Repeated exposure to fractional CO2 laser delays squamous cell carcinoma formation and prevents clinical and subclinical photodamage visualized by line-field confocal optical coherence tomography and histology

OBJECTIVES

Ablative fractional laser (AFL) is a well-established modality for treating ultraviolet radiation (UVR)-induced skin photodamage. We aimed to investigate the potential of AFL to delay squamous cell carcinoma (SCC) formation and prevent photodamage in a preclinical UVR-induced SCC model.

MATERIALS AND METHODS

Hairless C3.Cg-Hrhr /TifBomTac mice (n = 50) were exposed to UVR three times weekly throughout the study. UV-exposed mice were randomized to two groups that received dorsal CO2 AFL (10 mJ/mb, 10% density) or no treatment. AFL was performed every other week for a total of 16 weeks (nine treatments in total). The primary outcome was time to tumor occurrence. In a subset of mice on Day 150, prevention of clinical photodamage was assessed by examination of skin tightness and dyspigmentation. Concomitantly, assessment of subclinical photoprevention based on normalization of keratinocyte dysplasia, dermo-fiber morphology (collagen and elastin fibers), and skin thickness, was performed using line-field confocal optical coherence tomography (LC-OCT) and histology.

RESULTS

Repeated AFL treatments delayed SCC tumor development compared to UVR control mice by 12, 19, and 30 days for first, second, and third tumors, respectively (p ≤ 0.0017). Compared to UVR controls, AFL prevented photodamage both clinically and subclinically, based on LC-OCT and histology. In the epidermal layer, AFL imparted photopreventative effects including reduced dyspigmentation and keratinocyte dysplasia (1 vs. 2.5, p = 0.0079) and partial normalization of the epidermal thickness (p < 0.0001). In the dermis, AFL led to twofold greater skin tightness (p = 0.0079), improved dermo-fiber structure, and dermal thickness (p = 0.0011).

CONCLUSION

In conclusion, repeated AFL treatments of UVR-exposed skin significantly delayed SCC tumor formation and prevented clinical and imaging-assessed subclinical signs of photodamage, indicating a potential for AFL in prevention strategies for SCC and photodamage in high-risk populations.

Randomized controlled trial of fractionated laser resurfacing on aged skin as prophylaxis against actinic neoplasia

BACKGROUNDThe loss of insulin-like growth factor 1 (IGF-1) expression in senescent dermal fibroblasts during aging is associated with an increased risk of nonmelanoma skin cancer (NMSC). We tested how IGF-1 signaling can influence photocarcinogenesis during chronic UVB exposure to determine if fractionated laser resurfacing (FLR) of aged skin, which upregulates dermal IGF-1 levels, can prevent the occurrence of actinic keratosis (AK) and NMSC.METHODSA human skin/immunodeficient mouse xenografting model was used to test the effects of a small molecule inhibitor of the IGF-1 receptor on chronic UVB radiation. Subsequently, the durability of FLR treatment was tested on a cohort of human participants aged 65 years and older. Finally, 48 individuals aged 60 years and older with considerable actinic damage were enrolled in a prospective randomized clinical trial in which they underwent a single unilateral FLR treatment of one lower arm. Numbers of AKs/NMSCs were recorded on both extremities for up to 36 months in blinded fashion.RESULTSXenografting studies revealed that chronic UVB treatment with a topical IGF-1R inhibitor resulted in a procarcinogenic response. A single FLR treatment was durable in restoring appropriate UVB response in geriatric skin for at least 2 years. FLR resulted in sustained reduction in numbers of AKs and decreased numbers of NMSCs in the treated arm (2 NMSCs) versus the untreated arm (24 NMSCs).CONCLUSIONThe elimination of senescent fibroblasts via FLR reduced the procarcinogenic UVB response of aged skin. Thus, wounding therapies are a potentially effective prophylaxis for managing high-risk populations.TRIAL REGISTRATIONClinicalTrials.gov (NCT03906253).FUNDINGNational Institutes of Health, Veterans Administration.

Calcineurin inhibitor (CNI)-associated skin cancers: New insights on exploring mechanisms by which CNIs downregulate DNA repair machinery

The use of the calcineurin inhibitors (CNI) cyclosporine (CsA) and tacrolimus remains a cornerstone in post-transplantation immunosuppression. Although these immunosuppressive agents have revolutionized the field of transplantation medicine, its increased skin cancer risk poses a major concern. A key contributor to this phenomenon is a reduced capacity to repair DNA damage caused by exposure to ultraviolet (UV) wavelengths of sunlight. CNIs decrease DNA repair by mechanisms that remain to be fully explored. Though CsA is known to decrease the abundance of key DNA repair enzymes, less is known about how tacrolimus yields this effect. CNIs hold the capacity to inhibit both of the main catalytic calcineurin isoforms (CnAα and CnAβ). However, it is unknown which isoform regulates UV-induced DNA repair, which is the focus of this review. It is with hope that this insight spurs investigative efforts that conclusively addresses these gaps in knowledge. Additionally, this research also raises the possibility that newer CNIs can be developed that effectively blunt the immune response while mitigating the incidence of skin cancers with immunosuppression.

Dermatological Disease in Australian Heart and Lung Transplant Recipients

BACKGROUND

Research examining skin disease in heart and lung transplant recipients in Australia is limited. This study aims to determine the spectrum of skin diseases encountered in Australian heart and lung transplant recipients, their effect on quality of life, and potential risk factors for skin cancer.

