Recommendations for Solid Organ Transplantation for Transplant Candidates With a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion From the International Transplant Skin Cancer Collaborative (ITSCC).

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.

Skin cancer in transplant recipients, out of the woods. Scientific retreat of the ITSCC and SCOPE.

The International Transplant Skin Cancer Collaborative (ITSCC) is an organization of more than 300 members dedicated to the study and care of skin changes that develop in solid-organ transplant recipients. This group of medical and surgical dermatologists, transplant surgeons and basic science researchers was formed to better understand the basic science of transplant dermatology, and to work collaboratively to address the clinical challenges in this patient population. Transplant patients have an ∼100-fold increased risk of developing cutaneous squamous cell carcinoma than the general population and are also at an increased risk of developing basal cell carcinoma, melanoma, Merkel cell carcinoma and Kaposi's sarcoma. In October 2010, ITSCC and its European counterpart Skin Care in Organ Transplant Patients Europe (SCOPE) held a joint biennial 4-day scientific retreat in the woods near Essex, Massachusetts. In this meeting report we provide an up-to-date distillation of the novel findings presented in the 21 oral abstracts, at the tumor board and within the working groups.

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.

Sweet's syndrome and erythema nodosum: the simultaneous occurrence of 2 reactive dermatoses.

BACKGROUND: The simultaneous occurrence of Sweet's syndrome (SS) and erythema nodosum (EN) in 1 patient is rare. Our review of the literature revealed only 11 biopsy-proved cases in which the 2 reactive dermatoses occurred together. None were associated with an underlying malignant neoplasm. OBSERVATIONS: We report a biopsy-proved case of SS and EN occurring simultaneously in a patient with an underlying malignant neoplasm (specifically, acute myelogenous leukemia). We also report another biopsy-proved case of SS and EN occurring simultaneously in a patient with underlying Crohn's disease. CONCLUSIONS: The simultaneous occurrence of SS and EN in 1 patient is rarely reported. Both disorders are reactive dermatoses that share many overlapping features. Although individually distinctive, SS and EN are also part of a growing continuum of reactive dermatoses. Our expanded understanding of the similarities and simultaneous manifestation of SS and EN may help us in the future to identify a common underlying mechanism of pathogenesis.

Microcystic adnexal carcinoma. Case report and review of the literature.

Microcystic adnexal carcinoma is an aggressive, locally destructive cutaneous neoplasm with a high rate of recurrence. This tumor is often misdiagnosed clinically and histologically. It usually occurs in middle-aged to older adults. We describe a 44-year-old man with a large microcystic adnexal carcinoma that was present for more than 20 years. The tumor invaded the perichondrium, muscle, nerve, and blood vessel adventitia. A review of the literature suggests that these tumors are often histologically misdiagnosed because the biopsy specimens may be too small to reveal all the characteristic histologic features. The clinical presence of marked induration, a smooth surface, and, possibly, sensory changes should alert the clinician to the possibility of this neoplasm. The initial biopsy specimen must be large enough to demonstrate the identifying histologic features. Mohs surgery is currently the treatment of choice for microcystic adnexal carcinoma, as it often spreads far beyond clinically evident tumor.

Small nasal defects.

The nose occupies an important feature of a person's central face. The size, shape, and proportions of the various characteristics of the face provide a visual basis suggesting the character of the person. Scars, asymmetries, and any abnormalities of the central face are easily recognizable and noted by even a casual observer. Over the centuries, therefore, much attention has been paid to reconstruction of facial and nasal abnormalities of both acquired and congenital etiologies. The purpose of this article is to address the reconstruction of smaller defects of the nose, encompassing surface areas of 1.5 to 2 centimeters.

Intraoperative and postoperative bleeding problems in patients taking warfarin, aspirin, and nonsteroidal antiinflammatory agents. A prospective study.

