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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 156-158

Squamous cell carcinoma tongue in a postrenal transplant patient: A case report and review of literature


1 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication29-Jun-2018

Correspondence Address:
Dr. B Sangeetha Lakshmi
Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_10_18

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  Abstract 


The risk of malignancy in renal transplant patient is higher compared to general population. The prolonged immunosuppression received by these patients is considered to be one of the risk factors for the development of malignancies. Majority of the malignancies are epithelial in nature and predominantly are squamous cell carcinoma. The sites where squamous cell carcinoma develops in postrenal transplant patients include skin, lip, cervix, vulva, penis, scrotum, anus, and rarely lung. Very few cases of squamous cell carcinoma of the tongue after renal transplant have been documented in the literature. We present one such case where the patient developed squamous cell carcinoma of the tongue 16 years after renal transplant.

Keywords: Carcinoma tongue, hemiglossectomy, modified neck dissection, postrenal transplant, squamous cell carcinoma


How to cite this article:
Patnaik R, Lakshmi B S, Reddy M H, Kumar AC, Jena A, Kumar V S. Squamous cell carcinoma tongue in a postrenal transplant patient: A case report and review of literature. Indian J Transplant 2018;12:156-8

How to cite this URL:
Patnaik R, Lakshmi B S, Reddy M H, Kumar AC, Jena A, Kumar V S. Squamous cell carcinoma tongue in a postrenal transplant patient: A case report and review of literature. Indian J Transplant [serial online] 2018 [cited 2021 Apr 11];12:156-8. Available from: https://www.ijtonline.in/text.asp?2018/12/2/156/235584




  Introduction Top


The risk of malignancy in renal transplant patient is higher compared to general population.[1],[2] The prolonged immunosuppression received by these patients is considered to be one of the risk factors for the development of malignancies. Majority of the malignancies are epithelial in nature and predominantly are squamous cell carcinoma. The sites where squamous cell carcinoma develops in postrenal transplant patients include skin, lip, cervix, vulva, penis, scrotum, anus, and rarely lung. Very few cases of squamous cell carcinoma of the tongue after renal transplant have been documented in the literature.[1],[2] We present one such case where the patient developed squamous cell carcinoma of the tongue 16 years after renal transplant.


  Case Report Top


A 58-year-old male presented with a painful ulceroproliferative growth on the left lateral border of the tongue of 6-month duration. He was a live-related renal transplant recipient in the year 1992. He had stable graft function for 16 years. He received no induction therapy. He was on cyclosporine, azathioprine, and steroids. On examination, an ulcerative growth with induration measuring 6 cm × 5 cm presents on the left half of the tongue on anterior aspect [Figure 1]. There were no palpable neck nodes. The preradiotherapy biopsy from the ulcer was reported as moderately differentiated squamous cell carcinoma. He received neoadjuvant radiotherapy as the disease was extensive. However, it did not respond to radiotherapy and he presented with postradiotherapy progressive disease. He was planned for subtotal glossectomy, bilateral neck dissection, and reconstruction with pectoralis major myocutaneous (PMMC) flap.
Figure 1: Ulceroproliferative growth on the lateral border of the tongue

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Operative findings showed 6 cm × 5 cm ulceroproliferative growth on the lateral border of the tongue. It was crossing the midline and extending to the right side just 1 cm away at the lateral margin, extending to the floor of the mouth, but mandible was not involved. Extension of the growth was anteriorly 1 cm away from the tip of the tongue and posteriorly till sulcus terminalis. The base of the tongue was free. Subtotal glossectomy, left modified radical neck dissection, and right supraomohyoid neck dissection were done and reconstructed with PMMC flap.

The postoperative histopathology was reported as moderately differentiated squamous cell carcinoma with free resected margins and reactive lymph nodes [Figure 2]. He was discharged in a stable condition. After 11 months of diagnosis of squamous cell carcinoma of the tongue, the patient expired due to multiorgan failure secondary to sepsis.
Figure 2: Histopathology of squamous cell carcinoma with keratin pearls (H and E, ×100)

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  Discussion Top


In patients with terminal kidney diseases, renal transplant is an effective method to improve survival and quality of life. However, it is often associated with increased risk of malignancy.[1],[2] Posttransplant malignancies constitute a major cause of morbidity and mortality in renal transplant patients.[3] Malignancy is the third most common cause of death among kidney transplant recipients, after cardiovascular events and infections.[4] According to a report published by Australia and New Zealand Dialysis and Transplant Registry, cancer in posttransplant cases has even overtaken cardiovascular diseases as the leading cause of death.[5] The risk of malignancy increases with duration of the transplant. The incidence of malignancy has been estimated at 20% after 10 years of chronic immunosuppression.[6] The risk is also more with an increase in the average age of transplant recipients.[1],[5] The risk factors for the development of cancer in the transplant recipients include male gender, older age, preformed antibodies before transplantation and cumulative dose, and duration of immunosuppression.[2]

The overall incidence of malignancies in postrenal transplant recipients is approximately 5%–6%. Malignancies of the skin and posttransplant lymphoproliferative disorder are some of the common malignancies.[1] The most common cancer in the renal transplant recipients includes nonmelanoma skin cancer, renal cancer, and cancer of the pharynx, larynx, and oral cavity. However, the types of malignancies vary geographically.[7] A Korean study describes skin cancer, followed by thyroid, stomach, colorectal, and urologic cancers in posttransplant patients in order of frequency.[7] A Chinese study by Wu et al. listed urinary tract malignancies as the most frequent malignancies.[3] In another study from Portugal, the most common malignancy following renal transplantation was skin cancer, followed by malignant lymphoma and kidney cancer.[4] In contrast, a study from Turkey did not observe any increased risk of posttransplant malignancy. The authors opined that this finding could be due to the use of low-dosage immunosuppressive protocols.[8]

