ElSquamous-cell carcinomas (SCC) are the second most common neoplasm in the group of non-melanoma skin cancers. The incidence of this type of neoplasm is increasing worldwide amongst men and women. It is estimated that the incidence in Spain may be between 7% and 10% throughout a person's lifetime¹.

The main causes include an aging population, destruction of the ozone layer and the cultural fashion of sun tans (exposing the skin at the beach, more open-air activities without protection from the sun and the use of sun beds that emit UVA rays), and a growing number of patients receiving an iatrogenic immunosuppressant to prevent rejection after transplants¹.

Most of these tumours are resolved with surgery. Only 5% present metastasis in other areas, depending on a series of what are deemed to be high risk factors such as: the size of the tumour (over 2 cm), the depth of the invasion (over 2 mm), Clark's level (IV or higher), perineural invasion, lymphovascular invasion, the level of differentiation (poorly differentiated tumours), the histological type (desmoplastic, adenosquamous, invasive Bowen's disease or an SCC that appears in a chronic inflammatory process), immunosupression, infection by the human papilloma virus, presence in high risk areas (pinna, mucous membrane), the expression of certain tumour genes and inadequate resection of the tumour².

This case consists of a 44 year old patient who underwent a kidney transplant at 5 years in the Hospital de La Fe, in Valencia. Since then he has been treated with the immunosuppressants azathioprine and corticosteroids.

He entered prison in 2018, presenting a number of wart-like lesions on both hands and legs (Figure 1). Consultations were carried out with the dermatology unit, and actinic keratosis was diagnosed, which was treated with cryotherapy.

Figure 1. Wart-like lesions. 

In July 2018, the lesions began to recur, and the dermatology service opted to carry out biopsies: an excisional biopsy was performed on the right leg, the outcome of which was a well-differentiated hyperkeratotic SCC of 3 cm, with no perineural infiltration and with free margins.

The same type of lesion was diagnosed on the left leg, with identical features but of a smaller size (1 cm).

Another check was carried out in November 2018 and the SCC on the right leg was found to be larger. The patient also presented an SCC on the back of the right hand, along with a basal cell carcinoma on the chest and another on the left hand. Cyotherapy was carried out on the lesser lesions and the patient underwent surgery to remove all the lesions.

Another SCC appeared on the left forearm in May 2019, and the patient underwent surgery once again to remove it.

The patient was referred to the dermatology service once again in December 2019, where he was treated for several actinic keratoses on the back of the left hand and right leg, and was referred once again for surgery. The recommendation was made to contact the transplants unit of the Hospital La Fe to evaluate the possibility of changing to another immunosuppressant that would be less likely to cause the lesions.

The transplants unit recommended a new treatment regime with everolimus, while monitoring plasma levels and progressively increasing the dosage. As the dosage was increased, new SCCs appeared on the left arm and neck (Figures 2 and 3) and further surgery was required.

Figure 2. Squamous-cell carcinoma on the left forearm. 

Figure 3. Squamous-cell carcinoma on the back of the neck. 

The patient currently presents no lesions and undergoes regular check ups with the dermatology service.