www.elsevier.com/locate/humpath

De novo concurrent papillary renal cell carcinoma andangiomyolipoma in a kidney allograft: evidence ofdonor origin

Samuel Rotmana,*, Cedric Deruazb, Jean-Pierre Venetzb, Pascal Chauberta,Jean Benhattara, Jean-Yves Meuwlyc, Patrice Jichlinskid, Louis Guilloua,Solange Molle, Manuel Pascualb, Robert Lemoinef

aInstitute of Pathology, University Hospital, CH-1011 Lausanne, SwitzerlandbDepartment of Nephrology, University Hospital, CH-1011 Lausanne, SwitzerlandcDepartment of Radiology, University Hospital, CH-1011 Lausanne, SwitzerlanddDepartment of Urology, University Hospital, CH-1011 Lausanne, SwitzerlandeInstitute of Pathology, University Hospital, CH-1211 Geneva, SwitzerlandfInstitute of Pathology, CH-2007 Neuchatel, Switzerland

Received 28 January 2005; accepted 14 November 2005

0046-8177/$ – see front matter D 2006

doi:10.1016/j.humpath.2005.11.024

* Corresponding author.

E-mail address: samuel.rotman@chu

Keywords:Papillary renal cell

carcinoma;

Angiomyolipoma;

Renal allograft;

Molecular genetics

Summary In the general population, renal cell carcinoma (RCC) is a relatively common neoplasm;

however, the papillary RCC subtype is infrequent and represents only 10 to 15% of all RCC.

Angiomyolipoma is a well-known common benign tumor. The occurrence of RCC in association with

angiomyolipoma is a rare event, with only approximately 50 cases reported in the nontransplantation

setting. In transplant recipients, RCC can develop in native kidneys, but its occurrence bde novoQ in the

renal allograft is very rare with an estimated incidence of less than 0.5%. We report here the case of a

39-year-old woman who underwent cadaveric renal transplantation in 1990. No lesion was observed in

the allograft during the pre- and perioperative period or on early postoperative ultrasounds. No graft

rejection occurred under a standard triple immunosuppressive therapy. Thirteen years later, during a

routine ultrasonography, 2 solid masses were discovered in the allograft, both of them richly vascularized.

She underwent allograft nephrectomy and the histologic findings revealed that one of the tumors was a

chromophilic (type 1) papillary RCC (2.5 cm in diameter) and the other, an angiomyolipoma (1.5 cm).

Microsatellite analysis of the allograft, as compared with the recipient peripheral blood leukocytes,

demonstrated that the 2 tumors (1 malignant and 1 benign) were of donor origin. To our knowledge, this is

the first report of de novo concurrent papillary RCC and angiomyolipoma in a renal allograft.

D 2006 Elsevier Inc. All rights reserved.

Elsevier Inc. All rights reserved.

v.hospvd.ch (S. Rotman).

1. Introduction

Cancer of the kidney represents 2% of the total human

cancer burden, and papillary renal cell carcinoma (PRCC),

Human Pathology (2006) 37, 481–487

S. Rotman et al.482

approximately 10% of renal cell carcinomas (RCCs) [1,2].

Two histomorphological types of PRCC, type 1 and type 2,

have been described [3,4]. Type 1 PRCC is associated with

a longer survival than type 2 PRCC, and a better prognosis

than bclassicQ clear cell renal carcinoma [2]. Angiomyoli-

poma (AML) is a benign tumor frequently found in the

kidney [5,6], the radiological detection of which poses the

differential diagnosis of a malignant tumor [7]. The

occurrence of RCC in association with AML in the native

kidney is a very rare event, with only approximately 50

cases reported [8-12]. Most carcinomas were of the clear

cell type [11,13].

Studies have reported an increase in the prevalence of

RCC in native kidneys of renal transplant recipients

compared with the general population [14-17]. However,

bde novoQ RCC in a renal allograft is a rare event with an

estimated incidence of less than 0.5% [18].

