Skin cancers after liver transplantation: what to do?

Basal Cell Carcinoma and its Impact on Different Anatomical Regions

Basal cell carcinoma (BCC) is the most common skin cancer. We conducted a retrospective study over a period of two years (2018-2019), on 214 patients from the Plastic Surgery clinic in order to identify the clinical and histopathological aspects of the disease: the case distribution according to sex, living environment, age, histopathological subtype, location. Results. The F/M ratio was of 1.03 in favour of women. The incidence was higher for patients from rural areas (55.14%). The most affected group age was between 70-80 years old, with 76 patients (35.51%). The most frequent histological type was nodular basal cell carcinoma (65.42%), followed by micronodular subtype (17.29%). We observed the association of basal cell carcinoma with a number of other conditions such as: high blood pressure (92 cases), diabetes (19 cases), chronic kidney disease (2 cases), liver disease (5 cases), epilepsy (2 cases). Correlating the histopathological subtype and the invasion of the edges of the surgical excision specimen, we noticed that edge invasion was present: in the case of nodular basal cell carcinoma (15.71%), micronodular subtype (43.24%), superficial subtype (50%), morpheaform subtype (40%). Dividing the cases by location, we highlighted the risk areas: nasal region (29.44%), cheek (10.75%), orbital region (13.55%), scalp (10.75%), auricular region (7.48%), forehead (8.41%), etc. Thus, 89.72% of cases were located on photo-exposed areas (head and neck). Patients from rural areas registered a higher number of cases both in photo-exposed and non-exposed areas.

De novo malignancies after liver transplantation: The effect of immunosuppression-personal data and review of literature

BACKGROUND

Immunosuppression has undoubtedly raised the overall positive outcomes in the post-operative management of solid organ transplantation. However, long-term exposure to immunosuppression is associated with critical systemic morbidities. De novo malignancies following orthotopic liver transplants (OLTs) are a serious threat in pediatric and adult transplant individuals. Data from different experiences were reported and compared to assess the connection between immunosuppression and de novo malignancies in liver transplant patients.

AIM

To study the role of immunosuppression on the incidence of de novo malignancies in liver transplant recipients.

METHODS

A systematic literature examination about de novo malignancies and immunosuppression weaning in adult and pediatric OLT recipients was described in the present review. Worldwide data were collected from highly qualified institutions performing OLTs. Patient follow-up, immunosuppression discontinuation and incidence of de novo malignancies were reported. Likewise, the review assesses the differences in adult and pediatric recipients by describing the adopted immunosuppression regimens and the different type of diagnosed solid and blood malignancy.

RESULTS

Emerging evidence suggests that the liver is an immunologically privileged organ able to support immunosuppression discontinuation in carefully selected recipients. Malignancies are often detected in liver transplant patients undergoing daily immunosuppression regimens. Post-transplant lymphoproliferative diseases and skin tumors are the most detected de novo malignancies in the pediatric and adult OLT population, respectively. To date, immunosuppression withdrawal has been achieved in up to 40% and 60% of well-selected adult and pediatric recipients, respectively. In both populations, a clear benefit of immunosuppression weaning protocols on de novo malignancies is difficult to ascertain because data have not been specified in most of the clinical experiences.

CONCLUSION

The selected populations of tolerant pediatric and adult liver transplant recipients greatly benefit from immunosuppression weaning. There is still no strong clinical evidence on the usefulness of immunosuppression withdrawal in OLT recipients on malignancies. An interesting focus is represented by the complete reconstitution of the immunological pathways that could help in decreasing the incidence of de novo malignancies and may also help in treating liver transplant patients suffering from cancer.

De Novo Malignancies After Liver Transplantation: A Single Institution Experience

OBJECTIVES

Our objective was to analyze characteristics, risk factors, and incidence of de novo malignancies after liver transplant.

MATERIALS AND METHODS

The hospital records of 557 patients who underwent liver transplant were analyzed from the point of de novo malignancy development. We evaluated the demographic features and survival of these patients retrospectively.

