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Lepri G, Catalano M, Bellando-Randone S, Pillozzi S, Giommoni E, Giorgione R, Botteri C, Matucci-Cerinic M, Antonuzzo L, Guiducci S. Systemic Sclerosis Association with Malignancy. Clin Rev Allergy Immunol 2022; 63:398-416. [PMID: 36121543 DOI: 10.1007/s12016-022-08930-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
The association of systemic sclerosis (SSc) and cancer is well known from several decades suggesting common genetic and environmental risk factors involved in the development of both diseases. Immunosuppressive drugs widely used in SSc may increase the risk of cancer occurrence and different SSc clinical and serological features identify patients at major risk to develop malignancy. In this context, among serological features, presence of anti-RNA polymerase III and anti-topoisomerase I autoantibodies seems to increase cancer frequency in SSc patients (particularly lung and breast cancers). Lung fibrosis and a long standing SSc pulmonary involvement have been largely proposed as lung cancer risk factors, and the exposure to cyclophosphamide and an upper gastrointestinal involvement have been traditionally linked to bladder and oesophagus cancers, respectively. Furthermore, immune checkpoint inhibitors used for cancer therapy can induce immune-related adverse events, which are more frequent and severe in patients with pre-existing autoimmune diseases such as SSc. The strong association between SSc and cancer occurrence steers clinicians to carefully survey SSc patients performing periodical malignancy screening. In the present review, the most relevant bilateral relationships between SSc and cancer will be addressed.
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Affiliation(s)
- Gemma Lepri
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy.
| | - Martina Catalano
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy
| | - Serena Pillozzi
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Elisa Giommoni
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | | | - Cristina Botteri
- Medical Oncology Unit, Careggi University Hospital, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Antonuzzo
- Medical Oncology, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology, AOUC & Scleroderma Unit, Florence, Italy
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Robinett DM, Hummers LK, Morris M, Duffield AS, Shah AA. Primary CNS lymphoma in scleroderma: a case series. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:214-219. [PMID: 34350365 PMCID: PMC8330379 DOI: 10.1177/2397198320970395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/01/2020] [Indexed: 11/16/2022]
Abstract
Many studies have demonstrated an increased risk of cancer in patients with rheumatologic diseases, including systemic sclerosis. Less explored is the role of immunosuppressive therapy as a contributing factor in cancer emergence or detection. This series introduces two cases of patients with systemic sclerosis who demonstrated clinical improvement in their rheumatic disease process with immunosuppression, but both of whom developed neurologic symptoms in the setting of decreasing or discontinuing immunosuppressive therapy, leading to the ultimate diagnosis of Epstein Barr Virus positive (EBV+) diffuse large B cell lymphoma of the CNS. To our knowledge, primary CNS lymphoma has not been previously described in systemic sclerosis patients. Immunosuppressive therapies could promote the development of virus-associated malignancies due to decreased viral clearance. We hypothesize that removing immunosuppression could allow the immune system to generate an inflammatory response to an underlying tumor or viral antigen, contributing to development of neurologic symptoms and detection of underlying disease.
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Affiliation(s)
- Danielle M Robinett
- Division of Rheumatology, School
of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Laura K Hummers
- Division of Rheumatology, School
of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Meaghan Morris
- Department of Pathology, School of
Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Amy S Duffield
- Department of Pathology, School of
Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Ami A Shah
- Division of Rheumatology, School
of Medicine, The Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Scleroderma Center,
Baltimore, MD, USA
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3
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Abstract
Individuals with scleroderma have an increased risk of cancer compared with the general population. This heightened risk may be from chronic inflammation and tissue damage, malignant transformation provoked by immunosuppressive therapies, or a common inciting factor. In unique subsets of patients with scleroderma, there is a close temporal relationship between the onset of cancer and scleroderma, suggesting cancer-induced autoimmunity. This article discusses the potential mechanistic links between cancer and scleroderma, the serologic and clinical risk factors associated with increased cancer risk in patients with scleroderma, and implications for cancer screening.
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Affiliation(s)
- Emma Weeding
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 4100, Baltimore, MD 21224, USA
| | - Livia Casciola-Rosen
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 4100, Baltimore, MD 21224, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Building, Center Tower, Suite 4100, Baltimore, MD 21224, USA.
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Abstract
Links between autoimmune rheumatic diseases and cancer continue to be elucidated. In this review, we explore this complex, bidirectional relationship. First, the increased risk of cancer across the breadth of the autoimmune rheumatic diseases is described. The magnitude of risk and types of tumors seen can differ by the type of autoimmune disease, timing of disease course, and even clinical and laboratory features within a particular autoimmune disease, suggesting that targeted cancer screening strategies can be considered. Multiple mechanisms linking autoimmune rheumatic diseases and cancer are discussed, including the development of autoimmunity in the context of naturally occurring anti-tumor immune responses and malignancy arising in the context of inflammation and damage from autoimmunity. Immunosuppression for rheumatic disease can increase risk for certain types of cancers. Finally, immune checkpoint inhibitors, a type of cancer immunotherapy, which cause a variety of inflammatory syndromes of importance to rheumatologists, are reviewed.
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Affiliation(s)
- Laura C Cappelli
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Arthritis Center, Baltimore, MD, 21224, USA.
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason F. Lord Center Tower, Suite 4100, Baltimore, MD, 21224, USA.
