Renal Cell Carcinoma Detected by Preoperative Kidney Transplant Donor Examination: A Case Report T. Sato, Takahiro Yoneyama, K. Hagiwara, T. Narita, D. Noro, T. Tanaka, Y. Tanaka, Y. Tobisawa, Tohru Yoneyama, H. Yamamoto, A. Okamoto, A. Imai, S. Hatakeyama, Y. Hashimoto, T. Koie, and C. Ohyama ABSTRACT A 37-year-old man undertook preoperative examination for donor nephrectomy for living kidney transplantation. Computerized tomography revealed a small renal mass (1.9 cm in diameter) with contrast enhancement on his left kidney. We couldn’t exclude malignant potential for the small mass. Laparoscopic left partial nephrectomy without renal artery clamp was successfully carried out to obtain pathologic diagnosis while preserving his renal function and priority as a donor. He was judged to be an inappropriate donor candidate owing to the histopathologic report suggesting clear cell carcinoma. The patient has been followed for 27 months without any evidence of recurrence.
A
DVANCES in abdominal ultrasonography (USG), computerized tomography (CT), and other diagnostic imaging modalities have increased the frequency of the detection of incidental renal tumors. The detection rates of renal tumors during health check are reported to be w0.04%e0.10% [1]; however, these estimates are relatively high compared with the detection rates of other types of malignant tumors. Here, we report our experience with a case of small renal cell carcinoma detected by a preoperative kidney transplant donor examination and review a number of relevant past studies. CASE REPORT In September 2009, a 37-year-old man was identified as a potential living kidney donor for his mother and underwent a preoperative examination. CT revealed a small mass on the dorsal side of the left kidney. The patient was referred to and then admitted to the Hirosaki University hospital for a detailed examination and medical treatment. Plain CT revealed a cystic mass with a diameter of 1.9 cm on the dorsal side of the left kidney (Fig 1A). CT with contrast media showed enhancement of the cystic lesion (Fig 1B). Imaging could not exclude the possibility of a malignancy. Therefore, to arrive at a definitive histologic diagnosis, it was necessary to perform either a biopsy of the renal mass or a partial nephrectomy. Because the mass was cystic, we were concerned that a needle biopsy may disperse the contents of the mass. Furthermore, because it was necessary to preserve kidney function as well as the patient’s potential as a kidney donor, on October 8, 2009, the patient underwent a laparoscopic partial nephrectomy of the left kidney without renal artery clamp. The patient was administered general anesthesia and placed in the right lateral recumbent position. We 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.022 634
advanced into the retroperitoneum and exposed the entire mass to our visual field while maintaining sufficient adipose tissue on the periphery of the mass. After confirming the size and invasion depth with the use of ultrasonography, we performed a nonischemic resection of the mass with the use of a microwave coagulation surgical instrument. The surgery duration was 157 minutes, and blood loss was 30 mL. Macroscopic findings showed a cystic renal mass with thickened septi (Fig 2). Histopathologic findings revealed renal cell carcinoma (clear cell carcinoma), grade 2, pT1a (Fig 3). Surgical margin was negative. The patient’s postoperative progress was good, and he was discharged on post-hospitalization day 10. At the time of writing, he had been followed for 27 months without any evidence of recurrence after surgery.
DISCUSSION
Screening for malignancies during preoperative examination of living kidney donors is vital. Penn et al reported that out of 270 kidney recipients who received transplanted organs from donors with malignancies, including those with a medical history of malignancies, 117 later developed cancer originating from the donor organ. This finding suggests that transplanted organs from donors with malignancies are highly likely to spread the disease to the organ recipient [2]. The Japan Society for Transplantation stipulates that
From the Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan. Address reprint requests to Takahiro Yoneyama, MD, Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, Hirosaki 036-8562, Japan. E-mail: uroyone@ cc.hirosaki-u.ac.jp ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 634e636 (2014)
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Fig 1. Computerized tomography (CT) findings. (A) Plain CT shows a small cystic mass (1.9 cm in diameter) in the left kidney. (B) CT with contrast media shows enhancement of the cystic lesion.
