Malignant Skin Tumor in a Composite Tissue (Bilateral Hand) Allograft Recipient

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Sir: Composite tissue allografts are a clinical reality, with more than 40 hand allografts and three facial allografts transplanted worldwide.1 Composite tissue allografts require large amounts of immunosuppression to prevent acute rejection, increasing the likelihood of observing adverse outcomes resulting from their use. The state of nonspecific immunosuppression predisposes the patient to the development of malignant skin lesions. The overall incidence of skin cancers in the immunosuppressed transplant population is 20.6 times that of the general population,2 and the presentation of skin cancer is 20 to 30 years earlier than in nonimmunosuppressed patients.3 To date, there is no reported malignancy in a composite tissue allograft recipient (International Registry on Hand and Composite Tissue Transplantation).4 In this article, a malignant skin tumor in a composite tissue allograft recipient is reported, and brief guidelines for skin cancer prophylaxis are provided. A total of two bilateral hand allograft transplantations have been performed at our unit since 2006. Our first recipient was a 48-year-old woman who received alemtuzumab (Campath-1H; Ilex Pharmaceuticals, San Antonio, Texas) and triple therapy consisting of tacrolimus, mycophenolate mofetil, and prednisone. On postoperative day 190, tacrolimus was switched to sirolimus. The patient suffered a total of two acute rejection episodes on postoperative days 120 and 221 that were graded I and II, respectively. She was treated successfully using intravenous methylprednisolone boluses. On postoperative day 360, a pigmented, smooth, round, nodular, unfixed lesion 3 mm in diameter that had recently appeared on her right nasal ala was excised. It was diagnosed by the pathologist as a basal cell carcinoma with margins free of lesion. The patient has been free from recurrence since then. This the first report of a skin malignant lesion in a composite tissue allograft recipient so far. It underscores the fact that composite tissue allograft recipients under potent immunosuppressive regimens such as lymphocyte depleter and triple therapy plus intravenous steroid treatment for acute rejections should undergo careful follow-up for drug side effects and complications, including skin cancer. These patients should be screened at least every 6 months for skin lesions. Surgical excision offers a greater than 90 percent overall cure rate. Because most basal cell tumor recurrences appear 1 to 4 years after treatment, follow-up should continue for at least 5 years.5 Although exposure to ultraviolet light is just one factor important in the cause of skin cancer, it is the sole factor that can be avoided. The patients need to be educated about the dangers of ultraviolet exposure, and sun protection measures should start as soon as the patients are accepted in the composite tissue allograft program. Recommendations should include sun avoidance by using wide-brimmed hats, long-sleeved shirts, and long pants; avoidance of sunbathing; and scheduling activities so that the midday sun is avoided. The use of sunscreen creams is not a substitute for sun avoidance. Despite the efforts made, the avoidance strategies used by the patient are probably inadequate.6 We hope this report aids counseling on skin cancer prophylaxis for composite tissue allograft recipients, and helps to keep the risk of skin malignancy in the mind of composite tissue allograft surgeons. Luis Landin, M.D. Pedro C. Cavadas, M.D., Ph.D. Javier Ibañez, M.D. Ignacio Roger, M.D. Plastic and Reconstructive Surgery Division; Hand Transplantation Team; Clínica Cavadas; “La Fe” University Hospital; Valencia, Spain DISCLOSURES None of the authors has a financial interest in the drugs mentioned in this work. Alemtuzumab was used off label. The recipients signed a specific consent form approved by the Ministry of Health for the use of alemtuzumab in composite tissue allotransplantation.