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Horie K, Tsuchiya T, Iinuma K, Maekawa Y, Nakane K, Kato T, Mizutani K, Koie T. Risk factors and incidence of malignant neoplasms after kidney transplantation at a single institution in Japan. Clin Exp Nephrol 2019; 23:1323-1330. [PMID: 31372795 DOI: 10.1007/s10157-019-01769-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/16/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The risk of malignant neoplasms increases in kidney transplantation (KT) recipients (KTRs). However, Japanese registry studies have not been reported since 2000. METHODS We retrospectively reviewed the medical records of 346 patients who underwent KT at Gifu University Hospital, Japan since 2000. Patients were divided into two groups based on whether they developed malignancy after KT or not. The incidence, type of malignancy, risk factors, and prognosis for malignancy were examined. RESULTS In this study, 22 de novo malignant neoplasms were identified in 20 KTRs (7.3%), with a median follow-up period of 8.2 years. Cumulative incidence of any malignant neoplasms was 1.1% within 1 year and 4.4% within 5 years. The 5-year overall survival (OS) rates were 71.8% in KTRs with malignant neoplasms and 98.6% in KTRs without malignant neoplasms. Uni- and multivariate analysis revealed that age at KT and acute rejection (AR) episode were significant predictors for incidence of malignancy. CONCLUSIONS The development of malignant neoplasms was associated with poor OS and graft survival. We consider that appropriate screening and investigation of symptoms are important for KTRs, particularly for older KTRs at transplantation and those with AR episode.
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Affiliation(s)
- Kengo Horie
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Tomohiro Tsuchiya
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan.
| | - Koji Iinuma
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Yuka Maekawa
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Keita Nakane
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Taku Kato
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Kosuke Mizutani
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
| | - Takuya Koie
- Department of Urology, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1193, Japan
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Abstract
INTRODUCTION Treatment of sarcoidosis recommendations are often based on clinical experience and expert opinion. However, there are an increasing number of studies which are providing evidence to support decisions regarding treatment. Areas covered: Several studies have identified factors associated with increased risk for organ failure or death ('danger'). There have been several studies focused on the role of treatment to improve quality of life for the patient. Sarcoidosis treatment often follows a progression, based on response. Corticosteroids remain the initial treatment of choice for most patients. Second-line therapy includes cytotoxic agents. Immunosuppressives such as methotrexate, azathioprine, leflunomide, and mycophenolate have all been reported as effective in sarcoidosis. Biologics and other agents are third-line therapy. The monoclonal antibodies directed against tumor necrosis factor have been shown to be particularly effective for advanced disease. Infliximab has been the most studied drug in this class. Newer treatments, including repository corticotropin injection and rituximab have been reported as effective in some cases. Expert commentary: In this review, we use the GRADE system to evaluate the currently available evidence and make recommendations regarding treatment.
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Affiliation(s)
- W Ennis James
- a Division of Pulmonary and Critical Care , Medical University of South Carolina , Charleston , SC , USA
| | - Robert Baughman
- b Department of Medicine , University of Cincinnati Medical Center , Cincinnati , OH , USA
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Ascha M, Ascha MS, Tanenbaum J, Bordeaux JS. Risk Factors for Melanoma in Renal Transplant Recipients. JAMA Dermatol 2017; 153:1130-1136. [PMID: 28746700 DOI: 10.1001/jamadermatol.2017.2291] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Melanoma risk factors and incidence in renal transplant recipients can inform decision making for both patients and clinicians. Objective To determine risk factors and characteristics of renal transplant recipients who develop melanoma. Design, Setting, and Participants This cohort study of a large national data registry used a cohort of renal transplant recipients from the United States Renal Data System (USRDS) database from the years 2004 through 2012. Differences in baseline characteristics between those who did and did not develop melanoma were examined, and a survival analysis was performed. Patients with renal transplants who received a diagnosis of melanoma according to any inpatient or outpatient claim associated with a billing code for melanoma were included. A history of pretransplant melanoma, previous kidney transplantation, or transplantation after 2012 or before 2004 were exclusion criteria. The data analysis was conducted from 2015 to 2016. Exposure Receipt of a renal transplant. Main Outcomes and Measures Incidence and risk factors for melanoma. Results Of 105 174 patients (64 151 [60.7%] male; mean [SD] age, 49.6 [15.3] years) who received kidney transplants between 2004 and 2012, 488 (0.4%) had a record of melanoma after transplantation. Significant risk factors for developing melanoma vs not developing melanoma included older age among recipients (mean [SD] age, 60.5 [10.2] vs 49.7 [15.3] years; P < .001) and donors (42.6 [15.0] vs 39.2 [15.1] years; P < .001), male sex (71.5% vs 60.7%; P < .001), recipient (96.1% vs 66.5%; P < .001) and donor (92.4% vs 82.9%; P < .001) white race, less than 4 HLA mismatches (44.9% vs 37.1%; P = .001), living donors (44.7% vs 33.7%; P < .001), and sirolimus (22.3% vs 13.2%; P < .001) and cyclosporine (4.9% vs 3.2%; P = .04) therapy. Risk factors significant on survival analysis included older recipient age (hazard ratio [HR] per year, 1.06; 95% CI, 1.05-1.06; P < .001), recipient male sex (HR, 1.53; 95% CI, 1.25-1.88; P < .001), recipient white race, living donors (HR, 1.35; 95% CI, 1.11-1.64; P = .002), and sirolimus (HR, 1.54; 95% CI, 1.22-1.94; P < .001) and cyclosporine (HR, 1.93; 95% CI, 1.24-2.99; P = .004) therapy. The age-standardized relative rate of melanoma in USRDS patients compared with Surveillance, Epidemiology, and End Results patients across all years was 4.9. A Kaplan-Meier estimate of the median time to melanoma among those patients who did develop melanoma was 1.45 years (95% CI, 1.31-1.70 years). Conclusions and Relevance Renal transplant recipients had greater risk of developing melanoma than the general population. We believe that the risk factors we identified can guide clinicians in providing adequate care for patients in this vulnerable group.
