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Garman KA, Thoreson N, Strong J, Hallaert P, Gelb T, Shen M, Hall MD, Brownell I. Mycophenolate mofetil inhibits Merkel cell carcinoma growth. Br J Dermatol 2024; 190:593-595. [PMID: 38266271 PMCID: PMC10941324 DOI: 10.1093/bjd/ljae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/09/2024] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Abstract
The direct antitumour effects of mTOR inhibitors against cutaneous squamous cell carcinoma (SCC) have prompted a paradigm shift towards using sirolimus for allograft rejection prophylaxis in patients with high-risk SCC who have had a solid organ transplant (SOT). Patients who have had an SOT are at higher risk for Merkel cell carcinoma (MCC), yet there is little evidence concerning potential antitumour effects of immunosuppressive drugs against MCC. Screening seven immunosuppressive drugs in six MCC cell lines revealed that mycophenolate mofetil (MMF) had strong antitumour activity (surpassing mTOR inhibitors) and higher potency in MCC vs. other cancer types. MMF also inhibited MCC tumour growth in mice. Our preclinical findings strongly suggest the utility of MMF in patients with MCC who require immunosuppression.
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Affiliation(s)
- Khalid A Garman
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | | | - Jennifer Strong
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Patrick Hallaert
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Tara Gelb
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Min Shen
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Matthew D Hall
- Division of Pre-clinical Innovation, National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Isaac Brownell
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
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2
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Valentini R, Grant-Kels JM, Falcone M, Stewart CL. Merkel cell carcinoma and the eye. Clin Dermatol 2024:S0738-081X(24)00010-5. [PMID: 38325726 DOI: 10.1016/j.clindermatol.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine tumor with a poor five-year survival rate. Yearly cases have risen nearly 350% since the early 1980s, and these are predicted to increase as the overall US population ages. MCC of the eyelid is uncommon and can be misdiagnosed as other benign inflammatory and neoplastic eyelid disorders. Although MCC of the head and neck is often more aggressive than it is at other sites, eyelid MCC shows a lower disease-specific mortality rate. A biopsy is essential for accurate diagnosis, including an immunohistochemical panel of CK20 and TTF-1, although other markers may be necessary. Staging can be assessed clinically through physical examination findings and imaging and/or pathologically with sentinel lymph node biopsy or fine-needle aspiration. Pathologic staging more accurately predicts the prognosis. Eyelid MCC treatments include Mohs micrographic surgery to allow for complete clearance and adequate reconstruction of lost tissue, followed by adjuvant radiotherapy. In advanced disease, immunotherapies are preferred over traditional chemotherapy and are a subject of ongoing research.
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Affiliation(s)
- Rodolfo Valentini
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA; Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Madina Falcone
- Department of Surgery, Division of Ophthalmology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Campbell L Stewart
- Department of Dermatology, University of Connecticut School of Medicine, Farmington, Connecticut, USA.
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Ferrándiz-Pulido C, Leiter U, Harwood C, Proby CM, Guthoff M, Scheel CH, Westhoff TH, Bouwes Bavinck JN, Meyer T, Nägeli MC, Del Marmol V, Lebbé C, Geusau A. Immune Checkpoint Inhibitors in Solid Organ Transplant Recipients With Advanced Skin Cancers-Emerging Strategies for Clinical Management. Transplantation 2023; 107:1452-1462. [PMID: 36706163 DOI: 10.1097/tp.0000000000004459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Use of immune checkpoint inhibitors (ICIs) in solid organ transplant recipients (SOTRs) with advanced skin cancers presents a significant clinical management dilemma. SOTRs and other immunosuppressed patients have been routinely excluded from ICI clinical trials with good reason: immune checkpoints play an important role in self- and allograft-tolerance and risk of acute allograft rejection reported in retrospective studies affects 10% to 65% of cases. These reports also confirm that cutaneous squamous cell carcinoma and melanoma respond to ICI therapy, although response rates are generally lower than those observed in immunocompetent populations. Prospective trials are now of critical importance in further establishing ICI efficacy and safety. However, based on current knowledge, we recommend that ICIs should be offered to kidney transplant recipients with advanced cutaneous squamous cell carcinoma, melanoma, or Merkel cell carcinoma if surgery and/or radiotherapy have failed. For kidney transplant recipients, this should be first line ahead of chemotherapy and targeted therapies. In SOTRs, the use of ICIs should be carefully considered with the benefits of ICIs versus risks of allograft rejection weighed up on a case-by-case basis as part of shared decision-making with patients. In all cases, parallel management of immunosuppression may be key to ICI responsiveness. We recommend maintaining immunosuppression before ICI initiation with a dual immunosuppressive regimen combining mammalian target of rapamycin inhibitors and either corticosteroids or calcineurin inhibitors. Such modification of immunosuppression must be considered in the context of allograft risk (both rejection and also its subsequent treatment) and risk of tumor progression. Ultimately, a multidisciplinary approach should underpin all clinical decision-making in this challenging scenario.
