Accrual of non-melanoma skin cancer in renal-transplant recipients: Experience of a Victorian tertiary referral institution

Cutaneous squamous cell carcinoma tumor accrual rates in immunosuppressed patients with autoimmune and inflammatory conditions: A retrospective cohort study

BACKGROUND

Immunosuppression is a known risk factor for the development of cutaneous squamous cell carcinoma (CSCC), especially in solid organ transplant recipients and chronic lymphocytic leukemia. However, this risk is less well defined in autoimmune and inflammatory conditions.

OBJECTIVE

Assess the impact that disease-type, duration of immunosuppression, and systemic medications have on CSCC accrual rates, defined as the number of CSCCs a patient develops per year, in autoimmune and inflammatory conditions.

METHODS

Retrospective review of 94 immunosuppressed (rheumatoid arthritis: 31[33.0%], inflammatory bowel disease: 17[18.1%], psoriasis: 11[11.7%], autoimmune other (AO): 24[25.5%], inflammatory other: 21[22.3%]) and 188 immunocompetent controls to identify all primary, invasive CSCCs diagnosed from 2010 to 2020.

RESULTS

Immunosuppressed patients had higher CSCC accrual rates than immunocompetent controls (0.44 ± 0.36): total cohort (0.82 ± 0.95, P < .01), rheumatoid arthritis (0.88 ± 1.10, P < .01), inflammatory bowel disease (0.94 ± 0.88, P < .01), psoriasis (1.06 ± 1.58, P < .01), AO (0.72 ± 0.56, P < .01), and inflammatory other (0.72 ± 0.61, P < .01). There was an association between increased tumor accrual rates and exposure to systemic medications including, immunomodulators, tumor necrosis factor-alpha inhibitors, non-tumor necrosis factor inhibitor biologics, and corticosteroids, but not with number of systemic medication class exposures or duration of immunosuppression.

LIMITATIONS

Retrospective, singlecenter study.

CONCLUSION

Patients with autoimmune and inflammatory conditions accrue CSCCs at higher rates than immunocompetent patients.

Impact of UV Modifying Factors on the Incidence of Keratinocyte Carcinomas in Solid Organ Transplant Recipients: A Systematic Review

INTRODUCTION

Solid organ transplant recipients (SOTR) are at an increased risk for developing keratinocyte carcinomas (KC). Four ultraviolet (UV) modifying factors have been identified that impact the incidence of KC: Fitzpatrick Skin Type (FST), race, sun exposure, and sun-protective factors.

OBJECTIVES

We conducted a systematic review to summarize the association between UV modifying factors and the incidence of KC in SOTR.

METHODS

We systematically searched PubMed, Scopus, and Web of Science databases, and after screening for inclusion and exclusion criteria, we included 13 studies with 6,910 solid organ transplant recipients in our analysis.

RESULTS

Our review found that lower FST (I-II), white and Latinx populations, lack of regulated sunscreen application, and occupational and residential sun exposure are individual risk factors among solid organ transplant recipients for KC incidence. Although previous studies showed an in-creased SCC:BCC ratio, some studies found a contradictory increased BCC:SCC ratio. Limitations include few research studies that analyze these UV modifying factors and a lack of incorporating both varying immunosuppressant factors and transplantation follow-up times.

CONCLUSIONS

These findings support the need for dermatological advice in increased risk patient demographic populations, lower FST and white and Latinx populations, and subsequently moderating sun exposure and protective factors.

Higher mycophenolate dosage is associated with an increased risk of squamous cell carcinoma in kidney transplant recipients

BACKGROUND

Kidney transplant recipients are at increased risk of keratinocyte cancers, namely squamous cell and basal cell carcinomas (SCCs and BCCs). This is primarily due to the high levels of immunosuppression that are required to prevent allograft rejection. Different immunosuppressive medications confer different risks, and the effect of mycophenolate mofetil on SCC and BCC risk is unclear. We explored the relationship between mycophenolate dose prescribed over the entire transplant period and the risk of SCC and BCC.

