Year : 2008 | Volume
: 19 | Issue : 6 | Page : 973--975
A transplant recipient with a mixed germ-cell ovarian tumor
Hafed Ketata1, Mahdi Bouacida1, Abdelkader Bouhlel1, Ahmed Sahnoun1, Ali Bahloul1, Soumaya Yaich2, Jamil Hachicha2, Mohamed Nabil Mhiri1,
1 Department of Urology, CHU Habib Bourguiba, Tunisia
2 Department of Nephrology, CHU Hedi Chaker, Sfax, Tunisia
Department of Urology, CHU Habib Bourguiba, Av. Majida Boulila, Sfax 3029
Immunosuppressed renal transplant recipients seem to be at significantly increased risk of developing neoplasms comparatively to nonimmunosuppressed individuals. A history of malignancy exposes the patient to a high risk for relapse after transplantation. We present a transplant recipient with a history of an ovarian mixed germ-cell tumor, with choriocarcinoma component, which was treated seven years prior to transplantation. After three years of follow-up, there was no evidence of tumor relapse. To our knowledge, there is no report of such case in the English literature. Regarding our case report and patients with a history of ovarian germ-cell neoplasm, waiting time before transplantation must take into consideration the stage of the tumor, its prognosis, the proportion of different tumor components, and the overall prognosis of the patient if transplantation is withheld.
|How to cite this article:|
Ketata H, Bouacida M, Bouhlel A, Sahnoun A, Bahloul A, Yaich S, Hachicha J, Mhiri MN. A transplant recipient with a mixed germ-cell ovarian tumor.Saudi J Kidney Dis Transpl 2008;19:973-975
|How to cite this URL:|
Ketata H, Bouacida M, Bouhlel A, Sahnoun A, Bahloul A, Yaich S, Hachicha J, Mhiri MN. A transplant recipient with a mixed germ-cell ovarian tumor. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Jul 5 ];19:973-975
Available from: http://www.sjkdt.org/text.asp?2008/19/6/973/43475
With the increasing number of patients listed for organ transplantation, the issue of preexisting malignancies in remission becomes more relevant. Immunosuppressed transplant recipients seem to be at significantly increased risk of developing neoplasms comparatively to nonimmunosuppressed individuals. A history of malignancy exposes the patient to a high risk for relapse after transplantation. 
Malignant ovarian germ-cell tumors (GCT) are much more curable than their epithelial counterparts, with a surviving rate of more than 75% at five years.  Patients with a history of treated ovarian GCT and a free-interval disease of more than five years could be excellent candidates for kidney transplantation.
We report a case of a transplant recipient with a history of treated ovarian GCT. To our knowledge, this case report represents the first description of kidney transplantation in a recipient with a history of such type of tumor.
A 19-year-old woman with end-stage renal failure caused by undetermined glomerulonephritis had received hemodialysis for eight months prior to renal transplantation. Seven years ago, she was hospitalized for pelvic pain mimicking appendicitis. The pelvic ultrasonography revealed a solid pelvic mass measuring 10 cm × 6 cm on the right ovary. The patient underwent pelvic laparotomy, right salpingo-oopherectomy and lymphadenectomy. Histology showed a 10 cm mixed germ-cell tumor with dysgerminoma, choriocarcinoma, and embryonal carcinoma components of the right ovary with clear resection margin. Lymph nodes were free of tumor (International Federation of Gynecology and Obstetrics Stage I). Neither liver nor lung metastatic localizations were detected on CT scan of the abdomen, pelvis, and thorax. The patient was subsequently treated with three courses of PVB (cisplatin, vinblastine, bleomycin) chemotherapy. Six months after the end of chemotherapy, serum human chorionic gonadotrophin (βHCG), alpha fetoprotein, and LDH levels were within normal limits.
During seven years of follow-up, and at the time of evaluation prior to renal transplantation, there was no evidence of tumor recurrence. Therefore, a renal transplantation from a living donor was performed with insertion of the graft in the left iliac fossa. The Immunosuppressive regimen included azathioprine, methylprednisolone, mycophenolate mofetil (Cellcept® ) and antilymphocyte antibodies. Renal function became normal on the third post-operative day. Three months later, ultrasonography showed an 8 cm local lymphocele with compression of the ureter. The patient underwent marsupialization with epiploplasty by open surgery. Cytology analysis of the lymphocele liquid was negative for malignant cells. After three years of post transplantation follow-up, there is no radiological or biological evidence of tumor relapses.
Prevalence of malignancies in transplant candidates is imprecise and varies between 0.02% and 10%. ,, A history of previous malignancy influences patient survival of allograft recipients. The survival rate is significantly lower when compared with patient survival for recipients with no previous malignancy.  Criteria for the acceptance of patients onto transplantation waiting lists usually exclude those who have had a diagnosis of cancer within the previous two years. These policies are appropriate to avoid the recurrence of cancer after transplantation, since immunosuppressive therapy may promote growth of dormant malignant cells.
