En bloc skin excision for upper extremity cutaneous malignancies in renal allograft patients

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THERE IS an increased risk of developing cutaneous neoplasms in patients with renal transplants who are receiving immunosuppressive therapy. These cutaneous malignancies tend to be more invasive, have a higher recurrence rate, metastasize more frequently, and demonstrate multiplicity. Conventional management includes excision and primary closure of the individual lesions, which often results in recurrence or the development of numerous other lesions. We reviewed the outcome of en bloc skin excision and skin grafting on the upper extremity of three renal transplant patients who underwent extensive skin resections of the forearm and/or dorsal hand with subsequent skin grafting from non–sun-exposed areas. Patient ages were 43, 47, and 48 years. The mean duration of time from transplantation to skin resurfacing was 13.7 years (range 11 to 17 years). The areas grafted were 350 cm, 850 cm, and 1050 cm. Despite long-term immunosuppression therapy, skin graft take was excellent. All patients were pleased with the aesthetic outcome and no recurrences were noted in the grafted areas. En bloc excision and split-thickness skin grafting is an excellent treatment for numerous skin cancer lesions on sun-exposed upper extremities of renal transplant patients. Organ transplant recipients receiving immunosuppressive therapy have an increased risk of developing cutaneous malignancies. The association between skin cancer and immunosuppression was first described in the medical literature in 1971 and is now firmly established. The most frequent cancers in these patients are squamous cell carcinomas, which tend to be more invasive and have a higher recurrence rate, higher metastatic rate, and more multiplicity than squamous cell carcinomas in the general population. Ultraviolet radiation (UVB 290 to 320 nm) is considered an important factor in the pathogenesis of these skin malignancies because most of the lesions are found on sun-exposed areas. Human papillomavirus may also be involved as a promoter or cocarcinogenic agent. Some investigators also suggest that the immunosuppressive drugs themselves might have oncogenic potential. The propensity towards recurrent and multiple squamous cell carcinoma in this population is likely to result from a multifactorial pathogenesis with one or more of the aforementioned factors impairing the body’s immune system from identifying and destroying potentially oncogenic mutant cells. The standard treatment of individual skin malignancies is with excision and primary closure. Skin grafting may occasionally be required. Conventional surgical treatment in the immunosuppressed patient, however, is frequently followed by recurrences. We reviewed three renal transplant patients who had multiple squamous cell carcinomas on the dorsal hand and forearm and underwent en bloc skin excision followed by application of split-thickness skin grafts. Our assessment of this surgical procedure, including the complications and side effects, are herein described.