4. A 51-year-old CKD 5 patient on HD for the last 4 years secondary to IgAN presented to you in the transplant assessment clinic to consider suitability for kidney transplantation. His brother is willing to donate a kidney for him, 000 mismatch and no DSA. On routine examination this lesion was identified which developed 6 weeks ago
2. Keratoacanthoma is rapidly growing, locally destructive lesion
May heal spontaneously
But sometimes times resembles well differentiated Squamous cell carcinoma
and better to surgical resection
3. Full history and examination
Skin biopsy . Surgical excision of lesion
Keratoacanthoma (KA) is a common, rapidly growing, locally destructive skin tumour. KAs may regress spontaneously with scarring, but clinically they may be indistinguishable from well-differentiated squamous cell carcinoma (SCC) and the clinical course may be unpredictable. Thus, many clinicians and pathologists prefer the term SCC, KA-type and recommend surgical excision.
Keratoacanthoma (KA) is a common, rapidly growing, locally destructive skin tumour. KAs may regress spontaneously with scarring, but clinically they may be indistinguishable from well-differentiated squamous cell carcinoma (SCC) and the clinical course may be unpredictable. Thus, many clinicians and pathologists prefer the term SCC, KA-type and recommend surgical excision.
Council this patient regarding kidney transplantation?
This is most likely Keratoacanthoma. Biopsy of the lesion is must to confirm the diagnosis.Classification of KA is generally done as as a benign, spontaneously resolving tumor .But in rare cases metastasis happened in past by misdiagnsosis of squamous cell carcinoma as karatoacanthoma.No clinical or pathologic features can reliably differentiate KA and cutaneous squamous cell carcinoma.Though keratoacanthoma is not a contraindiacation of transplant, and we can wait for spontaneous resolution,i will council patient for surgery.
What is your workup strategy?
As no clinical or pathologic features can reliably differentiate KA and cutaneous squamous cell carcinoma ,i will search for metastasis and same workup as done squamous cell carcinoma. Conventional surgical excision is the treatment of choice for solitary KA since it allows for both the assessment of histopathologic features to aid in diagnosis and pathologic confirmation of the removal of the tumor.
The lesion presented shows the following features being of single, well circumscribed, elevated, dome-shaped displaying areas of increased keratin at the centre mostly benign Keratoacanthoma.
Other diagnoses are squamous cell carcinomas or basal cell carcinomas.
Counselling the patient depends on reassuring that it is of benign nature and undergoes spontaneous resolution after performing a skin biopsy from the lesion and confirming the diagnosis of Keratoacanthoma. A multidisciplinary team is necessary including dermatologists, oncologist and transplant team is advised.
If the lesion revealed to be malignant the donor should be rejected and enroll the patient to deceased donation programs or maintenance dialysis as a replacement therapy till transplantation is feasible.
Work up strategy:
If transplantation will be resumed after excluding the donor’s malignancy, low dose immunosuppression is needed. Better to avoid T and B cell depleting agents in induction. Maintenance immunosuppression would be based on low drug level i.e. the least dose required to avoid graft rejection as well as early switching to mTORi poses a better choice.
The patient is an end-stage kidney disease patient on hemolysis who is now undergoing evaluation for a kidney transplant (having a suitable donor with a mismatch of 0 and no DSA).
Six weeks ago, a cutaneous lesion appeared on his body.The lesion is a dome-shaped nodule containing keratinous material in the upper central region. This lesion’s differential diagnosis includes keratoacanthoma and crateriform squamous cell carcinoma. These nodular lesions may also be accompanied by nodular basal cell carcinoma, Merkel cell carcinoma, molluscum contagiosum, or prurigo nodularis.
The presence of keratinous material is characteristic of keratoacanthoma, a crater-shaped tumor composed of squamous epithelial cells that grows rapidly. By histology, it can be distinguished from squamous cell carcinoma: the crater is multilocular, the lips are perforated, and the cornified contents do not protrude from the crater’s mouth. 25% of keratoacanthomas undergo malignant transformation, particularly in sun-exposed regions and in older patients.
Council this patient regarding kidney transplantation?
The lesion should be biopsied for a definitive diagnosis, and if a localized lesion (keratoacanthoma or squamous cell carcinoma) is discovered, a kidney transplant can be performed immediately.
As and when the transplant is conducted, the patient must be counseled regarding the risk of skin cancer post-transplant due to the use of immunosuppressive medications.
The patient should also be counseled on the significance of post-transplant behavioral interventions, such as avoiding direct sunlight during peak hours, wearing protective clothing and sunscreen, and performing self-examinations of the skin.
What is your workup strategy
The approach for the index case (keratoacanthoma) includes:
Detailed history (pertaining to the onset of the lesion, any change in size or color, discharge from the lesion, etc.)
Clinical investigation, including skin examination, to search for any additional lesions at other body sites.
Dermatology consultation.
Investigations: For a definitive diagnosis, the lesion should be biopsied.
Once the diagnosis has been confirmed, the recommended treatment is full-thickness fusiform excision or deep curettage. Large lesions may be treated with intralesional chemotherapy consisting of methotrexate, 5-fluorouracil, or bleomycin prior to excision.
There is no transplant waiting period if the non-melanoma skin cancer lesion is completely excised and there are no metastases (in the event of malignant metamorphosis).
Patient counseling regarding the disease, its treatment, and the emphasis on post-transplant skin self-examination and use of sun-protective measures
What is your differential diagnosis? · This is a single well circumscribed dome-shaped skin lesion with areas of increased keratin at the Centre. · DD: · The benign Keratoacanthoma is on the top of the list. Keratoacanthomas (KAs) are nodular, keratin-filled, rapidly growing epithelial tumors that simulate the histology of SCC. Some authors consider KA to be low-grade SCC and refer to the tumor as SCC/KA-type. KA, KA typically heals spontaneously, but the mechanism of resolution is not completely understood. The treatment is excisional surgery but given the possibility of a natural remission, a non-invasive medical therapy to treat this kind of cancer may be considered in certain situations including 5-fluorouracil, retinoids, methotrexate, radiotherapy and imiquimod 5 percent cream(anti-tumor and anti-viral effects) · Squamous cell carcinoma · Basal cell carcinoma Council this patient regarding kidney transplantation? · Council the patient that the most likely diagnosis is keratoacanthoma which is a benign tumor that can resolve spontaneously. However, it resembles SCC. So, involving a dermatologist and doing a skin biopsy is crucial · Features that support malignant lesion are the aggressive nature of the lesion that may locally spread or cause metastasis, the Perineural or Vascular invasion, or both. Besides, the abnormal cytology of cells. · KA need no waiting period for transplantation but if there is malignant transformation, the waiting period is according to the AJCC stage. For low risk cases (T1 with no perineural invasion and less than 4mm in size) no waiting time, for High risk SCC without perineural invasion waiting time is 2 years, for High risk SCC and perineural invasion of 2-3 years interval, for High risk with nodal involvement 5 years interval. High risk with distant metastasis are usually not considered for renal transplantation. · There is a high risk of recurrence of skin cancer after kidney transplant especially with sun exposure. Therefore, counseling on skin protective practices like the use of sunscreens and protective clothing.
What is your workup strategy? · MDT approach with the oncologist and dermatologist. · Full history and detailed clinical examination · Skin biopsy and histopathology to confirm the diagnosis. An excisional procedure with 4 mm margins. · Imaging to look for metastasis · Avoid T cell depleting agents for induction and tailor Post transplantation immunosuppressive therapy with reduction of CNIs immunosuppression and Consider mTOR inhibitors · Keratoacanthoma has an excellent prognosis following surgical excision. skin protective practices like the use of sunscreens and protective clothing are important as 25% of keratoacanthoma undergo malignant transformation. References: · Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33. · Zwald et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413. · Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, et al., Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement. Am J Transplant. 2021 Feb;21(2):460-474. · Dendorfer M, Oppel T, Wollenberg A, Prinz JC. Topical treatment with imiquimod may induce regression of facial keratoacanthoma. Eur J Dermatol. 2003; 13: 80-2.
What is your differential diagnosis?
The differential diagnosis is keratinising squamous cell carcoma as the lesion has keratin structure.
Council this patient regarding kidney transplantation?
Screening for the diagnosis and staging of cancer. Waiting period is suggested before the transplant if it is a metastatic cancer.
What is your workup strategy?
Screening of lesion for metastasis and then waiting period is calculated. mTOR inhibitors are used for immunosuppression.
The lesion is a dome-shaped structure with central keratin filled on the sun-exposed area of the skin
Keratoacanthoma
Squamous cell carcinoma
Sebaceous cell carcinoma
Marjolin ulcer
melanoma
Basal cell carcinoma
Counseling the patient about kidney transplantation
Educate patient about skin cancers, common types, and the need to make a definitive diagnosis through a biopsy for histology
Involve a dermatologist and oncologist with an interest in transplantation
Educate the patient about the possibility of suspending the transplant and waiting for a certain period if it turns out to be malignant with metastasis
Educate the patient the result of the histology may allow us go ahead with the surgery immediately
Educate the patient on the possibility of reoccurrence after transplant even if the current lesion is surgically removed and treated in another site or the same place
Educate the patient on the available preventive method for the occurrence of skin cancers after transplantation
What is your work-up strategy?
Set up an MDT meeting that involves a dermatologist, and histopathologist
Biopsy of the skin lesion for histology
Imaging tests like CT or MRI to look out for metastasis or lymph nodes
If it turns out to be keratoacanthoma, a surgical approach can be used to excise the tumor since is a single small lesion that is not huge or generalized all over the body
Laser therapy and cryotherapy can be used
Medical therapy has a place for those that have widespread multiple lesions
Other investigations like cardiovascular work-up, infectious disease, and hematological work-up
Reference
Jerry D Brewer. Keratoacanthoma: Epidemiology, risk factors, and diagnosis. UpToDate. 2022.
Pooja Sharmaa, Anjali Narwalb, Mala Kambojb. Journal of oral biology and craniofacial research. 2019:352-354.
Q1: the most likely diagnosis is keratoacanthoma. The other differential diagnosis includes squamous cell carcinoma, basal cell carcinoma, or pyogenic granuloma.
Q2: To confirm the diagnosis, surgical excision, and histopathologic examination is necessary to rule out malignant lesions other than keratoacanthoma. In keratoacanthoma, there is no need to wait for TX, however, if malignant lesions are considered, waiting time according to staging is necessary.
Q3: consultation with a dermatologist and oncologist is necessary. Complete physical examination for other lesions and involvements is recommended.
After TX, sun protection and close follow-up are necessary.
Keratoacanthomas (KAs) are epithelial tumors, characterized by a keratin-filled, rapidly growing papule, that develops in a crater produced by pilosebaceous follicles. Even though these lesions histologically resemble squamous cell carcinoma (SCC), they are considered to be immunologically well-controlled carcinoma cells, which usually regress spontaneously. The elective treatment is excisional surgery. However, given the possibility of a natural remission, a non-invasive medical therapy to treat this kind of cancer may be contemplated in certain situations. The medical therapies for the management of KAs include the use of 5-fluorouracil, retinoids, bleomycin, methotrexate, triamcinolone acetonide, radiotherapy and, recently, imiquimod [1-7]. Imiquimod is an immune response modifier, with significant antiviral and antitumor effects. It induces cytokines and cell-mediated cytolytic activity, stimulating both innate and acquired immune responses. Over the last few years, numerous clinical trials have reported the efficacy of imiquimod for the treatment of epithelial skin cancer, including in transplant patients.
KAs are nodular cutaneous tumors that develop rapidly and simulate the histology of SCC. Some authors consider KA to be low-grade SCC and refer to the tumor as SCC/KA-type. KA, however, typically heals spontaneously, but the mechanism of resolution is not completely understood. Recent observations suggest that cutaneous tumor regression depends on an individual’s immune response, mediated by CD8 and CD4 T lymphocytes. Batinac et al. described an elevated number of T cells expressing granzyme B in regressing KAs as compared with SCC [8]. Granzyme B and perforin released by CD8 cells could kill tumor cells, leading to the regression of the neoplasm. Moreover, in SCCs, imiquimod therapy causes a change in the local environment, with a recruitment of CD8 T cells, enriched by granzyme B [9]. This treatment potentiates the cytotoxic effect of the T cell population, inhibiting cancer progression. The successful results obtained by treating KAs in transplant patients with imiquimod 5 percent cream have recently been reported in several journals [7, 10].
Imiquimod has both an indirect antiviral action and an anti-tumoral action. The drug stimulates the synthesis and release of Th1-dependent cytokines (INF-α, TNF-α, IL-1α, IL-6, IL-8, IL-12, PGE2), thus leading to antigenic presentation and activation due to Langerhans cells (LCs) in regional lymph nodes. Immunohistochemistry studies quantified the LCs in benign and malignant cutaneous tumors, demonstrating the highest number in benign lesions, e.g. KA, as compared with malignant and with normal tissues [11]. Besides the acquired immunity (through cytotoxic T lymphocytes) and natural killer cell stimulation, imiquimod has been shown to induce apoptosis by downregulating the anti-apoptotic protein, Bcl-2, and inducing the pro-apoptotic Fas receptor (CD 92-receptor) [12, 13]. Inhibition of tumor angiogenesis was also observed [14]. These recent findings confirm the efficacy of the drug and its rational use in the management of cutaneous tumors. The use of imiquimod in transplant patients afflicted by epithelial skin growths has also been described [15]. This drug activates an immune response only at the site of application, without influencing the systemic immune response [16]. Harrison et al., in a recent study, measured serum levels of imiquimod in 58 non-immunosuppressed patients after local application. Low serum levels of the drug were measured and the immunological effects were limited to the area of application [17]. In our patient, systemic adverse effects did not occur. Positive results were observed near the beginning of therapy. The patient was visited every 2 weeks and photos of the lesions were taken. Repeated blood counts and chemistries remained in normal ranges. Imiquimod treatment of the KA resulted in complete remission. In fact, after only 2 weeks of treatment, we observed a rapid involution of the tumor; after 6 weeks, the lesion had totally healed and the cosmetic outcome was excellent. No relapse was observed after 36 months of follow-up. Future clinical trials could further validate the efficacy and safety of imiquimod in immunosuppressed patients who have undergone organ transplants. We have reported our case to demonstrate the efficacy of imiquimod treatment of KA in transplant patients. Our patient’s tumor completely resolved without activating a systemic immune response.
3. Andreassi A, Pianigiani E, Taddeucci P, Lorenzini G, Fimiani M, Biagioli M.Guess what! Keratoacanthoma treated with intralesional bleomycin. Eur J Dermatol. 1999 Jul-Aug;9(5)
4. Melton JL, Nelson BR, Stough DB, Brown MD, Swanson NA, Johnson TM. Treatment of keratoacanthomas with intralesional methotrexate. J Am Acad Dermatol 1991; 25: 1017-23
5. Santosa Pham JC, Shelley ED, Shelley WB. Aggressive giant keratoacanthoma of the face treated with intramuscular methotrexate and triamcinolone acetonide. Cutis 1997; 59: 329-32.
6. Donahue B, Cooper JS, Rush S. Treatment of aggressive keratoacanthomas by radiotherapy. J Am Acad Dermatol 1990; 23: 489-93.
7. Dendorfer M, Oppel T, Wollenberg A, Prinz JC. Topical treatment with imiquimod may induce regression of facial keratoacanthoma. Eur J Dermatol. 2003; 13: 80-2. PubMed
Assalam o alaikum What is your differential diagnosis?
The image shows a single well circumscribed hyperkeratotic plaque with well-defined margins. Differentials include: 1. Keratoacanthoma. 2. Squamous cell carcinoma. 3. Basal Cell Carcinoma Counsel this patient regarding kidney transplantation?
Breaking the news and reassurance.
Discuss in detail the need to confirm diagnosis and evaluate for staging.
Counsel in detail regarding need to reduce sun exposure and use of sunscreen.
If it is confirmed then the patient might have to wait for a while to proceed for renal transplantation (depending on the AJCC stage). For low risk cases (T1 with no perineural invasion and less than 4mm in size) no waiting time necessary, for High risk SCC without perineural invasion waiting time of 2 years, for High risk SCC and perineural invasion 2-3 years interval, for High risk with nodal involvement 5 years interval. High risk with distant metastasis are usually not considered for renal transplantation. What is your workup strategy?
History and clinical examination with specific emphasis on size, location, and orientation (horizontal vs vertical extension).
Excision biopsy with wide margins (4mm at least). Rest of the management depends on histopathological diagnosis. Benign keratoacanthoma vs malignant SCC / BCC.
Full body skin examination that includes palpation of regional lymph nodes to evaluate for additional cSCCs and clinical signs of metastatic disease.
Contrast enhanced CT to look for metastasis (MRI & PET scan alternate options)
Sentinel Lymph node biopsy although not usually recommended in case of SCC, however a few studies support its use to detect nodal involvement.
REFERENCES:
1. Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499931/
2. Zwald F, Leitenberger J, Zeitouni N, et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016;16(2):407-413. doi:10.1111/ajt.13593
As this is dome-shaped lesion with a central area of depression on a sun-exposed area most likely diagnosis is Keratoacanthoma.
D/D includes :
Squamous cell carcinoma.
Basal cell carcinoma.
Pyogenic Granuloma
Councelling regarding kidney transplantation :
I will discuss in detail with the patient that this lesion is most likely keratoacanthoma which is most likely a benign tumour that can resolve spontaneously.
But As It has great resemblance to Squamous cell carcinoma so we need to investigate and treat it with surgical excision and SSC need to be excluded by histopathologist.
Features that support malignant lesion are :
(1) Metastasis
(2) Aggressive clinically apart from metastasis, that is, local expansion/recurrence on the clinical side
(3) Abnormal cytology of cells
(4) Perineural or Vascular invasion, or both
If proved to be keratoacanthoma no waiting period for transplantation is required.
If biopsy showed malignant transformation waiting period is according to staging.
There is a high risk of recurrence and of skin cancer after kidney transplant especially with sun exposure.
Workup strategy:
I’ll follow MDT Approach.
I’ll involve Onncologist, Dermatologist, Histopathologist and General Surgeon
I’ll take detailed history and examine other lesions and lymph nodes
Surgical removal and proceed to transplantation if benign
After transplantation self examination for recurrence and sun protection
Reference :
1.American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc
2.Am J Dermatopathol. 2021 Dec 1;43(12):1006. doi: 10.1097/DAD.0000000000001983
Council this patient regarding kidney transplantation?
Counseling should focus on the following point of view –
1. Regarding the Skin lesion
2. Possibility of recurrence & de novo melanoma after transplantation
3. Regarding protection from recurrence or de novo
Prior to transplantation we will need a skin biopsy to confirm the diagnosis and rule out other malignant possibilities like SCC and BCC. As because benign keratoacanthoma will proceed to transplantation without waiting time after it’s surgical excision but malignant lesions will require waiting time for 2 years before tranplantation.
Post transplant we will modify his immunosuppressive medications to include an MTOR inhibitor to decrease risk of skin cancer.
25% of keratoacanthoma undergo malignant transformation on areas exposed to sun especially in elderly patient .So
Regarding protection from recurrence or de novo Avoid intense sun exposure.
· Avoid sun exposure for an hour or two on either side of mid-day.
·Sun protective clothing: Long sleeve silk clothing, sunglass, cotton cricket hat is better.
·Regular use of high factor sun block (SPF 50+ UVA)
· Self examination before & after transplantation regularly
1)D/D:
Basal cell carcinoma
Squamous cell carcinoma
Keratoacanthoma
2)Counselling:
– discussion with the patient about possible
differential diagnosis
– if it is kerato akanthoma, no need to worry and
no need of waiting time
– if it is basal cell carcinoma or squamous cell
carcinoma (non melanoma skin cancer) –
transplant can be done after treating the
cancer. But first we need to confirmed
histopathological diagnosis.
– Regarding IgAN- There is chance of recurrence
of primary disease in transplant (30-35%)
3) Work up :
-MDT approaches(Dermatology,
Histopathology, surgery, nephrology)
– Skin biopsy and histopathology for
confirmation
– To see extent : CXR, USG W/A, CT if need
– If non melanoma skin cancer- wide
excision of lesion, 5FU.
– immunosuppressive therapy after renal
transplant: early conversion of
calcineurin inhibitor to mTor
– Protection: avoid mid day sun exposure,
Sun block, protective clothing
This is domed shape lesion with central keratosis and ulcerations it is rapidly growing with in 6 weeks the most likely diagnosis is keratoacanthoma other differential diagnosis : -Basal cell carcinoma -Squamous cell cancer – Merkel cell carcinoma
Council this patient regarding kidney transplantation?
I will discussed with the patient and his donor that this lesion most likely keratoacanthoma which is considered a benign tumour that can resolved spontaneously but has great resemblance to SSC so it has to be investigated and treated by surgical excision and SSC need to be excluded by pathologist ,however it may bedifficult even histologically.
Criteria that are often advanced to support a malignant lesion are :
(1) metastasis; (2) aggressive clinical behavior apart from metastasis, that is, local recurrence/destruction on the clinical side; (3) abnormal cytology of cells; (4) vascular or perineural invasion, or both; (5)
If proved keratoacanthoma no waiting proceed to transplantation if biopsy showed malignant transformation waiting is according to staging .
There is a high risk of recurrence and of skin cancer after kidney transplant especially with sun exposure .
What is your workup strategy?
The approach to this patient is MDT including ( oncologist ,plastic surgeon ,pathologist and nephrologist being prepared for transplantation. This patient needs proper history and examination, full blood count ,liver function and renal function test.
Exclusion of malignancy ,then surgical excision .
proceed to kidney transplantation .
Advice to avoid sun exposure
Reference :
1.American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc 2.Am J Dermatopathol. 2021 Dec 1;43(12):1006. doi: 10.1097/DAD.0000000000001983 3.https://doi.org/10.1016/j.clindermatol.2009.06.010
This is dome-shaped lesion with a central area of depression on a sun-exposed area most propably keratoacanthoma other differential is cutaneous squamous cell carcinoma and basal cell carcinoma.
Council this patient regarding kidney transplantation?
Firstly we discussing generally about this skin lesion and what is differential diagnosis
We need first to surgical exision of the lesion with clear margin and send for biopsy ,if keratoacanthoma proceed to transplantation . Other modalities of treatment include radiotherapy , intralesional injection of methotrexate or5-fluorouracil have also been used. Other issue in some cases of keratoacanthoma have recurrence after transplantation especially in sun exposed area therefore protection of sun is important.
What is your workup strategy?
We need to share the oncologist and dermatologist.
Taking good history and examination of other lesions and lymph nodes.
Surgical removal and proceed to transplantation.
After transplantation self examination and sun protection .
Council this patient regarding kidney transplantation?
What is your workup strategy
What is your differential diagnosis?
short duration (6week) in immunocompromised patient on dialysis – mostly infective
Pyogenic granuloma
fungal infection
atypical mycobacterial infection
Council this patient regarding kidney transplantation?
a)Risk of recurrence of IgAN after renal transplantation & chance of graft loss 30%.
b) Risk of recurrence of skin cancer( in case of SCC 40 – 60% risk at 20 years after transplantation)
c) No waiting time for non melanoma skin cancer
d) Avoid sun exposure & use sun protective clothing
e) Self examination regularly
What is your workup strategy?
a)Detail clinical examination
b) Skin biopsy to confirm diagnosis
c) Look for metastasis- detail imaging
d) Treatment of skin cancer- Surgical excision, Topical 5FU
e) Post transplantation immunosuppressive therapy-
i) Reduction of immunosuppression( early cyclosporin withdrawl)
ii) Consider mTOR inhibitor
f) Advice to patient regarding avoidance of sun exposure & self examination
There is a dome shaped nodule filled with keratinous material. So my differential dignosis of this lesion are-
a) Squamous cell carcinoma
b) Basal cell carcinoma
c) Markel cell carcinoma
d) Keratoacanthoma
Council this patient regarding kidney transplantation?
a)Risk of recurrence of IgAN after renal transplantation & chance of graft loss 30%.
b) Risk of recurrence of skin cancer( in case of SCC 40 – 60% risk at 20 years after transplantation)
c) No waiting time for non melanoma skin cancer
d) Avoid sun exposure & use sun protective clothing
e) Self examination regularly
What is your workup strategy?
a)Detail clinical examination
b) Skin biopsy to confirm diagnosis
c) Look for metastasis- detail imaging
d) Treatment of skin cancer- Surgical excision, Topical 5FU
e) Post transplantation immunosuppressive therapy-
i) Reduction of immunosuppression( early cyclosporin withdrawl)
ii) Consider mTOR inhibitor
f) Advice to patient regarding avoidance of sun exposure & self examination.
short duration (6week) in immunocompromised patient on dialysis – mostly infective
Pyogenic granuloma
fungal infection
atypical mycobacterial infection,
amelanotic melanoma – pink lesion with scattered black spots on the top
Keratoacanthoma – dome shaped skin lesion with keratinous deposit on top
Squamous cell Ca (atypical)
Mollucum Contagiosum
Council this patient regarding kidney transplantation?
It could be mostly an infective lesion; but could be cancerous also.
Shall take a Dermatologist’s opinion and shall involve onco-surgeon for evaluation, definitive curative treatment (wide local excision + Chemotherapy or Radiation)
Excision biopsy of lesion – infective and benign lesions shall be cured, with additional systemic antibiotic or antifungal drugs.
Even if it turns out to be cancerous, looks localized and superficial – not to worry much; surgical excision shall be curative.
Depending on histopathology report (skin cancer) – we have to wait 1-2 years before planning the transplant.
(Infective or benign lesion –> we can go ahead with transplant)
in general skin malignancies are common after transplant, and he has a high risk of recurrence.
So, he is advised to avoid sun exposure, especially 3-4 hours around mid day (10am to 3pm);
to apply broad spectrum sun screen / protective ointment with SPV 50
self examination time to time, and report to the physician at the earliest if any skin lesion is found.
Brother with good match being the donor and negative DSA – transplant is feasible with good outcome
What is your workup strategy?
History — Occupation of patient, sun exposure, sun screen use, tobacco use infections and infestations
Detail physical exam – any other lesion, lymphadenopathy to stop further transplant work up
Needle aspiration : if pus / caseative / fungal material –> Gram stain, culture, cytology ZN stain, KOH mount, Tuberculosis Gene X-pert test
FNAC and tru-cut biopsy – tumor and its type
MRI / CT /PET-CT for local deep muscle involvement and distant mets
Wide local excision by a Onco-surgeon – should be curative; being a small lesion,
Radiation therapy is not required
If it is Amelanotic melanoma – further chemotherapy may be required, to involve oncologist for further treatment.
Prognosis and further planning :
Keratoacnthoma is considered benign, has good prognosis, may progress to SCC
non-melanoma skin cancers like BCC and SCC – curative by wide local excision
Can proceed with transplant after a definitive curative treatment
3.Amelanotic Melanoma –> lymph node biopsy and additional chemotherapy may be required, with waiting of 2 years before transplant
on top of the list is Keratoacanthoma (KA) a low-grade, rapidly growing, 1 to 2 cm dome-shaped skin tumor with a centralized keratinous plug.
squamous cell carcinoma,
amelanotic melanoma,
molluscum contagiosum,
prurigo nodularis,
metastatic lesion to the skin,
Merkel cell carcinoma,
nodular basal cell carcinoma,
ulcerative basal cell carcinoma,
nodular Kaposi sarcoma,
hypertrophic lichen planus,
deep fungal infection,
atypical mycobacterial infection,
foreign body reaction,
verruca vulgaris.
Council this patient regarding kidney transplantation?
As a part of routine pretransplant evaluation alk kidney transplant candidates should have a dermatologist consultation ti seek skin cancers or precancerous lesions before the transplantion.
because after transplantation the risk of cancer in general and skin cancer in particular is increased due to the effect of immunosupression .so this lesion in particular requires a consultation and workup with appropriate dx and definitive Rx before proceeding the transplantation steps.
What is your workup strategy?
My work up strategy in collaboration with dermatologist is to :
take a detailed history including sun exposure,use of sun screen ,tobacco use and any possible exposure to carcinogens.
then clinical examination.
followed by exisional biopsy for Histopathological examination.
The classic keratoacanthoma has a crateriform appearance when viewed histologically at low power.
Higher power reveals enlarged atypical keratinocytes with eosinophilic cytoplasm that do not extend beyond the level of the sweat glands.
These features may be impossible to see in partial or shave biopsy samples, which are not recommended.
Some otherwise typical KAs show squamous cells in a peripheral zone with atypical mitotic figures, hyperchromatic nuclei, and penetration into surrounding tissue.
Such lesions are often reported as SCC, KA-type to reflect uncertainty about their true nature.
There is a term that keratoacanthoma is clinically benign and microscopically malignant
Most keratoacanthomas are treated surgically.
Although they may resolve spontaneously, it is usually prudent to excise them, unless there is clear evidence that regression is in progress.
It is usually best to assume a KA-like lesion is an SCC and to manage accordingly in line with local or national guidance, until proven otherwise.
In selected cases, experienced clinicians may consider other options, such as:
Cryosurgery
Curettage and electrodessication
Topical or intralesional chemotherapy (5-fluorouracil, imiquimod, bleomycin, methotrexate).
Regarding prognosis and outcome:
Keratoacanthoma is regarded as benign and thus has an excellent prognosis following surgical excision.
Lesions that progress and metastasise have probably been SCC, KA-type all along. Patients have an increased incidence of other sun-related skin cancers and should be advised about sun protection and self-examination.and regular follow up due to risk of recurrence or development of scc.
SKIN LESION is likely to be
keratoacanthoma
nodular bcc
amelanotic melanoma
merkel cell ca
SCC less likely
biopsy of lesion is must
if histopathology is benign , no further treatment is advised and we can go ahead with transplant
for bcc and other malignant lesion of skin , one year waiting time before transplant is advised
in general skin malignancy is common after transplant
this patient will be high risk in particular for recurrence
adv – avoid sun exposure , education and self examination
as brother is donor with good match, NO DSA, transplant is feasible with good outcome
work up
extensive work up with CT scan is not required at first go
biopsy and dermatology consultation is advised
counselling with patient is MUST regarding recurrence and prevention of future skin lesion
standard thriple drug like steroid/ mmf/tac without any induction is advised
early reduction of immunosuppression with addition of sirolimus will be considered if skin lesion is recurring
on the top of differential is Keratocanthoma ( cutaneous tumor that most commonly presents as a dome-shaped nodule with a central keratin-filled crate , KA is a distinct follicular-based squamous proliferation that usually follows a benign clinical course )
other differentials could be :
Nodular basal cell carcinoma
Merkel cell carcinoma
Deep fungal infection
Cutaneous metastases
What is your workup strategy?
1- Clinical assessment : obtaining a clear history of the lesion time course since a history of rapid growth within weeks favors this diagnosis. Patients should also be questioned regarding a history of prior similar lesions, sebaceous tumors, and visceral malignancies.
Since extensive sun-exposure is likely a precipitating factor for KA as well as multiple other cutaneous tumors, careful examination of the entire skin surface should be performed .
2- Biopsy : performing appropriate biopsy procedure is crucial for accurate assessment. Whenever feasible, biopsies should involve removal of the entire lesion .
Council this patient regarding kidney transplantation?
after the results of biopsy we can discuss the outcome with the patient , if its malignancy he should remove the lesion and CT for staging and waiting time from 2 to 5 year according to staging
if is benign Keratocanthoma we can proceed with transplantation after removal of the lesion but we should discuss the risk of post transplant skin malignancy with the patient
Council this patient regarding kidney transplantation?
need to exclude malignancy before transplant, as cancer may worsen with immunosuppressive drugs.
if positive for cancer, will need to wait. Can transplant if tumour free for 2-5 years depending on the clinical stage as per the ITSCC guidelines
If not not cancer or benign lesion, can proceed with surgery
There is a chance of tumour recurrence after transplant, even after waiting. Precautions like sun screen, avoiding mid-day sun and using Sirolimus will reduce the likelihood of recurrence.
What is your workup strategy?
Patient will need thorough history and examination, looking for other lesions
Excisional biopsy will need to be done with clear margins
Will need to look for local lymph node involvement and distant metastasis with imaging such as PET scanning
Zwald F, Leitenberger J, Zeitouni N, Soon S, Brewer J, Arron S, Bordeaux J, Chung C, Abdelmalek M, Billingsley E, Vidimos A, Stasko T. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016 Feb;16(2):407-13. doi: 10.1111/ajt.13593. Epub 2016 Jan 28. PMID: 26820755.
The lesion shows a well defined, palpable, papule with smooth margins and dome shape structure with crusting on top…The most likely differential diagnosis is keratacanthoma….The other differential diagnosis are squamous cell carcinoma, basal cell carcinoma, amelanotic melanoma, actinic keratosis, merkel cell carcinoma….
The patient needs a skin biopsy of the lesion…..The patient also needs to evaluate the spread of the disease by clinical examination to see for lymph nodes, PET scan to rule out metastasis…The patient needs to be counselled regarding the tumor after the biopsy report…If the tumour is keratoacanthoma, then it has excellent prognosis…Patient can be proceeded for transplant after wide skin excision of 4mm….There is no tendency for metastasis…..
There is good HLA match and no DSA…I would use IL2 blockers for induction with steroids, MMF and CNI initially..3 months later I will switch over to mTOR inhibitors and remove the CNI as many studies have proven the reduce incidence of de novo skin malignancy after transplant with mTOR inhibitors..
1. SCC, BCC, keratoacanthoma, Merkel cell carcinoma.
2. Council about the risk of recurrence of skin cancer, also proper management therapy & possible waiting time or unsuitability for Tx.
3. Skin biopsy for confirmation & staging, detailed systemic examination, dermatologist & oncology consultation.
51 years old CKD stage 5 on HD since 4 years ago due to IGA nephropathy came to transplant assessment clinic, has a donor his brother 000 mismatch and no DSA while on routine examination found the above lesion..
Differential diagnosis:-
-keratoacanthoma ( dome shaped lesion while Center filled with keratin developed in hair bearing skin and sun exposed area, either appear solitary or on context of specific disorder.
– nodular basal cell carcinoma.
-Merkel cell carcinoma.
– giant mollescoum contagiousm
– deep fungal infection (sporotrichosis).
– cutanons metastasis.
counselling regarding and kidney Transplantation:-
40% of patient post kidney transplant malignancy. related to skin which more common
in white races.
We must pay attention for prevention of dermatological malignancy by..
– educations awareness and = r observation.
– self skin examination by patient and by physician.
– suspect lesion must do biopsy.
– avoid excessive sun exposure with continuous using of sunblock.
Workup strategy
-MDT including dermatologist nephrologist oncologist and transplant surgeon.
-history from patient ( if rapidly growth within weeks, extensive sun exposures or prior similar lesion).
– dermoscopy for differentiation and biopsy is a-key for diagnosis.
– if giant lesion biopsy will be difficult so fusiform incisional biopsy from Center with extending to underlying fat can help.
– modification of immunosuppression ,sirolimus showed to decrease incidence non melanoma cameos and cause regression of pre-pro-existing skin lesion.
– patient precautions must be considered ( self examination with avoid sm exposure and continuous using of sunblock).
