Skin cancer following transplantation: the Israel Penn International Transplant Tumor Registry experience

Reducing non-melanoma skin cancer risk in renal transplant recipients

With an increasing number of renal transplant recipients (RTRs) and improving patient survival, a higher incidence of non-melanoma skin cancer (NMSC) has been observed. NMSC in RTRs are often more numerous and biologically more aggressive than the general population, thus contributing towards an increase in morbidity and to a lesser degree, mortality. The resultant cumulative health and financial burden is a recognized concern. Proposed strategies in mitigating risks of developing NMSC and early therapeutic options thereof include tailored modification of immunosuppressants in conjunction with sun protection in all transplant patients. This review highlights the clinical and financial burden of transplant-associated skin cancers, carcinogenic mechanisms in association with immunosuppression, importance of skin cancer awareness campaign and integrated transplant skin clinic, and the potential role of chemoprotective agents. A scheme is proposed for primary and secondary prevention of NMSC based on the available evidence.

Combination checkpoint blockade for metastatic cutaneous malignancies in kidney transplant recipients

BACKGROUND

Immune checkpoint blockade has emerged as a highly effective treatment for patients with metastatic melanoma and cutaneous squamous cell carcinoma. Nivolumab blocks the interactions between programmed cell death protein 1 and programmed death ligand 1 allowing for activation of a latent immune response against the malignancy. Ipilimumab binds to and blocks cytotoxic T-lymphocyte-associated protein 4, alleviating the negative regulation of T-cell activation that is mediated by that checkpoint. Combination therapy with nivolumab and ipilimumab is associated with longer overall survival at 5 years compared with nivolumab monotherapy. Solid organ transplant recipients have a significantly higher risk of malignancies compared with the general population. There is limited data surrounding the efficacy of combination immunotherapy in solid organ transplant recipients, as these patients were excluded from seminal trials due to risk of organ rejection.

CASE PRESENTATIONS

Here we present four cases of combination immunotherapy in kidney transplant recipients. Three patients had metastatic melanoma, and one patient had metastatic cutaneous squamous cell carcinoma. Two patients had radiographic responses from immunotherapy, one patient had stable disease, and one patient had disease progression. Only one patient had biopsy-proven rejection. At last follow-up, three patients had functioning grafts, though one required hemodialysis after treatment, and one patient succumbed to disease, but graft function remained intact throughout her course.

CONCLUSIONS

These cases describe the use of ipilimumab and nivolumab combination immunotherapy for cutaneous malignancies in kidney transplant recipients. They highlight the potential to preserve kidney graft function while effectively treating the disease.

TRIAL REGISTRATION NUMBER

NCT03816332.

Solid organ transplantation worsens the prognosis of patients with cutaneous squamous cell carcinoma of the head and neck region-Comparison between solid organ transplant recipients and immunocompetent patients

BACKGROUND

Cutaneous squamous cell carcinoma of the head and neck (CSCC-HN) appears to behave more aggressively in immunosuppressed patients. We aimed to investigate this hypothesis by comparing solid organ transplant recipients (SOTR) with CSCC-HN to immunocompetent patients.

METHODS

A retrospective comparative study was conducted for SOTR and immunocompetent patients who were treated for CSCC-HN.

RESULTS

A total of 177 SOTR and 157 immunocompetent patients with CSCC-HN were included. Lymph node metastases were more common in the SOTR group (9% vs 3%), and distant metastases occurred only in SOTR (3% of patients). SOTR had a higher rate of recurrences (19% vs 10%), which were mostly regional (7%) and distant (3%). The 2-year disease-specific survival of SOTR was lower (93% vs 100%).

CONCLUSIONS

SOTR with CSCC-HN has significantly worse outcomes compared to immunocompetent patients. Solid-organ transplantation should be regarded as a negative prognostic factor in patients with CSCC-HN.

Skin Cancer Development in Solid Organ Transplant Recipients in Switzerland (Swiss Transplant Cohort Study)

IMPORTANCE

Skin cancer, in particular squamous cell carcinoma, is the most frequent malignancy among solid organ transplant recipients with a higher incidence compared to the general population.

OBJECTIVE

To determine the skin cancer incidence in organ transplant recipients in Switzerland and to assess the impact of immunosuppressants and other risk factors.

DESIGN

Prospective cohort study of solid organ transplant recipients in Switzerland enrolled in the Swiss Transplant Cohort Study from 2008 to 2013.

PARTICIPANTS

2,192 solid organ transplant recipients.

MATERIALS AND METHODS

Occurrence of first and subsequent squamous cell carcinoma, basal cell carcinoma, melanoma and other skin cancers after transplantation extracted from the Swiss Transplant Cohort Study database and validated by medical record review. Incidence rates were calculated for skin cancer overall and subgroups. The effect of risk factors on the occurrence of first skin cancer and recurrent skin cancer was calculated by the Cox proportional hazard model.