RESULTS

The research covered 429 patients, 9 (2%) of whom developed de novo malignancy. All of these patients were male (100%), and their mean (SD) age was 51.33 (4.69) years (range, 45-65 y). Indications for transplant included alcohol related in 4 cases, chronic hepatitis B in 2 cases, chronic hepatitis B and C in 1 case, chronic hepatitis B and D in 1 case, and chronic hepatitis C and alcohol-related cirrhosis in 1 case. The mean (SD) time from transplant to cancer diagnosis was 63.41 (37.10) months (range, 17-122 mo). The types of tumors were lung cancer, lymphoma, neuroendocrine tumor of lung, nasopharyngeal cancer, and squamous cell carcinoma of the skin. Seven cases received chemotherapy with or without radiotherapy. Two cases received surgery and radiotherapy. One patient underwent surgical treatment. One patient died before treatment was started.

CONCLUSIONS

In recent years, improvements in surgical techniques and immunosuppressive therapies have helped prolong survival of patients who undergo liver transplant. However, this also has led to a rise in the incidence of long-term complications such as de novo malignancy. These patients are more likely to develop de novo malignancy than the general population, for which chronic immunosuppression is identified as a major risk factor. Early diagnosis and treatment of de novo malignancies can help obtain better prognosis and higher survival rates in these patients.

Neoplastic disease after liver transplantation: Focus on de novo neoplasms

De novo neoplasms account for almost 30% of deaths 10 years after liver transplantation and are the most common cause of mortality in patients surviving at least 1 year after transplant. The risk of malignancy is two to four times higher in transplant recipients than in an age- and sex-matched population, and cancer is expected to surpass cardiovascular complications as the primary cause of death in transplanted patients within the next 2 decades. Since exposure to immunosuppression is associated with an increased frequency of developing neoplasm, long-term immunosuppression should be therefore minimized. Promising results in the prevention of hepatocellular carcinoma (HCC) recurrence have been reported with the use of mTOR inhibitors including everolimus and sirolimus and the ongoing open-label prospective randomized controlled SILVER. Study will provide more information on whether sirolimus-containing vs mTOR-inhibitor-free immunosuppression is more efficacious in reducing HCC recurrence.

De novo malignancy after liver transplantation: a single-center experience of 14 cases

PURPOSE

The aim of this study is to evaluate the incidence of de novo malignancy after liver transplantation (LT) and compare with those among the general Chinese population.

METHODS

A total of 466 patients who had a minimum follow-up time of 6 months were enrolled in the study. All data of medical records and follow up were retrospectively reviewed.

RESULTS

The incidence rate of de novo malignancy was 3.0% (14 in 466 patients). The median elapsed time from transplant to the diagnosis of de novo malignancy was 42 months (range, 6 to 106 months). The cumulative risk for development of de novo malignancy was 1.6%, 2.7%, and 8.2% at 3, 5 and 10 years after LT, respectively. The patients were all male. The types of de novo tumors included digestive system tumor (8 in 14), lung cancer (2 in 14), urologic neoplasm (2 in 14), and hematologic malignant tumor (2 in 14). Over a mean follow-up of 24 months after diagnosis of de novo malignancy, 7 patients (50.0%) died; the overall 5-year patient survival rate was 54.5%. The relative risk of malignancy following LT was 9.5 folds higher than the general Chinese population.

CONCLUSION

The relative risk of malignancy following LT was much higher than the general Chinese population. Digestive system tumor is the most common type of de novo malignancy after LT in China.

De novo cancers following liver transplantation: a single center experience in China

BACKGROUND

De novo cancers are a growing problem that has become one of the leading causes of late mortality after liver transplantation. The incidences and risk factors varied among literatures and fewer concerned the Eastern population.

AIMS

The aim of this study was to examine the incidence and clinical features of de novo cancers after liver transplantation in a single Chinese center.

METHODS

569 patients who received liver transplantation and survived for more than 3 months in a single Chinese center were retrospectively reviewed.

RESULTS

A total of 18 de novo cancers were diagnosed in 17 recipients (13 male and 4 female) after a mean of 41 ± 26 months, with an overall incidence of 3.2%, which was lower than that in Western people. Of these, 8 (3.32%) cases were from 241 recipients with malignant liver diseases before transplant, while 10 (3.05%) cases were from 328 recipients with benign diseases. The incidence rates were comparable, p = 0.86. Furthermore, 2 cases developed in 1 year, 5 cases in 3 years and 11 cases over 3 years. The most frequent cancers developed after liver transplantation were similar to those in the general Chinese population but had much higher incidence rates.

