News & Events
5. A 46-year-old CKD 5 patient who was on HD for 4 years secondary to unknown aetiology presented to you in the transplant clinic 3 years after his transplantation with this lesion on the right side of his neck (see below). He is currently on tacrolimus-based immunosuppression with excellent kidney function.
- What is your differential diagnosis?
- Briefly outline his management
149 Comments
Leave a Reply
You must be logged in to post a comment.
Copyright © 2024 World Kidney Academy. All Rights Reserved. ICOM
What is your differential diagnosis?
Briefly outline his management
Reference:
Collins, L.; Asfour, L.; Stephany, M.; Lear, J.T.; Stasko, T. (2019). Management of Non-melanoma Skin Cancer in Transplant Recipients. Clinical Oncology, 31(11), 779–788.
Differential diagnosis
Squamous cell carcinoma
Basal cell carcinoma
History and examination
Skin biopsy
Metastasis workup ( CT chest, abdomen, pelvis )
Management by surgical excision
Reduction of immunosuppressive drugs
Switch CNI to mTor inhibitors
Non surgical lesion can be treated by topical fluorouracil
Regular self examination
Protective sun exposure measures
This lesion could be basal cell carcinoma or SCC, specially in sun exposure area.
the management need to reduce IS and change CNI to mTOR group
add to some prevention measures to protect the skin from the sun exposure
What is your differential diagnosis?
Differential diagnosis of a small nodular lesion over the neck in sun-exposed region after 3 years ost transplant are: Squamous cell carcinoma , Basal Cell carcinoma, amelanotic melanoma or Merkel cell carcinoma.
Briefly outline his management:
Multidisciplinary team should be involved including dermatologist, transplant physician and oncologist. Diagnosis can be confirmed with the help of skin lesion biopsy .
General measures will be to counsel the patient to avoid sun exposure and do self examination. routinely. Reduction of immunosuppression and switching of Tacrolimus to mTORi .
Specific treatment – Surgery -Curettage, cryosurgery, wide local excision, Mohs micrographic surgery
Topical therapy- Topical 5-fluorouracil, Imiquimod, Tazarotene:
Chemotherapy in metastatic or aggressive disease-Hedgehog pathway inhibitors (HHIs):Vismodegib (Erivedge), Sonidegib (Odomzo)
REFERENCES:
1- 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.
Organ transplant recipients (OTRs) are at greater risk of basal cell carcinomas (BCCs) than non-OTRs, but histopathologic differences between BCCs in OTRs and the general population are largely unknown.
We compared clinicopathologic features of BCCs in OTRs vs the general population in Queensland, Australia. Details of BCC tumors (site, size, level of invasion, subtype, biopsy procedure) were collected from histopathology reports in two prospective skin cancer studies, one in OTRs and one general-population-based.
Among head/neck BCCs, OTRs were more likely than general population cases to have BCCs on scalp/ear than on face/lip/neck (PR = 1.5, 95%CI 1.2–1.8). Although aggressive subtypes were less common among higher risk BCCs in OTRs, BCCs invading beyond the dermis were almost twice as prevalent in OTRs (PR = 1.8, 95% CI 1.3–2.6) than the general population.
https://link.springer.com/article/10.1007/s00403-022-02403-6
What is your differential diagnosis?
Basal cell carcinoma
Squamous cell carcinoma
Merkel cell carcinoma
Briefly outline his management
The assessment of risk for lesion recurrence is the most important step in the choice of treatment for BCC. It involves a detailed history (lesion history, use of immunosuppressive medications, presence of comorbidities), a physical examination, and a biopsy of the suspicious lesion.Surgical excision is generally recommended as first-line therapy for BCC at low risk of recurrence .For primary, nodular or superficial BCC <20 mm in diameter located on the trunk and extremities (excluding genitalia, pretibia, hands, and feet), standard surgical excision with postoperative margin evaluation as first-line therapy . Margins of 4 to 5 mm are thought to be appropriate
This lesion could be basal cell carcinoma then squamous cell carcinoma, these are the most common diagnoses. Confirmation by biopsy from the lesion is mandatory to offer the best treatment policy according to staging and differentiation as well.
The management ought to involve a multidisciplinary team including dermatologists, oncologists and transplant specialists. Tailoring of immunosuppression is mandatory with better switching to mTORi.
Excision of the lesion may be needed. Excluding metastasis is also required.
What is your differential diagnosis?
Briefly outline his management
What is your differential diagnosis?
This is a small papular lesion in the neck ( sun exposed area) with no ulceration, hyperpigmentation or extra keratin
DD:
· BCC (more likely in sun exposed area) with waxy appearance, raised border, no ulceration or erosion, Telangiectasia’s over the surface
· SCC
o Briefly outline his management
Full history including history of previous skin cancer and clinical examination including LNs and assess for metastatic spread of disease.
o MDT (dermatology and oncology involvement) with surgical excisional or deep incisional biopsy histopathology for definitive diagnosis and to guide for the management plan.
General measures:
· Proper education about the increased risk of skin cancer and the importance of self-examination and annual dermatology review with early reporting of any suspicious skin lesions
· Tailor immunosuppression and switch from tacrolimus to mTOR (sirolimus) with the close monitoring of graft function.
· Advice to avoid direct sun exposure and used protective sunscreen and clothes.
Specific measures:
Basal cell carcinoma: According to risk of recurrence
Low risk of recurrence:
· surgical excision and postoperative margin assessment. Curettage and electro-desiccation (C&E) is an alternative. Patients who prefer to avoid surgery or surgery unfit patients use Imiquimod/5-FU, C&E, and photodynamic therapy
·
Imiquimod is a topical immune-stimulatory agent used for the treatment of superficial BCC. It is used for limited periods on small areas (60 to 100 cm2) and appears to be safe in transplant recipients.
High risk of recurrence:
Mohs micrographic surgery (MMS) rather than standard surgical excision
Squamous cell carcinoma:
· Mohs MMS and surgical excision remain the mainstay of treatment for SCCs
· Inoperable cases or when surgery is refused by the patient. Primary radiotherapy provides high local cure rates. Adjuvant RT is considered for SCC that shows evidence of significant perineural involvement or positive margins after surgical excision.
· Chemotherapy (Systemic retinoids ) can reduce and delay SCC recurrence rates.
References:
1. Scrivener Y, Grosshans E, Cribier B. Variations of basal cell carcinomas according to gender, age, location and histopathological subtype. Br J Dermatol. 2002;147(1)
2. Collins, L.; Asfour, L.; Stephany, M.; Lear, J.T.; Stasko, T. (2019). Management of Non-melanoma Skin Cancer in Transplant Recipients. Clinical Oncology, 31(11), 779–788.
Most likely this basal cell carcinoma
Biopsy and histopathology examination
screening for metastasis like all body imaging including CT scans and X-rays
Reduction of immunsuppression drugs and use of sirolimus
What is your differential diagnosis?
The differential diagnosis is basal cell carcinoma and squamous cell carcinoma. Biopsy is recommended for the confirmation
Briefly outline his management
Reducing the immunosuppressants or switching to mTOR inhibitors
Differential diagnosis: SCC or basal cell carcinoma
excision biopsy should be done
minimise the immunosuppressive medication
change TAC to mTOR inhibitors
What is your differential diagnosis?
Briefly outline his management
Investigation
Treatment if it turns out to be SCC
Future prevention
References
Most probably this is a skin malignancy either squamous cell carcinoma vs Basal cell carcinoma
More common squamous cell carcinoma
Rare causes may be infected lesions.
Biopsy plus consultant a dermatologist and an oncologist
If biopsy proven skin malignancy :
1st reducing immunosuppression
2nd usage of mTOR inhibitors e. G Sirolimus
3rd sun protection esp from ultraviolet rays
4th according to biopsy and stage
If basal cell Ca : wide local excision, cryo, Mohs surgery
If Sq cell Ca : wide local excision, Mohs surgery, radio and chemo may have a role
Q1: ΔΔ includes: Basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and amelanotic malignant melanoma.
Q2: this lesion needs an excisional biopsy, R/O of metastasis, changing CNIs to mTOR inhibitors, and careful sun protection. Dermatologist and oncologist consultation and follow-up are needed.
Assalam o alaikum
What is your differential diagnosis?
Keeping in mind 3 years post-transplant patient on immunosuppressive with new lesion, should be managed as malignant lesion unless proven otherwise. Top 3 differentials on sun exposed area would be: 1. Squamous cell carcinoma. 2. Basal Cell carcinoma. 3. Merkel cell carcinoma.
Briefly outline his management:
· Counseling for sun protection and self-examination. Surveillance visits for skin examination by dermatologist alongwith self-examination as a routine.
· Dermatology consult for dermoscopy and excision biopsy with wide margins.
· Systemic retinoids, oral nicotinamide, oral capecitabine have all proven efficacy in reducing risk of development of skin cancer post-transplant.
· Switching CNI to mTOR as patient has stable renal functions and risk of dermatological malignancies is higher with CNIs. Antimetabolite drug though not mentioned, if patient is on Azathioprine it should be switched to MPA. With these changes in immunosuppressive therapy risk of graft dysfunction should be considered and a close eye should be kept on renal profile.
· Multidisciplinary management once proven to be malignant lesion, wide excision biopsy by Mohs surgery is standard of treatment. Radiotherapy can be offered to those patients who are not suitable for surgical procedures. In case of extensive or malignant lesions chemotherapeutic options can be considered as well.
REFERENCES:
1. Oh CC, Lee HY, Tan BK, Assam PN, Kee TYS, Pang SM. Dermatological conditions seen in renal transplant recipients in a Singapore tertiary hospital. Singapore Med J. 2018 Oct;59(10):519-523. doi: 10.11622/smedj.2018126. PMID: 30386860; PMCID: PMC6199188.
2. Knoll GA, Kokolo MB, Mallick R, et al. Effect of sirolimus on malignancy and survival after kidney transplantation: systematic review and meta-analysis of individual patient data [published correction appears in BMJ. 2014;349:g7543]. BMJ. 2014;349:g6679. Published 2014 Nov 24. doi:10.1136/bmj.g6679
3. Bottomley MJ, Massey PR, Thuraisingham R, Doyle A, Rao S, Bibee KP, Bouwes Bavinck JN, Jambusaria-Pahlajani A, Harwood CA. Interventions After First Post-Transplant Cutaneous Squamous Cell Carcinoma: A Proposed Decision Framework. Transpl Int. 2022 Nov 22;35:10880. doi: 10.3389/ti.2022.10880. PMID: 36484063; PMCID: PMC9722441.
Differential diagnosis :
Management:
Detailed history taking & physical examination
Skin biopsy & histopathological examination
Baseline investigations
Investigations to look for metastases- imaging of chest, abdomen, pelvis.
Treatment:
a) Excision of this lesion
b) Topical 5 FLUOROURACIL
c) Decreasing dose of immunosuppression (early cyclosporin withdrawl reduced the risk for cancer in adult renal transplant)
d) Option to start mTOR inhibitor(Sirolimus). This reduce cell growth & proliferation.
Counceling patient regarding:
a) Risk of recurrence
b) Avoid sun:
Avoid intense sun exposure especially
Avoid sun exposure for an hour or two on either side of mid day.
c) Sun protective clothing:
Long sleeve silk clothing, sunglasses, cotton cricket hat is better.
d) Regular use of high factor sun block(SPF 50)
e) Self examination regularly to check early recurrence
References:
1. Squamous cell carcinoma of the skin. Mayo Clinic. May 13, 2021. Accessed July 8, 2021. https://www.mayoclinic.org/diseases-conditions/squamous-cell-carcinoma/symptoms-causes/syc-20352480
What is your differential diagnosis?
1. Squamous cell carcinoma (more common than BCC in transplant patient unlike general population where BCC is more common).
2. Basal cell carcinoma
3. Merkel cell carcinoma
Briefly outline his management
1.Physical Examination
2.Dermatology consultation for biopsy: excisional,and histology
3.Oncology Review for staging (CT-chest abdomen and pelvis or PET-CT)
4.Modification of immunosuppression
Switching CNI to mTOR inhibit or
Switching to MMF if on azathioprine
5.Patient education regarding skin cancer and counseling 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 protectiv 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
This is post kidney transplant patient present with painless shiny raised skin lesion differential is :
-Basal cell carcinoma
– SSC
– Merkel cell carcinoma
– Amelanotic malignant melanoma.
