Skin cancer and immunosuppression

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Abstract

All immunosuppressive treatments, either pharmacological or physical, have the potential to impair the skin immune system network of cells and cytokines, thus leading to an increased incidence of skin cancer. Since skin cancer in transplant recipients may show uncommon clinical features and have an unusually aggressive course, transplant patients should be strictly followed up by experienced dermatologists in order to diagnose and treat properly any skin cancer in an early phase. Importantly, due to the fact that sun exposure increases immunosuppression in the skin, patients should be clearly informed about the additional risk of sun exposure and the preventive measures to be taken.

Section snippets

The skin immune system and its alterations produced by immunosuppressive treatments

It's now widely accepted that the skin is not only a passive, mechanical barrier protecting the body from outside dangers, yet it acts as a true peripheral immunological organ [1], [2], [3], [4]. Hence, the definition of skin immune system (SIS) [1] and skin-associated lymphoid tissue (SALT) [4]. The skin includes virtually all the cell types present in “classic” secondary lymphoid organ, such as the spleen, lymph nodes and tonsils. A network of dendritic antigen presenting cells (APC) is

Epithelial skin cancer (carcinoma) and oncogenic virus infection

Several skin cancers can develop as a consequence of the immune system suppression induced in patients under different therapeutical regimens. The most striking example is represented by transplant recipients, which often receive associations of heavily immunosuppressive drugs for a long time. Among all malignancies, non-melanoma skin cancers are the most frequent in transplanted patients, who show a very high incidence of squamous (SCC) and basal cell carcinomas (BCC), as well as of actinic

Kaposi's sarcoma

Kaposi's sarcoma (KS) is a vascular neoplasm consisting of slowly growing, spindle shaped endothelial cells expressing endothelial and macrophage markers, mainly localized in the skin [70], [71], [72]. It can be divided into four different clinical variants, i.e., the classical or sporadic form described by Moritz Kaposi, which affects elderly people and is characterized by an indolent course; the endemic form, observed in Africa and Mediterranean area and two immune-depression related forms,

Melanocytic skin cancer (melanoma)

Melanoma is a relatively common type of cancer in Caucasians, and its incidence is increasing in the general population [82]. It's not clear whether the incidence of melanoma and its potential precursors, melanocytic naevi (MN), is increased in transplant recipients. There are some reports indicating that MN develop in high number in transplant recipients [83], [84], [85], [86]. In particular, it has been reported that the mean total number of MN was significantly higher in renal transplant

Lymphoproliferative disorders of the skin (primary cutaneous lymphoma)

In addition to the reduced immune surveillance and direct oncogenic effect caused by immunosuppressive drugs, chronic antigen stimulation of skin-homing (CLA+) lymphocytes caused by grafts may have a specific role in the development of lymphoproliferative disorders of the skin. The possible role of chronic antigenic stimulation in the development of primary cutaneous lymphoma is witnessed by the progression to lymphoma from lymphoid reactive hyperplasia due to known stimuli-tattoo [99] and

Neuroendocrine skin cancer (Merkel cell carcinoma)

In addition to SCC and BCC, other rarer skin cancer, such as Merkel cell carcinoma (MCC) may have an increased frequency [104], [105], [106], [107], [108], [109], [110], [111], [112], [113], [114], [115]. MCC is a rare, aggressive cutaneous malignancy of neuroendocrine origin, that usually affects the head, neck and extremities of elderly patients. According to the Cincinnati Transplant Tumor Registry, MCC is not so uncommon in transplant recipients. Forty-one cases have been reported by Penn

Rare skin cancers

Uncommon tumours, such as sarcoma also seem to occur at increased rate in transplant recipients [114]. A case of locally invasive dermatofibrosarcoma protuberans (DFSP) has been described in a kidney transplant recipient 4 years after successful renal transplantation [116]. Another case of DFSP has been described at the site of an arteriovenus fistula in a renal recipient [117].

A report on a cohort of 642 renal transplant recipients suggests an elevated incidence of cutaneous malignant fibrous

Conclusions

Since skin cancer in transplant recipients may have uncommon clinical features and a more aggressive course than in non-immunosuppressed subjects, transplant patients should be followed up regularly and strictly by experienced dermatologists in order to identify and treat any skin cancer in an early phase. Additionally, as tumours which are generally rare in the general population have a higher incidence in transplant recipients, total excision or punch biopsy followed by histological analysis

Reviewers

Friedrich Breier, Dr., Univ.-Doz., Departments of Dermatology, Lainz Municipal Hospital Woldersbergenstr. 1, A-1130, Vienna, Austria.

Guenter Burg (M.D.), Professor and Chairman, Departments of Dermatology, University Hospital of Zuerich, CH-8091 Zuerich, Switzerland.

Gianni Gerlini was born in Florence on 19/02/1967. He graduated in Medicine and Surgery with a first-class honours degree at the University of Florence Medical School in 1993 (thesis entitled “Distribution and possible patogenetic role of IgE binding dermal dendritic cells in atopic dermatitis”). Research fellow at the Department of Dermatology, University of Zuerich (Switzerland) in the field of dendritic cell vaccination in melanoma (1999–2000). He obtained the specialisation in Dermatology

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  • Cited by (0)

    Gianni Gerlini was born in Florence on 19/02/1967. He graduated in Medicine and Surgery with a first-class honours degree at the University of Florence Medical School in 1993 (thesis entitled “Distribution and possible patogenetic role of IgE binding dermal dendritic cells in atopic dermatitis”). Research fellow at the Department of Dermatology, University of Zuerich (Switzerland) in the field of dendritic cell vaccination in melanoma (1999–2000). He obtained the specialisation in Dermatology and Venereology “cum laude” at the Department of Dermatological Sciences, University of Florence in November 1999, with a thesis entitled “Specific active immune-therapy with dendritic cell in melanoma”. He is currently working in Florence at the Regional Referral Centre for Surgical and Immunologic Therapy of Melanoma and in the Laboratory of Skin Immunology and Cell Cultures at the Department of Dermatological Sciences of Florence.

    Paolo Romagnoli graduated M.D. in 1974 and is full professor of Histology in the Medical Faculty of the University of Florence (Italy) since 1986. He has been research fellow of the Alexander von Humboldt Foundation in Hannover, Munich and Bonn (Germany), and visiting scientist at the Schepens Eye Research Institute in Boston (Massachusetts). His main research topics have been the behaviour of the Golgi apparatus and plasma membrane along the secretory cycle and the differentiation and intercellular relationships of cells of the skin immune system and of keratinocytes in physiology and pathology; he has authored 134 scientific papers (70 in indexed journals) until now.

    Nicola Pimpinelli was born in Florence on 24 may, 1957. Graduated M.D. in 1983 and Ph.D. in 1986. Specialist in Dermatology and Venreology since 1986. Associate professor of Dermatology in the Medical Faculty of the University of Florence (Italy) since 2001. His main clinical and research interests are in dermatoncology (current president of the International Society for Cutaneous Lymphomas; vice-coordinator of the Skin Cancer group of the Oncology Department in Florence) and skin immunology. He has authored more than 119 scientific papers (71 in indexed journals) to date.

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