Abstract The increased risk of malignancies is a well-recognized complication of organ transplantation. When renal cell carcinoma (RCC) occurs in kidney transplant recipients, less than 10% of it affects the allograft. Recent experience suggests that partial allograft nephrectomy for tumours less than 4 cm may be considered the treatment of choice. We report a case of a 3.3 cm RCC discovered in a renal allograft. Limited allograft function was due to segmental infarction after transplant surgery and chronic allograft nephropathy. She underwent successful partial allograft nephrectomy. At 36 months post-surgery, there is no evidence of RCC recurrence and she remains free of renal replacement therapy

H Coates

Jordan Y Z Li

Mohan Rao

P Toby

Tuck Y Yong

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NDT Plus (2009) 1 of 2
doi: 10.1093/ndtplus/sfp027
Case Report
Partial nephrectomy for renal cell carcinoma in an allograft kidney
with limited functional reserve
Jordan Y. Z. Li1,2, Tuck Y. Yong2,3, Mohan Rao1,4 and P. Toby H. Coates1,4
1Department of Nephrology and Transplantation Services, The Queen Elizabeth Hospital, 2Flinders University of South Australia,
3Department of General Medicine, Flinders Medical Centre and 4University of Adelaide, Adelaide, South Australia, Australia
Correspondence and offprint requests to: Jordan Li; E-mail: jordan.li@health.sa.gov.au
Abstract
The increased risk of malignancies is a well-recognized
complication of organ transplantation. When renal cell car-
cinoma (RCC) occurs in kidney transplant recipients, less
than 10% of it affects the allograft. Recent experience sug-
gests that partial allograft nephrectomy for tumours less
than 4 cm may be considered the treatment of choice. We
report a case of a 3.3 cm RCC discovered in a renal allograft.
Limited allograft function was due to segmental infarction
after transplant surgery and chronic allograft nephropathy.
She underwent successful partial allograft nephrectomy. At
36 months post-surgery, there is no evidence of RCC recur-
rence and she remains free of renal replacement therapy.
Keywords: immunosuppression; partial nephrectomy; renal cell
carcinoma; renal transplant
Introduction
Malignancy is a recognized complication of renal trans-
plantation. In Australia, it is estimated that 25% of all renal
transplant recipients surviving for 20 years will develop a
non-skin cancer [1]. Renal cell carcinoma (RCC) accounted
for 4.6% of de novo cancer in solid organ transplant recip-
ients, but the majority occurred in native kidneys and less
than 10% in allograft kidneys [2].
Most tumours arising in allograft kidneys were tradi-
tionally treated by radical nephrectomy. A number of case
reports have been published on partial nephrectomy as a
treatment option particularly when the RCC is less than
4 cm [3–6]. We report a case of RCC in a kidney allograft
compromised by previous segmental infarction and chronic
allograft nephropathy (CAN), which was treated success-
fully with nephron-sparing partial nephrectomy.
Case report
A 47-year-old woman with end-stage renal disease due
to reflux nephropathy underwent deceased donor renal
transplantation in 1994. This was complicated by upper
pole segmental infarction 12 days after transplantation. Her
serum creatinine on discharge was 140 µmol/L. Mainte-
nance immunosuppressive therapy included cyclosporine
and azathioprine. CAN was confirmed on biopsy 7
years after transplantation. Subsequently, cyclosporine was
changed to sirolimus. Sirolimus was changed to tacrolimus
2 years later due to heavy proteinuria (4.5 g/day).
Eleven years after transplantation, a 3.3 cm mass was
found in the lower pole of the renal allograft during trans-
abdominal ultrasound for investigation of pelvic pain. Mag-
netic resonance imaging confirmed the presence of a com-
plex cystic mass that was highly suspicious for a RCC.
There was no radiological evidence of local and distant
metastases or involvement of the native kidneys. At that
time serum creatinine was 259 µmol/L.
The patient underwent a partial allograft nephrectomy.
The surgical procedure was the same as described by Merkel
et al. [3]. Histopathology confirmed a multilocular cystic
RCC with free parenchymal resection margins.
Post-surgery, she developed acute tubular necrosis of the
allograft and required three haemodialysis sessions. She
subsequently made an uneventful recovery with serum cre-
atinine 272 µmol/L on discharge. The maintenance im-
munosuppressant was not altered before or after surgery.
Three years after surgery, there is no evidence of RCC re-