2.Counsel the patient regarding kidney transplanation
Skin malignancies prior to transplantation can be a hindrance to rtransplant, as the immunsuppression used in port transplant care puts the person at risk of developing cancers.
The stage of the skin cancer, the type and associated metastases are the determining factors. If the transplant cannot go on because the cancer is active/has metastasized, some years after treatment of the cancer the patient will be assessed again for fitness for transplant. Meanwhile dialysis will continue.
3.Workup strategy
History taking
Clinical examination for surrounding lymphadnopathy and organ involvement
Imaging
Biopsy of the lesion for histology
Dermatology Consultation
What is your differential diagnosis? This is a solitary nodule, site is not clear in this image, will circumscribed and demarcated, reddish or skin colored with central hyperkeratotic crusty or scaly covering.
This picture is typical for Keratoacanthoma. However, other cause of differential diagnosis should be ruled out:
1-Squamous cell carcinoma.
2-Nodular Basal Cell Carcinoma
3-Actinic Keratosis.
4-Amelanotic Melanoma.
5-Merkel cell carcinoma.
6-Dermatofibrosarcoma protuberans.
7-Giant Molluscum Contagiosum.
8-Nodular Prurigo.
9- Metastatic deposits.
10-Common warts.
Council this patient regarding kidney transplantation?
Pre-transplantation counselling regarding the following points:
1- Diagnosis and treatment of this lesion will guide the discussion and will direct the team if the patient can proceed for renal transplantation or he needs to wait.
2- There is a higher incidence of non-melanoma skin cancer like Kerato-acanthoma (recurrence and De-novo) in post renal transplant recipients than general population.
3- Kerato-acanthoma carries an excellent prognosis after total excision with 4mm safety margin.
5- The patient can proceed for kidney transplantation without waiting period after total excision with 4mm safety margin of keratoacanthoma.
6- Regular self-examination and annual dermatological examination are essential looking for recurrent or de-novo lesions.
7- Post-TX counselling regarding immunosuppression regimen and protection from sun exposure.
What is your workup strategy?
History and examination: local and systemic especially for other lesions, lymph nodes, distant metastasis, peripheral vascular disease.
Treatment options of keratoacanthoma include: surgical excision, methotrexate and 5-fluorouracil.
Dermatology review for examination and excisional skin biopsy.
Oncology Review for staging (CT-chest abdomen and pelvis or PET-CT) and advice regarding any further management.
Waiting time will be decided according to diagnosis and staging as mentioned above.
If the patient is deemed suitable and safe for transplantation, immunosuppression protocol is recommended as follows: lower immunosuppression as low as possible. Consider switching CNI to m-TOR inhibitors, Azathioprine to MMF.
Regular self-examination and annual dermatological examination are essential looking for recurrent or de-novo lesions.
Protective sun exposure measures.
References:
Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, et al., Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement. Am J Transplant. 2021 Feb;21(2):460-474. doi: 10.1111/ajt.16318. Epub 2020 Oct 23. PMID: 32969590; PMCID: PMC8576374.
Amanda Oakley, Martin Keefe.Keratoacanthoma.Derma net. November
Kasiske BL, Snyder JJ, Gilbertson DT, Wang C: Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905–913.
Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol. 2017 Jun 2;18(1):174. doi: 10.1186/s12882-017-0553-2. PMID: 28571571; PMCID: PMC5455080.
hand book of kidney transplant 6th edition
Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33. doi: 10.1016/j.jaad.2015.11.033. Epub 2016 Feb PMID: 26853179.
Sánchez Yus E, Simón P, Requena L, Ambrojo P, de Eusebio E. Solitary keratoacanthoma: a self-healing proliferation that frequently becomes malignant. Am J Dermatopathol. 2000 Aug;22(4):305-10. doi: 10.1097/00000372-200008000-00002. PMID: 10949454.
Council this patient regarding kidney transplantation?
Keratoacanthoma has a good prognosis after surgical remove. patients with keratoacanthoma and history of sun exposure should be followed for the development of primary skin cancer Denovo skin cancer. Metastases are rare, no need waiting time for transplant, advice the patient about sun exposure and use sun block daily with high SPF for more protection.
What is your workup strategy?
The preferred method is an excisional biopsy and differentiation from SCC. surgical excision is the treatment of choice for solitary KA, pharmacologic therapy, radiation therapy, and topical therapy and because of his brother is a donor with zero mismatch with a negative DSA, so early minimization of immunosuppressive with an early transfer CNI to mTORi will be preferable.
References:
· Keratoacanthoma: Management and prognosis. UpToDate.
This is a dome-shaped nodule with a central keratin-filled crater suggestive ofKeratoacanthoma
Recommended wait times for pre-transplantation for patients with a history of skin cancer before transplantation:
No history of SCC but at low risk for development of SCC: No delay necessary
High-risk SCC (not including perineural invasion): 2 years
High-risk SCC with Perineural invasion: 2 to 3 years
High risk with local nodal metastatic disease: 5 years
Distant metastasis: Not eligible for transplantation
Clinical assessment
· a history of rapid growth of the lesion within weeks favors the diagnosis.
· Since extensive sun-exposure is likely a precipitating factor for KA as well as multiple other cutaneous tumors, careful examination of the entire skin surface should be performed.
· Dermoscopy may aid in clinically distinguishing KA from other lesions but cannot reliably distinguish KA from squamous cell carcinoma
Biopsy
· Whenever feasible, biopsies should involve removal of the entire lesion, and performing the appropriate biopsy procedure is crucial for accurate assessment.
· The preferred method for obtaining a biopsy specimen is an excisional biopsy extending into the subcutaneous fat. At least a 4 mm margin
Histopathology
The histopathological features that typically characterize KA include:
· Epidermal hyperplasia with large eosinophilic keratinocytes
· Central invagination with a keratotic core (this may be less evident in early-stage lesions)
· “Lipping” or “buttressing” of the epidermis over the peripheral rim of the central keratotic plug
· Sharp demarcation between the tumor and the surrounding stroma
· Mixed inflammatory infiltrate in the dermis
Differentiation from squamous cell carcinoma
· among the pathologic features typically ascribed to KA, the presence of an epithelial lip and a sharp outline between the tumor and stroma appeared to be the most useful factors for the diagnosis of KA.
· In contrast, the presence of ulceration, mitoses, and pleomorphism or anaplasia favored a diagnosis of squamous cell carcinoma.
Management
There are no definitive guidelines on the treatment of Keratoacanthoma since there is debate over the classification of KA as a benign, spontaneously resolving tumor versus a variant of cutaneous squamous cell carcinoma with a rare potential for metastasis.
Conventional surgical excision is the treatment of choice for solitary KA since it allows for both the assessment of histopathologic features to aid in diagnosis and pathologic confirmation of the removal of the tumor.
Mohs surgery is a tissue-sparing surgical technique that also allows for the intraoperative assessment of 100 % of the tissue margins, and is the preferred treatment for KAs in areas such as the central face, ear, nose, and periocular and perioral skin to spare tissue.
Other effective options for the treatment of KA include electrodesiccation and curettage (ED&C), intralesional pharmacologic therapy, radiation therapy, and topical therapy. A disadvantage of these interventions compared with surgical excision is the lack of histopathologic confirmation of tumor removal.
1-What is your differential diagnosis?
-Keratoacanthomas (most likely)
-Merkel cell carcinoma.
-Squamous cell carcinoma.
-Melanotic Melanoma
-Dermatofibrosarcoma protuberans.
-Actinic keratosis.
-Nodular Basal cell carcinoma.
-Giant molluscum contagiosum.
-Metastatic deposit. 2-Council this patient regarding kidney transplantation?
-Keratoacanthoma has an excellent prognosis following surgical excision. Generally, patients with keratoacanthoma with history of sun exposure will need to be followed for the development of new primary skin cancers. Metastases are rare,So no wait time for TX,
-But this lesion is closely related to SCC and the patient will need close follow up for fear of developing skin cancer after immunosuppression,
-Regarding kidney transplant can proceed without delay although a skin biopsy is needed. Also should be counseled that 25% of keratoacanthoma undergo a malignant transformation in areas exposed to the sun, so have been on immunosuppression, exposure to ultraviolet sun rays, and the presence of keratoacanthoma put you in malignant disease risk,
-Use of sunscreen avoid sun exposure, frequent skin examination, and seek urgent medical advice if any skin lesion detected 3-What is your workup strategy?
-By local examination;Solitary Keratoacanthomas (KA):
-Solitary, rapidly growing nodule on sun-exposed skin of the face and upper limbs. Keratoacanthomas are sharply demarcated, firm, erythematous or skin-colored, with a classic central hyperkeratotic plug and an even shoulders..
-It is usually best to assume a KA-like lesion is an SCC and to manage accordingly in line with local or national guidance, until proven otherwise.
-Dermatology Referral;for possible Skin Biopsy
-Treatment is Surgical. Although they may resolve spontaneously, it is usually prudent to excise them, unless there is clear evidence that regression is in progress.
-Other options are:
-Cryosurgery
-Curettage and electrodessication
-Topical or intralesional chemotherapy (5-fluorouracil, imiquimod, bleomycin , methotrexate).
-Patients should be advised about Sun Protection and Self-Examination 4-References: –Keratoacanthoma: Management and prognosis. UpToDate. –Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation. 2005 Sep 1;5(9):2079-84.
-Risk of Invasive Cutaneous Squamous Cell Carcinoma After Different Treatments for Actinic Keratosis: A Secondary Analysis of a Randomized Clinical Trial.Ahmady S, Jansen MHE, Nelemans PJ, Kessels JPHM, Arits AHMM, de Rooij MJM, Essers BAB, Quaedvlieg PJF, Kelleners-Smeets NWJ, Mosterd K JAMA Dermatol. 2022;158(6):634.
Differential diagnosis is mainly : -Keratoacanthoma which is a low-grade, 1 to 2 cm dome-shaped skin tumor with a centralized keratinous plug characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases. Keratoacanthoma may progress rarely to invasive or metastatic carcinoma .
-It should be differentiated from squamous cell carcinoma -Molluscum Contagiosum -Merkel Cell Carcinoma -verrucous Carcinoma
-Investigations entails : biopsy is the most important step and management will be done accordingly
-labs
-waiting time according to the pathology – attached
-Recurrence or denovo malignancy
References:
1-Handbook of kidney transplantation-6th edition
2-Keratoacanthoma, SCC -Uptodate -2022
DD: SCC, BSC, malignant melanoma & other skin lesions
dermatology referral for biopsy, opinion & management plan (surgical excision, cryotherapy, curettage, intralesional injections).
staging will affect the decision & waiting time before transplantation (low risk SCC & malignant melanoma in situ requires no waiting time, otherwise 2-5 years will be needed according to staging)
Counselling about the possibility of recurrence post-transplantation.
education for self-examination of the skin after transplantation and follow-up every three months are required.
protective measures like protective clothing, sunscreen use & avoidance of prolonged sun exposure especially in peak hours should be instructed.
In the presence of his brother as a donor with ooo mismatch & no DSA, minimization of immunosuppressive with mTORi based protocols will be preferable.
Picture shows single Dome-shaped, skin-coloured lesion , symmetrical, covered with crust
DD
Keratoacanthoma
Squamous cell carcinoma.
Non melanotic melanoma.
Actinic keratosis.
Nodular Basal cell carcinoma.
Common warts.
Giant molluscum contagiosum.
Metastatic skin deposit.
Merkel cell carcinoma, ulcerative basal cell carcinoma, nodular Kaposi sarcoma, hypertrophic lichen planus, deep fungal infection, atypical mycobacterial infection, foreign body reaction, and verruca vulgaris.
Most probably Keratoacanthomas .
Keratoacanthoma (KA) is a low-grade, rapidly growing, 1 to 2 cm dome-shaped skin tumor with a centralized keratinous plug.
Etiologies includs:
ultraviolet (UV) radiation, exposure to chemical carcinogens, immunosuppression, use of BRAF inhibitors, genetic predisposition , viral exposure including human papillomavirus (HPV), and recent trauma or surgery to the location.
Peak incidence of solitary keratoacanthoma is between 50 and 69 years of age. They occur more frequently in men with a male to female ratio of 2:1
Lesions are evaluated with a careful history and physical examination.
The best diagnostic test is an excisional biopsy as a shave biopsy may be insufficient to examine the depth to differentiate keratoacanthoma from squamous cell carcinoma.
Keratoacanthoma is recognized as benign, treatment is recommended due to the relation to squamous cell carcinoma. Treatment of choice consists of an excisional procedure with 4 mm margins.
Council this patient regarding kidney transplantation:
Keratoacanthoma has an excellent prognosis following surgical excision. Generally, patients with keratoacanthoma with history of sun exposure will need to be followed for the development of new primary skin cancers. Metastases are rare,
So no wait time for TX
But this lesion is closely related to SCC and the patient will need close follow up for fear of developing skin cancer after immunosuppression
What is your workup strategy?
Excisional biopsy to confirm diagnosis .
Chest x ray and body imaging to role out internal organ malignancy
No wait time for transplantation
Avoid T cell depleting agents for induction and heavy immunosuppression as they are risk factors for skin malignancy
References
Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Keratoacanthoma of Skin: Keratoacanthoma (KA) is a cutaneous tumor that most commonly presents as a dome-shaped nodule with a central keratin-filled crater
squamous cell carcinoma Fungating skin lesion
Rx Excision Skin biopsy should be obtained. First-line therapy — Conventional surgical excision is the treatment of choice for solitary KA since it allows for both the assessment of histopathologic features to aid in diagnosis and pathologic confirmation of the removal of the tumor. Other effective options for the treatment of KA include electrodesiccation and curettage (ED&C), intralesional pharmacologic therapy, radiation therapy, and topical therapy. Incomplete removal of KA may result in lesion recurrence. Metastasis can occur.
Patient should be counselled regarding the higher risk for developing skin cancer post kidney transplant compared to the general population. Moreover, he should have annual check up post-transplant. He should be advised to have head-to-toe skin exams by a dermatologist at least once a year.
References:
· Keratoacanthoma: Management and prognosis. UpToDate.
· Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation. 2005 Sep 1;5(9):2079-84.
Solid organ transplant recipients are at increased risk for cutaneous malignancies (most commonly squamous cell carcinoma), a finding related to long-term immunosuppression. Because some skin cancers demonstrate aggressive biologic behavior in the setting of immunosuppression, care must be taken to identify and treat early lesions appropriately. In addition to treatments that directly target cutaneous malignancies, modulation of immunosuppression and preventive measures play an important role in the management of these patients. Organ transplant recipients with a history of skin cancer should be followed closely for the development of new lesions, locally recurrent lesions, and metastatic disease.
Council this patient regarding kidney transplantation?
PRETRANSPLANTATION SCREENING A dermatologic consultation is recommended before transplantation for the screening and treatment of skin cancer and precursor lesions. All suspicious lesions should be excised and sent for pathologic examination. Actinic keratoses, porokeratoses, and viral warts should be treated. A careful history of previous skin cancer should also be obtained to determine the appropriate follow-up frequency or the wait time before proceeding to transplantation
Wait time For patients with a history of prior cutaneous malignancy, the wait time before undergoing transplantation depends upon the tumor type and stage, presence or absence of high-risk features, and availability of a management approach alternative to transplantation. ●Transplant candidates with extensive field disease (ie, multiple actinic keratoses, disseminated porokeratosis) but without a history of skin cancer may proceed to transplantation, with the recommendations that all field disease be appropriately managed by the dermatologist.
●For patients with basal cell carcinoma or low-risk squamous cell carcinoma (SCC) that has been surgically excised with clear margins, no waiting time is required.
●For patients with a history of high-risk SCC and for those with Merkel cell carcinoma stage IIa or less (local disease; any tumor size not invading bone, muscle, fascia, or cartilage; negative lymph nodes a two- to three-year waiting time is required.
●For patients with SCC and local nodal disease, a five-year wait time is considered prudent, following appropriate treatment with lymph node dissection and adjuvant radiation therapy.
●For transplant candidates with a history of melanoma in situ/lentigo maligna, no waiting period is required, but the patient should be followed up with regular skin exams. ●For renal transplant candidates with a history of stage Ia/Ib/IIa melanoma, a two- to five-year wait time is required before transplantation. A five-year delay is required for patients with stage IIb/IIc melanoma.
●Patients with distant metastatic diseases are not eligible for transplantation in most circumstances.
What is your workup strategy?
Work up skin examination and palpation of draining lymph nodes. The need for additional laboratory or radiologic evaluation is based upon the detection of findings that suggest locoregional or metastatic spread of disease. Skin biopsy of the lesion Screen for distant metastasis Reducing immunosuppressive drugs Change the CNI to mTOR Change AZA to MMF Patient education concerning sun protection and skin self-examination
Post-transplantation surveillance by nephrologist and Dermatologist
Reference
Kang W, Sampaio MS, Huang E, Bunnapradist S. Association of Pretransplant Skin Cancer With Posttransplant Malignancy, Graft Failure and Death in Kidney Transplant Recipients. Transplantation 2017; 101:1303.
Zwald F, Leitenberger J, Zeitouni N, et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant 2016; 16:407
3-Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Curr Treat Options Oncol 2012; 13:354.
2-Councel the patient regarding kidney transplantation
Kidney transplantation is the best therapeutic for ESRD patients ,however transplantation in cancer patient carries 5-7 folds increased risk of recurrence and patients of high grade malignancy have low 5 years survival rates whether they were transplanted or not due to death from cancer related or cancer non related causes ,but low grade malignancy have a better prognosis ,while patient who remain on dialysis for long time are at increased risk for death from non cancer related causes specially cardiovascular complications , thus the treatment stratigey is personalized according to each patient specific conditions .
The initial step in management is a skin biopsy to reach a definite diagnosis .In case of malignant skin cancer further staging and examination for distant visceral and lymph node spread is needed.
Guidlines recommend waiting time for 1 year for localized melanoma and at least 2 years free of cancer recurrence for other cancers
Treat any risk factors for cancers as: stop smoking ,avoid excessive sun exposure and usesun block
Dematological expert consultation regarding suitable treatment and screening strategy.
Optimize the dialysis adequacy ,correct any electrolyte disturbance specially Ca,po4 to avoid calciphylaxis.
Ref
1- Knoll, Greg A. MD, MSc, FRCPC1,2; Chadban, Steven J. BMed, PhD, FRACP3. Preexisting Cancer in Transplant Candidates: Time for a Change in Practice?. Transplantation 102(7):p 1037-1038, July 2018. | DOI: 10.1097/TP.0000000000002177
2- Dahle, Dag Olav MD, PhD1; Grotmol, Tom MD, PhD2; Leivestad, Torbjørn MD, PhD3; Hartmann, Anders MD, PhD1; Midtvedt, Karsten MD, PhD1; Reisæter, Anna V. MD, PhD1; Mjøen, Geir MD, PhD1; Pihlstrøm, Hege K. MD, PhD1; Næss, Hege MD4; Holdaas, Hallvard MD, PhD1. Association Between Pretransplant Cancer and Survival in Kidney Transplant Recipients. Transplantation 101(10):p 2599-2605, October 2017.
Council this patient regarding kidney transplantation?
It will typically grow in weeks to months followed by spontaneous remission over 4-6 months.
Need biopsy to diagnosed, have to rule out SCC. In few case(25%) can convert to malignant. No waiting time needed for this unless the biopsy shows other thing
The patient needs to be counselled regarding the risk of occurrence of skin cancer post-transplantation due to use of immunosuppressive medications
The patient should also be counselled regarding the importance of preventive measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin
What is your workup strategy?
Detailed history and examination.
MDT with dermatologist
Non lymphocyte depleting agents in good match donor for transplantation The patient should also be counselled regarding the importance of preventive measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin
What is your differential diagnosis? Dome-shaped skin tumor with a centralized keratinous plug, mostly suggestive of keratoacanthoma Differential diagnosis: · Squamous cell carcinoma, · Amelanotic melanoma, · Molluscum contagiosum, · Prurigo nodularis, · Metastatic lesion to the skin, · Merkel cell carcinoma, · Nodular basal cell carcinoma, · Ulcerative basal cell carcinoma, · Nodular Kaposi sarcoma, · Hypertrophic lichen planus, · Deep fungal infection, · Atypical mycobacterial infection, · Foreign body reaction, · Verruca vulgaris. · Cutaneous Horn · Muir-Torre Syndrome · Sporotrichosis
Council this patient regarding kidney transplantation? · Rapid growth over a few weeks to months, followed by spontaneous remission over 4-6 months, is how Keratoacanthoma is typically described. In rare cases, keratoacanthoma can develop into aggressive or metastatic cancer. Whether these instances were SCCs or keratoacanthomas, the findings demonstrate how challenging it is to accurately categorize each individual case. (1) · The most frequent form of skin cancer after transplantation is SCC, which develops 65 times more frequently than in those who are not immunosuppressed. (2) · For those with a history of cSCC, dermatological follow-up for skin cancer screening is crucial both before and after transplantation, as well as instruction in sun protection, as there is an increased risk of developing subsequent skin cancers in renal transplant patients that ranges from 40% to 80%.(3, 4)
What is your workup strategy? · With the recommendation that all field diseases be handled by the dermatologist as thoroughly as possible, patients with significant field disease but no history of skin cancer may continue to transplantation. · The majority of patients with a history of low-risk SCC before transplantation proceeds to transplantation. · The staging of the primary tumor using head and neck computed tomography (CT) or, where possible, positron emission tomography (PET)/CT), followed by complete surgical removal when possible, are all steps in the careful evaluation of transplant candidates with a history of high-risk SCC before transplantation. (5)
1. Zwald, F.; Leitenberger, J.; Zeitouni, N, et al,. (2016). Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborate. American Journal of Transplantation, 16(2), 407–413. doi:10.1111/ajt.13593 2. Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: Part I. Epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol 2011; 65: 253–261, 3. Ismail F, Michell L, Casebonne D, et al. Specialist dermatology clinics for organ transplant recipients significantly improve compliance with photoprotection and levels of skin cancer awareness. Br J Dermatol 2006; 155: 916–925. 4. Ulrich C, Kanitakis J, Stockfleth E, Euvrard S. Skin cancer in organ transplant recipients: where do we stand today? Am J Transplant 2008; 8: 2192–2198. 5. Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol 1992; 26: 976–990.
The lesion is mostly keratoacanthoma but other DD:
SCC
Wart
BCC
Amelanotic melanoma
Council this patient regarding kidney transplantation?
He needs to know the waiting time:
If the diagnosis is KA , it is mostly benign and needs surgical excision with safety margin with no waiting time.
If the diagnosis is SCC waiting time ranges from 2-5 years according to aggressiveness.
He needs to protective measure:
Regular self examination
Avoid sun exposure
Protective clothes
Sun block
He needs to know about immunosuppressive medications, that lower immune system and increase the risk of recurrence , or occurrence of skin cancer which is higher than normal individuals.
Work up :
Full history and examination
Multidisciplinary team work between nephrologist, dermatologist, oncologist
CT or MRI can be done
The most probable diagnosis is Keratoacanthoma.
Other possible diagnoses:
1-Actinic keratosis
2-Squamous cell carcinoma.
3-Cutaneous horn
4-Molloscum Contagiosum
Council this patient regarding kidney transplantation?
The short duration of the lesion and its appearance points to the more benign lesion keratoacanthoma. However we need to differentiate from squamous cell carcinoma which is more sinister condition, as the decision to go for transplantation will depends on the histological diagnoses and the extent of the disease.
What is your workup strategy?
Detailed history and examination.
Excisional biopsy.
Dermatology consultation
Oncology consultation if the lesion is confirmed to be malignant.
References:
1-Medescape
2-Laamari K, Oukarfi S, Elloudi S, Douhi Z, Baybay H, Mernissi FZ, Aouinti L, Charai A, Kamal D, El Amine El Alami MN. Keratoacanthoma or squamous cell carcinoma. Our Dermatol Online. 2020;11(e):e76.1-e76.3.
Keratoacanthoma is a benign keratinocytic neoplasm which spontaneously regresses within 3-6 months and mimics well-differentiated squamous cell carcinoma (SCC). Increased incidence of keratoacanthoma and non-melanoma skin tumor is seen among immunosuppressed organ-transplants.
Counselling:
Total excision with clear margin is needed also the patient to be counselled regarding possibility of recurrence following RTX
The patient is advised for self examination.
-Workup strategy:
-history
– Thorough physical examination to look for other lesions& lymphadenopathy
– Routine investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion ; first-line treatment for a solitary lesion
– Multidisciplinary team management
– Kidney transplantation according to the outcome of the evaluation.
This patient seems to have a malignant lesion, could be basal or squamous cell carcinoma. Excisional biopsy is essential both for diagnosis and treatment. different lesions have offered different waiting times. earlier suggestions, as in the attached pictures. There have been scarce studies about malignant melanoma and lymphoma in recent years, but all data suggest waiting with careful monitoring.
The waiting time is mainly dependent on the type of malignancy and staging. dermatologic cancers with no invasion; in situ do not need time to wait. waiting time varies from 2-5 years after remission.
What is your differential diagnosis?
1. Keratoacanthoma (KA)
2. Squamous cell carcinoma
3. Nodular basal cell carcinoma
4. Amelanotic melanoma
5. Common warts
6. Metastatic deposit
7. Giant molluscum contagiosum
8. Nodular prurigo Council this patient regarding kidney transplantation
Surgical excision of the lesion and send it for histopathology. If the lesion is localized and no evidence of metastases and confirmed to be KA, transplantation can proceed. Avoid sun exposure with regular self examination. KA is considered benign and thus has an excellent prognosis following surgical excision. The risk of skin cancer post transplantation is high. What is your workup strategy?
Multidisciplinary approach
Keratoacanthoma is diagnosed on the basis of a typical history, the clinical signs and histopathology
Histologically: low power (has a crateriform appearance). High power (enlarged atypical keratinocytes with eosinophilic cytoplasm that do not extend beyond the level of the sweat glands)
KA may show squamous cells in a peripheral zone with atypical mitotic figures, hyperchromatic nuclei, and penetration into surrounding tissue. Such lesions are often reported as SCC, KA-type
Treatment is surgical. Other options are:
Patients should be advised about sun protection and self-examination Reference
1. Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016;74(6):1220–33. doi:10.1016/j.jaad.2015.11.033.
2. Gleich T, Chiticariu E, Huber M, Hohl D. Keratoacanthoma: a distinct entity? Exp Dermatol. 2016;25(2):85–91. doi:10.1111/exd.12880.
3. Misago N, Inoue T, Koba S, Narisawa Y. Keratoacanthoma and other types of squamous cell carcinoma with crateriform architecture: classification and identification. J Dermatol. 2013;40(6):443–52. doi:10.1111/1346-8138.12104.
Counselling
Non metastatic non melanoma skin cancer does not require a recurrence- free interval before transplantation. However, before this conclusion is made, extensive work up needs to be made to ascertain the histologic type and rule out metastasis.
She will need to be counselled for surgery.
Counselling on self-examination, avoidance of sun and use of sun protection.
What is your differential diagnosis?
Papular lesion with areas of increased keratin at the centre for differential diagnsis: Keratoacanthoma, Squamous cell carcinoma and others (referral to dermatology is a must given the cancer probability)
Council this patient regarding kidney transplantation?
Recurrenance post transplant:
There is a chance of recurrence post transplant and unfurtunatly the risk is higher than matched non tranaplant population up to 60 times however there are measures can be considered post transplant like limit sun exposure and use sun blocks with certain SPF and most importantly to monitor the skin and look for any recurrence.
When can we proceed with transplant:
It depends on the outcome from dermatology assessment and staging, there may be a waiting time that can exptend up to 2- 5 years depends on the staging and outcome. In some cases if proven to be metastatic lesion, other forms of therapy would be more important than renal transplant itself with potential better survival like immunotherapy (which is grey area at the momenet in term of suitability of organ transplant)
What is your workup strategy?
Extensive clinical examination, urgent referral to dermatology for their input and Mohs micrographic surgery. look for distant mets CT or PET scan
Rererences:
Al-Adra, David1; Al-Qaoud, Talal1; Fowler, Kevin2; Wong, Germaine3,4,5. De Novo Malignancies after Kidney Transplantation. CJASN 17(3):p 434-443, March 2022. | DOI: 10.2215/CJN.14570920
Łasińska, I., Kolenda, T., Teresiak, A., Lamperska, K. M., Galus, Ł., & Mackiewicz, J. (2019). Immunotherapy in Patients with Recurrent and Metastatic Squamous Cell Carcinoma of the Head and Neck. Anti-cancer agents in medicinal chemistry, 19(3), 290–303. https://doi.org/10.2174/1871520618666180910092356
What is your differential diagnosis?
——————————————————-
1-Squamous cell carcinoma.
2- Keratoacanthoma.
Council this patient regarding kidney transplantation?
————————————————————————————
1-The candidate should know the outcome of SCC post kidney transplantation;
SCC are considered as more aggressive in transplant recipients than in non immunosuppressed patients, as they recur locally in 13.4% of patients, generally during the first 6 months after excision, and metastasize in 5% to 8% of patients, usually within 2 years after excision. Factors of unfavorable prognosis of SCC in transplant patients are multiple.
2-The candidate must know the waiting time before transplant ;
The guidelines recommend a waiting period of 2 years in case of SCC with histological features of aggressiveness (considering the median delay to the occurrence of metastasis), and of 5 years in case of history of metastatic SCC. Nevertheless, the length of the wait period should be discussed on an individual patient basis, according to the background and the tolerance of dialysis.
3-The preventive measures should be discussed with the candidate ;
Preventive measures should be applied, especially in patients who accumulate several risk factors of aggressive SCC. These measures include adequate education about strict sun protection and regular dermatologic monitoring for early ablation of (pre)malignant lesions with adequate safety margins.
4-The candidate should understand the impact of immunosuppressant in his primary skin cancer ;
The availability of a well-matched donor should decrease the immunologic risk, allowing avoidance of a T cell–depleting induction treatment. An early tailored immunosuppression, including mTOR inhibitors, should be the best prevention of aggressive SCC but the risk o rejection is existed .
What is your workup strategy?
————————————————————
1-A multidisciplinary team (Nephrologist ,dermatologist ,oncologist and surgeon ) should evaluate this candidate .
2-The eligibility for transplantation;
Based on the existing evidence, the guidelines advocate ;
A- await time of 2 years before transplantation for patients with a history of high-risk SCC (i.e., large size [>2 cm], high-risk location,recurrent lesion, poorly differentiated), if there is no evidence of metastasis on CT or PET-CT, and the tumor has been cleared surgically .
B- For patients with evidence of perineural invasion, the group believes that it would be more prudent to extend the wait time to 2 to3 years.
C- For nodal disease, the combination of surgicalexcision and adjuvant radiation therapy (ART) is consideredbest practice for head and neck SCC .
D- For transplant candidates with SCC with nodal disease, a 5-year wait time is considered prudent, following appropriatetreatment with no radiological .
3- Immunosuppressant ;
Once graft function has stabilized, the transplant team should be encouraged to minimize immunosuppression asmuch as possible as per KDIGO guidelines (2).
Reference ;
——————————–
1-Zwald et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413. doi: 10.1111/ajt.13593.
2. Brantsch KD, Meisner C, Schönfisch B. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study Lancet Oncol 2008. 9713–720 [PubMed] [Google Scholar].
3. Schmults CD, Karia PS, Carter JB. Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study JAMA Dermatol 2013. 149541–547 [PubMed] [Google Scholar].
4. Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part II. Management of skin cancer in solid organ transplant recipients J Am Acad Dermatol 2011. 65263–279 [PubMed] [Google Scholar].
5. Singh MK, Brewer JD. Current approaches to skin cancer management in organ transplant recipients Semin Cutan Med Surg 2011. 3035–47 [PubMed] [Google Scholar]
6. Harwood CA, Mesher D, McGregor JM. A surveillance model for skin cancer in organ transplant recipients: a 22-year prospective study in an ethnically diverse population Am J Transplant 2013. 13119–129 [PubMed] [Google Scholar]
Squamous cell carcinoma Keratoacanthoma which is a special tumor. It was considered a pseudocancer, which appears in the form of an isolated nodule, generally on the face or exposed areas
Council this patient regarding kidney transplantation?
· kin cancer involves review of historical data, examination
· and assessment of the details of the prior cancers to es-
· timate the risk of recurrence, metastasis or formation of
· new primary cancer (Table 1). For patients with a history
· of skin cancer that is not readily identifiable as low risk,
· transplant dermatologists and Mohs surgeons may be of
· assistance to assess the clinical, surgical and pathologic
· details of the prior skin cancer and estimate a prognosis,
· taking into account the time elapsed since the occurrence
· of the skin cancer. Radiologic imaging may be indicated on a
· case-by-case basis but is subject to false-positive and false-
· negative findings. Positron emission tomography may be
· helpful in ascertaining any foci of metastatic melanoma,
· high-risk squamous cell carcinoma (SCC) or Merkel cell
· carcinoma, whereas computed tomography is only rarely
· helpful for detection of recurrent basal cell carcinoma (BCC)
· and other slow-growing tumors. In kidney-transplant recipients with at least one previous cutaneous squamous-cell carcinoma, conversion from calcineurin inhibitors to sirolimus was associated with a lower risk of subsequent skin cancers. The data suggest that the earlier the conversion occurs after an initial diagnosis of cutaneous squamous-cell carcinoma, the greater the efficacy.(1) KDIGO recommend that candidates with active malignancy be excluded from kidney transplantation except for those with superficial non-melanoma skin cancer (1B). no waiting time for candidates with curatively treated (surgically or otherwise) non-metastatic basal cell and squamous cell carcinoma of the skin; melanoma in situ .(2)
· btain a complete history and perform a physical examination,
· paying specific attention to sites of prior skin cancers and
· palpating the regional nodal basin for high-risk skin cancers.
· Review clinical and pathologic details of prior skin cancers.
· Transplant dermatologists may be helpful in this regard.
· Using prognostic data, estimate the risk of recurrence,
· metastasis and development of new primary cancers. When
· estimating risk, consider the time elapsed since skin cancer
· was treated.
· Consult Table 2 for general recommendations on the
· appropriateness of transplantation.
· Assess risk of cancer recurrence, risk of end organ disease and
· risks of transplantation to determine transplant status.
· Consider the ethics of limited organ availability, which may
· differ depending on whether the donor is a living relative or a
· cadaver.
· If the potential for occult micrometastasis exists, radiographic
· staging should be performed before considering listing the
· patient on the organ transplant waiting list.
· Periodic examinations and imaging are appropriate for patients
· with prolonged waits for transplant organs.
What is your workup strategy?