RESULTS

In 2,192 organ transplant recipients, 136 (6.2%) developed 335 cases of skin cancer during a median follow-up of 32.4 months, with squamous cell carcinoma as the most frequent one. 79.4% of skin cancer patients were male. Risk factors for first and recurrent skin cancer were age at transplantation, male sex, skin cancer before transplantation and previous transplantation. For a first skin cancer, the number of immunosuppressive drugs was a risk factor as well.

CONCLUSIONS AND RELEVANCE

Skin cancer following solid organ transplantation in Switzerland is greatly increased with risk factors: age at transplantation, male sex, skin cancer before transplantation, previous transplantation and number of immunosuppressive drugs.

In vitro Models of Breast Cancer Metastatic Dormancy

Delayed relapses at distant sites are a common clinical observation for certain types of cancers after removal of primary tumor, such as breast and prostate cancer. This evidence has been explained by postulating a long period during which disseminated cancer cells (DCCs) survive in a foreign environment without developing into overt metastasis. Because of the asymptomatic nature of this phenomenon, isolation, and analysis of disseminated dormant cancer cells from clinically disease-free patients is ethically and technically highly problematic and currently these data are largely limited to the bone marrow. That said, detecting, profiling and treating indolent metastatic lesions before the onset of relapse is the imperative. To overcome this major limitation many laboratories developed in vitro models of the metastatic niche for different organs and different types of cancers. In this review we focus specifically on in vitro models designed to study metastatic dormancy of breast cancer cells (BCCs). We provide an overview of the BCCs employed in the different organotypic systems and address the components of the metastatic microenvironment that have been shown to impact on the dormant phenotype: tissue architecture, stromal cells, biochemical environment, oxygen levels, cell density. A brief description of the organ-specific in vitro models for bone, liver, and lung is provided. Finally, we discuss the strategies employed so far for the validation of the different systems.

Analysis of neoplastic skin complications in transplant patients: experience of an Italian multidisciplinary transplant unit

BACKGROUND

Transplant patients need to be strictly followed, since the immunosuppressive therapies they usually receive can increase the risk of skin complications. This study aims to evaluate the prevalence of neoplastic skin complications in transplant patients.

METHODS

We analyzed 256 liver or kidney transplant patients. The follow-up mean period was 7±3.5 years. It was also evaluated the prevalence of cutaneous neoplastic complications according to the immunosuppressive regimen received by patients as follows: cyclosporine, tacrolimus, steroids, mycophenolate mofetil or everolimus, in single, double or triple therapy.

RESULTS

The 18.36% of patients developed neoplastic complications, among these 9.37% actinic keratoses, 8.20% non-melanoma skin cancer, and 0.78% cutaneous melanoma. Among patients who developed non melanoma skin cancer, 61.90% had basal cell carcinoma, 23.81% squamous cell carcinoma, 52% Kaposi's sarcoma and 4.76%, Malherbe's epithelioma.

CONCLUSIONS

This study demonstrated the increased risk of skin cancer in transplant patients during the first 7 years of follow-up and made the dermatologists aware about the need of a regular cutaneous follow-up for this subset of patients.

ACR Appropriateness Criteria(®) Aggressive Nonmelanomatous Skin Cancer of the Head and Neck

BACKGROUND

Aggressive nonmelanomatous skin cancer (NMSC) of the head and neck presents an increasingly common therapeutic challenge for which prospective clinical trials are lacking.

METHODS

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

RESULTS

The American College of Radiology Expert Panel on Radiation Oncology - Head and Neck Cancer developed consensus recommendations for guiding management of aggressive NMSC.

CONCLUSION

Multidisciplinary assessment is vital to guiding the ideal use of surgery, radiation, and systemic therapy in this disease.

Synchronous metastatic cutaneous squamous cell carcinoma and chronic lymphocytic leukaemia/small lymphocytic lymphoma in a cervical lymph node: Case report of an unusual event

The synchronous occurrence of two different neoplasias is an uncommon event, which may arise between tumors originating in the same organ or in cancer-to-cancer metastasis. We report a rare case of chronic lymphocytic leukaemia / small lymphocytic lymphoma associated with a cutaneous metastatic squamous cell carcinoma in a cervical lymph node. In the affected lymph node, it was observed an effacement of the normal architecture by neoplastic lymphocytes and it was noted the presence of neoplastic invasive epithelial islands. Immunohistochemical analysis demonstrated that lymphocytic proliferation was positive for CD20, CD5, CD23 and Kappa, and negative for CD3, CD10, Cyclin D1 and Lambda. The morphological and immunohistochemical profile lead to a phenotype of B-cell chronic lymphocytic leukaemia / small lymphocytic lymphoma. The epithelial cells were positive for CK5, thus rendering the diagnosis of synchronous metastatic cutaneous squamous cell carcinoma and chronic lymphocytic leukaemia/small lymphocytic lymphoma. Literature supports the poor prognosis in cases that present coexistence of squamous cell carcinoma and chronic lymphocytic leukaemia / small lymphocytic lymphoma. Thus, it is necessary to be aware about this unusual finding in order to provide specific treatment.