Low-Risk BCCs:
– Cryotherapy
-ED&C-Surgical excision
-Topical imiquimod
-Intralesional interferon
-Photodynamic therapy
High-Risk BCCs
-Mohs micrographic surgery
-Definitive radiation therapy
Referrence :
1. Current Approaches to Skin Cancer Management in Organ Transplant Recipients © 2011 Elsevier Inc. All rights reserved. 35 doi:10.1016/j.sder.2011.02.003
What is your differential diagnosis?
This patient transplanted 3 years on tacrolimus presented with this lesion in sun exposed are most propably :
Basal cell carcinoma other differential is
squamous cell carcinoma
keratoacanthomas
Briefly outline his management
We need to share the treatment with dermatologist and oncologist.
Take history and t check a level of tacrolimus.
Examination of all exposed area and lymph nodes .
Screening for metastasis.
Biopsy to confirm the diagnosis.
Surgical treatment plus 5 FU ,cryotherapy and radiation may need .
Shifted to sirolimus(MTOR) from tacrolimus .
Protective against sun exposure.
References
1. Squamous cell carcinoma of the skin. Mayo Clinic. May 13, 2021. Accessed July 8, 2021. https://www.mayoclinic.org/diseases-conditions/squamous-cell-carcinoma/symptoms-causes/syc-20352480
what is your differential diagnosis?
– History taking & physical examination
– Skin biopsy & histopathological examination
– Baseline investigations
– Search for metastases- imaging of chest, abdomen, pelvis.
– Treatment –
a) Surgical excision of this lesion
b)Topical 5 FU
c) Reduction of immunosuppression (early cyclosporin withdrawl reduced the risk for cancer in adult renal transplant)
d) Concider mTOR inhibitor(Sirolimus). This reduce cell growth & proliferation.
– Counceling patient regarding
a) Risk of recurrence
b) Avoid sun:
– Avoid intense sun exposure
-Avoid sun exposure for an hour or two on either side of mid day.
c) Sun protective clothing: Long sleeve silk clothing, sunglass, cotton cricket hat is better.
d) Regular use of high factor sun block(SPF 50)
e) Self examination regularly
a) Squamous cell carcinoma
b) Basal cell carcinoma
c) Amelanotic melanoma
d) Cutaneous lymphoma
– History taking & physical examination
– Skin biopsy & histopathological examination
– Baseline investigations
– Search for metastases- imaging of chest, abdomen, pelvis.
– Treatment –
a) Surgical excision of this lesion
b)Topical 5 FU
c) Reduction of immunosuppression (early cyclosporin withdrawl reduced the risk for cancer in adult renal transplant)
d) Concider mTOR inhibitor(Sirolimus). This reduce cell growth & proliferation.
– Counceling patient regarding
a) Risk of recurrence
b) Avoid sun:
– Avoid intense sun exposure
-Avoid sun exposure for an hour or two on either side of mid day.
c) Sun protective clothing: Long sleeve silk clothing, sunglass, cotton cricket hat is better.
d) Regular use of high factor sun block(SPF 50)
e) Self examination regularly
Kim C, Cheng J, Colegio OR. Cutaneous squamous cell carcinomas in solid organ transplant recipients: emerging strategies for surveillance, staging, and treatment. Semin Oncol. 2016 Jun;43(3):390-4. doi: 10.1053/j.seminoncol.2016.02.019. Epub 2016 Feb 23. PMID: 27178693.
– squamons cell carcinoma
– basal cell carcinoma.
– Merkel cell
– carcinoma.
> squamous cell carcinoma carries high risk of metastasis and increasings mortality rate
-Multidisciplinary Team (nephrologist, oncologist , dermatologist and transplant surgeon)
-skin biopsy to support diagnosis and stage differentiation in tumor.
-general examination for metastasis.
-imaging and pan CT
-change tacrolimus to sirolimus with close follow up of graft stability -patient education for self examination avoid sun exposure and sun protection.
-treatment by excision surgically
References
1- UpToDate
–
What is your differential diagnosis?
on top of my ddx list is
then other malignant skin conditions
or other benign skin conditions:
Briefly outline his management
First we take detailed history and perform physical examination.
and then dermatologist consultaion for skin biopsy to reach the definitive diagnosis
and from there we decide the treatment accordingly.
if the biopsy results confirms the diagnosis is cancer /BCC then treatment options are:
Topical 5-fluorouracil 5,Imiquimod,Tazarotene
Vismodegib
Sonidegib
we can switch tacrolimus to sirolimus+ _MMF dose reduction
but we should always balance this with the safety of the transplanted kidney.
also counseling the patien is vital regarding avoidance of sun exposure esp mid day sun and 2 hr around+protective clothing and sunscreen. also regular self examination.
other D/D are
Basal cell carcinoma
Merkel cell carcinoma
benign skin lesion – sebaceous cyst
Detail history and physical examination to look for other lesions, lypmhnodes and mets
SCC is more common than BCC in post transplant patients, mostly are multifocal, aggressive and metastatic
Dermatologist and Onco-surgeon consultation
It being a small lesion, Excision Biopsy should be curative – with or without topical 5FU application
reduction of immunosupression –
Switching from Tacrolimus to sirolimus
Reduction or stopping of MMF
regular follow up with nephrologist / transplant team – testing creatinine, urea and urine protein to look for rejection and proteinuria
heavy proteinuria may require additional drugs like ACE inhibitor / AR blocker
shall advise patient to
avoid sun exposure,
apply sun screen (broad spectrum cream with SPF50)
self examination; if any lesion found – report to ur physician at the earliest
What is your differential diagnosis?
co ordination with the dermatologist
and MDT discussion
SCC
naevus
skin tag
sebaceous cyst
Briefly outline his management
excisional biopsy and accordingly
The most likely diagnosis is Squamous cell carcinoma .
1- Full history and examination including lymph node , distant metastasis and looking for other skin lesion .
2- Oncology consultation : asking for CT scan or PET scan for staging and further management .
3- Dermatology consultation : looking for other differentials and to do excisional skin biopsy.
4- Nephrology : Consider switching CNI to m-TOR inhibitors, and to reduce MMF or stop it .
5- surgical excision and topical therapies (ie, imiquimod, topical fluorouracil), photodynamic therapy (PDT), or cryosurgery. according to oncology opinion
6- Regular self-examination and annual dermatological examination are essential looking for recurrent or de-novo lesions.
Protective sun exposure measures.
references
1) up to date
Also reduce dose of TAC & switch to SRL.
1. SCC, BCC, Merkel cell carcinoma, benign skin lesion.
2. Skin biopsy for confirmation.surgical excision, any need of radio/ chemo after consultation with dermatologist & oncologist. Future prevention by avoiding sun exposure & regular skin examination.
Surgery. Mohs Surgery
Curettage and electrodessication
Radiotherapy if needed
Topical creams if small and not invasive
Change in the immunosuppression: dose reduced or a change to mTOR- inhibitors
Regular monitoring for recurrence, and for immunosuppression effectiveness
What is your differential diagnosis?
Kidney Transplant Recipient on tacrolimus based immunosuppression presented with Single skin raised pinkish lesion in sun exposed area .
DD includes
SCC
Basal cell carcinoma.
Skin Metastasis .
Benign skin lesions.
Solid organ transplant recipients have an increased risk for developing squamous cell carcinoma, which been associated with a more aggressive disease course and an increased risk of metastasis and death compared with the general population.
Organ transplant recipients have a 10-fold increased risk for malignant neoplasms overall, and a 65- to 250-fold higher incidence of squamous cell carcinoma (SCC).
cSCC tumors harbor a high mutation burden, which has been associated with good response to immune checkpoint inhibitors.
Briefly outline his management:
First biopsy should be done to confirm diagnosis.
Full examination of the body ,LN, and body imaging to rule out metastases
Oncology consultation after results of the biopsy .
Switch from Tac to mTORi if stable graft function.
Education to the patient about self examination to detect early lesion, sun protection
Treatment mainly by surgery, chemo- and/or radiotherapy.
Two major concerns regarding the use of immune checkpoint inhibitors in solid organ transplant recipients (SOTR) are the risk of allograft rejection and the potential reduction in the anti-cancer response related to the concomitant immunosuppression,
Larger systematic review, showing that SOTR suffering from cSCC derived the most clinical benefit from treatment with ICI compared to other cancer types with an overall response rate (ORR) 68.2%.
The main concern of the usage of ICI in KTR is graft rejection.
Cancer after transplantation is mostly managed by a reduction in immunosuppression and with the addition of immune checkpoint inhibitors ICI this might trigger allograft rejection
Factors associated with graft rejection were a history of acute rejection, anti-PD-1 usage and single agent immunosuppressive treatment.
However, treatment with at least one other IS than corticosteroids, usage of mechanistic target of rapamycine inhibitors (mTORi) and longer time after transplantation (> 8 years) was associated with lower risk of rejection .
Reference T.VanMeerhaeghe,J.F.Baurain.Cemiplimab for advanced cutaneous squamous cell carcinoma in kidney transplant recipients.Front. Nephrol., 31 October 2022
What is your differential diagnosis?
Squamous cell carcinoma (most likely)
Basal cell carcinoma
Briefly outline his management
History and examination: local and systemic especially for other lesions, lymph nodes, distant metastasis.
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.
Treatment options include: surgical excision, methotrexate and 5-fluorouracil.
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.
Squamous cell carcinoma
Basal cell carcinoma
SCC more common than BCC in a solid organ transplant patient (1.8:1) compared to general population.
educate the patient about sun exposure, use sun block and skin self-examination.
skin biopsy.
early reduction of immunosuppression if there is no rejection risk, change CNI to mTOR.
Basal cell carcinoma (BCC)
Squamous cell carcinoma (SCC)
Squamous cell carcinoma is the most common cutaneous malignancy in solid organ transplant recipients, so biopsy should be done to confirm the diagnosis and decide the proper management.
PREVENTION
· Patient education concerning sun protection and skin self-examination
· Choice and modulation of immunosuppressive therapy
· Chemoprevention
· Post-transplantation surveillance
Choice and modulation of immunosuppressive regimen
· Regimens including mammalian target of rapamycin (mTOR) inhibitors such as sirolimus and everolimus rather than calcineurin inhibitors may reduce the risk for skin cancer and prolong the time to onset
· The benefit was most pronounced in patients who converted from an established immunosuppressive regimen to sirolimus.
· Mycophenolate mofetil versus azathioprine. A few studies have shown that mycophenolate mofetil and mycophenolic acid are associated with a lower incidence of skin cancer in solid organ transplant recipients compared with azathioprine
Reduction of immunosuppressive therapy.
· On the basis of the information from multiple RCTs and observational studies, we conclude that sirolimus use in kidney transplant recipients is associated with lower cancer risk, but this protective effect is largely limited to NMSC. Reduced NMSC incidence may be a result of the antiproliferative properties of sirolimus, or simply the removal of cyclosporine from the immunosuppressant regimen.
Chemoprevention for SCC: considered for patients who develop multiple (more than five) SCCs per year, aggressive SCCs, or accelerated development of SCCs
· Acitretin — Systemic retinoids such as acitretin, isotretinoin, have been used for the prevention or reduction of nonmelanoma skin cancers
· Capecitabine — may reduce the development of new cutaneous SCCs in solid organ transplant recipients.
MANAGEMENT
SCC in situ (Bowen’s disease) — Options for the treatment of SCC in situ are similar to those in immunocompetent patients. Frequently employed therapies include surgical excision, electrodesiccation and curettage (ED&C), and topical chemotherapy
Invasive lesions without additional high-risk features — Common treatments for SCCs in organ transplant recipients that lack other features of aggressive disease (eg, small, well-differentiated lesions in low-risk sites) include surgical excision and ED&C.
Basal cell carcinoma at low risk of recurrence
•Surgical candidates – For primary, nodular or superficial, low-risk BCCs, surgical excision with standard excision with 4 to 5 mm margins and postoperative margin assessment. Curettage and electrodesiccation (C&E) is an alternative, first-line therapy for low-risk BCC.
•Nonsurgical candidates – Therapeutic options for patients with low-risk BCC who are not surgical candidates or who prefer to avoid surgery include topical therapies (imiquimod or topical fluorouracil), C&E, and photodynamic therapy
For surgical candidates with high-risk BCCs of any size located on the head and neck, hands, feet, and genitalia, Mohs micrographic surgery (MMS) rather than standard surgical excision is suggested
Level of reduction of immunosuppression to consider depends on Skin cancer scenario
History of ≤1 NMSC per year
Mild reduction needed.
History of two to five NMSCs per year
Mild also is needed.
History of >25 NMSCs per year
Moderate reduction is needed.
