Squamous cell carcinoma in solid organ transplant recipients: Review of the literature

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(B) Image of the surgical specimen showing an oval lesion with well-defined margins. (C) Appearance of the anal region after surgical resection. Pathological study: (D) Cross-linked fascicles of spindle cells with eosinophilic cytoplasm, nuclei with conical ends and small nucleoli, consistent with smooth muscle cells (H&E stain, 200×) are visible. Immunohistochemistry study (E and F) showing strongly positive staining for actin (E) and negative for CD117, with positive mast cells as internal control, confirming the diagnosis of leiomyoma (F) (400×)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raquel Ruiz-Fernández, Daniel Fernández-Martínez, Iván Fernández-Vega" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Raquel" "apellidos" => "Ruiz-Fernández" ] 1 => array:2 [ "nombre" => "Daniel" "apellidos" => "Fernández-Martínez" ] 2 => array:2 [ "nombre" => "Iván" "apellidos" => "Fernández-Vega" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775324003671" "doi" => "10.1016/j.medcli.2024.04.034" "estado" => "S200" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775324003671?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624004637?idApp=UINPBA00004N" "url" => "/23870206/unassign/S2387020624004637/v1_202410210424/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Squamous cell carcinoma in solid organ transplant recipients: Review of the literature" "tieneTextoCompleto" => true "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Inés Oteiza Rius, Ana Morelló Vicente, Leyre Aguado Gil" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Inés" "apellidos" => "Oteiza Rius" ] 1 => array:4 [ "nombre" => "Ana" "apellidos" => "Morelló Vicente" "email" => array:1 [ 0 => "amorellovic@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Leyre" "apellidos" => "Aguado Gil" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Carcinoma escamoso cutáneo en pacientes trasplantados de órgano sólido: revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1876 "Ancho" => 3333 "Tamanyo" => 539329 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Summary of the main recommendations on prevention, treatment and follow-up of solid organ transplant patients diagnosed with cutaneous squamous cell carcinoma. SCC: squamous cell carcinoma." ] ] ] "textoCompleto" => "IntroductionThe incidence of cutaneous squamous cell carcinoma (SCC) is progressively increasing. Although high photoexposure is the main associated risk factor for this type of tumour in the general population, solid organ transplant recipients (SOTRs) have been found to have a higher susceptibility and, therefore, a higher incidence of SCC. In addition, their characteristics differ from SCC developed in the general population, as they are more aggressive tumours, with a 5–10 times higher probability of metastasis and a higher prevalence of associated death.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Given the scarcity of studies on this type of tumour in the context of immunosuppression due to transplantation, this article aims to review the evidence collected to date on the main differences in the development of SCC in SOTRs compared to immunocompetent patients and specific recommendations regarding treatment, management and follow-up in this group of patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>EpidemiologySOTRs are at high risk of developing SCC due to decreased immune monitoring as a result of the immunosuppressive drugs required to prevent transplant rejection. This risk is estimated to be approximately 65 times higher compared to the general population,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> and varies according to the degree of immunosuppression, the duration and type of treatment and the organ transplanted, with heart transplants being the highest risk, followed by kidney and then liver transplants.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Some studies report an incidence of up to 75% of at least one SCC in the first 20 years after transplantation.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In addition, these tumours have a higher risk of lymphatic metastasis (up to 8% compared to 2.1% in the general population)<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and higher recurrence rates. It is estimated that after a first diagnosis of SCC, the risk of developing another tumour within 3 years is up to 80%.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Therefore, prevention, follow-up and the choice of appropriate treatment in SOTRs is crucial in this type of tumour.PreventionRetinoidsSystemic retinoids (acitretin, isotretinoin and etretinate) have been used in the systemic chemoprevention of SCC in SOTRs. These drugs have been shown to be safe and effective for SOTRs with an active history of developing multiple SCC (more than 5 per year).<a class="elsevierStyleCrossRefs" href="#bib0015">3,5,6</a> Despite evidence of their effectiveness in reducing the development of these tumours, these drugs need to be maintained for long periods to achieve efficacy, and discontinuation can lead to a significant rebound in these tumours. Prospective studies have recently been published evaluating the role of long-term acitretin (10 to 35 mg/day depending on tolerance) in the prevention of SCC in SOTRs. Both studies show a significant long-term reduction.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> However, further studies are needed to determine their long-term efficacy as chemopreventive agents in SOTRs.NicotinamideNicotinamide is an amide form of vitamin B3 that prevents ATP depletion and enhances DNA repair. This drug reduces ultraviolet radiation-induced immunosuppression and has been shown to reduce the incidence of actinic keratosis and non-melanoma skin cancers (NMSC) at a dose of 500 mg/12 h in immunocompetent patients in a phase III clinical trial.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> In addition, it has a good tolerability profile with minimal side effects, although there are no long-term safety data in SOTR.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> However, a recent clinical trial found no statistically significant difference in the reduction of the number of keratinocytic cancers in SOTRs with and without nicotinamide treatment over 12 months.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Therefore, further studies are needed to validate its usefulness in the prevention of SCC in SOTRs. In addition, its potential long-term benefits, its safety in patients with co-morbidities such as chronic kidney disease and its effect after discontinuation need to be further evaluated.CapecitabineIt is a 5-fluorouracil (5-FU) prodrug used orally at low doses for chemoprevention in SOTRs who develop more than two SCC in 6 months. In a small case series, Endrizzi et al. demonstrated a reduction in SCC associated with low-dose capecitabine (0.5–1.5 g/m2 per day) over a 12-month period in liver and kidney transplant recipients.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> Side effects include fatigue, nausea, palmar-plantar erythrodysaesthesia and impaired renal function. The latter should be taken into consideration especially in renal transplant recipients, in whom it will be necessary to start with low doses, closely monitor renal function and assess risk-benefit on an individual basis.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> However, more randomised studies are needed to determine long-term efficacy and safety in SOTRs.Actinic keratosis and cancerisation field treatmentWe refer to areas of chronic sun damage with a high number of actinic keratosis, and therefore a higher risk of developing SCC, as field cancerisation. For this reason, in transplant patients it is essential to treat these areas in order to prevent the development of these tumours. Different topical therapies are available for this purpose, such as photodynamic therapy (PDT), 5-FU, imiquimod, tirbanibulin and cryotherapy. The efficacy of PDT for the prevention and treatment of SCC in SOTRs has recently been demonstrated in a meta-analysis.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Moreover, it is an option that is well tolerated by patients and has few side effects, apart from local adverse effects. There are clinical trials that demonstrate the effectiveness of both conventional PDT<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and daylight PDT<a class="elsevierStyleCrossRef" href="#bib0075">15</a> in the prevention of SCC in SOTRs, however, there are no studies in this population subgroup that compare both treatment modalities. Regarding the use of 5-FU and imiquimod, both are valid options in transplant patients and should be selected on a patient-by-patient basis, however, a recent study demonstrates the superiority of 5-FU (partial response rates of 58% vs. 29%) over imiquimod in 40 SOTR.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> As for tirbanibulin, there are currently no studies in transplant recipients.