KEY WORDS

Chronic lymphocytic leukaemia, small lymphocytic lymphoma, squamous cell carcinoma, metastasis.

CD8+ Immunosenescence Predicts Post-Transplant Cutaneous Squamous Cell Carcinoma in High-Risk Patients

Most morbidity associated with malignancy in long-term renal transplant recipients is due to cutaneous squamous cell carcinoma (SCC). Previously identified measures to stratify SCC risk have limited use, however. We hypothesized that an increased proportion of senescent, terminally differentiated CD8(+) T cells would identify renal transplant recipients at elevated SCC risk. Peripheral blood lymphocytes were isolated from 117 stable transplant recipients at high risk of SCC and analyzed phenotypically by flow cytometry. Participants were followed up prospectively for SCC development. The predictive value of variables was assessed using Cox regression. Age at transplant and enrollment, dialysis duration, and previous disease were predictive of SCC development during follow-up. Previously published clinical phenotype-based risk scores lost predictive value with the removal of age as a covariate. The percentage of CD57-expressing CD8(+) T cells was the strongest immunologic predictor of future SCC and correlated with increasing CD8(+) T cell differentiation. We dichotomized participants into those with a majority (CD57hi) and a minority (CD57lo) of CD8(+) T cells expressing CD57; CD57hi participants were more likely to develop SCC during follow-up (hazard ratio, 2.9; 95% confidence interval, 1.0 to 8.0), independent of potential confounders, and tended to develop earlier recurrence. The CD57hi phenotype was stable with time and associated with increasing age and cytomegalovirus seropositivity. Our results show that the CD57hi phenotype is a strong predictor of SCC development and recurrence in this cohort of long-term, high-risk renal transplant recipients. This information may allow identification of recipients who may benefit from intensive dermatologic screening and immunosuppression reduction.

Non-melanoma skin cancer in renal transplant recipients: a study in a Brazilian reference center

BACKGROUND

Non-melanoma skin cancer (NMSC) after kidney transplantation is common and can result in significant morbidity and mortality. Their incidence and risk factors in renal transplant recipients (RTRs) vary depending on geographic location and there is a scarcity of literature describing the features of NMSC in Brazil.

METHODS

NMSC data were retrospectively reviewed in charts of RTRs at the Clementino Fraga Filho University Hospital from January 2004 to December 2005, with the objectives of: 1) evaluating the occurrence of NMSC in RTRs transplanted between 2004 and 2005 at a reference center in Brazil; 2) verifying the frequency of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in these patients according to sex, race, age, and tumor site; and 3) determining the time between transplantation and neoplasia.

RESULTS

We found 202 RTRs, with 165 suitable for the study. There were 19 NMSC in eleven patients (6.67%), at a mean time of 37.7 months after transplantation. The mean follow-up time was 72.7 months. The ratio of SCC:BCC was 1.1:1. White race and age ≥40 years were associated with a higher incidence of NMSC and they appeared predominantly in sun-exposed sites.

CONCLUSION

Regular dermatological follow-up of RTRs can help to make earlier diagnoses, resulting in better quality of life and lower morbidity and mortality.

Immune profiling and cancer post transplantation

Half of all long-term (> 10 year) australian kidney transplant recipients (KTR) will develop squamous cell carcinoma (SCC) or solid organ cancer (SOC), making cancer the leading cause of death with a functioning graft. At least 30% of KTR with a history of SCC or SOC will develop a subsequent SCC or SOC lesion. Pharmacological immunosuppression is a major contributor of the increased risk of cancer for KTR, with the cancer lesions themselves further adding to systemic immunosuppression and could explain, in part, these phenomena. Immune profiling includes; measuring immunosuppressive drug levels and pharmacokinetics, enumerating leucocytes and leucocyte subsets as well as testing leucocyte function in either an antigen specific or non-specific manner. Outputs can vary from assay to assay according to methods used. In this review we define the rationale behind post-transplant immune monitoring assays and focus on assays that associate and/or have the ability to predict cancer and rejection in the KTR. We find that immune monitoring can identify those KTR of developing multiple SCC lesions and provide evidence they may benefit from pharmacological immunosuppressive drug dose reductions. In these KTR risk of rejection needs to be assessed to determine if reduction of immunosuppression will not harm the graft.

