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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 245-247

Squamous cell carcinoma of the alveolus and buccal mucosa in a renal transplant recipient on long-term immunosuppression


1 Department of Radiotherapy, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Pathology, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication21-Jan-2013

Correspondence Address:
Tamojit Chaudhuri
Department of Radiotherapy, Sanjay Gandhi Post-graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.106292

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  Abstract 

An increased risk of skin, head-neck (particularly lip) and lymphoreticular malignancies is well documented in renal transplant patients receiving long-term immunosuppressive therapy, but squamous cell carcinoma of the alveolus and buccal mucosa has not been reported previously in these patients.

Keywords: Immunosuppressive therapy, post-transplant malignancy, squamous cell carcinoma


How to cite this article:
Chaudhuri T, Yadava K. Squamous cell carcinoma of the alveolus and buccal mucosa in a renal transplant recipient on long-term immunosuppression. Clin Cancer Investig J 2012;1:245-7

How to cite this URL:
Chaudhuri T, Yadava K. Squamous cell carcinoma of the alveolus and buccal mucosa in a renal transplant recipient on long-term immunosuppression. Clin Cancer Investig J [serial online] 2012 [cited 2019 Oct 23];1:245-7. Available from: http://www.ccij-online.org/text.asp?2012/1/4/245/106292


  Introduction Top


We report a rare case of carcinoma of the alveolus and buccal mucosa arising in a 45 year-old male on long-term immunosuppression following successful cadaveric renal transplantation.


  Case Report Top


An apparently healthy, 45-year-old Asian man who was a non-smoker and had no history of alcohol or tobacco addiction presented with complaints of pain, swelling and loosening of tooth in his left lower jaw and trismus for past 4 months. He had undergone a successful cadaver renal transplant 13 years ago and had been maintained on cyclosporine 2.5 mg/day and prednisolone 7.5 mg/day since then. He had no family history of malignancy. A 3 × 5 cm exophytic lesion in the left lower alveolus and an ulcerative lesion in the adjacent left buccal mucosa were found on clinical examination, with no palpable cervical lymphadenopathy. Contrast enhanced computed tomography (CECT) scan of the face and neck revealed a 3.4 × 5.3 cm ill-defined soft tissue mass lesion in the left lower alveolus with associated destruction of left hemi-mandible and increased thickness of the adjacent left buccal mucosa [Figure 1]. His chest X-ray and routine hematological and biochemical tests did not show any abnormality. He underwent a biopsy of the lesion. Histopathologic examination of the biopsy specimen revealed squamous cell carcinoma [Figure 2]. The tumor cells were immunoreactive for cytokeratin 13 and 19 [Figure 3]; but negative for HMB-45 and S-100. He underwent wide local excision of the mass lesion along with left hemi-mandibulectomy and left modified radical neck dissection. Then he received radical radiotherapy, 60 Gray/30 fraction to the primary disease and 44 Gray/22 fraction to the left hemineck. There was partial response to therapy. After that he was kept on palliative chemotherapy with methotrexate (50 mg weekly). After 9 cycles of chemotherapy there was local disease progression and ultimately he died 2 weeks later due to cardiac failure.
Figure 1: Axial contrast enhanced computed tomography image showing infiltrative soft tissue mass in the left lower alveolus. Corresponding CT bone window axial image showing destruction of the body of left hemi-mandible

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Figure 2: Photomicrograph showing squamous cell carcinoma cells with pleomorphic, hyperchromatic nuclei and illdefined cytoplasm (H and E, ×200)

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Figure 3: Immunohistochemically the tumor cells were positive for cytokeratin 13 (×20)

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  Discussion Top


Recent improvements in immunosuppressive therapies have reduced the incidence of acute rejection and increased patient survival after renal transplantation. These agents may however, contribute to higher rates of mortality due to an increased risk of cardiovascular disease or malignancy. Malignant tumors develop in 15-20% of graft recipients after 10 years of chronic immunosuppression. [1],[2]

The commonest tumors encountered in immunosuppressed transplant recipients are cancer of the skin (particularly non-melanoma skin cancers), lip, tumors of the lymphoreticular system and Kaposi's sarcoma. [3],[4],[5],[6] However, the occurrence of some other cancers have also been reported, like cancer of the breast, tongue, colo-rectum, kidney, prostate etc. In spite of all the evidence for this increased incidence of malignant disease in transplant patients, it is difficult to prove a causal association in any individual. In view of the fact that our patient was a non-smoker, had no history of alcohol or tobacco addiction and was on immunosuppressive therapy for past 13 years, the development and behavior of the neoplasm in this case would seem to be related to immunosuppression.

