Thomas Stasko

Melanoma in solid organ transplant recipients.

This manuscript outlines estimated risk and clinical course of pretransplant MM, donor‐transmitted MM and de novo MM posttransplantation and includes an analysis of risk factors for metastasis, data from clinical studies and current and proposed management. MM in situ and thin melanoma (<1 mm) in the transplant population has similar recurrence and survival estimates to those in the general population. A minimum wait time of 2 years prior to transplantation is suggested for MM with a Breslow depth <1 mm and no clinical evidence of metastasis. More advanced MM may adopt a more aggressive course in transplant recipients. Sentinel lymph node biopsy may be of additional prognostic benefit. Revision of immunosuppression in the management of de novo melanoma in collaboration with the transplant team should be considered. Larger studies utilizing uniform staging criteria or at minimum Breslow depth, are required to assess true risk and outcome of MM in the immunosuppressed transplant population. Emphasis remains on patient education and regular screening to provide early detection of MM.

Systemic strategies for chemoprevention of skin cancers in transplant recipients

Abstract:  Background:  Solid organ transplant recipients (OTRs) are a growing population at high risk for cutaneous neoplasms, resulting in significant post‐transplant morbidity and mortality. Management of malignant and pre‐malignant cutaneous lesions in transplant recipients is challenging, making prevention of such neoplasms paramount. The objectives of the present study are to review and analyze systemic strategies for chemoprevention of malignant and pre‐malignant cutaneous neoplasms in OTRs.

Use of topical immunomodulators in organ transplant recipients

ABSTRACT:  Solid organ transplant recipients are a growing population at increased risk for the development of cutaneous premalignant and malignant lesions, resulting in significant morbidity and mortality. Topical immunomodulators, in particular imiquimod, have shown efficacy in the management of multiple malignant, precancerous, and viral conditions. The ability to locally induce an immune response, presumably against tumor and viral antigens, and induce apoptosis makes topical immunomodulators a promising therapeutic option in organ transplant recipients. Although limited, data have begun to accumulate on the use of imiquimod in transplant patients for the management of superficial, nodular, and infiltrative basal cell carcinomas; in situ and invasive squamous cell carcinomas; condyloma acuminata; and common warts. As more experience is gathered, the role of imiquimod and other topical immunomodulators in the care of OTRs will be clarified. The authors reviewed the existing data on the use of topical imiquimod in OTRs with mention of its presumed mechanisms of action and other immunomodulators with potential efficacy against cancerous and precancerous lesions.

Basaloid squamous cell carcinoma of the skin

BACKGROUND Basaloid squamous cell carcinoma (BSCC), an aggressive tumor of the aerodigestive tract, was described over 20 years ago, and its defining histologic parameters remain largely unchanged. While rare reports have noted cutaneous metastatic deposition, primary tumors have not been previously described. OBJECTIVE Although most cutaneous malignancies with basaloid features comprise variants of basal cell carcinomas, a subset exhibit histologic attributes suggestive of more aggressive tumors. We evaluated 3 such tumors submitted to our dermatopathology service over a 6-month period. METHODS Immunohistochemical stains useful in differentiating the lineage of cutaneous malignancies with basaloid-appearing tumor cells were employed. Human papillomavirus (HPV) detection and typing were performed by using polymerase chain reaction and sequencing. RESULTS The tumor cells expressed high molecular weight cytokeratin (34βE12) and cytokeratin 5/6 but not Ber-EP4 or bcl-2. This pattern of immunohistochemical staining and the histologic attributes of the neoplasms are inconsistent with those expected in better defined cutaneous basaloid malignancies but are characteristic of BSCC. Two of the tumors arose in the inguinal crease of middle-aged men, and two patients were known to be immunosuppressed. HPV genotype 33 was detected in the tumor tissue from both inguinal lesions. LIMITATIONS The number of cases available for evaluation is small and any prognostic implications therefore tenuous. CONCLUSIONS The differential diagnosis of cutaneous malignancies exhibiting basaloid cells should include BSCC, a tumor with an unusual pattern of immunohistochemical staining and a potentially poor prognosis.

Skin cancer after transplantation

Advances in transplantation technique and posttransplantation immunosuppression have resulted in continual improvements in survival and quality of life of transplant recipients. The improved quality of life afforded in the posttransplantation period allows patients to lead more active lifestyles, which often includes increased exposure to solar radiation. This growing population of active, immunosuppressed individuals is at marked risk, up to 65 times that of the general population, for the development of cutaneous neoplasms with associated morbidity and mortality. Prevention, prompt recognition, and effective treatment of skin cancer in this immunosuppressed population are vital.

