival of Kidney Transplant Recipients with Renal Cell Carcinoma

BACKGROUND

The incidence of renal cell carcinoma (RCC) is higher in kidney transplant recipients (KTRs) compared to the general population. However, the risk factors and outcomes based on the diagnosis of RCC after kidney transplantation are limited.

METHODS

We analyzed risk factors for the development of RCC in KTRs transplanted at our institution between 1994 and 2016. We compared the incidence of graft failure and mortality in KTRs with RCC to matched controls using 5:1 event density sampling. Identifying the risk factors of RCC and patient and graft survival were outcomes of interest.

RESULTS

There were 4,178 KTRs performed at our institution during the study period, and 51 patients were diagnosed with RCC. Recipients were followed until graft failure or death. We did not identify commonly looked at baseline characteristics associated with the risk of RCC. Comparing KTRs with RCC to matched controls, RCC patients were younger (47.5 vs. 49.6 years, p < 0.01), received basiliximab induction more commonly (p = 0.01), had hypertension and glomerulonephritis as causes of end-stage renal disease (p = 0.01), and were more likely to be smokers (p < 0.01). RCC was significantly associated with death-censored graft failure (adjusted hazard ratio [HR]: 1.76; 95% CI: 1.02-3.03; p = 0.04) but not patient death (adjusted HR: 0.95; 95% CI: 0.50-1.83; p = 0.89).

CONCLUSION

In our experience, RCC had a detrimental impact on graft survival among KTRs, highlighting the potential benefit of early diagnosis and optimal immunosuppression management in optimizing graft survival.

Bilateral renal cell carcinoma of the native kidneys in a 16-year-old boy: Report of a rare case and review of the literature

Bilateral renal cell carcinoma is rare and most commonly occurs in patients with background of hereditary and genetic diseases. Occurrence of bilateral renal cell carcinoma in native kidneys of a renal transplant patient is even more uncommon, and less than 10 cases have been reported in the English literature. Herein, we report our experience with the youngest renal transplant patient ever reported with bilateral renal cell carcinoma, who presented with intractable urinary tract infection. We also will review all of the reported cases of bilateral renal cell carcinoma in the last 20 years in the English literature according to the presentations, treatment modalities, prognosis, and graft outcome.

Oncological Screening of Kidney Transplant Patients: The Role of Ultrasound Examination

INTRODUCTION

Immunosuppressive therapy used after organ transplantation represents a considerable oncological risk. Abdominal ultrasound examinations play an essential role in the oncological screening of organ transplant patients. Our aim was to study the effectiveness of the ultrasound screening protocol currently used in our clinic.

METHODS

Reports of screening abdominal ultrasound examinations of kidney transplant recipients were processed at the Department of Transplantation and Surgery of Semmelweis University from January 2012 to December 2015.

RESULTS

In 1478 studies, 14 patients were diagnosed with a malignant tumor, 11 of which were formed in the native shrunken kidney. The mean age for tumor diagnosis was 55.6 ± 12.6 years, and 80% of the patients diagnosed with tumor were male. On average, 7.5 ± 4.6 years passed between the transplantation and recognition of the tumor. All of the kidney tumors were diagnosed at an early stage: histologic examination of removed kidneys showed 73% pT1a- and 17% pT1b-stage tumors.

CONCLUSION

In our study, early stage shrunken kidney cancers were outstandingly the most common post-transplant malignancies found by ultrasound screening. Annual ultrasound examinations as part of our current screening protocol allowed the detection of tumors at an early stage in kidney transplant recipients.

