Treatment options for localised renal cell carcinoma of the transplanted kidney

Abstract

Currently, there is no consensus among the transplant community about the treatment of renal cell carcinoma (RCC) of the transplanted kidney. Until recently, graftectomy was universally considered the golden standard, regardless of the characteristics of the neoplasm. Due to the encouraging results observed in native kidneys, conservative options such as nephron-sparing surgery (NSS) (enucleation and partial nephrectomy) and ablative therapy (radiofrequency ablation, cryoablation, microwave ablation, high-intensity focused ultrasound, and irreversible electroporation) have been progressively used in carefully selected recipients with early-stage allograft RCC. Available reports show excellent patient survival, optimal oncological outcome, and preserved renal function with acceptable complication rates. Nevertheless, the rarity and the heterogeneity of the disease, the number of options available, and the lack of long-term follow-up data do not allow to adequately define treatment-specific advantages and limitations. The role of active surveillance and immunosuppression management remain also debated. In order to offer a better insight into this difficult topic and to help clinicians choose the best therapy for their patients, we performed and extensive review of the literature. We focused on epidemiology, clinical presentation, diagnostic work up, staging strategies, tumour characteristics, treatment modalities, and follow-up protocols. Our research confirms that both NSS and focal ablation represent a valuable alternative to graftectomy for kidney transplant recipients with American Joint Committee on Cancer stage T1aN0M0 RCC. Data on T1bN0M0 lesions are scarce but suggest extra caution. Properly designed multi-centre prospective clinical trials are warranted.

Keywords: Renal cell carcinoma, Kidney transplant, Graftectomy, Nephron-sparing surgery, Focal ablation, Review

Core tip: Nephron-sparing surgery and ablative therapy have been increasingly recognised as a valuable alternative to transplantectomy in carefully selected kidney recipients with allograft renal cell carcinoma (RCC). The complexity of the disease, the numerosity of the treatments available, the lack of long-term follow-up data, and the relatively poor quality of the studies addressing this topic do not allow to properly define specific advantages and limitations of these conservative strategies. We performed an extensive review of the literature focusing on epidemiology, clinical presentation, diagnostic work up, staging strategies, tumour characteristics, treatment modalities, and follow-up protocols of localised RCC of the transplanted kidney.