Large de novo renal cell carcinoma in a 10-year-old transplanted kidney: successful organ-preserving therapy

BACKGROUND: A recent review of the Cincinnati Transplant Tumor Registry recorded 24 de novo renal cell carcinomas developing in renal allografts. However, late development of these tumors after transplantation is very rare. Only four reports exist regarding conservative surgery on kidney transplant tumors. METHODS: This is a report on a case of a large 6-cm de novo renal cell carcinoma in a 10-year-old transplanted kidney. Optimal therapy by transplant nephrectomy or tumor enucleation was discussed. RESULTS: Partial resections or enucleations of renal cell carcinoma are still less than ideal in carcinomas larger than 3 cm considering the higher risk of local recurrence. But the recipient in this case had done so well and had had such a high quality of life after transplantation that partial nephrectomy as therapy of choice was selected. Now the patient is 2 years tumor free. CONCLUSION: The case report demonstrates that in certain select cases of large tumors, organ-preserving surgery could be an alternative approach in combining complete tumor removal with preservation of graft function.     

A case of renal cell carcinoma arising in bilateral original kidneys after failure of transplant graft function]

We report a case of renal cell carcinoma arising in bilateral original kidneys after failure of transplant graft function. A 47-year-old man had received a living related renal transplantation on December 10, 1985. He had resumed hemodialysis (HD) therapy because of graft failure on January 8, 1996. Periodic computed tomography (CT), after resumption of HD, revealed multiple cystic change in bilateral original kidneys and a mass in the right kidney. He was referred to our hospital on August 4, 1998 for management of the increased right renal lesion. Abdominal angiography demonstrated a hypervascular and solid mass not only in the right kidney but also in the left kidney. He underwent transperitoneal bilateral nephrectomy. Histopathological examination revealed renal cell carcinoma, bilaterally, with alveolar type and granular cell subtype. He was free of evidence of recurrence and metastasis for 30 months after nephrectomy.     

Laparoscopic nephrectomy, ex vivo partial nephrectomy followed by allograft renal transplantation

A shortage of available kidneys exists. Forty percent of patients with end stage renal disease wait more than 2 years for renal transplant. We report a case of a 22-year-old man who underwent laparoscopic radical nephrectomy for a 2-cm central renal mass. Ex vivo partial nephrectomy and renorraphy were performed. The reconstructed kidney was allotransplanted to a 62-year-old man with end stage renal disease. The recipient has excellent graft function. Imaging shows no evidence of recurrence or metastasis at 2 years' follow-up. Incidence and management of de novo renal cell carcinoma in renal allografts are reviewed.     

Solitary pancreatic metastasis from renal cell carcinoma

A case of asynchronous bilateral renal cell carcinoma with pancreatic metastasis is described. Left nephrectomy and tumorectomy in the right kidney were performed. Solitary metastasis to the pancreas without symptoms was treated by distal pancreatectomy with tumor and splenectomy. Although bilateral renal cell carcinomas were histologically renal cell carcinoma (clear cell subtype, grade 2), the resected pancreatic tumor was renal cell carcinoma with sarcomatoid change. Therefore, the metastatic tumor had a more malignant potential than the primary tumor. The pancreatic metastasis was seen at 6 years 10 months and 2 years 6 months after left nephrectomy and enucleation of the right renal tumors, respectively. The patient is alive without disease and is being treated by alpha-interferon for 12 months after distal pancreatectomy. A careful long-term follow-up of the patient with renal cell carcinoma seems to be necessary.     

How Long Should We Follow the Post-transplantation Patient after Graft Loss? A Case Report of Renal Cancer in the Grafted Kidney that Occurred 16 Years after Graft Loss

Background

Renal cancers commonly occur in the native kidneys of renal transplant recipients, whereas renal cancer in the grafted kidney has been reported occasionally. Renal cancer in the grafted kidney occurred 16 years after graft loss in this case, which would be a more rare case.