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Affiliation(s)
- Mona Ascha
- Medical student at Case Western Reserve University School of Medicine, Cleveland, Ohio.,now with Department of Plastic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Mustafa S Ascha
- Center for Clinical Investigation, Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio
| | - Joseph Tanenbaum
- Medical student at Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeremy S Bordeaux
- Department of Dermatology, University Hospitals Case Medical Center, Cleveland, Ohio
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Mechanistic and clinical insights at the scleroderma-cancer interface. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:153-159. [PMID: 29264402 DOI: 10.5301/jsrd.5000250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Emerging data suggest tantalizing links between cancer and systemic inflammatory rheumatic syndromes. In scleroderma, patients may have an increased risk of cancer secondary to chronic inflammation and damage from the disease, malignant transformation promoted by immunosuppressive therapies, a shared susceptibility to both cancer and autoimmunity, or a common inciting exposure. However, it is increasingly recognized that a subset of patients develop cancer around the time that scleroderma clinically manifests, raising the question of cancer-induced autoimmunity. In this review, we discuss data suggesting a mechanistic link between cancer and the development of scleroderma, and the clinical implications of these findings.
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9
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Francis A, Johnson DW, Craig JC, Wong G. Incidence and Predictors of Cancer Following Kidney Transplantation in Childhood. Am J Transplant 2017; 17:2650-2658. [PMID: 28371054 DOI: 10.1111/ajt.14289] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/10/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Cancer risk is increased substantially in adult kidney transplant recipients, but the long-term risk of cancer in childhood recipients is unclear. Using the Australian and New Zealand Dialysis and Transplant Registry, the authors compared overall and site-specific incidences of cancer after transplantation in childhood recipients with population-based data by using standardized incidence ratios (SIRs). Among 1734 childhood recipients (median age 14 years, 57% male, 85% white), 289 (16.7%) developed cancer (196 nonmelanoma skin cancers, 143 nonskin cancers) over a median follow-up of 13.4 years. The 25-year cumulative incidences of any cancer were 27% (95% confidence intervals 24-30%), 20% (17-23%) for nonmelanoma skin cancer, and 14% (12-17%) for nonskin cancer (including melanoma). The SIR for nonskin cancer was 8.23 (95% CI 6.92-9.73), with the highest risk for posttransplant lymphoproliferative disease (SIR 45.80, 95% CI 32.71-62.44) and cervical cancer (29.4, 95% CI 17.5-46.5). Increasing age at transplantation (adjusted hazard ratio [aHR] per year 1.10, 95% CI 1.06-1.14), white race (aHR 3.36, 95% CI 1.61-6.79), and having a functioning transplant (aHR 2.27, 95% CI 1.47-3.71) were risk factors for cancer. Cancer risk, particularly for virus-related cancers, is increased substantially after kidney transplantation during childhood.
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Affiliation(s)
- A Francis
- Sydney School of Public Health, University of Sydney, Camperdown, NSW, Australia.,Centre for Kidney Research, Kids Research Institute at The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - D W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, Diamantina Institute, University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - J C Craig
- Sydney School of Public Health, University of Sydney, Camperdown, NSW, Australia.,Centre for Kidney Research, Kids Research Institute at The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - G Wong
- Sydney School of Public Health, University of Sydney, Camperdown, NSW, Australia.,Centre for Kidney Research, Kids Research Institute at The Children's Hospital at Westmead, Westmead, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia.,Australian and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
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10
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Kang W, Sampaio MS, Huang E, Bunnapradist S. Association of Pretransplant Skin Cancer With Posttransplant Malignancy, Graft Failure and Death in Kidney Transplant Recipients. Transplantation 2017; 101:1303-1309. [PMID: 27336396 DOI: 10.1097/tp.0000000000001286] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant malignancy (PTM) is one of the leading causes of late death in kidney recipients. Those with a cancer history may be more prone to develop a recurrent or a new cancer. We studied the association between pretransplant skin cancer, PTM, death, and graft failure. METHODS Primary adult kidney recipients transplanted between 2005 and 2013 were included. Malignancy information was obtained from Organ Procurement Kidney Transplant Network/United Network for Organ Sharing registration and follow-up forms. Posttransplant malignancy was classified into skin cancer, solid tumor, and posttransplant lymphoproliferative disorder (PTLD). Competing risk and survival analysis with adjustment for confounders were used to calculate risk for PTM, death and graft failure in recipients with pretransplant skin cancer compared with those without cancer. Risk was reported in hazard ratios (HR) with 95% confidence interval (CI). RESULTS The cohort included 1671 recipients with and 102 961 without pretransplant skin malignancy. The 5-year cumulative incidence of PTM in patients with and without a pretransplant skin cancer history was 31.6% and 7.4%, respectively (P < 0.001). Recipients with pretransplant skin cancer had increased risk of PTM (sub-HR [SHR], 2.60; 95% CI, 2.27-2.98), and posttransplant skin cancer (SHR, 2.92; 95% CI, 2.52-3.39), PTLD (SHR, 1.93; 95% CI, 1.01-3.66), solid tumor (SHR, 1.44; 95% CI, 1.04-1.99), death (HR, 1.20; 95% CI, 1.07-1.34), and graft failure (HR, 1.17; 95% CI, 1.05-1.30) when compared with those without pretransplant malignancy. CONCLUSIONS Pretransplant skin cancer was associated with an increased risk of posttransplant skin cancer, PTLD, solid organ cancer, death and graft failure.
