|Year : 2012 | Volume
| Issue : 3 | Page : 427-429
Adjuvant pelvic irradiation for cervical cancer in the setting of a transplanted pelvic kidney
Majid M Mohiuddin1, Usama Mahmood1, Andrea A Hall1, Neil Rosenshein2
1 Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
2 Department of Gynecological Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
|Date of Web Publication||17-Nov-2012|
Majid M Mohiuddin
Department of Radiation Oncology, University of Maryland School of Medicine, 22 S. Greene St, Baltimore, MD 21201
Source of Support: None, Conflict of Interest: None
Postoperative radiation therapy is often needed following resection for gynecological cancers. A pelvic kidney, whether ectopic or transplanted, is considered an absolute contraindication for radiation if the organ is left in place. A 45-year-old, immunosuppressed patient with FIGO IB1 cervical adenocarcinoma was treated with intensity-modulated radiation therapy (IMRT) to 45 Gy to the modified whole pelvis with a boost to 59.4 Gy to high-risk areas despite having a transplanted kidney in the right iliac fossa. The irradiation prevented further local failure in the pelvis at 36-month follow-up with no decrement in renal function. Radiation to the modified pelvis using IMRT while avoiding the renal allograft is technically feasible and should be offered to more high-risk patients.
Keywords: Adjuvant pelvic radiation, immunosuppression, intensity-modulated radiation therapy, kidney transplant
|How to cite this article:|
Mohiuddin MM, Mahmood U, Hall AA, Rosenshein N. Adjuvant pelvic irradiation for cervical cancer in the setting of a transplanted pelvic kidney. J Can Res Ther 2012;8:427-9
|How to cite this URL:|
Mohiuddin MM, Mahmood U, Hall AA, Rosenshein N. Adjuvant pelvic irradiation for cervical cancer in the setting of a transplanted pelvic kidney. J Can Res Ther [serial online] 2012 [cited 2020 Apr 2];8:427-9. Available from: http://www.cancerjournal.net/text.asp?2012/8/3/427/103525
| > Introduction|| |
Patients on long-term immunosuppression have an increased incidence of aggressive cancers, worse survival, and decreased treatment tolerance.  Renal transplant patients with pelvic malignancies confound the clinical dilemma further. The nephropathy rate exceeds 30% in immunosuppressed patients receiving >10 Gy to the whole kidney.  Adjuvant IMRT in the setting of immunosuppression and a transplanted pelvic kidney has not been reported before.
| > Case Report|| |
A 45-year-old Caucasian woman with autosomal dominant polycystic kidney disease had an abnormal Pap smear (January 2006). Her native kidneys were non-functional. She had received a living donor kidney transplant 2 years prior and was on tacrolimus and mycophenolate mofetil. Renal function tests were normal.
Radical hysterectomy with bilateral salpingo-oophorectomy exposed a 2.7 cm exophytic, moderately differentiated tumor in the anterior endocervix involving the lower uterine segment with 2.1 cm invasion (April). Parametrial and vaginal margins were negative. Lymphovascular invasion was absent. Ten external iliac and four obturator lymph nodes were negative. The right iliac lymph nodes remained undissected because the transplanted kidney was located in the right iliac fossa. She was staged as FIGO IB1 cervical adenocarcinoma with clear cell features and p16 immunostaining consistent with carcinosarcoma. Two radiation centers refused to administer adjuvant radiation because of the transplanted pelvic kidney.
One year later, PET revealed FDG-avid adnexal masses measuring 8.9 × 6.2 cm on the right and 5.2 × 4.2 cm on the left. Maximally safe resection of the tumor, the left ureter, rectosigmoid mesentery, and serosa was done (October 2007). Pathology confirmed recurrent adenocarcinoma with p16+ carcinosarcoma. The operation left gross residual tumor on the right due to the nearby kidney and a close margin (<1 mm) demarcated by surgical clips on the left.
