Correspondence
Skin Cancers after Organ Transplantation
N Engl J Med 2003; 349:612-614August 7, 2003
- Article
To the Editor:
Euvrard et al. (April 24 issue)1 note that adjuvant radiotherapy may be useful in the management of squamous-cell carcinoma. Primary irradiation is not mentioned as a therapeutic option. Although surgery may be preferable, radiotherapy should also be given consideration. Candidates for radiotherapy include patients who cannot undergo surgery for medical reasons, patients with large lesions for whom surgery may be functionally or cosmetically disfiguring, and patients who wish to consider a noninvasive therapeutic option.
Regarding the management of cutaneous T-cell lymphomas, the authors state that current treatment is “unsatisfactory.” Rituximab, bexarotene, and denileukin diftitox are described by the authors as promising therapeutic possibilities that are emerging. Radiotherapy is not presented as an option for management, although in the case of localized cutaneous T-cell lymphoma, it would be the first-choice therapy. The therapeutic options suggested by the authors are associated with response rates inferior to those achieved with localized irradiation or total-skin electron-beam irradiation, as documented in patients with cutaneous T-cell lymphoma or mycosis fungoides. Given its efficacy, ease of administration, and limited sequelae, radiotherapy should be considered for patients with cutaneous T-cell lymphoma.2-4
4 ReferencesLynn D. Wilson, M.D., M.P.H.
Yale University School of Medicine, New Haven, CT 06520
lynn.wilson@yale. edu 1
Euvrard S ,Kanitakis J ,Claudy A . Skin cancers after organ transplantation. N Engl J Med 2003;348:1681-1691
Full Text | Web of Science | Medline2
Jones GW ,Kacinski BM ,Wilson LD , et al. Total skin electron radiation in the management of mycosis fungoides. J Am Acad Dermatol 2002;47:364-370
CrossRef | Web of Science | Medline3
Wilson LD ,Kacinski BM ,Jones GW . Local superficial radiotherapy in the management of minimal stage IA cutaneous T-cell lymphoma (Mycosis Fungoides). Int J Radiat Oncol Biol Phys 1998;40:109-115
CrossRef | Web of Science | Medline4
Wilson LD ,Jones GW ,Kim D , et al. Experience with total skin electron beam therapy in combination with extracorporeal photopheresis in the management of patients with erythrodermic (T4) mycosis fungoides. J Am Acad Dermatol 2000;43:54-60
CrossRef | Web of Science | Medline
To the Editor:
Skin cancers are the most common tumors among persons who have undergone solid-organ transplantation. They cause substantial illness and may have a life-threatening course. Euvrard et al. stress the importance of regular dermatologic monitoring and treatment of such patients, but neglect to mention the role of photodynamic therapy. Photodynamic therapy uses exogenously applied or endogenously formed photosensitizers and their activation by light to induce cell death through the formation of singlet oxygen and other free radicals. This type of therapy is highly efficient in the treatment of premalignant and malignant skin tumors — such as solar keratoses, superficial basal-cell carcinomas, and initial squamous-cell carcinomas — that occur frequently in immunocompromised persons.1,2 Since there is evidence that photodynamic therapy is effective in the treatment of skin cancers, we believe that this therapy should be mentioned among the possible treatment options.
2 ReferencesLajos Kemeny, M.D.
University of Szeged, H-6721 Szeged, Hungary
kemenyla@freemail.hu Thomas Ruzicka, M.D.
Heinrich Heine University, D-40225 Düsseldorf, Germany1
Fritsch C ,Goerz G ,Ruzicka T . Photodynamic therapy in dermatology. Arch Dermatol 1998;134:207-214
CrossRef | Web of Science | Medline2
Fritsch C ,Lang K ,Neuse W ,Ruzicka T ,Lehmann P . Photodynamic diagnosis and therapy in dermatology. Skin Pharmacol Appl Skin Physiol 1998;11:358-373
CrossRef | Medline
To the Editor:
Euvrard et al. report that most cases of post-transplantation Kaposi's sarcoma develop as a result of reactivation of human herpesvirus 8 (HHV-8), although they recognize the possibility of viral transmission from the donor. In a review of the published literature, we have found, rather unexpectedly, that the transmission of HHV-8 from the donors of solid organs to recipients in whom Kaposi's sarcoma develops is much more common than is generally thought, occurring in one third of the reported cases of Kaposi's sarcoma in organ recipients (16 of 50 cases).1 We have also shown that in five of eight recipients of renal transplants, post-transplantation Kaposi's sarcoma originated from the seeding of Kaposi's sarcoma progenitor cells derived from their matched donors.2 Thus, the pathogenesis of Kaposi's sarcoma may differ from that of other post-transplantation skin cancers, resembling lymphoproliferative diseases in recipients of bone marrow transplants, which are known to result from the expansion of Epstein–Barr virus–infected B cells of donor origin. The screening of grafts for HHV-8 and preemptive interventions in HHV-8–infected recipients with the use of antiviral drugs, cellular therapies, or both should be pursued.