Case Report

A 60-year-old man who had a kidney transplant from his mother at the age of 31 years and had hemodialysis again because of chronic rejection from the age of 44 years had right lower abdominal pain. Computerized tomography (CT) showed tumor involvement in the grafted kidney. Positron-emission tomography–CT also showed hot spots in the liver, cervical vertebra, and costal bone. Needle biopsy for grafted kidney and liver tumors were done, and pathologic findings revealed renal cancer of grafted kidney and metastatic liver tumor. Graftectomy was done, and renal cancer was diagnosed as spindle cell carcinoma. Irradiation for cervical bone metastasis was done after the surgery. He complained of abdominal pain and eating disturbance 2 months after the surgery. CT showed a huge recurrence tumor and multiple tumor dissemination. Small intestine was involved and obstructed by the main tumor. He died of recurrence of renal cancer 3 months after the surgery.

Conclusions

It is reported that the rate of renal cell carcinoma in the grafted kidney was 0.19%–0.5% and it occurred at a mean of 12.6 years after renal transplantation. Herein, we report a rare case of renal cancer that occurred 29 years after renal transplantation. Long-term observation should be required for recipients who had rehemodialysis.     

Fate of a renal tubulopapillary adenoma transmitted by an organ donor

Organ transplantation from cadaveric donors has a risk of cancer transmission. However, some reports indicate that kidneys bearing small carcinomas can be safely transplanted, as can other organs harvested from the same donor. We report herein the case of two allograft recipients (left kidney and heart with no evidence of tumor) who developed a renal carcinoma soon after transplantation. The initial tumor of the donor was a 17-mm tubulopapillary adenoma found on the right kidney, which was not transplanted. The left kidney recipient rejected all residual tumoral cells after graft removal and immunosuppression discontinuation. The heart recipient died 7 months after transplantation from metastasis of a renal carcinoma. This strongly suggests that circulating carcinoma cells were present at the time of organ retrieval and that they were not cleared by in situ perfusion. In contrast with the literature data, this report indicates that patients with small renal tubulopapillary tumors should not be considered for organ donation.     

Nephron-sparing surgery for renal tumor: a choice of treatment in an allograft kidney

The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function.     

A case of renal cell carcinoma metastasizing to the contralateral kidney and renal pelvis

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. A 42-year-old man had undergone left radical nephrectomy for renal cell carcinoma (pT1b, grade 2) in March, 2000. Fifteen months later, he complained of macroscopic hematuria. Computed tomographic scanning and retrograde pyelography showed a right renal pelvic tumor. Enucleation of pelvic tumor was performed and a parenchyma mass incidentally identified in the right kidney was also resected. Histopathological examination of each tumor revealed renal cell carcinoma identical to the primary tumors in the left kidney suggesting metastasis to renal pelvis and de novo tumor or metastasis in the right kidney.     

Metastatic renal cell carcinoma associated with acquired cystic kidney disease 15 years after successful renal transplantation

Renal cell carcinoma (RCC) is a relatively uncommon cancer in renal transplant patients. From 1968 to 1987, 101 cases of RCC of native kidneys have been reported to the Cincinnati Transplant Tumor Registry. We describe here a case of metastatic RCC associated with acquired cystic kidney disease (ACKD) 15 years after successful renal transplantation. The patient presented with a subcutaneous nodule, which led to discovery of a large primary tumor in the left kidney. ACKD was present in the atrophic right kidney. The reported cases of ACKD-associated RCC in renal transplant recipients were reviewed. Most of these cases are middle-aged men with a long posttransplant course, good graft function, and usage of azathioprine and prednisone as immunosuppressive agents. ACKD can develop or persist and progress to RCC many years after successful renal transplantation. Transplant patients with flank pain, hematuria, or other suspicious symptoms should have imaging studies of their native kidneys.     