Adjuvant IMRT was now offered. The clinical target volume (CTV) incorporated the preoperative masses and the post-surgical, pelvic seromas. The initial planning target volume (PTV1) included the CTV and was expanded to the whole pelvis and lymphatics but excluded the transplanted right kidney with a 5-10 mm margin. A second planning target volume (PTV2) equaled the CTV plus 1-cm expansion with similar renal exclusion [Figure 1].
|Figure 1: Axial CT images of the modifi ed whole pelvis fi eld demonstrating the kidney (green), CTV (orange), PTV2 (cyan), PTV1 (blue), the 45 Gy isodose line (thin red), the 59.4 Gy line (thin yellow), and the 20 Gy line (thin purple)|
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PTV1 received 45 Gy at 1.8 Gy daily with nine fields as the "modified whole pelvis." PTV2 was a small field boost of 14.4 Gy with seven fields. The CTV received 59.4 Gy total [Figure 1]. No fields were directed through the kidney. No more than 28% of the kidney received 10 Gy on dose volume histogram [Figure 2].
|Figure 2: Dose volume histogram (DVH) of percentage dose to transplanted kidney (green), CTV (high-risk area, orange), and PTV1 (whole pelvis, blue) at 45 Gy (dashes) for the pelvis and a total 59.4 Gy (solid) when including the small field boost|
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Renal function tests were normal during and after treatment. Two months later, the patient complained of abdominal distention. PET/CT revealed an 18.8 × 16.0 × 18.5 cm soft tissue mass abutting the liver and enveloping the right transverse colon that pushed the transplanted kidney downwards without invasion, well above the pelvic irradiation field [Figure 3]a. The left-sided, pelvic seroma with surgical clips was smaller (3.3×3.7cm) than originally and PET negative [Figure 3]b.
|Figure 3: (a) Coronal CT scan of large abdominal recurrence displacing kidney from above but no pelvic disease, (b) axial image showing no recurrence near the kidney where the left-sided seroma with surgical|
clips has decreased from Figure 1 (bladder in blue)
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Right hemicolectomy, lymph node dissection and liver wedge resection confirmed p16+ carcinosarcoma without nodal or liver involvement. After carboplatin/taxol (30% dose reduction, weekly, with stem-cell support) for six cycles, the patient is disease-free at 29 months. PET/CT by November 2009 demonstrated stable kidney with complete resolution of previous seromas and blood urea nitrogen/creatinine levels were consistently normal. Thus, despite distant relapse in the upper abdomen, there has been no allograft renal impairment or pelvic recurrence after adjuvant radiation 36 months ago.
| > Discussion|| |
An ectopic or transplanted pelvic kidney in the setting of pelvic malignancies is rare. , Based on risk factors for the patient's cancer, adjuvant radiation may be recommended but impossible to deliver because of the pelvic kidney. Whole kidney dose constraints are nearly half of the 45-50.4 Gy required to prevent tumor recurrence.
Rosenshein et al. in 1980 suggested nephrectomy or translocation into the upper abdomen for an ectopic, normal kidney.  An already grafted kidney may require allograft autotransplantation.  Alternatively, the radiation oncologist can block the kidney, but conventional techniques may miss the high-risk target volume.  Mouzin et al. in 2004 used modern, three-dimensional planning for renal transplant recipients with prostate cancer but their fields were much smaller than the whole pelvis and targeted the prostate only. 
Castilho et al. reported in 2006 the first use of IMRT for an endometrial cancer patient with a congenital pelvic kidney.  Seven co-planar fields covered 95% of the whole pelvis and lymphatics to 45 Gy. The ectopic kidney was centrally located in the pelvis at the level of the sacro-iliac joints. Two-thirds of the ectopic kidney received 21 Gy, and one-third received 31 Gy. The patient suffered no recurrence or side-effects to both kidneys at 18 months.
Here we report the first use of pelvic IMRT in an immunosuppressed patient with a transplanted kidney. Our situation differs from Castilho et al. First, our patient's kidney is located in the low iliac fossa which is more common clinically. Second, the target area immediately next to this kidney was a site of proven recurrence. Third, our patient has only one working kidney with less functional reserve based on long-standing immunosuppression. Thus, we gave no more than 15 Gy to 10% of the transplanted kidney.
Cervical adenocarcinoma in a renal allograft patient was treated to 40 Gy with a modified pelvic field in 1995.  The upper and lower kidney poles were limited to 2 Gy and 6 Gy, respectively, based on radiation guidelines to prevent renal allograft rejection.  The patient failed at the radiation field edge where the common iliac lymph nodes were blocked to protect the kidney, representing inadequate coverage.
In our plan, all pelvic lymphatics were adequately covered by IMRT. The patient's clear cell histology likely increased her chance of spread to intraperitoneal surfaces. Our case is dramatic in that the patient recurred a second time not at the pelvic sites most at risk (CTV), but just above the pelvic irradiation field. This suggests that pelvic IMRT gave effective local control while avoiding the transplanted kidney in this immunosuppressed patient. Had adjuvant radiation been offered upon initial presentation, subsequent failures may have been avoided. Upfront treatment for similar high-risk patients should be considered over observation.
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[Figure 1], [Figure 2], [Figure 3]