Individual high-risk skin cancer: 1 percent mortality over three years
Mild
Individual high-risk skin cancer: 50 percent mortality over three years
Severe reduction is needed.
· Basal cell carcinoma (BCC), melanoma, and Merkel cell carcinoma are managed similarly in organ transplant recipients and immunocompetent patients.
· There are no definitive guidelines regarding alteration in immunosuppressive regimens in patients with BCC, melanoma, or Merkel cell carcinoma. The risks and benefits of reduction in immunosuppression should be considered carefully.
1) https://www.uptodate.com/contents/prevention-and-management-of-skin-cancer-in-solid-organ-transplant-recipients?search=skin%20cancer%20transplant&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2295760:~:text=Prevention%20and%20management%20of%20skin%20cancer%20in%20solid%20organ%20transplant%20recipients
2) https://www.uptodate.com/contents/epidemiology-and-risk-factors-for-skin-cancer-in-solid-organ-transplant-recipients?search=skin%20cancer%20transplant&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#:~:text=Epidemiology%20and%20risk%20factors%20for%20skin%20cancer%20in%20solid%20organ%20transplant%20recipients
3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4567030/#:~:text=Sirolimus%20effects%20on,A%20Engels1
1-What is your differential diagnosis?
-Basal cell carcinoma.
-Merkel cell carcinoma.
-Squamous cell carcinoma.
-Molluscum Contagiosum
-Sebaceous Hyperplasia
-Basal cell carcinoma.
-Raised, pink, waxy bumps that may bleed following minor injury
-May have superficial blood vessels and a central depression
-Locally invasive
-Rarely metastasizes
-Organ transplant recipients have a 10-fold higher risk for Basal Cell Carcinoma compared to the general population.
-Basal cell carcinoma is the most common type of non-melanoma skin cancer. This type of cancer often looks like a pink waxy bump that may bleed following minor trauma.
2-Briefly outline his management?
-Since basal cell carcinoma rarely metastasizes, lab and imaging tests are not needed with localized lesions but if deeper involvement is suspected then CT scan be done.
-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.
-Multi-disciplinary approach: involvement of nephrologist, dermatologist, oncologist.
-To confirm diagnosis excision and biopsy is needed;skin biopsy is needed to confirm diagnosis ,subtype and stages of BCC ,usually a shave biopsy can be suitable.
-Patient Behavioural educational programmes on the benefits of UV protection, periodic self-skin examinations.
-Regular screening and follow up is crucial because recurrence rate is high and there is a risk of developing NMSC or melanoma.
-Local therapy with chemotherapeutic and immune-modulating agents can be used in small superficial lesions.
-Topical 5% imiquimod or 5 Fluorouracil can be applied for superficial lesions.
-Photodynamic Therapy used in treatment and prevention of BCC.
–Surgery is the main therapy and the approach varies according to tumor size, depth, and location.
-High-risk cases need excision with postoperative margin assessment or a Mohs resection.
–Radiation therapy;BCCs are usually radiosensitive; radiation therapy (RT) can be used in patients with advanced and extended lesions, as well as in those for whom surgery is not suitable
-For the lesion if SCC, then options are surgical excision, curettage, cryotherapy, photodynamic therapy, radiation for non surgical candidate.
-Regarding Immunosuppression:
-Decrease overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential as MTORs,
-Tacrolimus can be switched to m TOR due to it’s anticarcinogenic effect with following of the renal function.
3-Reference:
1-Dennis P Kim, Kylee J B Kus, Emily Ruiz. Basal Cell Carcinoma Review.Hematology/oncology Clinics of North America 2019 February
2-National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Basal Cell Skin Cancer. NCCN. Version 1.2022 — November 17, 2021; Accessed: February 14, 2022.
Skin cancer, herpes infection
Confirm diagnosis, specific ttt accordingly. Optimise immune therapy, gradually reduce Tacrolimus or replace with mTOR inhibitor
– mostly a case of basal cell carcinoma
– dd: SCC, amelanotic melanoma & sebaceous cyst
– dermatology referral for diagnosis, biopsy, and management options (surgical excision, radiotherapy , cryotherapy )
– reduce immunosuppression, hold MMF, and shift to sirolimus should be considered
– pt education regarding protective measures.
Differential diagnosis includes :
-BCC ( most probable diagnosis )
-SCC
-hyperplastic sebaceous cyst
-keratoacanthoma
Excisional biopsy should be done
shifting Tac to mTORi
References:
1-Up to date skin cancer in solid organ transplants .2022
The given recipient is a post renal transplant patient with normal renal functions presented with 3 years later with papular lesion in the neck in sun exposed areas…The differential diagnosis should be Skin malignancy (BCC or SCC or amelanotic melanoma)..Rarely cutaneous infections after transplant like fungal infections or atypical mycobacteria could be another differential diagnosis….Clinical examination mostly looks like a Basal cell carcinoma in this case
Patient needs a skin biopsy of the lesion before further analysis..With the report we have to decide on the management.. SCC are less common in the general population, but in transplants SCC are more common than BCC… The patient also needs a whole body PET scan to assess the spread of the disease before deciding on treatment…we can probably decide on the need for PET scan after the skin biopsy report as BCC rarely metastasizes….
The current management plan is to reduce the immunosuppression…I would like to reduce the MMF, change tacrolimus to sirolimus and maintain low dose of steroids…Localized BCC/SCC can be excised…Topical application of 5 flurouracil and imiquimod has been successful.. Local radiation therapy is given for BCC/SCC…
The patient has to be counselled on recurrence…vigilant self skin examination for new lesions has to be taught…Skin protection measures with SPF atleast 10 against UVA is a must …Should avoid mid day exposure when the UVA exposure is maximum and should cover the skin exposed areas with clothes..
Ponticelli, C., Cucchiari, D. & Bencini, P. Skin cancer in kidney transplant recipients. J Nephrol 27, 385–394 (2014).
It can be a basal cell carcinoma. The patient should have an excisional skin biopsy for histological analysis.
Basal cell carcinoma (BCC) is not associated with the same level of morbidity and mortality as SCC in organ transplant recipients. The management of BCC in this population resembles management in general public patients.
Imiquimod is a topical immunostimulatory agent that is sometimes used for the treatment of superficial BCC. The use of imiquimod for limited periods on small areas (60 to 100 cm2) appears to be safe in organ transplant recipients.
For this patient, I might consider changing of MMF to mTOR i. Immunosuppression with sirolimus has been associated with a reduced risk of malignancy in organ transplant recipients.
Reference: Prevention and management of skin cancer in solid organ transplant recipients. UpToDate
What is your differential diagnosis?
· Actinic Keratosis
· Bowen Disease
· Cutaneous T-Cell Lymphoma
· Fibrous Papule of the Face
· Juvenile Nasopharyngeal Angiofibroma
· Malignant Melanoma
· Melanocytic Nevi
· Molluscum Contagiosum
· Psoriasis
· Sebaceous Hyperplasia
· Trichoepithelioma
Briefly outline his management
Management of such condition needs to be inducted with MDT with a dermatologist, plastic surgeon, and oncologist.
· In accordance with adverse events and aesthetic impacts, local therapies have been employed.
1. Imiquimod and 5-fluorouracil used topically for the treatment of superficial BCC are effective and safe (self-administered twice daily for several weeks) [1]
2. Topical photodynamic therapy for treating superficial BCC. [2].
3. The recommended course of treatment for primary, uncomplicated BCC is prompt excision or Mohs micrographic surgery [3].
4. For the treatment of AK, BCC, and SCC, topical retinoids such as tretinoin, tazarotene acitretin, or adapalene have been utilized [4].
· Replacing calcineurin inhibitors with an mTOR inhibitor[5].
· For these individuals to be successfully treated, early skin biopsy and Management of premalignant and malignant lesions are crucial. It is essential to treat the entire field as well as the lesion itself because of how these lesions manifest in cancerization fields [5].
· Following initial therapy, transplant patients require regular monitoring to allow for the prompt identification of both potential recurrences and the emergence of new malignancies [5].
1. Jirakulaporn T, Endrizzi B, Lindgren B, Mathew J, Lee PK, Dudek AZ. Capecitabine for skin cancer prevention in solid organ transplant recipients. Clin Transplant 2011;25(4): 541e548.
2. Endrizzi B, Ahmed RL, Ray T, Dudek A, Lee P. Capecitabine to reduce nonmelanoma skin carcinoma burden in solid organ transplant recipients. Dermatol Surg 2013;39(4):634e645.
3. Bangash HK, Colegio OR. Management of non-melanoma skin cancer in immunocompromised solid organ transplant recipients. Curr Treat Op Oncol 2012;13(3):354e376.
4. Jambusaria-Pahlajani A, Ortman S, Schmults CD, Liang C. Sequential curettage, 5-fluorouracil, and photodynamic therapy for field cancerization of the scalp and face in solid organ transplant recipients. Dermatol Surg 2016;42(Suppl. 1): S66eS72.
5. Collins, L.; Asfour, L.; Stephany, M.; Lear, J.T.; Stasko, T. (2019). Management of Non-melanoma Skin Cancer in Transplant Recipients. Clinical Oncology, 31(11), 779–788.
SCC
BCC
Melanoma
Patient evaluation
All lesions that are suspicious for SCC should be pathologically examined to confirm the diagnosis and to evaluate for features associated with aggressive disease
Patients who are determined to have cutaneous SCC should undergo a complete 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.
Sun protection
The daily use of sun-protective measures may decrease the incidence of actinic keratoses and SCC in organ transplant recipients.
Choice and modulation of immunosuppressive regimen
The choice of the immunosuppressive regimen may influence the risk of post-transplant skin cancer. Regimens including mammalian target of rapamycin (mTOR) inhibitors such as sirolimusand everolimus rather than calcineurin inhibitors may reduce the risk for skin cancer and prolong the time to onset
Mycophenolate mofetil versus azathioprine
mycophenolate mofetil and mycophenolic acid are associated with a lower incidence of skin cancer in solid organ transplant recipients compared with azathioprine
Reduction of immunosuppressive therapy
Because increased intensity and duration of immunosuppression appear to promote the development of cutaneous malignancies in organ transplant recipients, reduction of immunosuppression may be considered in patients who develop numerous lesions, recurrent disease, or metastatic disease
Nicotinamide
oral nicotinamide 500 mg twice daily for 12 months in nonmelanoma skin cancers found a 20 percent reduction in the number of new BCCs and a 30 percent reduction in the number of new SCCs
Capecitabine
Treatment with capecitabine, an oral chemotherapeutic agent, may reduce the development of new cutaneous SCCs in solid organ transplant recipients.
Post-transplantation surveillance
●No history of skin cancer or AK – Once yearly for high-risk patients, less frequently for lower-risk patients
●History of AK or one low-risk nonmelanoma skin cancer – Every six months
●Multiple nonmelanoma skin cancers or a history of a high-risk SCC – Every three months
●History of pretransplant melanoma or melanoma in situ – Every six months
●Post-transplant melanoma – Every three months for two years, then at least every six months
●Rapidly developing tumors, aggressive tumors, or metastatic skin cancer – Every four to six weeks
In all patients with a history of skin cancer, examination should include the palpation of lymph nodes.
Skin self-examination
Organ transplant recipients should be instructed to perform a skin self-examination on a monthly basis.
Reference
2-Vos M, Plasmeijer EI, van Bemmel BC, et al. Azathioprine to mycophenolate mofetil transition and risk of squamous cell carcinoma after lung transplantation. J Heart Lung Transplant 2018; 37:853.
3-Chen AC, Martin AJ, Choy B, et al. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med 2015; 373:1618.
4-Wu SZ, Jiang P, DeCaro JE, Bordeaux JS. A qualitative systematic review of the efficacy of sun protection education in organ transplant recipients. J Am Acad Dermatol 2016; 75:1238.
1- Differntial diagnosis
a- Basal cell carcinoma
b- Squamous cell carcinoma
c- Intradermal navus
d- Sebaeous hyperplasia
2- Management of this case
-First step is to establish the diagnosis of this skin lesin through skin biopsy. Then define its stage based on presence of lymph node and distant organ involvement .
– modify the IS regiment through stopping CNI ,shift to sirolimus and decrease the dose of MMF with close monitoring of graft function and consider protocol biopsy to detect signs of early rejection .
– General recommendation including : avoid exposure to direct sun rays , use sun screen creams.
1.Nodular Basal cell carcinoma
2.SCC
3.Dermal metastases from internal organs, such as the colon
4.Sebaceous hyperplasia
5.Dermal nevi
Regarding management:
Through history and clinical examination (complete skin examination and palpation of draining lymph nodes)
Histological biopsy is mainstay of treatment. (Clinical diagnosis is nodular basal cell carcinoma). Surgical excision with intraoperative frozen section for diagnosis and staging will be beneficial.