BACKGROUND: Many patients who undergo cutaneous surgery take medications that can affect bleeding. The role of these medications in postoperative bleeding complications is unclear. Dermatologists have no clear guidelines regarding the need to discontinue these medications preoperatively. OBJECTIVE: We designed a prospective study to evaluate the incidence of postoperative bleeding complications in patients taking aspirin, warfarin, or nonsteroidal antiinflammatory agents. METHODS: Data were collected from patients undergoing Mohs surgery regarding preoperative medication history, operative bleeding, and postoperative bleeding. Frequency of postoperative bleeding complications was then evaluated. RESULTS: There was no statistically significant difference in postoperative bleeding complications between patients on aspirin, warfarin, or nonsteroidal antiinflammatory agents, when compared with controls. CONCLUSION: It may not be necessary to discontinue aspirin, warfarin, or nonsteroidal antiinflammatory agents in patients undergoing many common dermatologic surgical procedures, such as Mohs surgery.

Awareness of skin cancer by kidney transplant patients.

BACKGROUND: Skin cancer is the most common malignancy occurring after kidney transplantation. OBJECTIVE: Our purpose was to identify the skin problems of kidney transplant recipients, the extent of their awareness of skin cancer, and interest in skin cancer screenings. METHODS: One hundred twenty-two patients were administered an oral questionnaire during regular follow-up at a renal transplant clinic. RESULTS: The average time from transplantation was 3.1 years. Thirty-nine percent of patients reported skin problems, including warts, fungal infection, and skin cancer. Forty-one percent of patients were unable to recall specific skin cancer education, and 52% expressed an interest in skin cancer screening. Twenty-seven percent of patients had seen a dermatologist since their transplant, but only 14% were followed up regularly by a dermatologist. CONCLUSION: We believe the need for continuing skin cancer education and early detection and treatment of skin lesions establishes an important role for the dermatologist on the transplant recipient's health care team.

Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus.

Paraneoplastic pemphigus (PNP) is a rare autoimmune blistering disease with circulating antibodies that bind the cell surface of the epidermis and other non-stratifying epithelia, and immunoprecipitate a complex of four or five proteins (250 kDa, 230 kDa, 210 kDa, 190 kDa and occasionally 170 kDa).1,2 Combinations of immunosuppressive agents are usually required to obtain even partial control of the skin lesions.3 Mucous membrane lesions are refractory to treatment. We describe a patient with PNP whose skin and oral lesions are quiescent following treatment with oral mycophenolate mofetil.

An unusually aggressive trichoblastoma.

Trichogenic tumors are neoplasms of the hair germ cell that usually exhibit benign behavior. We describe a case of a large invasive trichoblastoma requiring Mohs micrographic surgery for its removal. Immunohistochemical studies performed demonstrate overlapping features of this trichogenic tumor with basal cell carcinoma.

The heterogenous nature of in vivo basal cell carcinoma.

BACKGROUND: There have been nearly 70 different histologic subtypes of basal cell carcinoma (BCC) described. Some of the subtypes have been shown to have clinical relevance. The degree to which one type may merge to another, within the same tumor mass, has been poorly studied. OBJECTIVE: To determine if BCCs maintain biopsy histology throughout the entire architecture of the tumor. METHOD: Tumors were evaluated with a prospective histologic analysis of all primary BCCs using the Mohs "removal in layers" technique. All BCCs that required more than a single Mohs stage to clear were included in analysis. RESULTS: One hundred forty-nine tumors were examined. Fourteen of these were of mixed histologic subtype on biopsy and were not included in the analysis. Six biopsy specimens were inadequate to make a subtype diagnosis and were excluded from calculation. Of the remaining 129 tumors 59% maintained their biopsy diagnosis at first Mohs stage, and 49% at the second Mohs stage. Infiltrative tumors were the most likely to maintain their histologic subtype classification. Of the tumors that showed nodular BCC on biopsy, 13% were infiltrative or micronodular at first Mohs stage. CONCLUSION: While many BCCs demonstrate a single histological subtype, roughly 40% change in their microscopic appearance at the subclinical extension. This finding has the potential to alter therapy.

The spectrum of epidermal nevi: a case of verrucous epidermal nevus contiguous with nevus sebaceus.