METHODS

Ninety-four participants were recruited from an Australian heart and lung transplant centre between March and December 2016. The participants were asked to fill out a questionnaire which included the Dermatology Life Quality Index and were examined for malignant and non-malignant skin disease. The association of study variables with the presence of skin cancer and Dermatology Life Quality Index score were examined using logistic regression analysis.

RESULTS

A dermatological diagnosis was made in 82 patients (87%). Actinic keratosis was the most common diagnosis, affecting 50 participants (53%), followed by skin cancer (41; 44%) and warts (14; 15%). Other non-malignant skin diseases were less common. Risk factors associated with skin cancer on multivariate modelling included age at transplantation and a history of ≥5 post-transplant skin cancers. Skin disease had a negative effect on the quality of life of a minority of patients.

CONCLUSION

Actinic keratosis and skin cancer are very frequent in Australian heart and lung transplant recipients and more common than non-malignant skin diseases. Routine dermatological surveillance at regular intervals is advised.

Single Ablative Fractional Resurfacing Laser Treatment For Forearm Actinic Keratoses: 6-Month Follow-Up Data From An Intrapatient Comparison Between Treated and Untreated Sites

BACKGROUND AND OBJECTIVES

Actinic keratoses (AK) are common pre-cancerous lesions, which are associated with ultraviolet light exposure and aging. Wounding therapies such as fractionated laser resurfacing (FLR) have been previously demonstrated to effectively treat facial AK. However, the effectiveness of FLR on other sites commonly afflicted with AK has not been studied in detail. Previously, our group has reported that treatment of aged skin with wounding therapies including dermabrasion and ablative fractionated resurfacing results in the removal of senescent fibroblasts and normalizing the pro-carcinogenic acute ultraviolet B radiation responses associated with aged skin. The current studies were designed to test the effectiveness of FLR of the forearm skin of subjects aged 60 and older to remove AKs.

STUDY DESIGN/MATERIALS AND METHODS

Between February 2018 and March 2019, 30 subjects were enrolled in a study, in which they underwent a single FLR treatment of one extremity including the dorsal forearm, wrist, and dorsal hand. The number of AKs was recorded on both extremities at baseline, 3 and 6 months in a blinded fashion. Side effects of the FLR were documented.

RESULTS

A single FLR treatment resulted in a 62% reduction in the absolute number of AK in the treated arm at 6 months post-treatment. The laser treatment was well-tolerated without major complications.

CONCLUSIONS

These studies demonstrate that FLR using settings, which have demonstrated to remove senescent fibroblasts and normalize the pro-carcinogenic UVB-response of aged skin is a potentially effective and safe field therapy treatment that should be studied for long-term efficacy for use in treating upper extremity AKs. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

HLA alleles in renal transplant recipients with nonmelanoma skin cancer in southeastern Brazil

BACKGROUND

Renal transplant recipients are submitted to immunosuppression to avoid graft rejection, which makes them susceptible to various conditions. Furthermore, these individuals present malignant tumors more frequently than the general population, including nonmelanoma skin cancer. The individual genetic basis that acts in the pathogenesis of cutaneous cancer may present a protection or susceptibility factor for disease development. One of these factors is the HLA complex.

OBJECTIVE

To investigate HLA alleles association to the occurrence of nonmelanoma skin cancer in renal transplant recipients from São Paulo State.

METHODS

A total of 213 patients (93 renal transplant recipients with nonmelanoma skin cancer and 120 renal transplant recipients without nonmelanoma skin cancer) were evaluated by retrospective and cross-sectional study. Epidemiological, clinical and HLA typing data were found in databases. HLA class I (A, B) and class II (DR) alleles were compared to establish their association with nonmelanoma skin cancer.

RESULTS

Comparing renal transplant recipients with and without nonmelanoma skin cancer, the HLA-B*13 allele was associated with higher risk of developing nonmelanoma skin cancer while B*45 and B*50 alleles were associated with protection.

STUDY LIMITATIONS

The HLA A, B and DR alleles identification for the kidney transplantation routine is done by low and medium resolution techniques that do not allow discrimination of specific alleles.

CONCLUSION

The involvement of HLA alleles in nonmelanoma skin cancer in renal transplant recipients was confirmed in this study. Renal transplant recipients with HLA-B*13 showed higher risk for developing a skin cancer (OR= 7.29) and should be monitored for a long period of time after transplantation.

Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.

Skin cancer in organ transplant recipients: dynamics in the incidence and clinical predictors for the first and subsequent post-transplant non-melanoma skin cancer

BACKGROUND

Risk factors for primary non-melanoma skin cancer (NMSC) in organ transplant recipients (OTR) have been well described. Data for subsequent NMSC and dynamics in their occurrence in OTR are limited.

OBJECTIVE

To study long-term risks of primary and subsequent NMSC and associated risk factors in OTR.

METHODS

A retrospective single-centre cohort study analysing medical records from a dermato-oncological specialty clinic.

RESULTS

Of 464 OTR 110 (23.7%) developed at least one, 73 (15.7%) two and 51 (11%) three NMSC during a median follow-up of 9.6 years. Cumulative incidences at 5, 10 and 15 years were 14.7%, 23.5% and 34.5% for the first and 75.8%, 86.5% and 93.3% for the second. Median time-to-diagnosis declined from 22 years (95% CI 19-25) to 2 years (1-3) and about 1 year (0-2) for the first, second and third NMSC. Risk for subsequent NMSC only partially related to risk factors for the primary NMSC. Histologic type of the first NMSC predicted subtype and time-to-diagnosis of the subsequent NMSC.

