9.5.3Wound Healing

Wound healing is a particular concern in transplant patients due to the variable effects of immunosuppressant medications on the healing process. Many patients are on long-term systemic corticosteroids which have been shown to interfere with all stages of wound healing [65]. Surgeries longer than 200 min, lack of subcutaneous sutures, and use of sirolimus in kidney transplant patients have all been associated with poor wound healing, but this has not been demonstrated following Mohs surgery [66]. The immunosuppressants, azathioprine and cyclosporine, were not shown to inhibit wound healing in organ transplant patients [65]. Likewise, acitretin does not appear to significantly impede wound healing in this population, but large randomized controlled trials are lacking [67]. Additional risk factors implicated in poor wound healing for SOTR include BMI >26 and age >40 [68]. All surgical wounds should be evaluated closely at surgical follow-up to assure proper healing and perform timely interventions if needed.

with MMS applied to higher risk, more aggressive lesions and recurrent lesions. The efficacy of electrodessication and curettage in SOTR for selected lesions has been demonstrated [69].

Merkel cell carcinomas and melanomas should both be managed in the same manner as in the immunocompetent population; however, the transplant team should be notified of the diagnosis and the possibility of decreasing or altering medications discussed.

BCCs are more common in the setting of organ transplantation but behave similarly to their immunocompetent counterparts. The indications for Mohs micrographic surgery parallel those for the general population.

9.5.5Follow-Up

Immunocompromised patients with a history of skin cancer or multiple clinical risk factors for the development of skin cancer should be seen every 3–6 months with evaluation of all sun-exposed areas and palpation of associated regional lymph nodes. A full-body skin exam with assessment of regional lymph nodes at least annually is recommended for all highly

As in the general population, Mohs micrographic surgery (MMS) is recommended for SOTRs with an SCC >0.6 cm in the “mask” facial area; >1 cm for cheek, forehead, and scalp; and >2 cm on the trunk or extremities. Tumors occurring on the ears, genitalia, nail units, and along anatomic fusion planes should also be managed with MMS [35]. Histologic features including depth greater than 0.4 cm, poorly differentiated tumors, and perineural invasion may also merit MMS, in addition to recurrent tumors. Wide local excision with 0.6–1.0-cm margins and intraoperative or postoperative margin evaluation may be used as an alternative if MMS is unavailable. In patients with in situ or well differentiated tumors in non-cosmetically sensitive areas, treatment approaches will vary based on patient and physician preference. Additional options include use of electrodessication and curettage, topical chemotherapeutic agents (5-fluorouracil), immunomodulators (imiquimod), photodynamic therapy, and standard excision. Because of the large number of tumors, some SOTR develop; it may be necessary to treat multiple lesions with destructive modalities such as electrodesiccation and curettage or cryosurgery

should be reinforced at these visits and treatment of any actinic keratoses performed. The Mohs surgeon should have a low threshold for performing biopsies in this population given their increased risk of skin cancer [35].

Summary: Conclusion

•Mohs surgeons play a critical role in both the prevention and treatment of high-risk cutaneous neoplasms in the solid organ transplant population.

9.6Conclusion

SOTR have benefited greatly from advances in modern day immunosuppression, with decreased graft rejection and increased survival. These medications have also had the unfortunate side effect of significantly increasing patients’ chances of developing disfiguring and potentially deadly skin cancers. The Mohs surgeon has a unique opportunity to both manage high-grade

neoplasms in this population and aid in prevention of further skin cancers through routine surveillance and patient education.

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