Development of urological cancers in renal transplant recipients: 30-year experience at the Frankfurt Transplant Center

Experience of nine south eastern European transplant centers with testicular cancer in kidney transplant recipients

PURPOSE

Testicular cancer (TC) is the most common type of cancer among young men aged 25 to 45. This study represents the first population study of TC in kidney transplant recipients (KTRs).

METHODS

We conducted a multicentric, multinational, cross-sectional study across nine transplant centers in Croatia, Serbia, Montenegro, Slovenia, and Bosnia and Herzegovina. All KTRs over 18 years old who were regularly monitored at their transplant centers were included. Data were collected from electronic medical records at these centers.

RESULTS

Out of the 4426 KTRs who participated in our study, six (0.14%) developed TC after KT. Two of these patients had a history of malignancy before KT, while four had a positive family history of malignancy. The median age at diagnosis of TC was 41 years. Follow-up time ranged from 1 to 14 years. Most of the patients underwent surgical treatment and half received adjuvant chemotherapy and/or radiotherapy. Four patients had seminoma and two had non-seminoma. In most cases, the immunosuppressive therapy was adjusted. Half of the patients maintained stable kidney allograft function after TC treatment. One patient died due to COVID-19 and two required chronic dialysis 8-9 years after their TC diagnosis and treatment.

CONCLUSIONS

In our study, TC occurred in the same age range as in the general population. A personal or family history of malignancy was identified as a significant risk factor. Outcomes for kidney allograft function and overall survival were excellent for patients whose disease was detected early and treated with orchiectomy. Switching from calcineurin to mTOR inhibitors also supported allograft survival.

Testis and penile cancers in kidney transplant recipients: A systematic review of epidemiology, treatment options and oncological outcomes by the EAU-YAU Penile and Testis Cancer Working Group

INTRODUCTION

Kidney transplant (KT) recipients are at an elevated risk of developing de novo cancers. However, penile (PeCa) and testis cancers have received limited attention in this setting.

OBJECTIVE

To summarize the epidemiology, treatment options, and oncological outcomes of penile and testis cancer in KT recipients.

EVIDENCE ACQUISITION

We conducted a systematic review of prospective, retrospective and national transplant registries studies published up to December 2023. Data on the incidence of penile and testis cancers among KT recipients, diagnostic protocols, screening recommendations, and therapeutic strategies tailored for KT recipients were collected. The risk of bias (RoB) of included studies was determined using the Newcastle and Ottawa scale.

EVIDENCE SYNTHESIS

Overall, 21 studies involving 67924 KT male recipients were included. PeCa was diagnosed in 33 patients, yielding an incidence ranging from 0.04% to 0.3%. Additionally, 67 cases of testicular cancer were recorded, with an incidence ranging from 0.03% to 0.55%. Most tumors were localized, and histology variants were uncommon. While the surgical treatment of the primary tumor remains consistent with that of the general population, the use of radiotherapy and cytotoxic treatments are less frequently reported in this setting. These therapies should be considered on an individualized basis to minimize the risk of graft injury.

CONCLUSIONS

Penile and testis cancers are relatively uncommon among KT recipients. General screening protocols and deviation from current treatment guidelines are not recommended in localized diseases. Given the risk of graft damage, any non-cytotoxic option should be preferred in locally advanced cases.

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.

High grade urothelial carcinoma in kidney transplant patients with a history of BK viremia - Just a coincidence?

INTRODUCTION

Kidney transplant recipients (KTR) have a three-to-four-fold increased risk of developing urothelial carcinoma (UC) compared to the general population. BK polyoma virus (BKV) infection is known to affect approximately 15% of KTR. In vitro models support a potential pathogenic role for BKV in the development of UC. We describe a series of UC in kidney transplant recipients.

METHODS

Electronic patient records were searched to identify KTR with UC who had undergone kidney only or simultaneous kidney and pancreas transplantation in a single UK center between 2009 and 2015. Where available, stored pathological samples were retrieved, re-examined and stained for SV40 as a marker of BKV using standard staining protocols for kidney biopsy samples.