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Affiliation(s)
- Carla Ferrándiz-Pulido
- Department of Dermatology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ulrike Leiter
- Department of Dermatology, Eberhard-Karls University of Tuebingen, Tuebingen, Germany
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Charlotte M Proby
- Department of Dermatology, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, Eberhard-Karls-University, Tuebingen, Germany
| | - Christina H Scheel
- Department of Dermatology, Skin Cancer Center, Ruhr-University Bochum, Bochum, Germany
| | - Timm H Westhoff
- Medical Department I, University Hospital Marien Hospital Herne, Ruhr-University Bochum, Bochum, Germany
| | | | - Thomas Meyer
- Department of Dermatology, Skin Cancer Center, Ruhr-University Bochum, Bochum, Germany
| | - Mirjam C Nägeli
- Department of Dermatology, University Hospital of Zurich, Switzerland
| | - Veronique Del Marmol
- Service de Dermatologie, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Celeste Lebbé
- Dermato-Oncology Department, Université Paris Cite, AP-HP Hôpital Saint Louis, Cancer Institute APHP. Nord-Université Paris CiteINSERM U976, HIPI, Paris, France
| | - Alexandra Geusau
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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4
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Ferrándiz‐Pulido C, Gómez‐Tomás A, Llombart B, Mendoza D, Marcoval J, Piaserico S, Baykal C, Bouwes‐Bavinck J, Rácz E, Kanitakis J, Harwood C, Cetkovská P, Geusau A, del Marmol V, Masferrer E, Orte Cano C, Ricar J, de Oliveira W, Salido‐Vallejo R, Ducroux E, Gkini M, López‐Guerrero J, Kutzner H, Kempf W, Seçkin D. Clinicopathological features, MCPyV status and outcomes of Merkel cell carcinoma in solid-organ transplant recipients: a retrospective, multicentre cohort study. J Eur Acad Dermatol Venereol 2022; 36:1991-2001. [PMID: 35607918 PMCID: PMC9796956 DOI: 10.1111/jdv.18256] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/13/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The proportion of Merkel cell carcinomas (MCCs) in solid-organ transplant recipients (SOTR) harbouring Merkel cell polyomavirus (MCPyV) is unknown, as are factors affecting their outcomes. OBJECTIVE To describe clinicopathological features of MCC in SOTR, investigate the tumoral MCPyV-status and identify factors associated with tumour outcomes. METHODS Retrospective, international, cohort-study. MCPyV-status was investigated by immunohistochemistry and polymerase chain reaction. RESULTS A total of 30 SOTR and 44 consecutive immunocompetent patients with MCC were enrolled. SOTR were younger at diagnosis (69 vs. 78 years, P < 0.001). Thirty-three percent of SOTR MCCs were MCPyV-positive vs. 91% of immunocompetent MCCs (P = 0.001). Solid-organ transplantation was associated with an increased cumulative incidence of progression (SHR: 3.35 [1.57-7.14], P = 0.002), MCC-specific mortality (SHR: 2.55 [1.07-6.06], P = 0.034) and overall mortality (HR: 3.26 [1.54-6.9], P = 0.002). MCPyV-positivity and switching to an mTOR inhibitor (mTORi) after MCC diagnosis were associated with an increased incidence of progression (SHR: 4.3 [1.5-13], P = 0.008 and SHR: 3.6 [1.1-12], P = 0.032 respectively) in SOTR. LIMITATIONS Retrospective design and heterogeneity of SOTR cohort. CONCLUSIONS MCPyV appears to play a less prominent role in the aetiopathogenesis of MCC in SOTR. SOTR have a worse prognosis than their immunocompetent counterparts and switching to an mTORi after the diagnosis of MCC does not improve progression.
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Affiliation(s)
- C. Ferrándiz‐Pulido
- Department of DermatologyHospital Universitari Vall d'Hebron, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - A. Gómez‐Tomás
- Department of DermatologyHospital Universitari Vall d'Hebron, Universitat Autònoma de BarcelonaBarcelonaSpain
| | - B. Llombart
- Servicio de DermatologíaInstituto Valenciano de OncologíaValenciaSpain
| | - D. Mendoza
- Department of DermatologyFundación Jiménez DíazMadridSpain
| | - J. Marcoval
- Department of DermatologyHospital de Bellvitge, IDIBELL, University of BarcelonaBarcelonaSpain
| | - S. Piaserico
- Dermatology Unit, Department of MedicineUniversità di PadovaPadovaItaly
| | - C. Baykal
- Department of DermatologyIstanbul University, Istanbul Medical FacultyIstanbulTurkey
| | - J.N. Bouwes‐Bavinck
- Department of DermatologyLeiden University Medical CenterLeidenThe Netherlands
| | - E. Rácz
- Department of DermatologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - J. Kanitakis
- Department of DermatologyEdouard Herriot Hospital Group, Hospices Civils de LyonLyonFrance
| | - C.A. Harwood
- Centre for Cell Biology and Cutaneous ResearchBlizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - P. Cetkovská
- Department of DermatovenereologyFaculty of Medicine, Charles UniversityPilsenThe Czech Republic
| | - A. Geusau
- Department of DermatologyMedical University of ViennaViennaAustria
| | - V. del Marmol
- Service de DermatologieHôpital Erasme, Université Libre de BruxellesBrusselsBelgium
| | - E. Masferrer
- Department of DermatologyHospital Universitari Mútua de TerrassaBarcelonaSpain
| | - C. Orte Cano
- Service de DermatologieHôpital Erasme, Université Libre de BruxellesBrusselsBelgium
| | - J. Ricar
- Department of DermatovenereologyFaculty of Medicine, Charles UniversityPilsenThe Czech Republic
| | | | - R. Salido‐Vallejo
- Department of DermatologyUniversity Clinic of Navarra, School of Medicine, University of NavarraPamplonaSpain
| | - E. Ducroux
- Department of DermatologyEdouard Herriot Hospital Group, Hospices Civils de LyonLyonFrance
| | - M.A. Gkini
- Centre for Cell Biology and Cutaneous ResearchBlizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of LondonLondonUK
| | - J.A. López‐Guerrero
- Laboratory of Molecular BiologyFundación Instituto Valenciano de OncologíaValenciaSpain,IVO‐CIPF Joint Research Unit of Cancer, Príncipe Felipe Research Center (CIPF)ValenciaSpain,Department of PathologySchool of Medicine, Catholic University of Valencia ‘San Vicente Martir’ValenciaSpain
| | | | - W. Kempf
- Kempf und Pfaltz Histologische Diagnostik and Department of DermatologyUniversity Hospital ZurichZürichSwitzerland
| | - D. Seçkin
- Department of DermatologyBaşkent University Faculty of MedicineAnkaraTurkey
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Comorbid immunosuppression in Merkel cell carcinoma: A retrospective database study. JAAD Int 2022; 8:136-138. [PMID: 35879929 PMCID: PMC9307455 DOI: 10.1016/j.jdin.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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6
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Diagnosis and treatment of Merkel cell carcinoma: European consensus-based interdisciplinary guideline - Update 2022. Eur J Cancer 2022; 171:203-231. [PMID: 35732101 DOI: 10.1016/j.ejca.2022.03.043] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/22/2022]
Abstract
Merkel cell carcinoma (MCC) is a rare skin cancer, accounting for less than 1% of all cutaneous malignancies. It is found predominantly in white populations and risk factors include advanced age, ultraviolet exposure, male sex, immunosuppression, such as AIDS/HIV infection, haematological malignancies or solid organ transplantation, and Merkel cell polyomavirus infection. MCC is an aggressive tumour with 26% of cases presenting lymph node involvement at diagnosis and 8% with distant metastases. Five-year overall survival rates range between 48% and 63%. Two subsets of MCC have been characterised with distinct molecular pathogenetic pathways: ultraviolet-induced MCC versus virus-positive MCC, which carries a better prognosis. In both subtypes, there are alterations in the retinoblastoma protein and p53 gene structure and function. MCC typically manifests as a red nodule or plaque with fast growth, most commonly on sun exposed areas. Histopathology (small-cell neuroendocrine appearance) and immunohistochemistry (CK20 positivity and TTF-1 negativity) confirm the diagnosis. The current staging systems are the American Joint Committee on Cancer/Union for international Cancer control 8th edition. Baseline whole body imaging is encouraged to rule out regional and distant metastasis. For localised MCC, first-line treatment is surgical excision with postoperative margin assessment followed by adjuvant radiation therapy (RT). Sentinel lymph node biopsy is recommended in all patients with MCC without clinically detectable lymph nodes or distant metastasis. Adjuvant RT alone, eventually combined with complete lymph nodes dissection is proposed in case of micrometastatic nodal involvement. In case of macroscopic nodal involvement, the standard of care is complete lymph nodes dissection potentially followed by post-operative RT. Immunotherapy with anti-PD-(L)1 antibodies should be offered as first-line systemic treatment in advanced MCC. Chemotherapy can be used when patients fail to respond or are intolerant for anti-PD-(L)1 immunotherapy or clinical trials.
