Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

Evolving challenges with long-term care of liver transplant recipients

The number of liver transplants (LT) performed worldwide continues to rise, and LT recipients are living longer post-transplant. This has led to an increasing number of LT recipients requiring lifelong care. Optimal care post-LT requires careful attention to both the allograft and systemic issues that are more common after organ transplantation. Common causes of allograft dysfunction include rejection, biliary complications, and primary disease recurrence. While immunosuppression prevents rejection and reduces incidences of some primary disease recurrence, it has detrimental systemic effects. Most commonly, these include increased incidences of metabolic syndrome, various malignancies, and infections. Therefore, it is of utmost importance to optimize immunosuppression regimens to prevent allograft dysfunction while also decreasing the risk of systemic complications. Institutional protocols to screen for systemic disease and heightened clinical suspicion also play an important role in providing optimal long-term post-LT care. In this review, we discuss these common complications of LT as well as unique considerations when caring for LT recipients in the years after transplant.

Human papillomavirus in the setting of immunodeficiency: Pathogenesis and the emergence of next-generation therapies to reduce the high associated cancer risk

Human papillomavirus (HPV), a common sexually transmitted virus infecting mucosal or cutaneous stratified epithelia, is implicated in the rising of associated cancers worldwide. While HPV infection can be cleared by an adequate immune response, immunocompromised individuals can develop persistent, treatment-refractory, and progressive disease. Primary immunodeficiencies (PIDs) associated with HPV-related disease include inborn errors of GATA, EVER1/2, and CXCR4 mutations, resulting in defective cellular function. People living with secondary immunodeficiency (e.g. solid-organ transplants recipients of immunosuppression) and acquired immunodeficiency (e.g. concurrent human immunodeficiency virus (HIV) infection) are also at significant risk of HPV-related disease. Immunocompromised people are highly susceptible to the development of cutaneous and mucosal warts, and cervical, anogenital and oropharyngeal carcinomas. The specific mechanisms underlying high-risk HPV-driven cancer development in immunocompromised hosts are not well understood. Current treatments for HPV-related cancers include surgery with adjuvant chemotherapy and/or radiotherapy, with clinical trials underway to investigate the use of anti-PD-1 therapy. In the setting of HIV co-infection, persistent high-grade anal intraepithelial neoplasia can occur despite suppressive antiretroviral therapy, resulting in an ongoing risk for transformation to overt malignancy. Although therapeutic vaccines against HPV are under development, the efficacy of these in the setting of PID, secondary- or acquired- immunodeficiencies remains unclear. RNA-based therapeutic targeting of the HPV genome or mRNA transcript has become a promising next-generation therapeutic avenue. In this review, we summarise the current understanding of HPV pathogenesis, immune evasion, and malignant transformation, with a focus on key PIDs, secondary immunodeficiencies, and HIV infection. Current management and vaccine regimes are outlined in relation to HPV-driven cancer, and specifically, the need for more effective therapeutic strategies for immunocompromised hosts. The recent advances in RNA-based gene targeting including CRISPR and short interfering RNA (siRNA), and the potential application to HPV infection are of great interest. An increased understanding of both the dysregulated immune responses in immunocompromised hosts and of viral persistence is essential for the design of next-generation therapies to eliminate HPV persistence and cancer development in the most at-risk populations.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

A practical guide on the use of imiquimod cream to treat lentigo maligna

Lentigo maligna (LM) is a common in situ melanoma subtype arising on chronically sun-damaged skin and mostly affects the head and neck region. Localisation in cosmetically sensitive areas, difficulty to obtain wide resection margins and advanced patient age/comorbidities have encouraged investigation of less invasive therapeutic strategies than surgery in managing complex cases of LM. Radiotherapy and imiquimod have emerged as alternative treatment options in this context. The treatment of LM with imiquimod cream can be challenging due to the nature of the disease including its often large size, variegated appearance, involvement of adnexal structures, poorly defined peripheral edge and frequent localisation close to sensitive structures such as the eyes and lips, and elderly patients with multiple comorbidities. Prolonged and unpredictable inflammatory reaction and side effects and compliance with a patient-delivered therapy can also be challenging. In the literature to date, studies evaluating the use of imiquimod to treat LM have utilised varying methodologies and provided short follow-up and these limitations have impaired the development of clear guidelines for dosage and management of side effects. Based on our multidisciplinary experience and review of the literature, we propose practical clinical strategies for the use of imiquimod for treating LM, detailing optimal administration procedures in various clinical scenarios and long-term management, with the aim of facilitating optimal patient outcomes.

Acquired epidermodysplasia verruciformis: clinical presentation and treatment update

Acquired epidermodysplasia verruciformis (AEV) is a form of epidermodysplasia verruciformis (EV) that is most commonly found in immunocompromised or immunosuppressed patients. EV is commonly associated with human papillomavirus (HPV), which is often found in EV and AEV lesions. Clinical presentation of AEV in patients with organ transplantation, HIV+, congenital HIV+, hematological diseases, and other iatrogenic immunosuppression are reviewed. Treatment options include topical cidofovir, topical retinoids, topical imiquimod, topical glycolic acid, HPV 9-valent vaccine, acitretin, improving cellular immunity, and changing transplant medication to mycophenolate mofetil.

