2022 - Lesson 23 (Management of Urological Malignancies in the Transplant Candidate or Recipient)

Question 1

What is the AST recommended wait time and considerations for SOT candidates with very low risk prostate cancer (PSA <10 ng/mL, 3 or fewer cores of Gleason 6, T1c-T2a)?

Answer 1

No wait time is required. Surveillance is strongly recommended. Extenuating circumstances may require treatment.

Question 2

What is the management approach for low risk prostate cancer (PSA <10 ng/mL, Gleason 6, T1c-T2a) in SOT candidates?

Answer 2

No wait time is required. Surveillance is strongly recommended. Extenuating circumstances may require treatment.

Question 3

Describe the management for low-volume, intermediate risk prostate cancer in SOT candidates. Include criteria and considerations.

Answer 3

Criteria include one of the following: PSA >10 ng/mL, Gleason 7, T2b. If surveillance, no wait time is required. Surveillance or treatment should be considered, depending on patient and cancer characteristics. If treatment is initiated and the nomogram predicts Ca-specific death over the next 15 years <10%, no wait time.

Question 4

What are the considerations for high-volume intermediate, high risk, or very high risk prostate cancer (PSA >20 ng/mL or high-volume Gleason 7 or any Gleason 8-10, T3) in SOT candidates?

Answer 4

20%−70% risk of metastasis/death over 15 yrs. If treatment is initiated and the nomogram predicts Ca-specific death over the next 15 years <10%, no wait time is required.

Question 5

What is the median survival rate for metastatic castration-sensitive diseases in transplant candidates or recipients? Under what conditions may a transplant be considered for a patient with metastatic castration-sensitive disease? What are the best treatment options for managing metastatic castration-sensitive diseases in transplant candidates or recipients?

Answer 5

Median survival ~5-6 years. If stable disease for 2 years with prolonged estimated life expectancy, may consider transplant. Best systemic therapy ± local treatment is recommended.

Question 6

What is the recommended approach for metastatic castration-resistant prostate cancer?

Answer 6

Median survival 2-3 years. Not a candidate for SOT. Best systemic therapy is advised.

Question 7

What is the recommended wait time for transplantation for a SOT candidate with T1a (≤4 cm), N0, M0 stage RCC, and what is the 5-year recurrence-free survival rate for this stage?

Answer 7

The recommended wait time is “No wait time,” and the 5-year recurrence-free survival rate is 95%−98%.

Question 8

In the case of T1b (>4 cm ≤7 cm), N0, M0 stage RCC, what are the recurrence-free survival rates for Fuhrman grades 1-2 and 3-4, and what are the respective wait times?

Answer 8

The recurrence-free survival rate is 91% for Fuhrman grade 1-2 and 80%−82% for Fuhrman grade 3-4. The wait time is “no wait time” for Fuhrman grade 1-2 and 1−2 years for Fuhrman grade 3-4.

Question 9

What are the 5-year recurrence-free survival rates and recommended wait times for transplantation for stages T2, T3, and T4 (N0, M0) RCC?

Answer 9

For T2 (7−10 cm), the survival rate is 80%, with a 2-year wait time. For T3, the survival rate is 43%−80%, with a minimum 2-year wait time followed by reassessment. For T4, the survival rate is 28%−55%, with a minimum 2-year wait time followed by reassessment.

Question 10

What are the guidelines concerning transplantation candidacy for patients with Any T, node-positive, metastatic disease or Any T with sarcomatoid and/or rhabdoid histological features, Collecting duct, or medullary RCC?

Answer 10

Patients with Any T, node-positive, metastatic disease are generally not candidates (with exceptions for solitary metastasis + resected, requiring tumor board discussion). Any T with sarcomatoid and/or rhabdoid features has a 15%−27% survival rate, and those patients are not SOT candidates. Collecting duct or medullary RCC has less than a 10% survival rate, and those patients are also not SOT candidates.

Question 11

What is the recommended time interval to transplant for NMIBC low risk patients with a solitary, ≤3 cm, low grade, Ta tumor, and absence of CIS? What’s the 2-year local recurrence rate?

Answer 11

The recommended time interval to transplant is 6 months, with a 2-year local recurrence rate of 19%.

