Survival of patients with basal cell carcinoma, squamous cell carcinoma, and squamous cell carcinoma in situ: A whole population study

BACKGROUND

Keratinocyte carcinoma (KC) is the commonest type of malignancy in humans; however, the impact of KC on survival is poorly understood.

OBJECTIVES

This study characterizes the impact of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and squamous cell carcinoma in situ (SCCis) on the survival of Icelanders.

METHODS

This whole population study evaluated relative survival of KC in Iceland by using a cancer registry containing records of all BCC, SCCis, and SCC cases recorded in Iceland between 1981 and 2015.

RESULTS

Between 1981 and 2015, 8767 Icelanders were diagnosed with their first localized KC. A total of 6473 individuals with BCC, 1194 with SCCis, and 1100 with invasive SCC, respectively. BCC was not associated with decreased survival except for men diagnosed with BCC between 1981 and 1995 for whom decreased 10-year relative survival was observed (85.3, 95% CI [77.9-92.7]). SCC and SCCis were both associated with a decrease in relative survival for certain population subgroups such as individuals <50 years of age at time of diagnosis.

CONCLUSION

Our whole population cohort survival study examining the Icelandic Cancer Registry supports prior studies demonstrating that BCC is not associated with a reduction in relative survival and that SCC and SCCis are associated with comparatively poor relative survival in certain population subgroups.

Iatrogenic solid tumors following immunosuppressive therapy

Immunosuppression induced by chronic medication, such as occurs post-transplantation, may increase a patient's risk of developing solid tumors. These are often rare tumors characterized by odd presentations. This review focuses on commonly encountered iatrogenic, non-hematopoietic solid tumors following immunotherapy and provides a practical approach to their diagnosis. All of the malignancies covered in this review are viral-induced. They include human papillomavirus (HPV)-associated carcinomas, Epstein-Barr virus (EBV)-associated tumors, Merkel cell polyomavirus (MCPyV)-related Merkel cell carcinoma, and Human Herpesvirus 8 (HHV8)-related Kaposi sarcoma. The complementary diagnostic role of ancillary studies, such as immunohistochemistry and in-situ hybridization that target these oncogenic viruses, is addressed.

Uveitic macular edema

Macular edema (ME) may complicate anterior, intermediate, and posterior uveitis, which may be because of various infectious, neoplastic or autoimmune etiologies. BRB breakdown is involved in the pathogenesis of Uveitic ME (UME). Optical coherence tomography has become a standard tool to confirm the diagnosis of macular thickening, due to its non-invasive, reproducible, and sensitive features. Retinal fluorescein and indocyanine green angiography is helpful to study the macula and screen for associated vasculitis, detect ischemic areas and preretinal, prepapillary or choroidal neovascular complications, and it may provide information about the etiology and be needed to assess the therapeutic response. UME due to an infection or neoplastic infiltration may require a specific treatment. If it remains persistent or occurs in other etiologies, immunomodulatory treatments may be needed. Intravitreal, subconjunctival, or subtenon corticosteroids are widely used. Their local use is contraindicated in glaucoma patients and limited by their short-lasting action. In case of bilateral sight-threatening chronic posterior uveitis, systemic treatments are usually needed, and corticosteroids are used as the standard first-line therapy. In order to reduce the daily steroid dose, immunosuppressive or immunomodulatory agents may be added, some of them being now available intravitreally. Ongoing prospective studies are assessing biotherapies and immunomodulators to determine their safety and efficacy in this indication.

Oral Cancer and Oral Precancerous Lesions in Inflammatory Bowel Diseases: A Systematic Review

