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Case Reports
. 2025 Mar 17:15:1506324.
doi: 10.3389/fonc.2025.1506324. eCollection 2025.

Combined standard immunosuppression and immune checkpoint inhibition for BKPyV+ metastatic renal cell carcinoma of the graft in a kidney transplant recipient with chronic rejection: a case report

Ilaria Gandolfini #  1 , Martina Manini #  2 , Giuseppe Daniele Benigno  1 , Micaela Gentile  1 , Alessandra Palmisano  1 , Danio Somenzi  3 , Letizia Gnetti  4 , Marco Delsante  1 , Benedetta Mordà  5 , Marta D'Angelo  5 , Daniel Salvetti  5 , Enrico Fiaccadori  1   5 , Sebastiano Buti #  2 , Umberto Maggiore #  1   5
Affiliations
Case Reports

Combined standard immunosuppression and immune checkpoint inhibition for BKPyV+ metastatic renal cell carcinoma of the graft in a kidney transplant recipient with chronic rejection: a case report

Ilaria Gandolfini et al. Front Oncol. .

Abstract

We report on the first case of a dual-kidney transplant recipient diagnosed with a metastatic BK polyomavirus-positive clear renal cell carcinoma with sarcomatoid features, which caused extensive vena cava thrombosis. The patient was successfully treated with the immune checkpoint inhibitors (ICIs) ipilimumab plus nivolumab and continued immunosuppression with tacrolimus, mycophenolate, and steroids. He received ICIs despite the presence of graft dysfunction due to transplant glomerulopathy. As expected, the ICI treatment caused a progressive but asymptomatic decline of the graft function, which resulted in end-stage kidney disease. However, continuation of a full immunosuppression prevented acute rejection, graft intolerance syndrome episodes, or dual graft nephrectomy, which enabled the patient to successfully continue ICIs while on dialysis and to achieve sustained partial remission at the 17-month follow-up.

Keywords: BK polyomavirus; dialysis; immune checkpoint inhibitors; immunosuppression; kidney transplantation; renal cell carcinoma.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
(A, B) Basal contrast-enhanced CT of the pelvis and thorax at baseline. (A) Lobulated contrast-enhanced expansive lesion of approximately 12 cm in the left graft with extension in the context of the abdominal wall muscles (71 × 63 mm, red arrow). (B) Multiple parenchymal nodulations in both lungs suggestive for metastases, the largest of approximately 18 mm in the right lower lobe (blue arrows). (C, D) Contrast-enhanced CT of the pelvis and thorax at baseline 6 months post-immune checkpoint inhibitor (ICI) initiation. (C) Lobulated expansive lesion in the left graft (50 × 46 mm), with extension in the context of the abdominal wall muscles (42 × 22 mm). (D) Overall reduction of multiple parenchymal nodulations in both lungs. (E, F) Contrast-enhanced CT of the pelvis and thorax at baseline 17 months post-ICI initiation. (E) Stable lobulated expansive lesion in the left graft (43 × 39 mm), with extension in the context of the abdominal wall muscles (40 × 18 mm). (F) Overall lung progression, with increase of some pulmonary nodules, the largest of 14 mm at the upper left lobe and 15 mm at the right lower lobe.
Figure 2
Figure 2
Needle biopsy of the renal neoplasm (×4). Upper panel shows an undifferentiated carcinoma at hematoxylin and eosin stain (×4). Immunohistochemistry (IHC) was overall compatible with a clear cell carcinoma with sarcomatoid differentiation staining positive for CAIX, PAX8, and vimentin. Diffuse nuclear positivity for BKPyV SV40 by IHC was detected in neoplastic cells, while the surrounding healthy kidney tissue was negative.
See this image and copyright information in PMC

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