Complete response to pembrolizumab for metastatic urothelial carcinoma in the renal pelvis of allograft kidney

Introduction

We present a case of urothelial carcinoma in a renal allograft successfully treated with pembrolizumab.

Case presentation

A 39‐year‐old woman presented with nausea and anorexia 9 years after a renal transplantation. Positron emission tomography revealed a neoplasm of the renal pelvis of the allograft and multiple lymph nodes with peritoneal metastasis. A diagnosis of a non‐muscle‐invasive bladder tumor with peritoneal dissemination and jejunal metastasis of urothelial carcinoma was made. After five cycles of gemcitabine and carboplatin, the tumor progressed and pembrolizumab was administered. One week after the first dose, the allograft was rejected, necessitating arterial embolization. After the second cycle, the patient developed Stevens‐Johnson syndrome. After discontinuing pembrolizumab, positron emission tomography revealed no increased tumor activity. A complete response was achieved for 21 months without additional treatment.

Conclusion

Pembrolizumab was effective in treating urothelial carcinoma of the renal allograft; however, allograft rejection and loss should be considered.

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.

Rapidly Progressive Invasive Urothelial Carcinoma With Flat and Infiltrative Growth Pattern in the Graft Kidney After Living-Related Kidney Transplantation: A Case Report

BACKGROUND

Because immunosuppression is necessary for kidney transplant recipients, malignant tumorigenesis of recipient organs is a concern; however, few studies have discussed the malignant alteration of transplanted grafts that have been functional for a long time. In addition, a urothelial carcinoma (UC) in transplanted kidney graft is a rare disease.

CASE REPORT

A 62-year-old man had end-stage renal failure 31 years ago and received a kidney transplant from his father. Acute renal failure due to obstruction of the transplanted ureter was diagnosed. Ultrasound, ureterogram, and non-enhanced computed tomography scans revealed no obvious evidence of any neoplastic lesion. We treated the obstruction and hydronephrosis with transplant ureter stenting. However, the regional lymph nodes enlarged, and it became necessary to change the ureteral stent frequently because of stent stenosis; therefore, he underwent lower transplant ureteral resection and reconstruction. Histopathology confirmed a UC with a flat and infiltrative growth pattern. The patient then underwent graftectomy including right external iliac vein resection and reconstruction; however, because of numerous metastatic nodules, radical surgery could not be performed. The patient subsequently died because of septic shock after the second surgery.

CONCLUSION

We report a case of an invasive UC with a flat and infiltrative growth pattern derived from a transplant kidney graft that occurred 31 years after a living-donor transplant that could not be treated immediately and was difficult to diagnose.

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.

Urothelial carcinoma arising from the transplanted kidney: A single-center experience and literature review

Urothelial carcinoma (UC) is a malignancy predominantly arising in the bladder. Upper tract UC (UUC) is uncommon, accounting only for 5-10% of the cases. High incidence of neoplasms is associated with immunosuppressive therapy; thus, UCs of the transplanted grafts often lead to a more aggressive treatment, in order to withdraw completely the immunosuppression. It significantly affects the patient quality of life, meaning return to dialysis, along with the worse life expectancy. We present our single-institution experience of this rare malignancy in two mid-age kidney transplant recipients, with UCs successfully treated with radical nephroureterectomy: G3 pT3 N0 + G3 pT1 N0 in the first patient and G3 pT2 N0 in the second one. We also review the previous literature focusing on stage of presentation and treatment for the affected kidney transplant patients.

Practical applications of DNA genotyping in diagnostic pathology

INTRODUCTION

Among various human tissue identity testing platforms, short tandem repeat (STR) genotyping has emerged as the most powerful and cost-effective method. Beyond forensic applications, tissue identity testing has become increasingly important in modern medical practice, in areas such as diagnostic pathology. Areas covered: A brief overview of various molecular/genetic techniques for identity testing is provided. This includes restriction fragment length polymorphism, single nucleotide polymorphism array and STR genotyping by multiplex PCR. Diagnostic applications of STR genotyping are covered in greater details: genotyping diagnosis of gestational trophoblastic disease, resolving tissue specimen mislabeling or histologic contaminant or 'floaters', bone marrow engraftment/chimerism analysis and interrogation of the primary source of malignancy in patients receiving organ donation. Four clinical cases are then presented to further illustrate these important clinical applications along with discussion of the interpretation, limitations, and pitfalls of STR genotyping. Expert commentary: STR genotyping is currently the most applicable method of identity testing and has extended its role well into the practice of diagnostic pathology with novel and powerful applications beyond forensics.