Patient evaluation through examination of the lesion, lymph nodes palpation and looking for any evidence of locoregional or metastatic spread of disease. Then a through pathological examination with biopsies of lesions that extend into the deep reticular dermis. The need for additional laboratory or radiologic evaluation is based upon the detection of metastatic findings and classification. high-risk features: ●Location in the “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet ●Large size: ≥10 mm on scalp, forehead, cheeks, neck or pretibial area; ≥20 mm on trunk or extremities ●Indistinct borders ●Rapid growth ●Recurrent lesion ●Lesion in site of chronic inflammation or prior radiation therapy ●Presence of neurologic symptoms ●Histology Options for the treatment are surgical, chemotherapy and radiotherapy
1- surgical excision: Lesions should be excised with a margin of tissue that extends 4 to 6 mm beyond the peripheral edge of erythema, and the specimen should be sent for postoperative pathologic margin assessment. SCCs in immunosuppressed patients that demonstrate other high-risk features be managed with techniques that provide pathologic confirmation of tumor removal (Mohs surgery, surgical excision with intraoperative frozen sections or a conventional surgical excision with postoperative margin examination . Lesions treated with conventional surgical excision should be excised with at least 6 to 10 mm margins beyond the edge of erythema .Guidelines from the National Comprehensive Cancer Network state that lesions ≥20 mm on the trunk or extremities should be excised with 10 mm margins .
2- Electrodesiccation and curettage is a procedure that involves three cycles of scraping of the tumor with a curette followed by electrodesiccation, is an alternative treatment for lower risk lesions. Advantages are quick, generally well tolerated, and less expensive and disadvantage are the lack of histologic margin control, which underlies the importance of carefully selecting lesions for treatment. ED&C should generally not be performed in hair-bearing areas because the presence of terminal hair follicles may reduce the efficacy of the procedure. In addition, ED&C cannot reliably eradicate lesions that extend into the subcutaneous fat. If fat is reached early during the curettage stage, ED&C should be abandoned and the tumor should be removed surgically. All sites treated with ED&C should be followed closely for lesion recurrence.Some clinicians choose to perform ED&C at the time of biopsy on lesions that are clinically consistent with small, well-differentiated SCCs. If pathology results demonstrate aggressive histopathologic features, subsequent surgical excision should be performed to ensure adequate tumor removal.The efficacy of ED&C for SCC in organ transplant recipients is supported by the results of a retrospective study of 211 SCCs in 48 patients. After a mean follow-up period of 50 months, residual or recurrent SCC occurred in only 6 percent.
3- radiation therapy is for patients who are unable to tolerate surgery or as an adjunctive therapy for lesions that cannot be completely excised or that demonstrate extensive perineural involvement, especially nerves of larger diameter A disadvantage of radiation therapy is a possible increased risk for the future development of skin cancer in treated sites and possible increased difficulty in treating recurrences.
4- Chemotherapy :Severe or metastatic disease has responded to systemic therapies such as platinum-based chemotherapeutic agents, capecitabine, and cetuximab. Fatal diffuse alveolar damage has been reported in two lung transplant patients treated with cetuximab for metastatic cutaneous SCC. Treatment with immune checkpoint inhibitors has been reported in small case series of transplant recipients that included a few cutaneous SCCs. In a pooled analysis that included 64 transplant recipients with various metastatic cancers, disease control rates varied, from 35 percent with ipilimumab, 37 percent with nivolumab, and 53 percent with pembrolizumab . Unfortunately, organ rejection occurred in a substantial number of patients, ranging from 54 percent with nivolumab, 39 percent with pembrolizumab, and 23 percent with ipilimumab. (3,4)
References :
1- Sylvie Euvrard et al, Sirolimus and Secondary Skin-Cancer Prevention in Kidney Transplantation, N Engl J Med 2012; 367:329-339 DOI: 10.1056/NEJMoa1204166
2- 2-Chadban, Steven J. BMed, PhD1,*; Ahn, Curie MD, PhD2; Axelrod, David A. MD, MBA3; Foster, Bethany J. MD, MSCE4; Kasiske, Bertram L. MD5; Kher, Vijah MD, DM6; Kumar, Deepali MD, MSc7; Oberbauer, Rainer MD, PhD8; Pascual, Julio MD, PhD9; Pilmore, Helen L. MD10; Rodrigue, James R. PhD11; Segev, Dorry L. MD, PhD12; Sheerin, Neil S. BSc, PhD13; Tinckam, Kathryn J. MD, MMSc7; Wong, Germaine MD, PhD14; Knoll, Gregory A. MD, MSc15,*. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 104(4S1):p S11-S103, April 2020. | DOI: 10.1097/TP.0000000000003136
3- Unal E (2016) Skin Lesions after Kidney Transplantation: An updated Review Including Recent Rare Cases. Int J Transplant Res Med 2:017 Received: May 10, 2015 4- up to date
. What is your differential diagnosis?
-keratoacanthoma
-Cutaneous Squamous Cell Carcinoma(cSCC) Council this patient regarding kidney transplantation?
-He needs dermatological consultation and excisional biopsy ,and according to the result ,we can proceed .if it keratoacanthoma, it is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases and may progress rarely to invasive or metastatic carcinoma. Treatment of keratoacanthoma is primarily surgical and proceed for transplantation.
If it cSCC:
No history of SCC but at risk for development of SCC :No delay necessary
Low risk : No delay necessary
High-risk SCC (not including perineural invasion) : waiting 2 years
High-risk SCC with perineural invasion or 2 risk factors : waiting 2 to 3 years
High risk with local nodal metastatic disease : waiting 5 years
Distant metastasis :Not eligible for transplantation What is your workup strategy?
-Detail history and clinical examination.
-Dermatology consultation and excisional or deep incisional biopsy for histopathology.
– If it cSCC, CT scanning or MRI can be helpful in defining the extent of disease. Reference:
1. F. Zwald1.etal . Recommendations for Solid Organ Transplantation
for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc.
excision of lesion with clear margin
if lesion is localized than proceed with transplantation but
explain the risk of post-transplant recurrence of skin cancer.
avoidance of sun exposure 25% of keratoacanthoma undergo malignant transformation on areas exposed to sun especially in elderly patients.
Managment
multidisciplinary approach is needed. initially deep incisional biopsy with sufficient margins is the primary treatment of choice.
along with intra-lesion methotrexate, 5 FLU, bleomycin systemic retinoids and steroids all have been tried with good results.
to prevent recurrence long term monitoring would be essential with treatment after transplantation including mTOR, MMF, steroids.
It’s important to distinguish SCC from basal cell carcinoma & melanoma.
Compared to basal cell carcinoma, it makes up 20% of all non-melanomatous cancers & is somewhat aggressive. SCC frequently manifests as a growth or non-healing ulcer on exposed skin.
Keratoacanthoma (KA): is a typical skin tumor that is rapidly growing quickly & relatively benign. Scarring may cause it to spontaneously regress, but the clinical course may be unpredictable and they may not be easily distinguished from well-differentiated SCC. The term SCC, KA-type, and surgical excision are therefore preferred by many doctors and pathologists.
========================== Council this patient regarding kidney transplantation? I will council the patient as follows:
Although organ transplants save lives, he should be made aware that SCC is the most frequent variety and that organ recipients are far more likely to get it than the general population.
The body’s immune system is suppressed by the drugs that assist avoid transplant rejection, which will lower the ability to fight cancer.
Another factor is that some drugs given to transplant recipients make them more vulnerable to UV damage. Advice him to avoid exposure to the sun’s UV rays as it is the primary cause of most skin malignancies.
A significant risk factor for the development of skin cancer after transplantation is pre-existing skin cancer.
Cancers screening is a crucial responsibility for the transplant team because about 5% of renal transplant patients with functional grafts will pass away from it.
It is generally agreed that people with a history of cancer should only have a transplant if there is no sign of a residual disease.
The nature and clinical stage of the cancer will determine how long he must wait after a tumor has been successfully treated before receiving a transplant.
During the waiting time he may continue receiving dialysis.
Dermatologic follow-up is essential both before & after transplantation.
Sun protection education is essential as there is an increased risk of developing additional skin cancers after renal transplant.
========================== What is your workup strategy?
Most individuals with a history of low-risk SCC before transplantation are eligible to move through with the procedure.
Transplant candidates with a history of high-risk SCC constitute a special group that necessitates careful evaluation prior to transplantation, including staging of the primary tumor with head & neck CT or, where possible, PET/CT, followed by complete surgical removal when possible.
Based on the available data, patients with a history of high-risk SCC (i.e., large size [>2 cm], high-risk location, recurrent lesion, poorly differentiated) should wait two years before undergoing a transplant if there is no sign of metastasis on CT or PET-CT & the tumor has been surgically removed.
It might be more appropriate to increase the waiting period to two to three years for patients who had perineural invasion signs.
The recommended strategy for head & neck SCC for nodal illness is the combination of surgical excision & adjuvant radiation therapy (ART).
Following proper therapy & the absence of radiological signs of residual illness, a 5-year wait period is seen prudent for transplant candidates with SCC & nodal disease.
According to KDIGO recommendations, immuno-suppression should be reduced as much as possible once graft function has normalized.
References
Zwald et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413. doi: 10.1111/ajt.13593
Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, et al., Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement. Am J Transplant. 2021 Feb;21(2):460-474. doi: 10.1111/ajt.16318. Epub 2020 Oct 23. PMID: 32969590; PMCID: PMC8576374.
What is your differential diagnosis?
This is skin lesion with a centralized keratinous plug, the followings are the differentials:
· Keratoacanthoma.
· Cutaneous SCC.
· Nodular BCC.
· Merkel cell Carcinoma.
· Giant Molluscum Contagiosum.
· common wart.
· Nodular prurigo
· Amelanotic melanoma. Council this patient regarding kidney transplantation?
This patient’s lesion is most likely keratoacanthoma(KA). Although recognized as benign, KA shares histopathological features with SCC and require treatment(1). keratoacanthoma in a transplant recipient should be considered equivalent to a squamous-cell carcinoma(2).
· Surgical excision with safety margin may render him illegible to proceed for transplant without delay or waiting time, if cure is achieved at surgery. Keratoacanthoma is regarded as benign and thus has an excellent prognosis following surgical excision(3). Lesions that progress and metastasise have probably been SCC(3).
· Advice regarding post-transplant behavioral intervention to minimize the risk of recurrence:
a) Protective sunscreen and clothes.
b) Avoiding direct sunlight at the peak hours.
c) Doing routine self-examination of the skin for early detection of skin lesions or recurrence. What is your workup strategy? · Team work-up; including transplant nephrologist, oncologist, plastic surgery and dermatologist. · Histological diagnosis based on skin biopsy and staging of the lesion. · Treatment of choice consists of an excisional procedure with 4 mm margins. Lesions less than 2 cm on the extremities may be treated with electrodessication and curettage. · Nonsurgical interventions have been limited to case reports and retrospective reviews consisting of topical 5% imiquimod cream, topical 5% 5-fluorouracil (5-FU) cream, intralesional methotrexate injections, intralesional bleomycin, intralesional 5-FU, and oral isotretinoin. A case series for intralesional methotrexate have been in smaller numbers of patients but noted regression in 83% to 100% of patients (1).
References 1. NIH, National Library of Medicine;Keratoacanthoma. Patrick M. Zito; Richard Scharf. 2. New England Journal of Medicine, 348;17, www.nejm.org april 24, 2003;Review article; Skin Cancers after Organ Transplantation Sylvie Euvrard, M.D., Jean Kanitakis, M.D., and Alain Claudy, M.D. 3. DermaNet; Keratoacanthoma Authors: Associate Professor Amanda Oakley, 1999; updated by Katrina Tan, Medical Student, Monash University, Melbourne, Australia; Dr Martin Keefe, Dermatologist, Christchurch, New Zealand. Copy edited by Gus Mitchell. November 2021.
Counselling on transplant
The patient needs to be counselled that there is a high risk of skin cancer post-transplantation. Also due to the poor HLA match the patient will require aggressive immunosuppressive therapy that also puts him at high risk of skin cancer post-transplant.
Patient needs further information that if the lesion after biopsy is found to be malignant then the transplant would be delayed, duration depending on the stage of the malignancy. However if it’s a keratoacanthoma which is a benign lesion then the transplant need not be delayed.
Further counselling on skin protective practises should be done like use of sunscreen with high SPF and protective clothing.
Workup strategy.
Should be in collaboration with the dermatology team.
Includes a detailed history and a thorough physical exam.
An excision biopsy of the lesion to confirm the diagnosis.
Imaging of the brain, chest and abdomen to rule out any metastasis.
Keratoacanthoma;
The keratinous surface characteristic more with keratoacanthoma.
In background KA is a common tumor of skin with two striking features like spontaneous regression and nosological position on the border between benignity and malignancy. it has familial association. other differential could be
Basal cell carcinoma
Squamous cell carcinoma.
Hypertrophic lichen planus,
Nodular Kaposi sarcoma.
Diagnosis is based on laboratory, histological and clinical findings.
Good history,
family history for genetic association, because it could be familial, examination, specially for any lymphadenopathy,
deep excision biopsy up to subcutaneous tissue for histopathological examination,
whole body scan for any metastatic disease,
baseline investigations.
Regarding counselling; of the patient after confirmation of diagnosis, if KA, that has a good prognosis with spontaneous regression, can proceed for renal transplantation without waiting time.
Yes he should be monitored for recurrence despite there is very low risk of recurrence.
Self examination,
Avoid risk factors like prolong ultraviolet exposure,\
use of sunscreen >50%.
Post-transplantation immunosuppression modification like use of mTOR inhibitors after three months of transplantation.
Regarding treatment strategy;
Surgical excision as a first option, and after histological confirmation can try BRAF inhibitors (dabrafenib, encorafenib, vemurafenib.
Esthetic dermatologist opinion for,
intralesional chemotherapy,
topical and if needed systemic chemotherapy,
laser,
cryotherapy and photodynamic therapy.
Actually I discussed with dermatologist and our differential diagnoses are squamous cell carcinoma and keratoacanthoma.
excisional biopsy is absolutely indicated to plan long term transplant management.
In case its cutaneous squamous cell carcinoma cSSC:
Risk of cSSC post transplant is 65 times more than non transplant patient.Patients with per-transplant cSSC is at high risk of recurrence.Therefor, the key point over here is to stratify the risk of recurrence according to certain criteria that include : American joint committee on cancer AJCCwhich details features of severity of cSSC as follows:
tumors with zise more than 2 cm, depth more than 2 mm, perineural invasion, poor differentiation and site involve ear or lips in addition to diameter of the lesion with involvement of regional lymph nodes are high risk cSSC. CT of head and neck with PET scan might be indicated in high risk patients.
Each criterion is linked to a certain risk of metastasis and recurrence time frame from 2 to 5 years. Hence , in high risk cSSC its advised to wait for 5 years before proceeding to transplantation. In the contrary, low risk tumor there is a negligible risk, and can proceed with transplantation with waiting time. Post transplant follow up:
is crucial as immune suppressants are an important risk factor for recurrence. Keratoacanthoma:
References: 1)Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC).F.Zwald et al. American journal of transplantation,26 january 2016
Keratoacanthoma:
They are usually benign self-limiting tumor of the skin, caused by HPV , sun exposure and skin injury. Generally its not a contraindication for kidney transplantation with low risk of recurrence post excision.
This is a Keratoacanthoma which is a benign condition
we need to diffrentaiate between SCC and KA Keratoacanthoma (KA) is a benign keratinocytic neoplasm that spontaneously regresses after 3-6 months and shares features with well-differentiated squamous cell carcinoma (SCC). An increased incidence of both KA and non-melanoma skin tumor, including SCC, is seen among immunosuppressed, organ-transplant recipients.
Council this patient regarding kidney transplantation?
will go for total excision with clear maigin and the patient should be counselled regading possibility of recurrence after RTX
This type of lesion has high koebnerization becuase of that the patient is always advised self examination for the area .
What is your workup strategy?
Detailed history
– Thorough physical examination to look for lesions elsewhere, lymphadenopathy
– Routine baseline investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion – first-line treatment with a solitary lesion
– Multidisciplinary approach
– Proceed with kidney transplantation once all the above issues have been addressed
Patient counselling:
1. Excision of lesion with clear margin for diagnosis.
2. If KA then patient can proceed with transplantation.
3. Explain the risk of skin cancer post-transplant.
4. Avoidance of sun particularly at mid-day and sunscreen with SPF 50+ UVA 5*.
5. Self-examination by patient.
Management:
1. Complete physical examination
2. Biopsy of lesion (excision with clear margins.)
3. Consult with dermatologist/oncologist.
4. 5 FU, steroids, cryotherapy radiotherapy.
5. Monitor for recurrence.
6. Regular dermatology follow-up.
7. Reduction of immunosuppression post-transplant: mTOR based regime, avoidance of AZA, monitoring for rejection.
Solitary Keratoacanthoma(KA): characteristic features include (1)
rose nodule with a stretched shiny epidermis and keratotic centre,
small in size(less than 2 cms),
appeared recently(within 6 weeks),
over sun exposed area,
in relatively immunosuppressed ESRD patient
Differential diagnosis pertaining to this case:
Well differentiated cutaneous squamous cell carcinoma(cSCC)
Workup strategy:
The management of KA is controversial due to:
suspected regressing nature
masquerading with the diagnosis of well differentiated cutaneous squamous cell carcinoma.
It is also difficult to predict the maximum size of the lesion before it regresses or how it will eventually heal.(2, 3)
The current standard treatment for KA is that of a well-differentiated cSCC, i.e., surgical excision with clear margins, although this may be excessive given the dubious metastatic propensity of KA. (4, 5)
Other successful, less invasive treatment options for KAs are summarized in Table 2. (2)
Counseling of the patient regarding kidney transplantation (6):
Due to the uncertain nature of keratoacanthoma in terms of spontaneous regression, which will eventually increase wait list time and difficulty distinguishing it from well differentiated cSCC, surgical excision with clear margins is logical in this case.
If the primary pathology is keratoacanthoma or a low risk well differentiated SCC after excision, he can proceed for transplantation without delay.
He should be monitored for recurrence which ranges from 1 to 8%.
Because of koebnerization, which can occur after surgery, cryotherapy, imiquimod, and photodynamic therapy, a new KA can appear at the site of treatment within 1 week to 8 months.
Higher risk of new KA appearance after traumatizing medical or cosmetic procedures performed on photo-damaged skin and especially with immunosuppression after kidney transplantation
Avoid provoking factors, including intense and prolonged ultraviolet light exposure
Sunscreen application with SPF 50 and 5+ UVA star rating
Perform self- examination in all predisposed areas.
References:
Gleich T, Chiticariu E, Huber M, Hohl D. Keratoacanthoma: a distinct entity? Exp Dermatol. 2016;25(2):85-91.
Nagarajan P. Differentiating keratoacanthoma from squamous cell carcinoma-In quest of the holy grail. J Cutan Pathol. 2020;47(4):418-20.
Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery. JAMA Facial Plast Surg. 2013;15(5):337-43.
Tisack A, Fotouhi A, Fidai C, Friedman BJ, Ozog D, Veenstra J. A clinical and biological review of keratoacanthoma. Br J Dermatol. 2021;185(3):487-98.
Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016;74(6):1220-33.
What is your differential diagnosis? The lesion is a nodule which is dome-shaped and filled with keratinous material in the upper central part. The differential diagnosis for this lesion includes keratoacanthoma and squamous cell carcinoma. Other conditions which may present with such nodular lesions include nodular Basal Cell Carcinoma, Merkel cell carcinoma, molluscum contagiosum, or prurigo nodularis. The presence of keratinous material is characteristic of keratoacanthoma. It can be differentiated from squamous cell carcinoma by pathological evaluation, 25% of keratoacanthoma undergo malignant transformation on areas exposed to sun especially in elderly patients. Council this patient regarding kidney transplantation? The lesion should be biopsied for a clear diagnosis, and if a localized lesion (keratoacanthoma or squamous cell carcinoma) is present, a kidney transplant can be performed immediately. As and when the transplant is performed, the patient must be counseled regarding the potential of post-transplant skin cancer due to the use of immunosuppressive treatments. The patient should also be counseled on the necessity of post-transplant behavioral interventions, such as avoiding direct sunlight during peak hours, wearing protective clothes and sunscreen, and doing self-examinations of the skin. What is your workup strategy? The lesion will require an excisional or deep incisional biopsy because a shave biopsy cannot distinguish it from squamous cell cancer. Surgical excision with sufficient margins is the primary treatment, while medicinal intervention is reserved for inoperable instances. In addition to intralesional methotrexate, 5-fluorouracil, bleomycin, and steroids, systemic retinoids were administered to patients with numerous lesions who did not qualify for surgical intervention. Small lesions of keratoacanthoma react favorably to low-dose irradiation, laser therapy, and cryotherapy. To prevent the recurrence of NMSC, long-term monitoring with thorough skin examinations every 6–12 months in a specialized clinic and behavioral education are needed. Immunosuppression protocol should include m TORI instead of CNI and MMF due to its anticarcinogenic effect and low immunogenicity in the current case with low rejection risk.
4. A 51-year-old CKD 5 patient on HD for the last 4 years secondary to IgAN presented to you in the transplant assessment clinic to consider suitability for kidney transplantation. His brother is willing to donate a kidney for him, 000 mismatch and no DSA. On routine examination this lesion was identified which developed 6 weeks ago
• What is your differential diagnosis?
– Keratoacanthoma
– Squamous cell carcinoma
– Nodular basal carcinoma
– Nodular kaposi sarcoma
– Amelanotic melanoma
– Hypertrophic lichen planus
– Metastatic skin lesion
– Foreign body reaction
– Verruca vulgaris
• Counsel this patient regarding kidney transplantation?
– Skin biopsy – for histological diagnosis
– Sun protection (sun avoidance, sun-protective clothing, use of sunscreen) and practicing skin self-examination – sun protection decreases incidence of skin malignancies (1)
– Risk of development of skin cancer following kidney transplantation
– Proper treatment to be initiated prior to kidney transplantation – treatment accelerates lesion resolution
– Post-transplant surveillance appointments with a dermatologist – to monitor for development of new lesions, locally recurrent lesions and metastatic disease
• What is your workup strategy?
– Detailed history
– Thorough physical examination to look for lesions elsewhere, lymphadenopathy
– Routine baseline investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion – first-line treatment with a solitary lesion
– Other treatment options – electrodesiccation and curettage, intralesional therapy (topical fluorouracil, methotrexate, radiation), topical therapy (2)
– Multidisciplinary approach – specific/ definitive treatment as guided by the dermatologist, surgeon and oncologist
– Proceed with kidney transplantation once all the above issues have been addressed
References
1. Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Current treatment options in oncology. 2012 Sep;13(3):354-76. PubMed PMID: 22592596. Epub 2012/05/18. eng.
2. Tran DC, Li S, Henry S, Wood DJ, Chang ALS. An 18-year retrospective study on the outcomes of keratoacanthomas with different treatment modalities at a single academic centre. The British journal of dermatology. 2017 Dec;177(6):1749-51. PubMed PMID: 27943239. Pubmed Central PMCID: PMC5813161. Epub 2016/12/13. eng.
Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499931/
1_The provided photo has hyperkeratotic Dome shaped skin lesion most probably is keratoacanthoma.
Other differential diagnosis includes:
_basal cell carcinoma.
_sqauamous cell carcinoma.
_malihnant melanoma.
2_ counseling here depends on confirmed diagnosis through skin biopsy (excisional biopsy ) as
_ benign keratoacanthoma will proceed to transplantation without waiting time after it’s surgical excision.
_ malignant lesions will require waiting time for 2 years before tranplantation.
_ sun protective behaviours as (avoid sun exposure 2 hours around midday , sunscreen with SPF UVB 50+ and 5 * protection against UVA) and sun protective clothes made of silk and cotton hats without holes are essential to minimize the risk of skin cancer which is common among renal tranpslant recipients especially older ones.
_ Minimization of IS protocol (avoid ATG as he is low immunological risk and use of CNI free protocols with avoidance of azathioprine) all help in minimization of cancer risk.
3_ work up startegy:
_ skin biopsy is 1 st step to differentiate benign and malignant lesions.
_ Screening for organ involvement and metastasis in case of confirmed malignant lesions is essential for staging and determine the cancer free interval required before proceeding to kidney transplantation.
51-year old, on MHD with IgA Nephropathy transplant candidate have well matched donor presented with rapidly developeddome-shaped nodule with central keratin filled lesion in sun exposed area of skin Differential diagnosis: · Keratoacanthoma · Nodular basal cell carcinoma · Merkel cell carcinoma · Prurigo nodule · Giant molluscum contagiosum · Nodular Kaposi sarcoma · Deep fungal infection Confirm the diagnosis by excisional skin biopsy.
Counseling: To confirm diagnosis skin biopsy is needed. Regarding the risk of occurrence of skin cancer post-transplant also very important. Regarding the importance of behavioral interventions post-transplant in form of using measures avoiding direct sunlight in the peak hours, using protective clothing and sunscreen. Frequent examination of skin. Workup strategy: Detailed history and the course of the development of lesion. Clinical examinationincluding all systems and examine the lesion and any lymph node enlargement.
Opinion from dermatologist and excisional skin biopsy. Apart from skin lesion this is no problem of renal transplantation.
Reference: uptodate, lecture from Prof. Ahmad Halwa
The combination of clinical assessment and biopsies are also useful for narrowing the differential diagnosis.
Council this patient regarding kidney transplantation?
After confirmation of the diagnosis exclusion of skin malignancy
We should inform such patients about the risk of developing malignancies after transplantation and mainly skin cancer.
We must inform the patient about the the relationship between KA and squamous cell carcinoma which still controversial .
While some authors perceive KA as a distinct follicular-based squamous proliferation that usually follows a benign clinical course ,others counter that KA is actually a clinical variant of cutaneous squamous cell carcinoma prone to spontaneous regression and occasional aggressive behavior and metastasis .
Dissolution of this controversy is hampered by the lack of histopathologic criteria that definitively differentiate KA and squamous cell carcinoma .
Reports documenting transformation of KA to squamous cell carcinoma also raise questions about whether these lesions represent a continuum of a single disease rather than distinct entities.
Counseling such patient with Keratoacanthoma and the need of avoiding sun exposure especially at peak hours ,applying sun block cream with high SPF,wearing sun protection clothes,avoiding trauma ,regular follow up and self examination.
Keratoacathoma considered as benign lesion and no waiting time is need pre transplant.
What is your workup strategy?
Dermatologist and oncologist must be involved in such cases
Clinical assessment — The clinical assessment of patients with lesions suspicious for KA should always involve obtaining a clear account of the lesion time course since a history of rapid growth within weeks favors this diagnosis. Patients should also be questioned regarding a history of prior similar lesions, sebaceous tumors, and visceral malignancies. These questions may help to identify the presence of a syndromic disorders.
The diagnosis of KA is based upon the combination of clinical and histopathologic findings, as the differentiation of KA from cutaneous squamous cell carcinoma based upon histopathologic examination is challenging.
Complete removal of the lesion via surgical excision extending into the subcutaneous fat is the preferred procedure for the diagnosis of lesions suspicious for KA. Alternatively, a deep shave biopsy (also known as a saucerization procedure) that removes the entire lesion and extends into the subcutaneous fat can be performed by clinicians experienced in this procedure.
reference
uptodate Keratoacanthoma: Epidemiology, risk factors, and diagnosis
Possible risk factors in our case;
UV radiation exposure
Genetic
Previous trauma to the region.
Hemodialysis and CKD with associated chronic inflammatory state.
COUNSEL PT REGARDING KIDNEY TRANSPLANTATION.
1- Transplantation is associated wit immunosuppressive use to prevent ejection which increases risk of malignancies amongst them skin malignancy and the pt will have to be monitored post transplant with a MDT involving a dermatologist, oncologist and nephrologist.
2- Prior to transplantation we will need a skin biopsy to confirm the diagnosis in which case looks more like a keratoacanthoma and rule out other malignant possibilities like SCC and BCC. In the event it is keratoacanthoma, it is benign and after excision we will proceed with transplant without delay, If it turns out to be SCC, timing of transplantation will differ i.e, low risk-excise and proceed with transplant, High risk -excise and wait wor 2-5 yrs, Metastatic- No transplant.
3.Post transplant we will modify her immunosuppressive meds to include an MTOR inhibitor to decrease risk of skin cancer.
4.Post transplant he will have to avoid sun exposure, dress appropriately to minimize UVB and UVA exposure, Use sunscreen .
WORK UP STRATEGY.
-CT scan to assess spread.
-Lesion biopsy to get a definitive diagnosis
REFERENCES;
Prof Halawa lecture.
Keratoacanthoma; Management and Prognosis, Uptodate -2022
Tran DC et al; An 18 year old retrogressive study on outcomes of keratoacanthoma with different treatment modalities at a single academic centre;Br J Derm;2017;177(6);1749-1751
Keratoacanthoma is it dome-shaped nodule with central keratin -filled in hair-bearing, sun-exposed skin in middle-aged and older adults and usually has spontaneous resolution over months
other differential diagnoses:
1-squamous cell carcinoma.
2-nodular basal cell carcinoma.
3-Merkel cell ca
4-prurigo nodule.
5-nodular Kaposi sarcoma.
to confirm the diagnosis by excisional skin biopsy to differentiate histological from squamous cell carcinoma.
Council this patient regarding kidney transplantation?
regarding kidney transplant can proceed without delay although a skin biopsy is needed. Also should be counseled that 25% of keratoacanthoma undergo a malignant transformation in areas exposed to the sun, so have been on immunosuppression, exposure to ultraviolet sun rays, and the presence of keratoacanthoma put you in malignant disease risk.
use of sunscreen avoid sun exposure, frequent skin examination, and seek urgent medical advice if any skin lesion detected
What is your workup strategy?
history includes a detailed history and the course of the lesion and development examination including all systems and examine the lesion and any lymph node enlargement.
dermatology referral and excisional skin biopsy.
Counsel the patient about the risk of malignancy the use of sunscreen and self-skin examination.
no need to wait to proceed for transplant in such this lesion(keratoacanthoma) Reference uptodate -1Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol 2016; 74:1220.
The index patient is an ESRD patient on hemodialysis, now presenting for kidney transplant evaluation (having a suitable donor with 000 mismatch and no DSA).
He is having a skin lesion which developed 6 weeks back.
The lesion is a nodule which is dome-shaped and filled with keratinous material in the upper central part. The differential diagnosis for this lesion includes keratoacanthoma and crateriform squamous cell carcinoma (1). Other conditions which may present with such nodular lesions include nodular Basal Cell Carcinoma, Merkel cell carcinoma, molluscum contagiosum, or prurigo nodularis.
The presence of keratinous material is characteristic of keratoacanthoma, which is a rapidly growing crater-shaped tumor arising from squamous epithelial cells (2). It can be differentiated from squamous cell carcinoma by histology: the crater is multilocular, the lips are perforated, and the cornified contents do not project out of the mouth of the crater (3). 25% of keratoacanthoma undergo malignant transformation, on areas exposed to sun especially in elderly patients.
· Council this patient regarding kidney transplantation?
The lesion should be biopsied for a definitive diagnosis and, in case of a localized lesion (keratoacanthoma or squamous cell carcinoma), a kidney transplant can be proceeded without any wait-period (4).
The patient needs to be counselled regarding the risk of occurrence of skin cancer post-transplant (as and when the transplant is performed) due to use of immunosuppressive medications (5).
The patient should also be counselled regarding the importance of behavioural interventions post-transplant in form of using measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin (5).
· What is your workup strategy?
The strategy in the index case (keratoacanthoma) involves:
a) Detailed history (regarding onset of the lesion, any change in size/ colour, any discharge from the lesion etc)
b) Clinical examination, including skin examination, to look for any other lesion at any other site on body.
c) Dermatology consultation.
d) Investigations: The lesion should bebiopsied for definitive diagnosis.
e) Once the diagnosis is established, treatment should be full thickness fusiform excision, or deep curettage. Intralesional chemotherapy involving intralesional methotrexate, 5-Fluorouracil, or bleomycin may be used prior to excision in large sized lesions (1).
f) No waiting period before transplant if the lesion, a non-melanoma skin cancer (NMSC), is excised completely and there is no metastasis (in the event of having malignant transformation).
g) Patient counselling: Regarding the disease, its treatment, and emphasis on post-transplant self-examination of skin as well as use of sun-protective measures (5).
References:
1. Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33. doi: 10.1016/j.jaad.2015.11.033. Epub 2016 Feb 4. PMID: 26853179.
2. Berman H, Shimshak S, Reimer D, Brigham T, Hedges MS, Degesys C, Tolaymat L. Skin Cancer in Solid Organ Transplant Recipients: A Review for the Nondermatologist. Mayo Clin Proc. 2022 Dec;97(12):2355-2368. doi: 10.1016/j.mayocp.2022.07.004. Epub 2022 Nov 3. PMID: 36334939.
3. Sánchez Yus E, Simón P, Requena L, Ambrojo P, de Eusebio E. Solitary keratoacanthoma: a self-healing proliferation that frequently becomes malignant. Am J Dermatopathol. 2000 Aug;22(4):305-10. doi: 10.1097/00000372-200008000-00002. PMID: 10949454.
4. Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Knoll GA. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104(4S1 Suppl 1):S11-S103. doi: 10.1097/TP.0000000000003136. PMID: 32301874.
5. Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol. 2017 Jun 2;18(1):174. doi: 10.1186/s12882-017-0553-2. PMID: 28571571; PMCID: PMC5455080.
+EXPLAIN TO PATIENT THE POSSIBILITY OF RECURRENCE OF IGA AFTER RENAL TRANSPLANT AND GRAFT LOSS 30%
+EXPLAIN TO PATIENT Variety OF DIAGNOSIS AND POSSIBILTIES OF BEING HAVE Squamous cell carcinoma (SCC) AFTER EXCLUSION WORKUP AND INVESTIGATIONS DONE BY ONCOLOGY -DERMATOLOGY STAFF +SCC in solid organ transplant recipients.
The risk of SCC increases over time, with the incidence increasing to 40% to 60% at 20 years after transplantation.
Cutaneous SCC is also associated with a more aggressive behavior and a higher risk of metastasis and death
+Although most SCCs will be successfully treated, some show a very aggressive clinical course. Currently, the distinction between the many SCCs cured without sequelae and the few SCCs with an aggressive course can be hard to make at diagnosis.
****What is workup strategy?
SKIN BIOPSY
PAN CT SCAN
ROUTINE LAB (CBC-RFT -COAGULATION PROFILE -HORMONAL PTH-VIROLOGY SCREEN )
Treating Squamous Cell Carcinoma of the SkinExcision. Curettage and electrodesiccation Mohs surgery
Radiation THERAPY
CryotherapyLymph node dissection Immunotherapy: For advanced squamous cell cancers that can’t be cured with surgery or radiation therapy Systemic chemotherapy and/or targeted therapy
Harwood CA, Mesher D, McGregor JM, et al.. A surveillance model for skin cancer in organ transplant recipients: a 22-year prospective study in an ethnically diverse population. Am J Transplant. 2013;13(1):119-129. doi: 10.1111/j.1600-6143.2012.04292.x [PubMed] [CrossRef] [Google Scholar]
O’Reilly Zwald F, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management, part I: epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol. 2011;65(2):253-261. doi: 10.1016/j.jaad.2010.11.062 [PubMed] [CrossRef] [Google Scholar]
. Collett D, Mumford L, Banner NR, Neuberger J, Watson C. Comparison of the incidence of malignancy in recipients of different types of organ: a UK registry audit. Am J Transplant. 2010;10(8):1889-1896. doi: 10.1111/j.1600-6143.2010.03181.x [PubMed] [CrossRef] [Google Scholar]
▪︎51-year-old
▪︎CKD 5 patient due to IgAN
▪︎HD for 4 years
▪︎0 mismatch with his brother with no DSA.
