Immunosuppression and squamous cell carcinoma: a focus on solid organ transplant recipients

The Application of Lag Times in Cancer Pharmacoepidemiology: A Narrative Review

With the increasing utilization of medications worldwide, coupled with the increasing availability of long-term data, there is a growing opportunity and need for robust studies evaluating drug-cancer associations. One methodology of importance in such studies is the application of lag times. In this review, we discuss the main reasons for using lag times. Namely, we discuss the typically long latency period of cancer concerning both tumor promoter and initiator effects and outline why cancer latency is a key consideration when choosing a lag time. We also discuss how the use of lag times can help reduce protopathic and detection bias. Finally, we present practical advice for implementing lag periods. In general, we recommend that researchers consider the information that generated the hypothesis as well as clinical and biological knowledge to inform lag period selection. In addition, given that latency periods are usually unknown, we also advocate that researchers examine multiple lag periods in sensitivity analyses as well as duration analyses and flexible modeling approaches.

Guidelines of care for the management of actinic keratosis

BACKGROUND

Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma.

OBJECTIVE

This analysis examined the literature related to the management of AK to provide evidence-based recommendations for treatment. Grading, histologic classification, natural history, risk of progression, and dermatologic surveillance of AKs are also discussed.

METHODS

A multidisciplinary Work Group conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus.

RESULTS

Analysis of the evidence resulted in 18 recommendations.

LIMITATIONS

This analysis is based on the best available evidence at the time it was conducted. The pragmatic decision to limit the literature review to English language randomized trials may have excluded data published in other languages or limited identification of relevant long-term follow-up data.

CONCLUSIONS

Strong recommendations are made for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are made for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

Eosinophilic Fasciitis With a Malignant Outcome

Eosinophilic fasciitis (EF) is an uncommon localized fibrosing disorder affecting the fascial layers of the human body. To date less than 300 cases of EF have been reported worldwide. Due to the limited prevalence, extensive studying of its pathogenesis and treatment has not yet been established. Furthermore, little is known regarding the long-term prognosis and comorbidities associated with EF. In this case study, we discuss a 72-year-old female patient who was diagnosed with EF and subsequently developed squamous cell carcinoma (SCC) of the skin in areas of previously exposed EF. This case represents the first reported case of SCC of the skin in a patient with previously active EF in the same area of skin.

Guidelines of care for the management of actinic keratosis: Executive summary

BACKGROUND

Actinic keratoses (AK) are rough scaly patches that arise on chronically ultraviolet-exposed skin and can progress to keratinocyte carcinoma. Treatment options for AK include topical medications, photodynamic therapy, cryosurgery, and laser ablation.

OBJECTIVE

This executive summary provides a synopsis of the 18 evidence-based recommendations for the treatment of AK detailed in the Guidelines of Care for the Management of Actinic Keratosis.

METHODS

A multidisciplinary workgroup conducted a systematic review to address 5 clinical questions on the management of AKs and applied the Grading of Recommendations Assessment, Development and Evaluation approach for assessing the certainty of the evidence and formulating and grading clinical recommendations. Graded recommendations were voted on to achieve consensus.

RESULTS

Analysis of the evidence resulted in 18 recommendations, suggesting there are several effective treatments available for AK.

LIMITATIONS

The analysis informing the recommendations was based on the best available evidence at the time it was conducted. The results of future studies may necessitate a revision of current recommendations.

CONCLUSIONS

Strong recommendations are presented for using ultraviolet protection, topical imiquimod, topical 5-fluorouracil, and cryosurgery. Conditional recommendations are presented for the use of photodynamic therapy and diclofenac for the treatment of AK, both individually and as part of combination therapy regimens.