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7
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Harvey JA, Mirza SA, Erwin PJ, Chan AW, Murad MH, Brewer JD. Recurrence and mortality rates with different treatment approaches of Merkel cell carcinoma: a systematic review and meta-analysis. Int J Dermatol 2021; 61:687-697. [PMID: 34227108 DOI: 10.1111/ijd.15753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/29/2021] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Comprehensive treatment recommendations for Merkel cell carcinoma are complex. We aimed to systematically review the published data on recurrence and mortality rates associated with various treatment approaches for Merkel cell carcinoma. METHODS Search of MEDLINE, Embase, Web of Science, and Scopus from inception to August 2015. Studies were included that reported comparative survival and recurrence data for two or more treatment modalities. Two reviewers independently reviewed and abstracted recurrence and mortality rates. Event rates for individual treatment arms in each study were pooled and meta-analyzed across studies using a random-effects model. RESULTS Fifty-two retrospective studies met inclusion criteria, revealing a total of 1,804 patients with primary Merkel cell carcinoma with data available for analyses. The recurrence rate was higher for surgery alone (55.0%) versus a combination of surgery and radiotherapy (39.0%) (odds ratio, 2.089; 95% CI, 1.374-3.177; P < 0.001). Combination therapy including surgery, radiotherapy, and chemotherapy had a higher mortality rate (44.6%) than did combined surgery and radiotherapy (23.2%) (odds ratio, 2.688; 95% CI, 1.196-6.037; P = 0.02). CONCLUSIONS The treatment of Merkel cell carcinoma with surgery plus adjuvant radiotherapy may produce lower recurrence rates.
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Affiliation(s)
| | - Sultan A Mirza
- Mayo Clinic Health System - Southwest Minnesota Region, Mankato, MN, USA
| | | | - An W Chan
- Department of Dermatology & Mohs Surgery, Women's College Hospital, Toronto, Ontario, Canada
| | - M H Murad
- Division of Preventive, Occupational and Aerospace Medicine and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
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8
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Abstract
Merkel cell carcinoma (MCC) is a rare and highly aggressive neuroendocrine carcinoma of unknown origin. We performed a retrospective histologic review of primary cutaneous MCCs diagnosed from 1997 to 2018 in several clinical institutions and literature review to determine the frequency of various unusual morphologic appearances of MCC. Of the 136 primary MCCs identified, intraepidermal carcinoma or epidermotropism was noted in 11/136 (8%) cases. An association with pilar cyst in 1/136 (0.7%) case, with actinic keratosis in 2/136 (1.5%) cases, with either invasive or in situ squamous cell carcinoma (SCC) in 14/136 (10%) cases, with poroma in 1/136 (0.7%), and with basal cell carcinoma in 1/136 (0.7%) case was noted. Trabecular pattern and rosettes were noted in 7/136 (5%) and 3/136 (2%) cases, respectively. There was one case of metastatic MCC in a lymph node with chronic lymphocytic leukemia and one rare case of metastatic MCC and SCC in a lymph node. Although uncommon, differentiation toward other cell lineage can be observed in both primary and metastatic MCCs. The tumor can assume a variety of histologic appearances including association with SCC, basal cell carcinoma, melanocytic neoplasm, and follicular cyst; as well as exhibit glandular, sarcomatous, and mesenchymal differentiation. This diversity of morphologic appearance of MCC reflects the complexity of its underlying pathogenesis.
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9
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Maloney NJ, Yang JJ, Zaba LC. Merkel cell carcinoma patients with solid organ transplant or hematologic malignancy: Demographics, survival, and prognosticators. J Am Acad Dermatol 2021; 86:1385-1387. [PMID: 34082038 DOI: 10.1016/j.jaad.2021.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/05/2021] [Accepted: 05/20/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Nolan J Maloney
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California; Department of Dermatology, Stanford University School of Medicine, Palo Alto, California
| | - Jason J Yang
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California; Department of Dermatology, Stanford University School of Medicine, Palo Alto, California
| | - Lisa C Zaba
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California; Department of Dermatology, Stanford University School of Medicine, Palo Alto, California.