Question 12

For intermediate-risk bladder cancer (Solitary tumor >3 cm, recurrence within 12 months with low-grade Ta tumor, multifocal low-grade Ta tumor, low-grade T1 tumor, or high-grade tumor <3 cm), what is the time interval to transplant and the 2-year local recurrence rate?

Answer 12

The recommended time interval to transplant is 6 months, with a 2-year local recurrence rate of 39%.

Question 13

Define the characteristics of high-risk bladder cancer, the 2-year local recurrence rate, and the time interval to transplant.

Answer 13

High-risk bladder cancer includes any CIS, high-grade Ta tumor >3 cm, high-grade T1 tumor, multifocal high-grade Ta tumor, recurrence after BCG intravesical therapy, etc. The 2-year recurrence rate is 38%, and the recommended wait time is 2 years.

Question 14

What is the time interval to transplant for MIBC patients post-radical cystectomy, and what’s the recurrence rate?

Answer 14

The recommended time interval to transplant is 2 years, with a recurrence rate of 25%−37%.

Question 15

What is the status of MIBC patients post-chemoradiation for SOT candidacy, and what’s the recurrence rate?

Answer 15

MIBC patients post-chemoradiation are not considered SOT candidates. The recurrence rate ranges from 25%−30% over a 10-year period.

Question 16

What significant benefits are associated with solid organ transplantation (SOT) in patients with end-stage organ failure?

Answer 16

SOT leads to major increases in both quantity and quality of life. It is lifesaving for liver, heart, and lung transplantation. In renal failure, SOT offers advantages in health-related quality of life, long-term survival, and cost-effectiveness.

Question 17

How have the guidelines changed regarding the wait time for SOT after treatment for testis, bladder, and prostate cancers?

Answer 17

The old 2001 AST guidelines recommended a 2-year wait time. These blanket recommendations were not well-supported by data and were based on anachronistic management paradigms. Contemporary studies showed that cancer recurrence rates after SOT vary, and they may not be as high as previously reported.

Question 18

What does current evidence imply about patients with diseases other than high-risk bladder cancer in terms of cancer-specific mortality (CSM) after SOT?

Answer 18

Current evidence implies that patients with diseases other than high-risk bladder cancer have a similar risk of CSM compared to the general population after SOT.

Question 19

How has the management of previous or concurrent prostate, kidney, and bladder cancers evolved, and what are the implications for urologists?

Answer 19

The ability to predict who may benefit from SOT despite cancer recurrence post-transplant or even the presence of active malignancy has improved. The AST released a consensus statement addressing these cancers in SOT candidates and recipients, requiring updated guidelines based on modern data and management paradigms.

Question 20

What should be considered regarding PSA screening in SOT candidates or patients with organ failure, especially in relation to life expectancy and renal dysfunction?

Answer 20

PSA screening is not recommended for men with a life expectancy under 10-15 years. Free PSA levels are elevated in men with renal dysfunction, leading to a possibility of artificially elevated free PSA percentage. Clinicians should be aware of the greater false-negative risk in men with renal disease.

Question 21

How does liver disease affect PSA values and what are the implications for prostate cancer diagnosis?

Answer 21

Men with higher degrees of liver fibrosis have lower mean PSA values, leading to the possibility of underdiagnosis in patients with advanced liver fibrosis being investigated or followed for prostate cancer.

Question 22

What considerations should be made for using MRI in prostate cancer diagnosis in patients with renal dysfunction?

Answer 22

Standard multiparametric prostate MRI uses gadolinium contrast agents, which can be controversial in renal disease due to the risk of nephrogenic systemic fibrosis. Group II agents carry the lowest risk. If concerns persist, omission of the contrast-enhanced phase is acceptable, and the resulting biparametric MRI performs similarly to traditional multiparametric MRI.

Question 23

What is the general approach to managing localized prostate cancer in SOT candidates?

Answer 23

Oncologic outcomes are favorable, with 10-year CSM <8%. Men with a history of low-risk disease should proceed directly to transplantation. Intermediate- and high-risk patients should be individually assessed, with an approach that likely yields better patient outcomes compared to delaying SOT.

Question 24

How is metastatic prostate cancer managed in SOT candidates?

Answer 24

Carefully selected men with castrate-sensitive metastatic prostate cancer may be candidates for SOT, considering factors like low volume of metastases and durable response to therapies. Those with castration-resistant prostate cancer, having a median survival of approximately 2 years, should not undergo SOT.