Keratinocyte Cancer Mortality in Kidney Transplant Recipients

BACKGROUND

Kidney transplant recipients are at increased risk of developing and dying from keratinocyte cancer. Risk factors for keratinocyte cancer death have not been previously described.

METHODS

In a cohort of kidney transplant recipients transplanted in Queensland 1995-2014, we identified keratinocyte cancer deaths by searching national transplant and state death registries to March 2020. Standardized keratinocyte cancer mortality rates and mortality ratios were calculated. We used a competing risks model to identify factors associated with keratinocyte cancer death and calculated relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

There were 562 deaths in 1866 kidney transplant recipients (62% males; 86% Caucasian) with 25 934 person-years of follow-up, of which 36 were due to squamous cell carcinoma (SCC) and 1 to basal cell carcinoma (BCC) with standardized mortality rates of 78 (95% CI 53-111) and 2 (95% CI 0.1-11) per 100,000 person-years respectively. The standardized mortality ratio for keratinocyte cancer was 23 (95% CI 23-24). Besides Caucasian ethnicity (associated with 100% of keratinocyte cancer deaths), male sex (RR 3.24 95% CI 1.26-8.33), and older age at transplantation (≥ 50 versus <50 years RR 3.09 95% CI 1.38-6.89) were associated with increased risk of keratinocyte cancer death.

CONCLUSIONS

Keratinocyte cancer mortality in kidney transplant recipients is over 20 times higher than in the general population. Most keratinocyte cancer deaths are due to cutaneous SCC, however, BCC can be fatal. Education in skin cancer prevention is essential to avoid unnecessary deaths from keratinocyte cancer amongst kidney transplant recipients.

Skin Cancers and Lung Transplant

It is well known that solid-organ transplant recipients (SOTRs) have a 65- to 100-fold increase in the risk of developing skin cancer, namely, nonmelanoma skin cancers (NMSCs) such as cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC). In addition, these patients are also at increased risk for development of melanoma as well as other less common cutaneous malignancies (Merkel's cell carcinoma, Kaposi's sarcoma). SOTRs with NMSC (namely cSCC) are also at significantly increased risk of poor clinical outcomes including local recurrence, nodal and distant metastasis, and disease-specific death relative to patients who are not immunosuppressed. Increased surveillance and monitoring in patients at risk of aggressive disease and poor outcomes who are on immunosuppression is essential in patients with lung transplants given the high degree of immunosuppression. Increased awareness of risks, treatments, and management allows for improved outcomes in these patients. This article will provide an overview of the risk factors for the development of cutaneous malignancies in organ transplant recipients as well as a detailed discussion of various immunosuppressant and prophylactic medications used in this patient population that contribute to the risk of developing cutaneous malignancies, with an emphasis on NMSC (cSCC and BCC) in lung transplant recipients. Finally, this article includes a discussion on the clinical and dermatologic management of this high-risk immunosuppressed population including a review of topical and systemic agents for field therapy of actinic damage and chemoprevention of keratinocyte carcinomas. In addition, indications for additional treatment and preventive measures such as adjuvant radiation treatment after surgical management of cutaneous malignancies and potential modification of immunosuppressive medication regimens are discussed.

Japanese Dermatological Association Guidelines: Outlines of Guidelines for Cutaneous Squamous Cell Carcinoma 2020

In consideration of the development of treatment options for squamous cell carcinoma (SCC), the Japanese Skin Cancer Society issued the first guidelines of SCC in 2007 and revised them in 2015. Here, we report the English version of the 2020 edition of the Japanese SCC guidelines. The first half of this article is an overview of SCC including actinic keratosis and Bowen's disease, and the second half discusses three clinical questions: (i) treatment of actinic keratosis; (ii) determination of the resection margin of the primary lesion; and (iii) treatment of radically incurable cases, as contemporary problems encountered in treating SCC. In these evaluations, all processes were implemented according to the Grading of Recommendations, Assessment, Development, Evaluation system. Also, items of recommendation concerning each clinical question were determined by a multidisciplinary expert panel consisting of dermatologists, plastic/reconstructive surgeons, radiologists, and oncologists through a comprehensive literature search and systematic reviews.

Treatment approaches in immunosuppressed patients with advanced cutaneous squamous cell carcinoma

Immunosuppression, both iatrogenic and disease-related, is associated with a greatly increased incidence of cutaneous SCC (cSCC) and with aggressive cSCC and worse disease outcomes. Consequently, rapid access to skin cancer services and prudent surgical choices, such as circumferential margin assessment, is essential when treating advanced cSCC in an immunosuppressed patient. For high-risk cancers and control of cSCC multiplicity, additional strategies should be actively considered within the multidisciplinary clinical care team. These include minimization or revision of immunosuppressive medications, systemic chemoprevention (including retinoids, nicotinamide, capecitabine) and adjuvant therapies such as radiotherapy. Unfortunately, there is a relative paucity of good evidence for many of these treatments in the immunosuppressed. Systemic treatments for metastatic cSCC are often contraindicated in organ transplant recipients, notably checkpoint inhibitor immunotherapy. There are also toxicity concerns with some conventional chemotherapies and EGFR inhibitors. Until recently, clinical trials have largely excluded immunosuppressed individuals. Development of more effective treatment for advanced cSCC in this high-risk group and prospective clinical trials are now research priorities.

