Immunosuppression Linked To Aggressive Nonmelanoma Skin Cancer

Nonmelanoma skin cancer patients who are immunocompromised have an increased risk of aggressive subclinical extensions

medwireNews: The likelihood of aggressive subclinical extensions in patients with nonmelanoma skin cancer (NMSC) is elevated among immunocompromised individuals compared with their immunocompetent counterparts, research suggests.

Patients undergoing solid-organ transplants and those with haematological malignant cancers are especially at risk, but not patients with HIV, say Shang Jiang, from the University of California, San Diego in the USA, and co-authors.

They reviewed 2998 cases of NMSC diagnosed between 2007 and 2012, of which 805 were classified as lesions with aggressive subclinical extensions, defined as those requiring at least three Mohs micrographic surgery stages with final surgical margins of at least 10 mm.

Immunosuppressed patients were significantly more likely to develop aggressive lesions than those who were immunocompetent, with an odds ratio of 1.94.

When participants were stratified by type of immunosuppression, solid-organ transplant recipients (SOTRs) had a significant 2.74-fold increased risk of aggressive disease relative to non-SOTRs, while those with haematological malignancies had a 1.74-fold increased risk compared with immunocompetent participants.

But the risk of developing aggressive NMSCs was not increased for HIV patients compared with those who were immunocompetent.

In multivariate analysis adjusting for confounding factors, SOTR status and history of haematological malignancies remained significant predictors of aggressive NMSCs. And older age and lesion location in zone 1 (including central face, hands, feet etc) and zone 2 (including cheeks, forehead etc) versus zone 3 (trunk and extremities excluding hands, ankles, feet and nails) were also significantly associated with aggressive lesions.

The researchers explain in JAMA Dermatology: “Reliance on visual estimates of the tumor and conventional wide surgical margins may not be useful when treating patients with NMSCs with extensive subclinical spread.”

And highlighting that age, immunosuppression status and lesion location can all be ascertained prior to surgery, they say that their findings “may help dermatologists optimize the extent of excisional margins for tumors with substantial subclinical spread while allowing surgeons and patients to anticipate a larger and more extensive final surgical defect.”

Furthermore, Shang Jiang et al believe that “[i]n settings such as developing countries where [Mohs micrographic surgery] is not readily available, the findings from this study can help guide physicians in determining more appropriate excisional margins when treating patients with NMSCs.”


Song SS, Goldenberg A, Ortiz A, et al. Nonmelanoma skin cancer with aggressive subclinical extension in immunosuppressed patients.JAMA Dermatol 2016; Advance online publication 16 March. doi: 10.1001/jamadermatol.2016.0192

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