Donor kidneys with small renal cell cancers: can they be transplanted?
ABSTRACT The purpose of this study was to determine whether incidentally discovered, small renal cell cancers (RCC) in donor kidneys can be excised and safely transplanted.
The Israel Penn International Transplant Tumor Registry database was searched and all small RCC that were identified and resected prior to transplantation of deceased and living donor kidneys were reviewed. Patient demographics, tumor characteristics, recurrence, and survival were examined.
Fourteen kidneys were identified in which small RCC were noted at the time of procurement and where the tumors were excised ex vivo and then transplanted. Eleven kidneys were obtained from living related donors and three were from deceased donors. Median tumor size was 2 cm (range 0.5 to 4 cm). All 14 tumors were of histological Furhman grade II/VI (n = 8) or Furhman grade I/VI (n = 6). All kidneys had pathologically confirmed negative margins. The mean age of the recipients was 40.8 +/- 9.2 years, with the majority being men (11 men; 3 women). Median follow-up for this group was 69 months (range 14 to 200 months). There have been no recurrences of tumor in these recipients and the 1-, 3-, and 5-year patient and graft survivals are 100%, 100%, and 93%.
These data represent the only data available (to our knowledge) on this issue. This experience indicates that donor kidneys with small, incidental RCC and low histological grade (Furhman grade I and II/IV) can be managed with excision and transplantation, with a low risk of tumor recurrence in the recipient.
- [show abstract] [hide abstract]
ABSTRACT: 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.Pediatric Nephrology 07/2012; · 2.94 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: The ever-increasing disparity between the number of organs available for transplant and the need for organs drives further exploration into the use of compromised or marginal donors. There is now an emerging advocacy for the use of kidneys with existing tumors, which may be rendered tumor free after surgical excision and reconstruction. This practice is based on reliable data that renal cancers <3 cm in diameter behave with minimal malignant potential and likelihood of transmission to the immunosuppressed recipient. However, in the case of live donors this creates a potential ethical conflict between those treating patients with renal masses and those with an interest in renal donation. The best available treatment for patients with a small renal tumor is a form of nephron-sparing tumor excision or ablation, as this approach provides for the maximum amount of residual kidney function and enhances survival. Thus, patients newly diagnosed with small renal tumors should be referred to centers with expertise in nephron sparing techniques, not transplant centers. In the case of an individual undergoing a live donor evaluation in which a small renal tumor is detected, a careful analysis of risk and benefit for the potential donor and the recipient is indicated.American Journal of Transplantation 11/2011; 12(1):48-54. · 6.19 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Maligne Neoplasien stellen neben der Beherrschung kardiovaskulärer Erkrankungen und Stoffwechselveränderungen gegenwärtig die größte Herausforderung für die Transplantationsmedizin bezüglich der Langzeitfunktion transplantierter Organe dar. So sind prinzipiell präexistente Neoplasien von transplantierten Neoplasien und auch De-novo-Neoplasien zu unterscheiden. Das Risiko, an einem malignen Tumor während der Dialyse zu erkranken, ist vergleichsweise nicht zuletzt bedingt durch verschiedene spezifische Einflüsse erhöht. In Abhängigkeit von der Tumorart sollte nach Abschluss der kurativen Tumortherapie in der Regel ein Intervall von 2Jahren bis zur Rekrutierung auf der Transplantationswarteliste eingehalten werden. Die Wahrscheinlichkeit, einen Tumor mit dem Spenderorgan (am Beispiel der Niere „unbemerkt“) zu übertragen, ist gering (<0,2%). Vor dem Hintergrund des chronischen Organmangels wird international die Transplantation von Nieren mit kleineren Tumoren (<2cm im Durchmesser und niedriges Grading z.B. G1) nach entsprechender histologischer Diagnostik des vor der Transplantation zu exzidierenden Tumors wie auch kritischer Abwägung aller Einflussgrößen akzeptiert. Die Früherkennung von De-novo-Neoplasien ist entscheidend für die Prognose quoad vitam des transplantierten Patienten. Die Tumoren des Urogenitaltraktes (UGT) sind mit einem großen Anteil in der Gesamtzahl von De-novo-Tumoren vertreten. Um so mehr ist es erforderlich, ein klar definiertes Konzept eines engmaschigen Tumor-Screenings zu realisieren. Krebserkrankungen korrelieren sowohl bei immunsupprimierten Patienten in der terminalen Niereninsuffizienz während der Dialyse, als auch nach Transplantation aufgrund der erforderlichen Immunsuppression mit einer höheren Inzidenz im Vergleich zur Normalpopulation. Diese Inzidenz ist weltweit sehr unterschiedlich und hängt nicht zuletzt von den geographischen Bedingungen ab. So ist sie in Australien am höchsten, gefolgt von den USA und Europa. Speziell die Neuerkrankungen an Hautkrebs stehen offensichtlich im Zusammenhang mit hoher Sonneneinstrahlung. Together with cardiovascular disorders and metabolic changes, malignant diseases are considered as great challenges in clinical transplantation. As far as long-term function of transplanted organs is concerned, an impact of malignancies is obvious. However, it is important to distinguish between neoplastic disease originating from preexisting lesions in the transplanted organs and de novo graft tumors. Further, there is also a high risk of developing malignant disease during the dialysis, likely due to potential harmful metabolic changes associated with this procedure. After curative management of tumors in such patients, an interval of 2years for surveillance should be adhered to before patients are put back on the waiting list. The overall risk of transmission of a malignant disease with the transplanted graft has been considered to be as low as <0.2%. In this context, and considering the continual shortage of donated organs, there is an international consensus about the use of kidney grafts with a history of small tumors (<2cm in diameter und low-grade, i.e., G1). However, the lesions should have been removed with subsequent histopathologic characterization before the acceptance of the organ for transplantation. Early diagnosis and management of de novo malignant disease in transplant patients is crucial for the prognosis of graft function and patient survival. Genitourinary malignancies are frequent among de novo malignancies in transplanted patients. Thus, there is a need for clearly structured concepts for screening of transplant patients in order to detect early malignancies. The incidence of malignant disease correlates directly with the extent of immunosuppression in patients with end-stage renal disease (ESRD) on dialysis, as well as after transplantation with life-long immunosuppressant therapy. In addition, also geographic factors seem to play a role in the differential incidence of tumors among different populations. For instance, the highest incidence of malignancies among immunosuppressed patients has been observed in Australia followed by the USA and Europe. This might be due to the high incidence of de novo skin cancer, which has been linked to the extent of UV exposure.Der Urologe 04/2012; 48(12):1443-1451. · 0.46 Impact Factor