▪︎Dome-shaped, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris.
● Council this patient regarding kidney transplantation?
After we confirm that this lesion is safe by biopsy we can proceed transplantation
But if the lesion is malignant we have to treat and wait for Period of time before we proceed transplantaion
What is your workup strategy?
▪︎A full-body skin exam
▪︎A family history of skin cancer.
▪︎C.T scan for excluding metastasis and lymph node envolvement
▪︎MDT ( dermatologist , oncologist ,
surgeon)
▪︎Viral serology
▪︎Biopsy
An excision biopsy and If the biopsy shows safety, we can continue transplant
But if it shows a malignant lesion we have to determine the staging , metastasis , and
risk factors for recurrence after tramsplantation so
▪︎We need NDT ( oncologist , dermatologist , surgeon )
▪︎As for Keratoacanthoma which is considered a variant of squamous cell carcinoma prone to spontaneous involution, but it may also rapidly grow and invade surrounding tissues.
▪︎An increased incidence of KA is seen among immunosuppressed patients
▪︎For this patient sun protection and daily sunscreen decreases incidence of skin cancer after transplantation
What is your differential diagnosis?
Likely diagnosis in the above scenario is Keratoacanthoma,which is a dome shaped ,skin colored papule and filled with keratin. Other differentials which may be considered include-Squamous cell carcinoma, Molluscum contagiosum, Merkel cell carcinoma, Amelanotic melanoma,Nodular basal cell and kapsoi carcinoma. Council this patient regarding kidney transplantation.
Patient should be seen by dermatologist and surgeon , counseled about the benign nature of keratoacanthoma and that it usually resolves in 3- 6 months,but if not then surgical excision should be considered and then can proceed for transplantation with no waiting time.. It can mimic SCC and for that waiting time depends on risk assessment and distant spread. For nodal involvement –waiting time is 05 years, for high risk-02 years and for low risk-no waiting time. Patient should also be counseled to avoid exposure to sun, and chemical carcinogens . What is your workup strategy
Detailed history and examination
Skin biopsy followed by excision .
Laboratory investigations and radiological tests like chest x ray .CT Chest and abdomen for nodal involvement and distant metastasis.
Genetic testing in few cases. REFERENCES:
Zito PM, Scharf R. Keratoacanthoma. 2022 Aug 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
Council this patient regarding kidney transplantation:
keratoacanthoma is usually of benignnaturein immunocompetent patients. needs to go for excision biopsy in consultation with dermatologist and counsel the patient accordingly with Wait time of upto 2 years in remission. Needs to counsel the patient to be more vigilant for skin growth after transplant as skin cancer would tends to be more frequent in post transplant patients.
Workup strategy:
After confirming dx with tissue examination we needs to do,
1. Avoidance of sun exposure
2. Sun protection
3. Avoidance of tar, mineral oil and chemicals
4.self surveilance and regular examination by health care providers.
5.maintenance will triple regimen will CNI replacement by mTOR if no other contraindication.
-What is your differential diagnosis?
Mostly Keratoacanthoma representing an eruption of dome-shaped, skin-coloured papules
DD
Squamous cell carcinoma ,
Actinic Keratosis,
Cutaneous Horn ,
Dermatologic Manifestations of Metastatic Carcinomas ,
Verrucous Carcinoma
Molluscum Contagiosum
Muir-Torre Syndrome which is a cancer-associated genodermatosis with multiple sebaceous neoplasms
Prurigo Nodularis
Merkel Cell Carcinoma
Sporotrichosis which is a subacute or chronic infection due to the saprophytic dimorphic fungus Sporothrix schenckii.
-Council this patient regarding kidney transplantation?
A dermatologist need to be involved in this case.
Keratoacanthoma is a benign keratinocytic neoplasm that spontaneously regresses after 3–6 months and shares common features with well-differentiated squamous cell carcinoma
On the other hand having Keratoacanthoma pretransplant renders the patient more susceptible to develop NMSC post transplant in a more aggressive course compared to the general population therefore when his clinical status is stabilised and complete cure is confirmed , transplant can proceed with cautious follow up.
-What is your workup strategy?
Excisional or deep incisional biopsy of the lesion will be essential because shave biopsy cannot differentiate it from squamous cell carcinoma.
Surgical excision with adequate margins is the main therapy and medical intervention is only for inaccessible inoperable cases.
Systemic retinoids for cases with multiple lesion not fit for surgical intervention as well as Intralesional methotrexate, 5-fluorouracil, bleomycin, and steroids were used for cases not candidates for surgery.
Keratoacanthoma responds well to low dose of irradiation also laser and cryotherapy can be used in small lesions.
Long term monitoring with full skin examination every 6–12 months in a specialist clinic and behavioural education is essential to avoid development of subsequent NMSC.
Immunosuppression protocol need to include m TORI instead of CNI and MMF due to it’s anticarcinogenic effect and the low immunogenicity in the current case with low rejection risk render using m TOR I more suitable , meanwhile a study by Collett D .et al published that the incidence of NMSC in kidney transplant recipients was unaffected by azathioprine or MMF that was used at three months, nor by the use of tacrolimus or cyclosporine.
Reference
– Agudelo Higuita N. I .,Medscape2021
– Collett D. et al Comparison of the Incidence of Malignancyin Recipients of Different Types of Organ: A UK Registry Audit. American Journal of Transplantation 2010; 10: 1889–1896.
– Furudate S, Fujimura T, Kakizaki A, Kambayashi Y, Hashimoto A, Aiba S. Keratoacanthoma accompanied by multiple lung squamous cell carcinomas developing in a renal transplant recipient. Case Rep Dermatol. 2014;6(2):169-175.
What is your differential diagnosis?
A dome-shaped nodule with a central keratin-filled crater and its clinical course characterized by rapid initial growth.
1-Keratoacanthoma. 2-Squamous cell carcinoma . 3-Basal cell carcinoma. Council this patient regarding kidney transplantation?
After dermatological consultation and excision biopsy according to the result will counsel our patient.
If Keratoacanthoma usually follows a benign clinical course and can proceed for kidney transplant after surgical excision and no wait time is necessary. SCC should be evaluated and treated according to its stage and waiting time should be kept in mind such as high risk:(> 2cm, poorly differentiated, high risk location)— excision and wait for 2 years. What is your workup strategy?
1-Prevention by education, awareness and observation. ( about risk or recurrence).
2-Annual self-examination and examination by a physician.
3-Patients should be instructed to avoid excessive sun exposure and to use sunblock.
4-dermatologic surveillance on a regular basis.
5-De novo sirolimus based protocol should be priority with history of skin cancer. References:
1-Keratoacanthoma: Management and prognosis, UP TO DATE 2022.
2- Handbook of Kidney Transplantation, Gabriel M. Danovitch, MD.
3-Tran DC, Li S, Henry S, Wood DJ, Chang ALS. An 18-year retrospective study on the outcomes of keratoacanthomas with different treatment modalities at a single academic centre. Br J Dermatol. 2017;177(6):1749-1751. doi:10.1111/bjd.15225.
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
0
What is your differential diagnosis?
Melanoma
Keratoacanthoma
Basal cell carcinoma
squamous cell carcinoma
HPV
fungal infection
Council this patient regarding kidney transplantation?
The proposed donor is excellent, but there is a need for a closed diagnosis to define prognosis and treatment before proceeding with organ transplantation.
What is your workup strategy?
There is a need for joint follow-up with Dermatology and a biopsy of the lesion with free margins for diagnosis and possible treatment.
If the disease is localized (in situ) with free margins, an effective treatment may be considered in order to proceed with the transplant.
Some care is needed:
– Avoid sun exposure
– Wear clothing with UVA/UVB protection
– Investigation of infectious diseases (HIV, HPV, HSV8)
– Proceed with the appropriate treatment discussed with the multidisciplinary team and biopsy results and laboratory tests at hand
– Avoid induction with rATG and immunosuppression schemes with calcineurin inhibitors when proceeding with transplantation
I can appreciate that you are thinking of carcinoma as a possibility, however, this picture is typical of keratoacanthoma. I wish you could provide evidence to support your arguments.
Ajay
Council this patient regarding kidney transplantation?
Incidence of malignancy post transplant is high especially skin cancer and squamous cell carcinoma is most common skin cancer in kidney transplant patients which account 30-65% of malignancy in kidney transplant due to use of immunosuppressive agents and low immunity lead to risk of infection
Risk factors for skin cancer increase in kidney transplant and use of immunosuppressive drug and previous history of skin cancer before transplant and genetic factors, also exposure to infection with HHV and HPV.
Consider skin biopsy with annual screening by dermatologist and wearing protective clothes like silk and cotton material.
sunscreen lotion.
What is your workup strategy?
History and examination is important to exclude previous history of malignancy before transplant and family history of malignancy in case of genetic related factors.
Serology of HIV and HHV
skin biopsy and dermatologist opinion
surgical excision of tumor and histopathology for staging.
Free Calcinurine inhibitors therapy and dose reduction of immunosuppressive therapy.
use of mTOR inhibitors.
treat cancer by chemotherapy as ordered by oncologist
eradication of HPV infection if present.
Avoid sun exposure
Reference:
Henryk Witmanowski, Małgorzata Lewandowska; et al. The development of squamous cell carcinoma in a patient after kidney transplantation: a case report; Postepy Dermatol Alergol. 2013 Feb; 30(1): 65–71.
Published online 2013 Feb 20.
the lesion should be initial diagnosed and accordingly the process of proceeding to transplantation will take place.
If keratoacanthoma: it is a benign lesion and no need to wait after excision
If SCC: management and waiting time to transplantation will depend on the stage:
low risk : excision and no need to wait
high risk:(> 2cm, poorly differentiated, high risk location)— excision and wait for 2
years
Peri-neural invasion: 2-3 year waiting
nodal metastasis: 5 years wait after proper treatment (excision and LN excision
and XRT) and no evidence of recurrence
distant metastasis: not candidate for transplant
For OKD and mtach: no contraindication for donation with expected good long-term graft survival.
Work-up strategy:
1- Proper diagnosis of the lesion first:
proper hx, full examination including lip, scalp and ears
excisional biopsy and proper interpretation of the pathological desciption
CT scan +/- PET scan to exclude metastasis
2- Treatment of the lesion ( in cooperation with oncologist)
3- According to the result: follow the proposed waiting time
4- If no recurrence: prepare for transplantation
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
0
Sugiura K, Sugiura M, Uchida K. KunioMorozumi. A Keratoacanthoma With Squamous Cell Carcinoma Under Immunosuppressive Therapy After Renal Transplantation. Int J Clin Dermatol Res. 2022 Mar 26;10(1):275-7.
The picture shows well-circumscribed dome shaped nodule, with a keratotic core enlarged over 6 weeks. DD:
· Keratoacanthomas ( the likely diagnosis)
· well-differentiated SCC.
· Nodular BCC
· Giant molluscum contagiosum
· Metastatic deposit
· Nodular prurigo.
For definitive diagnosis an excisional biopsy is required.
Keratoacanthoma is characterized by initial rapid growth followed by a period of variable tumor stability and spontaneous regression.
It is divided into different subtypes with different presentations. Subtypes include solitary KA, subungual KA, mucosal KA, giant KA, KA centrifugum marginatum, generalized eruptive KA of Grzybowski, and multiple KA Ferguson-Smith syndrome.
Although recognized as benign, KA shares histopathological features with squamous cell carcinoma (SCC) requiring treatment.
Suggested risk factors:
· Fair-skin color the risk decreases with increasing skin pigmentation.
· UV radiation
· Exposure to chemical carcinogens
· Immunosuppression
· Genetic predisposition including mutations of p53 or H-Ras
· Viral exposure including HPV.
· Recent trauma or surgery to the location.
The relationship between KA and squamous cell carcinoma is controversial
While some perceive KA as a distinct follicular-based squamous proliferation that usually follows a benign clinical course, others counter that KA is actually a clinical variant of cutaneous squamous cell carcinoma prone to spontaneous regression and occasional aggressive behavior and metastasis
What is your workup strategy?
-Detailed history about the progression and course of the lesion, the presence of other lesions, drug exposure.
-Examination looking for other lesions, LN.
-Dermatologist and oncologist opinion.
-Excisional skin biopsy and histological diagnosis for definitive diagnosis.
-For patients with subungual keratoacanthomas, radiographic imaging is necessary of the affected digit in order to monitor for osteolysis.
-If SCC was suspected needs to search for mets.
-Treatment according to biopsy finding.
-Regular skin surveillance
-Avoid mid-day sun exposure and use of sun protection.
Treatment of KA:
· Excision with 4 mm margins (treatment of choice).
· Electrodessication and curettage for lesions less than 2 cm on the extremities
· Nonsurgical interventions: topical 5% imiquimod cream, topical 5% 5-fluorouracil (5-FU) cream, intralesional methotrexate injections, intralesional bleomycin, intralesional 5-FU, and oral isotretinoin. Of the intralesional therapy, 5-FU and methotrexate have the most data.
Council this patient regarding kidney transplantation?
Patient need to be aware about this suspicious lesion and the need for biopsy for definitive diagnosis.
If KA is confirmed it is recognized as benign lesion, and spontaneous regression is expected. However, treatment is recommended due to the relation to SCC.
It has an excellent prognosis following surgical excision.
Generally, patients will need to be followed for the development of new primary skin cancers.
Metastases are rare, but there are reports of this in addition to perineural spread in literature.
References: -Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls.
– UpToDate
– Hand book of kidney transplant 6th edition
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
It is round firm ,usually pink or flesh colored growths and have a central crater that is scaly or crusted some of it may be a form of squamous cell carcinoma .
Appear on sun exposure area
Diagnosis :
Biopsy
Treatment :
Ø Surgical excision
Ø Methotrxate
Ø 5-fluorouracil
Prevention: 1- Avoid sun exposure 2- Wearning protective clothing 3- Sun screen Counseling : · Keratacanthoma has an excellent prognosis following surgical treatment · Metastases are rare · Patient need follow up for the development of new skin cancer · Patient need follow up with physician and dermatologist · Good sun protection is vital to preventing certain damage · Long term administration of immunosuppressive agent associated with increase risk of non melanoma skin cancer
workup strategy?: Skin biopsy Surgical excision Laboratory investigation and imaging to detect any metastases chest x ray .CT Chest and abdomen Treatment of the patient till cure from the disease Regular follow up
References :
1-Engels EA, Pfeiffer RM, Fraumeni JF Jr, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011;32
2- hand book of kidney transplant 6th edition
I can appreciate that you are thinking of SCC, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
Keratoacanthomas Merkel cell carcinoma. Squamous cell carcinoma. Amelanotic melanoma. Dermatofibrosarcoma protuberans. Actinic keratosis. Nodular Basal cell carcinoma. Common warts. Giant molluscum contagiosum. Nodular prurigo.
Metastatic deposit. Solitary Keratoacanthomas (KA):
Solitary, rapidly growing nodule on sun-exposed skin of the face and upper limbs. Keratoacanthomas are sharply demarcated, firm, erythematous or skin-colored, with a classic central hyperkeratotic plug and an even shoulders.(1)
Most Keratoacanthomas are treated surgically. Although they may resolve spontaneously, it is usually prudent to excise them, unless there is clear evidence that regression is in progress.
It is usually best to assume a KA-like lesion is an SCC and to manage accordingly in line with local or national guidance, until proven otherwise.
Council this patient regarding kidney transplantation:
The is a risk for non-melanoma skin cancer in renal transplant recipients are related to the dosage and duration of administration of immunosuppression. SCC, one of the major histological types of non-melanoma skin cancer, exhibits more aggressive biological and clinical courses in RTRs, with higher rates of recurrence and mortality than in the general population (2).
Other reports also suggested that immunosuppressed patients, such as RTRs, show a higher incidence of KA.
What is your workup strategy?
Excisional biopsy with dermatologist. CXR. CT scan role out internal organ malignancy Prevention:. · Avoid the sun during peak hours. · Shield your skin and eyes. . · Apply sunscreen liberally and often. .
· Watch for changes.
· Stop smoking.
References:
1-Amanda Oakley, Martin Keefe.Keratoacanthoma.Derma net. November
2-Kasiske BL, Snyder JJ, Gilbertson DT, Wang C: Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905–913.
This is nodular dome shape hyperkeratotic skin lesion developed within 6 weeks on back ground of ESRD on dialysis, primary disease IgA nephropathy
Actinic keratoses (AKs), or solar keratoses, are keratotic or scaling macules, papules, or plaques resulting from the intraepidermal proliferation of atypical keratinocytes in response to prolonged exposure to ultraviolet radiation AKs are an alarm because the majority of cutaneous squamous cell carcinomas (cSCCs) arise from pre-existing AKs, and AKs that will progress to SCC cannot be distinguished from AKs that will spontaneously resolve or persist. With his back ground we should rule out a biologically aggressive lesions like invasive SCC.
DDX from other pre-malignant skin lesions and chronic inflammatory skin lesions like
• Nummular eczema or dermatitis, erythematous vesiculation, and crusting lesions
• Inflamed seborrheic keratosis
• Prugio nodularis which looks like A close-up of a pink, crusted nodule.
Council this patient regarding kidney transplantation?
need dermatology specialty referral and examination for another lesions, exceptional surgical biopsy with histopathological diagnosis and staging to rule out the possibility of local invasive SCC.
Preventive measures with regular sunblock use, close follow-up after transplantation and self-skin exanimation including lymph node examination.
What is your workup strategy?
As this patient candidate for kidney transplant this skin lesion need to referred to dermatology specialty for further work up including dermoscopic examination and surgical biopsy to rule out the possibility of local invasive cutaneous SCC, also through examination for another lesions and LAP. HPV viral screen
Depends on the numbers of the lesions, single or multiple also patient tolerance and preferences, cost, and nature of the lesions
lesion-directed treatments, such as Liquid nitrogen cryotherapy and surgical procedures, are the primary approach for isolated lesion and of certain diagnosis of AKs, with less cost and better cosmetic results, however Cryotherapy is contraindicated for lesions that need pathologic examination to exclude malignancy and in patients with cold urticaria or cryoglobulinemia.
Combination of cryosurgery and topical medication have been tested in few RCTS and its more effective compared to cryosurgery alone (2). Treatment options
1.Destructive therapies (cryotherapy, surgery, dermabrasion, photodynamic therapy [PDT])
2.Topical medications (, topical fluorouracil, imiquimod, topical tirbanibulin, diclofenac),
3.Field ablation treatments (, chemical peels, laser resurfacing).
The last two options preferred for multiple AK lesions.
4. photodynamic therapy like Photosensitizers and light sources
5. Daylight photodynamic therapy
Follow UP and Monitoring after transplant
Education and teaching the patients about the chronic nature of AKS and the need of continuing care and treatment close follow-up and good compliance with topical long-term therapy which is not free from local inflammatory side effects that increased the risk of treatment intolerance and nonadherence
Ongoing monitoring for lesion recurrence and cutaneous malignancies at 6 to 12 months post-treatment is required for all patients with a history of actinic keratoses (AKs).
In one recent study with secondary analysis of a randomized clinical trial, risk of invasive cSCC was highest in patients with Olsen grade III AK and was significantly increased in patients who received additional treatment. These patients should be closely followed up after treatment (3).
References:
1. Current issues in the management of actinic keratosis.Ceilley RI, Jorizzo JL J Am Acad Dermatol. 2013 Jan;68(1 Suppl 1):S28-38.
2.Cryosurgery combined with topical interventions for actinic keratosis: a systematic review and meta-analysis.Heppt MV, Steeb T, Ruzicka T, Berking C Br J Dermatol. 2019;180(4):740. Epub 2018 Dec 27.
3. Risk of Invasive Cutaneous Squamous Cell Carcinoma After Different Treatments for Actinic Keratosis: A Secondary Analysis of a Randomized Clinical Trial.Ahmady S, Jansen MHE, Nelemans PJ, Kessels JPHM, Arits AHMM, de Rooij MJM, Essers BAB, Quaedvlieg PJF, Kelleners-Smeets NWJ, Mosterd K JAMA Dermatol. 2022;158(6):634.
What is your differential diagnosis? This is a dome shaped raised lesion with central keratin and without much melanin. There is some ulceration also. Most likely it is keratocanthoma .
The other possibilities include: Squamous cell carcinoma Amelanotic melanoma Molluscum contagiosum Prurigo nodularis Metastatic lesion to the skin Merkel cell carcinoma Nodular basal cell carcinoma Ulcerative basal cell carcinoma Nodular Kaposi sarcoma Hypertrophic lichen planus Deep fungal infection Atypical mycobacterial infection Foreign body reaction Verruca vulgaris.
Council this patient regarding kidney transplantation? The management will depend on histology of excision biopsy specimen. Most of benign lesions and BCC or melanoma in situ are not a contraindication to transplantation . I will involve dermatologist and skin oncologist and decision to proceed with transplantation will depend disease free period.
I will counsel the patient about disease and need for disease free period if required. I will advise him about avoiding sun exposure , especially mid day and use sun screen.
What is your workup strategy? I will assess him in detail including any lymph node involvement. Assessment of systemic involvement in case of malignant lesion. The case will have to be discussed and Skin MDT. Keratocanthoma can be treated with imiquimod.
Following that it should be discussed in Transplant MDT to make decision about transplant timing.
F. J. Moloney, H. Comber, P. O’Lorcain, P. O’Kelly, P. J. Conlon, and G. M. Murphy, “A population-based study of skin cancer incidence and prevalence in renal transplant recipients,” British Journal of Dermatology, vol. 154, no. 3, pp. 498–504, 2006. Upto Date
What is your differential diagnosis? It is Keratoacanthoma most likely due to rapid growth dome shaped with central keratin crater usually occur in fair sun exposed skin, hair bearing skin, HPV has been identified in some such a lesion. Squamous cell carcinoma – some classify keratoacanthoma as a type of it. Nodular basal cell carcinoma. Merkel cell carcinoma. Prurigo nodules. Giant molluscum contagiosum. Nodular Kaposi sarcoma. Deep fungal infection. Cutaneous metastasis.
Council this patient regarding kidney transplantation? After the diagnosis established the issue of cure rate should be discussed with dermatologist as well as the disease free period recommended before doing transplantation. The pretransplant skin tumors are not necessarily a contraindication to organ transplant, but must be treated, and we will decide with the oncologist and dermatologist either to proceed or not. The patient should know that there is a higher risk of developing a skin cancer after organ transplant. So he should be disease free before transplantation as recommended by the oncologist. I’ll council him on sun exposure protective measures (behavioral and pharmacological) as it is a well-known etiology of such cancers.
What is your workup strategy? Full history and examination, if there is another lesions and evaluation of adjacent lymphnodes, full chemistry and blood tests, evaluation for other organ involvement. Refer the patient to dermatologist and oncologist for biopsy, diagnosis and treatment, either surgical, radiation or topical chemotherapy. Multidisciplinary team decision to proceed with transplantation or not. References: – UpToDate- Keratoacanthoma, epidemiology, risk factors and diagnosis. – Imko-Walczuk B, Kiełbowicz M, Dębska-Ślizień A, Rutkowski B. Skin Cancers as Contraindication to Organ Transplantation. Transplant Proc. 2015 Jul-Aug;47(6):1547-52. doi: 10.1016/j.transproceed.2015.03.047. PMID: 26293011.
Previous studies on other organ transplant types revealed a link between kidney transplantation and a rise in the frequency of non-melanoma skin cancer, which was probably brought on by immunosuppression.
It is very similar to the Squamous Cell Carcinoma (SCC).
However, this is a much more aggressive type of skin cancer that can cause considerable disfigurement.
The skin lesions experience rapid growth in the initial few weeks, then the Keratoacanthomas seem to go dormant for a while.
After 4 to 6 months the skin lesions will begin to spontaneously resolve.
On the skin, keratoacanthomas are a very typical development.
It is a benign skin tumor that starts in the hair follicles and grows quickly.
Unless there are several skin lesions, it is often not linked to any inside cancer.
The age range between 60 and 70 is the one where this skin problem is most prone to emerge.
However, there have also been instances of younger persons getting keratoacanthomas.
Keratoacanthoma is more common in light-skinned individuals than in dark-skinned individuals.
Because of this, Caucasians are more likely than Hispanics or Asians to develop Keratoacanthoma.
What is your differential diagnosis?
Differential diagnosis of a lesion consistent with
Akeratoacanthoma includes squamous cell carcinoma,
Amelanotic melanoma,
Molluscum contagiosum,
Prurigo nodularis,
Metastatic lesion to the skin,
Merkel cell carcinoma,
Nodular basal cell carcinoma,
Ulcerative basal cell carcinoma,
Nodular Kaposi sarcoma,
Hypertrophic lichen planus,
Deep fungal infection,
Atypical mycobacterial infection,
Foreign body reaction,
And verruca vulgaris.
Council this patient regarding kidney transplantation/workup strategy?
Decisions about cancer screening are becoming increasingly complex.
Screening decisions must be made with clear considerations of patients’ preferences and values, incorporating the potential harms and benefits of the various options.
Allograft function with immunosuppression can be compromised by the need to have a “cure” for cancer, and may require reduction or cessation to reduce the risk of cancer relapse.
The length of time from diagnosis to treatment is primarily extrapolated from data of potential recurrence in the general population, rather than based on individual patient data.
The recommended waiting time for candidates with varied between 2 -5 years,then candidate for transplantion (after treatment ) .
Recipients with pretransplant KA have a high risk of developing relapse, but because transplantation has been shown to improve survival rates and quality of life, recipients who have been cured of the condition can move through with transplantation.
A thorough physical examination and history are used to assess lesions.
To assess using a histological examination, a biopsy could be conducted.
As a shave biopsy may not be sufficient to investigate the depth to distinguish keratoacanthoma from squamous cell carcinoma, an excisional biopsy is the best diagnostic procedure.
The skin lesion may be removed by one of these three methods – cryotherapy, excision, and curettage or cautery.
The dermatologist must ensure that none of the affected tissue is left behind during the removal procedure.
Radiographic imaging of the afflicted finger is important for individuals with subungual keratoacanthomas in order to check for osteolysis.
The diagnosis and management of keratoacanthoma is with an interprofessional team that includes the nurse practitioner, pathologist, dermatologist, primary care provider, and may be ENT surgeon.
Keratoacanthoma has an excellent prognosis following surgical excision.
Generally, patients with keratoacanthoma will have a history of sun exposure and will need to be followed for the development of new primary skin cancers.
Metastases are rare, but there are reports of this in addition to perineural spread in literature.
van Leeuwen MT, Webster AC, McCredie MR, Stewart JH, McDonald SP, Amin J, Kaldor JM, Chapman JR, Vajdic CM, Grulich AE. Effect of reduced immunosuppression after kidney transplant failure on risk of cancer: population based retrospective cohort study. BMJ. 2010;340: c570.
de Fijter JW. Use of proliferation signal inhibitors in non-melanoma skin cancer following renal transplantation. Nephrol Dial Transplant. 2007;22(Suppl 1):i23-26.
Laupacis A, Keown P, Pus N, Krueger H, Ferguson B, Wong C, Muirhead N: A study of the quality of life and cost-utility of renal transplantation. Kidney Int 50: 235–242, 1996
Kirby JS, Miller CJ. Intralesional chemotherapy for nonmelanoma skin cancer: a practical review. J Am Acad Dermatol. 2010 Oct;63(4):689-702
Göktay F, Kaynak E, Güneş P, Yaşar Ş, Küçükodacı Z, Aytekin S. Relationship between Human Papilloma Virus and Subungual Keratoacanthoma: Two Case Reports and the Outcomes of Surgical Treatment. Skin Appendage Disord. 2017 Jan;2(3-4):92-99
I can appreciate that you are thinking of a range of cancers, however, this picture is typical of keratoacanthoma that you mention in DD. I like your evidence to support your arguments. Ajay
This is a pseudo skin cancer named KA (Keratoacanthoma), and it is a special destructive skin lesion, as an isolated nodule. Usually occurs on the face and it looks like squamous cell carcinoma, and some clinicians and pathologists named it SCC-KA type so: Differential diagnosis:
Keratoacanthoma.
Top-differentiated with Squamous cell carcinoma.
Basal cell carcinoma.
Non-melanoma skin cancer
Kaposi sarcoma.
Sebaceous cyst.
Keratoacanthoma:
Age-related, most common in the old patient.
Associated with patients who receive immunocompromise medication, exactly solid organ transplantation.
Patients who receive excessive treatment with psoralen-UVA, photochemotherapy for psoriasis.
Patient treated for metastatic melanoma with BRAF inhibitors such as vemurafenib and dabrafenib.
Patient treated from BCC.
Patient with genetic cancer syndrome:
Xeroderma pigmentosum.
Muir-Torre syndrome.
Multiple self-healing squamous epithelium.
Eruptive keratoacanthoma.
Incontinentia pigmentia.
Counseling regarding kidney transplantation:
Kidney transplantation is associated with a higher rate of malignancy incidence compared to the normal population as a complication of immunosuppressant medication.
As he already has such a tumor should first be treated for the tumor and wait for 2 years then proceed for transplantation.
Recipient with a pretransplant KA has a great chance to develop a recurrence rate, but as transplantation proved to have a better survival rate and quality of life, so recipient after cure of the disease can proceed for transplantation.
Workup:
Baseline blood investigation and imaging for diagnosis of a tumor condition.
Biopsy from the tumor.
Treatment according to the protocol.
After cure from the tumor stay for 2 years and proceed for transplantation.
References:
Gleich T, Chiticariu E, Huber M, Hohl D. Keratoacanthoma: a distinct entity? Exp Dermatol. 2016;25(2):85–91. doi:10.1111/exd.12880. PubMed
Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016;74(6):1220–33. doi:10.1016/j.jaad.2015.11.033. Journal
Misago N, Inoue T, Koba S, Narisawa Y. Keratoacanthoma and other types of squamous cell carcinoma with crateriform architecture: classification and identification. J Dermatol. 2013;40(6):443–52. doi:10.1111/1346-8138.12104. Journal
A 51-year-old CKD 5 patient on HD for the last 4 going for transplant develop skin lesion with differential diagnosis Ulcerative basal cell carcinoma Nodular Kaposi sarcoma Non melanoma skin cancer Molluscum contagiosum Hemangioma Infected lipoma
The rate of malignancy in renal transplant is higher than normal papulation some cancer like nonmelanoma skin cancer, lymphoma have high incidence compared to breast and prostatic cancer. Most of cancer have waiting time less than 2 years but some cancer have no waiting time like incidental renal and in situ carcinoma etc. But for most of cancer a period of 2-5 years is recommended and this period may be longer in some cancers like nodular breast, melanoma and colorectal cancers Counselling Regarding the reoccurrence and graft loss, Immunosuppression medicine may worsen this condition It is better to avoid in the presences of current condition and need to be investigate and treat before transplant surgery. Screening for cancer is very important as screening measure can enable to prevent or early detection of cancer that include self examination, avoidance of smoking and sun exposure. Also need to council regarding infection that may end up malignancy and screening of infection is paramount important before surgery.
1 Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341: 1725–1730.
2. Campbell S, Pilmore H, Gracey D, et al. KHA-CARI guideline: recipient assessment for transplantation. Nephrology (Carlton). 2013;18(6):455–462.
3. Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplantation candidates: Clinical practice guidelines. Am J Transplant. 2001;1(suppl 2):3–95.
4. Knoll G, Cockfield S, Blydt-Hansen T, et al. Canadian Society of Transplantation: Consensus guidelines on eligibility for kidney transplantation. CMAJ. 2005;173:S1–S25.
5.Education and counseling of renal transplant recipients Claudio Ponticelli1, Giorgio Graziani10.5301/jn.5000227
Diagnosis; This lesion looks like keratoacanthoma which appear similar to squamous cell cancer, which is a more serious skin condition. Keratoacanthoma is characterized by initial rapid growth followed by a period of variable tumor stability and spontaneous regression. Keratoacanthoma is further divided into different subtypes with different presentations. Subtypes include solitary keratoacanthoma, subungual keratoacanthoma, mucosal keratoacanthoma, giant keratoacanthoma, keratoacanthoma centrifugum marginatum, generalized eruptive keratoacanthoma of Grzybowski, and multiple keratoacanthomas Ferguson-Smith syndrome. Although recognized as benign, KA shares histopathological features with squamous cell carcinoma (SCC) requiring treatment. Symptoms include a raised, dome-shaped lesion with a central area of depression on a sun-exposed area such as the face, ears or hands. This patient requires skin biopsy to rule out squamous cell carcinoma.
Differential diagnosis;Differential diagnosis of a lesion consistent with a keratoacanthoma includes squamous cell carcinoma, amelanotic melanoma, molluscum contagiosum, prurigo nodularis, metastatic lesion to the skin, Merkel cell carcinoma, nodular basal cell carcinoma, ulcerative basal cell carcinoma, nodular Kaposi sarcoma, hypertrophic lichen planus, deep fungal infection, atypical mycobacterial infection, foreign body reaction, and verruca vulgaris.
Counseling; Once squamous cell carcinoma is excluded by a biopsy (sometimes is difficult to differentiate ), this patient must be inform that, Keratoacanthoma has an excellent prognosis following surgical excision. Generally, patients with keratoacanthoma will have a history of sun exposure and will need to be followed for the development of new primary skin cancers. Metastases are rare, but there are reports of this in addition to perineural spread in literature. The primary care provider should educate the patient about sun exposure and protecting the skin. In addition, the patient should be told to wear sunscreen and protective garments when going outdoors. Transplantation can be considered 2 to 5 years following the treatment which is basically surgical removal. The patient must be advised about the risk of post-transplant skin cancer may be higher than the those without pre-transplant skin cancer. He has some high risk features being male, white race, age > 50 years. He must be advice about the risk of recurrent IgAN post-transplant.
Work up; this patient must undergo skin biopsy, FBC, Urinanalysis UECs, LFTs, CXR, ECG, and ECHO
References;
1.Keratoacanthoma, CEM by Patrick M. Zito & Richard Scharf 2.De Novo malignancies after kidney transplanation, David Al-Adra et a.al
This rapid onset skin lesion, with a dome-shaped keratin-filled crater consist with keratoacanthoma.
What is your differential diagnosis?
Squamous cell carcinoma,
Amelanotic melanoma
Molluscum contagiosum,
Prurigo nodularis,
Metastatic lesion to the skin,
Merkel cell carcinoma,
Nodular basal cell carcinoma,
Ulcerative basal cell carcinoma,
Nodular Kaposi sarcoma.
Council this patient regarding kidney transplantation.
Keratoacanthoma (KA) is a benign keratinocytic neoplasm that spontaneously regresses after 3–6 months and shares features with well-differentiated squamous cell carcinoma (SCC).
Relationship between kerato and squamous cell carcinoma still controversial.
A longstanding debate over the classification of KA as benign resolving tumor versus a variant of cutaneous squamous cell carcinoma.
First we have to put the right diagnosis.
