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CHAPTER 15: Evaluation of Candidates with Current and/or Past Malignancies

Gayatri Nair; Vinay Nair

INTRODUCTION

Malignancy is one of the common causes of mortality and morbidity after kidney transplantation. Kidney transplant recipients have two to four times higher risk of cancer when compared to an age and gender-matched general population. The cumulative incidence of solid organ cancers after kidney transplantation is 4–5% after 5 years, 10% after 10 years, and >25% after 20 years. Differences in cancer risk depend on the cancer type for kidney transplant recipients. The most significant increase in cancer incidence among renal transplant recipients is seen with Kaposi sarcoma, non-melanoma skin cancers, lip cancer post-transplant lymphoproliferative disorders, and genitourinary cancers. It is essential to evaluate cancer risk in potential kidney transplant recipients to avoid organ transplantation in patients with a poor prognosis due to cancer progression and to avoid exacerbating the recurrence risk of a prior cancer.

RISK FACTORS ASSOCIATED WITH A HIGHER INCIDENCE OF CANCER AFTER TRANSPLANTATION

  • Older age

  • Male gender

  • Caucasian

  • Smoking

  • Longer time on dialysis

  • Prior history of cancer

Pre Transplant Cancer Screening

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TARGET ORGAN

TEST

FREQUENCY

AGE IN YEARS

Breast

Mammography

1–2 years

> 40

Colon

Colonoscopy

Every 10 years

> 45

Prostate

PSA

Annually

> 50

Bladder

Cystoscopy

Not routine

High-risk individuals which includes previous cyclophosphamide use or history of heavy smoking >30 pack-years.

Cervix

Pap Smear

1–2 years

>18 or within 2 years after becoming sexually active

Lung

  • CXR

  • CT Chest

  • Once

  • Annually

High-risk individuals, ages 50–80 years old with at least a 20 pack-year smoking history and are either current smokers or former smokers having quit within the past 15 years.

Liver

Imaging Study (USG/CT/MRI) and AFP

Annually

Patients with known cirrhosis

High-risk patients for renal cancer include long time on dialysis, family history of renal cancer, acquired cystic disease, and analgesic nephropathy. There are no specific guidelines regarding screening for renal cancer, but imaging of the kidneys (USG/CT/MRI) is usually done at least once in all patients who undergo a transplant evaluation.

PRE TRANSPLANT MALIGNANCY

A history of cancer before transplantation is associated with a 1.5- to 3-fold increase in risk of cancer death after transplantation compared with recipients who have no previous history of cancer. Pretransplant malignancy is also associated with an increased risk of all-cause mortality and developing de novo malignancies after transplantation. Hence, screening patients for cancer as a part of the evaluation process is essential. Once patients with current or past malignancies are identified, there are different guidelines that recommend specific wait times depending upon the type of malignancy before proceeding for transplantation. The most recent guidelines by Al-Adra et al. are based on a consensus workshop in 2019 that involved transplant clinicians and experts in surgical and medical oncology. The risk stratification for malignancy included TNM staging along with tumor marker analysis and epigenetics. The wait time recommended for ...

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