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Beta-HPV vaccinationHuman papillomaviruses (HPV) constitute a group of more than 170 subsets with 5 main genera, the most important of which are α and β. The genus β seems to be involved in the development of SCC in immunocompromised patients. However, the varying sensitivity and specificity of the methods used to detect it leads to ambiguous and controversial results between different studies. In addition, current vaccines target high-risk HPV-α, responsible for cervical, anogenital and oropharyngeal cancers. Despite a possible partial cross-protection against the other HPV-α types, their cross-protective efficacy against HPV-β types is not fully established. New vaccines are currently being developed that offer reactivity against HPV-β types.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Topical sirolimusBased on the indications for substitution of oral immunosuppressive therapy in transplant recipients, which recommend switching from calcineurin inhibitors to sirolimus, the authors Chong et al. studied the role of topical sirolimus 1% for 12 months as a preventive treatment of SCC in transplant recipients. The results showed a three-fold decrease in in situ SCC, with no difference in the number of SCCs.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Despite being a drug with several indications and no evidence of serious adverse effects, further studies are needed to substantiate its role in the prevention of SCC in this group of patients.DietThere is a recent study on the preventive effects of omega-3 polyunsaturated fatty acid intake on the development of NMSC in kidney and liver transplant recipients. The results showed a lower risk of SCC in patients with a high intake of long-chain omega-3 polyunsaturated fatty acids.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> In contrast, there is evidence for an increased risk of SCC in patients following a pro-inflammatory diet.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Photoprotection and health educationOf course, health education and photoprotection measures are key elements in the prevention of SCC in SOTRs. However, a recent systematic review of randomised clinical trials demonstrated the lack of evidence to date regarding photoprotection measures in this subgroup of patients.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Therefore, further studies are needed to support the true efficacy of photoprotection in SOTRs.TreatmentSurgical treatmentAs in immunocompetent patients, the choice of appropriate treatment will depend on both the characteristics of the tumour (anatomical location, size and stage) and the characteristics of the patient (comorbidities and patient preferences). This implies that in infiltrating tumours the treatment of choice will be mainly surgical. In addition, it is important to determine the stage of the tumour and to rule out the presence of features that determine whether it is a high-risk tumour. The eighth and latest edition of the American Joint Committee on Cancer (AJCC) states that the characteristics of a high-risk tumour include tumours equal to or larger than 4 cm in size, a thickness > 6 mm or invasion beyond the subcutaneous fat, the presence of perineural invasion (nerves greater than 0.1 mm, deeper than the dermis, or clinical or radiological involvement of nerves) and bone involvement.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> To date, there are no prognostic classifications of these tumours specific to transplant patients. For tumours classified as high risk, Mohs Micrographic Surgery (MMS) is the most recommended modality as it offers higher cure rates.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> It is important to note that although several studies consider immunosuppression, especially in transplant recipients, as a poor prognostic factor in these tumours (higher rates of local recurrence, higher likelihood of metastatic disease and higher prevalence of death)<a class="elsevierStyleCrossRef" href="#bib0125">25</a> and therefore amenable to MMS, there is a paucity of data in the literature on cure rates after MMS in SOTR.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> In cases where MMS is not available, surgical excision with postoperative margin assessment is a valid alternative. In these cases, the recommended optimal surgical margins in SOTRs are described in the literature with variations between 4 to 10 mm,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> with no clinical data on the proportion of residual or recurrent SCC depending on the recommended margins. However, it is important to bear in mind that immunosuppressed patients, especially SOTRs and those with haematological malignancies, are at increased risk of having a microscopically larger SCC compared to what is clinically and even dermoscopically visible.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> For this reason, MMS should be considered as first-line treatment in SOTRs, whenever circumstances allow. Likewise, after surgical treatment, it is essential to treat the cancerisation field where the tumour is located using topical therapies such as PDT, 5-FU or imiquimod, in order to prevent the development of other tumours in at-risk locations.<a class="elsevierStyleCrossRef" href="#bib0145">29</a>Sentinel nodeThe indication for sentinel node biopsy (SNB) in patients diagnosed with SCC is not fully established in the guidelines for the management of these tumours. Despite a higher incidence of metastasis in high-risk patients, there are studies that question its cost-effectiveness compared to clinical follow-up.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> It is also important to consider that the cost-effectiveness of SCC in the head and neck is particularly controversial due to the complexity of lymphatic drainage, the proximity of the primary tumour to the lymph nodes and the presence of anatomical structures such as the facial nerve.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> In contrast, several studies consider it necessary to perform this diagnostic test in the presence of several poor prognostic factors according to the Brigham and Women's (BWH) staging system. These factors include a diameter greater than 2 cm, poor histological differentiation, perineural invasion of a nerve greater than or equal to 1 mm, or tumour invasion beyond the subcutaneous cellular tissue.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Although immunosuppression is not considered, several studies postulate the need to include it among these factors and, according to the authors Pride et al., SNB should be considered in all immunosuppressed patients with tumours at stage T2b or greater (BWH).<a class="elsevierStyleCrossRef" href="#bib0165">33</a> However, there are insufficient data on the benefit of SNB in SOTRs with high-risk SCC and prospective studies are needed to clarify its true efficacy.RadiotherapyRadiotherapy is a well-accepted alternative for SOTRs with inoperable head and neck SCC or patients who are not candidates for surgical treatment. It is also recommended as adjuvant therapy in high-risk SCC or in cases of incomplete resection. For non-head and neck SCC, there is limited clinical evidence, particularly in SOTR.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> On the other hand, recent studies have shown the effectiveness of a type of radiotherapy called volumetric modulated arc therapy (VMAT) in the treatment of actinic keratosis and SCC<a class="elsevierStyleCrossRef" href="#bib0175">35</a> but there are no data yet in transplanted patients.Systemic therapyFor patients with advanced metastatic or locoregional disease, there is no current agreement on specific management in SOTR.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> To date, the guidelines are the same for the general population: radiation, chemotherapy and targeted therapy. However, despite the increasing use of targeted therapies (anti-PD-1/PDL-1 and EGFR inhibitors predominantly) in patients with advanced disease or unsuitable for surgical treatment, it is essential to note that anti-PD1 drugs have been associated with irreversible allograft rejection.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Despite this, there are cases described in the literature with good response to anti-PD-1, without associated rejection of the transplanted organ.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> To date, there is more evidence in kidney transplant patients because of the possibility of dialysis in the event of kidney failure, as opposed to heart and liver transplant patients, who have a higher risk of death in the event of organ rejection.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> However, there are studies showing satisfactory results in the latter, the largest series reported to date being a retrospective study of 39 patients in whom the prevalence of rejection was 40%.