Cutaneous Malignancies in Pediatric Solid Organ Transplant Recipients

Adult and late adolescent complications of pediatric solid organ transplantation

BACKGROUND

There have been over 51 000 pediatric solid organ transplants since 1988 in the United States alone, leading to a growing population of long-term survivors who face complications of childhood organ failure and long-term immunosuppression.

AIMS

This is an educational review of existing literature.

RESULTS

Pediatric solid organ transplant recipients are at increased risk for risk for cardiovascular and kidney disease, skin cancers, and growth problems, though the severity of impact may vary by organ type. Pediatric recipients often are able to complete schooling, maintain a job, and form family and social networks in adulthood, though at somewhat lower rates than the general population, but face additional challenges related to neurocognitive deficits, mental health disorders, and discrimination.

CONCLUSIONS

Transplant centers and research programs should expand their focus to include long-term well-being. Increased collaboration between pediatric and adult transplant specialists will be necessary to better understand and manage long-term complications.

Outcomes of skin cancers in pediatric solid organ transplant patients: A systematic review

BACKGROUND

The most frequently reported malignancies after solid organ transplant are cutaneous, but data on the risk in pediatric populations varies across studies.

OBJECTIVES

To perform a systematic review including reported features and outcomes of skin cancers in pediatric solid organ transplant recipients.

METHODS

EMBASE and MEDLINE were systematically searched (Prospero CRD42020201659).

RESULTS

The review summarizes data from 20 studies on 337 patients, with a median age ranging from 15.0 to 19.5 years as reported in 4 studies, who developed skin malignancies after pediatric solid organ transplantation. Median ages at transplant and skin cancer diagnosis ranged from 1.5 to 17.0 years and 15.3 to 33.5 years, respectively. Squamous cell carcinoma (SCC) was most commonly reported (218 cases), followed by basal cell carcinoma (BCC) (91 cases), melanoma (18 cases), and unspecified keratinocyte carcinomas (2 cases). The median latency period between transplantation and cancer diagnosis ranged from 2.2 to 21.0 years. Overall, 4 studies reported 17 cases of metastasis in total, and recurrence was reported in one case. Six deaths were reported in one study related to SCC and melanoma metastases. The incidence rate of skin cancer after pediatric transplantation per 100 person-years of follow-up was 2.1 based on 5 studies.

CONCLUSION

The most frequent post-transplant malignancy in pediatric organ transplant recipients was SCC.

The current outcomes and future challenges in pediatric vascularized composite allotransplantation

PURPOSE OF REVIEW

We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation.

RECENT FINDINGS

In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression.

SUMMARY

Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.

Imaging Assessment of Complications from Transplantation from Pediatric to Adult Patients: Part 1: Solid Organ Transplantation

End-stage organ failure is commonly treated with transplantation of the respective failing organ. Although outcomes have progressively improved over the decades, early and late complications do occur, and are often diagnosed by imaging. Given the increasing survival rates of transplant patients, the general radiologist may encounter these patients in the outpatient setting. Awareness of the normal radiologic findings after transplantation, and imaging findings of the more common complications, is therefore important. We review and illustrate the imaging assessment of complications from lung, liver, and renal transplantation, highlighting the key similarities and differences between pediatric and adult patients.

Recommendations for photoprotection in pediatric rheumatology patients

PURPOSE OF REVIEW

Patients seen at pediatric rheumatology are at increased risk of immediate and long-term consequences from sun exposure. The objective of this review is to build awareness of the need of sun protection in pediatric rheumatology patients.

RECENT FINDINGS

Sun exposure can lead to disease exacerbations in many rheumatic diseases. There is well documented literature linking the chronic use of immunosuppressants with long-term risk of skin cancer. Although there is a lack of literature in pediatric rheumatology addressing the need of sun protection in this patient population, the young age of patients, the nature of their disease and the treatments they receive, make them a high-risk population for the effects of the sun.

