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

Basal Cell Carcinoma Arising in a Previous Full-Thickness Graft Donor Site: A Case Report and Comprehensive Literature Review

Background/Objectives: Basal cell carcinoma (BCC), the most common skin malignancy, typically occurs in sun-exposed areas but can develop in atypical locations, such as scars, burns, and skin graft donor sites. BCC arising specifically in full-thickness skin graft donor sites is exceptionally rare. This study presents a unique case of BCC occurring 16 years post-graft harvesting and provides a comprehensive literature review to analyze clinical patterns, possible etiopathogenesis, and treatment strategies. Methods: A case report was described and a comprehensive literature review was conducted using PubMed, Scopus, and Web of Science (up to November 2024). Studies were screened for cases of BCC involving skin graft donor and recipient sites. Extracted data included demographics, graft type, latency period, histopathology, treatment, and outcomes. Results: A 68-year-old woman presented with biopsy-confirmed mixed nodular and micronodular BCC at the donor site of a full-thickness skin graft 16 years after its use for nasal reconstruction. Surgical excision with clear margins resulted in complete resolution without recurrence. A literature analysis revealed seven cases of graft-associated BCC, predominantly affecting older females. Partial-thickness grafts were frequently involved, with latency periods ranging from 1 to 61 years. Nodular BCC was the most common histological subtype, and surgical excision remained the primary and most effective treatment. Conclusions: Although rare, BCC can develop in skin graft donor sites after prolonged latency. Chronic trauma, impaired vascularization, and genetic alterations likely contribute to tumorigenesis. Lifelong surveillance, early detection, and timely intervention are critical to improving outcomes.

Polygenic scores and their applications in kidney disease

Genome-wide association studies (GWAS) have uncovered thousands of risk variants that individually have small effects on the risk of human diseases, including chronic kidney disease, type 2 diabetes, heart diseases and inflammatory disorders, but cumulatively explain a substantial fraction of disease risk, underscoring the complexity and pervasive polygenicity of common disorders. This complexity poses unique challenges to the clinical translation of GWAS findings. Polygenic scores combine small effects of individual GWAS risk variants across the genome to improve personalized risk prediction. Several polygenic scores have now been developed that exhibit sufficiently large effects to be considered clinically actionable. However, their clinical use is limited by their partial transferability across ancestries and a lack of validated models that combine polygenic, monogenic, family history and clinical risk factors. Moreover, prospective studies are still needed to demonstrate the clinical utility and cost-effectiveness of polygenic scores in clinical practice. Here, we discuss evolving methods for developing polygenic scores, best practices for validating and reporting their performance, and the study designs that will empower their clinical implementation. We specifically focus on the polygenic scores relevant to nephrology and other chronic, complex diseases and review their key limitations, necessary refinements and potential clinical applications.

Skin cancer incidence in Mexican renal transplant recipients: a cohort over 56 years

BACKGROUND

Skin cancer is a primary health concern in renal transplant recipients (RTRs). Existing research mainly stems from North America, Europe, and Australia, with limited data from Latin America.

METHODS

This 56-year (1967-2023) retrospective cohort study explores skin cancer incidence in Mexican RTRs. Our objective was to assess the long-term incidence of malignant cutaneous neoplasms in Mexican RTRs.

RESULTS

Over 56 years, 1642 RTRs (58% male) were studied. Median follow-up was 8.4 years; median age at transplantation was 32.6 years. Skin cancer incidence was 6.6% (95% CI: 5.5-7.9), with an incidence density rate of 6.5 (95% CI: 5.4-7.9) per 1000 person-years and a median latency of 9.8 years. Incidence increased with longer transplantation-related immunosuppression (TRI), with a relative risk for >30 years of TRI of 4.8 (95% CI: 2.6-9.1) for any skin cancer and 7.5 (95% CI: 3.8-14.6) for squamous cell carcinoma (SCC). SCC was the most common malignancy (76.1%), followed by basal cell carcinomas (BCC), with a 3.6:1 ratio. Metastatic SCC occurred in 6.5% of skin cancer patients, with a skin cancer-related mortality rate of 2.7%. Limitations of the study include its single-center and retrospective design and unassessed factors such as human papillomavirus infection and sun exposure.