Improved detection reveals active β-papillomavirus infection in skin lesions from kidney transplant recipients

The aim of this study was to determine whether detection of β-HPV gene products, as defined in epidermodysplasia verruciformis skin cancer, could also be observed in lesions from kidney transplant recipients alongside the viral DNA. A total of 111 samples, corresponding to 79 skin lesions abscised from 17 kidney transplant recipients, have been analyzed. The initial PCR analysis demonstrated that β-HPV-DNA was highly present in our tumor series (85%). Using a combination of antibodies raised against the E4 and L1 proteins of the β-genotypes, we were able to visualize productive infection in 4 out of 19 actinic keratoses, and in the pathological borders of 1 out of 14 squamous cell carcinomas and 1 out of 31 basal cell carcinomas. Increased expression of the cellular proliferation marker minichromosome maintenance protein 7 (MCM7), that extended into the upper epithelial layers, was a common feature of all the E4-positive areas, indicating that cells were driven into the cell cycle in areas of productive viral infections. Although the present study does not directly demonstrate a causal role of these viruses, the detection of E4 and L1 positivity in actinic keratosis and the adjacent pathological epithelium of skin cancer, clearly shows that β-HPV are actively replicating in the intraepidermal precursor lesions of kidney transplant recipients and can therefore cooperate with other carcinogenic agents, such as UVB, favoring skin cancer promotion.

Dermatologist and gastroenterologist awareness of the potential of immunosuppressants used to treat inflammatory bowel disease to cause non-melanoma skin cancer

BACKGROUND

  Immunosuppressants used to treat inflammatory bowel disease (IBD) may contribute towards the development of non-melanoma skin cancer (NMSC). Few studies have documented this increase in risk.

METHODS

  A mail-in survey was sent to practicing dermatologists and gastroenterologists in the state of Hawaii, USA. These physicians were asked if they had patients with IBD on immunosuppressants with NMSC and if they were aware of an association between immunosuppressants used in IBD and the occurrence of NMSC. Physicians were located via the Yellow Pages telephone directory and the websites http://www.healthgrades.com and http://www.ucomparehealthcare.com.

RESULTS

  Of the 96 surveys delivered, 45 were returned for analysis. Overall, 73.3% of responding physicians knew about an association between NMSC and immunosuppressants for IBD, but 26.7% had no knowledge of this association. When respondents were categorized according to specialty, 90.9% of dermatologists reported knowing about this association, but only 46.2% of responding gastroenterologists reported this awareness (P = 0.0034). Of the respondents who did not provide details of their specialty, 70.0% reported knowledge of the association.

CONCLUSIONS

  Immunosuppressants are helpful in controlling IBD symptoms and progression but should only be used after a thorough assessment of their risks and benefits in each patient. After the initiation of immunosuppressants, patients should have access to appropriate preventative and treatment modalities for NMSC.

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.

Therapeutic options to decrease actinic keratosis and squamous cell carcinoma incidence and progression in solid organ transplant recipients: a practical approach

BACKGROUND

Solid organ transplant recipients (SOTRs) have a 50 to 250 times greater risk of squamous cell carcinoma (SCC) than the general population and experience higher rates of invasive and metastatic disease. These greater risks are a product of the tumorigenic effects of their immunosuppressive medications. As the number of transplantations and the life expectancy of SOTRs increase, SCCs are becoming a major source of morbidity and mortality.

OBJECTIVE

To present a practical approach for busy practicing clinicians to the care of SOTRs who are developing SCCs. Topics include assessment and treatment of new and neglected SOTRs; the dermatologist's role with the transplantation team; and practical considerations in the choice of topical agents, systemic agents, and immunosuppressive therapy manipulation.

METHODS AND MATERIALS

An extensive literature search of the understanding of SCC pathophysiology and treatment in SOTRs was conducted.

RESULTS

Presented here is a logical, concise guide to the care of SOTRs who are developing actinic keratoses and SCCs.

CONCLUSION

Proper assessment of patients, understanding therapeutic alternatives and their application, and early institution of preventative and adjuvant therapies can help to decrease skin cancer-related morbidity and mortality in SOTRs.

Solid organ transplant recipients presenting for Mohs micrographic surgery: a retrospective case-control study

BACKGROUND

Solid organ transplant recipients (SOTR) have a high risk of cutaneous malignancy. Mohs micrographic surgery (MMS) is recommended for the treatment of skin cancers in this group. The characteristics of the tumors in SOTR presenting for MMS are not well documented.

OBJECTIVE

To describe the characteristics of tumors in SOTR presenting to a single institution over an 11-year period and compare them with tumors of non-SOTR who have also undergone MMS.

METHODS

A database query captured patients with a current organ transplant who underwent MMS. These patients (cases) were matched to controls who also underwent MMS. Statistical models were used to identify tumor and operative characteristics significantly associated with SOTR compared with matching controls.