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> In addition, Tsung et al. propose the use of oral glucocorticoid therapy before and after immunotherapy infusion (40 mg the day before, 20 mg/day for 5 days after infusion and 10 mg/day until 20 days after infusion).<a class="elsevierStyleCrossRef" href="#bib0190">38</a> Unfortunately, there are currently no clinical trial data to determine the management of these patients. On the other hand, the immunosuppression of SOTRs casts doubt on the efficacy of these drugs in terms of tumour shrinkage. However, a recent systematic review shows that a significant tumour response is observed in most SCC patients.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> On the other hand, there are new alternatives which are the subject of isolated descriptions in the literature. Recently, a case of complete response of metastatic SCC to treatment with talimogene laherparepvec (T-VEC) in SOTRs has been published. T-VEC is a genetically modified herpes simplex virus engineered to express granulocyte-macrophage colony-stimulating factor (GM-CSF). T-VEC is thought to exert its effects through 2 pathways: direct lysis of tumour cells at the injection site and induction of local and systemic immune responses.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> In addition, there are other cases described in the literature in patients transplanted for treatment of other tumours (Merkel carcinoma and melanoma), in which no damage to the transplanted organ is described. However, it is important to take into account the potential risk of encephalitis due to virus dissemination after the use of this therapy.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> Another novelty described in the treatment of multifocal disease in SOTRs is a case of disease-free response after weekly injections of intralesional IL-2 combined with topical imiquimod.<a class="elsevierStyleCrossRef" href="#bib0210">42</a>Modification of immunosuppressionThe diagnosis of aggressive SCC or the presence of multiple SCC suggests a review of immunosuppressive therapy in SOTR.<a class="elsevierStyleCrossRefs" href="#bib0215">43–45</a> In recent years, there has been increasing evidence to support switching from mTOR inhibitors to calcineurin inhibitors (tacrolimus). This substitution appears to be effective after the first post-transplant diagnosis of SCC. However, such a switch in patients without a history of SCC does not seem to extend the time to first diagnosis and therefore does not have any beneficial effect.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> As for mTOR inhibitors, their use is limited by a relatively high discontinuation rate (25–40%) due to side effects. These include hyperlipidaemia, glucose intolerance, interstitial pneumonias and lymphoedema. In addition, it is important to note an increased risk of death due to infections and cardiovascular diseases. On the other hand, mTOR inhibitors may affect the healing process, which needs to be taken into account for an appropriate post-operative approach and follow-up in these patients. Nevertheless, it is essential to consider that the use of low-dose sirolimus reduces the risk of SCC without increasing the risk of death from other causes and, for this reason, guidelines recommend its use in patients with very high-risk tumours or with rapid onset of multiple SCC.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> As for the use of everolimus, although there is less evidence, it seems to have similar results.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> On the other hand, older immunosuppressants, such as azathioprine or cyclosporine, have been associated with an increased risk of developing these tumours. It is true that this evidence has been more documented for azathioprine than for cyclosporine. Currently, both drugs are rarely used as maintenance immunosuppressive therapy, but in patients on such therapy with a history of multiple SCC, a switch to mycophenolate should be considered.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> Belatacept (selective CD80 and CD86 blocker) is another immunosuppressant approved for use in kidney transplantation for which the data on the relative risk of developing skin cancer compared with calcineurin inhibitors is inconclusive.<a class="elsevierStyleCrossRef" href="#bib0250">50</a>Treatment of squamous carcinoma in situThe optimal treatment of SCC in situ in SOTRs is controversial and more long-term prospective studies comparing surgical treatment with other types of therapies indicated in immunocompetent patients, such as cryotherapy, curettage or topical chemotherapy, are needed. Among the latter, imiquimod has demonstrated efficacy and safety in the treatment of SCC in situ in transplant recipients, despite initial suggestions of a potential risk of organ rejection in transplant recipients due to its immune-enhancing effect.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> Even so, there are studies that demonstrate a superiority of 5-FU over imiquimod in this population subgroup in the treatment of actinic keratosis and, therefore, in the prevention of SCC.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Recently, a study was published postulating the safety and efficacy of cryoimmunotherapy (5 weeks of daily imiquimod and cryosurgery on day 14) in renal transplant patients.<a class="elsevierStyleCrossRef" href="#bib0260">52</a> On the other hand, there are studies showing a higher prevalence of residual SCC after shave biopsy compared to non-immunosuppressed controls.<a class="elsevierStyleCrossRef" href="#bib0265">53</a>Follow-upTime intervalsThe main objectives of follow-up in SOTRs are early detection and prevention of actinic keratosis and NMSCs, in order to try to improve their prognosis. There is controversy about the monitoring interval. Given the growing population of transplant recipients, this should be short enough to detect precursors of malignant lesions and long enough to avoid overuse of available resources. According to the American Society of Transplantation (AST), these patients should undergo skin examinations by a qualified healthcare professional with expertise in skin tumours on an annual basis, or even more frequently in case of a history of skin cancer. In addition, there are expert consensus guidelines, mainly based on retrospective studies, that recommend full-body skin examinations annually in patients with no history of NMSCs, every 6 months if actinic keratosis or NMSC is present, every 3 months if there is a history of multiple NMSCs or high-risk SCC, and every 1–3 months for metastatic SCC.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Although more evidence is needed to determine the frequency of follow-up in SOTRs, there are some prospective studies that suggest the need to consider other risk factors such as age, phototype or previous history of sunburn.<a class="elsevierStyleCrossRef" href="#bib0270">54</a> In addition, it is important to consider that these risk factors may differ between regions, depending on different ethnic distributions and geographic location; therefore, it is essential to validate the follow-up interval in each country. On the other hand, the efficacy of periodic skin self-examinations has not been demonstrated in the early detection of SCC in OTR.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> To date, there is no specific indication to differentiate follow-up intervals according to the type of transplant or degree of immunosuppression.Previous rejectionsAnother factor to consider in the follow-up of these patients is the existence of previous episodes of rejection. This is a factor associated with a higher incidence of SCC, as well as a shorter time to the development of the first SCC, in kidney transplant recipients. This implies the need for closer monitoring in kidney transplant recipients after a rejection episode.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> To date, the importance of previous rejection has not been confirmed in other studies with other types of solid organ transplantation.CD57 expression on TCD8 cellsCD57 expression on TCD8 cells has also been considered as a possible risk factor in some studies. This marker is measured on cells obtained from peripheral blood and identifies cells that have undergone repeated rounds of antigenic stimulation, have shorter telomeres and impaired proliferation and cytokine production. CD57 expression may therefore represent a marker of T-cell exhaustion. There is a study comparing the incidence of SCC in SOTRs showing ≥ 50% CD8 with CD57 expression (flow cytometry) with those showing < 50% expression. A follow-up of 522 (434–607) days was carried out and statistically significant results were obtained regarding an increased likelihood of developing SCC (hazard ratio: 2.9; 95% CI: 1.0–8.0) and earlier recurrence in patients with higher CD57 expression, adjusted for age and previous history of SCC. Furthermore, stability of this marker over time and an association with older age and CMV seropositivity were observed. These results imply that this test could help identify high-risk SOTRs who require intensive dermatological screening and a reduction of their immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0280">56</a>PolymorphismsIn relation to genetic predisposition, a non-coding nucleotide polymorphism (rs34567942) has been identified as a predisposing factor for SCC in transplant recipients. This polymorphism has a deleterious effect on the FBXO25 gene, whose mutation is associated with head and neck SCC.