CONCLUSIONS

Our study provides unique insights into the epidemiology of skin cancer among Mexican RTRs. It constitutes the largest cohort of skin cancer cases among RTRs in Mexico and, to our knowledge, in Latin America. Despite the lack of recognition of a high skin cancer incidence in non-White RTRs, our 6.6% incidence underscores the need to enhance surveillance programs.

Therapeutic Approaches for Non-Melanoma Skin Cancer: Standard of Care and Emerging Modalities

Skin cancer encompasses a range of cutaneous malignancies, with non-melanoma skin cancers (NMSCs) being the most common neoplasm worldwide. Skin exposure is the leading risk factor for initiating NMSC. Ultraviolet (UV) light induces various genomic aberrations in both tumor-promoting and tumor-suppressing genes in epidermal cells. In conjunction with interactions with a changed stromal microenvironment and local immune suppression, these aberrations contribute to the occurrence and expansion of cancerous lesions. Surgical excision is still the most common treatment for these lesions; however, locally advanced or metastatic disease significantly increases the chances of morbidity or death. In recent years, numerous pharmacological targets were found through extensive research on the pathogenic mechanisms of NMSCs, leading to the development of novel treatments including Hedgehog pathway inhibitors for advanced and metastatic basal cell carcinoma (BCC) and PD-1/PD-L1 inhibitors for locally advanced cutaneous squamous cell carcinoma (cSCC) and Merkel cell carcinoma (MCC). Despite the efficacy of these new drugs, drug resistance and tolerability issues often arise with long-term treatment. Ongoing studies aim to identify alternative strategies with reduced adverse effects and increased tolerability. This review summarizes the current and emerging therapies used to treat NMSC.

Comparison of skin cancer risk between renal transplant recipients and patients with glomerular diseases in rural Queensland

INTROUDCTION

There is increased risk of skin cancer in patients with gloermular disease or those with renal transplant.

OBJECTIVES

To compare the risk of skin cancer between kidney recipients (KTRs) and patients with glomerular disease (GD).

DESIGN

The cohort comprised patients with KTRs (n = 61) and GD (n = 51) in Central and Central West Queensland, Australia. A quantitative cohort study was undertaken to study the risk of skin cancer in rural communities between two subgroups of patients with kidney diseases in relationship to immunosuppression. Statistical analyses of the differences in incidence of skin cancers between the two groups were done by chi-square test, Fisher's exact test, independent t-test and McNemar's test.

FINDINGS

KTRs with non-melanoma skin carcinoma (NMSC) increased significantly after treatment with immunosuppressants (pre-transplantation, n = 11 [18.0%], post-transplantation, n = 28 [45.9%]; p < 0.001). There were no differences in number of patients with NMSC observed in the GD group (pre-diagnosis, n = 6 [11.8%], post-diagnosis, n = 7 [13.7%]; p = 1.000). Compared to the risks at 1 year post-immunosuppressants, the incidence of NMSC of KTRs increased significantly at 3 years (20.3% vs. 35.4%, p < 0.001) and 5 years (20.3% vs. 62.2%, p < 0.001) post-immunosuppressants, whereas the increased incidence of NMSC was observed only at 5 years (2.1% vs. 11.8%, p = 0.012) in the GD cohort. The mean cumulative number of NMSC in KTRs increased significantly at 3 years (p = 0.011), and 5 years (p = 0.001) post-immunosuppressants, compared to the risks at 1 year post-immunosuppressants, however, no differences were noted in the GD cohort.

DISCUSSION

Immunosuppressants increased the risk of NMSC in KTRs. The increased risk is likely dependent on the intensity and duration of immunosuppressants.

CONCLUSION

In patients with a high risk of NMSC, reducing skin cancer risk should be considered in conjunction with the optimisation of treatment.