CONCLUSIONS

A first post-transplant NMSC, particularly a SCC, confers a high risk for subsequent NMSC arising with accelerated dynamics. Risk-adapted dermato-oncologic surveillance is advisable for all OTR.

Comparison of Skin Cancer Incidence in Caucasian and Non-Caucasian Liver Vs. Lung Transplant Recipients: A Tale of Two Regimens

BACKGROUND

Organ transplantation is a significant risk factor for the development of skin cancer. The impact of skin type, immunosuppressive regimens, and photosensitizing agents requires further study.

OBJECTIVE

The objective of this study was to compare skin cancer development between Caucasian and non-Caucasian transplant recipients at the University of Southern California.

METHODS

We performed a retrospective chart review of lung and liver transplantations to determine the incidence of post-transplant skin cancer. Participants included patients who underwent lung or liver transplantation between 2005 and 2013 at our institution. Patients included in the study were limited to those who survived through the study observation period.

RESULTS

We analyzed 475 patients who underwent transplantation, including 370 liver transplant recipients and 105 lung transplant recipients. Among these, 46.3% identified as Caucasian, while 53.7% were non-Caucasian. Over a mean follow-up of 7.9 years, 11.8% of Caucasian patients developed at least one skin cancer, compared with 2.7% of non-Caucasians (p < 0.001). However, irrespective of race, skin cancer development was significantly greater in lung compared with liver transplant recipients (20.0% vs. 3.2%, p < 0.001). The standard immunosuppressive and prophylactic regimens were mycophenolate mofetil and tacrolimus based for both transplants. Mycophenolate mofetil was maintained throughout the course in lung transplant patients, whereas this agent was reduced and terminated when possible in liver transplant recipients. In addition, during the years examined, voriconazole, a known photosensitizing agent, was used in lung transplant recipients to prevent aspergillosis.

CONCLUSIONS

Fair skin type increases post-transplant skin cancer development, irrespective of the immunosuppressive regimen. A higher risk of skin cancer is associated with different regimens; in particular photosensitizing agents may increase risk in transplant recipients.

Incidence of nonmelanoma skin cancer in renal transplant recipients: A systematic review and meta-analysis

Background

Nonmelanoma skin cancer (NMSC) in renal transplant recipients is common and associated with significant morbidity and mortality. The aim of the present systematic review and meta-analysis was to estimate the incidence of NMSC among renal transplant recipients.

Materials and Methods

We systematically searched PubMed, Medline, Scopus, and Web of Science databases for studies that assessed the incidence of NMSC in renal transplant recipients using a combination of relevant keywords. Two independent investigators included studies and extracted necessary information. Random effect meta-analysis was used to estimate pooled incidence of NMSC with 95% confidence intervals (CIs).

Results

Twenty-nine studies comprising 36,021 patients meet the criteria for the systematic review. The pooled incidence of NMSC in renal transplant recipients was 12.6% (95% CI: 12%-14%) with a majority of squamous cell carcinoma (SCC) 55% (95% CI: 47%-63%). The pooled estimate of the incidence rates of SCC and basal cell carcinoma was 2.7% (95% CI: 2%-3.4%) and 2.2% (95% CI: 1.5%-2.8%), respectively. Subgroup analysis per geographic location showed that pooled incidence of NMSC was 39.1% (95% CI: 26.3%-51.8%), 12.4% (95% CI: 8.8%-16%), and 1.2% (95% CI: 0.4%-2%) in Australia and New Zealand, Europe, and Middle East, respectively.

Conclusion

The results of the current meta-analysis demonstrated that the incidence of NMSC in renal transplant recipients varies widely. Regarding the high incidence of NMSC among renal transplant recipients, awareness of associated risk factors and early diagnosis of the malignancy in the population is a major clinical need.

Human Papillomavirus in Kidney Transplant Recipients

Human papillomavirus (HPV) is a common infection in kidney transplant recipients. HPV causes cervical, anal, vulvar, vaginal, penile and head and neck cancers. Kidney transplant recipients have a disproportionate burden of disease given prolonged immunosuppression. Given the long pre-invasive state of precancer lesions such as cervical intraepithelial neoplasia (CIN) and anal intraepithelial neoplasia (AIN) most HPV-cancers are preventable with screening and targeted treatment of disease. Pre-transplant vaccination of age-eligible kidney transplant recipients is otherwise ideal.

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.

Epidemiology and clinical evolution of non-melanoma skin cancer in renal transplant recipients: a single-center experience in São Paulo, Brazil

BACKGROUND

Non-melanoma skin cancer (NMSC) is very common among renal transplant recipients (RTRs) as a result of the immunosuppressed status of these patients and other factors. Few studies have examined the clinical characteristics and evolution of NMSC in RTRs in tropical countries.

OBJECTIVES

The aim of this study was to characterize the epidemiology and clinical evolution of NMSC in RTRs.

METHODS

We conducted a retrospective study including 68 RTRs with NMSC diagnosed from July 2004 to December 2009 with a minimum follow-up of three years. We analyzed demographic and transplant- and NMSC-related data.

RESULTS

The mean age of patients at the first diagnosis of NMSC was 51 years (range: 29-71 years). Most first diagnoses occurred within nine years post-transplant. The majority of patients (n = 48) had Fitzpatrick skin phototype II, although NMSC was also observed in those with skin phototypes III and IV. Forty-six (67.6%) RTRs had received a kidney from a living donor. Fifty-five (80.9%) RTRs had received cytotoxic immunosuppressives, 51 (75.0%) had received calcineurin inhibitors, and two (2.9%) had received mTOR inhibitors. Most of the RTRs developed about eight NMSC lesions, but up to 25 NMSC lesions were diagnosed in one patient. Most lesions (67.6%) were located on sun-exposed areas. Squamous cell carcinoma (SCC) represented the predominant tumor type, accounting for 70.6% of all tumors, whereas basal cell carcinoma accounted for 29.4% of all tumors. Invasive SCC predominated over in situ SCC. Finally, 48.5% of patients had a previous history of viral warts.