Ovary GCTs are rare and represent less than 5% of all ovarian tumors. No data are available on the prevalence of such tumors in the American or Australian and New Zealand databases of pre-transplant evaluation. ,
The prognosis of patients with ovarian GCTs has improved significantly as a result of advances in systemic treatment with cisplatincontaining chemotherapy, with 5-year survival rates varying between 75% and 100% for stage I and II.  In comparison with other solid tumors, gonadal malignancies have relatively good prognosis, maybe because of the easy complete resectability of the primary tumor. 
Due to its rarity and multiplicity of histological components, ovarian GCT was not especially concerned for in guidelines for waiting time in patients with malignant disease prior to transplantation. ,, Histology and evolution of ovarian GCT are comparable to the testicular ones.  According to the American and European guidelines, a waiting time of two years, after cancer remission, for testicular malignancies is recommended. , However, early recurrence of good prognosis testicular GCT (seminoma, Stage I) was described four months after transplantation despite a waiting time of two years with no evidence of relapse.  Accordingly, extrapolation of waiting time of testicular cancers to ovarian cancers should be made cautiously, particularly in case of mixed GCTs or choriocarcinoma component, which have worse outcomes than embryonal carcinoma or dysgerminoma. 
Early reports of previous malignancies in transplant recipients suggest varying rates of recurrence (0-67%) with varying follow-up periods (8-36 years). ,,, Recurrence rate of ovarian GCTs in immunosuppressed patients was not previously studied. In a study of 29 nonimmunosuppressed women treated for ovarian GCTs, the recurrence rate was 52% with a median interval from initial surgery to recurrence of 10 months. 
The most obvious strategy to prevent recurrence of preexisting malignancies is to avoid or delay organ transplantation and the concomitant immunosuppression. A five-year waiting period would eliminate the majority of recurrences. In our reported case, there was a freeinterval disease of seven years prior to kidney transplantation.
The choice of immunosuppressive therapy can also influence recurrence rate. Sirolimus (TOR inhibitor) based immunosuppressive therapy, after CsA withdrawal in the third month post transplantation, significantly reduced the risk for skin and non-skin cancer at five year after renal transplantation.  TOR inhibitors immunosuppression should be used for patients with a history of malignancy, or recurrence of a preexisting cancer. 
The factors that should be considered in each individual case are the histology, extent of cancer, duration between diagnosis and the proposed transplant, and timing of the diagnosis in relation to commencement of dialysis as well as natural history of cancer in the normal population, assuming that a 5 to 10% recurrence rate is deemed acceptable by the patient. 
Currently, recommendations based on evidence level for GCTs and population-specific characteristics are not available, which should also address frequency and enforcement of screening procedures.
We conclude that renal transplantation of a patient with a history of malignancy needs to be individually discussed, taking into account the prognosis of the tumor, stage and original extent of the disease, as well as the overall prognosis of the patient if transplantation is withheld. New immunosuppressive drugs may reduce recurrence rate of cancers and perhaps waiting time before transplantation. Additional trials are required to modify recommendations of waiting time for patients with malignancy.
|1||Dean C, Bloomfield D, Holt S. The challenge of germ cell tumour therapy in dialysis and transplantation. Nephrol Dial Transplant 2005; 20(12):2867-8.|
|2||Suita BS, Shono K, Tajiri T, et al. Malignant germ cell tumors: Clinical characteristics, treatment, and outcome. A report from the study group for pediatric solid malignant tumors in the Kyushu area, Japan. J Pediatr Surg 2002;37(12):1703-6.|
|3||Chapman JR, Sheil AG, Disney AP. Recurrence of cancer after renal transplantation. Transplant Proc 2001;33:1830-1.|
|4||Fischereder M, Jauch KW. Prevalence of cancer history prior to renal transplantation. Transplant Int 2005;18:779-84.|
|5||Penn I. Evaluation of transplant candidates with pre-existing malignancies. Ann Transplant 1997;2:14-7.|
|6||Kauffman HM, Cherikh WS, McBride MA, Cheng YA, Delmonico FL, Hanto DW. Transplant recipients with a history of a malignancy: risk of recurrent and de novo cancers. Transplant Rev 2005;19:55-64.|
|7||Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplantation candidates: Clinical practice guidelines. Am J Transplant 2001;1 Suppl 2:3-95.|
|8||The EBPG Expert Group on Haemodialysis. European Best Practice Guidelines for Renal Transplantation (part 1). Nephrol Dial Transplant 2000;15(Suppl 7):1-85.|
|9||Ayhan A, Taskiran C, Bozdag G, Altinbas S, Altinbas A, Yuce K. Endodermal sinus tumor of the ovary: The Hacettepe University experience. Eur J Obstet Gynecol Reprod Biol 2005;123:230-4.|
|10||Campistol JM, Eris J, Oberbauer R, et al. Sirolimus therapy after early Cyclosporine withdrawal reduces the risk of cancer in adult renal transplantation. J Am Soc Nephrol 2006; 17(2):581-9.|