Cutaneous squamous cell carcinoma in two pediatric lung transplant patients on prolonged voriconazole treatment

Outcomes of skin cancers in pediatric solid organ transplant patients: A systematic review

BACKGROUND

The most frequently reported malignancies after solid organ transplant are cutaneous, but data on the risk in pediatric populations varies across studies.

OBJECTIVES

To perform a systematic review including reported features and outcomes of skin cancers in pediatric solid organ transplant recipients.

METHODS

EMBASE and MEDLINE were systematically searched (Prospero CRD42020201659).

RESULTS

The review summarizes data from 20 studies on 337 patients, with a median age ranging from 15.0 to 19.5 years as reported in 4 studies, who developed skin malignancies after pediatric solid organ transplantation. Median ages at transplant and skin cancer diagnosis ranged from 1.5 to 17.0 years and 15.3 to 33.5 years, respectively. Squamous cell carcinoma (SCC) was most commonly reported (218 cases), followed by basal cell carcinoma (BCC) (91 cases), melanoma (18 cases), and unspecified keratinocyte carcinomas (2 cases). The median latency period between transplantation and cancer diagnosis ranged from 2.2 to 21.0 years. Overall, 4 studies reported 17 cases of metastasis in total, and recurrence was reported in one case. Six deaths were reported in one study related to SCC and melanoma metastases. The incidence rate of skin cancer after pediatric transplantation per 100 person-years of follow-up was 2.1 based on 5 studies.

CONCLUSION

The most frequent post-transplant malignancy in pediatric organ transplant recipients was SCC.

Bioavailability enhancement of voriconazole using liposomal pastilles: Formulation and experimental design investigation

Oral mucosa offers several advantages in the delivery of therapeutic molecules. It avoids presystemic metabolism, Nanoencapsulation techniques might be applied to conquer physical, chemical challenges and enhance drug penetration, formulation performance, prolonging drug residence time, and improving sensorial feeling. The present investigation is aimed to formulate liposomal pastilles with high bioavailability. Voriconazole Liposomes (VL) were produced by utilizing varied ratios of soya lecithin (SL) and cholesterol (CH) by solvent Injection method. RSM is utilized to identify the optimized formulation, as this design provides a thorough understanding of a process and also has great utilization in originating the robustness of the product. The main impact and interaction terms of the formulation variables were assessed quantitatively utilizing a mathematical-statistical approach indicating that both independent variables have significant ('P' value < 0.05) effects on particle size ('P' value: 0.0142), percentage entrapment efficiency ('P' value: 0.0120), percentage drug release through the dialysis membrane ('P' value: 0.0105), percentage drug release through porcine buccal mucosa ('P' value: 0.0171) and percentage zone of inhibition ('P' value: 0.0305). Optimal liposomal encapsulated in noticed in 15:10 lecithin: cholesterol concentration (VLP-6). Higher Lecithin and Cholesterol quantity in the liposome formulations resulted in lower drug entrapment efficiency and drug release when compared with middle levels of lecithin and cholesterol content formulation. The pastilles were prepared from the optimized liposomal formulation with a modified method reported in British Pharmaceutical Codex, 1907. These liposomal pastilles were subjected to evaluation of physicochemical parameters, In vitro drug release studies, stability studies, and In vivo bioavailability studies in comparison with pure voriconazole pastilles (PVP). The statistical data analysis results indicated that there was a significant difference in T_max, K_a, t_{1/2 abs}, t_{1/2 elim,} AUC_0-24, AUC_0-∞, AUMC_0-24 and AUMC_0-∞, values among PVP and VLP-6. There was no significant difference in C_max, K_el, MRT_0-24 and MRT_0-∞values among pure voriconazole pastilles and optimized liposomal formulation.

