Guarding against nonmelanoma skin cancer in solid organ transplant recipients
Periodic skin examination and ongoing counseling are central in your posttransplantation care of these patients at high risk of skin malignancy.
PRACTICE RECOMMENDATIONS
› Conduct a full-body skin examination at least once annually for solid organ transplant recipients. C
› Encourage daily use of broad-spectrum SPF ≥ 30 sunscreen and sun-protective clothing (long sleeves, pants, wide-brimmed hats) for these patients. A
› Consider chemoprophylactic agents for patients at especially high risk of nonmelanoma skin cancer. A
› Treat nonmelanoma skin cancer in a solid organ transplant recipient aggressively because of their increased risk of recurrence, local invasion, and metastasis. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Risk factors for invasive growth, recurrence, or metastasis of cSCC in SOTRs are multiple lesions or satellite lesions, indistinct clinical borders, rapid growth, ulceration, and recurrence after treatment.60 The risk of invasive growth, recurrence, and metastasis of cSCC also increases with size and location of the lesion, according to this framework60:
- any size in scar tissue, areas of chronic inflammation, and fields of prior radiation therapy
- ≥ 0.6 cm on hands, feet, genitalia, and mask areas of the face (central face, eyelids, eyebrows, nose, lips, chin, mandible, and temporal, preauricular, postauricular, and periorbital areas)
- > 1 cm on cheeks, forehead, neck, and scalp
- > 2 cm on the trunk and extremities.
In addition, specific findings on histologic analysis portend increased risk of invasive growth, recurrence, or metastasis:
- poor differentiation
- deep extension of the tumor into subcutaneous fat
- perineural invasion or inflammation
- perivascular or intravascular invasion.
Treatment modalities
Mohs surgery is preferred to ensure margin clearance while preserving noninvolved tissue3,7 (FIGURE 4). If Mohs surgery is not possible, the lesion should be excised with 3- to 10-mm margins.3,60 Based on current literature, the roles of nodal staging, sentinel lymph node biopsy, and adjuvant therapy are not well defined, but it is likely that these interventions will play a pivotal role in the management of advanced cSCC in SOTRs in the future.3
Nonsurgical therapeutic options for primary or adjuvant treatment of cSCC include systemic chemotherapy, radiotherapy, and programmed cell death protein 1 inhibitors. (For more on treatment modalities, see TABLE 3.3,7,58-61)
Recommendations: Treating BCC
BCC in SOTRs is treated similarly (TABLE 33,7,58-61) to how it is treated in the immunocompetent population—except that SOTRs require closer follow-up than nontransplant patients because they are at higher risk of recurrence and new NMSCs.3 Standard management after biopsy is either3,61:
- Mohs surgery to ensure margin control (for most BCCs on the head and neck and those with clinical or histologic risk factors for recurrence or aggressive behavior)
- excision with a 4- or 5-mm margin or a destructive modality (for BCCs on the trunk and extremities without risk factors for recurrence).
Radiotherapy is an alternative for patients with high-risk BCCs who are unable to tolerate surgery.3
CORRESPONDENCE
Lindsey Collins, MD, Department of Dermatology, University of Oklahoma Health Sciences Center, 619 NE 13th Steet, Oklahoma City, OK 73104; Lindsey-Collins@ouhsc.edu
