utaneous squamous cell carcinoma (SCC) is a malignant neoplasm deriving from epidermal keratinocytes. In the general population, SCC is the second most common form of keratinocyte carcinoma after basal cell basal cell carcinoma, 1,2 and in organ transplant recipients SCC is the most common skin cancer. [1][2][3][4][5][6][7][8][9][10][11] Previous studies 12-15 report a risk for nodal metastasis of 1.9% to 4.0% and a risk for diseasespecific death of 1.5% to 2.1% in the general population.The number of solid organ transplants and long-term survival in organ transplant recipients have increased over the 5 decades as a result of progress in both surgical techniques and drug-induced immunosuppression. 16 Notwithstanding the clear benefits of successful allograft transplantation, organ transplant recipients experience important adverse effects from long-term immunosuppressive medication, including a 10-fold increased risk for malignant neoplasms overall. 17,18 In particular, solid organ transplant recipients have a 65-fold to 250-fold higher incidence of SCC compared with those who have not received transplants. After transplantation, 20% to 75% of solid organ transplant recipients are affected by at least 1 SCC within 20 years. 8,19 After a first invasive SCC, multiple subsequent SCCs will develop in 60% to 80% of these patients within 3 years. The risk of SCC increases over time, with the incidence increasing to 40% to 60% at 20 years after transplantation. 20,21 Cutaneous SCC is also associated with a more aggressive behavior and a higher risk of metastasis and death in solid organ transplant recipients than in the general population. 6,7,22 The rate of metastasis in solid organ transplant recipients is reported to be 5% to 8%. 23 IMPORTANCE Squamous cell carcinoma (SCC) is the most frequent malignant neoplasm found in solid organ transplant recipients and is associated with a more aggressive disease course and higher risk of metastasis and death than in the general population.OBJECTIVES To report the clinicopathologic features of and identify factors associated with aggressive SCC in solid organ transplant recipients.METHODS This retrospective multicentric case series included 51 patients who underwent solid organ transplantation and were found to have aggressive SCC, defined by nodal or distant metastasis or death by local progression of primary SCC. Standard questionnaires were completed by the researchers between
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