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Affiliation(s)
- Woosun Kang
- 1 Division of Nephrology, UCLA Medical Center, Los Angeles, CA. 2 Division of Internal Medicine, Allegheny General Hospital, Pittsburgh, PA
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11
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Post-Transplant Malignancy after Pediatric Kidney Transplantation: Retrospective Analysis of Incidence and Risk Factors in 884 Patients Receiving Transplants Between 1963 and 2015 at the University of Minnesota. J Am Coll Surg 2017; 225:181-193. [DOI: 10.1016/j.jamcollsurg.2017.04.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
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Jiyad Z, Olsen CM, Burke MT, Isbel NM, Green AC. Azathioprine and Risk of Skin Cancer in Organ Transplant Recipients: Systematic Review and Meta-Analysis. Am J Transplant 2016; 16:3490-3503. [PMID: 27163483 DOI: 10.1111/ajt.13863] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/12/2016] [Accepted: 05/02/2016] [Indexed: 01/25/2023]
Abstract
Azathioprine, a purine antimetabolite immunosuppressant, photosensitizes the skin and causes the production of mutagenic reactive oxygen species. It is postulated to increase the risk of squamous cell carcinoma (SCC) and other skin cancers in organ transplant recipients (OTRs), but evidence from multiple, largely single-center studies to date has been inconsistent. We aimed to resolve the issue of azathioprine's carcinogenicity by conducting a systematic review of the relevant literature and pooling published risk estimates to evaluate the risks of SCC, basal cell carcinoma (BCC), keratinocyte cancers (KCs) overall and other skin cancers in relation to azathioprine treatment. Twenty-seven studies were included in total, with risk estimates from 13 of these studies able to be pooled for quantitative analysis. The overall summary estimate showed a significantly increased risk of SCC in relation to azathioprine exposure (1.56, 95% confidence interval [CI] 1.11-2.18). No significant associations between azathioprine treatment and BCC (0.96, 95% CI 0.66-1.40) or KC (0.84, 95% CI 0.59-1.21) risk were observed. There was significant heterogeneity between studies for azathioprine risk estimates and the outcomes of SCC, BCC and KC. The pooled findings of available evidence support the contention that treatment with azathioprine increases the risk of SCC in OTRs.
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Affiliation(s)
- Z Jiyad
- Cancer and Population Studies Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,Institute of Cardiovascular and Cell Sciences (Dermatology Unit), St. George's University of London, London, United Kingdom
| | - C M Olsen
- Cancer Control Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - M T Burke
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - N M Isbel
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - A C Green
- Cancer and Population Studies Group, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,CRUK Manchester Institute and Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, United Kingdom
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13
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Schrem H, Schneider V, Kurok M, Goldis A, Dreier M, Kaltenborn A, Gwinner W, Barthold M, Liebeneiner J, Winny M, Klempnauer J, Kleine M. Independent Pre-Transplant Recipient Cancer Risk Factors after Kidney Transplantation and the Utility of G-Chart Analysis for Clinical Process Control. PLoS One 2016; 11:e0158732. [PMID: 27398803 PMCID: PMC4939933 DOI: 10.1371/journal.pone.0158732] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study is to identify independent pre-transplant cancer risk factors after kidney transplantation and to assess the utility of G-chart analysis for clinical process control. This may contribute to the improvement of cancer surveillance processes in individual transplant centers. Patients and Methods 1655 patients after kidney transplantation at our institution with a total of 9,425 person-years of follow-up were compared retrospectively to the general German population using site-specific standardized-incidence-ratios (SIRs) of observed malignancies. Risk-adjusted multivariable Cox regression was used to identify independent pre-transplant cancer risk factors. G-chart analysis was applied to determine relevant differences in the frequency of cancer occurrences. Results Cancer incidence rates were almost three times higher as compared to the matched general population (SIR = 2.75; 95%-CI: 2.33–3.21). Significantly increased SIRs were observed for renal cell carcinoma (SIR = 22.46), post-transplant lymphoproliferative disorder (SIR = 8.36), prostate cancer (SIR = 2.22), bladder cancer (SIR = 3.24), thyroid cancer (SIR = 10.13) and melanoma (SIR = 3.08). Independent pre-transplant risk factors for cancer-free survival were age <52.3 years (p = 0.007, Hazard ratio (HR): 0.82), age >62.6 years (p = 0.001, HR: 1.29), polycystic kidney disease other than autosomal dominant polycystic kidney disease (ADPKD) (p = 0.001, HR: 0.68), high body mass index in kg/m2 (p<0.001, HR: 1.04), ADPKD (p = 0.008, HR: 1.26) and diabetic nephropathy (p = 0.004, HR = 1.51). G-chart analysis identified relevant changes in the detection rates of cancer during aftercare with no significant relation to identified risk factors for cancer-free survival (p<0.05). Conclusions Risk-adapted cancer surveillance combined with prospective G-chart analysis likely improves cancer surveillance schemes by adapting processes to identified risk factors and by using G-chart alarm signals to trigger Kaizen events and audits for root-cause analysis of relevant detection rate changes. Further, comparative G-chart analysis would enable benchmarking of cancer surveillance processes between centers.
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Affiliation(s)
- Harald Schrem
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- * E-mail:
| | - Valentin Schneider
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Marlene Kurok
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Gynecology and Obstetrics, KRH Klinikum Nordstadt, Hannover, Germany
| | - Alon Goldis
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Lean Six Sigma Black Belt, Amstelveen, The Netherlands
| | - Maren Dreier
- Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Trauma and Orthopedic Surgery, Federal Armed Forces Hospital Westerstede, Medical Service of the Federal Armed Forces, Westerstede, Germany
| | | | - Marc Barthold
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jan Liebeneiner
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Markus Winny
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
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Cancer and scleroderma: a paraneoplastic disease with implications for malignancy screening. Curr Opin Rheumatol 2016; 27:563-70. [PMID: 26352736 DOI: 10.1097/bor.0000000000000222] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Recent data suggest a paraneoplastic mechanism of scleroderma pathogenesis in unique subsets of scleroderma patients. In this article, we review these data, explore potential links between cancer and scleroderma, and propose an approach to malignancy screening in scleroderma. RECENT FINDINGS Emerging data have demonstrated that patients with scleroderma and RNA polymerase III autoantibodies have a significantly increased risk of cancer within a few years of scleroderma onset. Genetic alterations in the gene encoding RNA polymerase III (POLR3A) have been identified, and patients with somatic mutations in POLR3A have evidence of mutation specific T-cell immune responses with generation of cross-reactive RNA polymerase III autoantibodies. These data strongly suggest that scleroderma is a by-product of antitumor immune responses in some patients. Additional epidemiologic data demonstrate that patients developing scleroderma at older ages may also have a short cancer-scleroderma interval, suggestive of paraneoplastic disease. SUMMARY Scleroderma may be a paraneoplastic disease in unique patient subsets. Aggressive malignancy screening in these patients may aid in early cancer detection. Further study is required to determine whether cancer therapy could improve scleroderma outcomes in this patient population.
