Expert consensus on the management of immunosuppression for specific skin cancer scenarios

Skin cancer scenario*		Level of reduction of immunosuppression to consider^Δ
Skin cancer scenario*		Kidney allograft	Heart allograft	Liver allograft
1.	No history of actinic keratosis or skin cancer	None^◊	None^◊	None^◊
2.	History of actinic keratosis No risk of mortality Marker for increased skin cancer risk in future	None	None^◊	None^◊
3.	History of ≤1 NMSC per year Negligible risk of mortality, ≤1 minor surgical procedure per year Patients handle this with ease Warning sign of possible future skin cancers	Mild	None	Mild^◊
4.	History of two to five NMSCs per year Zero to five percent risk of mortality over three years, minor-moderate surgical procedure two to five times per year Patients can usually handle this, but it starts to bother them Likelihood of numerous future skin cancers	Mild^◊	Mild	Mild
5.	History of 6 to 10 NMSCs per year One percent risk of mortality over three years, minor-moderate surgical procedure 6 to 10 times per year Patients can usually handle this, but it bothers them High likelihood of numerous future skin cancers	Mild^◊	Mild^◊	Mild
6.	History of 11 to 25 NMSCs per year Two percent risk of mortality over three years, minor-moderate surgical procedure 11 to 25 times per year This level of morbidity causes moderate distress and moderate disfigurement, depression may begin High likelihood of severe future skin cancers	Mild^◊	Mild^◊	Mild
7.	History of >25 NMSCs per year Five percent risk of mortality over three years, moderate-severe surgical procedure >25 times per year This level of morbidity causes severe distress and disfigurement Patients question whether transplant was worth it; depression is common High likelihood of severe and possibly life-threatening future skin cancers	Moderate	Mild	Moderate
8.	Individual high-risk skin cancer: 1 percent mortality over three years Average-risk SCC Cutaneous and oral KS Stage IA melanoma^§	Mild^◊	None	Mild
9.	Individual high-risk skin cancer: 5 percent mortality over three years Moderate-risk SCC Stage IB melanoma^§	Mild	Mild	Mild
10.	Individual high-risk skin cancer: 10 percent mortality over three years High-risk SCC Early Merkel cell carcinoma Stage IIA melanoma^§	Moderate	Mild	Moderate
11.	Individual high-risk skin cancer: 25 percent mortality over three years Very high-risk SCC Stage IIB melanoma^§	Moderate	Mild	Moderate
12.	Individual high-risk skin cancer: 50 percent mortality over three years Metastatic SCC Stage IIC/III melanoma^§ Aggressive Merkel cell carcinoma Visceral KS	Severe^◊	Moderate	Moderate
13.	Individual high-risk skin cancer: 90 percent mortality over three years Untreatable metastatic SCC Stage IV melanoma^§ Metastatic Merkel cell carcinoma	Severe^◊	Severe	Severe

NMSC: nonmelanoma skin cancer; SCC: squamous cell carcinoma; KS: Kaposi's sarcoma.
* Estimates of mortality risk are derived from data in immunocompetent patients; risk may be higher in immunosuppressed patients.
Δ Appropriate level of reduction of immunosuppression should be individualized on the basis of specific patient- and tumor-related data.
◊ Unanimous opinion.
§ Melanoma staging derived from the American Joint Commission on Cancer.

Otley CC, Berg D, Ulrich C, et al. Reduction of immunosuppression for transplant-associated skin cancer: expert consensus survey. Br J Dermatol 2006; 154:395. Copyright © 2006. Reproduced with permission of John Wiley & Sons, Inc.

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