RESULTS

Ninety-two SOTR underwent MMS for 432 skin cancers; 163 controls had 269 skin cancers. Squamous cell carcinoma (SCC) was the most common tumor in SOTR, with a reversal of the usual ratio of basal cell carcinoma to SCC. Mean tumor and defect sizes were similar in SOTR and controls. Cardiac transplants were the predominant transplant.

CONCLUSIONS

SOTR referred for MMS have disproportionately more and different types of skin cancers than controls.

The 7th edition AJCC staging system for cutaneous squamous cell carcinoma accurately predicts risk of recurrence for heart and lung transplant recipients

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

LIMITATIONS

This study is limited to a specific patient subgroup at a tertiary care center, and may not be generalizable to all populations.

CONCLUSIONS

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.

Malignancies following lung transplantation

Malignancy is an important complication of thoracic organ transplantation and is associated with significant morbidity and mortality. Lung transplant recipients are at greater risk for cancer than immunocompetent persons, with cancer-specific incidence rates up to 60-fold higher than the general population. The increased risk for cancer is attributed to neoplastic properties of immunosuppressive medications, oncogenic viruses, and cancer-specific risk factors. This article addresses the epidemiology, presentation, and treatment of the most common malignancies after lung transplantation, including skin cancer, posttransplant lymphoproliferative disorder, and bronchogenic carcinoma.

Aggressive behavior of nonmelanotic skin cancers in solid organ transplant recipients

BACKGROUND

The increased incidence of skin cancers in solid organ transplant recipients (OTR) has been well established. However, our understanding of the potential aggressive behavior of these cancers has been largely based on the findings of multiple different studies analyzing isolated indicators of aggressive behavior. The purpose of this study was to determine the aggressiveness of nonmelanotic skin cancers in a large transplant population compared with an immunocompetent control population with similar cancers.

METHODS

Immunosuppressed transplanted patients and an immunocompetent control group matched in size with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) were evaluated for the factors of aggressiveness. A retrospective chart review was performed. Data obtained included transplant type, number of cancers, local recurrence rate, lymph node involvement, lymphatic invasion, perineural invasion, deep spread, subsequent treatment with radiation or chemotherapy, and death from disease.

RESULTS

Three hundred seven patients had SCC (OTR: 153, control: 154), and 246 patients had BCC (OTR: 123, control: 123). SCC in OTR was significantly more likely to have an increased number of primary tumors, deep tissue spread, perineural and lymphatic invasion, recurrence, and need for radiation or chemotherapy. BCC in OTR was not associated with more aggressive disease when compared with controls with BCC.

CONCLUSIONS

SCC in OTR behaves significantly more aggressively than in immunocompetent patients. BCC in the OTR population does not seem to act more aggressively.

Early and late effects of the immunosuppressants rapamycin and mycophenolate mofetil on UV carcinogenesis

Increased skin cancer risk in organ transplant recipients has been experimentally emulated with enhanced UV carcinogenesis from administering conventional immunosuppressants. However, newer generation immunosuppressive drugs, rapamycin (Rapa) and mycophenolate mofetil (MMF), have been shown to impair angiogenesis and outgrowth of tumor implants. To ascertain the overall effect on UV carcinogenesis, Rapa and MMF were admixed into the food pellets of hairless SKH1 mice receiving daily sub-sunburn UV dosages. With immunosuppressive blood levels neither of the drugs affected onset of tumors (<2 mm), but in contrast to MMF, Rapa significantly increased latency of large tumors (>or=4 mm, medians of 190 vs 125 days) and reduced their multiplicity (1.6 vs 4.5 tumors per mouse at 200 days). Interestingly, tumors (>2 mm) from the Rapa-fed group showed a reduction in UV-signature p53 mutations (39% vs 90%) in favor of mutations from putative base oxidation. This shift in mutation spectrum was not essentially linked to the reduction in large tumors because it was absent in large tumors similarly reduced in number when feeding Rapa in combination with MMF, possibly owing to an antioxidant effect of MMF. Significantly fewer tumor cells were Vegf-positive in the Rapa-fed groups, but a correspondingly reduced expression of Hif1alpha target genes (Vegf, Ldha, Glut1, Pdk1) that would indicate altered glucose metabolism with increased oxidative stress was not found. Remarkably, we observed no effect of the immunosuppressants on UV-induced tumor onset, and with impaired tumor outgrowth Rapa could therefore strongly reduce skin carcinoma morbidity and mortality rates in organ transplant recipients.

