“Alarmingly low” awareness of genital lesions after solid organ transplants

02/06/2018

By Marilynn Larkin

NEW YORK (Reuters Health) – Genital lesions associated with squamous cell carcinoma (SCC) and other malignant cutaneous genital tumors are common among organ transplant recipients, but patient awareness is “alarmingly low,” researchers say.

“Simply asking organ transplant patients if they have genital lesions is insufficient for screening, and all transplant recipients, particularly black males, should undergo thorough inspection of genital skin as a part of routine posttransplant total body skin examination,” Dr. Christina Lee Chung of Drexel University in Philadelphia told Reuters Health.

“Nonwhite transplant patients are more frequently affected than their white counterparts,” she said by email. “Other important findings are that high-risk HPV types were closely associated with genital squamous cell carcinoma development and that these lesions were sometimes quite subtle and clinically resembled benign lesions.”

Dr. Chung and colleagues reviewed data from 496 organ transplant recipients who had undergone a full skin examination at the Drexel dermatology center. The review was divided into two periods: before (era 1) and after (era 2) February 1, 2016, when quality improvement measures were adopted to ensure that a full genital examination was conducted.

As reported online January 31 in JAMA Dermatology, 376 patients (mean age, 60; 65% men, 44% white) were evaluated during era 1, and 120 patients (mean age, 56; 63% men; 25% white) in era 2. Most of the analyzed cases were kidney transplants: 71% of cases in era 1 and 82% in era 2.

In the era 1 cohort, five cutaneous genital SCC in situ lesions were diagnosed in three black patients (1.9% of the black patient population). No genital skin cancers were found in white, Asian or Hispanic patients during this period. The overall rate of malignant cutaneous tumors in this cohort was 0.80%.

In addition, five patients (1.2%) were diagnosed with condyloma acuminatum; of the four who were male, three were black.

In the era 2 cohort, 111 patients (92.5%) denied having a genital lesion during the history-taking portion of the examination. However, genital lesions were found in 53 patients (44%).

In six of those patients, seven genital SCCs in situ (five lesions in three black patients) - and one penile basal cell carcinoma on the shaft of a black patient - were diagnosed.

Genital skin cancer in era 2 occurred in four black (6.2%), one Hispanic (7.7%), and one Asian (8.3%) patient.

Twenty-nine patients were diagnosed with condyloma acuminatum: 83% were men and 79% were nonwhite.

During eras 1 and 2 combined, eight patients were diagnosed with 12 SCC in situ lesions and one with basal cell carcinoma. Eight of the 12 SCCs in situ tested positive for high-risk HPV, and seven tested positive for lower-risk HPV strains.

Dr. Chung said, “First, transplant teams and dermatologists need to recognize the need for post-transplant skin cancer screening.”

“Next,” she added, “organ transplantation programs need to advocate for the establishment of specialty transplant dermatology programs that combine a medical-surgical approach to post-transplant skin cancer management with an emphasis on prevention, early detection, and early intervention for cutaneous malignancy.”

“Finally, dermatology and transplant medicine programs need to work collaboratively to develop screening and education protocols for both patients and providers about genital skin cancer after transplantation."

“HPV vaccination rates in disproportionately affected (black) populations are persistently lower,” Dr. Chung observed. “This is a public health issue that needs to be addressed and, for the organ transplant population, further research is needed to evaluate the utility of pre-transplant HPV vaccination in the development of post-transplant cutaneous and genital SCC.”

Dr. Sarah Tuttleton Arron, associate director, Dermatologic Surgery and Laser Center at the University of California, San Francisco, said in an email to Reuters Health, “This is important data that highlights the important issue of risk for genital lesions for our transplant patients of color.”

“Our transplant services do a terrific job of counseling women, and our patients are screened routinely with gynecology as well as dermatology,” she noted. “However, for men, the dermatologist tends to be the primary doctor providing screening for genital lesions.”

“This study is from a single center, and so the data will need to be validated in larger, prospective studies,” Dr. Arron continued, “but I am pleased to see attention paid to two understudied issues: transplant patients of color, and genital lesions in immunosuppressed patients.”

“I am also interested to note that the majority of patients had no awareness of their own genital lesions,” she said. “We should be teaching patients this as part of skin self-inspection.”

"One caveat in generalizing this study to our own center is that our patient population is somewhat different from (the study group),” she noted. “We see patients who are older, and fewer patients of color, so our overall risk for genital cancer may be different from the one reported in the study.”

SOURCE: http://bit.ly/2DUCgu7

JAMA Dermatol 2018.

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