CONCLUSIONS

Liver transplant recipients were at increased risk for developing de novo cancers. The incidence rates and pattern of de novo cancers in Chinese population are different from Western people due to racial and social factors. Pre-transplant malignant condition had no relationship to de novo cancer. Exact risk factors need further studies.

Primary scalp angiosarcoma with metastasis to the liver in an orthotopic liver transplant patient

Angiosarcoma is a rare malignant neoplasm of vascular endothelial cells. A majority are primarily in the skin. Angiosarcoma of the head and neck is the most common form, but only constitutes 0.1% of all head and neck malignancies. We present an extraordinary case of a 71-year-old man 6 months status postorthotopic liver transplant secondary to end-stage liver disease from cryptogenic cirrhosis, who presented to the liver clinic with a rapidly growing scalp tumor and hypodense lesions within the liver. Further work-up and biopsies confirmed the first documented case of primary scalp angiosarcoma with metastasis to the liver in an orthotopic liver transplant patient.

Treatment of osteoporosis in patients with chronic liver disease and in liver transplant recipients

The pathogenesis of osteoporosis in chronic liver disease and post-liver transplantation is complex and heterogeneous. The development of hepatic osteodystrophy may be related to both increased bone resorption and decreased bone formation. Available medical treatments can be broadly classified into antiresorptive and bone-stimulating agents. Most published studies on the treatment of osteoporosis in patients with liver disease have used the commonly prescribed antiosteoporosis drugs approved for postmenopausal osteoporosis. These studies have included a small number of subjects and used bone mineral density (BMD) changes rather than fracture occurrence as an endpoint because of the short follow-up. Although the increases in BMD are promising, no intervention is proven to have antifracture efficacy in hepatic osteodystrophy. The natural history of bone disease following liver transplantation has not been fully investigated, although studies suggest that bone mineral loss is transient and generally reverses within a year following transplantation. The approach to treatment in liver transplant recipients should be targeted at preventing the early bone loss without interfering with the later recovery. Based on the available data, no single available agent can be considered as first-line therapy. In our opinion, the best treatment approach involves the elucidation of modifiable risk factors and the selection of agents targeted at the underlying derangements.

New concepts and best practices for management of pre- and post-transplantation cancer

Solid-organ transplant recipients are at increased risk of developing cancer compared with the general population. Tumours can arise de novo, as a recurrence of a preexisting malignancy, or from the donated organ. The ATOS (Aula sobre Trasplantes de Órganos Sólidos; the Solid-Organ Transplantation Working Group) group, integrated by Spanish transplant experts, meets annually to discuss current advances in the field. In 2011, the 11th edition covered a range of new topics on cancer and transplantation. In this review we have highlighted the new concepts and best practices for managing cancer in the pre-transplant and post-transplant settings that were presented at the ATOS meeting. Immunosuppression plays a major role in oncogenesis in the transplant recipient, both through impaired immunosurveillance and through direct oncogenic activity. It is possible to transplant organs obtained from donors with a history of cancer as long as an effective minimization of malignancy transmission strategy is followed. Tumour-specific wait-periods have been proposed for the increased number of transplantation candidates with a history of malignancy; however, the patient's individual risk of death from organ failure must be taken into consideration. It is important to actively prevent tumour recurrence, especially the recurrence of hepatocellular carcinoma in liver transplant recipients. To effectively manage post-transplant malignancies, it is essential to proactively monitor patients, with long-term intensive screening programs showing a reduced incidence of cancer post-transplantation. Proposed management strategies for post-transplantation malignancies include viral monitoring and prophylaxis to decrease infection-related cancer, immunosuppression modulation with lower doses of calcineurin inhibitors, and addition of or conversion to inhibitors of the mammalian target of rapamycin.