donors with melanoma, renal cell carcinoma, lung cancer, hematologic malignancy, gastric cancer, and other forms of cancer are not appropriate candidates for living kidney transplantation [3]. Yoshida et al reported several cases in which they struggled to deal with transplanted kidneys from donors who were discovered with malignant tumors immediately after live kidney transplantation, and they stressed the importance of preoperative examination [4]. Full-body examinations of potential donors, including interviews that include medical history, physical and hematologic tests, and endoscopic and imaging tests are necessary to determine the presence of malignant tumors. The reports of detecting malignancies in preoperative kidney transplant donor examinations were rare [5]. After an extensive review of the relevant medical literature, the present case with renal cell carcinoma appears to be the first such reported case in Japan. In recent years, small kidney masses have been incidentally detected with increasing frequency because of advances in CT, USG, and other types of diagnostic imaging [6]. Small kidney masses that require differentiation from renal cell carcinoma are often identified as oncocytomas, renal
angiomyolipomas, or other types of benign masses. In fact, Campbell et al reported that w80% patients with diagnostic imaging results that indicated possible renal cell carcinoma actually had renal cell carcinomas [7]. Moreover, Li et al obtained the same results in their study of the diagnostic accuracy of CT [8]. These findings indicate that accurate diagnosis of renal cell carcinoma remains extremely difficult despite the various advances in diagnostic imaging. Percutaneous needle biopsy is the standard diagnostic method for small kidney masses. However, Shannon et al reported that 22% of patients were difficult to diagnose by biopsy and concluded that this can be attributed to the size of a small kidney mass [9]. In our case, we encountered a small kidney mass, which made it challenging to obtain a sufficient portion of the tumor tissue to ensure an accurate pathologica diagnosis. Therefore, we opted for laparoscopic partial nephrectomy. Currently, the standard surgical procedure for small renal cell carcinoma is partial nephrectomy, because it is a radical cancer treatment and can potentially preserve kidney function [10e13]. Less invasive procedures to preserve kidney function include cryotherapy and radiofrequency ablation.
Fig 2. Macroscopic findings of the tumor specimen. The resected specimen has a cystic renal mass with thickened septi.
Fig 3. Histopathologic findings. The renal tumor was diagnosed as renal cell carcinoma (clear cell carcinoma). The surgical margin was negative for malignancy. Hematoxylin and eosin staining (100).
636
However, because of the danger of tumor cell dispersion during puncturing, these methods are not appropriate for treatment of cystic kidney tumors and are instead recommended only in cases that are inoperable because of complications or when surgery has been refused as a treatment option [14,15]. The small kidney tumor in our donor was incidentally detected, but malignancy could not be ruled out. If this small renal tumor was malignant, it would certainly have been treated with a carcinostatic agent, but if it had been diagnosed as benign, the patient would have remained a candidate for living kidney donation. Therefore, the renal hilum was not detached, and exfoliation in the area surrounding the kidney was kept to a minimum, because it was necessary to fully preserve kidney function and because a surgical procedure resulting in an accurate pathologic diagnosis, while allowing full tumor resection, was necessary. In this case, we opted for laparoscopic partial nephrectomy with use of the retroperitoneal approach, because it was minimally invasive for the donor and has reliable therapeutic value. Because the tumor was exophytic, the use of the microwave coagulation surgical instrument allowed us to perform nonischemic surgery without renal artery clamp. Unfortunately, the histopathologic diagnosis was renal cell carcinoma; therefore, the patient was judged to be inappropriate as a living kidney transplant donor. At the time of writing, he had been followed for 27 months without any evidence of recurrence after surgery, and function of the preserved portion of the kidney is good. His ability to once again be considered as a donor candidate will be carefully reevaluated after long-term observation of his condition. Small kidney tumors are difficult to accurately diagnose with the use of diagnostic imaging alone. In this case, to obtain an accurate pathologic diagnosis and preserve the patient’s kidney function as well as his potential as a donor, we opted for laparoscopic partial nephrectomy without renal artery clamp and recommend this procedure for potential kidney donors.