SUMMARY

Sun protection recommendations are outlined in the following manuscript, backed up by the rationale and biology of why it is important for pediatric rheumatology patients to be protected from the sun. The information reviewed in this article should be part of the education that all pediatric rheumatology patients should receive as part of their care.

Basal cell carcinoma in a 17 year-old organ transplant recipient

Skin cancer is among the most frequent cancers in pediatric organ transplant recipients. We report a 17-year-old Caucasian girl who had had a kidney transplant 6 years before and was referred to our outpatient clinic for a basal cell carcinoma of the scalp. This case emphasizes the importance of teaching sun-protective behavior to transplant recipients and their parents and having a high index of suspicion and arrange for early referral for dermatologic care if skin changes are observed.

Dermatologic considerations in pediatric transplant recipients

PURPOSE OF REVIEW

The pediatric transplant patient population is growing as the number of solid organ transplants and indications for hematopoietic stem cell transplant increase. Understanding cutaneous sequelae of pediatric transplant and treatment strategies to manage these outcomes is vital to the care of these patients.

RECENT FINDINGS

Important work in the past year enhances our understanding of the cutaneous implications of pediatric transplantation, including further work in areas of malignancy, infection, and graft versus host disease as well as newly reported risks.

SUMMARY

This review highlights recent developments in the recognition and management of dermatological complications of pediatric transplant that will be useful for the practicing pediatrician or dermatologist.

Dermatological Complications After Solid Organ Transplantation

Organ transplant recipients (OTRs) are a population at high risk for cutaneous adverse events. Their early recognition and appropriate treatment is an important component of the clinical management of OTRs and should be optimally dealt with by dermatologists working in the context of a transplant dermatology clinic. Skin examination should be a standard procedure before performing organ transplantation to assess conditions which may be difficult to manage after the transplant procedure has been performed or which may represent a contraindication to transplantation, e.g., malignant melanoma. It also offers an opportunity to educate patients on skin care after organ transplantation. Skin infections can occur at any time after organ transplantation and include viral, bacterial, and fungal opportunistic infections. The risk of reactivation of latent viruses, such as varicella-zoster virus (VZV) and cytomegalovirus (CMV), is high. Bacterial infections are frequent and may be caused by unusual agents such Actinomyces, Mycobacteria, Legionella, or Nocardia. A large spectrum of fungal infections may occur, ranging from superficial (e.g., dermatophytes) to deeper and more severe ones (Alternaria, Aspergillus, Cryptococcus, Histoplasma). Drug-related idiosyncratic reactions usually occur early after the introduction of the causative drug, e.g., hypersensitivity reaction to azathioprine. On the long-term run, cutaneous effects due to cumulative drug toxicity, e.g., sebaceous hyperplasia from cyclosporine, may appear. Rare immunologically driven inflammatory reactions may occur in OTRs such as GVH or autoimmune disease. Tumors are particularly frequent. Kaposi's sarcoma, associated with persistent human herpes virus 8 (HHV8) infection, and cutaneous anaplastic large-cell lymphoma (ALCL) occur early after transplantation. Other cancers, such as nonmelanoma skin cancer (NMSCs), associated with persistent human papillomavirus (HPV) infections, malignant melanoma, Merkel cell carcinoma, or adnexal tumors, manifest later with an incidence which is much higher than observed in the general population. The incidence increases further after a first NMSC occurs.

Pediatric liver transplantation

Considerable strides have been made over the last several decades toward improving outcomes in pediatric liver transplantation. Refinements in surgical technique has allowed for the use of living donor and deceased donor split-liver grafts, thus expanding the pool of available organs and reducing waitlist mortality. The use of a multidisciplinary team continues to be paramount in the care of the transplant recipient. With improvements in overall graft and survival, indications for liver transplantation have also broadened. Currently, pediatric transplant patients have a 5-year survival of over 85%. Long-term morbidity is mainly associated with complications from immunosuppression and chronic rejection. Here we review indications for liver transplantation in children, surgical considerations, post-operative complications, and long-term outcomes.