Kleinclauss F, Thuret R, Murez T, Timsit M O
Service d'urologie et transplantation rénale, CHRU de Besançon, 3, boulevard A.-Fleming, 25000 Besançon, France; Université de Franche-Comté, 25000 Besançon, France; Inserm UMR 1098, 25000 Besançon, France.
Service d'urologie et transplantation rénale, CHU de Montpellier, 34090 Montpellier, France; Université de Montpellier, 34000 Montpellier, France.
Prog Urol. 2016 Nov;26(15):1094-1113. doi: 10.1016/j.purol.2016.08.009. Epub 2016 Sep 21.
To review epidemiology and management of urologic neoplasms in renal transplant candidates and recipients.
Relevant publications were identified through Medline (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) database using the following keywords, alone or in association, "neoplasms"; "prostate cancer"; "renal carcinoma"; "renal transplantation"; "transitional carcinoma"; "waiting list". Articles were selected according to methods, language of publication and relevance. A total of 7730 articles were identified including 781 for solid tumors, 1565 for renal cell carcinoma (RCC), 2674 for prostate cancer (Pca), 385 for transitional carcinoma (TC) and 56 for testicular cancer; after careful selection, 221 publications were eligible for our review.
Renal transplant candidates and recipients are at higher risk of urologic neoplasms than general population, but prostate cancer has similar features. Thus, all therapeutic options are valid. Conversely to radiation therapy, radical prostatectomy provides precise staging and immediate affirmation of therapeutic success. Lymph nodes dissection needs to be discussed; systematic screening using PSA level and digital rectal examination should be offered in this specific population. RCC arising in native kidneys are usually low grade and stage and require total nephrectomy. In transplant candidates, there is no need to delay transplantation after treatment of low risk RCC according to published predictive nomograms. RCC of the allograft are rare, with a prevalence of 0.2 to 05% with a dialysis free survival ranging from 40 to 75% at 21.5 to 43 months. Treatment options are nephron sparing surgery, percutaneous ablation and immediate or deferred transplantectomy. Conversely to RCC or PCa, TC present with more unfavorable features as general population. Their management faces specific difficulties such as lower efficacy of BCG instillation or the technical challenge of urinary diversion.
Application of appropriate indication for transplantectomy relies on benefit-risk balance between the interruption of immunosuppressive agents versus survival and quality of life impairment after returning to dialysis. No robust recommendation exists regarding switch of immunosuppressive drugs. Cancer predictive factors and access to a subsequent transplantation are key decisive elements.
回顾肾移植候选者和接受者泌尿系统肿瘤的流行病学及管理情况。
肾移植候选者和接受者患泌尿系统肿瘤的风险高于普通人群，但前列腺癌具有相似特征。因此，所有治疗选择都是有效的。与放射治疗相反，根治性前列腺切除术可提供精确分期并能立即确认治疗成功。淋巴结清扫需要讨论；应在此特定人群中提供使用前列腺特异性抗原（PSA）水平和直肠指检进行系统筛查。原发肾中发生的RCC通常分级和分期较低，需要行根治性肾切除术。根据已发表的预测列线图，对于肾移植候选者，低风险RCC治疗后无需延迟移植。移植肾的RCC罕见，患病率为0.2%至0.5%，在21.5至43个月时无透析生存率为40%至75%。治疗选择包括保留肾单位手术、经皮消融以及立即或延期移植肾切除术。与RCC或PCa相反，TC与普通人群相比具有更不利的特征。其管理面临特殊困难，如卡介苗（BCG）灌注效果较差或尿路改道的技术挑战。
移植肾切除术合适适应证的应用取决于中断免疫抑制剂与恢复透析后生存及生活质量受损之间的获益风险平衡。关于免疫抑制药物的转换尚无有力推荐。癌症预测因素和后续移植的可及性是关键的决定性因素。
