Organ transplant recipients are at increased risk of melanoma due to their chronic state of immunosuppression [1, 12, 21]. Specifically, population-based cohort studies show a 3.4-fold greater risk for melanoma in OTRs in the Netherlands [14] and a standardized incidence ratio of 2.38 (2.14–2.63) for melanoma in OTRs in the USA (OPTN/SRTR 2011 Annual Report) when compared to the general population.

Melanoma is Otley considered to be an immunogenic tumor, causing immunosuppression in the tumor microenvironment through secretion of anti-inflammatory cytokines, downregulation of major histocompatibility class I antigens on tumor cells, induction of tolerance, and alteration of the typical T-cell response in the host immune system [18]. Specifically, regulatory T cells (CD4 + CD25+) are involved in secreting immunosuppressive cytokines and suppressing activation of the antitumor response of the host to melanoma [29]). As such, melanoma is more common in many patient settings associated with immunosuppression, including HIV/AIDS, lymphoma, and the pharmacologic immunosuppression associated with organ transplantation. After receiving transplantation, OTRs require lifelong pharmacologic immunosuppression to prevent potentially fatal organ rejection and loss. The type of immunosuppression and its duration and intensity of use in OTRs are known risk factors for skin cancer, including melanoma. The immunosuppressed state severely reduces immunosurveillance, impairing the normal detection and removal of precancerous or early cancerous lesions. In addition, immunosuppression is believed to aid in the promotion of cancer cell invasiveness and progression [26]. Organ transplant recipients often undergo aggressive induction immunosuppression in the first 3–6 months after transplantation to lower the T-cell response to donor organ antigens and to help avoid acute organ rejection. Following this acute period where the risk of organ loss is the highest, OTRs are placed on maintenance immunosuppression determined by the type of transplanted organ as well as preferences of the transplant team. In the event of life-threatening NMSC or melanoma skin cancer, immunosuppressive regimens are often altered to allow some immune upregulation as a partial treatment strategy. This is particularly the case in melanoma as it is an immunogenic tumor. In fact, several current therapies for melanoma harness the host immune system including IL-2, melanoma vaccines, and CTLA-4 inhibitors such as ipilimumab and PD-1 inhibitor nivolumab.

With the growing demand for organ transplantation in the USA, there has been increasing discussion on social equity in organ distribution. To assist in appropriate allocation of organs to recipients with the greatest predicted life expectancy and overall probability of success, OTRs undergo rigorous pretransplant evaluation. Pretransplant comorbidity profiles are reviewed in detail, and a 5-year posttransplant survival probability is estimated for all candidates. In patients with a prior history of invasive melanoma with a quantifiable risk of recurrence, this concept has led to the discussion of what are appropriate pretransplant “wait times” for patients deemed to be at elevated risk for mortality following transplantation.

Traditionally, patients with a prior history of invasive melanoma have been excluded from consideration for organ transplantation or, if listed, given prolonged wait times. There is a paucity of population-based data on patients with pretransplant melanoma, and many of these clinical decisions have been guided in part by data from a few small studies. Specifically, Penn et al. [24] reported recurrent disease and death in 19.4 % of 31 patients with pretransplant melanoma. Disease recurrence occurred between 6 and 30 months posttransplant, leading the authors to recommend a 5-year wait period until transplantation for “most melanoma” and 2 years for “very thin” melanoma. However, growing evidence suggests that a history of invasive melanoma may not be associated with increased recurrence or mortality risk after transplantation.

Recent studies suggest that there is no statistically significant increase in recurrence or mortality in patients with a history of malignant melanoma [7]. The Skin Care in Organ Transplant Patients, Europe (SCOPE) cohort found no melanoma recurrences or melanoma-related deaths in patients with a pretransplant melanoma after 60-month follow-up (n = 9) [17] posttransplantation. Similarly, a retrospective case series from Mayo Clinic followed 12 patients with pretransplant melanoma from 1978 to 2007 with no recurrences and 100 % 2-year melanoma-specific survival on an average follow-up of 3.5 years; the majority (90 %) were in situ or stage I melanoma [8]. Of note, these outcomes followed a median wait time between melanoma diagnosis and transplant of 7.8 and 3.8 years for the SCOPE and Mayo cohorts, respectively. Finally, Brewer et al. [5] found no recurrence and 100 % 10-year melanoma-specific survival in 17 patients with a history of melanoma and a median wait time of 10 years between melanoma diagnosis and transplantation. In aggregate, these data suggest that a pretransplant history of melanoma may not be an absolute contraindication to organ transplantation.

The incidence of de novo malignant melanoma developing in OTRs after transplantation is estimated to be three to five times higher than the general public [10

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