History
A 35-year-old woman presents to the dermatology clinic with several skin lesions over sun-exposed sites. A few lesions on the dorsi of her hands had become slightly tender but are otherwise asymptomatic. More recently she has developed a rapidly growing lesion on her lower lip that bleeds when traumatized. She had undergone cryotherapy and curettage and cautery to several scaly lesions in the past. Twenty years ago she had undergone a renal transplant for renal failure secondary to nephrotic syndrome. She is taking mycophenolate mofetil and azathioprine. When she was a young child she lived in East Africa with her parents who had helped set up a school. She herself had worked with an aid agency based in the United Kingdom. She has no history of atopy and is otherwise well.
Examination
She has a hyperkeratotic cutaneous horn on her lower lip (Fig. 91.1) with multiple ery-thematous scaly patches over the dorsum of the hands, forearms and face. In addition there are several previous surgical scar sites.
Questions
• What is the most likely diagnosis?
• What dermatological advice should be given to transplant recipients?
Medicine
Immunosuppressed patients are more vulnerable to the damaging effects of high-intensity ultraviolet (UV) light than immunocompetent ones. The most likely diagnosis in this case is a squamous cell carcinoma (SCC) on the lip, multiple actinic keratoses and superficial basal cell carcinomas (BCCs) elsewhere. Multiple skin cancers have arisen in this patient due to a combination of factors including immunosuppressant medication, fair skin and significant sun exposure in childhood.
Skin malignancy is the most frequently reported cancer in organ transplant recipients: the prevalence is 16.5 per cent in the UK. The majority of these are non-melanoma skin cancers (NMSCs) such as SCCs and BCCs. A NMSC presents at an earlier age and spreads more rapidly in transplant recipients than in the general population. Patients frequently have multiple lesions over time and consequently suffer substantial morbidity and a seven-fold increase in mortality from skin cancer. There is also an increased risk of devel-oping malignant melanoma and Kaposi’s sarcoma. In addition premalignant lesions are very commonly seen including actinic keratoses and Bowen’s disease. UV radiation is a significant risk factor for the development of skin malignancy. Organ transplant recipients require life-long immunosuppressant medication to prevent host organ rejection. The immunosuppressants impair the capacity of immune surveillance to repair and destroy UV damage and therefore leave patients vulnerable to skin cancers. In addition, transplant recipients are susceptible to infection with human papilloma virus, which may be associated with the development of some SCCs.
Photoprotection post-transplantation is essential in these patients. The high incidence, rapid growth, and increased metastatic potential of skin malignancy in these patients justifies the surveillance service provided in many dermatology units. In order to reduce the tumour burden in these patients, their management requires an interdisciplinary approach. Early detection and appropriate treatment of lesions are essential.
Complete excision is the ‘gold standard’ for SCCs in transplant recipients, if possible. Treatments of premalignant lesions may include topical therapy with 5-fluorouracil, 5% imiquimod cream, cryotherapy, and curettage and cautery. Finally, those transplant recipients who have had multiple SCCs should be commenced on a life-long oral retinoid such as acitretin to help reduce the number of new skin cancers developing.
KEY POINTS
• Skin cancer is the most frequently reported cancer in organ transplant recipients.
• The majority of these are non-melanoma skin cancers such as SCCs and BCCs.
• Photoprotection post-transplantation is essential in these patients.
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