Epidemiology of Cancer in Kidney Transplant Recipients

Kidney transplantation is the ideal treatment modality for patients with end-stage kidney disease, with excellent outcomes post-transplant compared with dialysis. However, kidney transplant recipients are at increased risk of infections and cancer because of the need for immunosuppression. Kidney transplant recipients have approximately two to three times greater risk of developing cancer than the general population, and cancer is a major contributor to morbidity and mortality. Most of the increased risk is driven by viral-mediated cancers such as post-transplant lymphoproliferative disorder, anogenital cancers, and Kaposi sarcoma. Nonmelanoma skin cancer is the most frequent type of cancer in kidney transplant recipients, likely due to an interaction between ultraviolet radiation exposure and decreased immune surveillance. Occurrence of the more common types of solid organ cancers seen in the general population, such as breast, prostate, lung, and colorectal cancers, is not, or is only mildly, increased post-transplant. Clinical care and future research should focus on prevention and on improving outcomes for important immunosuppression-related malignancies, and treatment options for other cancers occurring in the transplant setting.

A Review of Recent Advances in Computer-Aided Detection Methods Using Hyperspectral Imaging Engineering to Detect Skin Cancer

Skin cancer, a malignant neoplasm originating from skin cell types including keratinocytes, melanocytes, and sweat glands, comprises three primary forms: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma (MM). BCC and SCC, while constituting the most prevalent categories of skin cancer, are generally considered less aggressive compared to MM. Notably, MM possesses a greater capacity for invasiveness, enabling infiltration into adjacent tissues and dissemination via both the circulatory and lymphatic systems. Risk factors associated with skin cancer encompass ultraviolet (UV) radiation exposure, fair skin complexion, a history of sunburn incidents, genetic predisposition, immunosuppressive conditions, and exposure to environmental carcinogens. Early detection of skin cancer is of paramount importance to optimize treatment outcomes and preclude the progression of disease, either locally or to distant sites. In pursuit of this objective, numerous computer-aided diagnosis (CAD) systems have been developed. Hyperspectral imaging (HSI), distinguished by its capacity to capture information spanning the electromagnetic spectrum, surpasses conventional RGB imaging, which relies solely on three color channels. Consequently, this study offers a comprehensive exploration of recent CAD investigations pertaining to skin cancer detection and diagnosis utilizing HSI, emphasizing diagnostic performance parameters such as sensitivity and specificity.

Microbiome modulates immunotherapy response in cutaneous squamous cell carcinoma

The gut microbiome is increasingly recognized to alter cancer risk, progression and response to treatments such as immunotherapy, especially in cutaneous melanoma. However, whether the microbiome influences immune checkpoint inhibitor (ICI) immunotherapy response to non-melanoma skin cancer has not yet been defined. As squamous cell carcinomas (SCC) are in closest proximity to the skin microbiome, we hypothesized that the skin microbiome, which regulates cutaneous immunity, might affect SCC-associated anti-PD1 immunotherapy treatment response. We used ultraviolet radiation to induce SCC in SKH1 hairless mice. We then treated the mice with broad-band antibiotics to deplete the microbiome, followed by colonisation by candidate skin and gut bacteria or persistent antibiotic treatment, all in parallel with ICI treatment. We longitudinally monitored skin and gut microbiome dynamics by 16S rRNA gene sequencing and tumour burden by periodic tumour measurements and histologic assessment. Our study revealed that antibiotics-induced abrogation of the microbiome reduced the tumour burden, suggesting a functional role of the microbiome in non-melanoma skin cancer therapy response.

Dialysis and Transplant Considerations in Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is the fourth leading cause of kidney replacement therapy. Unfortunately, the need for dialysis or kidney transplantation is a foreseeable outcome for many patients affected by ADPKD. We review some of the unique issues that should be considered in the management of patients with ADPKD who require dialysis or kidney transplantation. The choice of dialysis modality may be influenced by the enlarged kidneys and liver, but peritoneal dialysis should not be excluded as an option, as studies do not consistently show that there is an increased risk for technique failure or peritonitis. The optimal kidney replacement therapy option remains kidney transplantation; however, nephrectomy may be needed if there is insufficient space for the allograft. Living donor candidates from at-risk families need to be excluded from carrying the disease either by diagnostic imaging criteria or genetic testing. Other potential transplant issues, such as malignancy and cardiovascular and metabolic risks, should also be recognized. Despite these issues, patients with ADPKD requiring dialysis or kidney transplantation generally have more favorable outcomes as compared to those with other causes of chronic kidney disease. Further studies are still needed to personalize the therapeutic approach for those receiving kidney replacement therapy and eventually improve clinical outcomes.