Incidence and Mortality of Renal Cell Carcinoma after Kidney Transplantation: A Meta-Analysis

Background: The incidence and mortality of renal cell carcinoma (RCC) after kidney transplantation (KTx) remain unclear. This study’s aims were (1) to investigate the pooled incidence/incidence trends, and (2) to assess the mortality/mortality trends in KTx patients with RCC. Methods: A literature search was conducted using the MEDLINE, EMBASE and Cochrane databases from inception through October 2018. Studies that reported the incidence or mortality of RCC among kidney transplant recipients were included. The pooled incidence and 95% CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO; no. CRD42018108994. Results: A total of 22 observational studies with a total of 320,190 KTx patients were enrolled. Overall, the pooled estimated incidence of RCC after KTx was 0.7% (95% CI: 0.5–0.8%, I² = 93%). While the pooled estimated incidence of de novo RCC in the native kidney was 0.7% (95% CI: 0.6–0.9%, I² = 88%), the pooled estimated incidence of RCC in the allograft kidney was 0.2% (95% CI: 0.1–0.4%, I² = 64%). The pooled estimated mortality rate in KTx recipients with RCC was 15.0% (95% CI: 7.4–28.1%, I² = 80%) at a mean follow-up time of 42 months after RCC diagnosis. While meta-regression analysis showed a significant negative correlation between year of study and incidence of de novo RCC post-KTx (slopes = −0.05, p = 0.01), there were no significant correlations between the year of study and mortality of patients with RCC (p = 0.50). Egger’s regression asymmetry test was performed and showed no publication bias in all analyses. Conclusions: The overall estimated incidence of RCC after KTX was 0.7%. Although there has been a potential decrease in the incidence of RCC post-KTx, mortality in KTx patients with RCC has not decreased over time.

Clinicopathological characteristics of surgically treated localized renal masses in patients previously exposed to chemotherapy

Purpose:

To explore the potential association between renal mass characteristics and a history of chemotherapy.

Materials and methods:

A retrospective review of records of patients surgically treated for a localized renal mass between 2000 and 2012 was undertaken following an institutional review board approval. Patients age and sex, renal mass clinical characteristics (radiological size and mode of presentation) and pathological characteristics (diagnosis, renal cell carcinoma subtype, Fuhrman grade and stage) were compared between patients with and without a history of chemotherapy, using Fisher's exact test, Student's t-test and Wilcoxon rank sum test. A multivariate logistic analysis was performed to evaluate the independent association of chemotherapy and tumor pathology.

Results:

Of the 1,038 eligible patients, 33 (3%) had a history of chemotherapy. The distribution of clinical stage, renal mass diagnosis, renal cell carcinoma subtype, Fuhrman grade, pathological stage, sex and median age were similar between the general population and the chemotherapy group. However, the latter had a higher rate of incidental presentation (P = 0.003) and a significantly smaller median radiological tumor size (P = 0.01). In a subset analysis of T1a renal cell carcinoma, the chemotherapy group presented an increased rate of high Fuhrman grade (P = 0.03). On multivariate analysis adjusted for radiological tumor size, sex and age the chemotherapy cohort had a 3.92 higher odds for high Fuhrman grade.

Conclusion:

Patients with a history of chemotherapy typically present with smaller renal masses that, if malignant, have higher odds of harboring a high Fuhrman grade and thus may not be suitable for active surveillance.

Incidental Eosinophilic Chromophobe Renal Cell Carcinoma in Renal Allograft

The incidence of renal cell carcinoma (RCC) in renal allograft in transplant recipients is 0.22-0.25%. De novo clear cell, papillary, and chromophobe RCCs and RCCs with sarcomatoid differentiation originating in renal allograft have been reported. Routine surveillance for graft tumours is not routinely practiced and these tumours are commonly asymptomatic and incidentally discovered. We describe a case of incidental, eosinophilic chromophobe RCC in a 31-year-old, long-term renal transplant male recipient, who presented with acute gastroenteritis 11 years after transplantation. The graft was nonfunctional at the time of presentation. Abdominal ultrasound and computed tomography scan demonstrated 1.8 cm well-defined, round enhancing lesion, confined to the renal allograft and suspicious for malignancy. Pathological examination of graft nephrectomy specimen showed gross, histopathological, and immunohistochemical features of eosinophilic chromophobe RCC. Fifty-five months after surgery, the patient was alive and free of malignancy. To the best of our knowledge, only five chromophobe RCCs originating in a renal allograft were previously described in English literature. We suggest that chromophobe RCC should be considered in the differential diagnosis of renal allograft mass, including eosinophilic tumours, and emphasise the importance of periodic screening of renal allograft in all renal transplant recipients.

