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Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases.

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Background It has been suggested that sunlight through production of vitamin D might have a protective effect on a number of internal cancers. Consequently, in spite of the well known skin cancer risks, some researchers advocate more exposure to ultraviolet radiation, supported by the solarium industry. We estimated the risk of internal cancer before the patient contracted a basal cell carcinoma (BCC) of the skin, the most common cancer in white populations and strongly associated with extensive sun exposure. Methods A nested case control study was undertaken in the whole Swedish population. 115,016 patients with BCC and 987,893 controls were linked to population based registers. Findings The cases had an increased risk of getting another form of cancer before the BCC diagnosis: odds ratio (OR) = 1.84; 95% confidence interval (CI) 1.81–1.86. This risk was mainly due to skin cancer: OR = 4.95; 95% CI 4.81–5.09 but also non-skin cancer risk was elevated: OR = 1.37; 95% CI 1.35–1.39. We adjusted the estimates for age, level of income, occupational status in national censuses, place of living and sex, where appropriate. Of the cancers specifically suggested to be related to vitamin D status: colon, prostate, breast, and ovary cancer, all had slightly increased ORs whilst for pancreatic and gastric cancer no increased OR was found. Interpretation Patients with BCC, a proxy for extensive sun exposure, run an increased risk of other forms of cancer prior to the diagnosis of BCC. The findings in this study contradict that vitamin D production through extensive sun exposure has any protective effect on internal cancer but emphasise the increased risk for skin cancer.

Organ transplant recipients (OTR) have a greatly increased risk (up to 100 times) of developing squamous cell carcinomas (SCC) in the skin. This is attributed specifically to chronic immunosuppression, causing dysfunctional viral defence and tumour protection. To investigate the possible link between increasing risk of SCCs and type of inflammation in these tumour-prone patients, we analysed the peritumoural infiltrates with regard to cell types and densities. Seven SCCs from immunosuppressed OTR and 14 SCCs from immunocompetent patients were immun-histochemically stained for CD3, CD4, CD8, CD56, CD20, CD138, CD14, CD68, CD1a. Cell counts were performed with the aid of computer-based image analysis of > 100,000 cells. When comparing the percentage distributions, significant differences were detected (outlined as median values (min-max)): T cells (CD3+): OTR 57% (35-78), controls 68% (48-80), p = 0.036; plasma cells (CD138+): OTR 2% (0.7-7), controls 0.2% (0-1.2), p = 0.001; mono-cytes (CD14+): OTR 3.2% (1.1-5.6), controls 9.3% (2.2-17.2), p = 0.014. Surprisingly, no differences in cell densities, i.e. cells/mm2 tumour section area, were detected between the 2 groups. In conclusion, we found that the peritumoural infiltrates in immunosuppressed compared with immunocompetent patients differ in cellular composition, inferring a more tumour-submissive environment in OTR. However, cellular densities were equal, suggesting deviating cellular functionality in OTR.

Background Risk of basal cell carcinoma (BCC) has been reported to be several-fold increased among organ transplant recipients (OTRs). However, due to lack of reliable BCC registration, population-based risk estimates are scarce. Objectives To characterize risk of BCC among OTRs compared with the general population, and contrast with risk of cutaneous squamous cell carcinoma (SCC). Subjects and methods OTRs transplanted during 2004-2011 were identified through national healthcare registers and linked with the nationwide Swedish BCC Register initialized in 2004. Relative risk of BCC was expressed as standardized incidence ratios (SIR) with 95% confidence intervals (CI). Results Altogether, 4023 transplanted patients developed 341 BCCs during follow-up. Compared with the general population, the relative risk of BCC was increased sixfold (SIR 6.1, 95% CI 5.4-6.9). The risk was higher in kidney and heart/lung than in liver recipients (SIRkidney 7.2, 6.3-8.3; SIRheart/lung 5.8, 4.0-8.2; SIRliver 2.6, 1.7-4.0), and risk increased with time since transplantation (P-trend l 0.01). The SCC to BCC ratio was 1 : 1.7 and BCC developed earlier after transplantation than SCC. Distribution of anatomical sites and histological types did not differ substantially between OTR- and population-BCCs. Conclusions Risk of BCC was strikingly elevated in OTRs compared with the general population. Risk was higher in kidney recipients and increased with follow-up time. These findings support a tumour-promoting effect of immunosuppressive drugs in BCC development. The low SCC to BCC ratio was possibly attributed to short follow-up time.