CONCLUSIONS

Long-term use of immunosuppressive therapy increases the risk for tumor occurrence. Multiple NMSC tumors can develop in patients in tropical countries, even in patients with a high skin phototype. Therefore, RTRs should understand the high risk for the development of malignant tumors and should be properly informed about the prevention and treatment of NMSC.

Epidemiological profile of nonmelanoma skin cancer in renal transplant recipients: experience of a referral center

BACKGROUND

Nonmelanoma skin cancer is the most common form of cancer in humans and also the malignant disease that is increasingly common among kidney transplant recipients.

OBJECTIVE

To determine the epidemiological characteristics of renal transplant recipients with nonmelanoma skin cancer seen at a referral transplantation center.

METHODS

Cross-sectional descriptive study with renal transplant recipients presenting nonmelanoma skin cancer, treated at a transplantation referral center between 08/01/2004 and 08/31/2009. Analyzed variables were: gender, age, skin phototype, occupational and recreational sun exposure, use of photoprotection, personal and family history of non-melanoma skin cancer, clinical type and location, time between transplantation and the appearance of the first nonmelanoma skin cancer, occurrence of viral warts, timing of transplantation, type of donor, cause of kidney failure, previous transplants, comorbidities, pre-transplant dialysis, type and duration of dialysis.

RESULTS

64 subjects were included. Males - 71.9%; low skin phototypes (up to Fitzpatrick III) - 89%; mean age - 57.0 years - and mean age at transplant - 47.3 years; sun exposure - 67.2% occupational - and 64.1% recreational; photoprotection - 78.2% (although only 34.4% in a regular manner); squamous cell carcinoma - 67.2%; squamous cell carcinoma/basal cell carcinoma ratio - 2:1; personal history of nonmelanoma skin cancer - 25% - and family history - 10.9%; location at photoexposed area - 98.4%; average latency time between transplantation and first nonmelanoma skin cancer appearance - 78.3 months; viral warts (HPV) after transplant - 53.1%; average timing of transplantation - 115.5 months; living donor - 64.1%; triple regimen (antirejection) - 73.2%; comorbidities - 92.2%; pre-transplant dialysis - 98.4%; hemodialysis - 71.7%; average duration of dialysis - 39.1 months; previous transplants - 3.1%; hypertension as cause of renal failure - 46.9%.

CONCLUSION

This study allowed the epidemiological characterization of a population of kidney transplant recipients with nonmelanoma skin cancer.

Peritumoral dermis of squamous cell carcinomas in renal transplant recipients contains less CD11c+ myeloid dendritic cells and FoxP3+ T cells compared to immunocompetent controls

BACKGROUND

Renal transplant recipients (RTR) have an increased risk of developing cutaneous squamous cell carcinomas (SCC). These SCC are often more aggressive than SCC in immunocompetent individuals.

OBJECTIVES

In this comparative study, we analysed the cell composition in the tissue immediately surrounding invasive SCC in immunosuppressed RTR and immunocompetent controls in an effort to further elucidate the role of the local immune system.

METHODS

Morphology and quantity of various dendritic cell (DC) subsets, macrophages and FoxP3+ T cells were analysed by immunohistochemical staining.

RESULTS

The number of CD11c+ myeloid DC and FoxP3+ T cells was significantly reduced in RTR, whereas the number of plasmacytoid DC, Langerhans cells and macrophages was similar in RTR and controls.

CONCLUSIONS

A reduction in CD11c+ mDC in peritumoral dermis in RTR might contribute to impaired immunosurveillance thus giving rise to an increased risk to develop aggressive SCC in these patients.

Lesiones cutáneas en pacientes con trasplante renal en el Hospital Universitario San Ignacio

Introducción: Las enfermedades cutáneas son frecuentes en los pacientes trasplantados renales, por lo cual el monitoreo de la piel es necesario para realizar un diagnóstico precoz e iniciar tratamiento temprano.Objetivo: Determinar la prevalencia de las manifestaciones cutáneas en pacientes con trasplante renal. Materiales y métodos: Se evaluaron en consulta de dermatología 86 pacientes del programa de trasplante renal del Hospital Universitario San Ignacio.Resultados: Las infecciones de piel fueron las manifestaciones más prevalentes, y dentro de estas las más frecuentes fueron las micosis superficiales presentes, en un 48 % de los pacientes; seguidas por las infecciones virales, en un 20 %, y las bacterianas, en un 15 %. Se encontraron dos casos de cáncer de piel: un carcinoma basocelular y un sarcoma de Kaposi. Doce pacientes tuvieron queratosis actínicas consideradas lesiones premalignas.Conclusión: Los resultados del estudio evidencian la necesidad de realizar un examen dermatológico rutinario en los pacientes trasplantados para detectar tempranamente la presencia de lesiones cutáneas y, de esta manera, iniciar un manejo oportuno. Los hallazgos más comunes fueron las micosis superficiales.

The role of new immunosuppressive drugs in nonmelanoma skin cancer in renal transplant recipients

INTRODUCTION

Nonmelanoma skin cancer (NMSC) is the most common malignancy in patients who have received a solid organ transplant. Multiple factors are involved in the onset of posttransplant NMSC.