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10
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Wilken R, Carucci J, Stevenson ML. Skin Cancers and Lung Transplant. Semin Respir Crit Care Med 2021; 42:483-496. [PMID: 34030209 DOI: 10.1055/s-0041-1728798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Reason Wilken
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - John Carucci
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
| | - Mary L Stevenson
- The Ronald O. Perelman Department of Dermatology, NYU Langone Health, New York, New York
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11
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Cutaneous Head and Neck Cancers in the High-Risk Immunosuppressed Population. Otolaryngol Clin North Am 2021; 54:397-413. [PMID: 33602516 DOI: 10.1016/j.otc.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The immunosuppressed (IS) population encompasses a diverse cohort of patients to include iatrogenically immunocompromised organ transplant recipients as well as patients with chronic lymphoid malignancies, human immunodeficiency virus/acquired immunodeficiency syndrome, and autoimmune disorders. Cutaneous cancers in this high-risk patient group are clinically distinct from the general immunocompetent population, showing aggressive behavior with associated poor outcomes. This article reviews the pathogenesis, epidemiology, incidence, prognosis, and special considerations required in managing cutaneous cancers in the IS patient population.
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12
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Yusuf MB, Gaskins J, Wall W, Tennant P, Bumpous J, Dunlap N. Immune status and the efficacy of radiotherapy on overall survival for patients with localized Merkel cell carcinoma: An analysis of the National Cancer Database. J Med Imaging Radiat Oncol 2020; 64:435-443. [PMID: 32372566 DOI: 10.1111/1754-9485.13039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/01/2020] [Accepted: 03/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Immunosuppressed (IS) patients with Merkel cell carcinoma (MCC) have worse outcomes compared to immunocompetent (IC) patients, and it is unclear if adjuvant radiotherapy (RT) is beneficial for these patients. We sought to determine the effect of immune status on adjuvant RT efficacy regarding overall survival (OS) for patients with localized MCC. METHODS This was an observational study of National Cancer Database (NCDB) identifying patients with stage I/II or III MCC with known immune status diagnosed from 2010 to 2014. The median follow-up time was 29 months. OS was described using Kaplan-Meier methods and compared for subgroups by immune status and adjuvant RT using log-rank tests, multivariable Cox regression and interaction effect testing. RESULTS A total of 2049 IC and 255 IS patients were included. Adjuvant RT was associated with decreased hazard of death for stage I/II MCC (HR 0.65, CI 0.54-0.78) adjusting for factors including immune status. Interaction effect testing did not demonstrate a significant difference in the effect of adjuvant RT on OS between IC and IS status in either stage I/II or III MCC (both P values > 0.05). CONCLUSIONS In this observational study, adjuvant RT was associated with decreased hazard of death for patients with stage I/II MCC regardless of immune status. Adjuvant RT should be considered for both IS and IC patients with localized MCC.
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Affiliation(s)
- Mehran B Yusuf
- Department of Radiation Oncology, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky, USA
| | - Weston Wall
- Department of Dermatology, Medical College of Georgia, Augusta, Georgia, USA
| | - Paul Tennant
- Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Jeffrey Bumpous
- Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Neal Dunlap
- Department of Radiation Oncology, University of Louisville Hospital, Louisville, Kentucky, USA
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13
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Song Y, Zheng C, Shannon AB, Fraker DL, Miura JT, Karakousis GC. Sentinel lymph node positivity and overall survival in immunosuppressed patients with Merkel cell carcinoma: a national cohort study. Br J Dermatol 2020; 183:569-571. [PMID: 32147810 DOI: 10.1111/bjd.19021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Y Song
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - C Zheng
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - A B Shannon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D L Fraker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J T Miura
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G C Karakousis
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Keeling E, Murray S, Williams Y, Sexton D, O'Kelly P, Deady S, O'Leary E, Dorman A, Roche M, Ni Raghallaigh S, McCormick A, Moloney F, O'Neill J, Conlon P. Merkel cell carcinoma in kidney transplant recipients in Ireland 1964–2018. Br J Dermatol 2019; 181:1314-1315. [DOI: 10.1111/bjd.18218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- E. Keeling
- Department of Dermatology Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - S.L. Murray
- Department of Nephrology & Transplantation Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - Y. Williams
- Department of Nephrology & Transplantation Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - D.J. Sexton
- Department of Nephrology & Transplantation Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - P. O'Kelly
- Department of Nephrology & Transplantation Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - S. Deady
- National Cancer Registry Ireland
| | | | - A. Dorman
- Department of Pathology Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - M. Roche
- Department of Dermatology Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - S. Ni Raghallaigh
- Department of Dermatology Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - A. McCormick
- Department of Hepatology & Liver Transplant St Vincent's Hospital Dublin Ireland
| | - F.J. Moloney
- Department of Dermatology Mater University Hospital Dublin Ireland
| | - J.P. O'Neill
- Department of Otolaryngology Head & Neck Surgery, Beaumont Hospital Dublin Ireland
| | - P.J. Conlon
- Department of Nephrology & Transplantation Head & Neck Surgery, Beaumont Hospital Dublin Ireland
- Department of Medicine Royal College of Surgeons in Ireland Dublin Ireland
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15
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Lopez J, Gourin CG, Tufaro AP. Aggressive Cutaneous Malignancies: A New and Dangerous Phenomenon in Transplant Patients. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0223-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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16
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Cook M, Baker K, Redman M, Lachance K, Nguyen MH, Parvathaneni U, Bhatia S, Nghiem P, Tseng YD. Differential Outcomes Among Immunosuppressed Patients With Merkel Cell Carcinoma: Impact of Immunosuppression Type on Cancer-specific and Overall Survival. Am J Clin Oncol 2019; 42:82-88. [PMID: 30211723 PMCID: PMC8666386 DOI: 10.1097/coc.0000000000000482] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin cancer with higher incidence among whites, elderly, and immunosuppressed patients. Although immunosuppressed MCC patients are at higher risk of recurrence and MCC-related death, it is unknown whether immunosuppression type is associated with differential outcomes. MATERIALS AND METHODS We retrospectively evaluated 89 nonmetastatic MCC patients with a diagnosis of chronic immunosuppression. Immunosuppression was categorized as chronic lymphocytic leukemia (31% of cohort), other hematologic malignancies (18%), solid organ transplant (21%), autoimmune disease (21%), and human immunodeficiency virus acquired deficiency syndrome (8%). Progression-free survival (PFS) and MCC-specific survival (MSS) were estimated with the cumulative incidence function. Overall survival (OS) was estimated by the Kaplan-Meier method. RESULTS With a median follow-up of 52 months, 53 deaths occurred (42 from MCC, 7 unknown, and 4 non-MCC). Two-year PFS, MSS, and OS were 30%, 55%, and 52%, respectively. Human immunodeficiency virus/acquired deficiency syndrome and solid organ transplant patients were diagnosed with MCC at a younger age (median 55 and 59 y, respectively) and with more advanced stage disease compared with other immunosuppressed subgroups. PFS did not significantly differ among the 5 immunosuppression subgroups (P=0.30), but significant differences were observed in MSS and OS (both P=0.01). Controlling for potential confounders for OS, including age and stage, immunosuppression type was still significantly associated with risk of death (P=0.01). CONCLUSIONS Among immunosuppressed MCC patients, recurrent MCC is the major cause of mortality. The risk of death from MCC differs among immunosuppression types, suggesting important biological differences in host-tumor immune interactions.
