title: Painful skin lesions and squamous cell carcinoma predict overall mortality risk in organ transplant recipients: a cohort study.
abstract: BACKGROUND
  Organ transplant recipients (OTRs) have a highly increased risk of cutaneous squamous cell carcinomas (SCCs). Sensation of pain in cutaneous tumours is a powerful patient-reported warning signal for invasive SCCs in OTRs.
  
  
  OBJECTIVE
  To investigate the impact of painful vs. painless skin lesions and SCC vs. other skin lesions on the overall mortality risk in OTRs.
  
  
  METHODS
  We followed 410 OTRs from 10 different centres across Europe and North America between 2008 and 2015. These patients had been enrolled in an earlier study to define clinically meaningful patient-reported warning signals predicting the presence of SCC, and had been included if they had a lesion requiring histological diagnosis. Cumulative incidences of overall mortality were calculated using Kaplan-Meier survival analysis, and risk factors were analysed with Cox proportional hazard analysis.
  
  
  RESULTS
  There was an increased overall mortality risk in OTRs who reported painful vs. painless skin lesions, with a hazard ratio (HR) of 1·6 [95% confidence interval (CI) 0·97-2·7], adjusted for age, sex and other relevant factors. There was also an increased overall mortality risk in OTRs diagnosed with SCC compared with other skin lesions, with an adjusted HR of 1·7 (95% CI 1·0-2·8). Mortality due to internal malignancies and systemic infections appeared to prevail in OTRs with SCC.
  
  
  CONCLUSIONS
  We suggest that OTRs have an increased overall mortality risk if they develop painful skin lesions or are diagnosed with cutaneous SCC.
authors.affiliation: Department of Dermatology, University Hospital Zürich, Zürich, Switzerland.
authors.forename: C C
authors.initials: CC
authors.lastname: Oh
authors.affiliation: Department of Dermatology, University Hospital Zürich, Zürich, Switzerland.
authors.forename: G F L
authors.initials: GFL
authors.lastname: Hofbauer
authors.affiliation: Epidemiology, Biostatistics and Prevention Institute, University of Zürich, Zürich, Switzerland.
authors.forename: A L
authors.initials: AL
authors.lastname: Serra
authors.affiliation: Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K.
authors.forename: C A
authors.initials: CA
authors.lastname: Harwood
authors.affiliation: Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K.
authors.forename: L
authors.initials: L
authors.lastname: Mitchell
authors.affiliation: Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K.|Division of Cancer Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, U.K.
authors.forename: C M
authors.initials: CM
authors.lastname: Proby
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI, U.S.A.
authors.forename: E B
authors.initials: EB
authors.lastname: Olasz
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI, U.S.A.
authors.forename: D D
authors.initials: DD
authors.lastname: Mosel
authors.affiliation: Department of Medicine, University of Padua, Padua, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Piaserico
authors.affiliation: Department of Medicine, University of Padua, Padua, Italy.
authors.forename: A B
authors.initials: AB
authors.lastname: Fortina
authors.affiliation: Department of Dermatology, Medical University of Vienna, Vienna, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Geusau
authors.affiliation: Department of Dermatology, Medical University of Vienna, Vienna, Austria.
authors.forename: K
authors.initials: K
authors.lastname: Jahn-Bassler
authors.affiliation: Radboud University Medical Centre, Nijmegen, the Netherlands.
authors.forename: M J P
authors.initials: MJP
authors.lastname: Gerritsen
authors.affiliation: Başkent University Faculty of Medicine, Ankara, Turkey.
authors.forename: D
authors.initials: D
authors.lastname: Seçkin
authors.affiliation: Başkent University Faculty of Medicine, Ankara, Turkey.
authors.forename: A T
authors.initials: AT
authors.lastname: Güleç
authors.affiliation: University Hospital Pilsen, Pilsen, Czech Republic.
authors.forename: P
authors.initials: P
authors.lastname: Cetkovská
authors.affiliation: University Hospital Pilsen, Pilsen, Czech Republic.
authors.forename: J
authors.initials: J
authors.lastname: Ricar
authors.affiliation: Nicolaus Copernicus Hospital, Gdańsk, Poland.
authors.forename: B
authors.initials: B
authors.lastname: Imko-Walczuk
authors.affiliation: Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.
authors.forename: A
authors.initials: A
authors.lastname: Dębska-Ślizień
authors.affiliation: Leiden University Medical Centre, Leiden, the Netherlands.
authors.forename: J N
authors.initials: JN
authors.lastname: Bouwes Bavinck
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000209:etiology / Q000401:mortality*; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007636:Keratoacanthoma; D008297:Male; D008875:Middle Aged; D009656:North America / Q000453:epidemiology; D010146:Pain / Q000209:etiology* / Q000401:mortality; D058748:Pain Perception / Q000502:physiology; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D012307:Risk Factors; D012878:Skin Neoplasms / Q000209:etiology / Q000401:mortality*; D066027:Transplant Recipients