2 ReferencesMario Luppi, M.D., Ph.D.
Patrizia Barozzi, Ph.D.
Giuseppe Torelli, M.D.
University of Modena and Reggio Emilia, 41100 Modena, Italy
mluppi@unimore.it 1
Luppi M, Barozzi P, Guaraldi G, et al. Human herpesvirus-8 (HHV-8) associated diseases in solid organ transplantation: importance of viral transmission from the donor. Clin Infect Dis (in press).
2
Barozzi P ,Luppi M ,Facchetti F , et al. Post-transplant Kaposi sarcoma originates from the seeding of donor-derived progenitors. Nat Med 2003;9:554-561
CrossRef | Web of Science | Medline
Author/Editor Response
We basically agree with the suggestion of Kemeny and Ruzicka that photodynamic therapy could be a possible treatment option for multiple or superficial premalignant and malignant skin tumors in organ-transplant recipients.1 However, to the best of our knowledge, no results of the use of photodynamic therapy in organ-graft recipients have yet been published, probably because this treatment is not yet widely available. Furthermore, the persistent photosensitivity induced by this treatment is of concern in this group of patients.
Wilson suggests that primary irradiation for squamous-cell carcinomas be considered in some patients — namely, those who are not candidates for surgery, those with large lesions for whom surgery may be functionally or cosmetically disfiguring, and those who decline to undergo an invasive procedure. However, this option does not allow control of the margins; furthermore, in our experience, local recurrences of squamous-cell carcinoma may occur during radiotherapy,2 so the final results are often unsatisfactory. We therefore believe that local immune modifiers might be preferable in this context. We agree that radiotherapy deserves consideration in cases of localized cutaneous T-cell lymphoma.3 However, cutaneous T-cell lymphoma is rare in organ-graft recipients and such patients usually present with diffuse lesions.
Regarding Kaposi's sarcoma originating from donors' cells, the recent findings of Barozzi et al.4 suggest that transmission of disease from the donor may be more frequent than previously thought (accounting for up to 30 percent of cases of Kaposi's sarcoma in organ recipients). The relative importance of viral transmission from the donor as compared with reactivation of virus in the recipient must be further assessed. We speculate that it may vary according to the ethnic origin of the patient, since the seroprevalence of HHV-8 is particularly high in some countries (such as Italy).
4 ReferencesSylvie Euvrard, M.D.
Jean Kanitakis, M.D.
Alain Claudy, M.D.
Edouard Herriot Hospital, 69437 Lyons CEDEX 03, France
sylvie.euvrard@numericable. fr 1
Fritsch C ,Goerz G ,Ruzicka T . Photodynamic therapy in dermatology. Arch Dermatol 1998;134:207-214
CrossRef | Web of Science | Medline2
Euvrard S ,Kanitakis J ,Pouteil-Noble C , et al. Aggressive squamous cell carcinomas in organ transplant recipients. Transplant Proc 1995;27:1767-1768
Web of Science | Medline3
Wilson LD ,Kacinski BM ,Jones GW . Local superficial radiotherapy in the management of minimal stage IA cutaneous T-cell lymphoma (Mycosis Fungoides). Int J Radiat Oncol Biol Phys 1998;40:109-115
CrossRef | Web of Science | Medline4
Barozzi P ,Luppi M ,Facchetti F , et al. Post-transplant Kaposi sarcoma originates from the seeding of donor-derived progenitors. Nat Med 2003;9:554-561
CrossRef | Web of Science | Medline
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Jacques Descotes. (2005) Immunotoxicology. Drug Safety 28:2, 127-136
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2004. Chapter 3 Health consequences of immunotoxic effects. , 55-126.
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