The Impact of the Circadian Clock on Skin Physiology and Cancer Development

Skin cancers are growing in incidence worldwide and are primarily caused by exposures to ultraviolet (UV) wavelengths of sunlight. UV radiation induces the formation of photoproducts and other lesions in DNA that if not removed by DNA repair may lead to mutagenesis and carcinogenesis. Though the factors that cause skin carcinogenesis are reasonably well understood, studies over the past 10–15 years have linked the timing of UV exposure to DNA repair and skin carcinogenesis and implicate a role for the body’s circadian clock in UV response and disease risk. Here we review what is known about the skin circadian clock, how it affects various aspects of skin physiology, and the factors that affect circadian rhythms in the skin. Furthermore, the molecular understanding of the circadian clock has led to the development of small molecules that target clock proteins; thus, we discuss the potential use of such compounds for manipulating circadian clock-controlled processes in the skin to modulate responses to UV radiation and mitigate cancer risk.

Metastatic Cutaneous Squamous Cell Carcinoma of the Colon Presenting as Transfusion-Dependent Hematochezia

Squamous cell carcinoma (SCC) of the colon is an exceedingly rare clinical diagnosis with few cases reported in the literature. We report a case of a 61-year-old man with a medical history of cutaneous SCC of the penis who presented with hematochezia and was found to have metastatic SCC to the distal transverse colon. To our knowledge, this is the first case of colonic SCC presenting as a metastatic disease from a primary penile site.

Novel approaches for managing aged skin and nonmelanoma skin cancer

The process of aging influences every bodily organ and tissue, and those with rapid epithelial cell turnover, are particularly affected. The most visible of these, however, is the skin (including the epidermis), the largest human organ that provides a barrier to external insults, structure to the body and its movements, facilitates thermoregulation, harbors immune cells, and incorporates sensory neurons (including mechanoreceptors, nociceptors, and thermoreceptors). Skin aging has traditionally been categorized into intrinsic and extrinsic, with the latter nearly exclusively restricted to "photoaging," (i.e., aging due to exposure to solar or artificial ultraviolet radiation). However, both intrinsic and extrinsic aging share similar causes, including oxidative damage, telomere shortening, and mitochondrial senescence. Also, like other malignancies, the risk of malignant and nonmalignant lesions increases with age. Herein, we review the most recent findings in skin aging and nonmelanoma skin cancer, including addition to traditional and developing therapies.

Single Ablative Fractional Resurfacing Laser Treatment For Forearm Actinic Keratoses: 6-Month Follow-Up Data From An Intrapatient Comparison Between Treated and Untreated Sites

BACKGROUND AND OBJECTIVES

Actinic keratoses (AK) are common pre-cancerous lesions, which are associated with ultraviolet light exposure and aging. Wounding therapies such as fractionated laser resurfacing (FLR) have been previously demonstrated to effectively treat facial AK. However, the effectiveness of FLR on other sites commonly afflicted with AK has not been studied in detail. Previously, our group has reported that treatment of aged skin with wounding therapies including dermabrasion and ablative fractionated resurfacing results in the removal of senescent fibroblasts and normalizing the pro-carcinogenic acute ultraviolet B radiation responses associated with aged skin. The current studies were designed to test the effectiveness of FLR of the forearm skin of subjects aged 60 and older to remove AKs.

STUDY DESIGN/MATERIALS AND METHODS

Between February 2018 and March 2019, 30 subjects were enrolled in a study, in which they underwent a single FLR treatment of one extremity including the dorsal forearm, wrist, and dorsal hand. The number of AKs was recorded on both extremities at baseline, 3 and 6 months in a blinded fashion. Side effects of the FLR were documented.

RESULTS

A single FLR treatment resulted in a 62% reduction in the absolute number of AK in the treated arm at 6 months post-treatment. The laser treatment was well-tolerated without major complications.