<a class="elsevierStyleCrossRef" href="#bib0285">57</a> While it is true that genetic variants alone can have virtually imperceptible effects, the combination of different variables can have more significant consequences. Thus, Stapleton et al. suggest the usefulness of polygenetic risk estimation in renal transplant patients. These findings could suggest a role for genomics in risk stratification of these patients, allowing the development of personalised treatment regimens in the future.<a class="elsevierStyleCrossRef" href="#bib0290">58</a>Painful lesionsThe sensation of pain in skin tumours should raise suspicion of invasive SCC in transplant recipients. There is evidence of increased overall mortality in SOTRs with painful skin lesions regardless of histological diagnosis. Despite the absence of a relationship between pain and perineural invasion in these tumours, there is an association between the number of painful lesions and overall mortality. For this reason, painful skin lesions should be used as a clinical indicator of increased risk.<a class="elsevierStyleCrossRef" href="#bib0295">59</a>Pre-transplant screeningTo date, there are no data validating the role of skin cancer screening and/or actinic keratosis screening prior to transplantation.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Paediatric patientsIn paediatric patients, the development of NMSCs occurs several years after transplantation (6 to 20 years after transplantation). For this reason, in paediatric transplant recipients these tumours occur at an earlier age than in the general population. To date, there are no guidelines on skin cancer screening for paediatric patients or publications on chemoprevention in this patient group.<a class="elsevierStyleCrossRef" href="#bib0300">60</a>ConclusionsSCC in SOTRs is more aggressive and more likely to metastasise, requiring a specific approach to prevention, treatment and follow-up for this group of patients. In terms of treatment, surgery is the treatment of choice in most cases, preferably by paraffin-embedded margin control surgery, although the availability and suitability of this technique may vary. On the other hand, modification of immunosuppression is an essential part of treatment in this group of patients, and switching from calcineurin inhibitors to mTOR inhibitors is an effective strategy, although with important side-effect considerations. With regard to follow-up, there is some controversy about specific monitoring intervals, as various risk factors that have not yet been established, such as previous rejections, CD57 expression on TCD8 cells or genetic polymorphisms, should be taken into account. However, these check-ups should be carried out regularly, at least every 12 months, and may be necessary every 3 months depending on the degree of immunosuppression and the presence of a history of NMSC. In summary, the management of SCC in SOTRs is an important challenge that requires a multidisciplinary approach, taking into account the unique characteristics of these patients and the need for ongoing research to improve the prevention, diagnosis and treatment of this disease in this population.Informed consentNo informed consent was required due to the absence of patients in the study.FundingWe have not received funding for this article." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2290733" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1903109" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2290734" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1903108" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Epidemiology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Prevention" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Retinoids" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Nicotinamide" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Capecitabine" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Actinic keratosis and cancerisation field treatment" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Beta-HPV vaccination" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Topical sirolimus" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Diet" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Photoprotection and health education" ] ] ] 7 => array:3 [ "identificador" => "sec0060" "titulo" => "Treatment" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Surgical treatment" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Sentinel node" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Radiotherapy" ] 3 => array:2 [ "identificador" => "sec0080" "titulo" => "Systemic therapy" ] 4 => array:2 [ "identificador" => "sec0085" "titulo" => "Modification of immunosuppression" ] 5 => array:2 [ "identificador" => "sec0090" "titulo" => "Treatment of squamous carcinoma in situ" ] ] ] 8 => array:3 [ "identificador" => "sec0095" "titulo" => "Follow-up" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0100" "titulo" => "Time intervals" ] 1 => array:2 [ "identificador" => "sec0105" "titulo" => "Previous rejections" ] 2 => array:2 [ "identificador" => "sec0110" "titulo" => "CD57 expression on TCD8 cells" ] 3 => array:2 [ "identificador" => "sec0115" "titulo" => "Polymorphisms" ] 4 => array:2 [ "identificador" => "sec0120" "titulo" => "Painful lesions" ] ] ] 9 => array:2 [ "identificador" => "sec0125" "titulo" => "Pre-transplant screening" ] 10 => array:2 [ "identificador" => "sec0130" "titulo" => "Paediatric patients" ] 11 => array:2 [ "identificador" => "sec0135" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0140" "titulo" => "Informed consent" ] 13 => array:2 [ "identificador" => "sec0145" "titulo" => "Funding" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2024-01-16" "fechaAceptado" => "2024-05-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1903109" "palabras" => array:3 [ 0 => "Squamous cell carcinoma" 1 => "Solid organ transplant recipients" 2 => "Immunosuppression" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1903108" "palabras" => array:3 [ 0 => "Carcinoma escamoso cutáneo" 1 => "Trasplantados de órgano sólido" 2 => "Inmunosupresión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Solid organ transplant recipients (SOTRs) exhibit an elevated incidence and aggressiveness of squamous cell carcinomas (SCCs) due to their immunosuppression. These tumors are associated with a heightened risk of metastasis and increased mortality. Therefore, an appropriate management of these patients is essential to improve their prognosis. Given the scarcity of studies on non-melanoma skin cancers (NMSCs) in SOTRs, this article aims to summarize and analyze the evidence gathered to date regarding therapeutic approaches, personalized monitoring, and prevention strategies for SCCs in these patients. Additionally, recent advancements in understanding SCCs within this patient group are also documented." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los pacientes trasplantados de órgano sólido (PTOS) presentan una mayor incidencia y agresividad de carcinomas escamosos (CECs) debido a su inmunosupresión. Estos tumores se asocian a un mayor riesgo de metástasis y a un aumento de la mortalidad. Por lo tanto, un adecuado manejo de estos pacientes resulta esencial para favorecer su pronóstico. Dada la escasez de estudios sobre los cánceres cutáneos no melanoma (CCNM) en PTOS, este artículo pretende resumir y analizar las evidencias recogidas hasta la fecha sobre el enfoque terapéutico, seguimiento personalizado y estrategias de prevención en estos pacientes en relación al CEC. Asimismo, se recogen las novedades sobre el CEC descritas en este grupo de pacientes durante los últimos años." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1876 "Ancho" => 3333 "Tamanyo" => 539329 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Summary of the main recommendations on prevention, treatment and follow-up of solid organ transplant patients diagnosed with cutaneous squamous cell carcinoma. SCC: squamous cell carcinoma." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:60 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Metastasis risk of cutaneous squamous cell carcinoma in organ transplant recipients and immunocompetent patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.E. Genders" 1 => "J.A.J. Osinga" 2 => "E.E. Tromp" 3 => "P. O’Rourke" 4 => "J.N. Bouwes Bavinck" 5 => "E.I. 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Squamous cell carcinoma in solid organ transplant recipients: Review of the literature

Carcinoma escamoso cutáneo en pacientes trasplantados de órgano sólido: revisión de la literatura

Inés Oteiza Rius, Ana Morelló Vicente

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amorellovic@unav.es

Corresponding author.