METHODS

Kidney transplant recipients from Queensland, Australia, were recruited between 2012 and 2014 and followed until mid-2016. During this time transplant recipients underwent regular skin examinations to diagnose incident SCCs and BCCs. Immunosuppressive medication regimens were obtained from hospital records, and the average mycophenolate dose/day over the entire transplantation period was calculated for each patient. Doses were divided into three ranked groups, and adjusted relative risks (RR_adj) of developing SCC and BCC tumours were calculated using negative binomial regression with the lowest dosage group as reference. Recipients who had used azathioprine previously were excluded; further sub-group analysis was performed for other immunosuppressant medications.

RESULTS

There were 134 kidney transplant recipients included in the study. The average age was 55, 31% were female and 69% were male. At the highest median mycophenolate dose of 1818 mg/day the SCC risk doubled (RR_adj 2.22, 95% CI 1.03-4.77) when compared to the reference group of 1038 mg/day. An increased risk persisted after accounting for ever-use of ciclosporin, ever-use of tacrolimus, and when excluding mammalian target of rapamycin users. This increased risk was mainly carried by kidney transplant recipients immunosuppressed for five or more years (RR_adj = 11.05 95% CI 2.50-48.81). In contrast, there was no significant association between BCC incidence and therapy with the highest compared with the lowest mycophenolate dosage (RR_adj = 1.27 95% CI 0.56-2.87).

CONCLUSION

Higher mycophenolate dosage is associated with increased SCCs in kidney transplant recipients, particularly those immunosuppressed for more than five years. The increased SCC risk persists after accounting for usage of other immunosuppressant medications.

A long-term cohort study of acitretin for prevention of keratinocyte carcinoma in solid organ transplant recipients

Background

Solid organ transplant recipients (SOTR) are at high risk of keratinocyte carcinoma (KC). Long‐term evidence for acitretin as chemoprophylaxis in this population is lacking.

Objective

To determine the benefit of long‐term acitretin for KC chemoprevention in SOTR.

Methods

A retrospective cohort study of SOTR treated with acitretin at an Australian transplant dermatology clinic was performed. General estimating equations were used to evaluate change in rates of histologically confirmed KC in the 6–12 months prior to acitretin and following a minimum 6 months of treatment. A control group of patients within the same service was included, comprising SOTR who were not treated with acitretin.

Results

Twenty‐two patients received acitretin treatment for at least 6 months, eighteen for at least 5 years and four for at least 9 years. The median KC rate pretreatment was 3.31 per year (IQR 1.93, 5.40). There was a significant reduction in the rate of KC in the first year of acitretin treatment (IRR 0.41, 95% CI 0.22, 0.76, P = 0.005), and this effect was observed for 5 years (IRR at 5 years 0.34, 95% CI 0.17, 0.67, P = 0.002). The control group had no statistically significant change in KC rate over time in the study.

Conclusions

Acitretin appears to be well‐tolerated and effective in reducing KC in SOTR for at least 5 years. Study limitations include its retrospective nature, small sample size and lack of blinding.

Reducing non-melanoma skin cancer risk in renal transplant recipients

With an increasing number of renal transplant recipients (RTRs) and improving patient survival, a higher incidence of non-melanoma skin cancer (NMSC) has been observed. NMSC in RTRs are often more numerous and biologically more aggressive than the general population, thus contributing towards an increase in morbidity and to a lesser degree, mortality. The resultant cumulative health and financial burden is a recognized concern. Proposed strategies in mitigating risks of developing NMSC and early therapeutic options thereof include tailored modification of immunosuppressants in conjunction with sun protection in all transplant patients. This review highlights the clinical and financial burden of transplant-associated skin cancers, carcinogenic mechanisms in association with immunosuppression, importance of skin cancer awareness campaign and integrated transplant skin clinic, and the potential role of chemoprotective agents. A scheme is proposed for primary and secondary prevention of NMSC based on the available evidence.

Recurrent squamous cell carcinoma in a post cardiac transplant patient

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Patient having recurrent carcinomas following heart transplant due to possible immunosuppression.

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Early Cancer surveillance in transplant patients is necessary to detect and treat malignancies early.

