A 58 year old gentleman from Kerala was a survivor of renal transplant for last 22 years. He was on regular medications and perfect follow up for over two decades.

Diagnosis:

In January 2016, he developed loose stools and blood in stools on and off. He planned to evaluate himself during his next check up with his nephrologist. The following month he saw his nephrologist and was advised a colonoscopy. The colonoscopy revealed a tumor in rectum (terminal part of large intestine) and on further evaluation with MRI and CT scans he was found to have a locally advanced disease, which means the disease has spread in the local area only and not elsewhere.

The real challenge:

Protocol wise he is a candidate for pre-operative radiation and chemotherapy, as it will help in shrinking the tumor size. But, the real challenge was in delivering the radiation only to his rectum without affecting his only functioning transplanted kidney. The problem is that the transplanted kidney lies in close proximity to rectum.

The tolerance dose for a transplanted organ in patients exposed to immunosuppression may be much lower. Therefore the renal transplant should be exposed to as low a dose as possible on the one hand, but without compromising that to the target volume(Cancer Rectum) on the other, in order to obtain a high cure rate A primitive method of radiation would damage his transplanted kidney and make him dialysis dependent again. Neither he could avoid radiation as the cancer was advanced; hence it will relapse again and kill him.

Treatment Plan:

To tackle this very rare and unique case scenario, many a oncology team would have deferred radiation and went ahead with direct surgery. But at MIOT, with our latest true beam machine and expert oncology team we were able to deliver targeted radiation only specifically to the rectum without radiation scatter affecting the transplanted kidney by using IMRT with SIB Technique.

INTENSITY-MODULATED RADIATION THERAPY (IMRT) is an advanced mode of high-precision radiotherapy that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumour or specific areas within the tumour.

The patient finished 50Gy in 25 fractions in 5 weeks and had near complete response of the cancer in the follow up scans. A mean dose of less than 4Gy is tolerated by the transplanted Kidney but we delivered a mean dose of only 1.38Gy to the Kidney and the mean dose to the Ureter was only 4.98Gy which is remarkably low and we could save the kidney from the harmful effects of radiation.

He then underwent a very technically demanding surgery in June 2017, which involves complete removal of the cancer of rectum without damaging the transplanted kidney and also to restore the normal pathway for his nature`s calls. The patient underwent a three hour long surgery and had perfect kidney function in the intra operative and post operative period.

Recovery:

He was mobilised the very next day and started on normal diet from day three of surgery. PET scan was done post surgery, which showed no evidence of cancer. He comes for regular check-ups. A recent PET scan taken on 30th Nov also depicts the same.

At MIOT Institute of Cancer Cure not only was this patient was cured of cancer but with its state of art facilities we were able to preserve his only functioning transplanted kidney which has given him a life of nearly 22 years so far.

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