Nephron-sparing surgery for de novo renal cell carcinoma in a 19-year-old transplanted kidney.

With improvements in the long-term outcome of kidney transplantation, cardiovascular disease and malignancies have emerged as a significant cause of morbidity and mortality. The incidence of malignant tumors in kidney graft recipients 10 years after transplantation is approximately 20%, which is 10-fold higher than that of the overall population (1). A recent review from the Cincinnati Transplant Tumor Registry and the literature collected a total of 9,688 cases of cancer developed in 9,032 renal graft recipients (2). The majority of reported tumors are posttransplant lymphoproliferative disease, skin cancers, carcinomas of the vulva and the perineum, in situ carcinomas of the cervix and uterus, Kaposi’s sarcomas, hepatocellular carcinomas, and renal cell carcinoma (RCC) (3). RCC accounts for 4.6% of posttransplant malignancies in kidney graft recipients, with the majority of reported cases occurring in native kidneys and less than 10% affecting the graft (3). We report on a patient affected with de novo cancer of the kidney graft presenting 19 years after transplantation who was successfully treated by means of tumor excision. To the best of our knowledge, this is one of the longest intervals from transplantation to diagnosis ever reported in the international literature (4). A 60-year-old male recipient of a cadaver kidney graft was referred to our institution for stage IIb lower limb chronic arteriopathy. The patient had undergone grafting at another institution 19 years earlier for chronic glomerulopathy and end-stage renal failure. No information was available about the kidney donor, donor–recipient human leukocyte antigen typing and mismatch, cold and warm ischemia time, and contralateral kidney graft recipient. It is our common policy that all recipients who have undergone grafting elsewhere be submitted to a careful laboratory and imaging workup irrespective of the patients’ main complaints. On admission to our department the patient presented with stable renal function (serum creatinine 0.9 mg/dL; 24-hr creatinine clearance 74 mL/min) on a double-immunosuppressive protocol with azathioprine (1.5 mg/kg/d) and prednisone (4 mg/d). Of note, the patient had never been administered calcineurin inhibitors. Examination of the kidney graft in the left iliac fossa was unremarkable. The laboratory workup revealed an increased carcinoma antigen 19.9 (59 IU/mL; normal value 37 IU/mL) in the absence of gastrointestinal symptoms. The patient underwent upper gastrointestinal endoscopy, colonoscopy, and total-body computed tomography and bone scans, which disclosed the presence of a 1.6-cm nodule in the upper pole of the kidney graft in the absence of clinically detectable distant disease. Before informed consent was obtained, the patient was referred for tumor excision. At surgery, a 1.6-cm yellowish-brown nodule was found on the posterior aspect of the upper renal pole. The nodule was excised with a 2-cm safe margin and sent for immediate analysis. Histology of the resected specimen was consistent with a renal tubular adenocarcinoma with clear margins (pT1N0M0). The postoperative course was uneventful. Azathioprine was withdrawn, and prednisone was tapered to 2 mg/day. The patient was discharged on postoperative day 4. At a follow-up of 17 months, the patient is alive with no signs of recurrence or distant disease; renal function is stable (serum creatinine 0.89 mg/dL), and immunosuppression consists of 2 mg of prednisone per day. At the last observation, the carcinoma antigen 19.9 was 27 IU/mL. Nephron-sparing surgery is a valid alternative to radical nephrectomy for low-stage RCC, but with increasing experience, organ-preserving procedures are being suggested for advanced tumors (5). In agreement with data emerging from the literature (4–5), the present case confirms that even in the setting of long-standing immunosuppression, de novo RCC of the kidney graft warrants a minimally invasive approach to spare patients graft loss and return to hemodialysis.