KA usually resolve after 3-6 mothns.
If the lesion doesn’t resolve surgical resection to confirm the diagnosis.
Avoid sun exposure is important.
As work team a dermatologist should be consulting.
A biopsy may be performed to evaluate with a histological exam. The best diagnostic test is an excisional biopsy .
The presence of an epithelial lip and sharp outline between tumor and stroma diagnos KA.
In contrast the prescene of ulceration,mitosis,and pleomorphism or anaplasia favored squamous cell carcinoma.
Genetic test maybe needed in some cases.
Refference:
1-Ko CJ.Keratoacanthoma: facts and controversies. Clin Dermatol 2010;28:254.
2-
Counsel this patient regarding kidney transplantation.
Transplantation is not possible if there is active malignancy, with the exception of nonmelanoma skin malignancies.
For the majority of cancer survivors, we and the majority of clinical guidelines suggest a two- to five-year recurrence-free period.
This is done to reduce the possibility of recurrence since immunosuppressive drugs promote the growth of micrometastases. The chance of recurrence varies significantly depending on the kind of tumor, which affects the recommendations for individuals who already have malignancies. It is advised that you have a conversation with a multidisciplinary team that includes an oncologist.
Based on the features of the patient and the tumor, the recommended cancer-free period before to transplantation should be tailored to the individual.
The patient has to be informed of the possibility of a recurrence after transplantation.
Long-term immunosuppressive therapy to maintain host tolerance raises the risk of malignancy in organ transplant recipients. The two skin cancers that are most common are cSCCs and BCCs. Due to geographic location, history of sun exposure, immunosuppressive intensity and duration, and ethnicity, these persons are more likely to get skin cancer.
What is your workup strategy?
-send for HPV PCR
Dermatology consultation for a possible biopsy.
Refer to oncology, If proven as malignancy.
Reference :
Vajdic CM, van Leeuwen MT. Cancer incidence and risk factors after solid organ transplantation. International Journal of Cancer. 2009;125(8):1747–54.
DD of skin lesion:
1- skin infection either local or systemic
2-skin cancer
3-drug induced skin lesion
counselling of the patient as regard renal transplantation:
the patient should be informed about caner rate post transplant and its incidence especially in the presence of this lesion and the importance of knowing the real diagnosis of this lesion , also counselling about sun exposure and use of sunscreen cream, and protective clothes.
workup strategy:
1- dermatology consultation
2-excisional biopsy for early diagnosis of precancerous lesion
Council this patient regarding kidney transplantation?
waiting until a further definite diagnosis of this lesion.
management will differ according to the diagnosis. if it is squamous cell carcinoma, he should wait for a cancer-free period of at least 2 years before transplantation while no waiting time for other lesions.
What is your workup strategy?
total excision biopsy.
dermatology opinion.
oncology opinion.
further workup according to the biopsy results including a screen for metastases if it was a squamous cell carcinoma.
Council this patient regarding kidney transplantation?
Cutaneous malignancy is the most common malignancy encountered in renal transplantation (1 ) and constitute around 40% of malignancies in renal transplant recipients, and are 7 fold higher in renal transplant recipients when compared to general population (1)
90% of cutaneous malignancies are due to SCC and BCC (2), other include melanoma, Kaposi sarcoma and Merkel cell carcinoma
In renal transplantation SCC occur more commonly than BCC (although in general population BCC is more common)
The most important risk factors for skin cancer include the type of transplant (isolated renal transplantation is associated with the lowest risk compared to heart, lung and pancreas-kidney transplant) and the degree of immunosuppression which will be minimal in the current patient
What is your workup strategy?
1- Dermatology consultation and assessment for the need of biopsy in the current case, and setting a definite diagnosis
2- Patient should receive treatment according to the diagnosis of the lesion
3- Counseling the patient about screening, wait time and the use of sunscreen
4- Post-transplant screening should be done by the patient every month and by expert dermatologist every year.
5- Wait time before transplantation (3)
Patients with BCC and low risk SCC that have successfully treated can proceed to transplantation without waiting time
Patients with high risk SCC should wait for 2-3 years
SCC with local lymph node extension should be treated first then wait for 5 years
Patients with distant metastasis are not eligible for transplantation
6- Patient should avoid sun exposure especially in the mid-day and the use of sun screen with high protection (5 stars 50+ SPF) is recommended especially in the early period after transplantation (using of triple therapy)
7- Reassuring the patient since the patient will receive minimal immunosuppression in the form of basiliximab induction and maintenance triple therapy including CNI, MMF, and corticosteroids for the first 3-6 months then we can switch to dual therapy including MMF and steroids. So we will stop CNI which is associated with higher incidence of skin cancer (4), and keep MMF which is associated with lower incidence of skin cancer when compared to azathioprine.
REFERANCES
1. Park CK, Fung K, Austin PC, et al. Incidence and Risk Factors of Keratinocyte Carcinoma After First Solid Organ Transplant in Ontario, Canada. JAMA Dermatol 2019; 155:1041.
2. Chockalingam R, Downing C, Tyring SK. Cutaneous Squamous Cell Carcinomas in Organ Transplant Recipients. J Clin Med 2015; 4:1229.
3. Zwald F, Leitenberger J, Zeitouni N, et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant 2016; 16:407.
4. Kuschal C, Thoms KM, Boeckmann L, et al. Cyclosporin A inhibits nucleotide excision repair via downregulation of the xeroderma pigmentosum group A and G proteins, which is mediated by calcineurin inhibition. Exp Dermatol 2011; 20:795.
Petter G, Haustein UF (2000)
•Potential risk factors for skin cancer after a transplant operation are:
•solar radiation,
•immunosuppressive therapy,
•genetic factors,
•infection with HPV
•and skin cancer transmission before transplantation.
Henryk W, 2013
•Immunosuppressive therapy is undoubtedly one of the most important risk factors for cancer in organ transplant recipients.
Berg D, Am Acad Dermatol. 2002
•Council this patient regarding kidney transplantation?
•Predictors of post tx. Skin cancer •Age > 50 y is a risk factor •Pre-tx skin cancer
•Post tx should do?
•-regular use broad spectrum sun screen •Sun protective clothing •Avoid mid day sun exposure •Regular self exam What is your workup strategy?
•Viral screen HPV
•Pre-malignant conditions APCKD
•Aggressive screen for skin cancer
•UVR B, A Exposue
•Immunosuppression
Prevention and treatment
•avoid exposure to UV radiation and use sun protection
•treatment of precancerous lesions
•treatment of HPV infection Treatment : •Surgical •Reduction IS •Conversion of CNI to SIROLIMUS •TOPICAL 5 FU •Avoid midday sun •Broad spectrum sunscreen Petter G, Haustein UF (2000)Dreno B, Dial Transplant. 2003 Hardwood CA, Med Virol. 2000 Kwiek B, Schwartz RA (2016).
I like one of the possible differentials that you have mentioned Dr Abdelhamid.
Is it really a carcinoma?
You do not need to type in bold unless it is a heading or sub-heading.
Ajay
What is your differential diagnosis?
Points of Counseling for the patient:
What is your work-up strategy?
1. Differential diagnosis
Keratoacanthoma
Squamous cell carcinoma
2. Keratoacanthoma is rapidly growing, locally destructive lesion
May heal spontaneously
But sometimes times resembles well differentiated Squamous cell carcinoma
and better to surgical resection
3. Full history and examination
Skin biopsy . Surgical excision of lesion
Keratoacanthoma (KA) is a common, rapidly growing, locally destructive skin tumour. KAs may regress spontaneously with scarring, but clinically they may be indistinguishable from well-differentiated squamous cell carcinoma (SCC) and the clinical course may be unpredictable. Thus, many clinicians and pathologists prefer the term SCC, KA-type and recommend surgical excision.
Keratoacanthoma (KA) is a common, rapidly growing, locally destructive skin tumour. KAs may regress spontaneously with scarring, but clinically they may be indistinguishable from well-differentiated squamous cell carcinoma (SCC) and the clinical course may be unpredictable. Thus, many clinicians and pathologists prefer the term SCC, KA-type and recommend surgical excision.
https://dermnetnz.org/topics/keratoacanthoma
This is case of dome-shaped nodule with a central keratin-filled crater.
What is your differential diagnosis?
keratoacanthoma
squamous cell carcinoma,
amelanotic melanoma,
molluscum contagiosum,
prurigo nodularis,
metastatic lesion to the skin,
Merkel cell carcinoma,
nodular basal cell carcinoma,
ulcerative basal cell carcinoma,
nodular Kaposi sarcoma,
Council this patient regarding kidney transplantation?
This is most likely Keratoacanthoma. Biopsy of the lesion is must to confirm the diagnosis.Classification of KA is generally done as as a benign, spontaneously resolving tumor .But in rare cases metastasis happened in past by misdiagnsosis of squamous cell carcinoma as karatoacanthoma.No clinical or pathologic features can reliably differentiate KA and cutaneous squamous cell carcinoma.Though keratoacanthoma is not a contraindiacation of transplant, and we can wait for spontaneous resolution,i will council patient for surgery.
What is your workup strategy?
As no clinical or pathologic features can reliably differentiate KA and cutaneous squamous cell carcinoma ,i will search for metastasis and same workup as done squamous cell carcinoma. Conventional surgical excision is the treatment of choice for solitary KA since it allows for both the assessment of histopathologic features to aid in diagnosis and pathologic confirmation of the removal of the tumor.
Differential diagnosis
The lesion presented shows the following features being of single, well circumscribed, elevated, dome-shaped displaying areas of increased keratin at the centre mostly benign Keratoacanthoma.
Other diagnoses are squamous cell carcinomas or basal cell carcinomas.
Counselling the patient depends on reassuring that it is of benign nature and undergoes spontaneous resolution after performing a skin biopsy from the lesion and confirming the diagnosis of Keratoacanthoma. A multidisciplinary team is necessary including dermatologists, oncologist and transplant team is advised.
If the lesion revealed to be malignant the donor should be rejected and enroll the patient to deceased donation programs or maintenance dialysis as a replacement therapy till transplantation is feasible.
Work up strategy:
If transplantation will be resumed after excluding the donor’s malignancy, low dose immunosuppression is needed. Better to avoid T and B cell depleting agents in induction. Maintenance immunosuppression would be based on low drug level i.e. the least dose required to avoid graft rejection as well as early switching to mTORi poses a better choice.
What is your differential diagnosis?
Council this patient regarding kidney transplantation?
What is your workup strategy
What is your differential diagnosis?
· This is a single well circumscribed dome-shaped skin lesion with areas of increased keratin at the Centre.
· DD:
· The benign Keratoacanthoma is on the top of the list.
Keratoacanthomas (KAs) are nodular, keratin-filled, rapidly growing epithelial tumors that simulate the histology of SCC. Some authors consider KA to be low-grade SCC and refer to the tumor as SCC/KA-type. KA, KA typically heals spontaneously, but the mechanism of resolution is not completely understood. The treatment is excisional surgery but given the possibility of a natural remission, a non-invasive medical therapy to treat this kind of cancer may be considered in certain situations including 5-fluorouracil, retinoids, methotrexate, radiotherapy and imiquimod 5 percent cream(anti-tumor and anti-viral effects)
· Squamous cell carcinoma
· Basal cell carcinoma
Council this patient regarding kidney transplantation?
· Council the patient that the most likely diagnosis is keratoacanthoma which is a benign tumor that can resolve spontaneously. However, it resembles SCC. So, involving a dermatologist and doing a skin biopsy is crucial
· Features that support malignant lesion are the aggressive nature of the lesion that may locally spread or cause metastasis, the Perineural or Vascular invasion, or both. Besides, the abnormal cytology of cells.
· KA need no waiting period for transplantation but if there is malignant transformation, the waiting period is according to the AJCC stage. For low risk cases (T1 with no perineural invasion and less than 4mm in size) no waiting time, for High risk SCC without perineural invasion waiting time is 2 years, for High risk SCC and perineural invasion of 2-3 years interval, for High risk with nodal involvement 5 years interval. High risk with distant metastasis are usually not considered for renal transplantation.
· There is a high risk of recurrence of skin cancer after kidney transplant especially with sun exposure. Therefore, counseling on skin protective practices like the use of sunscreens and protective clothing.
What is your workup strategy?
· MDT approach with the oncologist and dermatologist.
· Full history and detailed clinical examination
· Skin biopsy and histopathology to confirm the diagnosis. An excisional procedure with 4 mm margins.
· Imaging to look for metastasis
· Avoid T cell depleting agents for induction and tailor Post transplantation immunosuppressive therapy with reduction of CNIs immunosuppression and Consider mTOR inhibitors
· Keratoacanthoma has an excellent prognosis following surgical excision. skin protective practices like the use of sunscreens and protective clothing are important as 25% of keratoacanthoma undergo malignant transformation.
References:
· Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33.
· Zwald et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413.
· Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, et al., Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement. Am J Transplant. 2021 Feb;21(2):460-474.
· Dendorfer M, Oppel T, Wollenberg A, Prinz JC. Topical treatment with imiquimod may induce regression of facial keratoacanthoma. Eur J Dermatol. 2003; 13: 80-2.
Differential diagnosis include basal cell carcinoma, squamous cell carcinoma and keratoacanthoma.
Renal biopsy and histopathological examination
What is your differential diagnosis?
The differential diagnosis is keratinising squamous cell carcoma as the lesion has keratin structure.
Council this patient regarding kidney transplantation?
Screening for the diagnosis and staging of cancer. Waiting period is suggested before the transplant if it is a metastatic cancer.
What is your workup strategy?
Screening of lesion for metastasis and then waiting period is calculated. mTOR inhibitors are used for immunosuppression.
What is your differential diagnosis?
The lesion is a dome-shaped structure with central keratin filled on the sun-exposed area of the skin
Counseling the patient about kidney transplantation
What is your work-up strategy?
Reference
Q1: the most likely diagnosis is keratoacanthoma. The other differential diagnosis includes squamous cell carcinoma, basal cell carcinoma, or pyogenic granuloma.
Q2: To confirm the diagnosis, surgical excision, and histopathologic examination is necessary to rule out malignant lesions other than keratoacanthoma. In keratoacanthoma, there is no need to wait for TX, however, if malignant lesions are considered, waiting time according to staging is necessary.
Q3: consultation with a dermatologist and oncologist is necessary. Complete physical examination for other lesions and involvements is recommended.
After TX, sun protection and close follow-up are necessary.
Keratoacanthomas (KAs) are epithelial tumors, characterized by a keratin-filled, rapidly growing papule, that develops in a crater produced by pilosebaceous follicles. Even though these lesions histologically resemble squamous cell carcinoma (SCC), they are considered to be immunologically well-controlled carcinoma cells, which usually regress spontaneously. The elective treatment is excisional surgery. However, given the possibility of a natural remission, a non-invasive medical therapy to treat this kind of cancer may be contemplated in certain situations. The medical therapies for the management of KAs include the use of 5-fluorouracil, retinoids, bleomycin, methotrexate, triamcinolone acetonide, radiotherapy and, recently, imiquimod [1-7]. Imiquimod is an immune response modifier, with significant antiviral and antitumor effects. It induces cytokines and cell-mediated cytolytic activity, stimulating both innate and acquired immune responses. Over the last few years, numerous clinical trials have reported the efficacy of imiquimod for the treatment of epithelial skin cancer, including in transplant patients.
KAs are nodular cutaneous tumors that develop rapidly and simulate the histology of SCC. Some authors consider KA to be low-grade SCC and refer to the tumor as SCC/KA-type. KA, however, typically heals spontaneously, but the mechanism of resolution is not completely understood. Recent observations suggest that cutaneous tumor regression depends on an individual’s immune response, mediated by CD8 and CD4 T lymphocytes. Batinac et al. described an elevated number of T cells expressing granzyme B in regressing KAs as compared with SCC [8]. Granzyme B and perforin released by CD8 cells could kill tumor cells, leading to the regression of the neoplasm. Moreover, in SCCs, imiquimod therapy causes a change in the local environment, with a recruitment of CD8 T cells, enriched by granzyme B [9]. This treatment potentiates the cytotoxic effect of the T cell population, inhibiting cancer progression. The successful results obtained by treating KAs in transplant patients with imiquimod 5 percent cream have recently been reported in several journals [7, 10].
Imiquimod has both an indirect antiviral action and an anti-tumoral action. The drug stimulates the synthesis and release of Th1-dependent cytokines (INF-α, TNF-α, IL-1α, IL-6, IL-8, IL-12, PGE2), thus leading to antigenic presentation and activation due to Langerhans cells (LCs) in regional lymph nodes. Immunohistochemistry studies quantified the LCs in benign and malignant cutaneous tumors, demonstrating the highest number in benign lesions, e.g. KA, as compared with malignant and with normal tissues [11]. Besides the acquired immunity (through cytotoxic T lymphocytes) and natural killer cell stimulation, imiquimod has been shown to induce apoptosis by downregulating the anti-apoptotic protein, Bcl-2, and inducing the pro-apoptotic Fas receptor (CD 92-receptor) [12, 13]. Inhibition of tumor angiogenesis was also observed [14]. These recent findings confirm the efficacy of the drug and its rational use in the management of cutaneous tumors. The use of imiquimod in transplant patients afflicted by epithelial skin growths has also been described [15]. This drug activates an immune response only at the site of application, without influencing the systemic immune response [16]. Harrison et al., in a recent study, measured serum levels of imiquimod in 58 non-immunosuppressed patients after local application. Low serum levels of the drug were measured and the immunological effects were limited to the area of application [17]. In our patient, systemic adverse effects did not occur. Positive results were observed near the beginning of therapy. The patient was visited every 2 weeks and photos of the lesions were taken. Repeated blood counts and chemistries remained in normal ranges. Imiquimod treatment of the KA resulted in complete remission. In fact, after only 2 weeks of treatment, we observed a rapid involution of the tumor; after 6 weeks, the lesion had totally healed and the cosmetic outcome was excellent. No relapse was observed after 36 months of follow-up. Future clinical trials could further validate the efficacy and safety of imiquimod in immunosuppressed patients who have undergone organ transplants. We have reported our case to demonstrate the efficacy of imiquimod treatment of KA in transplant patients. Our patient’s tumor completely resolved without activating a systemic immune response.
References
1.Goette DG, Odom RB. Successful treatment of keratoacanthoma with intralesional fluorouracil. J Am Acad Dermatol 1980; 2: 212-6.
2. Rosenblum GA. Multiple palmar keratoacanthomas treated with acitretin. J Drugs Dermatol. 2006 Nov-Dec;5(10):1006-9.
3. Andreassi A, Pianigiani E, Taddeucci P, Lorenzini G, Fimiani M, Biagioli M.Guess what! Keratoacanthoma treated with intralesional bleomycin. Eur J Dermatol. 1999 Jul-Aug;9(5)
4. Melton JL, Nelson BR, Stough DB, Brown MD, Swanson NA, Johnson TM. Treatment of keratoacanthomas with intralesional methotrexate. J Am Acad Dermatol 1991; 25: 1017-23
5. Santosa Pham JC, Shelley ED, Shelley WB. Aggressive giant keratoacanthoma of the face treated with intramuscular methotrexate and triamcinolone acetonide. Cutis 1997; 59: 329-32.
6. Donahue B, Cooper JS, Rush S. Treatment of aggressive keratoacanthomas by radiotherapy. J Am Acad Dermatol 1990; 23: 489-93.
7. Dendorfer M, Oppel T, Wollenberg A, Prinz JC. Topical treatment with imiquimod may induce regression of facial keratoacanthoma. Eur J Dermatol. 2003; 13: 80-2. PubMed
No wait time post excision or removal of this non melanoma cancer
Yet proper counselling of the recipient
Assalam o alaikum
What is your differential diagnosis?
The image shows a single well circumscribed hyperkeratotic plaque with well-defined margins. Differentials include: 1. Keratoacanthoma. 2. Squamous cell carcinoma. 3. Basal Cell Carcinoma
Counsel this patient regarding kidney transplantation?
Breaking the news and reassurance.
Discuss in detail the need to confirm diagnosis and evaluate for staging.
Counsel in detail regarding need to reduce sun exposure and use of sunscreen.
If it is confirmed then the patient might have to wait for a while to proceed for renal transplantation (depending on the AJCC stage). For low risk cases (T1 with no perineural invasion and less than 4mm in size) no waiting time necessary, for High risk SCC without perineural invasion waiting time of 2 years, for High risk SCC and perineural invasion 2-3 years interval, for High risk with nodal involvement 5 years interval. High risk with distant metastasis are usually not considered for renal transplantation.
What is your workup strategy?
History and clinical examination with specific emphasis on size, location, and orientation (horizontal vs vertical extension).
Excision biopsy with wide margins (4mm at least). Rest of the management depends on histopathological diagnosis. Benign keratoacanthoma vs malignant SCC / BCC.
Full body skin examination that includes palpation of regional lymph nodes to evaluate for additional cSCCs and clinical signs of metastatic disease.
Contrast enhanced CT to look for metastasis (MRI & PET scan alternate options)
Sentinel Lymph node biopsy although not usually recommended in case of SCC, however a few studies support its use to detect nodal involvement.
REFERENCES:
1. Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499931/
2. Zwald F, Leitenberger J, Zeitouni N, et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016;16(2):407-413. doi:10.1111/ajt.13593
Differential diagnosis :
As this is dome-shaped lesion with a central area of depression on a sun-exposed area most likely diagnosis is Keratoacanthoma.
D/D includes :
Councelling regarding kidney transplantation :
I will discuss in detail with the patient that this lesion is most likely keratoacanthoma which is most likely a benign tumour that can resolve spontaneously.
But As It has great resemblance to Squamous cell carcinoma so we need to investigate and treat it with surgical excision and SSC need to be excluded by histopathologist.
Features that support malignant lesion are :
(1) Metastasis
(2) Aggressive clinically apart from metastasis, that is, local expansion/recurrence on the clinical side
(3) Abnormal cytology of cells
(4) Perineural or Vascular invasion, or both
If proved to be keratoacanthoma no waiting period for transplantation is required.
If biopsy showed malignant transformation waiting period is according to staging.
There is a high risk of recurrence and of skin cancer after kidney transplant especially with sun exposure.
Workup strategy:
I’ll follow MDT Approach.
I’ll involve Onncologist, Dermatologist, Histopathologist and General Surgeon
I’ll take detailed history and examine other lesions and lymph nodes
Surgical removal and proceed to transplantation if benign
After transplantation self examination for recurrence and sun protection
Reference :
1.American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc
2.Am J Dermatopathol. 2021 Dec 1;43(12):1006. doi: 10.1097/DAD.0000000000001983
3.https://doi.org/10.1016/j.clindermatol.2009.06.010
What is your differential diagnosis?
1. Keratoacanthoma
2. Squamous cell carcinoma
3. Nodular basal cell carcinoma
4. Merkel cell carcinoma
Council this patient regarding kidney transplantation?
1. Regarding the Skin lesion
2. Possibility of recurrence & de novo melanoma after transplantation
3. Regarding protection from recurrence or de novo
· Avoid sun exposure for an hour or two on either side of mid-day.
·Sun protective clothing: Long sleeve silk clothing, sunglass, cotton cricket hat is better.
·Regular use of high factor sun block (SPF 50+ UVA)
· Self examination before & after transplantation regularly
1)D/D:
Basal cell carcinoma
Squamous cell carcinoma
Keratoacanthoma
2)Counselling:
– discussion with the patient about possible
differential diagnosis
– if it is kerato akanthoma, no need to worry and
no need of waiting time
– if it is basal cell carcinoma or squamous cell
carcinoma (non melanoma skin cancer) –
transplant can be done after treating the
cancer. But first we need to confirmed
histopathological diagnosis.
– Regarding IgAN- There is chance of recurrence
of primary disease in transplant (30-35%)
3) Work up :
-MDT approaches(Dermatology,
Histopathology, surgery, nephrology)
– Skin biopsy and histopathology for
confirmation
– To see extent : CXR, USG W/A, CT if need
– If non melanoma skin cancer- wide
excision of lesion, 5FU.
– immunosuppressive therapy after renal
transplant: early conversion of
calcineurin inhibitor to mTor
– Protection: avoid mid day sun exposure,
Sun block, protective clothing
This is domed shape lesion with central keratosis and ulcerations it is rapidly growing with in 6 weeks the most likely diagnosis is keratoacanthoma other differential diagnosis :
-Basal cell carcinoma
-Squamous cell cancer
– Merkel cell carcinoma
I will discussed with the patient and his donor that this lesion most likely keratoacanthoma which is considered a benign tumour that can resolved spontaneously but has great resemblance to SSC so it has to be investigated and treated by surgical excision and SSC need to be excluded by pathologist ,however it may be difficult even histologically.
Criteria that are often advanced to support a malignant lesion are :
(1) metastasis;
(2) aggressive clinical behavior apart from metastasis, that is, local recurrence/destruction on the clinical side;
(3) abnormal cytology of cells;
(4) vascular or perineural invasion, or both; (5)
The approach to this patient is MDT including ( oncologist ,plastic surgeon ,pathologist and nephrologist being prepared for transplantation.
This patient needs proper history and examination, full blood count ,liver function and renal function test.
Reference :
1.American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc
2.Am J Dermatopathol. 2021 Dec 1;43(12):1006. doi: 10.1097/DAD.0000000000001983
3.https://doi.org/10.1016/j.clindermatol.2009.06.010
What is your differential diagnosis?
This is dome-shaped lesion with a central area of depression on a sun-exposed area most propably keratoacanthoma other differential is cutaneous squamous cell carcinoma and basal cell carcinoma.
Council this patient regarding kidney transplantation?
Firstly we discussing generally about this skin lesion and what is differential diagnosis
We need first to surgical exision of the lesion with clear margin and send for biopsy ,if keratoacanthoma proceed to transplantation . Other modalities of treatment include radiotherapy , intralesional injection of methotrexate or5-fluorouracil have also been used. Other issue in some cases of keratoacanthoma have recurrence after transplantation especially in sun exposed area therefore protection of sun is important.
What is your workup strategy?
We need to share the oncologist and dermatologist.
Taking good history and examination of other lesions and lymph nodes.
Surgical removal and proceed to transplantation.
After transplantation self examination and sun protection .
References
1. Keratoacanthoma. Ratner. 2004. http://www.medscape.com/viewarticle/467069 accessed 23 June 2015
2. Zito, Patrick M.; Scharf, Richard (2018), “Keratoacanthoma”, StatPearls, StatPearls Publishing, PMID 29763106, retrieved 17 September 2018
short duration (6week) in immunocompromised patient on dialysis – mostly infective
a)Risk of recurrence of IgAN after renal transplantation & chance of graft loss 30%.
b) Risk of recurrence of skin cancer( in case of SCC 40 – 60% risk at 20 years after transplantation)
c) No waiting time for non melanoma skin cancer
d) Avoid sun exposure & use sun protective clothing
e) Self examination regularly
a)Detail clinical examination
b) Skin biopsy to confirm diagnosis
c) Look for metastasis- detail imaging
d) Treatment of skin cancer- Surgical excision, Topical 5FU
e) Post transplantation immunosuppressive therapy-
i) Reduction of immunosuppression( early cyclosporin withdrawl)
ii) Consider mTOR inhibitor
f) Advice to patient regarding avoidance of sun exposure & self examination
There is a dome shaped nodule filled with keratinous material. So my differential dignosis of this lesion are-
a) Squamous cell carcinoma
b) Basal cell carcinoma
c) Markel cell carcinoma
d) Keratoacanthoma
a)Risk of recurrence of IgAN after renal transplantation & chance of graft loss 30%.
b) Risk of recurrence of skin cancer( in case of SCC 40 – 60% risk at 20 years after transplantation)
c) No waiting time for non melanoma skin cancer
d) Avoid sun exposure & use sun protective clothing
e) Self examination regularly
a)Detail clinical examination
b) Skin biopsy to confirm diagnosis
c) Look for metastasis- detail imaging
d) Treatment of skin cancer- Surgical excision, Topical 5FU
e) Post transplantation immunosuppressive therapy-
i) Reduction of immunosuppression( early cyclosporin withdrawl)
ii) Consider mTOR inhibitor
f) Advice to patient regarding avoidance of sun exposure & self examination.
short duration (6week) in immunocompromised patient on dialysis – mostly infective
It could be mostly an infective lesion; but could be cancerous also.
Shall take a Dermatologist’s opinion and shall involve onco-surgeon for evaluation, definitive curative treatment (wide local excision + Chemotherapy or Radiation)
Excision biopsy of lesion – infective and benign lesions shall be cured, with additional systemic antibiotic or antifungal drugs.
Even if it turns out to be cancerous, looks localized and superficial – not to worry much; surgical excision shall be curative.
Depending on histopathology report (skin cancer) – we have to wait 1-2 years before planning the transplant.
(Infective or benign lesion –> we can go ahead with transplant)
in general skin malignancies are common after transplant, and he has a high risk of recurrence.
So, he is advised to avoid sun exposure, especially 3-4 hours around mid day (10am to 3pm);
to apply broad spectrum sun screen / protective ointment with SPV 50
self examination time to time, and report to the physician at the earliest if any skin lesion is found.
Brother with good match being the donor and negative DSA – transplant is feasible with good outcome
History — Occupation of patient, sun exposure, sun screen use, tobacco use
infections and infestations
Detail physical exam – any other lesion, lymphadenopathy
to stop further transplant work up
Needle aspiration : if pus / caseative / fungal material –> Gram stain, culture, cytology ZN stain, KOH mount, Tuberculosis Gene X-pert test
FNAC and tru-cut biopsy – tumor and its type
MRI / CT /PET-CT for local deep muscle involvement and distant mets
Wide local excision by a Onco-surgeon – should be curative; being a small lesion,
Radiation therapy is not required
If it is Amelanotic melanoma – further chemotherapy may be required, to involve oncologist for further treatment.
Prognosis and further planning :
Can proceed with transplant after a definitive curative treatment
3.Amelanotic Melanoma –> lymph node biopsy and additional chemotherapy may be required, with waiting of 2 years before transplant
What is your differential diagnosis?
My ddx
Council this patient regarding kidney transplantation?
As a part of routine pretransplant evaluation alk kidney transplant candidates should have a dermatologist consultation ti seek skin cancers or precancerous lesions before the transplantion.
because after transplantation the risk of cancer in general and skin cancer in particular is increased due to the effect of immunosupression .so this lesion in particular requires a consultation and workup with appropriate dx and definitive Rx before proceeding the transplantation steps.
What is your workup strategy?
My work up strategy in collaboration with dermatologist is to :
Regarding prognosis and outcome:
Keratoacanthoma is regarded as benign and thus has an excellent prognosis following surgical excision.
Lesions that progress and metastasise have probably been SCC, KA-type all along.
Patients have an increased incidence of other sun-related skin cancers and should be advised about sun protection and self-examination.and regular follow up due to risk of recurrence or development of scc.
SKIN LESION is likely to be
keratoacanthoma
nodular bcc
amelanotic melanoma
merkel cell ca
SCC less likely
biopsy of lesion is must
if histopathology is benign , no further treatment is advised and we can go ahead with transplant
for bcc and other malignant lesion of skin , one year waiting time before transplant is advised
in general skin malignancy is common after transplant
this patient will be high risk in particular for recurrence
adv – avoid sun exposure , education and self examination
as brother is donor with good match, NO DSA, transplant is feasible with good outcome
work up
extensive work up with CT scan is not required at first go
biopsy and dermatology consultation is advised
counselling with patient is MUST regarding recurrence and prevention of future skin lesion
standard thriple drug like steroid/ mmf/tac without any induction is advised
early reduction of immunosuppression with addition of sirolimus will be considered if skin lesion is recurring
on the top of differential is Keratocanthoma ( cutaneous tumor that most commonly presents as a dome-shaped nodule with a central keratin-filled crate , KA is a distinct follicular-based squamous proliferation that usually follows a benign clinical course )
other differentials could be :
1- Clinical assessment :
obtaining a clear history of the lesion time course since a history of rapid growth within weeks favors this diagnosis. Patients should also be questioned regarding a history of prior similar lesions, sebaceous tumors, and visceral malignancies.
Since extensive sun-exposure is likely a precipitating factor for KA as well as multiple other cutaneous tumors, careful examination of the entire skin surface should be performed .
2- Biopsy : performing appropriate biopsy procedure is crucial for accurate assessment. Whenever feasible, biopsies should involve removal of the entire lesion .
after the results of biopsy we can discuss the outcome with the patient , if its malignancy he should remove the lesion and CT for staging and waiting time from 2 to 5 year according to staging
if is benign Keratocanthoma we can proceed with transplantation after removal of the lesion but we should discuss the risk of post transplant skin malignancy with the patient
reference :
Zwald F, Leitenberger J, Zeitouni N, Soon S, Brewer J, Arron S, Bordeaux J, Chung C, Abdelmalek M, Billingsley E, Vidimos A, Stasko T. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant. 2016 Feb;16(2):407-13. doi: 10.1111/ajt.13593. Epub 2016 Jan 28. PMID: 26820755.
The lesion shows a well defined, palpable, papule with smooth margins and dome shape structure with crusting on top…The most likely differential diagnosis is keratacanthoma….The other differential diagnosis are squamous cell carcinoma, basal cell carcinoma, amelanotic melanoma, actinic keratosis, merkel cell carcinoma….
The patient needs a skin biopsy of the lesion…..The patient also needs to evaluate the spread of the disease by clinical examination to see for lymph nodes, PET scan to rule out metastasis…The patient needs to be counselled regarding the tumor after the biopsy report…If the tumour is keratoacanthoma, then it has excellent prognosis…Patient can be proceeded for transplant after wide skin excision of 4mm….There is no tendency for metastasis…..
There is good HLA match and no DSA…I would use IL2 blockers for induction with steroids, MMF and CNI initially..3 months later I will switch over to mTOR inhibitors and remove the CNI as many studies have proven the reduce incidence of de novo skin malignancy after transplant with mTOR inhibitors..
1. SCC, BCC, keratoacanthoma, Merkel cell carcinoma.
2. Council about the risk of recurrence of skin cancer, also proper management therapy & possible waiting time or unsuitability for Tx.
3. Skin biopsy for confirmation & staging, detailed systemic examination, dermatologist & oncology consultation.
51 years old CKD stage 5 on HD since 4 years ago due to IGA nephropathy came to transplant assessment clinic, has a donor his brother 000 mismatch and no DSA while on routine examination found the above lesion..
Differential diagnosis:-
-keratoacanthoma ( dome shaped lesion while Center filled with keratin developed in hair bearing skin and sun exposed area, either appear solitary or on context of specific disorder.
– nodular basal cell carcinoma.
-Merkel cell carcinoma.
– giant mollescoum contagiousm
– deep fungal infection (sporotrichosis).
– cutanons metastasis.
counselling regarding and kidney Transplantation:-
40% of patient post kidney transplant malignancy. related to skin which more common
in white races.
We must pay attention for prevention of dermatological malignancy by..
– educations awareness and = r observation.
– self skin examination by patient and by physician.
– suspect lesion must do biopsy.
– avoid excessive sun exposure with continuous using of sunblock.
Workup strategy
-MDT including dermatologist nephrologist oncologist and transplant surgeon.
