J A Golden

University of California, San Francisco, San Francisco, California, United States

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Publications (149)988.11 Total impact

  • 09/2014; 2(3). DOI:10.1177/2324709614546866
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    ABSTRACT: Rationale:Obesity and underweight are contraindications to lung transplantation based on their associations with mortality in studies performed prior to implementation of the Lung Allocation Score (LAS)-based organ allocation system in the United States. Objectives:To determine the associations of the body mass index(BMI) and plasma leptin levels with survival after lung transplantation. Methods:We used multivariable-adjusted regression models to examine associations between (1) BMI and 1-year mortality in 9,073 adults who underwent lung transplantation in the United States between May 2005 and June 2011, and (2) plasma leptin and mortality in 599 Lung Transplant Outcomes Group study participants. We measured body fat and skeletal muscle mass using whole-body dual x-ray absorptiometry in 142 adult lung transplant candidates. Measurements and Main Results: Adjusted mortality rates were similar among normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9) and Class I obese (BMI 30-34.9) transplant recipients. Underweight (BMI<18.5) was associated with a 35% increased rate of death (95%CI 10-66%). Class II-III obesity (BMI≥35kg/m2) was associated with a nearly 2-fold increase in mortality (HR 1.9, 95%CI 1.3-2.8). Higher leptin levels were associated with increased mortality after transplant surgery performed without cardiopulmonary bypass (p for interaction=0.03). A BMI≥30 kg/m2 was 26% sensitive and 97% specific for total body fat-defined obesity. Conclusions: A BMI of 30.0-34.9kg/m2 is not associated with 1-year mortality after lung transplantation in the LAS era, perhaps due to its low sensitivity for obesity. The association between leptin and mortality suggests the need to validate alternative methods to measure obesity in candidates for lung transplantation. A BMI ≥30kg/m2 may no longer contraindicate lung transplantation.
    American Journal of Respiratory and Critical Care Medicine 09/2014; 190(9). DOI:10.1164/rccm.201405-0973OC · 11.04 Impact Factor
  • 05/2014; 2(5):e5. DOI:10.1016/S2213-2600(14)70075-X
  • The Journal of Heart and Lung Transplantation 04/2014; 33(4):S300. DOI:10.1016/j.healun.2014.01.805 · 5.61 Impact Factor
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    ABSTRACT: Late Breaking AbstractsSESSION TYPE: Slide PresentationPRESENTED ON: Saturday, March 22, 2014 at 09:00 AM - 10:00 AMPURPOSE: Human immunodeficiency virus seropositivity (HIV+) has been considered a contraindication to lung transplantation (LT) primarily due to potential risks of iatrogenic immunosuppression. With the recent passage of the HIV Organ Policy Equity (HOPE) Act on November 21, 2013, the donation of HIV+ organs for transplant in HIV+ recipients is now legal in the USA. As a result there may be an increase in donors for HIV+ recipients. However, there remains only one fully published case report of LT in an HIV+ patient, limiting the evidence base with which to guide medical decision making. We report 3 HIV+ patients at two different medical centers who underwent LT. Based on the experience of two centers, we compiled data for a case series of three HIV+ patients who underwent LT. Data was abtracted from medical records from the lung transplant programs at the University of California, San Francisco and Houston Methodist Hospital. We reviewed charts to investigate: 1.) Does LT affect the course of HIV infection? 2.) Do LT recipients demonstrate an increased risk for HIV-related opportunistic infections or malignancies? 3.) Can drug-drug interactions between immunosuppressive and antiretroviral medications be easily managed? 4.) Are HIV+ LT recipients at higher risk for acute rejection, similar to HIV+ liver and kidney transplant recipients? Patient 1, transplanted for HIV-associated pulmonary arterial hypertension, experienced recalcitrant acute rejection and the rapid development of bronchiolitis obliterans syndrome. Patients 2 and 3, transplanted for idiopathic pulmonary fibrosis, experienced mild acute rejection but remain free from chronic rejection at 3.5 and 1.5 years after transplant, respectively. We observed no instances of HIV-associated opportunistic infections or malignancies in any of the three cases. Drug-drug interactions, although challenging, were manageable. Unexpectedly, all 3 patients showed signs of pulmonary arterial vasculopathy on explant; all three also had at least one episode of acute cellular rejection in the first year after LT. In Patients 2 and 3, rejection was easily managed and did not recur, whereas Patient 1 required a lymphocyte-depleting agent. Based on this limited experience, LT appears feasible in the setting of HIV, although acute rejection appears to be common. As seen in other solid organ transplant populations, LT in the setting of HIV may be associated with good outcomes, but there may be increased rates of acute rejection. The following authors have nothing to disclose: Ryan Kern, Harish Seethamraju, Paul Blanc, Neeraj Sinha, Matthias Loebe, Jeffrey Golden, Jasleen Kukreja, Scott Scheinin, Steve Hays, Kleinhenz Mary Ellen, Leard Lorri, Charles Hoopes, Jonathan SingerNo Product/Research Disclosure Information.