RESULTS

Fourteen KTR had developed UC post-transplant. Of these, 10 KTR had a history of BKV infection post-transplant. Six of these 10 KTR developed a rare micropapillary tumor subtype of UC which is typically only found in <1% of UC cases. All six micropapillary tumor samples stained positive for SV40, including samples from metastases. Three tumor samples were available from the four KTR with no history of BKV infection and were not micropapillary subtype and were negative for SV40. Three micropapillary tumors from immunocompetent patients were examined as controls and were negative for SV40.

CONCLUSIONS

These findings would support a pathogenic role for BK virus in the development of rare micropapillary subtype urothelial tumors in the kidney transplant population.

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.

MANAGEMENT OF PROSTATE CANCER IN KIDNEY TRANSPLANT RECIPIENTS

Kidney transplantation is the treatment of choice in eligible patients with end-stage kidney disease. Prostate cancer (PC) is the second most common cancer in men worldwide. The prevalence of chronic kidney disease worldwide is 13.4%. The management of localized PC in these patients is challenging due to immunosuppressive therapy and pelvic graft localization. High graft and recipient survival rates have resulted in higher numbers of these patients in our everyday practice. A retrospective analysis of male patients who had undergone kidney transplantation at our center between 2002 and 2022 and were diagnosed and treated for PC was performed. We analyzed the incidence, treatment methods, and follow-up of PC patients in this population. A total of 1079 male patients were transplanted. PC was diagnosed in 12 patients (8 after and 4 before transplantation). The incidence of PC was 1.11%. Radical prostatectomy was performed in 11 patients, and one patient was treated with radical radiotherapy. Eleven patients had stable graft function; 1 graftectomy was performed, unrelated to PC. Three patients were indicated for salvage radiotherapy, one is in process for prostate-specific membrane antigen positron emission tomography (PSMA PET CT), and 7 patients are in follow-up and without recurrence. Radical prostatectomy is a safe treatment method for localized PC in kidney transplant recipients, which does not impair graft function and survival.

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.

Prostate Cancer Characteristics in Renal Transplant Recipients: A 25-Year Experience From a Single Centre

Objectives: The incidence of prostate cancer in renal transplant recipients (RTRs) is increasing, but few data are available in the literature. In this study, we reviewed the 25-year experience in the management of prostate cancer after kidney transplantation at the Florence Transplant Centre. Methods: We retrospectively reviewed the data from 617 RTR male patients who underwent renal transplantation at our institute between July 1996 and September 2016. Data regarding demographics, renal transplantation, prostate cancer and immunosuppressive treatment were analyzed. The probability of death was estimated by using the Kaplan-Meier method and differences between patients' groups were assessed by the log-rank test. Results: From July 1991 to September 2016, 617 kidney transplantations of male patients were performed at our institute. Among these, 20 patients were subsequently diagnosed with prostate cancer accounting for a cumulative incidence of 3.24%. After a median follow-up of 59 months, 10 patients underwent radical prostatectomy whereas 10 patients underwent primary radiotherapy. A biochemical recurrence was identified in five (25%) patients while a fatal event occurred in 11 (55%) patients. Univariate Cox regression showed that the basal value of PSA >10 ng/ml was the only significant factor negatively affecting the survival of patients. Conclusions: Standard treatments can be proposed to RTR with satisfactory results on both post-operative and oncological outcomes. Further studies are needed to address the issue of prostate cancer screening based on PSA levels and the optimal management of prostate cancer in RTRs.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

[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.

De-novo malignancies after kidney transplantation: A long-term observational study

BACKGROUND

De-novo malignancies after kidney transplantation represent one major cause for mortality after transplantation. However, most of the studies are limited due to small sample size, short follow-up or lack of information about cancer specific mortality.

