Status:
Ready to upload
Record number:
2323
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Most recent risk assessment for renal cell carcinoma (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 ed) 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 ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered low-risk; RCC > 4-7 cm (stage T1b AJCC 8th ed) and WHO/ISUP grade I/II (Fuhrman grade I/II) are considered intermediate-risk; RCC > 7 cm (stage T2 AJCC 8th ed) 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 ed) 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 uninvolved 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:
9 years after transplant (one out of 109 recipients who received kidneys with small renal tumors; all other recipients had no suspicion for tumor in the graft)
Alerting signals, symptoms, evidence of occurrence:
Imaging during regular post-transplant follow-up showed tumor recurrence in the kidney graft (remote from the original tumor resection site). The 71yo patient refused surgery as well as radiofrequency ablation. Ultrasound monitoring showed an increase in size from 1.0 to 1.2 cm in the following 18 months.
REMARK: These detailed informations were taken from the original paper (Brooks et al. Transpl Int. 2010 May 1;23(5):476-83).
Demonstration of imputability or root cause:
No biopsy has been reported from the tumor detected by imaging so a definite diagnosis cannot be confirmed but tumor recurrence has been stated by the authors.
Imputability grade:
Not Assessable
Groups audience:
Keywords:
Suggest new keywords:
Malignancy
Review article
Deceased donor
Living donor
Kidney transplant/Kidney recipient/Kidney transplantation
Renal cancer, type not specified
Kidney transplant
Therapy not discussed
Reference attachment:
Suggest references:
Hevia V, Hassan Zakri R, Fraser Taylor C, Bruins HM, Boissier R, Lledo E, et al. Effectiveness and Harms of Using Kidneys with Small Renal Tumors from Deceased or Living Donors as a Source of Renal Transplantation: A Systematic Review. Eur Urol Focus. 2018.
Note:
Uploaded 7/21/24 MN
First review done KM 8/12/24
Second review MN 8/13/24
Expert comments for publication:
This review analyses 19 non-randomized studies (until June 2017) with a total of 109 recipients who received kidneys with small renal tumors that had been resected prior to transplantation (living and deceased donors). Of these resected donor tumors, 88 were malignant RCC (mostly clear-cell type), the rest were benign. Median tumor size was 2cm (0.3 - 6.0), all had negative margins. A clear distinction between benign and malignant tumors is not made (the 6cm tumor was reported benign, though). 75 tumors showed low tumor grade G1-G2.
No transmission has been reported after a median follow-up of about 40 months (with different immunosuppression regimens applied, including 14 sirolimus-based therapies, 72 were not reported). The tumor detected in one kidney graft after 9 years has no reported biopsy result. Assuming an RCC histology, this would rather be interpreted as donor-derived than donor-transmitted due to the long time after transplant and the remote location from the initial tumor.
The data support that transplantation of kidneys after resection of small RCC seems to be a valuable source for waiting patients. A thorough tumor evaluation should be performed when RCC is detected during donor assessment in living donors and a complete resection with negative margins has to be ensured in living and deceased donation (where mostly incidental tumors occur during procurement). Recipient consent for these specific kidneys should be obtained. Surgical complications from the resection, such as urine leaks, may occur. Criteria that may qualify recipients for these kidneys and other implications for practice are briefly discussed.