|Year : 2022 | Volume
| Issue : 4 | Page : 438-440
Large de novo renal cell cancer in renal allograft: Rare case report and review of literature - A case report
Shashank Agrawal, Aditya Parikh, Ravindra B Sabnis, Mahesh R Desai
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
|Date of Submission||27-Apr-2021|
|Date of Acceptance||04-Jul-2021|
|Date of Web Publication||30-Dec-2022|
Dr. Aditya Parikh
Department of Urology, Muljhibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad - 387 991, Gujarat
Source of Support: None, Conflict of Interest: None
Renal cell cancer (RCC) in renal allograft is a rare entity. We report a case of RCC successfully diagnosed in a 42-year-old renal allograft recipient which developed 13 years after engraftment. The patient was initially evaluated using ultrasound for two episodes of hematuria followed by contrast-enhanced CT scan revealing 9.7 cm × 8.6 cm × 6.5 cm heterogeneously enhancing mass at mid-pole with involvement of renal sinus. Allograft nephrectomy was performed. A genetic study with DNA microsatellite analysis showed de novo RCC from donor origin. Seven months after surgery, the patient is alive with no evidence of tumor recurrence and is now planned for a second renal transplant. To the best of our knowledge, this is the largest allograft RCC reported in the Indian scenario.
Keywords: Allograft, de novo, posttransplant, renal cell carcinoma
|How to cite this article:|
Agrawal S, Parikh A, Sabnis RB, Desai MR. Large de novo renal cell cancer in renal allograft: Rare case report and review of literature - A case report. Indian J Transplant 2022;16:438-40
|How to cite this URL:|
Agrawal S, Parikh A, Sabnis RB, Desai MR. Large de novo renal cell cancer in renal allograft: Rare case report and review of literature - A case report. Indian J Transplant [serial online] 2022 [cited 2023 Feb 3];16:438-40. Available from: https://www.ijtonline.in/text.asp?2022/16/4/438/364621
| Introduction|| |
Tumors reported in the native kidney of renal transplant recipients are frequent, but tumor occurring in transplant kidney represents a rare entity. Currently, donor demographic is gradually shifting to older age to overcome the shortage of renal donors. Older donor has also increased risk of cancer transmission to recipients.
Information of origin of renal allograft tumor is crucial as it can improve the management, but tumor origin was determined in few studies only. Currently, no consensus on treatment of allograft renal cell cancer (RCC) among transplant communities exists because of rarity of disease and lack of properly designed studies.
Herein, we present the RCC originating in allograft kidney 13 years after renal transplant for which radical graft nephrectomy was done. Genetic analysis showed de novo RCC from donor origin. This is the largest RCC in graft kidney removed in the Indian scenario to date. The patient is now planned for a second renal transplant (6 months of postnephrectomy).
| Case Report|| |
The patient, 42 years male, with a medical history of hypertension was histologically confirmed hypertensive nephrosclerosis which led to end-stage renal disease. Hemodialysis was started in December 2007. In June 2008, at the age of 28 years, he received a kidney transplant from his father. Before the transplant, a complete angiographic examination of a donor was done to evaluate for any renal pathology. No induction immunosuppressive drugs were given as human leukocyte antigen was 10/12 match with no prior sensitization history. Immunosuppression was maintained with prednisolone + mycophenolate mofetil + tacrolimus. Posttransplant course was uneventful. Renal allograft function was stable with serum creatinine around 0.9 mg/dl. In September 2020, he presented with two episodes of hematuria. Ultrasound showed a heterogeneous mass sized 9.5 cm × 9 cm × 6.2 cm with internal vascularity. Contrast-enhanced computed tomography showed a large predominantly endophytic mass sized 9.7 cm × cm 8.6 × 6.5 cm heterogeneously enhancing soft-tissue mass lesion in mid-pole of allograft with extension into renal sinus fat [Figure 1]. No evidence of nodal/distant metastasis was seen. We performed radical allograft nephrectomy through previous incisional scar marks and hemodialysis was initiated. Histopathological examination revealed 9.4 cm × 8.7 cm × 6.8 cm was clear cell RCC, Fuhrman grade 2 with free margins, and renal sinus/perirenal fat-free of tumor, stage T2b N0 M0 [Figure 2].
|Figure 1: Contrast-enhanced computed tomography showing heterogeneously enhancing renal mass in allograft kidney|
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|Figure 2: (a) Cut specimen of allograft kidney with mass. (b) Microscopic examination suggestive of papillary renal cell cancer|
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| Discussion|| |
Post renal transplantation, RCC development in native kidneys is 10–15 fold more in the renal transplant recipients compared with the general population. Mostly, it involves the native kidneys, but the incidence of allograft RCC is greater than the normal population.,
Transplant kidney tumors are rare, but the prevalence is increasing because of increased donor age, prolonged graft and patient survival, long-term immunosuppression, and chronic allograft failure.
Conflicting guidelines exist for periodic radiological screening for allograft cancer because of a lack of strong evidence. The European Association of Urologists favors annual screening of native and allograft kidney, whereas the Kidney Disease Improving Global Outcomes, British Transplantation Society, and American society of Transplantation do not recommend for RCC screening.
Renal allograft tumor can be result of transmission by donors, de novo carcinomas arising posttransplantation, or metastatic cancer from native recipient organs. Conventionally, a tumor is thought to be transmitted by the donor if it is detected within a short posttransplant period, but the determination of tumor's origin based on the time interval between transplant and tumor detection is difficult as few studies reported de novo allograft tumor at 9 months after transplant.
