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the incidence of malignancy in transplant patients is higher than in the general population , ranging from 2% to 31% and approaching 50% in patients more than 20 years post - transplantation . here
we present the case of a 73-year - old woman who developed squamous cell carcinoma of the bladder 6 years following renal transplant .
this case report details the treatment course of a 73-year - old female with diabetes mellitus type ii , hypertension and end - stage renal disease who received a deceased donor renal transplant in 2008 .
the patient s surgical history also includes a right nephrectomy in 1960 secondary to what was presumably unilateral tubulointerstitial nephritis due to mycobacterium tuberculosis . since transplantation
, the patient s immunosuppression regimen has consisted of tacrolimus 0.5 mg twice daily and cellcept 500 mg twice daily .
the patient initially presented with nausea and vomiting , pain at the transplant site and decreased urine output .
laboratory studies revealed a serum creatinine of 5.5 mg / dl , a significant increase from her baseline of 0.6 mg / dl . her urinary analysis was negative for infection and revealed only 1 red blood cell per high - power field . upon admission , an ultrasound demonstrated hydronephrosis and increased resistive indices . a computed tomography ( ct ) scan without contrast of the abdomen and pelvis was performed .
the following day , the patient underwent nephrostomy tube placement by interventional radiology through which a nephrostogram was obtained .
the patient s serum creatinine improved and she was discharged from the hospital with plans for a cystoureterogram . in the interim ,
figure 1:saggital view of a mass at the dome of the decompressed bladder.figure 2:aterograde nephrostogram demonstrating the obstruction at the ureterovesical junction .
the patient underwent an attempted neoureterocystostomy in an effort to alleviate the stricture at the distal transplant ureter - vesical anastomosis .
once isolated , a 4  4 cm mass encircling the distal transplant ureter was visualized ( fig .
the mass was excised and sent to pathology for frozen section analysis , which revealed squamous cell cancer arising from the bladder wall .
the urology service was immediately available and elected to perform a partial cystectomy with transplant ureteroileal conduit creation .
the patient returned to the operating room for a radical cystectomy and regional lymph node dissection with a left nephroureterectomy .
the final pathology confirmed a diagnosis of invasive squamous cell carcinoma ( 4 cm in diameter ) with invasion into the transplant ureter , perinephric fat , lamina propria and muscularis propria .
two of nine peri - vesical lymph nodes were positive for metastatic squamous cell carcinoma , making her t3an2m0 ( stage iv ) .
the patient was switched from cellcept to everolimus postoperatively to take advantage of its antitumor properties .
it is well known that the incidence of malignancy is higher among transplant recipients than the non - grafted population .
specifically , the incidence of urologic cancer is 10 times higher among renal transplant patients than in the general population .
less than 5% of all bladder tumors are of squamous cell origin , with an incidence of 0.2/100 000 in the general population of western countries .
renal transplant patients have an incidence of 133/100 000 , reflecting the increased risk of developing cancer in this patient population .
the association between cyclophosphamide and azathioprine therapy and the development of bladder cancer is well established .
this patient s immunosuppressive therapy consisted of cellcept and tacrolimus . in their retrospective analysis of 3 741 consecutive renal transplants , davis et al . discovered that 80% of their patients who developed bladder squamous cell cancer received cellcept and tacrolimus for immunosuppression .
the remaining 20% received cyclophosphamide and azathioprine prior to the year 2000 at which time they were converted to cellcept and tacrolimus .
the patient discussed in this report was switched to everolimus , an mtor inhibitor , which has been demonstrated to reduce the occurrence of de novo cancer in kidney transplant patients .
this appears to be related to a suppressive effect on cell proliferation and neovascularization as well as a reduction in overall host immunosuppression . in transplant recipients who have developed cancer
, this appears to be an important component in the treatment strategy . in extreme cases , as with high - grade and invasive pathology , graft removal may be required so that immunosuppression may be avoided all together .
one study suggests screening patients with risk factors that may predispose them to the development of scc . in the single institution experience reported by davis et al .
each had notable risk factors such as a history of treatment with intravenous cyclophosphamide , chronic bladder outlet obstruction , long - term catheter use , chronic irritation to the genitourinary tract or a history of smoking .
interestingly , the patient described in this report did not possess a single one of these risk factors .
european guidelines have been developed supporting the screening of renal transplant recipients with known risk factors for developing bladder cancer , most notably persistent visible or microscopic hematuria .
they advocate for the use of urine cytology for non - visible hematuria ( > 5 red blood cells per high - power field ) in the absence of urinary tract infection or nephrolithiasis . based on their experience , davis et al .
advocate that patients with even one episode of microscopic hematuria should undergo urine cytology and ultrasound studies .
cystoscopy should be performed if the previous studies are non - revealing . as demonstrated by kim et al .
, this strategy may result in earlier detection of bladder cancer in renal transplant patients .
although the patient demonstrated neither visible nor microscopic hematuria , screening to identify potentially at risk - patients may facilitate early investigation and treatment .
there appears to be only one report in the literature describing renal tuberculosis requiring nephrectomy and the subsequent development of squamous cell carcinoma of the bladder following transplantation .
whether either of these patients were at a greater risk of developing squamous cell cancer of the bladder pre - transplant is unclear , but nevertheless an interesting query for meaningful investigation .
abstractit is well established in the literature that the incidence of malignancy is higher in transplant patients than in the general population . risk factors and screening guidelines for transplant patients 
 have been proposed , but are far from standardized . in this case report , we discuss the treatment course of a 73-year - old female with a history of renal tuberculosis , who developed squamous cell carcinoma at the transplant ureterovesical junction 6 years following graft placement . to our knowledge , this is the second reported case in a patient with a history of renal tuberculosis .