Vishal Anil Patel

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.

Advances in the management of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma is one of the most common non-melanoma skin cancers worldwide. While most cutaneous squamous cell carcinomas are easily managed, there is a high-risk subset of tumors that can cause severe morbidity and mortality. Tumor characteristics as well as patient characteristics contribute to the classification of cutaneous squamous cell carcinomas as low-risk vs. high-risk. Advances in the treatment of cutaneous squamous cell carcinomas largely relate to the management of this high-risk subset. Surgical and non-surgical management options, including newer targeted molecular therapies, will be discussed here. Larger, multicenter studies are needed to determine the exact significance of individual risk factors with respect to aggressive clinical behavior and the risks of metastasis and death, as well as the role of surgical and adjuvant therapies in patients with high-risk cutaneous squamous cell carcinomas.

A new polyomavirus-related dermatosis in a pancreatic transplant patient

Solid organ transplant recipients require constant immunosuppression to prevent graft failure of the transplanted organ. As a result, patients are at high risk for infections, some that are extremely rare and uncommon with unusual presentations. Herein, we describe a pancreatic transplant patient who suffered from an infection from a novel polyomavirus resulting in a unique constellation of symptoms and skin manifestations. This patient and novel polyomavirus have been previously reported but we revisit the case to highlight the dermatologic manifestations for dermatology providers who may similar patients.1

Voriconazole-induced multiple squamous cell carcinomas in a patient with chronic lymphocytic leukemia.

Voriconazole, a broad-spectrum triazole antifungal medication used for fungal infection treatment and prophylaxis in immunocompromised hosts, has recently been shown to induce photosensitivity. Several reports suggest that prolonged voriconazole exposure is associated with development of cutaneous squamous cell carcinomas (cSCCs) whose incidence may be dose dependent in organ transplant recipients (OTRs). The association between cSCC in solid OTRs and voriconazole is now established. The authors present the first case, to our knowledge, of multiple voriconazole-induced aggressive cSCCs in a patient with chronic lymphocytic leukemia (CLL).

Validity of skin cancer malignancy reporting to the Organ Procurement Transplant Network: A cohort study

Background The Organ Procurement Transplant Network (OPTN) registry collects data on posttransplant malignancies in solid organ transplant recipients. Complete and accurate registry data on skin cancer is critical for research on epidemiology and interventions. Objective The study goal was to determine the validity of Organ Procurement Transplant Network skin cancer data. Methods This cohort study compared reporting of posttransplant squamous cell carcinoma (SCC) and malignant melanoma (MM) in OPTN to medical‐record review‐derived data from the Transplant Skin Cancer Network (TSCN) database. In total, 4934 organ transplant recipients from the TSCN database were linked to patient‐level OPTN malignancy data. We calculated sensitivity, specificity, correct classification (CC), positive predictive value (PPV), and negative predictive value (NPV) for SCC and MM reporting in the OPTN database. Results OPTN reporting for SCC (population prevalence 11%) had sensitivity 41%, specificity 99%, PPV 88%, NPV 93%, and CC 93%. OPTN reporting for MM (population prevalence 1%) had sensitivity 22%, specificity 100%, PPV 73%, NPV 99%, and CC 99%. Limitations Only a subset of patients in the TSCN cohort had matched United Network for Organ Sharing cancer registry data for comparison. Conclusion OPTN reporting had poor sensitivity but excellent specificity for SCC and MM. Dermatologists and transplant physicians are encouraged to improve the validity of OPTN skin cancer data through improved communication and reporting.

Using Network Oriented Research Assistant (NORA) Technology to Compare Digital Photographic With In-Person Assessment of Acne Vulgaris

Importance Teledermatology has undergone exponential growth in the past 2 decades. Many technological innovations are becoming available without necessarily undergoing validation studies for specific dermatologic applications. Objective To determine whether patient-taken photographs of acne using Network Oriented Research Assistant (NORA) result in similar lesion counts and Investigator’s Global Assessment (IGA) findings compared with in-person examination findings. Design, Setting, and Participants This pilot reliability study enrolled consecutive patients with acne vulgaris from a single general dermatology practice in Los Angeles, California, who were able to use NORA on an iPhone 6 to take self-photographs. Patients were enrolled from January 1 through March 31, 2016. Each individual underwent in-person and digital evaluation of his or her acne by the same dermatologist. A period of at least 1 week separated the in-person and digital assessments of acne. Interventions All participants were trained on how to use NORA on the iPhone 6 and take photographs of their face with the rear-facing camera. Main Outcomes and Measures Reliability of patient-taken photographs with NORA for acne evaluation compared with in-person examination findings. Acne assessment measures included lesion count (total, inflammatory, noninflammatory, and cystic) and IGA for acne severity. Results A total of 69 patients (37 male [54%] and 32 female [46%]; mean [SD] age, 22.7 [7.7] years) enrolled in the study. The intraclass correlation coefficients of in-person and photograph-based acne evaluations indicated strong agreement. The intraclass correlation coefficient for total lesion count was 0.81; for the IGA, 0.75. Inflammatory lesion count, noninflammatory lesion count, and cyst count had intraclass correlation coefficients of 0.72, 0.72, and 0.82, respectively. Conclusions and Relevance This study found agreement between acne evaluations performed in person and from self-photographs with NORA. As a reliable telehealth technology for acne, NORA can be used as a teledermatology platform for dermatology research and can increase access to dermatologic care.

Management of High-Risk Primary Tumors Including Nodal Staging

Cutaneous squamous cell carcinoma (CSCC) is a growing epidemic in the United States. Recent evidence suggests that the mortality from CSCC may be just as common as that from melanoma, renal carcinoma and oropharyngeal carcinoma. While most CSCCs are easily treatable and curable, this textbook focuses on the high-risk subset of CSCC which exhibits more aggressive behavior and has a significant risk of recurrence. While many treatment options exist, optimal treatment depends on the benefits and shortcomings of each modality. The use of radiation, chemotherapy, and targeted molecular inhibitors as adjuvant therapy is likely to be critical to the management of high-risk CSCC but protocols and case selection parameters are just beginning to be investigated. Lastly, new evidence indicates that sentinel lymph node biopsy may be indicated in the work up of high-risk CSCC. This chapter will provide an overview of management options for high-risk CSCC primary tumors. Management of field cancerization, extensive local disease including in-transit metastases, nodal disease, and metastatic disease are covered in Chaps. 5, 7, 8, and 9, respectively.