-history from patient ( if rapidly growth within weeks, extensive sun exposures or prior similar lesion).
– dermoscopy for differentiation and biopsy is a-key for diagnosis.
– if giant lesion biopsy will be difficult so fusiform incisional biopsy from Center with extending to underlying fat can help.
– modification of immunosuppression ,sirolimus showed to decrease incidence non melanoma cameos and cause regression of pre-pro-existing skin lesion.
– patient precautions must be considered ( self examination with avoid sm exposure and continuous using of sunblock).
Squamous cell carcinoma
Basal cell carcinoma
Keratoacanthoma
Merkel cell carcinoma
2.Counsel the patient regarding kidney transplanation
Skin malignancies prior to transplantation can be a hindrance to rtransplant, as the immunsuppression used in port transplant care puts the person at risk of developing cancers.
The stage of the skin cancer, the type and associated metastases are the determining factors. If the transplant cannot go on because the cancer is active/has metastasized, some years after treatment of the cancer the patient will be assessed again for fitness for transplant. Meanwhile dialysis will continue.
3.Workup strategy
History taking
Clinical examination for surrounding lymphadnopathy and organ involvement
Imaging
Biopsy of the lesion for histology
Dermatology Consultation
What is your differential diagnosis?
This is a solitary nodule, site is not clear in this image, will circumscribed and demarcated, reddish or skin colored with central hyperkeratotic crusty or scaly covering.
This picture is typical for Keratoacanthoma. However, other cause of differential diagnosis should be ruled out:
1-Squamous cell carcinoma.
2-Nodular Basal Cell Carcinoma
3-Actinic Keratosis.
4-Amelanotic Melanoma.
5-Merkel cell carcinoma.
6-Dermatofibrosarcoma protuberans.
7-Giant Molluscum Contagiosum.
8-Nodular Prurigo.
9- Metastatic deposits.
10-Common warts.
Council this patient regarding kidney transplantation?
Pre-transplantation counselling regarding the following points:
1- Diagnosis and treatment of this lesion will guide the discussion and will direct the team if the patient can proceed for renal transplantation or he needs to wait.
2- There is a higher incidence of non-melanoma skin cancer like Kerato-acanthoma (recurrence and De-novo) in post renal transplant recipients than general population.
3- Kerato-acanthoma carries an excellent prognosis after total excision with 4mm safety margin.
4- Keratoacanthoma rarely shows distant metastasis.
5- The patient can proceed for kidney transplantation without waiting period after total excision with 4mm safety margin of keratoacanthoma.
6- Regular self-examination and annual dermatological examination are essential looking for recurrent or de-novo lesions.
7- Post-TX counselling regarding immunosuppression regimen and protection from sun exposure.
What is your workup strategy?
History and examination: local and systemic especially for other lesions, lymph nodes, distant metastasis, peripheral vascular disease.
Treatment options of keratoacanthoma include: surgical excision, methotrexate and 5-fluorouracil.
Dermatology review for examination and excisional skin biopsy.
Oncology Review for staging (CT-chest abdomen and pelvis or PET-CT) and advice regarding any further management.
Waiting time will be decided according to diagnosis and staging as mentioned above.
If the patient is deemed suitable and safe for transplantation, immunosuppression protocol is recommended as follows: lower immunosuppression as low as possible. Consider switching CNI to m-TOR inhibitors, Azathioprine to MMF.
Regular self-examination and annual dermatological examination are essential looking for recurrent or de-novo lesions.
Protective sun exposure measures.
References:
Al-Adra DP, Hammel L, Roberts J, Woodle ES, Levine D, et al., Pretransplant solid organ malignancy and organ transplant candidacy: A consensus expert opinion statement. Am J Transplant. 2021 Feb;21(2):460-474. doi: 10.1111/ajt.16318. Epub 2020 Oct 23. PMID: 32969590; PMCID: PMC8576374.
Amanda Oakley, Martin Keefe. Keratoacanthoma.Derma net. November
Kasiske BL, Snyder JJ, Gilbertson DT, Wang C: Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905–913.
Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol. 2017 Jun 2;18(1):174. doi: 10.1186/s12882-017-0553-2. PMID: 28571571; PMCID: PMC5455080.
hand book of kidney transplant 6th edition
Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33. doi: 10.1016/j.jaad.2015.11.033. Epub 2016 Feb PMID: 26853179.
Sánchez Yus E, Simón P, Requena L, Ambrojo P, de Eusebio E. Solitary keratoacanthoma: a self-healing proliferation that frequently becomes malignant. Am J Dermatopathol. 2000 Aug;22(4):305-10. doi: 10.1097/00000372-200008000-00002. PMID: 10949454.
Keratoacanthomas, SCC, BCC.
Keratoacanthoma has a good prognosis after surgical remove. patients with keratoacanthoma and history of sun exposure should be followed for the development of primary skin cancer Denovo skin cancer. Metastases are rare, no need waiting time for transplant, advice the patient about sun exposure and use sun block daily with high SPF for more protection.
The preferred method is an excisional biopsy and differentiation from SCC.
surgical excision is the treatment of choice for solitary KA, pharmacologic therapy, radiation therapy, and topical therapy and because of his brother is a donor with zero mismatch with a negative DSA, so early minimization of immunosuppressive with an early transfer CNI to mTORi will be preferable.
References:
· Keratoacanthoma: Management and prognosis. UpToDate.
This is a dome-shaped nodule with a central keratin-filled crater suggestive of Keratoacanthoma
Recommended wait times for pre-transplantation for patients with a history of skin cancer before transplantation:
No history of SCC but at low risk for development of SCC: No delay necessary
High-risk SCC (not including perineural invasion): 2 years
High-risk SCC with Perineural invasion: 2 to 3 years
High risk with local nodal metastatic disease: 5 years
Distant metastasis: Not eligible for transplantation
Clinical assessment
· a history of rapid growth of the lesion within weeks favors the diagnosis.
· Since extensive sun-exposure is likely a precipitating factor for KA as well as multiple other cutaneous tumors, careful examination of the entire skin surface should be performed.
· Dermoscopy may aid in clinically distinguishing KA from other lesions but cannot reliably distinguish KA from squamous cell carcinoma
Biopsy
· Whenever feasible, biopsies should involve removal of the entire lesion, and performing the appropriate biopsy procedure is crucial for accurate assessment.
· The preferred method for obtaining a biopsy specimen is an excisional biopsy extending into the subcutaneous fat. At least a 4 mm margin
Histopathology
The histopathological features that typically characterize KA include:
· Epidermal hyperplasia with large eosinophilic keratinocytes
· Central invagination with a keratotic core (this may be less evident in early-stage lesions)
· “Lipping” or “buttressing” of the epidermis over the peripheral rim of the central keratotic plug
· Sharp demarcation between the tumor and the surrounding stroma
· Mixed inflammatory infiltrate in the dermis
Differentiation from squamous cell carcinoma
· among the pathologic features typically ascribed to KA, the presence of an epithelial lip and a sharp outline between the tumor and stroma appeared to be the most useful factors for the diagnosis of KA.
· In contrast, the presence of ulceration, mitoses, and pleomorphism or anaplasia favored a diagnosis of squamous cell carcinoma.
Management
1) American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc.
2) https://pubmed.ncbi.nlm.nih.gov/10592399/#:~:text=Differentiating%20squamous%20cell%20carcinoma%20from%20keratoacanthoma%20using%20histopathological%20criteria.%20Is%20it%20possible%3F%20A%20study%20of%20296%20cases
3) https://www.uptodate.com/contents/keratoacanthoma-epidemiology-risk-factors-and-diagnosis?sectionName=DIAGNOSIS&search=Keratoacanthoma&topicRef=17112&anchor=H772735&source=see_link#:~:text=Keratoacanthoma%3A%20Epidemiology%2C%20risk%20factors%2C%20and%20diagnosis
4) https://www.uptodate.com/contents/keratoacanthoma-management-and-prognosis?search=Keratoacanthoma&topicRef=13718&source=related_link#:~:text=Keratoacanthoma%3A%20Management%20and%20prognosis
1-What is your differential diagnosis?
-Keratoacanthomas (most likely)
-Merkel cell carcinoma.
-Squamous cell carcinoma.
-Melanotic Melanoma
-Dermatofibrosarcoma protuberans.
-Actinic keratosis.
-Nodular Basal cell carcinoma.
-Giant molluscum contagiosum.
-Metastatic deposit.
2-Council this patient regarding kidney transplantation?
-Keratoacanthoma has an excellent prognosis following surgical excision. Generally, patients with keratoacanthoma with history of sun exposure will need to be followed for the development of new primary skin cancers. Metastases are rare,So no wait time for TX,
-But this lesion is closely related to SCC and the patient will need close follow up for fear of developing skin cancer after immunosuppression,
-Regarding kidney transplant can proceed without delay although a skin biopsy is needed. Also should be counseled that 25% of keratoacanthoma undergo a malignant transformation in areas exposed to the sun, so have been on immunosuppression, exposure to ultraviolet sun rays, and the presence of keratoacanthoma put you in malignant disease risk,
-Use of sunscreen avoid sun exposure, frequent skin examination, and seek urgent medical advice if any skin lesion detected
3-What is your workup strategy?
-By local examination;Solitary Keratoacanthomas (KA):
-Solitary, rapidly growing nodule on sun-exposed skin of the face and upper limbs. Keratoacanthomas are sharply demarcated, firm, erythematous or skin-colored, with a classic central hyperkeratotic plug and an even shoulders..
-It is usually best to assume a KA-like lesion is an SCC and to manage accordingly in line with local or national guidance, until proven otherwise.
-Dermatology Referral;for possible Skin Biopsy
-Treatment is Surgical. Although they may resolve spontaneously, it is usually prudent to excise them, unless there is clear evidence that regression is in progress.
-Other options are:
-Cryosurgery
-Curettage and electrodessication
-Topical or intralesional chemotherapy (5-fluorouracil, imiquimod, bleomycin , methotrexate).
-Patients should be advised about Sun Protection and Self-Examination
4-References:
–Keratoacanthoma: Management and prognosis. UpToDate.
–Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation. 2005 Sep 1;5(9):2079-84.
-Risk of Invasive Cutaneous Squamous Cell Carcinoma After Different Treatments for Actinic Keratosis: A Secondary Analysis of a Randomized Clinical Trial.Ahmady S, Jansen MHE, Nelemans PJ, Kessels JPHM, Arits AHMM, de Rooij MJM, Essers BAB, Quaedvlieg PJF, Kelleners-Smeets NWJ, Mosterd K JAMA Dermatol. 2022;158(6):634.
*Basal cell carcinoma,, Squamous cell carcinoma
*Transplant should postponed till cure and safe period passed .
*Confirm diagnosis, involve dermatologist and oncologist, biopsy, screening for metastatic lesion
Differential diagnosis is mainly :
-Keratoacanthoma which is a low-grade, 1 to 2 cm dome-shaped skin tumor with a centralized keratinous plug characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases. Keratoacanthoma may progress rarely to invasive or metastatic carcinoma .
-It should be differentiated from squamous cell carcinoma
-Molluscum Contagiosum
-Merkel Cell Carcinoma
-verrucous Carcinoma
-Investigations entails : biopsy is the most important step and management will be done accordingly
-labs
-waiting time according to the pathology – attached
-Recurrence or denovo malignancy
References:
1-Handbook of kidney transplantation-6th edition
2-Keratoacanthoma, SCC -Uptodate -2022
What is your differential diagnosis?
Picture shows single Dome-shaped, skin-coloured lesion , symmetrical, covered with crust
DD
Keratoacanthoma
Squamous cell carcinoma.
Non melanotic melanoma.
Actinic keratosis.
Nodular Basal cell carcinoma.
Common warts.
Giant molluscum contagiosum.
Metastatic skin deposit.
Merkel cell carcinoma, ulcerative basal cell carcinoma, nodular Kaposi sarcoma, hypertrophic lichen planus, deep fungal infection, atypical mycobacterial infection, foreign body reaction, and verruca vulgaris.
Most probably Keratoacanthomas .
Keratoacanthoma (KA) is a low-grade, rapidly growing, 1 to 2 cm dome-shaped skin tumor with a centralized keratinous plug.
Etiologies includs:
ultraviolet (UV) radiation, exposure to chemical carcinogens, immunosuppression, use of BRAF inhibitors, genetic predisposition , viral exposure including human papillomavirus (HPV), and recent trauma or surgery to the location.
Peak incidence of solitary keratoacanthoma is between 50 and 69 years of age. They occur more frequently in men with a male to female ratio of 2:1
Lesions are evaluated with a careful history and physical examination.
The best diagnostic test is an excisional biopsy as a shave biopsy may be insufficient to examine the depth to differentiate keratoacanthoma from squamous cell carcinoma.
Keratoacanthoma is recognized as benign, treatment is recommended due to the relation to squamous cell carcinoma. Treatment of choice consists of an excisional procedure with 4 mm margins.
Council this patient regarding kidney transplantation:
Keratoacanthoma has an excellent prognosis following surgical excision. Generally, patients with keratoacanthoma with history of sun exposure will need to be followed for the development of new primary skin cancers. Metastases are rare,
So no wait time for TX
But this lesion is closely related to SCC and the patient will need close follow up for fear of developing skin cancer after immunosuppression
What is your workup strategy?
Excisional biopsy to confirm diagnosis .
Chest x ray and body imaging to role out internal organ malignancy
No wait time for transplantation
Avoid T cell depleting agents for induction and heavy immunosuppression as they are risk factors for skin malignancy
References
Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Differential diagnosis:
Keratoacanthoma of Skin: Keratoacanthoma (KA) is a cutaneous tumor that most commonly presents as a dome-shaped nodule with a central keratin-filled crater
squamous cell carcinoma
Fungating skin lesion
Rx Excision Skin biopsy should be obtained. First-line therapy — Conventional surgical excision is the treatment of choice for solitary KA since it allows for both the assessment of histopathologic features to aid in diagnosis and pathologic confirmation of the removal of the tumor. Other effective options for the treatment of KA include electrodesiccation and curettage (ED&C), intralesional pharmacologic therapy, radiation therapy, and topical therapy.
Incomplete removal of KA may result in lesion recurrence. Metastasis can occur.
Patient should be counselled regarding the higher risk for developing skin cancer post kidney transplant compared to the general population. Moreover, he should have annual check up post-transplant. He should be advised to have head-to-toe skin exams by a dermatologist at least once a year.
References:
· Keratoacanthoma: Management and prognosis. UpToDate.
· Otley CC, Hirose R, Salasche SJ. Skin cancer as a contraindication to organ transplantation. American journal of transplantation. 2005 Sep 1;5(9):2079-84.
SCC
BCC
melanoma
Solid organ transplant recipients are at increased risk for cutaneous malignancies (most commonly squamous cell carcinoma), a finding related to long-term immunosuppression. Because some skin cancers demonstrate aggressive biologic behavior in the setting of immunosuppression, care must be taken to identify and treat early lesions appropriately. In addition to treatments that directly target cutaneous malignancies, modulation of immunosuppression and preventive measures play an important role in the management of these patients. Organ transplant recipients with a history of skin cancer should be followed closely for the development of new lesions, locally recurrent lesions, and metastatic disease.
PRETRANSPLANTATION SCREENING
A dermatologic consultation is recommended before transplantation for the screening and treatment of skin cancer and precursor lesions. All suspicious lesions should be excised and sent for pathologic examination. Actinic keratoses, porokeratoses, and viral warts should be treated. A careful history of previous skin cancer should also be obtained to determine the appropriate follow-up frequency or the wait time before proceeding to transplantation
Wait time
For patients with a history of prior cutaneous malignancy, the wait time before undergoing transplantation depends upon the tumor type and stage, presence or absence of high-risk features, and availability of a management approach alternative to transplantation.
●Transplant candidates with extensive field disease (ie, multiple actinic keratoses, disseminated porokeratosis) but without a history of skin cancer may proceed to transplantation, with the recommendations that all field disease be appropriately managed by the dermatologist.
●For patients with basal cell carcinoma or low-risk squamous cell carcinoma (SCC) that has been surgically excised with clear margins, no waiting time is required.
●For patients with a history of high-risk SCC and for those with Merkel cell carcinoma stage IIa or less (local disease; any tumor size not invading bone, muscle, fascia, or cartilage; negative lymph nodes a two- to three-year waiting time is required.
●For patients with SCC and local nodal disease, a five-year wait time is considered prudent, following appropriate treatment with lymph node dissection and adjuvant radiation therapy.
●For transplant candidates with a history of melanoma in situ/lentigo maligna, no waiting period is required, but the patient should be followed up with regular skin exams.
●For renal transplant candidates with a history of stage Ia/Ib/IIa melanoma, a two- to five-year wait time is required before transplantation. A five-year delay is required for patients with stage IIb/IIc melanoma.
●Patients with distant metastatic diseases are not eligible for transplantation in most circumstances.
Work up
skin examination and palpation of draining lymph nodes. The need for additional laboratory or radiologic evaluation is based upon the detection of findings that suggest locoregional or metastatic spread of disease.
Skin biopsy of the lesion
Screen for distant metastasis
Reducing immunosuppressive drugs
Change the CNI to mTOR
Change AZA to MMF
Patient education concerning sun protection and skin self-examination
Post-transplantation surveillance by nephrologist and Dermatologist
Reference
3-Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Curr Treat Options Oncol 2012; 13:354.
Differntial diagnosis:
A- Neoplastic condition :
1- Keratoacanthoma
2- squamous cell carcinoma
3- nodular basal cell carcinoma, ulcerative basal cell carcinoma
4- amelanotic melanoma
5- molluscum contagiosum
6- metastatic lesion to the skin
7- nodular Kaposi sarcoma
8- hypertrophic lichen planus,
B- Infectious condition :
-deep fungal infection
– atypical mycobacterial infection,
– foreign body reaction
-verruca vulgaris.
2-Councel the patient regarding kidney transplantation
Kidney transplantation is the best therapeutic for ESRD patients ,however transplantation in cancer patient carries 5-7 folds increased risk of recurrence and patients of high grade malignancy have low 5 years survival rates whether they were transplanted or not due to death from cancer related or cancer non related causes ,but low grade malignancy have a better prognosis ,while patient who remain on dialysis for long time are at increased risk for death from non cancer related causes specially cardiovascular complications , thus the treatment stratigey is personalized according to each patient specific conditions .
The initial step in management is a skin biopsy to reach a definite diagnosis .In case of malignant skin cancer further staging and examination for distant visceral and lymph node spread is needed.
Guidlines recommend waiting time for 1 year for localized melanoma and at least 2 years free of cancer recurrence for other cancers
Treat any risk factors for cancers as: stop smoking ,avoid excessive sun exposure and usesun block
Dematological expert consultation regarding suitable treatment and screening strategy.
Optimize the dialysis adequacy ,correct any electrolyte disturbance specially Ca,po4 to avoid calciphylaxis.
Ref
1- Knoll, Greg A. MD, MSc, FRCPC1,2; Chadban, Steven J. BMed, PhD, FRACP3. Preexisting Cancer in Transplant Candidates: Time for a Change in Practice?. Transplantation 102(7):p 1037-1038, July 2018. | DOI: 10.1097/TP.0000000000002177
2- Dahle, Dag Olav MD, PhD1; Grotmol, Tom MD, PhD2; Leivestad, Torbjørn MD, PhD3; Hartmann, Anders MD, PhD1; Midtvedt, Karsten MD, PhD1; Reisæter, Anna V. MD, PhD1; Mjøen, Geir MD, PhD1; Pihlstrøm, Hege K. MD, PhD1; Næss, Hege MD4; Holdaas, Hallvard MD, PhD1. Association Between Pretransplant Cancer and Survival in Kidney Transplant Recipients. Transplantation 101(10):p 2599-2605, October 2017.
1.Keratoacanthoma
2.Squamous cell carcinoma,
3.Amelanotic melanoma,
4.Nodular basal cell carcinoma,
5.Verruca vulgaris.
6.Cutaneous Horn
Most likely keratoacanthoma arising in 6 weeks
It will typically grow in weeks to months followed by spontaneous remission over 4-6 months.
Need biopsy to diagnosed, have to rule out SCC. In few case(25%) can convert to malignant.
No waiting time needed for this unless the biopsy shows other thing
The patient needs to be counselled regarding the risk of occurrence of skin cancer post-transplantation due to use of immunosuppressive medications
The patient should also be counselled regarding the importance of preventive measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin
Detailed history and examination.
MDT with dermatologist
Non lymphocyte depleting agents in good match donor for transplantation
The patient should also be counselled regarding the importance of preventive measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin
What is your differential diagnosis?
Dome-shaped skin tumor with a centralized keratinous plug, mostly suggestive of keratoacanthoma
Differential diagnosis:
· Squamous cell carcinoma,
· Amelanotic melanoma,
· Molluscum contagiosum,
· Prurigo nodularis,
· Metastatic lesion to the skin,
· Merkel cell carcinoma,
· Nodular basal cell carcinoma,
· Ulcerative basal cell carcinoma,
· Nodular Kaposi sarcoma,
· Hypertrophic lichen planus,
· Deep fungal infection,
· Atypical mycobacterial infection,
· Foreign body reaction,
· Verruca vulgaris.
· Cutaneous Horn
· Muir-Torre Syndrome
· Sporotrichosis
Council this patient regarding kidney transplantation?
· Rapid growth over a few weeks to months, followed by spontaneous remission over 4-6 months, is how Keratoacanthoma is typically described. In rare cases, keratoacanthoma can develop into aggressive or metastatic cancer. Whether these instances were SCCs or keratoacanthomas, the findings demonstrate how challenging it is to accurately categorize each individual case. (1)
· The most frequent form of skin cancer after transplantation is SCC, which develops 65 times more frequently than in those who are not immunosuppressed. (2)
· For those with a history of cSCC, dermatological follow-up for skin cancer screening is crucial both before and after transplantation, as well as instruction in sun protection, as there is an increased risk of developing subsequent skin cancers in renal transplant patients that ranges from 40% to 80%.(3, 4)
What is your workup strategy?
· With the recommendation that all field diseases be handled by the dermatologist as thoroughly as possible, patients with significant field disease but no history of skin cancer may continue to transplantation.
· The majority of patients with a history of low-risk SCC before transplantation proceeds to transplantation.
· The staging of the primary tumor using head and neck computed tomography (CT) or, where possible, positron emission tomography (PET)/CT), followed by complete surgical removal when possible, are all steps in the careful evaluation of transplant candidates with a history of high-risk SCC before transplantation. (5)
1. Zwald, F.; Leitenberger, J.; Zeitouni, N, et al,. (2016). Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborate. American Journal of Transplantation, 16(2), 407–413. doi:10.1111/ajt.13593
2. Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: Part I. Epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol 2011; 65: 253–261,
3. Ismail F, Michell L, Casebonne D, et al. Specialist dermatology clinics for organ transplant recipients significantly improve compliance with photoprotection and levels of skin cancer awareness. Br J Dermatol 2006; 155: 916–925.
4. Ulrich C, Kanitakis J, Stockfleth E, Euvrard S. Skin cancer in organ transplant recipients: where do we stand today? Am J Transplant 2008; 8: 2192–2198.
5. Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol 1992; 26: 976–990.
The lesion is mostly keratoacanthoma but other DD:
SCC
Wart
BCC
Amelanotic melanoma
Council this patient regarding kidney transplantation?
He needs to know the waiting time:
If the diagnosis is KA , it is mostly benign and needs surgical excision with safety margin with no waiting time.
If the diagnosis is SCC waiting time ranges from 2-5 years according to aggressiveness.
He needs to protective measure:
Regular self examination
Avoid sun exposure
Protective clothes
Sun block
He needs to know about immunosuppressive medications, that lower immune system and increase the risk of recurrence , or occurrence of skin cancer which is higher than normal individuals.
Work up :
Full history and examination
Multidisciplinary team work between nephrologist, dermatologist, oncologist
CT or MRI can be done
The most probable diagnosis is Keratoacanthoma.
Other possible diagnoses:
1-Actinic keratosis
2-Squamous cell carcinoma.
3-Cutaneous horn
4-Molloscum Contagiosum
The short duration of the lesion and its appearance points to the more benign lesion keratoacanthoma. However we need to differentiate from squamous cell carcinoma which is more sinister condition, as the decision to go for transplantation will depends on the histological diagnoses and the extent of the disease.
Detailed history and examination.
Excisional biopsy.
Dermatology consultation
Oncology consultation if the lesion is confirmed to be malignant.
References:
1-Medescape
2-Laamari K, Oukarfi S, Elloudi S, Douhi Z, Baybay H, Mernissi FZ, Aouinti L, Charai A, Kamal D, El Amine El Alami MN. Keratoacanthoma or squamous cell carcinoma. Our Dermatol Online. 2020;11(e):e76.1-e76.3.
DD: Keratoacanthoma &SCC
Keratoacanthoma is a benign keratinocytic neoplasm which spontaneously regresses within 3-6 months and mimics well-differentiated squamous cell carcinoma (SCC). Increased incidence of keratoacanthoma and non-melanoma skin tumor is seen among immunosuppressed organ-transplants.
Counselling:
Total excision with clear margin is needed also the patient to be counselled regarding possibility of recurrence following RTX
The patient is advised for self examination.
-Workup strategy:
-history
– Thorough physical examination to look for other lesions& lymphadenopathy
– Routine investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion ; first-line treatment for a solitary lesion
– Multidisciplinary team management
– Kidney transplantation according to the outcome of the evaluation.
This patient seems to have a malignant lesion, could be basal or squamous cell carcinoma. Excisional biopsy is essential both for diagnosis and treatment. different lesions have offered different waiting times. earlier suggestions, as in the attached pictures. There have been scarce studies about malignant melanoma and lymphoma in recent years, but all data suggest waiting with careful monitoring.
The waiting time is mainly dependent on the type of malignancy and staging. dermatologic cancers with no invasion; in situ do not need time to wait. waiting time varies from 2-5 years after remission.
Picture1:
Girndt, Matthias; Köhler, Hans. Waiting Time for Patients with History of Malignant Disease before Listing for Organ Transplantation. Transplantation 80(1S):p S167-S170, September 27, 2005. | DOI: 10.1097/01.tp.0000187112.81714.26
https://images.journals.lww.com/transplantjournal/Original.00007890-200509271-00018.T1-18.jpeg
Picture2:
https://www.uptodate.com/contents/kidney-transplantation-in-adults-evaluation-of-the-potential-kidney-transplant-recipient?search=renal%20trasnpalt%20after%20cancer&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H2486107638
Picture1
What is your differential diagnosis?
1. Keratoacanthoma (KA)
2. Squamous cell carcinoma
3. Nodular basal cell carcinoma
4. Amelanotic melanoma
5. Common warts
6. Metastatic deposit
7. Giant molluscum contagiosum
8. Nodular prurigo
Council this patient regarding kidney transplantation
Surgical excision of the lesion and send it for histopathology. If the lesion is localized and no evidence of metastases and confirmed to be KA, transplantation can proceed. Avoid sun exposure with regular self examination. KA is considered benign and thus has an excellent prognosis following surgical excision. The risk of skin cancer post transplantation is high.
What is your workup strategy?
Multidisciplinary approach
Keratoacanthoma is diagnosed on the basis of a typical history, the clinical signs and histopathology
Histologically: low power (has a crateriform appearance). High power (enlarged atypical keratinocytes with eosinophilic cytoplasm that do not extend beyond the level of the sweat glands)
KA may show squamous cells in a peripheral zone with atypical mitotic figures, hyperchromatic nuclei, and penetration into surrounding tissue. Such lesions are often reported as SCC, KA-type
Treatment is surgical. Other options are:
Patients should be advised about sun protection and self-examination
Reference
1. Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016;74(6):1220–33. doi:10.1016/j.jaad.2015.11.033.
2. Gleich T, Chiticariu E, Huber M, Hohl D. Keratoacanthoma: a distinct entity? Exp Dermatol. 2016;25(2):85–91. doi:10.1111/exd.12880.
3. Misago N, Inoue T, Koba S, Narisawa Y. Keratoacanthoma and other types of squamous cell carcinoma with crateriform architecture: classification and identification. J Dermatol. 2013;40(6):443–52. doi:10.1111/1346-8138.12104.
Differential diagnoses
Keratoacanthoma
Squamous cell carcinoma
Counselling
Non metastatic non melanoma skin cancer does not require a recurrence- free interval before transplantation. However, before this conclusion is made, extensive work up needs to be made to ascertain the histologic type and rule out metastasis.
She will need to be counselled for surgery.
Counselling on self-examination, avoidance of sun and use of sun protection.
Work up.
Incisional biopsy and histology.
What is your differential diagnosis?
Papular lesion with areas of increased keratin at the centre for differential diagnsis: Keratoacanthoma, Squamous cell carcinoma and others (referral to dermatology is a must given the cancer probability)
Council this patient regarding kidney transplantation?
Recurrenance post transplant:
There is a chance of recurrence post transplant and unfurtunatly the risk is higher than matched non tranaplant population up to 60 times however there are measures can be considered post transplant like limit sun exposure and use sun blocks with certain SPF and most importantly to monitor the skin and look for any recurrence.
When can we proceed with transplant:
It depends on the outcome from dermatology assessment and staging, there may be a waiting time that can exptend up to 2- 5 years depends on the staging and outcome. In some cases if proven to be metastatic lesion, other forms of therapy would be more important than renal transplant itself with potential better survival like immunotherapy (which is grey area at the momenet in term of suitability of organ transplant)
What is your workup strategy?
Extensive clinical examination, urgent referral to dermatology for their input and Mohs micrographic surgery. look for distant mets CT or PET scan
Rererences:
Al-Adra, David1; Al-Qaoud, Talal1; Fowler, Kevin2; Wong, Germaine3,4,5. De Novo Malignancies after Kidney Transplantation. CJASN 17(3):p 434-443, March 2022. | DOI: 10.2215/CJN.14570920
Łasińska, I., Kolenda, T., Teresiak, A., Lamperska, K. M., Galus, Ł., & Mackiewicz, J. (2019). Immunotherapy in Patients with Recurrent and Metastatic Squamous Cell Carcinoma of the Head and Neck. Anti-cancer agents in medicinal chemistry, 19(3), 290–303. https://doi.org/10.2174/1871520618666180910092356
What is your differential diagnosis?
——————————————————-
1-Squamous cell carcinoma.
2- Keratoacanthoma.
Council this patient regarding kidney transplantation?
————————————————————————————
1-The candidate should know the outcome of SCC post kidney transplantation;
SCC are considered as more aggressive in transplant recipients than in non immunosuppressed patients, as they recur locally in 13.4% of patients, generally during the first 6 months after excision, and metastasize in 5% to 8% of patients, usually within 2 years after excision. Factors of unfavorable prognosis of SCC in transplant patients are multiple.
2-The candidate must know the waiting time before transplant ;
The guidelines recommend a waiting period of 2 years in case of SCC with histological features of aggressiveness (considering the median delay to the occurrence of metastasis), and of 5 years in case of history of metastatic SCC. Nevertheless, the length of the wait period should be discussed on an individual patient basis, according to the background and the tolerance of dialysis.
3-The preventive measures should be discussed with the candidate ;
Preventive measures should be applied, especially in patients who accumulate several risk factors of aggressive SCC. These measures include adequate education about strict sun protection and regular dermatologic monitoring for early ablation of (pre)malignant lesions with adequate safety margins.
4-The candidate should understand the impact of immunosuppressant in his primary skin cancer ;
The availability of a well-matched donor should decrease the immunologic risk, allowing avoidance of a T cell–depleting induction treatment. An early tailored immunosuppression, including mTOR inhibitors, should be the best prevention of aggressive SCC but the risk o rejection is existed .
What is your workup strategy?
————————————————————
1-A multidisciplinary team (Nephrologist ,dermatologist ,oncologist and surgeon ) should evaluate this candidate .
2-The eligibility for transplantation;
Based on the existing evidence, the guidelines advocate ;
A- await time of 2 years before transplantation for patients with a history of high-risk SCC (i.e., large size [>2 cm], high-risk location,recurrent lesion, poorly differentiated), if there is no evidence of metastasis on CT or PET-CT, and the tumor has been cleared surgically .
B- For patients with evidence of perineural invasion, the group believes that it would be more prudent to extend the wait time to 2 to3 years.
C- For nodal disease, the combination of surgicalexcision and adjuvant radiation therapy (ART) is consideredbest practice for head and neck SCC .
D- For transplant candidates with SCC with nodal disease, a 5-year wait time is considered prudent, following appropriatetreatment with no radiological .
3- Immunosuppressant ;
Once graft function has stabilized, the transplant team should be encouraged to minimize immunosuppression asmuch as possible as per KDIGO guidelines (2).
Reference ;
——————————–
1-Zwald et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413. doi: 10.1111/ajt.13593.
2. Brantsch KD, Meisner C, Schönfisch B. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study Lancet Oncol 2008. 9713–720 [PubMed] [Google Scholar].
3. Schmults CD, Karia PS, Carter JB. Factors predictive of recurrence and death from cutaneous squamous cell carcinoma: a 10-year, single-institution cohort study JAMA Dermatol 2013. 149541–547 [PubMed] [Google Scholar].
4. Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part II. Management of skin cancer in solid organ transplant recipients J Am Acad Dermatol 2011. 65263–279 [PubMed] [Google Scholar].
5. Singh MK, Brewer JD. Current approaches to skin cancer management in organ transplant recipients Semin Cutan Med Surg 2011. 3035–47 [PubMed] [Google Scholar]
6. Harwood CA, Mesher D, McGregor JM. A surveillance model for skin cancer in organ transplant recipients: a 22-year prospective study in an ethnically diverse population Am J Transplant 2013. 13119–129 [PubMed] [Google Scholar]
Squamous cell carcinoma
Keratoacanthoma which is a special tumor. It was considered a pseudocancer, which appears in the form of an isolated nodule, generally on the face or exposed areas
· kin cancer involves review of historical data, examination
· and assessment of the details of the prior cancers to es-
· timate the risk of recurrence, metastasis or formation of
· new primary cancer (Table 1). For patients with a history
· of skin cancer that is not readily identifiable as low risk,
· transplant dermatologists and Mohs surgeons may be of
· assistance to assess the clinical, surgical and pathologic
· details of the prior skin cancer and estimate a prognosis,
· taking into account the time elapsed since the occurrence
· of the skin cancer. Radiologic imaging may be indicated on a
· case-by-case basis but is subject to false-positive and false-
· negative findings. Positron emission tomography may be
· helpful in ascertaining any foci of metastatic melanoma,
· high-risk squamous cell carcinoma (SCC) or Merkel cell
· carcinoma, whereas computed tomography is only rarely
· helpful for detection of recurrent basal cell carcinoma (BCC)
· and other slow-growing tumors.
