2022 - Lesson 23 (Management of Urological Malignancies in the Transplant Candidate or Recipient) Flashcards
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)?
No wait time is required. Surveillance is strongly recommended. Extenuating circumstances may require treatment.
What is the management approach for low risk prostate cancer (PSA <10 ng/mL, Gleason 6, T1c-T2a) in SOT candidates?
No wait time is required. Surveillance is strongly recommended. Extenuating circumstances may require treatment.
Describe the management for low-volume, intermediate risk prostate cancer in SOT candidates. Include criteria and considerations.
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.
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?
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.
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?
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.
What is the recommended approach for metastatic castration-resistant prostate cancer?
Median survival 2-3 years. Not a candidate for SOT. Best systemic therapy is advised.
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?
The recommended wait time is “No wait time,” and the 5-year recurrence-free survival rate is 95%−98%.
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?
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.
What are the 5-year recurrence-free survival rates and recommended wait times for transplantation for stages T2, T3, and T4 (N0, M0) RCC?
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.
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?
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.
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?
The recommended time interval to transplant is 6 months, with a 2-year local recurrence rate of 19%.
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?
The recommended time interval to transplant is 6 months, with a 2-year local recurrence rate of 39%.
Define the characteristics of high-risk bladder cancer, the 2-year local recurrence rate, and the time interval to transplant.
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.
What is the time interval to transplant for MIBC patients post-radical cystectomy, and what’s the recurrence rate?
The recommended time interval to transplant is 2 years, with a recurrence rate of 25%−37%.
What is the status of MIBC patients post-chemoradiation for SOT candidacy, and what’s the recurrence rate?
MIBC patients post-chemoradiation are not considered SOT candidates. The recurrence rate ranges from 25%−30% over a 10-year period.
What significant benefits are associated with solid organ transplantation (SOT) in patients with end-stage organ failure?
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.
How have the guidelines changed regarding the wait time for SOT after treatment for testis, bladder, and prostate cancers?
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.
What does current evidence imply about patients with diseases other than high-risk bladder cancer in terms of cancer-specific mortality (CSM) after SOT?
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.
How has the management of previous or concurrent prostate, kidney, and bladder cancers evolved, and what are the implications for urologists?
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.