Aggressive renal cell carcinoma in a 27-year-old kidney transplant

Sir,

The late development of a primary tumour in an allograft kidney is a rare event: the longest reported interval period, to our knowledge, is 21 years. In the case described below, we present the finding of an aggressive renal cell carcinoma in a transplanted kidney after 27 years.

A 29-year-old female underwent cadaveric renal transplantation in April 1976 for renal failure secondary to chronic reflux nephropathy. The donor was a ventilated 15-year-old male who sustained a subarachnoid haemorrhage following trauma. The graft displayed excellent function on low-dose immunosuppressants for 27 years. Late follow-up consisted of clinic review only: routine ultrasound screening was not performed. However, during investigation for anaemia and abnormal liver function tests in September 2003, an abdominal ultrasound detected the presence of a 5 x 6 cm lesion in the upper pole of the transplanted kidney. A transcutaneous renal biopsy revealed a high-grade primary renal cell carcinoma and a transplant nephrectomy was subsequently performed. At operation, a large multicentric tumour was seen to invade through the renal capsule; no lymphadenopathy was present. Macroscopic pathological examination showed multiple yellow/cream nodules diffusely involving the whole kidney (Figure 1). Histology revealed the presence of a high-grade type II papillary renal cell carcinoma with areas of sarcomatoid change (Figure 2). The duration from renal transplantation to formal histological diagnosis was 330 months. Sadly, despite surgery, the patient rapidly developed multiple bony and subcutaneous metastases and died 5 months post-nephrectomy.



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Fig. 1. Section through renal allograft showing multiple deposits of pale tumour.

 


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Fig. 2. Micrograph showing the typical findings of high grade renal cell carcinoma. Other areas displayed a more conventional grade II papillary subtype, whereas others were representative of sarcomatoid change.

 
The increased incidence of malignancy in renal allograft recipients has been well documented; renal tumours are reportedly more than twice as common in this group than in the general population [1]. Whilst most renal malignancies arise in native kidneys, a small but significant proportion arise within transplanted kidneys. In a retrospective series of 10 997 renal transplant patients, 16 recipients (0.145%) developed allograft tumours, all of which were renal cell carcinomas [2]. Results from the Cincinnati Transplant Tumour Registry report a higher incidence of 0.32% in 7596 kidney recipients [3]. Whilst most renal allograft tumours present within the first 7–10 years following transplantation, there are a few reports of late tumour presentation [2,4–6]. The longest published interval prior to this case, to our knowledge, is 21 years [6]. Here we report the development of an allograft tumour after 27 years. We believe this represents the longest reported interval between transplantation and tumour presentation, to date. The increased risk of malignancy, late presentation and aggressive course following allograft tumour development has prompted a recent call for lifelong ultrasound screening of renal allografts [7]. This case reinforces the view that if screening is to occur, it will be required for the life of the graft or at least until it is removed.

Conflict of interest statement. None declared.

Thomas J. Walton1, Thomas A. McCulloch2 and Michael C. Bishop1

1 Department of Urology2 Department of Histopathology Nottingham City Hospital Nottingham, UK Email: tom{at}pelhamcourt.clara.co.uk

References

  1. Penn I. Post-transplant kidney cancers and skin cancers (including Kaposi's sarcoma). In: Schmähl D, Peul, eds, Cancers in Organ Transplantation recipients. Springer-Verlag, New York: 1991; 46–53
  2. Wunderlich H, Wilelm S, Reichelt O, Zermann DH, Borner R, Schubert J. Renal cell carcinoma in renal graft recipients and donors: incidence and consequence. Urol Int 2001; 67: 24–27[CrossRef][ISI][Medline]
  3. Penn I. Primary kidney tumours before and after renal transplantation. Transplantation 1995; 59: 480–485[ISI][Medline]
  4. Feldman JD, Jacobs SC. Late development of renal cell carcinoma in allograft kidney. J Urol 1992; 148: 395–397[ISI][Medline]
  5. DeLong MJ, Schmitt D, Scott KM, Ramakumar S, Lien YH. Multicentric papillary renal carcinoma in renal allograft. Am J Kidney Dis 2003; 42: 381–384[CrossRef][ISI][Medline]
  6. Park KI, Inoue H, Arai Y, Yoshiki T, Tomoyoshi T. Enucleation of renal cell carcinoma in an allograft kidney 21 years after transplantation. Br J Urol 1997; 80: 339–340[ISI][Medline]
  7. Roupret M, Peraldi MN, Thaunat O et al. Renal cell carcinoma of the grafted kidney: how to improve screening and graft tracking. Transplantation 2004; 77: 146–148[ISI][Medline]




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