Interventions to Prevent Nonmelanoma Skin Cancers in Recipients of a Solid Organ Transplant: Systematic Review of Randomized Controlled Trials

BACKGROUND

Organ transplant recipients are at high risk of developing skin cancer. The benefits and harms of interventions to prevent nonmelanoma skin cancer in solid organ transplant recipients have not been summarized.

METHODS

We searched MEDLINE, Embase, and CENTRAL through April 2018. Risk of bias was assessed using the Cochrane tool, and evidence certainty was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation process. Prespecified outcomes were nonmelanoma skin cancer, clearance and prevention of keratotic skin lesions, and intervention-specific adverse events.

RESULTS

Ninety-two trials (20 012 participants) were included. The evaluated treatments were cancer-specific interventions (acitretin, imiquimod, photodynamic therapy, nicotinamide, topical diclofenac, and selenium) and immunosuppression regimes (azathioprine, mycophenolate mofetil, calcineurin inhibitors, mammalian target of rapamycin [mTOR] inhibitors, belatacept, induction agents, and withdrawal of calcineurin inhibitors or corticosteroids). Effects on nonmelanoma skin cancer were uncertain for photodynamic therapy (3 trials, 93 participants, risk ratio [RR] 1.42 [95% confidence interval (CI), 0.65-3.11]; low certainty evidence), nicotinamide (2 trials, 60 participants), acitretin (2 trials, 61 participants), and imiquimod (1 trial, 20 participants) compared to control. mTOR inhibitors probably reduced skin cancer compared to calcineurin inhibitors (12 trials, 2225 participants, RR 0.62 [95% CI, 0.45-0.85]; moderate certainty evidence). Photodynamic therapy may cause pain at the treatment site (4 trials, 95 patients, RR 17.09 [95% CI, 4.22-69.26]; low certainty evidence).

CONCLUSIONS

There is limited evidence for the efficacy and safety of specific treatments to prevent nonmelanoma skin cancers among solid organ transplant recipients.

Management of Non-melanoma Skin Cancer in Transplant Recipients

Transplant recipients have a significantly higher risk of developing non-melanoma skin cancers compared with the general population and squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are the most common post-transplant malignancies. Although in the general population BCC outnumbers SCC 4:1, in transplant patients this ratio is reversed and SCC is more common, with a 65- to 250-fold increased incidence. As patients in immunosuppressed states are living longer after transplants, the incidence of skin cancer in this population continues to increase. The skin cancers in transplant patients also tend to be more aggressive, with higher morbidity and mortality. Preventive strategies play an important role in transplant recipients given their increased frequency of developing both premalignant and malignant skin lesions. Sun protection and regular skin cancer screening are critical. In addition, chemoprophylaxis with systemic retinoids, nicotinamide and capecitabine can significantly reduce the development of new skin cancers. Topical 5-fluorouracil, imiquimod, photodynamic therapy and cyclooxygenase inhibitors have all been investigated in transplant patients for the treatment of field cancerisation. Adjusting the immunosuppressive regimen is also an important adjuvant therapeutic strategy for managing skin cancers in transplant recipients and requires integrated multidisciplinary care with the entire transplant team. This article reviews the epidemiology of non-melanoma skin cancer in transplant patients, discusses the prevention strategies and highlights the management and treatment strategies of both field cancerisation and non-melanoma skin cancers.

Dissecting the Multiplicity of Immune Effects of Immunosuppressive Drugs to Better Predict the Risk of de novo Malignancies in Solid Organ Transplant Patients

De novo malignancies constitute an emerging cause of morbidity after solid organ transplant (SOT), significantly affecting the long-term survival of transplant recipients. Pharmacologic immunosuppression may functionally impair the immunosurveillance in these patients, thereby increasing the risk of cancer development. Nevertheless, the multiplicity and heterogeneity of the immune effects induced by immunosuppressive drugs limit the current possibilities to reliably predict the risk of de novo malignancy in SOT patients. Therefore, there is the pressing need to better characterize the immune dysfunctions induced by the different immunosuppressive regimens administered to prevent allograft rejection to tailor more precisely the therapeutic schedule and decrease the risk of de novo malignancies. We herein highlight the impact exerted by different classes of immunosuppressants on the most relevant immune cells, with a particular focus on the effects on dendritic cells (DCs), the main regulators of the balance between immunosurveillance and tolerance.

Skin Cancer-Sun Knowledge and Sun Protection Behaviors of Liver Transplant Recipients in Turkey

The aim of this study was to compare liver transplant recipients (LTRs) with the general population regarding their knowledge of skin cancer, sun health, sun protection behaviors, and affecting factors. This cross-sectional study was conducted in Turkey between March 2016 and September 2016 with 104 LTRs and 100 participants from the general population group (GPG). The mean age of the LTRs was 53.2 ± 11.8 and that of the GPG was 42.7 ± 14.5. The LTRs' skin cancer and sun knowledge were significantly lower than in the GPG, but there was no difference between the two groups in terms of their sun protection behavior scores. The most commonly used sun protection behaviors of LTRs were not being outside and not sunbathing between 10 a.m. and 4 p.m., wearing clothing that covers the skin, and avoiding the solarium. Behaviors commonly practiced by the GPG were wearing sunglasses, wearing sunscreen with a sun protection factor of 15 or higher before going outside, wearing sunscreen at the beach, while swimming or doing physical activity outside, and reapplying it every 2 h. Results of our study will contribute to the development of education and training programs for LTRs on skin cancer. The results also demonstrated the importance of practicing adequate sun protection behaviors which will certainly impact their future health.