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Egiziano G, Bernatsky S, Shah AA. Cancer and autoimmunity: Harnessing longitudinal cohorts to probe the link. Best Pract Res Clin Rheumatol 2016; 30:53-62. [PMID: 27421216 DOI: 10.1016/j.berh.2016.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In many autoimmune rheumatic diseases, there is an increased risk of cancer compared to the general population. While reasons for this increased risk have not been elucidated, it has been hypothesized that the link between cancer and autoimmunity may be bidirectional. For instance, chronic inflammation and damage from the rheumatic disease or its therapies may trigger malignant transformation; conversely, antitumor immune responses targeting cancers may become cross-reactive resulting in autoimmunity. In rare rheumatic diseases, longitudinal observational studies can play a critical role in studying these complex relationships, thereby enabling investigators to quantify the extent of cancer risk, identify unique clinical phenotypes associated with cancer, investigate the biological link between these conditions, and define optimal strategies for screening and treatment of the underlying cancer. In this review, we discuss recent data on cancer in the rheumatic diseases and suggest a research agenda to address several gaps in our current knowledge base.
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Affiliation(s)
- Giordano Egiziano
- Resident Internal Medicine, McGill University, Royal Victoria Hospital, Glen Site, Rm D05.5840, 1001 Decarie Boulevard, Montreal, QC H4A 3J1, Canada.
| | - Sasha Bernatsky
- Division of Clinical Epidemiology, McGill University Health Center, 687 Pine Avenue, V Building, Montreal, QC H3A 1A1, Canada.
| | - Ami A Shah
- Johns Hopkins Scleroderma Center, 5501 Hopkins Bayview Circle, Room 1B.15, Baltimore, MD 21224, USA.
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Hertig A, Zuckermann A. Rabbit antithymocyte globulin induction and risk of post-transplant lymphoproliferative disease in adult and pediatric solid organ transplantation: An update. Transpl Immunol 2015; 32:179-87. [PMID: 25936966 DOI: 10.1016/j.trim.2015.04.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/21/2015] [Accepted: 04/24/2015] [Indexed: 02/06/2023]
Abstract
The most modifiable risk factor for post-transplant lymphoproliferative disease (PTLD) is the type and dose of induction and maintenance immunosuppressive therapy. It is challenging to identify the contribution of a single agent such as rabbit antithymocyte globulin (rATG) in the setting of multidrug therapy. Registry analyses can be helpful but are limited by methodological restrictions and inclusion of historical patient cohorts. These are typically from eras when rATG dosing was markedly higher than current dosing (e.g. total dose 14 mg/kg versus 6 mg/kg now), accompanied by higher exposure to maintenance therapies, and often an absence of antiviral prophylaxis. The largest registry analysis to assess rATG specifically found no risk of PTLD after kidney transplantation, but conflicting results have been reported, highlighting the difficulty of interpreting this type of analysis. The relative rarity of PTLD means that individually controlled trials are underpowered to assess its occurrence, but the available data do not suggest an effect of rATG. A pooled analysis of data from studies of rATG induction in kidney and heart transplantation found the incidence of PTLD to be comparable to published reports in the overall transplant population. Data on the effect of rATG dose are inconclusive, but in patients receiving antiviral prophylaxis it does not appear to be influential. Nevertheless, it would seem reasonable to employ the lowest dose of rATG compatible with effective induction, particularly in EBV-seronegative recipients and other high-risk groups such as heart-lung transplant recipients. Overall, the risk of PTLD following rATG induction therapy with modern dosing regimens and under current management conditions appears unlikely to make an important contribution to the risk:benefit balance.
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Affiliation(s)
- Alexandre Hertig
- AP-HP, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Sorbonne Universités, UPMC, Paris CEDEX 6, France.
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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Surveillance of nonmelanoma skin cancer incidence rates in kidney transplant recipients in Ireland. Transplantation 2015; 98:646-52. [PMID: 24798309 DOI: 10.1097/tp.0000000000000115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The incidence of nonmelanomatous skin cancer (NMSC) is substantially higher among renal transplant recipients (RTRs) than in the general population. With a growing RTR population, a robust method for monitoring skin cancer rates in this population is required. METHODS A modeling approach was used to estimate the trends in NMSC rates that adjusted for changes in the RTR population (sex and age), calendar time, the duration of posttransplant follow-up, and background population NMSC incidence rates. RTR databases in both Northern Ireland (NI) and the Republic of Ireland (ROI) were linked to their respective cancer registries for diagnosis of NMSC, mainly squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). RESULTS RTRs in the ROI had three times the incidence (P<0.001) of NMSC compared with NI. There was a decline (P<0.001) in NMSC 10-year cumulative incidence rate in RTRs over the period 1994-2009, which was driven by reductions in both SCC and BCC incidence rates. Nevertheless, there was an increase in the incidence of NMSC with time since transplantation. The observed graft survival was higher in ROI than NI (P<0.05) from 1994-2004. The overall patient survival of RTRs was similar in NI and ROI. CONCLUSION Appropriate modeling of incidence trends in NMSC among RTRs is a valuable surveillance exercise for assessing the impact of change in clinical practices over time on the incidence rates of skin cancer in RTRs. It can form the basis of further research into unexplained regional variations in NMSC incidence.
