Msk Dermatology · Year 2 · from Msk Dermatology
Case 2: Squamous Cell Carcinoma in Organ Transplant Recipient
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Rapidly growing nodule on left forearm
History of Present Illness: The patient noticed a small scaly patch on his forearm 6 months ago. Over the past 2 months, it has rapidly enlarged into a firm nodule. It is now 2.5 cm, tender, and occasionally bleeds. He received a kidney transplant 8 years ago and is on chronic immunosuppression.
Past Medical History:
- Kidney transplant 8 years ago
- Chronic immunosuppression: Tacrolimus, mycophenolate, prednisone
- Multiple actinic keratoses (treated with cryotherapy)
- History of two prior SCCs (excised)
Physical Examination:
- Left forearm:
- 2.5 cm firm, indurated nodule
- Central ulceration with keratinous crust
- Surrounding erythema
- Adherent to underlying tissue
- Regional lymphadenopathy (left epitrochlear node palpable)
Workup and Results
Excisional Biopsy:
- Invasive squamous cell carcinoma
- Moderately differentiated
- Depth: 6 mm
- Perineural invasion present
- Margins positive
Staging Workup:
- CT scan: Suspicious 2 cm epitrochlear lymph node
- Fine needle aspiration: Metastatic SCC
Clinical Image
Clinical photograph demonstrating squamous cell carcinoma presenting as a firm, indurated nodule with central ulceration and keratinous crust on the forearm of an immunosuppressed patient.
Diagnosis
High-Risk Squamous Cell Carcinoma with Nodal Metastasis
High-risk features present:
- Size >2 cm
- Depth >6 mm
- Perineural invasion
- Immunosuppression
- Regional lymph node metastasis
Discussion
This case illustrates SCC in immunosuppressed patients:
- Transplant Recipients at High Risk: The lecture states that organ transplant recipients have a 65-fold increased risk for SCC. This is due to chronic immunosuppression and impaired immune surveillance.
- Actinic Keratosis Precursor: The lecture identifies actinic keratosis as a precursor lesion for SCC, with 1-10% progressing to invasive SCC.
- Perineural Invasion: The lecture notes that perineural invasion is a high-risk feature associated with increased metastasis and local recurrence.
- Anti-PD-1 Therapy: The lecture identifies anti-PD-1 immunotherapy (cemiplimab, pembrolizumab) as first-line treatment for advanced/metastatic SCC. However, use in transplant recipients requires careful consideration of rejection risk.
Treatment Plan
- Surgical Management:
- Wide local excision with adequate margins (Mohs or standard excision)
- Lymph node dissection for confirmed nodal disease
- Adjuvant Therapy:
- Consider adjuvant radiation to primary site and nodal basin
- Discussion with transplant team about immunosuppression modification
- Immunotherapy Consideration:
- Cemiplimab or pembrolizumab for advanced disease
- CAUTION: Risk of transplant rejection with checkpoint inhibitors
- Requires multidisciplinary discussion
- Immunosuppression Modification:
- Consider conversion to sirolimus (mTOR inhibitor)
- May have antiproliferative effects
- Surveillance:
- Frequent skin exams (every 3 months)
- Field therapy for actinic keratoses (5-FU, imiquimod, PDT)
Teaching Points
- Organ transplant recipients have 65-fold increased SCC risk
- Actinic keratosis is a precursor to SCC (1-10% progress)
- Perineural invasion increases metastasis and recurrence risk
- Anti-PD-1 immunotherapy is first-line for advanced SCC
- Field cancerization requires field-directed therapy (5-FU, imiquimod, PDT)