We present the first case, to our knowledge, of concurrent

de novo PRCC and AML developing in a renal allograft,

with radiological, histological, and molecular (genetic) data.

Fig. 1 A, Longitudinal sonographic view of the transplanted kidney (B

pole. A hypoechoic badly delineated zone is visible on the convexity

demonstrates high-flow signal within and around the mass. C, Coronal

specimen. a, papillary RCC (2.5 cm). b, simple cyst. c, angiomyolipom

1.1. Case report

A 39-year-old woman presented with advanced renal

insufficiency of unknown etiology since 1986. She was

treated by hemodialysis for 1 year and in 1987 underwent

her first cadaveric renal transplantation. Three weeks later,

severe vascular rejection required an aggressive immuno-

suppressive therapy with corticoidsteroids, antithymocyte

globulin, and OKT3 without any amelioration of the renal

function. Hemodialysis had to be restarted, and in 1988, the

patient underwent her first allograft nephrectomy.

In May 1990, she received second renal allograft from

a male cadaveric donor. No lesion was identified in the

allograft during surgery, and in the 7 years after the trans-

plantation, 3 renal ultrasounds confirmed the absence of

lesions in the allograft. No graft rejection occurred under a

standard immunosuppressive therapy with cyclosporine,

prednisone, and azathioprine. In April 2003, during a

routine ultrasonography, 1 large cortical cyst and 2 solid

masses were discovered in the allograft. Both solid masses

mode). A rounded hypoechoic mass (arrow) is visible at the lower

(arrowheads). B, Color Doppler ultrasound of the upper lesion

T2 MRI shows a bright cyst and 2 solid masses. D, Nephrectomy

a (1.5 cm). Abbreviations: C, cyst; M1 and M2, masses.

De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 483

appeared heterogeneous on B mode and richly vascularized

on color Doppler ultrasound. A magnetic resonance imaging

confirmed the presence of 1 cortical cyst and 2 solid masses.

In June 2003, the patient underwent her second allograft

nephrectomy, and she returned to hemodialysis.

2. Materials and methods

2.1. Radiology

Sonography was performed with a HDI 5000 instrument

(Philips Ultrasound, Bothell, Wash) equipped with 5- to

12-MHz linear transducer. Gray scale (Fig. 1A) with

panoramic reconstruction and color Doppler (Fig. 1B)

explorations were obtained. The lower abdomen was im-

aged by using a phased-array torso coil with a 1.5-T unit

(Magnetom Symphony; Siemens Medical System, Erlangen,

Fig. 2 A and B, Papillary renal carcinoma, type 1, nuclear grade 1. The

small nuclei with inconspicuous nucleoli. The fibrovascular cores oft

magnification �100 and �200). C and D, Angiomyolipoma: benign tum

The vascular component shows tortuous and thick-walled blood vessel

demonstrates hypercellularity. A lymphocytic infiltrate (recipient cell

magnification �40 and �20).

Germany). Magnetic resonance imaging sequences included

T1- and T2-weighted sequences (Fig. 1C) without fat

saturation in transverse and coronal planes and T1-weighted

sequences with fat saturation in transverse plane after

intravenous injection of gadolinium.

2.2. Histology

For light microscopy examination, the tissue was fixed in

4.5% phosphate-buffered formalin, routinely processed, and

embedded in paraffin wax using standard methods. Sections

measuring 4 lm were stained with hematoxylin and eosin

and examined by 2 independent pathologists (S.R. and

L.G.). The morphological criteria described in the last World

Health Organization classification of tumors [19] were used

to establish the diagnosis of the renal tumors. Histologic

grade was established using the Fuhrman grading system

[20], and staging of RCC was performed according to the

2002 TNM classification [21].

tumor consists of a papillary growth of small cells containing oval

en contain foamy macrophages (hematoxylin and eosin, original

or composed of a mixture of fat, blood vessels, and smooth muscle.