Retroperitoneal cystic metastasis from a small clear cell renal carcinoma

A 39-year-old housewife was referred to our hospital for the treatment of a small renal tumor. A 25 x 35 mm cystic mass that had been detected by computerized tomography scan just caudal to the renal hilus proved to be a metastasis from the renal carcinoma of clear cell type. The pathogenesis may have been due to tumor cells obstructing a lymphatic vessel draining the kidney. Cystic metastasis from renal cell carcinoma is very rare and this appears to be the second published case in the world.     

Vaginal metastasis from transitional cell carcinoma of renal pelvis in horseshoe kidney

We describe a case of transitional cell carcinoma of the renal pelvis in a horseshoe kidney with vaginal tumor as the first manifestation of remote metastasis. While the occurrence of adenocarcinoma in a horseshoe kidney appears to be no higher than in nonfused kidneys, the incidence of transitional cell carcinoma among neoplasms in horseshoe kidneys is higher. Vaginal metastasis from transitional cell carcinoma of the renal pelvis is considered extremely rare. To our knowledge, this is the first case reported of transitional cell carcinoma of the renal pelvis in a horseshoe kidney with metastasis to the vagina. The patient was successfully treated with surgery, irradiation, and chemotherapy.     

Intramedullary spinal cord metastasis from renal cell carcinoma mimicking intramedullary hemangioblastoma

A rare case of intramedullary spinal cord metastasis from renal cell carcinoma mimicking intramedullary hemangioblastoma was described. A 57-year-old man had a nephrectomy for renal cell carcinoma in the left kidney 5 years ago, and no recurrence or metastasis was found in computed tomography and bone scintigraphy. Later, the patient was presented as having bilateral shoulder pain and severe palsy of bilateral upper and lower extremities, and a solitary tumor in the intramedullary spinal cord was found at the C4 level. Excision of the tumor was performed and the intraoperative pathological diagnosis suspected the tumor to be hemangioblastoma. However, a final pathological examination revealed characteristics consistent with metastasis of renal cell carcinoma. Although the patient’s neurological condition and neuralgia initially slightly deteriorated postoperatively, they then gradually improved. Twenty-two months after the operation, a follow-up magnetic resonance imaging showed no recurrence of intramedullary spinal cord tumor, and there were no other metastases found in other organs.     

Renal cell carcinoma in renal graft recipients and donors: incidence and consequence.

INTRODUCTION AND OBJECTIVES: Numerous studies have reported an increasing incidence of small renal cell carcinoma (RCC). De novo RCC in a renal allograft is a rare event and has special implications in renal transplant recipients. The objective of this study was to retrospectively evaluate the incidence of RCC in renal graft recipients and donors and to determine a procedure in cases with newly detected small renal tumors at the time of kidney preparation before transplantation. MATERIAL AND METHODS: We mailed a questionnaire to 38 German transplant clinics and received answers from 27 centers. A total of 10,997 renal graft recipients were included in the period of 1990-1998. RESULTS: In 30 kidneys (0.273%) RCC was detected at the time of preparation before transplantation. There were 23 male and 3 female donors. No bilateral RCC was described. The mean age of the donors with RCC was 50.9 years (range 37-72 years). The tumors had a mean size of 2.2 cm (range 0.4-6 cm). 67% of the patients had a renal tumor smaller than 20 mm. In 26/27 centers the decision to transplant relies on the result of the immediate section for microscopic examination. 16 patients (0.145%) developed RCC 3-12 years after renal transplantation (mean 7.4 years). The mean tumor size was 2.5 cm (range 2-2.8 cm). In 50% a grade 1 and in the other 50% a grade 2 carcinoma was found. CONCLUSIONS: Because of the RCC incidence in donor candidates we recommend an ultrasound screening of the native kidneys before renal explantation and an immediate preparation of the kidney surface especially in donors older than 45 years. In cases with small renal lesions we recommend an immediate section for microscopic examination before transplantation to prevent tumor implantation into an otherwise healthy patient. The frequency of RCCs after renal transplantation necessitates careful clinical and instrumental examinations in organ-transplanted recipients both before and at regular intervals after transplantation, including the patient's kidneys.     

