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Abstract
Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, 14080, Mexico.,Nephrology Department, American British Cowdray Medical Center, Mexico City, 05300, Mexico
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, MA, 02111, USA
| | - Jean M Francis
- Renal Section, Boston University Medical Center, Boston, MA, 02118, USA
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Laaksonen MA, Webster AC, McCaughan GW, Keogh AM, Grulich AE, Vajdic CM. Longitudinal immunosuppression data can minimize misclassification bias in solid organ transplantation cohorts. Clin Transplant 2018; 33:e13470. [PMID: 30586213 DOI: 10.1111/ctr.13470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 11/27/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Most cohort studies investigating the effect of immunosuppression on transplant outcomes use drugs at first hospital discharge. We evaluated the extent of drug exposure misclassification and its impact on outcome prediction. METHODS We retrospectively collected longitudinal immunosuppression data, at discharge and at 1, 5, 10, and 15 years after transplantation, and outcomes for solid organ transplant recipients 1984-2006 (n = 3133). We compared the risk of death from exposure to individual immunosuppressive drugs (cyclosporine, tacrolimus, azathioprine, and mycophenolate) and dual therapies, as defined by discharge only vs longitudinal immunosuppression data, using adjusted Cox proportional hazards models. RESULTS During a median follow-up of 5.2 years, immunosuppressive drugs were altered for 947 (30%) recipients and 955 recipients died. Longitudinal receipt of cyclosporine and azathioprine were associated with an increased risk (HR 1.41, 95% CI 1.07-1.89, and HR 1.34, 95% CI 1.00-1.80), and mycophenolate with a reduced risk (HR 0.35, 0.16-0.78), of death. Recipients on mycophenolate and tacrolimus dual therapy had a lower risk of death compared to those on azathioprine and cyclosporine dual therapy (HR 0.30, 0.10-0.93). The increased risk of death associated with the receipt of cyclosporine or azathioprine was not shown in the analyses based on drugs allocated at discharge, and all of the associations between immunosuppressive regimens and death were strengthened in the analyses based on longitudinal immunosuppression data. CONCLUSIONS Cohort findings based on immunosuppressive drugs allocated at discharge should be interpreted with caution due to potential exposure misclassification. The use of granular, longitudinal data on immunosuppressive regimens could improve prediction.
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Affiliation(s)
- Maarit A Laaksonen
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Angela C Webster
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Geoff W McCaughan
- The Centenary Research Institute, Australian National Liver Transplant Unit Royal Prince Alfred Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Anne M Keogh
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew E Grulich
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Claire M Vajdic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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53
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Abstract
Posttransplant malignancy is a leading cause of death after solid organ transplantation (SOT). Recipients of SOT are at significantly higher risk of multiple cancers compared with the general population, most notably nonmelanoma skin cancer and posttransplant lymphoproliferative disorders. Risk factors for posttransplant malignancy include history of malignancy, immunosuppression, oncogenic viral infections, sun exposure, and disease-specific associations. Early detection and treatment of malignancies can improve survival.
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54
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Iatrogénie médicamenteuse et cancers de la peau. ACTUALITES PHARMACEUTIQUES 2018. [DOI: 10.1016/j.actpha.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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55
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Abstract
Immunosuppressed patients are at significantly increased risk of developing cutaneous malignancies. These malignancies are often more aggressive compared with the general population and require multidisciplinary care. This article highlights the incidence and risk factors of cutaneous malignancies in this cohort. The treatment and prevention strategies are discussed. There continues to be a need for evidence-driven guidelines regarding the management of skin cancers in these patients.
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Affiliation(s)
- Lindsey Collins
- Department of Dermatology, The University of Oklahoma Health Sciences Center, 619 Northeast 13th Street, Oklahoma City, OK 73104, USA.