MDT with dermatologist and oncologist
References:
1.Scrivener Y, Grosshans E, Cribier B. Variations of basal cell carcinomas according to gender, age, location and histopathological subtype. Br J Dermatol. 2002;147(1):41-
2.Transplant Dermatology Clinic, Department of Dermatology, Yale School of Medicine, New Haven, CT 06520-8059, USA.PMID: 22592596
1-Basal Cell Carcinoma
2-Squamaus cell carcinoma
3-Molluscum Contagiosum
The most probable diagnosis basal is basal cell carcinoma as it has the following characteristics:
1-Waxy papules with central depression
2-Pearly appearance.
3-Erosion or ulceration.
4-Rolled (raised) border.
5-Transulancy.
6-Telangiectases over the surface
First, we need to confirm the diagnosis by involving dermatologist, surgeon and oncologist.
Detailed examination looking for other lesions.
Excisional biopsy.
If diagnosis confirm, then wide local excision, chemo and/or radiotherapy.
Decision to go for kidney transplant and timing for that depends on exact cancer type and its stage.
As stated in the KDIGO guidelines for kidney transplantation 2020:
11.2 Potential kidney transplant candidates with a prior
cancer
11.2.1: We recommend that candidates with active malignancy be excluded from kidney transplantation except for those with indolent and low-grade cancers such as prostate
cancer (Gleason score ≤ 6), superficial nonmelanoma skin cancer, and incidentally detected renal tumors (≤ 1 cm in maximum diameter).
11.2.2: Timing of kidney transplantation after potentially curative treatment for cancer is
dependent on the cancer type and stage at initial diagnosis.
11.2.3: We recommend 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; small renal cell carcinoma (< 3 cm); prostate cancer (Gleason score ≤ 6); carcinoma in situ (ductal carcinoma in situ, cervical, others); thyroid cancer (follicular/ papillary < 2 cm of low grade histology); and superficial bladder cancer.
Reference:
1-KDIGO guidelines for kidney transplantation 2020
What is your differential diagnosis?
Wart
Sebecious cyst
SCC
BCC
Amelanotic melanoma
Management :
Multidisciplinary team approach must be considered between nephrologist, dermatologist, surgeon
With excision and histopathology.
If he needs chemotherapy or radiotherapy according the to diagnosis
Minimizing immunosuppressive and CNI can be replaced with mTOR
Avoid sun exposure and water protective clothes and sun block
Self examination
DD:
SCC, Basal cell carcinoma ,amelanotic melanoma.
Management:
History :Onset and progression of skin lesion, history of recurrence, f/h of cancers, sun exposure, exposure to heavy metals, previous skin burns.
Examination – Sunburns, nevus, skin color& type, lymph nodes, weight, fever.
Treatment includes:
-Counselling on diagnosis, risk factors, treatment options and prognosis
-Incisional biopsy& histopathology
-Multidisciplinary approach including oncologist, dermatologists, plastic surgeons &radiologists.
Reduction of tacrolimus dose & addition of sirolimus or shifting from tacrolimus to sirolimus.
– Surgery, radiotherapy, cryotherapy, phototherapy & topical cytotoxic medications.
skin cancers/lesions after transplantation can be Basal-cell, squamous cell carcinoma, actinic keratosis, Bowen’s disease, Epidermal and hair-follicle keratinocytes, Melanoma, Kaposi’s sarcoma, Neuroendocrine skin carcinoma (Merkel) cells, Lymphoma, Malignant fibrous histiocytoma. Excision and pathologic evaluation will prove the diagnosis. (Euvrard, S., Kanitakis, J., & Claudy, A. (2003). Skin Cancers after Organ Transplantation. New England Journal of Medicine, 348(17), 1681-1691. doi:10.1056/nejmra022137.)
This patient should be managed surgically. Tacrolimus should be shifted to an mTOR inhibitor. avoidance of sunlight is also needed to lower the risk of skin cancers.
1-What is your differential diagnosis?
Actinic keratoses, porokeratoses, and viral warts
basal cell carcinoma
Merkel cell carcinoma
melanoma in situ/lentigo maligna
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.
2-Briefly outline his management
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.
Patient education concerning sun protection and skin self-examination
.
The daily use of sun-protective measures
Biopsies of papular or nodular lesions should extend at least into the deep reticular dermis
immunosuppression should be reduced to the minimal regimen necessary to maintain organ tolerance
Greater reduction in immunosuppression can be considered in advanced cases, if the benefits of doing so are perceived to exceed the risks associated with rejection of the transplanted organ.
Immunosuppression with sirolimus has been associated with a reduced risk of malignancy in organ transplant recipients
Basal cell carcinoma — Basal cell carcinoma (BCC) is not associated with the same level of morbidity and mortality as SCC in organ transplant recipients. The management of BCC in this population resembles management in the immunocompetent patients.
Patients who are determined to have cutaneous SCC should undergo a complete skin examination and palpation of draining lymph nodes.
Selection of treatment Based upon
Cryosurgery — Cryosurgery is infrequently used for the management of low-risk SCC in immunocompetent patients because of the difficulty in obtaining the requisite
The use of systemic immunomodulatory or molecularly targeted therapies for metastatic melanoma has not been specifically studied in the organ transplant population. Immunostimulatory therapies such as interferon are generally considered unfavorable due to the possibility of graft rejection
Merkel cell carcinoma — No specific guidelines exist for the management of Merkel cell carcinoma in organ transplant recipients
Surgical excision is the usual treatment of choice with radiation as an adjuvant therapy in some cases
Reductions in immunosuppressive regimens have been reported to lead to temporary and partial regression of Merkel cell carcinoma in a few patients
Solid organ transplant recipients who have been treated for skin cancer should have complete skin examinations on a regular basis. The palpation of lymph nodes should be performed at each visit. The frequency of visits depends upon the patient’s medical history and the type and clinical behavior of the tumor.
REFERRENCE UP TODATE
Knoll GA, Kokolo MB, Mallick R, et al. Effect of sirolimus on malignancy and survival after kidney transplantation: systematic review and meta-analysis of individual patient data. BMJ 2014; 349:g6679.
What is your differential diagnosis?
1. SCC
2. BCC
3. Amelanotic melanoma
Briefly outline his management
Full history and clinical examination (complete skin examination and palpation of draining lymph nodes)
MDT and patient counseling
Surgical excision and histopathology for definitive diagnosis
For SCC: Mohs surgery or conventional surgical excision, are the preferred treatments for invasive SCC
Immunosuppressant: reduction of immunosuppression should be considred carefully and modulation of immunosuppressions (changes CNIs to mTOR inhibitors, and if on azathioprine stops it). Modulation of immunosuppression is considered for patients with multiple lesions, recurrent lesions, or aggressive or metastatic SCC
Full skin examinations at least once yearly
Sun protection: patients should be counseled on the use of sunscreens, sun protective clothing, and the warning signs of cutaneous malignancy. In a non-randomized controlled study of 120 organ transplant recipients, participants using daily sunscreen developed fewer actinic keratoses and SCCs than subjects with intermittent sunscreen use
Reference: UpTodate
Differential diagnosis
Basal cell carcinoma
Management
History – Onset and progression of skin lesion, history of recurrence, family history of cancers, history of sun exposure, exposure to heavy metals, previous skin burns or skin diseases etc.
Examination – Sunburns, nevus, skin color and type, lymph nodes, weight loss, fever, etc
Treatment –
What is your differential diagnosis?
————————————————————
Nodular basal cell carcinoma(BCC)
Squamous cell carcinoma
Amelanocytic melanoma
Briefly outline his management;
——————————————————————-
1-Obtain 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.
2-Review clinical and pathologic details of prior skin cancers.
3-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.
4-Assess risk of cancer recurrence, risk of end organ disease and risks of transplantation to determine transplant status.
5-If the potential for occult micro metastasis 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.
6-Caunselling the candidate regarding his disease risk and the outcome of transplant .
6- Regular review of transplant-associated immunosuppression may permit optimization of the risks and benefits.Preliminary data suggesting that mammalian target of rapamycin (mTOR) inhibitors may be associated with a decreased incidence of skin cancer need to be confirmed by large-scale, long-term studies
Reference;
————————————-
1-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
2-Skin Cancer as a Contraindication to Organ Transplantation
https://onlinelibrary.wiley.com › doi › pdf This review provides prognostic guidance to transplant physicians evaluating transplantation candidates who have skin cancer .
What is your differential diagnosis?
papular lesion at sun exposed hairy areas with mutiple small dilated capillaries in the middle with no evidence of extra keratin layers, hyperpigmentations nor rodent ulcer for differntial diagnosis:
Briefly outline his management
Full skin inspectiona and examiantion and urgent dermatology consultaions for consideration of Moh surgical excision and send tissue for biopsy that can guide further invesitgations and patient discussions about risk profile and potential immunosupression modifications like switch to mTOR and use other chemoprophylaxis (retinoids and nicotinamide)
Reference:
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
DD:
1. NMSC
2. A melanocytic melanoma
3. Precancerous actinic keratosis
Outline of MM
1. History and clinical examination , local, regional LNs and systemic examination to detect mets
2. Treatment, ccording to histology and presence of mets
A: precancerous or superficial BCC or SCC: topical 5 FU cream or photodynamic therapy
B: curatage and electrodissication
3. Wide local excision if infelterative BCC and SCC with post surgery histological evaluation and repeat surgery till having histologically clear margin
4. If with mets surgery plus decrease IS treatment if possible and chemotherapy eg cisplatin and 5 FU. or recently EGF receptor inhibitors eg gefitinib.
5 surveillance: follow up every 3 to 6 months including skin, LN s and neurological examination and CT scan in SCC.
6. Strategies to decrease sun exposure.
Differential diagnoses :
Precancerous lesions (actinic keratosis, warts. verrucae vulgares and verrucae planae).
Malignancy (squamous cell ca, basal cell ca, sarcoma, lymphoma and melanoma,Merkel cell carcinoma)(1)
Management:
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.
Basal cell carcinoma
Imiquimod is a topical immunostimulatory agent that is sometimes used for the treatment of superficial BCC. The use of imiquimod for limited periods on small areas (60 to 100 cm2) appears to be safe in organ transplant recipients
Merkel cell carcinoma
No specific guidelines exist for the management of Merkel cell carcinoma in organ transplant recipients. Surgical excision is the usual treatment of choice with radiation as an adjuvant therapy in some cases
Reductions in immunosuppressive regimens have been reported to lead to temporary and partial regression of Merkel cell carcinoma in a few however, additional studies are necessary to determine the best approach to treatment in organ transplant recipients.
Follow up for skin cancer should have complete skin examinations on a regular basis. The palpation of lymph nodes should be performed at each visit. The frequency of visits depends upon the patient’s medical history and the type and clinical behavior of the tumor.
Ref:
1-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
2-up to date
What is your differential diagnosis?
-keratoacanthoma
-Squamous Cell Carcinoma(cSCC)
-Basal cell carcinoma
Briefly outline his management
–Detail history and clinical examination.
-Dermatology consultation and excisional or deep incisional biopsy for histopathology and according to the result put plan of management.
-Reduce the immunosuppression and switch tacrolimus to mTOR (sirolimus) with the close monitoring of graft function.
-Advice the patient to avoid direct exposure to the sun and used protective sunscreen and clothes.
DDx
1- C.Squamous cell carcinoma
2- nodular Basal cell carcinoma
3- keratoacanthoma
Management
– History taking focusing on exploring risk factors ( ?UV exposure) including pretransplant assessment And other system affection related symptoms
– Physical examination ( ( local for the lesion and examination for regional lymph nods and evidence for other system affection
– MDT approach (plastic surgeon, dermatology, oncology)
– Surgical excision with intraoperative frozen section for diagnosis and staging
– Ct scan or PET-CT
After the result the management will be according to the diagnosis and staging as follow
General outlines
Patient education about the risk of getting posttransplant skin cancer and importance of his rule in prevention by avoiding sun exposure especially middy day by wearing protective cloths and using recommended sunscreen
That his immunosuppressive regimen will be changed either reducing doses or changing to other type and risk associated with this changes
The importance of involvement of other specialties in his management
Prognosis of his disease
Specific outlines
According to the diagnosis
1- cSSC
Mohs micrographic surgery (MMS), excision. For immunosuppressed patients with high-risk features, margins of 6–10 mm beyond any surrounding erythema and resection into the subcutaneous fat have been recommended. American Joint Committee on Cancer (AJCC) high-risk features include invasion into the subcutaneous fat, poor differentiation, perineural invasion, and high-risk anatomical location (primary site on the ear or lip) (1)
However, in certain anatomic locations, such as on the hands or face, resection margins of 6–10 mm may be impractical and smaller margins may be justified.