Switch to a sirolimus-based immunosuppression in long-term renal transplant recipients: reduced rate of (pre-)malignancies and nonmelanoma skin cancer in a prospective, randomized, assessor-blinded, controlled clinical trial

Renal transplant recipients (RTR) have a 50-200-fold higher risk for nonmelanoma-skin cancer (NMSC) causing high rates of morbidity and sometimes mortality. Cohort-studies gave evidence that a sirolimus-based immunosuppression may inhibit skin tumor growth. This single-center, prospective, assessor-blinded, randomized trial investigated if switching to sirolimus treatment inhibits the progression of premalignancies and moreover how many new NMSC occur compared to continuation of the original immunosuppressive therapy. Forty-four RTR (mean age 59.9 years, mean duration of immunosuppression 229.5 months) with skin lesions were randomized to sirolimus or continuation of their original immunosuppression. Blinded dermatological assessment at month 6 and 12 by the same dermatologist evaluated the clinical change compared to baseline. Biopsy was performed in suspected malignancy. Already the 6-month-assessment showed significant superiority of sirolimus-therapy: a stop of progression, even regression of preexisting premalignancies (p < 0.0005). This effect was increased at month 12 (p < 0.0001). Nine patients developed histologically confirmed NMSC: one in the sirolimus group, eight in the control group, p = 0.0176. Sirolimus-based immunosuppression in RTR, even when established many years after transplantation, can delay the development of premalignancies, induce regression of preexisting lesions and decelerate the incidence of new NMSC.

Celecoxib reduces the effects of acute and chronic UVB exposure in mice treated with therapeutically relevant immunosuppressive drugs

Solid organ transplant recipients have a greatly increased risk for the development of non-melanoma skin cancers. We have previously shown in our mouse model that sirolimus given in combination with cyclosporine A resulted in fewer and smaller tumors than cyclosporine A alone. In the current study, we tested the hypothesis that an anti-inflammatory agent celecoxib applied topically after UVB exposure would further reduce UVB induced skin cancer in mice treated with cyclosporine A and sirolimus. The effect of celecoxib treatment on acute inflammation, initiation/promotion and tumor development was examined through a set of four experiments. Delayed tumor onset was observed in both tumor development experiments. Reduced tumor size and number compared to vehicle was observed when CX was administered concurrently with UVB and when CX was administered after cessation of UVB treatments, respectively. Prostaglandin E2 was confirmed to be significantly reduced in the dorsal skin of mice concurrently treated with immunosuppressants, CX and UVB for 13 weeks, suggesting a reduction in the inflammatory response could be the mechanism by which CX reduced tumorigenesis. Furthermore, topical celecoxib treatment following acute UVB exposure reduced dermal neutrophil number and activity compared to vehicle. In all of these experiments, unirradiated and vehicle treated mice were utilized as controls. In conclusion, these data suggest that even in the presence of cyclosporine A and sirolimus, topical celecoxib treatment can result in reduced inflammation, tumor number and size; properties which may be beneficial in the therapeutic reduction of skin cancer development in solid organ transplant recipients.

First and subsequent nonmelanoma skin cancers: incidence and predictors in a population of New Zealand renal transplant recipients

BACKGROUND

Renal transplant recipients (RTRs) have an increased risk of developing nonmelanoma skin cancers (NMSCs). The aims of this study were to determine the incidence and subsequent history of NMSCs in RTRs, together with risk factors.

METHODS

All patients transplanted between July 1972 and March 2007, and followed up at Christchurch Hospital, New Zealand, were studied. Immunosuppression regimens were mostly prednisone, azathioprine, cyclosporine and prednisone, mycophenolate mofetil, cyclosporine since 1998.

RESULTS

Of 384 RTRs, 96 developed at least one NMSC. The median time to first NMSC was 18.3 years (95% CI 14.2, 22.9) from transplant, as estimated by survival analysis. Individual predictors of first NMSC in RTRs were older age at first transplant (P < 0.0001), male sex (P = 0.006) and initial immunosuppression regimen (P = 0.001); only age (P < 0.0001) and male gender (P = 0.003) were significant predictors in a joint model. The mean rate of subsequent NMSCs was 1.67 per year (95% CI = 1.32, 2.11). Older age at first renal transplant (P = 0.009) or at discovery of the first NMSC (P = 0.01) was associated with a higher annual rate of new NMSC following the discovery of the first NMSC. The median survival time to a second NMSC was 2.2 years (CI 1.4, 3.0). Fourteen patients died of metastatic squamous cell carcinoma (15% case fatality).

CONCLUSIONS

NMSCs are a major health issue for RTRs, especially in older males. Once RTRs have developed their first NMSC, ongoing surveillance and prompt treatment are essential.

Vitamin D: bone and beyond, rationale and recommendations for supplementation

Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.

A survey of North American burn and plastic surgeons on their current attitudes toward facial transplantation

BACKGROUND

Feasibility of composite tissue allotransplantation (CTA) has been substantiated by transplantations of the hand, abdominal wall, and face. CTA has the potential to reconstruct "like with like," but the risk-to-benefit ratio and clinical indications have yet to be determined. We sought to examine the current attitudes about the emerging field of CTA from those who treat complex facial injuries.

