Peggy A. Wu

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Severe cutaneous eruptions on telaprevir

[1] Parker HM, Johnson NA, Burdon KA, Cohn JS, OConnor HT, George J. Omega-3 supplementation and non-alcoholic fatty liver disease: a systematic review and meta-analysis. J Hepatol 2012;56:944–951. [2] Kris-Etherton PM, Harris WS, Appel LJNutrition Committee of the American Heart Association. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease [Erratum appears in Circulation 2003;107:512]. Circulation 2002;106:2747–2757.

Simultaneous occurrence of infantile hemangioma and congenital melanocytic nevus: Coincidence or real association?

Both infantile hemangiomas (IH) and congenital melanocytic nevi (CMN) are common birthmarks that affect approximately 4% to 5% of infants and 1% of newborns, respectively. No previous association has been established between these birthmarks. We report a series of 6 patients who were remarkable for either the proximity or extent of anatomic involvement of their IH and CMN. Patient 1 had a large CMN in the area of her left eye and upper face in addition to a parotid IH. Likewise, patient 5 had a giant CMN on her back and a beard distribution IH. Patients 2, 3, and 4 were found to have small CMNs and localized IH in close anatomic proximity. Patient 6 was seen for a large left parietal scalp CMN with satellite nevi and multiple cutaneous hemangiomas. Although IH and CMN are common birthmarks, the clinical characteristics in these cases suggest a real, not coincidental association. Possible pathogenetic mechanisms to explain this association are discussed.

Topical Tretinoin, Another Failure in the Pursuit of Practical Chemoprevention for Non-Melanoma Skin Cancer

Given the high incidence of non-melanoma skin cancer (NMSC), a preventative intervention would be desirable. Except for regular sunscreen use, the quest for chemoprevention of NMSC in the general population has been unsuccessful. Weinstock et al. assessed the effects of 0.1% topical tretinoin on NMSC. Like earlier efforts at chemoprevention, this study failed to show therapeutic benefit. Future successful preventative strategies will likely rely on short-term, intermittent therapy or treatments used for other common indications.

Parenteral Nutrition-Associated Cholestasis Related to Parental Care

Parenteral nutrition-associated cholestasis (PNAC) is a complication not uncommon in the pediatric population. In severe cases, patients require a liver transplant. To our knowledge, we report the only case of PNAC with end-stage liver failure in a child with short bowel syndrome that resolved with a change in caretaker. Until his care was transferred from his abusive parents, he was frequently admitted for infection and sepsis. His liver function vastly improved from aspartate aminotransferase (AST) 3139 units/L, conjugated bilirubin 25.9 mg/dL to AST 47 units/L, direct bilirubin 0.3 mg/dL under the care of his attentive foster mother, and a liver transplant was no longer necessary. Bacterial infection and sepsis are risk factors correlated with patients with PNAC requiring liver transplant. Prevention of infection by a good caregiver may be a means to reduce the incidence of PNAC.

Degree of clinical concern and dysplasia affect biopsy technique and management of dysplastic nevi with positive biopsy margins: Results from a survey of New England dermatologists

REFERENCES 1. Hantash BM, Stewart DB, Cooper ZA, et al. Facial resurfacing for nonmelanoma skin cancer prophylaxis. Arch Dermatol. 2006;142:976-982. 2. Ostertag JU, Quaedvlieg PJ, Neumann MH, Krekels GA. Recurrence rates and long-term follow-up after laser resurfacing as a treatment for widespread actinic keratoses on the face and scalp. Dermatol Surg. 2006;32:261-267. 3. Weiss ET, Brauer JA, Anolik R, et al. 1927-nm fractional resurfacing of facial actinic keratoses: a promising new therapeutic option. J Am Acad Dermatol. 2013;68:98-102. 4. Olsen EA, Abernethy ML, Kulp-Shorten C, et al. A double-blind, vehicle-controlled study evaluating masoprocol cream in the treatment of actinic keratoses on the head and neck. J Am Acad Dermatol. 1991;24(5 Pt 1):738-743. 5. Morton CA, Szeimies RM, Sidoroff A, et al. European guidelines for topical photodynamic therapy part 1: treatment delivery and current indications—actinic keratoses, Bowen’s disease, basal cell carcinoma. J Eur Acad Dermatol Venereol. 2013;27: 536-544. 6. Werner RN, Sammain A, Erdmann R, et al. The natural history of actinic keratosis: a systematic review. Br J Dermatol. 2013; 169:502-518.

Leukocytoclastic vasculitis sparing a tattoo with halo effect

The phenomenon of cutaneous diseases sparing sites of previous trauma has been described, although there are few case reports that illustrate this rare phenomenon. We report an unusual case of leukocytoclastic vasculitis (LCV) that completely spared tattooed skin with an additional halo effect around the tattoo.

Safety of Cupping During Bevacizumab Therapy

OBJECTIVES This study reports on the safety of the complementary and alternative medicine (CAM) practice of cupping in a patient undergoing concomitant therapy with bevacizumab for advanced non-small-cell lung cancer (NSCLC), and raises awareness of the need for improved communication between CAM practitioners and oncologists during the care of patients with cancer. The practice of cupping generates local hyperemia, disrupts superficial vasculature in the dermis, and leads to cutaneous lesions including circular erythema, edema, and subsequently ecchymosis. There are no data on the safety of cupping in patients being treated with bevacizumab. DESIGN This is a single-institution case report. SETTINGS/LOCATION The setting for this study was a tertiary-care academic medical center. CONCLUSIONS A patient with advanced NSCLC received four cycles of carboplatin AUC 6, paclitaxel 200 mg/m(2), and bevacizumab 15 mg/kg, and was continued on every-3-week maintenance bevacizumab 15 mg/kg. The patient underwent glass dry cupping during cycle six of maintenance bevacizumab treatment without overt cutaneous adverse events or bleeding. The patient did not realize he should have communicated his cupping plans or recent bevacizumab treatment with his providers.