OBJECTIVES

To analyze the relationship between new immunosuppressive drugs and the onset of NMSC in renal transplant recipients.

METHOD

This was a combined retrospective and prospective observational study in which we studied 289 patients who received a kidney transplant between January 1996 and December 2010 at Hospital Universitario Doctor Peset in Valencia, Spain.

RESULTS

Seventy-three patients (25.2%) developed 162 NMSCs over a median follow-up of 72 months. There were no statistically significant differences in the onset of NMSC on comparing different induction therapy strategies involving monoclonal and polyclonal antibodies. NMSCs occurred less frequently in patients treated with mammalian target of rapamycin (mTOR) inhibitors than in those treated with other immunosuppressive regimens, although the differences were not statistically significant. Three of 5 patients with recurrent NMSC who were switched from calcineurin inhibitors to mTOR inhibitors developed additional NMSCs despite the change.

CONCLUSIONS

Induction therapy with monoclonal and polyclonal antibodies in renal transplant recipients is not associated with an increased risk of NMSC. While mTOR inhibitors are associated with a lower risk of posttransplant NMSC, it remains to be determined whether a switch to these drugs is useful in the management of patients who develop multiple NMSCs.

Study of dermatoses in kidney transplant patients

BACKGROUND

The increasing in the number of kidney transplant recipients has favored, more frequently than before, the emergence of dermatoses and warranted their study through subsequent publications.

OBJECTIVES

to evaluate the frequency of dermatoses in kidney transplant recipients.

METHODS

kidney transplant recipients with suspected dermatoses between March 1st 2009 and June 30th 2010.

RESULTS

53 patients (28 males and 25 females), aged between 22 and 69 (mean age = 45 years) were evaluated. Most of them came from the cities of Ceilândia, Samambaia and São Sebastião/DF, and had already been transplanted for 5 to 10 years before (37.7%); 62.3% were recipients of living donors and 83% were prednisone-treated. The most prevalent dermatoses were of fungal (45.3%) and viral (39.6%) etiologies. Among the non-melanoma malignant neoplasms, the basal cell carcinoma prevailed (six cases), in spite of the low incidence. Concerning fungal dermatoses, 12 cases of onychomycosis, five of pityriasis versicolor and four of pityrosporum folliculitis were reported. For diagnosis, in most cases (64.2%), laboratory examinations (mycological and histopathological) were performed.

CONCLUSION

cutaneous manifestations in kidney transplant recipients are generally secondary to immunosuppression. The infectious dermatoses, especially those of fungal origin, are frequently found in kidney transplant recipients and their occurrence increases progressively according to the time elapsed from the transplantation, which makes follow-up important.

Dermatology of the head and neck: skin cancer and benign skin lesions

Skin lesions are extremely common, and early detection of dangerous lesions makes skin cancer one of the most highly curable malignancies. By simply becoming aware of common lesions and their phenotypic presentation, dental professionals are empowered to detect suspicious dermatologic lesions in unaware patients. This article serves as an introduction to skin cancer and benign skin lesions for dental professionals.

Nonmelanoma skin cancer in solid organ transplant recipients: update on epidemiology, risk factors, and management

BACKGROUND

Nonmelanoma skin cancers (NMSC) are the most frequently observed cancers in solid organ transplant recipients (SOTR) and may have a significant disease burden.

OBJECTIVE

To provide an update regarding the epidemiology and management of NMSC in SOTR.

RESULTS

Ten-year incidence rates range from 10% in Italy to 20% in Northern Europe to 70% in Australia. More than 50% of NMSC are located on sun-exposed areas (head, dorsum of hands). Many risk factors have been identified, including age at transplantation, fair skin, type of immunosuppressive drugs, cumulative sun exposure, viral infections, and various genetic markers. Patients with a first NMSC have a 49 times higher risk of developing a subsequent NMSC. Skin self-examination and photoprotection should be encouraged in all transplanted patients. Long-term skin surveillance, early diagnosis and aggressive treatment of any suspicious lesion, reduction of immunosuppressive therapy, and conversion to m-TOR inhibitors can be also effective measures for reduction of NMSC incidence.

CONCLUSIONS

NMSC is the most frequent cancer observed in SOTR. Early diagnosis, patient education, and modification of immunosuppression are effective measures for reduction of NMSC incidence.

HPV-related (pre)malignancies of the female anogenital tract in renal transplant recipients

Renal transplantations (RTs) are performed routinely in many countries. After RT, the administration of lifelong immunosuppressive therapy is required. As a consequence, renal transplant recipients (RTRs) have a high risk to develop virus-associated (pre)malignancies, such as Human papillomavirus (HPV) related anogenital (pre)malignancies. It is known that the majority of the RTRs are infected with HPV and that these women have a 14-fold increased risk of cervical cancer, up to 50-fold of vulvar cancer and up to 100-fold of anal cancer. Often, treatment of these lesions requires concessions and may be suboptimal as radiation therapy and extensive surgery may damage the renal transplant. Therefore, prognosis may be compromised due to inadequately treated malignancies. Especially for these immunocompromised patients prevention is of utmost importance. Yearly cervical cancer screening for RTRs is advised, but appears to be executed poorly. For the future, optimizing screening and prevention of anogenital (pre)malignancies is an important issue for women after RT. This review gives a broad overview of all aspects regarding HPV-related (pre)malignancies of the female anogenital tract in RTRs.