METHODS

This long-term retrospective analysis included all adult patients with complete follow-up that underwent kidney transplantation between 1995 and 2016 at our centre. All patients with diagnosis of malignancy excluding non-melanoma skin cancer (NMSC) were identified and a matched control group was assigned to the kidney transplant recipients with post-transplant malignancies.

RESULTS

1417 patients matched the inclusion criteria. 179 malignancies posttransplant were diagnosed in 154 patients (n = 21 with two, n = 2 patients with three different malignancies). Mean age at cancer diagnosis was 60.3±13.3 years. Overall incidence of de-novo malignancies except NMSC was 1% per year posttransplant. Renal cell carcinoma was the most common entity (n = 49, incidence 4.20 per 1000 patient years; cancer specific mortality 12%), followed by cancer of the gastro-intestinal tract (n = 30, 2.57; 50%), urinary system (n = 24, 2.06; 13%), respiratory system (n = 18, 1.54; 89%), female reproductive system (n = 15, 1.29; 13%), posttransplant lymphoproliferative disorders and haematological tumours (n = 14, 1.20; 21%), cancers of unknown primary (n = 7, 0.60 100%) and others (n = 22, 1.89; 27%). Male sex, re-transplantation and time on dialysis were associated with de-novo malignancies after transplantation.

CONCLUSION

De-novo malignancies continue to be a serious problem after kidney transplantation. To improve long-term outcome after Kidney transplantation, prevention and cancer screening should be more tailored and intensified.

Risk of Genitourinary Malignancy in the Renal Transplant Patient

OBJECTIVE

To better understand the risk of genitourinary malignancies in the renal transplant patient. Currently, no consensus exists regarding screening and intervention, with much of the clinical decision-making based on historical practices established before recent progress in immunosuppression protocols and in genitourinary cancer diagnosis and management.

METHODS

A database of all solid organ transplants performed at the University of Minnesota from 1984 to 2019 was queried for renal transplant recipients in whom development of subsequent urologic malignancies (prostate, bladder, renal, penile, and testicular cancer) was found.

RESULTS

Among 6172 renal transplant recipients examined, cumulative incidence of all cancers of genitourinary etiology are presented over an average follow-up time of 10 years. Kidney cancer (combined graft and native), prostate cancer, and bladder cancer each demonstrated respective 30-year incidence of 4.6%, 8.7%, and 1.5% from the time of transplant. By comparison, age-matched data from the Surveillance, Epidemiology, and End Results database demonstrated 30-year cumulative incidence of 1.1%, 11.1%, and 1.7% for kidney cancer, prostate cancer, and bladder cancer respectively. The predominant genitourinary cancer was renal cell cancer, both of the native and of the transplanted kidney (native, n = 64; transplanted, n =11), followed by prostate cancer (n = 63), and bladder cancer (n = 37).

CONCLUSION

In this closely followed cohort of renal transplant recipients, renal cancer occurs at a higher incidence rate than in the non-transplanted population, while a lower rate of prostate cancer was found, with bladder cancer demonstrating a comparable cumulative incidence between transplant patients and the national age-matched population.

Resolution of a High Grade and Metastatic BK Polyomavirus-Associated Urothelial Cell Carcinoma Following Radical Allograft Nephroureterectomy and Immune Checkpoint Treatment: A Case Report

BACKGROUND

BK viral infection in the posttransplant setting continues to cause serious morbidity with effects ranging from allograft nephropathy and dysfunction to urothelial malignancy.

RESULTS

In this report, we present a patient that developed BK-associated nephropathy and, 6 years later, locally advanced urothelial malignancy in the renal allograft with nodal, muscle, and extremity involvement. Following radical allograft nephroureterectomy, he was treated with palliative radiation and the immune checkpoint inhibitor atezolizumab. Follow-up imaging at 1 year demonstrated radiographic complete response.

