01Role and principlesWho benefits and the main preventive aims.
Immune surveillance restrains ultraviolet- and virus-altered cells. When it is suppressed, SCC becomes more frequent and aggressive, while BCC, melanoma, Merkel-cell carcinoma, Kaposi sarcoma and HPV-associated anogenital or periungual cancers also increase. Record the immune diagnosis, medicines, transplant type and date, rejection history, previous cancers and cumulative field treatments.
Surveillance must be systematic and accessible. Examine areas patients cannot see and teach monthly self-checking with a partner or mirror when acceptable. In richly pigmented skin, focus beyond erythema: new keratin, tenderness, ulceration, scar change and nodal findings are important. Immunosuppression removes any justification for assuming a non-sun-exposed or pigmented lesion is low risk.
Prevention is layered. Use ultraviolet protection, smoking cessation support, HPV prevention where eligible, field therapy and prompt tumour treatment. High-burden transplant recipients may receive specialist systemic chemoprevention such as acitretin, but mucocutaneous, lipid, hepatic and teratogenic toxicity requires expert selection and monitoring. Changing the immunosuppressive regimen can reduce cancer risk but may endanger the graft or underlying disease.
Key points
- Solid-organ transplant recipients have a markedly increased cutaneous SCC burden, with greater multiplicity, recurrence, nodal spread and disease-specific mortality.
- Chronic lymphocytic leukaemia, lymphoma, HIV, stem-cell transplantation and long-term immunosuppressive medicines also change tumour behaviour and diagnostic thresholds.
- Do not wait for a lesion to satisfy every standard size criterion; rapid growth, pain, keratin, ulceration or an outlier pattern warrants urgent biopsy.
- Examine the whole skin, scalp, lips, ears, palms, soles, nails and genital region according to consent and risk, plus relevant nodal basins.
- Provide regular specialist surveillance based on immune state and previous tumour burden, with rapid access between routine appointments.
- Combine shade, clothing, broad-brimmed hats and broad-spectrum sunscreen; sunscreen complements rather than replaces physical protection.
- Treat actinic field change and every suspicious invasive focus separately; field cream must not conceal a thick or tender SCC.
- Never stop or reduce transplant, cancer or inflammatory-disease immunosuppression independently; balance graft or disease control with cancer risk in the multidisciplinary team.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Numerous new actinic keratoses, horns or SCCs over months signals inadequate immune control and high field risk.
Rapidly enlarging painful indurated keratin, ulceration, lip or ear site and recurrence demand urgent assessment.
Numbness, weakness, severe pain or a firm regional node indicates possible advanced SCC.
Extensive warts, anogenital plaques, violaceous Kaposi-like lesions or umbilicated papules require broader immune and oncological differential diagnosis.
One tender thick lesion among many rough keratoses needs biopsy before the surrounding field is treated.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Baseline full-skin and node examinationFirst step - Why
- Establish tumour burden, field damage and sites needing biopsy or surveillance.
- Interpretation and limitations
- Document a lesion map and immune context; examination interval depends on new and previous tumour frequency.
- 02
Early adequate-depth biopsy - Why
- Diagnose a suspicious lesion before rapid progression or field treatment obscures it.
- Interpretation and limitations
- Sample the most indurated or ulcerated area and provide immune status and prior cancer history to pathology.
- 03
Histological high-risk review - Why
- Identify depth, differentiation, nerves, vessels, margins and aggressive subtype.
- Interpretation and limitations
- Immune suppression adds risk even when other features appear moderate and should be visible to the multidisciplinary team.
- 04
Nodal ultrasound and imaging - Why
- Assess clinical nodes, perineural symptoms or deeply invasive tumours.
- Interpretation and limitations
- Use image-guided sampling for suspicious nodes and anatomy-directed MRI or CT for spread.
- 05
Chemoprevention safety tests - Why
- Establish liver, lipid, pregnancy and medicine baseline before specialist acitretin.
- Interpretation and limitations
- Testing follows current SmPC and individual comorbidity; risk reduction does not replace surveillance.
04InterventionsLifestyle, treatment and escalation options.
01Routine high-risk surveillanceBuild a rapid-access prevention systemFirst stepA patient has ongoing immune suppression with no current invasive warning.+
- 1Record immune therapy and previous tumours, perform risk-based full-skin and node examination and set the next interval.
- 2Teach practical self-examination and layered ultraviolet protection and provide direct instructions for lesions that cannot wait.
- 3Treat field change and review HPV prevention, smoking and occupational exposure while keeping invasive outliers outside field protocols.
02New suspicious lesionLower the biopsy thresholdA lesion grows, hurts, keratinises, ulcerates, bleeds or differs from the surrounding field.+
- 1Document speed, site, dimensions, nodes, neurological symptoms and the precise immune regimen.
- 2Arrange urgent specialist biopsy with adequate depth and avoid destructive empirical treatment.
- 3Use pathology and immune context to plan margin-controlled surgery, nodal staging and intensified follow-up.
03Multiple cancersCoordinate systemic risk reductionKeratinocyte cancers recur frequently despite local treatment and protection.+
- 1Review field therapy, adherence, surveillance access and cumulative tumour rate in a transplant or skin-cancer multidisciplinary meeting.
- 2Consider specialist acitretin and whether immunosuppressive class or intensity can safely change, discussing graft and disease consequences.
- 3Monitor medicine toxicity and tumour incidence and stop unsafe treatment without weakening prompt lesion biopsy.
05Medicines and treatment safetyRegimens, contraindications and review points.
Acitretin capsules
Use only a specialist-selected individual dose for secondary chemoprevention, commonly starting low and titrating to tolerability under the current SmPC.Highly teratogenic with prolonged post-treatment pregnancy prevention, hepatotoxic and lipid-altering; review alcohol, interactions, mood, bone and mucocutaneous effects and never use without expert monitoring.
06Targets, monitoring and follow-upResponse, safety and longer-term review.
- Record the number, site and pathology of new cancers per year to assess trajectory and chemoprevention value.
- At each review inspect scars, field change, nodes and areas the patient cannot readily examine.
- For acitretin, monitor liver tests, lipids, pregnancy prevention where applicable and mucocutaneous and musculoskeletal toxicity.
- Confirm that transplant or disease specialists own any immunosuppression modification and that graft or disease markers remain safe.
- Audit urgent access from patient-reported warning lesion to examination and biopsy, not only attendance at routine surveillance.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Immunity changes biology
The same-appearing SCC can recur and metastasise more readily in an immune-suppressed host.
Field therapy is not triage
A broad fluorouracil course cannot substitute for biopsy of one thick, tender or rapidly changing outlier.
Tumour rate is measurable
Cancers per patient-year provides a practical baseline for evaluating systemic prevention.
The graft remains central
Cancer-risk reduction must be balanced against rejection and organ loss through shared specialist decisions.
08Common pitfallsFrequent interpretation and management errors.
- 01
Using standard low-risk follow-up intervals despite several SCCs arising each year.
- 02
Treating a thick painful lesion as field change without biopsy.
- 03
Reducing transplant immunosuppression independently and precipitating rejection.
- 04
Prescribing acitretin without the extended teratogenic, liver and lipid safeguards.
- 05
Limiting examination to sun-exposed skin and missing genital, acral or scar-associated cancer.