Daunting but Worthy Goal: Reducing the De Novo Cancer Incidence After Transplantation

Solid-organ transplant recipients are at increased risk of developing de novo malignancies compared with the general population, and malignancies become a major limitation in achieving optimal outcomes. The prevention and the management of posttransplant malignancies must be considered as a main goal in our transplant programs. For these patients, immunosuppression plays a major role in oncogenesis by both impairement of immunosurveillance, enhancement of chronic viral infection, and by direct prooncogenic effects. It is essential to manage the recipient with a long-term adapted screening program beginning before transplantation to use a prophylaxis to decrease infection-related cancer, to propose a viral monitoring, and to modulate the immunosuppression toward lower doses especially for calcineurin inhibitors. Indeed, strategies to induce tolerance or to allow a dramatic reduction of the immunosuppression burden are the more promising approaches for the reduction of the posttransplant malignancies.

Renal Tumor in Allogeneic Kidney Transplant Recipient

BACKGROUND

Malignancies will be a leading cause of mortality in renal transplant recipients in the next 20 years. Renal cell cancer (RCC) is the most common urologic cancer in kidney transplant recipients. The risk of RCC development in kidney transplant recipients is 15-100 times higher than in the general population. The purpose of the current retrospective study was to assess the frequency of nephrectomies performed because of renal tumors in the native kidneys in kidney transplant recipients in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year; the identification of kidney recipients diagnosed with RCC; and epidemiologic, clinical, and histopathological aspects associated with RCC.

PATIENTS AND METHODS

A total of 319 nephrectomies were performed in the Department of General and Transplantation Surgery at the Medical University of Warsaw between 2010 and 2014 year. Renal tumors were diagnosed in 25 renal transplant recipients.

RESULTS

Among malignant tumors, 13 cases of RCC and 1 case of post-transplant lymphoproliferative disorder (PTLD) were observed. There was no significant difference between age and duration of pretransplantation dialysis in patients with RCC and patients with benign tumors (P = .14 and P = .91, respectively). Body mass index was significantly higher in patients with RCC than in patients with benign tumors (P = .04).

CONCLUSIONS

Renal cell cancer is more common among male kidney recipients. There is a good Polish screening system allowing detection of kidney cancer in native kidney. We recommend performing periodic screening for kidney cancers to obtain an early diagnosis.

Risk of Renal Cell Carcinoma Among Kidney Transplant Recipients in the United States

Renal cell carcinoma (RCC) is a common malignancy following kidney transplantation. We describe RCC risk and examine RCC risk factors among US kidney recipients (1987-2010). The Transplant Cancer Match Study links the US transplant registry with 15 cancer registries. Standardized incidence ratios (SIRs) were used to compare RCC risk (overall and for clear cell [ccRCC] and papillary subtypes) to the general population. Associations with risk factors were assessed using Cox models. We identified 683 RCCs among 116 208 kidney recipients. RCC risk was substantially elevated compared with the general population (SIR 5.68, 95% confidence interval 5.27-6.13), especially for papillary RCC (SIR 13.3 versus 3.98 for ccRCC). Among kidney recipients, RCC risk was significantly elevated for blacks compared to whites (hazard ratio [HR] 1.50) and lower in females than males (HR 0.56). RCC risk increased with prolonged dialysis preceding transplantation (p-trend < 0.0001). Risk was variably associated for RCC subtypes with some medical conditions that were indications for transplantation: ccRCC risk was reduced with polycystic kidney disease (HR 0.54), and papillary RCC was increased with hypertensive nephrosclerosis (HR 2.02) and vascular diseases (HR 1.86). In conclusion, kidney recipients experience substantially elevated risk of RCC, especially for papillary RCC, and multiple factors contribute to these cancers.