Question 25

What are the treatment considerations for prostate cancer in SOT recipients, particularly for renal transplants?

Answer 25

Treatment considerations include anatomical alterations due to graft placement, which must be considered during surgical and radiation-based approaches. Radical prostatectomy is safe and feasible, and radiation therapy is considered safe and effective, with outcomes comparable to the general population.

Question 26

What factors contribute to a marked elevation in RCC risk in patients with chronic kidney disease, and what diagnostic options are valuable?

Answer 26

Chronic kidney disease leads to a 30-50 fold increased risk for RCC due to its association with acquired cystic kidney disease. Imaging options include ultrasound and MRI with or without type II gadolinium contrast agents, as iodinated CT and some gadolinium MRI agents are contraindicated.

Question 27

What is the management approach for small renal masses (≤4 cm, T1a) in SOT candidates?

Answer 27

Small renal masses are often benign or low malignant potential, growing 1-2 mm/year with 1%-2% metastasis risk. Active surveillance is accepted, with surgical treatment having <5% recurrence risk. Presence of small renal mass should not delay SOT, and treatment (if needed) follows transplantation.

Question 28

How are Stage T1b lesions (4-7 cm) managed in SOT candidates?

Answer 28

These lesions have a 15% recurrence rate at 5 years. Renal mass biopsy confirms histology. Stratification by Fuhrman nuclear grade or ISUP classification guides wait time (1-2 years for grade 3-4). High-grade T1b treatment varies from immediate transplantation to 2-year observation.

Question 29

What considerations are made for T2 and T3 RCC in SOT candidates?

Answer 29

T2 RCC has a 20% recurrence rate within 5 years; T3 has 40% at 5 years. Surveillance for a minimum of 2 years is required for SOT. T4, node-positive, or metastatic RCC is generally a contraindication for SOT, with exceptions on a case-by-case basis.

Question 30

How is RCC managed in SOT recipients?

Answer 30

RCC incidence is 5 times higher post-renal transplant. Localized cancers are managed with radical nephrectomy. Allograft RCC is rare and treated with surgical or ablative techniques. PD-1 and PD-L1 inhibitors are prescribed with caution due to risk of graft rejection.

Question 31

When is active surveillance vs. treatment recommended for small renal masses and complex cysts in SOT candidates?

Answer 31

Active surveillance is accepted for small renal masses and complex cysts, even in good surgical candidates. Surveillance or treatment decisions are individualized for patients with longer median wait times for SOT, considering low short-term progression risk and treatment risks.

Question 32

What diagnostic considerations are recommended for patients with organ failure and microscopic or gross hematuria who are candidates for solid organ transplantation (SOT)?

Answer 32

Patients should be investigated similarly to the general population with cystoscopy, upper tract imaging, and potentially cytology. Excretory urography may be ineffective for those with advanced kidney disease, so retrograde pyelogram may be considered. Guidelines recommend cystoscopy screening for candidates with risk factors like a smoking history of over 30 pack-years. There are no recommendations for upper tract screening.

Question 33

How is urothelial carcinoma of the bladder divided, and what are the general statistics for Non-Muscle-Invasive Bladder Cancer (NMIBC)?

Answer 33

Urothelial carcinoma is divided into NMIBC and Muscle-Invasive Bladder Cancer (MIBC). About 70% of cases are NMIBC, risk-stratified into low-, medium-, and high-risk NMIBC. The 5-year recurrence rate is 30%-50%, and progression to MIBC ranges from 2%-13%.

Question 34

What are the management strategies for low- and intermediate-risk NMIBC in SOT candidates?

Answer 34

Low- and intermediate-risk NMIBC can typically be managed with transurethral resection and intravesical therapy. A 6-month disease-free interval is recommended prior to SOT. Individualized, multidisciplinary decision making is warranted in cases of small, solitary high-grade Ta bladder tumors.

Question 35

What is the gold standard for bladder-preserving treatment of high-risk NMIBC? What are the recommendations for SOT candidates with high-risk NMIBC?

Answer 35

Intravesical bacillus Calmette-Guérin (BCG) is the gold standard, but radical cystectomy is an option for some. A minimum 2-year disease-free interval before SOT is recommended. Decisions on BCG duration and SOT timing should be individualized.