"For your eyes only": ophthalmic complications following lung transplantation

Ophthalmic complications in the lung transplant population are a little-known entity. It includes a spectrum of diseases ranging from infections such as cytomegalovirus (CMV) retinitis, herpetic keratitis, Pseudallescheria boydii to non-infectious complications such as posterior subcapsular cataracts (PSCs), cyclosporine retinopathy, and post-transplant lymphoproliferative disorder (PTLD). These diseases can be attributed to high levels of immunosuppression, advanced age, and drug-specific side effects. Underlying comorbidities such as diabetes mellitus may also play a role in the pathogenesis. Patients can present with varied symptoms such as blurry vision, floaters or eye pain. Prompt diagnosis often requires a high index of suspicion. With increasing numbers of transplants being performed worldwide, it is imperative for the pulmonologist and transplant physician to recognize these often subtle symptoms. Any visual symptom should trigger an ophthalmological evaluation in order to manage these complications; some of which pose the risk of systemic dissemination and significant morbidity. The following article provides an in-depth review of the common presenting symptoms, treatments and recent advances related to common ophthalmic complications following lung transplantation. While this article focuses on the lung transplant sub-population, the authors would like to point out that some of these complications are shared by other solid-organ transplants as well, by virtue of their shared immunosuppressive therapies.

Malignancy development risk in psoriatic arthritis patients undergoing treatment: A systematic review and meta-analysis

BACKGROUND

Psoriatic arthritis (PsA) is a chronic and seronegative inflammatory arthritis occurring in patients with psoriasis. The current knowledge about the risk of malignancy associated with psoriatic arthritis (PsA) patients undergoing therapy is controversial. We focused on the relationship between malignancy and therapy and undertook a meta-analysis to address this issue.

METHODS

A systematic literature search of the PubMed, EMBASE, and Web of Science databases was performed to identify relevant studies and trials. Statistical analysis was conducted using STATA 11.2 software.

RESULTS

Nine cohort studies were included, corresponding to a total of 43,115 PsA patients undergoing therapy. A significant positive association between therapy and increased risk for overall malignancy was found relative to the general population as the reference group (pooled RR, 1.29; 95% CI: 1.04-1.60). High heterogeneity was found (I² = 71.37%). Subgroup analysis reported that PsA patients treated with conventional synthetic disease modifying antirheumatic drugs (csDMARDs) presented increased cancer risk (pooled RR, 1.75; 95% CI: 1.40-2.18) but patients treated with biological disease modifying antirheumatic drugs (bDMARDs) did not (pooled RR, 0.957; 95% CI: 0.80-1.14). Compared to controls, patients with PsA undergoing treatment specifically are at increased risk for non-melanoma skin cancers (pooled RR, 2.46; 95% CI: 1.84-3.28).

CONCLUSIONS

This study allowed the estimation of cancer risk in PsA patients during therapy. Large-scale longitudinal studies will be essential to draw firm conclusions regarding PsA-associated risk for treatment-induced malignancy.

Skin Cancers in Organ Transplant Recipients

Long-term utilization of immunosuppression in organ transplant recipients (OTRs) leads to decreased immune-mediated tumor surveillance and development of malignant tumors. A delicate balance needs to be maintained in the intensity of immunosuppression to keep the risk of malignancy low without jeopardizing life-saving graft function. OTRs are prone to developing skin cancers that exhibit unique epidemiologic, pathophysiologic, and prognostic characteristics. In this review, we discuss the most commonly reported skin cancers in OTRs: squamous cell carcinoma (SCC), basal cell carcinoma (BCC), Kaposi sarcoma, Merkel cell carcinoma, and malignant melanoma (MM). Tumors in this high-risk population are aggressive and may respond poorly to standard therapies; however, new targeted therapies are promising. Checkpoint inhibitor antibodies have been used for treatment of cutaneous SCC, Merkel cell carcinoma, and MM; epidermal growth factor receptor inhibitors have been used for cutaneous SCC; hedgehog pathway inhibitors have been used for BCC; and BRAF and MEK inhibitors are being used increasingly in the management of MM. Guidelines for dermatologic screening are variable and primarily based on expert opinion. Prospective evidence-based trials by multidisciplinary groups are needed to better define surveillance schedules for pre- and posttransplant cutaneous malignancies.