SATO, YONEYAMA, HAGIWARA ET AL
REFERENCES [1] Kawada S, Yonemitsu K, Morimoto S, et al. Current state and effectiveness of abdominal ultrasonography in complete medical screening. J Med Ultrasonics 2005;32:173. [2] Penn I. Transmission of cancer from organ donors. Ann Transplant 1997;2:7. [3] Editorial Commission, Japan Society for Transplantation. Indication for living donor kidney transplantation involving free kidney. Ishoku 2007;42:405. [4] Yoshida K, Yoneda R, Miyake M, et al. A case of pancreatic cancer in a donor after donating a kidney. Ishoku 2005;40:369. [5] Okamura M, Kamba T, Kanematsu A, et al. A case of elderly donor in living kidney transplant after radical radiotherapy for prostate cancer. Hinyoukiyou 2009;55:623. [6] Nguyen MM, Gill IS, Ellison LM. The Evolving Presentation of renal carcinoma in the United States: trends from the Surveillance, Epidemiology, and End Results program. J Urol 2006;176: 2397. [7] Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol 2009;182:1271. [8] Li G, Cuilleron M, Gentil-Perret A, et al. Characteristics of image-detected solid renal masses. Int J Urol 2004;63. [9] Shannon BA, Cohen RJ, de Bruto H, et al. The value of preoperative needle core biopsy for diagnosing benign lesions among small, incidentally detected renal masses. J Urol 2008;180: 1257. [10] Joniau S, Vander EK, van Poppel H. The indications for partial nephrectomy in the treatment of renal cell carcinoma. Nat Clin Pract Urol 2006;3:198. [11] Mitchell RE, Gilbert SM, Murphy AM, et al. Partial nephrectomy and radical nephrectomy offer similar cancer outcomes in renal cortical tumors 4 cm or larger. Urology 2006;67:260. [12] Gilbert SM, Russo P, Benson MC, et al. The evolving role of partial nephrectomy in the management of renal cell carcinoma. Curr Oncol Rep 2003;5:239. [13] Lucas SM, Stern JM, Adibi M, et al. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 2008;179:75. [14] Hatano T. Future prospects of minimally invasive treatment for small renal tumors; cryoablation for small renal cancer. J Urol surgery 2012;25:1457. [15] Japanese Urological Association. Evidence-based clinical practice guidelines for renal cell carcinoma. Int J Urol 2009;16:339.
A
DVANCES in abdominal ultrasonography (USG), computerized tomography (CT), and other diagnostic imaging modalities have increased the frequency of the detection of incidental renal tumors. The detection rates of renal tumors during health check are reported to be w0.04%e0.10% [1]; however, these estimates are relatively high compared with the detection rates of other types of malignant tumors. Here, we report our experience with a case of small renal cell carcinoma detected by a preoperative kidney transplant donor examination and review a number of relevant past studies. CASE REPORT In September 2009, a 37-year-old man was identified as a potential living kidney donor for his mother and underwent a preoperative examination. CT revealed a small mass on the dorsal side of the left kidney. The patient was referred to and then admitted to the Hirosaki University hospital for a detailed examination and medical treatment. Plain CT revealed a cystic mass with a diameter of 1.9 cm on the dorsal side of the left kidney (Fig 1A). CT with contrast media showed enhancement of the cystic lesion (Fig 1B). Imaging could not exclude the possibility of a malignancy. Therefore, to arrive at a definitive histologic diagnosis, it was necessary to perform either a biopsy of the renal mass or a partial nephrectomy. Because the mass was cystic, we were concerned that a needle biopsy may disperse the contents of the mass. Furthermore, because it was necessary to preserve kidney function as well as the patient’s potential as a kidney donor, on October 8, 2009, the patient underwent a laparoscopic partial nephrectomy of the left kidney without renal artery clamp. The patient was administered general anesthesia and placed in the right lateral recumbent position. We 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.022 634
advanced into the retroperitoneum and exposed the entire mass to our visual field while maintaining sufficient adipose tissue on the periphery of the mass. After confirming the size and invasion depth with the use of ultrasonography, we performed a nonischemic resection of the mass with the use of a microwave coagulation surgical instrument. The surgery duration was 157 minutes, and blood loss was 30 mL. Macroscopic findings showed a cystic renal mass with thickened septi (Fig 2). Histopathologic findings revealed renal cell carcinoma (clear cell carcinoma), grade 2, pT1a (Fig 3). Surgical margin was negative. The patient’s postoperative progress was good, and he was discharged on post-hospitalization day 10. At the time of writing, he had been followed for 27 months without any evidence of recurrence after surgery.