Question 36

What are the survival rates and treatment considerations for Muscle-Invasive Bladder Cancer (MIBC) in SOT candidates?

Answer 36

5-year overall survival rates are 50%-60%. Radical cystectomy with platinum-based neoadjuvant chemotherapy is the gold standard. Candidates who have not developed recurrence within 2 years of radical cystectomy should be considered for SOT, with individualized decisions for those treated with trimodal therapy.

Question 37

What are the treatment considerations for urothelial carcinoma in SOT recipients, including the use of BCG and cisplatin-based chemotherapy?

Answer 37

BCG is generally contraindicated due to concerns over decreased efficacy, infection, and graft rejection. Some may proceed with BCG, but evidence is limited. Cisplatin-based chemotherapy is a concern due to nephrotoxicity, especially in renal transplant recipients, but severe acute renal toxicity seems uncommon.

Question 38

What are the considerations for serum tumor markers in the diagnostic process of testis cancer in SOT candidates or patients with organ failure? Mention potential false-positive indicators.

Answer 38

Serum tumor markers are vital for staging in men with testis cancer. However, these markers can be artificially elevated in certain organ failure states. β-human chorionic gonadotropin may be falsely elevated in chronic kidney disease, and alpha-fetoprotein may be elevated by cirrhosis. Awareness of false-positive serum tumor markers in patients with renal or liver dysfunction is essential.

Question 39

What are the five-year survival rates and recurrence rates in stage I testis cancer?

Answer 39

The five-year survival rates in stage I testis cancer should approach 100%. Recurrence rates range from approximately 15% to 50% based on risk factors such as lymphovascular invasion and predominance of embryonal histology in nonseminoma. Most recurrences occur within the first 2 years, but some may recur later.

Question 40

Describe the individualized approach to managing stage I testis cancer in the SOT candidate.

Answer 40

Multidisciplinary decision-making should focus on risk factors for recurrence and the urgency of transplantation. Patients with urgent SOT needs, no risk factors, or who have received adjuvant treatment can proceed with transplantation, while those with higher recurrence risk or less urgency may benefit from adjuvant therapy or up to a 2-year observation period.

Question 41

What are the main treatments and 5-year survival rates for stage II-III testis cancer?

Answer 41

Stage II-III testis cancer is typically treated with cisplatin-based chemotherapy, radiation, or retroperitoneal lymph node dissection. 5-year OS estimates are 96%, 89%, and 67% for good, intermediate, and poor-risk nonseminoma, respectively. In seminoma, 5-year OS rates are 95% and 88% for good and intermediate risk, respectively. The approach to transplantation is often individualized, with good-risk patients proceeding without delay.

Question 42

What considerations are involved in managing testis cancer in the SOT recipient?

Answer 42

Low-level evidence suggests that SOT may increase the risk of developing testis cancer. The considerations in administering cisplatin to a patient with testis cancer and a renal transplant are similar to those for patients with urothelial cancer.

Question 43

What are the two primary management techniques for penile cancer, and what is the recurrence rate for those treated with penile-sparing techniques?

Answer 43

Penile cancer may be managed with penile-sparing techniques or partial/radical penectomy. The recurrence rate for those treated with penile-sparing techniques is approximately 30%.

Question 44

What is the chance of nodal or distant recurrence in a patient with treated local disease and pathologically negative inguinal lymph nodes after a node staging procedure?

Answer 44

The chances of nodal or distant recurrence are less than 5%.

Question 45

In patients with risk factors like lymphovascular invasion and high-grade disease, what is the risk of occult nodal metastases if they have not undergone an inguinal node staging procedure?

Answer 45

The risk of occult nodal metastases can be as high as 25% in these patients.

Question 46

The risk of occult nodal metastases can be as high as 25% in these patients.

Answer 46

The 5-year recurrence-free survival rate is 84%.

Question 47

What are the median times for recurrence and overall survival after recurrence in pathologically node-positive patients?

Answer 47

The median time to recurrence is approximately 6 months, and the median overall survival after recurrence is typically around 5 months.

Question 48

The median time to recurrence is approximately 6 months, and the median overall survival after recurrence is typically around 5 months.

Answer 48

Incidence rates for invasive penile cancer after SOT are up to 10 times those of the population average, and for carcinoma in situ, the rates are approximately 20 times higher.