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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 1  |  Page : 103-106
Carcinoma of the tongue in a renal transplant recipient: A rare post-transplant malignancy


1 Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

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Date of Web Publication8-Jan-2015
 

   Abstract 

Current immunosuppression improved long-term outcome of transplant patients, but it also increased the incidence of de novo malignancy. Organ transplant recipients have a threeto four-fold increased risk of developing carcinoma in comparison with the general population. Common malignancies encountered after transplantation include cancer of the skin, lips, post-transplant lymphoproliferative disease, ano-genital carcinoma and Kaposi sarcoma. Squamous cell carcinoma of the tongue is very rare. We report here a case of squamous cell carcinoma of the tongue in an adult male patient who developed it 11 years post-transplant. He underwent right hemiglossectomy and his graft function remained stable.

How to cite this article:
Prakash J, Prabhakar, Kumar M, Aralapuram K. Carcinoma of the tongue in a renal transplant recipient: A rare post-transplant malignancy. Saudi J Kidney Dis Transpl 2015;26:103-6

How to cite this URL:
Prakash J, Prabhakar, Kumar M, Aralapuram K. Carcinoma of the tongue in a renal transplant recipient: A rare post-transplant malignancy. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Jul 23];26:103-6. Available from: http://www.sjkdt.org/text.asp?2015/26/1/103/148753

   Introduction Top


The overall incidence of malignancy in renal transplant recipient is higher than in the dialysis patients and in the general population, and prolonged immunosuppression is the major risk factor. [1],[2],[3] Squamous cell carcinoma of the skin, lips, cervix, vulva, scrotum, penis and anus are commonly reported in renal transplant recipients. [4] However, squamous cell carcinoma of the tongue is rarely reported. [5],[6] We are presenting here the occurrence of squamous cell carcinoma of the tongue 11 years after renal transplant in an adult male renal transplant recipient with a well-functioning allograft. The patient had an excellent graft function throughout the course of his illness. He died of sepsis related to pneumonia 14 months after the diagnosis of the carcinoma of the tongue, with stable graft function at the time of death.


   Case Report Top


A 46-year-old man underwent a living unrelated renal allograft transplant in February 2001 due to end-stage renal disease secondary to chronic glomerulonephritis. The kidney donor was his cousin brother, who was ABO compatible with one HLA mismatch at HLAA and HLA-B loci. Viral markers were negative and his intraand post-operative course was uncomplicated. No immunosuppressive induction therapy was administered. He was maintained with triple immunosuppression regimen: Cyclosporine, azathioprine and steroids. Good graft function was achieved within a week and his baseline creatinine was 1.33 mg/ dL. He developed new-onset diabetes four months after transplantation. He had no episode of acute rejection during his post-transplant course. Eleven years post-transplant, he presented with a non-healing ulcer over the right lateral margin of his tongue for one month. The ulcer was whitish in color and painless [Figure 1]. There was no evidence of malignancy in the pre-transplant period. The patient was a non-smoker and non-alcoholic and denied any history of tobacco and betel chewing. He had no history of wearing dentures and no identifiable source of chronic irritation in his oral cavity.
Figure 1: Photograph showing non-healing ulcer over the right margin of the tongue of 1 month duration.

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The systemic physical examination was unremarkable except for the ulcer of the tongue. A biopsy from the ulcer area revealed a welldifferentiated squamous cell carcinoma. The patient underwent right hemiglossectomy. The histopathological examination revealed a welldifferentiated squamous cell carcinoma; the maximum depth of the infiltration was 2 cm, with 4 mm each of tumor-free excisional margins. Lymphatic and blood vessel invasion were not seen [Figure 2]. In view of the malignancy, the doses of cyclosporine and azathioprine were reduced after the hemiglossectomy. His graft function was continued to be stable in the subsequent follow-up. He presented with severe sepsis related to pneumonia 14 months after the diagnosis of the carcinoma of the tongue and died of multi-organ failure.
Figure 2: Photo-micrograph showing welldifferentiated squamous cell carcinoma of the tongue (hematoxylin and eosin, ×200).