Transitional cell carcinoma involving graft kidney in a kidney transplant recipient: a case report

Background

Kidney transplantation (KT) is the treatment option for patients with end stage renal disease (ESRD) to prolong survival and improve quality of life. Although the use of potent immunosuppressive agents increases graft survival in kidney transplantation recipients (KTRs), it may lead to the development of malignancy, including transitional cell carcinoma (TCC). TCC developing in the pelvis of graft kidney is very rare in KTRs.

Case Presentation

A 40-year-old male visited hospital with complaints of nausea, vomiting and gross hematuria. Eleven years ago, he was diagnosed ESRD of unknown origin, and received a living related KT from his father 1 year later. Radiologic findings showed a huge polypoid mass in the pelvis of graft kidney with pelvo-calyceal dilation and a 3.3 cm-sized nodule in aortocaval chain and a 2.5 cm-sized nodule in right iliac chain as TCC stage IV. Sonography-guided percutaneous needle biopsy of pelvis mass in the graft kidney revealed a low grade urothelial cell carcinoma. Radical graft nephroureterectomy was performed and histopathological diagnosis confirmed as a low grade urothelial carcinoma of graft pelvis and ureter lumen, which invaded to perirenal fat and renal parenchyma with lymphovascular presence (T3Nx). The patient started with adjuvant concurrent chemo-radiation therapy and returned to regular hemodialysis.

Conclusions

We report a rare case of TCC in the pelvis of graft kidney with already advanced disease at diagnosis in a young KTR. For the early diagnosis of TCC in KTRs, exposure history to Chinese herb or analgesics should be investigated before KT and high risk population in KTRs should be tightly performed regular postoperative surveillance for TCC and considered of less calcineurin inhibitor-based immunosuppressant protocol.

Urothelial carcinoma of the allograft kidney developed in a renal transplant patient

Renal transplantation is the best option in the treatment of end-stage renal disease However these patients are under the risk of developing malignancies particularly due to effects of immune supression. These malignancies tend to be more agressive compared to the general population. Here, we present a case of urothelial carcinoma develoing in the ureter of allograft kidney.

TCC in Transplant Ureter--When and When Not to Preserve the Transplant Kidney

We present four cases of transitional cell carcinoma of the transplant ureter (TCCtu). In three cases, localized tumor resection and a variety of reconstructive techniques were possible. Transplant nephrectomy with cystectomy was performed as a secondary treatment in one locally excised case. Transplant nephroureterectomy was performed as primary treatment in one case. The role of oncogenic viruses and genetic fingerprinting to determine the origin of TCCtu are described. Our cases and a systematic literature review illustrate the surgical, nephrological, and oncological challenges of this uncommon but important condition.

Successful treatment of metastatic urothelial carcinoma arising in a transplanted renal allograft with paclitaxel, cisplatin, and gemcitabine combination therapy: a case report

BACKGROUND

For locally advanced or metastatic urothelial carcinoma, cisplatin-based chemotherapy is the standard regimen. Nevertheless, almost all responding patients experience recurrence within the first year. When patients who have received prior cisplatin-based therapy become resistant, combination therapy with gemcitabine and paclitaxel has been reported. Few published case reports have addressed the utility of paclitaxel/cisplatin/gemcitabine combination therapy as second-line chemotherapy for advanced or metastatic urothelial carcinoma. This is the first report describing paclitaxel/cisplatin/gemcitabine combination therapy for metastatic urothelial carcinoma arising in a transplanted renal allograft and leading to a successful outcome.

CASE PRESENTATION

We present a case of metastatic urothelial carcinoma of a renal allograft in a 32-year-old Japanese man with a history of kidney transplantation ten years prior. Because the patient's serum creatinine increased, hemodialysis was resumed, and the surgical allograft was removed. Multiple lung metastases were resistant to gemcitabine/cisplatin adjuvant chemotherapy, so paclitaxel/cisplatin/gemcitabine combination chemotherapy was instituted. After paclitaxel/cisplatin/gemcitabine chemotherapy, all pulmonary metastatic tumors disappeared. The patient has survived without disease progression for more than four years since treatment.

CONCLUSION

Paclitaxel/cisplatin/gemcitabine combination therapy may be effective and lead to a survival advantage in patients with locally advanced or metastatic urothelial carcinoma when used as second-line chemotherapy following cisplatin-based therapy. However, further investigations may be required to confirm and evaluate the significance of this treatment.