    Chest 03/2014; 145(3 Suppl):642A. DOI:10.1378/chest.1923375 · 7.13 Impact Factor
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    ABSTRACT: Supplementary methods to identify acute rejection and to distinguish rejection from infection may improve clinical outcomes for lung allograft recipients. We hypothesized that distinct bronchoalveolar lavage (BAL) cell profiles are associated with rejection and infection. We retrospectively compared 2939 BAL cell counts and immunophenotypes against concomitantly obtained transbronchial biopsies and microbiologic studies. We randomly assigned 317 subjects to a derivation or validation cohort. BAL samples were classified into four groups: infection, rejection grade ≥A1, both or neither. We employed generalized estimating equation and survival modeling to identify clinical predictors of rejection and infection. We found that CD25(+) and natural killer cell percentages identified a twofold increased odds of rejection compared to either the infection or the neither infection nor rejection groups. Also, monocytes, lymphocytes and eosinophil percentages were independently associated with rejection. A four-predictor scoring system had high negative predictive value (96-98%) for grade ≥A2 rejection, predicted future rejection in the validation cohort and predicted increased risk of bronchiolitis obliterans syndrome in otherwise benign samples. In conclusion, BAL cell immunophenotyping discriminates between infection and acute rejection and predicts future outcomes in lung transplant recipients. Although it cannot replace histopathology, immunophenotyping may be a clinically useful adjunct.
    American Journal of Transplantation 02/2014; DOI:10.1111/ajt.12630 · 6.19 Impact Factor
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    ABSTRACT: Lung transplant (LT) aims to extend survival and improve patient-centred outcomes (PCOs) by reducing disability and improving health-related quality of life (HRQL). Few PCO instruments have been validated in LT populations. We aimed to develop and validate a shortened version of the valued life activities (VLA) disability scale specific to LT. We used data from 140 subjects participating in an ongoing cohort study of LT. Subjects completed a survey battery, including VLA items, and physical assessments before LT. To develop a shortened LT-specific VLA (LT-VLA), we iteratively deleted items from a longer 32-item VLA battery, retaining the instrument's conceptual framework, scoring and performance characteristics. We evaluated LT-VLA validity by testing correlations with a HRQL measure (Short Form-12 Physical Function (SF-12 PF) subscale), forced vital capacity % (FVC%) predicted and 6 minute walk distance (6MWD). Responsiveness was evaluated in 84 subjects who completed assessments before and after LT. The 15-item LT-VLA scoring closely matched the longer VLA (correlations ≥0.96) and had excellent internal consistency (Cronbach's α 0.92). The LT-VLA required only 3 min or less to administer. The LT-VLA, measured as mean difficulty in performing each of the 15 activities queried, correlated with FVC% predicted (r=-0.30), 6MWD (r=-0.38) and SF-12 PF (r=-0.47) (all p<0.01). The LT-VLA mean difficulty was responsive to change from before to after LT (63% improvement; effect size=1.60). The LT-VLA is a short, easy to administer, valid and responsive disease-specific PCO instrument that may be useful in clinical and research applications for lung transplantation.
