4th Edition

Chapter 32: The grateful politician

A 73-year-old politician had undergone a cadaveric renal transplant 4 years previously for chronic renal failure after 8 years of haemodialysis. His life had been transformed by the kidney transplant and he had been able to return to politics as an even stronger supporter of the NHS.

He developed numerous skin lesions that he showed to his renal physician.

On examination he has two features that confirm his history.

  • 1. What two features are shown?

    Correct answer:

    Surgical arteriovenous fistula for haemodialysis.
    Right inguinal scar at site of renal transplant.

  • 2. What skin cancers are shown?

    Correct answer:
    Multiple squamous cell cancers

    The features include:

    1. Opalescent plaque with tiny blood vessels associated with sun exposure (photodamage)
    2. Papule with raised edges and central depression with ulceratio
    3. Hard elevated nodule with central scaly (hyperkeratosis)
    4. Scaly or crusty surface due to keratinization

He has each lesion excised completely by a diligent plastic surgeon.

  • 3. What histological features of squamous cell cancer (SCC) are shown?

    Correct answer:

    Keratinous pearls.
    Nests of tumour cells.
    Abnormal keratinocytes with eosinophilic (pink) cytoplasm and large nuclei.

Skin cancers are much more common in allogeneic transplant recipients who are on immunosuppression. The most common skin cancer in transplant recipients is SCC and this can differ from SCC in the general populations:

  • Develop at younger age
  • Grow more quickly
  • Occur in greater numbers
  • Is more invasive and locally destructive
  • Has a greater risk for recurrence
  • Has a greater risk for metastasis

The relative risk of skin cancers in transplant recipients is reversed compared to the general population (where BCC is more common than SCC).

Skin cancer Relative risk (increase in incidence)
Squamous cell cancer (SCC) 65-fold
Basal cell cancer (BCC) 10-fold
Melanoma 3.4-fold
Kaposi’s sarcoma 84-fold

His support for the NHS was even greater but as he had been elevated to the House of Lords no one noticed him anymore.

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