Primary radiation therapy (RT) can also provide high local cure rates with good cosmesis. Adjuvant RT is considered for SCC that shows evidence of significant perineural involvement or positive margins after surgical excision. (2)
Although MMS and surgical excision remain the mainstay of treatment for SCCs, in cases deemed inoperable or when surgery is refused by the patient
Modification of immunosuppression
As The incidence of SCCs increases with increasing intensity and duration of immunosuppression in solid organ transplant recipient (SOTR). It is recommended mild reduction of transplant-associated immunosuppression once multiple skin cancers developed per year or with individual high-risk skin cancers but risk assessment is advised by weighting benefit versus risk . (3)
Moderate reductions were considered appropriate when patients experienced >25 skin cancers per year or for skin cancers with a 3-year mortality risk of 10%. (3)
Severe reductions were considered for life-threatening skin cancers (3)
Switching from calcineurin inhibitors, which confer a higher risk, to mammalian target or rapamycin (mTOR) inhibitors, which confer a lower risk (4)
However, the decreased risk of cutaneous malignancy associated with sirolimus is balanced by an increased risk of serious adverse effects. The most common adverse events are edema, acneiform eruption, aphthous ulcers, and proteinuria . The risk–benefit ratio improves with lower doses of sirolimus and a low conversion rate from calcineurin inhibitors (5)
Chemoprophylaxis
Systemic retinoids, capecitabine, and nicotinamide. Systemic retinoids can reduce and delay the recurrence of SCCs. Consequently, it is important to counsel patients on long-term side effects that may reduce their quality of life, including the possibility of disorders of the musculoskeletal system and inflammatory back pain (6)
2- Basal cell carcinoma
The current standard of care for BCC is surgical excision with methods similar to those detailed for cutaneous
SCC.
Ref
1- Dragieva G, Hafner J, Dummer R, et al. Topical photodynamic therapy in the treatment of actinic keratoses and Bowen’s disease in transplant recipients. Transplantation 2004; 77: 115–121.
2- Kyrgidis A, Tzellos TG, Kechagias N, et al. Cutaneous squamous cell carcinoma (SCC) of the head and neck: Risk factors of overall and recurrence-free survival. Eur J Cancer 2010; 46: 1563–1572.
3- Otley CC, Berg D, Ulrich C, et al. Reduction of immunosuppression for transplant-associated skin cancer: Expert consensus survey. Br J Dermatol 2006; 154: 395–400.
4- Colegio OR, Hanlon A, Olasz EB, Carucci JA. Sirolimus reduces cutaneous squamous cell carcinomas in transplantation recipients. J Clin Oncol 2013; 31: 3297–3298.
5- Euvrard S, Morelon E, Rostaing L, et al. Sirolimus and secondary skin-cancer prevention in kidney transplantation. N Engl J Med 2012; 367: 329–339.
6- Eksioglu E, Oztekin F, Unlu E, Cakci A, Keyik B, Karadavut IK. Sacroiliitis and polyneuropathy during isotretinoin treatment. Clin Exp Dermatol 2008; 33: 122–124
Thankyou this is a detailed review for scc, and a very short one for basal cell carcinoma which is the most probable diagnosis in the index case.!
This is a post-transplant and on immunosuppression tacrolimus since three years, on the basis of this patient is on risk for development of post-transplant drug induced tumors, and skin cancers are the most common tumors post-transplantation.
This picture and history of the patient until diagnosed, the risk of local, regional, or distant recurrence is most important factor in determining the approach of treatment.
the differentials are,
SCC,
BCC
Regarding management:
A good history,
Examination,
dermatologist opinion, may need of oncologist,
baseline investigation,
screening for metastasis and whole body scanning.
Immunosuppression reduction and to switch tacrolimus to mTOR inhibitors, may benefit but literature did not support for SCC lesion, however, reduction of immunosuppression may increase risk and loss of graft function,
other options,
the risk of local, regional, or distant recurrence is most important factor in determining the approach of treatment.
Surgical excision biopsy and histopathological diagnosis,
Curettage and electrodesiccation,
chemotherapy if distant disease,
radiotherapy.
photodynamic therapy,
ablation flection laser,
local application of imiquimode may modulate immunity but it was not studied, systemic absorption is rare but as it may interfere in immunosuppression etc,
tropical fluorouracil in low risk disease.
Overall prognosis is good with overall five year cure rate .90%.
references;
Well done.
Thank you Dr Mohamed Mohamed for your detailed response.
Few comments:
You mean prognosis varies. What you referred to is vague and I’m not aware that BCC is associated with severe comorbidity?
Do you think clinical diagnosis alone would be enough or you still will need surgical excision for these lesions? This means that you will need histological diagnosis regardless of the clinical diagnosis!
What is your differential diagnosis?
Briefly outline his management
References
Newlands C, Currie R, Memon A, Whitaker S, Woolford T. Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016 May; 130 (S2):S125-S132. doi: 10.1017/S0022215116000554. PMID: 27841126; PMCID: PMC4873942.
What is your differential diagnosis?
· Nodular BCC.
· SCC.
· Amelanocytic melanoma.
Briefly outline his management
· Team work-up; including plastic surgeon, dermatologist and oncologist.
· Skin biopsy, staging and ruling out metastasis.
· Surgical excision with safety margin. Mohs surgery has high cure rates for many forms of skin cancer. For basal cell carcinoma, the cure rate is around 99%. Mohs micrographic surgery (MMS) provides the best long-term cure rate of any treatment modality for BCC. MMS is the gold standard for treating high-risk BCCs and recurrent BCCs because of its high cure rate and tissue-sparing benefit. The high cure rate is attributed to an examination of 100% of all the tissue margins(1).
· Tapering down immunosuppression and shifting TAC to mTORi(sirolimus). Shifting AZA to MMF if the patient on AZA(2).
· Topical 5-flourouracil can be used for refractory lesions.
· 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.
References
1. Al-Adra D, Al-Qaoud T, Fowler K, Wong G. De Novo Malignancies after Kidney Transplantation. Clin J Am Soc Nephrol. 2022 Mar;17(3):434-443. doi: 10.2215/CJN.14570920. Epub 2021 Mar 29. PMID: 33782034; PMCID: PMC8975024.
2. NIH; National Library of Medicine; Basal Cell Carcinoma Brianna McDaniel; Talel Badri; Robert B. Steele. Last Update: September 19, 2022.
Thank you Dr Assafi Ibrahim Annour Mohammed
Well done.
You referred to
Tapering down immunosuppression and shifting TAC to mTORi(sirolimus). Shifting AZA to MMF if the patient on AZA(2).
What skin cancer you use this treatment strategy?
What is your evidence supporting this statement of replacing AZA by MMF as part of treatment of non melanoma skin cancer?
Differential diagnosis is
1)Basal cell carcinoma.
2) Sebaceous hyperplasia
3) Trichoepithelioma.
4) Amelanotic Melanoma
Excisional biopsy is mandatory for diagnosis and prognosis.
Thank you Dr Wael Jebur
you are right biopsy is essential to verify the nature of this lesion or any other similar lesion post solid organ transplant under immunosuppression.
Squamous cell carcinoma could be top on the differential list for this lesion?
Thank you Dr. Mohsen,
I dont think so , as the lesion is typical of BCC, However Basosquamous and metatypical BCC might be showing features of both BCC and SCC.
References:
1) Brian Mcdaniel, Talil Badri and Robert B. Steele. Basal Cell Carcinoma.National library of medicine.September 19 2022.
Squamaous cell carcnoima
Basal cell carcjnoma
First, I will examine the patient.
Then, biopsy of the lesion.
Consult with a dermatologists and oncologists.
Switching of CNI to mTOR inhibitor.
Routine examination and follow up.
Thank you Dr Tufayel Ahmed Chowdhury
Well done.
What important risk associated with mTOR switch? In your risk assessment if you felt this risk is high what alternative approach?
Nodular squamous cell carcinoma
Melanoma
it looks like a transparency nodule with a telangiectasia centre
it locates mainly in the head or neck.
This patient needs to be discussed with MDT and needs a proper physical examination and history taking.
The patient should be counselled regarding recurrence after the kidney transplant, as he will be on immunosuppression medications.
Thank you Dr Rihab Elidrisi
Do you think nodular basal cell carcinoma and keratoacanthoma could be on the differential list?
What is evidence for replacing AZA into MMF as part of the treatment of non melanoma skin cancer?
Diagnosis and Differential diagnosis:
Nodular Basal Cell Carcinoma
Squamous cell carcinoma
Melanoma
Management:
1. Complete physical examination
2. Biopsy of lesion
3. Staging and consult with dermatologist/oncologist.
4. Reduction of immunosuppression: switching from CNI to mTOR, if patient on AZA then switch AZA to MMF, monitor for rejection.
5. Avoid sun exposure, particularly at mid-day, SPF 50+, UVA 5* sunscreen, self-examination.
6. 5 FU therapy, radiotherapy.
Short and precise reply. I wish you could have supported your arguments by uploading scientific evidence with more details.
Ajay
Diagnosis: Nodular basal cell carcinoma(BCC)(1)
Characteristic features include:
Differential diagnosis
Management: must include multidisciplinary tumour board consultation
Step 1: Physical Examination
Thorough skin and lymph node examination
Step 2: Biopsy confirmation of diagnosis
Step 3: Risk stratification
After biopsy confirmation of BCC, there is a high risk of recurrence due to the following features:
Step 4: Modification of immunosuppression (3):
Step 5: Topical therapy (in view of multiple lesions)
Step 6: If still unresponsive
Radiation therapy: with increased risk of non-melanoma skin cancer(NMSC) in irradiated skin after treatment must be explained
Step 7: Systemic therapy(experimental evidence in solid organ transplantation)
Hedgehog pathway inhibitors or immune checkpoint inhibitor: higher chance of rejection with therapy should be explained
Patient education regarding skin cancer and counseling (3)
Follow-up:
Explaining role of systemic chemoprevention(4):It requires continuous administration for chemoprevention
Ensuring patient following all skin care education
References:
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
Thank you,Sir
A 46-year-old CKD 5 patient who was on HD for 4 years secondary to unknown aetiology presented to you in the transplant clinic 3 years after his transplantation with this lesion on the right side of his neck (see below). He is currently on tacrolimus-based immunosuppression with excellent kidney function.
What is your differential diagnosis?
Small lesion in sun exposed area, nodular with capillaries in its surface which might be :
Squamous cell carcinoma.
Basal cell carcinoma.
Briefly outline his management.
Multidisciplinary team (dermatologist , transplant nephrologist, oncologist, social worker, dietitian, clinical psychologist, and others).
Excisional biopsy for final diagnosis.
Reduction of immunosuppression is the main line of treatment.
Shifting of CNI to MTOR inhibitors .
Preventive measure to avoid recurrence such as skin self-examination, sun block and others.
References:
1- Handbook of Kidney Transplantation, Gabriel M. Danovitch, MD.
2- Epidemiology and risk factors for skin cancer in solid organ transplant recipients UP TO DATE 2022.
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
46year old 3 years post-kidney transplantation presents with a lesion in sun exposed area differential diagnosis include basal cell carcinoma, squamous cell carcinoma and keratoacanthoma.
Management should be in collaboration with dermatologist and oncologist which includes, history with interest of their sun exposure and protective practises, the immunosuppression regimen and the tacrolimus trough levels.
A full physical exam looking for other suspicious lesions in good lighting should then be done.
An excision biopsy and histology of the lesion to confirm the diagnosis.
Patient should then be advised on sun protective habits like use of sunscreen with high SPF and star rating, use of protective clothing and avoidance of midday sun.
Reduction of the immunosuppression should then be done since it’s associated with cumulative effect of the immunosuppressive drugs. If there is no resolution of the lesions then the CNI can be switched to MTOR inhibitors. Refractory lesions can be treated with topical 5-flourouracil.
Differential diagnosis;
Post renal transplant on CNI based IS has developed skin lesion on sun exposed area with possibility of malignancy d/d are,
Briefly outline his management;
Excision biopsy with multi-discipline management.
Sun-protection
Self examination(including picture for future reference)
Health care provider examination periodically
CNI to mTOR conversion in case of biopsy prove malignancy if no other contraindication for conversion.
Treatment of malignant lesion according to stage.