CONCLUSIONS

These studies demonstrate that FLR using settings, which have demonstrated to remove senescent fibroblasts and normalize the pro-carcinogenic UVB-response of aged skin is a potentially effective and safe field therapy treatment that should be studied for long-term efficacy for use in treating upper extremity AKs. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Head and Neck Cancer Immunotherapy beyond the Checkpoint Blockade

The success of immune checkpoint receptor blockade has brought exciting promises for the treatment of head and neck squamous cell carcinoma (HNSCC). While patients who respond to checkpoint inhibitors tend to develop a durable response, <15% of patients with HNSCC respond to immune checkpoint inhibitors, underscoring the critical need to alleviate cancer resistance to immunotherapy. Major advances have been made to elucidate the intrinsic and adaptive resistance mechanisms to immunotherapy. Central genomic events in HNSCC have been found to possess previously unknown roles in suppressing immune sensing. Such inhibitory function affects both the innate and adaptive arms of tumor-specific immunity. While checkpoint blockade effectively reinvigorates adaptive T-cell responses, additional targeting of the oncogenic inhibitors of innate immune sensing likely informs a novel and potent strategy for immune priming. This review discusses the recent advances on the identification of key HNSCC oncogenes that impair antitumor immunity and emerging immune-priming approaches that sensitize poorly immunogenic HNSCCs to checkpoint blockade. These approaches include but are not limited to cancer vaccine systems utilizing novel type I interferon agonists as immune adjuvants, radiation, DNA damage-inducing agents, and metabolic reprogramming. The goal of these multipronged approaches is to expand tumor-specific effector T-cells, break checkpoint receptor-mediated tolerance, and metabolically support sustained T-cell activation. The translation of therapeutics that reverses oncogenic inhibition of immune sensing requires thorough characterization of the HNSCC regulators of innate immune sensors, development of additional immunocompetent HNSCC mouse models, as well as engineering of more robust immune adjuvant delivery systems. Built on the success of checkpoint blockade, validation of novel immune-priming approaches holds key promises to expand the pool of responders to immunotherapy.

Metastatic Cutaneous Squamous Cell Cancer with Peritoneal Carcinomatosis: A Case Report

Peritoneal involvement as a metastatic site of squamous cell skin cancer is exceptionally rare. The current work analyzes a 52-year old male with high-risk cutaneous squamous cell nose carcinoma (cSCC) that was initially treated with surgery and platinum-based concurrent chemoradiation. Five years later, he presented jaundice and hypercalcemia. Further imaging revealed diffused liver, peritoneal and paraaortic lymph node metastases without evidence of locoregional recurrence. The patient underwent liver biopsy, which confirmed the diagnosis. High-risk features for metastasizing can be considered the maximum clinical diameter, the anatomical subsite (localization of the primary tumor in the ear and retroauricular area, cheek and lip are considered to significantly increase the risk of distant metastasis), poor histological differentiation, perineural invasion and lesions with a thickness of more than 2.0 mm. Late relapse that involves only disseminated abdominal disease is very uncommon and may justify closer follow-up and more aggressive chemotherapy in high-risk patients.

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

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

Cutaneous complications of immunosuppression in 812 transplant recipients: a 40-year single center experience

BACKGROUND

As a consequence of the improvement in survival after solid organ transplantation, to visit transplant recipients with neoplastic and non-neoplastic skin disorders due to immunosuppressive treatment has become common for dermatologists.

METHODS

Our endpoints were: 1) to investigate the most common skin diseases in a population of transplant recipients; 2) their associations with the type of immunosuppressant or transplant received; and 3) to compare our single center 40-year experience with the literature data. We retrospectively analyzed the clinical details of the adult patients transplanted in the years 1974-2014, visited for consultation at the Unit of Dermatology of our hospital.

RESULTS

Pathologic conditions were observed in more than 3/4 of 812 adults during the follow-up (mean 12.1 years): nonmelanoma skin cancers or actinic keratoses were seen in 44.0% (N.=357) of patients, non-neoplastic events in 55.2% (N.=448). Heart transplant had the statistically significant highest rate of NMSC and AK (52.6%, P=0.0352). Patients receiving cyclosporine A developed at least one non-melanoma skin cancer or actinic keratosis in 57.7% of cases (P=0.0001), while tacrolimus showed a lower risk (33%, P=0.0001).