Solid-type RCC originating from native kidneys in renal transplant recipients should be monitored cautiously

Incidental hemodialysis-related renal cell carcinoma (id-RCC) has been reported to have a good prognosis. However, we have observed rapid progression of id-RCC in some renal transplant patients. Operative indications for id-RCC detected via computed tomography (CT) immediately before renal transplantation (RTx) remain unclear. The purpose of this study was to examine the effects of immunosuppression on the progression of solid-type RCC (s-RCC) and cystic-type RCC (c-RCC). We divided 202 patients with id-RCC into four groups as follows: Group 1, s-RCC with RTx (n = 17); Group 2, c-RCC with RTx (n = 27); Group 3, s-RCC without RTx (n = 53); and Group 4, c-RCC without RTx (n = 105). Five-year cancer specific survival (CSS) rates were significantly worse in Group 1 than Group 3 (79.6% and 100%, respectively, P = 0.012), as were non-recurrence rates (NRRs) (59.2 and 100%, respectively, P < 0.001). In contrast, 5-year CSS rates were similar in Group 2 and Group 4 (100% and 95.7%, respectively, P = 0.295) as were NRR (100% and 98.7%, respectively, P = 0.230). Solid-type RCC should be removed immediately after RTx, and more carefully monitored for recurrence during follow-up.

Malignancies arising in allograft kidneys, with a first reported translocation RCC post-transplantation: A case series

BACKGROUND

The increased risk of malignancy in the post-renal transplant population has been well documented. Renal carcinoma is more common in this population, usually arising in native kidneys. Rarely, tumors arise in the transplanted kidney. Our case series reports four cases of malignancy in allograft kidneys, one of which is a first reported case of translocation RCC in a transplanted kidney.

METHODS

The renal transplantation database (1584 patients) at St. Michael's Hospital was reviewed for malignancies arising in allograft kidneys: reports and pathology slides were reviewed.

RESULTS

Four cases of malignancies arising in the allograft kidney were identified among our kidney transplant population. One patient developed a high grade urothelial carcinoma in the donor kidney post BK virus infection. The other 3 cases were renal cell carcinomas: one clear cell renal cell carcinoma, one translocation renal cell carcinoma, and one papillary renal cell carcinoma. The translocation renal cell cancer had confirmed TFE3 protein over-expression by immunohistochemistry. Molecular testing of the tumors in all 4 cases identified two separate genetic profiles, favored to represent tumors arising from donor tissues along with infiltrating recipient lymphocytes.

DISCUSSION

Previous reports suggested that epithelial malignancies in allograft kidneys are rare. We identified 4 such tumors in 1584 transplant patients. Further, we identified the first reported case of translocation RCC in an allograft kidney. While the rate of malignancy in allograft kidneys is low, screening of the donor kidneys by ultrasound and/or urine cytology may be of use in detecting these lesions.

Complete response of sunitinib therapy for renal cell cancer recurrence in the native kidney after renal transplantation: a case report

Background

No case report has yet shown that sunitinib therapy for the postoperative recurrence of renal cancer in a native kidney after renal transplantation can achieve complete response (CR).

Case presentation

A tumor was detected in the right native kidney of a 35-year-old Japanese male 10 years after renal transplantation. A tumor thrombus that reached the atrium was detected, which suggested cT3cN0M0. Because of the risk of perioperative complications, preoperative therapy with sunitinib was selected and 8 courses were administered. The size of the primary tumor was reduced by 33%, while that of the tumor thrombus was decreased by 39.5%.

Right nephrectomy and removal of the tumor thrombus were then performed. Contrast-enhanced computed tomography (CT) four months after surgery suggested local relapse. Sunitinib was administered for 9 months, which led to complete response (CR).

Conclusions

This study presented the case of sunitinib therapy for renal cancer in the native kidney after renal transplantation. The therapeutic efficacy and safety for such cases should be discussed.

Management of renal masses in transplant allografts at an Australian kidney-pancreas transplant unit

BACKGROUND

A shift towards partial nephrectomy (PN) in the management of small renal cell carcinoma (RCC) in recent years has prompted a parallel change in the management of rare cases of transplant allograft RCC. There are currently no guidelines on the management of allograft RCC. We present our center experience and review the latest evidence for management of RCC in renal transplant allografts.