| | - Andrew Quinn
- Department of Dermatology, The University of Oklahoma Health Sciences Center, 619 Northeast 13th Street, Oklahoma City, OK 73104, USA
| | - Thomas Stasko
- Department of Dermatology, The University of Oklahoma Health Sciences Center, 619 Northeast 13th Street, Oklahoma City, OK 73104, USA
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57
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Voriconazole exposure and risk of cutaneous squamous cell carcinoma among lung or hematopoietic cell transplant patients: A systematic review and meta-analysis. J Am Acad Dermatol 2018; 80:500-507.e10. [PMID: 30130598 DOI: 10.1016/j.jaad.2018.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/26/2018] [Accepted: 08/11/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Current evidence about the association between voriconazole and risk of cutaneous squamous cell carcinoma (SCC) remains inconsistent. OBJECTIVE To assess the association between voriconazole use and risk of SCC. METHODS We systematically searched PubMed and Embase and performed a random effects model meta-analysis to calculate the pooled relative risk (RR) with a 95% confidence interval (CI). RESULTS Of the 8 studies involving a total of 3710 individuals with a lung transplant or hematopoietic cell transplant that were included in the qualitative analysis, 5 were included in the meta-analysis. Use of voriconazole was significantly associated with increased risk of SCC (RR, 1.86; 95% CI, 1.36-2.55). The increased risk did not differ according to type of transplantation or adjustment for sun exposure. Longer duration of voriconazole use was found to be positively associated with risk of SCC (RR, 1.72; 95% CI, 1.09-2.72). Voriconazole use was not associated with increased risk of basal cell carcinoma (RR, 0.84; 95% CI, 0.41-1.71). LIMITATIONS There were some heterogeneities in the retrospective observational studies. CONCLUSIONS Our findings support an increased risk of SCC associated with voriconazole in individuals with a lung transplant or hematopoietic cell transplant. Routine dermatologic surveillance should be performed, especially among individuals at high risk of developing SCC.
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58
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Howard MD, Su JC, Chong AH. Skin Cancer Following Solid Organ Transplantation: A Review of Risk Factors and Models of Care. Am J Clin Dermatol 2018; 19:585-597. [PMID: 29691768 DOI: 10.1007/s40257-018-0355-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The number of solid organ transplants has been increasing annually worldwide. Advances in transplantation surgery and community awareness of organ donation have been key contributors. Combined with increased understanding of immunosuppression, there are a growing number of solid organ transplant recipients in the community as a result of improved long-term outcomes. There remains a high incidence of deaths worldwide post-transplant due to non-melanoma skin cancer (NMSC), which has greater morbidity and mortality in this population than in the general community. Many transplant candidates are not screened prior to organ transplantation and not followed up dermatologically after transplant. After a comprehensive review of the MEDLINE database, we present an update of literature on risk factors for melanoma and non-melanoma skin cancer development in transplant recipients. Medications used by transplant recipients, including immunosuppressants and antibiotics, are discussed along with their respective risks of skin cancer development. We conclude with evidence-based recommendations for models of care, including patient education and dermatological review of transplant recipients.
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59
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Azathioprine to mycophenolate mofetil transition and risk of squamous cell carcinoma after lung transplantation. J Heart Lung Transplant 2018; 37:853-859. [DOI: 10.1016/j.healun.2018.03.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/15/2018] [Accepted: 03/14/2018] [Indexed: 01/08/2023] Open
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60
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Peters FS, Peeters AMA, Mandaviya PR, van Meurs JBJ, Hofland LJ, van de Wetering J, Betjes MGH, Baan CC, Boer K. Differentially methylated regions in T cells identify kidney transplant patients at risk for de novo skin cancer. Clin Epigenetics 2018; 10:81. [PMID: 29946375 PMCID: PMC6006560 DOI: 10.1186/s13148-018-0519-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/11/2018] [Indexed: 01/08/2023] Open
Abstract
Background Cutaneous squamous cell carcinoma (cSCC) occurs 65–200 times more in immunosuppressed organ transplant patients than in the general population. T cells, which are targeted by the given immunosuppressive drugs, are involved in anti-tumor immune surveillance and are functionally regulated by DNA methylation. Prior to kidney transplantation, we aim to discover differentially methylated regions (DMRs) in T cells involved in de novo post-transplant cSCC development. Methods We matched 27 kidney transplant patients with a future de novo cSCC after transplantation to 27 kidney transplant patients without cSCC and studied genome-wide DNA methylation of T cells prior to transplantation. From 11 out of the 27 cSCC patients, the DNA methylation of T cells after transplantation was also examined to assess stability of the observed differences in DNA methylation. Raw methylation values obtained with the 450k array were confirmed with pyrosequencing. Results We found 16 DMRs between patients with a future cSCC and those who do not develop this complication after transplantation. The