CONCLUSIONS

This report supports the growing body of evidence supporting the association of urothelial malignancy and BK virus infection in renal transplant recipients. Further, it highlights the novel application of immune checkpoint inhibitors in the treatment of advanced posttransplant malignancy, in particular when the allograft is removed and the tumor is possibly of donor origin.

Robot-Assisted Radical Prostatectomy in a Post-Kidney Transplant Patient: An Initial Case Report in China

OBJECTIVE

Our aim was to evaluate the general applicability, feasibility, and safety of robot-assisted radical prostatectomy (RARP) in Chinese renal allograft patients for prostate cancer removal.

PATIENTS AND METHODS

A 62-year-old patient diagnosed as having biopsy-proven localized prostate cancer in March 2016 who had undergone renal transplant 12 years ago was studied. The preoperative prostate-specific antigen value was determined to be 11.82 ng/mL and the Gleason score was determined to be 3 + 3. The RARP was carried out using a transperitoneal and posterior approach with 5 ports in May 2016. The most important technique was ensuring that the transplanted kidney and ureter remained untouched during the surgery. Only the right obturator lymph nodes were dissected because the renal allograft was overlying the iliac vessels.

RESULTS

The RARP was successfully concluded following 230 minutes with an estimated blood loss of 200 mL. There were no postoperative complications. Final pathology was T2cN0M0, Gleason 3 + 3. Following catheter removal, the patient was completely continent and was discharged with no change in serum creatinine or glomerular filtration rate levels. During a 21-month follow-up, unobstructed urination, no incontinence, no biochemical recurrence, and normal kidney function were observed.

CONCLUSION

RARP in Chinese renal allograft patients is a feasible method that can be accomplished with no injuries to the transplanted kidney or ureter and is achieved with favorable oncological and functional outcomes. In addition, post-kidney transplant male patients are recommended to have routine prostate-specific antigen screening for the early detection of prostate cancer.

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis

OBJECTIVES

Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence.

MATERIAL AND METHODS

We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed.

RESULTS

A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%.

CONCLUSIONS

Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.

Polyomavirus Replication and Smoking Are Independent Risk Factors for Bladder Cancer After Renal Transplantation

BACKGROUND

Solid organ transplant recipients are at increased risk for developing malignancies. Polyomaviruses (PV) have been historically associated with experimental tumor development and recently described in association with renourinary malignancies in transplant patients. The aim of this study was to investigate the relationship between PV replication and smoking, and the development of malignant neoplasms in kidney transplant recipients.

METHODS

A retrospective case-control study was conducted for PV replication in all kidney biopsies and urine cytologies performed between 1998 and 2014 from kidney transplant recipients at the University of Maryland Medical Center. Polyomavirus-positive patients (n = 943) were defined as having any of the following: a kidney biopsy with PV associated nephropathy, any urine cytology demonstrating "decoy" cells, and/or significant polyomavirus BK viremia. Polyomavirus-negative matched patients (n = 943) were defined as lacking any evidence of PV replication. The incidence of malignancy (excluding nonmelanoma skin tumors) was determined in these 1886 patients and correlated with demographic data and history of smoking.

RESULTS

There was a 7.9% incidence of malignant tumors after a mean posttransplant follow-up of 7.9 ± 5.4 years. Among all cancer subtypes, only bladder carcinoma was significantly associated with PV replication. By multivariate analysis, only PV replication and smoking independently increased the risk of bladder cancer, relative risk, 11.7 (P = 0.0013) and 5.6 (P = 0.0053), respectively.

CONCLUSIONS

The findings in the current study indicate that kidney transplant recipients with PV replication and smoking are at particular risk to develop bladder carcinomas and support the need for long-term cancer surveillance in these patients.

Bladder cancer in renal allograft recipients: risk factors and outcomes

BACKGROUND

Solid organ transplant recipients have an increased cancer risk owing to immunosuppression and oncogenic viral infections. We report on the incidence and types of bladder cancer in kidney transplant recipients in Ireland, describing possible additional risk factors and outcomes in these patients.