METHODS

We performed a retrospective review of the transplant patient registry of a kidney-pancreas transplant center between 1984 and 2012. All confirmed allograft kidney RCC cases were included in this series. MEDLINE search of current literature on renal allograft RCC and selection of appropriate studies were conducted.

RESULTS

A total of 1,241 patients had received either a living, cadaveric, or combined kidney-pancreas transplant at our center, and four cases of allograft RCC were identified. The first case underwent a radical nephrectomy given the central location of the tumor and his young age. The second case underwent an open PN in the setting of a central tumor with minimal morbidity. The third case involved multiple renal lesions that were subsequently treated with radiofrequency ablation (RFA). The fourth case underwent a non-ischemic open PN in the setting of a midpole tumor with minimal morbidity. There have been no cases of local recurrence or metastatic progression at median 21.5 months' follow-up.

CONCLUSION

We have shown the safety and efficacy of minimally invasive techniques such as PN and RFA in a variety of tumors. We consider PN as an appropriate therapy for localized, clinical T1 allograft RCC tumors.

Malignancies: pre and post transplantation strategies

The overall incidence of cancer is increased 2-3 fold in solid organ transplant recipients compared to the general population. The increase in risk is not uniform for all malignancies, in all ages or in all regions of the world. Several cancers are greatly increased, many are increased 2-4 fold and others do not appear to be increased at all. The pattern of increase is similar to patients with acquired immunodeficiency syndrome and those cancers most increased are associated with viral infections. These observations support the concept that much of the increased risk is from immunosuppression. Nonetheless there are differences between specific organ groups that deserve further examination. Those with advanced organ failure are also at increased risk for certain malignancies, which suggest either organ damage per se may pre-dispose to cancers or there are exposures to carcinogens in common. The purpose of this review to examine cancer incidence and mortality in solid organ transplantation and the role of pre transplant screening and post-transplant surveillance to reduce the burden of disease and improve patient outcomes. This review will focus on cancers that are common, associated with significant case fatality rates and have potential screening strategies to reduce burden of disease.

Five-year decline in estimated glomerular filtration rate associated with a higher risk of renal disease and atherosclerotic vascular disease clinical events in elderly women

BACKGROUND

Estimated glomerular filtration rate (eGFR) has been demonstrated to predict atherosclerotic vascular disease (ASVD)-associated clinical events independent of traditional vascular risk factors. Recent studies have demonstrated that eGFR decline over time may improve prediction of ASVD-associated mortality risk in chronic kidney disease (CKD) patients.

AIM

The aim of this study is to evaluate the association between 5-year change in eGFR with renal disease and ASVD-associated clinical events.

DESIGN

Prospective observational study.

METHODS

A total of 1012 women over the age of 70 years from the Calcium Intake Fracture Outcome Study were included. Baseline characteristics including baseline and 5-year creatinine, participants' comorbidities and complete verified 10-year records for ASVD and renal disease-associated hospitalization and/or mortality were obtained using the Western Australian Data Linkage System.

RESULTS

Participants were stratified according to annual rate of eGFR change in quartiles [≤-1.2 (first quartile), >-1.2 to 0.1 (second quartile), >0.1-1.7 (third quartile) and >1.7 ml/min/1.73 m(2)/year (fourth quartile)]. In the adjusted model, compared with participants in the fourth quartile, those in the first and/or second quartiles of annual eGFR change had significantly higher risk of renal disease and/or ASVD-associated clinical events. However, the association with renal clinical events was more pparent in participants with baseline eGFR of <60 ml/min/1.73 m(2).

CONCLUSION

The results of this study suggest that the inclusion of long-term eGFR change over time might augment prognostication for renal disease and ASVD-associated clinical events in elderly women.

Clinical characteristics and outcomes in renal transplant recipients with renal cell carcinoma in the native kidney

BACKGROUND/AIMS

We investigated the incidence and clinical characteristics of renal cell carcinoma (RCC) in the native kidney of renal transplant recipients.