majority of the DMRs were located in regulatory genomic regions such as flanking bivalent transcription start sites and bivalent enhancer regions, and most of the DMRs contained CpG islands. Examples of genes annotated to the DMRs are ZNF577, coding for a zinc-finger protein, and FLOT1, coding for a protein involved in T cell migration. The longitudinal analysis revealed that DNA methylation of 9 DMRs changed significantly after transplantation. DNA methylation of 5 out of 16 DMRs was relatively stable, with a variation in beta-value lower than 0.05 for at least 50% of the CpG sites within that region. Conclusions This is the first study demonstrating that DNA methylation of T cells from patients with a future de novo post-transplant cSCC is different from patients without cSCC. These results were obtained before transplantation, a clinically relevant time point for cSCC risk assessment. Several DNA methylation profiles remained relatively stable after transplantation, concluding that these are minimally affected by the transplantation and possibly have a lasting effect on post-transplant cSCC development. Electronic supplementary material The online version of this article (10.1186/s13148-018-0519-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fleur S Peters
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annemiek M A Peeters
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pooja R Mandaviya
- 2Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joyce B J van Meurs
- 2Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Leo J Hofland
- 3Endocrinology, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jacqueline van de Wetering
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Michiel G H Betjes
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Carla C Baan
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Karin Boer
- 1Neprology and Transplantation, Department of Internal Medicine, Rotterdam Transplant Group, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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61
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Raymond AK. Risk factors revealed: keratinocyte carcinoma following transplant. Br J Dermatol 2017; 177:1152-1153. [PMID: 29192992 DOI: 10.1111/bjd.15975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A K Raymond
- Department of Dermatology, University of California, San Francisco, CA, U.S.A
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62
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Rizvi SMH, Aagnes B, Holdaas H, Gude E, Boberg KM, Bjørtuft Ø, Helsing P, Leivestad T, Møller B, Gjersvik P. Long-term Change in the Risk of Skin Cancer After Organ Transplantation: A Population-Based Nationwide Cohort Study. JAMA Dermatol 2017; 153:1270-1277. [PMID: 29049612 PMCID: PMC5817449 DOI: 10.1001/jamadermatol.2017.2984] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/20/2017] [Indexed: 12/19/2022]
Abstract
Importance The high risk of skin cancer after organ transplantation is a major clinical challenge and well documented, but reports on temporal trends in the risk of posttransplant cutaneous squamous cell carcinoma (SCC) are few and appear contradictory. Objective To study temporal trends for the risk of skin cancer, particularly SCC, after organ transplantation. Design, Setting, and Participants Population-based, nationwide, prospective cohort study of 8026 patients receiving a kidney, heart, lung, or liver transplant in Norway from 1968 through 2012 using patient data linked to a national cancer registry. The study was conducted in a large organ transplantation center that serves the entire Norwegian population of approximately 5.2 million. Exposures Receiving a solid organ transplant owing to late-stage organ failure, followed by long-term immunosuppressive treatment according to graft-specific treatment protocols. Main Outcomes and Measures Occurrence of first posttransplant SCC, melanoma, or Kaposi sarcoma of the skin. Risk of skin cancer was analyzed using standardized incidence ratios (SIRs) and, for SCC, multivariable Poisson regression analysis of SIR ratios, adjusting for 5-year time period of transplantation, different follow-up time, age, sex, and type of organ. Results The study cohort included 8026 organ transplant recipients, 5224 men (65.1%), with a mean age at transplantation of 48.5 years. Median follow-up time was 6.7 years per recipient; total follow-up time, 69 590 person-years. The overall SIRs for SCC, melanoma, and Kaposi sarcoma were 51.9 (95% CI, 48.4-55.5), 2.4 (95% CI, 1.9-3.0), and 54.9 (95% CI, 27.4-98.2), respectively. In those who underwent transplantation in the 1983-1987 period, the unadjusted SIR for SCC was 102.7 (95%, 85.8-122.1), declining to 21.6 (95% CI, 16.8-27.0) in those who underwent transplantation in the 2003-2007 period. Adjusting for different follow-up times and background population risks, as well as age, graft organ, and sex, a decline in the SIR for SCC was found, with SIR peaking in patients who underwent transplantation in the 1983-1987 period and later declining to less than half in patients who underwent transplantation in the 1998-2002, 2003-2007, and 2008-2012 periods, with the relative SIRs being 0.42 (95% CI, 0.32-0.55), 0.31 (95% CI, 0.22-0.42), and 0.44 (95% CI, 0.30-0.66), respectively. Conclusions and Relevance The risk of SCC after organ transplantation has declined significantly since the mid-1980s in Norway. Less aggressive and more individualized immunosuppressive treatment and close clinical follow-up may explain the decline. Still, the risk of SCC in organ transplant recipients remains much higher than in the general population and should be of continuous concern for dermatologists, transplant physicians, and patients.