Development of malignant tumours in chronic burn wounds or scars is extremely rare, but a frequently reported complication. Most of these tumours are squamous cell carcinoma and, more occasionally, basal cell carcinoma and malignant melanoma are reported. The interval between the initial burn and the diagnosis of the tumour is usually long; 20-30 years or more. A large number of case reports and small series of selected patients have been published. Only one epidemiological study has been performed recently, but it could not confirm any increased risk. We conducted a historical cohort study to assess the risk of cancer in Swedish patients with burn injuries. Using the national Inpatient Registry we identified 37,095 patients who had been hospitalized for burn injuries. This cohort was linked with the Swedish Cancer Registry for a virtually complete follow-up with regard to cancer. The mean follow-up time was 16.4 years (range >0-39). The risk of developing any form of cancer was slightly increased: standardized incidence ratio (SIR) 1.11 (95% confidence interval (CI) 1.06-1.16) based on 2227 patients with cancer. However, squamous cell carcinoma: SIR 0.88 (95% CI 0.70-1.09) and malignant melanoma: SIR 0.88 (95% CI 0.68-1.12) did not occur more often than expected. Also, in a subgroup of 12,783 patients who were followed for 20-39 years, no increased risk of skin cancer could be detected. This study does not support any casual association between burn injuries and a later risk of skin cancer.

Organ transplant recipients are at increased risk of a wide range of malignancies, especially cutaneous squamous cell carcinomas (SCC). Few previous population-based studies have quantified and compared cancer risks according to graft type and with long-term follow-up. Using nationwide Swedish registers, we identified 10,476 recipients transplanted from 1970 to 2008 and followed them for cancer occurrence. Relative risks of cancer in comparison with the general population were expressed as standardized incidence ratios (SIR) and within the transplanted cohort as incidence rate ratios (IRR). During a total follow-up of 93,432 person-years, patients were diagnosed with 1,175 cancers excluding SCC, and with 2,231 SCC, SIR(cancer excl SCC) 2.4 (95% CI, 2.2-2.5); SIR(SCC) 121 (95% CI, 116-127). Cancer risks were most increased among heart and/or lung recipients SIR(cancer excl SCC) 3.3 (95% CI, 2.8-4.0); SIR(SCC) 198 (95% CI, 174-224), followed by kidney SIR(cancer excl SCC) 2.3 (95% CI, 2.1-2.4); SIR(SCC) 121 (95% CI, 116-127) and liver recipients SIR(cancer excl SCC) 2.3 (95% CI, 1.9-2.8); SIR(SCC) 32 (95% CI, 24-42). During follow-up, risk of cancer excluding SCC remained stable while risk of SCC tripled over 20 years irrespective of graft type, partly due to a subgroup of patients developing new SCCs at a rapidly increasing rate. In summary, post-transplant cancer risk varied by transplanted organ and by cancer site, with the bulk of the excess risk driven by an exceptionally high and accelerating risk of SCC. These findings underscore the importance of regular skin screening in organ transplant recipients.

Background Risk of cutaneous melanoma is increased among organ transplant recipients (OTRs) but outcome has rarely been evaluated. Objective We sought to assess melanoma characteristics and prognosis among OTRs versus the general population. Methods Using Swedish health care registers, we identified melanomas in OTRs (n = 49) and in the general population (n = 22,496), given a diagnosis between 1984 and 2008 and followed up through December 31, 2012. Tumor slides of posttransplantation melanomas were reviewed. Odds ratios for comparison of histopathological characteristics and hazard ratios of melanoma-specific death were calculated. Results Among OTRs the trunk was the most common anatomic melanoma site (50% among female vs 51% among male) and 73% (n = 36) of all melanomas were histologically associated with a melanocytic nevus, 63% (n = 31) atypical/dysplastic. Compared with population melanomas, posttransplantation melanomas were more advanced at diagnosis (Clark level III-V: odds ratio 2.2 [95% confidence interval 1.01-4.7, P = .03], clinical stages III-IV: odds ratio 4.2 [1.6-10.8, P = .003]). Risk of melanoma-specific death was increased among OTRs: adjusted hazard ratio 3.0 (1.7-5.3, P = .0002). Limitations Only posttransplantation melanoma slides were reviewed. Conclusions Melanomas were more advanced at diagnosis and melanoma-specific survival was poorer in OTRs than in the general population. Prophylactic excision of truncal nevi among OTRs may be advised.