Novel Immunotherapies for Autoimmune Hepatitis

Autoimmune hepatitis (AIH) is a multifactorial autoimmune disease of unknown pathogenesis, characterized by a loss of immunological tolerance against liver autoantigens resulting in the progressive destruction of the hepatic parenchyma. Current treatments are based on non-specific immunosuppressive drugs. Although tremendous progress has been made using specific biological agents in other inflammatory diseases, progress has been slow to come for AIH patients. While current treatments are successful in the majority of patients, treatment discontinuation is difficult to achieve, and relapses are frequent. Lifelong immunosuppression is not without risks, especially in the pediatric population; 4% of patient with type 1 AIH will eventually develop hepatocellular carcinoma with a 2.9% probability after 10 years of treatment. Therefore, future treatments should aim to restore tolerance to hepatic autoantigens and induce long-term remission. Promising new immunotherapies have been tested in experimental models of AIH including T and B cell depletion and regulatory CD4+ T cells infusion. Clinical studies on limited numbers of patients have also shown encouraging results using B-cell-depleting (rituximab) and anti-TNF-α (infliximab) antibodies. A better understanding of key molecular targets in AIH combined with effective site-specific immunotherapies could lead to long-term remission without blanket immunosuppression and with minimal deleterious side effects.

Cutaneous Malignancies in Pediatric Solid Organ Transplant Recipients

Pediatric organ transplant recipients (POTRs) are at risk of developing malignancies due to a combination of immunosuppression, impaired DNA damage repair, and infection with oncogenic viruses. The most commonly developed malignancies in this population are skin cancers, which include nonmelanoma skin cancer, melanoma, Kaposi's sarcoma, and anogenital carcinoma. The literature shows that skin cancers account for 13% to 55% of all cancers that occur after transplantation. Given the increasing number and life expectancy of POTRs, prevention and management of skin cancer in these patients is essential, but there is a substantial knowledge gap in our understanding of the differences in skin cancer development, prevention, and management between POTRs and adult organ transplant recipients (AOTRs), for whom more data are available. Substantial differences have been observed in the patterns of malignancy development between POTRs and AOTRs, and data specific to pediatric populations are needed. The objective of this review is to provide updated information on posttransplantation skin cancer development in POTRs, including epidemiologic research on transplant patients and disease development, medication management, surveillance, and education efforts.

Resistance of Nonmelanoma Skin Cancer to Nonsurgical Treatments. Part I: Topical Treatments

A wide range of treatments is now available for nonmelanoma skin cancer (NMSC), including 5-fluorouracil, ingenol mebutate, imiquimod, diclofenac, photodynamic therapy, methotrexate, cetuximab, vismodegib, and radiotherapy. All are associated with high clinical and histologic response rates. However, some tumors do not respond due to resistance, which may be primary or acquired. Study of the resistance processes is a broad area of research that aims to increase our understanding of the nature of each tumor and the biologic features that make it resistant, as well as to facilitate the design of new therapies directed against these tumors. In this article we review resistance to the authorized topical treatments for NMSC.

Tissue-specific conditional PKCε knockout mice: a model to precisely reveal PKCε functional role in initiation, promotion and progression of cancer

PKCε is a transforming oncogene and a predictive biomarker of various human cancers. However, a precise in vivo link of PKCε to cancer induction, progression and metastasis remain undefined. To achieve these goals, we generated tissue specific conditional PKCε knockout mice (PKCε-CKO) using cre-lox technology. Homozygous PKCε^LoxP/LoxP mice have normal body weight and phenotype. To determine what effect loss of PKCε would have on the prostate, the PKCε^LoxP/LoxP mice were bred to probasin cre (PB-Cre4⁺) mice which express cre specifically in the prostate epithelium of postnatal mice. Western blot and immunohistochemical analyses showed reduced levels of PKCε specifically in the prostate of PKCε-CKO mice. Histopathological analyses of prostate from both PKCε^LoxP/LoxP and prostate PKCε-CKO mice showed normal pathology. To determine the functional impact of prostate specific deletion of PKCε on prostate tumor growth, we performed an orthotopic xenograft study. Transgenic adenocarcinoma of the mouse prostate (TRAMP) cells (TRAMPC1, 2×10⁶) were implanted in the prostate of PKCε-CKO mice. Mice were sacrificed at 6th week post-implantation. Results demonstrated a significant (P<0.05) decrease in the growth of TRAMPC1 cells-derived xenograft tumors in PKCε-CKO mice compared to wild type. To determine a link of PKCε to ultraviolet radiation (UVR) exposure-induced epidermal Stat3 phosphorylation, PKCε^LoxP/LoxP mice were bred to tamoxifen-inducible K14 Cre mice. PKCε deletion in the epidermis resulted in inhibition of UVR-induced Stat3 phosphorylation. In summary, our novel PKCε^LoxP/LoxP mice will be useful for defining the link of PKCε to various cancers in specific organ, tissue, or cells.

Disease-modifying anti-rheumatic drugs and non-melanoma skin cancer in inflammatory arthritis patients: a retrospective cohort study

OBJECTIVES

The aim was to determine the non-melanoma skin cancer (NMSC) risk in patients with RA or PsA exposed to MTX and other DMARDs.

METHODS

Information on medication was collected on 405 patients with RA or PsA in two private rheumatology practices and was matched to comprehensive histologically confirmed cancer registry data for the years 1978-2005. Relative risks (RRs) were estimated by logarithmic binomial modelling, and standardized incidence ratios (SIRs) were calculated from year-, sex- and age-specific rates of NMSC for the local population.