CONCLUSIONS

As transplant recipients are susceptible to skin changes, especially after immunosuppressant treatments, a dermatological follow-up should be scheduled for each patient.

Clinical Characteristics of Non-Melanoma Skin Cancers Recurring within 5 years after Mohs Micrographic Surgery: Single Institution Retrospective Chart Review

Background

Mohs micrographic surgery (MMS) is used to treat certain high-risk non-melanoma skin cancers (NMSC) due to its high cure rate. However, clinical recurrences do occur in a small number of cases.

Objective

We examined specific clinical characteristics associated with NMSC recurrences following MMS.

Methods

We employed a retrospective chart review of the 1467 cases of NMSC that underwent MMS at UC San Diego from January 1, 2008 through December 31, 2009. A total of 356 cases were excluded due to lack of follow-up.

Results

Five (0.45%) of 1111 cases developed recurrences of NMSC at the site of MMS. There were 741 cases of basal cell carcinomas (BCC); 3 were recurrences (0.40%). There were 366 cases of squamous cell carcinomas (SCC); 2 were recurrences (0.55%). Review of MMS histopathology of these recurrent tumors showed that there were no errors or difficulty with the processing or interpretation of the slides.

Conclusion

Five-year recurrence rate of NMSC following MMS at our institution is below the reported average. Our retrospective chart review identified specific clinical characteristics associated with NMSC recurrence including a history of smoking, anatomical location on the cheeks, ears or nose, and a history of immunosuppression for SCCs.

Jejunal perforation: an unusual presentation of metastatic cutaneous squamous cell carcinoma (SCC) in an immunosuppressed patient

We report the rare occurrence of a small bowel perforation secondary to a metastatic cutaneous squamous cell carcinoma (cSCC). A 70-year-old woman, who had previously undergone renal transplantation, presented with severe, sudden-onset abdominal pain. She was peritonitic on initial examination, with evidence of free intra-abdominal air on radiographic imaging. During an exploratory laparotomy, she was found to have a perforated jejunum secondary to disseminated metastases seen throughout her peritoneum. Following histopathological analysis, as well as further imaging studies, the primary malignancy was eventually identified as a cSCC on her upper back. Palliative care was started and the patient died 8 weeks following her initial presentation.

Metastatic Cutaneous Squamous Cell Carcinoma with Gastrointestinal Involvement: A Case Report

Metastatic squamous cell carcinoma (SCC) involving the gastrointestinal tract as the sole site of metastatic disease is exceedingly rare. We report a patient with known cutaneous SCC that metastasized to regional lymph nodes who, after therapy, appeared to be disease free until a small metastatic lesion was identified on colonoscopy within a diverticular orifice. He was subsequently noted to have more diffuse gastrointestinal involvement, including a small bowel lesion not previously identified on imaging. The presence of a gastrointestinal metastatic lesion in this setting should prompt consideration to exclude other synchronous lesions and the need for possible additional systemic therapy.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

HLA-C -35kb expression SNP is associated with differential control of β-HPV infection in squamous cell carcinoma cases and controls

A single nucleotide polymorphism (SNP) 35 kb upstream of the HLA-C gene is associated with HLA-C expression, and the high expressing genotype (CC) has been associated with HIV-I control. HLA-C is unique among the classical MHC class I molecules for its role in the control of viral infections and recognition of abnormal or missing self. This immunosurveillance is central to the pathogenesis of non-melanoma skin cancer (NMSC), and of squamous cell carcinoma (SCC) in particular. While sun exposure is a major risk factor for these cancers, cutaneous infections with genus β-HPV have been implicated in the development of SCC. We hypothesized that the high expression HLA-C genotype is associated with β-HPV infections. Therefore, we investigated the association between β-HPV serology and the -35 kb SNP (rs9264942) in a population-based case-control study of 510 SCC cases and 608 controls. Among controls, the high expression -35 kb SNP genotype (CC) reduced the likelihood of positive serology for multiple (≥2) β-HPV infections (OR = 0.49, 95% CI: 0.25-0.97), and β-HPV species 2 infection (OR = 0.43, 95% CI: 0.23-0.79). However, no association with β-HPV status was observed among SCC cases. Our findings suggest that underlying immunogenotype plays an important role in differential control of β-HPV in SCC cases and controls.