Oral cancer is historically linked to well-known behavioural risk factors such as tobacco smoking and alcohol consumption. Other risk factors include age over 40, male sex, several dietary factors, nutritional deficiencies, viruses, sexually transmitted infections, human papillomavirus, chronic irritation, and possibly genetic predisposition. Precancerous lesions in the oral cavity include leukoplakia, erythroplakia, and lichen planus. Histology of oral cancer varies widely but the great majority are squamous cell carcinomas.Epidemiological studies and cancer registries have shown a consistently increased risk of oral malignancies in kidney, bone marrow, heart, or liver transplantation, in graft vs host disease, and in patients with HIV infection. Because of the increasing use of immunosuppressive drugs in patients with inflammatory bowel disease, it is useful to more accurately delineate the consequences of chronic immunosuppression to the oral cavity. Oral cancer and precancerous oral lesions in patients with inflammatory bowel disease [IBD] have been scarcely reported and reviews on the topic are lacking.We conducted a literature search using the terms and variants of all cancerous and precancerous oral manifestations of inflammatory bowel diseases. By retrieving the existing literature, it is evident that patients with IBD belong to the high-risk group of developing these lesions, a phenomenon amplified by the increasing HPV prevalence. Education on modifiable risk behaviours in patients with oral cancer is the cornerstone of prevention.Oral screening should be performed for all IBD patients, especially those who are about to start an immunosuppressant or biological drug.

Periocular Skin Cancer in Solid Organ Transplant Recipients

PURPOSE

To determine the proportion of solid organ transplant recipients developing periocular nonmelanoma skin cancer and to describe the morbidity of these cancers in transplant recipients.

DESIGN

Cohort study.

PARTICIPANTS

Consecutive patients undergoing solid organ transplantation at the Cleveland Clinic between 1990 and 2008.

METHODS

The charts of all patients receiving a solid organ transplant from 1990-2008 evaluated in the dermatology department for a subsequent biopsy-proven head and neck malignancy through April 2015 were reviewed. Patients with a periocular region nonmelanoma skin cancer (NMSC) or a nonperiocular NMSC causing a complication requiring eyelid surgery were included. Charts were reviewed for demographic data; transplant date, type, and source; immunosuppressive agents received at diagnosis; and type of NMSC, number of nonperiocular NMSCs, ophthalmologic findings, and periocular sequelae after the repair.

MAIN OUTCOME MEASURES

Primary outcome measures included the type, location, final defect size, tumor-node-metastasis classification, presence of perineural invasion, and reconstruction technique(s) used for each periocular NMSC. Secondary outcome measures included the type and treatment of ocular sequelae due to nonperiocular facial NMSC.

RESULTS

A total of 3489 patients underwent solid organ transplantation between 1990 and 2008. Of these, 420 patients were evaluated in the dermatology clinic for biopsy-proven NMSC of the head and neck during the study period, and 11 patients (15 malignancies) met inclusion criteria. Nine patients developed 12 periocular malignancies and 3 patients required eyelid surgery for facial malignancies outside the periocular zone. All 11 patients developed a squamous cell carcinoma (14 malignancies), and 1 patient (1 malignancy) also developed a periocular basal cell carcinoma. There was orbital invasion in 4 cases and paranasal and/or cavernous sinus invasion in 3 cases. Two patients underwent exenteration. Seven cases required reconstruction with a free flap or graft. Periocular sequelae included lower eyelid ectropion (6 malignancies), dry eye and/or exposure symptoms (8 malignancies), unilateral vision loss (3 malignancies), and facial nerve paresis (5 malignancies).

CONCLUSIONS

Squamous cell carcinoma affecting the periocular region represents a risk of solid organ transplantation and may produce significant ocular morbidity, including the need for major eyelid reconstruction, globe loss, and disfiguring surgery.

Malignant and noninvasive skin tumours in renal transplant recipients

Background. Transplant recipients require immunosuppression to prevent graft rejection. This conveys an increased risk of malignancy, particularly skin tumours. There is a need for up-to-date data for the South of England. Method. Pathology records were reviewed for 709 kidney transplant recipients on immunosuppression at our hospital from 1995 to 2008. Skin tumours were recorded/analysed. Results. Mean age at transplant was 46 years. Mean length of follow-up was 7.2 years and total follow-up was 4926 person-years. 53 (7.5%) patients (39/458 (8.5%) males and 14/251 (5.6%) females) developed ≥1 skin malignancy. Cumulative incidences of 4.0%, 7.5%, and 12.2% were observed for those with <5, <10, and ≥10 years follow-up, respectively. The rate was 45 tumours per 1000 person-years at risk. Additionally, 21 patients (3.0%) only had noninvasive tumours. 221 malignant skin tumours were found: 50.2% were SCCs, 47.1% BCCs, and 2.7% malignant melanomas. Mean years to first tumour were 5.8. Mean number of tumours per patient was 4, with mean interval of 12 months. Conclusions. Despite changes in transplantation practice during the time since the last data were published in this region, these findings are similar to previous studies. This adds to the evidence allowing clinicians to inform patients in this region of their risk.

