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De novo concurrent papillary renal cell carcinoma andangiomyolipoma in a kidney allograft: evidence ofdonor origin
Samuel Rotmana,*, Cedric Deruazb, Jean-Pierre Venetzb, Pascal Chauberta,Jean Benhattara, Jean-Yves Meuwlyc, Patrice Jichlinskid, Louis Guilloua,Solange Molle, Manuel Pascualb, Robert Lemoinef
aInstitute of Pathology, University Hospital, CH-1011 Lausanne, SwitzerlandbDepartment of Nephrology, University Hospital, CH-1011 Lausanne, SwitzerlandcDepartment of Radiology, University Hospital, CH-1011 Lausanne, SwitzerlanddDepartment of Urology, University Hospital, CH-1011 Lausanne, SwitzerlandeInstitute of Pathology, University Hospital, CH-1211 Geneva, SwitzerlandfInstitute of Pathology, CH-2007 Neuchatel, Switzerland
Received 28 January 2005; accepted 14 November 2005
0046-8177/$ – see front matter D 2006
doi:10.1016/j.humpath.2005.11.024
* Corresponding author.
E-mail address: samuel.rotman@chu
Keywords:Papillary renal cell
carcinoma;
Angiomyolipoma;
Renal allograft;
Molecular genetics
Summary In the general population, renal cell carcinoma (RCC) is a relatively common neoplasm;
however, the papillary RCC subtype is infrequent and represents only 10 to 15% of all RCC.
Angiomyolipoma is a well-known common benign tumor. The occurrence of RCC in association with
angiomyolipoma is a rare event, with only approximately 50 cases reported in the nontransplantation
setting. In transplant recipients, RCC can develop in native kidneys, but its occurrence bde novoQ in the
renal allograft is very rare with an estimated incidence of less than 0.5%. We report here the case of a
39-year-old woman who underwent cadaveric renal transplantation in 1990. No lesion was observed in
the allograft during the pre- and perioperative period or on early postoperative ultrasounds. No graft
rejection occurred under a standard triple immunosuppressive therapy. Thirteen years later, during a
routine ultrasonography, 2 solid masses were discovered in the allograft, both of them richly vascularized.
She underwent allograft nephrectomy and the histologic findings revealed that one of the tumors was a
chromophilic (type 1) papillary RCC (2.5 cm in diameter) and the other, an angiomyolipoma (1.5 cm).
Microsatellite analysis of the allograft, as compared with the recipient peripheral blood leukocytes,
demonstrated that the 2 tumors (1 malignant and 1 benign) were of donor origin. To our knowledge, this is
the first report of de novo concurrent papillary RCC and angiomyolipoma in a renal allograft.
D 2006 Elsevier Inc. All rights reserved.
Elsevier Inc. All rights reserved.
v.hospvd.ch (S. Rotman).
1. Introduction
Cancer of the kidney represents 2% of the total human
cancer burden, and papillary renal cell carcinoma (PRCC),
Human Pathology (2006) 37, 481–487
S. Rotman et al.482
approximately 10% of renal cell carcinomas (RCCs) [1,2].
Two histomorphological types of PRCC, type 1 and type 2,
have been described [3,4]. Type 1 PRCC is associated with
a longer survival than type 2 PRCC, and a better prognosis
than bclassicQ clear cell renal carcinoma [2]. Angiomyoli-
poma (AML) is a benign tumor frequently found in the
kidney [5,6], the radiological detection of which poses the
differential diagnosis of a malignant tumor [7]. The
occurrence of RCC in association with AML in the native
kidney is a very rare event, with only approximately 50
cases reported [8-12]. Most carcinomas were of the clear
cell type [11,13].
Studies have reported an increase in the prevalence of
RCC in native kidneys of renal transplant recipients
compared with the general population [14-17]. However,
bde novoQ RCC in a renal allograft is a rare event with an
estimated incidence of less than 0.5% [18].
We present the first case, to our knowledge, of concurrent
de novo PRCC and AML developing in a renal allograft,
with radiological, histological, and molecular (genetic) data.
Fig. 1 A, Longitudinal sonographic view of the transplanted kidney (B
pole. A hypoechoic badly delineated zone is visible on the convexity
demonstrates high-flow signal within and around the mass. C, Coronal
specimen. a, papillary RCC (2.5 cm). b, simple cyst. c, angiomyolipom
1.1. Case report
A 39-year-old woman presented with advanced renal
insufficiency of unknown etiology since 1986. She was
treated by hemodialysis for 1 year and in 1987 underwent
her first cadaveric renal transplantation. Three weeks later,
severe vascular rejection required an aggressive immuno-
suppressive therapy with corticoidsteroids, antithymocyte
globulin, and OKT3 without any amelioration of the renal
function. Hemodialysis had to be restarted, and in 1988, the
patient underwent her first allograft nephrectomy.