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Unique in having two recurrences post-transplant.

Introduction and importance

Solid organ transplantation has evolved along with dramatic advancements in definitive treatment for irreversible and uncompensated organ failure. Transplanted organ survival has improved as a result of reduced allograft rejection. However, negative long-term outcomes which were largely due to the adverse effects of rapidly evolving immunosuppressive regimens are still evident. The emergence of malignancies following prolonged exposure to immunosuppression treatment has affected the quality of life in transplant recipients. They are approximately one hundred times more likely to develop squamous cell carcinoma (SCC) compared to the general population and the incidence of malignant melanomas, basal cell carcinomas, and Kaposi’s sarcomas are also on the rise. The incidence of de novo malignancies ranges from 9 to 21% and is commonly seen in the skin and the lymphoreticular system in these patients.

Case presentation

A 78-year-old male presented with a lump in the right axilla, which had grown in size over a 4-week period. Patient had received a cardiac transplant 9 years prior and was on a regimen of Tacrolimus and Mycophenolate Mofetil since then.

Clinical discussion

Following 4 years of immunosuppression therapy, the patient developed a non-healing ulcer on his right forearm and the biopsy confirmed SCC. The recent biopsy performed on the new axillary lump also confirmed SCC. Iatrogenic immune suppressive treatment is associated with the occurrence of de novo, non-melanoma skin cancers in the solid organ transplant recipients and this necessitates early and comprehensive cancer surveillance models to be included in the pre and post-transplant assessment.

Conclusion

Advances in immunology suggest that peripheral blood mononuclear cell sequencing and immune profiling to identify immune phenotypes associated with keratinocyte cancers allow us to recognize patients who are more susceptible for SCC following organ transplantation and immunosuppression.

Melanoma in a cohort of organ transplant recipients: Experience from a dedicated transplant dermatology clinic in Victoria, Australia

BACKGROUND

There is limited information on the profile of melanomas diagnosed in a specialist transplant dermatology clinic.

OBJECTIVE

To describe the incidence and characteristics of incident primary melanomas in a cohort of organ transplant recipients (OTRs) attending a specialized transplant dermatology clinic and determine the number of pigmented lesions needed to excise for every melanoma diagnosed.

METHODS

A retrospective study of 327 OTRs monitored by an Australian clinic during a 10-year period.

RESULTS

There were 11 incident melanomas diagnosed during a total follow-up of 1280 patient-years. The mean interval between the first transplant and diagnosis was 5.5 years. Only 2 melanomas were >1 mm in Breslow thickness. Seven melanomas (64%) arose de novo. A contiguous nevus was present in 4 cases. Metastatic disease did not develop in the melanoma patients during the follow-up period, and all remain alive. The needed to excise for every melanoma diagnosed ratio was 16:1.

LIMITATIONS

The crude incidence rates were age standardized, unlike the comparison rates of melanoma in the general population, and the cohort was small.

CONCLUSION

Most melanomas diagnosed in OTR patients attending a specialized transplant dermatology service were detected early. Our data suggest early detection may reduce the proportion of OTRs presenting with thick melanomas, thus improving prognosis and patient outcomes. A needed to excise for every melanoma diagnosed ratio of 16:1 is not unreasonable for this cohort of high-risk patients. To our knowledge, this is the first time this ratio has been calculated for a cohort of OTRs.

Skin Cancer Following Solid Organ Transplantation: A Review of Risk Factors and Models of Care

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.

Incidence of nonmelanoma skin cancer in renal transplant recipients: A systematic review and meta-analysis

Background

Nonmelanoma skin cancer (NMSC) in renal transplant recipients is common and associated with significant morbidity and mortality. The aim of the present systematic review and meta-analysis was to estimate the incidence of NMSC among renal transplant recipients.

Materials and Methods

We systematically searched PubMed, Medline, Scopus, and Web of Science databases for studies that assessed the incidence of NMSC in renal transplant recipients using a combination of relevant keywords. Two independent investigators included studies and extracted necessary information. Random effect meta-analysis was used to estimate pooled incidence of NMSC with 95% confidence intervals (CIs).

