Renal transplantation and prostate cancer: guidelines for screening and treatment

Kidney transplantation in prostate cancer patients after local therapy with curative intent: a systematic review

PURPOSE

It is still unclear whether kidney transplantation can be safely performed in patients with prostate cancer after local therapy with curative intent.

METHODS

The protocol was registered in PROSPERO. We systematically searched Google, MEDLINE, the Cochrane Library, and the ICTRP for studies, official standards, clinical practice guidelines and organ transplant laws. Two review authors independently examined the full-text reports and identified relevant studies and one review author extracted the data. We assessed the overall certainty of the evidence for each outcome according to the GRADE approach.

RESULTS

We identified 1346 references through electronic database searching and finally included 6 references for official standards, clinical practice guidelines, and organ transplant laws, and 6 references for retrospective studies with very low certainty of evidence. We identified no prospective or ongoing studies and reported all results narratively.

CONCLUSION

We recommend that decisions on kidney transplantation in patients with prostate cancer after local therapy with curative intent should be made on a case-by-case basis. It is indispensable to consult with health care professionals or specialists at transplant centers to obtain individualized information regarding the waiting time requirements for renal transplantation in prostate cancer patients after local therapy with curative intent. No recommendation can be made regarding the waiting times after prostate cancer therapy with curative intent.

History of urological malignancies before kidney transplantation, oncological outcome on the long term

INTRODUCTION

We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT).

MATERIAL AND METHOD

Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival.

RESULTS

In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period.

CONCLUSIONS

Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

History of urological malignancies before kidney transplantation, oncological outcome on the long term

INTRODUCTION

We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT).

MATERIAL AND METHOD

Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival.

RESULTS

In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period.

CONCLUSIONS

Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

[Localized Prostate cancer in candidates for renal transplantation and recipients of a kidney transplant: The French Guidelines from CTAFU]

OBJECTIVE

To define guidelines for the management of localized prostate cancer (PCa) in kidney transplant (KTx) candidates and recipients.

METHOD

A systematic review (Medline) of the literature was conducted by the CTAFU to report prostate cancer epidemiology, screening, diagnosis and management in KTx candidates and recipients with the corresponding level of evidence.

RESULTS

KTx recipients are at similar risk for PCa as general population. Thus, PCa screening in this setting is defined according to global French guidelines from CCAFU. Systematic screening is proposed in candidates for renal transplant over 50 y-o. PCa diagnosis is based on prostate biopsies performed after multiparametric MRI and preventive antibiotics. CCAFU guidelines remain applicable for PCa treatment in KTx recipients with some specificities, especially regarding lymph nodes management. Treatment options in candidates for KTx need to integrate waiting time and access to transplantation. Current data allows the CTAFU to propose mandatory waiting times after PCa treatment in KTx candidates with a weak level of evidence.

CONCLUSION

These French recommendations should contribute to improve PCa management in KTx recipients and candidates, integrating oncological objectives with access to transplantation.

Radical Prostatectomy for Localized Prostate Cancer in Renal Transplant Recipients: 13 Cases Studied at a Single Center

OBJECTIVES

We aimed to evaluate the feasibility and efficacy of surgical prostatectomy in renal transplant recipients (RTRs).

METHODS

Between January 2008 and February 2017, we identified 13 RTRs who were diagnosed with localized prostate cancer and underwent radical prostatectomy. We reviewed all available clinicopathologic data for these 13 patients.

RESULTS

The median patient age was 61 years and median serum prostate-specific antigen (PSA) was 8.79 ng/mL. The mean period between transplantation and diagnosis of prostate cancer was 136 months. The sources for the kidney transplants included 10 living and 3 deceased donors. Biopsies indicated that the Gleason scores were 7 in 10 patients and 8 to 10 in 3 patients. Meanwhile, the D'Amico risk classification indicated an intermediate risk in 9 patients and a high risk in 4 patients. Eight patients were at stage cT1 and 5 were at stage cT2. The surgical procedure was retropubic radical prostatectomy in one recipient, laparoscopic radical prostatectomy in 3 recipients, and robot-assisted radical prostatectomy in 9 RTRs. Intraoperative complications were not noted in any patient, although one patient demonstrated postoperative complications (Clavien grade ≥ 3). An indwelling urinary catheter was required in 3 patients for over 3 weeks due to delayed wound healing. Biochemical recurrence evaluated by PSA monitoring occurred in four patients. Postoperative graft function was stable in all but one patient who required resumption of dialysis before prostatectomy; however, all patients are alive at the time of publication with 12 patients showing well-functioning renal allografts.

