Surgical Intervention for Skin Cancer in Organ Transplant Recipients

Abstract

An important complication of solid organ transplantation and chemical immunosuppression is the potential for the development of multiple skin cancers, especially squamous cell carcinomas [1]. The magnitude and severity of these malignancies are troublesome. They are often multiple, are associated with verrucal lesions, are more likely to occur at a younger age, and have a higher recurrence rate than in those who do not receive transplants, are capable of rapid growth, have an aggressive histological growth pattern [2, 3], and are prone to metastasis on the trunk and extremities as well as the head and neck. More than half of patients receiving organ transplants develop tumors. In most transplant recipients, these tumors occur de novo and are associated with a history of sun exposure, the types of immunosuppressant medications, the degree of immunosuppression, and sometimes the human papillomavirus or human herpesvirus 8 [4]. Usually, in patients with skin cancer, basal cell carcinoma occurs more frequently than squamous cell carcinoma, but in transplant recipients, this frequency is reversed. Compared with generally observed occurrence rates, squamous cell carcinomas are increased between 65- and 250 fold, basal cell carcinomas 10 fold, malignant melanoma 3- to 5 fold, and Kaposi’s sarcoma 84 fold. The severity of Merkel cell carcinoma is increased, as is that of atypical fibroxanthoma. Cancers typically begin 7 to 8 years after the patient receives the transplant, but this interval is shorter, 3 years or less, in heart transplant recipients. The number of malignancies and the percentage of patients involved increase with the duration of immunosuppression. For example, in Australia, 7% of patients had skin cancer after 1 year and 70% after 20 years [5]. The trend is the same in the Netherlands but to a lesser degree; 0.2% had skin cancer after 1 year and 40% after 20 years. The surgical approach to skin cancers in transplant recipients is detailed below. In general, treatment is based on high-risk factors such as rapid growth, potential for or presence of metastasis, and the number of occurrences of the same type of cancer present at the time of the initial dermatological examination. Standard surgical treatments include electrodesiccation and curettage, excision with or without