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Affiliation(s)
- Syed Mohammad Husain Rizvi
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Hallvard Holdaas
- Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristin Muri Boberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterology and Hepatology, Oslo University Hospital, Oslo, Norway
| | - Øystein Bjørtuft
- Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Per Helsing
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
| | | | | | - Petter Gjersvik
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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63
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Harwood CA, Toland AE, Proby CM, Euvrard S, Hofbauer GFL, Tommasino M, Bouwes Bavinck JN. The pathogenesis of cutaneous squamous cell carcinoma in organ transplant recipients. Br J Dermatol 2017; 177:1217-1224. [PMID: 29086420 DOI: 10.1111/bjd.15956] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2017] [Indexed: 12/14/2022]
Abstract
The pathogenesis of keratinocyte carcinoma following organ transplantation is multifactorial, and recent evidence suggests a complex and often synergistic interplay between the carcinogenic effects of ultraviolet radiation, compromised immune surveillance, direct pro- and anticarcinogenic effects of drugs, oncogenic viruses (in particular, beta-genus human papillomaviruses) and host genetic susceptibility factors. We present an overview of those factors for which there is currently the most convincing evidence and highlight important gaps in our knowledge. In particular, a clear understanding of the interdependence and relative contributions of these co-factors is currently lacking, yet has important implications for rational development of clinically relevant biomarkers and targeted strategies for treatment and prevention of post-transplant keratinocyte cancers.
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Affiliation(s)
- C A Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
| | - A E Toland
- Cancer Biology and Genetics, The Ohio State University, Columbus, OH, U.S.A
| | - C M Proby
- Division of Cancer Research, School of Medicine, University of Dundee, Dundee, U.K
| | - S Euvrard
- Hospices Civils de Lyon, Department of Dermatology, Edouard Herriot Hospital, Lyon, France
| | - G F L Hofbauer
- Department of Dermatology, University of Zurich, Zurich, Switzerland
| | - M Tommasino
- Infections and Cancer Biology Group, International Agency for Research on Cancer, Lyon, France
| | - J N Bouwes Bavinck
- Department of Dermatology, Leiden University Medical Centre, Leiden, The Netherlands
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64
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Blomberg M, He SY, Harwood C, Arron ST, Demehri S, Green A, Asgari MM. Research gaps in the management and prevention of cutaneous squamous cell carcinoma in organ transplant recipients. Br J Dermatol 2017; 177:1225-1233. [PMID: 29086412 PMCID: PMC5711582 DOI: 10.1111/bjd.15950] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 12/13/2022]
Abstract
Although tremendous progress has been made in recent years in skin cancer care for organ transplant recipients, significant gaps remain in data-driven clinical guidelines, particularly for the treatment and prevention of cutaneous squamous cell carcinoma (cSCC), the most common malignancy among this population. In this review, we aim to summarize current knowledge around the management of cSCC and highlight the most significant gaps in knowledge that continue to pose challenges in the delivery of skin cancer care for organ transplant recipients. We suggest future directions for research that will bridge existing gaps and establish evidence-driven guidelines for primary prevention, screening and treatment of cSCC in this high-risk patient population.