Long-term strategies for management of advanced basal cell carcinoma with hedgehog inhibitors

Basal cell carcinoma (BCC), the most common type of skin cancer, is characterized by aberrant activation of the hedgehog molecular pathway. Systemic therapy is indicated when local approaches, such as surgery and radiation, are inappropriate. In this article, a group of clinical experts recommends the long-term management strategy for advanced BCC patients treated with systemic therapy. The hedgehog inhibitors sonidegib and vismodegib are first-line treatments for advanced BCC with a long-lasting response, but long-term treatment with hedgehog inhibitors is often challenged by tolerability issues. However, several strategies for adverse effect management are available, such as dose interruptions, on-label alternate-day dosing and supportive medications. In conclusion, although BCC shows a high tumor mutational burden that favors a response to immunotherapy, experts recommend keeping patients on hedgehog inhibitors limiting immunotherapy to those who developed resistance during hedgehog inhibitor therapy or in case of persisting toxicity despite long-term management of adverse events.

Microbiome modulates immunotherapy response in cutaneous squamous cell carcinoma

The gut microbiome is increasingly recognized to alter cancer risk, progression, and response to treatments such as immunotherapy, especially in cutaneous melanoma. However, whether the microbiome influences immune checkpoint inhibitor (ICI) immunotherapy response to non-melanoma skin cancer has not yet been defined. As squamous cell carcinomas (SCC) are in closest proximity to the skin microbiome, we hypothesized that the skin microbiome, which regulates cutaneous immunity, might affect SCC-associated anti-PD1 immunotherapy treatment response. We used ultraviolet radiation to induce SCC in SKH1 hairless mice. We then treated the mice with broad-band antibiotics to deplete the microbiome, followed by colonization by candidate skin and gut bacteria or persistent antibiotic treatment, all in parallel with ICI treatment. We longitudinally monitored skin and gut microbiome dynamics by 16S rRNA gene sequencing, and tumor burden by periodic tumor measurements and histologic assessment. Our study revealed that antibiotics-induced abrogation of the microbiome reduced tumor burden, suggesting a functional role of the microbiome in non-melanoma skin cancer therapy response.

Skin Microbiome Variation with Cancer Progression in Human Cutaneous Squamous Cell Carcinoma

The skin microbiome plays a critical role in skin homeostasis and disorders. UVR is the major cause of nonmelanoma skin cancer, but other risk factors, including immune suppression, chronic inflammation, and antibiotic usage, suggest the microbiome as an additional, unexplored risk factor and potential disease biomarker. The overarching goal was to study the skin microbiome in squamous cell carcinoma (SCC) and premalignant actinic keratosis compared with that in healthy skin to identify skin cancer‒associated changes in the skin microbiome. We performed a high-resolution analysis of shotgun metagenomes of actinic keratosis and SCC in healthy skin, revealing the microbial community shifts specific to actinic keratosis and SCC. Most prominently, the relative abundance of pathobiont Staphylococcus aureus was increased at the expense of commensal Cutibacterium acnes in SCC compared with that in healthy skin, and enrichment of functional pathways in SCC reflected this shift. Notably, C. acnes associated with lesional versus healthy skin differed at the strain level, suggesting the specific functional changes associated with its depletion in SCC. Our study revealed a transitional microbial dysbiosis from healthy skin to actinic keratosis to SCC, supporting further investigation of the skin microbiome for use as a biomarker and providing hypotheses for studies investigating how these microbes might influence skin cancer progression.

