Squamous cell carcinoma in a chronically rejected renal allograft

Management of renal cell carcinoma in transplant kidney: a systematic review and meta-analysis

INTRODUCTION

After transplantation, approximately 10% of renal cell carcinomas are detected in graft kidneys. These tumors (gRCC) present surgeons with the difficulty of finding a treatment that guarantees both oncological clearance and maintenance of function. We conducted a systematic review and an individual patient data meta-analysis on the oncology, safety and functional outcomes of the available treatments for gRCC.

EVIDENCE ACQUISITION

A systematic search was performed across MEDLINE, EMBASE, and Web of Science including any study reporting perioperative, functional and survival outcomes for patients undergoing graft nephrectomy (GN), partial nephrectomy (PN) or thermal ablation (TA) for gRCC. Quade's ANCOVA, Spearman Rho and Pearson χ², Kaplan-Meier, Log-rank and Standard Cox regression and other tests were used to compare treatments. Studies' quality was evaluated using a modified version of Newcastle Ottawa Scale.

EVIDENCE SYNTHESIS

A number of 29 studies (357 patients) were included. No differences between TA and PN were found in terms of safety, functional and oncological outcomes for T1a gRCCs. When applied to pT1b gRCC, PN showed no difference in complications, progression or cancer-specific deaths compared to smaller lesions; PN validity for pT2 gRCCs should be considered unverified due to lack of sufficient evidence. The efficacy and safety of PN or TA for multiple gRCC remain controversial. In case of non-functioning, large (T≥2), complicated or metastatic gRCCs, GN appears to be the most reasonable choice. Quality of evidence ranged from very low to moderate. Studies with large cohorts and longer follow-up are still needed to clarify oncological and functional differences.

CONCLUSIONS

PN and TA might be offered as a nephron-sparing treatment in patients with T1a gRCC. There is no significant difference between these options and GN in terms of oncological outcomes and complications. PN and TA offer similar functional outcomes and graft preservation. PN for T1b gRCC seems feasible and safe, but its validity should be considered unverified.

De novo renal carcinoma arising in non-functional kidney graft: a national retrospective study

AIM

Characteristics of renal carcinoma arising in non-functional graft in renal transplant recipients (RTR) are unknown. We studied a large national retrospective cohort to analyze circumstances of diagnosis, treatment and outcome compared to the literature.

METHODS

Study included all RTR presenting with kidney graft tumors irrespective of the histology, except those with lymphoma and including those tumors arising in non-functional renal graft. Between January 1988 and December 2018, 56,806 patients had renal transplantation in the 32 centers participating in this study. Among this cohort, 18 renal graft tumors were diagnosed in non-functional grafts.

RESULTS

The median patient age at the time of diagnosis was 42.1 years (31.7-51.3). Median age of kidney grafts at the time of diagnosis was 56.4 (23.2-63.4). Eight (44.4%) tumors were discovered fortuitously on renal graft histologic analysis. Fourteen tumors (77.8%) were papillary carcinomas. Two patients had clear cell carcinomas and one patient had a pTa high-grade multifocal urothelial carcinoma in the graft of the upper tract with an in situ carcinoma.

CONCLUSION

Renal carcinomas in non-functional grafts are rare entities and most of them are diagnosed fortuitously. Despite the fact that these tumors are small, low grade and with a good prognosis, regular monitoring of non-functional grafts should be performed with at least an annual ultrasonography.

Kidney Graft Urothelial Carcinoma: Results From a Multicentric Retrospective National Study

OBJECTIVE

To calculate the incidence of renal graft urothelial carcinoma in renal transplant recipients in a national large retrospective cohort and to analyze circumstances of diagnosis, treatment and outcome.

MATERIAL AND METHODS

We conducted a national retrospective, multicenter study. Thirty two transplant centers were asked to report its cases of kidney graft tumors and the number of kidney transplantations performed since the beginning of their transplantation activity.

RESULTS

Between January 1988 and December 2018, 56,806 patients were transplanted in the 32 centers participating in this study. Among this cohort, 107 renal graft tumors (excluding lymphoma) were diagnosed among them 11 renal transplant recipients were diagnosed with an urothelial carcinoma in the kidney graft. The calculated incidence was 0.019%. The median patient age at the time of diagnosis was 56.7 years (49.8-60.9) and 51.4 years (47-55.7) at the time of transplantation. The median time between transplantation and diagnosis was 66.6 months (14.3-97). Before treatment, 3 patients had graft tumor biopsies revealing urothelial carcinomas, 3 patients had endoscopic retrograde uretero-pyelography showing lacunary images. Two patients had a diagnostic flexible ureteroscopy with biopsies. Total nephrectomy was performed in all cases.

CONCLUSION

Even though occurring in the context of immune suppression, most of these tumors seemed to have a relatively good prognosis. With regards to functional outcomes histological diagnosis should always be sought for before radical treatment of these tumors. Treatment should be a transplant nephrectomy including all the ureter with a bladder cuff to ensure optimal carcinologic control.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report

RATIONALE

Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.

PATIENT CONCERNS

We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.

DIAGNOSES

The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.

INTERVENTIONS

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.

OUTCOMES

No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.

LESSONS

In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization

PURPOSE

To determine the impact of transplant nephrectomy on morbidity and mortality and HLA immunization.

METHODS

All patients who underwent transplant nephrectomy in our centre between 2000 and 2016 were included in this study. A total of 2822 renal transplantations and 180 transplant nephrectomies were performed during this period.

RESULTS

The indications for transplant nephrectomy were graft intolerance syndrome: 47.2%, sepsis: 22.2%, vascular thrombosis: 15.5%, tumour: 8.3% and other 6.8%. Transplant nephrectomies were performed via an intracapsular approach in 61.7% of cases. The blood transfusion rate was 50%, the morbidity rate was 38% and the mortality rate was 3%. Transplant nephrectomies more than 12 months after renal transplant failure were associated with more complications (p = 0.006). Transfusions in the context of transplant nephrectomy had no significant impact on alloimmunization.