METHODS

We identified kidney transplant recipients diagnosed with de novo bladder cancer between January 1, 1994, and July 31, 2012, by integrating data from the Irish National Cancer Registry and National Renal Transplant Registry. We calculated the standardized incidence ratio (SIR) and examined patient and tumor characteristics and 1-year survival rate.

RESULTS

Fifteen patients were diagnosed with de novo bladder cancer during the study period, representing 0.48% of kidney transplant recipients. The SIR was 2.5 (95% CI, 1.4-4.2; P < .001). The mean interval between transplantation and diagnosis of bladder tumor was 8.6 years and mean age at time of diagnosis was 55.7 years. Sixty percent of patients were male. The tumor types were transitional cell carcinoma (9 patients), squamous cell carcinoma (3 patients), adenocarcinoma (1 patient), carcinoma in situ (1 patient), and diffuse large B-cell lymphoma (1 patient). Beside immunosuppression, risk factors associated with bladder cancer were urogenital disease (6 patients), cyclophosphamide exposure (2 patients), BK nephropathy (1 patient), analgesic nephropathy (1 patient), and extensive smoking (1 patient). Eight patients underwent radical cystectomy for invasive tumors, with resection of other pelvic organs in 7 patients. Mortality rate within the first year was 40%.

CONCLUSION

Bladder cancer occurred more commonly in kidney transplant recipients with a predominance of aggressive tumors and a high mortality. In patients with preexisting risk factors such as urologic abnormalities and cyclophosphamide exposure careful assessment before transplantation and vigilant monitoring posttransplantation with a low threshold for cystoscopy may improve outcomes.

(131)I treatment in Differentiated Thyroid Cancer and End-Stage Renal Disease

PURPOSE

Radioiodine (RAI) is a cornerstone in the treatment of Differentiated Thyroid Cancer (DTC). In patients on haemodialysis due to End-Stage Renal Disease (ESRD), it must be used cautiously, considering the renal clearance of this radionuclide. Also, the safety of the procedure and subsequent long-term outcome is still not well defined. In 2001, we described a dosimetric method and short-term results in three patients, with a good safety profile. We hypothesize that our method is safe in a long-term scenario without compromising the prognosis of both renal and thyroid disease.

MATERIAL AND METHODS

Descriptive-retrospective study. A systematic search was carried out using our clinical database from 2000 to 2014.

INCLUSION CRITERIA

DTC and radioiodine treatment while on haemodialysis.

EXCLUSION CRITERIA

peritoneal dialysis.

RESULTS

Final sample n=9 patients (n=5 males), age 48 years (median age 51 years males, 67 years female group); n=8 papillary thyroid cancer, n=1 follicular thyroid cancer; n=5 lymph node invasion; n=1 metastatic disease. Median RAI dose administered on haemodialysis 100mCi. 7.5 years after radioiodine treatment on haemodialysis, n=7 deemed free of thyroid disease, n=1 persistent non-localised disease. No complications related to the procedure or other target organs were registered. After 3.25 years, n=4 patients underwent successful renal transplantation; n=4 patients did not meet transplantation criteria due to other conditions unrelated to the thyroid disease or its treatment. One patient died due to ischemic cardiomyopathy (free of thyroid disease).

CONCLUSIONS

Radioiodine treatment during haemodialysis is a long-term, safe procedure without worsening prognosis of either renal or thyroid disease.

[De novo urologic tumors in kidney transplant patients]

CONTEXT

The ability of a transplant recipient to accept a graft depends on the ability of immunosuppressive drugs to regulate the immune system. Such treatments have been associated with tumor promotion and progression.

EVIDENCE ACQUISITION

A systematic literature review was carried out. Electronic searches were performed in PubMed database. The searching criterion was "urological tumors in kidney transplant recipients". The most important issues regarding incidence, urological tumor-specific features, and relevant ones about the treatment are summarized.