The incidence of malignant disease in transplant recipients has been shown to increase steadily with the interval from transplantation. An incidence of cancer in transplant recipients surviving beyond one, five and nine years of 23%, 39% and 44% respectively has been reported. [7]

Apart from the increased incidence, increased biological aggressiveness is another specific point about malignant diseases in transplant patients. There are reports on the increased aggressiveness of squamous cell carcinoma of skin, [7] head-neck, [8] gastrointestinal tumors and lymphomas [9] in solid organ transplant recipients.

There are evidences to suggest a role for proliferation signal inhibitors (PSIs) in the management of post-transplantation malignancy, with reports of partial and complete resolution of primary and metastatic tumors after conversion from a calcineurin inhibitor (CNI) to a PSI in cases of non-melanoma skin cancer, [3] post-transplant lymphoproliferative disorder, [5] and Kaposi's sarcoma. [6] Though the role of mammalian target of rapamycin (mTOR) inhibitors has been firmly established for the treatment of post-transplant Kaposi's sarcoma but its role in the management of patients with other post-transplant malignancies is yet to be clarified. [10]


  Conclusion Top


We report the first case of post-renal transplant de novo cancer of the alveolus and buccal mucosa in a 45 year-old Asian man, who was on long term immunosuppression. The possible role of immunosuppression on the development and on the outcome of treatment of post renal transplant malignancies is discussed.

 
  References Top

1.Marcen R. Immunosuppressive drugs in kidney transplantation: Impact on patient survival, and incidence of cardiovascular disease, malignancy and infection. Drugs 2009;69:2227-43.  Back to cited text no. 1
    
2.Lutz J, Heemann U. Tumors after kidney transplantation. Curr Opin Urol 2003;13:105-9.  Back to cited text no. 2
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3.de Fijter JW. Use of proliferation signal inhibitors in non-melanoma skin cancer following renal transplantation. Nephrol Dial Transplant 2007;22 Suppl 1:i23-6.  Back to cited text no. 3
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4.Lopez-Pintor RM, Hernandez G, de Arriba L, de Andres A. Lip cancer in renal transplant patients. Oral Oncol 2011;47:68-71.  Back to cited text no. 4
    
5.Pascual J. Post-transplant lymphoproliferative disorder-The potential of proliferation signal inhibitors. Nephrol Dial Transplant 2007;22 Suppl 1:i27-35.  Back to cited text no. 5
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6.Campistol JM, Schena FP. Kaposi's sarcoma in renal transplant recipients-the impact of proliferation signal inhibitors. Nephrol Dial Transplant 2007;22 Suppl1:i17-22.  Back to cited text no. 6
    
7.Sheil AG, Mahoney JF, Horvath JS, Johnson JR, Tiller DJ, Kelly GE, et al. Cancer following renal transplantation. Aust NZ J Surg 1979;49:617-20.  Back to cited text no. 7
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8.Preciado DA, Matas A, Adams GL. Squamous cell carcinoma of the head and neck in solid organ transplant recipients. Head Neck 2002;24:319-25.  Back to cited text no. 8
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9.Dantal J, Pohanka E. Malignancies in renal transplantation: An unmet medical need. Nephrol Dial Transplant 2007;22 Suppl 1:i4-10.  Back to cited text no. 9
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10.Gutierrez-Dalmau A, Campistol JM. Immunosuppressive therapy and malignancy in organ transplant recipients: A systematic review. Drugs 2007;67:1167-98.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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