METHODS

Between 1991 and 2010, 1,425 patients underwent kidney transplantation at our institution. We retrospectively evaluated the clinical features and outcomes in renal transplant patients with RCC in the native kidney after renal transplantation.

RESULTS

The patients included three males and two females with a mean age of 63 years (range, 52 to 74). The incidence of RCC was 0.35%. The median interval between renal transplantation and RCC occurrence was 16.2 years (range, 9 to 20). All of our patients with RCC had developed renal cysts either before (n = 3) or after (n = 2) renal transplantation. The mean duration of dialysis was 12 months (range, 2 to 39). Of the five patients, four underwent dialysis treatment for less than 8 months. All the RCCs were low grade at the time of diagnosis. Four patients underwent radical nephrectomy, and one patient refused the operation. The four patients who underwent radical nephrectomy showed no evidence of local recurrence or distant metastasis during the median follow-up of 2.9 years. However, the patient who did not undergo surgery developed spinal metastasis from the RCC 6 years later.

CONCLUSIONS

This study suggests that the follow-up period is an important factor for the development of RCC in renal transplant recipients, and more vigorous screening with a longer follow-up period is required in renal transplant recipients.

The epidemiology and risk factors for renal cancer

BACKGROUND

Renal cancer is a frequently occurring malignancy with over 270,000 new cases diagnosed and it being responsible for 110,000 deaths annually on a global basis. Incidence rates have gradually increased whilst mortality rates are starting to plateau.

OBJECTIVE

To review epidemiology and risk factors for renal cancer.

METHODS

The current data is based on a thorough review of available original and review articles on epidemiology and risk factors for renal cancer with a systemic literature search utilising Medline.

RESULTS

The prevalence of associated risk factors such as genetic susceptibility, smoking, hypertension and obesity are changing and could account for the changes in incidence whilst the role of diet and occupational exposure to carcinogens requires further investigation.

CONCLUSION

Despite the evidence of various associated risk factors, further work is required from well designed studies to gain a greater understanding of the etiology of renal cancer.

Incidence of primary and second cancers in renal transplant recipients: a multicenter cohort study

Limited data exist about cancer prognosis and the development of second cancers in renal transplant recipients. In a retrospective cohort study on 3537 patients incidence rates of the first and, if any, of a second cancer, and standardized incidence ratios [SIR (95% CI)] were computed. Two hundred and sixty-three (7.5%) patients developed a NMSC, and 253 (7.2%) another type of cancer after a median follow-up of 6.5 and 9.0 years, respectively. A statistically significant excess risk, if compared to an age- and sex-matched reference general population, was observed for Kaposi sarcoma and NMSC, followed by non-Hodgkin lymphoma and carcinoma of cervix uteri; a small number of unusual cancers such as tumors of the salivary glands, small intestine and thyroid also were detected at a level worthy of additional scrutiny. Ten-year survival rate of all noncutaneous cancers was 71.3%, with lower rates for lung carcinoma and non-Hodgkin lymphoma (0% and 41.7%, respectively). Patients with NMSC had an increased risk of developing a second NMSC [SIR 8.3 (7.0-10.0)], and patients with a primary noncutaneous cancer had increased risk of developing a second noncutaneous cancer [SIR 1.8 (1.2-2.8)], if compared to the whole cohort. Our study underscore that the high risk of primary and second cancer in renal transplant recipients, including unusual cancers.

Papillary renal carcinoma arising in an ectopic native kidney and status after renal transplant: a report of a unique case and review of the literature

Renal ectopia is an uncommon developmental defect of upper urinary tract. Except for hydronephrosis and urinary calculus formation, it is believed that ectopic kidneys are not more susceptible to diseases compared to the normally positioned kidneys. Primary renal carcinoma in ectopic kidneys is rarely observed. Our literature review identified eight cases in nontransplanted patients; seven were clear-cell carcinoma and one was papillary renal carcinoma. On the other hand, native kidneys of renal transplant patients are fifteen times more likely to develop renal carcinoma than those of nontransplanted patients. Renal malignancy has never been reported in native ectopic kidneys of transplant recipients. We report the first case of a papillary renal carcinoma in a native ectopic kidney of a 30 year-old female, six-year status after renal transplantation.