Advances in the management of cutaneous squamous cell carcinoma

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

Knowledge, understanding, and use of preventive strategies against nonmelanoma skin cancer in healthy and immunosuppressed individuals undergoing Mohs surgery

BACKGROUND

Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies.

OBJECTIVES

To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients.

MATERIALS AND METHODS

Survey-based study conducted on 140 individuals undergoing Mohs surgery.

RESULTS

Seventy-three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self-rating of daily use of any protective strategy.

CONCLUSION

General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.

Capecitabine to reduce nonmelanoma skin carcinoma burden in solid organ transplant recipients

BACKGROUND

Solidorgan transplant recipients (SOTRs) are at greater risk of nonmelanoma skin cancer (NMSC) than the general population, in large part because of their immunosuppression. Select individual SOTRs demonstrate a rate of tumor development at the upper end of their cohort. Capecitabine, a prodrug converted in the body to 5-fluorouracil (5-FU), may alter the risk for development of NMSC in an individual SOTR with a high rate of tumor development.

OBJECTIVE

To report observations of a series of 10 SOTRs treated with capecitabine as adjuvant prevention for high-incidence NMSC.

METHODS

Ten SOTRs were administered cycles of low-dose oral capecitabine (0.5-1.5 g/m(2) per day) for days 1 to 14 of a 21-day treatment cycle. Measurements (skin screenings, laboratory and toxicity monitoring) were performed every 1 to 3 months. Incidence rates of squamous cell carcinoma (SCC) before and during treatment were determined and compared using the Wilcoxon signed-rank test.

RESULTS

The average incidence rate (mean ± SD) of SCC before treatment (0.56 ± 0.28 SCCs/month, range 0.17-1.17 SCCs/month) declined to 0.16 ± 0.11 SCCs/month (range 0-0.33 SCCs/month) during the first 12 months of treatment (mean reduction 68 ± 30.0%, range 0-100%, p < .005). Reduction in actinic keratosis was observed. Common side effects included fatigue, nausea, hand-and-foot syndrome, gout, and poor renal function. Seven of 10 participants required dose adjustment, and two of these were discontinued from the study drug because of side effects.

LIMITATIONS

Case series design, small observational population.

CONCLUSIONS

SOTRs experienced a clinically and statistically significant decline in incident SCCs during treatment with low-dose oral capecitabine, with varying degrees of side effects. Larger randomized trials will determine the dose and efficacy of capecitabine for adjuvant treatment of NMSC in SOTRs.

Systemic therapy for squamous cell carcinoma of the skin in organ transplant recipients

During the second half of the 20th century, organ transplantation saved thousands of lives. This, unfortunately, also led to unforeseen consequences that need to be addressed to help extend the lives of patients who require these life-saving procedures. Secondary malignancies have been recognized as a potential consequence for decades. One of these malignancies, squamous cell carcinoma of the skin, not only appears more frequently in organ transplant recipients than the general population, but also is more aggressive in organ transplant recipients. It also shows a high propensity to nodal spread and metastasis in transplant patients. Unfortunately, there are no clear guidelines for a chemotherapy in this population, who have an increased need for alternative therapies to surgery given the high recurrence and metastasis rate. In this review, we attempt to describe the characteristics of squamous cell carcinoma of the skin in transplant recipients and discuss what chemotherapeutic options can be used to treat this aggressive malignancy.