CONCLUSION

Prostatectomy may be a feasible and effective technique as an initial treatment for RTRs with localized prostate cancer.

Prostate cancer in renal transplant recipients

As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant

Extraperitoneal robotic-assisted radical prostatectomy in carefully selected renal allograft recipients may be feasible in avoiding injury to the renal allograft, transplanted ureter, and ureteroneocystostomy.

Introduction:

Renal transplantation is the treatment of choice for patients with end-stage renal failure. With advances in immunosuppression, the short-term and long-term outcome has improved significantly. Subsequently, urologists are encountering more transplant recipients with genitourinary malignancies, and therefore urologists are becoming increasingly compelled to offer curative treatment options.

Materials and Methods:

We present modifications to facilitate E-RARP in these patients that include modified trocar arrangement, delayed bladder neck transection, utilizing the robotic Hem-o-lok applier, and posterior reconstruction of the anastomosis using a barbed V-loc suture. A 68-year-old male with a history of polycystic kidney disease, end-stage renal failure, and an allograft renal transplantation in the right iliac fossa, presented with T1c, Gleason 3+4 prostate cancer. He had a preoperative PSA of 6.93ng/mL, ASA score of 3, and a BMI of 26kg/m². Follow-up for metastasis (MRI and bone scan) was negative. E-RARP was performed via the extraperitoneal approach using a 5-port 2-arm approach at an insufflation pressure of 10mm Hg.

Results:

The radical prostatectomy was successfully performed. Ureterovesical anastomosis was completed, and total console time was 130 minutes, with an estimated blood loss of 125mL. Final pathology was T2bNx, Gleason 3+4 with negative surgical margins. The patient was discharged with no change in serum creatinine or GFR. The catheter was removed on POD 10 with no intraoperative or immediate postoperative complications.

Conclusion:

E-RARP in the carefully selected renal allograft recipient is feasible and accomplished safely with technical modifications to avoid injuring the renal allograft, transplanted ureter, and ureteroneocystostomy.

De novo cancers arising in organ transplant recipients are associated with adverse outcomes compared with the general population

BACKGROUND

Transplant recipients are at increased risk of malignancy; however, the influence of transplantation on cancer outcomes has not been rigorously defined. The purpose of this study was to examine the influence of transplantation on the outcomes of individual cancers.

METHODS

De novo nonsmall cell lung cancer, colon cancer, breast cancer, prostate cancer, bladder cancer, renal cell cancer (RCC), and malignant melanoma data in 635 adult (>18 years of age) transplant recipients (from the Israel Penn International Transplant Tumor Registry) were compared with data from 1,282,984 adults in the general population (from the Surveillance, Epidemiology, and End Results database).

RESULTS

Compared with the general population, transplant patients were more likely to have early stage (AJCC stage 0-II) RCC, but more advanced (AJCC stage >II) colon cancer, breast cancer, bladder cancer, and malignant melanoma. Compared with the general population, disease-specific survival was worse in the transplant population for colon cancer (all stages), nonsmall cell lung cancer (stage II), breast cancer (stage III), prostate cancer (stage II, III, and IV), bladder cancer (stage III), and RCC (stage IV). Multivariate analyses demonstrated transplantation to be a negative risk factor for survival for each cancer studied, and transplantation and cancer stage at diagnosis to be the most profound negative survival predictors.

CONCLUSIONS

These analyses indicate that, for several common cancers, transplant patients experience worse outcomes than the general population. The data also suggest that cancers in transplant recipients are more aggressive biologically at the time of diagnosis.

Prostate cancer screening and treatment in the transplant population: current status and recommendations

PURPOSE

We reviewed the current status of and recommendations for prostate cancer screening and treatment in the solid organ transplant population.

MATERIALS AND METHODS

We performed a MEDLINE search to identify published data regarding prostate cancer screening, risk, treatment and outcomes in the solid organ transplant population. The literature was reviewed and summarized.