currence and she remains free of renal replacement therapy.
Discussion
Traditionally, the treatment for RCC arising from kidney
allografts has been allograft nephrectomy, withdrawal of
immunosuppressive therapy and resumption of dialysis.
However, recent data suggest that partial nephrectomy is
emerging as a viable alternative option. Butler et al. re-
ported that radical nephrectomy and partial nephrectomy
provided equally effective treatment for single, localized
RCC of less than 4 cm in native kidneys [7]. One long-term
follow-up study has found the cancer-specific survival to
be 100% at 10 years in patients who underwent partial
C© The Author [2009]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
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2 J. Y. Z. Li et al.
nephrectomy with tumours less than 4 cm [8]. RCC involv-
ing transplant recipients appear to have similar biological
behaviour as those involving patients without immunosup-
pression [9]. As a result, the use of partial nephrectomy has
been extrapolated into the management of RCC in kidney
allografts.
There were 18 cases of tumour in renal allografts treated
by partial nephrectomy reported in the worldwide literature
[6]. Of these cases, 13 (81%) had RCC, 2 had oncocytoma,
1 had angiomyolipoma and the pathology was not reported
in 2 cases. Of the RCC cases, 11 cases (85%) were small
lesions measuring less than 4 cm while one was 6 cm and
the other 9 cm. Mean time of diagnosis after transplanta-
tion was 11.1 years (range: 1 month to 21.5 years). In this
series, mean follow-up after partial allograft nephrectomy
was 32 months (range: 0.5–138 months) with no patient re-
ported to develop local recurrence, renal failure or distant
dissemination.
Although the data are limited, the evidence so far in-
dicates that nephron-sparing surgery provides a durable
cancer control of tumours less than 4 cm without signif-
icant compromise to graft function. Therefore, partial graft
nephrectomy may be proposed as the treatment of choice for
tumours less than 4 cm. This would avoid returning patients
to dialysis that is associated with inferior life expectancy
and quality of life when compared with a functioning graft.
Moreover, partial graft nephrectomy avoids overtreatment
of unexpected non-malignant tumours.
In the majority of previous cases, partial graft nephrec-
tomy was performed on good functioning allograft with
serum creatinine between 79 and 158 µmol/L. However,
in the case described, the graft function is compromised
because of segmental infarction and CAN. Partial graft
nephrectomy in allograft kidneys with severe compromised
function has only been reported in two previous cases, one
with creatinine of 211 µmol/L and 222 µmol/L in the other
[4,5]. Graft function in these two cases was still preserved
after 6 and 22 months, respectively. To our knowledge, the
described case is the first to have undergone successful
partial allograft nephrectomy in the setting of segmental
infarction.
Partial nephrectomy of the renal allograft is a challeng-
ing procedure to undertake. It is performed in a non-naı̈ve
surgical field where severe inflammation and scarring are
usually present, making kidney mobilization, pedicle con-
trol and parenchymal resection often difficult. The contin-
uous perfusion of the allograft with the cooled Ross so-
lution preserved the residual kidney function, as seen in
the Merkel’s case [3] and the current case. This continuous
perfusion also made it easier to identify and individually
ligate all vessels in the cut surface to minimize blood loss.
Intra-operative ultrasound can assist in gaining satisfactory
clearance and preserve renal parenchyma for optimal renal
function. It also allowed exact determination of the extent
of these lesions if polycentricity is present [10].
RCC arising from a renal allograft is rare. Data are ac-
cumulating to suggest that preservation of renal function
can be achieved by partial nephrectomy without sacrificing
control of the malignancy.
Conflict of interest statement. None declared.
References
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Received for publication: 9.2.09; Accepted in revised form: 16.2.09
 at Pennsylvania State U
niversity on O
ctober 6, 2016
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Partial nephrectomy for renal cell carcinoma in an allograft kidney with limited functional reserve

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Partial nephrectomy for renal cell carcinoma in an allograft kidney with limited functional reserve

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