Coexistence of Cutaneous Squamous Cell Carcinoma and Basal Cell Carcinoma in a Renal Transplant Recipient: A Case Report

In solid organ transplant patients, non-melanoma skin cancer remains a leading cause of mortality. The most common skin malignancies in solid organ transplant patients are squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). In organ transplant patients, SCC is 100 times more prevalent, and BCC is 10 times more prevalent than in the general population. Many risk factors for developing such malignancies are equivalent to those in the general population. However, in the transplant population, such cancers occur at an earlier age, act more aggressively, and often appear at multiple locations. Thus, assiduousness on the patient's part and healthcare providers is the highest priority. The concurrence of SCC and BCC together is rarely encountered in a post-transplant individual. We report a rare case of coexistence of SCC and BCC in the same patient. A 63-year-old man had been diagnosed with SCC and BCC simultaneously by a punch biopsy performed at two different scalp lesions of different diameters. This review describes an unusual occurrence of both skin cancers concurrently in a kidney transplant recipient.

Unconventional T cells and kidney disease

Unconventional T cells are a diverse and underappreciated group of relatively rare lymphocytes that are distinct from conventional CD4⁺ and CD8⁺ T cells, and that mainly recognize antigens in the absence of classical restriction through the major histocompatibility complex (MHC). These non-MHC-restricted T cells include mucosal-associated invariant T (MAIT) cells, natural killer T (NKT) cells, γδ T cells and other, often poorly defined, subsets. Depending on the physiological context, unconventional T cells may assume either protective or pathogenic roles in a range of inflammatory and autoimmune responses in the kidney. Accordingly, experimental models and clinical studies have revealed that certain unconventional T cells are potential therapeutic targets, as well as prognostic and diagnostic biomarkers. The responsiveness of human Vγ9Vδ2 T cells and MAIT cells to many microbial pathogens, for example, has implications for early diagnosis, risk stratification and targeted treatment of peritoneal dialysis-related peritonitis. The expansion of non-Vγ9Vδ2 γδ T cells during cytomegalovirus infection and their contribution to viral clearance suggest that these cells can be harnessed for immune monitoring and adoptive immunotherapy in kidney transplant recipients. In addition, populations of NKT, MAIT or γδ T cells are involved in the immunopathology of IgA nephropathy and in models of glomerulonephritis, ischaemia-reperfusion injury and kidney transplantation.

Skin conditions in liver transplant recipients in a Singapore academic medical center: A retrospective cohort study

Background

Liver transplant recipients are at lifelong risk of immunosuppression-related cutaneous complications, such as malignancy and infection.

Objective

Our study aims to assess the epidemiology of dermatologic conditions among liver transplant recipients in an academic medical center in Singapore.

Methods

Medical records of liver transplant recipients on follow-up with gastroenterology and dermatology departments at the Singapore General Hospital between 2006 and 2021 were retrospectively reviewed. A literature review was subsequently performed on the keywords “liver transplant” and “dermatology.”

Results

A total of 99 liver transplant recipients were identified in this study. Sixty-nine patients (70%) had at least 1 dermatologic condition. Inflammatory skin conditions were the most common (53%), followed by cutaneous infection (36%) and benign cutaneous tumors (30%). Malignant and premalignant lesions were the least common skin conditions reported (10%). Our study results concurred with many other studies reported worldwide, demonstrating a low cutaneous malignancy burden after liver transplantation.

Limitations

The study included a small population size in a single center and did not have a pre-existing protocol for pretransplant dermatologic surveillance.

Conclusion

Although the incidence of skin cancer after liver transplant in Singapore is low, the patients will benefit from long-term dermatology surveillance, given the long-term risks of infection and malignant skin conditions.

Reducing non-melanoma skin cancer risk in renal transplant recipients

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

Cancer survival in kidney transplant recipients in Ireland

BACKGROUND

Transplantation is a well-known risk factor for malignancy. However, outcomes of cancer in transplant recipients compared with non-transplant recipients are less well studied. We aim to study the survival in kidney transplant recipients who develop cancer and compare this with cancer outcomes in the general population.

METHODS

We linked data from the National Cancer Registry Ireland with the National Kidney Transplant Database. The period of observation was from 1 January 1994 until 31 December 2014. Transplant recipients were considered at risk from the time of diagnosing cancer. We administratively censored data at 10 years post-cancer diagnosis. Survival was compared with all patients in the general population that had a recorded diagnosis of cancer.

