Breast and lung cancers in two cyclosporin-A-treated psoriatic women

The use of ciclosporin in psoriasis

Ciclosporin is a cyclic undecapeptide discovered in the 1970s to possess a potent inhibitory action on T lymphocytes. The subsequent discovery, in 1979, that it was remarkably effective in treatment of psoriasis transformed thinking about the nature of the disease, which subsequently became generally recognized as autoimmune in nature. Ciclosporin remains one of the most effective and rapidly acting treatments currently available for psoriasis. Virtually all the diverse manifestations of this disease can respond. The main side effects are nephrotoxicity and hypertension. There is considerable variation between individuals in susceptibility to these so careful monitoring is required. Ciclosporin should be used in single or intermittent short courses for all except the most severe cases as this is safer than continuous treatment. The rate of improvement depends very much on the dose, which ranges from 2 to 5.0 mg/kg/day. Ciclosporin can be combined with any topical treatment and a useful dose-sparing effect can be achieved in this way if patients are compliant. In severe cases ciclosporin is often used in combination with other systemic antipsoriatic drugs in order to spare the dose of each agent and reduce toxicity. Concurrent or intercurrent use of ultraviolet therapy is discouraged due to the increased risk of non-melanoma skin cancer. This article reviews the mode of action, pharmacokinetics, indications, contraindications, side effects, dosage regimens, pretreatment screening and monitoring, drug interactions, and use of treatment combinations with ciclosporin in the management of psoriasis.

Psoriasis and risk of incident cancer: an inception cohort study with a nested case-control analysis

Psoriasis has been associated with lymphohematopoietic and solid cancers; however, reports have been inconsistent. Cancer incidence was compared between psoriasis and psoriasis-free patients, and the roles of psoriasis duration and treatment were explored in this observational study using the UK General Practice Research Database. Among 67,761 patients, 1,703 patients had incident cancer; of whom 54% had a history of psoriasis. Incidence rate ratios for lymphohematopoietic and pancreatic cancers were 1.81 (95% confidence interval (CI) 1.35-2.42) and 2.20 (95% CI 1.18-4.09), respectively. In a nested case-control analysis, adjusted odds ratios (ORs) for cancer overall were 1.50 (95% CI 1.30-1.74) for psoriasis of >or=4 years duration and 1.53 (95% CI 0.97-2.43) for patients receiving systemic treatment (marker of disease severity). Lymphohematopoietic malignancy risk was highest in patients with systemic treatment. The OR for patients without systemic treatment was 1.59 (95% CI 1.01-2.50) for psoriasis of <2 years and 2.12 (95% CI 1.45-3.10) for that of >or=2 years duration. Risks of bladder/kidney and colorectal cancers were increased with longer-duration psoriasis. Psoriasis patients may have an increased overall risk of incident cancer (mainly lymphohematopoietic and pancreatic). Longer-term psoriasis and more severe disease may increase the risk of some cancers. These observations need further confirmation, particularly because of the potential of findings by chance in observational studies with subgroup analyses.

Characteristic imaging features of breast fibroadenomas in women given cyclosporin A after renal transplantation

PURPOSE

This retrospective study was conducted to determine the characteristic imaging and histopathologic features of breast fibroadenomas in kidney-transplant recipients given chronic cyclosporin A immunosuppressive therapy after the transplantation and to compare these characteristics with those from a control group.

METHODS

From January 1, 1990, through December 31, 1999, 486 women underwent renal transplantation at our institution. All patients subsequently received immunosuppressive therapy with cyclosporin A and prednisolone. Ten (2%) of these women had developed breast fibroadenomas during this chemotherapy. We compared the data obtained on this group's fibroadenomas with those obtained from those in the control group, which comprised 100 women with fibroadenomas but who had never undergone organ transplantation or immunosuppressive therapy.