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.

On the roles of solar UV irradiance and smoking on the diagnosis of second cancers after diagnosis of melanoma

Several recent papers have reported standardized incidence ratios (SIRs) for second cancers after diagnosis of cutaneous malignant melanoma. This review divides the types of cancer into five types: (1) those for which UV-B (UVB) irradiance and vitamin D reduces risk; (2) those for which UVB/vitamin D reduces risk and smoking increases risk; (3) smoking related; (4) unknown UVB/vitamin D and smoking sensitivity and (5) those for which UV irradiance increases risk. For those in category 1, SIRs were either significantly elevated or not significantly different from 1.0. For those in category 2, the SIR for kidney cancer was significantly elevated, whereas the SIRs for cervical, laryngeal and rectal cancer were significantly reduced. For those in category 3, all SIRs were significantly reduced. For those in categories 4 and 5, SIRs for all types except lip cancer were significantly elevated. A registry linkage study found significantly reduced SIRs for second cancers after diagnosis of nonmelanoma skin cancer in sunny countries but found increased SIRs in less sunny countries. The SIRs for second cancer for melanoma were elevated in both sunny and less sunny countries. This review concludes that sun exposure without sufficient vitamin D production may explain the elevated SIRs for vitamin D-sensitive cancers, whereas smoking-through production of skin elastosis, thereby reducing the risk of melanoma-probably explains the findings for smoking-related cancers. Thus, guidelines on UV irradiance should emphasize regular moderate UVB irradiance rather than avoidance for those who can tan.

Sun exposure in young adult cancer survivors on and off the beach: results from Project REACH

BACKGROUND

Although cancer survivors are at risk for future skin cancers, many do not practice recommended sun protection. Studies have demonstrated poor adherence to specific behaviors (e.g., sunscreen, artificial tanning) during sunbathing, but less is known about survivors' typical amount of sun exposure during activities other than sunbathing.

METHODS

We conducted a mailed survey of 153 adults (median age = 26.1) diagnosed with a non-skin cancer before age 30. Information on recent sunbathing and incidental sun exposures, protective behaviors, and perceived vulnerability was collected. Analyses focused on characterizing survivors with the lowest levels of recommended sun protection.

RESULTS

Twenty-nine percent of participants exhibited low sun protection adherence during sunbathing and 31% during incidental exposure. Younger age was associated with low adherence, but this difference was significant only for sunbathing (OR=0.4; 95% CI, 0.2-0.9). Women were more likely than men to have low adherence during sunbathing (34.0% vs. 20.3%; OR = 2.44; 95% CI, 1.1-5.5). Survivors treated with radiation did not differ on exposures, adherence, or perceived vulnerability to the sun, despite feeling more susceptible to skin cancers (p = 0.03).

CONCLUSIONS

Despite known skin cancer risks, many young cancer survivors receive significant sun exposure. Assessment of sunbathing alone fails to capture sun exposure behaviors, particularly in men. Survivors treated with radiation may recognize their increased risk of skin cancer, but not the role of sun protection in modifying that risk.

Cutaneous Hodgkin-type lymphoproliferative lesion associated with immunomodulatory therapy for ulcerative colitis

Immunomodulatory drugs have demonstrated efficacy in the therapy against autoimmune diseases such as rheumatoid arthritis, Crohn's disease or ulcerative colitis. Tumor necrosis factor-α (TNF-α) represents a target molecule for the treatment of these entities. Use of monoclonal antibodies can block the proinflammatory function of TNF-α. It has been shown that this action can reactivate quiescent chronic diseases as well as modify the immune response or potentiate carcinogens, thereby increasing the risk of secondary tumor development. In this context, different types of solid or hematological tumors have been documented. We present the case of a male with chronic ulcerative colitis who secondarily developed a cutaneous Hodgkin-type lymphoproliferative lesion associated with immunodeficiency. This secondary tumor developed after 6 months of treatment with anti-TNF-α.