Increased risk of nonmelanoma skin cancers among individuals with inflammatory bowel disease

BACKGROUND & AIMS

There are limited data on the risk of nonmelanoma skin cancer (NMSC) among individuals with inflammatory bowel disease (IBD), including those with or without exposure to immunosuppressant medications.

METHODS

Individuals with IBD (n = 9618) were identified from the University of Manitoba IBD Epidemiology Database and matched with randomly selected controls (n = 91,378) based on age, sex, and postal area of residence on the date of IBD diagnosis (index date). Groups were followed up from the index date until a diagnosis of any invasive cancer (including NMSC), death, migration from the province, or the end of the study (December 31, 2009), whichever came first. Cox regression analysis was performed to calculate the relative risk of NMSC among the individuals with IBD, adjusting for frequency of ambulatory care visits and socioeconomic status.

RESULTS

Of the individuals followed, 1696 were diagnosed with basal cell skin cancer (BCC) and 341 were diagnosed with squamous cell skin cancer (SCC). Individuals with IBD had an increased risk for BCC, compared with controls (hazard ratio, 1.20; 95% confidence interval [CI], 1.03-1.40). Among patients with IBD, use of thiopurines increased the risk of SCC (hazard ratio, 5.40; 95% CI, 2.00-14.56), compared with controls. Use of thiopurines also was associated with SCC in a case-control, nested analysis of individuals with IBD (odds ratio, 20.52; 95% CI, 2.42-173.81).

CONCLUSIONS

The risk of BCC could be increased among individuals with IBD. Use of thiopurines increases the risk of SCC among individuals with IBD.

Update on the management of high-risk squamous cell carcinoma

Cutaneous squamous cell carcinoma (CSCC) is the second most common malignancy occurring in white patients in the United States and incidence rates are increasing. While the majority of the 87,000-760,000 cases that occur yearly in the U.S. are curable, 4% develop lymph node metastases and 1.5% die from the disease. Given the frequency of occurrence of CSCC, it is estimated to cause as many deaths yearly as melanoma, with the majority occurring in patients with high risk tumors or in those at high risk for metastasis due to a variety of host factors, most commonly systemic immunosuppression. There are currently no standardized prognostic or treatment models to assist clinicians in most effectively identifying and managing these patients. Identification of patients at risk for poor outcomes as well as standardization regarding classification, staging, and treatment of high-risk tumors is critical for optimizing patient care. In this article, available literature on the classification and management of high risk CSCC is briefly summarized, emphasizing new information.

Increased expression of activating transcription factor 3 is related to the biologic behavior of cutaneous squamous cell carcinomas

Activating transcription factor 3, a member of the activating transcription factor/cyclic adenosine monophosphate response element-binding family of transcription factors, is an adaptive response gene that plays an oncogenic role in the development of various cancers. To our knowledge, few information are available on the possible role of activating transcription factor 3 in skin cancer. In this study, we investigated the expression of activating transcription factor 3 in basal cell carcinomas (n = 5), actinic keratoses (n = 7), squamous cell carcinomas (n = 19), and Bowen disease (n = 14) by immunohistochemistry. In results, activating transcription factor 3 was significantly expressed in squamous cell carcinomas (15/19), suggesting that it is involved in the pathogenesis of squamous cell carcinomas but not in basal cell carcinomas (0/5). In addition, higher expression of activating transcription factor 3 was observed in squamous cell carcinomas that were metastatic (P < .01) or arose in organ transplant recipients (P < .05). Therefore, activating transcription factor 3 appears to play an oncogenic role in the development of squamous cell carcinomas and may be related to the biologic behavior of them.