There are very few reported cases of carcinoma tongue in renal transplant recipients.[1],[2]

The incidence of carcinoma of the tongue in the general population is quite high. Worldwide, it occurs most commonly in elderly males associated with various factors such as tobacco chewing, smoking, chronic irritation, and human papillomavirus infection.[2]

The exact pathogenesis of the increased incidence of cancer in posttransplant patients is not known. One hypothesis is that the changing trends in immunosuppressive therapy may lead to carcinogenesis.[9] The various proposed mechanisms for the development of cancer in transplant recipients include immunosuppression-mediated inhibitory effect on tumor surveillance, tumor-promoting effect of immunosuppression, uncontrolled proliferation of oncogenic viruses, and cause of primary kidney disease including the milieu of end-stage renal disease.[2]

In general, the etiopathogenesis of posttransplant malignancy is multifactorial and includes chronic disease, chronic immunosuppressive therapy, and oncogenic viruses.

The study by Aguiar et al. documented that postrenal transplant patients with cancer were older, had a longer duration of graft function, and had more episodes of acute rejection. In their study, they noted that a higher number of patients were treated with cyclosporine and azathioprine as initial immunosuppressive regimen.[4]

Our patient had received cyclosporine and azathioprine as part of immunosuppressive therapy.

Cyclosporine is a calcineurin inhibitor (CNI). CNIs have been linked with posttransplant malignancies. Possible mechanism of oncogenicity of CNI includes impairment inability to repair damaged DNA and production of pro-oncogenic cytokines. Azathioprine is also associated with increased risk of the development of malignancies. The mechanisms suggested are impairment in the ability to repair damaged DNA and elicitation of codon misreads.[9]

In our case, the cause of squamous cell carcinoma of the tongue could attribute to the prolonged usage of immunosuppression.

There are clinical studies which demonstrate a lower incidence of new malignancies after renal transplantation in recipients receiving immunosuppression with mammalian target of rapamycin (mTOR) inhibitors compared with CNIs. These mTOR inhibitors have shown to possess antineoplastic activities. Therapeutic protocols involving mTOR inhibitors may protect an allograft from immunological rejection and help to reduce the incidence of cancer in high-risk population. The dual efficacy of sirolimus, a mTOR inhibitor as an immunosuppressive and antitumor agent, has been demonstrated both experimentally and clinically.[6] Therefore, Alberú et al. suggested that a mTOR-inhibitor CNI-free regimen should be considered for transplant recipients at high risk for cancer development.[10]

Strategies for posttransplant malignancy screening should be based on the recipient's age at the time of transplantation, the posttransplant interval, and the national trend of posttransplant malignancy.[7] A perfect transplant follow-up system, regular follow-up, and careful physical examination taking care not to overlook any early feature of tumor are some of the means to achieve early diagnosis of tumor. This, in turn, will result in early treatment to improve the cure rate of postoperative malignancies of renal transplantation patients.[3]

The overall management of cancers in renal transplant patients is aggressive and includes appropriate surgical, radio, and chemotherapy.

Clinicians should be aware of various types of cancer including rarer ones as an increasing cause of late mortality in transplant patients.


  Conclusion Top


This is an additional uncommon case of carcinoma tongue which developed 16 years after renal transplant. The transplant patients should be kept under continuous surveillance to detect cancer at an early stage to provide early treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malleshappa P, Aghariya M, Tampi C, Shah BV. Squamous cell carcinoma of tongue in a renal transplant recipient. Indian J Med Paediatr Oncol 2009;30:136-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Prakash J, Prabhakar, Kumar M, Aralapuram K. Carcinoma of the tongue in a renal transplant recipient: A rare post-transplant malignancy. Saudi J Kidney Dis Transpl 2015;26:103-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Wu B, Wang K, Mo CB, Shen ZY. De novo malignancies in renal transplant recipients: Experience at a single center in China. Int J Clin Exp Med 2015;8:2911-6.  Back to cited text no. 3
[PUBMED]    
4.
Aguiar B, Santos Amorim T, Romãozinho C, Santos L, Macário F, Alves R, et al. Malignancy in kidney transplantation: A 25-year single-center experience in Portugal. Transplant Proc 2015;47:976-80.  Back to cited text no. 4
    
5.
Sheil AG. Cancer report 2001. In: Ross GR, editor. ANZDATA Registry Report 2001. Adelaide, South Australia: Australia and New Zealand Dialysis and Transplant Registry; 2001. p. 84-90.  Back to cited text no. 5
    
6.
Kapoor A. Malignancy in kidney transplant recipients. Drugs 2008;68 Suppl 1:11-9.  Back to cited text no. 6
[PUBMED]    
7.
Ju MK, Joo DJ, Kim SJ, Huh KH, Kim MS, Jeon KO, et al. Chronologically different incidences of post-transplant malignancies in renal transplant recipients: Single center experience. Transpl Int 2009;22:644-53.  Back to cited text no. 7
[PUBMED]    
8.
Keles Y, Tekin S, Duzenli M, Yuksel Y, Yücetin L, Dosemeci L, et al. Post-transplantation malignancy after kidney transplantation in Turkey. Transplant Proc 2015;47:1418-20.  Back to cited text no. 8
    
9.
Fletchner SM. Cancer and renal transplant. Adv Stud Med 2007;7:411-9.  Back to cited text no. 9
    
10.
Alberú J. Clinical insights for cancer outcomes in renal transplant patients. Transplant Proc 2010;42:S36-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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