Abstract
Background Donor-derived malignancy is a rare complication in patients who undergo organ transplant. Approaches to treatment have largely been individualized based on clinical circumstances given the lack of evidence-based guidelines, with therapeutic options ranging from discontinuation of immunosuppression and transplantectomy to the addition of chemotherapy or radiotherapy. Case Presentation. Herein, we describe a 60-year-old woman with metastatic donor-derived upper tract urothelial carcinoma (UTUC) discovered nine years postrenal transplant. Molecular diagnostic studies using polymerase chain reaction amplification of short tandem repeat alleles and HLA tissue typing proved that the urothelial carcinoma originated from donor tissue. She achieved sustained complete remission with transplant nephroureterectomy, retroperitoneal lymphadenectomy, immunosuppression withdrawal, and immunotherapy with pembrolizumab. Routine radiologic surveillance has demonstrated 15-month progression-free survival to date off pembrolizumab, and she is now under consideration for retransplantation. Conclusions Immunotherapy using checkpoint inhibitors can serve as a novel treatment option for patients in the clinical predicament of having a solid organ transplant and simultaneous metastatic malignancy. In this report, we also discuss the oncogenic potential of BK virus, the use of checkpoint inhibitors in urothelial carcinoma, and the feasibility of retransplant for this patient population.
Highlights
Donor-derived malignancy is a rare complication in patients who undergo organ transplant
Features reported in 36 published allograft upper tract urothelial carcinoma (UTUC) cases include long latency from transplant to disease presentation, immunosuppression and BK infection as risk factors, and highly aggressive tumor biology [10]
Ortega et al described a case of donor-derived UTUC discovered nine years postrenal transplant and complicated by BK viremia six years posttransplant successfully managed with transplant nephrectomy and immunosuppression withdrawal [11]
Summary
36,500 transplants were performed in the U.S in 2018, of which renal transplants comprised the majority at over 21,100 [1]. There are several reported cases of donor-related malignancies achieving complete remission after transplant organ resection, immunosuppression withdrawal, and occasionally chemotherapy or radiotherapy [7,8,9,10]. Features reported in 36 published allograft upper tract urothelial carcinoma (UTUC) cases include long latency (mean 10 years) from transplant to disease presentation, immunosuppression and BK infection as risk factors, and highly aggressive tumor biology [10]. Ortega et al described a case of donor-derived UTUC discovered nine years postrenal transplant and complicated by BK viremia six years posttransplant successfully managed with transplant nephrectomy and immunosuppression withdrawal [11]. Our patient was treated with transplant nephroureterectomy, retroperitoneal lymphadenectomy, immunosuppression withdrawal, and immunotherapy with pembrolizumab, achieving a sustained complete response
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