RESULTS

Twenty-two fibroadenomas developed in the 10 transplant recipients. Eight of those 10 had multiple lesions, and 7 were affected bilaterally. The mean diameter of the fibroadenomas was 4.2 +/- 2.5 cm. Mammographically, the lesions were round or oval high-density masses with well-circumscribed margins and no calcification or spiculation. Sonographically, the lesions were relatively highly echogenic and had a lower ratio of the longitudinal to the anteroposterior diameter (L /AP) than did those in the control group. Histopathologically, the features of these lesions were generally typical of fibroadenomas, but some were more typical of malignant lesions. Among the 100 control patients, 146 fibroadenomas developed; 33 women had multiple lesions, and 12 were affected bilaterally. Their fibroadenomas had a mean diameter of 2.1 +/- 1.5 cm, and the imaging features of these lesions were typical of fibroadenomas.

CONCLUSIONS

The fibroadenomas that developed in kidney-transplant recipients given chronic cyclosporin A and prednisolone immunosuppressive therapy had a tendency to be multiple, bilateral, and larger than those that developed in the control patients. These fibroadenomas also exhibited some imaging features that differed from those of typical fibroadenomas that develop in women who have not undergone organ transplantation or immunosuppressive therapy.

Cancer risk in a population-based cohort of patients hospitalized for psoriasis in Sweden

Studies of clinical series of psoriasis patients have suggested an increased risk of nonmelanoma skin cancer and melanoma; the risk of other neoplasms has rarely been studied. In order to assess the incidence of cancer in a nationwide series of psoriasis patients from Sweden, we followed up, for the years 1965-89, 9773 patients with a hospital discharge diagnosis of psoriasis made during 1965-83, who were alive and free from malignancy 1 y after first discharge. We compared their incidence of neoplasms with that of the national population by computing standardized incidence ratios (SIR). We observed a total of 789 neoplasms [SIR 1.37, 95% confidence interval (CI) 1.28, 1.47]. There was an increase in the risk of cancers of the oral cavity and pharynx (SIR 2.80, 95% CI 1.96, 3.87), liver (SIR 1.91, 95% CI 1.28, 2.74), pancreas (SIR 1.56, 95% CI 1.02, 2.23), lung (SIR 2.13, 95% CI 1.71, 2.61), skin (squamous cell carcinoma, SIR 2.46, 95% CI 1.82, 3.27), female breast (SIR 1.27, 95% CI 1.00, 1.58), vulva (SIR 3.24, 95% CI 1.18, 7.06), penis (SIR 4.66, 95% CI 1.50, 10.9), bladder (SIR 1.43, 95% CI 1.03, 1.92), and kidney (SIR 1.56, 95% CI 1.04, 2.25). The risk of malignant melanoma was decreased (SIR 0.32, 95% CI 0.10, 0.74). Despite some limitations (possible diagnostic misclassification, lack of data on treatment, relatively short follow-up), our study provides evidence against an increased risk of melanoma among patients hospitalized for psoriasis. In addition to nonmelanoma skin and genital cancers, patients hospitalized for psoriasis were at increased risk of several malignancies, in particular those associated with alcohol drinking and tobacco smoking.

Would cyclosporin A be beneficial to mitigate drug-induced toxic epidermal necrolysis?

Drug-induced toxic epidermal necrolysis (TEN) is a rare life-threatening disease whose mortality remains high. The treatment of the disease is badly settled. Several kinds of drugs have been tested, including systemic corticosteroids, cyclophosphamide, pentoxifylline and thalidomide, but without any clear-cut outcome. Cyclosporin A (CsA) has many inhibitory effects on the main cell populations involved in TEN (T lymphocytes, macrophages and keratinocytes). CsA could also act on tumor necrosis factor alpha metabolism, a cytokine which is important in TEN epidermal destruction. Moreover, apoptosis is the mechanism leading to keratinocyte death and CsA has antiapoptotic properties. CsA has already been used successfully on a limited series of TEN patients. We have reviewed the potential theoretical useful effects of CsA in TEN. We conclude that CsA could be a good candidate to reverse TEN progression.