Clinical Spectrum of Atypical Fibroxanthoma and Undifferentiated Pleomorphic Sarcoma in Solid Organ Transplant Recipients: A Collective Experience

BACKGROUND Atypical fibroxanthoma (AFX) and undifferentiated pleomorphic sarcoma (UPS) are uncommon, spindle cell cutaneous malignancies. Solid organ transplant recipients (SOTRs) are immunosuppressed and therefore have a higher incidence of cutaneous malignancies. OBJECTIVE We describe the clinical spectrum of AFX and a more‐aggressive, deeper variant, UPS, in SOTRs. MATERIALS AND METHODS A retrospective chart review of AFX and UPS in SOTRs was implemented. Cases from Vanderbilt University, Emory University, Mayo Clinic—Jacksonville, and University of Rochester were included. A literature search included previously published cases. RESULTS The average age of SOTRs at time of tumor presentation was younger than typically seen in immunocompetent patients for AFX. Rates of local recurrences and metastases were higher in the SOTRs than is noted in the immunocompetent literature. Rates of recurrence were higher in those treated with excision than in those treated with Mohs micrographic surgery (MMS). CONCLUSION AFX and UPS may have a greater risk for recurrence, metastases, and mortality in SOTRs, in whom early treatment with MMS may demonstrate certain advantages in terms of minimizing risk of recurrence and metastasis. UPS and recurrent tumors should be staged appropriately and may respond to adjuvant radiation therapy and reduction of immunosuppression. Immunohistochemical evaluation is recommended to exclude other spindle cell tumors. The authors have indicated no significant interest with commercial supporters.

Skin Disease in Organ Transplantation

Part I. Transplant Dermatology Part II. Transplant Medicine and Dermatology Part III. Pathogenic Factors in Transplant Dermatology Part IV. Cutaneous Effects of Immunosuppressive Medications Part V. Infectious Diseases of the Skin in Transplant Dermatology Part VI. Benign and Inflammatory Skin Diseases in Transplant Dermatology Part VII. Cutaneous Oncology in Transplant Dermatology Part VIII. Special Scenarios in Transplant Cutaneous Oncology Part IX. Educational, Organizational, and Research Efforts in Transplant Dermatology.

LN2, CD10, and Ezrin Do Not Distinguish Between Atypical Fibroxanthoma and Undifferentiated Pleomorphic Sarcoma or Predict Clinical Outcome

BACKGROUND Atypical fibroxanthoma (AFX) is a rare cutaneous spindled cell neoplasm. For both diagnostic and therapeutic purposes, it is important to distinguish AFX from other poorly differentiated tumors, including undifferentiated pleomorphic sarcoma (UPS). OBJECTIVE The authors aimed to identify the clinical, histologic, and immunohistochemical expression of LN2, ezrin, and CD10 in AFX and UPS tumors. METHODS AND MATERIALS The authors retrospectively examined the charts of patients with AFX and UPS treated with Mohs micrographic surgery (MMS) at 2 academic institutions. Patient demographics, tumor characteristics, and clinical course data were collected. Immunohistochemical stains were performed on primary and recurrent AFX and UPS tumors with monoclonal antibodies against the B-cell marker LN2 (CD74), CD10, and ezrin. RESULTS In the series of 169 patients with AFX included in this study, local recurrence was rare at 3%. In contrast, the seven patients with UPS had an aggressive clinical course with 1 local recurrence and 2 distant metastases. Immunohistochemistry staining for ezrin, LN2, and CD10 were similar in AFX and UPS tumors. CONCLUSION AFX can be treated with MMS with rare instances of recurrence. Undifferentiated pleomorphic sarcoma has a more aggressive clinical course with increased risk for recurrence and metastasis. Staining with ezrin, LN2, and CD10 did not differentiate AFX or UPS tumors.

Recommendations for Solid Organ Transplantation for Transplant Candidates with a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma

Advancements in solid organ transplantation successfully extend the lives of thousands of patients annually. The tenet of organ stewardship aims to prevent the futile expenditure of scarce donor organs in patient populations with high mortality risk, to the detriment of potential recipients with greater predicted life expectancy. The development of skin cancer posttransplantation portends tremendous morbidity, adversely affecting quality of life for many transplant recipients. This special article, provided by of members of the International Transplant Skin Cancer Collaborative (ITSCC), will provide the transplant professional with a consensus opinion and recommendations as to an appropriate wait period pretransplantation for transplant candidates with a history of either cutaneous squamous cell carcinoma, malignant melanoma, or Merkel cell carcinoma.

Special Considerations for Mohs Micrographic Surgery in Organ Transplant Recipients

Immunosuppressed patients have an increased risk of skin cancer, particularly virally mediated types. Squamous cell carcinomas in this population tend to behave more aggressively than in the general population. Mohs micrographic surgery is considered standard of care for treating high-risk squamous cell carcinomas.