New concepts and best practices for management of pre- and post-transplantation cancer

Solid-organ transplant recipients are at increased risk of developing cancer compared with the general population. Tumours can arise de novo, as a recurrence of a preexisting malignancy, or from the donated organ. The ATOS (Aula sobre Trasplantes de Órganos Sólidos; the Solid-Organ Transplantation Working Group) group, integrated by Spanish transplant experts, meets annually to discuss current advances in the field. In 2011, the 11th edition covered a range of new topics on cancer and transplantation. In this review we have highlighted the new concepts and best practices for managing cancer in the pre-transplant and post-transplant settings that were presented at the ATOS meeting. Immunosuppression plays a major role in oncogenesis in the transplant recipient, both through impaired immunosurveillance and through direct oncogenic activity. It is possible to transplant organs obtained from donors with a history of cancer as long as an effective minimization of malignancy transmission strategy is followed. Tumour-specific wait-periods have been proposed for the increased number of transplantation candidates with a history of malignancy; however, the patient's individual risk of death from organ failure must be taken into consideration. It is important to actively prevent tumour recurrence, especially the recurrence of hepatocellular carcinoma in liver transplant recipients. To effectively manage post-transplant malignancies, it is essential to proactively monitor patients, with long-term intensive screening programs showing a reduced incidence of cancer post-transplantation. Proposed management strategies for post-transplantation malignancies include viral monitoring and prophylaxis to decrease infection-related cancer, immunosuppression modulation with lower doses of calcineurin inhibitors, and addition of or conversion to inhibitors of the mammalian target of rapamycin.

Renal cell carcinoma (RCC) arising in native kidneys of dialyzed and transplant patients: are they different entities?

What's known on the subject? and What does the study add? Patients with end-stage renal disease (ESRD) have an increased risk of developing RCC in their native kidneys. The prevalence of RCC is 3-4% in cases of ESRD in dialyzed and/or transplanted patients, which corresponds to a rate 100-times higher than that in the general population. This is the first study, to our knowledge, comparing the characteristics of kidney cancer in the ESRD population according to their dialysis or transplantation status at the time of diagnosis. The differences in stage and survival we observed may be due to differences in surveillance strategies between transplanted and not transplanted patients, nevertheless, the differences in pathological subtypes suggest they could also be due to differences in the tumorigenesis process.

OBJECTIVE

• To compare clinical, pathological and outcome features of renal cell carcinomas (RCCs) arising in patients with chronic renal failure (CRF) with or without renal transplantation.

PATIENTS AND METHODS

• In all, 24 French University Departments of Urology and Kidney Transplantation participated in this retrospective study comparing RCCs arising in patients with CRF according to their dialysis or transplantation status at the time of diagnosis. • Information about age, sex, symptoms, duration of CRF, mode and duration of dialysis, renal transplantation, tumour staging and grading, histological subtype and outcome were recorded in a unique database. • Qualitative and quantitative variables were compared by using chi-square and Student statistical analysis. Survival was assessed by Kaplan-Meier and Cox methods.

RESULTS

• Data on 303 RCC cases diagnosed between 1985 and 2009 were identified in 206 men (76.3%) and 64 women (23.7%). • Transplanted and not transplanted patients accounted for 213 (70.3%) and 90 cases (29.7%), respectively. • In transplant recipients, RCC was diagnosed at a younger age [mean (sd) 53 (11) vs 61 (14) years, P < 0.001), the mean tumour size was smaller [3.4 (2.3) vs 4.2 (3.1) cm, P= 0.02), pT1a stage (75 vs 60%, P= 0.009) and papillary histological subtype (44 vs 22%, P < 0.001) were more frequent than in their dialysis-only counterparts. • Nodal (1 vs 6%, P= 0.03) and distant metastases rates (0 vs 5%, P < 0.001) were significantly increased in patients who had not had a transplant. However, Fürhman grading, symptoms, tumour multifocality or bilaterality, presence of acquired cystic kidney disease, were not significantly different between the groups. • Estimated 5-year survival rates were 97% and 77% for transplanted and not transplanted patients, respectively (P < 0.001). In univariate analysis, presence of symptoms (P= 0.008), poor performance status (P= 0.04), large tumour size, advanced TNM stage (P < 0.001), high Führman grade (P= 0.005) and absence of transplantation (P < 0.001) were all adverse prognostic factors. In multivariate analysis, only T stage remained an independent predictor for cancer-related death (P < 0.001).