What types of cancers are associated with immune suppression in HIV? Lessons from solid organ transplant recipients

PURPOSE OF REVIEW

To examine recently published evidence of cancer risk after solid organ transplantation to gain insight into cancers that are associated with immune suppression in HIV.

RECENT FINDINGS

Data from several population-based studies comparing cancer risk in recipients of solid organ transplants with that in the general population have demonstrated increased risk for a broad range of cancers, predominantly those with a known or suspected infectious cause. This increase in risk is independent of cohort aging and probably independent of established behavioral and other risk factors for cancer. Epidemiological risk factor data are limited but appear to indicate a relationship with severity and duration of immune suppression. A recent meta-analysis indicates a striking similarity in the pattern of cancer occurrence in transplant recipients and people with HIV/AIDS.

SUMMARY

The similarity of the increased risk of cancer in these two immunosuppressed populations, who differ with respect to their underlying conditions and lifestyles, is compelling evidence that these cancers are associated with immune deficiency. The mechanisms are not fully understood but appear to be related to impaired immune surveillance. These data challenge the classification of only a narrow range of cancers as associated with immune suppression in people with HIV/AIDS.

Identification of the neoplastically transformed cells in Marek's disease herpesvirus-induced lymphomas: recognition by the monoclonal antibody AV37

Understanding the interactions between herpesviruses and their host cells and also the interactions between neoplastically transformed cells and the host immune system is fundamental to understanding the mechanisms of herpesvirus oncology. However, this has been difficult as no animal models of herpesvirus-induced oncogenesis in the natural host exist in which neoplastically transformed cells are also definitively identified and may be studied in vivo. Marek's disease (MD) herpesvirus (MDV) of poultry, although a recognized natural oncogenic virus causing T-cell lymphomas, is no exception. In this work, we identify for the first time the neoplastically transformed cells in MD as the CD4(+) major histocompatibility complex (MHC) class I(hi), MHC class II(hi), interleukin-2 receptor alpha-chain-positive, CD28(lo/-), phosphoprotein 38-negative (pp38(-)), glycoprotein B-negative (gB(-)), alphabeta T-cell-receptor-positive (TCR(+)) cells which uniquely overexpress a novel host-encoded extracellular antigen that is also expressed by MDV-transformed cell lines and recognized by the monoclonal antibody (MAb) AV37. Normal uninfected leukocytes and MD lymphoma cells were isolated directly ex vivo and examined by flow cytometry with MAb recognizing AV37, known leukocyte antigens, and MDV antigens pp38 and gB. CD28 mRNA was examined by PCR. Cell cycle distribution and in vitro survival were compared for each lymphoma cell population. We demonstrate for the first time that the antigen recognized by AV37 is expressed at very low levels by small minorities of uninfected leukocytes, whereas particular MD lymphoma cells uniquely express extremely high levels of the AV37 antigen; the AV37(hi) MD lymphoma cells fulfill the accepted criteria for neoplastic transformation in vivo (protection from cell death despite hyperproliferation, presence in all MD lymphomas, and not supportive of MDV production); the lymphoma environment is essential for AV37(+) MD lymphoma cell survival; pp38 is an antigen expressed during MDV-productive infection and is not expressed by neoplastically transformed cells in vivo; AV37(+) MD lymphoma cells have the putative immune evasion mechanism of CD28 down-regulation; AV37(hi) peripheral blood leukocytes appear early after MDV infection in both MD-resistant and -susceptible chickens; and analysis of TCR variable beta chain gene family expression suggests that MD lymphomas have polyclonal origins. Identification of the neoplastically transformed cells in MD facilitates a detailed understanding of MD pathogenesis and also improves the utility of MD as a general model for herpesvirus oncology.