    Thorax 12/2013; DOI:10.1136/thoraxjnl-2013-204557 · 8.56 Impact Factor
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    ABSTRACT: Interstitial Lung Disease Cases ISESSION TYPE: Affiliate Case Report SlidePRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AMINTRODUCTION: Lung transplantation (LT) can be a lifesaving therapy for patients suffering from advanced lung disease due to hypersensitivity pneumonitis (HP). Published data are limited addressing recipient outcomes post-lung transplantation (LT) in HP. In particular, although recurrence of primary disease in the recipient allograft has been described for a number of conditions1 this phenomenon is not well documented in HP. We present a case of recurrent HP in a LT recipient.CASE PRESENTATION: Bilateral LT was performed in 2009 on a 49-year-old woman with advanced fibrotic HP. She initially presented in 1991 complaining of cough and dyspnea, with imaging suggestive of HP and confirmation by surgical biopsy. She had no clear indoor exposure history; the possibility of ambient environmental exposures was considered. Serologic testing demonstrated precipitating antibodies to both bird proteins and fungi. Despite immunosuppressive therapy and potential ambient antigen avoidance by relocating, she had a slow decline in respiratory function and underwent bilateral LT in 2009. She did well for the first 2 years post-LT. By 3 years, however, she developed worsening cough and exertional dyspnea. She had an immune suppressive regimen of prednisone 10 mg daily, mycophenolate mofetil 500 mg bid, and tacrolimus (trough 8-10 ng/mL). CT scanning revealed air trapping; lung function testing showed a declining FEV1. Transbronchial lung biopsies (TBBX) showed non-necrotizing granulomas (culture negative). Repeat TBBXs at 1 month were unchanged. Bronchial alveolar lavage (BAL) showed 29% lymphocytes. The patient noted that pigeons were roosting outside her windows at her new home. Prednisone was increased, the patient again changed residence and her FEV1 stabilized. Subsequent TBBXs show no granulomas; the BAL lymphocytosis has resolved. She now has grade 3/3 bronchiolitis obliterans syndrome. It is unclear whether the recurrent HP contributed to this outcome.DISCUSSION: HP represents an immune reaction to inhaled organic antigens. Despite standard post-LT immunosuppressive regimens, intercurrent or ongoing exposure to an offending antigen may lead to recurrent disease in the allograft. Suggestive findings can include BAL lymphocytosis and non-necrotizing granulomas in the absence of infection.CONCLUSIONS: Our case highlights the importance of antigen recognition and aggressive avoidance or abatement post-LT for HP. This can be particularly problem-ridden if the exposure is poorly characterized. A detailed exposure history not only pre-LT but also at post-LT visits is imperative for this patient population.Reference #1: Collins, J. et al. Frequency and CT findings of recurrent disease after lung transplantation. Radiology 219, 503-509 (2001).DISCLOSURE: The following authors have nothing to disclose: Ryan Kern, Jonathan Singer, Kirk Jones, Kukreja Jasleen, Jeffrey Golden, Steven Hays, Leard Lorriana, Paul BlancNo Product/Research Disclosure Information.
    Chest 10/2013; 144(4_MeetingAbstracts):432A. DOI:10.1378/chest.1701931 · 7.13 Impact Factor
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    ABSTRACT: BACKGROUND: Lung disease is the leading cause of death in systemic sclerosis (SSc). The diagnosis of SSc-related lung disease (SSc-LD) is often a contraindication to lung transplantation (LT) due to concerns that extrapulmonary involvement will yield worse outcomes. We sought to evaluate posttransplantation outcomes in persons with SSc-LD with esophageal involvement compared with persons with nonconnective tissue disease-related interstitial lung disease (nCTD-ILD). METHODS: From 1998 to 2012, persons undergoing LT for SSc-LD were age and gender matched in a 2:1 fashion to controls undergoing LT for nCTD-ILD. Esophageal function was assessed by pH testing and manometry. We defined esophageal dysfunction as the presence of a DeMeester score >14 or dysmotility more severe than "mild nonspecific disorder". The primary outcome was posttransplantation survival. Secondary outcomes included freedom from bronchiolitis obliterans syndrome (fBOS) and rates of acute rejection. Survival and fBOS were estimated with Kaplan-Meier methods. Acute rejection was compared with Student's t test. RESULTS: Survival was similar in 23 persons with SSc-LD and 46 controls who underwent LT (P=0.47). For the SSc-LD group, 1- and 5-year survival was 83% and 76% compared with 91% and 64% in the nCTD-ILD group, respectively. There were no differences in fBOS (P=0.83). Rates of acute rejection were less in SSc-ILD (P=0.05). Esophageal dysfunction was not associated with worse outcomes (P>0.55). CONCLUSIONS: Persons with SSc-LD appear to have similar survival and fBOS as persons transplanted for nCTD-ILD. The risk of acute rejection after transplantation may be reduced in persons with SSc-LD. Esophageal involvement does not appear to impact outcomes.
