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1 - Introduction to Transplant Dermatology
- from SECTION ONE - TRANSPLANT DERMATOLOGY: AN EVOLVING DYNAMIC FIELD
- Edited by Clark C. Otley, Thomas Stasko, Vanderbilt University, Tennessee
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- Book:
- Skin Disease in Organ Transplantation
- Published online:
- 18 January 2010
- Print publication:
- 21 January 2008, pp 3-6
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Summary
INTRODUCTION TO TRANSPLANT DERMATOLOGY
Forty years ago, the world marveled at the news of the first heart transplant and was saddened by the transplant recipient's not unexpected death 18 days later. Today it is not uncommon to see a cardiac transplant recipient living well 15 or more years after transplantation. Unfortunately, it is also common to see that patient plagued with multiple skin cancers. When solid organ transplantation was in its infancy in the 1960s and 1970s, surviving the immediate transplant period was the most pressing concern. Today, patients leave the hospital quickly after transplantation, and the challenges involve managing the complications of years of illness and immunosuppression: diabetes, hypertension, coronary artery disease, peripheral vascular disease, and skin cancer.
SOLID ORGAN TRANSPLANTATION AND SKIN CANCER
Over many years, solid organ transplantation has evolved into a commonly practiced, successful life-saving medical intervention. An intersection of advances in physiology, immunology, pharmacology, surgical technique, and critical-care medicine has made solid organ transplantation the standard of care for many instances of kidney, heart, lung, and liver failure. Initial attempts at organ transplantation were disappointing in terms of both allograft and patient survival. Although there were widely publicized successes in living related kidney transplants in the 1950s, it was not until 1962 that a long-term successful cadaveric renal transplant was performed in the United States. Surviving a transplant for more than a brief time was accomplished with the use of potent immunosuppressive agents.
25 - Squamous Cell Carcinoma in Organ Transplant Recipients
- from Section Seven - Cutaneous Oncology in Transplant Dermatology
- Edited by Clark C. Otley, Thomas Stasko, Vanderbilt University, Tennessee
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- Book:
- Skin Disease in Organ Transplantation
- Published online:
- 18 January 2010
- Print publication:
- 21 January 2008, pp 172-181
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Summary
There are currently over 150,000 solid organ transplant recipients (OTRs) living in the United States. As more transplants are performed and postoperative survival improves, the complications of chronic immunosuppression, including development of cutaneous squamous cell carcinoma (SCC), have become more prevalent.
INCIDENCE
SCC occurs in OTRs with an incidence approximately 65 to 100 times that in the general population. In contrast to the nonimmunosuppressed population in which SCC is outnumbered by basal cell carcinoma at a 1:4 ratio, SCC occurs approximately 2 to 4 times more frequently than basal cell carcinoma in OTRs, making it the most common skin cancer in these patients.
The incidence of SCC in OTRs is related to the patient's age at transplantation, gender, skin phototype, degree of pretransplant and posttransplant ultraviolet radiation (UVR) exposure, and duration and level of immunosuppression. Chronic immunosuppression contributes to increased cutaneous malignancies, with the prevalence of nonmelanoma skin cancer (NMSC) reaching 40–75% 20 years after transplantation. OTRs with lighter skin phototypes, corresponding to a tendency to burn rather than tan with sun exposure, develop SCC at a higher frequency than those with darker phototypes residing in the same geographic area. Males experience a higher incidence of SCC than females, as do patients receiving their transplants at a greater age.
Residence in a geographic location with a lower latitude, and therefore higher ambient UVR exposure, is also associated with increased rates of SCC following transplantation.
Preface
- Edited by Clark C. Otley, Thomas Stasko, Vanderbilt University, Tennessee
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- Book:
- Skin Disease in Organ Transplantation
- Published online:
- 18 January 2010
- Print publication:
- 21 January 2008, pp xix-xx
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- Chapter
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Summary
The miracle of successful solid organ transplantation is one of the most inspiring accomplishments of modern medicine and an impressive example of multidisciplinary collaboration. Due to the frequent involvement of the skin of transplant patients by infectious, neoplastic, and systemic diseases, dermatologists have always been an important part of the medical team caring for solid organ transplant recipients. As a by-product of the success in assuring prolonged survival for most organ transplant patients, the chronic and potent systemic immunosuppression has given rise to a new set of challenges for patients and providers alike, manifest by alarming increases in skin cancer and unusual manifestations of skin disease.
Dermatologists are part of a larger community of what we refer to as “non-organ-specific transplant physicians,” composed of providers unbound by allograft-specific considerations. This non-organ-specific community includes infectious disease, endocrinology, bone, metabolism, hypertension, psychiatry, internal medicine, family medicine, and pediatric physicians, as well as general, plastic, head and neck, ophthalmologic, and orthopedic surgical colleagues. Additionally, this community includes nephrologists, cardiologists, hepatologists, and pulmonologists who care for patients with allografts transplanted by other allograft-specific specialists. Closely and critically allied are the transplant coordinators, nurses, dieticians, appointment coordinators, and social services providers who provide and coordinate the majority of care in these complex patients. The transplant patients themselves are a critical and inspiring part of the team, upon which the most critical responsibility rests. This is the family of transplantation, a family of which dermatology is proud to be part.