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Affiliation(s)
- M Blomberg
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, U.S.A
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, U.S.A
| | - S Y He
- Department of Dermatology, Weill Cornell Medical College, New York, NY, U.S.A
| | - C Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, U.K
| | - S T Arron
- Department of Dermatology, University of California, San Francisco, CA, U.S.A
| | - S Demehri
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, U.S.A
| | - A Green
- QIMR Berghofer Medical Research Institute, Brisbane, Qld, Australia
- Cancer Research UK Manchester Institute, University of Manchester, Manchester, U.K
| | - M M Asgari
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, U.S.A
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, U.S.A
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65
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Madeleine M, Patel N, Plasmeijer E, Engels E, Bouwes Bavinck J, Toland A, Green A. Epidemiology of keratinocyte carcinomas after organ transplantation. Br J Dermatol 2017; 177:1208-1216. [DOI: 10.1111/bjd.15931] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 12/14/2022]
Affiliation(s)
| | - N.S. Patel
- University of South Florida Tampa FL U.S.A
| | - E.I. Plasmeijer
- QIMR Berghofer Medical Research Institute Queensland Australia
| | | | | | - A.E. Toland
- The Ohio State University Medical Center Columbus OH U.S.A
| | - A.C. Green
- QIMR Berghofer Medical Research Institute Queensland Australia
- CRUK Manchester Institute and University of Manchester Manchester Academic Health Sciences Centre Manchester U.K
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Krisl JC, Doan VP. Chemotherapy and Transplantation: The Role of Immunosuppression in Malignancy and a Review of Antineoplastic Agents in Solid Organ Transplant Recipients. Am J Transplant 2017; 17:1974-1991. [PMID: 28394486 DOI: 10.1111/ajt.14238] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/07/2017] [Accepted: 02/11/2017] [Indexed: 01/25/2023]
Abstract
It is estimated that solid organ transplant recipients have a two- to fourfold greater overall risk of malignancy than the general population. Some of the most common malignancies after transplant include skin cancers and posttransplant lymphoproliferative disorder. In addition to known risk factors such as environmental exposures, genetics, and infection with oncogenic viruses, immunosuppression plays a large role in the development of cancer through the loss of the immunosurveillance process. The purpose of this article is to explain the role of immunosuppression in cancer and to review the classes of chemotherapeutics. The field of anticancer drugs is continually expanding and developing, with limited data on use in transplant recipients. This article aims to provide information on class review, adverse effects, dose adjustments, and drug interactions that are pertinent to the care of transplant recipients.
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Affiliation(s)
- J C Krisl
- Houston Methodist Hospital, Houston, TX
| | - V P Doan
- The University of Texas MD Anderson Cancer Center, Houston, TX
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67
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Clinical and Economic Consequences of Early Cancer After Kidney Transplantation in Contemporary Practice. Transplantation 2017; 101:858-866. [PMID: 27490413 DOI: 10.1097/tp.0000000000001385] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Current clinical and economic consequences of cancer after kidney transplantation are incompletely defined. METHODS We examined United States Renal Data System records of Medicare-insured kidney transplant recipients in 2000 to 2011 to determine clinical and economic impacts of cancer diagnosed within the first 3 years posttransplantation. Cancer diagnoses were identified using Medicare billing codes and categorized as nonmelanoma skin cancer (NMSC), viral-linked and "other" cancers. Associations of cancers with mortality and graft loss were estimated by time-varying Cox regression. Impacts of cancer diagnoses on inpatient and outpatient costs within each year were quantified by multivariate linear regression modeling. RESULTS Among 67 157 recipients, by 3 years posttransplant, NMSC was diagnosed in 5.7%, viral-linked cancer in 1.9%, and "other" cancers in 6.3%. Viral-linked cancer was associated with more than 3-fold increased risk in subsequent mortality until the third transplant anniversary, and nearly twice the mortality risk after year 3. "Other" cancers had similar associations with death and graft loss, whereas NMSC was associated with 33% higher mortality beyond the third year posttransplant. Viral-linked cancer had the largest inpatient and outpatient cost impacts per case, followed by "other" cancer, whereas NMSC impacted only outpatient costs. Care of new cancer diagnoses was generally more costly than care of previously established diagnoses. Cancer accounted for 3% to 5.5% of total inpatient Medicare expenditures and 1.5% to 3.3% of outpatient expenditures in the first 3 years posttransplant. CONCLUSIONS Early posttransplant malignancy is an expensive and morbid condition that warrants attention in efforts to improve pretransplant screening and management protocols before and after transplant.
