105 148
In a large cohort of solid organ transplant recipients
(1970
–
2008), Brattströmt et al
[11]reported a 30% increased
mortality risk for recipients with a history of cancer.
However, this risk was moderately increased for renal
transplant recipients (hazard ratio:1.2%, 95%: 1.0
–
1.4,
p
<
0.05) and mainly concerned recipients of other organs
(hazard ratio: 1.8).
An active cancer is a contraindication for transplanta-
tion and a patient with (except active surveillance for
prostate cancer) a history of malignancy must be in
remission before transplantation. Pretransplant evaluation
includes a systematic search for subclinical active or latent
tumours. For patients with a history of treated malignancy,
the waiting period before transplantation varies from 2 yr
to 5 yr after cancer treatment. These recommendations are
based on the Israel Penn International Transplant Tumour
Registry
[4,9].
However, these studies from 10 yr ago now have several
shortcomings and may no longer reflect the epidemiology
of patients currently seen in pretransplantation evaluation.
Several oncological data were missing: stage, histological
subtype, grade, and type of treatment. For PC, the Penn
[4]study essentially included T3 tumours diagnosed in the
preprostate-specific antigen era. For RCC, the tumours were
mainly large and symptomatic. For bladder tumours, the
stage, grade, multifocality, type of adjuvant intravesical
instillation, and the distinction between nonmuscle inva-
sive and muscle invasive tumours were not reported.
4.2.1.
Real cell carcinoma and chronic kidney disease
In this systematic review, the main histological subtype was
clear cell RCC (53
–
79%), followed by tubulo-papillary RCC
(17
–
50%). The tumours were mainly of low stage (78
–
100%
of pT1), and/or low grade (51
–
92% grade I
–
II;
Table 8 ).
RCC diagnosed in a context of CKD may have a better
prognosis for several reasons. ESRD patients are often
monitored more closely than the normal population,
favouring early diagnosis with smaller size and lower
grade. The main risk factor of RCC is acquired cystic kidney
disease, which increases with the duration of dialysis
[12]. RCC is more common for patients with CKD compared
with the general population. The standardised incidence
ratio of RCC in dialysis patients is 14
–
17 times higher than
that in the general population
[13]. The systematic review
data were consistent with the current knowledge on RCC in
CKD patients, reporting an increased prevalence of low-
grade tumours (51
–
100%) and the papillary subtype (17
–
37%;
Table 6 ) [14 – 16]. The duration of dialysis alters the
histological spectrum of tumours: clear cell RCC is the
predominant subtype for patients with short dialysis
duration, papillary RCC being the predominant type in
patients on dialysis for more than 4 yr
[14].
4.2.2.
Prostate cancer and chronic kidney disease
In this systematic review, the series included were mainly
cohorts of patients who were transplanted after their PC
treatment (111 transplanted patients vs 6 patients who
remained on dialysis) with mainly localised PC of excellent
prognosis (D
’
Amico low to intermediate risk or stage II).
By contrast, in 2005 the report of Woodle et al
[9]included
12% with stage III PC. In 2001, Chapman et al
[46]did not
report the histology and prognosis of the patients included
( Table 7 ).
To date, there is no evidence of worse prognosis for PC in
ESRDs. Although the increased prevalence of hypogonadism
was suspected to induce PC of worse prognosis, there is no
study validating this hypothesis
[17]. It was not demon-
strated that the prognostic performance of pretherapy
(D
’
Amico, Partin) and post-therapy (Kahn, Kattan) nomo-
grams is altered for CKD patients
[18,19].
4.2.3.
Urothelial carcinoma and chronic kidney disease
In this systematic review, the most common tumour site of
UC was the upper urinary tract (57
–
100% of the case series).
The prevalence of a synchronous bladder tumour was 42
–
81% and the prevalence of a bilateral tumour was 10
–
16%
[20,21]. Concerning the stage, 72% (56
–
100%) of the patients
were diagnosed with a nonmuscle invasive tumour. All
publications followed the three-stage classification accord-
ing to the 1973 World Health Organization classification
with a high-grade distribution ranging from 15% to 69%
( Table 7 ).
There were few studies on bladder cancer. Among them,
tumour stage (tumour invading muscle or not) and use of
adjuvant intravesical therapy were rarely mentioned.
Most studies dealing with UUTUC concerned patients
with aristolochic nephropathy and seemed to have a higher
risk of recurrence and multifocality than UUTUC induced by
tobacco and toxic substances
[22] .4.2.4.
Testicular cancer
We found no comparative study concerning TC. TC had a low
risk of recurrence according to Penn
[4] .A single clinical
case indicated the possibility of recurrence for stage I
seminoma
[8] .4.3.
Implications for practice
Considering the rates of recurrence and the prognostic
factors of recurrence reported in this systematic review of
the literature, it seems possible to optimise the waiting
period between treatment for cancer and transplantation.
4.3.1.
Real cell carcinoma
The main prognostic factors of recurrence identified in this
systematic reviewwere: stage, tumour size, Fuhrman grade,
tumour solid nature, symptomatic tumours on diagnosis,
conventional renal cell carcinoma subtype, and lymph node
involvement
( Table 5).
This systematic review reported a significant risk of
recurrence even for low-stage and low-grade tumours. In
Sheashaa et al
[23]and Denton et al
[24], in particular, where
ipsilateral nephrectomy was performed systematically dur-
ing transplantation, there was a risk of recurrence of up to
25% at 5 yr, even though these were low-grade and low-stage
infraradiological tumours. In these studies, contralateral
involvement occurred in up to 36% of the cases. Recurrences
were essentially recurrent/second contralateral RCC with an
E U R O P E A N U R O L O GY 7 3 ( 2 0 18 ) 9 4
–
10 8
105