In kidney-transplant recipients with at least one previous cutaneous squamous-cell carcinoma, conversion from calcineurin inhibitors to sirolimus was associated with a lower risk of subsequent skin cancers. The data suggest that the earlier the conversion occurs after an initial diagnosis of cutaneous squamous-cell carcinoma, the greater the efficacy.(1) KDIGO recommend that candidates with active malignancy be excluded from kidney transplantation except for those with superficial non-melanoma skin cancer (1B). no waiting time for candidates with curatively treated (surgically or otherwise) non-metastatic basal cell and squamous cell carcinoma of the skin; melanoma in situ .(2)
· btain a complete history and perform a physical examination,
· paying specific attention to sites of prior skin cancers and
· palpating the regional nodal basin for high-risk skin cancers.
· Review clinical and pathologic details of prior skin cancers.
· Transplant dermatologists may be helpful in this regard.
· Using prognostic data, estimate the risk of recurrence,
· metastasis and development of new primary cancers. When
· estimating risk, consider the time elapsed since skin cancer
· was treated.
· Consult Table 2 for general recommendations on the
· appropriateness of transplantation.
· Assess risk of cancer recurrence, risk of end organ disease and
· risks of transplantation to determine transplant status.
· Consider the ethics of limited organ availability, which may
· differ depending on whether the donor is a living relative or a
· cadaver.
· If the potential for occult micrometastasis exists, radiographic
· staging should be performed before considering listing the
· patient on the organ transplant waiting list.
· Periodic examinations and imaging are appropriate for patients
· with prolonged waits for transplant organs.
Patient evaluation through examination of the lesion, lymph nodes palpation and looking for any evidence of locoregional or metastatic spread of disease.
Then a through pathological examination with biopsies of lesions that extend into the deep reticular dermis. The need for additional laboratory or radiologic evaluation is based upon the detection of metastatic findings and classification.
high-risk features:
●Location in the “mask areas” of face (central face, eyelids, eyebrows, periorbital, nose, lips, chin, mandible, preauricular and postauricular skin/sulci, temple, ear), genitalia, hands, and feet
●Large size: ≥10 mm on scalp, forehead, cheeks, neck or pretibial area; ≥20 mm on trunk or extremities
●Indistinct borders
●Rapid growth
●Recurrent lesion
●Lesion in site of chronic inflammation or prior radiation therapy
●Presence of neurologic symptoms
●Histology
Options for the treatment are surgical, chemotherapy and radiotherapy
1- surgical excision: Lesions should be excised with a margin of tissue that extends 4 to 6 mm beyond the peripheral edge of erythema, and the specimen should be sent for postoperative pathologic margin assessment. SCCs in immunosuppressed patients that demonstrate other high-risk features be managed with techniques that provide pathologic confirmation of tumor removal (Mohs surgery, surgical excision with intraoperative frozen sections or a conventional surgical excision with postoperative margin examination . Lesions treated with conventional surgical excision should be excised with at least 6 to 10 mm margins beyond the edge of erythema .Guidelines from the National Comprehensive Cancer Network state that lesions ≥20 mm on the trunk or extremities should be excised with 10 mm margins .
2- Electrodesiccation and curettage is a procedure that involves three cycles of scraping of the tumor with a curette followed by electrodesiccation, is an alternative treatment for lower risk lesions. Advantages are quick, generally well tolerated, and less expensive and disadvantage are the lack of histologic margin control, which underlies the importance of carefully selecting lesions for treatment. ED&C should generally not be performed in hair-bearing areas because the presence of terminal hair follicles may reduce the efficacy of the procedure. In addition, ED&C cannot reliably eradicate lesions that extend into the subcutaneous fat. If fat is reached early during the curettage stage, ED&C should be abandoned and the tumor should be removed surgically. All sites treated with ED&C should be followed closely for lesion recurrence.Some clinicians choose to perform ED&C at the time of biopsy on lesions that are clinically consistent with small, well-differentiated SCCs. If pathology results demonstrate aggressive histopathologic features, subsequent surgical excision should be performed to ensure adequate tumor removal.The efficacy of ED&C for SCC in organ transplant recipients is supported by the results of a retrospective study of 211 SCCs in 48 patients. After a mean follow-up period of 50 months, residual or recurrent SCC occurred in only 6 percent.
3- radiation therapy is for patients who are unable to tolerate surgery or as an adjunctive therapy for lesions that cannot be completely excised or that demonstrate extensive perineural involvement, especially nerves of larger diameter A disadvantage of radiation therapy is a possible increased risk for the future development of skin cancer in treated sites and possible increased difficulty in treating recurrences.
4- Chemotherapy :Severe or metastatic disease has responded to systemic therapies such as platinum-based chemotherapeutic agents, capecitabine, and cetuximab. Fatal diffuse alveolar damage has been reported in two lung transplant patients treated with cetuximab for metastatic cutaneous SCC. Treatment with immune checkpoint inhibitors has been reported in small case series of transplant recipients that included a few cutaneous SCCs. In a pooled analysis that included 64 transplant recipients with various metastatic cancers, disease control rates varied, from 35 percent with ipilimumab, 37 percent with nivolumab, and 53 percent with pembrolizumab . Unfortunately, organ rejection occurred in a substantial number of patients, ranging from 54 percent with nivolumab, 39 percent with pembrolizumab, and 23 percent with ipilimumab. (3,4)
References :
1- Sylvie Euvrard et al, Sirolimus and Secondary Skin-Cancer Prevention in Kidney Transplantation, N Engl J Med 2012; 367:329-339
DOI: 10.1056/NEJMoa1204166
2- 2-Chadban, Steven J. BMed, PhD1,*; Ahn, Curie MD, PhD2; Axelrod, David A. MD, MBA3; Foster, Bethany J. MD, MSCE4; Kasiske, Bertram L. MD5; Kher, Vijah MD, DM6; Kumar, Deepali MD, MSc7; Oberbauer, Rainer MD, PhD8; Pascual, Julio MD, PhD9; Pilmore, Helen L. MD10; Rodrigue, James R. PhD11; Segev, Dorry L. MD, PhD12; Sheerin, Neil S. BSc, PhD13; Tinckam, Kathryn J. MD, MMSc7; Wong, Germaine MD, PhD14; Knoll, Gregory A. MD, MSc15,*. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 104(4S1):p S11-S103, April 2020. | DOI: 10.1097/TP.0000000000003136
3- Unal E (2016) Skin Lesions after Kidney Transplantation: An updated Review Including Recent Rare Cases. Int J Transplant Res Med 2:017 Received: May 10, 2015
4- up to date
. What is your differential diagnosis?
-keratoacanthoma
-Cutaneous Squamous Cell Carcinoma(cSCC)
Council this patient regarding kidney transplantation?
-He needs dermatological consultation and excisional biopsy ,and according to the result ,we can proceed .if it keratoacanthoma, it is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases and may progress rarely to invasive or metastatic carcinoma. Treatment of keratoacanthoma is primarily surgical and proceed for transplantation.
If it cSCC:
No history of SCC but at risk for development of SCC :No delay necessary
Low risk : No delay necessary
High-risk SCC (not including perineural invasion) : waiting 2 years
High-risk SCC with perineural invasion or 2 risk factors : waiting 2 to 3 years
High risk with local nodal metastatic disease : waiting 5 years
Distant metastasis :Not eligible for transplantation
What is your workup strategy?
-Detail history and clinical examination.
-Dermatology consultation and excisional or deep incisional biopsy for histopathology.
– If it cSCC, CT scanning or MRI can be helpful in defining the extent of disease.
Reference:
1. F. Zwald1.etal . Recommendations for Solid Organ Transplantation
for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). American Journal of Transplantation 2016; 16: 407–413 Wiley Periodicals Inc.
Differential Diagnosis
squamous cell carcinoma
basal cell carcinoma
keratoacanthoma
counselling this patient
excision of lesion with clear margin
if lesion is localized than proceed with transplantation but
explain the risk of post-transplant recurrence of skin cancer.
avoidance of sun exposure
25% of keratoacanthoma undergo malignant transformation on areas exposed to sun especially in elderly patients.
Managment
multidisciplinary approach is needed. initially deep incisional biopsy with sufficient margins is the primary treatment of choice.
along with intra-lesion methotrexate, 5 FLU, bleomycin systemic retinoids and steroids all have been tried with good results.
to prevent recurrence long term monitoring would be essential with treatment after transplantation including mTOR, MMF, steroids.
The waiting time is the main issue which have to be addressed.
What is your differential diagnosis?
==========================
Council this patient regarding kidney transplantation?
I will council the patient as follows:
==========================
What is your workup strategy?
References
Well done.
What is your differential diagnosis?
This is skin lesion with a centralized keratinous plug, the followings are the differentials:
· Keratoacanthoma.
· Cutaneous SCC.
· Nodular BCC.
· Merkel cell Carcinoma.
· Giant Molluscum Contagiosum.
· common wart.
· Nodular prurigo
· Amelanotic melanoma.
Council this patient regarding kidney transplantation?
This patient’s lesion is most likely keratoacanthoma(KA). Although recognized as benign, KA shares histopathological features with SCC and require treatment(1). keratoacanthoma in a transplant recipient should be considered equivalent to a squamous-cell carcinoma(2).
· Surgical excision with safety margin may render him illegible to proceed for transplant without delay or waiting time, if cure is achieved at surgery. Keratoacanthoma is regarded as benign and thus has an excellent prognosis following surgical excision(3). Lesions that progress and metastasise have probably been SCC(3).
· Advice regarding post-transplant behavioral intervention to minimize the risk of recurrence:
a) Protective sunscreen and clothes.
b) Avoiding direct sunlight at the peak hours.
c) Doing routine self-examination of the skin for early detection of skin lesions or recurrence.
What is your workup strategy?
· Team work-up; including transplant nephrologist, oncologist, plastic surgery and dermatologist.
· Histological diagnosis based on skin biopsy and staging of the lesion.
· Treatment of choice consists of an excisional procedure with 4 mm margins. Lesions less than 2 cm on the extremities may be treated with electrodessication and curettage.
· Nonsurgical interventions have been limited to case reports and retrospective reviews consisting of topical 5% imiquimod cream, topical 5% 5-fluorouracil (5-FU) cream, intralesional methotrexate injections, intralesional bleomycin, intralesional 5-FU, and oral isotretinoin. A case series for intralesional methotrexate have been in smaller numbers of patients but noted regression in 83% to 100% of patients (1).
References
1. NIH, National Library of Medicine;Keratoacanthoma. Patrick M. Zito; Richard Scharf.
2. New England Journal of Medicine, 348;17, www.nejm.org april 24, 2003;Review article; Skin Cancers after Organ Transplantation Sylvie Euvrard, M.D., Jean Kanitakis, M.D., and Alain Claudy, M.D.
3. DermaNet; Keratoacanthoma Authors: Associate Professor Amanda Oakley, 1999; updated by Katrina Tan, Medical Student, Monash University, Melbourne, Australia; Dr Martin Keefe, Dermatologist, Christchurch, New Zealand. Copy edited by Gus Mitchell. November 2021.
Thank you Assafi but this workup planis for which condition is it ssc or keratoacanthoma?
Differential diagnosis
Keratoacanthoma
Basal cell carcinoma
Squamous cell carcinoma
Counselling on transplant
The patient needs to be counselled that there is a high risk of skin cancer post-transplantation. Also due to the poor HLA match the patient will require aggressive immunosuppressive therapy that also puts him at high risk of skin cancer post-transplant.
Patient needs further information that if the lesion after biopsy is found to be malignant then the transplant would be delayed, duration depending on the stage of the malignancy. However if it’s a keratoacanthoma which is a benign lesion then the transplant need not be delayed.
Further counselling on skin protective practises should be done like use of sunscreen with high SPF and protective clothing.
Workup strategy.
Should be in collaboration with the dermatology team.
Includes a detailed history and a thorough physical exam.
An excision biopsy of the lesion to confirm the diagnosis.
Imaging of the brain, chest and abdomen to rule out any metastasis.
References.
Prof Halawa lecture
Short but clear.
Squamous cell carcinoma
Basal cell carcinoma
First, confirm the diagnosis by biopsy.
Inform patient, that there is a possibility of recurrence of carcinoma post transplant.
Avoidence of sun specially mid day and use of sun protection cream.
Physical examination
Excisional biopsy
Surgical excision with clear margin
OpInion from dermatologists and oncologists
Chemotherapy
Differentials are;
Keratoacanthoma;
The keratinous surface characteristic more with keratoacanthoma.
In background KA is a common tumor of skin with two striking features like spontaneous regression and nosological position on the border between benignity and malignancy. it has familial association. other differential could be
Basal cell carcinoma
Squamous cell carcinoma.
Hypertrophic lichen planus,
Nodular Kaposi sarcoma.
Diagnosis is based on laboratory, histological and clinical findings.
Good history,
family history for genetic association, because it could be familial,
examination, specially for any lymphadenopathy,
deep excision biopsy up to subcutaneous tissue for histopathological examination,
whole body scan for any metastatic disease,
baseline investigations.
Regarding counselling; of the patient after confirmation of diagnosis, if KA, that has a good prognosis with spontaneous regression, can proceed for renal transplantation without waiting time.
Yes he should be monitored for recurrence despite there is very low risk of recurrence.
Self examination,
Avoid risk factors like prolong ultraviolet exposure,\
use of sunscreen >50%.
Post-transplantation immunosuppression modification like use of mTOR inhibitors after three months of transplantation.
Regarding treatment strategy;
Surgical excision as a first option, and after histological confirmation can try BRAF inhibitors (dabrafenib, encorafenib, vemurafenib.
Esthetic dermatologist opinion for,
intralesional chemotherapy,
topical and if needed systemic chemotherapy,
laser,
cryotherapy and photodynamic therapy.
References;
1.https://www.uptodate.com/contents/keratoacanthoma-epidemiology-risk-factors-and-diagnosis/abstract/1.
2.https://pubmed.ncbi.nlm.nih.gov/26853179/.
3.CJASN 16(8):p 1247-1255, August 2021. | DOI: 10.2215/CJN.00910121.
4.Schell AE, Russell MA, Park SS. Suggested excisional margins for cutaneous malignant lesions based on Mohs micrographic surgery. JAMA Facial Plast Surg. 2013;15(5):337-43.
5.Module 2 lecture.
Thankyou but a MDT is highly needed (dermatology opinion) so as not to miss another less benign lesion.
Actually I discussed with dermatologist and our differential diagnoses are squamous cell carcinoma and keratoacanthoma.
excisional biopsy is absolutely indicated to plan long term transplant management.
In case its cutaneous squamous cell carcinoma cSSC:
Risk of cSSC post transplant is 65 times more than non transplant patient.Patients with per-transplant cSSC is at high risk of recurrence.Therefor, the key point over here is to stratify the risk of recurrence according to certain criteria that include :
American joint committee on cancer AJCC which details features of severity of cSSC as follows:
tumors with zise more than 2 cm, depth more than 2 mm, perineural invasion, poor differentiation and site involve ear or lips in addition to diameter of the lesion with involvement of regional lymph nodes are high risk cSSC. CT of head and neck with PET scan might be indicated in high risk patients.
Each criterion is linked to a certain risk of metastasis and recurrence time frame from 2 to 5 years. Hence , in high risk cSSC its advised to wait for 5 years before proceeding to transplantation. In the contrary, low risk tumor there is a negligible risk, and can proceed with transplantation with waiting time.
Post transplant follow up:
is crucial as immune suppressants are an important risk factor for recurrence.
Keratoacanthoma:
References:
1)Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC).F.Zwald et al. American journal of transplantation,26 january 2016
Keratoacanthoma:
They are usually benign self-limiting tumor of the skin, caused by HPV , sun exposure and skin injury. Generally its not a contraindication for kidney transplantation with low risk of recurrence post excision.
Well done clear and well understood.
Well done
This is a Keratoacanthoma which is a benign condition
we need to diffrentaiate between SCC and KA
Keratoacanthoma (KA) is a benign keratinocytic neoplasm that spontaneously regresses after 3-6 months and shares features with well-differentiated squamous cell carcinoma (SCC). An increased incidence of both KA and non-melanoma skin tumor, including SCC, is seen among immunosuppressed, organ-transplant recipients.
will go for total excision with clear maigin and the patient should be counselled regading possibility of recurrence after RTX
This type of lesion has high koebnerization becuase of that the patient is always advised self examination for the area .
Detailed history
– Thorough physical examination to look for lesions elsewhere, lymphadenopathy
– Routine baseline investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion – first-line treatment with a solitary lesion
– Multidisciplinary approach
– Proceed with kidney transplantation once all the above issues have been addressed
VERYGOOD though exision biopsy should be the first step.
Diagnosis and Differential diagnosis:
Keratoacanthoma
Squamous cell carcinoma
Basal cell carcinoma
Patient counselling:
1. Excision of lesion with clear margin for diagnosis.
2. If KA then patient can proceed with transplantation.
3. Explain the risk of skin cancer post-transplant.
4. Avoidance of sun particularly at mid-day and sunscreen with SPF 50+ UVA 5*.
5. Self-examination by patient.
Management:
1. Complete physical examination
2. Biopsy of lesion (excision with clear margins.)
3. Consult with dermatologist/oncologist.
4. 5 FU, steroids, cryotherapy radiotherapy.
5. Monitor for recurrence.
6. Regular dermatology follow-up.
7. Reduction of immunosuppression post-transplant: mTOR based regime, avoidance of AZA, monitoring for rejection.
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
Diagnosis:
Solitary Keratoacanthoma(KA): characteristic features include (1)
Differential diagnosis pertaining to this case:
Workup strategy:
The management of KA is controversial due to:
The current standard treatment for KA is that of a well-differentiated cSCC, i.e., surgical excision with clear margins, although this may be excessive given the dubious metastatic propensity of KA. (4, 5)
Other successful, less invasive treatment options for KAs are summarized in Table 2. (2)
Counseling of the patient regarding kidney transplantation (6):
References:
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
Thank You
What is your differential diagnosis?
The lesion is a nodule which is dome-shaped and filled with keratinous material in the upper central part. The differential diagnosis for this lesion includes keratoacanthoma and squamous cell carcinoma. Other conditions which may present with such nodular lesions include nodular Basal Cell Carcinoma, Merkel cell carcinoma, molluscum contagiosum, or prurigo nodularis.
The presence of keratinous material is characteristic of keratoacanthoma. It can be differentiated from squamous cell carcinoma by pathological evaluation, 25% of keratoacanthoma undergo malignant transformation on areas exposed to sun especially in elderly patients.
Council this patient regarding kidney transplantation?
The lesion should be biopsied for a clear diagnosis, and if a localized lesion (keratoacanthoma or squamous cell carcinoma) is present, a kidney transplant can be performed immediately.
As and when the transplant is performed, the patient must be counseled regarding the potential of post-transplant skin cancer due to the use of immunosuppressive treatments.
The patient should also be counseled on the necessity of post-transplant behavioral interventions, such as avoiding direct sunlight during peak hours, wearing protective clothes and sunscreen, and doing self-examinations of the skin.
What is your workup strategy?
The lesion will require an excisional or deep incisional biopsy because a shave biopsy cannot distinguish it from squamous cell cancer.
Surgical excision with sufficient margins is the primary treatment, while medicinal intervention is reserved for inoperable instances.
In addition to intralesional methotrexate, 5-fluorouracil, bleomycin, and steroids, systemic retinoids were administered to patients with numerous lesions who did not qualify for surgical intervention.
Small lesions of keratoacanthoma react favorably to low-dose irradiation, laser therapy, and cryotherapy.
To prevent the recurrence of NMSC, long-term monitoring with thorough skin examinations every 6–12 months in a specialized clinic and behavioral education are needed.
Immunosuppression protocol should include m TORI instead of CNI and MMF due to its anticarcinogenic effect and low immunogenicity in the current case with low rejection risk.
I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
4. A 51-year-old CKD 5 patient on HD for the last 4 years secondary to IgAN presented to you in the transplant assessment clinic to consider suitability for kidney transplantation. His brother is willing to donate a kidney for him, 000 mismatch and no DSA. On routine examination this lesion was identified which developed 6 weeks ago
• What is your differential diagnosis?
– Keratoacanthoma
– Squamous cell carcinoma
– Nodular basal carcinoma
– Nodular kaposi sarcoma
– Amelanotic melanoma
– Hypertrophic lichen planus
– Metastatic skin lesion
– Foreign body reaction
– Verruca vulgaris
• Counsel this patient regarding kidney transplantation?
– Skin biopsy – for histological diagnosis
– Sun protection (sun avoidance, sun-protective clothing, use of sunscreen) and practicing skin self-examination – sun protection decreases incidence of skin malignancies (1)
– Risk of development of skin cancer following kidney transplantation
– Proper treatment to be initiated prior to kidney transplantation – treatment accelerates lesion resolution
– Post-transplant surveillance appointments with a dermatologist – to monitor for development of new lesions, locally recurrent lesions and metastatic disease
• What is your workup strategy?
– Detailed history
– Thorough physical examination to look for lesions elsewhere, lymphadenopathy
– Routine baseline investigations
– Skin biopsy for histopathologic examination
– Surgical excision of the lesion – first-line treatment with a solitary lesion
– Other treatment options – electrodesiccation and curettage, intralesional therapy (topical fluorouracil, methotrexate, radiation), topical therapy (2)
– Multidisciplinary approach – specific/ definitive treatment as guided by the dermatologist, surgeon and oncologist
– Proceed with kidney transplantation once all the above issues have been addressed
References
1. Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Current treatment options in oncology. 2012 Sep;13(3):354-76. PubMed PMID: 22592596. Epub 2012/05/18. eng.
2. Tran DC, Li S, Henry S, Wood DJ, Chang ALS. An 18-year retrospective study on the outcomes of keratoacanthomas with different treatment modalities at a single academic centre. The British journal of dermatology. 2017 Dec;177(6):1749-51. PubMed PMID: 27943239. Pubmed Central PMCID: PMC5813161. Epub 2016/12/13. eng.
Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499931/
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
1_The provided photo has hyperkeratotic Dome shaped skin lesion most probably is keratoacanthoma.
Other differential diagnosis includes:
_basal cell carcinoma.
_sqauamous cell carcinoma.
_malihnant melanoma.
2_ counseling here depends on confirmed diagnosis through skin biopsy (excisional biopsy ) as
_ benign keratoacanthoma will proceed to transplantation without waiting time after it’s surgical excision.
_ malignant lesions will require waiting time for 2 years before tranplantation.
_ sun protective behaviours as (avoid sun exposure 2 hours around midday , sunscreen with SPF UVB 50+ and 5 * protection against UVA) and sun protective clothes made of silk and cotton hats without holes are essential to minimize the risk of skin cancer which is common among renal tranpslant recipients especially older ones.
_ Minimization of IS protocol (avoid ATG as he is low immunological risk and use of CNI free protocols with avoidance of azathioprine) all help in minimization of cancer risk.
3_ work up startegy:
_ skin biopsy is 1 st step to differentiate benign and malignant lesions.
_ Screening for organ involvement and metastasis in case of confirmed malignant lesions is essential for staging and determine the cancer free interval required before proceeding to kidney transplantation.
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
51-year old, on MHD with IgA Nephropathy transplant candidate have well matched donor presented with rapidly developed dome-shaped nodule with central keratin filled lesion in sun exposed area of skin Differential diagnosis:
· Keratoacanthoma
· Nodular basal cell carcinoma
· Merkel cell carcinoma
· Prurigo nodule
· Giant molluscum contagiosum
· Nodular Kaposi sarcoma
· Deep fungal infection
Confirm the diagnosis by excisional skin biopsy.
Counseling:
To confirm diagnosis skin biopsy is needed.
Regarding the risk of occurrence of skin cancer post-transplant also very important.
Regarding the importance of behavioral interventions post-transplant in form of using measures avoiding direct sunlight in the peak hours, using protective clothing and sunscreen.
Frequent examination of skin.
Workup strategy:
Detailed history and the course of the development of lesion.
Clinical examination including all systems and examine the lesion and any lymph node enlargement.
Opinion from dermatologist and excisional skin biopsy.
Apart from skin lesion this is no problem of renal transplantation.
Reference: uptodate, lecture from Prof. Ahmad Halwa
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
What is your differential diagnosis?
dome-shaped nodule with a central keratin-filled crater
squamous cell carcinoma
Nodular basal cell carcinoma
Merkel cell carcinoma
Giant molluscum contagiosum
Deep fungal infection (eg, sporotrichosis)
Nodular Kaposi’s sarcoma
Cutaneous metastases
viral warts
incontinentia pigmenti
The combination of clinical assessment and biopsies are also useful for narrowing the differential diagnosis.
Council this patient regarding kidney transplantation?
After confirmation of the diagnosis exclusion of skin malignancy
We should inform such patients about the risk of developing malignancies after transplantation and mainly skin cancer.
We must inform the patient about the the relationship between KA and squamous cell carcinoma which still controversial .
While some authors perceive KA as a distinct follicular-based squamous proliferation that usually follows a benign clinical course ,others counter that KA is actually a clinical variant of cutaneous squamous cell carcinoma prone to spontaneous regression and occasional aggressive behavior and metastasis .
Dissolution of this controversy is hampered by the lack of histopathologic criteria that definitively differentiate KA and squamous cell carcinoma .
Reports documenting transformation of KA to squamous cell carcinoma also raise questions about whether these lesions represent a continuum of a single disease rather than distinct entities.
Counseling such patient with Keratoacanthoma and the need of avoiding sun exposure especially at peak hours ,applying sun block cream with high SPF,wearing sun protection clothes,avoiding trauma ,regular follow up and self examination.
Keratoacathoma considered as benign lesion and no waiting time is need pre transplant.
What is your workup strategy?
Dermatologist and oncologist must be involved in such cases
Clinical assessment — The clinical assessment of patients with lesions suspicious for KA should always involve obtaining a clear account of the lesion time course since a history of rapid growth within weeks favors this diagnosis. Patients should also be questioned regarding a history of prior similar lesions, sebaceous tumors, and visceral malignancies. These questions may help to identify the presence of a syndromic disorders.
The diagnosis of KA is based upon the combination of clinical and histopathologic findings, as the differentiation of KA from cutaneous squamous cell carcinoma based upon histopathologic examination is challenging.
Complete removal of the lesion via surgical excision extending into the subcutaneous fat is the preferred procedure for the diagnosis of lesions suspicious for KA. Alternatively, a deep shave biopsy (also known as a saucerization procedure) that removes the entire lesion and extends into the subcutaneous fat can be performed by clinicians experienced in this procedure.
reference
uptodate Keratoacanthoma: Epidemiology, risk factors, and diagnosis
I like your precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
DIFERENTIAL DIAGNOSIS.
DX;
Keratoacanthoma.
DDX;
SCC
BCC
KS
Non melanoma skin cancer.
Merkel cell Carcinoma
Giant Molluscum Contagiosum.
Possible risk factors in our case;
UV radiation exposure
Genetic
Previous trauma to the region.
Hemodialysis and CKD with associated chronic inflammatory state.
COUNSEL PT REGARDING KIDNEY TRANSPLANTATION.
1- Transplantation is associated wit immunosuppressive use to prevent ejection which increases risk of malignancies amongst them skin malignancy and the pt will have to be monitored post transplant with a MDT involving a dermatologist, oncologist and nephrologist.
2- Prior to transplantation we will need a skin biopsy to confirm the diagnosis in which case looks more like a keratoacanthoma and rule out other malignant possibilities like SCC and BCC. In the event it is keratoacanthoma, it is benign and after excision we will proceed with transplant without delay, If it turns out to be SCC, timing of transplantation will differ i.e, low risk-excise and proceed with transplant, High risk -excise and wait wor 2-5 yrs, Metastatic- No transplant.
3.Post transplant we will modify her immunosuppressive meds to include an MTOR inhibitor to decrease risk of skin cancer.
4.Post transplant he will have to avoid sun exposure, dress appropriately to minimize UVB and UVA exposure, Use sunscreen .
WORK UP STRATEGY.
-CT scan to assess spread.
-Lesion biopsy to get a definitive diagnosis
REFERENCES;
Prof Halawa lecture.
Keratoacanthoma; Management and Prognosis, Uptodate -2022
Tran DC et al; An 18 year old retrogressive study on outcomes of keratoacanthoma with different treatment modalities at a single academic centre;Br J Derm;2017;177(6);1749-1751
It is very well structured.
Ajay
Keratoacanthoma is it dome-shaped nodule with central keratin -filled in hair-bearing, sun-exposed skin in middle-aged and older adults and usually has spontaneous resolution over months
other differential diagnoses:
1-squamous cell carcinoma.
2-nodular basal cell carcinoma.
3-Merkel cell ca
4-prurigo nodule.
5-nodular Kaposi sarcoma.
to confirm the diagnosis by excisional skin biopsy to differentiate histological from squamous cell carcinoma.
regarding kidney transplant can proceed without delay although a skin biopsy is needed. Also should be counseled that 25% of keratoacanthoma undergo a malignant transformation in areas exposed to the sun, so have been on immunosuppression, exposure to ultraviolet sun rays, and the presence of keratoacanthoma put you in malignant disease risk.
use of sunscreen avoid sun exposure, frequent skin examination, and seek urgent medical advice if any skin lesion detected
history includes a detailed history and the course of the lesion and development
examination including all systems and examine the lesion and any lymph node enlargement.
dermatology referral and excisional skin biopsy.
Counsel the patient about the risk of malignancy the use of sunscreen and self-skin examination.
no need to wait to proceed for transplant in such this lesion(keratoacanthoma)
Reference uptodate
-1Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol 2016; 74:1220.
It is very well structured.
Ajay
· What is your differential diagnosis?
The index patient is an ESRD patient on hemodialysis, now presenting for kidney transplant evaluation (having a suitable donor with 000 mismatch and no DSA).
He is having a skin lesion which developed 6 weeks back.
The lesion is a nodule which is dome-shaped and filled with keratinous material in the upper central part. The differential diagnosis for this lesion includes keratoacanthoma and crateriform squamous cell carcinoma (1). Other conditions which may present with such nodular lesions include nodular Basal Cell Carcinoma, Merkel cell carcinoma, molluscum contagiosum, or prurigo nodularis.
The presence of keratinous material is characteristic of keratoacanthoma, which is a rapidly growing crater-shaped tumor arising from squamous epithelial cells (2). It can be differentiated from squamous cell carcinoma by histology: the crater is multilocular, the lips are perforated, and the cornified contents do not project out of the mouth of the crater (3). 25% of keratoacanthoma undergo malignant transformation, on areas exposed to sun especially in elderly patients.
· Council this patient regarding kidney transplantation?
The lesion should be biopsied for a definitive diagnosis and, in case of a localized lesion (keratoacanthoma or squamous cell carcinoma), a kidney transplant can be proceeded without any wait-period (4).
The patient needs to be counselled regarding the risk of occurrence of skin cancer post-transplant (as and when the transplant is performed) due to use of immunosuppressive medications (5).
The patient should also be counselled regarding the importance of behavioural interventions post-transplant in form of using measures for sun-protection like avoiding direct sunlight during peak hours, using protective clothing and sunscreen, as well as self-examination of skin (5).
· What is your workup strategy?
The strategy in the index case (keratoacanthoma) involves:
a) Detailed history (regarding onset of the lesion, any change in size/ colour, any discharge from the lesion etc)
b) Clinical examination, including skin examination, to look for any other lesion at any other site on body.
c) Dermatology consultation.
d) Investigations: The lesion should be biopsied for definitive diagnosis.
e) Once the diagnosis is established, treatment should be full thickness fusiform excision, or deep curettage. Intralesional chemotherapy involving intralesional methotrexate, 5-Fluorouracil, or bleomycin may be used prior to excision in large sized lesions (1).
f) No waiting period before transplant if the lesion, a non-melanoma skin cancer (NMSC), is excised completely and there is no metastasis (in the event of having malignant transformation).
g) Patient counselling: Regarding the disease, its treatment, and emphasis on post-transplant self-examination of skin as well as use of sun-protective measures (5).
References:
1. Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol. 2016 Jun;74(6):1220-33. doi: 10.1016/j.jaad.2015.11.033. Epub 2016 Feb 4. PMID: 26853179.
2. Berman H, Shimshak S, Reimer D, Brigham T, Hedges MS, Degesys C, Tolaymat L. Skin Cancer in Solid Organ Transplant Recipients: A Review for the Nondermatologist. Mayo Clin Proc. 2022 Dec;97(12):2355-2368. doi: 10.1016/j.mayocp.2022.07.004. Epub 2022 Nov 3. PMID: 36334939.
3. Sánchez Yus E, Simón P, Requena L, Ambrojo P, de Eusebio E. Solitary keratoacanthoma: a self-healing proliferation that frequently becomes malignant. Am J Dermatopathol. 2000 Aug;22(4):305-10. doi: 10.1097/00000372-200008000-00002. PMID: 10949454.
4. Chadban SJ, Ahn C, Axelrod DA, Foster BJ, Kasiske BL, Kher V, Kumar D, Oberbauer R, Pascual J, Pilmore HL, Rodrigue JR, Segev DL, Sheerin NS, Tinckam KJ, Wong G, Knoll GA. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation. 2020 Apr;104(4S1 Suppl 1):S11-S103. doi: 10.1097/TP.0000000000003136. PMID: 32301874.
5. Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol. 2017 Jun 2;18(1):174. doi: 10.1186/s12882-017-0553-2. PMID: 28571571; PMCID: PMC5455080.
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
*****What is differential diagnosis?
keratoacanthoma
squamous cell carcinoma-basal cell carcinoma and melanoma
Bowen’s disease
sebaceous cyst infected
cutaneous horn, actinic keratosis, wart
blastomycosis, chondrodermatitis nodularis helicis
*****Council patient regarding kidney transplantation?
+EXPLAIN TO PATIENT THE POSSIBILITY OF RECURRENCE OF IGA AFTER RENAL TRANSPLANT AND GRAFT LOSS 30%
+EXPLAIN TO PATIENT Variety OF DIAGNOSIS AND POSSIBILTIES OF BEING
HAVE Squamous cell carcinoma (SCC) AFTER EXCLUSION WORKUP AND INVESTIGATIONS DONE BY ONCOLOGY -DERMATOLOGY STAFF
+SCC in solid organ transplant recipients.
The risk of SCC increases over time, with the incidence increasing to 40% to 60% at 20 years after transplantation.
Cutaneous SCC is also associated with a more aggressive behavior and a higher risk of metastasis and death
+Although most SCCs will be successfully treated, some show a very aggressive clinical course. Currently, the distinction between the many SCCs cured without sequelae and the few SCCs with an aggressive course can be hard to make at diagnosis.
****What is workup strategy?
SKIN BIOPSY
PAN CT SCAN
ROUTINE LAB (CBC-RFT -COAGULATION PROFILE -HORMONAL PTH-VIROLOGY SCREEN )
Treating Squamous Cell Carcinoma of the SkinExcision.
Curettage and electrodesiccation
Mohs surgery
Radiation THERAPY
CryotherapyLymph node dissection
Immunotherapy: For advanced squamous cell cancers that can’t be cured with surgery or radiation therapy
Systemic chemotherapy and/or targeted therapy
References
Aasi SZ, Hong AM. Treatment and prognosis of low-risk cutaneous squamous cell carcinoma. UpToDate. 2019. Accessed at https://www.uptodate.com/contents/treatment-and-prognosis-of-low-risk-cutaneous-squamous-cell-carcinoma on June 4, 2019.