    Transplantation 04/2013; 95(7):975-980. DOI:10.1097/TP.0b013e3182845f23 · 3.78 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2013; 32(4):S59. DOI:10.1016/j.healun.2013.01.958 · 5.61 Impact Factor
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    ABSTRACT: DSAs prior to lung transplantation (LT) have been associated with adverse outcomes, but the implications of weak DSAs detected by sensitive microarrays remain poorly understood. We examined the incidence of DSAs before transplant and immunodominant DSA (iDSA) profiles after LT.Methods and MaterialsLT recipients (n=66) from a single center with single antigen testing (LABScreen®) before LT, within the first 45 days after LT and at least one subsequent time point were studied. Patients were excluded if they received any desensitization or antibody directed therapy. We defined the iDSA as the DSA with the highest mean fluorescence intensity (MFI). We used iDSA levels pre-LT to categorize subjects into 3 groups: No DSA, iDSA MFI of 500-1000 MFI, and iDSA MFI >1000.ResultsPre-LT, no DSAs were detected in 36 (55%) patients. Of these, 6 (17%) developed iDSA >1000 MFI post-LT (range 1685-6071 MFI). These iDSAs were initially detected 12-32 days after transplant, against HLA Class II, and accompanied by additional DSAs. At the last time point (93-560 days post-LT), the DSAs were below peak levels or were eliminated. Pre-LT iDSAs with MFI 500-1000 were observed in 12 (18%) of patients. Of these, 5 (42%) developed iDSA >1000 MFI post-LT. In 2 of these 5, the post-LT iDSA specificity was different from the pre-LT iDSA. At the last time point, DSA levels were declining or eliminated in 3 recipients. Pre-LT iDSA >1000 MFI were detected in 18 (27%) recipients (range 1023-5246 MFI; 11 Class II, 7 Class I). Post-LT, 4 had no DSA >1000 MFI. The maximum iDSA level after LT was 9659 MFI. In 13 (72%) of these recipients, iDSA specificity pre- and post-LT was identical. Of the 18 recipients, 9 (50%) had all DSA <500 MFI at the last serum, 8 (44%) had DSA declining from peak levels, and 1 was stable.Conclusions Weak DSAs are observed in nearly half of patients pre-LT. While variable, the majority of DSAs decline post-LT. Additional study is needed to determine the impact of weak pre-LT DSAs and declining post-LT DSAs on clinical outcomes.
    The Journal of Heart and Lung Transplantation 04/2013; 32(4):S171. DOI:10.1016/j.healun.2013.01.407 · 5.61 Impact Factor
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    ABSTRACT: Despite the adoption of antifungal prophylaxis, fungal infections remain a significant concern in lung transplant recipients. Indeed, some concern exists that such prophylaxis may increase the risk of infection with drug-resistant fungal organisms. Here, we describe a case of disseminated Scedosporium prolificans infection, presenting as pericarditis, which developed in a lung transplant patient receiving prophylactic voriconazole for 8 months. The epidemiology and clinical presentation of S. prolificans infections are reviewed, and controversies surrounding antifungal prophylaxis and the development of resistant infections are discussed.
    Transplant Infectious Disease 02/2013; DOI:10.1111/tid.12056 · 1.98 Impact Factor
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    ABSTRACT: BACKGROUND: Community acquired respiratory virus (CARV) infections in lung transplant recipients (LTR) have been associated with adverse outcomes, including acute rejection (AR) and decline in allograft function, in some but not in all studies. METHODS: Spirometry and transbronchial biopsy results of LTR diagnosed with CARV infection over a two-yr period were extracted from clinical records. Primary outcomes, studied at 1-2.5 months postinfection, were as follows: (i) incidence of biopsy-proven AR (grade >A0) and (ii) allograft function, defined by forced expiratory volume in one s (FEV(1) ). A reference group of biopsies (n = 526) collected during the study period established the baseline incidence of AR. Rhinovirus (RV) and non-rhinovirus (non-RV) infections were analyzed as subgroups. RESULTS: Eighty-seven cases of CARV infection were identified in 59 subjects. Incidences of AR were similar in the post-CARV and reference groups and did not differ significantly after RV vs. non-RV infection. Allograft function declined significantly after non-RV infection, but not after RV infection. CONCLUSIONS: In LTR, CARV infections other than RV are associated with allograft dysfunction at 1-2.5 months after infection. However, CARVs do not appear associated with AR at this time point. The impact of specific CARVs on lung allografts, including the development of chronic allograft rejection, merits further study.