Cutaneous manifestations in 100 renal and reno-pancreatic recipients of Uruguay

Uruguay is the second country of Latin America in prevalence of renal replacement therapies, including functioning kidney allografts. Long-term immunosuppressive therapy is essential for adequate graft function, but results in reduced immunosurveillance leading to an increased risk of complications such as infections and malignancies. A variety of cutaneous manifestations as well as an increase in non-melanoma skin cancers have been reported in this population. The objective of this study was to evaluate the frequency and clinical spectrum of cutaneous manifestations in renal and reno-pancreatic recipients in Uruguay. One hundred renal or reno-pancreatic recipients aged between 21- and 77-years-old were evaluated between September 2009 and September 2010. A total of 104 dermatoses were observed; 68% of the patients had at least one cutaneous manifestation. The most frequent dermatoses were cutaneous side effects due to immunosuppressive treatment (43.3%), followed by infections (27.9%), miscellaneous causes (22.1%), as well as malignant and premalignant lesions (6.7%). This is the first study evaluating dermatological complications in organ transplant recipients in our country. Most of the patients had at least one dermatological manifestation of immunosuppression, including a malignant or pre-malignant lesion, highlighting that this is a high-risk dermatological population. Cancer is one of the most important causes of death in recipients with functioning grafts. Its prevention is a major goal in the care of transplant recipients. Physicians in transplant units should be aware of the importance of dermatological screening and skin cancer surveillance.

Angiogenesis and host immune response contribute to the aggressive character of non-melanoma skin cancers in renal transplant recipients

AIMS

The aim of this study was to determine the contribution of tumour angiogenesis to the aggressive growth of non-melanoma skin cancers (NMSCs) in renal transplant recipients (RTRs).

METHODS AND RESULTS

The study cohort included RTRs (n = 38) with formalin-fixed paraffin-embedded tumour samples available from first post-transplant NMSC (NMSC1) surgically excised at Christchurch Hospital, New Zealand, from 1997 to 2007. Comparable samples excised from immunocompetent individuals (ICIs) (n = 36) were selected to accommodate confounding factors. Markers of tumour angiogenesis were evaluated by immunohistochemistry, and analysed for associations with clinicopathological variables. As compared with ICIs, RTRs had a higher proportion of tumours with high microvessel density (P = 0.008), high proliferating capillary index (P < 0.0001) and low microvessel pericyte coverage index (P < 0.0001), and RTRs had a shorter cumulative second NMSC (NMSC2)-free interval (P < 0.0001). ICIs had a higher proportion of tumours with a 'marked' number of vascular endothelial growth factor (VEGF)-A-positive leukocytes than RTRs (P = 0.04), and RTRs with a 'moderate/marked' number of VEGF-A-positive leukocytes had longer cumulative NMSC2-free intervals than those with a 'minimum' number (P = 0.02).

CONCLUSIONS

This study demonstrates increased tumour angiogenesis in NMSC in RTRs, and suggests a role for VEGF-A-positive peritumoural leukocytes in suppressing NMSC development.

The challenges of UV-induced immunomodulation for children's health

Exposure to solar ultraviolet radiation (UVR) is recognised to have both beneficial and harmful effects on human health. With regard to immune responses, it can lead to suppression of immunity and to the synthesis of vitamin D, a hormone that can alter both innate and adaptive immunity. The consequences in children of such UV-induced changes are considerable: first there are positive outcomes including protection against some photoallergic (for example polymorphic light eruption) and T cell-mediated autoimmune diseases (for example multiple sclerosis) and asthma, and secondly there are negative outcomes including an increased risk of skin cancer (squamous cell carcinoma, basal cell carcinoma and cutaneous malignant melanoma) and less effective control of several infectious diseases. Many uncertainties remain regarding the amount of sun exposure that would provide children with the most effective responses against the variety of immunological challenges that they are likely to experience.

Ultraviolet radiation: a hazard to children and adolescents

Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Public awareness of the risk is not optimal, overall compliance with sun protection is inconsistent, and melanoma rates continue to rise. The risk of skin cancer increases when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Yet, people continue to sunburn, and teenagers and adults alike remain frequent visitors to tanning parlors. Pediatricians should provide advice about UVR exposure during health-supervision visits and at other relevant times. Advice includes avoiding sunburning, wearing clothing and hats, timing activities (when possible) before or after periods of peak sun exposure, wearing protective sunglasses, and applying and reapplying sunscreen. Advice should be framed in the context of promoting outdoor physical activity. Adolescents should be strongly discouraged from visiting tanning parlors. Sun exposure and vitamin D status are intertwined. Cutaneous vitamin D production requires sunlight exposure, and many factors, such as skin pigmentation, season, and time of day, complicate efficiency of cutaneous vitamin D production that results from sun exposure. Adequate vitamin D is needed for bone health. Accumulating information suggests a beneficial influence of vitamin D on many health conditions. Although vitamin D is available through the diet, supplements, and incidental sun exposure, many children have low vitamin D concentrations. Ensuring vitamin D adequacy while promoting sun-protection strategies will require renewed attention to children's use of dietary and supplemental vitamin D.