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BK virus-associated urothelial carcinoma of a ureter graft in a renal transplant recipient: a case report. Transplant Proc 2014; 46:616-9. [PMID: 24656027 DOI: 10.1016/j.transproceed.2013.09.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/20/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Urothelial carcinomas of ureter grafts in renal transplant patients are rare. Here we report our experience with a case of BK virus-associated urothelial carcinoma in a ureter graft. CASE REPORT A 47-year-old man developed chronic renal failure secondary to diabetes mellitus and started maintenance hemodialysis in September 2007. Two months later, the patient received a renal transplant from his 70-year-old mother. The patient developed BK virus-associated nephropathy 1 year after transplantation and presented with a decline in renal function and hydronephrosis in the transplanted kidney 4 years 6 months after transplantation. Cystoscopy and retrograde pyelography revealed an irregular filling defect in the ureter graft. Cytologic diagnosis of his urine revealed a high-grade urothelial carcinoma. Computerized tomography showed a cT2 ureteral tumor and no involvement of other organs. The patient subsequently underwent a transplant nephroureterectomy with bladder cuff resection. Histopathologic findings revealed a high-grade urothelial carcinoma, pT2, in the ureter graft with SV40-positive staining. The patient was closely observed without adjuvant chemotherapy therapy and remained disease free 1 year after surgery. Renal transplant recipients with BK virus infection are at high risk of developing urologic malignancies. Close attention is necessary to diagnose post-transplantation urologica malignancies as early as possible.
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Cantarovich D, Rostaing L, Kamar N, Ducloux D, Saint-Hillier Y, Mourad G, Garrigue V, Wolf P, Ellero B, Cassuto E, Albano L, Völp A, Soulillou JP. Early corticosteroid avoidance in kidney transplant recipients receiving ATG-F induction: 5-year actual results of a prospective and randomized study. Am J Transplant 2014; 14:2556-64. [PMID: 25243534 DOI: 10.1111/ajt.12866] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 06/05/2014] [Accepted: 06/15/2014] [Indexed: 01/25/2023]
Abstract
One hundred ninety-seven patients received anti-T-lymphocyte globulins Fresenius, mycophenolate mofetil and delayed cyclosporine, and were randomized to ≥6-month corticosteroids (+CS; n=99) or no CS (-CS; n=98). One- and five-year actual graft survival (censored for death) was 93.2% and 86.4% in the +CS group versus 94.9% and 89.8% in the -CS group (5-year follow-up, p=0.487). Freedom from clinical rejection was 86.9% and 81.8% versus 74.5% and 74.5% (p=0.144), respectively, at 1 and 5 years; 5-year freedom from biopsy-proven rejection was 88.9% versus 83.7% (p=0.227). More late first rejections occurred in the +CS group. Significantly lower 5-year graft survival in patients experiencing rejection was observed for +CS (55.6% vs. 92.0%; p=0.005) with 8/18 versus 2/25 graft losses. Renal function at 5 years was stable and comparable (median serum creatinine, 159 vs. 145 µmol/L; creatinine clearance, 53.5 vs. 56.6 mL/min). More +CS patients developed diabetes, dyslipidemia and malignancies. Rejections in -CS patients occurred early after transplantation and did not impair long-term renal function. In patients receiving CS, rejections occurred later and with a higher risk for subsequent graft failure. A similar and not inferior 5-year efficacy profile and a reduced morbidity were observed in CS-free patients compared to patients who received CS for at least 6 months.
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Affiliation(s)
- D Cantarovich
- Institut de Transplantation-Urologie-Néphrologie (ITUN), Centre Hospitalier et Universitaire de Nantes, Nantes, France
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Hsiao FY, Hsu WWY. Epidemiology of post-transplant malignancy in Asian renal transplant recipients: a population-based study. Int Urol Nephrol 2013; 46:833-8. [PMID: 24009082 DOI: 10.1007/s11255-013-0544-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 08/14/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE 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. PATIENTS AND METHODS 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. RESULTS 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. CONCLUSIONS 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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Affiliation(s)
- F Y Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, 1 Jen-Ai Road, Section 1, Taipei, 10051, Taiwan,
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Li J, Chong AH, Green J, Kelly R, Baker C. Mycophenolate use in dermatology: A clinical audit. Australas J Dermatol 2013; 54:296-302. [DOI: 10.1111/ajd.12042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 02/04/2013] [Indexed: 01/27/2023]
Affiliation(s)
- Jane Li
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - Alvin H Chong
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
| | - Jack Green
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
| | - Robert Kelly
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
| | - Christopher Baker
- Department of Dermatology; St. Vincent's Hospital Melbourne; Melbourne Victoria Australia
- Skin and Cancer Foundation Inc.; Melbourne Victoria Australia
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McLaughlin J, Equils O, Somerville K, Aram J, Schlamm H, Welch V, Mardekian J, Barbers R. Risk-adjusted relationship between voriconazole utilization and non-melanoma skin cancer among lung and heart/lung transplant patients. Transpl Infect Dis 2013; 15:329-43. [DOI: 10.1111/tid.12063] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 10/01/2012] [Accepted: 10/10/2012] [Indexed: 11/30/2022]
Affiliation(s)
| | - O. Equils
- Pfizer, Inc.; New York; New York; USA
| | | | - J.A. Aram
- Pfizer, Inc.; New York; New York; USA
| | | | | | | | - R.G. Barbers
- Adult Asthma and Allergy Center; Lung Transplantation Program; Keck School of Medicine; University of Southern California; Los Angeles; California; USA
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Spanogle JP, Kudva YC, Dierkhising RA, Kremers WK, Roenigk RK, Brewer JD, Prieto M, Otley CC. Skin cancer after pancreas transplantation. J Am Acad Dermatol 2012; 67:563-9. [DOI: 10.1016/j.jaad.2011.11.939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 11/08/2011] [Indexed: 10/28/2022]
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Urologic De Novo Malignancies After Kidney Transplantation: A Single Center Experience. Transplant Proc 2012; 44:1293-7. [DOI: 10.1016/j.transproceed.2011.11.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 11/04/2011] [Indexed: 01/20/2023]
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Baughman RP, Nunes H. Therapy for sarcoidosis: evidence-based recommendations. Expert Rev Clin Immunol 2012; 8:95-103. [PMID: 22149344 DOI: 10.1586/eci.11.84] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The options for treatment of sarcoidosis have expanded. In this article, we outline a stepwise approach to treatment. Recommendations for treatment are based on available evidence. While corticosteroids remain the treatment of choice for initial systemic therapy, other agents have been shown to be steroid sparing, and therefore useful for long-term management. In addition, new agents have proved to be useful for patients with refractory disease.
