Skin cancers

Vigilance required in transplant patients


Dermatologists have to be more proactive than usual in helping to manage the risk of skin cancer in the 18,000-20,000 living solid organ transplant recipients in Australia.

Professor Alvin Chong, head of transplant dermatology at the Skin and Cancer Foundation, told the limbic that dedicated clinics like his could not meet the needs of the increasing number of transplant patients.

Therefore GPs and dermatologists in the community had to step up to deliver intensive education, screening and treatment.

“When things really get out of control, sometimes they will refer their patients onto these specialised services. But we don’t have enough specialised clinics to look after all transplant patients,” he said.

Associate Professor Chong told the ACD ASM that transplant recipients were very grateful for their new lease on life and were particularly compliant with treatments and advice.

For example, a local study he co-authored found renal transplant recipients were more likely to cover up from the sun and use sunscreens than other Melbourne residents.

However it was difficult in general for most Australians to avoid the sun completely.

“The best time to start sun protection is 20 years ago. The next best time is today,” he quipped.

Some of Professor Chong’s practice tips included:

  • Oral acitretin was recommended for chemoprophylaxis of actinic keratoses and SCCs in transplant recipients.
  • The role of oral nicotinamide in this patient group would be clarified by the ongoing ONTRANS study, which is assessing skin cancer and actinic keratoses incidence in transplant recipients.
  • Topical 5-fluorouracil was the treatment of choice – cheap and effective – for managing cutaneous dysplasia. The aim was to control not cure dysplasia.
  • The current role of mTOR inhibitors was unclear but they should be considered in high-risk patients along with a reduction in immunosuppression.

Professor Chong also recommended a low threshold for biopsy of pigmented lesions given the four-fold risk of death from melanoma in transplant recipients compared to non-transplant recipients.

“The average benign-to-malignant ratio for biopsied pigmented lesions in normal patients is about 5 to 1. That’s the gold standard. Mine is about 16 to 1, which might seem pretty bad but this is a high-risk group. They die from melanoma so we have to be a little bit more cautious. And they are kind of tricky – they are stable, they don’t really change.”

He said vigilance was key.

“If the transplant recipients are carefully screened, and their pigmented lesions are removed early, compared to what you would expect you can actually keep them alive. Be proactive, screen them, remove the things that need to be removed and just keep watching.”

 

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