Renal cell carcinoma of native kidney in Chinese renal transplant recipients: a report of 12 cases and a review of the literature

Chi Yuen Cheung 0 1 2 3 Man Fai Lam 0 1 2 3 King Chung Lee 0 1 2 3 Gavin Sheung Wai Chan 0 1 2 3 Kwok Wah Chan 0 1 2 3 Ka Foon Chau 0 1 2 3 Chun Sang Li 0 1 2 3 Tak Mao Chan 0 1 2 3 Kar Neng Lai 0 1 2 3 0 K. C. Lee Department of Pathology, Queen Elizabeth Hospital , Kowloon, Hong Kong 1 M. F. Lam T. M. Chan K. N. Lai (&) Renal Unit, Department of Medicine, Queen Mary Hospital, The University of Hong Kong , 102 Pokfulam Road, Pok Fu Lam, Hong Kong 2 C. Y. Cheung K. F. Chau C. S. Li Renal Unit, Department of Medicine, Queen Elizabeth Hospital , Kowloon, Hong Kong 3 G. S. W. Chan K. W. Chan Department of Pathology, Queen Mary Hospital , Pok Fu Lam, Hong Kong Objectives To present and discuss the epidemiological and clinical aspects, as well as therapeutic options and outcome of de novo renal cell carcinoma (RCC) of the native kidneys in a series of Chinese renal transplant recipients. Patients and Methods A retrospective, cohort study examining all renal transplant recipients with the diagnosis of RCC of native kidney followed up in two major regional hospitals in Hong Kong between January 2000 and December 2009. Clinical data included age, gender, cause of renal failure, symptoms at presentation, duration of transplantation, immunosuppressive therapy, and history of acquired cystic kidney disease (ACKD). Laboratory, radiographic, operative, and pathology reports were used to assess the tumor extent. Results Among the 1,003 renal transplant recipients recruited, 12 transplant recipients had a nephrectomy for a total of 13 RCC. The prevalence of de novo RCC was 1.3%. The mean age at diagnosis of RCC was 48.4 years, and the median time from transplantation to diagnosis was 6.1 years. ACKD was found in 6 (50%) of the patients. All patients except one were asymptomatic. pT1 disease was found in ten patients with a mean tumor size of 3.2 cm. All patients were treated successfully with radical nephrectomy. After a median follow-up of 38 months, two patients (16.7%) died. One died of sepsis, and the other died of metastatic carcinoma. Conclusions With increasing data showing a better prognosis if RCC is detected early by screening, it is time to consider screening all kidney transplant recipients for ACKD and RCC. - Renal transplantation remains the best treatment option for patients with end stage renal disease (ESRD) for their survival and quality of life. There is a significant increased risk of malignancy, most common skin malignancies and non-Hodgkin lymphomas, in renal transplant recipients as a result of the use of immunosuppressive medication [1]. On the other hand, carcinoma of the native kidney accounts for less than 5% of all malignancies found in transplant recipients [2]. After successful renal transplantation, the risk of developing renal cell carcinoma (RCC) in native kidneys is about 15 times higher than in the normal population [1]. There has been only a few reported series comprising few renal transplant patients with RCC of native kidneys due to the relative rarity of the condition. Furthermore, there is scarcity of such data in the Asian population. In this study, we present and discuss the epidemiological and clinical aspects, as well as therapeutic options and outcome of de novo RCC of the native kidneys in our renal transplant recipients. Patients and methods This is a retrospective, cohort study examining all renal transplant recipients with the diagnosis of RCC of native kidney followed up in two major regional hospitals in Hong Kong, Queen Mary Hospital and Queen Elizabeth Hospital, between January 2000 and December 2009. During the time period examined, there was no protocol of including routine ultrasound monitoring of native kidney in all patients as a part of follow-up. Clinical, pathological, and follow-up data were retrieved from each patients medical record. Clinical data included age, gender, cause of renal failure, symptoms at presentation, duration of dialysis, duration of transplantation, immunosuppressive therapy, and history of acquired cystic kidney disease (ACKD). ACKD was defined as three or more cysts per kidney on ultrasound scan [3]. Laboratory, radiographic, operative, and pathology reports were used to assess the tumor extent. Tumor stage was determined according to the 2002 TNM classification [4]. The subtype of the tumor was classified according to the Heidelberg classification of the kidney tumors [5]. Tumors were graded according to the Fuhrman scheme [6]. Continuous data are expressed as means standard deviation (SD) while categorical data are expressed as percentages. Among the 1,003 renal transplant recipients recruited, 12 transplant recipients had a nephrectomy for a total of 13 RCC. The prevalence of de novo RCC in our present series was 1.3%. The demographic and clinicopathologic characteristics of our patients were shown in Table 1 and 2. There were 10 men and two women with mean age of 40 years (SD 10.6 years; range 27.568.3 years) at the time of transplant. Nine patients Immunosuppressive regimen ESRD end stage renal disease, RCC renal cell carcinoma, GN glomerulonephritis, ACKD acquired cystic kidney disease, Pred prednisolone, Tac tacrolimus, MMF mycophenolate mofetil, CsA cyclosporine Table 1 Demographic data of renal transplant recipients with RCC Age at diagnosis of RCC (years) Interval between transplant and RCC diagnosis (months) Table 2 Clinicopathologic characteristics of renal transplant recipients with RCC Follow-up (month) Lap nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Open nephrectomy Lap nephrectomy LK left kidney, RK right kidney, Lap laparoscopic received deceased kidney transplantation, and the remaining three received kidneys from living donors. The mean age at diagnosis of RCC was 48.4 years (SD 8 years; range 39.669.5 years), and the median time from transplantation to diagnosis of malignancy was 6.1 years (range 1.221.5 years). The underlying causes of end-stage renal failure were chronic glomerulonephritis in five patients and unknown in the remaining seven. ACKD was found in 6 (50%) of the patients. Only one patient presented with gross hematuria while the remaining patients were totally asymptomatic. None of them had polycythemia. All RCC were detected by ultrasound and later confirmed by computed tomography. The ultrasound was arranged when a post-transplant medical or surgical complication was suspected during follow-up. For maintenance immunosuppressive therapy before the diagnosis of RCC, five received triple immunosuppressive therapy (all were on corticosteroids, one on cyclosporine, four on tacrolimus, one on azathioprine, and four on mycophenolate mofetil) and seven patients received two immunosuppressive agents (all were on corticosteroids and cyclosporine). None of them had induction therapy. Four patients received treatment for acu (...truncated)