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68
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Squamous Cell Carcinoma Originating from a Crohn's Enterocutaneous Fistula. Case Rep Surg 2017; 2017:1929182. [PMID: 28487805 PMCID: PMC5401721 DOI: 10.1155/2017/1929182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 03/03/2017] [Accepted: 03/28/2017] [Indexed: 01/29/2023] Open
Abstract
Purpose. Squamous cell carcinoma (SCC) developing within fistulae and chronic wounds in patients with Crohn's disease is a rare phenomenon with few reported studies in the literature. Clinical suspicion for SCC in Crohn's disease patients with chronic painful fistulae is low, leading to delayed diagnosis and treatment. We present a patient with long-standing Crohn's disease complicated by malignant degeneration of an enterocutaneous fistula tract. Methods. Workup with MRI, CT, and fistulogram revealed a 7 × 3 cm fistulous connection between a loop of small intestine and the patient's perineum. Biopsies of the fistula tract confirmed the diagnosis of SCC. Results. The patient underwent an abdominoperineal resection with positive margins and is currently awaiting radiation therapy. Conclusions. This is the second case reported within the English literature of SCC arising from an enterocutaneous fistula in the setting of Crohn's disease. Based on the findings in this case report and others presented in the literature, a high degree of suspicion of malignancy should be present in patients with chronic painful, poor-healing fistulae, especially in the absence of infection.
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Ducroux E, Martin C, Bouwes Bavinck JN, Decullier E, Brocard A, Westhuis-van Elsäcker ME, Lebbé C, Francès C, Morelon E, Legendre C, Joly P, Kanitakis J, Jullien D, Euvrard S, Dantal J. Risk of Aggressive Skin Cancers After Kidney Retransplantation in Patients With Previous Posttransplant Cutaneous Squamous Cell Carcinomas: A Retrospective Study of 53 Cases. Transplantation 2017; 101:e133-e141. [PMID: 28099404 PMCID: PMC7228575 DOI: 10.1097/tp.0000000000001644] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 12/05/2016] [Accepted: 12/09/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The course of skin cancer after retransplantation in organ-transplant recipients who have already developed posttransplant skin cancer has not been assessed. METHODS This retrospective multicentric study included 53 patients with a history of cutaneous squamous cell carcinoma (SCC) after a first kidney transplantation who received a second kidney transplantation. The primary endpoint was the occurrence of aggressive cutaneous SCC after the second transplantation. Secondary endpoints included the course of skin cancers over 3 periods (first transplantation, return to dialysis, second transplantation), the time to occurrence, and risk factors for aggressive SCC after retransplantation. RESULTS The first SCC developed in 47 patients with a functional graft and in 6 after return to dialysis. After the first transplantation, 17 (33.3%) patients developed SCC in dialysis and 39 (73.6%) after the second transplantation, respectively. Twenty aggressive SCC developed over the study period. They occurred in 14 (26.4%) patients after retransplantation vs 5 (9.4%) after the first transplantation with a median delay of 50 months and were responsible for 5 deaths. Fair skin type, multiple tumors before retransplantation, treatment with azathioprine, T cell-depleting antibodies, and delayed revision of immunosuppression were associated with an increased risk of aggressive cutaneous SCC after retransplantation. CONCLUSIONS Candidates to retransplantation with a history of posttransplant SCC have a high risk of aggressive SCC. Our data suggest that the risk could be reduced by a tailored immunosuppression. A wait period may be required depending on the clinicopathological characteristics of the previous SCC and discussed on an individual patient basis.
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Affiliation(s)
- Emilie Ducroux
- 1 Department of Dermatology, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France. 2 Department of Dermatology, Leiden University Medical Center, Leiden, The Netherlands. 3 Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Unité de Recherche Clinique, Lyon, France. 4 Université de Lyon, Laboratoire Santé Individu Société, Lyon, France. 5 Department of Dermatology, Nantes University Medical Center, Nantes, France. 6 Department of Dermatology, Saint Louis Hospital, APHP, University Paris VII, Paris, France. 7 Department of Dermatology, Tenon Hospital, APHP, University Paris VI, Paris, France. 8 Department of Transplantation and Nephrology, Edouard Herriot Hospital, Université de Lyon, Lyon, France. 9 Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France. 10 Department of Dermatology, Charles-Nicolle University Medical Center, Rouen, France. 11 Department of Renal Medicine and Transplantation, Nantes University Medical Center, Nantes, France
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