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   Discussion Top


Morbidity and mortality due to graft dysfunction have declined due to improved immunosuppressive therapy, but at the same time transplant-related malignancies have emerged as one of the important complications. [6] Currently, malignancy is a major factor limiting the life expectancy of the transplant patients. The recent analysis of the Australia and New Zealand Transplant Registry (ANZTR) demonstrated that cancer had exceeded cardiovascular disease as the leading cause of late post-transplant death after 2002. [5],[7] Information regarding the incidence of cancer in renal transplant patients originates primarily from registries including the Isreal Penn International Transplant Tumor Registry (IPITTR) and the ANZTR. [5],[8],[9] The IPITTR reported 9,688 different types of cancer in 9032 renal transplant recipients in 2000. [1] The main types of cancer in the transplant recipients were lymphomas, post-transplant lymphoproliferative disease, cancer of the skin and lips followed by uro-genital malignancies, Kaposi sarcoma and hepato-cellular and renal cell carcinoma. [1] Similar results have been reported in the ANZTR registry, which included 13,077 renal transplant recipients from 1980 to 2003. [7] The cumulative risk of developing at least one cancer was approximately 30% by 20 years posttransplant. [7] Wimmer et al, in their observational study of 2419 renal transplant recipients from 1978 to 2005, observed that the cumulative incidence of cancer in renal transplant patients over 25 years of follow-up was 49.3% compared with 21% for the healthy sexand age-matched controls. [5] They also observed that 45% of the recipients developed all tumors within five years and that 71% developed all tumors within 10 years post-transplant, whereas the tumor incidence gradually increased with time in the normal population. [5] The most common cancer in the renal transplant recipients was the non-melanoma skin cancer (20.5%), followed by the kidney cancers (12%) and cancer of the pharynx, larynx and oral cavity (8.2%). [6]

Squamous cell carcinoma of the tongue was rarely reported in the transplant registries. Young et al were the first to report a case of a squamous cell carcinoma of the tongue in a 26-year-old male, nine years after transplantation in 1978. [10] Malleshappa et al from India reported a case of a squamous cell carcinoma of the tongue in a 30-year-old male nine years post-transplant in 2009. [11] In contrast to the rare occurrence of the carcinoma of the tongue in transplant recipients, the squamous cell carcinoma of the tongue is the most common intraoral malignancy in the general population. [10] It occurs most commonly in the males in the sixth to eighth decades, and tobacco chewing, smoking, chronic irritation and human papilloma virus play an important role in the incidence of tongue carcinoma. [10] The risk factors for the development of cancer in the transplant recipients include male gender, older age, pre-formed antibodies before transplantation and cumulative dose and duration of immunosuppression. [6] The pathogenesis of the increased incidence of cancer in post-transplant patients is not well known. The proposed mechanisms for the development of cancer in transplant recipients include immunosuppression-mediated inhibitory effect on tumor surveillance of the neoplastic cells, tumor-promoting effect of immunosuppression, uncontrolled proliferation of oncogenic viruses and cause of primary kidney disease (analgesic abuse, herbal preparation, hepatitis B and C infection) and end-stage renal disease milieu itself (acquired renal cystic kidney disease). [4]

In our case, the cause of squamous cell carcinoma of the tongue in a patient without a risk factor could be due to prolonged immunosuppression or reactivation of human papilloma virus. This case highlights the possible occurrence of the carcinoma of the tongue, the most common malignancy of oral cavity in the general population, in transplant patients.

Conflict of interest: None

 
   References Top

1.
Penn I. Cancers in renal transplant recipients. Adv Ren Replace Ther 2000;7:147-56.  Back to cited text no. 1
    
2.
Lutz J, Hemann U. Tumors after kidney transplantation. Curr Opin Urol 2003;7:105-9.  Back to cited text no. 2
    
3.
Kauffman HM, Cherikh WS, Mc Bride MA, Cheng Y, Hanto DW. Post transplant de novo malignancies in renal transplant recipients: The past and present. Transpl Int 2006;19:607-20.  Back to cited text no. 3
    
4.
Jane CT, Stephan B, John DS. Clinical management. In Brenner and Rector's, The Kidney 9th ed. Philadelphia, USA: Saunders Press; 2012. p. 2515-55.  Back to cited text no. 4
    
5.
Wimmer CD, Rentsch M, Crispin A, et al. The janus face of immunosuppressionde novo malignancy after renal transplantation: the experience of transplantation center Munich. Kidney Int 2007;71:1271-8.  Back to cited text no. 5
    
6.
Flechner SM. Cancer and renal transplantation. Adv Stud Med 2007;7: 411-9.  Back to cited text no. 6
    
7.
Chapman J, Webster AC. Cancer Report: ANZDATA Registry 2004 Report. Adelaide, Australia: Australia and New Zealand Dialysis and Transplant registry; 2004.  Back to cited text no. 7
    
8.
Penn I. Occurrence of cancer in immunosuppressed organ transplant recipient. Clin Transpl 1998:147-58.  Back to cited text no. 8
    
9.
Chapman JR, Sheil AG, Disney AP. Recurrence of cancer after renal transplantation. Transplant Proc 2001;33:1830-1.  Back to cited text no. 9
    
10.
Young WL, Susan DG. Squamous cell carcinoma of tongue in a nine year renal transplant survivor: A case report with a discussion of the risk of development of epithelial carcinoma in renal transplant survivors. Cancer 1978;41:1-6.  Back to cited text no. 10
    
11.
Malleshappa P, Aghariya M, Tampi C, Shah BV. Squamous cell carcinoma of tongue in a renal transplant recipient. Indian J Med Paediatr Oncol 2009;30:136-7.  Back to cited text no. 11
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Correspondence Address:
Dr. Jai Prakash
Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
India
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DOI: 10.4103/1319-2442.148753

PMID: 25579725

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