CONCLUSION

• RCC arising in native kidneys of transplant patients seems to exhibit many favourable clinical, pathological and outcome features compared with those diagnosed in dialysis-only patients. Further research is needed to determine whether it is due to particular molecular pathways or to biases in relation to mode of diagnosis.

Renal cell carcinoma in the native and allograft kidneys of renal transplant recipients

PURPOSE

Renal cell carcinoma develops in renal transplant recipients 30 or more times more commonly than in the general population. We assessed the prevalence, histology and outcome of renal cell carcinoma in a large, single center recipient population.

MATERIALS AND METHODS

We examined outcomes in patients who underwent renal transplantation at our center to determine the prevalence, histology and outcome of those in whom renal cell carcinoma developed.

RESULTS

A total of 3,568 patients received a renal allograft at our institution between 1966 and 2009. A total of 45 renal cell carcinomas were diagnosed in the native kidney of 39 patients (1.1%) and in 8 (0.2%) renal cell carcinoma developed in the allograft kidney. Mean age at diagnosis was 51.6 and 48.2 years in patients with native kidney and allograft tumors, respectively. The mean interval between transplantation and the native or allograft renal cell carcinoma diagnosis was 10.6 and 12.1 years, respectively. Clear cell renal cell carcinoma was the most common tumor histology in native kidneys, diagnosed in 21 cases, while papillary renal cell carcinoma was diagnosed in 20. Five allograft tumors were papillary renal cell carcinoma and 3 were clear cell renal cell carcinoma. Native kidney tumors were managed by radical nephrectomy in 44 or by observation after biopsy. Allograft tumors were managed by transplant nephrectomy in 3 cases, radio frequency ablation in 3 and partial nephrectomy in 2. At a mean 6.6-year followup 32 patients with native kidney renal cell carcinoma were alive while 7 with allograft tumors were alive at a mean 3.6-year followup.

CONCLUSIONS

Renal cell carcinoma is more prevalent in patients with renal transplantation than the general population, although the subtype distribution differs. Excellent survival is seen at more than 6 years after treatment.

Epidemiology and risk factors for kidney cancer

After more than two decades of rising rates, in recent years the total kidney cancer incidence worldwide has shown signs of stabilizing, or even decreasing. In adults, kidney cancer consists of renal cell carcinoma (RCC), the predominant form, and renal transitional cell carcinoma (RTCC); these types primarily arise in the renal parenchyma and renal pelvis, respectively. Although temporal trends by kidney cancer type are not well established worldwide, incidence of RCC in the US has continued to rise, mainly for early-stage tumors, while that of RTCC has declined, and total kidney cancer mortality rates have leveled. Stabilization of kidney cancer mortality rates has also been reported in Europe. These trends are consistent with reports of increasing incidental diagnoses and a downward shift in tumor stage and size in clinical series. The changing prevalence of known risk factors for RCC, including cigarette smoking, obesity, and hypertension, is also likely to affect incidence trends, although their relative impact may differ between populations. Accumulating evidence suggests an etiologic role in RCC for physical activity, alcohol consumption, occupational exposure to trichloroethylene, and high parity among women, but further research is needed into the potential causal effects of these factors. Genetic factors and their interaction with environmental exposures are believed to influence risk of developing RCC, but a limited number of studies using candidate-gene approaches have not produced conclusive results. Large consortium efforts employing genome-wide scanning technology are underway, which hold promise for novel discoveries in renal carcinogenesis.