A germline variant in the interferon regulatory factor 4 gene as a novel skin cancer risk locus

Genome-wide association studies on pigmentary phenotypes provide a pool of candidate genetic markers for skin cancer risk. The SNPs identified from a genome-wide association study of natural hair color were assessed for associations with the risk of three types of skin cancer simultaneously in a nested case-control study within the Nurses' Health Study [218 melanoma, 285 squamous cell carcinoma (SCC), and 300 basal cell carcinoma (BCC) cases, and 870 common controls]. Along with two known pigmentation loci, MC1R and OCA2, the IRF4 rs12203592 T allele was associated with an increased risk of each type of skin cancer (P value, 6.6 × 10(-4) for melanoma, 7.0 × 10(-7) for SCC, and 0.04 for BCC). This association was further replicated in additional samples (190 melanoma, 252 SCC, and 634 common controls). The P value in the replication set was 0.03 for melanoma and 4.2 × 10(-3) for SCC. The risk of BCC was replicated in an independent set of 213 cases and 718 controls (P value, 0.02). The combined results showed that the association with SCC reached the genome-wide significance level [odds ratio (OR) for additive model = 1.61, 95%CI, 1.36-1.91, P = 3.2 × 10(-8)]. The OR was 1.49 for melanoma (95%CI, 1.23-1.80; P = 4.5 × 10(-5)), and 1.32 for BCC (95%CI, 1.11-1.57; P = 1.6 × 10(-3)). Given that the T allele was shown previously to be associated with increased expression of IRF4 locus, further studies are warranted to elucidate the role of the IRF4 gene in human pigmentation and skin cancer development.

Critical Review of Preclinical Approaches to Evaluate the Potential of Immunosuppressive Drugs to Influence Human Neoplasia

Many immunosuppressive drugs are associated with an increased risk of B-cell lymphoma, squamous cell carcinoma, and Kaposi sarcoma. Thirteen immunosuppressive drugs have been tested in 2-year carcinogenicity studies (abatacept; azathioprine; busulfan; cyclophosphamide; cyclosporine; dexamethasone; everolimus; leflunomide; methotrexate; mycophenolate mofetil; prednisone; sirolimus; and tacrolimus) and in additional models including neonatal and genetically modified mice; chemical, viral, ultraviolet, and ionizing radiation co-carcinogenesis, and in models with transplanted tumor cells. The purpose of this review is to outline the mechanisms by which immunosuppressive drugs can influence neoplasia, to summarize the available preclinical data on the 13 drugs, and to critically review the performance of the models. A combination of primary tumor and metastasis assays conducted with transplanted cells may provide the highest value for hazard identification and can be applied on a case-by-case basis. However, for both small molecules and therapeutic proteins, determining the relative risk to patients from preclinical data remains problematic. Classifying immunosuppressive drugs based on their mechanism of action and hazard identification from preclinical studies and a prospective pharmacovigilance program to monitor carcinogenic risk may be a feasible way to manage patient safety during the clinical development program and postmarketing.

Potential risk factors for cutaneous squamous cell carcinoma include oral contraceptives: results of a nested case-control study

Recently, a population-based case-control study observed a 60% increased odds ratio (OR) for cutaneous squamous cell carcinoma (SCC) among women who had ever used oral contraceptives (OCs) compared with non users (95% confidence interval (CI) = 1.0-2.5). To further characterize the putative association between OC use and SCC risk, we conducted a nested case-control study using a large retrospective cohort of 111,521 Kaiser Permanente Northern California members. Multivariable conditional logistic regression was used to estimate ORs and CIs adjusting for known and hypothesized SCC risk factors. Pre-diagnostic OC use was associated with a statistically significant increased OR for SCC in univariate analysis (OR = 2.4, CI = 1.2-4.8), with borderline statistical significance in multivariable analysis (CI = 2.0, CI = 0.91-4.5). Given the high incidence of SCC in the general population and the prevalent use of OCs among women in the United States, there is a need for more large, carefully designed epidemiologic studies to determine whether the observed association between OC use and SCC can be replicated and to better understand the etiologic basis of an association if one exists.