CONCLUSION

The risk of bleeding, and therefore of transfusion, constitutes the major challenge of this surgery in patients eligible for retransplantation. Even if transfusions in this context of transplant nephrectomy had no significant impact on alloimmunization, this high-risk surgery, whenever possible, must be performed electively in a well-prepared patient.

Primary renal squamous cell carcinoma mimicking the renal cyst: a case report and review of the recent literature

Background

Renal squamous cell carcinoma is a rare neoplasm with poor prognosis. Chronic irritation from nephrolithiasis and/or pyelonephritis is the leading cause.

Case presentation

We described a 51-year-old male patient who was admitted because of left flank pain. Ultrasonography showed a renal cyst containing calculus. However, contrast-enhanced ultrasonography and CT scan revealed an irregular-shaped mass derived from a calculi-containing cyst. Ultrasound guided biopsy confirmed the diagnosis of renal squamous cell carcinoma. The patient refused any further therapeutic management and died six months later.

Conclusions

Our present case emphasizes that the careful diagnostic work-up and use of multiple imaging modalities in cases of unusual renal calculi is quite necessary, since they may carry the risk of co-existing hidden malignancy.

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.

Transplant nephrectomy

About 10% of all renal allografts fail during the first year of transplantation and thereafter approximately 3%-5% yearly. Given that approximately 69 400 renal transplants are performed worldwide annually, the number of patients returning to dialysis following allograft failure is increasing. A failed transplant kidney, whether maintained by low dose immunosuppression or not, elicits an inflammatory response and is associated with increased morbidity and mortality. The risk for transplant nephrectomy (TN) is increased in patients who experienced multiple acute rejections prior to graft failure, develop chronic graft intolerance, sepsis, vascular complications and early graft failure. TN for late graft failure is associated with greater morbidity and mortality, bleeding being the leading cause of morbidity and infection the main cause of mortality. TN appears to be beneficial for survival on dialysis but detrimental to the outcome of subsequent transplantation by virtue of increased level of antibodies to mismatched antigens, increased rate of primary non function and delayed graft function. Many of the studies are characterized by a retrospective and univariate analysis of small numbers of patients. The lack of randomization in many studies introduced a selection bias and conclusions drawn from such studies should be applied with caution. Pending a randomised controlled trial on the role of TN in the management of transplant failure patients, it is prudent to remove failed symptomatic allografts and all grafts failing within 3 mo of transplantation, monitor inflammatory markers in patients with retained failed allografts and remove the allograft in the event of a significant increase in levels.

Biopsy-confirmed de novo renal cell carcinoma (RCC) in renal grafts: a single-centre management experience in a 2396 recipient cohort

OBJECTIVE

To study the natural history of renal cell carcinoma (RCC) development in renal grafts and their management.

PATIENTS AND METHODS

We report a single-centre series of de novo RCC in allografts from a cohort of 2396 consecutive renal transplant recipients.

RESULTS

In all, 17 RCCs were detected in 12 patients, representing 0.5% of kidney recipients. The mean patient age was 55 years and the time to RCC diagnosis since transplantation was 13 years. The mean diameter of the RCC was 23 mm. Biopsies were taken in all cases. Concordance between biopsy and surgical specimens was 100% for nuclear grade and pathological type. Four graft removals were performed and six patients underwent nephron-sparing surgery (NSS). Two cryoablations were performed. Overall, nine papillary RCC, five clear cell carcinomas, and one chromophobe cell carcinoma were removed surgically. The mean follow-up was 43 months. One local recurrence was reported in a patient treated by NSS.

CONCLUSIONS

Our findings support evidence that radiological screening of kidney recipients allows the detection of small tumours for which a conservative management by NSS or non-surgically destructive techniques can be proposed with mid-term oncological safety. Systematic tumour biopsy may help in the management and treatment decision. Several questions remain unanswered such as the importance of mammalian target of rapamycin inhibitors in the chemoprevention of the recurrence and the genetic cell origin of RCC in renal grafts.

Squamous cell carcinoma of the renal pelvis associated with kidney stones: a case report

A 70-year-old female with a long-standing history of kidney calculi presented with vague abdominal pain. Work-up included a CT and MRI of the kidneys. A mass was demonstrated in the superior pole of the left kidney. The mass was biopsied percutaneously under CT guidance. Pathology revealed a poorly differentiated carcinoma, but was inconclusive for a definitive cell type. The patient subsequently underwent a nephrectomy that revealed squamous cell carcinoma of the renal collecting system. She had an uneventful postoperative recovery. Chronic renal calculi pose a risk for the development of squamous metaplasia that may lead to squamous cell carcinoma. Although this malignancy is rare in the upper urinary tracts, patients with long-standing nephrolithiasis should be monitored. This diagnosis should be included in one's differential when evaluating a renal mass that is associated with chronic inflammatory conditions.

[Post-transplant renal tumors: a report of three cases]

We report three cases of primary renal tumors occurring on post-transplant kidneys, after a delay of 4, 8 and 12 years respectively following transplantation in a population of 1134 post kidney transplant followed at our institution. All three tumors underwent early detection because of the yearly ultrasound evaluation recommended for all post kidney transplant patients. The diagnosis was suggested by CT in all three cases but confirmed by preoperative percutaneous biopsy in two cases. The final pathology results confirmed two cases of clear cell renal carcinomas and one case of oncocytoma. Tumorectomy was undertaken for all three patients with successful results in two cases and return to hemodialysis in the third patient with a 4 cm tumor with mass effect on the collecting system.