Post-transplant malignancies in pediatric organ transplant recipients

The majority of cancer diagnoses in pediatric solid organ transplant recipients (SOTRs) are post-transplantation lymphoproliferative disorders (PTLD) or skin cancers. However, pediatric SOTRs are also at significantly elevated risk for multiple other solid and hematological cancers. The risks of specific cancers vary by transplanted organ, underlying disease, and immunosuppression factors. More than one-quarter of pediatric SOTRs develop cancer within 30 years of transplantation and their risk of solid cancer is 14 times greater than the general population. Pediatric SOTRs are at significantly higher risk of cancer-associated death. Improving patient survival among pediatric SOTRs puts them at risk of adult epithelial cancers associated with environmental carcinogenic exposures. Vaccination against oncogenic viruses and avoidance of excessive immunosuppression may reduce the risk of solid cancers following transplantation. Patient and family education regarding photoprotection is an essential component of skin cancer prevention. There is significant variability in cancer screening recommendations for SOTRs and general population approaches are typically not validated for transplant populations. An individualized approach to cancer screening should be developed based on estimated cancer risk, patient life expectancy, and screening test performance.

Drug-Induced Photosensitivity-An Update: Culprit Drugs, Prevention and Management

Photosensitive drug eruptions are cutaneous adverse events due to exposure to a medication and either ultraviolet or visible radiation. In this review, the diagnosis, prevention and management of drug-induced photosensitivity is discussed. Diagnosis is based largely on the history of drug intake and the appearance of the eruption primarily affecting sun-exposed areas of the skin. This diagnosis can also be aided by tools such as phototesting, photopatch testing and rechallenge testing. The mainstay of management is prevention, including informing patients of the possibility of increased photosensitivity as well as the use of appropriate sun protective measures. Once a photosensitivity reaction has occurred, it may be necessary to discontinue the culprit medication and treat the reaction with corticosteroids. For certain medications, long-term surveillance may be indicated because of a higher risk of developing melanoma or squamous cell carcinoma at sites of earlier photosensitivity reactions. A large number of medications have been implicated as causes of photosensitivity, many with convincing clinical and scientific supporting evidence. We review the medical literature regarding the evidence for the culpability of each drug, including the results of phototesting, photopatch testing and rechallenge testing. Amiodarone, chlorpromazine, doxycycline, hydrochlorothiazide, nalidixic acid, naproxen, piroxicam, tetracycline, thioridazine, vemurafenib and voriconazole are among the most consistently implicated and warrant the most precaution by both the physician and patient.

Cutaneous Malignancies in Pediatric Solid Organ Transplant Recipients

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

Liposomal voriconazole (VOR) formulation for improved ocular delivery

Treating infectious eye diseases topically requires a drug delivery system capable of overcoming the eye's defense mechanisms, which efficiently reduce the drug residence time right after its administration, therefore reducing absorption. In order to try to surpass such administration issues and improve life quality for patients with fungal keratitis, liposomal voriconazol (VOR) formulations were prepared. Formulations were composed of soy phosphatidylcholine (PC) containing or not 1,2-dioleoyl-3-trimethylammonium-propane (DOTAP) and cholesterol. Liposomes were characterized by their drug entrapment efficiency (EE), drug recovery (DR), average diameter (size) and polydispersivity index (PdI). In vitro mucosal interaction and irritancy levels, ex vivo permeation, as well as the short-term stability were also assessed. Liposomal VOR formulation produced with 7.2:40mM VOR:PC showed to be the most promising formulation: mean size of 116.6±5.9nm, narrow PdI (0.17±0.06), negative zeta potential (∼-7mV) and over 80% of EE and yield, remaining stable for at least 30 days in solution and 90 days after lyophilization. This formulation was classified as 'non-irritant' after HET-CAM's test and was able to deliver about 47.85±5.72μg/cm(2) of VOR into porcine cornea after 30min of permeation test. Such drug levels are higher than the minimal inhibitory concentrations (MIC) of several fungi species isolated from clinical cases of corneal keratitis. Overall results suggest VOR can be effectively incorporated in liposomes for potential topical treatment of fungal keratitis.