Chapter

Cancer after renal transplantation

Kadiyala V. Ravindra, Michael Marvin and Joseph F. Buell

in Cancer and the Kidney

Second edition

Published on behalf of Oxford University Press

Published in print November 2010 | ISBN: 9780199580194
Published online November 2012 | e-ISBN: 9780191753404 | DOI: http://dx.doi.org/10.1093/med/9780199580194.003.0013

Series: Oxford Clinical Nephrology Series

Cancer after renal transplantation

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Most conditions associated with a state of profound immune suppression are associated with an increased risk of malignancy. Individuals with known congenital defects of antibody production or immune response mechanisms have higher incidences of non Hodgkin’s lymphoma, leukemias, and other malignancies. In states of acquired immunodeficiencies, such as the acquired immunodeficiency syndrome (AIDS), higher incidences of skin and lymphoid malignancies (such as Kaposi’s sarcoma and non Hodgkin’s lymphoma) exist. Immunosuppressed transplant recipients have a three- to fourfold overall increased risk of cancer, with some individual cancers having risk increases a hundredfold or greater over the general population.

The improved survival with solid organ transplantation has brought focus on the long term adverse sequelae of immunosuppression—the most serious being post-transplant neoplasia. Malignancy after transplantation is now the third leading cause of mortality in kidney transplant recipients. Malignancy is projected to surpass cardiovascular disease as the leading cause of death in these patients in the next two decades. The effect of immunosuppression has been thought to be cumulative, with the occurrence of the malignancy reaching 20% in all solid organ recipients by 20 years post-transplantation. In 2004, malignancy was the cause of mortality in 7% of kidney transplant recipients in the US (US Renal Data System (USRDS) 2006 annual data report). Post-transplant mortality associated with de novo cancers is high—ten-year survival in patients with malignancy being 57% compared with 93% in those without cancer.

A large cohort study from Australia and New Zealand demonstrated the site-specific cancer risk for kidney transplant recipients (Table13.1 and Fig. 13.1). Cancer rates amongst kidney recipients are similar to those of non-transplanted people 20 to 30 years older.

Malignancies that are more commonly seen in the general population, such as lung, colon, and breast cancer, do not appear with a greatly increased frequency in the transplant population. In contrast, malignancies that are virally driven have the highest increased incidence. These include post-transplant lymphoproliferative disease (PTLD, Epstein–Barr virus), Kaposi’s sarcoma (human herpesvirus-8), and cervical and vulvar cancers (human papillomavirus).

The most common malignancies encountered in the post-transplant setting are non-melanoma skin cancers (NMSCs—up to 80%), PTLD (5–10%), and Kaposi’s sarcoma (<5%). Among the skin cancers, squamous cell cancer (SCC) is the commonest subtype with an incidence 65–250 times higher than in the general population. Several differences have been noted between the skin malignancies appearing in immunosuppressed patients and those found in the general population. Skin malignancies in kidney transplant recipients tend to occur at earlier ages, occur in multiple sites, and often have multiple recurrences. The transplant patients also demonstrate a higher incidence of squamous cell cancers compared to basal cell cancers. Even in non-skin cancers a higher incidence of malignancy has been observed. In a recent single-center study of almost 2000 kidney transplant recipients, a calculated relative risk of 1.4 was observed when compared to the general population.

The Israel Penn International Transplant Tumor Registry (IPITTR) has accrued data on transplant-related malignancies for over 30 years (Fig. 13.2). Following Dr. Penn’s death in 1999, the Registry was renamed in his honor, and the data was computerized, thereby preserving his vision. The IPITTR now provides over 300 consult services per year to transplant centers and oncologists worldwide.

Chapter.  8482 words.  Illustrated.

Subjects: Nephrology ; Medical Oncology

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