In May 1990, she received second renal allograft from
a male cadaveric donor. No lesion was identified in the
allograft during surgery, and in the 7 years after the trans-
plantation, 3 renal ultrasounds confirmed the absence of
lesions in the allograft. No graft rejection occurred under a
standard immunosuppressive therapy with cyclosporine,
prednisone, and azathioprine. In April 2003, during a
routine ultrasonography, 1 large cortical cyst and 2 solid
masses were discovered in the allograft. Both solid masses
mode). A rounded hypoechoic mass (arrow) is visible at the lower
(arrowheads). B, Color Doppler ultrasound of the upper lesion
T2 MRI shows a bright cyst and 2 solid masses. D, Nephrectomy
a (1.5 cm). Abbreviations: C, cyst; M1 and M2, masses.
De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 483
appeared heterogeneous on B mode and richly vascularized
on color Doppler ultrasound. A magnetic resonance imaging
confirmed the presence of 1 cortical cyst and 2 solid masses.
In June 2003, the patient underwent her second allograft
nephrectomy, and she returned to hemodialysis.
2. Materials and methods
2.1. Radiology
Sonography was performed with a HDI 5000 instrument
(Philips Ultrasound, Bothell, Wash) equipped with 5- to
12-MHz linear transducer. Gray scale (Fig. 1A) with
panoramic reconstruction and color Doppler (Fig. 1B)
explorations were obtained. The lower abdomen was im-
aged by using a phased-array torso coil with a 1.5-T unit
(Magnetom Symphony; Siemens Medical System, Erlangen,
Fig. 2 A and B, Papillary renal carcinoma, type 1, nuclear grade 1. The
small nuclei with inconspicuous nucleoli. The fibrovascular cores oft
magnification �100 and �200). C and D, Angiomyolipoma: benign tum
The vascular component shows tortuous and thick-walled blood vessel
demonstrates hypercellularity. A lymphocytic infiltrate (recipient cell
magnification �40 and �20).
Germany). Magnetic resonance imaging sequences included
T1- and T2-weighted sequences (Fig. 1C) without fat
saturation in transverse and coronal planes and T1-weighted
sequences with fat saturation in transverse plane after
intravenous injection of gadolinium.
2.2. Histology
For light microscopy examination, the tissue was fixed in
4.5% phosphate-buffered formalin, routinely processed, and
embedded in paraffin wax using standard methods. Sections
measuring 4 lm were stained with hematoxylin and eosin
and examined by 2 independent pathologists (S.R. and
L.G.). The morphological criteria described in the last World
Health Organization classification of tumors [19] were used
to establish the diagnosis of the renal tumors. Histologic
grade was established using the Fuhrman grading system
[20], and staging of RCC was performed according to the
2002 TNM classification [21].
tumor consists of a papillary growth of small cells containing oval
en contain foamy macrophages (hematoxylin and eosin, original
or composed of a mixture of fat, blood vessels, and smooth muscle.
s. The adipose tissue is of a mature type, and the smooth muscle
s) is admixed with the tumor (hematoxylin and eosin, original
S. Rotman et al.484
2.3. Fluorescent in situ hybridization analysis
Briefly, for fluorescent in situ hybridization (FISH),
4-lm frozen sections were treated with a protein-digesting
enzyme at 378C for 40 minutes. Preparations were denatured
in 70% formamide/2� standard saline citrate (SSC), pH 7, at
758C, for 2 minutes. Then, a solution containing a specific
probe for the centromere of chromosomes X, Y, 7, and 17,
coupled with SpectrumGreen (Vysis, Downers Grove, Ill)
was applied to the tissue sections at 378C for 15 hours. After
hybridization, the unannealed probe was washed in 0.4�SSC/NP40 0.3% at 738C for 3 minutes then in 2� SSC/
NP40 0.1% at 378C for 2 minutes. Nuclei were counter-
stained using a 4,6-diamidine, 2-phenyllindol/antifade solu-
tion. A Zeiss Axioplan 2 imaging microscope (Zeiss,
Feldbach, Switzerland) equipped with appropriate filters
for 4,6-diamidine, 2-phenyllindol and SpectrumGreen was
used to score the number of centromeres of each chromo-
some in tumoral tissue and nontumoral tissue.
2.4. Microsatellite analysis
Frozen tissue samples from tumoral and nontumoral renal
allografts were used for microsatellite analysis. A blood
leukocyte sample was obtained from the patient. DNA was
extracted from blood and tissues using the DNeasy Tissue Kit
(Qiagen, Hilden, Germany). Two highly polymorphic
Fig. 3 Fluorescent in situ hybridization on papillary RCC: the papilla
chromosome 17. The loss of chromosome Y is typically observed in this
tumor (male donor versus female recipient).
markers (D8S255 and D9S156) were used to determine the
origin of the tumoral tissues. Primers were obtained from the
Genome Data Base (http://gdbwww.gdb.org). Polymerase
chain reaction cycling conditions were 35 cycles at 948C for
30 seconds, 568C for 45 seconds, and 728C for 45 seconds,
followed by 10 minutes at 728C. Products were separated byelectrophoresis in denaturing 6% polyacrylamide gels.