Christensen SR, Wilson LD, Leffell DJ. Chapter 90: Cancer of the Skin. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.
Martins RG. Systemic treatment of advanced cutaneous squamous and basal cell carcinomas. UpToDate. 2019. Accessed at https://www.uptodate.com/contents/systemic-treatment-of-advanced-cutaneous-squamous-and-basal-cell-carcinomas on June 4, 2019.
Harwood CA, Mesher D, McGregor JM, et al.. A surveillance model for skin cancer in organ transplant recipients: a 22-year prospective study in an ethnically diverse population. Am J Transplant. 2013;13(1):119-129. doi: 10.1111/j.1600-6143.2012.04292.x [PubMed] [CrossRef] [Google Scholar]
O’Reilly Zwald F, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management, part I: epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol. 2011;65(2):253-261. doi: 10.1016/j.jaad.2010.11.062 [PubMed] [CrossRef] [Google Scholar]
. Collett D, Mumford L, Banner NR, Neuberger J, Watson C. Comparison of the incidence of malignancy in recipients of different types of organ: a UK registry audit. Am J Transplant. 2010;10(8):1889-1896. doi: 10.1111/j.1600-6143.2010.03181.x [PubMed] [CrossRef] [Google Scholar]
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
▪︎51-year-old
▪︎CKD 5 patient due to IgAN
▪︎HD for 4 years
▪︎0 mismatch with his brother with no DSA.
▪︎Dome-shaped, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris.
● Differential diagnosis
keratoacanthoma
SCC.
Amelanotic melanoma
Nodular basal cell carcinoma
Common warts
Giant molluscum contagiosum
Metastatic deposit
Nodular prurigo.
● Council this patient regarding kidney transplantation?
After we confirm that this lesion is safe by biopsy we can proceed transplantation
But if the lesion is malignant we have to treat and wait for Period of time before we proceed transplantaion
What is your workup strategy?
▪︎A full-body skin exam
▪︎A family history of skin cancer.
▪︎C.T scan for excluding metastasis and lymph node envolvement
▪︎MDT ( dermatologist , oncologist ,
surgeon)
▪︎Viral serology
▪︎Biopsy
An excision biopsy and If the biopsy shows safety, we can continue transplant
But if it shows a malignant lesion we have to determine the staging , metastasis , and
risk factors for recurrence after tramsplantation so
▪︎We need NDT ( oncologist , dermatologist , surgeon )
▪︎As for Keratoacanthoma which is considered a variant of squamous cell carcinoma prone to spontaneous involution, but it may also rapidly grow and invade surrounding tissues.
▪︎An increased incidence of KA is seen among immunosuppressed patients
▪︎For this patient sun protection and daily sunscreen decreases incidence of skin cancer after transplantation
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
What is your differential diagnosis?
Likely diagnosis in the above scenario is Keratoacanthoma,which is a dome shaped ,skin colored papule and filled with keratin. Other differentials which may be considered include-Squamous cell carcinoma, Molluscum contagiosum, Merkel cell carcinoma, Amelanotic melanoma,Nodular basal cell and kapsoi carcinoma.
Council this patient regarding kidney transplantation.
Patient should be seen by dermatologist and surgeon , counseled about the benign nature of keratoacanthoma and that it usually resolves in 3- 6 months,but if not then surgical excision should be considered and then can proceed for transplantation with no waiting time.. It can mimic SCC and for that waiting time depends on risk assessment and distant spread. For nodal involvement –waiting time is 05 years, for high risk-02 years and for low risk-no waiting time. Patient should also be counseled to avoid exposure to sun, and chemical carcinogens .
What is your workup strategy
Detailed history and examination
Skin biopsy followed by excision .
Laboratory investigations and radiological tests like chest x ray .CT Chest and abdomen for nodal involvement and distant metastasis.
Genetic testing in few cases.
REFERENCES:
Zito PM, Scharf R. Keratoacanthoma. 2022 Aug 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.
I like that you have supported your arguments by uploading scientific evidence.
Ajay
Differential diagnosis:
1.Keratoacanthoma
2.Basal cell carcinoma
3.Squamous cell carcinoma
4.Molluscum contagiosum
Council this patient regarding kidney transplantation:
keratoacanthoma is usually of benign nature in immunocompetent patients. needs to go for excision biopsy in consultation with dermatologist and counsel the patient accordingly with Wait time of upto 2 years in remission. Needs to counsel the patient to be more vigilant for skin growth after transplant as skin cancer would tends to be more frequent in post transplant patients.
Workup strategy:
After confirming dx with tissue examination we needs to do,
1. Avoidance of sun exposure
2. Sun protection
3. Avoidance of tar, mineral oil and chemicals
4.self surveilance and regular examination by health care providers.
5.maintenance will triple regimen will CNI replacement by mTOR if no other contraindication.
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
-What is your differential diagnosis?
Mostly Keratoacanthoma representing an eruption of dome-shaped, skin-coloured papules
DD
Squamous cell carcinoma ,
Actinic Keratosis,
Cutaneous Horn ,
Dermatologic Manifestations of Metastatic Carcinomas ,
Verrucous Carcinoma
Molluscum Contagiosum
Muir-Torre Syndrome which is a cancer-associated genodermatosis with multiple sebaceous neoplasms
Prurigo Nodularis
Merkel Cell Carcinoma
Sporotrichosis which is a subacute or chronic infection due to the saprophytic dimorphic fungus Sporothrix schenckii.
-Council this patient regarding kidney transplantation?
A dermatologist need to be involved in this case.
Keratoacanthoma is a benign keratinocytic neoplasm that spontaneously regresses after 3–6 months and shares common features with well-differentiated squamous cell carcinoma
On the other hand having Keratoacanthoma pretransplant renders the patient more susceptible to develop NMSC post transplant in a more aggressive course compared to the general population therefore when his clinical status is stabilised and complete cure is confirmed , transplant can proceed with cautious follow up.
-What is your workup strategy?
Excisional or deep incisional biopsy of the lesion will be essential because shave biopsy cannot differentiate it from squamous cell carcinoma.
Surgical excision with adequate margins is the main therapy and medical intervention is only for inaccessible inoperable cases.
Systemic retinoids for cases with multiple lesion not fit for surgical intervention as well as Intralesional methotrexate, 5-fluorouracil, bleomycin, and steroids were used for cases not candidates for surgery.
Keratoacanthoma responds well to low dose of irradiation also laser and cryotherapy can be used in small lesions.
Long term monitoring with full skin examination every 6–12 months in a specialist clinic and behavioural education is essential to avoid development of subsequent NMSC.
Immunosuppression protocol need to include m TORI instead of CNI and MMF due to it’s anticarcinogenic effect and the low immunogenicity in the current case with low rejection risk render using m TOR I more suitable , meanwhile a study by Collett D .et al published that the incidence of NMSC in kidney transplant recipients was unaffected by azathioprine or MMF that was used at three months, nor by the use of tacrolimus or cyclosporine.
Reference
– Agudelo Higuita N. I .,Medscape2021
– Collett D. et al Comparison of the Incidence of Malignancyin Recipients of Different Types of Organ: A UK Registry Audit. American Journal of Transplantation 2010; 10: 1889–1896.
– Furudate S, Fujimura T, Kakizaki A, Kambayashi Y, Hashimoto A, Aiba S. Keratoacanthoma accompanied by multiple lung squamous cell carcinomas developing in a renal transplant recipient. Case Rep Dermatol. 2014;6(2):169-175.
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
What is your differential diagnosis?
A dome-shaped nodule with a central keratin-filled crater and its clinical course characterized by rapid initial growth.
1-Keratoacanthoma.
2-Squamous cell carcinoma .
3-Basal cell carcinoma.
Council this patient regarding kidney transplantation?
After dermatological consultation and excision biopsy according to the result will counsel our patient.
If Keratoacanthoma usually follows a benign clinical course and can proceed for kidney transplant after surgical excision and no wait time is necessary.
SCC should be evaluated and treated according to its stage and waiting time should be kept in mind such as high risk:(> 2cm, poorly differentiated, high risk location)— excision and wait for 2 years.
What is your workup strategy?
1-Prevention by education, awareness and observation. ( about risk or recurrence).
2-Annual self-examination and examination by a physician.
3-Patients should be instructed to avoid excessive sun exposure and to use sunblock.
4-dermatologic surveillance on a regular basis.
5-De novo sirolimus based protocol should be priority with history of skin cancer.
References:
1-Keratoacanthoma: Management and prognosis, UP TO DATE 2022.
2- Handbook of Kidney Transplantation, Gabriel M. Danovitch, MD.
3- Tran DC, Li S, Henry S, Wood DJ, Chang ALS. An 18-year retrospective study on the outcomes of keratoacanthomas with different treatment modalities at a single academic centre. Br J Dermatol. 2017;177(6):1749-1751. doi:10.1111/bjd.15225.
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
0
What is your differential diagnosis?
Melanoma
Keratoacanthoma
Basal cell carcinoma
squamous cell carcinoma
HPV
fungal infection
Council this patient regarding kidney transplantation?
The proposed donor is excellent, but there is a need for a closed diagnosis to define prognosis and treatment before proceeding with organ transplantation.
What is your workup strategy?
There is a need for joint follow-up with Dermatology and a biopsy of the lesion with free margins for diagnosis and possible treatment.
If the disease is localized (in situ) with free margins, an effective treatment may be considered in order to proceed with the transplant.
Some care is needed:
– Avoid sun exposure
– Wear clothing with UVA/UVB protection
– Investigation of infectious diseases (HIV, HPV, HSV8)
– Proceed with the appropriate treatment discussed with the multidisciplinary team and biopsy results and laboratory tests at hand
– Avoid induction with rATG and immunosuppression schemes with calcineurin inhibitors when proceeding with transplantation
I can appreciate that you are thinking of carcinoma as a possibility, however, this picture is typical of keratoacanthoma. I wish you could provide evidence to support your arguments.
Ajay
Thank you for the knowledge, Professor.
Sequmous cell carcinoma
Melanoma
Basal cell carcinoma
Incidence of malignancy post transplant is high especially skin cancer and squamous cell carcinoma is most common skin cancer in kidney transplant patients which account 30-65% of malignancy in kidney transplant due to use of immunosuppressive agents and low immunity lead to risk of infection
Risk factors for skin cancer increase in kidney transplant and use of immunosuppressive drug and previous history of skin cancer before transplant and genetic factors, also exposure to infection with HHV and HPV.
Consider skin biopsy with annual screening by dermatologist and wearing protective clothes like silk and cotton material.
sunscreen lotion.
History and examination is important to exclude previous history of malignancy before transplant and family history of malignancy in case of genetic related factors.
Serology of HIV and HHV
skin biopsy and dermatologist opinion
surgical excision of tumor and histopathology for staging.
Free Calcinurine inhibitors therapy and dose reduction of immunosuppressive therapy.
use of mTOR inhibitors.
treat cancer by chemotherapy as ordered by oncologist
eradication of HPV infection if present.
Avoid sun exposure
Reference:
Henryk Witmanowski, Małgorzata Lewandowska; et al. The development of squamous cell carcinoma in a patient after kidney transplantation: a case report; Postepy Dermatol Alergol. 2013 Feb; 30(1): 65–71.
Published online 2013 Feb 20.
Is it really a carcinoma?
It will be good to type in bold or underline when you write heading or sub-heading.
Ajay
1- keratoacanthoma
2- SCC
If keratoacanthoma: it is a benign lesion and no need to wait after excision
If SCC: management and waiting time to transplantation will depend on the stage:
low risk : excision and no need to wait
high risk:(> 2cm, poorly differentiated, high risk location)— excision and wait for 2
years
Peri-neural invasion: 2-3 year waiting
nodal metastasis: 5 years wait after proper treatment (excision and LN excision
and XRT) and no evidence of recurrence
distant metastasis: not candidate for transplant
1- Proper diagnosis of the lesion first:
proper hx, full examination including lip, scalp and ears
excisional biopsy and proper interpretation of the pathological desciption
CT scan +/- PET scan to exclude metastasis
2- Treatment of the lesion ( in cooperation with oncologist)
3- According to the result: follow the proposed waiting time
4- If no recurrence: prepare for transplantation
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
0
Sugiura K, Sugiura M, Uchida K. KunioMorozumi. A Keratoacanthoma With Squamous Cell Carcinoma Under Immunosuppressive Therapy After Renal Transplantation. Int J Clin Dermatol Res. 2022 Mar 26;10(1):275-7.
What is your differential diagnosis?
The picture shows well-circumscribed dome shaped nodule, with a keratotic core enlarged over 6 weeks.
DD:
· Keratoacanthomas ( the likely diagnosis)
· well-differentiated SCC.
· Nodular BCC
· Giant molluscum contagiosum
· Metastatic deposit
· Nodular prurigo.
For definitive diagnosis an excisional biopsy is required.
Keratoacanthoma is characterized by initial rapid growth followed by a period of variable tumor stability and spontaneous regression.
It is divided into different subtypes with different presentations. Subtypes include solitary KA, subungual KA, mucosal KA, giant KA, KA centrifugum marginatum, generalized eruptive KA of Grzybowski, and multiple KA Ferguson-Smith syndrome.
Although recognized as benign, KA shares histopathological features with squamous cell carcinoma (SCC) requiring treatment.
Suggested risk factors:
· Fair-skin color the risk decreases with increasing skin pigmentation.
· UV radiation
· Exposure to chemical carcinogens
· Immunosuppression
· Genetic predisposition including mutations of p53 or H-Ras
· Viral exposure including HPV.
· Recent trauma or surgery to the location.
The relationship between KA and squamous cell carcinoma is controversial
While some perceive KA as a distinct follicular-based squamous proliferation that usually follows a benign clinical course, others counter that KA is actually a clinical variant of cutaneous squamous cell carcinoma prone to spontaneous regression and occasional aggressive behavior and metastasis
What is your workup strategy?
-Detailed history about the progression and course of the lesion, the presence of other lesions, drug exposure.
-Examination looking for other lesions, LN.
-Dermatologist and oncologist opinion.
-Excisional skin biopsy and histological diagnosis for definitive diagnosis.
-For patients with subungual keratoacanthomas, radiographic imaging is necessary of the affected digit in order to monitor for osteolysis.
-If SCC was suspected needs to search for mets.
-Treatment according to biopsy finding.
-Regular skin surveillance
-Avoid mid-day sun exposure and use of sun protection.
Treatment of KA:
· Excision with 4 mm margins (treatment of choice).
· Electrodessication and curettage for lesions less than 2 cm on the extremities
· Nonsurgical interventions: topical 5% imiquimod cream, topical 5% 5-fluorouracil (5-FU) cream, intralesional methotrexate injections, intralesional bleomycin, intralesional 5-FU, and oral isotretinoin. Of the intralesional therapy, 5-FU and methotrexate have the most data.
Council this patient regarding kidney transplantation?
Patient need to be aware about this suspicious lesion and the need for biopsy for definitive diagnosis.
If KA is confirmed it is recognized as benign lesion, and spontaneous regression is expected. However, treatment is recommended due to the relation to SCC.
It has an excellent prognosis following surgical excision.
Generally, patients will need to be followed for the development of new primary skin cancers.
Metastases are rare, but there are reports of this in addition to perineural spread in literature.
References:
-Zito PM, Scharf R. Keratoacanthoma. [Updated 2022 Aug 25]. In: StatPearls.
– UpToDate
– Hand book of kidney transplant 6th edition
I can appreciate that you are thinking of SCC as second possibility, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
0
Differential diagnosis:
1-Sequmous cell carcinoma
2- Keratoacanthoma
Keratoacanthoma:
It is round firm ,usually pink or flesh colored growths and have a central crater that is scaly or crusted some of it may be a form of squamous cell carcinoma .
Appear on sun exposure area
Diagnosis :
Biopsy
Treatment :
Ø Surgical excision
Ø Methotrxate
Ø 5-fluorouracil
Prevention:
1- Avoid sun exposure
2- Wearning protective clothing
3- Sun screen
Counseling :
· Keratacanthoma has an excellent prognosis following surgical treatment
· Metastases are rare
· Patient need follow up for the development of new skin cancer
· Patient need follow up with physician and dermatologist
· Good sun protection is vital to preventing certain damage
· Long term administration of immunosuppressive agent associated with increase risk of non melanoma skin cancer
workup strategy?:
Skin biopsy
Surgical excision
Laboratory investigation and imaging to detect any metastases chest x ray .CT Chest and abdomen
Treatment of the patient till cure from the disease
Regular follow up
References :
1-Engels EA, Pfeiffer RM, Fraumeni JF Jr, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011;32
2- hand book of kidney transplant 6th edition
I can appreciate that you are thinking of SCC, however, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
Keratoacanthomas
Merkel cell carcinoma.
Squamous cell carcinoma.
Amelanotic melanoma.
Dermatofibrosarcoma protuberans.
Actinic keratosis.
Nodular Basal cell carcinoma.
Common warts.
Giant molluscum contagiosum.
Nodular prurigo.
Metastatic deposit.
Solitary Keratoacanthomas (KA):
Solitary, rapidly growing nodule on sun-exposed skin of the face and upper limbs. Keratoacanthomas are sharply demarcated, firm, erythematous or skin-colored, with a classic central hyperkeratotic plug and an even shoulders.(1)
Most Keratoacanthomas are treated surgically. Although they may resolve spontaneously, it is usually prudent to excise them, unless there is clear evidence that regression is in progress.
It is usually best to assume a KA-like lesion is an SCC and to manage accordingly in line with local or national guidance, until proven otherwise.
Council this patient regarding kidney transplantation:
The is a risk for non-melanoma skin cancer in renal transplant recipients are related to the dosage and duration of administration of immunosuppression. SCC, one of the major histological types of non-melanoma skin cancer, exhibits more aggressive biological and clinical courses in RTRs, with higher rates of recurrence and mortality than in the general population (2).
Other reports also suggested that immunosuppressed patients, such as RTRs, show a higher incidence of KA.
Excisional biopsy with dermatologist.
CXR.
CT scan role out internal organ malignancy
Prevention:.
· Avoid the sun during peak hours.
· Shield your skin and eyes. .
· Apply sunscreen liberally and often. .
· Watch for changes.
· Stop smoking.
References:
1- Amanda Oakley, Martin Keefe. Keratoacanthoma.Derma net. November
2-Kasiske BL, Snyder JJ, Gilbertson DT, Wang C: Cancer after kidney transplantation in the United States. Am J Transplant 2004; 4:905–913.
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
What is your differential diagnosis?
This is nodular dome shape hyperkeratotic skin lesion developed within 6 weeks on back ground of ESRD on dialysis, primary disease IgA nephropathy
Actinic keratoses (AKs), or solar keratoses, are keratotic or scaling macules, papules, or plaques resulting from the intraepidermal proliferation of atypical keratinocytes in response to prolonged exposure to ultraviolet radiation AKs are an alarm because the majority of cutaneous squamous cell carcinomas (cSCCs) arise from pre-existing AKs, and AKs that will progress to SCC cannot be distinguished from AKs that will spontaneously resolve or persist. With his back ground we should rule out a biologically aggressive lesions like invasive SCC.
DDX from other pre-malignant skin lesions and chronic inflammatory skin lesions like
• Nummular eczema or dermatitis, erythematous vesiculation, and crusting lesions
• Inflamed seborrheic keratosis
• Prugio nodularis which looks like A close-up of a pink, crusted nodule.
Council this patient regarding kidney transplantation?
need dermatology specialty referral and examination for another lesions, exceptional surgical biopsy with histopathological diagnosis and staging to rule out the possibility of local invasive SCC.
Preventive measures with regular sunblock use, close follow-up after transplantation and self-skin exanimation including lymph node examination.
What is your workup strategy?
As this patient candidate for kidney transplant this skin lesion need to referred to dermatology specialty for further work up including dermoscopic examination and surgical biopsy to rule out the possibility of local invasive cutaneous SCC, also through examination for another lesions and LAP. HPV viral screen
Depends on the numbers of the lesions, single or multiple also patient tolerance and preferences, cost, and nature of the lesions
lesion-directed treatments, such as Liquid nitrogen cryotherapy and surgical procedures, are the primary approach for isolated lesion and of certain diagnosis of AKs, with less cost and better cosmetic results, however Cryotherapy is contraindicated for lesions that need pathologic examination to exclude malignancy and in patients with cold urticaria or cryoglobulinemia.
Combination of cryosurgery and topical medication have been tested in few RCTS and its more effective compared to cryosurgery alone (2).
Treatment options
1.Destructive therapies (cryotherapy, surgery, dermabrasion, photodynamic therapy [PDT])
2.Topical medications (, topical fluorouracil, imiquimod, topical tirbanibulin, diclofenac),
3.Field ablation treatments (, chemical peels, laser resurfacing).
The last two options preferred for multiple AK lesions.
4. photodynamic therapy like Photosensitizers and light sources
5. Daylight photodynamic therapy
Follow UP and Monitoring after transplant
Education and teaching the patients about the chronic nature of AKS and the need of continuing care and treatment close follow-up and good compliance with topical long-term therapy which is not free from local inflammatory side effects that increased the risk of treatment intolerance and nonadherence
Ongoing monitoring for lesion recurrence and cutaneous malignancies at 6 to 12 months post-treatment is required for all patients with a history of actinic keratoses (AKs).
In one recent study with secondary analysis of a randomized clinical trial, risk of invasive cSCC was highest in patients with Olsen grade III AK and was significantly increased in patients who received additional treatment. These patients should be closely followed up after treatment (3).
References:
1. Current issues in the management of actinic keratosis.Ceilley RI, Jorizzo JL J Am Acad Dermatol. 2013 Jan;68(1 Suppl 1):S28-38.
2.Cryosurgery combined with topical interventions for actinic keratosis: a systematic review and meta-analysis.Heppt MV, Steeb T, Ruzicka T, Berking C Br J Dermatol. 2019;180(4):740. Epub 2018 Dec 27.
3. Risk of Invasive Cutaneous Squamous Cell Carcinoma After Different Treatments for Actinic Keratosis: A Secondary Analysis of a Randomized Clinical Trial.Ahmady S, Jansen MHE, Nelemans PJ, Kessels JPHM, Arits AHMM, de Rooij MJM, Essers BAB, Quaedvlieg PJF, Kelleners-Smeets NWJ, Mosterd K JAMA Dermatol. 2022;158(6):634.
What is your differential diagnosis?
This is a dome shaped raised lesion with central keratin and without much melanin. There is some ulceration also. Most likely it is keratocanthoma .
The other possibilities include:
Squamous cell carcinoma
Amelanotic melanoma
Molluscum contagiosum
Prurigo nodularis
Metastatic lesion to the skin
Merkel cell carcinoma
Nodular basal cell carcinoma
Ulcerative basal cell carcinoma
Nodular Kaposi sarcoma
Hypertrophic lichen planus
Deep fungal infection
Atypical mycobacterial infection
Foreign body reaction
Verruca vulgaris.
Council this patient regarding kidney transplantation?
The management will depend on histology of excision biopsy specimen. Most of benign lesions and BCC or melanoma in situ are not a contraindication to transplantation . I will involve dermatologist and skin oncologist and decision to proceed with transplantation will depend disease free period.
I will counsel the patient about disease and need for disease free period if required.
I will advise him about avoiding sun exposure , especially mid day and use sun screen.
What is your workup strategy?
I will assess him in detail including any lymph node involvement. Assessment of systemic involvement in case of malignant lesion. The case will have to be discussed and Skin MDT. Keratocanthoma can be treated with imiquimod.
Following that it should be discussed in Transplant MDT to make decision about transplant timing.
F. J. Moloney, H. Comber, P. O’Lorcain, P. O’Kelly, P. J. Conlon, and G. M. Murphy, “A population-based study of skin cancer incidence and prevalence in renal transplant recipients,” British Journal of Dermatology, vol. 154, no. 3, pp. 498–504, 2006.
Upto Date
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
Thank you Prof.
What is your differential diagnosis?
It is Keratoacanthoma most likely due to rapid growth dome shaped with central keratin crater usually occur in fair sun exposed skin, hair bearing skin, HPV has been identified in some such a lesion.
Squamous cell carcinoma – some classify keratoacanthoma as a type of it.
Nodular basal cell carcinoma.
Merkel cell carcinoma.
Prurigo nodules.
Giant molluscum contagiosum.
Nodular Kaposi sarcoma.
Deep fungal infection.
Cutaneous metastasis.
Council this patient regarding kidney transplantation?
After the diagnosis established the issue of cure rate should be discussed with dermatologist as well as the disease free period recommended before doing transplantation.
The pretransplant skin tumors are not necessarily a contraindication to organ transplant, but must be treated, and we will decide with the oncologist and dermatologist either to proceed or not.
The patient should know that there is a higher risk of developing a skin cancer after organ transplant. So he should be disease free before transplantation as recommended by the oncologist.
I’ll council him on sun exposure protective measures (behavioral and pharmacological) as it is a well-known etiology of such cancers.
What is your workup strategy?
Full history and examination, if there is another lesions and evaluation of adjacent lymphnodes, full chemistry and blood tests, evaluation for other organ involvement.
Refer the patient to dermatologist and oncologist for biopsy, diagnosis and treatment, either surgical, radiation or topical chemotherapy.
Multidisciplinary team decision to proceed with transplantation or not.
References:
– UpToDate- Keratoacanthoma, epidemiology, risk factors and diagnosis.
– Imko-Walczuk B, Kiełbowicz M, Dębska-Ślizień A, Rutkowski B. Skin Cancers as Contraindication to Organ Transplantation. Transplant Proc. 2015 Jul-Aug;47(6):1547-52. doi: 10.1016/j.transproceed.2015.03.047. PMID: 26293011.
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
History:
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What is your differential diagnosis?
Differential diagnosis of a lesion consistent with
Council this patient regarding kidney transplantation/workup strategy?
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Reference
I can appreciate that you are thinking of a range of cancers, however, this picture is typical of keratoacanthoma that you mention in DD. I like your evidence to support your arguments.
Ajay
Thak you alot Prof.Sharma
This is a pseudo skin cancer named KA (Keratoacanthoma), and it is a special destructive skin lesion, as an isolated nodule.
Usually occurs on the face and it looks like squamous cell carcinoma, and some clinicians and pathologists named it SCC-KA type so:
Differential diagnosis:
Keratoacanthoma:
Counseling regarding kidney transplantation:
Workup:
References:
Cancer in kidney transplant recipients Eric Au 1, Germaine Wong 1 2, Jeremy R Chapman 3
Affiliations expand
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
A 51-year-old CKD 5 patient on HD for the last 4 going for transplant develop skin lesion with differential diagnosis
Ulcerative basal cell carcinoma
Nodular Kaposi sarcoma
Non melanoma skin cancer
Molluscum contagiosum
Hemangioma
Infected lipoma
The rate of malignancy in renal transplant is higher than normal papulation some cancer like nonmelanoma skin cancer, lymphoma have high incidence compared to breast and prostatic cancer.
Most of cancer have waiting time less than 2 years but some cancer have no waiting time like incidental renal and in situ carcinoma etc.
But for most of cancer a period of 2-5 years is recommended and this period may be longer in some cancers like nodular breast, melanoma and colorectal cancers
Counselling
Regarding the reoccurrence and graft loss,
Immunosuppression medicine may worsen this condition
It is better to avoid in the presences of current condition and need to be investigate and treat before transplant surgery.
Screening for cancer is very important as screening measure can enable to prevent or early detection of cancer that include self examination, avoidance of smoking and sun exposure.
Also need to council regarding infection that may end up malignancy and screening of infection is paramount important before surgery.
1 Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341: 1725–1730.
2. Campbell S, Pilmore H, Gracey D, et al. KHA-CARI guideline: recipient assessment for transplantation. Nephrology (Carlton). 2013;18(6):455–462.
3. Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplantation candidates: Clinical practice guidelines. Am J Transplant. 2001;1(suppl 2):3–95.
4. Knoll G, Cockfield S, Blydt-Hansen T, et al. Canadian Society of Transplantation: Consensus guidelines on eligibility for kidney transplantation. CMAJ. 2005;173:S1–S25.
5.Education and counseling of renal transplant recipients Claudio Ponticelli 1, Giorgio Graziani 10.5301/jn.5000227
1.Keratoacanthoma, CEM by Patrick M. Zito & Richard Scharf 2.De Novo malignancies after kidney transplanation, David Al-Adra et a.al
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
Thanks, prof
This rapid onset skin lesion, with a dome-shaped keratin-filled crater consist with keratoacanthoma.
Keratoacanthoma (KA) is a benign keratinocytic neoplasm that spontaneously regresses after 3–6 months and shares features with well-differentiated squamous cell carcinoma (SCC).
Relationship between kerato and squamous cell carcinoma still controversial.
A longstanding debate over the classification of KA as benign resolving tumor versus a variant of cutaneous squamous cell carcinoma.
First we have to put the right diagnosis.
KA usually resolve after 3-6 mothns.
If the lesion doesn’t resolve surgical resection to confirm the diagnosis.
Avoid sun exposure is important.
As work team a dermatologist should be consulting.
A biopsy may be performed to evaluate with a histological exam. The best diagnostic test is an excisional biopsy .
The presence of an epithelial lip and sharp outline between tumor and stroma diagnos KA.
In contrast the prescene of ulceration,mitosis,and pleomorphism or anaplasia favored squamous cell carcinoma.
Genetic test maybe needed in some cases.
Refference:
1-Ko CJ.Keratoacanthoma: facts and controversies. Clin Dermatol 2010;28:254.
2-
Yes, this picture is typical of keratoacanthoma. I like your evidence to support your arguments.
Ajay
Dear All
None of the answers is correct regarding the differential diagnosis.
-Skin Wart
-infected sebaceous cyst
-malignant skin lesion(SCC, BCC, or melanoma)
-acquired perforating dermatosis
Transplantation is not possible if there is active malignancy, with the exception of nonmelanoma skin malignancies.
For the majority of cancer survivors, we and the majority of clinical guidelines suggest a two- to five-year recurrence-free period.
This is done to reduce the possibility of recurrence since immunosuppressive drugs promote the growth of micrometastases. The chance of recurrence varies significantly depending on the kind of tumor, which affects the recommendations for individuals who already have malignancies. It is advised that you have a conversation with a multidisciplinary team that includes an oncologist.
Based on the features of the patient and the tumor, the recommended cancer-free period before to transplantation should be tailored to the individual.
The patient has to be informed of the possibility of a recurrence after transplantation.
What is your workup strategy?
-send for HPV PCR
Reference :
Let us see how the discussion in this thread evolves.
DD of skin lesion:
1- skin infection either local or systemic
2-skin cancer
3-drug induced skin lesion
counselling of the patient as regard renal transplantation:
the patient should be informed about caner rate post transplant and its incidence especially in the presence of this lesion and the importance of knowing the real diagnosis of this lesion , also counselling about sun exposure and use of sunscreen cream, and protective clothes.
workup strategy:
1- dermatology consultation
2-excisional biopsy for early diagnosis of precancerous lesion
Thomas Stasko, Allison M Hanlon. Prevention and management of skin cancer in solid organ transplant recipients. UpToDate.2021.
What is your differential diagnosis?
Council this patient regarding kidney transplantation?
What is your workup strategy?
I like one of the possible differentials that you have mentioned Dr Omar.
Is it really a carcinoma?
Ajay
What is your differential diagnosis?
Council this patient regarding kidney transplantation?
What is your workup strategy?
1- Dermatology consultation and assessment for the need of biopsy in the current case, and setting a definite diagnosis
2- Patient should receive treatment according to the diagnosis of the lesion
3- Counseling the patient about screening, wait time and the use of sunscreen
4- Post-transplant screening should be done by the patient every month and by expert dermatologist every year.
5- Wait time before transplantation (3)
6- Patient should avoid sun exposure especially in the mid-day and the use of sun screen with high protection (5 stars 50+ SPF) is recommended especially in the early period after transplantation (using of triple therapy)
7- Reassuring the patient since the patient will receive minimal immunosuppression in the form of basiliximab induction and maintenance triple therapy including CNI, MMF, and corticosteroids for the first 3-6 months then we can switch to dual therapy including MMF and steroids. So we will stop CNI which is associated with higher incidence of skin cancer (4), and keep MMF which is associated with lower incidence of skin cancer when compared to azathioprine.
REFERANCES
1. Park CK, Fung K, Austin PC, et al. Incidence and Risk Factors of Keratinocyte Carcinoma After First Solid Organ Transplant in Ontario, Canada. JAMA Dermatol 2019; 155:1041.
2. Chockalingam R, Downing C, Tyring SK. Cutaneous Squamous Cell Carcinomas in Organ Transplant Recipients. J Clin Med 2015; 4:1229.
3. Zwald F, Leitenberger J, Zeitouni N, et al. Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC). Am J Transplant 2016; 16:407.
4. Kuschal C, Thoms KM, Boeckmann L, et al. Cyclosporin A inhibits nucleotide excision repair via downregulation of the xeroderma pigmentosum group A and G proteins, which is mediated by calcineurin inhibition. Exp Dermatol 2011; 20:795.
I like one of the possible differentials that you have mentioned Dr Yusuf
Is it really a carcinoma?
Ajay
My DD?
•Squamous cell carcinoma should be differentiated from melanoma and basal cell carcinoma, Keratoacanthoma, Dermatofibroma, dermatofibrosarcoma, Sebaceous hyperplasia, …..
•It accounts for 20% of all non-melanomatous tumors and is fairly invasive contrary to its counterpart, basal cell carcinoma.
Petter G, Haustein UF (2000)
•Cutaneous squamous cell carcinoma=> Patch, Plaque, Papule, Nodule=> hyperkeratotic=> sun-exposed areas
Petter G, Haustein UF (2000)
•Potential risk factors for skin cancer after a transplant operation are:
•solar radiation,
•immunosuppressive therapy,
•genetic factors,
•infection with HPV
•and skin cancer transmission before transplantation.
Henryk W, 2013
•Immunosuppressive therapy is undoubtedly one of the most important risk factors for cancer in organ transplant recipients.
Berg D, Am Acad Dermatol. 2002
•Council this patient regarding kidney transplantation?
•Predictors of post tx. Skin cancer
•Age > 50 y is a risk factor
•Pre-tx skin cancer
•Post tx should do?
•-regular use broad spectrum sun screen
•Sun protective clothing
•Avoid mid day sun exposure
•Regular self exam
What is your workup strategy?
•Viral screen HPV
•Pre-malignant conditions APCKD
•Aggressive screen for skin cancer
•UVR B, A Exposue
•Immunosuppression
Prevention and treatment
•avoid exposure to UV radiation and use sun protection
•treatment of precancerous lesions
•treatment of HPV infection
Treatment :
•Surgical
•Reduction IS
•Conversion of CNI to SIROLIMUS
•TOPICAL 5 FU
•Avoid midday sun
•Broad spectrum sunscreen
Petter G, Haustein UF (2000)Dreno B, Dial Transplant. 2003
Hardwood CA, Med Virol. 2000
Kwiek B, Schwartz RA (2016).
I like one of the possible differentials that you have mentioned Dr Abdelhamid.
Is it really a carcinoma?
You do not need to type in bold unless it is a heading or sub-heading.
Ajay