Interventions for mycosis fungoides: critical commentary on a Cochrane Systematic Review.

The authors performed a systematic review of randomized controlled trials (RCTs) on interventions for any stage of typical mycosis fungoides (MF). They searched electronic databases including the Cochrane Central Register of Controlled Trials, Medline, Embase, and the Latin American and Caribbean Health Science Information database, and included reports from conference proceedings and unpublished data without language restrictions. The authors also searched trial registries affiliated with the U.S.A., Australia, the World Health Organization and the European Organisation of Research and Treatment of Cancer for studies on ‘mycosis fungoides’ or ‘cutaneous T‐cell lymphoma’. These searches were supplemented by correspondence with the groups or individuals who conducted the RCTs.

How Likely Is Another Nonmelanoma Skin Cancer?: Better Informing Patients and Clinicians

Among white non-Hispanics older than 50 years, nonmelanoma skin cancer (NMSC) incidence is likely to exceed 3.5 million annually in the United States.1 From a clinical and public health perspective, identifying the characteristics of those at the highest risk would allow allocating limited resources to screen those most at need. Those with a prior NMSC are known to be at high risk, but data on the magnitude of and patient characteristics related to this risk are particularly important in deciding how these patients should be monitored. The United States Preventive Services Task Force (USPTF) and the National Cancer Institute (NCI) do not recommend skin cancer screening for all at-risk persons. The number of persons at risk for NMSC greatly exceeds the total number of visits each year to dermatologists. With a prevalence exceeding 13 million persons with a history of at least 1 NMSC,2 current annual screening of patients with a history of NMSC would alone account for more than one-third of visits to dermatologists.3,4 In this issue of JAMA Dermatology, Wehner et al5 provide data that help to identify patients at highest risk for subsequent NMSCs and highlight additional information needed to rationally direct resources for monitoring patients with this history. This study of 1284 immunocompetent patients with NMSC treated at a university academic practice and the San Francisco Veterans Administration assessed timing of subsequent basal cell cancer (BCC) or squamous cell cancer (SCC). Patients were followed up for an average of 5.7 years (0-12.3 years). Basal cell cancers (1234 [75.6%]) were more common than SCCs (399 [24.4%]). The authors found that the risk of a subsequent SCC or BCC occurring within 2 years of the first tumor was 41%, half as great as the risk after a non-first BCC or SCC (81%). For those who had a BCC at study entry and remained tumor free for 2 years, the incidence of BCC in subsequent years was relatively low, less than 5% per year. For comparable patients with SCC, the development of another SCC after year 2 was almost twice as high (data supporting this finding are reported by Wehner et al5 in their online supplemental materials). Subsequent tumors were usually of the same types: only 5.1% of the study cohort subsequently developed both BCCs and SCCs. These findings support those of prior studies indicating that patients tend to develop a single type of NMSC.6,7 Although the incidence of SCC is lower than that of BCC, the risk of developing a second tumor of the same type was higher in SCC: 69% of those with 1 SCC developed at least 1 additional tumor. Over half of the patients who had multiple SCCs were likely to develop another SCC within 2 years (Wehner et al,5 online supplemental materials). Given the higher morbidity and the risk of mortality with SCCs, closely monitoring patients with SCCs is clearly indicated. According to the findings of this study, about 12 patients with SCC would have to be screened each year to detect another SCC. For persons with a single BCC, a second BCC will be detected for about every 20 patients screened annually.5 In a similar study of the Dutch population, slightly higher numbers of persons with a BCC would need to be screened to detect another BCC.8 These risk and incidence estimates are in line with results from previous publications on subsequent NMSCs in patients with a history of NMSC.7 Both Australian and Dutch data suggest fairly long median intervals between new tumors (1.5 to ≥2 years).8,9 Reflecting this observation, Dutch guidelines suggest yearly follow-up only for patients with an SCC, 2 or more BCCs, or a BCC in a high-risk zone.8 The National Comprehensive Cancer Network (NCCN) recommends that every patient with a history of low-risk BCC or SCC be screened with skin examinations every 6 to 12 months for life.10 The data from this and prior studies combined with the high incidence of BCC suggest that the wisdom and feasibility of such a recommendation is in doubt. With an increased number of screenings, a higher proportion of BCCs is likely to be detected in sites other than the head and neck, forearms, and hands—areas such as the trunk, where superficial BCCs are the most common histologic subtype.11 The magnitude of benefit of earlier detection of slowgrowing asymptomatic tumors in less cosmetically sensitive areas is not clear.12 The frequency with which screenings will allow clinicians to detect a subsequent BCC of the head and neck or hands sooner (or later, due to waiting for the annual appointment) than it would otherwise be detected by an educated patient with a prior BCC is also uncertain. Nor is it known the extent to which regular dermatologic examinations for patients who have gone 2 years without a subsequent BCC result in earlier detection and better outcomes. For patients who remain tumor free for 2 years after the first BCC and who are likely to recognize a subsequent tumor, further follow-up may not provide much value. About two-thirds of BCCs occur on the head and neck.5,8,13 The authors did not analyze the association of anatomic site or histologic subtype on the first and subsequent NMSCs. This information could be useful to practitioners and patients in targeting areas for surveillance and identifying suspect lesions that could be NMSC. Related article page 382 Opinion