, Leyre Aguado Gil

Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona, Spain

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            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Anal lesion&#58; &#40;A&#41; Tumour measuring 4<span class="elsevierStyleHsp" style=""></span>cm in greatest diameter&#44; pedunculated and located in the right posterolateral quadrant of the anus&#46; &#40;B&#41; Image of the surgical specimen showing an oval lesion with well-defined margins&#46; &#40;C&#41; Appearance of the anal region after surgical resection&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pathological study&#58; &#40;D&#41; Cross-linked fascicles of spindle cells with eosinophilic cytoplasm&#44; nuclei with conical ends and small nucleoli&#44; consistent with smooth muscle cells &#40;H&#38;E stain&#44; 200&#215;&#41; are visible&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Immunohistochemistry study &#40;E and F&#41; showing strongly positive staining for actin &#40;E&#41; and negative for CD117&#44; with positive mast cells as internal control&#44; confirming the diagnosis of leiomyoma &#40;F&#41; &#40;400&#215;&#41;&#46;</p>"
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    "titulo" => "Squamous cell carcinoma in solid organ transplant recipients&#58; Review of the literature"
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        "autoresLista" => "In&#233;s Oteiza Rius, Ana Morell&#243; Vicente, Leyre Aguado Gil"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of the main recommendations on prevention&#44; treatment and follow-up of solid organ transplant patients diagnosed with cutaneous squamous cell carcinoma&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCC&#58; squamous cell carcinoma&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of cutaneous squamous cell carcinoma &#40;SCC&#41; is progressively increasing&#46; Although high photoexposure is the main associated risk factor for this type of tumour in the general population&#44; solid organ transplant recipients &#40;SOTRs&#41; have been found to have a higher susceptibility and&#44; therefore&#44; a higher incidence of SCC&#46; In addition&#44; their characteristics differ from SCC developed in the general population&#44; as they are more aggressive tumours&#44; with a 5&#8211;10 times higher probability of metastasis and a higher prevalence of associated death&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Given the scarcity of studies on this type of tumour in the context of immunosuppression due to transplantation&#44; this article aims to review the evidence collected to date on the main differences in the development of SCC in SOTRs compared to immunocompetent patients and specific recommendations regarding treatment&#44; management and follow-up in this group of patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0010" class="elsevierStylePara elsevierViewall">SOTRs are at high risk of developing SCC due to decreased immune monitoring as a result of the immunosuppressive drugs required to prevent transplant rejection&#46; This risk is estimated to be approximately 65 times higher compared to the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and varies according to the degree of immunosuppression&#44; the duration and type of treatment and the organ transplanted&#44; with heart transplants being the highest risk&#44; followed by kidney and then liver transplants&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Some studies report an incidence of up to 75&#37; of at least one SCC in the first 20 years after transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition&#44; these tumours have a higher risk of lymphatic metastasis &#40;up to 8&#37; compared to 2&#46;1&#37; in the general population&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and higher recurrence rates&#46; It is estimated that after a first diagnosis of SCC&#44; the risk of developing another tumour within 3 years is up to 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; prevention&#44; follow-up and the choice of appropriate treatment in SOTRs is crucial in this type of tumour&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Prevention</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Retinoids</span><p id="par0015" class="elsevierStylePara elsevierViewall">Systemic retinoids &#40;acitretin&#44; isotretinoin and etretinate&#41; have been used in the systemic chemoprevention of SCC in SOTRs&#46; These drugs have been shown to be safe and effective for SOTRs with an active history of developing multiple SCC &#40;more than 5 per year&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> Despite evidence of their effectiveness in reducing the development of these tumours&#44; these drugs need to be maintained for long periods to achieve efficacy&#44; and discontinuation can lead to a significant rebound in these tumours&#46; Prospective studies have recently been published evaluating the role of long-term acitretin &#40;10 to 35&#8239;mg&#47;day depending on tolerance&#41; in the prevention of SCC in SOTRs&#46; Both studies show a significant long-term reduction&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; further studies are needed to determine their long-term efficacy as chemopreventive agents in SOTRs&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Nicotinamide</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nicotinamide is an amide form of vitamin B3 that prevents ATP depletion and enhances DNA repair&#46; This drug reduces ultraviolet radiation-induced immunosuppression and has been shown to reduce the incidence of actinic keratosis and non-melanoma skin cancers &#40;NMSC&#41; at a dose of 500&#8239;mg&#47;12&#8239;h in immunocompetent patients in a phase III clinical trial&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition&#44; it has a good tolerability profile with minimal side effects&#44; although there are no long-term safety data in SOTR&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; a recent clinical trial found no statistically significant difference in the reduction of the number of keratinocytic cancers in SOTRs with and without nicotinamide treatment over 12 months&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Therefore&#44; further studies are needed to validate its usefulness in the prevention of SCC in SOTRs&#46; In addition&#44; its potential long-term benefits&#44; its safety in patients with co-morbidities such as chronic kidney disease and its effect after discontinuation need to be further evaluated&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Capecitabine</span><p id="par0025" class="elsevierStylePara elsevierViewall">It is a 5-fluorouracil &#40;5-FU&#41; prodrug used orally at low doses for chemoprevention in SOTRs who develop more than two SCC in 6 months&#46; In a small case series&#44; Endrizzi et al&#46; demonstrated a reduction in SCC associated with low-dose capecitabine &#40;0&#46;5&#8211;1&#46;5&#8239;g&#47;m<span class="elsevierStyleSup">2</span> per day&#41; over a 12-month period in liver and kidney transplant recipients&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Side effects include fatigue&#44; nausea&#44; palmar-plantar erythrodysaesthesia and impaired renal function&#46; The latter should be taken into consideration especially in renal transplant recipients&#44; in whom it will be necessary to start with low doses&#44; closely monitor renal function and assess risk-benefit on an individual basis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However&#44; more randomised studies are needed to determine long-term efficacy and safety in SOTRs&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Actinic keratosis and cancerisation field treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">We refer to areas of chronic sun damage with a high number of actinic keratosis&#44; and therefore a higher risk of developing SCC&#44; as field cancerisation&#46; For this reason&#44; in transplant patients it is essential to treat these areas in order to prevent the development of these tumours&#46; Different topical therapies are available for this purpose&#44; such as photodynamic therapy &#40;PDT&#41;&#44; 5-FU&#44; imiquimod&#44; tirbanibulin and cryotherapy&#46; The efficacy of PDT for the prevention and treatment of SCC in SOTRs has recently been demonstrated in a meta-analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Moreover&#44; it is an option that is well tolerated by patients and has few side effects&#44; apart from local adverse effects&#46; There are clinical trials that demonstrate the effectiveness of both conventional PDT<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and daylight PDT<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> in the prevention of SCC in SOTRs&#44; however&#44; there are no studies in this population subgroup that compare both treatment modalities&#46; Regarding the use of 5-FU and imiquimod&#44; both are valid options in transplant patients and should be selected on a patient-by-patient basis&#44; however&#44; a recent study demonstrates the superiority of 5-FU &#40;partial response rates of 58&#37; vs&#46; 29&#37;&#41; over imiquimod in 40 SOTR&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> As for tirbanibulin&#44; there are currently no studies in transplant recipients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Beta-HPV vaccination</span><p id="par0035" class="elsevierStylePara elsevierViewall">Human papillomaviruses &#40;HPV&#41; constitute a group of more than 170 subsets with 5 main genera&#44; the most important of which are &#945; and &#946;&#46; The genus &#946; seems to be involved in the development of SCC in immunocompromised patients&#46; However&#44; the varying sensitivity and specificity of the methods used to detect it leads to ambiguous and controversial