Microsatellite analysis of the allograft and the 2 tumors were
compared with that of leukocytes from the patient.
3. Results
3.1. Macroscopic findings
The nephrectomy specimen measured 12 � 6.5 � 4 cm
with a weight of 237 g. A solid, yellowish, and well-
demarcated mass, measuring 2.5 cm, was located in the lower
cortical pole (Fig. 1D and A). A second mass (Fig. 1D and C),
which measured 1.5 cm, was located between the hilar region
and the medulla of the kidney. This mass was less well-
demarcated than the first one and showed a gray-white and
striped appearance. These 2 tumors were completely separate
from each other. A cortical cyst (Fig. 1D and B) measuring
3.5 cm was located in the vicinity of the smaller mass but
clearly separated from it. Except for these 3 lesions, the renal
parenchyma was unremarkable.
ry RCC presents a triploidy and/or a polyploidy of chromosome 7,
type of RCC but does not allow us to determine the origin of this
Fig. 4 Fluorescent in situ hybridization on angiomylipoma: angiomylipoma presents an XY phenotype showing that the tumor developed
from the donor. This technique, together with the microsatellite analysis, demonstrates that both tumors originated from the donor organ.
Abbreviations: Ly, lymphocytes (recipient cells); End, endothelial (tumor cells); My, myocytes (tumor cells).
Fig. 5 Microsatellite analysis of the allograft as compared with
the recipient’s peripheral blood leukocytes, showing that the PRCC
and the AML originated from the donor’s organ, using the
2 markers D8S225 and D9S156.
De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 485
3.2. Histology
The 2.5-cm cortical mass (Fig. 1D and A) showed a
papillary growth pattern. The central cores of the papillae
were frequently filled with foamy macrophages. Papillae
were covered by a single layer of small cells (Fig. 2A and B)
with scant cytoplasm. This tumor corresponded to a PRCC
type 1 according to the 2004 classification of renal tumors
[19] and was of grade 1 according to the Fuhrman grading
system [20].
The 1.5-cm medial mass (Fig. 2C and D) was composed
of a mixture of adipose tissue, smooth muscle cells, and
numerous thick walled vessels of varying size. The adipose
tissue was composed of mature adipocytes. The smooth
muscle component was composed of intersecting fascicles
of smooth muscle cells without any visible mitotic activity
or necrosis. A relatively abundant lymphocytic infiltrate
accompanied all different tumoral components. This neo-
plasm corresponded to an angiomyolipoma according to the
2004 classification of renal tumors [19].
The cystic structure (Fig. 1D) corresponded to a simple
cyst with no evidence of malignancy.
3.3. Fluorescent in situ hybridization analysis
Fluorescent in situ hybridization using chromosome
7 and 17 probes showed trisomy 7 and 17 in many PRCC
cells (Fig. 3). In addition, a loss of chromosome Y and a
conservation of chromosome X was observed in this tumor
(Fig. 3) using chromosomes X and Y probes, confirming the
diagnosis of PRCC.
Fluorescent in situ hybridization using chromosome X
and chromosome Y probes on the AML showed the
presence of these 2 chromosomes in endothelial and smooth
muscle cells (Fig. 4). Two signals were observed in the
lymphocytic nuclei originating from the recipient, whereas
S. Rotman et al.486
no signals were observed with chromosome Yprobe (Fig. 4).
This indicated that the AML tumor was of donor origin but
that lymphocytes within it were of recipient origin.
3.4. Microsatellite analysis
Polymerase chain reaction amplification products
obtained from the PRCC presented the same band profile
as that of allograft DNA (non PRCC tissue) but was
different from that of recipient peripheral blood leukocytes
(Fig. 5), indicating the donor origin of the PRCC tumor.
For the AML, DNA amplification products showed a
band profile corresponding to a mixture of that of donor
allograft and recipient leukocyte profiles (Fig. 5).
4. Discussion
Papillary renal cell carcinoma comprises approximately
10% of RCC in the general population. Two morphological
types of PRCC have been described. Type 1 PRCC is usual-
ly of lower stage and grade than type 2 neoplasm [3] and
shows a better prognosis [2]. Papillary renal cell carcinoma
is associated with karyotypic changes with trisomy or
tetrasomy 7, trisomy 17, and a loss of chromosome Y [22].
Nephrectomy is a common treatment of malignant tumors,
although partial nephrectomy is sometimes preferred to spare
some renal tissue and preserve the renal function depending
on tumor size and stage [23].