RESULTS

Most data regarding outcomes of prostate cancer treatment in the transplant population are limited to case reports and small series, and primarily involve renal insufficiency. It does not appear that the development or natural history of prostate cancer is significantly affected by organ failure or subsequent transplantation. Thus, prostate specific antigen testing and screening protocols can be extrapolated from the general population. However, the balance of comorbid diseases and estimated limitations in life expectancy must be carefully considered, and emphasis should be placed on risk assessment. Prostatectomy appears to be feasible with outcomes comparable to those in the non-transplant population, while data regarding the use of radiation therapy are limited.

CONCLUSIONS

The expansion of organ transplant criteria, including older donors and recipients, combined with improved allograft survival has enhanced the relevance of prostate cancer screening and treatment in this group. Greater awareness of the issues surrounding prostate cancer incidence, detection and natural history should promote improved data collection, screening and treatment of prostate cancer in the transplant population.

Management of solid tumours in organ-transplant recipients

Malignancy is a well-recognised complication of transplantation and can occur de novo, as a recurrence of a pre-existing malignancy, or from transmission of malignancy from the donor. Common de-novo malignancies are those of the skin and the lymphoreticular system. Various solid-organ cancers have also been reported in transplant recipients and each poses a unique management challenge in view of the unusual setting. We review solid-organ cancers in transplant recipients and their management, including surveillance and prevention.

Prostate Cancer Prior to Solid Organ Transplantation: The Israel Penn International Transplant Tumor Registry Experience

INTRODUCTION

Prostate adenocarcinoma (PCA) is the second leading cause of cancer-related deaths in men, and with routine prostrate specific antigen (PSA) screening, is being diagnosed with increasing frequency. To date, reported experiences with transplantation in men with a history of PCA are limited to only a few patients. This study presents the first series of transplant recipients with a history of PCA.

METHODS

Analysis of transplant recipients with a history of pretransplant PCA was performed on the Israel Penn International Transplant Tumor Registry database. PCA were staged using American Joint Committee on Cancer criteria. Statistics analysis was performed by chi-square and Student t tests.

RESULTS

Ninety patients with preexisting PCA were identified: 77 renal, 10 heart, and three liver transplant recipients. Mean age at PCA diagnosis was 61.3 +/- 6.3 years. Median interval between diagnosis and transplantation was 19.3 months, and median follow-up after transplantation was 20.5 months. Median time to PCA recurrence was 10.6 months after transplantation and median survival time with recurrent PCA was 49.2 months after transplant. Patient mortality was 28.8%, and PCA-related death rate was 7.8%. PCA recurrence rate was 17.7%. Tumor recurrence rates in stage I and II disease (14 and 16%) were lower than in stage III disease (36%).

CONCLUSIONS

In conclusion, death rate to disease other than PCA is three times that due to PCA. PCA recurrence rates are relatively low in patients who initially presented with stage I and II disease, and are half that of patients with stage III disease.

Current Recommendations for Delaying Renal Transplantation after Localized Prostate Cancer Treatment: Are They Still Appropriate?

BACKGROUND

Since the advent of prostate-specific antigen (PSA) testing, most men diagnosed with prostate cancer (PC) have localized disease, which is curable with surgery or radiation therapy. Current policy for patients with end-stage renal disease (ESRD) and PC recommends waiting 5 years after primary therapy before enrollment on the transplant waiting list. The risk of dying during 5 years of dialysis is approximately 59%, whereas the risk of PC recurrence after surgery is generally much lower. Prognostic tools called nomograms can accurately assess a patient's probability of PC recurrence. This prompted the authors to reexamine current transplantation policy for patients with PC.

METHODS

The authors reviewed the Sloan-Kettering PC database to identify patients on dialysis undergoing radical prostatectomy. Clinical and pathologic features were analyzed to determine the likelihood of disease recurrence.

RESULTS

The authors identified two patients with ESRD in their PC database. Both men had elevated serum PSA detected during routine pretransplantation evaluation, and biopsy confirmed the PC. Both opted for surgery, with pathologic analysis revealing organ-confined disease and negative surgical margins. The postoperative nomogram predicted 7-year progression-free probabilities of 95% and 98%. Given the high likelihood of cure of their PC, immediate consideration for renal transplantation seemed appropriate for both patients.

CONCLUSIONS

PSA-based screening of the dialysis population has ensured earlier detection of PC. Given that nomograms will accurately predict the risk of PC recurrence, the time a patient must wait for a transplant should be based on this individualized risk assessment rather than on a general rule.