During the normal development of skin, pluripotential cells give rise to keratinocytes, sebaceous glands, hair follicles, apocrine glands, and eccrine glands. In epidermal nevi, these components emerge in an abnormal mixture within a circumscribed site. Many authors have categorized epidermal nevi based on their predominant component; however, there is often notable overlap that occurs within a single area or within contiguous areas. We report a verrucous epidermal nevus contiguous to a nevus sebaceus of Jadassohn. The categories of epidermal nevi are somewhat artificial. Our case supports the view that epidermal nevi have a spectrum of manifestations, including verrucous epidermal nevi and nevus sebaceus of Jadassohn.

Rapidly growing squamous cell carcinoma.

BACKGROUND: Squamous cell carcinoma (SCC) may present with a history of rapid growth. Although multiple subtypes have been described regarding histologic characteristics and etiology, the subset of rapidly growing squamous cell carcinomas (RGSCC) has not been described. OBJECTIVE: To evaluate and describe the clinical and histologic characteristics of squamous cell carcinomas that grow rapidly. METHODS: Recorded clinical data and biopsies of 26 lesions with a history of rapid growth and histologically diagnosed as SCC were reviewed. RESULTS: Rapidly growing SCC occurred most commonly on the head and neck, followed by hands and extremities, and had an average duration of 7 weeks before diagnosis. The average size of the lesions was 1.29 cm and nearly 20% occurred in immunosuppressed patients. CONCLUSIONS: Some SCCs may grow rapidly. The reason for the rapid growth is not clear and several hypotheses are discussed including immunosuppression and viral etiology. These lesions should be treated aggressively as their behaviour and prognosis are not yet well described.

Diagnosing basal cell carcinoma by dermatoscopy.

BACKGROUND: Dermatoscopy (DS) has been used primarily to evaluate pigmented skin lesions. Little information is available on DS findings of basal cell carcinoma (BCC). Dermatoscopy is a noninvasive technique that allows visualization of cutaneous features from the skin surface to the papillary dermis. Basal cell carcinoma, the most common cutaneous malignancy, is traditionally diagnosed clinically and confirmed with biopsy. OBJECTIVE: To determine the dermatoscopic features of nonpigmented basal cell carcinomas. METHODS: The dermatoscopic findings of 27 lesions that clinically were suspicious for BCC were analyzed. RESULTS: Of these 27 clinically suspect lesions, the biopsies revealed BCC in 20 specimens and squamous cell carcinoma (SCC) in two specimens. Twenty of these 22 specimens had dermatoscopic findings of BCC: diffusely distributed, branching blood vessels, asymmetric, and narrow blood vessels distributed deeper in the dermis, or a milky-red corona with superficial wide blood vessels. One nodular BCC in our study showed no distinct findings. CONCLUSIONS: Many BCCs have characteristic DS findings; however, dermatoscopic examination of some tumours will not demonstrate any known characteristic findings. As such, the DS criteria we propose for BCC are best utilized as an adjunctive study of clinical impressions. Biopsy remains the definitive diagnostic tool.

Dense inflammation does not mask residual primary basal cell carcinoma during Mohs micrographic surgery.

BACKGROUND: Areas of dense inflammation are commonly removed during Mohs micrographic surgery for basal cell carcinoma because of the concern that they may mask areas of tumor. OBJECTIVE: Our purpose was to determine whether inflammation masks tumor during Mohs surgery for primary basal cell carcinoma. METHODS: Twenty-five consecutive cases of primary basal cell carcinoma with areas of dense inflammation encountered during Mohs surgery were sectioned and stained with hematoxylin and eosin and Ber-EP4. RESULTS: In no cases did the dense inflammation mask residual tumor. CONCLUSION: Dense inflammation does not mask primary basal cell carcinoma during Mohs surgery and should be carefully evaluated before additional surgery is performed.

Localized limb cutaneous metastases.

Cutaneous metastatic disease may be evident in a variety of forms and locations. Anatomically, it may on occasion be confined as localized limb metastases. We report on two patients with localized limb metastases, one from melanoma and the other from Merkel cell carcinoma. Patients with localized limb metastasis have a poor prognosis; however, treatment options not available for generalized cutaneous metastatic disease, such as amputation or isolated limb perfusion with chemotherapeutic agents, can be at times be beneficially employed.