results between different studies&#46; In addition&#44; current vaccines target high-risk HPV-&#945;&#44; responsible for cervical&#44; anogenital and oropharyngeal cancers&#46; Despite a possible partial cross-protection against the other HPV-&#945; types&#44; their cross-protective efficacy against HPV-&#946; types is not fully established&#46; New vaccines are currently being developed that offer reactivity against HPV-&#946; types&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Topical sirolimus</span><p id="par0040" class="elsevierStylePara elsevierViewall">Based on the indications for substitution of oral immunosuppressive therapy in transplant recipients&#44; which recommend switching from calcineurin inhibitors to sirolimus&#44; the authors Chong et al&#46; studied the role of topical sirolimus 1&#37; for 12 months as a preventive treatment of SCC in transplant recipients&#46; The results showed a three-fold decrease in <span class="elsevierStyleItalic">in situ</span> SCC&#44; with no difference in the number of SCCs&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Despite being a drug with several indications and no evidence of serious adverse effects&#44; further studies are needed to substantiate its role in the prevention of SCC in this group of patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diet</span><p id="par0045" class="elsevierStylePara elsevierViewall">There is a recent study on the preventive effects of omega-3 polyunsaturated fatty acid intake on the development of NMSC in kidney and liver transplant recipients&#46; The results showed a lower risk of SCC in patients with a high intake of long-chain omega-3 polyunsaturated fatty acids&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In contrast&#44; there is evidence for an increased risk of SCC in patients following a pro-inflammatory diet&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Photoprotection and health education</span><p id="par0050" class="elsevierStylePara elsevierViewall">Of course&#44; health education and photoprotection measures are key elements in the prevention of SCC in SOTRs&#46; However&#44; a recent systematic review of randomised clinical trials demonstrated the lack of evidence to date regarding photoprotection measures in this subgroup of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Therefore&#44; further studies are needed to support the true efficacy of photoprotection in SOTRs&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Treatment</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical treatment</span><p id="par0055" class="elsevierStylePara elsevierViewall">As in immunocompetent patients&#44; the choice of appropriate treatment will depend on both the characteristics of the tumour &#40;anatomical location&#44; size and stage&#41; and the characteristics of the patient &#40;comorbidities and patient preferences&#41;&#46; This implies that in infiltrating tumours the treatment of choice will be mainly surgical&#46; In addition&#44; it is important to determine the stage of the tumour and to rule out the presence of features that determine whether it is a high-risk tumour&#46; The eighth and latest edition of the American Joint Committee on Cancer &#40;AJCC&#41; states that the characteristics of a high-risk tumour include tumours equal to or larger than 4&#8239;cm in size&#44; a thickness &#62;&#8239;6&#8239;mm or invasion beyond the subcutaneous fat&#44; the presence of perineural invasion &#40;nerves greater than 0&#46;1&#8239;mm&#44; deeper than the dermis&#44; or clinical or radiological involvement of nerves&#41; and bone involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> To date&#44; there are no prognostic classifications of these tumours specific to transplant patients&#46; For tumours classified as high risk&#44; Mohs Micrographic Surgery &#40;MMS&#41; is the most recommended modality as it offers higher cure rates&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> It is important to note that although several studies consider immunosuppression&#44; especially in transplant recipients&#44; as a poor prognostic factor in these tumours &#40;higher rates of local recurrence&#44; higher likelihood of metastatic disease and higher prevalence of death&#41;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and therefore amenable to MMS&#44; there is a paucity of data in the literature on cure rates after MMS in SOTR&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In cases where MMS is not available&#44; surgical excision with postoperative margin assessment is a valid alternative&#46; In these cases&#44; the recommended optimal surgical margins in SOTRs are described in the literature with variations between 4 to 10&#8239;mm&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> with no clinical data on the proportion of residual or recurrent SCC depending on the recommended margins&#46; However&#44; it is important to bear in mind that immunosuppressed patients&#44; especially SOTRs and those with haematological malignancies&#44; are at increased risk of having a microscopically larger SCC compared to what is clinically and even dermoscopically visible&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> For this reason&#44; MMS should be considered as first-line treatment in SOTRs&#44; whenever circumstances allow&#46; Likewise&#44; after surgical treatment&#44; it is essential to treat the cancerisation field where the tumour is located using topical therapies such as PDT&#44; 5-FU or imiquimod&#44; in order to prevent the development of other tumours in at-risk locations&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Sentinel node</span><p id="par0060" class="elsevierStylePara elsevierViewall">The indication for sentinel node biopsy &#40;SNB&#41; in patients diagnosed with SCC is not fully established in the guidelines for the management of these tumours&#46; Despite a higher incidence of metastasis in high-risk patients&#44; there are studies that question its cost-effectiveness compared to clinical follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> It is also important to consider that the cost-effectiveness of SCC in the head and neck is particularly controversial due to the complexity of lymphatic drainage&#44; the proximity of the primary tumour to the lymph nodes and the presence of anatomical structures such as the facial nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In contrast&#44; several studies consider it necessary to perform this diagnostic test in the presence of several poor prognostic factors according to the Brigham and Women&#39;s &#40;BWH&#41; staging system&#46; These factors include a diameter greater than 2&#8239;cm&#44; poor histological differentiation&#44; perineural invasion of a nerve greater than or equal to 1&#8239;mm&#44; or tumour invasion beyond the subcutaneous cellular tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Although immunosuppression is not considered&#44; several studies postulate the need to include it among these factors and&#44; according to the authors Pride et al&#46;&#44; SNB should be considered in all immunosuppressed patients with tumours at stage T2b or greater &#40;BWH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> However&#44; there are insufficient data on the benefit of SNB in SOTRs with high-risk SCC and prospective studies are needed to clarify its true efficacy&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Radiotherapy</span><p id="par0065" class="elsevierStylePara elsevierViewall">Radiotherapy is a well-accepted alternative for SOTRs with inoperable head and neck SCC or patients who are not candidates for surgical treatment&#46; It is also recommended as adjuvant therapy in high-risk SCC or in cases of incomplete resection&#46; For non-head and neck SCC&#44; there is limited clinical evidence&#44; particularly in SOTR&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> On the other hand&#44; recent studies have shown the effectiveness of a type of radiotherapy called volumetric modulated arc therapy &#40;VMAT&#41; in the treatment of actinic keratosis and SCC<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> but there are no data yet in transplanted patients&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Systemic therapy</span><p id="par0070" class="elsevierStylePara elsevierViewall">For patients with advanced metastatic or locoregional disease&#44; there is no current agreement on specific management in SOTR&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> To date&#44; the guidelines are the same for the general population&#58; radiation&#44; chemotherapy and targeted therapy&#46; However&#44; despite the increasing use of targeted therapies &#40;anti-PD-1&#47;PDL-1 and EGFR inhibitors predominantly&#41; in patients with advanced disease or unsuitable for surgical treatment&#44; it is essential to note that anti-PD1 drugs have been associated with irreversible allograft rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Despite this&#44; there are cases described in the literature with good response to anti-PD-1&#44; without associated rejection of the transplanted organ&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> To date&#44; there is more evidence in kidney transplant patients because of the possibility of dialysis in the event of kidney failure&#44; as opposed to heart and liver transplant patients&#44; who have a higher risk of death in the event of organ rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> However&#44; there are studies showing satisfactory results in the latter&#44; the largest series reported to date being a retrospective study of 39 patients in whom the prevalence of rejection was 40&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> In addition&#44; Tsung et al&#46; propose the use of oral glucocorticoid therapy before and after immunotherapy