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Adverse Occurrence type:
(Council of Europe, 2022): To provide valid histological staging, complete tumour resection (R0) is required for acceptance of all organs; additionally, tumour-free margins are a prerequisite for transplant of the affected kidney. Paraffin section is superior to frozen section for the assessment of such biopsies. The contralateral kidney should always be examined for synchronous RCC (5 % of patients). RCC < 1 cm (stage T1a AJCC 8th edn) and WHO/ISUP grade I/II (Fuhrman grade I/II) can be considered minimal-risk for transmission; RCC 1-4 cm (stage T1a AJCC 8th edn) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered low-risk; RCC > 4-7 cm (stage T1b AJCC 8th edn) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered intermediate-risk; RCC > 7 cm (stage T2 AJCC 8th edn) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered high-risk; RCC with extension beyond the kidney (stages T3/T4 AJCC 8th edn) is considered a contraindication to transplant; All RCC with WHO/ISUP grade III/IV (Fuhrman grade III/IV) are considered high-risk for transmission; Contralateral kidneys and other organs that are un¬involved in carcinoma are considered to represent minimal risk for transplantation when the RCC in the involved kidney is 4 cm or less and WHO/ISUP grade I-II. In all cases, follow-up surveillance is desirable. RCC in the donor history: The transmission risk of treated RCC depends on the histological type of tumour  and its 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:
Patient 1: 10 years; Patient 2: 23 years
Alerting signals, symptoms, evidence of occurrence:
Patient 1: Allograft failure 6 years posttransplant; immunosuppression stopped, allograft not removed. At 10 years posttransplant he developed a chest wall mass and biopsy showed poorly differentiated clear cell carcinoma. Involvement of mediastinal, retroperitoneal and iliac nodes as well as left hemipelvic mass and multiple lytic bony lesions also found. Patient 2: elevated renal function studies found during preoperative evaluation for knee surgery 23 years post-renal transplant and renal biopsy showed papillary renal carcinoma. Imaging showed 3 lesions in the allograft. Subsequent allograft nephrectomy showed innumerable foci of cystic papillary and clear cell renal carcinoma limited to allograft.
Demonstration of imputability or root cause:
Patient 1: Fluorescent in situ hybridization showed tumor to have XX genotype consistent with female (donor) origin in this male recipient. Patient 2: Tumor confined to allograft kidney.
Suggest new keywords:
FISH (fluorescence in situ hybridization)
Renal cell carcinoma
McHayleh W, Morcos JP, Wu T, Shapiro R, Yousem S, Appleman L, et al. Renal cell carcinoma from a transplanted allograft: two case reports and a review of the literature. Clinical genitourinary cancer. 2008;6(1):53-5.
OK to upload. MN 1/3/19
Expert comments for publication:
Although both of these cases would be classified as "donor-derived" as opposed to "donor-transmitted" RCC due to the long intervals between transplant and tumor development, the presentation with metastatic disease in patient 1, despite the fact that immunosuppression had been discontinued 4 years earlier, points out the potential danger of these tumors and the fact that risk of tumor development remains in the nonfunctional allograft. The presentation of intrarenal RCC in patient 2 appears to be the more common presentation of late-onset allograft-derived RCC.