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Kidney Week

Abstract: PO2470

A Retroperitoneal Cyst of Pancreatic Origin in a Renal Transplant Recipient: Expect the Unexpected

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Saleem, Muhammad Omar, Augusta University, Augusta, Georgia, United States
  • Chughtai, Ambreen, FMH College of Medicine and Dentistry, Lahore, Punjab, Pakistan
  • Gani, Imran Yaseen, Augusta University, Augusta, Georgia, United States
  • Saeed, Muhammad Irfan, Augusta University, Augusta, Georgia, United States
  • Kapoor, Rajan, Augusta University, Augusta, Georgia, United States
Introduction

The immunosuppression required to maintain a renal allograft function puts the recipient at a higher risk of malignancy. We report a rare case that presented a diagnostic challenge when a retroperitoneal hemorrhagic cystic mass turned out to be an adenocarcinoma of pancreaticobiliary origin.

Case Description

43-year-old female with a history of End Stage Renal Disease due to IgA Nephropathy and two renal transplantations, first in 1999 from her sister and second in 2005 from a deceased donor, presented with complaint of left sided abdominal pain and distention for one month. Her graft function was stable with creatinine of 1.8mg/dl on immunosuppression with tacrolimus, mycophenolic acid, and prednisone. The CT scan showed a large 12 x 13 x 16 cm well-defined septated cystic mass. She subsequently underwent exploratory laparotomy which revealed a retroperitoneal 1.7L cystic hematoma with no association to native or transplant kidneys. The histopathology showed adenocarcinoma with mucinous and enteric features. Based on the morphology and immunoprofile, the differential diagnosis included an ovarian, gastrointestinal or peritoneal primary. Tumor markers showed elevated CA19-9, but normal CEA and CA-125. Given the positivity for both CK 7 and CK 20, colonic origin was unlikely but could not be completely excluded. Negative EGD and colonoscopy ruled out GI Primary. PET scan was unremarkable. Molecular analysis predicted 90% probability of pancreaticobiliary adenocarcinoma. Subsequently patient was started on adjuvant chemotherapy with Gemcitabine. She failed first and second lines of chemotherapy with progression of cancer. Then she received PD-L1 inhibitor, Nivolumab which could not prevent progression of disease but resulted in renal graft failure. Per last reports, patient was on palliative chemotherapy and in terminal phase of her life.

Discussion

Post-transplant malignancy is one of the most feared complications. It is the third leading cause of mortality and accounts for 8-10% of all deaths in United States and 30% in Australia in kidney transplant recipients. Compared with general population, the risk is increased 2-3 folds and mortality rates are higher. The occurrence of pancreatic cancer is high too. But finding a pancreaticobiliary cancer from a retroperitoneal cyst with negative pancreas imaging is rare.