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Affiliation(s)
- Robert P Baughman
- Interstitial Lung Disease and Sarcoidosis Clinic, Department of Medicine, University of Cincinnati, Cincinatti, OH 45267, USA.
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Zhang Z, Yu D, Yuan J, Guo Y, Wang H, Zhang X. Cigarette smoking strongly modifies the association of complement factor H variant and the risk of lung cancer. Cancer Epidemiol 2012; 36:e111-5. [DOI: 10.1016/j.canep.2011.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 10/29/2011] [Accepted: 11/06/2011] [Indexed: 11/26/2022]
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Karczewski M, Stronka M, Karczewski J, Wiktorowicz K. Skin cancer following kidney transplantation: a single-center experience. Transplant Proc 2012; 43:3760-1. [PMID: 22172842 DOI: 10.1016/j.transproceed.2011.08.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 08/30/2011] [Indexed: 10/14/2022]
Abstract
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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Affiliation(s)
- M Karczewski
- Department of Transplantology and General Surgery, District Hospital in Poznan, and Poznan University of Medical Sciences, Poznan, Poland.
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Abstract
The last two decades have witnessed a pandemic in antibody development, with over 600 entering clinical studies and a total of 28 approved by the FDA and European Union. The incorporation of biologics in transplantation has made a significant impact on allograft survival. Herein, we review the armamentarium of clinical and preclinical biologics used for organ transplantation--with the exception of belatacept--from depleting and IL-2R targeting induction agents to costimulation blockade, B-cell therapeutics, BAFF and complement inhibition, anti-adhesion, and anti-cytokine approaches. While individual agents may be insufficient for tolerance induction, they provide possibilities for reduction of steroid or calcineurin inhibitor use, alternatives to rejection episodes refractory to conventional therapies, and specialized immunosuppression for highly sensitized patients.
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Affiliation(s)
- Eugenia K Page
- Department of Surgery, Emory University Hospital, Atlanta, GA, USA
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Post-transplant lymphoproliferative disorder after lung transplantation: a review of 35 cases. J Heart Lung Transplant 2011; 31:296-304. [PMID: 22112992 DOI: 10.1016/j.healun.2011.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 09/08/2011] [Accepted: 10/22/2011] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) is a complication of organ transplantation. The risk of developing PTLD varies depending on a number of factors, including the organ transplanted and the degree of immunosuppression used. METHODS We report a retrospective analysis of 35 patients with PTLD treated at our center after lung transplantation. Of 705 patients who received allografts, 34 (4.8%) developed PTLD. One patient underwent transplantation elsewhere and was treated at our center. RESULTS PTLD involved the allograft in 49% of our patients and the gastrointestinal (GI) tract lumen in 23%. Histologically, 39% of tumors were monomorphic and 48% polymorphic. The time to presentation defined the location and histology of disease. Of 17 patients diagnosed within 11 months of transplantation, PTLD involved the allograft in 12 (71%) and the GI tract in 1 (p = 0.01). This "early" PTLD was 85% polymorphic (p = 0.006). Conversely, of the 18 patients diagnosed more than 11 months after transplant, the lung was involved in 5 (28%) and the GI tract in 7 (39%; p = 0.01). "Late" PTLD was 71% monomorphic (p = 0.006). Median overall survival after diagnosis was 18.57 months. Overall survival did not differ between all lung transplant recipients and those who developed PTLD. CONCLUSIONS PTLD is an uncommon complication after lung transplantation, and its incidence declined remarkably in the era of modern immunosuppression. We report several factors that are important for predisposition toward, progression of, and treatment of PTLD after lung transplantation.
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Abstract
Over the past several decades, there has been increasing interest in understanding the roles of the immune system in the development and progression of cancer. The importance of the immune system in human skin cancer has been long recognized based primarily upon the increased incidence of skin cancers in organ transplant recipients and mechanisms of ultraviolet (UV) radiation-mediated immunomodulation. In this review, we integrate multiple lines of evidence highlighting the roles of the immune system in skin cancer. First, we discuss the concepts of cancer immunosurveillance and immunoediting as they might relate to human skin cancers. We then describe the clinical and molecular mechanisms of skin cancer development and progression in the contexts of therapeutic immunosuppression in organ transplant recipients, viral oncogenesis, and UV radiation-induced immunomodulation with a primary focus on basal cell carcinoma and squamous cell carcinoma. The clinical evidence supporting expanding roles for immunotherapy is also described. Finally, we discuss recent research examining the functions of particular immune cell subsets in skin cancer and how they might contribute to both antitumour and protumour effects. A better understanding of the biological mechanisms of cancer immunosurveillance holds the promise of enabling better therapies.
