Kidney Matters - Issue 14 - 2021

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24Kidney ClinicSkin deep: skin cancer after a transplantSkin cancer is the most common type of anycancer in the UK. The risk is especially high aftera kidney or other solid-organ transplant. How isskin cancer diagnosed and treated? And what canpatients do to reduce their risk?There are two main categories of skin cancer:melanoma and non-melanoma. Melanoma, alsoknown as malignant melanoma, is the fifth mostcommon cancer in the UK. It originates frommelanocytes, the skin cells that produce melanin, thenatural pigment that gives the skin its colour. The twomain non-melanoma skin cancers (NMSC), also knownas keratinocyte cancers, are basal cell carcinoma(BCC) and squamous cell carcinoma (SCC). Theydiffer from melanoma in developing from skin cells orkeratinocytes in the epidermis, which is the outer layernearest the surface of the skin.What causes skin cancer?The main preventable cause of skin cancer is damageto skin cells from exposure to ultraviolet (UV) radiationfrom the sun or sunbeds, especially during the first20 years of life (Table 1). People who have received akidney or other solid-organ transplant are at higherrisk of skin cancer, because the medications used toprevent rejection impair the immune system’s abilityto repair or destroy cells damaged by UV radiation.The risk increases with time, so that in one UK studyone third (32%) of people with a kidney transplant formore than 10 years had been diagnosed with NMSC.According to Dr Eleanor Mallon: “The risk ofdeveloping skin cancer is said to be higher withinthe first five years of a kidney transplant. The typeof immunosuppressant therapy is important. Therisk is higher with azathioprine than with newerimmunosuppressive drugs.” Eleanor is ConsultantDermatologist at Imperial College Healthcare and hasa special interest in skin cancer.Table 1: Factors increasing the risk of skin cancer• Skin that always or usually burns easily in the sunand never or rarely tans• Past episodes of severe sunburn, often withblisters, particularly in childhood• History of sun exposure; e.g. previously living in acountry close to the equator, outdoor hobbies,outdoor work• A personal history of skin cancer• Skin cancer in a family member• Numerous moles“Transplant patientsshould have a lowthreshold to see theirdoctor and never thinkthat they are botheringdoctors if they areconcerned abouttheir skin“www.kidneycareuk.org
25Skin cancer risk is greatest in people with type 1skin—i.e. with fair skin that freckles and always burnsand never tans, and often with blond or red hair andblue or green eyes—than in people with type 5 or 6skin that always tans and who are generally of Asian orAfrican heritage. However, it is still possible for peoplewith darker skin to develop skin cancer, especially afteran organ transplant.“The number of moles or melanocytic naevi increasesthe risk of melanoma, especially if the moles aredifferent shapes, sizes and colours (called atypicalmole syndrome). These people need particularly closemonitoring, together with ‘mole mapping’ where eachmole is photographed and held in a database thatclinicians can consult should there be any history ofchange in an individual mole,” adds Eleanor.What are the signs of skin cancer?BCCs vary in appearance: while some look like a scaly,red mark on the skin, others form a lump with a rimsurrounding a central crater. If left untreated, BCCscan eventually cause an ulcer—sometimes called arodent ulcer. Most BCCs are painless, although theycan sometimes be itchy or bleed. SCCs can also varyin appearance, but usually look like a scaly or crustyraised area of skin with a red, inflamed base. AnSCC can grow slowly or rapidly, and is more seriousthan a BCC because there is a small risk that, if leftuntreated, it can spread or metastasise to other partsof the body.Melanoma usually develops in or near a mole whenthe melanocytes become cancerous and multiplyuncontrollably. Although melanoma is less commonthan NMSC, it is more serious because, if leftuntreated, the cancer can invade the surrounding skinand may also spread to other parts of the body suchas the lymph nodes, liver and lungsRenal Association guidelines advise kidney transplantpatients to check their skin regularly, and tell theirdoctor about any unusual change in appearance of theskin, such as:• New lumps, spots, ulcers, scaly patches or molesthat have recently appearedbumps or any change to an existing lesion (size orshape or colour or itching or bleeding). Transplantpatients should have a low threshold to see theirdoctor and never think that they are bothering doctorsif they are concerned about their skin,” she says.How is skin cancer treated?When diagnosing a possible skin cancer, the firststep is a personal medical and family history. Thedermatologist will ask how long the lesion has beenpresent, how it has changed, and if it has produced anydischarge or bleeding. The lesion will be palpated orfelt and carefully examined using a dermatoscope (ahandheld instrument rather like a magnifying glass).Eleanor says: “Often the lesion is not skin cancer andis benign. That is good, because it’s great to be able toreassure a patient that the lesion is nothing to worryabout. We would not generally remove a benign lump,such as a cyst or lipoma, because there are risks tosurgery such as bleeding, infection and scarring.“If I am concerned about a lesion, I either arrangeto remove it completely or, if it is a large lump, I willremove a small section for a biopsy. Fortunately, BCCvery rarely progresses, while less than one in ten SCCswill metastasise. There is a higher risk that melanomawill invade the surrounding skin and metastasise. Thisis why early diagnosis is so important. When patientspresent late, there is a high chance that melanoma hasspread to lymph nodes, the lungs or liver and patientswill need immunotherapy,” she adds.• Marks (including moles) on the skin that havechanged in shape, colour, texture or size• Sores that do not heal• Any areas on the skin that are itchy, painful orbleedYour GP can refer urgently via the NHS two-week waitskin cancer referral pathway if you do not already haveregular follow-up with a dermatologist.Eleanor advises that checking your skin is particularlyimportant as you get older. “While it can be normalto develop new moles in your 20s or 30s, the olderyou are, the more you should be alert to new lumps,How can skin cancer be prevented?Since UV radiation is the main cause of skin cancer,protection against exposure to the sun, sunbeds orsun lamps is essential. This includes not only a high sunprotection factor (SPF), broad-spectrum sunscreen,but also protective clothing (Table 2).Issue 14 | Autumn 2021
Page 1 and 2: Autumn 2021Issue 14Aari, ourthree-y
Page 3 and 4: 3Welcome toKidney MattersHi all,As
Page 5 and 6: 5small grants to pay for bills or f
Page 7 and 8: 7Projects such as the expert patien
Page 9 and 10: 9Why are so few pancreas transplant
Page 11 and 12: 11Professor Friend talked about the
Page 13 and 14: 13Living donors tend to play down t
Page 15 and 16: LEARN MORE15Figure 1: Kidney exchan
Page 17 and 18: 17Aari’s legacy“Aari was a mira
Page 19 and 20: September 10 th - 19 th 2021 via Zo
Page 21 and 22: Cooking in the kidney kitchen with
Page 23: Superhero Teddy -toddler fundraiser
Page 27 and 28: “Skin cancer is themost common ty
Page 29 and 30: 29Organ Donation Week 2021and ‘Th
Page 31 and 32: 31“Seeing patients brought a newu
Page 33 and 34: 33Watch out forOrgan Donation Week2
Page 35 and 36: 35But if I don’t allow myself the
Page 37 and 38: 37side effects, but none of these e
Page 39 and 40: Sign up foryour freecopyWhether you

Kidney Matters - Issue 14 - 2021

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