s. The adipose tissue is of a mature type, and the smooth muscle

s) is admixed with the tumor (hematoxylin and eosin, original

S. Rotman et al.484

2.3. Fluorescent in situ hybridization analysis

Briefly, for fluorescent in situ hybridization (FISH),

4-lm frozen sections were treated with a protein-digesting

enzyme at 378C for 40 minutes. Preparations were denatured

in 70% formamide/2� standard saline citrate (SSC), pH 7, at

758C, for 2 minutes. Then, a solution containing a specific

probe for the centromere of chromosomes X, Y, 7, and 17,

coupled with SpectrumGreen (Vysis, Downers Grove, Ill)

was applied to the tissue sections at 378C for 15 hours. After

hybridization, the unannealed probe was washed in 0.4�SSC/NP40 0.3% at 738C for 3 minutes then in 2� SSC/

NP40 0.1% at 378C for 2 minutes. Nuclei were counter-

stained using a 4,6-diamidine, 2-phenyllindol/antifade solu-

tion. A Zeiss Axioplan 2 imaging microscope (Zeiss,

Feldbach, Switzerland) equipped with appropriate filters

for 4,6-diamidine, 2-phenyllindol and SpectrumGreen was

used to score the number of centromeres of each chromo-

some in tumoral tissue and nontumoral tissue.

2.4. Microsatellite analysis

Frozen tissue samples from tumoral and nontumoral renal

allografts were used for microsatellite analysis. A blood

leukocyte sample was obtained from the patient. DNA was

extracted from blood and tissues using the DNeasy Tissue Kit

(Qiagen, Hilden, Germany). Two highly polymorphic

Fig. 3 Fluorescent in situ hybridization on papillary RCC: the papilla

chromosome 17. The loss of chromosome Y is typically observed in this

tumor (male donor versus female recipient).

markers (D8S255 and D9S156) were used to determine the

origin of the tumoral tissues. Primers were obtained from the

Genome Data Base (http://gdbwww.gdb.org). Polymerase

chain reaction cycling conditions were 35 cycles at 948C for

30 seconds, 568C for 45 seconds, and 728C for 45 seconds,

followed by 10 minutes at 728C. Products were separated byelectrophoresis in denaturing 6% polyacrylamide gels.

Microsatellite analysis of the allograft and the 2 tumors were

compared with that of leukocytes from the patient.

3. Results

3.1. Macroscopic findings

The nephrectomy specimen measured 12 � 6.5 � 4 cm

with a weight of 237 g. A solid, yellowish, and well-

demarcated mass, measuring 2.5 cm, was located in the lower

cortical pole (Fig. 1D and A). A second mass (Fig. 1D and C),

which measured 1.5 cm, was located between the hilar region

and the medulla of the kidney. This mass was less well-

demarcated than the first one and showed a gray-white and

striped appearance. These 2 tumors were completely separate

from each other. A cortical cyst (Fig. 1D and B) measuring

3.5 cm was located in the vicinity of the smaller mass but

clearly separated from it. Except for these 3 lesions, the renal

parenchyma was unremarkable.

ry RCC presents a triploidy and/or a polyploidy of chromosome 7,

type of RCC but does not allow us to determine the origin of this

Fig. 4 Fluorescent in situ hybridization on angiomylipoma: angiomylipoma presents an XY phenotype showing that the tumor developed

from the donor. This technique, together with the microsatellite analysis, demonstrates that both tumors originated from the donor organ.

Abbreviations: Ly, lymphocytes (recipient cells); End, endothelial (tumor cells); My, myocytes (tumor cells).

Fig. 5 Microsatellite analysis of the allograft as compared with

the recipient’s peripheral blood leukocytes, showing that the PRCC

and the AML originated from the donor’s organ, using the

2 markers D8S225 and D9S156.