infusion &#40;40&#8239;mg the day before&#44; 20&#8239;mg&#47;day for 5 days after infusion and 10&#8239;mg&#47;day until 20 days after infusion&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Unfortunately&#44; there are currently no clinical trial data to determine the management of these patients&#46; On the other hand&#44; the immunosuppression of SOTRs casts doubt on the efficacy of these drugs in terms of tumour shrinkage&#46; However&#44; a recent systematic review shows that a significant tumour response is observed in most SCC patients&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> On the other hand&#44; there are new alternatives which are the subject of isolated descriptions in the literature&#46; Recently&#44; a case of complete response of metastatic SCC to treatment with talimogene laherparepvec &#40;T-VEC&#41; in SOTRs has been published&#46; T-VEC is a genetically modified herpes simplex virus engineered to express granulocyte-macrophage colony-stimulating factor &#40;GM-CSF&#41;&#46; T-VEC is thought to exert its effects through 2 pathways&#58; direct lysis of tumour cells at the injection site and induction of local and systemic immune responses&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> In addition&#44; there are other cases described in the literature in patients transplanted for treatment of other tumours &#40;Merkel carcinoma and melanoma&#41;&#44; in which no damage to the transplanted organ is described&#46; However&#44; it is important to take into account the potential risk of encephalitis due to virus dissemination after the use of this therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Another novelty described in the treatment of multifocal disease in SOTRs is a case of disease-free response after weekly injections of intralesional IL-2 combined with topical imiquimod&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Modification of immunosuppression</span><p id="par0075" class="elsevierStylePara elsevierViewall">The diagnosis of aggressive SCC or the presence of multiple SCC suggests a review of immunosuppressive therapy in SOTR&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#8211;45</span></a> In recent years&#44; there has been increasing evidence to support switching from mTOR inhibitors to calcineurin inhibitors &#40;tacrolimus&#41;&#46; This substitution appears to be effective after the first post-transplant diagnosis of SCC&#46; However&#44; such a switch in patients without a history of SCC does not seem to extend the time to first diagnosis and therefore does not have any beneficial effect&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> As for mTOR inhibitors&#44; their use is limited by a relatively high discontinuation rate &#40;25&#8211;40&#37;&#41; due to side effects&#46; These include hyperlipidaemia&#44; glucose intolerance&#44; interstitial pneumonias and lymphoedema&#46; In addition&#44; it is important to note an increased risk of death due to infections and cardiovascular diseases&#46; On the other hand&#44; mTOR inhibitors may affect the healing process&#44; which needs to be taken into account for an appropriate post-operative approach and follow-up in these patients&#46; Nevertheless&#44; it is essential to consider that the use of low-dose sirolimus reduces the risk of SCC without increasing the risk of death from other causes and&#44; for this reason&#44; guidelines recommend its use in patients with very high-risk tumours or with rapid onset of multiple SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> As for the use of everolimus&#44; although there is less evidence&#44; it seems to have similar results&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> On the other hand&#44; older immunosuppressants&#44; such as azathioprine or cyclosporine&#44; have been associated with an increased risk of developing these tumours&#46; It is true that this evidence has been more documented for azathioprine than for cyclosporine&#46; Currently&#44; both drugs are rarely used as maintenance immunosuppressive therapy&#44; but in patients on such therapy with a history of multiple SCC&#44; a switch to mycophenolate should be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Belatacept &#40;selective CD80 and CD86 blocker&#41; is another immunosuppressant approved for use in kidney transplantation for which the data on the relative risk of developing skin cancer compared with calcineurin inhibitors is inconclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment of squamous carcinoma <span class="elsevierStyleItalic">in situ</span></span><p id="par0080" class="elsevierStylePara elsevierViewall">The optimal treatment of SCC <span class="elsevierStyleItalic">in situ</span> in SOTRs is controversial and more long-term prospective studies comparing surgical treatment with other types of therapies indicated in immunocompetent patients&#44; such as cryotherapy&#44; curettage or topical chemotherapy&#44; are needed&#46; Among the latter&#44; imiquimod has demonstrated efficacy and safety in the treatment of SCC <span class="elsevierStyleItalic">in situ</span> in transplant recipients&#44; despite initial suggestions of a potential risk of organ rejection in transplant recipients due to its immune-enhancing effect&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Even so&#44; there are studies that demonstrate a superiority of 5-FU over imiquimod in this population subgroup in the treatment of actinic keratosis and&#44; therefore&#44; in the prevention of SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Recently&#44; a study was published postulating the safety and efficacy of cryoimmunotherapy &#40;5 weeks of daily imiquimod and cryosurgery on day 14&#41; in renal transplant patients&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> On the other hand&#44; there are studies showing a higher prevalence of residual SCC after shave biopsy compared to non-immunosuppressed controls&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Follow-up</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Time intervals</span><p id="par0085" class="elsevierStylePara elsevierViewall">The main objectives of follow-up in SOTRs are early detection and prevention of actinic keratosis and NMSCs&#44; in order to try to improve their prognosis&#46; There is controversy about the monitoring interval&#46; Given the growing population of transplant recipients&#44; this should be short enough to detect precursors of malignant lesions and long enough to avoid overuse of available resources&#46; According to the American Society of Transplantation &#40;AST&#41;&#44; these patients should undergo skin examinations by a qualified healthcare professional with expertise in skin tumours on an annual basis&#44; or even more frequently in case of a history of skin cancer&#46; In addition&#44; there are expert consensus guidelines&#44; mainly based on retrospective studies&#44; that recommend full-body skin examinations annually in patients with no history of NMSCs&#44; every 6 months if actinic keratosis or NMSC is present&#44; every 3 months if there is a history of multiple NMSCs or high-risk SCC&#44; and every 1&#8211;3 months for metastatic SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Although more evidence is needed to determine the frequency of follow-up in SOTRs&#44; there are some prospective studies that suggest the need to consider other risk factors such as age&#44; phototype or previous history of sunburn&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> In addition&#44; it is important to consider that these risk factors may differ between regions&#44; depending on different ethnic distributions and geographic location&#59; therefore&#44; it is essential to validate the follow-up interval in each country&#46; On the other hand&#44; the efficacy of periodic skin self-examinations has not been demonstrated in the early detection of SCC in OTR&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> To date&#44; there is no specific indication to differentiate follow-up intervals according to the type of transplant or degree of immunosuppression&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Previous rejections</span><p id="par0090" class="elsevierStylePara elsevierViewall">Another factor to consider in the follow-up of these patients is the existence of previous episodes of rejection&#46; This is a factor associated with a higher incidence of SCC&#44; as well as a shorter time to the development of the first SCC&#44; in kidney transplant recipients&#46; This implies the need for closer monitoring in kidney transplant recipients after a rejection episode&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> To date&#44; the importance of previous rejection has not been confirmed in other studies with other types of solid organ transplantation&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">CD57 expression on TCD8 cells</span><p id="par0095" class="elsevierStylePara elsevierViewall">CD57 expression on TCD8 cells has also been considered as a possible risk factor in some studies&#46; This marker is measured on cells obtained from peripheral blood and identifies cells that have undergone repeated rounds of antigenic stimulation&#44; have shorter telomeres and impaired proliferation and cytokine production&#46; CD57 expression may therefore represent a marker of T-cell exhaustion&#46; There is a study comparing the incidence of SCC in SOTRs showing &#8805;&#8239;50&#37; CD8 with CD57 expression &#40;flow cytometry&#41; with those showing &#60;&#8239;50&#37; expression&#46; A follow-up of 522 &#40;434&#8211;607&#41; days was carried out and statistically significant results were obtained regarding an increased likelihood of developing SCC &#40;hazard ratio&#58; 2&#46;9&#59; 95&#37; CI&#58; 1&#46;0&#8211;8&#46;0&#41; and earlier recurrence in patients with higher CD57 expression&#44; adjusted