Ultraviolet radiation: a hazard to children and adolescents

Sunlight sustains life on earth. Sunlight is essential for vitamin D synthesis in the skin. The sun's ultraviolet rays can be hazardous, however, because excessive exposure causes skin cancer and other adverse health effects. Skin cancer is a major public health problem; more than 2 million new cases are diagnosed in the United States each year. Ultraviolet radiation (UVR) causes the 3 major forms of skin cancer: basal cell carcinoma; squamous cell carcinoma; and cutaneous malignant melanoma. Exposure to UVR from sunlight and artificial sources early in life elevates the risk of developing skin cancer. Approximately 25% of sun exposure occurs before 18 years of age. The risk of skin cancer is increased when people overexpose themselves to sun and intentionally expose themselves to artificial sources of UVR. Public awareness of the risk is not optimal, compliance with sun protection is inconsistent, and skin-cancer rates continue to rise in all age groups including the younger population. People continue to sunburn, and teenagers and adults are frequent visitors to tanning parlors. Sun exposure and vitamin D status are intertwined. Adequate vitamin D is needed for bone health in children and adults. In addition, there is accumulating information suggesting a beneficial influence of vitamin D on various health conditions. Cutaneous vitamin D production requires sunlight, and many factors complicate the efficiency of vitamin D production that results from sunlight exposure. Ensuring vitamin D adequacy while promoting sun-protection strategies, therefore, requires renewed attention to evaluating the adequacy of dietary and supplemental vitamin D. Daily intake of 400 IU of vitamin D will prevent vitamin D deficiency rickets in infants. The vitamin D supplementation amounts necessary to support optimal health in older children and adolescents are less clear. This report updates information on the relationship of sun exposure to skin cancer and other adverse health effects, the relationship of exposure to artificial sources of UVR and skin cancer, sun-protection methods, vitamin D, community skin-cancer-prevention efforts, and the pediatrician's role in preventing skin cancer. In addition to pediatricians' efforts, a sustained public health effort is needed to change attitudes and behaviors regarding UVR exposure.

Dermatologic findings in renal transplant recipients: Possible effects of immunosuppression regimen and p53 mutations

OBJECTIVE

To analyze the dermatologic lesions and possible effects of immunosuppression treatment and p53 gene mutations on dermatologic findings in renal transplant recipients.

MATERIALS AND METHODS

The study included 163 renal transplant recipients. After dermatologic examination, cultures, and histopathologic and genetic analyses were performed. A single-strand conformation polymorphism technique was used to analyze p53 gene mutations. Patients were categorized into 3 groups according to time since the transplantation procedure. Results were analyzed using the χ(2) test, using a software program (SPSS version 13.0; SPSS, Inc, Chicago, Illinois).

RESULTS

Mean (SD) age of the 163 transplant recipients (65 women and 98 men) was 40 (11) years, and posttransplantation follow-up was 65 (55) months. The most frequently observed drug-related lesion was hypertrichosis, in 46 of 150 patients. Of 115 lesions, the most commonly observed were verruca vulgaris (n = 34) from viruses, and pityriasis versicolor (n = 21) from superficial fungal infections. Of the total group, 20 patients (12.2%) were mutation carriers. Compared with the entire cohort, the group with premalignant lesions demonstrated more p53 mutations (11% vs 50%; P = .004). Patients given cyclosporine therapy exhibited more premalignant or malignant cutaneous lesions compared with patients who received other agents (P = .03).

CONCLUSION

Patients carrying p53 mutations developed a malignant lesion in the late posttransplantation period, which suggests the importance of prediction of risk.

Ultraviolet radiation and skin cancer

Skin cancer is the most common type of cancer in fair-skinned populations in many parts of the world. The incidence, morbidity and mortality rates of skin cancers are increasing and, therefore, pose a significant public health concern. Ultraviolet radiation (UVR) is the major etiologic agent in the development of skin cancers. UVR causes DNA damage and genetic mutations, which subsequently lead to skin cancer. A clearer understanding of UVR is crucial in the prevention of skin cancer. This article reviews UVR, its damaging effects on the skin and its relationship to UV immunosuppression and skin cancer. Several factors influence the amount of UVR reaching the earth's surface, including ozone depletion, UV light elevation, latitude, altitude, and weather conditions. The current treatment modalities utilizing UVR (i.e. phototherapy) can also predispose to skin cancers. Unnecessary exposure to the sun and artificial UVR (tanning lamps) are important personal attributable risks. This article aims to provide a comprehensive overview of skin cancer with an emphasis on carefully evaluated statistics, the epidemiology of UVR-induced skin cancers, incidence rates, risk factors, and preventative behaviors & strategies, including personal behavioral modifications and public educational initiatives.

A germline variant in the interferon regulatory factor 4 gene as a novel skin cancer risk locus

Genome-wide association studies on pigmentary phenotypes provide a pool of candidate genetic markers for skin cancer risk. The SNPs identified from a genome-wide association study of natural hair color were assessed for associations with the risk of three types of skin cancer simultaneously in a nested case-control study within the Nurses' Health Study [218 melanoma, 285 squamous cell carcinoma (SCC), and 300 basal cell carcinoma (BCC) cases, and 870 common controls]. Along with two known pigmentation loci, MC1R and OCA2, the IRF4 rs12203592 T allele was associated with an increased risk of each type of skin cancer (P value, 6.6 × 10(-4) for melanoma, 7.0 × 10(-7) for SCC, and 0.04 for BCC). This association was further replicated in additional samples (190 melanoma, 252 SCC, and 634 common controls). The P value in the replication set was 0.03 for melanoma and 4.2 × 10(-3) for SCC. The risk of BCC was replicated in an independent set of 213 cases and 718 controls (P value, 0.02). The combined results showed that the association with SCC reached the genome-wide significance level [odds ratio (OR) for additive model = 1.61, 95%CI, 1.36-1.91, P = 3.2 × 10(-8)]. The OR was 1.49 for melanoma (95%CI, 1.23-1.80; P = 4.5 × 10(-5)), and 1.32 for BCC (95%CI, 1.11-1.57; P = 1.6 × 10(-3)). Given that the T allele was shown previously to be associated with increased expression of IRF4 locus, further studies are warranted to elucidate the role of the IRF4 gene in human pigmentation and skin cancer development.

