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Nephron-sparing Surgery for Renal Cell Carcinoma of the AllograftAfter Renal Transplantation: Report of Two Cases

A. Tuzuner, F. Çakir, C. Akyol, Z.K. Çelebi, S. Ceylaner, G. Ceylaner, S. Sengül, and K. Keven

ABSTRACT

The risk of renal transplanation patients developing de novo malignancy is increased100-fold compared with the healthy nontransplantation population. Renal cell carcinoma(RCC) arising from native kidneys is diagnosed among up to 4.6% of the renal transplantrecipients as a consequence of immunosuppression. These tumors tend to behave moreaggressively.1 Although tumors occurring in allografted kidneys can be treated by partial(to save functional graft) or total nephrectomy, there is a paucity of data the outcomes.From 1978 to 2012, we performed 804 kidney transplantations including two cases in whichRCC arose from the allografted kidney, both of which were treated with nephron-sparingsurgery. The first patient has been followed for 30 months with a well functioning graftwithout an RCC recurrence. The second patient has returned to dialysis after 6 monthsdue to an insufficient remnant nephron mass. In conclusion, nephron-sparing surgery is anovel alternative to total nephrectomy for allograft RCC. The remaining kidney can

preserve function and the patient may not need chronic dialysis.

THE risk for renal transplantation patients to develop denovo malignancy is increased 100-fold compared with

the healthy nontransplantation population. Renal cell car-cinoma (RCC) arising from native kidneys as a conse-quence of immunosuppression is diagnosed among up to4.6% of renal transplantation recipients. These tumors tendto behave more aggressively.1 Reviewing the Cincinnatiransplant registry of 7248 renal transplant recipients witholid tumors Penn et al, described 21 tumors arising in thellograft versus 239 in the native kidneys.2 Although tumors

occurring in the allografted kidneys can be treated bypartial (to save functional graft) or total allograft nephrec-tomy, there is a paucity of data regarding their outcomes.From 1978 to 2012, we performed 804 kidney transplanta-tions including two RCCs arising in the allografted kidney,both of which were treated with nephron-sparing surgery.

CASE REPORTPatient 1

A 34-year-old female patient underwent living donor renal trans-plantation in 2007. A left allograft was placed in the left iliac fossawith anastomoses to the external iliac vein and artery in thestandard fashion. The patient was prescribed immunosuppressionwith tacrolimus, mycophenolic acid, and steroid. Her creatininelevel stabilized to 1.1 mg/dL thereafter. At postoperative month 55,renal allograft ultrasonography revealed a 4 � 4.5 cm–exophytic mass

in the upper pole of the allograft. Dynamic computerized tomography

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showed a suspicious neoplasm (Fig 1). Percutaneous ultrasound-guided biopsy revealed a clear cell renal carcinoma. The tumor wasresected with adequate and clear surgical margins with intraoper-ative ultrasonography. The postoperative course was uneventful.The pathology revealed Fuhrman grade 2 clear cell RCC with clearsurgical margins. The patient was switched to rapamycin fromtacrolimus at postoperative month 1. Thirty months after nephron-sparing surgery, she has stable allograft function with a serumcreatinine value of 1.6 mg/dL and no sign of recurrence.

Patient 2

A 38-year-old male patient who underwent a living donor rightkidney transplantation to the left iliac fossa 13 years prior wasadmitted due to a 3-cm mass located in the mid portion of theallograft by ultrasonography. Dynamic magnetic resonance imag-ing revealed a mass suspicious for malignancy (Fig 2). There was noother abnormal finding including examination of the native kid-neys. Ultrasound-guided biopsy revealed papillary RCC. Nephron-sparing surgery was performed. Intraoperative ultrasonographyand frozen section confirmed clear surgical margins. His creatinine

From the Department of General Surgery (A.T., F.C., C.A.), andthe Department of Nephrology (Z.K.C., S.S., K.K.), Ankara Uni-versity Medical Faculty, and the Intergen Genetic Center (S.C.,G.C.), Ankara, Turkey.

Address reprint requests to Acar Tuzuner, MD, KizilcasarMahallesi 1233, Sokak, 27-3 (D14) Ankaville Sitesi, Golbasi,

06830, Ankara, Turkey. E-mail: atuzuner@yahoo.com

© 2013 by Elsevier Inc. All rights reserved.360 Park Avenue South, New York, NY 10010-1710

Transplantation Proceedings, 45, 958–960 (2013)

NEPHRON SPARING SURGERY 959

value elevated from 2.2 mg/dL to 3.2 mg/dL upon postoperativefollow-up which was complicated by a urinary tract infectiontreated with intravenous antibiotics. The pathology revealed aFuhrman grade 2 clear cell renal carcinoma. Short tandem repeatsanalysis of the mass suggested that his mother (the donor) was theorigin of the tumor. Mycophenolic acid was switched to rapamycinafter the first postoperative month. The patient remained indepen-dent of dialysis for 6 months after nephron-sparing surgery;however, he commenced on peritoneal dialysis due to a serumcreatinine level of 5.5 mg/dL. At postoperative month 8, afollow-up MRI showed a 3-cm malignant tumor in the lower poleof his right native kidney. A laparoscopic right nephrectomy yieldeda papillary type RCC, Fuhrman grade 2 on pathologic examination.

Fig 1. Three-dimensional computed tomography scan of firstcase: renal cell carcinoma is located at the upper pole of theallograft kidney.

Fig 2. Magnetic resonance image of case 2; renal cell carci-

noma is located in the upper-middle portion of the allograft.

The patient has had no recurrence at 12 months after nephron-sparingsurgery (Fig 3).

DISCUSSION

RCC is uncommon in allograft kidneys after renal trans-plantation. Only 2 among 804 patients in our series werediagnosed with RCC in the allograft. Both patients werediagnosed by incidental renal ultrasonography. Anothersimilar series of 2000 renal transplantation patients in-cluded 1 subject who was diagnosed by emergency surveil-lance after a tree fall incident.3 Although Kidney DiseaseImproving Global Outcomes (KDIGO) guidelines for renaltransplantation do not recommend routine screening forRCC, several European and Asian centers do suggest thisprocedure for RCC in native kidneys.4–7 Most series havereported a few cases after incidental imaging.3–8 As thefrequency of allograft kidney RCC is low, routine screeningmay outweigh its benefit. However, routine abdominalscreening for other diseases might detect masses in anallograft kidney.

There are multiple options for the treatment of RCCincluding total nephrectomy, partial nephrectomy, and ra-diofrequency ablation.9 Nephron-sparing surgery keeps pa-tients independent of dialysis. However, clear surgical mar-gin must be achieved to assure a low recurrence rate.Intraoperative ultrasonography and frozen section may beuseful tools in this matter situation. We consider the massin the native kidney in our second case as a de novomalignancy rather than a metastasis given that the geneticanalysis revealed the meaternal origin of first tumor. Thesecond tumor probably originated from the recipient, con-sidering his previous history of heavy smoking and normalpositron emission tomography scans throughout his follow-up. However, we did not performed genetic testing on thesecond tumor in his native kidney.

Fig 3. Postoperative magnetic resonance image of case 2;

allograft kidney after nephron-sparing surgery.

960 TUZUNER, ÇAKIR, AKYOL ET AL

The first patient is currently independent from dialysis.Although the second patient has returned to dialysis asallograft function diminished secondarily to chronic allo-graft nephropathy, the nephron-sparing surgery kept himdialysis independent for least 6 months. We believe thatnephron-sparing surgery is a good option for RCC in therenal allograft to prevent the need for dialysis.

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