INTRODUCTION

The incidence, clinical presentation, and outcome of transplant-associated malignant melanoma (MM) are discussed more fully in Chapter 26. Surveys on the incidence of transplant-associated MM are limited, but those available have described a range from no increased risk up to an 8-fold increase relative to the nontransplanted immunocompetent population. Donor-derived MM accounts for 28% of cases of donor-derived transplanted tumors, making this the most common type of transplanted metastatic disease in organ transplant recipients (OTR). Information on other forms of posttransplant MM is scarce, and data on the incidence, management, and course of metastatic MM in OTR are almost nonexistent (Figure 34.1). The staging of metastatic (stage IV) melanoma was revised in 2001, and is now delineated as summarized in Table 34.1. Treatment of posttransplant metastatic MM is directed by our experience in immunocompetent individuals, with the crucial added consideration of whether graft-preserving immunosuppression should be withdrawn or altered. Management of this difficult clinical problem is unlikely ever to be strictly protocol-driven given the current lack of a robust evidence base, but rather requires a careful balancing of many complex allograftand tumor-related factors, which is possible only through a multidisciplinary approach.

INCIDENCE AND PROGNOSIS OF METASTATIC MELANOMA IN OTR

Available literature suggests a very poor prognosis (62% mortality) for transplant recipients with a history of MM before transplantation who have a recurrence of MM after transplantation. Similarly, OTR with donor-derived MM have high mortality rates with a 5-year survival of only 5%.