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Affiliation(s)
- S Rangwala
- Baylor College of Medicine, Houston, TX, USA
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Abstract
Transplantation of solid organs and haematopoietic stem cells requires immunosuppressive drug therapy in order to prevent rejection or graft-versus-host disease. Depending on dosage and type of drug, the risk of developing an Epstein-Barr virus (EBV)-associated post-transplant lymphoproliferative disease (PTLD) is increased. The lesion spectrum ranges from hyperplastic lesions to manifest lymphomas, the latter being classified as monomorphic PTLD. Hyperplastic changes, which are not distinguishable from viral reactions, comprise early or mononucleosis-like lesions. Those with effaced lymph node architecture or extranodal manifestation without a lymphoma-like phenotype are designated polymorphic PTLD. Monomorphic PTLD are either high grade B cell lymphomas, plasma cell neoplasms or Hodgkin lymphomas and only very rarely T cell lymphomas. Low grade B cell lymphomas do not occur. In a subfraction of cases, including even monomorphic PTLD, reduction of immunosuppression alone is sufficient to induce remission of the pathological process.
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Jothimani D, Cramp ME, Mitchell JD, Cross TJS. Treatment of autoimmune hepatitis: a review of current and evolving therapies. J Gastroenterol Hepatol 2011; 26:619-27. [PMID: 21073674 DOI: 10.1111/j.1440-1746.2010.06579.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Autoimmune hepatitis (AIH) is an immune-mediated necroinflammatory condition of the liver. Presentation can vary from the asymptomatic individual with abnormal liver function test to fulminant liver failure. The diagnosis is based on the combination of biochemical, autoimmune, and histological parameters, and exclusion of other liver diseases. Standard therapy consists of a combination of corticosteroids and azathioprine, which is efficacious in 80% of patients. Alternative therapies are increasingly being explored in patients who do not respond to the standard treatment and/or have unacceptable adverse effects. This review examines the role of alternative drugs (second-line agents) available for AIH treatment non-responders. These agents include budesonide, mycophenolate mofetil, cyclosporin, tacrolimus, 6-mercaptopurine, 6-thioguanine, rituximab, ursodeoxycholic acid, rapamycin, and methotrexate. In addition, the risk of opportunistic infections and malignancies are discussed. A treatment algorithm is proposed for the management of patients with AIH treatment non-responders.
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Affiliation(s)
- Dinesh Jothimani
- The Southwest Liver Unit, Derriford Hospital, Plymouth, Devon, UK
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An Integrated Safety Profile Analysis of Belatacept in Kidney Transplant Recipients. Transplantation 2010; 90:1521-7. [DOI: 10.1097/tp.0b013e3182007b95] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Smith MA, Irving PM, Marinaki AM, Sanderson JD. Review article: malignancy on thiopurine treatment with special reference to inflammatory bowel disease. Aliment Pharmacol Ther 2010; 32:119-30. [PMID: 20412066 DOI: 10.1111/j.1365-2036.2010.04330.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Immunosuppression is a risk factor for carcinogenesis. Thiopurines specifically contribute to this. As thiopurines are used more aggressively in the treatment of IBD, it is likely that we will see more thiopurine-related malignancy. AIM To review the literature, exploring how immunosuppression, thiopurines specifically, might cause cancer and which malignancies occur in practice, placing specific emphasis on IBD cohorts. METHODS Search terms included 'malignancy' 'cancer' 'azathioprine' 'mercaptopurine' 'tioguanine (thioguanine)' 'thiopurine' and 'inflammatory bowel disease' 'Crohn's disease' 'ulcerative colitis'. We also searched for specific cancers (lymphoma, colorectal cancer, skin cancer, cervical cancer) and reviewed the reference lists of the articles detected. RESULTS Immunosuppression is associated with an increased risk of cancer. Thiopurines are associated with specific additional risks. In IBD cohorts, very few thiopurine-related malignancies have been reported. However, studies suggest a relative risk of 4-5 for lymphoma. This still translates into a low actual risk, (one extra lymphoma in every 300-1400 years of thiopurine treatment). CONCLUSIONS Whilst we must be aware of this risk and counsel our patients appropriately, thiopurines remain a mainstay of IBD therapy. We present practical advice aimed at minimizing our patients' risk of developing malignancy, whilst optimizing the benefits that thiopurines can provide.
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Affiliation(s)
- M A Smith
- Department of Gastroenterology Guy's & St. Thomas' NHS Foundation Trust, London, UK
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Using Epstein-Barr viral load assays to diagnose, monitor, and prevent posttransplant lymphoproliferative disorder. Clin Microbiol Rev 2010; 23:350-66. [PMID: 20375356 DOI: 10.1128/cmr.00006-09] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Epstein-Barr virus (EBV) DNA measurement is being incorporated into routine medical practice to help diagnose, monitor, and predict posttransplant lymphoproliferative disorder (PTLD) in immunocompromised graft recipients. PTLD is an aggressive neoplasm that almost always harbors EBV DNA within the neoplastic lymphocytes, and it is often fatal if not recognized and treated promptly. Validated protocols, commercial reagents, and automated instruments facilitate implementation of EBV load assays by real-time PCR. When applied to either whole blood or plasma, EBV DNA levels reflect clinical status with respect to EBV-related neoplasia. While many healthy transplant recipients have low viral loads, high EBV loads are strongly associated with current or impending PTLD. Complementary laboratory assays as well as histopathologic examination of lesional tissue help in interpreting modest elevations in viral load. Circulating EBV levels in serial samples reflect changes in tumor burden and represent an effective, noninvasive tool for monitoring the efficacy of therapy. In high-risk patients, serial testing permits early clinical intervention to prevent progression toward frank PTLD. Restoring T cell immunity against EBV is a major strategy for overcoming PTLD, and novel EBV-directed therapies are being explored to thwart virus-driven neoplasia.
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Abstract
Ultraviolet (UV) radiation is a complete carcinogen. The effects of UV radiation are mediated via direct damage to cellular DNA in the skin and suppression of image surveillance mechanisms. In the context of organ transplantation, addiction of drugs which suppress the immune system add greatly to the carcinogenicity of UV radiation. This review considers the mechanisms of such effects.
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Affiliation(s)
- G M Murphy
- Department of Dermatology, Beaumont & Mater Misericordiae Hospital, Dublin, Ireland.
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