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Adverse Occurrence type:
Renal Cell Carcinoma: (Council of Europe, 2018): To provide a valid assessment, complete tumour resection (R0) prior to transplantation is required for the acceptance of all organs; additionally, tumour-free margins are a prerequisite for transplant of the affected kidney. The contralateral kidney should always be examined for synchronous RCC. RCC < 1 cm (Stage T1a AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) can be considered minimal risk for transmission. RCC 1-4 cm (Stage T1a AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered low risk. RCC > 4-7 cm (Stage T1b AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered intermediate risk. RCC > 7 cm (Stage T2 AJCC 8th ed.) and nucleolar grade I/II (Fuhrman grade I/II) are considered high risk. RCC with extension beyond the kidney (Stages T3 or T4 AJCC 8th ed.) is considered a contraindication to transplant. All RCC with nucleolar grade III/IV (Fuhrman grade III/IV) are considered high risk for transmission. Contralateral kidneys and other organs that are uninvolved by carcinoma are considered to represent minimal risk for transplantation when the RCC in the involved kidney is 4 cm or less and Fuhrman or nucleolar grade I-II. Followup surveillance is recommended. In the case of a donor with a history of renal cell carcinoma, the transmission risk of treated RCC depends on the recurrence-free follow-up period. In general, in the first 5 years after initial diagnosis, risk categories correspond to those stated above (RCC diagnosed during donor procurement) if there is no suspicion of tumour recurrence in the donor. After this time, the risk of advanced stages may decrease.
Time to detection:
One year after bilateral kidney transplantation
Alerting signals, symptoms, evidence of occurrence:
Bilateral kidney recipient complained of abdominal pain, distention, nausea and vomiting of 2 days duration. Physical examination showed diffuse abdominal tenderness and high-pitched bowel sounds, tachycardia and slight arterial hypertension. Labs were normal. Ultrasound presented the right kidney transplant with a heterogeneous hyperechoic mass, CT scan and whole body PET both confirmed a 7x6x6cm tumor in the right kidney graft suspicious for renal cell carcinoma or lymphoma. Nephrectomy revealed a high grade carcinoma with squamous differentiation and scarcomatoid areas, involving renal pelvis and calyceal system, with invasion into renal parencyhma, peripelvic adipose tissue (pT3) and periureteral tissue but no lymphovascular invasion. One month later, PET/CT scan showed soft tissue fullness at nephrectomy site compatible with recurrent local malignancy. Retroperitoneal and inguinal lymphnodes were unsuspicious. The patient refused chemotherapy but radiotherapy was performed. After 18 months recipient was alive without any recurrence of cancer.
Demonstration of imputability or root cause:
Cytogenetic analysis is described but neither assessed nor discussed. There is no information about the donor (gender, history, cause of death etc.). The short time between transplantation and diagnosis as well as the disease being limited to the kidney graft may be indicative for donor origin.
Suggest new keywords:
Renal cancer, type not specified
Sarcoma, other or type not specified
Dhakal P, Giri S, Siwakoti K, Rayamajhi S, Bhatt VR. Renal Cancer in Recipients of Kidney Transplant. Rare Tumors. 2017;9(1):6550.
Expert comments for publication:
Besides the case report, the authors reviewed the literature and found 48 cases of different malignancies reported in renal grafts after transplantation (25 studies). This small total number of cases contains a large mixture of donor-transmitted, donor-derived and recipient derived cancers. In detail, many different entities of renal cell cancers but also thyroid, lung, hepatocellular cancer and carcinoma of unknown primary are decribed. This is a nice summary of the available literature but due to its heterogeneity, does not allow any conclusion but the fact that there is a certain risk for tumor transmission from donor to recipient.