Skin Cancer Following Kidney Transplantation: A Single-Center Experience
Department of Transplantology and General Surgery, District Hospital in Poznan, and Poznan University of Medical Sciences, Poznan, Poland.Transplantation Proceedings (Impact Factor: 0.98). 12/2011; 43(10):3760-1. DOI: 10.1016/j.transproceed.2011.08.080
One of the major problems associated with prolonged immunosuppression is a high occurrence of skin malignancies among kidney recipients. Studies have shown that nonmelanoma skin cancer is the most frequently occurring tumor after organ transplantation. The aim of this study was to determine the incidence of and identify possible risk factors for skin malignancies among a population of kidney recipients. This retrospective, single-center cohort comprised 1672 patients transplanted from 1994 to 2011. Only patients with a confirmed diagnosis of skin cancer were selected for medical records review. Among 836 kidney transplant recipients remaining under our care since 1994, skin malignancies were diagnosed in 16 patients (1.9%). The histological diagnoses included squamous cell carcinoma (n=8; 50.0%); basal cell carcinoma (n=6; 37.5%) or malignant melanoma (n=2; 12.5%). The slightly lower incidence of skin malignancies noted in our study compared with other reports might result from differences in the length of follow-up. Some patients diagnosed with skin cancer were treated in local dermatology clinics. Also, a lower exposure to the sun characteristic for the latitude and differences in immunosuppressive therapies could be partially responsible for the lower skin cancer incidence. We also did not observe any association between other reported risk factors, such as age, human leukocyte antigen mismatch, duration of pretransplant hemodialysis, particular immunosuppressive therapies and the skin cancer occurrence among our kidney recipients.
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ABSTRACT: The management of non-melanoma skin cancers (NMSCs) in solid organ transplant recipients (OTRs) presents a variety of clinical challenges for physicians. OTRs are at a 65-fold increased risk for developing cutaneous squamous cell carcinomas (SCC), the most common NMSC that develops after transplantation. Risk factors contributing to the development of NMSCs in OTRs include a past medical history of any previous skin cancer, a personal history of significant sun exposure and a fair skin complexion or phototype. Further, greater immunosuppressive medication levels lead to an increased risk of NMSCs. Among immunosuppressants, specific older agents such as azathioprine and cyclosporine may increase the risk of developing NMSCs in contrast to newer agents such as sirolimus. Early skin biopsy and treatment of premalignant and malignant lesions are essential for treating these patients successfully. In this regard, the concept of field cancerization has been instructive in broadening treatments to include entire affected areas rather than individual lesions given that the areas with significant ultraviolet irradiation will continue to develop numerous individual precancerous and cancerous lesions. Field therapy with photodynamic therapy or topical 5-fluorouracil, imiquimod or diclofenac is often used in OTRs according to individual patient tolerability. Prompt excision or Mohs micrographic surgery is the standard of care of primary, uncomplicated squamous cell and basal cell carcinomas. For patients with in-transit or metastatic squamous cell carcinomas, adjuvant radiation, chemotherapy, and staging by sentinel lymph node dissection may be employed. For patients who develop numerous SCC per year, chemoprophylaxis can be effective in limiting the burden of disease. In consultation with the multidisciplinary transplant team, the immunosuppressive regimen can be revised to lower overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential in OTRs. The greatest impact may be made by the prevention of NMSCs through simple, but rigorous, patient education on the benefits of UV protection, periodic self-skin examinations, and regular follow-ups. Accordingly, vitamin D and calcium supplementation should also be incorporated in transplant recipients. Management of OTRs requires patient education, frequent motivation for vigilance, regular follow-up, and interdisciplinary collaboration between transplant surgeons, nephrologists, hepatologists, cardiologists, transplant nurses, dermatologists, oncologists, pharmacists, and other relevant physicians ideally orchestrated by the essential transplant coordinators.
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ABSTRACT: Vascularized composite allotransplantation may now be considered a viable treatment option in patients with complex craniofacial and limb defects. However, the field is still in its infancy, and challenges continue to exist. These challenges, most notably the adverse effects of lifelong immunosuppression, must be weighed against the benefits of the procedure. Improvements in this risk-benefit ratio can be achieved by achieving tolerance and preventing rejection. Five decades after Dr. Joseph E. Murray introduced the field of transplantation to the world, we now have a better understanding of the immunologic factors that may contribute to rejection and inhibit tolerance. In this article, we review emerging evidence that suggests that "danger signals" associated with ischemia-reperfusion injury contribute to innate immune activation, promoting rejection, and inhibiting tolerance. Based on this understanding, we also describe several strategies that may ameliorate the damaging effects of ischemia-reperfusion and the clinical implications of ischemia-reperfusion on the vascularized composite tissue allotransplantation outcome.
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ABSTRACT: Using Taiwan's National Health Insurance Research Database, this large population-based study was conducted to explore the incidences and risk factors of post-transplant malignancy in Asian renal transplant recipients. A total of 642 patients who firstly underwent renal transplant between January 1, 2000 and December 31, 2008 were identified from a 2 million cohort. The primary endpoint was a subsequent hospitalization with a primary diagnosis of malignancy (ICD-9-CM code: 140.xx-239.xx) after renal transplantation. All patients were followed until the occurrence of endpoints or the end of the study (December 31, 2010), whichever came first. Adjusted risks of post-transplant cancer were analyzed using Cox proportional hazards regression model. All models were adjusted for baseline characteristics, comorbid diseases, transplant year, and exposure to immunosuppressive agents. Among 642 renal transplant patients, 54 cancers (8.4 %) were identified. The median time between transplant and cancer diagnosis was 46.2 (range 8.5-107.4) months. Cancers of kidney and other unspecified urinary organs was the most common cancer sites, accounted for 18.5 % of the malignancies diagnosed. The next most common cancer sites were trachea, bronchus, and lung (14.8 %), bladder (13.0 %), liver and intrahepatic bile ducts (11.1 %), colon (5.6 %), and prostate (5.6 %). Age at transplantation was a statistically significant risk factor of post-transplant cancer in our study. Increased risks of post-transplant cancer were observed in patients who received immunosuppression agents (cyclosporine (HR 1.26, 95 % CI 0.58-2.77, p = 0.5603), tacrolimus (HR 1.99, 95 % CI 0.66-6.00, p = 0.2197), and mycophenolate (HR 1.00, 95 % CI 0.40-2.45, p = 0.9874)) although the estimates were not statistically significant. Our population-based cohort study offers additional insight into post-transplant cancers in Asian population. Further studies are warranted to assess the association between specific immunosuppression agents and post-transplant cancers.
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