for age and previous history of SCC&#46; Furthermore&#44; stability of this marker over time and an association with older age and CMV seropositivity were observed&#46; These results imply that this test could help identify high-risk SOTRs who require intensive dermatological screening and a reduction of their immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Polymorphisms</span><p id="par0100" class="elsevierStylePara elsevierViewall">In relation to genetic predisposition&#44; a non-coding nucleotide polymorphism &#40;rs34567942&#41; has been identified as a predisposing factor for SCC in transplant recipients&#46; This polymorphism has a deleterious effect on the FBXO25 gene&#44; whose mutation is associated with head and neck SCC&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">57</span></a> While it is true that genetic variants alone can have virtually imperceptible effects&#44; the combination of different variables can have more significant consequences&#46; Thus&#44; Stapleton et al&#46; suggest the usefulness of polygenetic risk estimation in renal transplant patients&#46; These findings could suggest a role for genomics in risk stratification of these patients&#44; allowing the development of personalised treatment regimens in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Painful lesions</span><p id="par0105" class="elsevierStylePara elsevierViewall">The sensation of pain in skin tumours should raise suspicion of invasive SCC in transplant recipients&#46; There is evidence of increased overall mortality in SOTRs with painful skin lesions regardless of histological diagnosis&#46; Despite the absence of a relationship between pain and perineural invasion in these tumours&#44; there is an association between the number of painful lesions and overall mortality&#46; For this reason&#44; painful skin lesions should be used as a clinical indicator of increased risk&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">59</span></a></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Pre-transplant screening</span><p id="par0110" class="elsevierStylePara elsevierViewall">To date&#44; there are no data validating the role of skin cancer screening and&#47;or actinic keratosis screening prior to transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Paediatric patients</span><p id="par0115" class="elsevierStylePara elsevierViewall">In paediatric patients&#44; the development of NMSCs occurs several years after transplantation &#40;6 to 20 years after transplantation&#41;&#46; For this reason&#44; in paediatric transplant recipients these tumours occur at an earlier age than in the general population&#46; To date&#44; there are no guidelines on skin cancer screening for paediatric patients or publications on chemoprevention in this patient group&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">60</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">SCC in SOTRs is more aggressive and more likely to metastasise&#44; requiring a specific approach to prevention&#44; treatment and follow-up for this group of patients&#46; In terms of treatment&#44; surgery is the treatment of choice in most cases&#44; preferably by paraffin-embedded margin control surgery&#44; although the availability and suitability of this technique may vary&#46; On the other hand&#44; modification of immunosuppression is an essential part of treatment in this group of patients&#44; and switching from calcineurin inhibitors to mTOR inhibitors is an effective strategy&#44; although with important side-effect considerations&#46; With regard to follow-up&#44; there is some controversy about specific monitoring intervals&#44; as various risk factors that have not yet been established&#44; such as previous rejections&#44; CD57 expression on TCD8 cells or genetic polymorphisms&#44; should be taken into account&#46; However&#44; these check-ups should be carried out regularly&#44; at least every 12 months&#44; and may be necessary every 3 months depending on the degree of immunosuppression and the presence of a history of NMSC&#46; In summary&#44; the management of SCC in SOTRs is an important challenge that requires a multidisciplinary approach&#44; taking into account the unique characteristics of these patients and the need for ongoing research to improve the prevention&#44; diagnosis and treatment of this disease in this population&#46;</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">No informed consent was required due to the absence of patients in the study&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Funding</span><p id="par0130" class="elsevierStylePara elsevierViewall">We have not received funding for this article&#46;</p></span></span>"
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology"
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        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Prevention"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Retinoids"
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              "titulo" => "Nicotinamide"
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              "titulo" => "Capecitabine"
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              "titulo" => "Actinic keratosis and cancerisation field treatment"
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              "identificador" => "sec0040"
              "titulo" => "Beta-HPV vaccination"
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              "titulo" => "Topical sirolimus"
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              "titulo" => "Diet"
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              "identificador" => "sec0055"
              "titulo" => "Photoprotection and health education"
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              "titulo" => "Treatment of squamous carcinoma in situ"
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              "titulo" => "Previous rejections"
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              "identificador" => "sec0110"
              "titulo" => "CD57 expression on TCD8 cells"
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              "titulo" => "Polymorphisms"
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          "titulo" => "Pre-transplant screening"
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    "fechaAceptado" => "2024-05-02"
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            0 => "Squamous cell carcinoma"
            1 => "Solid organ transplant recipients"
            2 => "Immunosuppression"
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            0 => "Carcinoma escamoso cut&#225;neo"
            1 => "Trasplantados de &#243;rgano s&#243;lido"
            2 => "Inmunosupresi&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Solid organ transplant recipients &#40;SOTRs&#41; exhibit an elevated incidence and aggressiveness of squamous cell carcinomas &#40;SCCs&#41; due to their immunosuppression&#46; These tumors are associated with a heightened risk of metastasis and increased mortality&#46; Therefore&#44; an appropriate management of these patients is essential to improve their prognosis&#46; Given the scarcity of studies on non-melanoma skin cancers &#40;NMSCs&#41; in SOTRs&#44; this article aims to summarize and analyze the evidence gathered to date regarding therapeutic approaches&#44; personalized monitoring&#44; and prevention strategies for SCCs in these patients&#46; Additionally&#44; recent advancements in understanding SCCs within this patient group are also documented&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los pacientes trasplantados de &#243;rgano s&#243;lido &#40;PTOS&#41; presentan una mayor incidencia y agresividad de carcinomas escamosos &#40;CECs&#41; debido a su inmunosupresi&#243;n&#46; Estos tumores se asocian a un mayor riesgo de met&#225;stasis y a un aumento de la mortalidad&#46; Por lo tanto&#44; un adecuado manejo de estos pacientes resulta esencial para favorecer su pron&#243;stico&#46; Dada la escasez de estudios sobre los c&#225;nceres cut&#225;neos no melanoma &#40;CCNM&#41; en PTOS&#44; este art&#237;culo pretende resumir y analizar las evidencias recogidas hasta la fecha sobre el enfoque terap&#233;utico&#44; seguimiento personalizado y estrategias de prevenci&#243;n en estos pacientes en relaci&#243;n al CEC&#46; Asimismo&#44; se recogen las novedades sobre el CEC descritas en este grupo de pacientes durante los &#250;ltimos a&#241;os&#46;</p></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of the main recommendations on prevention&#44; treatment and follow-up of solid organ transplant patients diagnosed with cutaneous squamous cell carcinoma&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">SCC&#58; squamous cell carcinoma&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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                    0 => array:2 [
                      "titulo" => "Metastasis risk of cutaneous squamous cell carcinoma in organ transplant recipients and immunocompetent patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;E&#46; Genders"
                            1 => "J&#46;A&#46;J&#46; Osinga"
                            2 => "E&#46;E&#46; Tromp"
                            3 => "P&#46; O&#8217;Rourke"
                            4 => "J&#46;N&#46; Bouwes Bavinck"
                            5 => "E&#46;I&#46; Plasmeijer"
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                      "doi" => "10.2340/00015555-2901"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Derm Venereol"
                        "fecha" => "2018"
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Article information

ISSN: 23870206
Original language: English

DOI:10.1016/j.medcle.2024.05.024

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