What is your differential diagnosis?
Skin cancer including BCC and SCCKeratoacanthomaAmelanotic melanoma
Briefly outline his management
Consultation of a dermatologist is the initial step for evaluation of the need for excisional biopsy in the current situation, and establishment of a definitive diagnosis.
In addition to various types of intervention, the reduction of immunosuppression is the primary focus of treatment for malignant skin cancer. The greatest advantage was seen in patients with Kaposi sarcoma; however, the extent of any benefit seen in patients with melanoma, Merkel cell carcinoma, or basal cell carcinoma is unclear.
But how should we approach the reduction in immunosuppression.
If there are less than 25 NMSCs reported per year, a mild reduction is advised.
If there are more than 25 NMSCs reported each year, a moderate decrease is recommended. High risk SCC also require a moderate reduction in immunosuppression.
In cases of metastatic SCC, a severe decrease is indicative.
Along with reduction of the dose, particularly those involving Kapoci sarcoma, a switch from CNI to sirolimus may be warranted, as use of sirolimus has been associated with a 40% reduction in malignancy, including skin cancer. However, this benefit must be weighed against the increased risk of rejection, cardiovascular, infection-related mortality, and post-transplant diabetes.
If immunosuppression reduction or shifting to sirolimus did not improve skin lesions, other therapeutic approaches should be followed including radiotherapy, cryotherapy, and in metastatic diseases chemotherapy.
5. A 46-year-old CKD 5 patient who was on HD for 4 years secondary to unknown aetiology presented to you in the transplant clinic 3 years after his transplantation with this lesion on the right side of his neck (see below). He is currently on tacrolimus-based immunosuppression with excellent kidney function.
· What is your differential diagnosis? (1)
– Squamous cell carcinoma
– Basal cell carcinoma
– Amelanotic melanoma
– Cutaneous lymphoma
· Briefly outline his management (2)
– Detailed history and thorough physical examination
– Baseline lab tests
– Screen for metastases
– Skin biopsy for histopathologic diagnosis – essential for appropriate management – preferably excision biopsies
– Multidisciplinary approach – engage the dermatologist and oncologist
– Sun protection – sun avoidance, sun-protective clothing, use of sunscreen
– Practice skin self-examination (3)
– Treatment options – based on the presence/ absence of high-risk feature
– Modulation of immunosuppression
– Electrodesiccation and curettage – for small well-differentiated lesions
– Surgical excision for aggressive disease on histopathologic analysis
– Mohs surgery – for patients with additional high-risk features
– Radiation therapy – for patients who cannot tolerate surgery, lesions that cannot be fully excised
– Chemotherapy – for metastatic disease
References
1. Ponticelli C, Cucchiari D, Bencini P. Skin cancer in kidney transplant recipients. J Nephrol. 2014 Aug;27(4):385-94. PubMed PMID: 24809813. Epub 2014/05/09. eng.
2. Kim C, Cheng J, Colegio OR. Cutaneous squamous cell carcinomas in solid organ transplant recipients: emerging strategies for surveillance, staging, and treatment. Seminars in oncology. 2016 Jun;43(3):390-4. PubMed PMID: 27178693. Epub 2016/05/15. eng.
3. 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.
I like that you have supported your arguments by uploading scientific evidence.
Ajay
_Differential diagnosis of the provided photo:
_ any skin lesion in transplant patient should be considered malignancy until probed otherwise (especially older age, more than 2 years lost tranpslant and was on HD for long time).
So possibilities include:
_squamous cell carcinoma (more common than BCC in transplant patient unlike general population where BCC is more common).
_ basal cell carcinoma.
_ non melanotic melanoma.
_Management plan:
_ excisional biopsy to confirm diagnosis.
_ sun protective measures (sunscreen , protective clothes and avoidance of sun exposure around midday).
_ treatment by surgical excision plus topical 5FU .
_syatemic chotherapy in case metastasizing lesions.
_ regular screening by self examination and expert dermatologist examination every 6 months.
_ minimization of IS protocol as CNI withdrawal and shift to sirolimus can help in regression of the lesions.
_ avoid azathioprine as it is well described as a risk factor for skin cancer.
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
A 46-year-old, CKD 5 patient on MHD for 4 years, had kidney transplantation 3 years back on
tacrolimus-based immunosuppression with excellent kidney function.
Presented with erythematous papule on the right side of his neck.
Differential diagnosis:
· Squamous cell carcinoma
· Basal cell carcinoma
· Bowen’s disease – cutaneous squamous cell carcinoma in situ
Management:
· Multi-disciplinary approach: involvement of nephrologist, dermatologist, oncologist.
· To confirm diagnosis excision and biopsy is needed
· For the lesion if SCC, then options are surgical excision, curettage, cryotherapy, photodynamic therapy, radiation for non surgical candidate.
· Regarding Immunosuppression:
– Stop CNI
– Start m-TOR inhibitor eg. Sirolimus
– Reduce dose of MMF and steroid.
· Behavioral therapy: avoid UV light, sunscreen, clothing.
· Frequent skin examination.
Reference: uptodate, lecture from Prof. Halwa
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
What is your differential diagnosis?
Basal cell carcinoma (BCC) most likely
squamous cell carcinoma (SCC)
keratoacanthomas
dermal metastases from internal organs, such as the colon
sebaceous hyperplasia
dermal nevi
Chronic immunosuppression may increase risk for the development of BCC, although the increase in risk is less than that observed for SCC .
The risk for BCC after solid organ transplantation appears to increase linearly over time, whereas the risk for SCC rises exponentially .
As in other populations, sun exposure, phenotype, and other factors influence the likelihood that an organ transplant recipient will develop BCC.
Briefly outline his management
MDT including nephrologist,dermatologist ,oncologist and surgeon.
Clinical assessment, routine labs ,excisional biopsy with histopathology and pan CT scan with pet scan for staging and distant metastasis.
Reference
uptodate
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
Thank you prof
DIFFERENTIAL DIAGNOSIS
SCC
BCC
KERATINOCYTTE CARCINOMA
FEATURES;
RAISED
WELL DEFINED MARGINS
SUN EXPOSED AREA – NECK
ERTHEMATOUS
NON ULCERATED
RISK FACTORS;
SUN EXPOSURE
POST TRANSPLANT.
TACROLIMUS.
MANAGEMENT.
MDT APPROACH – DERMATOLOGIST,ONCOLOGIST,NEPHROLOGIST INPUT.
DO BASELINES –
FHG – LOW HB OR PANCYTOPENIA WOULD INDICATE METS AMONGST OTHER REASONS IN OUR PT.
UECS – TO EVALUATE GRAFT STATUS POST TRANSPLANT.
TAC LEVELS- APPROPRIATE LEVELS DEPENDANT ON TIME POST TRANSPLANT KEY IN AVERTING OR REDUCING MALIGNANCIES POST TRANSPLANT.
CHEST CT SCAN – TO ASSESS SPREAD.
DEFINITIVE – SKIN BIOPSY .- SHAVE OR PUNCH BIOPSY
DEPENDING ON GRADE OF TUMOR ;
1.SURGICAL EXCISION WITH WIDE MARGINS IF LOCALIZED.
2.CRYOTHERAPY IF TUMOR LESS THAN 3MM DEEP.
3.MOHS MICROGRAPHIC SURGERY IF LESION MORE THAN 2CM ON THE TRUNK.
4.RADIOTHERAPY WHERE INDICATED.
5.MEDICAL- 5FU TOPICAL,5% IMIQUIMOD CREAM.
6.SUPPORTIVE,AVOID SUN EXPOSURE,USE SUNSCREEN.
7.SWITCH TO MTOR INHIBITORS SIROLIMUS FROM TAC TO DECREASE RISK OF SKIN MALIGNANCIES.
REFERENCES;
1.Prof Halawa lecture.
2.Uptodate.
3.Nouri K Ballard et al, Basal Cell Carcinoma,China,2008,61-81
There is no need to type in capitals. It is more difficult to read. It amounts to ‘shouting’, though I know well that you are not.
Noted .I will correct that.
postrenal transplant recipient with a nodular lesion in the sun-exposed area so the differential diagnosis is
cutaneous squamous cell and basal cell carcinoma
other differential diagnoses
Merkel cell ca
Bowen’s disease
skin ca in renal transplant recipients has an incidence up to 100 times higher than in the general population and squamous cell CA is the most common type of skin cancer
I like that you have supported your arguments by uploading scientific evidence.
Ajay
A 46-year-old
CKD 5 patient ( unknown aetiology )
HD for 4 years
Kidney transplantation before 3 years
tacrolimus-based immunosuppression
excellent kidney function.
lesion on the right side of his neck look like a scaly, red mark on the skin
● What is your differential diagnosis?
Basal cell carcinoma
SSC
Bowen disease
People who have received a kidney or other solid-organ transplant are at higher risk of skin cancer, because the medications used to prevent rejection impair the immune system’s ability to repair or destroy cells damaged by UV radiation. The risk increases with time
Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), account for the most common malignancies developing in OTRs as a result of chronic immunosuppression, light exposure, and possibly also human papillomavirus infection
● Briefly outline his management
▪︎A personal medical and family history
( how long the lesion has been present, how it has changed, and if it has produced any discharge or bleeding )
▪︎ examin the lesion using a dermatoscope
▪︎Councel the dermatologist.
▪︎If the lesion is benign we reassure a patient that the lesion is nothing to worry about.
《 removing a benign lump, such as a cyst or lipoma has risks to surgery such as bleeding, infection and scarring 》
▪︎If it is a suspention lesion, we need early excision biopsy and treatment of premalignant and malignant lesions
▪︎If biopsy-confirmed cases of BCC
Most superficial BCCs were efficiently treated by cryotherapy (after biopsy), and the remaining ones were treated by simple surgical excision. Contrary to SCCs, which may have an aggressive course,34 in the OTRs we did not encounter BCCs with particularly aggressive behavior, in accordance with the very low BCC-related mortality rate (1%) reported in larger registries.
▪︎consultation with the multidisciplinary transplant team ( transplant surgeons, nephrologists, hepatologists, cardiologists, transplant nurses, dermatologists, oncologists, pharmacists )
▪︎Decrease overall immunosuppression or altered to include newer drugs that have decreased oncogenic potential as MTORs
▪︎patient education on the benefits of UV protection, periodic self-skin examinations, and regular follow-ups.
▪︎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.
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
What is your differential diagnosis?
The skin lesion in the index case is most probably basal cell carcinoma. It is caused secondary to immunosuppression that enhances ultraviolet-induced DNA damage and leads to reactivation of potential oncogenic viruses. The most common skin cancer in transplant recipients is squamous cell carcinoma followed by basal cell carcinoma, while in the general population this ratio is reversed.
DD:
squamous cell carcinoma
Sebaceous Hyperplasia
skin biopsy is an essential tool for appropriate diagnosis.
Briefly outline his management
Firstly prevention:
-Patient education concerning sun protection and skin self examination
–Choice and modulation of immunosuppressive therapy as per immunological risk assessment. Immunosuppression protocol including (mTOR) inhibitors such rather than CNIs may reduce the risk for skin cancer and prolong the time to onset. A few studies have shown that mycophenolate mofetil and mycophenolic acid are associated with a lower risk of skin cancer compared with azathioprine.
-The other alternative to switch immunosuppression is reduction of immunosuppression provided that stable graft function and low immunologic risk.
–Post-transplantation surveillance for skin lesions.
Treatment of BCC:
–Imiquimod is a topical immunostimulatory agent that is used for the treatment of superficial BCC.
–Standard surgical excision :For primary, nodular or superficial BCC <20 mm.
–Curettage and electrodesiccation
-Cryosurgery
-Radiation therapy
References:
-Stoff B, Salisbury C, Parker D, O’Reilly Zwald F (2010) Dermatopathology of skin cancer in solid organ transplant recipients. Transplant Rev 24(4):172–189.
–Euvrard S, Morelon E, Rostaing L, et al. Sirolimus and secondary skin-cancer prevention in kidney transplantation. N Engl J Med 2012; 367:329
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
-What is your differential diagnosis?
· Mostly Basal cell carcinoma due to clinical scenario and the site being sun exposed which is side of the neck
· Squamous cell carcinoma
· Actinic Keratosis
· Bowen Disease
· Cutaneous T-Cell Lymphoma
· Malignant Melanoma
· Melanocytic Nevi
· Molluscum Contagiosum
· Sebaceous Hyperplasia
-Briefly outline his management
The patient has to be refered to a dermatologist .
