BACKGROUND Lung transplant recipients (LTR) have an increased risk of cutaneous squamous cell carcinoma (SCC) due to immunosuppressive therapy. Voriconazole, which is associated with phototoxic side effects in some patients, may be an additional risk factor for SCC in this population. METHODS To test whether voriconazole is a risk factor for developing SCC in LTR, we evaluated cumulative exposure to voriconazole in 327 adults who underwent lung transplantation at a single center between 1991 and 2010. Voriconazole exposure was assessed as a time-varying covariate. We analyzed risk of developing SCC over time using survival analysis methods. RESULTS Exposure to voriconazole was associated with a 2.6-fold increased risk for SCC. This phenomenon was dose-dependent; the risk for SCC increased by 5.6% with each 60-day exposure at a standard dose of 200mg twice daily. At five years posttransplant, voriconazole conferred an absolute risk increase for SCC of 28%. CONCLUSIONS These results suggest that caution should be taken when using voriconazole in LTR, as this drug increases the already high risk for SCC in this population.

Background Solid organ transplant recipients are at an increased risk of developing squamous cell carcinoma of the skin after transplant. In predominantly Caucasian cohorts, Fitzpatrick skin type (FST) has been reported to be a risk factor for developing post-transplant skin cancers. Objective Our goal was to determine if Fitzpatrick skin type is a statistically significant risk factor for the development of squamous cell carcinomas after solid organ transplant in a diverse US population of transplant recipients. Methods A cohort of transplant recipients completed a questionnaire of demographic factors, transplant type, Fitzpatrick skin type and skin cancer history. Univariate and multivariate analysis was performed to determine the risk factors for development of squamous cell carcinoma after transplant. Results As expected, male subjects had an increased risk for SCC compared to females (p=0.02), and subjects age 50 and over at the time of transplantation were more likely to develop SCC compared to those under 50 (p<0.001). The risk of SCC increased with each incremental decrease in Fitzpatrick skin type, from FST VI to FST I (linear test for trend p<0.001). Limitations Our questionnaire did not ask specifically about immunosuppressive medications; instead, organ transplant category was used as a proxy for level of immunosuppression. Conclusions Fitzpatrick skin type, a patient-reported variable, is an independent risk factor for the development of SCC in organ transplant recipients, and should be elicited from patients who have gone or will undergo organ transplantation.

Voriconazole is a triazole antifungal used to prevent and treat invasive fungal infections after lung transplantation, but has been associated with an increased risk for developing cutaneous squamous cell carcinoma (SCC). Despite widespread use, there are no clear guidelines for optimal prophylactic regimens that balance its competing risks and benefits. We conducted a retrospective cohort study of all lung transplant recipients at the University of California, San Francisco transplanted between October 1991 and December 2012 (n=455) to investigate whether voriconazole exposure impacted development of SCC, Aspergillus colonization, invasive aspergillosis, and all-cause mortality. Voriconazole exposure was associated with a 73% increased risk for developing SCC (HR=1.73; 95% CI: 1.04–2.88; p=0.03), with each additional 30-day exposure at the standard dose increasing the risk by 3.0% (HR=1.03; 95% CI: 1.02–1.04; p<0.001). Voriconazole exposure reduced risk of Aspergillus colonization by 50% (HR=0.50; 95% CI: 0.34–0.72; p<0.001), but we were underpowered to detect risk reduction for invasive aspergillosis. Voriconazole exposure significantly reduced all-cause mortality among subjects who developed Aspergillus colonization (HR=0.34; 95% CI: 0.13–0.91; p=0.03), but had no significant impact on those without colonization. Physicians should consider patient-specific factors that modify the potential risks and benefits of voriconazole in the care of lung transplant recipients.

Nonmelanoma skin cancer (NMSC) is the most common cancer in the U.S.A. The two most common NMSCs are basal cell carcinoma and squamous cell carcinoma. The associations of single-nucleotide polymorphisms (SNPs) in pigmentation pathway genes with NMSC are not well characterized. There is a series of epidemiological studies that have tested these relationships, but there is no recent summary of these findings. To explain overarching trends, we undertook a systematic review of published studies. The summarized data support the concept that specific SNPs in the pigmentation pathway are of importance for the pathogenesis of NMSC. The SNPs with the most promising evidence include MC1R rs1805007(T) (Arg151Cys) and rs1805008(T) (Arg160Trp), and ASIP AH haplotype [rs4911414(T) and rs1015362(G)]. There are a few other SNPs found in TYR, OCA2 and SLC45A2 that may show additional correlation after future research. With additional research there is potential for the translation of future findings to the clinic in the form of SNP screenings, where patients at high risk for NMSC can be identified beyond their phenotype by genotypically screening for predisposing SNPs.

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