A patient receives a cadaveric kidney transplant. Six months later, he develops a renal mass in the native kidney. Which of the following immunosuppressants has evidence for ANTI-tumour properties and should be preferentially used in post-transplant malignancy settings?

• A Tacrolimus — most potent calcineurin inhibitor
• B mTOR inhibitors (sirolimus/everolimus) — reduce cancer risk compared to calcineurin inhibitors ✓
• C Mycophenolate mofetil — has direct cytotoxic properties
• D Cyclosporine — least associated with post-transplant malignancy

Explanation

mTOR inhibitors (sirolimus, everolimus) have demonstrated anti-tumour properties in addition to immunosuppression — they inhibit the mTOR pathway which drives cell proliferation and angiogenesis, and have shown reduced incidence of post-transplant malignancy compared to calcineurin inhibitors. Switching from calcineurin inhibitor-based to mTOR inhibitor-based regimens is therefore considered in post-transplant patients who develop malignancy. Tacrolimus and cyclosporine are calcineurin inhibitors associated with higher malignancy risk.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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