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Vancouver,
BC—
Solid organ transplant recipients are at a significantly higher
risk for skin cancer, and dermatologists can expect to see increasing
numbers of these patients as the number of organ transplants being
done increases, Jason Rivers, MD, Professor of Dermatology, University
of British Columbia, said.
“The longer the patient has been immunosuppressed, the higher
the risk of malignancy,” Dr. Rivers said at Dermatology Update.
With regard to squamous cell carcinoma, the risk for metastatic
disease is approximately seven per cent. For patients who receive
a transplant before 18 years of age, there is an associated eight
per cent mortality rate. “We don’t generally see our patients
dying of skin cancer, but they do in this situation.”
He cited five studies1-5 showing that the systemic retinoid acitretin
will significantly slow the rate of tumour acquisition in the first
one or two months. Long-term use showing a low incidence of side
effects has been documented in at least one five-year study. Low
doses are preferred, and early on, but if treatment is stopped the
tumours recur.
“The mechanism of action for acitretin is unclear, but you
can use relatively low doses to achieve this effect. It should probably
be used on a common basis for those patients at very high risk for
developing multiple lesions,” he said.
Demographics also play a role in skin cancer incidence. Fair-skinned,
blue-, and hazel-eyed males living for years in a hot climate and
who had previous skin cancers are at particular risk for squamous
cell carcinoma.
Dr. Rivers suggested a multidisciplinary approach for treating transplant
recipients, in which dermatologists should play a role. Patients
must be counselled on the need for constant protection from the
sun. Early lesions and suspected lesions should be excised early,
with radiation and chemotherapy as the next step. In some cases,
reducing immunosuppression may be advisable.
Older patients get their malignancies primarily on sun-exposed areas
of the head and neck. Young individuals get them on the hands and
backs of the arms. Lesions on the ear or lip have been known to
be highly aggressive with a high metastatic rate.
Squamous cell carcinoma on the lip is common in individuals who
have received transplants in childhood or their early teens.
This lecture, delivered at Dermatology Update 2003, was sponsored
by Roche Canada, manufacturer of Soriatane (acitretin).
References
1. McNamara IR, Muir J, Galbraith AJ. Acitretin for prophylaxis
of cutaneous malignancies after cardiac transplantation. J Heart
Lung Transplant 2002;21:1201-1205.
2. Blokx WA, Smit JV, de Wilde PC, et al. Immunohistochemical effects
of temporary cessation of long-term acitretin
treatment in keratinocytic intraepidermal neoplasia of renal transplant
recipients. Arch Dermatol 2003;139:671-673.
3. de Sevaux RG, Smit JV, de Jong EM, et al. Acitretin treatment
of premalignant skin disorders in renal transplant recipients: clinical
effects of a randomized trial comparing two doses of acitretin.
J Am Acad Dermatol 2003;49:407-412.
4. Bavinck JN, Tieber LM, Van der Woude FJ, et al. Prevention of
skin cancer and reduction of keratotic skin lesions during acitretin
therapy in renal transplant recipients: a double-blind, placebo-controlled
study. J Clin Oncol 1995;13:1933-1938.
5. McKenna DB, Murphy GM. Skin cancer chemoprophylaxis in renal
transplant recipients:
5 years of experience using low-dose actretin. Br J Dermatol 1999;140:650-660.
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