Monday, August 19, 2019

Post-transplant anti-rejection drugs, the sun, and skin cancer

“Protect your skin” should not be an advice taken lightly for transplant patients. It is especially true for bald men. Skin cancer is a major problem after organ transplant. The longer a patient lives the higher the incidence is. Since transplant patients are living longer than ever before, we are seeing more skin cancer but sometimes it hits as early as during the first year. People, it is not a joke when your doctors or transplant coordinators warn you of using precautions under the sun. Some studies also show heart and kidney transplant recipients being more at risk than the other organs. The reasons remain unknown at this moment. Organ transplant patients have up to 100-fold higher risk of getting any type of skin cancer than the general population.

Types of Skin Cancer

The one kind of skin cancer we see frequently in organ transplant patients is squamous cell carcinoma (SCC). If caught early (before it spreads) and treated aggressively, it usually causes no major problem. We see SCC appear usually in the face or on the arms and it looks like a benign red spot at first. It looks like a small red ulcer and grows slowly. Transplant recipients are strongly advised to start seeing a dermatologist (skin doctor) at their one year anniversary with yearly or as needed follow-ups. Patient education is a big part to prevent skin cancer from developing and/or getting out of control. Any skin changes or discoloration should be reported immediately to your transplant doctor.

Your transplant team should also be informed of any new skin cancer diagnosed and treated by your dermatologist because a change in your immunosuppressant (anti-rejection drugs) may be necessary. Just as a reminder, your anti-rejection drugs weaken your immune system which in turn is not as efficient in destroying the skin cancer cells. The other two forms of skin cancer that we see less in organ transplant patients is basal cell carcinoma (BCC) and melanoma. Those have respectively 10% and 4% higher incidence for post-transplant patients.

Risk factors

The more pale the skin the more chance for skin cancer. The older a patient is the more risk for skin cancer too. So a 65 years old white man with pale skin, bald, 2-3 years post transplant is the typical patient who will end up with most likely a SCC. It is also important to note that your lifetime exposure to UV also matters. By example, a patient living in the south who was an outdoors-man will be more at risk then a northerner who never went outside his whole life. I don’t remember seeing a dark skin person (black, dark Hispanic, etc) ever being diagnosed with a skin cancer. It is only based on my experience so it could possibly have happened somewhere else. In short, wherever you live, don’t let your skin burn in the sun.

Medical Treatment

Several treatment options are available and is usually chosen based on the location, size, occurrence and training of the dermatologist. Sometimes a medical management is warranted and that includes chemotherapy and radiation. Chemo drugs may go from cream to pills and intravenous once again on a case by case basis. The medical therapy of last resort will be to decrease the amount of anti-rejection drugs. The indications for decreasing those medications are if there is metastasis or more than 5 to 10 episodes of cancer per year. It is usually last resort because the transplant doctors are afraid of losing the function of the graft and cause chronic rejection.

Surgical Treatment

There are two main surgical treatment options that I have seen patients get. The first one is called cryosurgery (cryo means cold). The doctor uses a really cold instrument, spray-gun or cotton-tipped applicator at a temperature of-321°F or -196°C, and burns the cancerous cells. It is the treatment of choice when the skin lesions are deemed to be pre-cancerous.

If a more invasive therapy is needed for skin cancer in organ transplant patients then the next step would a surgical excision. The actual technique is called Mohs micrographic surgery. It is named after Dr Frederick Mohs who first developed the technique in the 1930’s. Basically, the Mohs procedure trained dermatologist will numb the skin around the area and then cut out what is visible to the eye along with a little bit of healthy tissue. Once that is completed the dermatologist will remove one thin layer at a time and look at it under the microscope to make sure all cancer cells have been removed. It may take several thin cut to get it all. The goal here is to preserve as much healthy tissue as possible to allow healing with less scarring. This procedure seems to have one of the highest cure rates of skin cancer.

For organ transplant patients or anybody else, the main thing to remember is prevention. Use some sunscreen lotion or cover your skin if you don’t want to use the lotion. Monthly skins self-check is recommended at home to notice any change on your skin. If you see something suspicious, don’t hesitate, consult a dermatologist.

 source: https://www.skincancer.org/prevention/are-you-at-risk/transplant

Pierre Luc Charland
Pierre Luc Charlandhttps://www.transplantcafe.com/profile/Pierrecharland
Aside from being a very experienced transplant coordinator in the Houston area, Pierre is also an amazing content creator for our properties. Pierre plays a key role in driving our mission and offering expert insight to the ever evolving world of transplantation.

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