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Affiliation(s)
| | - Kelsey Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center
| | - Mary Redman
- Clinical Research Division, Fred Hutchinson Cancer Research Center
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17
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Mitchell N, Connell A, Kurth B. Venous thromboembolism leading to diagnosis of de novo malignancy in an organ transplant recipient. BMJ Case Rep 2018; 2018:bcr-2018-225125. [PMID: 30196255 DOI: 10.1136/bcr-2018-225125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a patient with remote orthotopic liver transplant who was ultimately diagnosed with Merkel cell carcinoma following admission for initial venous thromboembolism. Additionally, we review pertinent literature related to the risk of skin cancer in solid organ transplant recipients and discuss the importance of yearly skin exams in this patient population.
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Affiliation(s)
- Natalie Mitchell
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Alana Connell
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Benjamin Kurth
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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18
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Howard MD, Su JC, Chong AH. Skin Cancer Following Solid Organ Transplantation: A Review of Risk Factors and Models of Care. Am J Clin Dermatol 2018; 19:585-597. [PMID: 29691768 DOI: 10.1007/s40257-018-0355-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The number of solid organ transplants has been increasing annually worldwide. Advances in transplantation surgery and community awareness of organ donation have been key contributors. Combined with increased understanding of immunosuppression, there are a growing number of solid organ transplant recipients in the community as a result of improved long-term outcomes. There remains a high incidence of deaths worldwide post-transplant due to non-melanoma skin cancer (NMSC), which has greater morbidity and mortality in this population than in the general community. Many transplant candidates are not screened prior to organ transplantation and not followed up dermatologically after transplant. After a comprehensive review of the MEDLINE database, we present an update of literature on risk factors for melanoma and non-melanoma skin cancer development in transplant recipients. Medications used by transplant recipients, including immunosuppressants and antibiotics, are discussed along with their respective risks of skin cancer development. We conclude with evidence-based recommendations for models of care, including patient education and dermatological review of transplant recipients.
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19
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Tseng YD, Nguyen MH, Baker K, Cook M, Redman M, Lachance K, Bhatia S, Liao JJ, Apisarnthanarax S, Nghiem PT, Parvathaneni U. Effect of Patient Immune Status on the Efficacy of Radiation Therapy and Recurrence-Free Survival Among 805 Patients With Merkel Cell Carcinoma. Int J Radiat Oncol Biol Phys 2018; 102:330-339. [PMID: 30191867 DOI: 10.1016/j.ijrobp.2018.05.075] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 05/17/2018] [Accepted: 05/29/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE Patients with Merkel cell carcinoma (MCC) with chronic immunosuppression (IS) have worse outcomes, but the mechanisms are not well understood. We hypothesized that these differences may be mediated in part by differential response to treatment, and we evaluated whether radiation therapy (RT) efficacy is altered among IS compared with immune-competent (IC) patients with MCC. METHODS AND MATERIALS Among 805 patients with MCC, recurrence-free survival (RFS) and patterns of first recurrence were compared between 89 IS and 716 IC patients with stage I to III MCC treated with curative intent. We used a Fine and Gray's competing risk multivariable analysis to estimate associations with RFS. RESULTS IS and IC patients with MCC had similar demographic and disease characteristics. Most (77% IC, 86% IS) were irradiated (median, 50.4 Gy IC, 50.3 Gy IS), although more IS patients were irradiated to the primary site (97% vs 81%). With a median follow-up of 54.4 months, IS patients had inferior RFS (2-year: 30% vs 57%; P < .0001) and higher rates of local recurrence as the first site of relapse (25% vs 12%; P = .0002). The association between RT and RFS differed by immune status (interaction P = .01). Although RT was associated with significantly improved RFS among IC patients (hazard ratio 0.56, 95% confidence interval 0.44-0.72), no difference in RFS was observed with RT among IS patients (hazard ratio 1.49, 95% confidence interval 0.70-3.17). CONCLUSIONS Radiation therapy efficacy at current standard RT doses for MCC is impaired among immunosuppressed patients with MCC. Although a strong link between durability of RT response and immune function does not appear to be evident in most cancers, our results may reflect an especially dynamic interaction between immune status and RT efficacy in MCC.