De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 485

3.2. Histology

The 2.5-cm cortical mass (Fig. 1D and A) showed a

papillary growth pattern. The central cores of the papillae

were frequently filled with foamy macrophages. Papillae

were covered by a single layer of small cells (Fig. 2A and B)

with scant cytoplasm. This tumor corresponded to a PRCC

type 1 according to the 2004 classification of renal tumors

[19] and was of grade 1 according to the Fuhrman grading

system [20].

The 1.5-cm medial mass (Fig. 2C and D) was composed

of a mixture of adipose tissue, smooth muscle cells, and

numerous thick walled vessels of varying size. The adipose

tissue was composed of mature adipocytes. The smooth

muscle component was composed of intersecting fascicles

of smooth muscle cells without any visible mitotic activity

or necrosis. A relatively abundant lymphocytic infiltrate

accompanied all different tumoral components. This neo-

plasm corresponded to an angiomyolipoma according to the

2004 classification of renal tumors [19].

The cystic structure (Fig. 1D) corresponded to a simple

cyst with no evidence of malignancy.

3.3. Fluorescent in situ hybridization analysis

Fluorescent in situ hybridization using chromosome

7 and 17 probes showed trisomy 7 and 17 in many PRCC

cells (Fig. 3). In addition, a loss of chromosome Y and a

conservation of chromosome X was observed in this tumor

(Fig. 3) using chromosomes X and Y probes, confirming the

diagnosis of PRCC.

Fluorescent in situ hybridization using chromosome X

and chromosome Y probes on the AML showed the

presence of these 2 chromosomes in endothelial and smooth

muscle cells (Fig. 4). Two signals were observed in the

lymphocytic nuclei originating from the recipient, whereas

S. Rotman et al.486

no signals were observed with chromosome Yprobe (Fig. 4).

This indicated that the AML tumor was of donor origin but

that lymphocytes within it were of recipient origin.

3.4. Microsatellite analysis

Polymerase chain reaction amplification products

obtained from the PRCC presented the same band profile

as that of allograft DNA (non PRCC tissue) but was

different from that of recipient peripheral blood leukocytes

(Fig. 5), indicating the donor origin of the PRCC tumor.

For the AML, DNA amplification products showed a

band profile corresponding to a mixture of that of donor

allograft and recipient leukocyte profiles (Fig. 5).

4. Discussion

Papillary renal cell carcinoma comprises approximately

10% of RCC in the general population. Two morphological

types of PRCC have been described. Type 1 PRCC is usual-

ly of lower stage and grade than type 2 neoplasm [3] and

shows a better prognosis [2]. Papillary renal cell carcinoma

is associated with karyotypic changes with trisomy or

tetrasomy 7, trisomy 17, and a loss of chromosome Y [22].

Nephrectomy is a common treatment of malignant tumors,

although partial nephrectomy is sometimes preferred to spare

some renal tissue and preserve the renal function depending

on tumor size and stage [23].

Angiomyolipoma is a relatively uncommon benign tumor

of the kidney (1% of renal tumors), with a 4:1 female-to-

male ratio [19]. It may arise either in the cortex or medulla of

the kidney. It may occur sporadically or in patients with

tuberous sclerosis (TS), an inherited autosomal dominant

syndrome. The genes TSC1, located on chromosome 9p34

[24], and TSC2, located on chromosome 16p13 [25], play a

pathogenic role in TS. AML frequently show a loss of

heterozygosity of TSC2 gene locus in both sporadic and TS-

associated neoplasms [25]. Loss of heterozygosity of the

TSC1 gene in AML is also occasionally observed [26].

Because AML contains a significant vascular compo-

nent, radiological imaging can be misleading, mimicking a

malignant process. Because needle biopsy is generally

contraindicated in this kind of highly vascularized tumor,

definitive diagnosis relies upon pathological examination of

excision specimens. The development of concurrent renal

cell carcinoma and AML in a native kidney is a very rare

event, with about only 50 cases described in the literature

[8,10,13]. Sporadic cases of PRCC and AML developing

together in the same native kidney have been reported, but

to our knowledge, none of these concurrent tumors were

described in a renal allograft.