RESULTS

Compared with no MTX usage, any MTX usage was associated with a higher rate of at least one histopathologically confirmed NMSC (SIR 4.64, 95% CI: 0.67, 33.2). The SIR was 4.81 (95% CI: 3.60, 6.29) for those receiving a cumulative dose >8000 mg compared with SIR 2.31 (95% CI: 1.58, 2.36) for <5000 mg. An increased risk was shown for both basal cell carcinomas and squamous cell carcinomas, with an apparent dose-response relationship for basal cell carcinomas but not for squamous cell carcinomas. There was an increased risk of NMSC in patients taking CSA (RR = 2.51, 95% CI: 1.23, 5.13) and D-Pen (RR 3.49, 95% CI: 1.34, 4.63) in addition to MTX, but not for patients taking AZA or LEF.

CONCLUSION

MTX, and concurrent MTX and CSA or D-Pen use, is associated with an increased risk of NMSC. These results should encourage greater clinical vigilance for NMSC in treated patients with RA and PsA.

Periocular Skin Cancer in Solid Organ Transplant Recipients

PURPOSE

To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients.

DESIGN

Cohort study.

PARTICIPANTS

Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008.

METHODS

The charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair.

MAIN OUTCOME MEASURES

Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC.

RESULTS

A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies).

CONCLUSIONS

Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.

Skin Cancers as Contraindication to Organ Transplantation

The period of preparing patients for organ transplantation is a suitable time for dermatologic screening and examination that guarantee early diagnosis and easier treatment of precancerous states and skin cancers. In most cases, diagnosis of skin cancer in the pretransplantation period is not a contraindication to transplantation. Knowledge of risk factors and etiopathogenesis of skin cancers after transplantation make it easier to point out patients with increased risk of skin carcinogenesis. Patients with skin phototype I-III (Fitzpatrick classification) and with high cumulative doses of ultraviolet radiation have an increased risk of skin cancers. Patients who had skin cancers in the past should be carefully examined, and the skin cancer histopathology should be analyzed in detail. These examinations have to be done from the clinical, surgical, and histopathologic aspects. It helps dermatologists to estimate the risk and predict the patient's health after a possible organ transplantation. Basal cell carcinoma and squamous cell carcinoma that are present before transplantation indicate the possibility of similar cancer occurrence after transplantation; however, they are not a contraindication to transplantation after treatment of the primary foci. The waiting period to transplantation in the case of melanoma in situ takes 2 years, but in more serious forms of melanoma this time is prolonged to ≥ 5-10 years. Different skin cancers have a 3-year asymptomatic period to renewed indication for transplantation.

Topically applied Hsp90 inhibitor 17AAG inhibits UVR-induced cutaneous squamous cell carcinomas

We present here that heat-shock protein 90 (Hsp90) inhibitor 17-(allylamino)-17-demethoxygeldanamycin (17AAG), when topically applied to mouse skin, inhibits UVR-induced development of cutaneous squamous cell carcinoma (SCC). In these experiments, DMSO:acetone (1:40 v/v) solution of 17AAG (500 nmol) was applied topically to mouse skin in conjunction with each UVR exposure (1.8 kJ m(-2)). The UVR source was Kodacel-filtered FS-40 sun lamps (approximately 60% UVB and 40% UVA). In independent experiments with three separate mouse lines (SKH-1 hairless mice, wild-type FVB, and protein kinase C epsilon (PKCɛ)-overexpressing transgenic FVB mice), 17AAG treatment increased the latency and decreased both the incidence and multiplicity of UVR-induced SCC. Topical 17AAG alone or in conjunction with UVR treatments elicited neither skin nor systemic toxicity. 17AAG-caused inhibition of SCC induction was accompanied by a decrease in UVR-induced (1) hyperplasia, (2) Hsp90β-PKCɛ interaction, and (3) expression levels of Hsp90β, Stat3, pStat3Ser727, pStat3Tyr705, pAktSer473, and matrix metalloproteinase (MMP). The results presented here indicate that topical Hsp90 inhibitor 17AAG is effective in prevention of UVR-induced epidermal hyperplasia and SCC. One may conclude from the preclinical data presented here that topical 17AAG may be useful for prevention of UVR-induced inflammation and cutaneous SCC either developed in UVR-exposed or organ transplant population.

HPV Carcinomas in Immunocompromised Patients

Human papillomavirus (HPV) infection is the most common sexually transmitted disease worldwide and can result in pre-malignancies or overt malignancies of the skin and mucosal surfaces. HPV-related illnesses are an important personal and public health problem causing physical, mental, sexual and financial detriments. Moreover, this set of malignancies severely affects the immunosuppressed population, particularly HIV-positive patients and organ-transplant recipients. There is growing incidence of HPV-associated anogenital malignancies as well as a decrease in the average age of affected patients, likely related to the rising number of high-risk individuals. Squamous cell carcinoma is the most common type of HPV-related malignancy. Current treatment options for HPV infection and subsequent disease manifestations include imiquimod, retinoids, intralesional bleomycin, and cidofovir; however, primary prevention with HPV vaccination remains the most effective strategy. This review will discuss anogenital lesions in immunocompromised patients, cutaneous warts at nongenital sites, the association of HPV with skin cancer in immunocompromised patients, warts and carcinomas in organ-transplant patients, HIV-positive patients with HPV infections, and the management of cutaneous disease in the immunocompromised patient.