RESULTS

There were 907 renal transplant recipients and 426679 individuals in the general population diagnosed with cancer between 1 January 1994 and 31 December 2014. In those with non-melanoma skin cancer, the hazard ratio (HR) for 10-year, all-cause mortality [HR = 3.06, 95% confidence interval (CI) 2.66-3.52] and cancer-specific mortality (HR = 3.91, 95% CI 2.57-5.96) was significantly higher among transplant recipients than the general population. Patients who developed non-Hodgkin lymphoma (HR = 2.89, 95% CI 1.96-4.25) and prostate cancer (HR = 4.32, 95% CI 2.39-7.82) had increased all-cause but not cancer-specific mortality. Colorectal, lung, breast and renal cell cancer did not show an increased risk of death in transplant recipients.

CONCLUSION

Cancer-attributable mortality is higher in kidney transplant recipients with non-melanoma skin cancer compared with non-transplant patients. The American Joint Committee on Cancer staging should reflect the increased hazard of death in these immunosuppressed patients.

Comparison of skin cancer awareness and sun protection behaviours between renal transplant recipients and patients with glomerular disease treated with immunosuppressants

BACKGROUND

There is no previous study that compare skin cancer awareness and photoprotective behaviours between renal transplant recipients (RTR) and patients with glomerular disease (GD).

OBJECTIVES/METHODS

Sixty-one RTR and 51 patients with GD were given a self-reported questionnaire to evaluate skin cancer awareness and photoprotective behaviours in this cross-sectional study. The former group received a formal education on skin cancer and the latter an informal session prior to immunosuppressant use.

RESULTS

Ninety-three percent (n = 57) of RTRs and 88% (n = 45) of patients with GD responded to the survey. Majority of participants from both groups were aware that ultraviolet radiation could play a role in the occurrence of skin cancers and the awareness increased in participants with higher education (odds ratio [OR] = 1.50, 95% confidence interval [CI] = 1.15-1.95, P = .003). Ninety-eight percent vs 71% were aware that immunosuppressants can increase the risk of developing cancer (P < .001) and higher awareness was noted in younger participants (OR = 0.92, 95% CI = 0.87-0.97, P = .003). Suboptimal photoprotective behaviours (sun avoidance, sunscreen usage and sun-protective clothing) were noted in both cohorts and slightly lower sun protection rates were reported in RTR when compared with patients having GD. The level of sun protective measures in RTR based on high, moderate and minimal use of photoprotective measures were 21%, 46% and 33%, respectively. In terms of patients with GD, the latter practices were 13%, 50% and 37%, respectively (P = .560). Higher educational status was significantly associated with better sunscreen usage in RTR (P = .017) whereas this finding was not observed in patients with GD.

CONCLUSION

Patients with GD and RTR should have formal education on the risks of skin cancers before starting immunosuppressants. Follow-up education and surveillance is required to improve skin protective practices in these patients.

The incidence of post-transplant malignancies in kidney transplant recipients treated with Rituximab

BACKGROUND

Rituximab has been proposed as induction therapy in kidney transplant recipients (KTRs) with preformed donor-specific antibodies (DSA) or a positive flow cross-match. We here evaluated whether adding rituximab was associated with a higher incidence of post-transplant malignancies (PTM) due to greater immunosuppression.

PATIENTS AND METHODS

Forty-eight HLA-sensitized KTRs received induction therapy with anti-thymocyte globulin (ATG) and rituximab because of preformed DSA or a positive flow cross-match (RTX group). They were compared with a control group of 154 patients receiving ATG alone.

RESULTS

Thirty-nine of 202 (19.3%) patients developed PTM; the rate was similar in the RTX and no-RTX groups (14.6% vs. 20.8%, respectively, P = .3). The distributions of the types of cancer were similar between the two groups, with the majority being non-melanoma skin cancer (NMSC, n = 24). The risk factors for PTM were male gender, age, history of cancer, and azathioprine.

CONCLUSION

Our data do not indicate a higher rate of post-transplantation de novo malignancies after kidney transplantation in high-immunological risk patients who received induction therapy based on ATG and rituximab.