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BIODERMA Congress Reports EADO 2022

Reports written by Prof. Lise Boussemart (Dermatologist, France), Dr. Oriol Yelamos (Dermatologist, Spain)

30 min read

Prof. Lise Boussemart
Dermatologist , France

Dear colleagues,

I’m very pleased to be reporting to you again this year with summaries from the EADO Congress, which is being held in-person (at long last!) in Seville. This is the first international oncodermatology conference to be held in-person since the pandemic, and it’s really a wonderful feeling.

Speakers: Dr. Alessandra Handisurya, Dr. Alexandra Geusau, Dr. Bruno Watschinger, Deniz Seckin, Prof. Catherine A. Harwood, Dr. Jan Nico Bouwes Bavinck and Dr. Nageli

Report written by Prof. Lise Boussemart

 

The conference started on 21/04 with an update to our knowledge of cutaneous risks in organ transplant patients by the “SCOPE” network (Skin Care in Organ-transplant Patients), a group of European dermatologists founded over 20 years ago to optimise dermatological care for the specific needs of transplant patients.

More information on their website: https://www.scopenetwork.org/

 

The incidence of squamous cell carcinomas of the skin is still greatly increased among transplanted patients

Although the first kidney transplant was performed in Boston in 1954, the increased risk of skin cancers was first described only in 1973, and remains unresolved to this day. In this context, Alessandra HANDISURYA reminded us that the incidence of squamous cell carcinomas of the skin is still greatly increased among transplanted patients (65 to 100 times greater than in the general population). There are a number of these carcinomas, which are subject to relatively rapid and painful growth, and often in connection with an HPV (human papillomavirus) co-infection. Beta-HPV DNA is detectable in 80% of squamous cell carcinomas in transplant patients, vs. 40% of “traditional” squamous cell carcinomas of the skin. HPV allows keratinocytes to survive after genotoxic exposure. In fact, beta-HPV seropositivity at the time of the transplant even tends to predict the later occurrence of squamous cell carcinomas (p=0.043). HPV is also responsible for the higher incidence of skin warts, orogenital papillomas/condylomas, and even genital neoplasms in this population.

In the example of a transgenic mouse expressing beta-HPV8 in its epidermis, an increase in skin papillomas and squamous cell carcinomas was observed under UV exposure (Uberoi A. et al., PLOS pathog 2016), particularly in case of immunodepression (Dorfer S. et al., Am J Transplant 2021). Interestingly, HPV seems to play a facilitating role in triggering the carcinoma, but is not required to maintain its later development. This raises the question of whether a preventative HPV vaccine should be given to all organ transplant patients, even post-adolescence (clinical trials in progress).

 

The role of sun exposure in the occurrence of squamous cell carcinomas in transplant patients

Alexandra Geusau then discussed the role of sun exposure in the occurrence of squamous cell carcinomas in transplant patients, particularly with regard to intentional exposure of the entire body during recreational activities (beach, etc.). The increased risk is particularly notable in light phototypes, especially in patients with certain variants of the MC1R gene who have blue or green eyes or actinic keratoses. The Skin Ageing score (with its intrinsic and extrinsic components) can be used to calculate the TSA score (Total Skin Ageing score) to more precisely determine individual risk.

 

Questioned the definitive theoretical contraindication of kidney transplants in patients with a history of cancer

Nephrologist Bruno Watschinger questioned the definitive theoretical contraindication of kidney transplants in patients with a history of cancer (including skin cancer). He criticised decisions based solely on the SIR (standardised incidence ratio, Benoni et al, Transplant Int 2020). To be sure, many cancer SIRs are higher in kidney transplant patients than in the general population (squamous cell carcinomas of the skin; lips, etc.). But Dr Watschinger argues that in this population, the SIR should be interpreted in comparison to the population of dialysis patients, since dialysis is still the only alternative to a kidney transplant. He notes that in dialysis patients, there is a 4x higher risk of kidney cancer, but also a 9x higher risk of Kaposi’s sarcoma, a 2x higher risk of melanoma, etc. In practice, there is a 10% risk of all types of cancer combined over 5 years of dialysis, and a mortality risk of 5% per year, notably due to extreme cardiovascular risk, which is much lower in transplant patients (although the latter is of course a selected population). This explains the current tendency to reduce the theoretical contraindication of kidney transplants in patients with a history of cancer in remission. For example, a history of melanoma in situ should no longer be considered a formal contraindication. For invasive melanomas, decisions can be discussed on a case-by-case basis.

 

PTLDs: post-transplant lymphoproliferative disorders

Deniz Seckin was the 4th speaker of the day. She talked about PTLDs: post-transplant lymphoproliferative disorders (1 to 2% of kidney transplant patients). PTLD is often linked to an EBV infection subsequent to the transplant, and primarily affects men (77%) around the age of 58.

Certain PTLDs have a cutaneous presentation, more commonly secondary than primary, but they must be understood as an entity that can present in the form of anaplastic large cell lymphoma or mycosis fongoides, and particularly aggressively in the context of a transplant. The majority of primary skin PTLDs have their origin in T lymphocytes (69%), while the remaining cases derive from B lymphocytes (31%, associated with EBV in 91%, with a relatively better prognosis). The speaker expressed her disappointment that this entity is often forgotten in classifications of cutaneous lymphomas.

 

Skin complications in transplant patients “of colour” (phototypes IV to VI)

Catherine A. Harwood discussed the topic of skin complications in transplant patients “of colour” (phototypes IV to VI), who represent 2/3 of transplant candidates in London where her practice is located. Unsurprisingly, carcinomas and melanomas of the skin are much rarer in these populations than in transplant patients with light phototypes. The only case of metastatic melanoma that she has reported for a patient with a dark phototype was actually a case transmitted by the organ donor.

However, transplant patients with dark phototypes are still subject to induced HPV neoplasms, which requires careful clinical attentiveness to the anogenital region by the dermatologist. Kaposi’s sarcomas particularly affect people with sub-Saharan African origins, due to the high endemic prevalence of HHV8.

Finally, sun avoidance combined with a dark phototype tends to produce vitamin D deficiencies, which practitioners should look out for and supplement if needed.

 

30-year retrospective on dermatology with organ transplant patients

The final speaker in the session on transplant patients, Jan Nico Bouwes Bavinck, presented his 30- year retrospective on dermatology with organ transplant patients in Leiden. He was involved in demonstrating the clinical interest of acitretin, which slowed the appearance of squamous cell carcinomas at a dose of 30mg/day in a double-blind study vs. placebo (JN Bavinck et al., JCO 1995). Today, he recommends starting at 10mg/day, and limiting the dose to a maximum of 20mg/day, due to side effects such as dry lips and hair loss. The clinical value of sirolimus after excision of a squamous cell carcinoma was described in JCO 2013, but this immunosuppressive treatment is relatively poorly tolerated and its utility is debatable beyond 2 years post-excision.

Prevention is key, as we were reminded by Dr Nageli, with his case of a lung transplant patient suffering from a metastatic squamous cell carcinoma (primary site was the lip, high mutational load), who died due to transplant rejection while taking PD-1 inhibitors (cemiplimab), despite a complete remission of the carcinoma.

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