Sir,
We read with great interest the article by RC Gerringet al1 regarding prognostic factors and survival rates in a retrospective case series of patients who underwent orbital exenteration for non-melanoma skin cancers (NMSC). The authors have thoroughly described the correlation between survival rates and some factors which are thought to influence the prognosis after orbital exenteration.
Their article does not make any reference to the important relation between immunosuppression and the behaviour of NMSC. There is a good deal of evidence that shows that azathioprine and cyclosporin, as well as other agents, adversely affect such cancers.2, 3 A direct carcinogenic effect has been described in transplant patients for both azathioprine and cyclosporin, beside their primary immunosuppressive role. The former acts as mutagen and photosensitizer by increasing the level of its metabolite 6-thioguanine, while the latter seems to upregulate the transforming growth factor β (TGF-β), a cytokine implicated in cells proliferation and transformation.
Immunological cancer surveillance systems in patients using these drugs in the long term are known to be impaired in the detection and eradication of precancerous lesions. Finally, evidences suggest that also immunosuppression related to HIV/AIDS, non-Hodgkin lymphoma and chronic lymphocytic leukaemia may increase the risk of developing more aggressive SCCs.4, 5
Even assuming that no immunosuppressed individuals were present in Gerring et al's1 sample, we believe that considering immunosuppression among the potential prognostic factors is mandatory as far as NMSC are concerned. This is extensively outlined in many studies, including major reviews and meta-analysis.
References
Gerring RC, Ott CT, Curry JM, Sargi ZB, Wester ST . Orbital exenteration for advanced periorbital non-melanoma skin cancer: prognostic factors and survival. Eye 2017; 31: 379–388.
Jiyad Z, Olsen CM, Burke MT, Isbel NM, Green AC . Azathioprine and risk of skin cancer in organ transplant recipients: systematic review and meta-analysis. Am J Transplant 2016; 16: 3490–3503.
Berg D, Otley CC . Skin cancer in organ transplant recipients: epidemiology, pathogenesis, and management. J Am Acad Dermatol 2002; 47 (1): 1–17.
Wilkins K, Turner R, Dolev JC, LeBoit PE, Berger TG, Maurer TA . Cutaneous malignancy and human immunodeficiency virus disease. J Am Acad Dermatol 2006; 54 (2): 189–206.
Otley CC . Non-Hodgkin lymphoma and skin cancer: a dangerous combination. Australas J Dermatol 2006; 47 (4): 231–236.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Rights and permissions
About this article
Cite this article
Albanese, G., Abercrombie, L. The importance of immunosuppression as risk and prognostic factor for periorbital non-melanoma skin cancers. Eye 32, 159–160 (2018). https://doi.org/10.1038/eye.2017.169
Published:
Issue Date:
DOI: https://doi.org/10.1038/eye.2017.169