SYNTHESIS OF EVIDENCE

In renal transplant, 15% of all tumors are urological neoplasias; furthermore, they are the leading neoplastic cause of death. In transplant population the incidence rate of renal cell carcinoma (RCC), transitional cell bladder carcinoma (TCBC), testicular carcinoma (TC) and prostate cancer are increased 15, 3, 3 and 2 times respectively. Treatments used in transplant patients are similar to those employed in the general population:radical nephrectomy for the native kidney and conservative surgery for the graft are indicated for RCC. Radical prostatectomy is technically feasible for localized PC.Regarding to transitional cell carcinoma BCG or MMC is not contraindicated.

CONCLUSIONS

The incidence rate of cancer has increased among transplant population. These tumors can be managed following the same criteria than in general population. Because in this population the prognosis is worse for the immunosuppression, closer monitoring is required.

BK virus-associated urothelial carcinoma of a ureter graft in a renal transplant recipient: a case report

BACKGROUND

Urothelial carcinomas of ureter grafts in renal transplant patients are rare. Here we report our experience with a case of BK virus-associated urothelial carcinoma in a ureter graft.

CASE REPORT

A 47-year-old man developed chronic renal failure secondary to diabetes mellitus and started maintenance hemodialysis in September 2007. Two months later, the patient received a renal transplant from his 70-year-old mother. The patient developed BK virus-associated nephropathy 1 year after transplantation and presented with a decline in renal function and hydronephrosis in the transplanted kidney 4 years 6 months after transplantation. Cystoscopy and retrograde pyelography revealed an irregular filling defect in the ureter graft. Cytologic diagnosis of his urine revealed a high-grade urothelial carcinoma. Computerized tomography showed a cT2 ureteral tumor and no involvement of other organs. The patient subsequently underwent a transplant nephroureterectomy with bladder cuff resection. Histopathologic findings revealed a high-grade urothelial carcinoma, pT2, in the ureter graft with SV40-positive staining. The patient was closely observed without adjuvant chemotherapy therapy and remained disease free 1 year after surgery. Renal transplant recipients with BK virus infection are at high risk of developing urologic malignancies. Close attention is necessary to diagnose post-transplantation urologica malignancies as early as possible.

Three solid malignancies and a myelodysplastic syndrome with a protracted course after kidney transplantation

Although a well-known complication after transplantation, multiple non-skin malignancies within a patient are rare. We report on a kidney transplant recipient who over the course of 20 years developed breast cancer twice, a uroepithelial carcinoma, and myelodysplasia transforming into acute leukaemia. Breast cancer was treated as usual. The transitional cell carcinoma was managed with partial cyst ureterectomy with transposition of the native ureter to the graft. Withdrawal of immunosuppression followed under a “watchful waiting” regime. In conclusion, alertness is requested regarding development of malignancies. Creative solutions are necessary in the management of such patients. Under exceptional circumstances, withdrawal of immunosuppression may be an option.

Metastatic germ cell tumour following renal transplantation

BACKGROUND

Treatment of germ cell tumours with cisplatin-based chemotherapy results in cure for the majority of patients. There is, however, a small but significant mortality rate, reported to be higher in patients with multiple co-morbidities.

CASE REPORT

We report our management of a renal transplant patient with spina bifida, who was diagnosed with stage IIIC, poor-risk, non-seminomatous germ cell carcinoma. A marker-negative partial response, which has been maintained more than 2 years following completion of treatment, was seen following chemotherapy with cisplatin and etoposide. Performance status has been preserved at pre-treatment levels.

CONCLUSION

Administration of cisplatin-based chemotherapy is feasible for treatment of renal transplant patients with advanced non-seminomatous germ cell tumours. Treatment strategies require careful planning and monitoring. Dose modifications may be required. This case highlights a favourable outcome in spite of multiple obstacles to ideal management.

