Combined liver transplantation together with partial/total nephrectomy in patients with renal cell cancer and nonalcoholic steatohepatitis

Renal cell cancer (RCC) accounts for 3% of all new diagnosed cancers, and is the 10th most common malignancy in the USA with a reported incidence of 12/100.000, which seems to be rising during the past decades. The von Hippel–Lindau syndrome is commonly complicated by RCC and a common indication for renal transplant after bilateral nephrectomy [1]. Therapy of RCC consists of radical nephrectomy or nephron sparing partial nephrectomy. Partial nephrectomy is preferred if a patient presents with bilateral tumors, a tumor in a solitary kidney, compromised renal function or small (T1a, <4 cm) and polar tumors (elective indication) [2]. Liver transplantation (LT) has emerged as the treatment of choice for end-stage liver disease (ESLD) with excellent long-term survival [3]. The guideline for management of small RCC that is incidentally found during the pretransplant evaluation of ESLD patients is not known. Traditionally, the presence of cancer has been an exclusion criterion; this was based on hypothesis that after introduction of immunosuppression an accelerated tumor progression may be expected, however, no prospective data are available at all regarding this issue. Given the high-risk nature of any abdominal surgery in ESLD patients [4], we have advocated that an optimal approach would be to perform a combined resection of the RCC at the time of the LT under a single anesthetic setting. We treated a 64-year-old male, who was evaluated for liver transplantation for nonalcoholic steatohepatitis (NASH) complicated by hepatocellular carcinoma (HCC). During transplant evaluation a 1.5 cm mass was found in the lower pole of his left kidney. A partial nephrectomy combined with a LT was performed in April 2003. The patient tolerated both procedures well. The final histopathology revealed a 0.5-cm multicystic grade I RCC of the clear cell type and hepatocellular carcinoma within a cirrhotic liver. The patient was discharged with immunosuppression consisting of tacrolimus (trough levels 4–10 ng/ ml), mycophenol-mofetil and a steroid taper, which was switched to sirolimus (4–8 ng/ml) after 1 year. Another patient was a 62-year-old female who was evaluated for LT due to NASH. On Doppler ultrasound, she was found to have a 2-cm enhancing mass in the anterior mid-right kidney, which was confirmed on magnetic resonance imaging. Right nephrectomy together with the LT was performed in February 2005. Following nephrectomy, the new liver was implanted without complications. Histopathology revealed a 2.2-cm grade II, pT1, clear cell type RCC and a cirrhotic liver. The patient was discharged with immunosuppression consisting of tacrolimus (trough levels 4–10 ng/ml), mycophenol-mofetil and a steroid taper. With worsening renal function and an increase in the serum creatinine to >2.0 mg/dl, she was switched to sirolimus monotherapy (4–8 ng/ml) at 3 months post-transplant. At 22 months follow-up in the male patients and 1-year follow-up in the female patient the graft function is stable, the patients are both doing well showing no evidence for recurrent RCC on CT scan and the renal function remained stable with a serum creatinine at 62.0 mg/dl. The management of RCC that is found during the evaluation process for a liver transplant has not been defined. Our experience suggests that first the presence of a small RCC should not be considered contraindication against LT; second, the partial or whole nephrectomy of the involved organ at the time of LT may be the surgical approach of choice. At King’s College Hospital, ‘patients with a history of malignancy were considered for OLT provided the malignancy appeared clinically, radiologically, biochemically and serologically to have been eradicated and the stage of the neoplasm did not predict a poor prognosis’ was adopted [5]. Among the 12 patients with pre-existing malignancies, there were two RCCs that were identified at the time of transplant [5]. Unilateral nephrectomy was performed at the time of LT in one case, and at 3 months post-transplant in the second case. The first RCC patient died within 1 month following the transplant without evidence of cancer recurrence. The second patient showed no cancer recurrence at 78 months post-transplant [5]. In terms of technical feasibility, Johnston et al. [6] reported on successful retroperitoneal minimal invasive