    Clinical Transplantation 12/2012; 27(1). DOI:10.1111/ctr.12054 · 1.49 Impact Factor
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    ABSTRACT: RATIONALE: Lung transplantation offers great promise for otherwise terminal lung diseases, but the development of bronchiolitis obliterans syndrome (BOS) continues to limit survival. While acute rejection and lymphocytic bronchiolitis have been identified as risk factors for the development of BOS, it is unclear whether large-airway lymphocytic inflammation conveys the same risk. OBJECTIVES: We evaluated lymphocytic bronchitis on endobronchial biopsies as a risk factor for BOS and mortality. METHODS: Endobronchial biopsies were collected and graded during surveillance following lung transplantation. We assessed samples with negative cultures collected in the first 90 days from 298 subjects and compared large-airway lymphocytic bronchitis assessed by a 0 to 2 "E-score" and with standard A and BR pathology scores for acute rejection and small-airway lymphocytic bronchiolitis, respectively. RESULTS: We found surprisingly little association between large- and small-airway lymphocytic inflammation scores from a given bronchoscopy. Endobronchial lymphocytic bronchitis was more prevalent in subjects in BOS stage 0p and BOS stages 1-3 at the time of biopsy. Within 90 days after transplantation, increasing maximum E-score was associated with greater risk of BOS (adjusted hazards ratio 1.76, 95% CI 1.11-2.78, P = 0.02) and in this analysis 90-day maximum E-scores were the only score type predictive of BOS (P < 0.01). CONCLUSIONS: These results would support a multicenter study to evaluate endoscopic biopsies for the identification of patients at increased risk for BOS. The association of endobronchial lymphocytic inflammation and BOS may have mechanistic implications.
    American Journal of Respiratory and Critical Care Medicine 12/2012; DOI:10.1164/rccm.201206-1025OC · 11.04 Impact Factor
  • American Thoracic Society 2012 International Conference, May 18-23, 2012 • San Francisco, California; 05/2012
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    ABSTRACT: Lung transplant recipients (LTR) have an increased risk of cutaneous squamous cell carcinoma (SCC) due to immunosuppressive therapy. Voriconazole, which is associated with phototoxic side effects in some patients, may be an additional risk factor for SCC in this population. To test whether voriconazole is a risk factor for developing SCC in LTR, we evaluated cumulative exposure to voriconazole in 327 adults who underwent lung transplantation at one center between 1991 and 2010. Voriconazole exposure was assessed as a time-varying covariate. We used survival analysis methods to assess the risk of developing SCC over time. Exposure to voriconazole was associated with a 2.6-fold increased risk for SCC. This phenomenon was dose-dependent: the risk for SCC increased by 5.6% with each 60-day exposure at a standard dose of 200 mg twice daily. At 5 years after transplant, voriconazole conferred an absolute risk increase for SCC of 28%. These results suggest that caution should be taken when using voriconazole in LTR because this drug increases the already high risk for SCC in this population.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 04/2012; 31(7):694-9. DOI:10.1016/j.healun.2012.02.033 · 5.61 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2012; 31(4):S238. DOI:10.1016/j.healun.2012.01.707 · 5.61 Impact Factor
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    ABSTRACT: The relationship of mast cells to the pathogenesis of lung fibrosis remains undefined despite recognition of their presence in the lungs of patients with pulmonary fibrosis. This study was performed to characterize the relationship of mast cells to fibrotic lung diseases. Lung tissues from patients with idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis (HP), systemic sclerosis (SSc)-related interstitial lung disease (ILD) and normal individuals were subjected to chymase immunostaining and the mast cell density quantified. Eosinophils were quantified by immunostaining for eosinophil peroxidase. Changes in lung function were correlated with mast cell density. Lung tissue obtained from IPF patients had a higher density of chymase-immunoreactive mast cells than that from patients with HP, SSc-related ILD or normal lungs. IPF lung tissue had a higher density of eosinophils than normal lung. There was no correlation between mast cell density and eosinophil density in IPF lung. IPF patients with high mast cell density had a slower rate of decline in forced vital capacity (FVC) than IPF patients with low mast cell density. Mast cell density in IPF lungs is higher than in other fibrotic lung diseases and normal lungs. Increased mast cell density in IPF may predict slower disease progression.