Skin biopsy is needed to confirm diagnosis ,subtype and stages of BCC ,usually a shave biopsy can be suitable
Since basal cell carcinoma rarely metastasizes, lab and imaging tests are not needed with localized lesions but if deeper involvement is suspected then CT scan be done.
Surgery is the main therapy and the approach varies according to tumor size, depth, and location.
High-risk cases need excision with postoperative margin assessment or a Mohs resection.
Local therapy with chemotherapeutic and immune-modulating agents can be used in small superficial lesions
Topical 5% imiquimod or 5 Fluorouracil can be applied for superficial lesions
Photodynamic Therapy used in treatment and prevention of BCC
Regular screening and follow up is crucial because recurrence rate is high and there is a risk of developing NMSC or melanoma .
Behavioural educational programmes are essential to educate the patient about sun protection and UV radiation hazards.
Tacrolimus can be switched to m TOR due to it’s anticarcinogenic effect with following of the renal function.
Reference
– Bader R. S. et al , Basal Cell Carcinoma Differential Diagnoses, Medscape 2022
– Trakatelli M, Morton C, Nagore E, Ulrich C, Del Marmol V, Peris K, et al. Update of the European guidelines for basal cell carcinoma management. Eur J Dermatol. 2014 . 24 (3):312-29.
– National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Basal Cell Skin Cancer. NCCN. Version 1.2022 — November 17, 2021; Accessed: February 14, 2022.
I like that you have supported your arguments by uploading scientific evidence.
Ajay
In sun exposed area in patient with renal transplantation, skin malignancy should be considered
1- SCC
2- BCC
3- amelaotic melanoma
1- for lesion:
excisional biopsy
if malignant: work up for metastasi
referral to oncologist
2- Immunosuppression:
Short and precise reply. Although my first diagnosis is BCC, yet this was diagnosed SCC on histopath.
Ajay
A skin lesion 3 yrs after transplant , in sun exposed area of neck need evalation in view of skin cancer
DIFF DIAGNOSIS
SCC , MORE COMMON THAN BCC , AND TOGETHER 90% PROBABILTY IN SUCH SCENARIO
BCC
AMELANOTIC MELANOMA
NEUROFIBROMATOUS LESION
LIPOMA
MERKEL CELL CARCINOMAA
APPROACH AND MANAGEMENT
EDUCATION OF PATIENT TO REDUCE SUN EXPOSURE
SELF EXAMINATION OF ENTIRE BODY
MULTIDISCIPLINARY APPROACH WITH DERMATOLOGIST
SURGICAL ONCOLOGIST WITH BIOPSY OF LESION FOR HISTOPATHOLOGY DIAGNOSIS
OVERALL REDUCTION OF CNI AND STEROIDS AND AZATHIOPRINE WITH ADDITION OF mTOR INHIBITORS ARE CONSIDERED
MOST LESIONS RESOLVES WITH THI APPROACH
FOR MULTIPLE LESIONS AND VISCERAL EXTENSION , CHEMOTHERAPY CAN BE CONSIDERED
RECURRENCE IS COMMON AND EDUCATION OF PATIENT IS MUST
WHITS ARE MORE PRONE SO COUNSELLING IS ADVISED
USE OF SUN SCREENS , CAPS , CLOTHS FOR EXPOSED AREA
What is your differential diagnosis?
Melanoma
Keratoacanthoma
Basal cell carcinoma
squamous cell carcinoma
HPV
Hemangioma
Intradermal nevus
Fibroadenoma
Briefly outline his management
There is a need for joint follow-up with Dermatology and a biopsy of the lesion with free margins for diagnosis and possible treatment.
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 CNI and consider Sirolimus
– If the cause is infectious, consider decreasing immunosuppression as renal function is normal and there are no signs of rejection.
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Merkle cell cancer
Incidence of squamous cell carcinoma more evident than basal cell carcinoma post kidney transplant in comparison to general population; squamous cell carcinoma is 100 times more in kidney transplant and basal cell carcinoma is 10 times evident post transplant.
Basal cell carcinoma more aggressive, it’s has high risk of metastasis and recurrence and may occur in multiple locations and more evident in young age groups.
Reduce immunosuppressive dose and shift azathioprine to MMF
Free calcinurine inhibitors and use of mTOR inhibitors
Avoid ultraviolet ray
Use of sunscreen with high SPF
immunocryosergery
Fallow up by dermatologist and oncologist annually screening for skin cancer.
Reference:
Voloshyna D, Shaik T, Shrestha S, et al. Coexistence of Cutaneous Squamous Cell Carcinoma and Basal Cell Carcinoma in a Renal Transplant Recipient: A Case Report. Cureus 14(9): e28764. doi:10.7759/cureus.28764
( September 04, 2023).
Thank you Dr Sahar Kharraz
You referred to Basal cell carcinoma more aggressive, it’s has high risk of metastasis and recurrence!
Can you please review these statements?
You also referred to: Reduce immunosuppressive dose and shift azathioprine to MMF?
Do you think switching from Aza to MMF will reduce immunosuppression?
Is there any better way to avoid risk of graft rejection with immunosuppression for this lesion?
You added melanoma to your differential? what features that suggest melanoma?
What is your differential diagnosis?
The patient is post- KT on Tacrolimus based IS, he has flesh- or pink-colored, pearly papules in sun exposed area.
Differential diagnosis:
-Non-melanoma skin cancers: cSCC and BCC on top of DD.
· Skin cancer Account for almost 40 % of malignancies in SOT.
· The most common skin cancer in transplant recipients is SCC followed by BCC, while in the general population this ratio is reversed.
-Other differential includes:
· Amelanotic melanoma.
· Dermatofibroma.
· Intradermal nevus.
· Metastatic skin lesion.
Briefly outline his management:
-A biopsy should be performed in all patients to confirm the diagnosis and determine the histologic subtype.
– Dermatology and oncology team opinion is essential.
– Thorough examination for other lesions, LN.
– CT looking for metastases.
– The treatment will be guided by the histopathological finding, staging. Options include: surgery, radiation, and Topical therapy 5-FU,and systemic therapy if there is metastases.
– Reduction of immunosuppression.
– Switch from Tacrolimus to mTORi.
– Frequent skin examination and surveillance for development od any skin lesion.
– Sun protective methods. Avoid mid-day sun exposure, avoid bed tanning, apply broad spectrum sunscreen, Patients should cover up with long sleeved shirts and pants, wear a hat and sunglasses when outdoors.
References;
· Ponticelli, C., Cucchiari, D. & Bencini, P. Skin cancer in kidney transplant recipients. J Nephrol 27, 385–394 (2014). https://doi.org/10.1007/s40620-014-0098-4.
· Euvrard S, Kanitakis J, Claudy A. Skin cancers after organ transplantation. N Engl J Med. 2003 Apr 24;348(17):1681-91. doi: 10.1056/NEJMra022137. PMID: 12711744.
· UpToDate.
Well done Dr Hadeel Badawi
Do you need immunosuppression reduction in a lesion like this? In case you answer yes, when this is indicated?
– Standard surgical treatments; superficial destructive modalities and surgical techniques including curettage, cryosurgery, wide local excision, and Mohs micrographic surgery are usually effective
– Systemic agents for locally advanced and metastatic BCC.
– Intensity and duration of IS appear to promote the development of SK in SOT.
– Reduction of IS as a strategy to manage Kaposi sarcoma and PTLD is effective and well established.
-in NMSK; No guideline established about what threshold of cancer development would warrant initiation of reduction of IS, may be considered if:
· Numerous lesions.
· Recurrent disease.
· Metastatic disease.
· High-risk skin cancers that may metastasize and cause death.
– An expert consensus by the International Transplant Skin Cancer Collaborative and Skin Care for Organ Transplant Patients Europe Reduction of Immunosuppression Task Force has been published. They suggested mild IS reduction in kidney allograft recipient with History of =< 1 NMSC per year (negligible risk of mortality, =< 1 minor surgical procedure per year; patients handle this with ease; warning sign of possible future skin cancers).
-Trial that compared sirolimus-based versus CNI-based IS in KT recipients with one or multiple cutaneous SCCs:
· Sirolimus group maintained a lower SK rate over 5 years, with no difference in rejection or mortality between the two groups
· At five years, the rates of new skin cancers in the sirolimus group were significantly lower than those in the CNI group (22 vs 59 % for SCC, 20 vs 37.5 % for BCC, and 34 vs 66 % for other skin cancers).
· The benefit was most marked in patients who converted to a sirolimus-based regimen after the development of the first cutaneous SCC HR 0.20
Conclusion:
In this case, I will start with the surgical management if there is no other lesions, no mets. IS reduction may be considred according to consensus opinion.
References:
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
.
Basal cell carcinoma.
Merkel cell carcinoma.
Squamous cell carcinoma.
Basal Cell Carcinoma:
Basal cell carcinoma is the most common type of non-melanoma skin cancer. This type of cancer often looks like a pink waxy bump that may bleed following minor trauma.
· Shave biopsy: Most often, the only biopsy that is required
Management:
The current standard of care for BCC is surgical excision with methods similar to those detailed for cutaneous SCC.
Techniques used include the following:
· Electrodesiccation and curettage
· Mohs micrographically controlled surgery
· Cryosurgery
In very rare instances, BCC may be locally advanced or metastasize. For these patients, newer tar-geted therapies may be a promising option.
Radiation therapy
BCCs are usually radiosensitive; radiation therapy (RT) can be used in patients with advanced and extended lesions, as well as in those for whom surgery is not suitable
Pharmacologic therapy
Topical agents used in the treatment of superficial BCC include the following.
· Topical 5-fluorouracil 5%: May be used to treat small, superficial BCCs in low-risk areas
· Imiquimod: for the treatment of nonfacial superficial BCC
· Tazarotene: Can also be used to treat small, low-risk BCCs.
Oral agents approved by the FDA for advanced forms of BCC include the following Hedgehog pathway inhibitors (HHIs):
· Vismodegib (Erivedge)
· Sonidegib (Odomzo)
The checkpoint inhibitor cemiplimab (Libtayo) is approved for patients with locally advanced BCC and has been granted accelerated approval for metastatic BCC previously treated with an HHI or for whom an HHI is not appropriate.
Reference:
1_Dennis P Kim, Kylee J B Kus, Emily Ruiz. Basal Cell Carcinoma Review.Hematology/oncology Clinics of North America 2019 February
2_Michel Dandurand, Thomas Petit, Philippe Martel, Bernard Guillot. Management of basal cell carcinoma in adults Clinical practice guidelines.European Journal of Dermatology : EJD 2006 July.
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
Differential diagnosis:
Ø Basal cell carcinoma
Ø Melanoma
Ø Squamous cell carcinoma
Management :
Biopsy
Surgical excision
Immunosuppressant modulator start sirolimus .
Sun protection and use sun screen
Follow up with dermatological department .
To do further imaging and work up for the patient.
Oncogenic viral screen .
References :
1-Engels EA, Pfeiffer RM, Fraumeni JF Jr, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011;306:1891–1901.
· What is your differential diagnosis?
The index patient transplant recipient (on tacrolimus, with excellent graft function) presented 3 years post-transplant with a small nodular lesion over his neck (sun-exposed region).
The differential diagnosis in this scenario include (1,2):
1) Skin malignancy (Basal cell carcinoma- BCC, Squamous cell carcinoma – SCC, amelanotic melanoma)
2) Infectious lesion (non-tuberculous mycobacteria, fungal infections)
· Briefly outline his management
The patient requires a dermatology consultation and histopathological diagnosis by performing a biopsy of the lesion. Oncologist should be involved in widespread/ metastatic disease.
In case of skin cancer, the treatment includes:
1) Reduction in immunosuppression
2) Change of immunosuppression from Tacrolimus to mTOR inhibitors
3) Behavioural intervention with respect to sun-protection measures
4) Surgical resection of the lesion
5) Diagnosis specific treatment (3):
a. Basal Cell Carcinoma: Curettage, cryosurgery, wide local excision, Mohs micrographic surgery and systemic therapy like vismodegib and sonidegib.
b. Squamous Cell Carcinoma: Mohs surgery and wide local excision, Systemic therapy and radiation therapy in metastatic disease.
References:
1) Al-Adra D, Al-Qaoud T, Fowler K, Wong G. De Novo Malignancies after Kidney Transplantation. Clin J Am Soc Nephrol. 2022 Mar;17(3):434-443. doi: 10.2215/CJN.14570920. Epub 2021 Mar 29. PMID: 33782034; PMCID: PMC8975024.