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Affiliation(s)
- Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
| | - Macklin H Nguyen
- University of Washington School of Medicine, Seattle, Washington
| | - Kelsey Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Maclean Cook
- Division of Dermatology, University of Washington, Seattle, Washington
| | - Mary Redman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kristina Lachance
- Division of Dermatology, University of Washington, Seattle, Washington
| | - Shailender Bhatia
- Division of Medical Oncology, University of Washington, Seattle, Washington
| | - Jay J Liao
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | | | - Paul T Nghiem
- Division of Dermatology, University of Washington, Seattle, Washington
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20
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Inherited and acquired clinical phenotypes associated with neuroendocrine tumors. Curr Opin Allergy Clin Immunol 2018; 17:431-442. [PMID: 29040209 DOI: 10.1097/aci.0000000000000406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Overview of neuroendocrine neoplasms in the context of their associations with primary and secondary immunodeficiency states. RECENT FINDINGS Malignancies of neuroendocrine origin are well known to be associated with hereditary syndromes, including multiple endocrine neoplasia type 1, von Hippel-Lindau syndrome, neurofibromatosis type 1, and tuberous sclerosis. This review includes the X-linked form of hyper-IgM syndrome (XHIGM), due to mutations in the CD40Ligand gene (CD40LG), as an additional inherited disorder with susceptibility to such malignancies, and discusses neuroendocrine tumors (NETs) arising in other immunocompromised states. Of all primary immune deficiency diseases, NETs appear to be unique to XHIGM patients. Outcomes for XHIGM patients with NETs is poor, and the mechanism behind this association remains unclear. In secondary immune deficiency states, NET occurrences were primarily in patients with HIV or AIDS, the autoimmune disease systemic lupus erythematosus and solid organ transplant recipients. Gastroenteropancreatic NETs were most frequent in XHIGM patients, whereas nongastroenteropancreatic-NETs, like Merkel cell carcinoma and small-cell lung carcinoma, affected HIV/AIDS patients. Possible mechanisms as to the nature of these associations are discussed, including chronic infections and inflammation, and CD40-CD40L interactions. Many questions remain, and further studies are needed to clarify the predisposition of patients with XHIGM to the development of NETs. Given that many of these patients present late in their disease state and have poor outcomes, it is imperative to keep a high index of suspicion at the advent of early signs and symptoms. Regular monitoring with laboratory or imaging studies, including tumor markers, may be warranted, for which further studies are needed. SUMMARY Of all primary immunodeficiency diseases, NETs appear to be unique to XHIGM, and the mechanism behind this association remains unclear. Outcome for XHIGM patients with NETs is poor, and it is imperative to keep a high index of suspicion at the advent of early signs and symptoms.
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21
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Canavan TN, Baddley JW, Pavlidakey P, Tallaj JA, Elewski BE. Human polyomavirus-7-associated eruption successfully treated with acitretin. Am J Transplant 2018; 18:1278-1284. [PMID: 29275541 DOI: 10.1111/ajt.14634] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 12/13/2017] [Accepted: 12/18/2017] [Indexed: 01/25/2023]
Abstract
Advances in molecular technologies have led to the discovery of several novel human polyomaviruses (HPyVs), including human polyomavirus-7 (HPyV-7). Although low levels of HPyV-7 are shed from apparently normal skin, recent reports have described clinically significant cutaneous infection in immunocompromised patients that manifests as generalized pruritic plaques. The pruritus can be severe, and treatment options have not been described. Herein we report HPyV-7 cutaneous infection in a heart transplant patient who experienced temporary improvement with intravenous cidofovir, and complete remission with acitretin. We report a case of HPyV-7 cutaneous infection demonstrating a good response to treatment.
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Affiliation(s)
- T N Canavan
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J W Baddley
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - P Pavlidakey
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J A Tallaj
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - B E Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Abstract
Merkel cell carcinoma (MCC), a rare skin cancer, is associated with high mortality, especially in a metastatic setting. Though conventional chemotherapy with platinum and etoposide has had high response rates, many of the patients have had early relapse without any effective therapy thereafter. Recently, immune check point inhibitors have shown very good durable responses, leading to the approval of a programmed death-ligand 1 inhibitor Avelumab for these patients. We briefly review the epidemiology and immune basis of the pathogenesis of MCC, which therefore explains the excellent response to check point inhibitors, and throw light on future directions of immunotherapy for this cancer.
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Affiliation(s)
- Amruth R Palla
- Department of Internal Medicine, Division of Hematology and Oncology, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO, USA
| | - Donald Doll
- Department of Internal Medicine, Division of Hematology and Oncology, Ellis Fischel Cancer Center, University of Missouri, Columbia, MO, USA
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23
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Garrett GL, Yuan JT, Shin TM, Arron ST. Validity of skin cancer malignancy reporting to the Organ Procurement Transplant Network: A cohort study. J Am Acad Dermatol 2017; 78:264-269. [PMID: 29031659 DOI: 10.1016/j.jaad.2017.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/25/2017] [Accepted: 09/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Organ Procurement Transplant Network (OPTN) registry collects data on posttransplant malignancies in solid organ transplant recipients. Complete and accurate registry data on skin cancer is critical for research on epidemiology and interventions. OBJECTIVE The study goal was to determine the validity of Organ Procurement Transplant Network skin cancer data. METHODS This cohort study compared reporting of posttransplant squamous cell carcinoma (SCC) and malignant melanoma (MM) in OPTN to medical-record review-derived data from the Transplant Skin Cancer Network (TSCN) database. In total, 4934 organ transplant recipients from the TSCN database were linked to patient-level OPTN malignancy data. We calculated sensitivity, specificity, correct classification (CC), positive predictive value (PPV), and negative predictive value (NPV) for SCC and MM reporting in the OPTN database. RESULTS OPTN reporting for SCC (population prevalence 11%) had sensitivity 41%, specificity 99%, PPV 88%, NPV 93%, and CC 93%. OPTN reporting for MM (population prevalence 1%) had sensitivity 22%, specificity 100%, PPV 73%, NPV 99%, and CC 99%. LIMITATIONS Only a subset of patients in the TSCN cohort had matched United Network for Organ Sharing cancer registry data for comparison. CONCLUSION OPTN reporting had poor sensitivity but excellent specificity for SCC and MM. Dermatologists and transplant physicians are encouraged to improve the validity of OPTN skin cancer data through improved communication and reporting.
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Affiliation(s)
- Giorgia L Garrett
- Department of Dermatology, University of California at San Francisco, San Francisco, California
| | - Joyce T Yuan
- Department of Dermatology, University of California at San Francisco, San Francisco, California
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Pennsylvania
| | - Sarah T Arron
- Department of Dermatology, University of California at San Francisco, San Francisco, California.