The high rate of de novo graft carcinomas in renal transplant recipients

BACKGROUND

To investigate the incidence, the clinical characteristics and outcomes of renal graft carcinomas in the same renal transplant population.

METHODS

From April 1989 to April 2012, 1,037 consecutive renal transplantations were performed in our department. Data were collected prospectively in an extensively maintained database. For all recipients, monitoring consisted of clinical examination and an abdominopelvic CT scan or ultrasonography at least once a year.

RESULTS

After 1,037 renal transplantations, 48 men and 14 women (sex ratio 3:4) with a mean age of 54 years (25.1-78.9) were included for urological malignancies. Eight graft carcinomas were identified: 7 renal cell carcinomas (5 papillary carcinomas and 2 clear cell carcinomas of the renal graft) and 1 transitional cell carcinoma of the ureteral graft (incidence 0.78%). Nephron-sparing surgery was chosen for 5 patients with good outcomes. All graft renal cell carcinomas were classified as pT1a and the mean size of tumors was 28.4 mm (range 6-45). The 5-year specific survival rate was 100%. No recurrence was observed with a mean follow-up of 36.8 months (4.1-84.3).

CONCLUSION

Thus confirming an increased risk of de novo graft cancer, close monitoring of renal transplant recipients should be discussed with at least an abdominopelvic ultrasonography and PSA measurement once a year. Renal cell graft carcinomas seemed to be mostly small and of papillary type and low grade.

Transperitoneal laparoscopic nephroureterectomy for native upper tract urothelial carcinoma in renal transplant recipients

PURPOSE

To analyze the safety and clinical outcome of laparoscopic nephroureterectomy (LNUT) for native upper tract urothelial carcinoma (UC) in renal transplant (RT) recipients.

METHODS

We conducted a retrospective analysis of 956 RT recipients from January 2003 to December 2010 to evaluate the benefit of LNUT for patients who were diagnosed with de novo UC after renal transplantation.

RESULTS

Women predominated (10/11, 91 %) in the 11 patients with upper tract UC who underwent LNUT. Five patients underwent LNUT ipsilateral to the transplanted kidney, 4 patients underwent contralateral LNUT, and 2 patients underwent bilateral LNUT. Nine were operated with LNUT combining resection of bladder cuff, 2 with right ureteral cancer underwent open ureterectomy with bladder cuff due to severe adhesions attached to the lesion. The mean surgical duration was 184.2 min (105-305), the mean blood loss was 182.3 ml (20-500), and the mean hospitalization time was 6.7 days (5-9). The mean levels of preoperative and postoperative serum creatinine were 0.99 mg/dl (0.78-1.16) and 1.01 mg/dl (0.89-1.18), respectively. No intraoperative complications occurred. One patient died of multiple metastases at 13 months after LNUT. The mean follow-up of the remaining 10 patients after diagnosis was 21.7 months (3-48). Two patients had recurrent bladder cancer and underwent transurethral resection of the tumor. Eight patients showed no evidence of disease during the follow-up.

CONCLUSIONS

LNUT is a safe and effective approach with low morbidity in transplant recipients, and this therapy provides less trauma, quicker recovery, and acceptable oncological outcomes.

Prostate cancer, tumor immunity and a renewed sense of optimism in immunotherapy

The recent FDA approval of the first therapeutic vaccine against prostate cancer has revitalized the public interest in the fields of cancer immunology and immunotherapy. Yet, clinical results are modest. A reason for this limited success may reside in the capacity of the tumor to convert inflammation in a tumor-promoting condition and eventually escape immune surveillance. Here we present the main known interactions between the prostate tumor and the immune system, showing how the malignancy can dodge the immune system by also exerting several immunosuppressive mechanisms. We also discuss experimental and clinical strategies proposed to counteract cancer immune evasion and emphasize the importance of implementing appropriate murine models like the transgenic adenocarcinoma of the mouse prostate model for investigating the biology of prostate cancer and novel immunotherapy approaches against it.