In transplantation, the prevalence of tumors has been

linked to the immunosuppression status [14,16]. The

prevalence of renal malignant tumors in renal transplant

recipients is 7.8% [27], compared with 4% to 5% in the

general population [19]. The great majority of renal cell

carcinomas are found in the native kidneys of renal

transplant recipients [9,17]. The occurrence of de novo

tumors in the renal allograft is very rare and represents less

than 10% of RCC developing in renal transplant recipients

[28]. Most cases of RCC are of clear cell type, but sporadic

PRCC have also been reported. The type of renal cell

carcinoma is of prognostic importance because clear-cell

neoplasms show a more aggressive behavior than PRCC [1].

In this report, we present the first case, to our knowledge,

of concurrent PRCC and AML in a renal allograft,

developing several years after transplantation.

No lesions were identified in the allograft at the time of

the operation, and routine postoperative radiological inves-

tigations of the allograft were normal. However, during a

routine ambulatory ultrasound, the presence of these 2 renal

tumors was discovered. Radiological imaging revealed

2 distinct richly vascularized tumoral lesions.

For technical reasons a nephrectomy of the allograft was

performed after discussion with the urological team.

Microscopic examination revealed the presence of 2

distinct tumors, 1 type 1 PRCC, and 1 AML. In absence of

any radiological lesions during the years after the renal

allograft, these tumors were considered as de novo tumors.

Differential diagnosis included a metastasis from a PRCC

located in the native kidney of the recipient and an AML,

which could have developed from the periallograft mesen-

chymal tissue of the recipient. Yet, knowing that the

recipient was a woman and that the kidney allograft came

from a male donor, the FISH analysis using chromosome X

and chromosome Y probes clearly demonstrated that the

AML came from the male donor. The lymphocytic infiltrate

of the recipient within the AML provided a good binternalcontrolQ of the FISH technique. The presence of a large band

obtained by microsatellite analysis of AML cells was

explained by a mixture of this lymphocytic infiltrate

(recipient cells) with tumoral cells (donor origin) in the

amplification (polymerase chain reaction) product.

The loss of chromosome Y, which is classically observed

in PRCC [22], cannot be used as a proof for the origin of the

tumoral cells by FISH technology. However, this technique,

which is able to detect the polyploRdy 7 and 17 of the PRCC,allowed us to confirm the histologic diagnosis of PRCC

[22]. A microsatellite analysis was subsequently performed

to circumvent the problem of loss of chromosome Y in

PRCC. This technique showed the same band profile for the

PRCC cells and the normal (nontumoral) renal cells of

the allograft and, thus, demonstrated the donor origin of the

PRCC. As previously mentioned, the absence of a prior

radiological lesion was consistent with a de novo PRCC

developing in the allograft.

To conclude, we report of case of a de novo concurrent

PRCC and AML developing in a renal allograft. Using

FISH and microsatellite analysis, we have demonstrated that

both PRCC and AML were tumors of donor origin.

Interestingly, recipients of other allografts from the

same cadaveric donor did not develop tumors during their

De novo concurrent papillary renal cell carcinoma and angiomyolipoma in a kidney allograft 487

follow-up. An extensive radiological workup of our patient

did not reveal any other tumors, nor were profile metastasis

of the PRCC found. This, taken in combination with the

low grade and low stage of RCC and benign nature of the

AML, indicates an excellent prognosis for our patient after

her allograft nephrectomy. Fifteen months after the

nephrectomy, she is doing well on maintenance hemodial-

ysis with no tumor recurrence.

A review of all allograft nephrectomies (n = 25) at our

center over the last 11 years did not reveal any other case of

de novo RCC in allografts, confirming the rarity of this

clinicopathologic complication.

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