A case of small simple renal cyst associated with renal cell carcinoma

A 61-year-old male was admitted to our clinic for the purpose of further examination of the small renal mass discovered incidentally by ultrasonography. Subtraction angiography disclosed a small renal cell carcinoma of the upper-lateral margin of the left kidney dramatically. Enucleating surgery of the tumor was performed successfully (about 2 cm in diameter). Histological examination revealed a small simple renal cyst associated with renal cell carcinoma. The patient is well without evident metastasis 1 year postoperatively. Since this is a very rare case in the literature, we report this case and discuss the preoperative diagnosis of small renal cell carcinoma. We believe that ultrasonography is a simple and very useful method for mass screening of small urological malignancies.     

A case of bilateral renal cell carcinoma showing a rapid course of death in a long-term hemodialysis patient due to polycystic kidney

A case of bilateral renal cell carcinoma in a 42-year-old polycystic kidney male is reported. He had been treated with hemodialysis for 22 years. An abnormal small mass was found in one of the left renal cystic lesions by screening ultrasonography and CT scan at the 19th year of the hemodialysis. Left radical nephrectomy was performed and the histological diagnosis was a renal cell carcinoma (RCC). There was no evidence of recurrence and metastasis, however, he presented with asymptomatic macrohematuria two years after the operation. CT scan demonstrated the rapidly progressing right renal tumor and multiple para-aortic lymph node swelling. Right nephrectomy and lymphadenectomy were performed and pathological examination showed the advanced RCC with multiple lymph node metastasis. Eleven months after the second operation followed by interferon therapy. he died of multiorgan metastasis of the RCC. This is the first bilateral RCC case in polycystic kidney patient treated with hemodialysis in Japan.     

Noninvasive therapy of incidental de novo renal cell carcinoma in a kidney allograft 12 years after transplantation: report of a case and review of literature

BACKGROUND: Immunosuppressive therapy increases the incidence of posttransplantation cancer. Primary renal cell carcinoma (RCC) represents 4.6% of all cancers in transplant recipients. The treatment options for RCC in a renal allograft include radical nephrectomy or nephron-sparing surgery. We report the case of a patient who underwent percutaneous radiofrequency ablation (RFA) of a RCC in the grafted kidney. PATIENT AND METHODS: Twelve years after undergoing heterotopic, allogenic kidney transplantation, a de novo lesion was diagnosed in the upper pole of the kidney graft in a 77-year-old patient during routine duplex ultrasonography. The magnetic resonance image showed a spherical lesion of 17 mm in diameter, which undoubtedly showed radiological signs of a RCC. After adequately informing the patient about alternative treatment strategies and the associated risks, we made an interdisciplinary decision for a percutaneous RFA of the lesion. RESULTS: After the intervention, graft function remained unchanged and is still good at 6 months with no signs of local recurrence on follow-up MRI. A small coagulation defect at the site of the former lesion was the only morphological change. There was also no evidence of distant tumor spread. CONCLUSION: Percutaneous RFA seems an acceptable, allograft-preserving treatment option associated with low morbidity and mortality for RCC in a renal allograft considering the significant risks associated with open partial nephrectomy in a kidney graft.     

Acyclovir plus CMV immunoglobulin prophylaxis and early therapy with ganciclovir are effective and safe in CMV high-risk renal transplant pediatric recipients

