Skin Cancer after Organ Transplantation

Organ transplantation has been performed for almost 40 years with steadily increasing success regarding long-time survival of the graft, as well as quality of life for the patient. However, graft tolerance only can be achieved via induction and maintenance of an impaired immunological surveillance. An increase of skin cancers as a consequence of the lowered cellular immunoresponse seems to parallel the overall increased long-time survival rate of organ transplant recipients. Against the background of chronic immunosuppression known risk factors like the amount of sun exposure prior and post transplantation, oncogenic viruses as well as the genetic background, and place of residence (latitude) are strongly related with the increased skin cancer incidence.

The increasing incidence of non-melanoma skin cancer, paralleling a prolonged survival of patients after organ transplantation, represents a significant reason for morbidity and long-term morbidity in organ transplant recipients worldwide. The incidence of non-melanoma skin cancer in liver-, kidney- and heart transplant recipients varies from 1.5 to 22 %, 2 to 24 % and 6 to 34 % after < 5 years post transplant. Ultraviolet radiation as well as immunosuppressive therapy are crucial risk-factors regarding the induction and progression of skin cancer. Ultraviolet radiation is related to the induction of DNA damage, as well as interference with Langerhans cell antigen presentation and a Th1 – Th2 shift induced via a release of IL-10. Whereas the overall duration of immunosuppression and the cumulative dosage applied are relevant parameters in the evaluation of an increased tumor risk, individual differences between specific immunosuppressive agents remain unclear. The workup of genetic as well as other unclear phenomenon like the reverse BCC/SCC ratio might shed some further light into the genesis and immunology of the non-melanoma skin cancer in general.

Skin Cancer after Organ Transplantation presents the state-of-the-art knowledge of cutaneous malignancies following organ transplantation. The life promoting and life enhancing benefits of solid organ transplantation is a major medical advance, but at the cost of the life-long immunosuppression needed to prevent rejection of the donated organ. This induction and maintenance of impaired immunological surveillance is paralleled by a significant increase in the incidence of specific cancers, of which skin cancers are highest.

The book is divided into four sections, providing a basic overview on transplantation medicine, different immunosuppressive agents and their impact on the skin’s immune system, epidemiology and pathophysiology of skin cancer, applicable prophylaxis and therapeutic measures.

1. Transplant medicine: Addresses the immunological background of organ transplantation, immunosuppression and the impact on the cutaneous immunosurveillance. Different immunosuppressive drugs are presented and their interaction with mechanisms of the cutaneous immunosurveillance against skin cancer, are discussed.

2. Post-transplant skin malignancies: Explores the pathogenesis of transplant skin cancer, epidemiological patterns in different geographical regions, clinical and histological features, etiological factors and molecular events in skin cancer induction and progression, i.e., photocarcinogenesis and UV-induced immunosuppression, and oncogenic viruses like human papillomavirus and human herpesvirus, type 8.

3. Specific skin cancers: Focuses on specific skin cancers in organ transplant recipients, especially the most predominant types, like squamous cell carcinoma, its precursor actinic keratoses, and basal cell carcinoma, but also malignant melanoma, Kaposi’s sarcoma, cutaneous T-cell lymphoma and other, more rare skinmalignancies.

4. Prophylaxis and therapies: Experts in the field recommend management strategies for preventing and treating transplant skin cancer, with an emphasis on a multidisciplinary approach. As scientists and clinicians strive together to develop effective chemopreventative agents in the face of this accelerated carcinogenesis, there is a real opportunity for advances in the treatment of transplant skin malignancies to translate into reduced skin cancer in the general population.

"Immunosuppression is an essential component of organ transplantation. Unfortunately, the risk of skin cancer is drastically increased in this setting. Distinguished investigators discuss the cause and therapeutic strategies involving the spectrum of cutaneous malignancies associated with immunosuppression."  Steven T. Rosen, M.D., Series Editor