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24
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Mittal A, Colegio OR. Skin Cancers in Organ Transplant Recipients. Am J Transplant 2017; 17:2509-2530. [PMID: 28556451 DOI: 10.1111/ajt.14382] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 05/05/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- A Mittal
- Departments of Dermatology, Yale University School of Medicine, New Haven, CT
| | - O R Colegio
- Departments of Dermatology, Yale University School of Medicine, New Haven, CT.,Departments of Pathology, Yale University School of Medicine, New Haven, CT.,Departments of Surgery, Yale University School of Medicine, New Haven, CT.,Yale Cancer Center, Yale University School of Medicine, New Haven, CT.,Yale-New Haven Transplantation Center, Yale University School of Medicine, New Haven, CT
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25
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Harms KL, Chubb H, Zhao L, Fullen DR, Bichakjian CK, Johnson TM, Carskadon S, Palanisamy N, Harms PW. Increased expression of EZH2 in Merkel cell carcinoma is associated with disease progression and poorer prognosis. Hum Pathol 2017; 67:78-84. [PMID: 28739498 DOI: 10.1016/j.humpath.2017.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 06/24/2017] [Accepted: 07/12/2017] [Indexed: 12/21/2022]
Abstract
Enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase that affects tumorigenesis by epigenetic gene silencing. Merkel cell carcinoma (MCC) is a rare cutaneous neuroendocrine carcinoma that has a high risk of disease progression with nodal and distant metastases. Here, we evaluated EZH2 expression by immunohistochemistry in a cohort of 85 MCC tumors (29 primary tumors, 41 lymph node metastases, 13 in-transit metastases, and 2 distant metastases) with clinical follow-up. We show strong/moderate EZH2 expression in 54% of tumors. Importantly, weak expression of EZH2 in the primary tumor, but not nodal metastases, correlated with improved prognosis compared to moderate/strong EZH2 expression (5-year MCC-specific survival of 68% versus 22%, respectively, P=.024). In addition, EZH2 was expressed at higher levels in nodal metastases compared to primary tumors (P=.005). Our data demonstrate that EZH2 has prognostic value and may play an oncogenic role in MCC.
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Affiliation(s)
- Kelly L Harms
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA; Comprehensive Cancer Center, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Heather Chubb
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Lili Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109, USA
| | - Douglas R Fullen
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Christopher K Bichakjian
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA; Comprehensive Cancer Center, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Timothy M Johnson
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA; Comprehensive Cancer Center, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Shannon Carskadon
- Vattikuti Urology Institute, Department of Urology, Henry Ford Health System, Detroit, MI 48202, USA
| | - Nallasivam Palanisamy
- Vattikuti Urology Institute, Department of Urology, Henry Ford Health System, Detroit, MI 48202, USA
| | - Paul W Harms
- Department of Dermatology, University of Michigan Health System, Ann Arbor, MI 48109, USA; Department of Pathology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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26
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Rehailia-Blanchard A, Pigné G, Guy JB, Vallard A, El Meddeb Hamrouni A, Rancoule C, Magné N. [Care of Merkel cell carcinoma and role of the radiotherapy]. Bull Cancer 2016; 104:101-108. [PMID: 27989628 DOI: 10.1016/j.bulcan.2016.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 11/30/2022]
Abstract
Merkel cell carcinoma is a rare neuro-endocrine tumor of skin with a poor prognosis. Data available in literature are scarce. Current treatment for locoregional disease is based on combined treatment by surgery and radiotherapy. However these treatments are controversial. The aim of the present review is to sum up the different available studies and to compare national and international guidelines.
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Affiliation(s)
- Amel Rehailia-Blanchard
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Grégoire Pigné
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Jean-Baptiste Guy
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de radiobiologie cellulaire et moléculaire de Lyon Sud, CNRS UMR 5822, 165, chemin du Grand-Revoyet, BP 12, 69921 Oullins cedex, France
| | - Alexis Vallard
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Anis El Meddeb Hamrouni
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France
| | - Chloé Rancoule
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de radiobiologie cellulaire et moléculaire de Lyon Sud, CNRS UMR 5822, 165, chemin du Grand-Revoyet, BP 12, 69921 Oullins cedex, France
| | - Nicolas Magné
- Institut de cancérologie Lucien-Neuwirth, département de radiothérapie, 108 bis, avenue Albert-Raimond, BP 60008, 42271 Saint-Priest en Jarez, France; Laboratoire de radiobiologie cellulaire et moléculaire de Lyon Sud, CNRS UMR 5822, 165, chemin du Grand-Revoyet, BP 12, 69921 Oullins cedex, France.
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27
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History of chronic inflammatory disorders increases the risk of Merkel cell carcinoma, but does not correlate with Merkel cell polyomavirus infection. Br J Cancer 2016; 116:260-264. [PMID: 27978533 PMCID: PMC5243985 DOI: 10.1038/bjc.2016.391] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/25/2016] [Accepted: 11/03/2016] [Indexed: 01/25/2023] Open
Abstract
Background: We aimed to assess the connection between chronic inflammatory disorders (CIDs) and Merkel cell carcinoma (MCC). Methods: Merkel cell carcinoma cases diagnosed in 1978–2009 were extracted from the Finnish Cancer Registry and controls from the Population Registry. Information on reimbursed CIDs was linked to clinicopathological data including Merkel cell polyomavirus (MCV) status by qPCR and immunohistochemistry for the large T antigen of MCV (LTA), Ki-67 and tumour-infiltrating lymphocytes. Results: Chronic inflammatory disorders increased the risk of MCC significantly (odds ratio (OR) 1.39, 95% confidence interval (CI) 1.03–1.88), specifically connective tissue/systemic diseases (OR 1.75, 95% CI 1.09–1.80) and diabetic conditions (OR 1.51, 95% CI 1.03–2.22). Chronic inflammatory disorders associated with larger tumour diameter (P=0.02) and higher Ki-67 expression (P=0.005). The expression of LTA was seen significantly more often in the absence of CIDs (P=0.05). Conclusions: Patients with CID are at significantly higher risk for aggressive MCC. Merkel cell polyomavirus positivity is more common in MCC patients unafflicted by CID.