Genetic study to determine host versus donor origin of allograft tumor is important for staging and management but is performed in few studies. RCC originating from host cells is considered to be Stage 4 (metastatic stage) and will need native and allograft nephrectomies with targeted therapies while RCC arising de novo from allograft kidney mirrors management in the nontransplant population., We performed DNA microsatellite analysis from the tumor DNA, donor DNA purified from tumor-free area of allograft kidney, and host DNA derived from peripheral blood. In our case report, de novo papillary RCC allograft kidney diagnosed 13 years past renal transplantation and was genetically confirmed to be of donor origin. Most of the de novo RCCs in allograft kidney are confirmed to be donor origin and one case is reported of recipient origin by microsatellite analysis.
As no guidelines for the management of renal allograft mass exist, treatment of RCC needs to be tailored individually according to tumor size, localization, stage, allograft function, and patient's preference. We did radical nephrectomy of allograft as the tumor was predominantly endophytic, large in size with involvement of renal sinus on imaging (RENAL Nephrometric Score 11p).
Nephron sparing surgery is suggested in T1a and selective T1b tumors. Thermal ablation in small renal mass <3 cm is reserved for frail or comorbid patients as it is associated with higher recurrence rate.,
Tillou et al. performed a histological study of kidney graft tumor and found that papillary carcinoma was the most common type and low-grade tumor (Fuhrman grade 1 and 2) in 65% of renal graft tumors. In our case as well, histology was papillary cell carcinoma with Fuhrman grade 2.
Currently, there is not enough evidence to support a fixed waiting time for renal transplantation for patients with symptomatic RCC as different guidelines have different recommendations ranging from 2 to 5 years waiting time. In 2003, Leibovich et al. developed another scoring system containing T stage, N stage, tumor size, nuclear grade, and tumor necrosis as parameters which proved to have higher than 80% predictive accuracy and enabled identification of three groups of patients with a different risk of developing metastasis: high, intermediate, and low, respectively. In our case, Leibovich score is 5 (intermediate risk) which implies 64% being metastatic-free after 10 years and thus planned for second transplant 6 months after nephrectomy.
In summary, tumor in transplant kidney is a rare entity which usually manifests in patients with long graft survival. Periodic radiological screening for RCC may result in early detection where renal-preserving procedure can be done. Genetic analysis for tumor origin is important for management. Treatment of allograft mass needs to be individualized and also plan for subsequent renal transplant should be tailored as per the established scoring system.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tillou X, Doerfler A, Collon S, Kleinclauss F, Patard JJ, Badet L, et al. De novo
kidney graft tumors: Results from a multicentric retrospective national study. Am J Transplant 2012;12:3308-15.
Robin AJ, Cohen EP, Chongkrairatanakul T, Saad E, Mackinnon AC. A single center's approach to discriminating donor versus host origin of renal neoplasia in the allograft kidney. Ann Diagn Pathol 2016;23:32-4.
Motta G, Ferraresso M, Lamperti L, Di Paolo D, Raison N, Perego M, et al.
Treatment options for localised renal cell carcinoma of the transplanted kidney. World J Transplant 2020;10:147-61.
Pandya VK, Sutariya HC. Post-renal transplantation de novo
renal cell carcinoma in a middle-aged man. Int J Organ Transplant Med 2016;7:51-6.
Obayemi JE, Zhao K, Guzzo TJ, Abt PL. Management of large allograft mass following living donor kidney transplantation. Am J Kidney Dis 2020;76:A16-7.
Chewcharat A, Thongprayoon C, Bathini T, Aeddula NR, Boonpheng B, Kaewput W, et al
. Incidence and Mortality of Renal Cell Carcinoma after Kidney Transplantation: A Meta-Analysis. J Clin Med 2019;8:E530.
Végső G, Toronyi É, Deák PÁ, Doros A, Langer RM. Detection and management of renal cell carcinoma in the renal allograft. Int Urol Nephrol 2013;45:93-8.
Warren H, Olsburgh J. Management of renal cell carcinoma and other renal masses in the kidney graft. Curr Urol Rep 2020;21:8.
Gunji Y, Sakamoto K, Yamada K, Hamaguchi K, Kashiwabara H, Hori S, et al.
Successful surgical treatment of renal cell carcinoma in a transplanted kidney from a cadaveric donor: Report of a case. Surg Today 2001;31:374-7.
Griffith JJ, Amin KA, Waingankar N, Lerner SM, Delaney V, Ames SA, et al.
Solid renal masses in transplanted allograft kidneys: A closer look at the epidemiology and management. Am J Transplant 2017;17:2775-81.
Naruke Y, Ito M, Mihara Y, Umezaki Y, Matsuya F, Hayashi M, et al. De novo
papillary renal cell carcinoma in an allograft kidney: Evidence of donor origin. Pathol Int 2011;61:694-6.
Boix R, Sanz C, Mora M, Quer A, Beyer K, Musulen E, et al.
Primary renal cell carcinoma in a transplanted kidney: Genetic evidence of recipient origin. Transplantation 2009;87:1057-61.
Frascà GM, Brigante F, Volpe A, Cosmai L, Gallieni M, Porta C. Kidney transplantation in patients with previous renal cancer: A critical appraisal of current evidence and guidelines. J Nephrol 2019;32:57-64.
[Figure 1], [Figure 2]