Angiomyolipoma is a relatively uncommon benign tumor
of the kidney (1% of renal tumors), with a 4:1 female-to-
male ratio [19]. It may arise either in the cortex or medulla of
the kidney. It may occur sporadically or in patients with
tuberous sclerosis (TS), an inherited autosomal dominant
syndrome. The genes TSC1, located on chromosome 9p34
[24], and TSC2, located on chromosome 16p13 [25], play a
pathogenic role in TS. AML frequently show a loss of
heterozygosity of TSC2 gene locus in both sporadic and TS-
associated neoplasms [25]. Loss of heterozygosity of the
TSC1 gene in AML is also occasionally observed [26].
Because AML contains a significant vascular compo-
nent, radiological imaging can be misleading, mimicking a
malignant process. Because needle biopsy is generally
contraindicated in this kind of highly vascularized tumor,
definitive diagnosis relies upon pathological examination of
excision specimens. The development of concurrent renal
cell carcinoma and AML in a native kidney is a very rare
event, with about only 50 cases described in the literature
[8,10,13]. Sporadic cases of PRCC and AML developing
together in the same native kidney have been reported, but
to our knowledge, none of these concurrent tumors were
described in a renal allograft.
In transplantation, the prevalence of tumors has been
linked to the immunosuppression status [14,16]. The
prevalence of renal malignant tumors in renal transplant
recipients is 7.8% [27], compared with 4% to 5% in the
general population [19]. The great majority of renal cell
carcinomas are found in the native kidneys of renal
transplant recipients [9,17]. The occurrence of de novo
tumors in the renal allograft is very rare and represents less
than 10% of RCC developing in renal transplant recipients
[28]. Most cases of RCC are of clear cell type, but sporadic
PRCC have also been reported. The type of renal cell
carcinoma is of prognostic importance because clear-cell
neoplasms show a more aggressive behavior than PRCC [1].
In this report, we present the first case, to our knowledge,
of concurrent PRCC and AML in a renal allograft,
developing several years after transplantation.
No lesions were identified in the allograft at the time of
the operation, and routine postoperative radiological inves-
tigations of the allograft were normal. However, during a
routine ambulatory ultrasound, the presence of these 2 renal
tumors was discovered. Radiological imaging revealed
2 distinct richly vascularized tumoral lesions.
For technical reasons a nephrectomy of the allograft was
performed after discussion with the urological team.
Microscopic examination revealed the presence of 2
distinct tumors, 1 type 1 PRCC, and 1 AML. In absence of
any radiological lesions during the years after the renal
allograft, these tumors were considered as de novo tumors.
Differential diagnosis included a metastasis from a PRCC
located in the native kidney of the recipient and an AML,
which could have developed from the periallograft mesen-
chymal tissue of the recipient. Yet, knowing that the
recipient was a woman and that the kidney allograft came
from a male donor, the FISH analysis using chromosome X
and chromosome Y probes clearly demonstrated that the
AML came from the male donor. The lymphocytic infiltrate
of the recipient within the AML provided a good binternalcontrolQ of the FISH technique. The presence of a large band
obtained by microsatellite analysis of AML cells was
explained by a mixture of this lymphocytic infiltrate
(recipient cells) with tumoral cells (donor origin) in the
amplification (polymerase chain reaction) product.
The loss of chromosome Y, which is classically observed
in PRCC [22], cannot be used as a proof for the origin of the
tumoral cells by FISH technology. However, this technique,
which is able to detect the polyploRdy 7 and 17 of the PRCC,allowed us to confirm the histologic diagnosis of PRCC
[22]. A microsatellite analysis was subsequently performed
to circumvent the problem of loss of chromosome Y in
PRCC. This technique showed the same band profile for the
PRCC cells and the normal (nontumoral) renal cells of
the allograft and, thus, demonstrated the donor origin of the
PRCC. As previously mentioned, the absence of a prior
radiological lesion was consistent with a de novo PRCC
developing in the allograft.
To conclude, we report of case of a de novo concurrent
PRCC and AML developing in a renal allograft. Using
FISH and microsatellite analysis, we have demonstrated that
both PRCC and AML were tumors of donor origin.
Interestingly, recipients of other allografts from the
same cadaveric donor did not develop tumors during their
De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 487
follow-up. An extensive radiological workup of our patient
did not reveal any other tumors, nor were profile metastasis
of the PRCC found. This, taken in combination with the
low grade and low stage of RCC and benign nature of the
AML, indicates an excellent prognosis for our patient after
her allograft nephrectomy. Fifteen months after the
nephrectomy, she is doing well on maintenance hemodial-
ysis with no tumor recurrence.
A review of all allograft nephrectomies (n = 25) at our
center over the last 11 years did not reveal any other case of
de novo RCC in allografts, confirming the rarity of this
clinicopathologic complication.
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