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28
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Zaragoza J, Kervarrec T, Touzé A, Avenel-Audran M, Beneton N, Esteve E, Wierzbicka Hainaut E, Aubin F, Machet L, Samimi M. A high neutrophil-to-lymphocyte ratio as a potential marker of mortality in patients with Merkel cell carcinoma: A retrospective study. J Am Acad Dermatol 2016; 75:712-721.e1. [PMID: 27544490 DOI: 10.1016/j.jaad.2016.05.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 04/11/2016] [Accepted: 05/29/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND The prognostic relevance of a high blood neutrophil-to-lymphocyte ratio (NLR) has been reported in many cancers, although, to our knowledge, not investigated in patients with Merkel cell carcinoma (MCC) to date. OBJECTIVE We assessed whether the NLR at baseline was associated with specific survival and recurrence-free survival in MCC. METHODS We retrospectively included MCC cases between 1999 and 2015 and collected clinical data, blood cell count at baseline, and outcome. A Cox model was used to identify factors associated with recurrence and death from MCC. RESULTS Among the 75 patients included in the study, a high NLR at baseline (NLR ≥4) was associated with death from MCC in univariate (hazard ratio 2.76, 95% confidence interval 1.15-6.62, P = .023) and multivariate (hazard ratio 3.30, 95% confidence interval 1.21-9.01, P = .020) analysis, but not with recurrence. LIMITATIONS Because of the retrospective design, we excluded patients with missing data and not all confounding factors that may influence the NLR were available. CONCLUSION A high NLR at baseline was independently associated with specific mortality in patients with MCC. The NLR seems to constitute an easily available and inexpensive prognostic biomarker at baseline.
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Affiliation(s)
- Julia Zaragoza
- Department of Dermatology, Centre Hospitalier Universitaire Tours, Université François Rabelais, Tours, France
| | - Thibault Kervarrec
- Department of Pathology, Centre Hospitalier Universitaire Tours, Université François Rabelais, Tours, France
| | - Antoine Touzé
- Institut National de la Recherche Agronomique, Unité Mixte de Recherche 1282 Infectiologie et Santé Publique, Université François Rabelais, Tours, France
| | - Martine Avenel-Audran
- Dermatology Department, Centre Hospitalier Universitaire Angers, L'Université Nantes Angers Le Mans (LUNAM), Angers, France
| | - Nathalie Beneton
- Dermatology Department, Centre Hospitalier Régional Le Mans, Le Mans, France
| | - Eric Esteve
- Dermatology Department, Centre Hospitalier Régional Orléans, Orléans, France
| | | | - François Aubin
- Dermatology Department, Centre Hospitalier Universitaire Besançon, Université de Franche Comté, Equipe d'Accueil 3181, Institut Fédératif de Recherche 133, Besançon, France
| | - Laurent Machet
- Department of Dermatology, Centre Hospitalier Universitaire Tours, Université François Rabelais, Tours, France
| | - Mahtab Samimi
- Department of Dermatology, Centre Hospitalier Universitaire Tours, Université François Rabelais, Tours, France; Institut National de la Recherche Agronomique, Unité Mixte de Recherche 1282 Infectiologie et Santé Publique, Université François Rabelais, Tours, France.
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Trends of skin cancer mortality after transplantation in the United States: 1987 to 2013. J Am Acad Dermatol 2016; 75:106-12. [DOI: 10.1016/j.jaad.2016.02.1155] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/01/2016] [Accepted: 02/11/2016] [Indexed: 01/29/2023]
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Tufaro AP, Azoury SC, Crompton JG, Straughan DM, Reddy S, Prasad NB, Shi G, Fischer AC. Rising incidence and aggressive nature of cutaneous malignancies after transplantation: An update on epidemiology, risk factors, management and surveillance. Surg Oncol 2015; 24:345-52. [DOI: 10.1016/j.suronc.2015.09.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/16/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023]
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Garrett GL, Zargham H, Schulman JM, Jafarian F, Yu SS, Arron ST. Merkel cell carcinoma in organ transplant recipients: Case reports and review of the literature. JAAD Case Rep 2015; 1:S29-32. [PMID: 27051805 PMCID: PMC4809574 DOI: 10.1016/j.jdcr.2015.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Giorgia L Garrett
- Department of Dermatology, University of California, San Francisco, California
| | - Hanieh Zargham
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Joshua M Schulman
- Department of Dermatology, University of California, San Francisco, California
| | - Fatemeh Jafarian
- Division of Dermatology, McGill University, Montreal, Quebec, Canada
| | - Siegrid S Yu
- Department of Dermatology, University of California, San Francisco, California
| | - Sarah T Arron
- Department of Dermatology, University of California, San Francisco, California
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Porceddu SV, Veness MJ, Guminski A. Nonmelanoma Cutaneous Head and Neck Cancer and Merkel Cell Carcinoma: Current Concepts, Advances, and Controversies. J Clin Oncol 2015; 33:3338-45. [PMID: 26351348 DOI: 10.1200/jco.2014.60.7333] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Nonmelanoma skin cancer (NMSC) is the most common cancer worldwide and the most frequently observed malignancy in whites. Approximately 75% to 80% are basal cell carcinomas and 20% to 25% are squamous cell carcinomas. Incidence is increasing, partly reflecting an ageing population, and NMSC is more commonly seen in men. The predominant causative agent is ultraviolet solar radiation exposure, with the majority of cases occurring on the head and neck. Surgical excision is typically the treatment of choice, providing histopathologic information, high cure rates, and acceptable cosmetic and functional outcomes. Radiation therapy is reserved for cases where surgery is not the preferred choice or for high-risk cases where adjuvant therapy is recommended. Although overall mortality rates are low, patients with complex cases such as those with immunosuppression should be considered for management within multidisciplinary tumor boards. In contrast, Merkel cell carcinoma is a rare and aggressive malignancy, frequently arising on the head and neck in older whites, with a poorer prognosis. This article focuses on the current evidence guiding practice, recent advances, and areas of controversy in NMSC and Merkel cell carcinoma of the head and neck.
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Affiliation(s)
- Sandro V Porceddu
- Sandro V. Porceddu, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland; Michael J. Veness, Westmead Cancer Cancer Centre; Michael J. Veness and Alexander Guminski, University of Sydney; and Alexander Guminski, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| | - Michael J Veness
- Sandro V. Porceddu, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland; Michael J. Veness, Westmead Cancer Cancer Centre; Michael J. Veness and Alexander Guminski, University of Sydney; and Alexander Guminski, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Alexander Guminski
- Sandro V. Porceddu, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland; Michael J. Veness, Westmead Cancer Cancer Centre; Michael J. Veness and Alexander Guminski, University of Sydney; and Alexander Guminski, Royal North Shore Hospital, Sydney, New South Wales, Australia
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