Skin cancer evaluation in transplant patients: a physician opinion survey with recommendations

BACKGROUND

Non-melanoma skin cancer is the most common malignancy in transplant patients. However, routine skin cancer evaluation is currently not the standard of care.

OBJECTIVE

To investigate the current barriers among transplant physicians to skin cancer screening in their patients. To provide recommendations for appropriate routine skin surveillance.

METHODS

A web-based survey was conducted among Baylor, Dallas transplant physicians. Thirty-seven of 46 responses were received, and 13 physicians (28%) were classified as "high screeners."

RESULTS

The univariate analysis revealed three main barriers including the perception of difficulty in seeing a dermatologist (p = 0.017), skin cancer evaluation is not an important aspect of transplant care (p = 0.038), and thirdly, the belief that there is insufficient evidence to warrant universal skin cancer screening in transplant patients (p = 0.013). The fully adjusted multivariable analysis resulted in two significant conclusions; the most important predictor was the perceived lack of medical evidence for skin cancer screening.

LIMITATIONS

The small sample size and all responses being from the same institution in Texas.

CONCLUSION

The dermatologic evidence for regular skin cancer screening in transplant patients needs dissemination to our transplant colleagues. This is a significant practice gap which can be appropriately closed by integrating dermatologists into the transplant team.

Risk of hepatobiliary cancer after solid organ transplant in the United States

BACKGROUND & AIMS

Studies of liver cancer risk in recipients of solid organ transplants generally have been small, yielding mixed results, and little is known about biliary tract cancers among transplant recipients.

METHODS

We identified incident hepatobiliary cancers among 201,549 US recipients of solid organs, from 1987 through 2008, by linking data from the US transplant registry with 15 cancer registries. We calculated standardized incidence ratios (SIRs), comparing risk relative to the general population. We also calculated incidence rate ratios (RRs), comparing risk for hepatocellular carcinoma (HCC) and total (intrahepatic and extrahepatic) cholangiocarcinoma among subgroups of recipients.

RESULTS

Of transplant recipients, 165 developed hepatobiliary cancers (SIR, 1.2; 95% confidence interval [CI], 1.0-1.4). HCC risk was increased among liver recipients (SIR, 1.5; 95% CI, 1.0-2.2), especially 5 or more years after transplant (SIR, 1.8; 95% CI, 1.0-3.0). Cholangiocarcinoma was increased among liver (SIR, 2.9; 95% CI, 1.6-4.8) and kidney recipients (SIR, 2.1; 95% CI, 1.3-3.1). HCC was associated with hepatitis B virus (RR, 3.2; 95% CI, 1.3-6.9), hepatitis C virus (RR, 10; 95% CI, 5.9-16.9), and non-insulin-dependent diabetes (RR, 2.5; 95% CI, 1.2-4.8). Cholangiocarcinoma was associated with azathioprine maintenance therapy (RR, 2.0; 95% CI, 1.1-3.7). Among liver recipients, primary sclerosing cholangitis was associated with an increased risk of cholangiocarcinoma, compared with the general population (SIR, 21; 95% CI, 8.2-42) and compared with liver recipients without primary sclerosing cholangitis (RR, 12.3; 95% CI, 4.1-36.4).

CONCLUSIONS

Risks for liver and biliary tract cancer are increased among organ transplant recipients. Risk factors for these cancers include medical conditions and potentially medications taken by recipients.

Advances in the management of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma is one of the most common non-melanoma skin cancers worldwide. While most cutaneous squamous cell carcinomas are easily managed, there is a high-risk subset of tumors that can cause severe morbidity and mortality. Tumor characteristics as well as patient characteristics contribute to the classification of cutaneous squamous cell carcinomas as low-risk vs. high-risk. Advances in the treatment of cutaneous squamous cell carcinomas largely relate to the management of this high-risk subset. Surgical and non-surgical management options, including newer targeted molecular therapies, will be discussed here. Larger, multicenter studies are needed to determine the exact significance of individual risk factors with respect to aggressive clinical behavior and the risks of metastasis and death, as well as the role of surgical and adjuvant therapies in patients with high-risk cutaneous squamous cell carcinomas.

The cutting edge of skin cancer in transplant recipients: scientific retreat of international transplant Skin Cancer Collaborative and Skin Cancer in Organ Transplant Patients Europe

The International Transplant Skin Cancer Collaborative (ITSCC) is an organization of more than 300 physicians and scientists focused on the study of dermatologic changes following solid organ transplantation. Transplant patients have a 100-fold increased risk of developing skin cancer. In October 2012, ITSCC and its European counterpart Skin Cancer in Organ Transplant Patients Europe held a joint biennial retreat in Essex, MA to discuss novel findings in the pathogenesis and management of skin cancer in solid organ transplant recipients. This meeting report is a summary of the novel findings discussed.

The cutting edge of skin cancer in transplant recipients: scientific retreat of international transplant Skin Cancer Collaborative and Skin Cancer in Organ Transplant Patients Europe

The International Transplant Skin Cancer Collaborative (ITSCC) is an organization of more than 300 physicians and scientists focused on the study of dermatologic changes following solid organ transplantation. Transplant patients have a 100-fold increased risk of developing skin cancer. In October 2012, ITSCC and its European counterpart Skin Cancer in Organ Transplant Patients Europe held a joint biennial retreat in Essex, MA to discuss novel findings in the pathogenesis and management of skin cancer in solid organ transplant recipients. This meeting report is a summary of the novel findings discussed.