Autosomal dominant polycystic kidney disease: risk factor for nonmelanoma skin cancer following kidney transplantation

Nonmelanoma skin cancers (NMSC) are the most common malignant tumors following solid organ transplantation. Risk factors for NMSC mainly include immunosuppression, age, sun exposure and patient phototype. Recent findings have suggested that autosomal dominant polycystic kidney disease (ADPKD) may increase the risk of developing NMSC. We performed a monocenter retrospective study including all kidney recipients between 1985 and 2006 (n = 1019). We studied the incidence of NMSC, solid cancers and post-transplantation lymphoproliferative disease (PTLD), and analyzed the following parameters: age, gender, phototype, time on dialysis, graft rank, immunosuppressive regimen, history of cancer and kidney disease (ADPKD versus others). Median follow-up was 5.5 years (range: 0.02-20.6; 79 838 patient-years). The cumulated incidence of NMSC 10 years after transplantation was 12.7% (9.3% for solid cancers and 3.5% for PTLD). Autosomal dominant polycystic kidney disease and age were risk factors for NMSC (HR 2.63; P < 0.0001 and HR 2.21; P < 0.001, respectively) using univariate analysis. The association between ADPKD and NMSC remained significant after adjustments for age, gender and phototype using multivariate analysis (HR 1.71; P = 0.0145) and for immunosuppressive regimens (P < 0.0001). Autosomal dominant polycystic kidney disease was not a risk factor for the occurrence of solid cancers after transplantation (HR 0.96; P = 0.89). Our findings suggest that ADPKD is an independent risk factor for developing NMSC after kidney transplantation.

Non-melanoma skin cancer

The rising incidence and morbidity of non-melanoma skin cancers has generated great interest in unravelling of their pathogenesis and in the search for new non-invasive treatments. Whereas the role of cumulative sun exposure in pathogenesis of squamous-cell carcinoma seems clear, the relation between sun-exposure patterns and subtypes of basal-cell carcinoma remains undetermined. Several complex genotypic, phenotypic, and environmental factors contribute to pathogenesis of non-melanoma skin cancers. Unlike basal-cell carcinoma, squamous-cell carcinomas can arise from precursor lesions. Diagnosis of non-melanoma skin cancer is made clinically and confirmed by histological testing. Prognosis depends on lesion and host characteristics, which also dictate choice of treatment. Prevention strategies aim at reduction of sun exposure, but are of unproven benefit, especially for basal-cell carcinoma. Surgical excision with predetermined margins is the mainstay of treatment for squamous-cell carcinoma and for most basal-cell carcinomas. Of the new non-invasive treatments, only photodynamic therapy and topical imiquimod have become established treatments for specific subtypes of basal-cell carcinoma, and the search for more effective and tissue-salvaging therapies continues.

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.

Merkel cell polyomavirus sequences are frequently detected in nonmelanoma skin cancer of immunosuppressed patients

Recently, a new human polyoma virus has been identified in Merkel cell carcinomas (MCC). MCC is a highly aggressive neuroendocrine nonmelanoma skin cancer (NMSC) associated with immunosuppression. Clonal integration of this virus which was termed Merkel cell polyoma virus (MCPyV) was reported in a number of MCC. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are also NMSC and are the most frequent cancers in the setting of immunosuppression. A unique group of 56 NMSC from 11 immunosuppressed patients and 147 NMSC of 125 immunocompetent patients was tested for MCPyV by DNA PCR, targeting the Large T Antigen and the structural Viral Protein 1. NMSC included SCC, BCC and Bowen's disease (BD). In addition, normal skin and 89 colorectal cancers were tested. MCPyV specific sequences were significantly more frequently found in NMSC of immunosuppressed patients compared to immunocompetent patients (p < 0.001). In particular BD and BCC revealed a significant increased association of MCPyV of immunosuppressed patients (p = 0.002 and p = 0.006). Forty-seven of 147 (32%) sporadic NMSC were MCPyV positive. Interestingly, 37.5% (36/96) of sporadic BCC of immunocompetent patients were MCPyV positive. No MCPyV was detected within normal skin and only 3 out of 89 of additionally tested colorectal cancers were MCPyV positive. Our data show that MCPyV is a frequently reactivated virus in immunocompromized patients. How MCPyV contributes to the pathogenesis of NMSC, i.e., BD, SCC and BCC, in immunosuppressed patients and in addition, potentially to the pathogenesis of a subset of sporadic BCC needs further investigations.

Epigenetics and dermatological disease

Epigenetics is the study of differences in phenotype, in the absence of variation in the genetic code. Epigenetics is relevant in the pathogenesis of many skin diseases. In the case of the common skin cancers, aberrant methylation of tumor suppressor gene promoters is associated with their transcriptional inactivation. Environmental carcinogens such as ultraviolet radiation and arsenic may act through epigenetic mechanisms. Hypomethylation is associated with activation of systemic autoimmune diseases, such as systemic lupus erythematosus, subacute cutaneous lupus erythematosus and scleroderma. This may be through a mechanism of immunological cross-reactivity with hypomethylated DNA from pathogenic bacteria. Epigenetic factors may also be relevant in the pathogenesis of psoriasis and other inflammatory skin diseases, as well as in the pathogenesis of the disorders of genomic imprinting with cutaneous features.