The management of transitional cell carcinoma (TCC) in a European regional renal transplant population

Abstract

Study Type – Therapy (prospective cohort) Level of Evidence 2a What's known on the subject? and What does the study add? In the West, transitional cell carcinoma (TCC) in renal transplant patients is uncommon, but aggressive. Conversely, it appears to be frequent in the Far East, necessitating aggressive surgical approaches such as prophylactic nephroureterectomy. There are few European case series to date. TCC in the present population was predominantly low‐grade and superficial, with no progression in patients with those tumours. Endoscopic management was sufficient for most patients. The behaviour of TCC in the present population was much less aggressive than that described in the Far East. Altering immunosuppression regimes may have a role to play in managing bladder cancer in renal transplant patients. OBJECTIVE To examine the clinical characteristics, management and long‐term outcomes of patients with transitional cell carcinoma (TCC) who also have had renal transplantation. PATIENTS AND METHODS A retrospective case note review was performed for the 15‐year period 1995–2009. Searches from three different urological centres in the UK, using multiple sources, yielded 1647 patients with renal transplants, 12 of whom had TCC. Eight cases were identified who developed de novo TCC after transplantation (0.48%). Four patients had pre‐existing TCC who then had renal transplantation. The current literature was reviewed. RESULTS In the eight de novo TCC cases, the bladder was the site in all with no upper tract TCC; seven were superficial (pTa/T1) and five were low grade (G1/2). The mean time to development of TCC after transplant was 5 years, with a mean follow‐up of 11 years. There was no progression in low‐grade superficial disease that was managed endoscopically. The 5‐ and 10‐year overall survival was 83% and 72%, respectively. In patients with pre‐existing TCC prophylactic bilateral nephroureterectomy before transplantation was performed once. There was progression of superficial disease whilst on immunosuppression in one patient. Sirolimus was used in patients with TCC and reports suggest this may have a role to play in modifying malignancy in this setting. The number of patients involved in studies particularly focusing on TCC in renal transplantation is small (136 patients), with 60% from China/Taiwan where there is a high incidence of upper tract TCC and high‐grade muscle‐invasive disease. CONCLUSIONS Although this is one of the largest European case series of renal transplant patients with TCC, the numbers are small making clear conclusions difficult. The frequency of TCC in our renal transplant population is low, consistent with previous studies. However, contrary to prior studies, TCC after renal transplantation in this European population was predominantly superficial, low‐grade, non‐progressive and confined to the bladder. Altering immunosuppression regimes in patients with TCC may have a role to play, although further work is required to clarify and substantiate this.

De Novo Bladder Urothelial Neoplasm in Renal Transplant Recipients: A Retrospective, Multicentered Study

“…Concerning bladder urothelial neoplasms in the present study, 28 cases of de novo BC have been retrospectively reviewed. BC incidence in the present study is 0.9%, which is in line with literature findings that ranges between 0.3 and 2% [4]. A recent meta-analysis of most actual and well-conducted available studies has been performed by Yan et al [10] to determine whether the overall standard incidence ratio (SIR) of BC is increased in RTRs compared to standard population.…”

“…When stratified by ethnicity, the SIR for BC was 2.00 (95% CI 1.51-2.65, p = 0.001) among Europeans and much higher (14.74) among Asian RTRs (95% CI 3.66-59.35, p < 0.001) suggesting the presence of ethnicity-based differences [10]. The marked difference in incidence of TCC in RTRs in the far east compared with Western countries could be due, in part, to the use of Chinese herbs such as rhubarb and aristolochic acid, which have been associated with an increased cancer risk [4]. These substances are frequently used in the traditional Chinese medicine as an aid to the digestion and for weight reduction.…”

“…These substances are frequently used in the traditional Chinese medicine as an aid to the digestion and for weight reduction. They are also used in ESRD patients because they decrease creatinine serum levels [4].…”

“…Based on the few series available, TCCs in RTRs seem to present with more aggressive patterns and worse prognosis than the general population [4], potentially reflecting inadequate therapeutic management in this population mainly for the high-risk non-muscle-invasive (NMI) group.…”

“…Among all urologic malignancies in RTRs, renal cell carcinoma in native kidneys represents the 4.6% of all neoplasms, followed by transitional cell carcinoma (TCC), which represents the 0.48% in this population [4]. Based on the few series available, TCCs in RTRs seem to present with more aggressive patterns and worse prognosis than the general population [4], potentially reflecting inadequate therapeutic management in this population mainly for the high-risk non-muscle-invasive (NMI) group.…”