Dermatology and Solid Organ Transplantation

Nathalie C. Zeitouni, Faramarz H. Samie, Nathalie C. Zeitouni, Faramarz H. Samie

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000415926
• Edition: 1
• Topic: Medicine
• Subtopic: Dermatology

This textbook brings together experts in the field of transplant dermatology to review both state of the art and practical knowledge regarding the clinical presentation and management of the various cutaneous diseases seen in patients with solid organ transplant. Practicing dermatologists, trainees, and other health care providers involved in the care of transplant patients can learn the current diagnostic and management options, and how to apply these guidelines and principles in their everyday practice.

1
History of Transplant Dermatology and Current Epidemiologic Trends in Posttransplant Skin Cancer

Deniz Seçkin and Megan H. Trager

DOI: 10.1201/9781003001461-1

INTRODUCTION

Over the years, solid organ transplantation has provided the opportunity for a new life to many people all over the world who suffer from the physical and psychological burdens of various failing organs. Early attempts at organ transplantation failed in terms of both allograft and recipient survival. The first successful renal transplantation was performed in 1954 in Boston between monozygotic twins.¹ In 1962, the first long-term successful cadaveric renal transplantation was accomplished in the United States (U.S.).^2–3 The other organs (lungs, pancreas, liver, intestines, heart, and bone) were successfully transplanted in the following few years.² The dark days of transplantation were over once it became clear that the transplanted organs, especially the allograft ones, failed because of biological rather than surgical factors,⁴ and immunosuppression was needed to prevent the graft rejection, an immunologic event. Initially, total body irradiation, and then chemical immunosuppression with 6-mercaptopurine were introduced in 1959.² Over the following years, use of systemic corticosteroids and azathioprine either alone or in combination, and the introduction of cyclosporine, a calcineurin inhibitor (CNI), in 1983 led to a marked improvement of graft survival.^2,3 Combination of the immunosuppressive drugs, and more recently the use of tacrolimus, mTOR inhibitors (mTORi; sirolimus, everolimus), and other immunosuppression methods have resulted in even better success rates.

ADVANCES IN SOLID ORGAN TRANSPLANTATION

In the early transplantation era, prognosis after solid organ transplantation was highly variable. Over the past 60 years, significant advances in the field of solid organ transplantation,⁵ including improvements in antimicrobial treatments, surgical techniques, medical diagnosis, selection of organ transplant recipients (OTRs), and posttransplant immunosuppression have contributed to increased survival of recipients.⁶ A review of liver transplant recipients (LTRs) in Colorado found that between 1963 and 1977, 28% of patients had an overall survival of at least 1 year.⁷ The reasons for the high mortality rate included graft rejection as well as technical or mechanical issues during surgery, such as complications from biliary duct reconstruction.⁷ When these issues were identified and addressed in 1976, patient prognosis was reevaluated and drastically improved; 50% of patients survived at least 1 year in the Colorado cohort.⁷ Today, survival is significantly longer, and renal transplantation is one of the most successful organ transplant procedures.⁷ The median survival of renal transplant recipients (RTRs) is 12.4 years, and over 50% of liver and heart transplant recipients have a survival of >7 years posttransplant.⁸ Establishment of legal definitions of brain and cardiac death as well as advances in organ preservation led to an increase in the use of cadaveric organs in the 1980s and a rise in the number of transplants performed. According to the Global Observatory on Donation and Transplantation, the number of transplants performed worldwide is continuing to increase (www.transplant-observatory.org/data-charts-and-tables/).⁶ Between 2018 and 2019, the rate of transplant per million population rose dramatically from 19.31 to 29.33. In 2019, a total of 143,146 transplants were performed (65% kidney, 23% liver, 5.8% heart, 4.4% lung, 1.5% pancreas, 0.09% small bowel). Figure 1.1 shows the number of transplants in 2019 broken down by geographic region and solid organ.

SOLID ORGAN TRANSPLANTATION AND CANCER

With the prolonged lifespan and the increased number of OTRs over the years, medical complications secondary to long-term immunosuppression have been identified including various infections and malignancies. Cutaneous malignancies, especially cutaneous squamous cell carcinoma (SCC), are increasingly recognized as patients live longer posttransplant, and the incidence of cutaneous malignancy rises with time from transplantation.⁹ Early diagnosis and management of these cancers is of utmost importance as they are recognized as the second leading cause of death in solid OTRs.¹⁰

In 1969, Israel Penn and his colleagues from the University of Colorado were the first to recognize the relationship between organ transplantation and malignant disease by reporting the development of lymphomas in five RTRs.¹¹ They proposed that this was “an indirect complication of organ transplantation or the measures taken to prevent rejection.” By 1971, Schneck and Penn reported a series of 11 posttransplant brain neoplasms in 184 OTRs.¹² Dr. Penn started an informal registry (the Denver Transplant Tumor Registry), and after he moved to Cincinnati, Ohio, this registry became known as the Cincinnati Transplant Tumor Registry, which has tracked data on more than 15,000 posttransplant malignancies. After Dr. Penn passed away in 1999, the registry was renamed as the Israel Penn International Transplant Tumor Registry (https://ipittr.uc.edu/registry).² This database showed that the frequencies of cancers that are common in the general population (e.g., lung, prostate, breast, and colon) were not increased in OTRs. Instead, other malignancies (e.g., lymphomas, SCC of the lip, Kaposi’s sarcoma [KS], carcinomas of the vulva, kidney, and liver) were more frequent in the OTRs.

In their 1971 Lancet article, Walder et al.¹³ reported a 14% increase in skin cancer in OTRs along with a reversal of the ratio of SCC to basal cell carcinoma (BCC) from 1 to 5 in the general population to 1.8 to 1 in transplant recipients. Since then, the relationship between organ transplantation and increased risk of various skin cancers (SCC, BCC, melanoma, KS, and Merkel cell carcinoma [MCC]) has been confirmed by other publications from different tran...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• List of Contributors
• 1 History of Transplant Dermatology and Current Epidemiologic Trends in Posttransplant Skin Cancer
• 2 Immunosuppressive Therapy for Solid Organ Transplantation
• 3 Dermatologic Imaging for Immunosuppressed Patients
• 4 Skin Cancer Prevention, Chemoprevention, and Revision of Immunosuppression
• 5 Topical and Intralesional Modalities for Actinic Keratoses and Nonmelanoma Skin Cancer in Transplant Recipients
• 6 Advances in Photodynamic Therapy for the Treatment of Actinic Keratoses and Nonmelanoma Skin Cancer in Solid Organ Transplant Recipients
• 7 Pediatric Transplant Dermatology
• 8 Melanoma in Solid Organ Transplant Recipients
• 9 Cutaneous Squamous Cell Carcinoma in Solid Organ Transplant Recipients
• 10 Management of Squamous Cell Carcinoma in Solid Organ Transplant Recipients
• 11 Merkel Cell Carcinoma in Solid Organ Transplant Recipients
• 12 Rare Skin Cancers: Kaposi’s Sarcoma, Sebaceous Carcinoma, Atypical Fibroxanthoma, and Dermatofibrosarcoma Protuberans
• 13 Immunotherapy in Organ Transplant Recipients
• 14 Bacterial, Fungal, and Viral Skin Infections in Organ Transplant Recipients
• 15 Direct Dermatologic Side Effects of Immunosuppressive Therapy in Solid Organ Transplant Recipients
• 16 Nail Disease and Nail Surgery in Solid Organ Transplant Recipients
• 17 How to Build a Transplant Dermatology Clinic
• Index