STUDY DESIGN

In 2007, a Web-based blinded survey was sent to both burn and plastic surgeons involved in facial reconstruction. We examined the practice profile with regard to complex facial injuries and asked respondents to assess the level of risk in CTA and indications for facial transplantation. Surgeons were asked to evaluate three clinical cases (two closely mirroring clinical face transplantations) for suitability for treatment with CTA.

RESULTS

One hundred sixty-four surgeons responded (54% response rate) and averaged 17.3 years in practice. They saw 12.1 severe facial-injury patients per year. A total of 78.7% agreed that current techniques do not provide adequate reconstruction for severe facial injuries, and 26.2% were in favor of performing CTA on immunosuppression. Acceptable indications for CTA were multiple failed reconstructions (70%), total facial burn (59%), and absence of remote tissue (55%). Ten percent saw no acceptable indication for CTA. The scenarios that mimicked recent transplantations had moderate support in favor of CTA (20.7% for the Chinese patient and 29.3% for the French patient).

CONCLUSIONS

This survey demonstrates support for use of CTA to reconstruct complex facial deformities. Surgeons continue to be wary of immunosuppression and chronic rejection, and many want to wait for better immunologic treatment options.

Skin Cancer Education in Transplant Recipients

In the past 20 years, long-term survival for solid-organ transplant recipients has improved dramatically; about 223 000 patients are alive in the United States with organ transplants today. As survival rates improve, however, the morbidity and mortality associated with lifelong immunosuppressive therapy is increasing in significance. Skin cancer is common among recipients of all major organ transplants, including the kidney, liver, heart, lung, and pancreas. Although skin cancer is the most common cancer in transplant recipients, many cases can be prevented by sun protection, skin self-examinations, and physician examinations. Because transplant recipients visit the transplant clinic frequently, clinicians have ample opportunities to teach patients about the importance of prevention and detection of skin cancer. At a routine visit, the clinician should inquire about sun protection practices, especially for tanned, light-skinned, or freckled patients or patients who are planning a warm-weather vacation or time in the sun during the summer. Skin cancer education should be integrated into the care of transplant patients as part of their numerous visits to the transplant clinic. Although some transplant recipients may resist adopting new behaviors at first, use of the ample clinic opportunities for patient education can dramatically reduce their risk of skin cancer.

Sirolimus reduces the incidence and progression of UVB-induced skin cancer in SKH mice even with co-administration of cyclosporine A

Transplant immunosuppressants have been implicated in the increased incidence of non-melanoma skin cancer in transplant recipients, most of whom harbor considerable UVB-induced DNA damage in their skin prior to transplantation. This study was designed to evaluate the effects of two commonly used immunosuppressive drugs, cyclosporine A (CsA) and sirolimus (SRL), on the development and progression of UVB-induced non-melanoma skin cancer. SKH-1 hairless mice were exposed to UVB alone for 15 weeks, and then were treated with CsA, SRL, or CsA+SRL for 9 weeks following cessation of UVB treatment. Compared with vehicle, CsA treatment resulted in enhanced tumor size and progression. In contrast, mice treated with SRL or CsA+SRL had decreased tumor multiplicity, size, and progression compared with vehicle-treated mice. CsA, but not SRL or combined treatment, increased dermal mast cell numbers and TGF-beta1 levels in the skin. These findings demonstrate that specific immunosuppressive agents differentially alter the cutaneous tumor microenvironment, which in turn may contribute to enhanced development of UVB-induced skin cancer in transplant recipients. Furthermore, these results suggest that CsA alone causes enhanced growth and progression of skin cancer, whereas co-administration of SRL with CsA causes the opposite effect. JID JOURNAL CLUB ARTICLE: For questions, answers, and open discussion about this article please go to http://network.nature.com/group/jidclub

Immunosuppression and squamous cell carcinoma: a focus on solid organ transplant recipients

As transplant medicine advances, new immunosuppressive regimens are increasing the long-term survival of solid organ transplant recipients (SOTRs). This growing population is at significantly increased risk for developing cutaneous malignancies, particularly squamous cell carcinoma (SCC), as a result of chronic immunosuppression. Conventional risk factors for the development of skin cancer, including fair skin type, advanced age, sun exposure, and genetic predisposition, also play a crucial role in the initiation and progression of SCC in SOTRs. Immunosuppressed patients develop more aggressive and more numerous SCCs than immunocompetent individuals, however. It is important to understand the mechanisms underlying immunosuppression-mediated SCC development to identify prognostic markers and to develop effective prevention and treatment strategies. This article addresses the fundamental differences between SCC in SOTRs and those in the general population, focusing on the role that immunosuppression plays in the pathogenesis of this malignancy.