Results

Twenty-nine studies comprising 36,021 patients meet the criteria for the systematic review. The pooled incidence of NMSC in renal transplant recipients was 12.6% (95% CI: 12%-14%) with a majority of squamous cell carcinoma (SCC) 55% (95% CI: 47%-63%). The pooled estimate of the incidence rates of SCC and basal cell carcinoma was 2.7% (95% CI: 2%-3.4%) and 2.2% (95% CI: 1.5%-2.8%), respectively. Subgroup analysis per geographic location showed that pooled incidence of NMSC was 39.1% (95% CI: 26.3%-51.8%), 12.4% (95% CI: 8.8%-16%), and 1.2% (95% CI: 0.4%-2%) in Australia and New Zealand, Europe, and Middle East, respectively.

Conclusion

The results of the current meta-analysis demonstrated that the incidence of NMSC in renal transplant recipients varies widely. Regarding the high incidence of NMSC among renal transplant recipients, awareness of associated risk factors and early diagnosis of the malignancy in the population is a major clinical need.

Prevalence of skin cancer in Native American kidney transplant recipients

BACKGROUND

Skin cancer prevalence is well-characterized for white solid organ transplant recipients. Although the prevalence of skin cancer in non-white (Black, Asian, Hispanic) kidney transplant recipients (KTRs) has been assessed, no study has reported the prevalence of skin cancer in Native American (NA) KTRs. The aim of this study is to determine if the prevalence of skin cancer in NAKTRs is the same as in white KTRs.

METHODS

We conducted a case-controlled retrospective review from a single transplant center. One hundred thirteen NAKTRs who received a transplant between 2001 and 2011 were age- and transplant-year matched with 113 white controls.

RESULTS

The 226 KTRs consisted of 141 (62.4%) men and 85 (37.6%) women, with a mean age of 50.2 ± 10.8 years. There was no skin cancer found in NAKTRs prior to or post transplantation, while seven (6.2%) white KTRs had eight skin cancers prior to transplantation, and 28 (24.8%) white KTRs developed 66 skin cancers post transplantation. Twenty-two (19.5%) NAKTRs did not follow-up with dermatology at this institution. The median follow-up in NAKTRs was 3.3 years compared to 3.0 years in white KTRs.

CONCLUSION

NAKTRs have a decreased prevalence of skin cancer compared to their white counterparts.

[Exclusive radiotherapy for a facial basal cell carcinoma with trigeminal ganglion involvement]

Basal cell carcinomas with symptomatic perineural invasion are rare entities. We report the case of a 60year-old man (with a grafted kidney), surgically treated in 2007 for a sclerodermiform basal cell carcinoma infiltrating the left nostril. Five years later, a painful left hemifacial hypoesthesia associated with an ulcus rodens of the nasolabial fold appeared. A biopsy confirmed a recurrence. MRI showed an enhancement of the trigeminal ganglion. The patient had a trigeminal perineural invasion secondary to a cutaneous basal cell carcinoma. He received a local intensity-modulated radiotherapy alone (70Gy in 33 sessions), administered from the skin tumour to the skull base. Three years after the end of treatment, the patient is in radiological and clinical remission, with partial recovery of the hypoesthesia. Evolution was marked by iterative corneal ulcers and decreased visual acuity. Modalities of treatment by surgery and/or radiation therapy and complications are poorly described in the literature.

Photocarcinogenesis: an epidemiologic perspective on ultraviolet light and skin cancer

Photocarcinogenesis is the result of a complex interplay between ultraviolet radiation, DNA damage, mutation formation, DNA repair, apoptosis, and the immune system. Recent trends show an increase in incidence of both melanoma and nonmelanoma skin cancers. Some individuals have a genetic predisposition toward increased risk for skin cancer, whereas others experience increased risk through ultraviolet exposure and subsequent mutation formation. The initiation and propagation pathways of melanoma and nonmelanoma skin cancers differ but have some elements in common. The increase in incidence of skin cancer has been discovered to vary among age groups and gender.