DISCUSSION
Screening for malignancies during preoperative examination of living kidney donors is vital. Penn et al reported that out of 270 kidney recipients who received transplanted organs from donors with malignancies, including those with a medical history of malignancies, 117 later developed cancer originating from the donor organ. This finding suggests that transplanted organs from donors with malignancies are highly likely to spread the disease to the organ recipient [2]. The Japan Society for Transplantation stipulates that
From the Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan. Address reprint requests to Takahiro Yoneyama, MD, Department of Urology, Hirosaki University Graduate School of Medicine, 5 Zaifu-chou, Hirosaki 036-8562, Japan. E-mail: uroyone@ cc.hirosaki-u.ac.jp ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 634e636 (2014)
RENAL CELL CARCINOMA
635
Fig 1. Computerized tomography (CT) findings. (A) Plain CT shows a small cystic mass (1.9 cm in diameter) in the left kidney. (B) CT with contrast media shows enhancement of the cystic lesion.
donors with melanoma, renal cell carcinoma, lung cancer, hematologic malignancy, gastric cancer, and other forms of cancer are not appropriate candidates for living kidney transplantation [3]. Yoshida et al reported several cases in which they struggled to deal with transplanted kidneys from donors who were discovered with malignant tumors immediately after live kidney transplantation, and they stressed the importance of preoperative examination [4]. Full-body examinations of potential donors, including interviews that include medical history, physical and hematologic tests, and endoscopic and imaging tests are necessary to determine the presence of malignant tumors. The reports of detecting malignancies in preoperative kidney transplant donor examinations were rare [5]. After an extensive review of the relevant medical literature, the present case with renal cell carcinoma appears to be the first such reported case in Japan. In recent years, small kidney masses have been incidentally detected with increasing frequency because of advances in CT, USG, and other types of diagnostic imaging [6]. Small kidney masses that require differentiation from renal cell carcinoma are often identified as oncocytomas, renal
angiomyolipomas, or other types of benign masses. In fact, Campbell et al reported that w80% patients with diagnostic imaging results that indicated possible renal cell carcinoma actually had renal cell carcinomas [7]. Moreover, Li et al obtained the same results in their study of the diagnostic accuracy of CT [8]. These findings indicate that accurate diagnosis of renal cell carcinoma remains extremely difficult despite the various advances in diagnostic imaging. Percutaneous needle biopsy is the standard diagnostic method for small kidney masses. However, Shannon et al reported that 22% of patients were difficult to diagnose by biopsy and concluded that this can be attributed to the size of a small kidney mass [9]. In our case, we encountered a small kidney mass, which made it challenging to obtain a sufficient portion of the tumor tissue to ensure an accurate pathologica diagnosis. Therefore, we opted for laparoscopic partial nephrectomy. Currently, the standard surgical procedure for small renal cell carcinoma is partial nephrectomy, because it is a radical cancer treatment and can potentially preserve kidney function [10e13]. Less invasive procedures to preserve kidney function include cryotherapy and radiofrequency ablation.
Fig 2. Macroscopic findings of the tumor specimen. The resected specimen has a cystic renal mass with thickened septi.
Fig 3. Histopathologic findings. The renal tumor was diagnosed as renal cell carcinoma (clear cell carcinoma). The surgical margin was negative for malignancy. Hematoxylin and eosin staining (100).