Cytomegalovirus (CMV) infection is still a major cause of morbidity in high-risk renal transplant recipients. In the present report, we have reviewed our records of renal transplant pediatric recipients (RTPR; mean age 14.1 ± 4.9 years) since 1991, when we started a policy of CMV prophylaxis constituting high-dose oral acyclovir plus CMV hyperimmune immunoglobulins (Hlg) followed by early i. v. ganciclovir therapy in high-risk patients (i. e., CMV donor + / recipient ?). Four patients received a kidney from a living relative (LR), 2 patients had one previous transplant, and 1 had a combined liver – kidney transplant. Thirty-three patients who were negative for CMV antibodies (ab) before transplantation received a kidney from CMV ab positive donors. The immunosuppressive regimen included cyclosporine A and steroids, with the addition of azathioprine in the 4 patients who received an LR kidney. Serial assessments for CMV antigenemia (pp 65) were routinely performed for 6 months after transplantation to define CMV infection. Among the 33 CMV seronegative recipients (R ?) who received the graft from a CMV seropositive donor (D +), 18 (54.5 %) experienced CMV infection, whereas among the 28 CMV R +, who received a graft from a CMV D +, 11 (39.3 %) experienced CMV infection. With regard to CMV ? related symptoms, only 2 patients suffered from a CMV syndrome (fever and leukopenia in 1 patient, fever and arthralgia in the other). In no case did the spectrum of CMV disease occur; only minor symptoms were present in 7 of the remaining CMV-infected patients (fever in 6 and leukopenia in 1). Rejection episodes and renal function did not differ between CMV-infected and non-CMV-infected patients. Our experiences support the use of prophylactic acyclovir plus CMV HIg followed by early therapy with i. v. ganciclovir to combat the risk of increased morbidity in high risk RTPR.     

Living-donor transplantation after excision of unrecognized renal cancer diagnosed after transplant

Background

Published data on kidneys transplanted after resecting small renal cancers during the transplantation surgery are very rare and, to the best of our knowledge, no pediatric cases have been reported in the literature.

Case-Diagnosis/Treatment

Our patient was diagnosed with a bilateral Wilms tumor when he was 15 months old. A total bilateral nephrectomy was required to control the disease. Two years later, a human leukocyte antigen (HLA)-identical living-donor transplant from his father was performed. A small mass in the father’s left kidney was diagnosed as an angiomyolipoma during the pretransplant donor evaluation. During the surgery, the mass was excised and the kidney implanted. One week later, the pathological study revealed the mass to be a clear cell renal carcinoma. After joint discussion, the urologic and nephrologic teams and the family decided to maintain the transplant, managing the patient with monotherapy based on rapamycin and close ultrasound control. To date, 8 years after transplantation, no signs of malignancy have been detected, and renal function is normal.

Conclusion

This is the first reported pediatric case of a living-donor graft with a small renal carcinoma excised in the operating room. No malignancy has been observed in 8 years of follow-up.     

Lymph nodal involvement by renal angiomyolipoma

Angiomyolipoma of the kidney is a clonal neoplasm, apparently part of a family of neoplasms derived from perivascular epithelial cells. A 40-year-old woman presented with right flank pain and an otherwise non-significant medical history. An abdominal computed tomography scan revealed an 18 cm solid mass in the mid-portion of the right kidney and multiple perihilar lymph nodes. Presumptive diagnosis was renal cell carcinoma. Right radical nephrectomy and a perihilar lymph node dissection was performed through a Chevron incision for the anticipated diagnosis of renal adenocarcinoma. The renal tumor was diagnosed as angiomyolipoma and a component was identified pathologically in a dissected lymph node. There was no evidence of tumor recurrence in the follow-up period of eight years. The consensus from other studies suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than due to metastasis. Genetic studies may resolve this question in the future.     

Solitary brain metastasis from renal cell carcinoma 14 years after nephrectomy: a case report

We report a case of solitary brain metastasis from renal cell carcinoma (RCC) 14 years after nephrectomy. A 46-year-old female had sudden onset of headaches, aphasia, gait disturbance and right hemiparesis. A brain CT revealed a cystic tumor in the left parietal area, which was surgically removed completely. Microscopic appearances of the brain tumor were similar to those of the primary RCC. Positive immunoreaction for epithelial membrane antigen (EMA) and keratin confirmed the diagnosis of metastatic RCC. This is the second case of solitary brain metastasis from RCC occurring more than 10 years after nephrectomy.