2) Caroti L, Zanazzi M, Rogasi P, Fantoni E, Farsetti S, Rosso G, Bertoni E, Salvadori M. Subcutaneous nodules and infectious complications in renal allograft recipients. Transplant Proc. 2010 May;42(4):1146-7. doi: 10.1016/j.transproceed.2010.03.115. PMID: 20534246.
3) 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.
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
This lesion looks like an erythematous, demarcated papule in sun exposure area like the neck, likely clinical diagnosis of cutaneous Squamous cell carcinoma lesion vs BCC ( basal cell carcinoma , Dermo scope and a skin biopsy required to confirm the diagnosis and permitted for staging, prognosis and further treatment plan.
Usually this type of skin lesion arises from the sites with regular sun exposure like head neck, and extremities, lower limbs and non-sun exposed area like genital skin and cutaneous lesions more with HPV infection .
Differential diagnosis is wide including other non -melanoma skin lesion, like malignant , early Cutaneous squamous cell carcinoma in situ, cSCC in situ (Bowen’s disease) which can be differentiated by histopathologic examination reveals keratinocytes dysplasia involving the full thickness of the epidermis without infiltration of atypical cells into the dermis actinic keratoses demonstrate only partial-thickness epidermal dysplasia and very similar to the SCCwith scale overlying the erythematous macules. ·invasive cSCCs have dysplastic keratinocytes involving the full thickness of the epidermis that penetrate the epidermal basement membrane to involve the dermis or deeper tissues
·Several histopathologic variants of invasive cSCC exist, including spindle cell SCC, acantholytic (adenoid) cSCC, clear cell cSCC, adenosquamous (mucin-producing) cSCC, desmoplastic cSCC, single-cell cSCC, and others(1,2).
Other DDX Prugio nodularis which looks like A close-up of a pink, crusted nodule. Or Merkel cell carcinoma dome like nodular lesion .
Briefly outline his management
1.Preventive measures including raise awareness and proper education about the self- skin examination and care for any new lesions , sun protective measures like sunscreen and protective clothes .
2.Diagnosis and intervention is important as such skin tumors are behaving very aggressive over time, with modification of immunosuppression change to sirolimus or everolimus based IS
3. surgical excision BY using the mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue which is preferred in treatment of high risk locally invasive BCC , SCC
References
1. Histopathological variants of cutaneous squamous cell carcinoma: a review.Yanofsky VR, Mercer SE, Phelps RG J Skin Cancer. 2011; 2011:210813. Epub 2010 Dec 29.
2.Histologic subtyping and malignancy assessment of cutaneous squamous cell carcinoma.
Petter G, Haustein UF Dermatol Surg. 2000;26(6):521.
3.prevention of non-melanoma skin cancer in organ transplant patients by regular use of a sunscreen: a 24 months, prospective, case-control study.Ulrich C, Jürgensen JS, Degen A, Hackethal M, Ulrich M, Patel MJ, Eberle J, Terhorst D, Sterry W, Stockfleth E Br J Dermatol. 2009;161 Suppl 3:78.
4. Prevention and management of skin cancer in solid organ transplant recipient. Up to date medicine accessed 17.1.2023.
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
References;
1.ITSCC
2.Basal Cell Carcinoma, Continuing Education Activity by Brianna McDaniel et.al
What is your differential diagnosis?
This is a raised lesion with some vascularity and lack of melanin.
The possibilities include :
BCC
Squamous cell carcinoma
Amelanotic melanoma
Deramtofibroma
Keratosis
Skin infections
Drug reactions
Briefly outline his management
I will seek dermatology consultation and then consider an excision biopsy. If lesion is malignant then further workup for systemic involvement will be done
Modification of immune suppression. shift from Tacrolimus to Sirolimus can help in reduction and resolution of lesion.
Dantal J, Morelon E, Rostaing L, et al . Sirolimus for Secondary Prevention of Skin Cancer in Kidney Transplant Recipients: 5-Year Results. J Clin Oncol. 2018 Sep 1;36(25):2612-2620.
History
====================================================================
What is your differential diagnosis?
Others
====================================================================
Briefly outline his management
Most basal cell carcinomas may be treated by one of the following methods.
The choice of treatment is influenced by:
Physical:
1- Electrodesiccation and curettage is an appropriate choice for low-risk primary nonfibrosing tumors.
2- Consider cryotherapy for low-risk BCC when more effective therapies are contraindicated or impractical.
3–If surgical excision of BCC is not feasible, contraindicated, or not preferred by the patient, radiotherapy is an additional treatment option.
4- Mohs micrographic surgery has the lowest recurrence rate.
5- Radiotherapy requires multiple sessions, and postradiation changes can include dyspigmentation and radiodystrophy.
6- Protection from further skin exposure.
Medical
Chemotherapy(topical chemotherapy (5-Fluorouracil (5-FU)))
Immune Response Modifiers(Imiquimod 5% Cream)
====================================================================
Reference
It is very well structured. I like that you have supported your arguments by uploading scientific evidence.
Ajay
Thanks alot Prof.Sharma for your support
Differential diagnosis:
Brief outline of managemant:
Surgery:
Immuntherapy:
Topical chemotherapy:
Refferences:
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.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Basal Cell Skin Cancer. Version 1.2019. Accessed at http://www.nccn.org/professionals/physician_gls/PDF/nmsc.pdf on June 4, 2019.
Short and precise reply. I like that you have supported your arguments by uploading scientific evidence with more details.
Ajay
What is your differential diagnosis?
This is a well-defined vascularized raised skin lesion (nodular) in the neck (sun exposed area) most likely diagnosis is Basal cell carcinoma. Other differential diagnosis are:
Squamous cell carcinoma, intradermal nevus, Fibroepithelioma of Pinkus, Adnexal carcinoma, Sebaceous hyperplasia, and metastatic malignancy.
However, SCC is more common than BCC in solid organ transplantation patients. Sun exposure is the cause in non-melanoma skin cancers.
Briefly outline his management:
Refer the patient to a dermatologist for diagnosis – and biopsy.
Prevention is better than cure – I would highlight the effect of behavioral and pharmacological measures of sun exposure protection measures, including clothing, sun protective factor and avoid mid-day sun exposure.
The treatment includes:
– Surgery: Complete removal of the tumor, correct any functional impairment cuased by tumor, and give the best cosmetic results.
– Radiation: when surgery is contraindicated.
– Cryosurgery: is another treatment option for low risk BCC.
– Topical therapy: 5-FU and Imiquimod 5% cream for superficial/multiple BCC.
– In organ transplant patients: stop MMF and CNI and substitute them with sirolimus (m-TOR inhibitor). With pretreatment quantification of urinary protein and regular monitoring of urinary protein.
References:
– McDaniel B, Badri T, Steele RB. Basal Cell Carcinoma. 2022 Sep 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 29494046.
– James LJ, Saglimbene V, Wong G, Tong A, Luu LDW, Craig J, Howard K, Howell M. Behavioural and pharmaceutical interventions for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomised controlled trials. BMJ Open. 2020 May 17;10(5):e029265. doi: 10.1136/bmjopen-2019-029265. PMID: 32423925; PMCID: PMC7239542.
Yes Dr Hasan.
This was shown to be SCC on histopathology, though my first impression is that of BCC.
Lesson: biopsy of such lesions is must.
Dear All
Thank you very much. What is the take-home message?
Self-skin examination monthly and total skin examination by dermatologist / 6-12 months is advised to detect early skin lesions.
Any skin lesion appears after transplantation should be taken seriously.
Dermatological consultation is mandatory.
Definitive diagnosis should be settled by excision biopsy.
Assessment of lymph node involvement and distant metastasis is important especially in aggressive lesions.
Behavioral therapy for sun protection is important (sun screen, protective clothing, avoiding mid day sun exposure).
Reduction of immunosuppression or conversion from CNI to sirolimus will be beneficial only in recurrent, aggressive or metastatic skin tumors and should be balanced against the risk of AR and adverse effects of mTORS.
Local therapy, systemic chemotherapy (in case of metastasis) and chemoprophylaxis (in recurrent NMSC) may be needed according to the case.
1.Frequent examination of the skin after organ transplantation.
2.behavioral and pharmacological sun exposure protection measures- brochures, mobile applications .. etc.
3.early conversion to sirolimus post transplant could be a successful option to decrease cancer incidence.
focus on preventive measures by increasing awareness among the patients at risk by proper education regarding self-examination and work on modifiable risk factors like sun UV light protection by using sunblock, early screening, Limiting skin exposure, dermatologic screening, and prophylactic retinoids can help lower the incidence rate of skin malignancy, rationalized the immunosuppression use and limit the exposure CNI, viral screen, vaccination and use antiviral therapy to limit the further risk of skin malignancies with some oncologic viral infections
American Academy of Dermatology Skin Center Resource Center
1) Regular self-examination of skin
2) Sun-protection measures to be taken at all times
3) Dermatology consultation in case a new skin lesion is detected
4) Biopsy of the lesion for definitive diagnosis and management is essential.
5) Early detection and treatment of skin malignancies will lead to better outcomes.
Skin cancer is the most common malignancy post kidney transplant.
We should be highly suspicion.
Biopsy is mandatory for diagnosis.
Dermatological review is mandatory.
Reducing the immunosuppression is the corner stone in the treatment.
What is your differential diagnosis?
Briefly outline his management >
Hi Dr Omar,
I do not like your 3,4,5th among differentials.
Why one would do FNAC for this?
I like your suggestion of excisional biopsy.
Ajay
What is your differential diagnosis?
Briefly outline his management
Surgical excision with margin control is the preferred treatment for invasive SCCs in these patients to prevent local recurrence and disease spread.
There are no definitive guidelines regarding alterations in immunosuppressive regimens in patients with BCC, melanoma, or Merkel cell carcinoma. The risks and benefits of a reduction in immunosuppression should be considered carefully.
The impact of specific immunosuppressants on the development of skin cancer is unclear.
Tumor development seems to be most related to the intensity and duration of immunosuppression.
Compared with other immunosuppressive regimens, immunosuppression with mTOR inhibitors may reduce the risk of nonmelanoma skin cancer in organ transplant recipients.
Reference :
-Euvrard S, Morelon E, Rostaing L, Goffin E, Brocard A, Tromme I, et al. Sirolimus and secondary skin-cancer prevention in Kidney Transplantation. New England Journal of Medicine. 2012;367(4):329–39.
Many thanks Dr Nazer
DD of skin lesion post renal transplant:
1- skin infections; skin nodules may reflect systemic infections
2-skin cancers
3-drug induced
L Caroti, M Zanazzi, P Rogasi, E Fantoni, S Farsetti, G Rosso, E Bertoni, M Salvadori. Subcutaneous nodules and infectious complications in renal allograft recipients. Transplant Proc. 2010 May;42(4):1146-7
Choon Chiat Oh, Haur Yueh Lee, Bien Keem Tan, Pryseley Nkouibert Assam,Terence Yi Shern Kee, Shiu Ming Pang.Dermatological conditions seen in renal transplant recipients in a Singapore tertiary hospital. Singapore Med J. 2018 Oct; 59(10): 519–523.
management:
1- skin biopsy
2- shift from tacrolimus to sirolimus
Your reply is too brief. I like your DD
What is your differential diagnosis?
Briefly outline his management
A- Dermatology consultation and assessment for the need for excision biopsy in the current case, and setting a definite diagnosis
B- Reduction of immunosuppression
Maximum benefit was observed in Kaposi sarcoma, may have benefit in SCC but benefit is not clear in melanoma, BCC and Merkel cell carcinoma. Benefit should be weighed against risk of graft failure
C- Modification of immunosuppression
In summary, I will do excision biopsy and if it revealed BCC I will assure the patient and I will do nothing except keeping tacrolimus level between 5-7 and avoid higher level and consider mild reduction of tacrolimus level if recurrence occur
REFERANCES
1- uptodate
Hi Dr Yusuf,
Besides BCC and SCC, I would keep amelanotic melanoma as one of the posssibilities.
•My DD? Nodular basal cell carcinoma
•Basal cell carcinoma cell carcinoma should be differentiated from Squamous cell carcinoma , melanoma and , Keratoacanthoma, Dermatofibroma, dermatofibrosarcoma, Sebaceous hyperplasia, Kaposi sarcoma..
•Basal cell carcinoma=> Papule => Flesh-colored=> Focused, bright red, and branching arborizing vessels, Loosely arranged blue-gray dots=> “rolled” border=> Sun-exposed areas, Head (cheek and nose), Trunk
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 Exposure
•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 all your differentials that you have mentioned Dr Abdelhamid.
You do not need to type in bold unless it is a heading or sub-heading.
Ajay