636
However, because of the danger of tumor cell dispersion during puncturing, these methods are not appropriate for treatment of cystic kidney tumors and are instead recommended only in cases that are inoperable because of complications or when surgery has been refused as a treatment option [14,15]. The small kidney tumor in our donor was incidentally detected, but malignancy could not be ruled out. If this small renal tumor was malignant, it would certainly have been treated with a carcinostatic agent, but if it had been diagnosed as benign, the patient would have remained a candidate for living kidney donation. Therefore, the renal hilum was not detached, and exfoliation in the area surrounding the kidney was kept to a minimum, because it was necessary to fully preserve kidney function and because a surgical procedure resulting in an accurate pathologic diagnosis, while allowing full tumor resection, was necessary. In this case, we opted for laparoscopic partial nephrectomy with use of the retroperitoneal approach, because it was minimally invasive for the donor and has reliable therapeutic value. Because the tumor was exophytic, the use of the microwave coagulation surgical instrument allowed us to perform nonischemic surgery without renal artery clamp. Unfortunately, the histopathologic diagnosis was renal cell carcinoma; therefore, the patient was judged to be inappropriate as a living kidney transplant donor. At the time of writing, he had been followed for 27 months without any evidence of recurrence after surgery, and function of the preserved portion of the kidney is good. His ability to once again be considered as a donor candidate will be carefully reevaluated after long-term observation of his condition. Small kidney tumors are difficult to accurately diagnose with the use of diagnostic imaging alone. In this case, to obtain an accurate pathologic diagnosis and preserve the patient’s kidney function as well as his potential as a donor, we opted for laparoscopic partial nephrectomy without renal artery clamp and recommend this procedure for potential kidney donors.
SATO, YONEYAMA, HAGIWARA ET AL
REFERENCES [1] Kawada S, Yonemitsu K, Morimoto S, et al. Current state and effectiveness of abdominal ultrasonography in complete medical screening. J Med Ultrasonics 2005;32:173. [2] Penn I. Transmission of cancer from organ donors. Ann Transplant 1997;2:7. [3] Editorial Commission, Japan Society for Transplantation. Indication for living donor kidney transplantation involving free kidney. Ishoku 2007;42:405. [4] Yoshida K, Yoneda R, Miyake M, et al. A case of pancreatic cancer in a donor after donating a kidney. Ishoku 2005;40:369. [5] Okamura M, Kamba T, Kanematsu A, et al. A case of elderly donor in living kidney transplant after radical radiotherapy for prostate cancer. Hinyoukiyou 2009;55:623. [6] Nguyen MM, Gill IS, Ellison LM. The Evolving Presentation of renal carcinoma in the United States: trends from the Surveillance, Epidemiology, and End Results program. J Urol 2006;176: 2397. [7] Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol 2009;182:1271. [8] Li G, Cuilleron M, Gentil-Perret A, et al. Characteristics of image-detected solid renal masses. Int J Urol 2004;63. [9] Shannon BA, Cohen RJ, de Bruto H, et al. The value of preoperative needle core biopsy for diagnosing benign lesions among small, incidentally detected renal masses. J Urol 2008;180: 1257. [10] Joniau S, Vander EK, van Poppel H. The indications for partial nephrectomy in the treatment of renal cell carcinoma. Nat Clin Pract Urol 2006;3:198. [11] Mitchell RE, Gilbert SM, Murphy AM, et al. Partial nephrectomy and radical nephrectomy offer similar cancer outcomes in renal cortical tumors 4 cm or larger. Urology 2006;67:260. [12] Gilbert SM, Russo P, Benson MC, et al. The evolving role of partial nephrectomy in the management of renal cell carcinoma. Curr Oncol Rep 2003;5:239. [13] Lucas SM, Stern JM, Adibi M, et al. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 2008;179:75. [14] Hatano T. Future prospects of minimally invasive treatment for small renal tumors; cryoablation for small renal cancer. J Urol surgery 2012;25:1457. [15] Japanese Urological Association. Evidence-based clinical practice guidelines for renal cell carcinoma. Int J Urol 2009;16:339.