Immunosuppressive therapy and malignancy in organ transplant recipients: a systematic review

Post-transplant malignancy is recognised as being a major limitation to the success of solid organ transplantation and it is currently considered one of the unavoidable costs of long-term immunosuppressive therapy. However, the continual introduction of new immunosuppressive drugs and the growing knowledge about their different oncogenic profiles, requires a continuous evaluation of the available evidence on this topic. The incidence and risk of malignancy is elevated in solid organ transplant recipients compared with the general population. As proof of the relationship between immunosuppressive therapy and post-transplant malignancy, epidemiological data reveal that the length of exposure to immunosuppressive therapy and the intensity of therapy are clearly related to the post-transplant risk of malignancy, and that once cancer has developed, more intense immunosuppression can translate into more aggressive tumour progression in terms of accelerated growth and metastasis and lower patient survival. The association between malignancy and immunosuppressive therapy is mediated through several pathogenic factors. Indirectly, immunosuppressive drugs greatly increase the post-transplant risk of malignancy by impairing cancer surveillance and facilitating the action of oncogenic viruses. However, the direct pro- and anti-oncogenic actions of immunosuppressants also play an important role. The cancer-promoting effect of calcineurin inhibitors, independently of depressed immunosurveillance, has been demonstrated in recent years, and currently only mammalian target of rapamycin (mTOR) inhibitors have shown simultaneous immunosuppressive and antitumour properties. Reports of the initial results of the reduced incidence of cancer in organ transplant recipients receiving mTOR inhibitor therapy strongly indicate separate pathways for pharmacological immunosuppression and oncogenesis. The role of mTOR inhibitors has been firmly established for the treatment of post-transplant Kaposi's sarcoma and its role in the management of patients with other post-transplant malignancies should be clarified as soon as possible. Prevention of morbidity and mortality resulting from post-transplant malignancy should become a main endpoint in solid organ transplant programmes, and the choice and management of immunosuppressive therapy in each phase of transplantation plays a central role in this objective. Although comprehensive and rigorous information about the management of immunosuppressive therapy in transplant recipients at risk of or affected by cancer is still lacking, new experimental and clinical data about mTOR inhibitors offers novel approaches to this problem.

Sunlight, skin cancer and vitamin D: What are the conclusions of recent findings that protection against solar ultraviolet (UV) radiation causes 25-hydroxyvitamin D deficiency in solid organ-transplant recipients, xeroderma pigmentosum, and other risk groups?

A connection between vitamin D deficiency and severe health problems including various types of cancer has been demonstrated. We have shown that patients that have to protect themselves against solar UV radiation for medical reasons, including patients with xeroderma pigmentosum (XP), basal cell nevus syndrome (BCNS), lupus erythematodes (LE) or transplant recipients, are at risk to develop vitamin D deficiency. We conclude that 25-hydroxyvitamin D serum levels as a measure of vitamin D status have to be analyzed in patients that have to protect themselves against solar UV radiation for medical reasons. Suboptimal vitamin D status has to be substituted (e.g. via oral treatment) to protect against serious vitamin D deficiency-related health problems without increasing the risk to develop solar UV-induced skin cancer. Our finding that protection against solar UV radiation causes vitamin D deficiency underlines the need for re-defining dermatological recommendations for solar UV protection in skin cancer prevention programs.

[Skin tumors in organ-transplant recipients]

Skin cancers are a significant medical problem for organ-transplant recipients. Squamous cell carcinoma and basal cell carcinoma are most common tumors. An increasing incidence of melanoma, Kaposi sarcoma, Merkel cell carcinoma, as well as uncommon skin malignancies, is also seen. Predisposing factors include cumulative sun exposure, cumulative immunosuppression, age, gender, skin type, virus detection and genetic alterations. Skin tumors grow rapidly and their number continues to increase in the years following transplantation. Large numbers of tumors, aggressive courses and appearance in young patients are other characteristics of these skin tumors. More general awareness of the need for preventive measures and regular dermatological examinations is desirable. In addition standardized registries are needed to assure the comparability of data, to better correlate immunosuppression with skin tumors and to plan therapeutic studies.

Modelling cancer in human skin tissue

The capacity to induce neoplasia in human tissue in the laboratory has recently provided a new platform for cancer research. Malignant conversion can be achieved in vivo by expressing genes of interest in human tissue that has been regenerated on immune-deficient mice. Induction of cancer in regenerated human skin recapitulates the three-dimensional architecture, tissue polarity, basement membrane structure, extracellular matrix, oncogene signalling and therapeutic target proteins found in intact human skin in vivo. Human-tissue cancer models therefore provide an opportunity to elucidate fundamental cancer mechanisms, to assess the oncogenic potency of mutations associated with specific human cancers and to develop new cancer therapies.