title: Nonmelanoma Skin Cancer With Aggressive Subclinical Extension in Immunosuppressed Patients.
abstract: Immunosuppression (IS), such as in solid-organ transplant recipients (SOTRs) and patients with human immunodeficiency virus (HIV) or hematologic malignant neoplasms, increases the risk of developing nonmelanoma skin cancers (NMSCs). However, it is unknown whether IS patients are at increased risk of developing NMSCs with aggressive subclinical extensions (NMSC-ASE), which may extend aggressively far beyond conventional surgical margins.
  
  
  
  To study clinical characteristics of NMSC-ASE among immunocompetent (IC) and various subgroups of IS patients and to suggest a predictive model for NMSC-ASE lesions.
  
  
  
  A 6-year retrospective review of 2998 NMSC cases between February 26, 2007, and February 17, 2012, at the Dermatologic and Mohs Micrographic Surgery Unit of the University of California, San Diego, Medical Center. Nonmelanoma skin cancers that required at least 3 Mohs micrographic surgery stages with final surgical margins of at least 10 mm were defined as ASE lesions. All cases were categorized into 1 of 2 groups, IS or IC. Immunosuppressed cases were further subcategorized into 3 subgroups: SOTRs and patients with HIV or hematologic malignant neoplasm. The data were analyzed in December 2012.
  
  
  
  We evaluated the odds ratio of having NMSC-ASE lesions in IS patients (SOTRs, HIV, hematologic malignant neoplasm) compared with IC patients. Other clinical characteristics and preoperative risks were analyzed and compared.
  
  
  
  Of all 2998 cases, we identified 805 NMSC-ASE cases: 137 IS and 668 IC. Immunosuppressed patients had an odds ratio of 1.94 of having ASE lesions compared with IC patients (95% CI, 1.54-2.44; P < .001). Additionally, the SOTR subgroup was associated with a 2.74 odds of having NSMC-ASE compared with non-SOTRs (95% CI, 2.00-3.76; P < .001), and the presence of hematologic malignant neoplasm was associated with 1.74 times the odds compared with IC patients (95% CI, 1.04-2.90; P = .04). Multivariate analysis found older age (P < .001), lesion locations such as zone 1 (OR, 1.39 [95% CI, 1.04-1.85]; P = .02) or zone 2 (OR, 1.45 [95% CI, 1.08-1.94]; P = .01), and IS status (OR, 1.94 [95% CI, 1.54-2.44]; P < .001) to be significant predictors of ASE.
  
  
  
  The findings of this study suggest an increased risk for NMSC-ASE lesions in IS patients, especially in SOTRs and those with hematologic malignant neoplasm, but not patients with HIV. Statistically significant predictors of NMSC-ASE lesions such as age, location, and IS status can help physicians choose the most appropriate treatment modalities and optimize surgical planning.
authors.affiliation: Department of Dermatology, University of California, San Diego2Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Silvia Soohyun
authors.initials: SS
authors.lastname: Song
authors.affiliation: Department of Dermatology, University of California, San Diego.
authors.forename: Alina
authors.initials: A
authors.lastname: Goldenberg
authors.affiliation: Department of Dermatology, University of California, San Diego.
authors.forename: Arisa
authors.initials: A
authors.lastname: Ortiz
authors.affiliation: Department of Dermatology, Siriraj Hospital, Bangkok, Thailand.
authors.forename: Sasima
authors.initials: S
authors.lastname: Eimpunth
authors.affiliation: Department of Dermatology, Kaiser Permanente Fontana Medical Center, Fontana, California.
authors.forename: Gagik
authors.initials: G
authors.lastname: Oganesyan
authors.affiliation: Department of Dermatology, University of California, San Diego.
authors.forename: Shang I Brian
authors.initials: SI
authors.lastname: Jiang
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D015658:HIV Infections / Q000150:complications; D019337:Hematologic Neoplasms / Q000150:complications; D006801:Humans; D007121:Immunocompetence; D016867:Immunocompromised Host; D007165:Immunosuppression Therapy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D015580:Mohs Surgery; D012189:Retrospective Studies; D012307:Risk Factors; D012878:Skin Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery; D066027:Transplant Recipients