Oncologic issues and kidney transplantation: a review of frequency, mortality, and screening

Kidney transplant recipients are at increased risk for development of malignancy compared with the general population, and malignancies occur at an earlier age. This increased risk, as expressed by the standard incidence ratio (SIR), varies widely, but it is highest in malignancies triggered by oncogenic viruses. For other cancers, this increased risk is the direct consequence of immunosuppressants promoting tumor growth and lowering immune system tumor surveillance. In this review, we briefly discuss the common malignancies with increased risk after kidney transplantation, explore the pros and cons associated with screening, and summarize current prevention and treatment recommendations.

Squamous cell carcinoma of the skin: Emerging need for novel biomarkers

The incidence of non-melanoma skin cancers (NMSC) is rising worldwide resulting in demand for clinically useful prognostic biomarkers for these malignant tumors, especially for invasive and metastatic cutaneous squamous cell carcinoma (cSCC). Important risk factors for the development and progression of cSCC include ultraviolet radiation, chronic skin ulcers and immunosuppression. Due to the role of cumulative long-term sun exposure, cSCC is usually a disease of the elderly, but the incidence is also growing in younger individuals due to increased recreational exposure to sunlight. Although clinical diagnosis of cSCC is usually easy and treatment with surgical excision curable, it is responsible for the majority of NMSC related deaths. Clinicians treating skin cancer patients are aware that certain cSCCs grow rapidly and metastasize, but the underlying molecular mechanisms responsible for the aggressive progression of a subpopulation of cSCCs remain incompletely understood. Recently, new molecular markers for progression of cSCC have been identified.

Papillomavirus-associated squamous skin cancers following transplant immunosuppression: one Notch closer to control

The frequent occurrence of cutaneous squamous cell carcinomas (SCCs) containing weakly tumorigenic human papillomaviruses (HPVs) following iatrogenic immunosuppression for organ transplantation remains incompletely understood. Here we address this problem in the light of recent insights into (1) the association of low-risk β-HPVs with skin SCCs in the rare genetic syndromes of epidermodysplasia verruciformis and xeroderma pigmentosum, (2) the frequent recovery of post-transplant tumor control on substituting calcineurin-inhibitory with mTOR-inhibitory immunosuppression, (3) the unexpectedly favorable prognosis of node-positive SCCs containing high-risk α-HPVs originating in the activated immune niche of the oropharynx, (4) the rapid occurrence of HPV-negative SCCs in ultraviolet (UV)-damaged skin of melanoma patients receiving Raf-inhibitory drugs, and (5) the selective ability of β-HPV E6 oncoproteins to inhibit Notch tumor-suppressive signaling in cutaneous and mesenchymal tissues. The crosstalk so implied between oncogenic UV-induced mutations, defective host immunity, and β-HPV-dependent stromal-epithelial signaling suggests that immunosuppressants such as calcineurin inhibitors intensify mitogenic signalling in TP53-mutant keratinocytes while also abrogating immune-dependent Notch-mediated tumor repression. This emerging interplay between solar damage, viral homeostasis and immune control makes it timely to reappraise strategies for managing skin SCCs in transplant patients.

Skin side effects of inflammatory bowel disease therapy

Skin manifestations are common in patients suffering from inflammatory bowel disease (IBD) and can be associated with the disease itself, with nutritional deficiencies, or with therapy. All drugs currently used for treating IBD have the potential to cause dermatologic manifestations that can have a wide range of clinical presentations, from mild drug eruptions to potentially life-threatening immune-mediated reactions. The wider use of thiopurines and anti-tumor necrosis factor in the past years has led to the recognition of 2 more skin complications of IBD therapy: the potentially disfiguring non-melanoma skin cancer associated with the current or past use of thiopurines and the paradoxical new onset or exacerbation of anti-tumor necrosis factor-associated psoriasis. Despite being rare, these complications can be severe and lead to therapy discontinuation, and therefore, gastroenterologists need to become familiar with their epidemiology, diagnosis, and management. Herein, we reviewed the skin side effects of IBD therapy, specially focusing in thiopurines and anti-tumor necrosis factor therapy and in the recently described skin cancer and psoriasis, and we tried to advance some practical algorithms that can provide some help to the clinicians dealing with these complications in their day-by-day practice.

Extrinsic aging: UV-mediated skin carcinogenesis

Age-associated skin lesions linked to UV radiation (UVR) include actinic keratosis, non-melanoma skin cancer-such as basal cell carcinoma and squamous cell carcinoma-lentigo senilis and lentigo maligna. Their incidence is increasing worldwide, mainly due to exaggerated UV exposure and to an aging population. Early diagnosis and therapy of pre-malignant cutaneous lesions is crucial for the secondary prophylaxis of invasive and highly aggressive skin cancers. Combined efforts to increase public awareness, patient education about self-examination, prophylactic modalities, such as consistent and sufficient UV protection, and rigorous follow-up of high-risk groups are of highest importance.