Screening of de novo tumors after liver transplantation

De novo malignancies are frequent complications after liver transplantation. They are one of the leading causes of late death. Some authors have reported promising results following implementation of extensive cancer surveillance programs. Screening protocols might benefit patients by providing a diagnosis at an earlier stage when tumors may be cured. These protocols should be based on the specific risk factors of every patient. Unfortunately, the scientific evidence supporting screening protocols is still very weak both in the general population and in the transplant patients. On this basis, there is not enough evidence to recommend routine screening for all liver transplant recipients, apart from the recommendations accepted for the general population. Multicenter studies in selected groups of patients at high risk for malignancy may be the only way of defining the potential benefit of screening programs post-transplantation.

Organ transplantation and skin cancer: basic problems and new perspectives

Solid organ transplant and subsequent graft survival have increased worldwide, while immunosuppression has prevented rejection with increasing success. Side effects of cutaneous infection and neoplasm, however, affect the majority of solid organ transplant recipients (OTRs). Squamous cell carcinoma of the skin (SCC) is the most common neoplasm overall following organ transplant with a risk that is 60-100 times greater than for the immunocompetent population. This review focuses on questions of ongoing debate about SCC formation in OTRs such as viral carcinogenesis, systemic photoprotection, photosensitization by drugs, the impact of immunosuppressive drugs and inflammation as a driver of carcinogenesis.

De novo malignancies following liver transplantation: impact and recommendations

1. De novo malignancy is one of the leading causes of late mortality after liver transplantation. 2. The risks of skin cancers and lymphoma are more than 10-fold greater than the risks in an age-matched and sex-matched general population. 3. Some types of neoplasia, such as lung, head and neck, and colorectal cancer, are more frequent in liver transplant recipients than in an age-matched and sex-matched population. The risks of other frequent malignancies, such as prostate and breast cancer, do not seem to be increased. 4. The most important risks for posttransplant malignancy are Epstein-Barr virus seronegativity (for lymphoma), sun exposure (for skin cancer), smoking, and increasing age. 5. Despite the absence of evidence, general recommendations (such as avoidance of overimmunosuppression, sunlight protection, and cessation of smoking) should be given. Screening protocols may help to detect neoplasia at an early stage of disease.

Skin cancer in organ transplant recipients--where do we stand today?

Skin cancers are the most frequent malignancies in organ transplant recipients (OTR), with 95% being nonmelanoma skin cancers (NMSC), especially squamous (SCC) and basal cell carcinomas. Most OTR with a first SCC subsequently develop multiple NMSC within 5 years, highlighting the concept of 'field cancerization', and are also at high risk for noncutaneous cancers. In order to reduce the tumor burden in these patients, their management requires an interdisciplinary approach including revision of immunosuppression, new dermatological treatments and adequate education about photoprotection in specialized dermatology clinics for OTR. Whereas surgery remains the gold-standard therapy for NMSC, noninvasive methods have shown promising results to treat superficial keratoses and subclinical lesions on large body areas. Although the threshold of skin cancer necessitating revision of immunosuppression is debated, this measure should be envisaged at the occurrence of the first SCC, or in case of multiple non-SCC NMSC. While the role of immunosuppressants in the occurrence of NMSC is widely recognized, the best immunosuppressive strategies remain to be defined. Presently, randomized prospective studies assess the burden of new skin tumors, as well as graft and patient survival, in patients with one or several NMSC after the introduction of mTOR (mammalian target of rapamycin) inhibitors.

De novo posttransplantation nonlymphoproliferative malignancies in liver transplant recipients

The risk of developing de novo malignancies after liver transplantation is around 1% per year. The incidence varies from 3% to 15%; it is greater than that in the general population. The potential causes for cancer after solid organ grafting are: chronic immunosuppression and human herpes viral infection. The objective of this paper was to review the medical literature about the subject to verify the incidence of de novo malignancies in our service. We performed retrospective analysis of the medical files of 325 successive patients undergoing orthotopic liver transplantation from September 1991 to December 2006. We analyzed the type of tumor, the risk factors, the treatment modality, and the patient survivals. Recurrences of hepatocellular carcinoma were excluded. There were 5 (1.54%) men of average age 50.2 years, and an 80% mortality rate. Their survival time was affected by the nature of the tumor and by the late manifestations of intestinal obstruction allowing adequate surgical treatment. Four of the patients displayed heavy alcohol and tobacco consumption before transplantation. Screening for premalignant lesions must be strongly encouraged to achieve better postoperative results.