    Histopathology 03/2012; 61(1):98-106. DOI:10.1111/j.1365-2559.2012.04197.x · 3.30 Impact Factor
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    ABSTRACT: The optimal method of both predicting and preventing cytomegalovirus (CMV) disease in lung transplant recipients remains unclear. In particular, the most appropriate duration of CMV prophylaxis post transplant is unresolved. We report herein our experience with a planned indefinite regimen of valganciclovir prophylaxis and monitoring of quantitative CMV load in bronchoalveolar lavage (BAL) fluid. We performed a single-center observational study with both prospective and retrospective components. The included patients (n = 128) received a planned regimen of indefinite valganciclovir prophylaxis post transplant, regardless of donor (D)/recipient (R) CMV serostatus. Real-time polymerase chain reaction assay for detection of CMV in BAL was prospectively performed over a 1-year period. Clinical data were reviewed retrospectively; median follow-up was 24.8 months (range 1-93 months). Sixty-five patients (50.6%) discontinued valganciclovir prophylaxis, either temporarily or permanently, with a primary cause of mild leukopenia. Six cases of CMV disease were identified (4.7%), with no significant difference between those who were on continuous prophylaxis or not (4.6% vs. 4.9%; P = non-significant [ns]). However, those who discontinued prophylaxis showed an increased incidence of laboratory-detected CMV infection (40.7% vs. 12.7%; P = 0.001). High-risk D+/R- patients did not demonstrate a significantly increased incidence of CMV disease (8.1% vs. 3.3% other serotypes; P = ns). Three patients (2.3%) developed valganciclovir-resistant CMV disease. Molecular detection of CMV in BAL fluid was significantly more sensitive than shell vial culture. However, BAL CMV viral load was not predictive of subsequent disease development. Extended valganciclovir prophylaxis for all lung transplant recipients led to a low incidence of CMV disease and resistance. In such low-incidence populations, routine quantitation of CMV in BAL did not confer significant clinical benefit over non-quantitative methods in prediction of CMV disease onset.
    Transplant Infectious Disease 03/2012; 14(3):248-58. DOI:10.1111/j.1399-3062.2012.00723.x · 1.98 Impact Factor
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    ABSTRACT: Cutaneous squamous cell carcinoma (cSCC) is the most common malignancy after solid organ transplantation, with an increased risk of recurrence and metastasis over the general population. The newly updated 7th edition American Joint Committee on Cancer (AJCC) staging system for cSCC is based on consensus expert opinion and requires validation in large cohort studies and in specific patient subpopulations. Our objective was to evaluate the risk of cSCC recurrence in a high-risk population of heart and lung transplant recipients, based on the 7th edition AJCC staging system. We performed a 10-year retrospective cohort study of all primary cSCC diagnosed in heart and lung transplant recipients at a tertiary care academic dermatology center. The cumulative incidence of local recurrence was 4% for cSCC in situ and 19% for stage I cSCC at 5 years, and 54% for stage II cSCC at 3 years. Stage II tumors had a 10-fold greater risk of recurrence than stage I, and a 43-fold greater risk of recurrence than in situ tumors. This study is limited to a specific patient subgroup at a tertiary care center, and may not be generalizable to all populations. Heart and lung transplant recipients are at high risk for local recurrence of cSCC. These data substantiate the prognostic accuracy of the newly updated 7th edition AJCC staging system for stage 0, I, and II cSCC in this population and demonstrate the aggressive behavior of this cancer in immunosuppressed patients.
    Journal of the American Academy of Dermatology 01/2012; 67(5):829-35. DOI:10.1016/j.jaad.2012.01.010 · 5.00 Impact Factor

Publication Stats

3k Citations
988.11 Total Impact Points


  • 1985–2014
    • University of California, San Francisco
      • • Division of Hospital Medicine
      • • Department of Medicine
      • • Department of Surgery
      • • Department of Epidemiology and Biostatistics
      San Francisco, California, United States
  • 2010
    • CSU Mentor
      Long Beach, California, United States
  • 2006
    • University of California, Los Angeles
      Los Angeles, California, United States
  • 1991
    • Howard Hughes Medical Institute
      Ashburn, Virginia, United States